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Time to shine a light on mental health in passenger transport…
…Getting our heads around mental health & transport
A huge thank you to everyone who helped and contributed to this research, whether by forwarding on or filling surveys, providing me with information or meeting up to talk about the issues, including and not only:
Niki Glazier – previously at the Mental Health Action Group ~ who was at the heart of the Mental Health & Transport Summit 2016 and who has been a huge support and inspiration
Sian Easton – Anxiety UK ~ for disseminating the passenger survey to your members
Claire Walters and Vicki Pulman – Bus Users UK~ for disseminating the passenger surveys to your members and Vicki’s excellent pair of eyes over the survey questions
Professor David Begg~ for disseminating the operator survey and for your continual support
Anthony Smith – Transport Focus~ for invaluable input, data and discussion (to be used in the next phase of study)
Stephen Smith and Graham Sutton – CPT UK ~ for tremendous support and circulating the operator survey to your networks
Mark Fowles and Thomas Knowles – ALBUM (Association of Local Bus Company Managers) ~ for circulating the operator survey to your network
Austin Birks – CILT/uTrack~ for hearty support and also writing a blog on the subject
Saila Action and Jonathan Bray – Urban Transport Group ~ for support and circulating the operator survey to your members
Daisy Chapman-Chamberlain – Community Rail Lancashire~ for support and keeping up the good work
Stephen Joseph – Campaign for Better Transport~ for advice, input and contacts
Everyone at the TAS Partnership ~ for your continued support and understanding, and survey-filling
My Other Half for support and contending with me disappearing for weeks on end
The PTRC and TPM Conference for providing the arena to create and present this paper
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ContentsIntroduction……………………………………………………………… 4Approach Beyond this paper
The Mental Health Perspective......................................................... 7A few statistics Summary table - mental health illnessesSome common themes Mental illness in pictures
The Passenger Perspective………………………………………….... 20How does it feel? Summary of experiences Passenger survey findings at a glanceOperator survey findings in more depth
The Operator Perspective……………………………………………… 28Who’s doing what Operator survey findings at a glanceOperator survey findings in more depth
Conclusions & next steps……………………………………………… 38Who feels whatWho needs what Who does whatWhat more needs to be done
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IntroductionOn 25 February 2016, a conference blew my mind in the best possible way – it shone a light
on and united two areas I feel very passionately about: public transport and mental health.
It was the most refreshing and most welcome bolt out of the blue! The Mental Health and
Transport Summit 2016 brought together transport operators, mental health campaigners
and organisations - such as Mind, Anxiety UK and Time to Change - and Government
Ministers into one room to start a big and really important conversation.
We heard directly from people for whom journeys on trains, planes and buses have been
agonisingly painful – people with illnesses such as Bi-Polar Disorder, Obsessive
Compulsive Disorder (OCD) and Post Traumatic Stress Disorder (PTSD).
We heard about horror stories of passengers suffering panic attacks being offered
wheelchairs, on the one hand. On the other, we heard about the great things some
operators are doing to educate, train and offer support to their staff regarding mental health
illness – promoting understanding and awareness.
We discussed how it can be possible to make life easier – for staff and passengers alike. It
triggered a journey – the first stage being to shine a light on the subject and getting people
to understand before the ultimate stage of spurring action or some kind of change.
My experienceIt was also around the time that I started to disappear down the all-too-familiar tunnel of
depression and anxiety – which I have suffered from, on and off, over the years. This time a
year ago I was due to write and deliver a paper for the TPM Conference but pulled out due
to this depression. This year, however, I’m back and writing a paper a conference on the
very issue and proud!
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Why am I writing this?I’m far from alone (though it often feels like you are in depression or similar): 1 in 4 people
suffer from mental health issues in the UK and, likewise 1 in 6 employees. That’s an awful
lot of passengers and staff.
In the passenger transport sector, mental health illnesses such as anxiety and PTSD can
have crippling though ‘hidden’ impacts on staff in the industry and on passengers travelling
on services. In some cases, passengers are prevented from travelling and even leaving the
home at all.
This paper aims to continue the debate from the Summit, spread awareness and gauge
current levels of awareness; find out what it feels like for passengers with mental illness
who find public transport horribly challenging and what is being done by operators to
support passengers and staff alike with mental health issues; and, finally, to identify what
more can be done. More than words, this paper is intended to be a springboard for
encouraging actual change where change is needed and, crucially, also realistic.
My approach: perspectives & surveyMy approach is perspectives-based – in this paper, those of passengers who travel or
would travel on passenger transport services and those of all staff who work to make those
services happen, whether engineers, fitters, drivers, cleaners or managers who are
responsible for staff.
At the heart of this approach are two surveys conducted in April/May 2017:
a passenger survey – open to the general public, friends and passengers and;
an operator survey – open to bus, coach, rail and aviation operators and the wider
industry such as consultants, commentators and suppliers/manufacturers, thanks to
the support of contacts and their networks.
Both surveys ask respondents about their personal experience of mental health, awareness
of friends/family with mental health illness and what steps both passengers and operators
think would help make life easier for those suffering with mental illness in the transport
context.
