mental health, resilience and inequalities: some ... · mental health, resilience and inequalities:...

Mental health, resilience and inequalities: some reflections on the challenges of

equity, effectiveness and ethics

Dr Lynne Friedli

WHO Collaborating Centre for Mental Health Promotion, Prevention and Policy

October 12th 2011, Helsinki

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 Ethical challenges for mental health promotion lynne.friedli@btopenworld.com

Ethical challenges for mental health promotion lynne.friedli@btopenworld.com

Source: Ingram Pinn, Financial Times

Summary

• Mental wellbeing and the zeitgeist

• Mental wellbeing: the new determinant

• Mental wellbeing and inequalities

• Some ethical reflections

Pockets People & Places

Prospects

What’s in a name.....

Ethical challenges for mental health promotion

mental health

positive mental health

happiness

wellbeing

quality of life

resilience

mental capital

flourishing

emotional wellbeing

lynne.friedli@btopenworld.com

A subjective evaluation of how we feel about and experience

our lives

It‟s a hearts and minds thing....

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

Dimensions of wellbeing

Mental wellbeing

How we feel... coping style, mood, emotions, subjective

wellbeing

How we think ... learning style,

knowledge, flexibility, innovation, creativity

Relationships with others… listening, communicating, co operating, participating,

empathy, tolerance

Meaning and purpose .... sense of coherence, values, goals, spirituality, politics, beliefs

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?

(Source: Friedli 2009)

Mental wellbeing and current debates

There‟s a difference between starving and fasting... Amartya Sen

UK National Wellbeing Debates

It's time we admitted that there's more to life than money, and it's time we focused not just on GDP but on GWB - general wellbeing David Cameron

http://www.ons.gov.uk/well-being

Measuring our progress Find out how well-being data can start to transform politics

Money Economy, Core Economy

environmental instability

psycho-social instability

Social recession

Economic/ fiscal policy focussed on GDP

materialism consumerism individualism

Economic recession

Well-being depends on certain freedoms being upheld, as well as on economic assets Amartya Sen

Who is responsible for sad children?

Return to the social....

Equity and Social Justice

Wellbeing Solidarity

and the core economy

I am, because we are...

•Wellbeing is produced socially

•Quality of social relationships is key factor in resilience

•Social integration buffers effects of low SES

Mental wellbeing as a core asset...

• Resilient places

• Resilient communities

• Resilient individuals

“extent to which communities are able to exercise informal social controls or come together to tackle common problems”

“mostly to do with the quality of social relationships” Bartley 2006

an appreciative approach that recognises the intrinsic worth in people and places. O‟Leary et al 2011

Appreciative inquiry

Mental wellbeing: the new determinant

New approach to public health

Source: North

West Living Well

National

outcomes

Children have

best start

Longer

healthier lives

Resilient

communities

Tackled

inequalities

Improved

life chances

Improve mental

wellbeing

(WEMWBS)

Reduce

mental

illness GHQ12

High level

outcomes

Improved healthy life expectancy

Reduce

suicide

Increase quality of life

Intermediate

outcomes

Increased Healthy

behaviour Increased

learning &

development

Increased

General

health

Increased

Participation

Stronger social

networks

Greater social

support

Increased Trust

Increased Safety Increased

Equality Increased Social

inclusion

Decreased

Discrimination Increased

Financial

security & less

debt Better Physical

environment

Better Working life

Deceased

Violence

Increased

emotional

intelligence

Increased

meaning &

purpose

Individual

behaviours

Social,

economic &

physical

environments

Service

delivery

outcomes Short-term outcomes related to service delivery

Activities

www.lanarkshirementalhealth.org.uk

Outcome Triangle: Mental Health & Well-being

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 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

Adults reporting chronic muscular-skeletal illness (first) in HSE 2006

odds of reporting illness as "limiting" - adjusted for age and self assessed pain

best second third fourth worst

quintiles of wellness

Recover from, and manage illness sooner

Source: Tom Hennell 2010 The nature of wellbeing and its relationship to inequalities

