Response to Scottish Government Mental Health and Wellbeing Strategy Consultation

A Mental Health and Wellbeing Strategy for Scotland.

The Scottish Government operates a consultation process through which individuals and organisations can submit their views on a wide range of policy and legislation issues. One of the areas currently out for consultation relates to the national Mental Health and Wellbeing Strategy, which reflects an intention to revisit and update the comprehensive mental health strategy position statement that was published in 2017. Anyone reading these documents can see that the Scottish Government takes mental health seriously, and has developed detailed initiatives that address many aspects of this topic. While retaining a focus on services delivered through the NHS, existing policy also acknowledges the importance of education, housing, policing and other areas of government-funded provision, as well as the contribution made by third sector organisations. The consultation process – which closes on 9th September – invites responses from organisations, individual practitioners, service users and carers. It is clear that there is a lot of good work being done, and that a lot of people are being helped.  It is also evident that the Government recognises that there is room for improvement. 

The experience of mental health problems, and the struggle to maintain a sense of wellbeing and a good life, are challenges faced by all individuals and families. In principle, everyone in Scotland has something to offer in respect of the questions raised in the present mental health and wellbeing consultation. As a recipient, practitioner and teacher of counselling and psychotherapy, I would like to offer a perspective that considers broader possibilities for moving forward, rather than focusing on specific areas of provision.

On the whole, these Scottish Government documents describe the process of managing mental health as involving the selection and application of interventions delivered by mental health professionals. Although it does not spell this out, what this means in practice, is being referred for a course of brief cognitive-behavioural therapy or receiving a prescription for anti-depressant medication. While there is evidence that these particular interventions can be helpful, their effectiveness depends on the active participation of the patient. For example, anti-depressant medication does not in itself cure or resolve depression. What happens, instead, is that it can create a window of enhanced mood and energy that provides the person with a chance to re-shape troubled aspects of their life.

Also, long-term use of antidepressant medication can be harmful – the person needs to be willing to talk to their GP about when and how to taper it off.  In addition, as recognised by the Scottish Government policy documents, people suffering from anxiety, depression or any other mental health condition, generally engage with other sources of help under their own initiative. A lot of the time, this consists of simply talking to other people, or being open to the various forms of assistance offered by people close to you who can see you are suffering. But there are also a huge number of specific self-help strategies that can be activated: physical exercise, change of diet, reading, being in nature, yoga, membership of a faith community, and many more.  

For me, one of the weaknesses of existing policies in the area of mental health and well-being is that they do not devote sufficient attention to the ways that people function as active self-healers supported by active carers. Scottish Government policy seems to be organised around an implicit assumption that treatment choices and pathways always need to be created and managed by professionals. Certainly, there will always be those who are so depleted at a particular point in time, disadvantaged, or socially isolated, that they need and want their GP, nurse or social worker to make these decisions on their behalf. But, for most of us, it makes more sense to view our mental health struggles from a recovery perspective that involves continually making use of whatever resources are available to enable us to come to terms with adverse experiences that we have undergone.

It would be a wonderful thing if the Scottish Government could invest in systems for making information about mental health/wellbeing services and resources readily available on-line, in a standardised easy-to-follow format. To be useful, this information would need to include details of how to access a service (Do I need a GP referral? Can I just phone them? Is it free?), exactly what it is the service offers, and what the waiting times might be. On the whole, such information is not readily found in respect of most counselling, psychotherapy and other mental health services, in terms of being available in one place, in a standard format that allows the person seeking help to weight up the pros and cons of different options. A huge array of other activities that are potentially relevant – wild swimming groups, reading groups, various types of befriending networks and support groups – may not be easy to track down on the internet, or may be described in ways that do not highlight their possible value in relation to different types of personal recovery trajectory. 

