It Takes Balls to Talk (ITBTT) – Coventry & Warwick – WINNERS – #MHAwards18

It Takes Balls to Talk is a community campaign which uses an unusual approach to enhance mental wellbeing and address previously unaddressed suicidal feelings in a high-risk group, by taking a straightforward message directly to men and those that care about them. It is a grass-roots campaign, highlighting the importance to men’s mental wellbeing of them talking about their emotions. Volunteers share a simple powerful message at sporting events and male dominated workplaces; that “It's okay to talk about how you feel” and also encourage them to be “A Listening Mate”. It Takes Balls to Talk attends events and venues where there are large groups of men.


  • From start: Yes
  • During process: Yes
  • In evaluation: No


  • Peer: Yes
  • Academic: No
  • PP Collaborative: Yes

Find out more




It Takes Balls to Talk is a community campaign which uses an unusual approach to enhance mental wellbeing and address previously unaddressed suicidal feelings in a high-risk group, by taking a straightforward message directly to men and those that care about them. It is a grass-roots campaign, highlighting the importance to men’s mental wellbeing of them talking about their emotions. Volunteers share a simple powerful message at sporting events and male dominated workplaces; that “It’s okay to talk about how you feel” and also encourage them to be “A Listening Mate”. It Takes Balls to Talk attends events and venues where there are large groups of men.

The volunteers not only role-model the ease and effectiveness of brief conversations about mental well-being, but also sign-post those who identify a need to appropriate services in their area. Volunteers leave men, and those who care about them with information and encouragement to “be a listening mate”. It Takes Balls to Talk enhances this face-to-face contact at events with an online presence that is rapidly developing. Project aim: • To encourage people, particularly men to talk about how they feel and direct them to appropriate sources of help and support, when they need it. Project objectives: • To target men and the people who care about them • To utilise sporting venues, to reach people – particularly men • To build emotional resilience • To ensure people are aware of the support services available to them • To encourage people, particularly men, to talk to family and friends about how they feel • To make sure that individuals know it’s OK and not a weakness to talk about how you feel • To reduce stigma about mental health and increase education about emotional wellbeing • To utilise social media and a range of promotional events to reach out to a wide group of people

The Project began in Coventry and Warwickshire back in 2016 and after a positive evaluation of the initial pilot, has completed 18months of events in the local area. Current plans include the potential expansion of the campaign into the sporting venues and workplaces across the whole of the West Midlands region alongside a consolidation of processes and structure and an academic evaluation of outcomes. Following this, if the outcomes of evaluation match the very positive informal feedback as to the effectiveness of the campaign, a national structure granting licences to roll out the model into additional regional hubs have been envisaged in the longer term.


What makes your service stand out from others?

The Five Year Forward plan for Mental Health highlights the issue that only 28% of people who take their life have had contact with mental health services in the previous 12 months. ITBTT is a campaign that reaches out to people, particularly men in the environment where they feel most comfortable and for many this is at sporting events or their workplaces. They do not have to visit their GP or get any sort of a referral which is often a stumbling block for many men to access the help that they need. The campaign is delivered by peers, who are volunteers and able to demonstrate that being a “Listening Mate” and having someone to talk to makes a problem easier to cope with. Alex Cotton’s work in her main role as part of the Street Triage Team brought into sharp relief the statistics about men who take their life without contacting mental health services. Police often asked if men who had been found after taking their lives had had contact with services and sadly the answer was often no. She was inspired while attending a football match to develop a campaign that fundamentally changed the method of engagement and take the message and service directly to men in their places of leisure and work.

Conversations reveal how the approach supports men to open up about their feelings when attending sporting events. For example, one volunteer reported that “The very first person I spoke to as a volunteer was a gentleman who was polite enough to stop and listen to what the campaign was about. He started to tell me about a friend of his who has lost his job and had struggled with loneliness and the lack of routine. Half way through the conversation he switched from making reference to his friend to himself and continued this for the remainder of our conversation. He wasn’t comfortable to start with admitting it was him who was the friend in question but as we talked he relaxed and seemed appreciative to be having the chat and discussing the mental health services open to him. This was a 10 minute conversation between strangers and in that moment it became crystal clear the vital importance of the It Takes Balls To Talk campaign. The passion and enthusiasm of all those involved and the numerous conversations I’ve had with strangers and friends and colleagues makes me feel incredibly proud of being a small part of it. On a personal note being part of and knowing the importance of the It Takes Balls To Talk message gave me the confidence and strength to admit to, and seek treatment for, a bout of depression I was struggling with earlier in the year.” We often find that when we return to sporting venues, men are approaching volunteers to talk about the support they sought after meeting a volunteer at a previous event.



How do you ensure an effective, safe, compassionate and sustainable workforce?

