Cumberland Public Health Annual Report, 2023/4 - Chapter 6: Conclusion and Recommendations

The current situation regarding mental health and neurodiversity is simply untenable. Too many people are suffering in one way or another, and existing services are unable to meet their needs. Doing nothing is not an option, and doing more of what we’re currently doing is unsustainable. Implementing the approach outlined in the previous chapters within local mental health and neurodiversity services requires a shift in perspectives, policies, and practices across a wide range of sectors.

Some of the most comprehensive work on the effectiveness of public mental health interventions has been done recently by the Royal College of Psychiatrists Public Mental Health Implementation Centre (2022). These recommendations draw heavily on their reviews.

Recommendations for all national and local governmental agencies

1. The fundamental factors underlying our crisis in mental health are no different to those underlying a wide range of other health and social challenges. All agencies need to work systematically and consistently to address poverty, poor living and working conditions, social power imbalances, abuse and trauma, prejudice, marginalisation, exclusion and exploitation. I recognise of course that this is a very broad recommendation, the detail of which is outside the scope of this report; however it is crucial to recognise that while these factors remain, even full implementation of every other recommendation in this report will only scratch the surface of the problem.

Recommendations for public health and prevention services

2. The importance of secure and loving childhood environments cannot be overstated for long term mental health and wellbeing. The forthcoming redesign of Cumberland’s children and families universal services and early help system, including the Healthy Child Programme, should invest heavily in work to help develop attachment, build parenting skills, and support families from a very early stage of them starting to show signs of struggling. This should be established as an integrated and holistic response that families can interpret positively rather than being seen as stigmatising or punitive.

3. Changing culture at a local level in the face of national and global forces is extremely challenging. Nonetheless Cumberland should conduct community-based campaigns and educational programs aimed at encouraging people to recognise the normality of a diverse range of experiences both in mental health and neurodiversity; the potential for some of these to be responded to without clinical support; and the way in which Cumberland could truly foster a sense of belonging among those with very diverse experiences.

4. One specific challenge in changing culture is the sometimes pernicious influence of social media. Consideration should be given to local campaigns and support for schools to delay the start of social media use and to ensure that children and young people are prepared to have realistic expectations of what social media is.

5. While experiencing mental health problems should never be seen as being in any way an individual weakness, there is no doubt that people can respond differently to similar stressors as a result of their previous experience and their cognitive styles, and that more resilient approaches can be learned. Further development of widely available resilience programmes should therefore be considered.

Recommendations for health services

6. Like (and often linked to) the childhood environment, the importance of trauma as a driver of mental health problems can hardly be overstated. Trauma-informed principles should therefore become infused into a wide range of health services. Staff should be trained in recognising the signs of trauma and responding sensitively and compassionately, and services should be provided in trauma-informed spaces that prioritise safety, trust, and empowerment for individuals seeking support.

7. There is a specific gap in Cumberland regarding the specialist therapeutic response to trauma, and particularly to complex trauma. While trauma-informed services can go a long way to supporting many people, in some cases considerable expertise is required and such a service should be commissioned as part of the wider transformation of local services.

8. Traditional diagnostic models are clearly not adequately meeting the range of needs and demands currently being placed on services. Service offerings should therefore be expanded beyond these traditional diagnosis and treatment models. Within mental health services a programme of training and development around the Power/Threat/Meaning Framework should be put in place to enable it to be widely adopted and to support a transformation of the local approach to identifying and supporting mental health problems.

9. Changing the way we think about things can change the way society responds. Health professionals should therefore adopt assessments based on social challenges rather than solely relying on diagnostic labels. Imagine how powerful it would be if a GP, rather than diagnosing someone as having “mixed anxiety and depressive disorder” (which in electronic patient records would use the SNOMED code 231504006), instead “diagnosed” them as suffering from the effects of being financially poor (11403006), a victim of domestic violence (1279539006) and having a history of being a victim of child sexual abuse (288411000119107); the appropriate service response would be very different, and so eventually would our understanding of the epidemiology around demand for services.

10. One implication of becoming more clearly trauma-informed is that strength-based approaches to supporting people have the potential to be more successful than traditional treatment models. Services should therefore focus on identifying individual strengths and resources to tailor interventions that support personal growth and well-being. Coaching models are a good example of this, and the success of Cumberland’s Health and Wellbeing Coach service (see Box 6) should be further built on to enable such services to be more widely accessible.

11. Given that people’s experience of mental health will be highly individual, influenced by their very specific experiences and thinking patterns, their support needs will be equally variable. A wide range of interventions should therefore be provided, including trauma-focused therapies, mindfulness-based approaches, support groups, and psychoeducation programs that address everyday emotional experiences and promote mental wellness.

