The Practical Democracy Podcast. A podcast about practical change, with guests from public bodies and civil society.

Episode 17: Does our mental health effect democratic participation? With Antonis Kousoulis

Featuring: Dr Antonis Kousoulis

We talk to Dr Antonis Kousoulis, the Director of Mental Health Foundation, to chat about the relationship between mental health and public participation.

Dr Kousoulis explores the democratic landscape post-COVID and discusses how we can remove the barriers that hinder people from participating.

Episode 17 transcript

Antonis Kousoulis: The whole issue of participation, we need to invest more time in it. We need to be more creative. We need to trust people.

Sabine Groven: Hello, and welcome to the Practical Democracy podcast by Delib. My name is Sabine Groven, and I’ll be speaking with some great movers and shakers working to make practical change today. On this episode we’ll be talking about mental health and its effects on political participation. What are the links between social inequality and experiences of mental illness? How does this relate to political participation? And what can be done to improve involvement? To answer my questions I spoke with Dr. Antonis Kousoulis. He is the Mental Health Foundation’s director of England and Wales. Antonis has got an academic background in public health and works on mental health research programmes and policy functions. Firstly, I wanted to hear what he thought about the links between social inequality and the experiences of mental illness.

AK: What we have seen over the past maybe 10 or 15 years is the development of a much clearer understanding of the links between social inequality and our experience of mental health, and for many people the experience of mental illness. Obviously for many centuries, I would say, mental health has been misunderstood, it has been mistreated in many ways, and we haven’t really, we have thought about mental health problems as a result of bad genes or something wrong in the biology for some people, which is obviously we now know is not true. The experience of mental health and mental illness is very much linked to our social experience and our experience, the deeply kind of human experiences that we have as we go through life. So the structure of our societies, the culture of our societies, how people are systematically treated, such as discrimination or disability or access to certain services, access to benefits, the income that we have, the relationships that we have. These are all really fundamental for our mental health, and we cannot really see mental health independently from the whole of the human experience. This means that for many people who experience a lot more systematically social inequalities, they would be at much higher risks of also experiencing mental health problems, in some cases quite persistent and quite severe.

SG: Something I wanted to hear about is the level of trust people experience in mental illness can have in their government.

AK: Yes, I think this is what we have seen in our experience. We do see people who experience inequality really consider the role of the society around them in their experience, will consider the role of politicians in their experience, the decisions that politicians and governments make across different years or different administrations, and this is something that is certainly affecting how people are seeing the world around them. And we can talk about the different ways in which this is affecting people, but I would certainly expect that a person who has been, for example, racially abused in a public service to lose, which would have a severe impact on their mental health, to really lose trust in that service as well. So I think there is a very reasonable connection, and I think this is also quite visible in some of the evidence and research that we have seen.

SG: I also wanted to hear what other effects of social inequality Antonis had seen when it comes to democratic participation.

AK: Well we know that mental health problems, especially the ones that are more chronic or persistent or severe do have an impact on our emotions and how we see the world and how we participate in the world. A common symptom of a lot of mental health problems is that depression as a symptom, low mood or severely low mood as a symptom, and also this is often linked with maybe reduced hope about the future, a reduced ability to see, to look at the future with optimism and making plans and setting targets and things like that. So this is one of the factors, not the only factor, but one of the factors that leads to sometimes people with mental health problems being less interested in participating, for example, in elections and voting or kind of in their local economy, political participation. As I said, this is one reason. .

There’s a second reason I think which is really linked to a stigma of mental health problems and even though we’ve come a long way to addressing that, it’s certainly not entirely addressed yet, especially when we’re thinking about severe mental illness. I think there’s a combination of factors within our society, like stigma and structure and how easy it is for some people to participate compared to others, and also actually what is happening within our psyches, if you like, within our emotions and how keen and willing we are to participate or look at things from a long-term point of view. The whole point of, for example, voting in an election is because you hope that something will change, that what you’ve seen people, politicians campaigning for, they will apply, that this will happen in the next few years. If you don't have quite substantial hopes for yourself and your family and your relationships where you will be in the next few years, this will be an issue. This would affect your motivation and your willingness to vote in this example.

SG: So what did Antonis and his team see when the pandemic hit? How did this affect mental health issues and participation?

