Written submission from Mind (MHM0011)

Who we are

We're Mind, the mental health charity for England and Wales. We believe no one should have to face a mental health problem alone. We provide advice and support to empower anyone experiencing a mental health problem. We work to ensure that people with mental health problems have their voices heard, and are treated fairly, positively and with respect. We campaign to improve services, raise awareness and promote understanding.

Mind in Harrow

Mind in Harrow is an independent charity affiliated to National Mind, and has inputted into this response. Mind in Harrow’s User Involvement Project ran a focus group in January 2019. They spoke to men aged 30-55 from Black, Asian and minority ethnic (BAME) communities to gather their experiences of mental health and their experiences as men. Some of the responses reflect direct experience and some reflect thoughts about society in a wider context. Names have been changed to ensure confidentiality.

The scope of Mind’s response

As a leading mental health charity, we welcome the opportunity to submit evidence into this inquiry into the mental health of men and boys. We have chosen to answer the questions we feel we can offer value and expertise, as well as those identified as important by our user involvement group. Our response will focus primarily on under-represented and high risk groups, with a particular focus on men and boys from BAME communities.

1. What are the most pressing issues that affect men and boys’ mental health, and how are these different to the wider population?

Gender can be an important determinant of an individual’s sense of self, and can play a significant role in how mental health problems are experienced. Social influences and life experiences are crucial to men and boy’s view of mental health, and their likelihood of seeking advice, help and support. Cultural expectations of men – particularly the belief that men and boys should not express vulnerability – can inhibit men’s ability to prioritise their mental wellbeing and seek support.[1] In 2011, Mind and the Men’s Health Forum published Delivering Male, a report detailing some of the issues that affect men’s mental health, many of which are still relevant today.

Currently 13% of men are recorded as having a common mental health problem (compared with 21% of women),[2] although this is thought to underestimate the extent of mental health problems in men.[3] Men may struggle to reach out for help and they may find available service models, such as talking therapies, difficult to engage with. A survey of 2,500 people with lived experience conducted by the Mental Health Foundation in 2016 found that over a third of men waited more than two years or never disclosed a mental health problem to a friend or family member, compared to a quarter of women.[4] This can make it more difficult to gather evidence on the mental health of men and boys. More community-based outreach and research will make it easier to establish better quality data and understand the true extent of mental health problems in men and boys.

Our user involvement group also identified a number of other factors that affect men’s mental health negatively, including a lack of social networks (particularly compared to women), an unwillingness to discuss emotions or emotional health, and an unwillingness to go to the GP or seek counselling. These, along with many others, will be explored in more detail throughout the response.

2. What is the effect of the following on men and boys’ mental health:

To answer this question, we have chosen to use a number of case studies from our user involvement group.

Gender stereotyping in childhood

It is widely recognised that gender stereotyping in childhood decreases the likelihood that men will seek mental health support.[5] Our user involvement group have told us that these gendered expectations – the need to be ‘strong and silent’ with a ‘stiff under lip’ – can contribute to poor mental health in men and boys. These stereotypes make it harder for boys and men to identify a mental health problem in the first place, and to seek support either from family or friends or professionals.

Gendered expectations around work and household finances

Similarly, gendered expectations around work includes the expectation that men should be the breadwinner of the family. Research suggests that a reliance on these traditional ideals negatively impacts men’s mental health.[6]

Fatherhood

A recent Australian study conducted by the Parenting Research Centre found that one in five fathers had experienced symptoms of depression and/or anxiety since having children.[7] This included nearly one in ten fathers who reported experiencing postnatal depression. Fathers with poorer mental health reported that they were less likely to feel effective as parents and were less confident in their own parenting. 

There is an increasing emphasis on the importance of perinatal health in the UK, and the government has rightly identified it as a priority area in its recently published Long Term Plan. Supporting mothers at such a crucial and sometimes vulnerable life stage is essential, but it’s also important to recognise the effect that becoming a parent can have on a father. We welcome the commitment in the Long Term Plan to offering an evidence-based assessment and signposting to partners of women accessing specialist perinatal mental health services. But we would like to see a more universal offer of support and information that goes beyond the partners of women accessing these services.

Media portrayals of masculinity

Men and boys with mental health problems are often portrayed negatively in the media and advertising. The stigmatising of mental health problems, which is damaging for both sexes, may present some particular problems for men. Our user involvement group tells us that if you are a male with mental health problems, you may be seen as a threat to society. As a result, you may find that your mental health difficulties are viewed less sympathetically. These kinds of attitudes need to be challenged, but instead the media can perpetuate these stereotypes. Time to Change exists to tackle the stigma around mental health: one of its most recent campaigns, #AskTwice, encourages men to speak to each other about wellbeing and mental health.

