Senedd Health & Social Care Committee Inquiry – Mental health inequalities
Introduction
The British Association for Counselling and Psychotherapy (BACP) welcomes this important inquiry into mental health inequalities in Wales. BACP is the leading and largest professional body for counselling and psychotherapy in the UK, with over 60,000 members and over 2,441 in Wales, where our membership has grown by 32% in the last 5 years. BACP is committed to improving equality, diversity, and inclusion (EDI) by creating ‘a profession for the future’, addressing systemic barriers within the profession to improve access to psychological therapies for all who need them.
The COVID-19 pandemic and the social distancing restrictions resulting from it have taken an enormous toll on people’s wellbeing and mental health. This represents an unprecedented challenge for the Welsh Government considering mental health is a key determinant of educational success, productivity, future earnings, and life expectancy (Layard, 2020).
Whilst inequalities in health and wellbeing have historically presented themselves within society, the Covid-19 pandemic has exacerbated and widened the gap, shining a light on inequalities in a way never seen before. Evidence has emerged on the disproportionate impact of Covid-19 on Black and Minority Ethnic communities; people with disabilities; older people; people from the LGBTQ+ community and various other sections of society. There is an urgent need to take a proactive stance and develop a preventative range of methods and long-term support systems that are individually relevant and suitable to people from these underrepresented communities.
1. Which groups of people are disproportionately affected by poor mental health in Wales? What factors contribute to worse mental health within these groups?
For people within marginalised groups, the pandemic intensified the level of risk, the precariousness of maintaining good mental health, and difficulties accessing the right support at the right time. In testament to the pervasiveness of mental health inequalities, the people who have historically endured the biggest risks for poor mental health, and the worst access to and experiences of support, were those most exposed to the worst of the immediate shock of Covid-19. These same groups will also be the most vulnerable to mental health difficulties longer term, as the pandemic leaves behind an unequal legacy of complicated bereavement, trauma and economic repercussions.
Throughout the pandemic it has become evident that Black and Minority Ethnic communities have disproportionately been impacted. Analysis by the Office of National Statistics (ONS) found that Black people in England and Wales were more than four times as likely to die as white people of the same age to die from Covid-19. The ONS adjusted its figures to filter out the effect of the region where people lived, deprivation, household composition, socioeconomic status, education, and health and disability. Once these factors were adjusted for, there were still disproportionate deaths among Black and Asian people. People of BAME backgrounds are more likely to be engaged in jobs such as public transport driving, cleaning, caring and Band 5 nursing, and all of these jobs cannot be done from home.
These factors have clearly had a detrimental effect on those from marginalised communities in Wales. For example, in June 2020, BAME individuals in Wales reported on average more than 4.1 problems associated with mental distress, whilst White British individuals reported 2.7, a difference of 55% in relative terms (Cardiff University, 2021)
The impacts of the pandemic on disabled people further shines light upon UK health inequalities. A 2021 study by the Health Foundation found that disabled people are more likely to report that COVID-19 restrictions have had a negative impact on their lives than those who did not identify as disabled. Similarly, disabled people are more likely to report that their medical treatment has been disrupted during the pandemic. This inequality is further highlighted through recent figures from the ONS, showing that disabled people had on average poorer well-being ratings than non-disabled people across all four well-being measures (life satisfaction, feeling that things done in life are worthwhile, happiness and anxiety). Furthermore, the explanation given that many Covid-19 deaths arise from ‘underlying health conditions’ – intended as a reassurance to the majority – unsurprisingly left many disabled people feeling frightened and othered (The Health Foundation, 2021)
Older people with pre-existing health conditions were some of the hardest hit by the pandemic, and those who were shielding were more likely again to be feeling more anxious since lockdown than those who were not (Age UK, 2020). A report by Amnesty International says prolonged isolation from family and friends had a “devastating” impact on the physical and mental health of care home residents. This included loss of movement, reduced cognitive functions and appetite and loss of motivation.
