Mental health & wellbeing: crucial contribution to public health challenges – or becoming a bit of a distraction....? Lynne Friedli National Leading Health & Wellbeing Programme Peterborough 16 th May 2014
Feb 26, 2016
Mental health & wellbeing: crucial contribution to public
health challenges – or becoming a bit of a distraction....?
Lynne Friedli
National Leading Health & Wellbeing Programme Peterborough 16th May 2014
Mental health & public health [email protected]
‘What are illusions?’ Milo asked‘Illusions,’ explained Alec, ‘ are like
mirages. And mirages are things that aren’t really
there that you can see very clearly.’‘How can you see something that isn’t
there’? yawned Humbug‘Sometimes it’s much simpler than seeing
things that are’, said Alec.
Norton Juster, The Phantom Tollbooth
Seeing things
Summary•Inequalities and social justice: mental health and the social determinants of health
•Money or love; class or character: public health and the wellbeing debates
•Count your assets: reasons to be cautious when it comes to strengths based approaches?
•Call in the jury: is there really no (public) health without mental health?
Mental health & public health [email protected]
Public health
Health inequalities are a symptom, an outcome, of inequalities in income, wealth and power
CSDH
“At least show you know what we’re up against; stop saying the causes of poor health round here is smoking and fat ....”
Advice to a DPH
Public health: understand & act upon the distribution & causes of population patterns of health, disease & wellbeing
Krieger 2012; Birn 2009)Mental health & public health [email protected]
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Mental health & public health [email protected]
Deepening the relationship...
What is the special contribution of mental health to the policy and practice of public health – and vice versa?
Key competencies of leaders
1.Integrate mental wellbeing within all policy and take action to mitigate any negative impacts of policy on mental wellbeing. (PH3)
1.Promote the value of mental health and wellbeing and the reduction of inequalities across settings and agencies (PH4L6)
1.Advocate for mental wellbeing (PH4L7) as central to reducing inequalities and creating thriving communities and economies.
1.Create organisations that nurture and sustain the wellbeing and mental health of employees
Source: PHE/Stansfield MH leadership: core competencies (draft)
Know Believe Act
1. Know the nature and dimensions of mental wellbeing and mental illness.
2. Know the determinants at a structural, community and individual level.
3. Know how mental wellbeing is a positive asset and resource to society
4. Know what works to improve mental wellbeing and prevent mental illness within own area of work.
1. Understand own mental wellbeing, what influences it, its impact on others and how you improve it.
2. Appreciate that there is no health without mental health and the mind and body work as one system.
3. Commitment to a life-course approach and investment in healthy early environments.
4. Recognise and act to reduce discrimination against people experiencing mental illness;
1. Communicate with children, young people and adults about mental wellbeing.
2. Integrate mental wellbeing into own area of work and address mental and physical health holistically.
3. Consider social inequalities in your work and act to reduce them and empower others to.
4. Support people who disclose lived experience of mental illness;
Source: PHE/Stansfield MH leadership: core competencies (draft)
A subjective evaluation of how we feel about,
experience & interpret our lives
Mental health & public health [email protected]
It’s a hearts and minds thing....
(Mental)...Wellbeing......
What we all need....
To be:• Heard• Believed• Understood• Respected
Picture Source: http://sarahdrummond.wordpress.com/2010/12/13/an-assets-alliance-scotland/
It’s in illness, old age and disability that we know what love is
Julia Fernandez
Best start
Quality work
Income
Prevention
Healthy places
Education & skills
Mental health & public health [email protected]
S
Mental
Health
Social Determinants
‘all forms of suffering involve layers of personal history, embedded in
relationships that are, in turn, embedded in cultural and political systems’
Bracken, Thomas et al 2012
What’s the offer?
Mental health & public health [email protected]
Picture source: Sleeping with spirit #2 Bradley Guiboche courtesy www.artbeatstudio.ca
An evidence base that is transforming how we understand and deliver
public health
Because it’s worth it....
Mental health & public health [email protected]
• Contribution mental wellbeing and mental illness make to wide range of outcomes
• The ‘unexplained excess’ – classical risk factors do not account for level of variation in outcomes
• Improving mental health & wellbeing saves (a lot of) money
• Improving mental health delivers social (as well as economic) returns
• Improving mental health reduces inequalities
While there are multiple barriers to economic growth, the growth of human potential is unlimited
Coote and Franklin 2010
Contribution of mental health to inequalities
Key domains: education/employment/behaviour /health/ consequences of illness /services
(Whitehead & Dahlgren 2006)Mental health is a significant intermediary determinant in each case, influencing:
• readiness for school/learning• relationships: care of self/others• employment• every day habits of living• risk for physical ill-health (e.g. coronary heart
disease), • chronic disease outcomes (e.g. diabetes) • medically unexplained symptoms• relationship to health services, including
uptake/treatment
Mental health & public health [email protected]
Health
topics:
RIP?
Explaining the social gradient: mental illness journeys...
