Mental Health, Resilience and Inequalities
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Lynne Friedli
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Mental Health, Resilience and Inequalities
- 1. Mental health, resilience and inequalities: some reflections on current debates Lynne Friedli Inequality and Mental Health Seminar Socialist Health Association 9th February 2010
- 2. Summary A just society is one that is aware that it is not yet sufficiently just, that is haunted by this awareness and thereby spurred into action Zygmunt Bauman razy like us; happy like us: diagnosis and its discontents he true causes of things: mental health as a determinant am, because we are: relationships and the core economy Respectful responses to misfortune ind the gap: mental health and inequalities Socialist Health Association lynne.friedli@btopenworld.com hat can we do: priorities for action?
- 3. 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
- 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) Meaning and Social skills e.g. listening, purpose e.g. vision, relating, communicating, spiritual growth, co operating, accepting goals, connectedness Socialist Health Association lynne.friedli@btopenworld.com
- 5. Mental health as a determinant? Can mental health help to explain outcomes that cannot be wholly accounted for by other factors? • Contribution mental health and mental illness make to wide range of outcomes • The ‘unexplained excess’ – classical risk factors do not account for level of variation in outcomes • Presence as well as absence... • Key element of resilience (Friedli 2009) Socialist Health Association lynne.friedli@btopenworld.com
- 6. 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
- 7. Resilience, health assets and capabilities Towards an Index of Multiple Assets... • Resilient places “extent to which communities are able to exercise informal social controls or come • Resilient communities together to tackle common problems” • Resilient individuals “mostly about the quality of human relationships” Socialist Health Association lynne.friedli@btopenworld.com
- 8. Figure 3 Comparison between mortality in resilient and non-resilient constituencies, and between resilient constituencies and the British average (1996-2001). Tunstall, H. et al. J Epidemiol Community Health 2007;61:337-343 Socialist Health Association lynne.friedli@btopenworld.com Copyright ©2007 BMJ Publishing Group Ltd.
- 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 ndividual skills and attributes ocial relationships, support and networks aterial resources Socialist Health Association lynne.friedli@btopenworld.com
- 10. “...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
- 11. Mental wellbeing and rebuilding the core economy “It gets so lonely around here that I phone myself seven or eight times a day, just to see how I am” (Phantom Tolbooth) Socialist Health Association lynne.friedli@btopenworld.com
- 12. Economic policy, sustainability and wellbeing 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 environmental Economic/ instability Social fiscal policy psycho-social recession instability Socialist Health Association lynne.friedli@btopenworld.com
- 13. Return to the social.... To value the contribution of those whom the market excludes or devalues and whose genuine work is not acknowledged or rewarded Edgar Cahn I am, because we are... Socialist Health Association lynne.friedli@btopenworld.com
- 14. Untangling the politics of wellbeing How things are distributed: How things are done: economic/fiscal policy culture and values well-being: critique inequalities: critique of of materialism how material assets are distributed Socialist Health Association lynne.friedli@btopenworld.com
- 15. Mental health and inequalities The importance of mental health is directly and indirectly related at every level to human responses to inequalities Socialist Health Association lynne.friedli@btopenworld.com
- 16. 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 Socialist Health Association lynne.friedli@btopenworld.com
- 17. Equalities Review 2007 Crown Copyright Socialist Health Association lynne.friedli@btopenworld.com
- 18. CMD, by household income and sex 30 24 25.1 25 23.5 20.1 20 18.1 16.2 percent 13.1 Men 15 10.1 Women 8.8 8.6 10 5 0 Highest Second Middle Second Lowest quintile highest lowest quintile Equivalised household income Source: APMS 2007, all adults, age-standardised
- 19. Mental health of children by parental income Percentage of children with a mental disorder 25% 20% 15% 10% 5% 0% under £100-£199 £200-£299 £300-£399 £400-£499 £500-£599 £600-£770 Over £770 £100 Gross weekly household income Source: Meltzer et al 2000 Mental health of children and adolescents in Great Britain Socialist Health Association lynne.friedli@btopenworld.com
