Consultation response Relate Cymru: Suicide Prevention
December 2017
The Committee is calling for evidence about:
· The extent of the problem of suicide in Wales and evidence for its causes - including numbers of people dying by suicide, trends and patterns in the incidence of suicide; vulnerability of particular groups; risk factors influencing suicidal behaviour.
· The social and economic impact of suicide.
· The effectiveness of the Welsh Government’s approach to suicide prevention - including the suicide prevention strategy Talk to me 2 and its impact at the local, regional and national levels; the effectiveness of multi-agency approaches to suicide prevention; public awareness campaigns; reducing access to the means of suicide.
· The contribution of the range of public services to suicide prevention, and mental health services in particular.
· The contribution of local communities and civil society to suicide prevention.
· Other relevant Welsh Government strategies and initiatives - for example Together for Mental Health, data collection, policies relating to community resilience and safety.
· Innovative approaches to suicide prevention.
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Your name:
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Gwilym Roberts |
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Organisation (if applicable):
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Relate Cymru |
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XXXXXXXXXXXXXXXXXXXX |
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Contact telephone number
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XXXXXXXXXXX |
Relate Cymru exist to build stronger relationships in Wales.
Relationship breakdown is a well acknowledged, common contributor to suicide. Also, having strong relationships is a well acknowledged contributing factor to stronger mental health.
Choice of evidence-based therapies
Currently missing from Together for Mental Health delivery plans is any mention of the importance of patients’ choice of psychological therapy. Priority Area 7 stipulates that ‘People with a mental health problem have access to appropriate, evidence-based and timely services’ (which requires the expansion of psychological therapies to increase access), but the Delivery Plan currently does not include as a priority area the importance of patients’ choice of evidence-based psychological therapy.
However, the Together for Mental Health strategy includes as one of its six high-level outcomes “Individuals have a better experience of the support and treatment they receive and have an increased feeling of input and control over related decisions”, and notes that not only should “People of all ages benefit from evidence-based interventions delivered as early as possible and from improved access to psychological therapies”, but also that “Wherever possible, [people] should be able to exercise choice”.
It is therefore disappointing that the Delivery Plan makes no mention of ensuring people can exercise choice of evidence-based therapies. Individual choice requires that the full range of NICE-recommended therapies is made available. However, in Wales the NICE-recommended therapy Couple Therapy for Depression is not commissioned – which means that choice of this evidence-based therapy is not available. Furthermore, the Welsh Government’s Policy Implementation Guidance, Psychological Therapies in Wales(http://gov.wales/docs/dhss/publications/120326psychologicalen.pdf) makes no mention of Couple Therapy for Depression.
The evidence is clear, however, that Couple Therapy for Depression – which is the only NICE-recommended talking therapy for depression which focuses on the couple[i] – is effective. Evidence from the Improving Access to Psychological Therapies programme in England indicates that Couple Therapy for Depression achieves a recovery rate of 52.0% (the target is 50%, although the national recovery rate is currently 44.8%), compared to Cognitive Behavioural Therapy (by far the most common psychological therapy) which achieves a recovery rate of 44.1%.[ii]
The strong evidence for the link between relationships and mental health should also make choice of evidence-based therapy, including Couple Therapy for Depression – a priority in the Delivery Plan. The evidence is now clear that relationship quality and mental health are closely linked, with relationship distress linked to depression[iii] and anxiety.[iv]
l People who live in distressed and troubled relationships are three times as likely to suffer from mood disorders (e.g. depression), and two and a half times as likely to suffer from anxiety disorders, as people who do not experience such relationship distress.[v]
l Poor quality relationships are a risk factor for depression,[vi]and while evidence supports the conclusions both that poor relationship quality leads to depression and that, in its turn, depression leads to poor relationship quality, there is stronger support for the former,[vii]with longitudinal studies showing that marital dissatisfaction predicts increased depressive symptoms over time,[viii] and adults in the lowest-quality relationships are twice as likely to develop depression as those in the highest quality relationships.[ix]
l Some studies find over 60% of those with depression attribute relationship problems as the main cause of their illness.[x]
l Studies indicate that treatment of relationship distress may have the potential alleviate up to 30% of cases of major depression.[xi]
We would like to see everyone having access to the mental health support that is most effective for them – including Couple Therapy for Depression. This requires up-skilling mental health service commissioners, service providers, and frontline professionals such as GPs to better recognize the link between relationships and mental health.
We would like to see the Welsh Government introduce a clear policy ambition setting out the level of meaningful choice that should be available to patients through GP referred talking therapy services, going beyond simply increasing the number of clients who are able to make a choice, to consider whether this is a fully-informed choice from a diverse range of options that includes Couple Therapy for Depression. There are a range of mechanisms which need to be explored to achieve this aim:
· Clearer guidance and training for commissioners to ensure that they understand the benefits of the full range of NICE-recommended talking therapies and the importance of meaningful choice.
