Mentally under-resourced

Global Mental Health is a movement that has come a long way. We have amassed evidence that people with mental health problems can access care, support and treatment that make most conditions manageable in their local context. We know that people do not need access to high levels of mental health professionals for the bulk of their care and support. We know how important it is to tackle stigma and discrimination to ensure people are able to access their rights and we have growing evidence of how to do so. We have a voice at the top table: the UN is committed to mental health care provision and national governments are making commitments around the world. We have high profile supporters and backers, both celebrities and global corporations. We have a raft of civil society organisations, led by inspirational people who are making waves in their local communities and countries.  And yet… we have so much still to do.

These local civil society organisations are running on very limited resources. They are new, small and, for the most part, struggling to access the resources they need to grow as organisations. Many would fall over with the loss of a handful of key individuals. There are no representative structures in place internationally, regionally or nationally to support people with mental health problems to speak out and access their rights. There are very limited resources globally to support the development of these organisations and help the global infrastructure that is needed to develop. There are few sectors where organisations are working to embed mental health into critical areas of work such as education, public health and sports.

So, what do we need to do? Traditionally, to support such a global sector you would give to one of the high-profile organisations who fundraise for work in that sector. Or donate to a public appeal or lend time and energy to fundraise such a cause. This is not currently an option, there are no public appeals, there are no organisations fundraising, there is nowhere to donate. If I were a well-intentioned student wanting to fundraise to support the development of services and support for people with mental health problems in the global south then I have no one to fundraise for. If I were a senior person in the financial sector who had my own experience and wanted to support others facing similar challenges in the global south I will struggle to make my donation. If you were an organisation seeking to improve the wellbeing of your staff and looking to choose a charity of the year working at the grassroots to improve mental wellbeing you would have to work pretty hard to find someone to support.

I have worked with several of the leading new initiatives in global mental health (citiesRISE, Time to Change Global, Librum) and been CEO of BasicNeeds. My background includes running a pioneering perinatal mental health charity, providing dementia care services and setting up humanitarian relief programmes. I want to develop a mechanism that will enable public and corporate donations to find their way to civil society organisations in the global south who are working to protect the rights of people with mental health problems. If you want to help, or have ideas, or can introduce me to people who might want to support the set-up of the venture then get in touch now.

The Risks of Talking About Mental Health as a Universal Human Condition

In the UK, according to the statistics, one in four people will experience a mental health problem each year. Depending on how you define it I would suggest that we all experience some mental ill health, stress or distress during most years of our lives. Just as we may be laid low with a cold or another minor physical malady, we are all prone to times when we feel that life is getting on top of us or we are listless and down. This can result in us struggling to function in a normal fashion. Because phoning into work and saying “I can’t come in today because I am depressed/stressed/anxious” is generally not seen as acceptable people will often transfer psychological issues into physical ones – that do then offer an acceptable reason to phone in sick.

In some ways, we are getting better at allowing for these fluctuations. The introduction of ‘duvet days’, the increased reporting of stress in the workplace and the increase in flexible working all allow for people to take time off to recover when they are struggling psychologically. It would be good, though, if we could get to a point where our illness or malady can be discussed openly whether it be physical or mental without fear of being seen as malingering or mad.

One of the good things about the increase in conversations about mental health is that it increases our ability to be open about these fluctuations in our lives. It grounds mental health in something we can all understand and relate to. It is mental health as a universal human condition that is, in all its complexity, a wonderful part of who we are. We can all understand these struggles. The growth of public figures such as pop stars, actors and models talking openly about their mental health is, generally, a good thing because it helps reduce stigma and promote openness.

I say generally because there is a risk inherent in this conversation. Namely that we forget that there are many people for whom mental health is not a periodic challenge and fluctuation but a constant, and often exhausting, struggle to function, live and participate in life as they would like to. Their mental ill-health is serious, enduring and, for some, disabling. They know that they will often be stigmatised, marginalised and excluded. They know that they are likely to be poorer and more poorly served by support services as a result of their condition. They know that their lives are likely to be less healthy and shorter as a result of their condition.

For people who feel this way, the upsurge in interest in mental health is potentially good news. It is potentially beneficial to their situation. The risks manifest, however, through attitudes that reflect people’s lack of understanding of what the reality is that they are facing. People thinking that positive lifestyle choices will improve or remove the illness. People thinking that getting off the drugs you are on would be a good thing. People thinking that you just need to ‘pull yourself together’ and life will be so much better. These attitudes will often reflect an experience and understanding of mental illness that is shallow and sketchy.

So, while we celebrate the growth in conversations about mental health. While we pat ourselves on the back for getting so much better at talking out our anxieties or neuroses. Let us not forget that ‘being a bit bipolar’ gives us little insight into what bipolar disorder really is. And that being a bit depressed doesn’t mean we can understand what genuine depression feels like after a lifetime of struggling with it. It is the difference between being breaking a leg and losing a leg. The difference between a Temporary headache and a permanent throbbing pain in your cortex.