AK: We have been researching at the Mental Health Foundation the mental health impacts of the Covid-19 pandemic, for example, for the last couple of years, and one of the things we’ve seen in tracking the biggest stressors that people have is that for substantial part of the population, a big stress, and it’s depending on the time frame and the different points in the pandemic and lockdown measures, for maybe 20 percent in some cases there was a stress of actually having enough to put food on the table for your family or to cover your basic needs, and huge job uncertainty for many people. So I think if you experience real stress for these fundamentals of life, because these are really the fundamentals for our survival, everything else would be affected. Everything else becomes secondary.

SG: How far does this reach then? How many people are affected?

AK: If you look at common mental health problems, which affect large numbers of the population, like depression, anxiety, OCT or PTSD, this is one in six of us every week. This is the official statistics, one in six of us every week is experiencing diagnosable levels of a common mental health problem, and this varies a lot between communities, between different people, between different areas, as we’ve identified. So severe mental illness is slightly different, is more, it’s not as common as a common mental health problems. Probably looking at numbers maybe one in 20 or depending on, obviously because of different categories, depending on that. So it does vary. We have seen in the past 10 years an increase in poverty and people living on the poverty line, so this would affect those numbers and then participation I would imagine as well.

SG: I ask Antonis how the situation is progressing. Is it getting better or worse?

AK: So we’re now pretty certain, it has been questioned I think in the past, but we’re now pretty certain that the past 10 years roughly we have seen an increase in mental health problems in England and I think across the UK as well. It’s probably the case in other places around the world. Poverty plays a role, has played a role in this. We know that the long term impacts of the economic crisis and the late notice, and we have Covid, we have issues around migration, we have obviously what comes now we’re at the moment in the middle of a cost of living crisis. So we know that all of these is affecting our mental health experience, and it is affecting the number of children that live in poverty or on the poverty line, or their families are not able to afford what may seem as luxuries.

The trends are increasing I’m afraid. So it’s a little bit sad to think about it because generally speaking we should be getting healthier as a population. We should be living longer. We should be living more comfortably, especially in countries that have the resources, and this is not a trend. Obviously not withstanding forces such as the pandemic, but this is not what we are seeing in the UK and in fact the US and other places around the world as well.

SG: How does mental health affect the way people vote? Are people voting for the status quo because they don’t hold hopes for change? Or are people more likely to get out and vote if they want a change?

AK: I think it depends and it varies heavily by area, by where you live in relation to the historical kind of forces in power in that region. I think in some cases what we have seen is, we’ve probably seen both extremes if you like. So we’ve seen people voting for the status quo even though this is directly going against their rights in some cases, but also seeing people really looking at things from the point of view of activism and kind of trying to address that with either through voting or through other means. So there’s not a definitive trend. What is positive is that there are issues such as voting by post or voting by proxy have enabled some people to vote that potentially in the past were not finding it that easy.

SG: Are there any ways to include people more? How can you further remove the barriers to participation?

AK: Yes, I think this is a really important point. It kind of takes us right at the heart of the issue of inclusion, and it’s something that we have looked at, other organisations have as well, but it’s also been looked at very, and probably even more so in issues, for example, such as gender equality, race equality, things like that. So there is a lot of learning around inclusion these days. So some of the things that work, I think the most fundamental thing that works is finding a way to involve people in a decision that will affect their future, and this needs to happen in the pre-election periods, needs to happen between elections, it needs to happen at every turn and every step of the way. Sometimes we, politicians, but also researchers and others as well, have found it more difficult to engage with people in communities who in the past they have not really engaged at all. There’s a lot of distrust, and in many cases quite rightly so. And also there is a sense of forgetting about the people who are potentially maybe more disadvantaged.

So to achieve an inclusive society you really have to think about the people who are the furthest away from enjoying the benefits of the prosperity that society has in other places. To do that people might never be, might never feel the same trust to current government or to, even industry or kind of companies or researchers that are not local, but don’t understand the nuance, the difficulties of people’s lives, so we really have to work with local, maybe leaders, people who have influence at a local level, people from the communities we want to engage. We need to build those partnerships, and I think politicians it’s truly fundamental that they do that to enable good decisions for their citizens.

Work with the communities they want to reach and work with people from those communities, and they don't have to do it directly. They can work with people who can then be empowered to take messages and get feedback from different communities. And however a community is defined, I’m not making any assumptions here, there are communities defined by region, geography, by race, by religion, by income, by experience of illness, there’s a range of different communities, and we belong to many of those at any time. So yes, I think the whole issue of participation, we need to invest more time in it. We need to be more creative, we need to trust people that could play the role of the intermediary, and it starts from a position of caring, it starts from a position of, do you actually care about the citizens who are quite often the margins of society. So yes, it fundamentally starts from that.

