Attitudes to Mental Health in Scotland: Scottish Social Attitudes Survey 2013

3 Attitudes to Mental Health Recovery

3.1 The findings in Chapter 3 are based on the analysis of questions about recovery which were only asked of those who have, or have had at some point in their life, a mental health problem. The sample size throughout is 417^[22]. In particular this chapter explores:

• Views of which factors have supported or hindered their recovery
• How views about which factors support or hinder recovery varied across socio-demographic groups
• Views on what recovery means to people with mental health problems and how these varied between sub-groups
• Whether people with mental health problems have received positive or negative messages about recovery from professionals, from family and/or friends, and how these messages varied between sub-groups.

3.2 The Mental Health Strategy for Scotland: 2012-2015 (Scottish Government, 2012) contains seven themes. Theme 6 relates to the continued support for a recovery-focused approach to mental health and states its aims as: 'Developing the outcomes approach to include personal, social and clinical outcomes'. This builds on the Scottish Government's commitment to promoting the recovery approach which was first established in 2001 through the National Programme for Improving Mental Health and Wellbeing (see Chapter 1 for details). In 2004 the Scottish Recovery Network (SRN) was set up specifically to promote the recovery approach in Scotland. SRN developed the Scottish Recovery Indicator which supports mental health services to develop recovery-focused practice. Although there are different definitions of recovery, the SRN describe it as:

'being able to live a meaningful and satisfying life, as defined by each person, in the presence or absence of symptoms. It is about having control over and input into your own life. Each individual's recovery, like his or her experience of the mental health problems or illness, is a unique and deeply personal process.'^[23]

3.3 We recognise that there are multiple interpretations which may be applied to the idea of recovery in this context, and we cannot assume that the SRN conceptualisation is one which respondents have used when answering. In particular we cannot know whether our respondents think that recovery must mean that someone is 'symptom free'. We return to this point throughout this report, as part of our discussion of the interpretation of findings - particularly findings about trends over time.

3.4 The Scottish Social Attitudes survey asked people who identified themselves as having mental health problems about their attitudes to recovery, as well as their experience of recovery from professionals, and from family and/or friends. These questions repeat those previously asked in 2004, 2006 and 2008 as part of the Well? survey series allowing us to track changes over time.

Factors supporting recovery

3.5 People who identified themselves as having, or having had, a mental health problem were first asked which two or three factors were most important in supporting their recovery. The response options included a wide range of potential factors which could support recovery including forms of treatment, interaction with others and self-help strategies. As respondents could choose up to three answer options for this question, the addition in 2006 of four new answer categories makes it difficult to make comparisons with 2004. The findings from 2004 and 2006 are included in Table 3.1 but the discussion focuses on changes between 2008 and 2013. Comparisons between years in the proportion choosing a specific answer category are affected if a different average number of answer categories was chosen in different years. Increases in percentages may simply be a feature of people choosing more responses in one year than in previous years. The average number of responses given to the question on factors that support recovery was similar in 2008 and 2013 allowing for a valid comparison (2.39 in 2008 and 2.29 in 2013).

3.6 In 2013 the five factors that support recovery which were chosen most often were (see Table 3.1 below):

• Medication (42%)
• Support from family or friends (41%)
• Other forms of treatment/therapy (e.g. psychology, counselling, alternative treatments, support groups) (27%)
• Developing my own coping strategies (26%)
• Finding out more about mental health (e.g. through support groups, leaflets, web information etc.) (19%)

Table 3.1: Factors supporting recovery (2004, 2006, 2008, 2013)

	2004	2006	2008	2013
	%	%	%	%
Medication	38	35	39	42
Support from family or friends	76	56	62	41
Other forms of treatment/therapy (e.g. psychology, counselling, alternative treatments, support groups)	29	30	19	27
Developing my own coping strategies	n/a	30	24	26
Finding out more about mental health (e.g. through support groups, leaflets, web information etc)	6	8	8	19
Having belief in myself	n/a	27	31	15
Having something worthwhile to do during the day (e.g. work, volunteering, education, hobbies etc.)	21	11	13	11
Having others believe in me	n/a	12	12	6
Support from colleagues/work	18	8	12	7
Support from people with a similar experience	14	11	13	3
Having a chance to contribute and be valued	n/a	2	5	3
I don't believe myself to be in recovery	2	*	2	2
Other	3	6	-	1
None of these	4	3	3	5
Don't know	*	*	*	7
Average no. of responses chosen	n/a	n/a	2.39	2.29
Weighted bases	351	n/a	335	428
Unweighted bases	377	384	359	417

Base = all respondents who identified as having a mental health problem.

