Mental Health
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The document discusses mental health and how society should respond. It argues that mental health is produced socially and influenced by factors like inequality, poverty, and quality of social relationships. A fair response needs to reduce inequalities, provide meaningful social roles and activities, build social support networks, and treat those with mental health issues with respect as part of the human experience rather than a moral failure.
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Mental Health
- 1. mental health; mental illness: how should we respond? Lynne Friedli Fair Deal for Mental Illness Debate: Socialist Health Association Coventry 16th May 2009
- 2. This being human is a guest house. Every morning a new arrival. A joy, a depression, a meanness, Some momentary awareness comes As an unexpected visitor. Welcome and entertain them all. Even if they’re a crowd of sorrows, Who violently sweep your house Empty of its furniture. Still treat each guest honourably. He may be clearing you out for some new delight. The dark thought, the shame, the malice, Meet them at the door laughing, And invite them in. (Jelaluddin Rumi, 1207-73) Socialist Health Association lynne.friedli@btopenworld.com
- 3. During these months something had matured in me All I’d to do was let it flourish. Just to have grown enough to accept my destiny. Every pretty blouse I put on a kind of celebration. I feel so light and radiant and cheerful. In suffering we share our loss with all creation. No admittance to Jews. The air I breathe is mine. That man cycling on Beethovenstraat, His yellow star of David a crocus in the sunshine. Such ripening strength. Gone the Bohemian waif. I want to be there at every front. I don’t ever want to be what they’ll call ‘safe’. from Etty Hillesum by Micheal O’Siadhail Socialist Health Association lynne.friedli@btopenworld.com
- 4. Dimensions of mental health If I am not for myself, who will be for me? And if I am only for myself, what am I? If not now, when? Emotional resources Cognitive resources e.g. coping style, e.g. learning style, mood, emotional knowledge, flexibility, intelligence innovation, creativity Mental health (capital) Social skills e.g. listening, Meaning and relating, communicating, purpose e.g. vision, co operating goals, connectedness Socialist Health Association lynne.friedli@btopenworld.com
- 5. Outcomes associated with positive mental health A worthwhile goal in itself and leads to better outcomes: • reduces prevalence of mental illness • physical health: mortality/morbidity • health behaviour • employability, productivity, earnings • educational performance • crime / violence reduction • pro-social behaviour/social integration/relationships • quality of life Socialist Health Association lynne.friedli@btopenworld.com
- 6. Promoting mental health: two routes A disembodied psychology which separates ‘what goes on inside people’s heads’ from social structure and context Critical Psychology Forum Public mental health •Self efficacy •Collective efficacy •Autonomy •Social responsibility •Individual responsibility •Wider determinants •Health behaviours •Social solutions • Money economy •Core economy •Volunteering •Timebanks •CBT •Social prescribing Socialist Health Association lynne.friedli@btopenworld.com
- 7. Policy context and current debates.. If “being poor” once derived its meaning from being unemployed, today it draws its meaning primarily from the plight of a flawed consumer. Zygmunt Bauman • Decline of family/community/quality of life • Culture of materialism and consumerism • Plight of poor, dependent and ‘non-productive’ • Capacity of public services, lack of trust and democratic deficit environmental Economic/ instability Social fiscal policy psycho-social recession instability Socialist Health Association lynne.friedli@btopenworld.com
- 8. Mental health and recession Socialist Health Association lynne.friedli@btopenworld.com
- 9. Untangling the determinants I do worry about this emphasis on individual psychology; You can’t separate thoughts, feelings, self esteem, motivation from the material circumstances of people’s lives. Is it great to be positive? Maybe people are right to be pissed off.” Positive steps interviews • Individual skills and attributes • Material resources • Inequalities in distribution of resources Socialist Health Association lynne.friedli@btopenworld.com
- 10. Mental health and deprivation Not ‘every family in the land’ Findings from 9 large scale population based studies: • Material and relative deprivation • Childhood socio-economic position • Low educational attainment • Unemployment • Environment: poor housing, poor resources, violence • Adverse life events • Poor support networks (Melzer et al 2004; Rogers & Pilgrim 2003; Stansfeld et al 2008; APMS 2007) Cycle of invisible barriers: • Poverty of hope, self-worth, aspirations Towards a mentally flourishing Lanarkshire lynne.friedli@btopenworld.com