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To put it in real terms, this paper aims to identify:
Who feels what
Who needs what
Who does what
What more needs to be done
Beyond this paperBeyond this paper and the TPM Conference, I will continue to build up as many survey
responses as possible, consult and share the results with stakeholders and develop the
findings and exploration of this paper further, so I can approach stakeholders and decision-
makers such as the Department for Transport with a compelling evidence base for
education, change and action. This will be a continual work in progress…
Further steps might involve information guides and checklists for action for operators and
means of connecting operators with passengers whose mental health issues are a huge
barrier to travelling – a headline find which operators and passengers alike identified as a
solution in the surveys.
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The mental health perspective Let’s start from the all-important first principles: what are mental health illnesses? What do
they feel like?
There is what seems like a never-ending list of illnesses out there. Thanks to organisations
like the Mental Health Foundation, Mind and Anxiety UK, there is detailed information
available and online.
I have firstly summarised the information provided by Mind listing some of the illnesses, with
short descriptions, in a table. While this is not an exhaustive list, it gives a snapshot which I
would like to develop and pass on to operators as a resource. (This is an abbreviated
version and the full table, which includes possible treatments and links where help can be
sought, is included in the appendices.)
I have drawn out the common themes, where relevant, across the variety of illnesses.
Finally, I have featured the drawings of one artist which depict very powerfully, the emotions
and suffering unique to some of the illnesses in the table.
But first a few simple statistics taken from the Summit:
• 1 in 4 people experience mental health issues in any given year: mental health is the largest single cause of disability.
• 1 in 5 people are anxious a lot or all of the time.
• 1 in 6 employees suffer from mental health issues.
• 1 in 10 people is living with a severe and enduring mental health condition.
This is no small-scale issue – mental health is commonplace and not to be ignored…
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Mental health illnesses in a snapshot
Name of illness or issue
Brief Description of illness
Agoraphobia Agoraphobia is widely thought to be a fear of open spaces, but it is more complex. Its essential feature is feeling anxious about being in places or situations that it would be difficult or embarrassing to get out of, or where you might not be able to get help if you have a panic attack. It is likely to generate high levels of anxiety and sufferers may avoid everyday situations such as:
being outside the home alone being in open spaces being in a crowd of people travelling by car, bus or plane being in enclosed spaces such as a lift or in a shop
Anxiety & panic attacks
Anxiety describes feelings of unease, worry and fear, incorporating both emotions and the physical sensations. It is usually related to the ‘fight or flight’ response – our normal biological reaction to feeling threatened.
Because anxiety is a normal human experience, it's sometimes hard to know when it's becoming a problem but if feelings of anxiety are very strong, or last for a long time, it can be overwhelming leading to:
Worrying all the time, perhaps about things that are a regular part of everyday life, or about things that aren’t likely to happen – or even worrying about worrying.
Panic attacks.
Bipolar Disorder The term 'bipolar' refers to the way your mood can change between two very different states – mania and depression. This can vary from feeling uncontrollably excited and feeling like you are untouchable or can’t be harmed, being more active than usual, talking a lot, fast and not making sense – to feeling tired or sluggish, not finding enjoyment in things, low self-esteem and worthlessness, leading to avoiding people or sleeping and eating too much or too little.
Depression Depression is a low mood that lasts for a long time, and affects your everyday life. In its mildest form, depression can mean just being in low spirits. It doesn’t stop you leading your normal life but makes everything harder to do and seem less worthwhile. At its most severe, depression can be life-threatening because it can make you feel suicidal or simply give up the will to live.
“It starts as sadness then I feel myself shutting down, becoming less capable of coping. Eventually, I just feel numb and empty.” (MIND website)
Generalised anxiety disorder (GAD)
If you have felt anxious for a long time and often feel fearful, but are not anxious about anything specific that is happening in your life, you might be diagnosed with generalised anxiety disorder (GAD). Symptoms of anxiety can include nausea, tense muscles and headaches, difficulty sleeping, feeling tense, nervous and on edge, having a sense of dread, or fearing the worst
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Obsessive-compulsive disorder (OCD)
Obsessive compulsive disorder (OCD) is an anxiety disorder. It has two main parts:
Obsessions are unwelcome thoughts, images, urges, worries or doubts that repeatedly appear in your mind. They can make you feel very anxious.
Compulsions are repetitive activities that you do to reduce the anxiety caused by the obsession. It could be something like repeatedly checking a door is locked, repeating a specific phrase in your head or checking how your body feels.
Panic disorder If you experience panic attacks that seem completely unpredictable and you can’t identify what triggers them, you might be given a diagnosis of panic disorder.
“Never knowing when I was going to get a panic attack was the worst feeling in the world.” (MIND website)
Phobias A phobia is a type of anxiety disorder: an intense fear of something, even when that thing is very unlikely to be dangerous to you. If you have a phobia, your anxiety may be triggered by very specific situations or objects. For example, you may know that it is safe to travel on a bus, but feel terrified to go out on or even look at a bus vehicle.
Post-traumatic stress disorder (PTSD)
Post-traumatic stress disorder (PTSD) is a type of anxiety disorder which you may develop after being involved in, or witnessing, traumatic events. The condition was first recognised in war veterans and but a wide range of traumatic experiences can cause PTSD from a serious car accident to surviving a natural disaster.
