Written evidence submitted by the British Association for Counselling and Psychotherapy (BACP) (MH0021)

Introduction

The British Association for Counselling and Psychotherapy (BACP) is pleased to provide a submission to the Environment, Food and Rural Affairs Committee inquiry into Rural Mental Health.

BACP is the leading and largest professional body for counselling and psychotherapy in the UK, with over 60,000 members. Our members are drawn from the various professional disciplines in the field of counselling and psychotherapy, working in a broad range of settings including agriculture, education, private practice, healthcare, workplace support and within the third sector, as well as working with clients across all age-groups.

Background

Over recent years we have been working closely with a network of rural support organisations, research institutions, Trade Unions and charities working to tackle a growing ‘mental health pandemic’ in UK farming. During this time, we have also worked closely with and listened to our members, many of whom provide frontline counselling services to farmers and their families. We have long been aware of a growing mental health crisis in UK farming, with services struggling to meet demand as pressures increase on workers. Many people living and working in rural communities have reached tipping point, with their ability to cope outweighed by the scale of the problems they face; including poor weather, rising unemployment, policy challenges, changing consumer trends, supply chain issues and disease.

The COVID-19 pandemic has exacerbated existing challenges within rural farming communities, and the legacy impacts of the pandemic will likely outlast the health crisis itself, including changes to communities, widening inequalities, mental ill-health, revenue challenges for government and rising unemployment. In rural communities, the pandemic has served to exacerbate existing problems including the supply of migrant labour, supply chain issues and increased isolation for some already vulnerable or ‘harder-to-reach’ farmers.

In an industry so integral to our daily lives, and one already affected by high rates of poor mental health and suicide, it is vitally important to understand the issues and we therefore welcome the opportunity to participate in discussions and make recommendations about how the government can improve mental health provision and outcomes for those in rural communities. 

Summary

• Poor mental health was already prevalent among agricultural workers, the COVID-19 pandemic has exacerbated many of the underlying causes of poor mental health and suicide
• A myriad of factors contributes to poor mental health in rural farming communities, COVID-19 has added to these by restricting access to support services, creating a backlog in delivery
• Higher than average suicide rates among agricultural workers are influenced by a number of often related factors
• There is a growing demand for mental health services, including counselling, for farmers/farm workers and their families across the UK
• Where available, multiple barriers exist to access mental health services, including isolation/accessibility, availability, and cultural factors including gender and age
• Efforts to address mental health in rural communities need to consider the different experiences and needs of farmers and their families.
• Charitable support organisations require additional funding to meet growing demand for mental health services, and better coordination between support organisations is important to avoid duplication and service gaps
• Counselling, both face to face and online/telephone, is effective in helping farmers and their families build resilience, address feelings of isolation and anxiety and build resilience within communities

What specific mental health challenges are faced by those living and working in rural communities?

People living and working in rural communities face a multitude of challenges, many related, that can place them at a greater risk of mental and physical ill health. These include farm succession and family relationships, policy changes, rising unemployment changing consumer demands, isolation, inequality and challenges with disabilities, adverse weather and disease.

Within rural communities, some groups have been shown to be at greater risk of mental ill health than others. For example, women, farmers who keep livestock, and those running smaller enterprises are the most likely to be struggling with their mental health, according to the Royal Agricultural Benevolent Institution (RABI) Big Farming Survey (2021).

The survey found that whilst 36% of the entire farming community described themselves as “probably” or “possibly” depressed, for women in agriculture, the figure was 43%.  Similarly, the survey showed a strong correlation between farms with livestock and reduced mental wellbeing, with 47% of farmers in the pig sector, and 39% of upland grazing and dairy reporting that they were “probably” or “possibly” depressed.

With the vast majority of UK farms day-to-day farm management issues can lead to family conflict and tensions about the business, including feeling a loss of control, communication breakdowns, verbal and physical abuse and marital difficulties – all of which can contribute to higher stress levels. 

