Mental health is a huge issue, and one-in-four of us will experience a mental health problem at some time in our lives, while one-in-10 is living with a severe and enduring condition.
Such conditions can be debilitating, especially when mixed with crowded, stressful and unfamiliar situations on public transport: unexpected last-minute platform or schedule changes can prevent people leaving their homes at all, with women more likely to fear going out than men.
While the global pandemic has exacerbated some existing conditions, it has also created new ones, from bereavements and job loss, to heightened health anxieties.
Mental health conditions, along with those such as Alzheimer’s, are known as ‘hidden disabilities’ – because often they are hard, on the face of it, to detect.
An online survey of transport and mental health, by Roger Mackett, emeritus professor of Transport Studies at UCL, recruited 385 people with different mental health conditions. A vast majority (90%) of respondents had
anxiety issues, 68% depression, 71% panic attacks, 51% difficulty communicating and 45% had memory loss.
This research was intended “to draw attention to the many issues that face people with mental health conditions when they travel or why they do not travel, and to stimulate public debate about ways of addressing the issues”.
“I was aware that people with non-visible disabilities tend to be overlooked when we’re talking about disabled people. The inferences tend to be on people with visual impairments, or visible disabilities. For people with non-visible disabilities, it’s not an engineering solution, it’s about people.”
Roger Mackett, emeritus professor of Transport Studies at UCL
Policies and practices
According to the mental health charity, Mind, the bare minimum level of compliance for transport operators under the Equality Act includes considering the needs of people with mental health conditions when developing
policies and practices – either directly or indirectly.
Further to this, the Public Sector Equality Duty is a proactive responsibility to consider the needs of someone with an impairment. This means understanding what people with mental health need and how policies will affect them.
Mackett’s research found the main cause of anxiety, when travelling, is the attitude of others – “what other people think of me”. A fear of becoming lost was another major worry, while 40% were anxious about finding suitable toilets when travelling, particularly older people.
More than a third of respondents were frequently unable to leave home because of their mental health. This happened to nearly all respondents some of the time.
More than half can’t buy rail tickets in advance because they don’t know how they will feel on the day – so they don’t benefit from cheaper advanced tickets.
Separate research on the transport experiences of people living with a mental health condition revealed a “unanimous plea for the transport industry to be educated about their needs and difficulties so they could receive appropriate support as, and when, needed”.
Many people with mental health conditions could not access transport and their needs were not being recognised. Change could “open up possibilities for thousands of people across the UK to visit friends and family, to
participate fully in their community, to seek volunteering and work opportunities and to make the best possible recovery”.
Conditions impact people differently according to their age.
For example, anxieties about finding toilets, having to talk to bus drivers, using ticket machines and accessing help, becoming disoriented, or remembering where they are going, are more common concerns in older age groups.
For younger passengers, fears of feeling out of control, how other people behave, getting lost and having to take decisions on where to go are more common.
Public transport avoidance risks worsening isolation and exclusion. And the longer this goes on, the more entrenched and severe mental health issues can become. A kind member of staff can make or break a journey as someone returns to public transport.
Mackett’s report recommendations, based on survey responses, include greater involvement of those with mental health conditions in the design of services.
He recommended staff training on interacting with people with mental health conditions to improve understanding and empathy with customers living with a condition, along with public and employer-
targeted campaigns on the needs and behaviours of people with mental health difficulties.
'Safe spaces' at stations
The report notes training can allow customers to familiarise themselves with available services and advertising of those services. In terms of physical spaces, “safe places” at stations, with staff on-hand; availability of on-board staff via phone; panic buttons for mental health issues; more public toilets and quiet coaches would also be beneficial.
Wider use and promotion of travel assistance cards (where customers can show a driver, non-verbally, they have extra needs), and “please offer me a seat” badges were other suggestions.
Also mooted was clearer information and multiple options for ticket purchasing, from simplifying ticket machines, to pay-as-you-go ticketing, would make ticket buying available to more people; discounted on-the-day tickets for those unable to buy in advance; broadening the Disabled Person’s Railcard availability; improving transport provision in rural areas; and action on overcrowding were also said to be important.