“When something traumatic happens in your life it rocks you to the core. The world is no longer a safe place. It becomes somewhere that bad things can and do happen.” (MIND website)
Social phobia / Social anxiety or social anxiety disorder
A lot of people can find social situations difficult. However, if you have social phobia, you will feel a sense of intense fear in social situations, and will often try to avoid them. You might worry about the social event before, during and after it has happened. Social phobia can make it very difficult to engage in everyday activities such as:
talking in groups or starting conversations speaking on the phone meeting new people talking to authority figures going to work
Stress Being under pressure is a normal part of life and be a useful drive, but if you often become overwhelmed by stress, these feelings could become problematic. Stress isn't a psychiatric diagnosis, but it's closely linked to your mental health in two important ways:
Stress can cause mental health problems, and make existing problems worse. For example, if you often struggle to manage feelings of stress, you might develop a mental health problem like anxiety or depression.
Mental health problems can cause stress. You might find coping with the day-to-day symptoms of your mental health problem, and potentially needing to manage medication, heath care or treatments, can become extra sources of stress.
This can start to feel like a vicious circle, and it might be hard to see where stress ends and your mental health problem begins. You might find that your first clues about being stressed are physical signs, like tiredness, headaches or an upset stomach.
“[When I'm stressed] I feel like I'm on the verge of a breakdown.” (MIND website)
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Some common themesWhile these illnesses have their own characters, there are some common or parallel issues, triggers and symptoms across them. These centre around the overarching and obvious impacts on:
Well-being Mood Sense of self Emotional security/stability
A ‘word cloud’ depicting key words in the text highlights: feeling(s), anxiety, disorder, people, problems, panic, phobia and symptoms.
I have identified the following groupings, which have different focuses and emotions and which will provide useful context to problems, barriers and symptoms encountered by passengers on public transport services:
Fear, anxiety & worry – many of the illnesses are driven by a fear that a particular trigger or triggers will result in a particular reaction or chain of events. Harm to the person is the envisaged outcome, whether that is phobia or OCD. The overriding feeling becomes one of threat and negativity.
Control vs avoiding issues – many of the illnesses centre around control or lack of it; OCD leads to rituals ultimately seeking to claim or restore a feeling of control and security by foisting off potential harm if such rituals are not carried out. Conversely, addiction to drugs or alcohol seeks to lose control and escape rather than deal with particular issues, memories, experiences and/or feelings.
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Self-esteem and self-confidence – well-being can be closely linked with sense of self and illnesses such as depression and anxiety affect self-esteem to different extents – sometimes in extreme, leading to self-doubt and doubts about worth, ability and performance and focus, instead, on failure and not being worthy.
Space: known & unknown – panic attack, anxiety and, in particular, agoraphobia are permeated by a fear of space – unknown and/or open space and panic attacks can be induced by or not helped by crowded places. Indeed, some of the symptoms seem to be triggered by a sense of closing in and sensory suffocation.
Energy & rest (breathing and heartbeat) – panic affects breathing and heart rate and many of the illnesses affect sleep detrimentally, cause restlessness (whether stress, depression or mania) and all illnesses and their worrying and restlessness are likely to be exhausting – both emotionally and physically.
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Mental illness in pictures
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The passenger perspective So how does this all relate to travelling on public transport? What are the impacts of people
with these illnesses travelling on bus or rail? For me the answer lies or at least starts at the
Summit of 2016. Here we heard and saw for ourselves from people who suffer from or who
have suffered from mental illness relating in detail the agonising experiences they have had
travelling on a crowded train or going through the stress of a flight – through speakers and
through videos. I defy anyone to watch those videos and stay dry-eyed or at least not feel
some level of empathy.
The Summit came about because the Mental Health Action Group (MHAG), who played a
key part in organising it, launched its national survey on the transport experiences of people
living with a mental health condition in 2011 and were astonished and moved by the volume
and quality of the responses which flooded in.
How does it feel? Let’s start with the words of former Labour spin doctor for Tony Blair – Alastair Campbell,
ambassador for Time to Change, a campaign to break the stigma around mental health,
who opened the day:
At the Summit, we heard of the huge numbers of people with mental health conditions who
find catching all sorts of transport – buses, trains, planes, boats - very difficult. Many have
given up completely on one or more transport modes and “yet their difficulties have, to date,
remained largely unnoticed and unaddressed”.
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“Imagine getting on the tube or bus in a state of real anxiety. You feel pressures people can’t see. Right now, 1000s of people are feeling anxious on planes, trains and buses right now!”
Alastair Campbell, Ambassador - Time to Change
These are vivid and intense feelings – abject panic, feeling utterly self-conscious,
uncertainty a fearful enemy, isolation an unwelcome friend. The ‘fight or flight’ phrase
captures the all or nothing nature of the experience. Laura from Anxiety UK, describes the
key question brilliantly.
Bus Case Study Shona who has Bi-Polar Disorder described very powerfully her first attempt to catch a bus
on her own after over 30 years.