12. The approach to mental health outlined in this report has significant optimism behind it: it strongly endorses the view that recovery should be at the heart of our service response, and that this is absolutely achievable for many or most people. Support should therefore be given to increasing the capacity of Lived Experience Recovery Organisations (see Box 2) and the Recovery College (see Box 7) to provide community-based opportunities for people to take greater control of their own recovery.

The recovery College Concept .

A recovery college is a place – sometimes a virtual or online one – that supports individuals in their journey of recovery from mental health difficulties. These colleges focus on learning and education, which are co-produced by people with lived experience and professionals with expertise in mental health.

The North Cumbria Recovery College, which opened its virtual doors in 2021, hosts a number of co-produced courses delivered by individuals with lived experience. The courses develop an individual’s understanding and skills base of their mental and physical health. The courses focus on symptoms of conditions being on a continuum of impact to the person throughout their life. Courses are not based on diagnosis: instead they encourage skills acquisition and connections between people with similar symptoms. This creates a recovery community and builds hope for an individual to manage their symptoms throughout their life. NCRC also develops those individuals wanting to develop their own peer led groups by equipping them with the skills and mentoring to do this.

“I’ve had problems with my mental health and physical health for a few years now. I have engaged with the NHS mental health services but have found the recovery college to be one of the most beneficial. Having engaged with the NCRC I have been better able to manage my mental health in particular. I have worked on being able to stop worsening symptoms sooner, talk to others with similar experiences and learn skills to manage my symptoms. This has meant I has accessed my GP, A&E and my services less often and faster than I used to. I feel supported and empowered to manage my mental health, without feeling alone.”

This example, drawn from a real case study, shows how the recovery college can be impactful and hope filled, and builds resilience.

Box 7: Recovery Colleges

Recommendations for multiple agencies

13. Cumberland should fully embrace the Portsmouth ND Model, adopting this approach systematically across mental health services, education, and children’s services. This should be done in full partnership with parents and carers of children currently within the Special Educational Needs system.

14. People with (sometimes protected) minority characteristics are more likely to experience adversity and trauma, and to find that available services are not adequately designed to meet their needs. Relevant services should therefore review their approaches in the light of community and service user feedback about equality, diversity and inclusion.

Recommendations for the education sector

15. A lot of the pressure around neurodiversity support falls on schools, which find themselves under-resourced to respond to the increasing demand. While resources will remain challenging, educational institutions should be supported to implement inclusive practices and provide resources for neurodiverse individuals without the need for clinical diagnoses. This will require investment in ongoing professional development as well as the widespread adoption of Universal Design for Learning principles.

16. The role of trauma in shaping mental health and behaviour in children and young people is clear. Trauma-informed principles should therefore become infused into schools and further and higher education institutions as much as they should be in health services. Staff should be trained in recognising the signs of trauma and responding sensitively, and services should be provided in trauma-informed spaces that prioritise safety, trust, compassion and empowerment for individuals seeking support.

Recommendations for employers and workplaces

17. Diversity is a strength in the workplace, and employers should promote inclusive cultures that celebrate diversity, foster empathy, and reduce stigma associated with neurodiverse traits. This should include peer support programs and awareness campaigns to help to promote understanding and acceptance.

Recommendations for research

18. The agenda set out in this report could, if fully embraced, be a radical departure from the mainstream approach to mental health and neurodiversity, and it is crucial that it should be rigorously evaluated to ensure that it is actually improving mental health and wellbeing, and the experience of neurodiverse individuals. Cumberland Council’s new Health Determinants Research Collaborative should therefore adopt mental health and neurodiversity as a key theme of its research programme. This research should be used to continuously improve service delivery, ensuring that the approach remains responsive and effective for diverse populations.

Conclusions

Mental health and neurodiversity are posing substantial challenges to society at the moment, both in terms of the scale of the distress and suffering being experienced, and the inadequacy of our response. This report has presented a vision for a new approach to mental health and neurodiversity in Cumberland, based on the principles of human rights, social justice, and empowerment. It has outlined the challenges and opportunities facing local services, and made a number of recommendations for policy and practice changes that could make a positive difference for the wellbeing of the community. The report has also highlighted the need for further research and evaluation to ensure that the proposed changes are evidence based and effective.

None of this will be easy: however the “burning platform” of unsustainable demand is widely recognised in Cumberland and there is therefore a real opportunity to lead the way in creating a more inclusive and supportive environment for people with diverse mental health and neurodiversity needs, and to demonstrate the benefits of such an approach for the whole society.