- 11. Mental Health in Relation to Income Inequality Developed from: Pickett KE, James O, Wilkinson RG. Income inequality and the prevalence of mental illness: a preliminary international analysis. Journal of Epidemiology and Community Health 2006; 60: 646-7 http://www.equalitytrust.org.uk/why/evidence/mental-health
- 12. Health and Social Problems in Relation to Inequality Correlation: r=0.81, p < 0.0001 (excl USA: r=0.79, p < 0.0001) Index of: Life expectancy, Math & Literacy, Infant mortality, Homicides, Imprisonment rate, Teenage births, Trust, Obesity, Mental illness, Social mobility. Socialist HealthPickett KE The Spirit Level 2009 Wilkinson RG, Association lynne.friedli@btopenworld.com
- 13. Health and Social Problems in relation to average incomes (GDP per capita US$ ppp) Index of: Correlation: r=0.81, p < 0.0001 Life (excl USA: r=0.79, p < 0.0001) expectancy, Math & Literacy, Infant mortality, Homicides, Imprisonment rate, Teenage births, Trust, Obesity, Mental illness, Social mobility. Socialist HealthPickett KE The Spirit Level 2009 Wilkinson RG, Association lynne.friedli@btopenworld.com
- 14. “...the Greeks and Romans lived, I suppose, very comfortably though they had no linen. But in the present times, through the greater part of Europe, a creditable day labourer would be ashamed to appear in public without a linen shirt, the want of which would be supposed to denote that disgraceful degree of poverty which, it is presumed, nobody can fall into without extreme bad conduct. Custom in the same manner has rendered leather shoes a necessary of life in England. The poorest creditable person of either sex would be ashamed to appear in pubic without them” (Adam Smith Wealth of Nations 1776 cited in Zaveleta 2008) Socialist Health Association lynne.friedli@btopenworld.com
- 15. Resilience, health assets and capabilities ‘To value the contribution of those whom the market excludes or devalues and whose genuine work is not acknowledged or rewarded’ Edgar Cahn Distribution of resources • Resilient places Quality of relationships • Resilient communities Policy responses to misfortune • Resilient individuals Valued social role Socialist Health Association lynne.friedli@btopenworld.com
- 16. (the ecology of)Relationships matter Tend to the social and the individual will flourish Jonathon Rutherford ental health is produced socially resence or absence of mental health is above all a social indicator ocial as well as individual solutions Socialist Health Association lynne.friedli@btopenworld.com
- 17. The quality of policy responses to misfortune ‘Belonging' : trusting in the benefits of human solidarity and in the institutions that arise out of that solidarity Zygmunt Bauman • We are all vulnerable and dependent • We’re all in this together • Collective efficacy • ‘Other regarding’ agency Socialist Health Association lynne.friedli@btopenworld.com
- 18. What would a fair deal look like? Resources, relationships, meaning, respect • Reduce economic inequalities i.e. Mind the gap • Include social outcomes: the quality of relationships matters • Valued roles and multiplicity of meanings • Treat people experiencing problems with respect: vulnerability and dependency are part of the human condition, not a mark of moral failure Socialist Health Association lynne.friedli@btopenworld.com
- 19. A (wider) framework for effective action And what I shall endure, you shall endure For every atom belonging to me as good belongs to you...... Walt Whitman Reduce poverty Respectful policy and the impact of responses to misfortune poverty Mental health Opportunities and Mental Quality of social for meaningful Capital relationships activity: education, (family, schools, training, volunteering workplace, communities) Build capacity for Reduce material collective action inequalities (collective efficacy) Socialist Health Association lynne.friedli@btopenworld.com
- 20. Figure 1 (A) Pyramid of capitalist system. Issued by Nedeljkovich, Brashick and Kuharich, for the International Workers of the World (IWW), 1913.18 Krieger, N J Epidemiol Community Health 2008;62:1098-1104 Socialist Health Association lynne.friedli@btopenworld.com Copyright ©2008 BMJ Publishing Group Ltd.
- 21. Socialist Health Association lynne.friedli@btopenworld.com
- 22. Socialist Health Association lynne.friedli@btopenworld.com
- 23. Socialist Health Association lynne.friedli@btopenworld.com
Editor's Notes
- Born in Persia (now part of Afghanistan) – last year 800 th anniversary of his birth. Lived most of his life in Turkey – but wrote in Persian, and hence is generally claimed by Iran.