Train Case StudiesOn train travel, Liese described an attempt she made to use passenger assistance. She
was told that there wasn’t a tick box for her problem and the staff did not give her
appropriate assistance. She was left in the middle of Birmingham New Street in a major
panic attack and had to return home, as she couldn’t complete her journey. Nowadays she
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Alex, Derbyshire Mind
Diagnosed with PTSD and Borderline Personality Disorder
When you say you are feeling anxious, people seem to react with ‘there, there dear’; have a cup of tea, you’ll be fine. But it is much more disabling than that: you can’t breathe, you can’t think; you feel everyone is against you – they’re coming in at you and you need to get out very quickly. It’s the flight or fight response.
“What is about these journeys which make them so difficult? What is our ramp for people like us? Let’s start building ramps for people like us.”
Laura WhitehurstAnxiety UK
“Just getting to the bus stop is absolutely exhausting - all the time your head is telling you to turn back. Having made it to the bus stop and stepped on the bus the first thing you see is the driver and if he/she is intimidating or frightening then that’s it, you’re off!
A friendly and helpful manner from the driver is therefore vital and can mean all the difference between a successful journey and a completely aborted journey.”
only travels on familiar journeys – the same time, the same station, if there is any change in
routine her confidence would be shattered and if she had to try a new journey she wouldn’t
feel able to cope without appropriate assistance.
A friend of mine revealed in an email to me that he experienced two incidents this year over
ticket inspections on trains “which completely threw me completely”. It was hard for me to
read - one led to him dashing off the train at the next station, not his stop, in a state of panic
attack and the other led to a “complete meltdown” at Euston which put him in bed for the
rest of the day.
Can you imagine how this feels? A whole day reeling after something which might at the
very least be the cause of annoyance to many of us. Or the feeling, of Liese, stranded and
panicking in the middle of a busy, crowded, noisy and confusing mainline station – not only
not being able to complete the journey but having to make the journey back home from that
station. These are experiences which would lead some to never repeat the experience
again and avoid travelling, even avoid leaving the house: too traumatic.
Laura Whitehurst from Anxiety UK told delegates that the impact of not being able to access
transport is profound on someone who is trying to recover from a mental health condition.
For Laura, the consequences of not having that lifeline were nearly tragic. She found herself
in £2,324.60 of debt, with no job, not able to travel, not able to get her doctor, she became
very isolated and depressed and made an attempt to take her life.
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“The most worrying thing is how something so routine as a ticket inspection can invoke such a massive response and transport professionals need to be aware of these things.”
“If you are deprived of a bus pass, a blue badge and the kind of travel assistance that other disabled people are normally able to access, it is extremely hard to overcome the obstacles to recovery.”
What is the ‘ramp’?So, what form does that ramp take - what will make life easier for people such as Alex,
Liese and Laura? To answer her own question, Laura said it could be something tangible
like a passenger card or a simple act of human kindness. Another speaker at the Summit
talked about being given a glass of water on a train during a particularly bad experience of
panic and anxiety. It was such a small thing but made a huge difference and was a source
of comfort and reassurance that someone cared.
I went back to my friend and asked him what exactly would have helped and actually, he
found it difficult to answer and said that he didn’t really know. To help gain deeper insight
and find out exactly who feels what and who needs what, I issued a survey on mental health
and travel for passengers, or would-be passengers and members of the public.
The survey was disseminated:
to my friends on my personal and my transport Facebook page
via Mental Health Action Group
via Anxiety UK to their members
via Bus Users UK to their members
Questions specific to the passenger survey sought to identify from respondents:
whether a mental health illness actively deters/prevents them from using a particular
form or forms of passenger transport
whether they have used operator assistance, ease of booking and quality of service
what would help make their journey easier, if they find travelling difficult due to
mental health issues.
The results of this survey follow.
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Survey findings… at a glance Experience & awareness
114 respondents: 80% have experienced some form of mental illness – this is no small problem.
o 17% have not experienced some form of mental health illness
o 4% said they didn’t know
87% have experienced friends or family experiencing mental illness
65% have received treatment such as medication or counselling
Travel experience
Bus (42%) and rail (40%) are the main modes of transport used
49% of respondents said they were put off from using or never use public
transport due to mental illness
o 10% said they ‘never use public transport because of ongoing
mental illness’
54% have experienced a symptom of mental illness such as panic attack
on public transport – 43% have not.
Only 8% have contacted an operator to organise assistance in travel
specifically because of any mental health issues or concerns – 91% have
not and of those:
o 36% said no - they didn’t know they could
o 15% said no - it’s too much hassle
Ways forward
What would help make your journey easier? Top 3 prompted measures:
o Positive interaction from staff/customer assistants e.g. cup of tea,
ease of upgrade to First Class (40%)
o A card scheme or other tool to communicate simply, assistance or
understanding needed (33%)
o Travel training (13%)
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How can assistance from operators be improved?
o Better communication/support in person on day of travel from
guard/driver/customer assistant (42%)
o More detailed information on and options for support on operator
website / printed material (42%)
o Better way of communicating mental health needs to operator
(34%)
What would better help operators to understand & improve how they
tackle mental health illness?
o Training on mental health and how it can affect pax (85%)
o More interaction with and feedback from those who with mental
health illness who find travelling difficult (84%)
o More interaction with and feedback from mental
health organisations 63%
Survey findings – in more depth Passenger/people’s experience of mental health is significant: two thirds are receiving
treatment for mental illness, under half are put off or prevented from using passenger
transport as a result of mental illness and over half have experienced a symptom such as
panic attack while travelling.
