Social disadvantage and inequality tug at the very fabric of what makes society functional. It is time to reflect this in our conversation about mental ill health
First published on 20/5/2018 by The Independent during Mental Health Awareness week. Republished here on World Mental Health Day (Photo by Tom Parsons on Unsplash)
Annabel Head and Jessica Bond
In 2018, mental health and psychological distress are high on the agenda. And this is great progress. The increased awareness of mental health issues and the willingness to discuss them that we are currently seeing is vital. It keeps pressure on policymakers to fulfil their promise to put mental health on an equal footing with physical health.
To really make a difference, though, we need to take the conversation to the next level – to raise a different kind of awareness that leads to a different kind of action. Awareness about the root causes of psychological distress. We need to spread the message that the society and communities we live in and the way they are organised by social, political and economic forces play a significant role in our wellbeing. We need that message to become part of the conversation around mental health so that the ideas are built into the heart of all of our society’s policies, not viewed as only relevant to NHS mental health services.
The case for the role that social, economic and environmental factors play in mental health and distress is robust. Psychological distress (often categorised as “mental disorders” and other terms we, as psychologists, are not always comfortable with) is not distributed equally across society. People lower down the socioeconomic ladder suffer more mental distress than those higher up, with the gradient particularly pronounced for women. Inequality is also associated with poorer wellbeing for those at the sharp end.
Multiple studies have shown a link between low socioeconomic position and increased rates of depression and anxiety. Debt and having a poor-quality job – such as those with zero-hour contracts or where there is little control or reward to be had – are risk factors for experiencing distress.
Unemployment is associated with a higher risk of suicide. Similarly, poor quality or overcrowded housing is linked to poorer mental health in adults and is worse for children’s educational and health outcomes. Living in a neighbourhood blighted by violence or with a high crime rate is associated with trauma. Those experiencing oppression through living in communities in which there are high levels of racial inequality and discrimination are more likely to feel distressed.
Social injustice and inequality in the care system Part 1: How professionals can inadvertently make things worse
Psychologists and social workers who see risk rather than need are doing families living in poverty a disservice
Photo by Emma Goldsmith on Unsplash
On August 16, the British Association for Social Workers (BASW) and Psychologists for Social Change (PSC) co-hosted an event to highlight social injustice and inequalities within the child protection and care systems.
I work as a clinical psychologist in a service for people with a learning disability and have been an active member of London PSC for three years. At the event, the audience heard presentations based on research and practical experience of psychologists, social workers and people with lived experience of the care system. I agreed to summarise the points that resonated with me, along with some of my own thoughts.
After the main presentations small groups discussed what they had heard and came together to think about individual and collective action. I've collated our ideas in part 2 of this blog: "We need to be more 'counter', committed and personal". You can read BASW's Eve Wilson's take on the event here and watch a recording of part of the event here.
What does the research say?
Professor Anna Gupta discussed her research, alongside that of Paul Bywaters, Andy Bilson and Michal Krumer-Nevo. Professor Gupta explained that a child is ten times more likely to be taken into care if they come from an area of high deprivation compared to an area of low deprivation. (Deprivation refers to a community's access, or lack of access, to important resources such as income, education, employment or health). This is also the case for children on a child protection plan, which is drawn up by the local authority and the family after an investigation to keep a child safe or improve their living conditions.
As local authorities have continued to be hit by austerity, there has been an increase in the numbers of children on protection plans, most often for emotional abuse or neglect (the proportion of children in care for physical or sexual abuse appears to stay the same). Despite this increase, a large proportion of children are not being offered any service after the investigation. So, families are labelled as not providing “good enough” care but not “bad enough” to warrant support, a situation that Professor Gupta suggested has contributed to the relationship between services and families feeling increasingly authoritarian and coercive.
What then is driving these differences in the involvement of child protection services? There is no evidence to suggest that parents in Blackpool (an area of high deprivation) love their children any less than parents in Wokingham (low deprivation). Is it down to the differing levels of deprivation?