· Similarly, guidance and training for those signposting into talking therapy services (e.g. GPs) to ensure that patients are offered an informed choice of therapy from the full range of NICE-recommended psychological therapies.
· Improved information and brokerage support directly to people accessing talking therapy services to ensure that all patients can make choices about the psychological therapies that are best for them.
· Indicators on choice among talking therapy users included in commissioning frameworks.
In Wales we need to see Couple Therapy for Depression commissioned so that everyone with a mental health problem referred to a talking therapy can access the most effective therapy for them
In relation to access to Welsh language support, we know that providing talking therapies via phone and via webcam have been beneficial for clients who want counselling in the Welsh language. As a proportion of Wales’ counsellors and therapists are able to deliver in Welsh, it is sensible to develop new ways to allow a wider range of clients access to their services.
In addition, being able to access support from our homes, is often preferable to clients, especially in rural areas where travel to a counsellor is challenging or for those with mobility problems.
The Together for Mental Health strategy includes an important definition of wellbeing from the WHO which includes the recognition that “[Wellbeing] is enhanced by conditions that include supportive personal relationships”, and this is supported by a wealth of evidence:
· Research shows the importance of good-quality relationships for health, life satisfaction, and wellbeing.[xii]
· Relationship distress is linked to depression and anxiety,[xiii] and people who live in distressed and troubled relationships are three times as likely to suffer from mood disorders (e.g. depression) as people who do not experience such relationship distress.[xiv]
· While evidence suggests the poor relationships-depression link runs in both directions, there is stronger support for depression as an effect of poor quality relationships,[xv] and marital dissatisfaction predicts increased depressive symptoms over time.[xvi]
· Studies find over 60% of those with depression attribute relationship problems as the main cause,[xvii] and indicate that treatment of relationship distress may alleviate up to 30% of cases of major depression.[xviii]
· Researchers estimate that 14% of adults who have very poor quality social relationships will experience depression later in life, compared to seven per cent of adults with high quality relationships.[xix]
· Relate’s report with New Philanthropy Capital on the links between relationships and long term health conditions highlighted how health and relationships interplay with each other, with good quality relationships being crucial protective factors which shield us from the effects of long term health conditions, aid recovery, and can prevent illness in the first place, while poor quality relationships are risk factors.[xx]
· Relationships with friends and family are top of the nation’s list of things that matter most to wellbeing, joint with health (89%).[xxi]
· The Office for National Statistics (ONS) identifies relationships as a domain which influences subjective wellbeing[xxii] and includes satisfaction with family life, social life, and the extent to which people have a spouse, family member, or friend to rely on in its national wellbeing measures.[xxiii]
· The 2008 Commission on the Measurement of Economic Performance and Social Progress (the ‘Stiglitz Commission’) counted social connections and relationships among its eight recommended core components for measuring national wellbeing.[xxiv]
· The 2014 Commission on Wellbeing and Policy similarly recently recognised the role of relationships in wellbeing, noting that across the world, the quality of home life – which is ultimately based on family relationships – is a universal ingredient of life satisfaction.[xxv]
· The ONS also recognises that social capital – our relationships, networks and shared values that enable our society to function – is a key influence on our wellbeing.[xxvi]
In the light of this evidence for the importance of relationships to wellbeing, we are therefore disappointed that the Together for Mental Health Delivery Plan makes no mention of relationships and their importance for achieving the admirable objectives it sets out.
In particular, we contend that the following policy recommendations would be highly beneficial to support the achievement of the Together for Mental Health strategy:
· ‘Relational’ training for health professionals
Frontline professionals are not widely supported to talk to patients about their relationships, and given increasing pressures on time as well as the absence of any targets around relationships, these issues are rarely prioritised.[xxvii] GPs, for instance, do not always know what support services are available to refer people onto, and responses tend to vary between signposting to counselling services and simply prescribing medication.[xxviii] Similarly, research in the UK in 2010 found the vast majority of couples had never spoken to their health visitor about their relationship, with only four-to-ten per cent having done so and few having found it helpful[xxix] - and a more recent study confirms this picture.[xxx]
However, due to the strong link between mental health and relationships as evidenced above, health professionals regularly come into contact with relationship issues. 30-40% of people have approached their GP about relationship issues,[xxxi] and 92% of GPs report patients have raised issues about personal relationship problems with them over the last month.[xxxii] Given this link, it is therefore imperative that psychological wellbeing practitioners in GP-referred talking therapy services actively assess whether a patient’s relationship with their partner is a factor in that patient’s depression.
