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Adjusting to life circumstances: mental health, resilience and inequalities Lynne Friedli Adjusting to Life Adjusting to life circumstances: mental health, resilience and inequalities Lynne Friedli Adjusting to Life Circumstances: the Impact they can have on Mental Health All Wales Mental Health Promotion Network Conference Cardiff 22 nd October 2008

Something to hold on to …. I did not hear the bird sounds They Something to hold on to …. I did not hear the bird sounds They had left. I did not see the speechless clouds. I saw only the little white dish of my faith, breaking in the crater. I kept saying: I’ve got to have something to hold on to. Anne Sexton Adjusting to life circumstances - Wales MHP Network lynne. friedli@btopenworld. com

This being human is a guest house. Every morning a new arrival. A joy, 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) Adjusting to life circumstances - Wales MHP Network lynne. friedli@btopenworld. com

How important is mental health? Can mental health help to explain outcomes that cannot How important is mental health? 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. . . (Friedli forthcoming) Adjusting to life circumstances - Wales MHP Network lynne. friedli@btopenworld. com

Wider policy context: the well-being agenda If “being poor” once derived its meaning from Wider policy context: the well-being agenda If “being poor” once derived its meaning from the condition of being unemployed, today it draws its meaning primarily from the plight of a flawed consumer. Zygmunt Bauman • Social/economic prosperity and quality of life • Culture of materialism and consumerism Economic/ fiscal policy environmental instability psycho-social instability Adjusting to life circumstances - Wales MHP Network Social recession lynne. friedli@btopenworld. com

Adverse childhood experiences predict health-risk behaviour and morbidity Adverse childhood experiences Health-risk behaviours Social, Adverse childhood experiences predict health-risk behaviour and morbidity Adverse childhood experiences Health-risk behaviours Social, emotional, cognitive damage Source: Felitti et al 1998 Smoking Obesity Physical inactivity Depression Alcoholism Illicit/injected drug use Sexual promiscuity Morbidity Ischemic heart disease Diabetes Stroke Cancer Suicide Skeletal fractures Chronic bronchitis/ emphysema STDs Hepatitis

Adverse Childhood Experiences • emotional, physical or sexual abuse • household substance abuse • Adverse Childhood Experiences • emotional, physical or sexual abuse • household substance abuse • mental illness • incarceration • parental domestic violence • separation or divorce

Conceptual life-course models • Critical period model • With or without later life risk Conceptual life-course models • Critical period model • With or without later life risk factors • With later life effect modifiers • Accumulation of risk • With independent and uncorrelated insults • With correlated insults • "Risk clustering" • "Chains of risk" with additive or trigger effects (Ben-Shlomo and Kuh 2002 ) Adjusting to life circumstances - Wales MHP Network lynne. friedli@btopenworld. com

JRF summary of social evils and influential bodies Big Business Media Government Crime and JRF summary of social evils and influential bodies Big Business Media Government Crime and violence Drugs and alcohol Religion Decline of family Truncated opportunities Decline of community Adjusting to life circumstances - Wales MHP Network Poverty Immigration lynne. friedli@btopenworld. com

Key elements of positive mental health Emotional/cognitive and social well-being • Emotion (affect/feelings ) Key elements of positive mental health Emotional/cognitive and social well-being • Emotion (affect/feelings ) • Cognition (perception, thinking, reasoning) • Social functioning (relationships, engagement) • Coherence (sense of meaning and purpose) Status, Control, Connection, Interaction Adjusting to life circumstances - Wales MHP Network lynne. friedli@btopenworld. com

WEMWBS – Well and HEPS Adults with above average, average and below average WEMWBS WEMWBS – Well and HEPS Adults with above average, average and below average WEMWBS score: 2006 100% 90% 80% 70% % 60% 50% 40% 30% 20% 10% 0% Well? (aged 16+) HEPS (aged 16 -74) Above average Average Below average (Taulbut & Parkinson forthcoming) Adjusting to life circumstances - Wales MHP Network lynne. friedli@btopenworld. com

Benefits of positive mental health A worthwhile goal in itself and leads to better Benefits of positive mental health A worthwhile goal in itself and leads to better outcomes • overall prevalence • physical health: mortality/morbidity • health behaviour • employability, productivity, earnings • educational performance • crime / violence reduction • pro-social behaviour/social integration/relationships • quality of life Adjusting to life circumstances - Wales MHP Network lynne. friedli@btopenworld. com