Long working hours also add considerable strain to farmers and their families. A major survey of farmers, farm managers and farm workers, undertaken by Farmers Weekly, found that British farmers work on average 65 hours per week, with some growers and livestock producers working in excess of 100 hours, rarely taking a day off, let alone an annual holiday. The survey revealed that the key creators of stress include workload, finances and relationships, with many farmers suffering the effects of sleep deprivation, including fatigue, as they juggle competing priorities.

Alongside the devastating financial impact of the COVID-19 pandemic, disruption to everyday life have also taken their toll on those in rural communities. The cancellation of important events in the farming calendar, as well as limitations on being able to travel and visit others, have served to exacerbate the feelings of isolation and loneliness already common in rural communities. This also made accessing face-to-face support even more challenging. The Big Farming Survey found that for farmers the pandemic ranked alongside ‘unpredictable weather’ and ‘concern about the future of the farm’ as the most significant causes of stress and anxiety.

Research commissioned by the National Rural Mental Health Forum and Support in Mind Scotland (SiMS) showed that 93% of people living and working in marginalised rural communities believed that the COVID-19 pandemic had a negative impact on their mental health and wellbeing. The report, launched in February 2021, focused on the experiences of LGBT+ people, young carers and refugees and asylum seekers living in rural Scotland. Two of the key issues it highlights are the loss of face-to-face contact and a lack of access to local support.

What is the current state of mental health & suicide prevention service provision for those working in agriculture and those living in rural areas more generally? Do they meet the specific needs of that community?

Current provision for mental health and suicide prevention services do not adequately meet demand. This was the case prior to the pandemic, which has placed further strain on a network of services made up of a combination of IAPT (in England), community and voluntary providers.

BACP accredited service providers, many of whom work exclusively with rural workers, point to an urgent need for better designed service tailored to meet the specific needs of those in rural communities. Those providing counselling would benefit from training to better understand the rural context and improve engagement with communities that are traditionally hard to reach due to cultural and physical barriers.

Online counselling services, such as those provided by Kooth and Quell via RABI, provide an opportunity to reach more people, though the digital divide may make access problematic in some remote areas. Additionally older people are less likely to seek help through these channels, partly due to a lack of digital capability and partly due to a preference for traditional face to face services.

The 2017 report, Agriculture in the UK, revealed that the percentage of older people living in rural areas is as high as 56 per cent, with a third of all agricultural workers in the UK over the typical retirement age of 65 years. Those in these age groups are more vulnerable to isolation and loneliness, unlike younger farm workers who tend to be more mobile, physically active and more willing to engage with a range of support services. 

Two-thirds of people with dementia live and work in rural areas, and charities like the Farming Community Network (FCN), a voluntary organisation and charity that supports farmers and families within the farming community, has reported helping an increasing number of people affected by the illness. This includes providing help with accessing GP surgeries post-diagnosis support from other services, which tend to be patchy and inadequate in many rural areas.

The underutilised but highly capable counselling and psychotherapeutic workforce is ideally placed to provide this much needed support, however more work is needed to identify what existing provision looks like, where the gaps are and what investment is needed.

What are the causes of the higher-than-average rate of suicide amongst those working in agriculture? Are there other linked professions, such as vets, that have similar issues? How effective are suicide prevention services offered to these groups?

A review of the literature on rural suicide indicates that a growing body of empirical, theoretical, and prevention work has been conducted on the topic, with an increasing number of countries represented and articles written. These show that a range of risk factors contribute to the higher-than-average suicide rate amongst those working agriculture, and they include:

• Rural Isolation, including geographical, social, and cultural isolation. Farmers who lived remotely reported worse mental health and wellbeing than remote non-farm workers regardless of financial hardship, rural specific factors (e.g., drought worry), or recent adverse events. Lack of social supports and networks also feature which could contribute towards a poor work-life balance.