What would make this information even more useful for those seeking help would be evidence of how effective the service or activity has been, in terms of evaluations made by previous users. One of the most significant developments within the field of counselling, psychotherapy and mental health over the past twenty years has been the adoption of brief questionnaires that clients or patients complete at every visit. This kind of data has provided to be a useful way for clients and therapists to keep track of whether progress is being made, or whether they need to consider some kind of change to how they are working together. It also generates data around the proportion of case seen in a clinic or service that have recovered/improved, stayed the same, or deteriorated, over the course of treatment. Although these brief measures are not perfect, there is a broad agreement within the mental health professions that they provide a generally accurate estimate of outcomes. All NHS mental health and psychological therapies services, the majority of counselling services, and maybe about half of private practice therapists, already use such tools. However, these data are seldom made available to potential service users: it is extremely difficult, at the present time, to learn about the extent to which different mental health services actually help people. Most of us have figured out how to search for, and interpret, consumer ratings and reports for different products and services, and for schools and universities, and know how to balance such data with other sources such as word of mouth recommendations. Such publicly-available information would similarly be useful in terms of deciding on which mental health and wellbeing resources and activities might be worth trying. In setting up a mental health and wellbeing resources website, the Government could require that each organisation that is included should provide user/consumer reviews appropriate to its aims and activities, and – ideally – evidence of how it responds to such feedback. 

It is important for information about emotional support, learning, and recovery activities to be organised on a local basis. Some services are available on-line and therefore equally accessible anywhere in the country, and other activities operate as events or residential blocks that operate on the basis that participation will likely involve some travelling. But the majority of mental health and well-being activities – weekly counselling, being a member of a choir, creative arts or community garden group, yoga classes, befriending visits,  involvement in support networks – are locality-based. It is also likely that new activities and services, that fill gaps in existing provision, are usually developed by small groups of people who are in immediate contact with each other and identify a local need. This issue is particularly relevant for individuals and families who are marginalised in some way, for instance in respect of cultural heritage or gender identity, or through experiencing multiple life difficulties that do not readily fit into a single category. A further initiative that the Scottish Government could at least trial on a pilot basis, therefore, would be to establish community-run mental health and wellbeing advisory groups, responsible for collecting and disseminating information about local mental health and wellbeing resources and activities, supporting the production and utilisation of appropriate outcome data, and looking more widely in the community at whose needs are not being met. 

A crucial dimension of a mental health strategy for the next 5 years and beyond, is concerned with the ways that people are likely to be affected by the climate crisis. There already exists a substantial literature on the increasing incidence and severity of climate anxiety, grief and trauma in many countries. There are important aspects of the emotional and psychological consequences of climate breakdown that are not readily assimilated into contemporary mental health theory and practice. For example, although human beings can draw on thousands of years of accumulated knowledge around how to cope with loss and bereavement through the death of a loved one, the extent to which these strategies are readily applicable to the loss of biodiversity and coastal landscapes is far from clear. The Scottish Government has started the process of formulating a response to these issues, in the form of its policy statement on mental health needs during the covid-19 pandemic.  An international survey of how different countries adapted to mental health aspects of the covid-19 lockdown, found that many low income countries fared better than more prosperous neighbours in the Global North because their care systems were more flexible. It makes sense for mental health provision in Scotland to embrace this kind of ability to imagine and enact novel ways of responding to potentially overwhelming societal crises at times of great uncertainty about whether it might ever be possible to reclaim earlier modes of functioning. 

Ultimately, mental health and wellbeing are about living a life that is meaningful, convivial and joyful, and in balance with the other-than-human world. Without detracting from the usefulness of medical approaches in some circumstances, it is obvious that the history and cultural traditions within which we live on a day-to-day basis, and our land itself, afford us many life-enhancing opportunities. Most people understand that despair and suffering are not illnesses to be treated, but instead represent potential openings for personal growth and learning. And that more family-owned weekend huts, or ceilidhs and libraries, have the potential to be just as valuable as more therapists and more prescriptions for antidepressant medication.