Life course benefits crime smoking drugs depression suicide no quals • top 50% (no Life course benefits crime smoking drugs depression suicide no quals • top 50% (no conduct problems) 1. 00 • middle 45% (some problems) 1. 95 1. 24 1. 51 1. 24 1. 69 1. 18 • bottom 5% (conduct disorder) 4. 13 1. 59 2. 39 1. 57 3. 00 1. 45 Adjusting to life circumstances - Wales MHP Network lynne. friedli@btopenworld. com

Life course benefits (2) per case £ • Prevention (move bottom 5% to middle Life course benefits (2) per case £ • Prevention (move bottom 5% to middle 45% • Promotion (move middle 45% to top 50%) total for 1 -year cohort in UK £ million Scotland £ million 150, 000 5, 250 4. 2 75, 000 23, 625 18. 9 (Friedli & Parsonage 2007) Adjusting to life circumstances - Wales MHP Network lynne. friedli@btopenworld. com

Contribution of mental health to inequalities Key domains: Education; Employment; Behaviour; Health; Consequences of Contribution of mental health to inequalities Key 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), • chronic disease outcomes (e. g. diabetes) • relationship to health services, including uptake/treatment Adjusting to life circumstances - Wales MHP Network lynne. friedli@btopenworld. com

Mental health and deprivation Not ‘every family in the land’ Findings from 9 large Mental health and deprivation Not ‘every family in the land’ Findings from 9 large scale population based studies: • Material and relative deprivation • Low educational attainment • Unemployment • Environment: poor housing, poor resources, violence • Adverse life events • Poor support networks (Melzer et al 2004; Rogers & Pilgrim 2003) Cycle of invisible barriers: • Poverty of hope, self-worth, aspirations Adjusting to life circumstances - Wales MHP Network lynne. friedli@btopenworld. com

Prevalence of common mental health problems • Lone parents • Economically Inactive • Physical Prevalence of common mental health problems • Lone parents • Economically Inactive • Physical Illness 36% of neurotic disorders 20% of Population 39% of limiting disorders 51% of disabling conditions (Melzer et al 2004)

Psycho-biological pathways. . Status Control Relatedness Chronic low level stress ‘gets under the skin’ Psycho-biological pathways. . Status Control Relatedness Chronic low level stress ‘gets under the skin’ through the neuro-endocrine, cardiovascular and immune systems, influencing : • hormone release e. g. cortisol, • cholesterol levels • blood pressure • inflammation e. g. C-reactive proteins. Adjusting to life circumstances - Wales MHP Network lynne. friedli@btopenworld. com

Untangling the determinants I do worry about this emphasis on individual psychology; You can’t 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 Adjusting to life circumstances - Wales MHP Network lynne. friedli@btopenworld. com

“. . . the Greeks and Romans lived, I suppose, very comfortably though they “. . . 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) Adjusting to life circumstances - Wales MHP Network lynne. friedli@btopenworld. com

Resilience, health assets and capabilities ‘Doing better than expected notwithstanding adversity’ • Resilient places Resilience, health assets and capabilities ‘Doing better than expected notwithstanding adversity’ • Resilient places • Resilient communities • Resilient individuals • Resilient policies Adjusting to life circumstances - Wales MHP Network lynne. friedli@btopenworld. com

Figure 3 Comparison between mortality in resilient and non-resilient constituencies, and between resilient constituencies 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 Adjusting to life circumstances - Wales MHP Network Copyright © 2007 BMJ Publishing Group Ltd. lynne. friedli@btopenworld. com

Resilient children • Secure attachment/home learning environment • Emotional and cognitive capital • Delayed Resilient children • Secure attachment/home learning environment • Emotional and cognitive capital • Delayed transition to adulthood Adjusting to life circumstances - Wales MHP Network lynne. friedli@btopenworld. com

Equalities Review 2007 Crown Copyright Adjusting to life circumstances - Wales MHP Network lynne. Equalities Review 2007 Crown Copyright Adjusting to life circumstances - Wales MHP Network lynne. friedli@btopenworld. com