3.7 In 2008 'support from family or friends' was the factor chosen most often by people with mental health problems with 62% saying it was important in their recovery. This was the second highest factor in 2013 but the proportion who chose this option had declined from 62% in 2008 to 41% in 2013. Similarly the proportion who chose 'having belief in myself' was 31% in 2008, the third most popular response, but this dropped to the sixth most popular response in 2013 and was only chosen by 15% of those with mental health problems.

3.8 The proportion choosing the response 'other forms of treatment/therapy' has increased significantly since 2008 from 19% to 27%. And the proportion choosing 'finding out more about mental health' increased by 11 percentage points from 8% in 2008 to 19% in 2013.

How attitudes to factors that support recovery varied between sub-groups

3.9 In 2013 there were some differences in attitudes to recovery based on socio-demographic factors^[24] (for full details see Table A.6 in Annex A). Figure 3.1 shows that women were more likely than men to include medication as one of the supporting factors they chose: 49% of women chose this option compared with only 31% of men. Almost twice as many women as men chose 'other forms of treatment or therapy' (33% of women compared with 17% of men). Men, however, were more likely to choose 'developing my own coping strategies' than women (32% of men compared with 22% of women^[25]).

3.10 Age was only significantly related to believing that medication was important in supporting recovery. People over 45 years old were more likely than younger people to choose medication as a supporting factor in their recovery: 41% of people over 65 years old compared with 25% of those aged 18 to 24.

3.11 Differences in levels of educational qualifications were related to whether people chose 'other forms of treatment or therapy' or 'developing my own coping strategies'. People with degrees were more likely than those with no formal qualifications to choose 'other forms of treatment or therapy' (38% compared with 18%). Similarly there were marginally significant differences^[26] between those with higher levels of qualifications (degrees or Highers) and those with Standard grades or no formal qualifications in the proportions who chose 'developing my own coping strategies' (about 1 in 3 of those with higher levels of qualifications compared with 1 in 5 of those with Standard Grades and 1 in 6 with no formal qualifications).

3.12 An exploratory analysis was undertaken to examine whether the perspectives of people with different types of mental health diagnosis were distinctive. However, due to the small numbers of people in the sample with specific diagnoses and the number of people with more than one diagnosis, it was not possible to draw any substantive conclusions from this analysis.

Figure 3.1: Factors supporting recovery by gender (2013)

Base: All respondents who identified as having a mental health problem
Sample size: 417

Factors hindering recovery

3.13 People were also asked to choose up to three factors which hindered their recovery. In 2013 the five factors chosen most often were (see Table 3.2):

• Not acknowledging I had a problem (18%)
• Not understanding what was going on (16%)
• Not feeling able to tell people about my mental health problem (15%)
• Continuing to experience symptoms (13%)
• Negative attitudes of people around me (11%)

3.14 A much larger proportion of people chose at least one factor which supported their recovery than selected a factor which they thought hindered their recovery. Eighteen percent of people chose the most popular response ('not acknowledging I had a problem') compared with 42% of people who chose the most popular response in relation to factors supporting recovery ('medication'). This is explained in part by the fact that 27% of people chose 'none of these' and 14% said they could not choose an answer in relation to what factors hindered their recovery. This compares with only 5% of people who chose 'none of these' for factors supporting recovery and 7% who said they could not choose. There has been very little change over time in relation to the factors chosen that hinder people's recovery.

Table 3.2: Factors hindering recovery (2006, 2008, 2013)

	2006	2008	2013
	%	%	%
Not acknowledging I had a problem	19	17	18
Not understanding what was going on	17	19	16
Not feeling able to tell people about my mental health problem	12	15	15
Continuing to experience symptoms	17	19	13
Negative attitudes of people around me	13	11	11
Not being able to access appropriate services or treatment	4	7	9
Lack of support or understanding from family or friends	9	6	8
Not getting the right medication	6	12	7
Lack of access to employment, education or training opportunities	4	5	6
Lack of support or understanding from colleagues/work	5	6	5
Other	6	*	1
None of these	34	34	27
(Can't choose / Don't know)	2	4	14
Average no. of responses chosen	n/a	1.91	2.00
Sample size	384	359	417

Base = All respondents who identified as having a mental health problem.
Sample size: 417

How attitudes to factors that hinder recovery varied between sub-groups

3.15 In 2013 there was very little variation between socio-demographic groups in people's views on the factors that hindered recovery (for full details see Table A.7 in Annex A). Men were more likely than women to say that 'not understanding what was going on' hindered their recovery: 22% of men compared with 12% of women. People on lower incomes were more likely to say that the 'negative attitudes of people around me' hindered their recovery compared with all other income groups (Figure 3.2 below): 19% of those in the lowest income group compared with 2% of those in the highest income group. And those educated to degree level, compared with all other groups, were more likely to say that 'continuing to experience symptoms' had hindered their recovery: 24% of those with degrees, compared with between 6-10% of those with lower levels of, or no formal, qualifications.