I hope the conversation on mental health continues, and I hope that public awareness continues to be raised by people with profile and influence. But I also hope that the conversation is not dominated by the ‘worried well’ or the bulk of people for whom struggles with mental ill health are transitory and low-level. Only by using the insights we have through our own experiences to think about the experiences of others, can we hope to ensure that the conversation on mental health does not become yet another way that people with serious and enduring conditions feel excluded.

Exercise, eat, sleep

In a previous post, I talked about how fundamental relationships are to our mental health and wellbeing. I’ve also written in the past, as part of Time to Talk, about how important having a strong network of friends and family can be to help you get through difficult times. We all need someone to lean on from time to time, and I have also been the person trying to provide support to other people when they are going through difficult times. I hold no formal qualification in counselling, psychotherapy, as a psychologist or a psychiatrist – most of us don’t – but I have considerable experience of managing and working with people in a range of settings. I also undertook a Masters at the Tavistock and Portman Clinic – one of the country’s leading mental health training centres.

As a result, I consider myself a well-informed individual with some relevant experience and skills when it comes to trying to support other people. In common with most people, I will try to listen, offer observations and suggestions (as well as the inevitable cup of tea). Most people will have worked out some coping mechanisms along the way. Some of these may be useful in the short-term but less so in the longer-term – alcohol is firmly in that category for me. Such stress and emotional management approaches can be useful but if used over a protracted period risk increasing the distress we are experiencing.

What we need to do is ensure that the bulk of our coping strategies are drawn from the more positive means of managing and coping with the stress, distress or mental health issue we are confronting. These will vary from person to person; one person might have a desire to paint, another to get out in the garden, another to go for a walk. In one sense, there are no rights and wrongs here, if it works for you then it is good. However, we know a lot about what tends to work for most people, and the three that stand out in that regard are exercise, food and sleep. The quality of the content is also important here.

Exercise has become, for me, a fundamental part of how I regulate my emotions and find time to reflect and think through what is happening in my life. I cycle, I run, I walk and occasionally take part in other activities (I used to play badminton, football, squash and other sports but a knee injury put paid to that). If I do not get some proper exercise for a few days I get grumpy (my wife has been known to almost physically push me out the door to go for a run). I used to say I exercised to keep fit, I now say that I do so to keep sane. It also helps, for me, to keep at bay a tendency towards getting a bit SAD at this time of year.

Food is a another fundamental building block of our lives. The calories, fibre, vitamins, amino acids, fats, micro-nutrients and so forth that we eat literally fuel us through our lives. Junk food won’t kill us quickly but if it is all we eat then we greatly increase our chances of suffering ill-health and dying sooner. I suspect this is even more important when we are battling with stress, depression or anxiety. Press coverage of what we should, and should not, eat is often profoundly unhelpful. While our knowledge is growing, I don’t think you can go far wrong with the words of Michael Pollan, “Eat food, not too much, mostly plants”.

Finally, sleep, this is one area which can be harder to control yourself. Insomnia can be a terrible affliction and despite the training in sleep deprivation that having children offers you, I don’t think not getting enough sleep is something that anyone learns to cope with. For me though, following the first two steps above helps considerably with any problems I may have sleeping. Get some exercise, eat healthily, lay off the alcohol and, more often than not, I will sleep pretty well. I know that some will consider me lucky on that count!

That is my experience mixed in with some of the evidence and knowledge we have on maintaining, recovering and managing when you are experiencing challenges with your mental health. The critical thing though, is what works for you both in the short and longer-term. The evidence is what works for the majority, you may be different, and finding out what works for you is a journey that is well worth undertaking.

Relationships and Mental Health

Relationships are, for me and many others, the most wonderful things in life. Our loves, friendships and associations give meaning and significance to our lives. It is, therefore, unsurprising to me that they are so critical to our mental health and wellbeing. As a result, they should form the foundation of any community-based health system.

From the start of life, our earliest relationships give us a working model for what to expect from other people as we move out into the world. Eye contact and cooing with a baby is a wonderful thing for an adult but also critical for the baby who is still trying to make sense of the jumble of stimuli and experiences. As we grow, the support and positive feedback from parents, carers, family and friends helps to develop our confidence and sense of self. This early social and emotional foundation enables us to navigate the often chaotic array of interactions we experience at school as we sit among a group of peers all trying to work out who we are, how others perceive us and how we can best relate to one another.

The ability to form and sustain close relationships, and the more distant associations, is critical to our longer-term welfare and happiness. Evidence shows that the quality of our closest relationships and the number of our wider associates is a critical factor in how happy and healthy we are. In any aspect of life, it is clear that relationships form the basis of negotiations, business deals, partnerships and good team-work.