(the ecology of)Relationships matter (1) • Quality of social relationships is key factor in (the ecology of)Relationships matter (1) • Quality of social relationships is key factor in resilience in the face of adversity; • Social integration buffers effects of low SES Adjusting to life circumstances - Wales MHP Network lynne. friedli@btopenworld. com

Rates of poor social/emotional adjustment (Graham & Power 2004) Adjusting to life circumstances - Rates of poor social/emotional adjustment (Graham & Power 2004) Adjusting to life circumstances - Wales MHP Network lynne. friedli@btopenworld. com

Equalities Review 2007 Crown Copyright Adjusting to life circumstances - Wales MHP Network lynne. Equalities Review 2007 Crown Copyright Adjusting to life circumstances - Wales MHP Network lynne. friedli@btopenworld. com

Figure 3 Comparison between mortality in resilient and non-resilient constituencies, and between resilient constituencies 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 Adjusting to life circumstances - Wales MHP Network Copyright © 2007 BMJ Publishing Group Ltd. lynne. friedli@btopenworld. com

Resilient policies • Policy responses to misfortune • Exposure • Susceptibility • Resistance • Resilient policies • Policy responses to misfortune • Exposure • Susceptibility • Resistance • Service responses • Lay perceptions of poverty and health • Community assets • Collective action • Social relationships Adjusting to life circumstances - Wales MHP Network lynne. friedli@btopenworld. com

(the ecology of)Relationships matter ‘tend to the social and the individual will flourish ’ (the ecology of)Relationships matter ‘tend to the social and the individual will flourish ’ Rutherford 2008 • Mental health is produced socially • Presence or absence of mental health is above all a social indicator • Quality of social relationships is key factor in resilience • Social as well as individual solutions Adjusting to life circumstances - Wales MHP Network lynne. friedli@btopenworld. com

A (wider) framework for action And what I shall endure, you shall endure For A (wider) framework for action And what I shall endure, you shall endure For every atom belonging to me as good belongs to you. . . Walt Whitman Reducing poverty and the impact of poverty Challenging material inequalities Respectful policy responses to misfortune Mental health and well-being Build capacity for collective action (collective efficacy) Adjusting to life circumstances - Wales MHP Network Quality of social relationships lynne. friedli@btopenworld. com

A just society is one that is aware that it is not yet 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 Adjusting to life circumstances - Wales MHP Network lynne. friedli@btopenworld. com

Select bibliography Carlisle Sandra Series of papers on cultural influences on mental health and Select bibliography Carlisle Sandra Series of papers on cultural influences on mental health and well-being in Scotland (http: //www. wellscotland. info/publications/consultations 4. html). Equalities Review (2007) Fairness and Freedom: the final report of the equalities review London: Cabinet Office www. theequalitiesreview. org. uk see also CEHR http: //www. cehr. org. uk/ Lyybomirsky S, King L and Diener E (2005) The benefits of frequent positive affect: does happiness lead to success? Psychological Bulletin 131: 6 Killeen Damian (2008) Is poverty in the UK a denial of people’s human rights? York: Joseph Rowntree Foundation http: //www. jrf. org. uk/knowledge/findings/socialpolicy/2183. asp Commission on Social Determinants of Health http: //www. who. int/social_determinants/resources/en/index. html Adjusting to life circumstances - Wales MHP Network lynne. friedli@btopenworld. com

Select bibliography Bartley M (editor) (2006) Capability and Resilience: beating the odds www. ucl. Select bibliography Bartley M (editor) (2006) Capability and Resilience: beating the odds www. ucl. ac. uk/capabilityandresilience ESRC Friedli L (in press) Mental health, resilience and inequalities – a report for WHO Europe and the Mental Health Foundation London/Copenhagen Felitti VJ Anda RF et al (1998) Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults, AJPM, 14: 4 Friedli L and Parsonage M (2007) Mental health promotion: building an economic case Belfast: Northern Ireland Association for Mental Health Jones C, Burström B et al (2006) Studying social policy and resilience in families facing adversity in different welfare state contexts – the case of Britain and Sweden. International Journal of Health Services 36 (3): 425– 442. Zaveleta RD (2007) The ability to go about without shame: a proposal for internationally comparable indicators of shame and humiliation Oxford: OPHI Adjusting to life circumstances - Wales MHP Network lynne. friedli@btopenworld. com