Professor Gupta talked about the direct and indirect impacts of poverty on children and families – both of which play a role. A direct impact would be the inability to buy food for your family if you do not have access to money. An indirect impact would be the lack of power that people living in poverty hold, blocking their access to roles, rights and opportunities as well as having an impact on the way professionals interact with them.
Social injustice and inequality in the care system Part 2: “We need to be more ‘counter’, committed and personal”
There are lots of things psychologists and social workers can do to ensure that families are treated more humanely by the care system
Photo by João Rafael on Unsplash
On August 16, the British Association for Social Workers (BASW) and Psychologists for Social Change (PSC) co-hosted an event to highlight social injustice and inequalities within the child protection and care systems. This is the second part of a blog responding to the event. You can read the first part 'How professionals can inadvertently make things worse' here.
While there might always be cases when children need to be taken into care, the focus of the event was on “reclaiming humanity” in child protection services. How can we ensure that families are treated more humanely? How can we ensure that services don’t worsen their situation?
Care leaver, social work student and children’s support worker Aijannah de Nisci shared an initiative in her workplace which challenges the assumptions underpinning the labelling and “othering” processes at work in the system. She explained that whenever “neglect” is discussed in meetings, other team members ask “what do you mean by that?” and “what does that look like”? This opens up a wider discussion of the family’s experience and allows for the possibility of change at a preventative stage. This led us to consider how professionals can help tackle smaller problems for families, before children are put onto child protection plans or taken into care.
Shoda Rackal, a breastfeeding peer supporter and member of Legal Action for Women, shared some of the community groups available to support families in the child protection system. She spoke about a monthly support group for mothers whose children have gone into the care system, and the monthly picket held outside a family court on the first Wednesday of every month. She also recommended the Legal Action for Women dossier, available online, on the unjust separation of children and their mothers.
Professor Gupta presented a quote from Michal Krumer-Nevo which encourages social workers to become more comfortable resisting – or countering – “the system”, more committed to social action, and more personal in their interactions, standing alongside families. As a psychologist, these are aspects to our practice which I think we can all incorporate, both those working in the care system and in other areas of health and social care. We could also look to Community Psychology. Community psychologists have long acknowledged the importance of working with marginalised groups to challenge social conditions, through both therapy and activism. Sue Holland’s social action model of psychotherapy is often used as an example of this, and I wonder whether some of the psychologists involved in the event might be able to incorporate some of the examples of collective action listed below into their clinical practice.
Far from being "transformational", the plan fails to address the fundamental barriers to long-term improvements to the nation’s mental health
Photo by Redd Angelo on Unsplash
Jen Daffin, Sally Zlotowitz and Jessica Bond
By 2023, children in about a quarter of UK schools will learn about mental health and wellbeing in their PSHE (personal, health and social education) classes. Those who are struggling with their mental health will be identified by a trained staff member and will be supported by new Mental Health Support Teams or directed to the right specialist service - services that will be more accessible thanks to four-week waiting time targets.
At least that’s the plan. The finalised proposals, announced by the government at the end of July after a public consultation, are an attempt to improve the mental health of children and young people in the UK. They will be rolled out in pilot areas from the end of 2019, with the aim of reaching between 20% and 25% of the country’s children four years later.
From the beginning, the Department of Health and Social Care and the Department of Education have made much of their “transformational” plan’s focus on early intervention and prevention and the “brand new workforce” that will be created to carry it out. In our view, their initial proposal, published as a Green Paper in December, was woefully inadequate in this regard. As part of the public consultation, Psychologists for Social Change submitted an open letter signed by 1400 psychologists, teachers, social workers, counsellors, as well as young people with lived experience of mental health issues and their parents. We explained that the proposal was a huge diversion away from the real issues surrounding children, young people and families’ mental health because it failed to address poverty, reduced social mobility and the growing number of people living in inadequate housing. These issues have been indisputably linked to poorer mental health. We urged the government to “take a genuinely preventative approach” by acknowledging and addressing these societal risk factors and bringing an end to the austerity policies that have exacerbated them.