Later in life, the number of relationships we have as we step into retirement is a strong predictor of how long, and how healthily, we will live. Sustaining an array of friendships and social contacts into later life is key to enjoying a time of life that can offer considerable freedom but also risks increasing isolation. Relationships with people across a spectrum of ages can help to insulate us from the inevitable losses and challenges of later life.

What does this mean for global mental health policy and practice? Pathways of diagnosis, care and treatment are clearly needed for good population mental health. Similarly, support groups, peer networks, mental health literacy, user representation, and stigma reduction campaigns all need to be a core part of what we do to try and promote good mental (and physical) health in our populations. But, for me, the foundation stone has to be relationships or social connectedness to use a term from research. Programmes and interventions that promote greater social interaction and strengthen social connectivity are critical.

Inevitably, any community will have an array of groups: social, faith, artistic, sporting and so forth. Programmes should seek to build on these, increase their reach and inter-connectivity. Identify where there are gaps or barriers to these groups forming and sustaining and try to address them. Support the array of people who will be driving and developing these groups. The world is, in my experience, full of inspiring people who are doing wonderful things at the local community level. Finding these people and supporting them through a variety of means will pay dividends. By increasing the number of groups, by strengthening the groups that exist and through building links between different groups you can lay a foundation for positive mental health and well-being that is cheap, sustainable and highly rewarding for everyone involved.

The above work does not need psychiatrists, psychologists, counsellors, mental health nurses, or even a formal health system to be in place. What it does, is lay a foundation on which those more formal services can be overlaid if and when funding is available. It offers a setting into which mental health literacy and anti-stigma initiatives can be easily added. One into which low-level psychological support or group support programmes can be inserted. It offers a foundation which provides people with interesting, rewarding and engaging activities to do. What could be simpler, or more valuable for us to do?

Talking about Mental Health

The language of mental health is loaded and complicated. You can start with some quite simple definitions and premises and then, quite quickly, lose yourself in a complex array of sensitivities, viewpoints and issues. So, let me try to walk through what I mean.

Mental health is a straightforward concept that is analogous to physical health. We all have days when we feel better and days when we feel worse. We know that some people are, in some regards, very healthy and others, less so – although such things often mask a huge amount of complexity – e.g. top athletes will often do long-term harm to their bodies in pursuit of short-term physical advantage. Similarly, someone who is very intelligent may not be so strong with regard to their emotional health.

Another definition that is used, for example by the WHO, is MNS, namely Mental, Neurological and Substance Abuse disorders. Mental disorders here being such things as depression, schizophrenia and bipolar disorder. Neurological disorders being diseases of the brain such as Parkinson’s, Epilepsy and Stroke. Finally substance abuse disorders which can relate to alcohol, legally available or illegal drugs.

A third definition worth being aware of is that of psychosocial disability. This is where someone has a mental health condition that affects them within their societal situation in such a way that they are not able to fully participate in what would be considered ‘normal’ life. The interaction with society is here, crucial, because someone who is chained or drugged to prevent them from behaving unpredictably in one setting may be able to manage their condition perfectly ably in another.

You may have noticed that I haven’t used the word “illness” anywhere above. What, in light of the above, is mental illness? To me it is analogous to physical illness but until we live in a society that is as comfortable with people phoning in sick because of anxiety or depression that is clearly not a widely held view. Recognising and respecting people’s descriptions of themselves as having a mental illness is important, with or without a diagnosis. Just as we are able to self-diagnose physical ailments (within limits) so to are we able to understand and identify mental maladies that may affect us.

Some people would dismiss the notion of mental illness, labelling, or even the use of the word ‘condition’ as I have used it above. Each of us has a brain that is unique and lives within our own social and emotional context. How then can a sweeping term such as “depression” or “schizophrenia” be used in the face of such diversity? Especially when our understanding of the causes and treatments for such conditions is so poor. It isn’t like a physical illness where we can (usually) identify what the problem is and have some idea of how to treat it. There is not a gene or a part of the brain that is at fault in someone who is depressed. There may be lower levels of some chemical (e.g. serotonin) in the bodies of many people who are depressed, but not all, not consistently and we have no understanding of the links or causality.

So, where does this leave us? For me, if I am talking about mental health, I tend to give the technical definitions but then try to personalise it and root it in our own experiences. Just as you will probably have experienced a cold or flu in the last year, there will probably be times when you were stressed, anxious or depressed. Maybe not so much that you could be clinically diagnosed so but noticeably below your normal state of functioning. Just as you struggle through a cold for a few days and then crack on with life, so you can struggle through minor mental lows and carry on. Understanding this and reflecting on the difference between that experience and the experience of someone who has a lifelong condition (either mental or physical) is worth doing.

Finally, avoiding derogatory or insulting terms is in some ways obvious but taking cues on this from people who are speaking to their own experience is critical. Mental health terminology can be highly personal and while words such as madness and insanity may feel dated in some cultures there are people who are actively trying to reclaim them. Respect the views and language of the person you are talking to and engage with an open mind