Relationship and family breakdown

According to Samaritans research conducted in 2012, people who are divorced and separated have a higher suicide rate than those who are married, but this risk appears to be greater for men than women.[8] This is partly because men in mid-life (a high-risk group for death by suicide) can be dependent primarily on female partners for support. When relationships fail, men are less likely to be awarded custody of their children and may have less access than before. Separation from children appears to be a significant factor in the suicide of some men.[9]

3. Which groups of men and boys are particularly at risk of poor mental health and what is leading to this?

Mental health problems are not equally experienced by all sections of our society, with some people at higher risk of developing a mental health problem than others. The factors that contribute to someone’s increased risk of mental health problems are complex and often interrelated. They include trauma and stressful life events; poverty; unemployment and insecure housing; social isolation and loneliness; and discrimination and inequality.[10]

High risk groups

Men and boys from Black, Asian and minority ethnic (BAME) communities

Historically, there has been a lack of quality data from national surveys on the prevalence of mental ill health among members of BAME communities.[11] The most recent mental health prevalence survey combined data from the 2007 and 2014 surveys to indicate that young black men are:

• Around 11 times as likely as white young men to present with major psychiatric conditions such as psychotic type disorders – mainly schizophrenia
• Around three times more likely to present with suicidal risk
• Around 1.5 times more likely than white men to present with diagnosable level post-traumatic stress disorder.[12]

The evidence we do have demonstrates poor experiences and outcomes within African and Caribbean communities in relation to mental health. Men and boys from BAME communities are far more likely to experience severe mental ill health but less likely to access the support they need.[13] Black or Black British people are more than four times more likely to be detained under the Mental Health Act than white people,[14] and are more than eight times more likely to be given a Community Treatment Order.[15] They are also at greater risk of restraint, seclusion and other restrictive practices.[16] At the same time, they are less likely to access IAPT (Improving Access to Psychological Therapies) than the general population and consistently record lower recovery rates.[17]

Mind’s steering group of people from BAME communities, which informed our submission to the recent Independent Review of the Mental Health Act, highlighted the importance of recognising the role racism plays in not only service delivery but also as a significant factor in why so many people from these communities become unwell in the first place.[18] Experiences of racism include both interpersonal and institutional forms of racial discrimination. This will be discussed in more detail later in the response.
 

Lesbian, Gay, Bisexual, Transgender, Questioning + others (LGBTQ+) 

People who identify as LGBTQ+ are two to three times more likely to experience a mental health problem compared to the general population.[19] They are also at higher risk of self-harm and suicide attempts. Stonewall’s 2018 health report revealed that 54% of male respondents identifying as gay, bisexual and trans (GBT) had experienced anxiety in the last year and 12% reported having harmed themselves in the last year.[20] Stonewall’s Gay and Bisexual Men’s Health Survey (2012) revealed that of black and minority ethnic gay and bisexual men: one in twelve (eight per cent) had harmed themselves in the last year compared to just one in 33 men in general who have ever harmed themselves, and one in six had problems with their weight or eating in the last year compared to four per cent of men in general.[21]

Exploring sexual orientation or gender identity should be a positive experience for all young people, but Stonewall’s 2017 School Report revealed that nearly three in five boys identifying as LGBT are bullied for being LGBT, and boys are three times more likely than girls to be bullied with physical abuse. [22] [23] More than four in five trans young people have self-harmed. For lesbian, gay and bi young people who aren’t trans, three in five have self-harmed.[24] These numbers are unacceptably high.

Research suggests the reasons are likely due to LGBTQ+ people of all ages being more likely to experience stigma and discrimination and to be subject to hate crimes. People from LGBTQ+ communities report difficulty and discrimination when accessing mainstream services, sometimes due to a lack of understanding of their specific health needs.[25] More research is needed into the intersectional experiences of men with multiple protected characteristics, such as those with learning disabilities who identify as LGBTQ+.

Criminal justice system

Men and young men in contact with the criminal justice system have a higher prevalence of poor mental health than that of the broader population, and face specific challenges in accessing appropriate support and services. The Ministry of Justice figures for 2018 show that self-harm in prisons has increased by 25% from the previous year, and suicide by 32%.[26] Many marginalised groups, such as some BAME communities and people with learning disabilities, are overrepresented in the criminal justice system. This disparity starts early: 42% of children in Secure Training Centres and 51% of children in Young Offender Institutes are BAME. This is important since a number of marginalised groups are already at higher risk of developing mental health problems.