Influencing costs for: employers, NHS, social care, independent living

Meta analysis: comparative odds of decreased mortality

The relative value of social support/ social integration Source: Holt-Lundstad et al 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 •employability •capacity, motivation and rationale for healthy behaviours •risk for physical health (e.g. coronary heart disease), •chronic disease outcomes (e.g. diabetes) •relationship to health services, including uptake/treatment

Trends in economic analysis

Dept of Health (2011) Economic case for improving quality and efficiency in mental health

•Early intervention and life course savings

•Quality of life, physical health, recovery

•Risk/protective factors and outcome „clusters‟

•Workplace: employability/productivity

•Social context/total place/whole system

•Asset mapping

The economic analyses summarised in this report show that, over and above gains in health and quality of life, the interventions also generate very significant economic benefits including savings in public expenditure.

Image: Banksy; Quote: Annabel Ferriman

Reducing inequalities ‘Can you tell your nudge from your nanny?’

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

Mental health and deprivation

What matters most?

• Individual skills and attributes – (behaviour, attitudes and feelings)

• Family, relationships, support &networks – (people in our lives)

• Material resources – (financial security, environment)

• Inequalities in distribution of resources – (what we have in relation to others)

One of the „hidden costs of individualism‟ is the failure to recognise that people‟s wellbeing can be enhanced by opportunities to act in solidarity with others. Friedli 2011

Commission on the Social Determinants of Health

three key domains for action:

•material requisites

•psycho-social (control over lives)

•political voice (participation in decision making)

“...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)

Some ethical reflections

All societies cater for the disabilities of the average person Martha Nussbaum

Psycho-social factors are used to account for „health damaging behaviours‟, not to deepen understanding of structural inequities Friedli 2011

Supporting individuals

Involving communities

Supporting community initiatives

Community empowerment

Adapted from : Stuteley and Parrish (2010) The Emergence of the HELP Fieldwork Method www.healthempowermentgroup.org.uk

Revisiting community development

Economic modelling supports the conviction that when community engagement is done well, it can be extremely good value for money. NICE 2009 Means that communities:

•Take control •Define issues •Lever in resources •Negotiate with services

Local Economy

Neighbourhood resources

Dimensions of Community wellbeing

Knowledge, skills, wisdom, enterprise

Cultural pride, local traditions,

sense of belonging

Citizens and citizenship

Care, support and mutual aid

Political voice

Informal social control

Social capital Collective

efficacy

Intergenerational solidarity

Source: adapted from StobsWELLbeing Equally Well test site

Association

Focus of interventions

material

individual

social

collective

Policy responses that enhance connections, collectivity and financial security

„Public disregard ruins the spine‟ Brecht

„Power of collective socialisation is often overlooked‟

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)

Select Bibliography Bartley M (ed.) (2006) Capability and Resilience: beating the odds. ESRC Human Capability and Resilience Research Network London www.ucl.ac.uk/capabilityandresilience Friedli L (2009) Mental health, resilience and inequalities – a report for WHO Europe and the Mental Health Foundation London/Copenhagen: Mental Health Foundation and WHO Europe http://www.euro.who.int/document/e92227.pdf Friedli L (2011) Reasons to be cheerful: the count your assets approach to public health Perspectives 30 Summer http://democraticleftscotland.wordpress.com/perspectives/ Solar O and Irwin A (2011) A conceptual framework for action on the social determinants of health Geneva: WHO http://whqlibdoc.who.int/publications/2010/9789241500852_eng.pdf

Select Bibliography Smith Mark K. (2006) James Gustave Speth, green Jazz, social Jazz and community development the encyclopaedia of informal education. http://www.infed.org/community/jazz.htm O‟Leary T, Burkett I and Braithwaite K (2011) Appreciating Assets Dunfermline: IACD/Carnegie UK Trust http://www.iacdglobal.org/files/Carnegie_UK_Trust_Appreciating_Assets_FINAL-1.pdf Friedli L (2011) Speaking allowed: the political voice of public health Slovenian Journal of Public Health (in press)

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