All mental health advocacy is political

This post was originally published at Huffington Post.

Equating mental health issues with physical illness is fashionable amongst health commentators. From analogies associating mental health issues with a broken leg or cancer, to calls for parity of esteem, the inference is that mental illness and physical illness ought to be considered in the same way. But while the message may have served a purpose in recent years, it’s also a simplistic and increasingly misleading interpretation of mental health, and we owe it to our society and to the millions struggling with mental health issues to do better.

In the aftermath of the general elections last month, New Statesman journalist Laurie Penny wrote an impassioned article that linked the election result with depression. Social media backlash quickly followed, accusing the author of being insensitive and naive about the seriousness of mental illness.

A political commentator lacking insight into mental health might have been inclined to admit error, even if only to avoid confrontation. But Penny is no stranger to the subject of mental health. Quite the opposite. One of her first roles in journalism was writing for One in Four, a magazine whose raison d’etre was to provide a voice for those with mental health issues.

What Penny knows, and what we perhaps all need to remind ourselves of, is that mental health and sociopolitical factors are deeply intertwined. Not least of which is the economy, with studies showing dramatic rises in suicide during periods of recession and high unemployment.

There is also a strong relationship between inequality and mental illness. And an underlying risk factor for poor mental health is a perceived lack of control over our lives – something that almost every political decision could be said to have an influence on. Interpreting mental health with a strictly medical model precludes all of this.

None of this is to say that mental illness doesn’t also have a biological basis. Of course it does. Medical interventions can help. And a medical interpretation of mental illness can reduce blame associated with those who are suffering. But a denial of social and environmental factors can also leave us feeling helpless and insensitive to what’s going on around us.

Studies have also indicated that a narrow, brain-based interpretation of mental illness may increase pessimism about recovery, reduce confidence in psychotherapies, and actually increase aspects of stigma.

The solution, needless to say, is with an integration of biological and sociopolitical factors. That may be difficult and uncomfortable to do in our dualist, western society with its love of clear definitions and boundaries, but only when it happens will we be on the right path. Not just for the benefit of those with mental illness but also for those with mental health. (Yes, I mean everyone.)

Mental health advocates have a tendency to lose sight of this. While some campaigners delighted in political parties putting mental health service funding in their 2015 election manifestos – others were skeptical in light of the government’s rhetoric-defying NHS cuts.

Irrespective, rises in mental illness and suicide should not only prompt an increase in medical service provision – which is a given – but also an examination and reversal of social and political contributors. Like the canary dying in the coal-mine, it should be seen as a sign that something is not right.

The onus to point this out shouldn’t only fall on the mental health community. It should fall on the political ‘left’. If the left is lacking direction, as some have claimed, it would do well to reflect on its attitude towards mental health, and its neglect of the social sciences. The Conservative government has mined the area, with its‘behavioural insights’ and ‘wellbeing index’. Why has the left not done the same, and used the the abundance of social sciences literature that inherently supports its position?

Were it to do so, it wouldn’t refer to the rise in mental health issues only in terms of health services, but in terms of a need for broad social and political reform. Reform that starts by recognising that the association between recession and suicide is a symptom of a society failing to do enough to protect its people from the downsides of misfortune, whether economic or otherwise.

There is no biological reason for why economic depression should lead to clinical depression. It’s entirely social and political. We’re all affected, and we need more public figures to be talking about it.

In Praise Of Student Support Staff

At a Student Welfare event I was speaking at yesterday, I tried to catch a student support advisor after one of the sessions. She had left the room swiftly, and was on the phone in the corridor outside. There was a look of concern on her face, and at first I wondered if it was a logistics issue – perhaps a son or daughter that needed picking up from school, or some other personal matter. But it wasn’t anything like that. She was phoning to check on a student at her university that was having a particularly tough time.

I don’t often meet someone who shows this level of compassion and concern for others, but when I do, it’s invariably a member of student support staff. There has been an increase in the number of articles examining student mental health and questioning whether universities are doing enough, but very few of these have recognised the extraordinary work done by existing support staff.