Figure 3.2: Negative attitudes of people around me by income (2013)

Base: All respondents who identified as having a mental health problem
Sample size: 417

What recovery means?

3.16 People with a mental health problem were asked: 'What does recovery mean to you?' and could choose as many answer options as applied to them from a list of possible factors^[27]. Change over time is not included in this section of the report due to the difficulty in clarifying whether these changes are genuine or a feature of the different data collection methods. The five most commonly chosen answer options in 2013 were (for full results see Table A.8 in Annex A):

• Having a satisfying and fulfilling life (55%)
• Getting back to normal (46%)
• Taking charge of my life again (44%)
• Feeling able to cope in general (37%)
• Getting more sleep (20%)

3.17 With regard to what recovery means to people, the only demographic factors which showed a significant association were gender and education (for full details see Table A.9 in Annex A). Women were more likely than men to say that recovery means 'feeling able to cope in general' (42% compared with 30% of men). People with higher levels of education (degrees or Highers) were more likely than those with lower levels of education to choose 'taking charge of my life again' and 'feeling able to cope in general'.

Messages about recovery from professionals, and from family and/or friends

3.18 People with mental health problems were asked to what extent professionals (nurses, doctors, support workers etc), and family and/or friends, gave them a positive or negative message about their recovery (Figure 3.3 below). The possible answer categories were: completely positive, mainly positive, mixed, mainly negative and completely negative. Hope and optimism have been evidenced to be core elements of personal recovery (Leamy et al, 2011). As such it is important that the messages which are shared with people experiencing problems are positive. Overall, the vast majority of people received either a completely or mainly positive message from both professionals, and from family and/or friends. A higher proportion of people said that their family and/or friends gave them a completely positive message about their recovery (36%) than said the same about professionals (28%). Twenty percent of people said they had received 'mixed' messages about their recovery from professionals and 21% had from their family and/or friends. Only 2% of people said they were given either a mainly or completely negative message about their recovery from professionals and 3% said this of their family and/or friends.

Figure 3.3: Messages about recovery from professionals, and from family and/or friends (2013)

Base: All respondents who identified as having a mental health problem.
Sample size: 417

3.19 In 2013, 65% of people received either a completely or mainly positive message about their recovery from professionals. This is similar to the levels recorded in 2006, when 66% of people received a positive message from professionals, although lower than the proportion recorded in 2008 (73%), which had been cautiously interpreted in the 2008 Well? survey report as the start of an upward trend. However, given the lower proportion in 2013, there is no evidence of an upward trend.

3.20 In both 2006 and 2008 over three-quarters of people had received positive messages from family and/or friends (76% and 79% respectively). This proportion had declined by 13 percentage points between 2008 and 2013 from 79% to 66%. The reasons for this change are unclear. This decline may reflect different understandings of the use of the term 'recovery' in the context of mental health; for example, some may view 'recovery' as living symptom-free while others may see it as living well and managing on-going symptoms. However, more in-depth, qualitative research would be needed to explore how people understand 'recovery', both in terms of their own experience and in a wider sense.

3.21 Both income and education levels showed a significant association with how positive the messages were that people received about their recovery from professionals (for full details see Table A.10 in Annex A). People in the lowest income group were less likely than those in higher income groups to have received a positive message from professionals about their recovery. A similar pattern was seen in relation to positive messages from family and/or friends.

3.22 People with degrees were more likely than those with lower levels of educational qualifications to have received a positive message about their recovery: 76% of those with degrees compared with 64% with no formal qualifications and 56% with either Highers or Standard Grade level education said they had had a positive message from professionals. Education levels were not, however, significantly related to messages about recovery from family and/or friends.

3.23 Those with lower than average levels of life satisfaction^[28] were less likely to say that they had received positive messages about their recovery, from both professionals and family and/or friends, than those with average or high levels. Fifty-seven percent of people with below average levels of life satisfaction compared with 71% of those with average or above levels said they had received positive messages about their recovery from professionals.