The Covid-19 pandemic has also been found to disproportionately affect women, who are more vulnerable than men to socioeconomic inequalities, gender inequalities, domestic violence and economic insecurity (Roberton et al., 2020; WHO, 2020). Additionally, women face challenges to their sexual and reproductive health rights (Roberton et al., 2020; WHO, 2020). During the lockdown period(s), pregnant women and parents were unable to access their usual support network of family and friends, as well as the face-to-face contact from the professionals providing support during the prenatal period. Prenatal maternal distress can negatively impact the course of pregnancy, fetal development, offspring development, and later psychopathologies; signifying the need for more support for pregnant women during the pandemic. In Wales, women exhibited worsened levels of mental health after the onset of the pandemic, with the gap of reported wellbeing between men and women increasing from 9.9% to 14.1%.
This lack of access to social support during the pandemic has also been acutely felt by those within the LGBTQ+ community. Social support is known to be effective in reducing poor mental health in trans and gender diverse people (e.g., Pflum et al., 2015; Veale et al., 2017). More specifically, social support from family and friends has been identified as a predictor of quality of life (Davey et al., 2014), reduced depressive symptoms, suicidal ideation (Veale et al., 2017; Wilson et al., 2016) and increased mental wellbeing (Alanko & Lund, 2020). The near total absence of this important support network during the pandemic has led to worse mental health outcomes for LGBT+ populations, compared with before the COVID-19 pandemic or compared with heterosexual/cisgender populations, suggesting worsening health inequities (McGwoan et al, 2021).
2. For the groups identified, what are the barriers to accessing mental health services? How effectively can existing services meet their needs, and how could their experience of using mental health services be improved?
The mental health needs of people from a wide range of communities are often unmet by available services and many people are still experiencing a ‘triple barrier’ of worsened health, reduced access to services, and poorer outcomes when services are accessed (Centre for Mental Health 2021). The Covid-19 pandemic has brought to greater attention the long-standing and enduring health inequalities across society and highlighted a need for action. People from marginalised and racialised community backgrounds and those with protected characteristics as defined in the 2010 Equality Act are less likely to seek help for their mental health; this may be due to cultural stigmas associated with help-seeking or people feeling that clinicians have a poor understanding of different cultural needs, and even expecting or experiencing racism within services.
The latest NHS Race & Health Observatory report found evidence to suggest clear barriers to seeking help for mental health problems rooted in a distrust of both primary care and mental health care providers, as well as a fear of being discriminated against in healthcare. One of the reasons cited for this lack of trust in health professionals and its subsequent impact on avoiding or delaying seeking help was patients’ views that healthcare professionals (GPs and mental healthcare professionals) did not either 1) understand what racism was or 2) understand how racist experiences and other individual experiences impacted both their experiences of mental health services and the outcome of the receipt of services.
Moreover, the report cited a qualitative study of Pakistani service users in the UK, finding that mental health services were not meeting the needs of Pakistani people. A key reason for this was the lack of interpreters available to people who did not speak English.
Those from marginalised communities often struggle to access a wide choice of mental health services. A study into service users who self-identified as Chinese reported that participants felt disempowered due to a lack of choice in treatment, whilst a similar study into Black Caribbean and Black African service users reported a similar narrow choice of medication, rather than any offering of counselling or talking therapies (Tang, 2017; Rabiee and Smith, 2013).
The Centre for Mental Health has reported that ‘mainstream mental health services often fail to understand or provide services that are acceptable and accessible to non-white British communities and meet their particular cultural and other needs’ (The Centre for Mental Health (2020) Mental health for All? – The Final Report of The Commission for Equality in Mental Health). Barriers to accessing the right support at the right time can be understood and overcome through engagement with diverse communities, and third sector organisations that have the trust of people from marginalised community background.