One of the things I’m most proud of from my time at NUS-USI earlier this year was the groundwork we laid for an Open Your Mind awards programme. We wanted to recognise not just things done by students to promote mental health, but also the tireless work done by support staff to help thousands upon thousands of students every year. It wasn’t that we thought staff would want the recognition (they are too selfless for that) but we hoped maybe it would help others to see why student support is so valuable.

I don’t know why support staff don’t get more recognition. Maybe because they don’t make a fuss about things. Maybe because others think they are only ‘doing their job’. Anyone who has spent time with support staff will know that this is not the case, and that they give a huge amount to others. Nobody gets involved in student support for their own interests – they do it because they care, deeply.

Referring Back To CR166 (And A Note For Journalists)

Blind Men And The Elephant
During the past few months, there have been articles about the mental health of students in the Guardian (here, here, here, here, and here), the Independent (here and here), Times Higher Education (here, here, and here), and now the BBC (here). It’s great to see the issue being covered, even if it’s because of tragic statistics and stories.

If there’s one issue with the coverage it’s that it tends to focus a lot on problems and not much on solutions. It’s important that those covering the subject don’t ignore the work that’s already been done to provide us with answers.

The Royal College of Psychiatrists’ report doesn’t have all the answers. It doesn’t even have all the questions. (It makes it clear that more research and data is needed – some of which has since become available thanks to the work of organisations such as NUS and the Equality Challenge Unit). But the report does give us a few clear guidelines and recommendations that can be acted on immediately. More than that, it’s the most comprehensive report on student mental health we have, with input from organisations across the higher education and mental health sectors. It gets us on the same page. We should all be referring to it.

When I get phone calls from journalists looking to cover student mental health, it’s usually immediately apparent that they are full of compassion and sensitivity for the subject. I enjoy talking with them. But I don’t think I’ve had a single journalist start by asking me what needs to be done. The focus has always been on what’s wrong, and why. I suppose that’s the nature of journalism, but hopefully it can begin to shift a little.

I wrote a review of the Royal College of Psychiatrists’ report after it’s publication, summarising key points and adding a few things that were omitted. I’ve now updated this paper, adding data and developments from the past 18 months. If you’re a journalist or policymaker looking to do something around the mental health of students, take a look.

University Mental Health Policies: Better Communication = Better Mental Health

In March I was part of an online discussion about the role of mental health policies in promoting students’ mental health – a subject brought to prominence by the Royal College of Psychiatrists. The starting point for the discussion was simple: should all universities have a mental health policy?

At first there seemed to be unanimous agreement from panelists: yes, all universities should have a mental health policy. Since all of the panelists were (to some degree) involved in supporting students’ mental health, this probably wasn’t surprising. Why would anyone not want to make it easier for students to access support, right? But the discussion grew more complex, and an opposing point was raised that I hadn’t anticipated. After reflection it became clear though that the disagreement was not based on a difference of views, but on an ambiguity found in the RPsych’s recommendations – one that I hope to clear up here.

The argument put forward by one of the panellists was that, whilst all universities should have mental health policy, it should not necessarily be based in a single ‘mental health policy’ document. The wider point that they alluded to was that, since the mental health of students is interrelated with other subject areas (such as disability issues and student services), it cannot be looked at in isolation; to expect universities to be able to extricate mental health policy from related policy areas and present it in a single uniform document risks oversimplifying the issues.

In some ways, this view aligns with the principles of the Healthy Universities project (based on the World Health Organisation’s settings-based approach), which recognizes that health and wellbeing is not a standalone issue but one that necessarily involves wider environmental factors. We know that social factors have a profound influence on mental health, therefore for universities to modernize and adopt settings-based approaches they need to recognize the links between mental health and wider campus issues – even those issues traditionally considered to be academic (as alien as this idea may be to certain VCs). The panellist was surely right, then: mental health policy must be embedded into wider institutional policy. And yet, the content of policy and the presentation of policy are not necessarily the same thing.