SG: So to be able to involve more people having a creative approach is helpful. There are digital and non-digital means, and sometimes perhaps you have to do them all, making an effort to have more people getting their voices heard. I’ve seen this change and improve at a local level, but what about on a national one? What does Antonis want to see change when it comes to elections and referendums to make sure people are as included as possible?

AK: When we think about mental health, you have to think about the challenges that the person is facing. Obviously these days, mental illness is classified as a disability, so even under our own laws there is clear allowance to make reasonable adjustments to include people. So there’s a certain level of cognitive impairment or emotional difficulty, we can take that into account. As you say using digital means and non-digital means, doing things in person, or remotely, thinking about using images and not just text. There are things that have become quite standard. For example, a leaflet in different font sizes and things like that. So there are similar adjustments that we can make for disabilities related to mental health or learning. So there are ways to build routes to engage people and to hear those voices that are offering different perspectives.

I’ll give you an example. In Wales, for a fair amount of years, probably close to 10 years now, there has been a national forum of people living with mental illness that is, it’s a government advisory forum, so when there are decisions related to mental health or around elections, or at the moment there’s a new mental health strategy being developed, there are sessions with that forum. So this one, you know straight forward, very straight forward way of engaging people, you just need to offer some good secretariat support and show that people, as we said, can be engaged with different means. That said I think we have to go more broadly because mental health experience is shaped by the settings that we live in and the experiences that we have. I think we also need to think about those different factors of inequality.

Not everyone with experience of poor mental health would be defined by a specific diagnosis. So it’s not just about engaging people with a diagnosis. It's also but engaging people from marginalised community or a racialised community or young people for that matter, which is often kind of forgotten when talking about political participation where you've not reached the voting age. And older people as well. A lot of things in the past couple of years have been digitised, and this has impacted more than anyone else communities of older people in terms of the levels of digital literacy. So I think at the level of strategic national decisions there can be national forums, national groups, or there can be good communication between local government and the knowledge and the nuance that is understood at that level with central government as well.

SG: Antonis mentioned children and young people, and I wanted to pick up on this. The last few years in particular we’ve seen many protests and heard frustrated voices from young people not feeling involved, not having their voices heard. I wanted to hear more about how this has affected young people’s mental health.

AK: Yes, I think it’s actually interesting generation, if I’m allowed to kind of generalise and talk about a whole generation. But I think what we’ve seen, we’ve seen a lot of dismissal I think of young people in the past few years. So it’s not, I don’t think it’s a random accident, the fact that activism has become a lot stronger amongst the younger generations. I think their views have been dismissed, I think their needs have been dismissed in many cases and not really been taken into account. There hasn’t been a lot of participation. And quite often being dismissed is- We’ve had really toxic debates around snowflake generation and social media generation and things like that. It’s failing to understand the unprecedented challenges that young people are facing at the moment and no previous generations have been raised in the same kind of context of the digital world and the issues around the climate anxiety and things like that. So I think it’s no accident, and I’m really pleased to see this greater activism and political participation from young people. I think it has an influence. I think it does make a difference, and it makes a difference I think in two ways.

First, it really pushes people to respond, politicians to respond. It pushes people who are not politicians but are kind of adults and other ages to really think about what our young people are saying and to really listen. And the second way is this about our point, a lot of our mental health experiences are linked to experiences of trauma, and for many people, young people, the experience of growing up in a context where there’s increased bullying, there’s increased mental health problems, there’s increased eco-anxiety and things like that, would be quite I think a traumatic experience, and actually there is evidence and good research that shows that political participation and activism is protective against trauma. It is protective against the experience, traumatic experience. So one of the things that you can do, we can all do as individuals if we feel neglected, disadvantaged, if we have experiences of trauma related to social inequalities is actually to try and look at things, think about the bigger picture.

Think about the groups that we belong to, how we can contribute to those, how we can play a role in influencing our community, in shaping our society, in influencing the direction of politics, peaceful protesting. There’s a number of different things that can be done, and they have benefits both socially and for our own mental health. They’re very clear mechanisms that through which this happens. First of all there’s the issue of connection, these things are not, actually you're doing things in conjunction with others. There is also the issue of belonging, which is really fundamental for our mental health, the groups that we belong to, finding people to interact with to feel that we belong. As I said, connecting to something bigger, thinking about where we belong as people, who we are as people, what are the values that we have, this is also quite fundamental. Remarkable benefits to our mental health with participation, and a lot of these things we often feel that are outside of our control, so participating locally, nationally, online, whatever it may be, gives us a sense of control and makes us feel more involved, and powerlessness and lack of control are huge stressors for us, are huge triggers for us as humans, so claiming some of this control back, some of this power back is actually quite beneficial for our own wellbeing.