Boys experiencing adversity

There is also growing evidence about the importance of economic and social factors on a child’s chances of enjoying good mental health. Children growing up in poverty and facing housing insecurity are at far higher risk of multiple mental health difficulties. Reducing child poverty and family homelessness should therefore be a priority for improving children’s mental health. Looked-after children are another high-risk group: 60% have some form of emotional or mental health problem.[27]

It would be helpful for more data on the experience of boys and young men facing adversity (distinct from girls and young women). Only then can we draw stronger conclusions on the specific needs of different genders/gender identities. 

4. What measures are needed to most effectively tackle poor mental health in men and boys and what are the barriers that prevent these being implemented?

1. Focus on prevention

Millions of pounds are spent every year to prevent people developing problems like heart disease or cancer, but only 1.51% of the public health budget is spent on public mental health initiatives.[28] We were pleased to see the Department of Health and Social Care set out its commitment to prevention in its vision paper published in 2018, with the Minister proposing a greater focus and spending on prevention, rather than just cure.[29]

In the context of mental health, effective prevention needs a holistic approach which considers the social factors that can contribute to mental ill health (this includes a number of factors from unemployment to debt to poor/inadequate housing). The Government should ensure all government policies, whether new or existing, are assessed for their impact on mental health. For example, mental health should be considered in the development of policy in areas such as housing, employment and benefits, as well as statutory and non-statutory service development.

2. Diversify and design appropriate services

Mind’s submission to the recent Independent Review of the Mental Health Act highlighted the need for access to culturally competent and relevant community services at an earlier point.[30] This will require investment in initiatives to address the cultural barriers to certain groups seeking support. There also needs to be a commitment to wider reforms to promote social justice, equality and inclusion to help reduce the social determinants of mental health problems for these communities.

These additional measures include:

• Rights based advocacy
• Action to counter bias in assessment and clinical decision-making
• Better quality data and more transparent monitoring
• Co-produced care planning and more support for the BAME voluntary and community sector

Research has highlighted that reinforced fear and mistrust are critical drivers of the disproportionally poor experiences that African and Caribbean people face in mental health services.[31] Mental health interventions are more likely to occur at a point of crisis, involving the police. People are therefore more likely to have experiences of the mental health and criminal justice system that are painful, frightening and coercive rather than supportive.

Improving services: examples of best practice

Mind’s Up My Street programme ran between June 2015 and June 2017 and engaged with 298 African Caribbean boys and young men and 501 community members. Up My Street’s main aim was to develop and pilot approaches that could reduce the number of young African Caribbean men in inpatient mental health services. We worked with organisations that support young African Caribbean men, to help build people’s resilience and address the factors that could put people at risk of mental health problems. We also built links to enable the wider community to support the mental health needs of young people more effectively. The programme was evaluated by the Centre for Mental Health and was found to improve participants’ wellbeing.[32]

300 Voices is an engagement model developed by Time to Change.[33] It was designed to improve the poor experiences that young African and Caribbean men have encountered historically, and continue to face, when using mental health services and coming into contact with the police and other front-line service providers. Whilst supporting attitude and behaviour change among professionals, 300 Voices addressed some of the fear and mistrust that exist between young African and Caribbean men and professionals.

These types of co-produced, community led services should be replicated elsewhere and managed by a consistent cross-government approach.
 

3. Tackling stigma

Research conducted by Time to Change in 2016 revealed that half of teenage boys would not be comfortable talking to their dads about their mental health (including stress, anxiety and depression). The survey also revealed that 37% of young men chose to ‘put a brave face on’ when struggling with mental health problems and 33% would rather keep it to themselves.[34] It’s vital that the government commits to supporting organisations like Time to Change, who continue to work to challenge stigma and encourage men and boys to talk about their mental health.

4. Tackling suicide

Three-quarters of those who take their own life are men.[35] We urgently need to develop a more coherent and consistent approach to suicide prevention. This includes building on existing local multi-agency suicide plans, with the ambition of significantly reducing the number of suicides both among people who are in contact with mental health services and those who are not. In particular, specific focus is needed on those groups where the risk of suicide is known to be higher than average, such as men aged 45-49.

Organisations like Samaritans and initiatives like the men’s sheds programme provide much needed support in crisis, but this support must be echoed and sustained by government at national and local level.

5. How effective are the following at tackling poor mental health in men and boys:

6. NHS England

We know that men tend to under-use mental health services, due in part to stigma and ‘traditional’ male attitudes, which can make the acknowledgement of vulnerability hard for men. Our user involvement group have emphasised that the expectations on men and boys to be tough and not to be overly emotional can lead to an inability to discuss emotional problems with healthcare professionals. Although a large body of evidence exists which shows differences between the experiences of men and women in relation to mental health, many NHS services are delivered on a gender-neutral basis. NHS England should encourage gender informed practices, including communicating examples of best practice and co-designing services with people with experience of mental health problems.

