Seeing things

1. Mental health & wellbeing: crucial contribution to public health challenges – or becoming a bit of a distraction....?Lynne FriedliNational Leading Health & Wellbeing ProgrammePeterborough16th May 2014

2. Seeing things ‘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 lynne.friedli@btopenworld.com

3. 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? lynne.friedli@btopenworld.com

4. Public health “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 Health inequalities are a symptom, an outcome, of inequalities in income, wealth and power CSDH Public health: understand & act upon the distribution & causes of population patterns of health, disease & wellbeingKrieger 2012; Birn 2009) lynne.friedli@btopenworld.com

5. Deepening the relationship... What is the special contribution of mental health to the policy and practice of public health – and vice versa? lynne.friedli@btopenworld.com

6. lynne.friedli@btopenworld.com Source: PHE/Stansfield MH leadership: core competencies (draft)

7. lynne.friedli@btopenworld.com Source: PHE/Stansfield MH leadership: core competencies (draft)

8. (Mental)...Wellbeing...... A subjective evaluation of how we feel about, experience & interpret our lives It’s a hearts and minds thing.... lynne.friedli@btopenworld.com

9. What we all need.... It’s in illness, old age and disability that we know what love is Julia Fernandez To be: • Heard • Believed • Understood • Respected Picture Source: http://sarahdrummond.wordpress.com/2010/12/13/an-assets-alliance-scotland/ lynne.friedli@btopenworld.com

10. Best start Quality work Healthy places Income Prevention Education & skills

11. ‘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 S Mental Health Determinants Social lynne.friedli@btopenworld.com

12. What’s the offer? An evidence base that is transforming how we understand and deliver public health Picture source: Sleeping with spirit #2 Bradley Guiboche courtesywww.artbeatstudio.ca lynne.friedli@btopenworld.com

13. Because it’s worth it.... While there are multiple barriers to economic growth, the growth of human potential is unlimited Coote and Franklin 2010 • 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 lynne.friedli@btopenworld.com

14. 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? lynne.friedli@btopenworld.com

15. 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 lynne.friedli@btopenworld.com

16. ‘It gets so lonely around here that I phone myself seven or eight times a day, just to see how I am’ Phantom Tolbooth • 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 lynne.friedli@btopenworld.com

17. What SDOH can help with 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 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 lynne.friedli@btopenworld.com

18. Public (Mental) health leadership Over to you...... • What are responsibilities of leadership around public mental health? • What does it mean to act on the social determinants of mental health? lynne.friedli@btopenworld.com

19. Public health & the wellbeing debates All societies cater for the disabilities of the average person Martha Nussbaum lynne.friedli@btopenworld.com

20. ‘Grace beats karma’ a paradox.... As material inequalities grow, so the pursuit of non material explanations proliferates Picture source: Dolly Sen My story is on my skin http://mentalhealthrecovery.omeka.net/items/show/90 lynne.friedli@btopenworld.com

21. Commission on the Social Determinants of Health 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 • material requisites • psycho-social (control over lives) • political voice (participation in decision making) Status Control Relatedness lynne.friedli@btopenworld.com

22. Capabilities & fundamental entitlements Source: Nussbaum 2011

23. Social Epigenesis: biological embedding * Early in life, the environment talks to genes, and the genes listen Status Control Relatedness “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 lynne.friedli@btopenworld.com

24. 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 lynne.friedli@btopenworld.com

25. Count your assets? ‘...the development of their own capabilities to manage their way out of poverty’ Scottish Government 2011 They 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 lynne.friedli@btopenworld.com

26. Strengths based lexicon • 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 • 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 lynne.friedli@btopenworld.com

27. 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 lynne.friedli@btopenworld.com

28. 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 lynne.friedli@btopenworld.com

29. Framing and erasure 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 • Construction of psychological ideal • Poor outcomes are a result of psychological deficit • Erasure of economic realities & social determinants • Compulsory positive affect & psychological coercion lynne.friedli@btopenworld.com

30. 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

31. 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) lynne.friedli@btopenworld.com

32. 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 lynne.friedli@btopenworld.com

33. Big fish/little fish: questions of power are unavoidable • Services, rights and resources • Respect & relationships • Social justice lynne.friedli@btopenworld.com

34. Pathways to Mental health & Wellbeing interventions Economic capital Human capital Identity capital Social capital Environmental capital Mental health and well-being Adapted from Centre for Research on the Wider Benefits of Learning (http://www.learningbenefits.net/) lynne.friedli@btopenworld.com

35. Responding to the determinants Resources, relationships, meaning, respect Relationships and Respect Social support, collectivity, respect for people experiencing misfortune Material resources Increasing equitable access to assets that support mental wellbeing Interventions to promote mental wellbeing Meaningful activity Valued opportunities to contribute Inner resources Opportunities to develop senses, imagination, reason, thought (Martha Nussbaum Capabilities) lynne.friedli@btopenworld.com

36. 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’ lynne.friedli@btopenworld.com

37. Appendices lynne.friedli@btopenworld.com

38. Select Bibliography Living on nothing is trying not to hear the intellectual arguments and lofty ideals about living on nothing put forward by those who are not living on nothing. living on nothing is dying Out of the Shadows: Liz Prest Escape by Kathleen V Crosby lynne.friedli@btopenworld.com

39. 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 lynne.friedli@btopenworld.com

40. 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 healthCritical 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 lynne.friedli@btopenworld.com