Evidence also suggests that there is a general under-provision of many services which could potentially be beneficial to disabled people in Wales including rehabilitation services and mental healthcare provision (Welsh Government, 2018). This was also highlighted in a survey of disabled people in Wales (DW December 2020); which said just 15% of respondents felt that their rights are enforced in health and social care, 56% of respondents did not think they are enforced and 29% did not think they are well enforced at all. Further evidence suggests a clear relationship between reductions and withdrawals in available social care during the pandemic and a negative impact on well-being among disabled people. Survey evidence from Mencap (August 2020) shows that people with a learning disability, for example, have experienced a negative impact on their mental health (69%), relationships (73%), physical health (54%) and independence (67%), according to family carers.
Similarly, The National LGBT Survey (2018) found that 24% of respondents had accessed mental health services in the last year, but a further 8% had tried to get help and failed. Long waiting lists and unsupportive response from GPs were cited as the key reasons for this. When LGBT+ people did have access to mental health services, they found mental health professionals often failed to deal with their experiences of trauma, and therefore were less likely to meet their needs (LGBT Foundation, 2020).
3. To what extent does Welsh Government policy recognise and address the mental health needs of these groups? Where are the policy gaps?
Whilst there is good recognition of these issues across a range of relevant strategies in Wales, including the Welsh Government's flagship Mental Health Strategy and Action Plan - Together for Mental Health and specific action plans for those from marginalised groups. The evidence shows that there is often a disconnect between policy rhetoric and the reality of local delivery.
The pandemic has increased demand for mental health services to a level where current plans are now out of step with the realities many people are facing across Wales, particularly marginalised communities. The proposed refresh of Together for Mental Health in 2022-23 provides an important opportunity to re-evaluate and reflect this this the new strategy in light of Covid 19, ensuring adequate investment and provision of accessible and culturally sensitive mental health services, including counselling and psychotherapy
4. What further action is needed, by whom/where, to improve mental health and outcomes for the groups of people identified and reduce mental health inequalities in Wales?
We know that a ‘one-size-fits-all’ approach is an ineffective strategy for meeting the needs of diverse populations (Mantovani et al., 2016). Thus, BACP believes that it is beneficial for the therapeutic relationship to offer clients full and informed choice when accessing mental health services and psychological therapies. This should include choice around therapists (for example based on those characteristics protected in the Equalities Act 2010 (HM Gov, 2010), as well as therapy type, appointment times and location of intervention.
A focus on understanding socio-cultural issues within the specific communities as well as recognising shared common features is likely to reduce the barriers faced by marginalised communities when accessing mental health services. For instance, improving awareness and understanding of cultural and religious influences which may affect access and referral to mental health services. In doing so, this will improve understanding on how these cultural interpretations may impact on potential access and may therefore decrease stigma.
In its 2019 report ‘Racial disparities in Mental Health’, the Race Equality Foundation calls upon policy makers and commissioners to provide better access to talking therapies according to local need, and engagement with black and minority ethnic communities to ensure the therapies are culturally appropriate and geographically accessible. The report encourages practitioners in all disciplines to increase understanding of cultural and faith beliefs of Black and minority ethnic communities and how this impacts on beliefs and behaviours around mental health. The report also recognises the importance of the role of the voluntary, community and social enterprise sectors in supporting people from BAME communities, filling the gap where statutory service is missing or inadequate to meet needs.
BACP is the professional body for 2,441 counsellors and psychotherapists across Wales. Our members are drawn from the various professional disciplines in the field of counselling and psychotherapy, working in a broad range of settings including education, private practice, healthcare, workplace support and within the third sector, as well as working with clients across all age-groups.
Our members are a capable, highly trained yet underutilised workforce. Our most recent Workforce Survey demonstrates that our members in Wales have capacity to undertake an average of 4.5 additional client hours per week, which amounts to almost 10,000 client hours per week, across our membership. This untapped resource could play a critical role in fixing gaps in the Mental Health system and ensure that vulnerable people across Wales get the support they most desperately need.
Contact details
Please contact Steve Mulligan, Four Nations Lead at BACP, if you would like to discuss our submission further.