Training and educational marketing for frontline professionals who are likely to come into contact with mental health and relationship issues, such as GPs, psychiatrists, psychologists, health visitors, social workers and others involved in mental health care, would help to up-skill professionals in relational approaches. Training for frontline professionals has been shown to lead to improvements in couples being signposted to appropriate relationship support services and resources.[xxxiii]
· Preventative relationship support, especially for people with long-term conditions
We would like to see a focus on relationships in public health embedded as a core part of a prevention strategy. In particular, in recognition of the links between relationships and long-term health conditions - and the evidence that good-quality relationships can protect against deterioration, aid recovery and even prevent us from becoming ill in the first place, while poor-quality relationships are health risks[xxxiv] - we would like to see the NHS providing preventative mental health and wellbeing support to people living with long-term conditions – those with the conditions, their carers/partners, and families. We would like to see the Welsh Government establishing targets for the numbers of people living with a long-term health condition having access to support for their relationships as a part of person-centred care.
· Relationships should be inserted into national health policy frameworks, including outcomes frameworks.
In order to review existing frameworks and ensure relationships are given the place they deserve, we recommend that the Welsh Government establishes an inquiry into relationships in health policy to make recommendations on how relationships should be included in policy frameworks, including the NHS Wales’ and Public Health Wales’ outcomes frameworks.
· Couple, family and social relationships should become a core part of the work of local Health Boards.
The Welsh Government should issue guidance, encouraging Health Boards to evaluate the quality of relationships and support relationships as core social determinants of health and wellbeing. In addition, local couple, family and social relationships should be addressed in needs assessments.
· Directors of Public Health should consider the best way to gather data on the quality and stability of relationshipsat the local level, in order to inform decisions made by local authorities and commissioners.
The absence of any standardised local data or strategies to support family relationships impedes the ability of commissioners and planners to direct services and of researcher to further understand the links between relationship quality, stability and other outcomes. Work is needed to develop a measure of family functioning available at the local authority level, which includes parental self-efficacy and relationship quality. Use of such a measure would help identify areas of need, as well as better understand the antecedent characteristics of family functioning. Reporting on this data annually would allow for better local scrutiny of local decisions to improve the quality and stability of relationships.
[i] Hewinson, D. (2011) A Brief Guide to Couple Therapy for Depression. Healthcare Counselling and Psychotherapy Journal, April, 11, 32-33
[ii] HSCIC (2015) Psychological Therapies: Annual Report on the use of IAPT services. England, 2014/15
[iii] Whisman M. (2001) The association between depression and marital distress. In Beach, S. Marital and Family Processes in Depression: A Scientific Foundation for Clinical Practice. Washington DC: American Psychological Association, pp. 3-24
[iv] Conger, R. D., & Elder Jr, G. H. (1994). Families in troubled times: The Iowa youth and families project. Families in troubled times: Adapting to change in rural America, 3-19.
[v] Whisman, M.A., Uebelacker, L. A. (2003) Comorbidity of Relationship Distress and Mental and Physical Health Problems. In Snyder, D. K., Whisman, M. A. (eds.) Treating Difficult Couples, Guilford Press
[vi]Teo, A. R., Choi, H., Valenstein, M. (2013). Social Relationships and Depression: Ten-Year Follow-Up from a Nationally Representative Study. PLOS ONE, 10.1371/journal.pone.0062396
[vii] Proulx, C., Helms, H. & Buehler, C., 2007. Marital quality and personal well-being: A meta- analysis. Journal of Marriage and Family, 69(3), 576-593
[viii] Mead, E., 2002. Marital distress, co-occurring depression and marital therapy. A review. Journal of Marital And Family Therapy, 28(3), 299-314
[ix] Teo, A. R., Choi, H., Valenstein, M. (2013). Social Relationships and Depression: Ten-Year Follow-Up from a Nationally Representative Study. PLOS ONE, 10.1371/journal.pone.0062396.
[x] O’Leary, K., Riso, L. and beach, R. (1990) Attributions about the marital discord/depression link and therapy outcome, Behaviour therapy, 21(4), 413-422; Rounsaville, B., Weissman, M., Prusoff, B. and Herceg-Baron, R. (1979) Marital disputes and treatment outcomes in depressed women. Comprehensive Psychiatry, 20(5), 483-490
[xi] Whisman, M. A. & Bruce, M. L. (1999). Marital dissatisfaction and incidence of major depressive episode in a community sample. Journal of Abnormal Psychology, 108, 674-678
[xii] Proulx, C., Helms, H. & Buehler, C., (2007) Marital quality and personal well-being: A meta- analysis. Journal of Marriage and Family, 69(3), 576-593; Coleman, L. & Glenn, F., 2009. When couples part: Understanding the consequences for adults and children. London: OnePlusOne; Robles, R., Slatcher, R., Tombello, J. & McGinn, M., (2013), Marital quality and health: A meta-analytic review. Psychological Bulletin, DOI: 10.1037/a0031859.