- Mental capital underpins resilience – levels of mental capital will contribute significantly to Europe’s capacity to recover from the economic crisis and to respond to changes in the global economy and world of work Mental capital is likely to become more important – lifelong learning, productivity, innovation
- By increasing mental health, we can modify certain outcomes, even if mental illness remains, even if other risk factors remain
- Communities in control Putting people first World class commissioning decline of family and community public safety, fear of crime excessive individualism, fuelled by consumerism and a materialist culture public disaffection and disengagement with civic life the role and capacity of public services, notably in relation to the shift towards promotion, prevention and ‘well-being’
- Well-being as organising concept for concerns about environmental and social fragmentation e.g. in the well rehearsed rhetoric on limitations of GDP as a measure of progress Current patterns of consumption destroying natural/ psycho/social environment Material possessions don’t make you happy etc So – well-being as organising concept rather than unequal distribution Result is failure to distinguish between critique of materialism and critique of how material wealth is distributed – we’re coming close to running progs which attempt to adapt people’s cognitive style to accept injustice. Non income benefits much more available to those in higher social classes – the most frequently cited happiness factors in the well-being literature – health, autonomy, environmental quality, social embededness, intimate relationships – are not just influenced by ses but a product of it. Major causes of unhappiness: loss, threat of loss, and inability to meet valued goals – everyday currency of fifth of Scots living in poverty, (half of whom are in work) quarter of kids growing up in poor households
- First class travel story At the core of this is the relative importance of: psycho-social factors or attributes (relationships, life satisfaction, positive affect, cognitive style) material factors (income, housing, employment) the influence of inequalities or more precisely, injustice as a mediator between poor socio economic circumstances and poor health Context is crucial in interpreting individual attributes – lack of trust, lack of participation, failure to vote – survival/rational/ Contradictory trend – as inequalities in income and wealth widen, so pursuit of (and influence of) non material explanations for the social gradient in health outcomes increases. Puzzling – very strong relationship between subjective well-being (life satisfaction and happiness) and income – both within countries and between countries - income is a powerful force shaping distribution of happiness Material goods are not just functional but symbolic
- an enduring perception that mental illness is a random misfortune CMD – 1993 – 15.5% 2000 17.5% 2007 17.6% - largest increase for women 45-64 rose by one fifth. Self harm increase women 16-24 it is the poorest and most deprived families who bear the main burden of mental distress. Lone parents, those with physical illnesses and the unemployed make up 20% of the population, but 51% of those with disabling mental disorders A strong social gradient in mental health was found, the prevalence of psychological distress increasing by decreasing social status. Psychosocial factors, including self-efficacy, sense of powerlessness, control of work, social support and negative life events, in particular economic problems, as well as life style factors (physical exercise, BMI, smoking) and somatic health, likewise showed a social gradient, all risk factors increasing by decreasing social status. When adjusting for the risk factors in multivariate statistical analyses, the social gradient in mental health was eliminated. Low self-efficacy and sense of powerlessness emerged as important explanatory factors, alongside with poor social support, economic problems, smoking and somatic disorder.
- Reducing inequality is necessary, but not sufficient – there are other factors
- Amartya Sen has suggested that the ability to go about without shame is a basic human freedom or capability and should be included as a core indicator of poverty Reminder – how we feel matters Inseparable from current debates about social justice – ethical and not merely instrumental dimensions
- Whether we look at drug abuse, specific diseases e.g. CHD, CVD, overall morbidity, mortality, education, crime, alcohol – known risk factors do not explain all variation; not everyone who is exposed has poor outcomes. Very considerable body of research suggests that psychological assets confer resilience and protection – at all levels
- Collective efficacy as well as personal efficacy Other regarding agency Freedom enhanced by acting with and for others Attachment style – poverty and disadvantage have indirect influence on attachment style Impact of individual, cultural, environmental and economic factors on relationships: social skills, transport, child friendly spaces, somewhere to meet, financial reciprocity (it’s my round....) More and more aware of status and social recognition – less aware of the disadvantages we share with others and the benefits of collective redress – individual responsibility for failure and adversity
- Quality of relationships between institutions and individuals – building linking/vertical social capital
- Asset building: reduce risk of debt Meaningful activity: alternatives to employment Co-production: reduce risk of cuts in services Social solutions: families, schools, workplaces, communities credit unions, debt counselling, landshare, social protection agenda Volunteering, training, skills exchange, incentives to keep people employed Time banks, social prescribing, community referrals
- Driven to Excess Hart (2008)