What the Royal College of Psychiatrists’ report fails to do is recognise the dual roles of a mental health policy. If we explore the definition of ‘policy’, we’re confronted by two interpretations. Whilst on the one hand policy exists to provide standards and guidelines for policy-makers and those policing policy, on the other hand, it exists as a public statement of intent – a contract between those with the power to implement policy, and those whom the policy affects. The former, we can think of as ‘policy‘ (or a number of related policies), the latter as ‘a policy‘ – which is about communicating ‘policy’ to stakeholders through a single document.

The reason I first got involved in mental health campaigning was not to address gaps in support, but gaps in communication. The Mind Matters Society was launched to ‘bring mental health out of the shadows on campus’ – by challenging stigma around mental health issues, but also by making information about mental health more available to students so that they could make their own choices. The latter of these goals (although not as topical as the former) is just as crucial. The sharing of good information necessarily reduces discrimination, but a reduction in discrimination does not necessarily lead to useful information being shared. As long as information about a university’s mental health and support provision remains impenetrable to students, mental health will be a subject difficult to grapple with. It’s for this reason that a formal statement outlining the university’s commitment to student mental health is so important.

The task for universities,therefore, is to provide a policy document on the subject of mental health that is accessible to those it affects, whilst also ensuring that policy on mental health remains embedded within its wider system. The dozens of university mental health policies already in place suggest that this is achievable.

If universities need to provide multiple policy documents then so be it, as long as there’s one starting document that sets out the university’s commitment to the mental health of students. As Chris Brill, the ECU’s policy advisor suggested during the discussion, irrespective of the complexity of policy, universities can offer a reference document that outlines the university’s position on mental health. It’s this that I believe the RPsych’s report is referring to it when it speaks of a ‘mental health policy’, and it’s this that I am campaigning around. Whether the title of this policy document contains the term ‘mental health’ is up to them, but  when ‘mental health’ is the universally used term to capture psychological issues and treatments, why complicate matters further by calling it anything else?

The cause of low mental health disclosure rates: "Fear of appearing weak" or poor publicity?

Yesterday, The Times Higher Education (THE) published an article suggesting that the low number of students and staff disclosing mental health problems could be explained by “a fear of appearing weak”. I’m not sure that’s a good explanation.

Firstly, the context — The article refers to a report from the Equality Challenge Unit (a charity that, according to its website, “works to further and support equality and diversity for staff and students in higher education”) highlighting that just 0.7% of students and 0.2% of staff are reporting a mental health problem. Even using conservative estimates about the prevalence of mental health problems, there is clearly a very significant number of students and staff that are not disclosing their condition.

The consensus is that stigma prevents disclosure, and that if people feel less stigmatised then the number reporting their conditions will grow. That may be true. But there’s a question in this discussion that needs more attention: Why should they disclose?

If the sector believes that students and staff will benefit from disclosing a mental health problem to their institution then they need to explain how. And it would follow that if the numbers still aren’t increasing then it’s because students and staff don’t think the advantages are significant enough. Or they still know nothing about them.

The ECU’s report states that students with a disability who access Disability Support Allowance don’t only benefit financially, but are also more likely to receive a first class or upper-second class degree. If institutions want more DSA uptake then they need to publicise this, and use it as a way of communicating the benefits of disclosure. They can start by addressing the issue of most students and staff not knowing that they would be entitled to DSA due to confusion around the use of the word ‘disability’. Or by developing, and making available to all staff and students, a university-wide mental health policy – as recommended in the Royal College of Psychiatrists’ report into student mental health.

Stigma is a part of this. But stigma should not be used by policy-makers as a way of shifting responsibility away from their role. If institutions want more of their members to disclose a mental health problem then it’s up to them to give good reasons for doing so. Gary Loke doesn’t seem to understand this:

Gary Loke, head of policy at the Equality Challenge Unit, said the survey showed that many people in the academy with mental illness were suffering in silence.

“If you do not disclose you have a problem, universities cannot help you,” he said. “Institutions are generally very supportive to disabled staff, but people need to feel they can come forward and talk about their mental health problems.”

You may mean well, Gary, but the bigger question to answer is this: how will universities help those that talk about their mental health problems? And what exactly do you mean when you say that institutions are “generally” very supportive? The burden of responsibility for low disclosure rates does not end with those that are not disclosing;  institutions must work on creating settings in which people feel inclined to disclose.