“Start of a consensus to build something better”: Platfform’s perspective on the ‘Connecting the dots: tackling mental health inequalities in Wales’ debate

At the Senedd debate on 3rd May 2023, there was the start of a consensus. But we need a broader shared understanding of social determinants. What do they mean for people without experience of trauma, poverty or discrimination?

Yesterday (May 3rd), members of the Senedd debated the Health and Social Care Committee report: Connecting the dots: tackling mental health inequalities in Wales. Watching it, we did have a sense that our approaches and attitudes towards mental health have changed massively in a short space of time.

The number of times that the impact of trauma and poverty on mental health was mentioned was an indication that we are starting to understand across the political spectrum, the role that these experiences play in shaping our mental health.

It felt to us like the start of a consensus to build something better in Wales. That’s where policy in Wales has always been inspiring. Even when we might disagree passionately, this exchange of views, on a foundation of shared understanding, has led to world-leading legislation and a policy approach that has changed people’s lives for the better.

That was what it felt like yesterday.

It is not without its challenges and stumbling blocks, of course – and we can’t be complacent.

1: We saw recognition of the need for cross-government working

To improve our collective mental health must work across departments. We were pleased that the Deputy Minister recognised this, and that contributors to the debate shared ideas for how to monitor and measure the impact of other policy decisions on improving mental health. This is key to driving the evolution that we need in our mental health policy – a recognition that it cannot be impacted solely by one minister, and then the need to create mechanisms to drive change at all levels of government in Wales. This was raised eloquently by James Evans MS and Ken Skates MS, in their call for the use of “ministerial advice submissions”, to better identify the impact of department decision making on mental health.

2: We need a shared understanding of social determinants

As we watched the debate, we saw the need for a shared understanding of what we mean by our mental health being largely determined by our circumstances (the social determinants). From contributions by members of the Senedd, it was evident that the impact of poverty on our mental health was widely recognised. But that is only one part of the picture when it comes to social determinants. It is the toxic stress of poverty that is a key driver, but toxic stress also plays out in many other important ways.

This is why we talk about poverty, trauma and discrimination. Our mental health is determined by either, any, or all those factors because they impact upon our ability to have our relational health needs met.

The Deputy Minister raised a key challenge to the idea of the social determinants, which we want to expand on. Responding to the debate, Lynne Neagle MS said:

The social determinants of mental health will be a key part of our new strategy, but it will not be the only part, and I want to be really clear with Members about that today. We all have mental health, and, yes, people's mental health is affected by the social determinants of mental health and by trauma, but there are also many, many people who have had much easier lives, lived comfortable lives and who haven't experienced trauma who suffer with their mental health. And this Government will develop a strategy for all of those people. — Lynne Neagle, MS

Firstly, this is fantastic to hear – after years of a mental health system that has medicalised people’s distress, it is refreshing to see a politician who recognises the limitations of our current approach. We are pleased to see that mental health is viewed in context to people’s circumstances and that this will be a key part of the new strategy.

We hear the challenge above, or echoes of it, in our daily work to shift the system towards a relational understanding of mental health. This is because mental health is complex. We have heard the statistic that 1 in 4 of us will experience a mental health problem in our lifetimes for years – this has helped normalise experiences of mental health and reduce the stigma that still damages people today.

However, it isn’t fully accurate.

What ‘causes’ mental health is not simple. We cannot point to one person, with the same experiences as someone else, and predict that they will experience the same resulting distress. There are a vast, almost infinite, number of variables.

We do know certain things though.

Yes, statistically, 1 in 4 of us will experience mental health problems – but those experiences are clustered in areas of poverty. If you have experiences of adversity, you are four times more likely to experience associated difficulties such as heart disease, cancer, diabetes and mental health problems. And people who are faced with discrimination day to day, who are not able to have positive relationships in their families, or communities, will be more likely to experience distress and resulting mental health problems as well.

We know that there are no specific genes that determine mental health diagnosis. There is no gene for emotionally unstable personality disorder, for example.

We also know there is growing evidence in the field of epigenetics expanding on our understanding of social determinants. In this field, evidence has been building for decades, that trauma that happens sometimes carries across generations through the alterations that toxic stress causes to these genes as a survival response. The result of this can mean the next generation could live with a vulnerability to stress and trauma.

Often, we are asked exactly the question that was posed in the debate: how is it that mental health problems can arise in families that are comfortable, have no history of trauma, and who have had, on paper, ‘easier’ lives? To answer that question, we must delve deeper into the ideas behind epigenetics. Exposure to toxic stress can, influence the epigenetics of up to three to five generations. Unpicking that can take time and can help obscure the original social determining factors. It is one of the ways in which mental health can ‘appear’ in a family that does not have immediate trauma, poverty or discrimination.

If we incorporate the evidence that mental health is determined largely by social factors, with influences through epigenetics, we must consider the implications for our future generations through this lens if we are to ensure their mental health.

Dr Jen Daffin, in a blog for Platfform, spoke about the need for positive relations, and the role they play in helping our mental health:

Relational health refers to the capacity to develop and sustain safe, stable and nurturing relationships (SSNR’s), which in turn prevent the extreme or prolonged activation of the body’s stress response systems (Garner, 2021). Not only do SSNRs buffer adversity and turn potentially toxic stress responses into tolerable or positive responses, but they are also the primary vehicle for building the foundational resilience skills that allow children to cope with future adversity in an adaptive, healthy manner. — Dr. Jen Daffin for Platfform

Our point is this: focusing on social determinants, on trauma-informed and relational approaches to our mental health system are not either/or. They are not exclusive to the realms of people in poverty or facing trauma. Shifting our mental health system to think about our relational health through a social determinants lens and challenge our widespread misunderstanding of mental health, will benefit us all.

We still need to meet the needs of people who are in distress right now. Paramount to breaking this cycle is ensuring people in distress have access to timely and appropriate rights-based support so that they have the best chance to build relational health – and pass those skills on to their future children. This is why intervening early in a child’s life and taking a whole family approach is so important in breaking this cycle.

3: We finished the debate with a sense of positivity

Although the report cycle has concluded now, it is clear it has made a significant impact on the policy debate within the Welsh Parliament, and that the Deputy Minister has heard the range of voices involved and is committed to making a real difference.

We were pleased that the understanding of links between trauma, poverty and discrimination are becoming more widely understood, and we are looking forward to working with the Welsh Government, and other stakeholders across Wales, in ensuring this approach becomes central to the new mental health strategy for Wales.

Finally – it was heart-warming to see so many passionate speakers, all of them committed to the mental health of people across Wales. Between the challenging and robust debate, the consensus around trauma and poverty, and a fierce advocate for people in the Deputy Minister, we feel positive about the future.

A good day for Wales – but with work to be done.