- 20. Rates of poor social/emotional adjustment (Graham & Power 2004) Socialist Health Association lynne.friedli@btopenworld.com
- 21. Equalities Review 2007 Crown Copyright Socialist Health Association lynne.friedli@btopenworld.com
- 22. Contribution of mental health to inequalities ey domains: education/employment/behaviour /health/ consequences of illness /services (Whitehead & Dahlgren 2006) Mental health is a significant determinant in each case, influencing: • readiness for school/learning • employability • capacity, motivation and rationale for healthy behaviours • risk for physical health (e.g. coronary heart disease), Socialist Health Association lynne.friedli@btopenworld.com • chronic disease outcomes (e.g. diabetes)
- 23. What can we do? Priorities for action Tend to the social and the individual will flourish Jonathan Rutherford I have a deep conviction: we will not change our behaviour until we change our performance measures. And our behaviour absolutely must change. President Nicolas Sarkozy Social networks make change possible. Social networks are the very immune system of society. Co production: a manifesto Socialist Health Association lynne.friedli@btopenworld.com
- 24. Scope of public mental health Social and material outcomes Material resources Relationships and Increasing equitable access Respect to assets that support Social support, collectivity, mental wellbeing respect for people Action to experiencing misfortune promote mental wellbeing Meaningful activity Inner resources Expand opportunities Strengthening to contribute psycho-social, life skills and resilience Socialist Health Association lynne.friedli@btopenworld.com
- 25. Developing social and material solutions • Maximize Income: debt; credit; social enterprise; asset transfer, benefits; pay; training; co production; online markets • Optimize Space: green; blue; public; landshare •Expand opportunities to contribute: time banks; volunteering, value those who contribute to core economy •Social Contact: social prescribing; reduce barriers – think ‘social impact’ (bureaucracy, MVT, street level incivilities; transport) •Imagination: arts, culture and creativity •Think children: parenting support; play; contact with nature •Life long learning: HLE; literacy, basic skills, apprenticeships Socialist Health Association lynne.friedli@btopenworld.com
- 26. (the ecology of)Relationships matter We do not have to be a Gandhi, or a Martin Luther King, or a Nelson Mandela or a Desmond Tutu or an Aung San Suu Kyi, to recognise that we can have aims or priorities that differ from the single minded pursuit of our own well being only. Amartya Sen ental health is produced socially uality of social relationships is key factor in resilience ocial integration buffers effects of low SES e-building the core economy: home, lynne.friedli@btopenworld.com Socialist Health Association family, community,
- 27. Responding to the determinants of mental health and well-being Resources, relationships, meaning, respect • Reduce economic inequalities i.e. Mind the gap • Include social outcomes: the quality of relationships matters • Strengthen opportunities for meaningful activity e.g. volunteering, community participation, timebanks • 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
- 28. 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
- 29. 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
- 30. ‘To value the contribution of those whom the market excludes or devalues and whose genuine work is not acknowledged or rewarded’ Edgar Cahn Landshare: 3620 Landowners; 28452 Growers; 4335 Helpers http://landshare.channel4.com/ Socialist Health Association lynne.friedli@btopenworld.com
- 31. http://www.capitalgrowth.org/home/ Socialist Health Association lynne.friedli@btopenworld.com
- 32. Socialist Health Association lynne.friedli@btopenworld.com
- 33. What if? http://www.what-if.info/SIT_IN_part1.html Socialist Health Association lynne.friedli@btopenworld.com
- 34. Socialist Health Association lynne.friedli@btopenworld.com
Editor's Notes
- Sen’s capability approach, by comparison, assesses individual well-being with reference to capability sets that describe what individuals are free to do or to become
- 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
- Although there is clear evidence for biological factors (neuroendocrine markers, genetic factors and neuroimaging indices of brain structure and function), these occur in the context of environmental influences the ability to reinterpret an adverse event to find meaning or opportunity. neuroimaging research has increasingly entered the realms of social neuroscience, with studies examining the neural basis of social behaviours. Given the clear importance of social factors in adaptive and resilient behaviours Both social cooperation and inclusion/exclusion may be relevant to understanding how social support networks modulate resilience.