SG: I think once you’ve made that change, you’ve seen it, you have a place and you can make a difference, it gets easier. But there is a challenge in getting to that stage. So I asked Antonis if a policy maker was struggling to engage with a community or an area because they were experiencing mental health challenges, what would he say to that policy maker? How can they be better at involving more people?

AK: Yes, I think first of all probably three or four pieces of advice. First of all, are you the right person, do you have to do directly or should you work with others from that community first and then kind of go deeper in to the experience of that community. That’s the first question. The second piece of advice is do you have experiences that you can relate? Are there shared experiences because of local proximity, because of anything else? I think it’s important to be able to be open about our experiences. We actually have seen politicians in the past few years being a lot more open about their mental health experiences, for example, or in some cases growing up in more difficult circumstances. So can you use your own experiences, can you be transparent and open and honest about your own experience in engaging? The third is that to engage you have to really create a listening space.

So it really has to be about listening and learning and actively showing that this is important, and to do that you have to think about what is the context in which you are engaging. Are you creating the circumstances to make its easier for people to participate, to express their opinion, to share their experience? You may have to co-produce it. Is it a workshop? Is it a local kind of seminar? Is it something more creative? People can participate through other means, not through conversation. So the how is important as well. These would be I think my starter for 10, and I think that we cannot expect that this saying of, “If you build it, they will come,” I don’t think we can expect it. I think there is a history of not engaging with people in communities, and we’re kind of parachuting measures within certain communities and then leaving.

That may be a fifth piece of advice would be what happens next. If people have given you the time, their insights, have shared their experience, their honesty, what are you doing next? At the very least you should go back and feed back about how they have been heard, or not. I think this honest and ongoing dialogue is really important.

SG: So if those who are consulting do involvement really well, if they get people engaged who aren’t used to having their voices heard, their attitudes towards participation might change and be more positive.

AK: Yes, absolutely, and to link that to mental health, what do we want from it? We want people to be happier. We want people to be able to contribute to their communities and society, to being at work, to be in good relationships. That should be what we are hoping for within our society, and this is fundamentally linked to our mental health. So the inclusion of people with mental health problems, taking into account of these experiences, the strategies to improve mental health at scale, these are really important challenges that we are facing at the moment, and we should really step up our game and address those and make some progress.

SG: But the level of involvement is not the only thing that needs changing. So I wanted to know what is the Mental Health Foundation owning on for the next few years? What are their goals?

AK: For us the influence in shaping our society in ways so that more people can enjoy better mental health is really fundamental. So we are putting a lot of pressure to the government to think about those cross departmental issues, to think about mental health not just in the context of health services but also in the context of education, employment, criminal justice, housing, all of those kind of issues that offer a holistic view of shaping our health. We are also interested in preventing distress and preventing people reaching those crisis points. So we will continue the best things on the ground. We’re working with some of the most marginalised communities, in partnership with those communities, to see what works and to help create more opportunities for community support and for services to be available outside of the narrow health and care system as well. And there’s still a point to make about continuing to keeping the mental health conversation strong at a national level, at a local level as well.

The foundation is over 70 years old. We started mental health awareness week 22 years ago, and we’ve seen huge shifts in this period. But it is, it’s still really important to continue those conversations. We don’t want the public and politicians and decision makers to lose interest in mental health. We’ve seen a big interest in the past few years. We don’t want that to wane. So we will continue to fighting this fight and ensuring that mental health can stay high on everyone’s agenda, really, because to address the scale of the severity of the issue we need it to be everyone’s business.

SG: That’s it for now. Thank you so much to Dr Antonis Kousoulis director of Mental Health Foundation for joining the podcast, sharing some very interesting ideas and knowledge. If you want to follow the work Mental Health Foundation does, you can find them on Twitter at @mentalhealth Or visit Thank you very much for listening. Should you wish to contact us you can tweet at @DelibThinks or email This episode is hosted, edited and produced for Delib by me, Sabine Groven, our creative director is Tiffany Maddox. I’ll be back in a month with another episode. Until then you can visit for great content and people making practical change, improving democracy. Bye.