Transport reflects society as a whole, and mental health has not, historically, been well understood or discussed. In 2016, the then Mental Health Action Group (MHAG) and Anxiety UK, held a summit to try to change this. In the short years since, improvements have happened across the industry.
At the time, Niki Glazier, co-ordinator of MHAG, and Nicky Lidbetter, chief executive of Anxiety UK, in a joint introduction, said: “To get mental health firmly on the map across all transport sectors and across providers, regulators, policymakers, umbrella bodies and watchdog bodies was essential.”
Summit participants made pledges across three call-to-action areas: policies and practices to support the needs and protect rights of customers; staff training to benefit both passengers and colleagues; and
introducing and advertising initiatives and assistance for people with mental health conditions, to improve confidence to travel.
Five years on, Smart Transport followed up with transport organisations’ pledges this year.
TAS Partnership CEO, Sarah Huntley, says improvements in the intervening years centred around workplace culture. For clients, TAS introduced ‘communication groups’ and safe zones for drivers to talk informally about their work, with mental health champions at their seniority level.
“As a driver, you can get abuse daily and it’s something you don’t talk about because it’s a bit of a culture where you can’t be upset if someone shouts at you”
Sarah Huntley, TAS Partnership CEO
Improvements around policies and practices internally included “semi-formal forums” to develop mental health awareness among staff and clients, as well as therapy sessions, personal days,
flexible working and group sessions. Over time, clients’ interest in such schemes has increased, and Huntley notes mental health is now a feature at transport conferences. “I hadn’t missed it until it was there in 2020,” she says. “No one really questioned it before.”
Transport for London (TfL) has a Peer Support Service for employees, working with psychotherapists as part of TfL’s Trauma Support Group for staff who deal with the travelling public when things go wrong.
Peer support is particularly important immediately after experiencing trauma. It is about being able to detect distress in others, and knowing how to open up a conversation, even with someone you may not know well, and offering compassionate support. This can make a world of difference to someone going through a difficult patch, or suffering a mental health episode, TfL’s Jess Evans had told the MHAG conference.
Another resource is journey planning, helping people walk through the steps of their journey before they travel.
‘What if’ scenarios
Dave Smithson, operations director at Anxiety UK, says this allows someone to go through “what if” scenarios, so they know what to expect. “It’s a fear of the unexpected, to an extent, that creates the anxiety, which can then build and spiral out of control causing a panic attack,” he says.
“Knowing there’s going to be someone there to assist you or you can plan your journey in advance, can help you address some of those ‘what if’ questions before you set out.”
Go-Ahead introduced “Drama on the Bus”, a partnership with Brighton and Hove Buses, Metrobus and Grace Eyre, a mental health and learning disability charity. This involved role-playing different challenging scenarios to help give people confidence they could cope, should difficulties arise.
Crewe railway station opened a “calm corner” in summer 2019 to offer people with hidden disabilities some respite while travelling. The room features calming green and grey colours, plants and specially designed furniture and lighting, as well as a child’s play table, and photos of the old station to help trigger memories for passengers with dementia. A rail point Totem offers helpful advice.
Urban Transport Group says it delivers mental health awareness presentations to directors and staff training, as well as signing a Time to Change pledge in 2017, an employer commitment to improving
mental health in the workplace, with an associated action plan – now signed by more than 1,500 organisations.
Saila Acton, mental health champion at the Urban Transport Group, says: “In addition to our work on mental health, we’re also working to increase awareness of neurodiversity (such as ADHD, Autism, Dyslexia, Dyspraxia) in the workplace. In March 2021, we held a webinar to inspire our members to become ‘neurodiversity smart’ by taking action to encourage and support staff to achieve their full potential.”
Mental health may be the number one reason people take sick days, according to Rosie McKearney, of Time to Change, and reducing stigma is key, helping staff talk about issues, improving mental health
literacy at all levels so they can also identify signs in customers. She says the more those in the transport industry know about mental health the more confidence and knowledge they have to support each other and customers. This may include resources and information for staff, or their colleagues, who may be struggling.
Encouraging staff to reflect on resources that are important for their own mental well-being can help build resilience and ability to self-care.