• Socio economic status – parental income, tenure, education, occupation, employment
• Adverse life events: violence, abuse, neglect, illness
• Contact with criminal justice system • Racism and other forms of discrimination• Institutional care in childhood
Mental health & public health [email protected]
Mental health & public health [email protected]
Declaration of Intent of the Mental Patients Union • We proclaim the dignity of society's so-called mental
patients. • We challenge repressive psychiatric practice &its ill-
defined concepts of 'mental illness'• We state that the present appalling situation in
'mental health' primarily arises from acute problems in housing, unemployment & social inequality
• Mental patients in our society are treated as people with no human rights
‘It gets so lonely around here that I phone myself seven or eight times a day, just to see how I am’
Phantom Tolbooth
What SDOH can help with
Minding the gap: • Social gradient in mental wellbeing and mental
illness• Inequalities in how and where people end up in
the system• Inequalities in who does and doesn’t recover
Mental health & public health [email protected]
Distress needs to be understood as a legitimate response to life events, socio-political oppression, spiritual crises, trauma and stress – taking into account the pre-story of a person’s life...
African, African-Caribbean & South Asian Women’s Narratives of Recovery
Public (Mental) health leadership
• What are responsibilities of leadership around public mental health?
• What does it mean to act on the social determinants of mental health?
Mental health & public health [email protected]
Over to you......
Public health & the wellbeing debates
Mental health & public health [email protected]
All societies cater for the disabilities of the average person
Martha Nussbaum
Mental health & public health [email protected]
Picture source: Dolly Sen My story is on my skin
As material inequalities grow,
so the pursuit of non material explanations
proliferates
a paradox....
‘Grace beats karma’
http://mentalhealthrecovery.omeka.net/items/show/90
Commission on the Social Determinants of Health
• material requisites• psycho-social (control over lives)• political voice (participation in decision making)
Mental health & public health [email protected]
Status Control Relatedness
Some living conditions deliver to people a life that is worthy of the human dignity that they possess, and others do not. Dignity can be like a cheque that has come back marked ‘insufficient funds’Martha Nussbaum
Mental health & public health
Life Bodily healthBodily integrity Sense, imagination,
thought
Emotions Practical reason
Affiliation Other species
Play Control over environment:a) Politicalb) Material
Source: Nussbaum 2011
Capabilities & fundamental entitlements
Social Epigenesis: biological embedding *
“The most effective interventions will require a deeper understanding of how common social risks “get under the skin” to affect human biology and influence the causal pathways to disease”
* Clyde Hertzman 2012
*Clyde Hertzman 2011
Mental health & public health [email protected]
Status Control Relatedness
Early in life, the environment talks to genes, and the genes listen
Mental health & public health [email protected]
Is recovery about being well enough to be thrown into the world of sharks? Where is the recovery model for the society of sharks?
Dolly Sen
Source: http://mentalhealthrecovery.omeka.net/exhibits/show/dollysen/isrecoverytherightword
Count your assets?
Mental health & public health [email protected]
‘...the development of their own capabilities to manage their way out of poverty’
Scottish Government 2011They speak to the resistance of deprived
communities to being pathologised, criminalised, ostracised; to being described in public health reports in terms of multiple deficits and disorders: ‘chaotic, unengaged, and disaffected’
Friedli 2013
Strengths based lexicon
• assets; resilience; recovery; • agency; self-efficacy; empowerment, self
reliance; • Autonomous, entrepreneurial, aspirational• Responsibility; social productivity• Sense of coherence (strengths not deficits);
hope, optimism• well note replaces sick note• Self + management, examination, care,
improvementMental health & public health [email protected]
m
Basically what I'm saying in short is that I feel there is no place in society for a quiet, shy, creative person like me.http://soisthismylifenow.blogspot.co.uk/2013/08/how-work-programme-makes-me-feel.html
Reasons to be cautious about assets...
• Time trends: no association between KAM & health behaviours (Rutherford & Reid 2013)
• Substitution: removal of one risk factor (smoking) is replaced by another (obesity) (Scott et al 2013) Phelan et al 2010)
• Steepest social gradient in most preventable causes of mortality (Scott et al 2013)
• No evidence (to date) that assets approaches can reverse main avoidable causes of morbidity & mortality
• Scottish effect? Neither SOC nor psychological outlook explain Glasgow’s excess mortality (Walsh et al 2013)
• Abstracting psycho-social from material realities?
• New pathologies: dependency and need
Psychologising of public health....
I’d like to see psychology think more
about positive pain: the grief that
expresses love, the fear that
expresses a true sense of threat, the
compassion that shares the pain of a
suffering person, the anger that says
‘this is deeply wrong’.
Martha Nussbaum
Mental health & public health [email protected]
Framing and erasure
• Construction of psychological ideal• Poor outcomes are a result of psychological
deficit• Erasure of economic realities & social
determinants• Compulsory positive affect & psychological
coercion
Mental health & public health [email protected]
solutions to the widening gap in health inequalities will need to take into account early life & personality, as well as the more the classically recognised factors such as smoking, diet, cholesterol & blood pressure if we are to stand a chance of narrowing the gap in health by improving the health of those most in need.
