How we make decisions

Text on a colourful background. Text reads: "how we make decisions, Akiko Hart"
By Akiko Hart, NSUN CEO

This piece is the first in a series of NSUN staff blogs that aim to go deeper into specific areas of our thinking during our period of strategic reflection in the first half of 2022. This led to a new articulation of our priorities and direction.

Recently, NSUN went through a period of strategic reflection. We came out of it with a Theory of Change, and, I think, clearer answers as to who we are, what we do, and how we work.

Part of this process involved thinking about which pieces of work we undertake, or which campaigns we might support.

Like many charities, we are constantly approached to sign letters or position statements, endorse reports or campaigns, join advisory boards, or take part in studies and policy initiatives.

To formalise a process for evaluating what we take on or what we endorse, we created a ‘decision-making matrix’. We look at our capacity, the cost of the work including the emotional cost, and we check that the work fits with our Theory of Change. Some of the questions we are asking ourselves include:

  • Is the work ethical?
  • Is there scope to meaningfully influence as part of this work or effect change for our members?
  • Where the work involves sharing or collecting people’s experiences, focus groups or significant emotional or other investment, is the likelihood of these views being heard proportionate? Will people’s lived experience be heard?
  • Is another organisation better placed to do this work?

But before we even ask ourselves some of those questions, the first question we must ask ourselves is why. Why are we being asked to do something?

Sometimes, it is because our input is genuinely wanted and welcomed. However, it is often more complicated.

Endorsement from the voluntary sector can bring a veneer of authenticity and legitimacy to a project. This is heightened when, as with NSUN, the organisation brings a lived experience perspective. Too often, we are asked to be “the voice” of all survivors and service users in decision-making settings, when there is no such thing as one survivor and service user voice. Our involvement can become politically expedient and a shortcut to legitimacy, inadvertently validating harmful work. We can end up not being heard, ticking someone else’s inclusion box, and perpetuating the status quo.

As well as asking ourselves why we are being asked, we must also look at the context behind the ask.

Campaigns cannot be divorced from their political contexts – who is driving them and why, or their political consequences – what might happen because of them. Some pieces of work or positions seem OK on the surface but can have unforeseen repercussions.

The reality is we are about to go through a number of years of economic pain and most likely contraction. Mental health is no longer the hot political topic it was, and even if it were, this would be unlikely to herald a period of substantial investment beyond any spending already agreed.

Over the next few years, what decisions makers in mental health will be looking for is efficiencies, economies of scale, and cuts.

This is the political context in which campaigns are landing. And if these campaigns are then weaponised to justify, say, wider cuts to mental health services, then it won’t matter that that’s not what they originally asked for. We cannot afford to be naïve about our intentions being good or somehow mattering.

These are the judgement calls we at NSUN are trying to make when we are approached for endorsement, tacit or otherwise. It is also why we rarely intervene in some debates, for example the endless online discussions about diagnosis or medication. How would that serve us or our members? Becoming a pawn in someone else’s culture war has no good outcomes.

NSUN’s position on so many issues is rarely either/or, and is far more often both/and. Yes, the mental health system can cause great harm, and yes, we need more alternatives, and yes, we also need more services but can they be less bad. Yes, medication can cause great harm, and yes, it can also help people, and yes, we need solutions beyond medication, and yes, please can we have better meds as well. Multiple things can be true at once. That’s because it’s about people, now.

Our focus is on lived experience, in its messiness and plurality. It’s about people’s lives, not conceptual debates. Too often, people who live with mental ill-health, distress or trauma are faced with hollow choices. Informed consent barely registers when you get to choose between Bad Choice A and Bad Choice B, when you are on your knees and the alternative is nothing. Our starting point is lived experience and the world as it is, and side-by-side, we hold the world we want to build. The work we choose to do, the campaigns we choose to endorse must also engage with these realities, hopes and tensions.