- By increasing mental health, we can modify certain outcomes, even if mental illness remains, even if other risk factors remain
- 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
- Difference in mortality between deprived areas that are resilient and non resilient: for 30-44 year old is about 25% - Although the resilient constituencies have low mortality relative to their economic peers, their rates remain high (25%) relative to the British average. The effects of economic disadvantage on health are lessened but not entirely removed. Excess greatest in the most deprived areas
- 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
- 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
- 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’ Unequal outcomes from economic growth – plus increase in inequality Economic indicators e.g. GDP don’t capture quality of life outcomes that influence wellbeing
- 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
- 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.
- In general, Britain is a happy nation: nine in ten people say they are happy. Women, young adults and oldest age groups, people in good health, and people who are married or cohabiting are more likely to say they are happy. People tend to be optimistic about the future, with seven in ten expecting to have more good experiences than bad in the next fi ve to ten years. However, there is a social gradient in both happiness and optimism, with people from social grades AB signifi cantly more likely than people from social grades DE to expect to have more positive than negative experiences in the future (77% compared with 64%).
- DECLINING HOUSEHOLD INCOME ASSOCIATIED WITH INCREASED CMD ACROSS THE DISORDERS WOMEN IN THE SECOND HIGHEST HOUSEHOLD INCOME GROUP – THOUGHTS?
- Mental health problems are of course correlated with parental income What more than parental income matters for adult outcomes?
- Those who are well resourced are more likely to have better mental health Marked socio-economic gradients in social and emotional adjustment across childhood, with no evidence that the gradients narrow as children get older. SES patterns anxiety, aggression, confidence, emotional and cognitive development, concentration and hence readiness for school For those who are poor, the effects of material disadvantage are only partially offset by better emotional and cognitive skills Take the impressive results of pre-school programmes e.g. Perry High Scope – among deprived children, those on the programme did very much better than those not on the programme – but better off children had better outcomes without any programme at all
- Relationship between social/emotional adjustment and outcomes is extremely strong – for crime, drug and alcohol misuse, suicide, smoking Even so, the power of early indicators of emotional and cognitive attributes is strongly influenced by ses By age 16, clever poorer children (reading skills at 5) are doing worse in exams than richer children who had poorer skills at 5. EPPE research – largest pre school effectiveness study HLE – structure, reading, educational stimuli and activities, sense of efficacy (believed success down to child making more effort/ paying attention at school), high expectations, The strongest effect on children’s resilience at age 5 and 10 is their level of self-regulation (independence and concentration) at the start of school. EPPE found that b eing female, higher parental education and income, quality of ‘home learning environment’, quality of pre-school and amount of time in pre-school all are associated with increases in self-regulation, whilst lower birth weight, eligibility for free school meals, developmental and behavioural problems are associated with decreases in self-regulation. Personal capital – self esteem, self efficacy, readiness to learn, positive social identity
- Although it is frequently noted that health enables a person to function as an agent and contributes to inequalities in people’s capability to function (Anand 1993), it is mental health that constitutes the key determinant of agency and helps to explain the relationship between low levels of mental well-being and neglect of self, neglect of others and a range of self harming behaviours, including self sedation and self medication e.g. through alcohol, high fat and sugar consumption.
- Closeness and accessibility of green spaces in residential areas also influences overall levels of physical activity among children and young people. The more green space there is, the greater the amount of physical activity The Communities that Care programme clusters of risk factors with strong social themes, with deprivation intersecting with family conflict, school disorganisation, community disorganisation and neglect, high turnover and lack of place attachment, alienation and lack of social commitment. Protective factors were very similar to those identified by Clements et al (2008) including: • strong bonds with family, friends and teachers; • opportunities for involvement in families, schools and communities; • good social and learning skills; • recognition and praise for positive behaviour. The average resident on a busy street had less than one quarter of local friends compared with those living on a similar street with little traffic. Hart found that levels of motor traffic on residential streets are associated both with poor health and weakened social cohesion.
- Attachment style – poverty and disadvantage have indirect influence on attachment style individual-level variables and area wide variables predict trust – youth, ethnicity, class, non home owners – area wide – poorer neighbourhoods, high crime, diverse neighbourhoods we should beware lest a preoccupation with trust obscure what should be a more central concern with social justice. 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....)
- 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
- London’s Great Outdoors – A Manifesto for Public Space Capital Growth