[xiii] Whisman M. (2001) The association between depression and marital distress. In Beach, S. Marital and Family Processes in Depression: A Scientific Foundation for Clinical Practice. Washington DC: American Psychological Association, 3-24; Conger, R. D., & Elder Jr, G. H. (1994) Families in troubled times: The Iowa youth and families project. Families in troubled times: Adapting to change in rural America, 3-19
[xiv] Whisman, M.A., Uebelacker, L. A. (2003) Comorbidity of Relationship Distress and Mental and Physical Health Problems. In Snyder, D. K., Whisman, M. A. (eds.) Treating Difficult Couples, Guilford Press
[xv] Proulx, C., Helms, H. & Buehler, C., (2007) Marital quality and personal well-being: A meta- analysis. Journal of Marriage and Family, 69(3), 576-593
[xvi] Mead, E., 2002. Marital distress, co-occurring depression and marital therapy. A review. Journal of Marital And Family Therapy, 28(3), 299-314
[xvii] O’Leary, K., Riso, L. and beach, R. (1990) Attributions about the marital discord/depression link and therapy outcome, Behaviour therapy, 21(4), 413-422; Rounsaville, B., Weissman, M., Prusoff, B. and Herceg-Baron, R. (1979) Marital disputes and treatment outcomes in depressed women. Comprehensive Psychiatry, 20(5), 483-490
[xviii] Whisman, M. A. & Bruce, M. L. (1999) Marital dissatisfaction and incidence of major depressive episode in a community sample. Journal of Abnormal Psychology, 108, 674-678
[xix] Teo, A. R., Choi, H., & Valenstein, M. (2013) Social Relationships and Depression: Ten-Year Follow-Up from a Nationally Representative Study. PLOS ONE, 10.1371/journal.pone.0062396.
[xx] Handley, S., Joy, I, Hestbaek, C. & Marjoribanks, D. (2015) The Best Medicine? The importance of relationships for health and wellbeing. London: Relate and NPC
[xxi] ONS (2011) Findings from the national well-being debate, ONS
[xxii] Randall, C. (2015) Measuring National Well-being: Our Relationships, ONS http://www.ons.gov.uk/ons/rel/wellbeing/measuring-national-well-being/our-relationships--2015/art-measuring-national-well-being--our-relationships--2015.html
[xxiii] ONS (2014) National Wellbeing Measures, September 2014 http://www.ons.gov.uk/ons/rel/wellbeing/measuring-national-well-being/domains-and-measures---september-2014/art-national-well-being-measures--september-2014.html#tab-Where-to-find-national-Well-being-measures-data
[xxiv] Stiglitz, J., Sen, A., & Fitoussi, J-P., (2009) Report by the Commission on the Measurement of Economic Performance and Social Progress http://www.stiglitz-sen-fitoussi.fr/documents/rapport_anglais.pdf
[xxv] O’Donnell, G., Deaton, A., Durand, M., Halpern, D. & Layard, R. (2014) Wellbeing and policy. Legatum Institute
[xxvi] ONS (2015) Measuring national wellbeing – an analysis of social capital in the UK
[xxvii] Handley, S., Joy, I., Hestbaek, C. & Marjoribanks, D. (2015) The Best Medicine? The importance of relationships for health and wellbeing. London: Relate and NPC
[xxviii] Walker, J., Barrett, H., Wilson, G. & Chang, Y-S. (2010) Relationships Matter: Understanding the Needs of Adults (Particularly Parents) Regarding Relationship Support. London: Department for Children, Schools and Families
[xxix] Walker, J., Barrett, H., Wilson, G. & Chang, Y-S. (2010) Relationships Matter: Understanding the Needs of Adults (Particularly Parents) Regarding Relationship Support. London: Department for Children, Schools and Families
[xxx] Gabb J., Klett-Davies, M., Fink, J., & Thomae, M. (2013) Enduring love? Couple relationships in the 21st Century. Survey Findings. An Interim Report
[xxxi] Anderson, S., Brownlie, J. & Given, L. (2009) Therapy Culture: Attitudes towards emotional support in Britain, in Parks, A. (Ed.) British Social Attitudes Survey 25th Report. London: Sage
[xxxii]
Citizens Advice (2015) A Very General Practice: How much time do
GPs spend on issues
other than health? Citizens Advice, May 2015
[xxxiii] Simons, J., Reynolds, J., & Morison, L., (2001) Randomised controlled trial of training health visitors to identify and help couples with relationship problems following a birth. British Journal of General Practice 53, 793–799
[xxxiv] Handley, S., Joy, I., Hestbaek, C. & Marjoribanks, D. (2015) The Best Medicine? The importance of relationships for health and wellbeing. London: Relate and NPC