Mental health & wellbeing: crucial contribution to public health challenges – or becoming a bit of a distraction....? Lynne Friedli National Leading Health

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?


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]

m


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)

[email protected]

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)

[email protected]

A subjective evaluation of how we feel about,

experience & interpret our lives


It’s a hearts and minds thing....

(Mental)...Wellbeing......

What we all need....

To be:• Heard• Believed• Understood• Respected

[email protected]

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

http://sarahdrummond.files.wordpress.com/2010/12/dsc05405.jpg

Best start

Quality work

Income

Prevention

Healthy places

Education & skills


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?


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

http://www.artbeatstudio.ca/

Because it’s worth it....


• 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


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



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


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?


Over to you......

Public health & the wellbeing debates


All societies cater for the disabilities of the average person

Martha

Nussbaum


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)


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 health

Bodily 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


Status Control Relatedness

Early in life, the environment talks to genes, and the genes listen


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?


‘...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,

improvement


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

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

[email protected]

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


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


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)


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


Big fish/little fish: questions of power are

unavoidable

A cautionary tale.... [email protected]

• Services, rights and resources

• Respect & relationships

• Social justice


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

wellbeing

Inner resources

Opportunities to develop

senses, imagination,

reason, thought

Meaningful activityValued

opportunities to

contribute

Resources, relationships, meaning, respect

[email protected]

(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’


Appendices


Select Bibliography


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


http://www.academia.edu/3366809/Introduction_The_Politics_of_Resilience_and_Recovery_in_Mental_Health_Care

http://www.academia.edu/3366809/Introduction_The_Politics_of_Resilience_and_Recovery_in_Mental_Health_Care

[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

http://www.tandfonline.com/doi/full/10.1080/09581596.2012.748882

http://www.tandfonline.com/doi/full/10.1080/09581596.2012.748882

http://www.tandfonline.com/toc/ccph20/current

http://crisis-scape.net/conference/item/180-unravelling-false-choice-urbanism

http://crisis-scape.net/conference/item/180-unravelling-false-choice-urbanism

http://www.opendemocracy.net/opensecurity/tom-slater/resilience-of-neoliberal-urbanism

http://www.opendemocracy.net/opensecurity/tom-slater/resilience-of-neoliberal-urbanism

Documents

Mental health & wellbeing: crucial contribution to public health challenges – or becoming a bit of a distraction....? Lynne Friedli National Leading Health