More must be done to improve the experiences of BAME men within mental health services. For these groups, health interventions are more likely to occur at a point of crisis, involving the police. People are therefore more likely to have experiences of the mental health and criminal justice system that are painful and frightening rather than supportive.[36] We were pleased to see the Organisational Competence Framework and the Patient Carer Experience Tool proposed in the Mental Health Act Review final report, which will aim to make services more attractive and responsive to people from BAME backgrounds. However, we would urge that throughout the next stage of implementation planning, there must be attention to accountability and making the reforms work in practice.

NHS England should also work with the wider public sector, including the police, to improve the delivery of culturally competent services.

Public Health England

Public Health England should develop a cohesive public mental health plan which prioritises mental health prevention and ensure targeted programmes for people with mental health problems. They should also provide local authorities necessary support to ensure prevention and early intervention, such as promoting community and youth groups (these are particularly important for communities who might be disengaged from services).

The Five Year Forward View for Mental Health set out clear recommendations on suicide prevention and reduction, and made a commitment to reduce suicides by 10% nationally by 2020/21. We are calling for funding to be made available to deliver a 50% reduction in the number of suicides by 2029. For this to be achieved, there will need to be a concerted focus on the mental health of men and boys.

Child and Adolescent Mental Health Services

The most recent data has revealed that one in eight children now has a clinically diagnosable mental health problem.[37] Yet young people experiencing mental health problems face a number of barriers to support. Pressure on schools, cuts to youth services and a lack of information on where to turn make support hard to identify and even harder to access. In the recent report published by NHS Digital, only one in four children with a mental health problem reported accessing specialist mental health services in the previous year,[38]  and waiting times between referral, assessment, and treatment are still unacceptably long. FOIs conducted by the Health Service Journal showed that, in 2017/18, more than 500 young people had waited more than a year between assessment and the start of treatment. Around half of young people had waited more than 18 weeks.[39] With the Long Term Plan commitment to dramatically improving the mental health of children and young people, we would like to see access to CAMHS significantly improved and a full roll out of four week waiting times. This may include a review of the model of service delivery, funding structure, and workforce recruitment and retention.

Not enough research has been conducted into the experiences of boys and young men in CAMHS. We would like to see data at CCG level collected more consistently and made available so CAMHS equalities data becomes more transparent.

Local authorities

Local authorities are uniquely placed to assess and understand the needs of their communities, to make strategic plans for reducing inequalities, and to provide a catalyst for partnership working and change management. Yet just 1.51% of public health budgets was spent on mental health initiatives in 2017/18.[40] All directorates within local authorities, as well as partner organisations (CCGs and service providers), play a role in promoting good mental health, preventing mental health problems and early detection.

NHS and social care services are experiencing unprecedented budget pressures, and mental health services in particular have historically been underfunded. It is therefore essential that we invest in reducing the impact mental health problems have in our local communities and local services. Integration of budgets between health and social care services provides further impetus to invest in public mental health because this takes away the barrier that spending on prevention provides cost savings to other budgets and services.[41]

Mind supports a public health approach to mental health which protects existing funding and prioritises additional funding for public health, social care and other local authority funding alongside the NHS settlement, so that resources are available for effective early intervention and relapse prevention work.

Schools

The current evidence for what works in schools is mixed and limited. Our user involvement group have told us that education on mental health in schools is important, suggesting a ‘family learning’ curriculum focusing on maintaining good mental health. Mind is currently piloting a ‘whole school approach to mental health’ to support the mental health of everyone involved in the school community. The evaluation of this work will be published in Autumn 2019, and we would be happy to share this with the Committee at a later date.

We know that others are also interested in and developing the evidence base for what works in schools. The Department for Education is working with the Anna Freud National Centre for Children and Families to trial what works to support mental health and wellbeing in schools. We hope as this work develops that the specific experiences of different groups, including boys, is taken into account.

Local support groups, faith groups, carers, friends and family

We know that many local support groups are struggling with cuts to local authority funding, and we know that many of these groups provide much needed support for people less likely to access statutory services (including men).

Schools, youth clubs, colleges and other services that come into contact with young people have a role to play in promoting positive mental wellbeing to all young people. They are also essential for picking up issues early so that young people experiencing mental health problems can get the support they need as quickly as possible. Youth workers should also have an understanding of young people’s mental health and the ability to link any young person up to appropriate services.

February 2019