Matt Hancock should listen to NHS staff about the impact his predecessor's decisions have had, and learn from it
While celebrating its 70th birthday, the NHS found it had a new captain at the helm. Matt Hancock, former Culture Secretary, has been re-shuffled into the role of Health and Social Care Secretary. But in what state does Mr Hancock find the UK’s health and social care services? What aspects of these services should he look at addressing?
Over the last five years, there has been an inescapable gulf between the experiences of NHS workers, and the statements given about the NHS by those at the top. PSC urge Mr Hancock to take note of the experience of NHS workers and address our concerns.
After more than half a decade under his predecessor’s leadership, the NHS has never been in worse shape. Patient safety has been put at risk to such a degree that last year the Red Cross said that the NHS was in a “humanitarian crisis”. At the time, underfunding had reached such crisis levels that NHS services in North London were facing a £183m deficit, leaving 1.44 million people living under commissioners who were forced to choose service delivery options “that impact on quality of care”. Things have not changed, with a Kings Fund analysis in May showing that the NHS has one of the lowest levels of doctors, nurses and hospital beds in the western world.
Yet there are those making profit from this atrocious state of affairs. Tenders are being given to private companies at a rate never before seen in the history of the NHS. Worse still, where private companies don’t win tenders, they are now suing the NHS for lost profits.
We aim to use psychological knowledge, galvanise psychologists and support others to campaign for a more equitable and psychologically healthier society
In our first blog post, we outlined our vision for a more equitable and psychologically healthier society. Here, we are going to talk about how PSC has been working towards this.
First of all, who are we? Psychologists for Social Change, PSC for ease, is a network of applied psychologists, researchers, citizens, academics, therapists and students, and anyone else who is interested in applying psychology to policy and campaigning for progressive social change.
The group formed in London in 2014, originally as ‘Psychologists Against Austerity’, after a meeting of like-minded community psychologists. We now have groups across the UK - in Northern Ireland, Wales, and northern England. In 2017, we changed the name to Psychologists for Social Change, so it could become the umbrella group from which we could run different campaigns, with Psychologists Against Austerity being the first. Psychologists Against Austerity is still a campaign in its own right and people use both names depending on what fits best. Although PSC initially came out of a meeting of community psychologists, not all of its members define themselves as community psychologists. However, the values of PSC very much align with community psychology – namely social justice, stewardship, and community.
You can read more about the development of the group from an article that some of us wrote for Critical and Radical Social Work: An International Journal which is available here
What would one look like? What needs to change? The PSC blog is a place to discuss issues and stumbling blocks on the road to creating a society that works for everyone
Photo by Samantha Gades on Unsplash
A more equitable and psychologically healthier society. A society which is more socially just, more peaceful, and more ecologically attuned. A society that, at its heart, encompasses the beauty of the human spirit, enhancing the values of compassion, solidarity, interdependence, and cooperation. Such a society would lessen psychological distress and would bring better individual and collective well-being, including for people who are currently marginalised.
Sounds good, doesn’t it? But what would such a society look like in reality? Day to day? Would yours be the same as mine? How do we create one? What is it about the current system that needs changing? These are some of the questions that we are hoping to address on this blog, ideally with your help.
We have some ideas, but we want to discover what this vision means to other people and other groups, and the ways you think we can get there. We want to hear from people for whom the current system is not working, from people who have an idea for how to change it, from those who have made it happen, and from people who can argue for a different way of doing things from their personal or professional stand-point (whether they are a psychologist or not). We will also post blogs about PSC campaigns and about how we work as an organisation.