GCPH ‘assets’ 2014
Personality and health in Glasgow
'the identification of individuals whose personality styles render them vulnerable to particular health risks‘ Millar et al 2013 p.8
‘to establish if those who need to take on board lifestyle messages (weight loss, physical activity) are in a position affectively and intellectually to receive them.’ Velupillai et al 2008 p2
‘(brain) that is less robust and less efficient in information processing ... some evidence of the relationship between socioeconomic deprivation and brain network topology.’
Krishnadas et al 2013
GCPH pSoBid Study http://www.gcph.co.uk/assets/0000/4244/pSoBid_FINAL_REPORT_2013_update_February2014.pdf
Substitution of outcomes
‘Evidence from this evaluation suggests that while there was no significant difference in job outcomes …. the OCM & CAP trailblazer strands were successful in achieving soft outcomes such as increases in motivation, confidence, job-seeking behaviour and a positive change in attitudes to work. These softer impacts may yet translate into job outcomes and sign off from JSA.’
Rahim et al (2012) Evaluation of SVLTU DWP Research Summary (emphasis added)
Mental health & public health [email protected]
Call in the jury...
The disadvantages of prioritising well-being may lie not in the idea itself, but in how it is used
Hanratty & Farmer 2012
Mental health & public health [email protected]
Big fish/little fish: questions of power are
unavoidable
A cautionary tale.... [email protected]
• Services, rights and resources
• Respect & relationships
• Social justice
Mental health & public health [email protected]
Economic capital
Pathways to Mental health & Wellbeing
interventions
Mental health and well-being
Human capitalIdentity
capitalSocial capital
Adapted from Centre for Research on the Wider Benefits of Learning (http://www.learningbenefits.net/)
Environmentalcapital
Mental health & public health
Responding to the determinants
Relationships and Respect
Social support, collectivity, respect for people experiencing
misfortune
Material resourcesIncreasing equitable access
to assets that support mental wellbeing
Interventions to
promote mental
wellbeingInner
resourcesOpportunities
to develop senses,
imagination, reason, thought
Meaningful activityValued
opportunities to
contribute
Resources, relationships, meaning, respect
(Martha Nussbaum Capabilities)
Mental health contribution:social archaeology
•Developing an inequalities imagination* (Angie Hart)
•Life course approaches: interventions & economic modelling
•Strengths based approaches: resilience, assets, wellbeing, recovery
•Human rights: UN conventions – disabilities, children
•Epigenetics and disease ‘signatures’
Mental health & public health [email protected]
Appendices
Mental health & public health [email protected]
Select Bibliography
Mental health & public health [email protected]
Escape by Kathleen V Crosby
Living on nothing is trying not to hearthe intellectual arguments and lofty ideals aboutliving on nothing put forward by those who are not living on nothing.living on nothing is dying
Out of the Shadows: Liz Prest
Thomas, R., Dorling, D. and Davey Smith, G. ‘Inequalities in premature mortality in Britain: observational study from 1921 to 2007’ (BMJ 2010; 341:c3639)
Akerlof, G. & Shiller, R. (2009) ‘Animal Spirits: How Human Psychology Drives the Economy, and Why It Matters for Global Capitalism’ Princeton/Oxford, Princeton University Press
Dolan, P., Hallsworth, M., Halpern, D. Et al (2010) ‘Mindspace: Influencing behaviour through public policy’ Institute for Government and Cabinet Office
Shildrick T et al 2012 Poverty and Insecurity: Life in low-pay, No-pay Britain Studies in Poverty, Inequality & Social Exclusion Series
Howell A & Veronka J The Politics of Resilience & recovery in mental health care http://www.academia.edu/3366809/Introduction_The_Politics_of_Resilience_and_Recovery_in_Mental_Health_Care
Birn AE (2009) “Making it Politic(al): Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health.” Social Medicine
Mental health & public health [email protected]
Select bibliography Krieger, N. 2011. Epidemiology and the People’s Health: Theory and Context. Oxford: Oxford University Press.
Nussbaum, M. 2011. Creating Capabilities – The Human Development Approach Cambridge Massachussets: Harvard University Press
Berlant Lauren Cruel Optimism Differences 17, 5 (2006): 21-36; and New Formations (2008; longer version) Slow Death in Critical Inquiry 33 (Summer 2007): 754-780
Friedli L (2013) ‘What we’ve tried, hasn’t worked’: the politics of assets based public health Critical Public Health
Imogen Tyler (2012) Revolting subjects: Social Abjection
Slater T (2014) Unravelling false choice urbanism http://crisis-scape.net/conference/item/180-unravelling-false-choice-urbanism; The resilience of neoliberal urbanism http://www.opendemocracy.net/opensecurity/tom-slater/resilience-of-neoliberal-urbanism