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How it feels - reasons for feeling deterred Digging deeper into why respondents said they were either put off from using or never use
public transport because of mental illness, included:
Feeling trapped
Crowding – people
Not having immediate access or any access to a toilet
Pressure – by time or conditions e.g. rushed into buying a ticket
Pressure by the idea of and wanting to avoid having to converse with someone e.g.
taxi driver or other passengers
Stress
Being/feeling alone
Not having staff on hand to ask for help
A word cloud developed from the responses on this question highlights the words:
anxiety/anxious, crowded, panic, need, avoid, trapped, conversation.
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Here are some of the excerpts of comments – the last particularly reflects the sense of
panic and fear very powerfully.
I don't use any sort of public transport because I suffer with extreme
anxiety/depression. Any sort of excessive noise/ vibration/ too many people/ no
personal space would cause me to have a panic attack. I’m not too bad on certain buses but terrified of lone train journeys. Completely lack
confidence that I will find the right info or be able to ask someone what to do.
CHANGES. I get really anxious about whether the bus will turn up.... So when it
doesn't I get anxious n that starts my anti-social [Panic Disorder] to kick off.... I'll then
start swearing n shouting..... So of the reason I get so upset, I get serious back
problems, the extra wait hurts (hurts a lot), this gets me stressed which gets my
anxiety up.... Not knowing how long I'll have to wait n how much extra pain before I
can get on a bus or if they just cancel [the] 2nd bus on a row.
Organising operator assistance in advance
3%4% 1%
36%
1%
15%
39%
1%
Have you ever contacted an operator to organise assistance in advance of travel specifically be-cause of any mental health issues or concerns?
Yes - I have done previouslyYes - sometimes Yes - every time I travelNo - I didn't know I couldNo - I don't find it helpfulNo - it's too much hassleNo / Not applicable
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What is needed - what would helpSolutions suggested by passengers, and there were many, centred around:
Help and assistance
Staff presence
o Understanding & sympathy
o Training – including ability to spot certain signs
o Friendliness
…factors which are not at odds with the general principle behind customer service
Information from operators
Noise mitigation
Safety & security
Access to Quiet carriage, First Class & proximity to toilets
Specific suggestions include: Timetabled days where certain buses or trains have dedicated helpers
Loop app to alert bus driver to vulnerable person at next bus stop
Discrete way of asking for assistance – registered card scheme
Positive mental health campaign from operator
Priority seats (equivalent to seats for wheelchair users)
Excerpts of suggestions on way forwards are as follows.
The answer is not easy, the entire journey is frightening from start to finish.
Understanding from the staff coupled with extra staff to help keep passengers safe
and eliminate problems with their presence. It's a really tough one. I'm sure most people like me don't want to draw attention to
themselves. Also, nothing can really be done about crowds on trams or buses - there
is no quiet place to go.
I am now trying to do better, and treat physical and mental health issues with same
mindset, and try to simply assess what accommodation I can make. But I still know
so little about what I can do, because mental health issues are still not well
publicised, that I find it difficult. Understanding staff, who know some of the signs to spot.
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The operator perspective Having chewed over the cud of the Summit, I spoke to a senior figure in the bus and coach
industry and to my dismay rather than the shared enthusiasm, his response was ‘how will
we know if people are genuine’?
Though I wanted to dismiss his words, I pondered them and the need to be mindful of the
concern and to find ways to tackle it and validate the needs of people with mental illnesses
– but so as to empower and arm them and discourage wholly against drivers or staff who
dismiss something they can’t ‘see’. The question I ask back is: can you afford to not do
anything about this in order to avoid the risk of people crying wolf but at the risk of alienating
a substantial amount of potential and current users? As the Summit report highlights:
1 in 4 of your customers will experience a mental health condition at some time in
their life
1 in 10 of your customers is living with a severe and enduring mental health condition
The question of what steps to take isn’t necessarily easy and is in some respects very easy.
Strong customer service – staff presence, clear, accessible information, friendly customer
service staff is something all passengers want anyway. On the other hand, guaranteeing a
significant number of people access to a quiet, uncrowded carriage near a toilet might not,
sadly, be a realistic option. And it is “reasonable adjustments” which people at the Summit
and responding to the passenger survey have called for.
Another facet to be mindful of was underlined by one operator survey respondent I spoke
to. Providing support to passengers and indeed staff on mental illness doesn’t mean that
anti-social behaviour should be accepted or tackled, he said. People do often need help but
operators, he said, aren’t necessarily the ones to give this help – they aren’t social services
but they do need to ensure that other passengers or other staff are not negatively affected
by these behaviours.
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The Summit explored the potential ramps and showcased initiatives which operators are
already undertaking – relatively low-cost ramps such as:
training for customer facing staff
assistance cards
pre-journey orientation sessions
mental health first aiders
The assistance cards were amongst the key recommendations – cards specifically for
people with hidden disabilities operated on all transport modes and clear training standards
for staff in mental health awareness which equips them to deliver appropriate and
empathetic support.