At PSC, we believe psychology, mental health and well-being services - and the discourse around them - has become too ‘individualised’ in UK society. We believe people are being offered medication and talking therapies in a way that can obscure and downplay social issues, such as being overwhelmed at work, being poor, living in insecure housing, experiencing racism, feeling chronically stressed, and bearing the brunt of political policies like austerity. We are not advocating that psychologists should abandon individual therapy, nor should our stance be read as tacit support for the continued cuts to services. We are simply trying to move beyond the over-emphasis on individual mental health treatment.
If this sounds inspiring, please get in touch by emailing firstname.lastname@example.org or giving us a shout-out on Facebook or Twitter. Tell us what you’d like to see on here and, even better, if you would like to write it. We can send you some guidance we’ve put together for writers.
As PSC does not have access to funds, we cannot pay you for your blog. We hope that any subject you would want to write about for this space would also be relevant to you, so by publishing and promoting simultaneously, we can ‘signal-boost’ the message. We are happy to include links to campaigns or fundraising pages. We hope that you feel that this is a decent trade but please let us know if there is anything else we can do in exchange.
A behaviour change programme minus the behaviour change: What happens when health services are run as businesses?
In austere times, outsourcing health services to private providers is becoming more common. To ensure service-users aren’t short changed and public spending isn’t wasted, commissioners need to take a much more hands on approach
Behaviour change programme for weight-loss: changing eating habits is one of the 'active ingredients'
Recently, I spent a period working as a clinical psychologist in a health and well-being service, commissioned by a local authority in response to the UK’s obesity rate. The service is run by a small private organisation and was set up to promote healthy lifestyle behaviours. One of its aims is to support people to achieve a healthy weight to reduce the risk of preventable weight-related diseases and the human and economic costs associated with these. It does this with programs designed to change people’s behaviours around food and eating and increase their physical activity.
Aspects of the service were very encouraging. The team deployed creative ways of engaging local communities, statutory services and charities, ensuring a steady stream of suitable people referred to the service. It had established a strong presence in the community by taking part in health and wellbeing campaigns. The programs were delivered by an enthusiastic though overstretched team that strongly abided by the “code” of the healthy lifestyle behaviours they promoted. A particularly exciting aspect of the service was that commissioners had recognised the role psychological and psychosocial factors play in the development and maintenance of obesity and behavioural change – hence the opening for a psychologist. I was excited to get stuck into my role, supporting this already vibrant service by integrating psychological theory and practice into the service delivery.
Alas, my enthusiasm was short-lived. As I gained insights into how the service functioned, a nagging sense of unease took hold. A feeling, I now think, that stemmed from a tension created by the outsourcing of public services to private providers. It is hard to believe that the consequences of this tension are limited to this particular service - after all, in current economic times, this model of service procurement is becoming the norm. In fact, whilst writing this article, I had numerous conversations with colleagues working within the public and education sectors who found my experiences resonated with their own. This further convinced me to share my experiences as I hope they will stir up a discussion.
What is a behaviour change programme?
Within the context of public health, a behaviour change program refers to efforts to change people’s behaviours and habits to prevent disease. The main emphasis of such programs is the prevention of disease to save healthcare and human costs. The National Institute of Health and Care Excellence outlines 8 main principles for the development of such programs, within the domains of planning, delivery and evaluation.
One of the first things that struck me about the service was the lack of theoretical understanding of behavioural change models and the processes of achieving behaviour change across the organisation, though the term was often used. There was little acknowledgement of the interaction between biological, psychological and social factors that play a role in health and in particular, obesity - or even curiosity about these. Little attention was given to the characteristics of service-users, their cultural and socioeconomic context and how harmful behaviours might be caused and maintained by a complex interaction between external determinants and internal processes. No thought was paid to differences between service-users and delivery staff nor how these differences might affect engagement. Instead, the team positioned themselves as “experts” in relation to service-users, who needed to be educated on what was good for them.
