MENTAL HEALTH FOUNDATION – WRITTEN EVIDENCE (PSR0056)

 

Submission to the House of Lords Select Committee on Public Services’ inquiry into ‘Public services: lessons from coronavirus’.

The Mental Health Foundation’s vision is for a world with good mental health for all.  We work to prevent mental health problems.  We do this by driving change to create a mentally healthy society for all, and support communities, families and individuals to live mentally healthier lives, with a particular focus on those at greatest risk. The Foundation is the home of Mental Health Awareness Week.

 

Introduction

For many people, the negative mental health effects of the pandemic are likely to last much longer than its physical health impacts. The effects of social distancing, lockdown measures such as social isolation, and the increases we have seen in domestic violence and the deaths of loved ones, all have a significant impact on individual mental wellbeing and increase the mental health challenges for the UK population.

The Coronavirus: Mental Health in the Pandemic Study (the “MHF Pandemic Study”), led by the Mental Health Foundation,[1] is tracking the effects and consequences for population mental health of the pandemic and the measures taken to combat it. Like other studies, it is showing that the mental health effects are falling unequally across society, with people in some social groups, those with existing mental health conditions and people with long-term physical health conditions bearing more of the mental health burden than others. These effects are likely to deepen during the pandemic and its aftermath. For example, a much higher proportion of single parents (24%), 18-24 year olds (21%), unemployed (21%), and people with long-term health conditions (20%) report having had suicidal thoughts or feelings, compared to the overall population (10%).

One area of particular concern relates to individuals who will have experienced trauma or retraumatisation as a result of the crisis. While we do not know exactly how many people will be affected, we do know that large numbers of the population will be exposed to traumatic experiences that put them at higher risk of developing or worsening mental health problems. Evidence also points to increased rates of post-traumatic stress disorder following pandemics.[i]. This will not necessarily develop immediately, but public services need to be fully aware of this risk, and shape their responses to people accordingly, to reduce the likelihood of people developing PTSD. Only this week, leading psychiatrists and psychologists called for all covid-19 survivors to be screened for post-traumatic stress disorder.[ii]

 

Front-line NHS staff and other front-line workers, those experiencing or at risk of unemployment, victims of domestic violence and abuse, those who have been bereaved and children returning to school following harmful experiences in lockdown, are examples of groups at risk of experiencing trauma or re-traumatisation who will need responses from public services and organisations that are listening, understanding, meaningful and trauma-informed. 

 

Trauma-informed care

Trauma-informed care is focused on creating conditions within services and / or organisations that reduce harm and promote healing, especially for individuals who have already experienced trauma.[iii] It recognises that past experience of trauma can affect how a person perceives and responds to their environment in the present. For example, aspects of a situation that may seem benign to someone with no history of trauma can trigger overwhelming feelings of distress in a trauma-survivor.

Trauma-informed care is actively mindful that, in these ways and others, service design and delivery have the potential to perpetuate distress and lead to disengagement in traumatised people. Based on this awareness, it endeavours to bring about organisational changes that will, at a minimum, prevent services from reawakening individuals’ old traumas, or causing them new traumas; and, at best, create an environment that is sufficiently understanding and safe for healing to take place.

Before the pandemic, it was estimated that 70% of the general population have been exposed, either directly or indirectly, to a traumatic event at some point in their lifetime.[iv] Our growing recognition of the prevalence of trauma within our society has led to an increased understanding of the role that public organisations and institutions can often inadvertently play in perpetuating trauma, causing further harm to some of the most vulnerable people they work with. 

 

As a result, there have been attempts in the UK to develop trauma-informed public services, including schools, workplaces, “blue light” emergency services and the criminal justice services (to name a few) that acknowledge, understand and respond to people’s trauma in appropriate ways. This approach is still in its infancy in the UK and small pockets of good practice can be found across the country. As we begin to consider the immediate and longer-term repercussions of the coronavirus pandemic, there is growing recognition that trauma-informed approaches are now needed more than ever.  

 

Context

 

The impact of trauma on people’s lives, and the need for trauma-informed responses from a range of public services, is an area that has been growing in recognition before the pandemic. In 2017, Jackie Doyle-Price MP, then Parliamentary Under Secretary of State for Mental Health, Inequalities and Suicide Prevention, set up and co-chaired the Women’s Mental Health Taskforce in partnership with Agenda. This aimed to define and make recommendations for addressing priorities for improving women’s mental health.

One of the key priorities it identified was the impact of trauma on women’s lives. Research has found that approximately one in every 20 women in England has experienced physical violence, sexual violence or abuse across their life course, compared to one in every 100 men.[v] This problem has been exacerbated during the pandemic both on a global and national scale. In the UK, calls to a national domestic abuse helpline run by the charity Refuge increased by 49%, and fatalities for women related to domestic violence doubled in the first three weeks of lockdown.[vi]

Given the strong relationship between women’s mental ill health and their experiences of interpersonal violence and abuse, an understanding of trauma is crucial to any service supporting women. Yet, the Taskforce found evidence that such understanding is lacking.[vii] To redress this situation, the Taskforce developed a set of gender- and trauma-informed principles (see table 1 below) to guide service providers and commissioners in supporting women with mental health problems.