Following conference pledges, Blackpool Transport Services introduced a staff well-being policy, and a “culture of openness”, as well as producing best practice resources with Lancashire Mind and Mental Health England, with the latter training several staff to be mental health first aiders.
There is also an “internal community of well-being ambassadors” to listen to and help other colleagues.
Stagecoach introduced a number of initiatives, including regional (and soon to be a national) health and well-being champions, a health and well-being activity calendar, a confidential employee assistance programme, and a speak up programme.
A company spokesperson adds: “We carry out regular engagement with local disability groups in relation to staff training and wider community work. This provides an opportunity to engage with wider mental health groups and explore ways of breaking down barriers to using the bus. Our drivers all complete a course on hidden disabilities as part of their training.”
FirstBus pioneered an ‘Extra Help to Travel’ card, for a range of non-visible impairments, for customers unsteady on their feet who need the driver to wait until they’re seated before driving off, or hard of hearing passengers, those with learning difficulties who may need someone to talk slower, or a mental health condition. Passengers could write their needs on the card, and show it to drivers, without having to talk to anyone.
In 2018, the Government conducted a consultation on improving public transport, and, although delayed by the pandemic, a national travel assistance card will soon be launched.
TfL offers a ‘please offer me a seat’ badge, to help facilitate passenger kindness, without customers needing to explain themselves. A new TfL Go app is being updated, to show busy times around
stations, allowing anxious customers to avoid those times. A Turn Up and Go service, allows any customer to ask for assistance at the station without needing to pre-book.
Anxiety UK’s Smithson says: “I think what we have seen over the past five years since the conference, generally, is a greater understanding of public transport providers in all fields of the needs of people with
He says TfL is at the forefront of understanding the needs of people with hidden disabilities, including anxiety.
“The fact they have encouraged people to be mindful and aware of the some of their campaigns on the needs of passengers, just helping people be more considerate, I think is really powerful.”
He adds the solutions often aren’t that complex – and tend to relate to people – “it’s about asking people to be thoughtful and considerate of other fellow passengers”.
Mackett’s research found staff on board was key for half of those with mental health issues on train travel, ahead of better behaviour by others (45%). Better trained station and on-board staff was key for the same percentage of respondents.
TfL is among transport operators offering dementia awareness training. More than 850,000 people in Britain live with the condition.
Anne Frye, a specialist on the mobility needs of people with disabilities, says: “There’s an awful lot of people with early-stage dementia out and about, many of whom are undiagnosed and won’t be aware they have it.”
This means people may get on a bus and forget where they are, or where they’re going. One area of good practice is the airline industry, which provides Alzheimer’s training for staff because the air within aircraft can suddenly cause sufferers to become confused and even aggressive, moments after seeming fine.
The Leeds-Morecambe Community Rail Partnership created Britain’s first ever dementia-friendly railway route on the Bentham Line, training partnership staff and volunteers to become Dementia Friends, an Alzheimer’s Society initiative, and simplifying display information, ticket buying and station navigation, as well as timetable posters. Four dementia-friendly walks were created at stations along the line, and special trips to Morecambe Bay and the Forest of Bowland.
Frye says: “Training on dementia is all about empathy. It’s about being calm, being kind, being patient. If a bus driver starts getting flustered and angry when a passenger becomes confused that will increase the distress a person feels.”
Street design can exacerbate confusion, too, says Frye. “Dementia sufferers can be affected by pools of light, shiny surfaces, different textures and patterns, which can look like water. Then they freeze because they don’t want to get wet.
“Local authorities may think ‘we’ll make the pedestrian crossing more fun with blobs of colour’, but for anyone with dementia or autism that is a nightmare, it’s disorienting.”
The Government’s Accessible Travel Policy was published last year, requiring train operators to meet accessible travel policy guidance across their services, from websites to physical services – including hidden disabilities.
This means passengers requiring assist-ance should, over the next year or so, no longer need to book 24 hours in advance: according to the Cabinet Office, it will eventually drop to two hours. The policy requires operators to better communicate between themselves when a customer crosses between services, to avoid the stress of arriving at a destination by train, only to find no one is there to help them disembark. Operators can be required to retrospectively fit things like ramps, if a service or station doesn’t meet regulations.