The lack of understanding and conversation around the wider issues meant that staff, who often found themselves at a loss as to how to engage clients past the initial assessment meeting, had a tendency to blame service-users, characterising them as lacking motivation or not owning the responsibility to change. Attitudes were foisted on the whole group – “they did not care” about their health or were “unmotivated” to make change and instead “made excuses” not to. This process of “othering” service-users created a division between us and them, which fed into stigmatising scripts about people who are overweight. There was no support for staff, who by no fault of their own, had been assigned a task that often took them out of their comfort zone, causing anxiety but also a sense of complacency and hopelessness. As such, frustrations were left unacknowledged and unprocessed. This was covered up by the need to be positive and press on with a focus on the solutions - on doing.
Us vs them
And the service was certainly good at doing. As the weeks went by it became clear that the teams operated within a highly performance driven environment. I was astonished to hear staff across all teams talk about the number of “starters” they needed to sign up to the programs by the end of each quarter. Everyone was aware of the day-to-day performance of the service and the need to push on when they were not meeting the average monthly target. On the ground, this meant that clinics were booked back to back with no breaks for staff, who spent their time with clients collecting outcome data before signing them up to the programs. When targets were achieved, staff were rewarded financially. Everyone worked hard and was very committed to meeting the key performance indicators, or KPIs, set by the service commissioners. However, the more time I spent observing, experiencing and learning about the processes of the service, the more I realised that this activity seemed somewhat hollow and that something important was amiss.
Signs that things were not all that good were noticeable. The delivery team felt unsupported, overworked and burdened by high caseloads as well as repetitive and duplicative administrative work. The relentless pressure to achieve targets allowed little space for them to engage service-users in meaningful conversations about their behaviours. There were high drop-out rates from the programs, a threat to service performance which increased anxiety among the team, as well as heightening the “us” vs “them” mentality.
Despite these frustrations, on paper, the service was doing very well. The reports showed consistent achievement of the set KPIs. Yet when I completed an audit of one of the pathways through the service it revealed this was belied by a different kind of consistency: a systematic lack of reliable data collection and coding practices that had huge implications for the validity of the data analysis. One of the most worrying practices was the use of “zero” for missing data. For example, entering zero for missing data on symptoms of anxiety after the program had been carried out means the intervention was so successful that the individual no longer experienced any anxiety. Whereas in actual fact, the meaning of the “zero” is the absence of data. When included in the entire sample, this drives down the average anxiety level, resulting in a “false positive”. As a scientific practitioner, I was shocked by such practices.
My role as a psychologist meant that I worked with both management and delivery staff, which gave me the opportunity to reflect upon the split between the two teams. I noticed that staff team dynamics seemed to mirror what was happening in the patient group - that a parallel process of “us” vs “them” had emerged. At the delivery level, I was struck by how the service KPIs had crept into the weight management materials, disguised as service-user goals. Service-users were encouraged to work towards a “10% reduction in weight” or to “increase their score” on a diet questionnaire. At managerial levels, there was a preoccupation with the need to ensure continued funds and reduce costs, which translated into role restructuring, diversifying the business plan, and spending money on performance management software and external expert advice on digitalising work processes.
As a psychologist recruited into the service to provide psychological thinking and put evidence into practice, I began to realise that this was only welcomed if it maintained the status-quo and resisted when it was felt to impinge on the established system. Even though my tasks and objectives had been agreed with management, I found that the work I needed to do to achieve them was not fully supported. The more I questioned and challenged established thinking, the more isolated and unsupported I felt in my role. This reminded me of yet another parallel process – of how complex and challenging change is at an individual but also an organisational level.
A clash of tasks
So how did we get here? How had the focus of the service become so rigidly about data collection and outcome monitoring rather than meaningful behavioural change? How had it become all about the service rather than the service-users?
