mental health, resilience and inequalities: some reflections on the
TRANSCRIPT
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 [email protected]
Ethical challenges for mental health promotion [email protected]
Source: Ingram Pinn, Financial Times
Summary
• Mental wellbeing and the zeitgeist
• Mental wellbeing: the new determinant
• Mental wellbeing and inequalities
• Some ethical reflections
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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
A subjective evaluation of how we feel about and experience
our lives
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It‟s a hearts and minds thing....
(Mental)...Wellbeing......
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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
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There‟s a difference between starving and fasting... Amartya Sen
UK National Wellbeing Debates
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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
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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
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Who is responsible for sad children?
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Return to the social....
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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
Ethical challenges for mental health promotion
“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
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New approach to public health
Source: North
West Living Well
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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
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Because it’s worth it....
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•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
0
0.5
1
1.5
2
2.5
3
3.5
best second third fourth worst
quintiles of wellness
Od
ds
of
rep
ort
ing
ill
ne
ss
as
"li
mit
ing
“ c
om
pa
re w
ith
mo
st
we
ll
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
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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
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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
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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.
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Image: Banksy; Quote: Annabel Ferriman
Reducing inequalities ‘Can you tell your nudge from your nanny?’
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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)
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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)
Ethical challenges for mental health promotion [email protected]
Ethical challenges for mental health promotion [email protected]
“...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
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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
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Ethical challenges for mental health promotion
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
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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‟
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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
Ethical challenges for mental health promotion [email protected]
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)
Ethical challenges for mental health promotion [email protected]