Advice was given to employers by Time to Change’s Employer Manager Rosie McKearney
in her talk Fixing your own Oxygen Mask before helping Others, summarised briefly below.
1. Promote mental wellbeing for all staff. This prevents some people with a diagnosed
condition being labelled as ‘other’ or ‘different’. Senior level buy-in from managers who are
prepared to talk openly about mental wellbeing is very important for employees.
2. Equip your line managers to feel confident in spotting signs and symptoms and having
supportive conversations with their staff.
3. Increase your employees’ mental health literacy. The more we know about mental health
the better we can support each other and our customers. Some companies have a page on
their intranet where staff can go for resources and information if they are struggling or want
to help a colleague who is struggling.
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“If your workforce can’t talk openly about mental health they will struggle to identify signs and symptoms in their customers and to have the courage to step in and offer help.”
Rosie McKearney - Time to Change, Employer Manager
Who’s doing whatThere are various training tools, initiatives and policies around mental health taking place
across different operators. This table summarises some but not all of who is doing what,
based on information from the Summit and from operators who got in touch with me as part
of the project.
Transport Provider
Initiative
TfL TfL has been trialling a new form of peer support training called
Mental Health First Aid: Built onto existing approaches and offering staff specific training to help them
recognise their own resources and build resilience in themselves and in their
colleagues.
Transpennine
Express
‘Blue Assist’ Scheme A card, specifically designed for non-visible disabilities, offers an alternative
symbol to the blue wheelchair sign. Card owners can write on the reverse of
the card the kind of assistance they would like.
Designed for use in all service sectors.
It is not essential to provide specific training to staff because requests are
generally clear and obvious.
If recognised across all transport modes, it would allow the user to simply
carry one card throughout the whole journey.
Virgin Atlantic Rig visits enable customers with severe anxiety and other mental health
conditions to make journeys that would otherwise seem impossible.
Customers are able to book an individual visit to discuss their needs and to
experience the upper class and economy cabins can make all the difference.
Virgin Atlantic are also liaising with Gatwick Airport to enable customers to
book an accompanied airport experience as well.
Bespoke crew briefings ensure that assistance is tailored to individual
customer needs.
Nottingham
City
Transport
(NCT)
Jacqueline Poole is a full-time trainer at NCT and has been delivering the ‘1 in 4 People’ training module for bus drivers - which was developed by Confederation
of Passenger Transport (CPT) UK.
Drawing on feedback from participants and from her own observations NCT
have adapted CPT UK’s material to suit their own needs. The training features
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CPT UK first-hand experience from members of the Mental Health Action Group (MHAG)
and shows how relatively small adjustments in attitude and approach can make
all the difference.
Forum of
Mobility
Centres
Supporting Anxious Car Drivers provides support to people who are anxious
first drivers or who have become anxious.
Travel for
West
Midlands
(TfWM)
TfWM have a range of initiatives which focus purely on customers:
Production of a number of accessibility products that can help people when
travelling including people with mental health issues
Mental health awareness training for customer facing staff
Equality champions within customer facing staff
Funded mental health awareness training for National Express (NX) which
has now been mainstreamed within their training programme
Working with NX to produce a disability awareness video for their drivers (to
also be disseminated more widely within the bus alliance) to include a mental
health awareness component
Operator survey The operator survey sought to dig deeper into the level of awareness and training which
takes place on mental health, who is doing what and what operators feel could be done to
increase awareness and support for passengers and for staff. Questions specific to the
passenger survey sought to identify from respondents included:
Whether they have been able to support and whether they have received support
from staff/colleagues
Whether they have had training to deal with staff and/or passengers with mental
health issues
What access to information/literature about mental health issues at work they’ve had
How informed they feel on the issues
The operator surveys were disseminated via CPT UK Committees, ALBUM (Association of
Local Bus Company Managers), to colleagues at the TAS Partnership and to and via
transport contacts and friends in the industry.
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Surveying findings …at a glance Experience, awareness & support
67 respondents – 15% of whom MD, director or chief executive
o 64% bus, 8% coach & 5% rail operators
47% have experienced some form of mental illness
o 42% have not experienced some form of mental health illness
o 11% said they didn’t know
81% have experienced friends or family experiencing mental illness
(compared to 87% of passenger survey respondents)
28% have received or awaiting treatment such as medication or
counselling
o 67% have not
o 5% would rather not say
93% have been aware of staff or colleagues experiencing mental
health issues
75% said yes, they have been able to support staff/colleagues Have you ever received support yourself from a colleague or manager?
o 28% said yes
o 66% said no
o 6% would rather not say
69% have been aware of passengers experiencing mental health
conditions
59% said yes, they are aware of specific support available from your
organisation to passengers and/or staff with mental health conditions.