In an economic period defined by austerity, perhaps this focus isn’t surprising. Outsourcing services to private providers is one way to save resources while fulfilling responsibility. To ensure resources are spent appropriately with the desired result i.e. disease prevention, commissioners outline the service they want and a set of KPIs that the provider must meet to demonstrate effectiveness. The latter is achieved by collecting and reporting outcome data. Commissioners do this to commission cost effective, evidence-based programs (their primary task). For a private provider, a decision to bid for a public service will largely depend on the profitability of the contract and their competence to deliver the program in a way that meets the KPIs at a profitable margin, thus ensuring their continued income (their primary task).
This is standard procedure and, on the surface, it is nothing untoward; there ought to be accountability for how taxpayers’ money is spent, and it can be argued that the competition this creates makes service delivery more innovative. The trouble is that this introduces a competing set of tasks between the provider and commissioner, and those responsible for achieving them on their behalf. The unavoidable consequence is that the service is no longer a service, but a business. Thus a conflict between the tasks of the delivery team (providing the behavioural change interventions) and the management team (ensuring steady income through targeted performance management) is created.
I wonder if a lot of the issues I came across can be traced to the set-up of these public-private partnerships. The focal point for both the commissioner and the provider is the set of KPIs. The provider is usually left to decide and manage how they achieve them. They outline their approach in the bidding process but it is usually not what the commission hinges on. In other words, the contract prioritises the what over the how.
But the how is significant. Behavioural change programs are undoubtedly complex interventions, and require careful consideration of many factors. These include what needs to be achieved (the behaviour change), the theoretical understanding behind it (how that change happens), the methods required to achieve it (the “active ingredients”), the variance in the population as well as consideration of how best to monitor progress (how the behavioural change is measured) and evaluate programs (can we identify what is working and capitalise on this to refine the program?)
The what is also significant. As others have pointed out, the outcome of a behavioural change program is a behaviour. But too often what is considered an outcome and crystallised as a KPI is a consequence of the behaviour (weight loss), not the behaviour itself (eating more vegetables). There are many reasons for this, but it is health behaviours that such behaviour change programs need to focus on. Focusing on the wrong outcome can have serious implications. At my service, designing programs focused on weight loss unintentionally contributed to weight- and obesity-related stigma.
Where do we go from here?
It seems justified to worry that businesses might not have the skill set and understanding needed to develop complex behavioural change interventions. To manage the possibility of this knowledge gap, I think it is reasonable to ask commissioners to take a more hands-on approach. This could mean giving clearer direction about the evidence-based practices that providers need to perform. Appropriate outcome measures and methods of evaluation could be discussed upfront. These should be informed by appropriate theories to avoid over-reliance on simplistic and potentially harmful KPIs. A simple example would be for commissioners to set a KPI as “Have 300 people attend 75% of the behavioural change program” as opposed to “Have 300 people signed up to a behavioural change program.” The end result might be the same but the process of getting there is different: one engages people and one recruits them.
Service-users should be involved at all stages of the program development, delivery and evaluation to ensure that they have a voice and opportunity to shape services according to their needs. Commissioned programs could be evaluated by an independent group of health and social science practitioners with a sound understanding of the theories of behavioural change. Paying more attention to the process underlying behaviour change could help the field long-term. A robust continuous evaluation of and shared learning from such programs would help identify “active ingredients” that facilitate behavioural change across diverse groups, informing theoretical understanding and leading to improvements in service development and practice, generally.
It has been frustrating to witness private providers with next to no knowledge of behaviour change winning public health contracts based on business models designed predominantly to perform well financially. KPIs are a useful accountability tool but only when they are set as meaningful guides to service delivery. As I witnessed, when they don’t accurately reflect the complexity of the work needed, this can have negative consequences for staff, commissioners and service-users. One thing feels certain - we should be talking about what makes us uncomfortable at work, about what shocks us. If we don’t speak out, we’ll never realise how sick our services are, nor work out what we need to do to make them better.
Over to you
If any of the themes in this blog resonate with you or if you have a different take on what is needed, please let us know in the comments below.
PSC is a network of people interested in applying psychology to generate social and political action. You don't have to be a member of PSC to contribute to the blog