• Help seeking behaviours: Rural workers may prefer to manage themselves rather than access help for physical health or mental health needs, particularly older men. Pride, awareness of available services and financial constraints can all further influence help seeking behaviour. In the latter case seeing a therapist in private practice implies a monetary investment which can be hard to meet when part of the problem is actually financial.

• Gender: Farmers were more likely to be older, male, married, suffering financial hardship, have lived in a rural area for longer, live more remotely and in an area of disadvantage. 

• Structural barriers to seeking help: including geographical location and decline in rural infrastructure at regional and community levels.

• Factors beyond farmers’ control: including climate change, commodity markets, interest rates, weather, disease and policy changes.

• Farm succession: the intergenerational aspects of farming families was mentioned and the difficulties that could occur when there was no communication between generations about the future of the farm.

• Financial worries/pressure: with some farmers reported having to take an additional job off the farm to supplement their income rather than sell the farm which was running at a loss.

• Physical health problems: such as farm-related injuries, chronic physical symptoms, back problems, and respiratory problems were identified as influencing factors.

• Trust: There are certainly many examples of solidarity and camaraderie among farmers, but there is also a strong sense of competition that raises suspicion and makes it difficult to trust and to know the people you could safely share intimate matters with. One service provider commented on this, saying that “some farmers are reluctant to talk to ‘outsiders’ who may either not understand the context in which they work or may fear disclosing things within therapy that could lead to perverse consequences, such as the loss of firearms licenses”.

• Suicide prevention: The need to form networks and the use of multiple strategies to prevent suicide among farmers are themes that feature in the literature. Many rural areas benefit from voluntary service providers, including rural community councils, some of which provide suicide awareness training and, in some cases, support. However, and due to contracting funding, the availability of such services are patchy and inconsistent. More joined-up working between key stakeholder organisations, including funders, policy makers and frontline delivery organisations, is required to better shape and target investment at the local level.

Is sufficient mental health support made available to rural communities following “shocks” such as flooding or mass animal culls?

As previously noted, the demand for mental services outstrips supply in many rural areas. The focus of any additional mental health investment has to be concerned with levelling up the inequities in provision in a targeted way that is designed to meet the specific needs of those living and working in rural communities. In doing so there will be less need to respond reactively to crises or shocks with temporary interventions or measures. The goal instead is to be build resilience and empower rural communities for the longer term.

Does the Government’s recent investment in mental health services adequately provide for agricultural mental health?

We welcome the government’s investment in mental health services, but as already been noted, the rural mental health landscape requires specialist, targeted investment to meet the unique myriad of challenges faced by those living and working in rural communities. This cannot be achieved by a one size fits all approach or within a single funding settlement. Targeted additional investment is required to support existing service providers and develop new approaches to addressing the growing mental health crisis in UK farming.

In recent months we have worked closely with RABI and BACP organisational members providing counselling services to develop and pilot an innovative new model of face-to-face delivery – alongside existing online services – that will shortly be rolled out for rural workers in England. The model includes a number of elements that will aim to address some of the key challenges associated with delivering mental health services in rural communities. This includes providing qualified BACP registered therapists with training designed to increase their awareness of the rural context and challenges, ensuring that they better understand the needs of farm workers (and their families) and to help build trust and improve engagement. We aim to work closely with the service delivery organisations over the course of the pilot and will capture and share any key lessons.

How joined up are key actors, such as Defra, DHSC, NHS England, Public Health England and Local Government in their approach to improving quality of, and access to, mental health service in rural and agricultural communities?

Many commentators refer to a rural ‘mental health crisis’ and, as the above shows, there are a number of factors that contribute to the landscape of poor mental health in rural/agricultural communities. Addressing this complex picture will require a joined up multi-agency approach, one in which public bodies, policy makers, funders, charities, stakeholder organisations and those living and working in rural areas work together.

It is unclear how joined up these key agencies are, though the view from the ground is that they are not. Defra and other devolved administrations should consider what role they might play in co-ordinating, supporting, or facilitating a joined-up landscape of support for farming mental health.