Table 1

 

For full details of how each principle should be applied by services and health professionals, see The Women’s Mental Health Taskforce Final Report (DHSC, 2018, pp.35-42). For example, the principle ‘Respectful’ can be actioned by enabling women to have a choice of a female health professional and by ensuring that all staff in services are knowledgeable and understanding about the needs of women.

 

Theme

Principle

Governance and leadership

There is a whole-organisation approach and commitment to promoting women’s mental health with effective governance and leadership in place to ensure this.

Equality of access

Services promote equality of access to good quality treatment and opportunity for all women.

Recognise and respond to trauma

Services recognise and respond to the impact of violence, neglect, abuse and trauma.

Respectful

Relationships with health and care professionals are built on respect, compassion and trust.

Safe

Services provide and build safety for women.

Empowerment through co-production

Services engage with a diverse group of women who use mental health services to co-design and co-produce services.

Holistic

Services prioritise understanding women’s mental distress in the context of their lives and experiences, enabling a wide range of presenting issues to be explored and addressed, including a focus on future prevention.

Effective

Services are effective in responding to the gendered nature of mental distress.

 

It is important to note that the gender- and trauma-informed principles detailed above are targeted primarily at supporting people accessing mental health services. This is perhaps unsurprising if we consider the worrying absence of trauma-informed approaches identified by the Mental Health Act Review (2018) in these settings. This included large proportions of the mental health estate being identified as unfit for therapeutic purpose and the need to invest in mental health trusts’ dilapidated buildings and poor facilities, including the £139 million backlog in high and significant-risk repairs.

However, given that the principles are underpinned by evidence as to the value of gender-specific and trauma-informed ways of working, the Taskforce also urged those beyond the mental health system to take note and apply them in their own fields to improve outcomes for women who have experienced trauma or mental health problems. The Taskforce recognised that these are of interest, but not limited to, those working in the criminal justice system, addiction treatment, domestic and sexual abuse services, and housing and homelessness services.

In 2019, in partnership with the Centre for Mental Health, the Mental Health Foundation published ‘Engaging with complexity: providing effective trauma-informed care for women’.[2] This report built on the work of the Women’s Mental Health Taskforce and offers public services a brief guide to the principles of trauma-informed care and how to put it into practice. It covers the four essential aspects of trauma-informed care identified by our research – listening, understanding, responding, and checking – and considers what each of these looks like in practice. It also anticipates some of the challenges services might face on their journey to becoming trauma-informed. Whilst the principles are also gender-specific (focusing on women), they are appropriate for supporting a range of different population groups who will be accessing public services.

             

Summary of recommendations

In response to the pandemic, understanding and developing trauma-informed approaches should be a priority for all public services. In the medium and long-term, it is important that public services should be designed in line with trauma-informed principles and good practice. This was important before the pandemic and will become even more so afterwards. The recommendations below build on the learning detailed above and identify what is needed more immediately. 

  1. The government should implement all of the recommendations from the Women’s Mental Health Taskforce: final report.

 

  1. Trauma-informed public services: Relevant government departments and their arms-length bodies should ensure that standards of practice, guidance and training are made widely available to all public sector services during the recovery phase, ensuring that trauma-informed values and principles act as a framework for organising procedures and practice.

 

In the coming months it is vitally important that public sector services and providers are supported to adopt trauma-informed approaches within their own organisations and that the necessary support, care and attention is given to every individual affected by the pandemic. A good practice example is the Distress Brief Intervention (DBI) in Scotland which supports NHS Education Scotland’s National Trauma Training Framework. The DBI programme aims to provide compassionate support to people in distress across a range of public services. An additional investment of more than £1 million has been provided by the Scottish Government to help people in distress due to COVID-19. 

 

  1. The Department for Education should work with schools, local authorities, education and mental health charities to develop guidance for teachers and schools to increase their understanding of trauma-informed approaches and enable them to support children and young people returning to school.

Children returning to school following bereavement, abusive experiences and/or major disruption to learning and support, are all at risk of having experienced trauma and need schools and teachers that can respond with trauma-informed approaches.  This is important not only for children and young people’s mental health, but also for enabling them to learn, and for improving their educational outcomes. 

 

This poses its own challenges, as, for trauma-informed care to be effective, it will often need to be a long-term process and requires a system-wide cultural transformation in relation to understanding, skills, values, attitudes, policies and cultures.[viii] We recognise that schools and teachers will be challenged and tested in the coming months, including by children continuing with blended learning, and extended periods of time at home, so their time and capacity for taking on new information may be limited.  