Training & information
Only 28% have had training to deal with staff and/or passengers with
mental health issues – 73% have not had any such training
o 13% said yes – for staff and passengers
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o 10% said yes – for staff
o 5% said yes – for passengers
53% have had access to any information/literature about mental health
issues at work – 47% have not
39% said they do not feel informed enough to support other staff and/or
pax with mental health issues – 37% said yes, they do:Rating of company on mental health
How would you rate the company you work for on understanding and
awareness of mental health issues?
o 50% - good
o 36% - room for improvement
o 9% - very poor
o 5% - excellent
How would you rate the company you work for on dealing with and
offering support on mental health issues?
o 43% - good
o 43% - room for improvement
o 10% - excellent
o 3% - very poor
Improving awareness, understanding & support
How could the industry improve its awareness and understanding of
mental health issues? (more than one prompted option)
o 58% - hearing directly from people who suffer from mental health
conditions about the difficulties / support needed
o 54% - training/role playing on mental health & how it can affect staff
o 51% - training/role playing on mental health and how it can affect
passengers
How could operators improve the support given to passengers with
mental health issues?
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o 58% - better communication and support in person on day of travel
from guard/driver/customer assistant
o 56% - better way of communicating mental health needs to
operator
o 46% - more detailed information on and options for support on
operator website/printed materialNext steps
80% would like to learn more about mental health you so you can better
understand and support colleagues and passengers - 20% would not
98% would like their company to be more proactive on mental health issues:
o 61% - yes but there are challenges
o 37% - yes definitely
o 2% - no we have more urgent priorities
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Survey findings – in more depth Examples of support to passengers Respondents were asked to provide examples of times when they have been able to
support a passenger.
Talk to them. It's seems sometimes that's all people want is someone to listen to them
and make them realise they are not alone in the World.
When I was a bus Driver some years ago; by giving them information in a way they have
understood, time to reach a seat and understanding their needs
Supporting those experiencing difficulties to achieve their travel, ticket, plan their travel
and explain the way in which a service or member of staff may have behaved towards
them in a way that can be understood and processed
Successfully managed to steer a girl who self-harmed into counselling in school
Some passengers have clearly been identified as needing help which has been offered
via either the police or social services
A young man on the autistic spectrum who was distressed when an unplanned security
incident disrupted his travel plans. He was travelling with his family but I offered
additional supportive and calm reassurance that everything would be OK. I continued to
accompany him and his family to to help him feel safe and secure. I met the young
man's Mum by chance some weeks after and she offered her grateful thanks…
Most of the cases with which I am involved involve behaviour which is anti-social or even
criminal. In some cases, setting clear rules can bring order to that person's life and this
can have a very positive effect if they are trapped in a negative cycle. Sometimes,
enforcement sanctions can force them to obtain treatment and this can also have a
positive effect.
Support from companies to staff & passengers Operators were asked what specific support is offered by their workplace. In a similar
question, 42 respondents alluded to policies/measures that are place in the company they
work for. Answers from both questions and mentioned by multiple respondents included:
Employee Assistance Programme
Staff welfare and occupational health
Mental health awareness training to front line staff
Counselling offered (mentioned by multiple respondents)
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Reasons for rating company for support Operators were asked to rate their workplace: ‘Very good’, ‘good’, ‘room for improvement’ or
poor’ for a) understanding and awareness and b) dealing with mental health issues and
providing support. Excerpts of their reasons on support are as follows:
This is an area of training where we really should be paying more attention.
Mental health issues are not swept under the carpet, but recognised as an illness which
needs support, in the same way as physical illness does.
Almost all staff have training regarding this however a few are not so good at putting that
training into practice.
It's not something that is talked about as openly as it should be.
I am unaware of procedures.
As a company we don't concentrate on these issues at all as there are "always bigger fish to
fry".
On the occasions where colleagues have had problems, they have generally been very
understanding.
Improving support for passengers 45% of respondents rated their workplace as ‘room for improvement’ or ‘very poor’ on
understanding and awareness, while 46% gave the same ratings on providing support.
Excerpts of comments on improving support given to passengers are as follows:
Treat [passengers] as a human being. Most people with mental health conditions feel
second class and unworthy. Treat them as normal people- don't go overboard making them
feel sorry for themselves either.
Incorporation of interaction with people with mental health issues in "swap with me" events
for drivers.
Sadly you cannot teach basic life skills in role play or from a text book.
Better informed/trained staff that interact with customers, not just procedural training but
emotional education.
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Conclusions & next steps What a journey that was: powerful and, I think, fascinating – and in places very moving and
humbling. I can’t wait to share the results of this paper – with operators, passenger groups,
mental health organisations and trade press. That’s my first main conclusion (and thank you
for ‘listening’ this far).
I feel there is much in these figures that is positive – not least the two operator survey
statistics below showing that there is considerable appetite for change and learning.
98% of the industry survey would like their company to be more proactive on mental health issues and 80% would like to learn more about mental health to better understand and support colleagues and passengers
A comparison of the parallel passenger and operator survey findings show that awareness
on both sides is high and that communication is vital. The experience of mental health in the
passenger survey group is high but 47% of the operator survey group with direct experience
of mental health illness is very significant indeed. This is not a small-scale issue.
Passenger survey results(114 respondents)
Operator survey results (67 respondents)
MH = mental health issues; pax = passengers
personal experience MH - 80% 47% - personal experience MH
received treatment for MH – 65% 28% - received treatment for MH
awareness of MH in friends/family – 87% 81% - awareness of MH in friends/family
put off from using public transport – 49% 69% - aware of pax experiencing MH
How can assistance from operators be
improved?
better communication/support in person on the day of travel – 42%
How could operators improve the support given to
pax with MH?
better communication/support in person on day 58% - of travel
Overall, I set out to identify who feels what, who needs what, who does what and what more
could be done and here is, in summary, what I found out.