However, any such collaborative work must seek to address a number of factors contributing to poorer mental health, including the economic, social, physical and psychological determinants. This work could be captured within dedicated local rural mental health strategies and action plans, which would aim to build better opportunities for good mental health and wellbeing, community strength and more responsive and accessible services.

Implications and Recommendations

• Agricultural workers/communities face a myriad of potential stressors, many of which are long term, therefore there is a need for long-term support for organisations to help build resilience and improve mental health services
• Provide support to those who come into regular contact with farmers (e.g. vets and feed merchants) to access mental health first aid training and be equipped to signpost to available support services.
• Strategies need to be identified to develop networks and normalise conversations around mental health, in order to help reduce stigma as a barrier to help-seeking behaviour and prevent suicide among farmers
• Mental health issues are often multidimensional (e.g. stress and anxiety related to finances, family issues and physical health) so support services need to be designed and accessible in a way that is equally multidimensional in rural areas. These need to promote greater access and choice to a range of psychological therapies, including counselling and psychotherapy
• Short term targeted investment is urgently needed to meet the extra demand and treatment backlog created by the pandemic
• The use of online counselling provision makes addressing the digital divide / rural broadband issue urgent
• Dedicated rural mental health strategies could play role in tackling the economic, social, physical and psychological determinants of mental ill health.
• The root causes of poor farming mental health also need to be addressed as well as improving support.

Sources and further reading

Big Farming Survey (2021). Royal Agricultural Benevolent Institution (RABI). https://rabi.org.uk/wp-content/uploads/2021/10/RABI-Big-Farming-Survey-FINAL-single-pages-No-embargo-APP-min.pdf

Brew et al. (2016). The health and wellbeing of Australian farmers: a longitudinal cohort study. BMC public health, 16.

British Academy 2021. The COVID decade: Understanding the long-term societal impacts of COVID-19, British Academy, London.

Davies AR, Grey CNB, Homolova L. 2021. Supporting farmer and fisher communities in Wales through uncertainty: two mixed methods studies, European Journal of Public Health, Volume 31, Issue Supplement_3, October 2021, ckab165.587.

Ford et al. (2018). Access to primary care for socio-economically disadvantaged older people in rural areas: A qualitative study. PLos One. https://doi.org/10.1371/journal.pone.0193952

Guerrero et al. (2018). Rural Mental Health Training: an Emerging Imperative to Address Health Disparities. Academic psychiatry, 43, 1-5.

Garnett P, Doherty B & Heron T. 2020. Vulnerability of the United Kingdom’s food supply chains exposed by COVID-19. Nat Food 1, 315–318.

Goffin (2014). Farmers’ mental health: A review of the literature. ACC Policy team.

Hagen et al. (2019). Research trends in farmers’ mental health: A scoping review of mental health outcomes and interventions among farming populations worldwide. PLoS One. https://doi.org/10.1371/journal.pone.0225661

Herron et al. (2020). “Talk about it”: changing masculinities and mental health in rural places?. Social Science and Medicine, 8, 258.

Hirsch, J. K., & Cukrowicz, K. C. (2014). Suicide in rural areas: An updated review of the literature. Journal of Rural Mental Health, 38(2), 65–78. https://doi.org/10.1037/rmh0000018

Hubbard et al. Are Rurality, Area Deprivation, Access to Outside Space, and Green Space Associated with Mental Health during the COVID-19 Pandemic? A Cross Sectional Study (CHARIS-E). International journal of environmental research and public health, 18(8). https://www.mdpi.com/1660-4601/18/8/3869#

Jensen, E. J., Wieling, E., & Mendenhall, T. (2020). A phenomenological study of clinicians’ perspectives on barriers to rural mental health care. Journal of Rural Mental Health, 44(1), 51–61. https://doi.org/10.1037/rmh0000125

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