 

With this in mind, the information and guidance provided should seek not to over-burden schools and act only as a starting point in supporting them to develop a greater awareness and understanding of trauma-informed approaches and how they can be used to support children and young people. It may most easily be provided as part of more general guidance offered to schools around supporting children and young people’s mental health following the pandemic. The Foundation has produced guidance for schools and teachers returning to school following lockdown. An overview can be found on our website.

 

 

  1. All frontline NHS and care staff should be offered tailored wellbeing and mental health checks and support on coping with exceptional (and sometimes traumatic) circumstances both during and following the pandemic. This must include services able to respond to post-traumatic stress disorder and moral injury.  

 

During the pandemic, frontline healthcare professionals may have been caring for individuals who are feeling upset and isolated, asked to make difficult decisions in relation to allocating resources for those unwell, and supporting people who have ultimately not recovered. They may also have experienced their own anxieties from working in close proximity to a potentially fatal disease and worry about infecting family and friends. Being exposed to these circumstances on a regular basis means that frontline staff are at greater risk of experiencing post-traumatic stress disorder and ‘moral injury’.[ix]

Moral injury is a concept traditionally explored in the context of military service and occurs when an individual is involved in, fails to prevent or witnesses a serious act that transgresses their deeply held moral beliefs, often resulting in feelings of shame and guilt.[x] In extreme cases it can develop into mental health problems including depression, post-traumatic stress disorder (PTSD) and suicidal ideation or behaviour.  In the context of Covid-19, moral injury might include frontline professionals feeling unable to provide the kind of care they want to be able to provide for their patients, and coping with the comparatively high death rates in intensive care for patients who need to be put on ventilators.

In April 2020, the NHS in England launched a 24-hour helpline to support health professionals with their mental health. It also made a range of digital mental health apps free to use and most recently set up a bereavement and trauma helpline for Filipino health and care staff. Whilst these steps are welcome and important, much more will be needed if we are to ensure that frontline healthcare staff receive an appropriate level of support. During the pandemic, and in the months and years that follow, it is vital that mental health checks and tailored support are made widely available to front-line staff to support them in recovering from the impact of the pandemic. This must include services able to respond to post-traumatic stress disorder and moral injury.

 


[1] The “Coronavirus: Mental Health in the Pandemic” study is a UK-wide, long-term study of how the pandemic is affecting people’s mental health. The study is led by the Mental Health Foundation, in collaboration with the University of Cambridge, Swansea University, the University of Strathclyde and Queen’s University Belfast. Since mid-March 2020, the project has undertaken regular, repeated surveys of more than 4,000 adults who are representative of people aged 18+ and living in the UK. The surveys are conducted online by YouGov. The survey covers approximately 20 topics, including impact on mental health and the key drivers of risk. Further information and releases are available at https://www.mentalhealth.org.uk/our-work/research/coronavirus-mental-health-pandemic

[2] 


[i] 

 

 

 

 

 

 

References

 

Sprang, G. and Silman, M. (2013) Posttraumatic Stress Disorder in Parents and Youth After Health-Related Disasters, published online by Cambridge University Press. 

 

[ii] UCL, Oxford University, King’s College London, the NHS and Haifa University in Israel. (2020). Covid-19 Guidelines.

 

[iii] Bowen, E.A. and Murshid, N.S. (2016). Trauma-informed social policy: A conceptual framework for policy analysis and advocacy. American journal of public health, 106(2), p223229.

 

[iv] Benjet, C., Bromet, E., Karam, E.G., Kessler, R.C., McLaughlin, K.A., Ruscio, A.M., Shahly, V., Stein, D.J., Petukhova, M., Hill, E. and Alonso, J. (2016). The epidemiology of traumatic event exposure worldwide: Results from the World Mental Health Survey Consortium. Psychological medicine, 46(2), p327-343. 

 

[v] Scott, S. and McManus, S. (2016) Hidden hurt: Violence, abuse and disadvantage in the lives of women [Online] Agenda.

 

[vi] Karen Ingala Smith. Counting Dead Women. (2020). Coronavirus doesn’t cause men’s violence against women.

 

[vii] DHSC (2018) The Women’s Mental Health Taskforce final report.

 

[viii] Sweeney, A., Filson, B., Kennedy, A., Collinson, L. and Gillard, S. (2018) A paradigm shift: Relationships in trauma-informed mental health services. BJPsych advances, 24(5), pp. 319-333.

 

[ix] Greenberg, N. (2020) Managing mental health challenges faced by healthcare workers during covid-19 pandemic BMJ 2020; 368 doi: https:// doi.org/10.1136/bmj.m1211.

 

[x] Litz, B.T., Stein, N., Delaney, E., Lebowitz, L., Nash, W.P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war Veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29, p695-706.