A new strategy for disabled people will launch this spring (and had not been seen at the time of writing), which will change policies including in transport, and the built environment, to help people with impairments to participate in society – including those with mental health conditions and learning disabilities.
It’s Everyone’s Journey was an advertising campaign launched before the pandemic, encouraging people to be considerate of others’ needs, and is set to relaunch as restrictions ease. It depicts a bull-human barging onto the train, or a chameleon that disappears when someone needs help, before having a change of heart.
While Blue Badge schemes and Disabled Persons Railcard are now available for people whose mental health condition makes leaving the house challenging, this tends to be via a Personal Independence Payment score. As Mackett puts it, “anything that requires an assessor to decide becomes subjective and people may not want to subject themselves to going along and talking about their problems”.
As restrictions lift…
Anxiety UK says demand for its helpline (03444 775 774) increased 400% during the pandemic, with people presenting with anything from health anxieties, anxiety-based depression, anxiety-related phobias, obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD) and panic attacks.
For those suffering OCD, for example, anxiety about potentially stressful situations can trigger obsessive thoughts and compulsions.
In a survey, the charity found worries about returning to public transport was the third top concern about restrictions lifting.
“If people have been told for a year, you mustn’t go out and come into contact with other people, suddenly it’s OK to go back to work, jump back on that bus, or tube, and go back to work as normal. That’s creating a lot of anxiety for people around whether it’s safe”
Dave Smithson, operations director at Anxiety UK
Practical solutions include seats blocked out to maintain social distancing. He adds: “Some people might prefer to cycle to work”.
Driving is a solution for some, but it’s an unsustainable one, and if public transport fears rise, people are left with fewer options, among them expensive taxis or private transport.
With 66% of all journeys made in Britain covering less than five miles, many people can benefit from the mental health boosting benefits of active travel, i.e. cycling and walking – not least if travel and working patterns, and with it our daily commutes, change. Active travel stands apart as a mode of transport that positively benefits people’s mental health, not only in the activity itself, but in the environments created when space is made for walking and cycling.
Cycling for health
A cycling for health referral scheme, delivered by national cycling charity, Cycling UK, offered 1,000 participants with long-term conditions 12 weeks of cycle skills training. Those who took part reported improvements in mental well-being, with 32% feeling more confident, 29% close to others and 26% feeling relaxed. One participant, Andrea, who suffered with anxiety, says: “I’m more confident. I’m able to be out with other people more than I would normally. My fitness has improved, my lung function is a lot better than it has been and now I actually want to go out and do other things, and keep cycling, keep active and really start living my life.”
A recent survey by Sport England found 75% of physical activity, among those getting a healthy 150-plus minutes of physical activity a week, was by walking and cycling, which makes safe local streets key to help more people enjoy those benefits, and travel more sustainably.
Frye says while, overall, things have come a long way with transport and mental health, there is much more to do.
“Physical accessibility is there, but so much of what’s going wrong comes down to the human influence, the bus driver who can’t be bothered to put down the ramp, or the person on the station who won’t repeat something for someone who didn’t understand it the first time. It’s the training that’s missing,” she says.
“More and more stations now have no staff. The law says you have to be able to get on a train if you have a disability, but if there’s no one at the station and with trains coming in that only have a driver, no conductor, how are transport providers meeting that requirement? By removing staff on the station, you reduce the confidence to travel drastically.”
Anne Frye, a specialist on the mobility needs of people with disabilities
Frye adds: “The Government is spending money putting in lifts and ramps, but taking away the things that make the biggest difference, which is the people. It feels like we’re moving forward two steps and one back step some of the time.”
Smithson adds: “Transport providers surely want to make their offer attractive and encourage people that need to use it to want to use it. It’s about putting forward a service that people feel welcome in and attracted to and, if you don’t, people will vote with their feet.
“There’s always ways you can look to improve the quality of service in any walk of life, but I think we are on the right track, heading in the right direction and there have certainly been improvements in the past few years. Let’s hope that continues.”