This project has grown organically, with Alex (the Founder) working voluntarily but supported and mentored by a multi-agency team. Time to Change supported the project in its initial stages, supporting Coventry & Warwickshire Mind with Volunteer recruitment and offering early volunteer training. The campaign currently has a team of 60 volunteers, who are encouraged to attend a minimum of 3 sporting events each year, to support the work of the campaign, many attend considerably more than this. Following the initial evaluation, a small amount of funding was secured to enable Alex and a colleague to be trained to deliver a specialist training course to ensure that all ITBTT volunteers as part of their induction are trained in suicide awareness, this we have found increases the volunteers confidence in addressing difficult subjects when having initial conversations with the public and giving them a valuable tool to use in their daily lives.

The team ensure that a clinician is available at every event with a clear process identified to ensure that volunteers are completely comfortable with the immediate steps to take, should someone disclose current significant distress. The clinician can then offer immediate triage at the event and will support the volunteer as appropriate following this. A volunteer co-ordinator offers informal support to volunteers alongside practical event preparations and can signpost anyone experiencing difficulties following an event to a clinician for support as required. The clinical volunteers, including Alex Cotton, are all offered a formal supervision and reflective practice as part of their professional role and Coventry & Warwickshire Partnership Trust have supported and recognised the work these clinical volunteers undertake. Many volunteers are prompted to join the team of ITBTT due to their own lived experience or the experience of supporting friends and family who are experiencing mental distress. In their feedback from training, volunteers often report that it has increased their confidence and in some cases enabled them to speak out about their own mental health needs.


Who is in your team?

Founder : Alex Cotton Band/Grade: n/a – however, soon to be paid band TBC. Post: 1 FTE: 0.4 Volunteer Co-ordinator Band/Grade: Voluntary Post: 1 FTE: 0.1 Volunteers (Listening Mates) Band/Grade: Voluntary Post: 60 FTE: n/a Board & Steering Group Members from partner organisations Band/Grade: n/a Post: 12 FTE: 0.4


Working together

As described above, the Project is supported by a multi-agency board and steering group. The project signposts to all relevant local services, such as IAPT, CW Mind, Drug & Alcohol services, Debt Management services, Samaritans etc. and where an immediate referral/signpost is not appropriate the volunteers will encourage the individual to self-referral to them. Initial evaluation showed an increase in male referrals, particularly into the IAPT service following matches. Quantifying the impact of this will be an area of consideration for the formal evaluation being planned.


Do you use co-production approaches?

It Takes Balls to Talk campaign was the brain child of Alex Cotton from CWPT who originally approached a number of potential partners in January 2016 to discuss the idea of developing a campaign to reach out to Middle Aged Men, encouraging them to talk about their feelings and seek help during times of mental distress and in particular suicidal thoughts. Having discussed the idea it was agreed that a steering group needed to be established with invites given to a number of partner agencies such as Coventry & Warwickshire Mind, Samaritans, Public Health, Time to Change and Unite the Union. However, one thing that all interested parties felt strongly about was the need to ensure that we had the involvement of people with Lived experience to co-produce, co-design and co-deliver the programme. Coventry & Warwickshire Mind supported this by approaching their inhouse Experts by Experience (EbE) group to see if there was anyone who had a particular interest and also experience to support the process.


Having presented to the group a young man in his 20s, who had his own personal experience of contemplating and attempting suicide and had also lost his father to suicide agreed to join our steering group and played an active role in the development of the programme for the first year. Since then he has moved on but we have been fortunate to have a number of people volunteer as champions in ITBTT who have their own experiences and still rely heavily on their involvement, particularly from a co-delivery angle. As described above, volunteers are often motivated to work with the Project due to personal experience. Athletes from various sports regularly offer personal perspectives and experiences which are now being used via a series of recorded “sofa conversations” with Alex, to increase the reach of the project across their fan base. The evaluation in planning, will seek to actively use co-production to deliver as accurate as possible reflection of the impact of the project on the lives of those who do not usually speak about their feelings.


Do you share your work with others?

A wide reaching social media campaign, has had an audience in excess of 1.5 million contacts. Alex and other members of the ITBTT steering group regularly speaks at conferences and events and a report of the pilot was published in the Mental Health Nursing Journal. As described above, there are plans to offer the Project model to other regions following formal evaluation of it’s efficacy and further development of processes.


Outcomes and evaluation

A combination of informally accrued PROMS, CROMS and PREMS have been gathered. PROMS: Men self-report having sought support following contact with the Project. CROMS: Impact of conversations at events. E.g. the example above of a man feeling able to move from “I have a friend” to “I” while talking about challenges to their mental wellbeing. PREMS: fans repeatedly speak of how good they think the project is. An additional informal measure is that there are always very few cards left on the floor after an event, even when thousands have been handed out. At every match data are collected about % of attendees accepting a card, and the number of brief and of meaningful conversations held. In total since the commencement of the campaign over 30,000 infinity cards have been given out at events. Brief Conversations are conversations with members of the public that occurred as part of the process of handing out the Infinity Cards Meaningful Conversations are conversations on the subject of male mental health, sometimes based on personal experience, which may or may not result in signposting or referral to sources of support During the week of 8th-15th October 2016 of a total event attendance of 13,206 people at 5 events Campaign messages were distributed to around 25% of spectators. 142 meaningful conversations were recorded 34 people were referred or signposted onto other agencies as a direct consequence of the meaningful conversation. One crisis intervention was recorded.