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Who feels what: Common feelings across some of the mental health illnesses listed in this paper traverse:
Fear, anxiety & worry – threat of harm
Control vs avoiding issues – uncertainty, insecurity
Self-esteem and self-confidence – insecurity, self-doubt
Space: known & unknown – fear, anxiety
Energy & rest, breathing and heartbeat – restlessness, too much/too little sleep
As well as the effects and impacts the illnesses and symptoms have on passengers,
imagine too staff coming into work with these experiences and feelings attached like
unwanted baggage.
The Summit and survey findings show the following issues for passengers:
Feel anxious, alone - isolated, panicked, overwhelmed, stressed, terrified
Find things difficult, exhausting, confusing, unfamiliar
Fight or flight
Go into meltdown
Fear of crowding – people and/or having to interact with them
Panic at not having immediate access or any access to a toilet
Pressure – by time or conditions e.g. rushed into buying a ticket
A feeling of not having staff on hand to ask for help
Who needs whatRamps and reasonable adjustments! Solutions suggested by passengers centred around:
Help and assistance
Staff presence
o Understanding & sympathy
o Training – including ability to spot certain signs
o Friendliness
Information from operators
Escape/access – e.g. quiet carriage, First Class carriage & toilets
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The above is not far away from what staff are likely to need or are likely to be helped by –
support, someone to listen, pay attention to them, spot signs. At the Summit, transport
companies were urged to invest strongly in the mental wellbeing of their own employees.
“Staff who are encouraged to look after their own mental health and are trained to recognise
early signs of distress will feel equipped to meet the needs of their customers.” (Rosie
McKearney, Time to Change)
Who is doing whatIt is great to see that some operators have introduced and are offering a plethora of different steps, training and tools, including:
All sorts of training – such as ‘1 in 4 People’ CPC training module for bus drivers and
mental health awareness training for customer-facing staff
Card schemes designed for non-visible disabilities
Employee Assistance Programmes
Staff welfare and occupational health
In-house counselling
Mental health leads/ambassadors; and not forgetting…
The example glass of water and ‘there, there’ from one rail operation
What more needs to be & could be done: What are the messages from this research and surveys? Asked what would improve their
journey, passengers gave answers centring on communication, information and training.
In short, passengers want as much certainty as possible, reassurance, at times comfort,
peace where possible and, overall, knowing help is at hand.
As stated several times in this paper, factors requested are not at all odds with good
customer service and what all passengers would want – staff presence, clear, accessible
information, friendly customer service staff. It seems to me to be a matter of applying and
rethinking these steps and approaches in the context of mental health issues and being
aware and sensitive to them. This rethink on existing practices may not require onerous
steps – but it does need a concerted push. Indeed, reasonable adjustments were spoken
of at the Summit and this phrase sums up the next steps well – they need to be realistic, not
impact negatively on other users and should take into account the needs and symptoms of
passengers with mental illness.
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Suggestions made by people in the passenger survey included:
Timetabled days where certain buses or trains have dedicated helpers
Discrete way of asking for assistance – registered card scheme
Priority seats (equivalent to seats for wheelchair users)
My sense from reading the responses and my own knowledge on mental health is that we
as an industry should not rule out any ideas at this stage. An App such as Headspace (a
meditation app which seeks to alleviate anxiety and stress) could be adapted with targeted
meditations to help passengers who find public transport panic-inducing.
Another friend of mine who also finds rail travel potentially traumatic had a remarkable
journey recently. She was just struck by the sheer power of a particular colour scheme on
the inside of the train she was on – and the calming and game-changing impact on her
experience. “The colours were lovely. Not like the utilitarian and rather unfriendly colours
usually chosen. The strict navy and harsh red and grey colours which are great for covering
mindless acts of vandalism are, it seems, part of my panic/stressing. They seem to
reinforce the unyielding and unfriendly feeling that I get.”
However, a headline find that screams out from both the operator and passenger surveys is
that a top priority for improving and changing support is for operators to hear directly from
the passengers whose journeys feel like nightmares due to the impacts of mental illnesses
– before any adjustments reasonable or more wholescale can be made.
Closing thoughtsHowever small and reasonable the support or in some cases mechanisms needed for
passengers, they are not to be underestimated. For Laura, the consequences of not having
access to transport nearly cost her life…
At the same time, the impact of behaviours and of support needed for passengers on
frontline staff and other passengers needs to be considered and explored. Indeed, I was
very struck by and will end with the following excerpt of one operator respondent who
captures so exquisitely and so powerfully the various perspectives that need to,
simultaneously, be taken on board.
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Persons with mental health issues often do not like issues which deviate from the habitual
norm, the nature of public transport is that it can be a chaotic environment often subject to
factors beyond its control. If the two worlds collide then you may have a vulnerable person
scared to approach a member of staff who themselves is agitated by a stressful situation.
Both need to be protected here and this should be recognised.
Ticking boxes just will not do"
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