Has your service been evaluated (by peer or academic review)?

The campaign has not been formally evaluated but we do have an in-house evaluation report for the first 6 months of the campaign. Formal evaluation will be carried out in the near future.


Development and sustainability

The campaign has currently secured funding for the next two years from the NHSE funding allocated to Coventry and Warwickshire and to enable us to meet the objectives of expanding into the West Midlands we will be working with local commissioners and the West Midlands Combined Authority (WMCA) to secure additional resources to allow this to happen. A key element of the success of the campaign has been the governance arrangements and these are currently being formalised through a collaborative agreement that addresses succession planning and continuity of the campaign, should there be changes in management. The campaign is highlighted in both the Coventry & Warwickshire Suicide Prevention Strategies as a key element and this has the support of both local authority Public Health teams and local health commissioners.

What aspects of your service would you share with people who want to learn from you?

A critical element in the inception and early development of this project was the ability and willingness of key individuals to recognise the innovation in the project model and its capacity to reach the people not being addressed by traditional services. Key individuals from partner organsiations nurtured and supported the founder, who had no experience in management, project delivery or even public speaking; but who had a clear vision and a burning passion to deliver this intervention. Without support in the very early days from the Director of Coventry & Warwickshire Mind, the founder’s line manager within Coventry & Warwickshire Partnership NHS Trust and her Union (Unite), the project would have been much less likely to succeed. This seems unconnected to the service itself, but offers an opportunity for Trusts and formal bodies to consider how they would encourage and nurture staff with other such innovative ideas born of years of grass-roots experience to make them a reality.





Having managed this project without dedicated funding it has been difficult to maintain the evaluation of how many people have been supported over the last 18 months, however what we do know is that we have given out in excess of 30,000 infinity cards, which are the cards that are given out by our volunteers at sporting events and other places where large numbers of men congregate. We have also had in excess of 200,000 visits to our website and other social media


How do people access the service?

The campaign is designed to target men and those who care about them through attendance at sporting venues and male dominated workplaces. We have also linked the campaign with a number of local universities.


How long do people wait to start receiving care?

The ITBTT campaign is not a service, however, If immediate care may be required, immediate triage by a clinician at the event is offered and referral into other services is made as required. This would be equivalent to the Street Triage service where emergency services had been called.


How do you ensure you provide timely access?

The project aims to attend a broad range of male dominated environments, focusing primarily on sporting venues and male dominated places of employment. The project is actively seeking engagement with a wider range of sports and small and larger venues.


Advancing mental health equalities


The project is not yet formally identifying any inequalities, but is seeking to address a known one. In the formal evaluation phase, considering how the events attended matches the demographics of that community would be valuable to allow targeted approaches to venues to ensure the most representative access to the message is obtained.


What inequalities have you identified regarding access to, and receipt and experience of, mental health care?

The inequality of men’s lack of take-up of mental health care both formal, via services and informal, via supportive open conversations about their emotions and experiences is at the core of this Project.




Further information

It Takes Balls to Talk is a campaign that is widely regarded and has received significant support from local commissioners, service providers, communities and wider it has been spoken about in parliament. Recently it has been shortlisted for the Parliamentary Awards to celebrate 70 years of the NHS.

Population details

Coventry & Warwickshire has a population in excess of 870,000 and although there are urban areas where the majority of the population reside, there is also a significant expanse of rural areas across Warwickshire and reaching these communities is always difficult. Coventry in particular has some of the most deprived areas in the country and also has high levels of diversity, with over 100 different languages spoken by different communities in the city. 55% of the population fall within the average age supported by this campaign, which is 20 – 59 years old, although we do not discriminate and the campaign message is suitable for all ages from teenagers up to an including older adults.

Coventry & Warwickshire has a combined population in excess of 870,000 – 320,000 in Coventry and the remaining 550,000 across Warwickshire. The ITBTT campaign reaches out to all communities and is currently providing support across the whole of Coventry & Warwickshire

Commissioner and providers

ITBTT has to date not received any funding through the commissioning of services. With all agencies involved and in particular Alex working on a voluntarily basis to enable the project to succeed. There has been significant support from a range of organisations who have been involved in both the steering group and the ITBTT board, these include CW Mind, Unite the Union, CWPT, Samaritans, Public Health (both Coventry & Warwickshire) and Time to Change. In the early stages small amounts of financial support were received from both of our Public Health partners, Unite the Union, who encourage local branches to give funds to the campaign and a range of fundraising events. Having been operational for the past 18 months funding has just been secured for the next two years from NHSE as part of a larger programme to tackle the increase in suicides across Coventry & Warwickshire. These funds will be managed as part of the local Sustainablity Transformation Plan (STP) and will allow the ITBTT campaign to resource the time that existing staff are putting into this project on a voluntary or in-kind basis.

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