Promoting mental wellbeing and resilience

Dr Gillian Richardson, Policy and International Health - WHO Collaboration Centre, Public Health Wales

Together for Mental Health 2019

People don't want much. They want:

"Someone to love, somewhere to live, somewhere to work and something to

hope for."

Norman Kirk (1923-1974)A personal philosophy

from the 29th Prime Minister of New Zealand

“a dynamic state, in which the individual is able to develop their potential, work productively and creatively, build strong and positive relationships with others, and contribute to their community. It is enhanced when an individual is able to fulfil their personal and social goals and achieve a sense of purpose in society.”Foresight Mental Capital and Wellbeing Project (2008) Final Project report –Executive summary. London: The Government Office for Science.

How can we define mental wellbeing ?

• Somewhere to Live, Something to Do, Someone to Love: Examining Levels and Sources of Social Capital Among People with Disabilities

• Christina Dimakos Department of Psychology, Wilfrid Laurier University

• Stuart B. Kamenetsky Department of Psychology, University of Toronto Mississauga

• Al Condeluci Community Living and Support Services

• Jamie Curran Community Living Mississauga

• Patti Flaherty CONNECT Communities, Vancouver

• Jeffrey Fromknecht Side Project Inc.

• Marti Howard John F. Murphy Homes

• Janet Williams Communityworks, Inc.

Canadian Journal of Disability Studies Vol 5 No 4 (2016)

• Social Trust

• Social support

• Diversity of Friendships

• Participation

• Civic/Community Involvement

• Informal Socialising

Social Capital Index

Social capital theory advocates that the support systems provided by our networks of family, friends, neighbours, coworkers,acquaintancesand other associations have value and offer benefits in concrete and measurable ways.

• Robert Putnam (2000)

• “connections among individuals - social networks and the norms of reciprocity and trustworthiness that arise from them”

Is Mental Wellbeing a Personal or Social Construct or Both?The role of relationships

Photographs; Telegraph.co.uk;ForeignAffairs.com;Uyghuramerican.org

‘Perfect love casts out fear, because fear has to do with punishment’ (1 John 4:18, NIV New Testament)

• Whitehall & Finnish studies - low position in chain of command, less control over life. Less predictability, more stress. Cortisol response to real or anticipated threat.

• Peace-time repression/social exclusion/rights denial

Fear and loss - The antitheses to hope

A fifth pre-requisite to mental wellbeing - Freedom from fear

Positive Stress –

Mild and short lived stress response required for healthy development

Tolerable Stress –

More severe stress response but limited in time and

allows for recovery

Toxic Stress –

Extreme, frequent or extended activation of body's

stress response without buffering of supported adult

Positive role model, emotional buffering, resilience. Intense, repeated, unaddressed.

Impact of stress

Photographs: ABC online, Guardian online (Darrin ZammitLupi/Reuters);nytimes.com

Freedom from fear

• Reporters and human rights lawyers

• Conflict and genocide – victims and sanctuary seekers

• People living in poverty

• Child/Adult living in domestic violence

By Karte: NordNordWest, Lizenz: Creative Commons by-sa-3.0 de, CC BY-SA 3.0 de, https://commons.wikimedia.org/w/index.php?curid=80887311

Reporters without Borders and the Press Freedom Index2019 Map

• Natural order of loss - bereavement

• Loss outside the natural order – not predicted/usual

• Loss of health

• Loss of marriage/relationships

• Loss of job/peer support network/status

• Loss of Home/Country/Culture

• Loss of freedom/choice

LossPart of human experience

At RestThreat

Fight or Flight

Exhausted

Recovery At Rest

Healthy response

Stress hormone release

Affects brain development and alters development of nervous, hormonal and immune systems

Chronic Stress from ACEs over-develop ‘life-preserving’ part of the brain –on high alert.

ACEs

FixedAllostatic load,

Decreased repair

Tau et al, 2010; Mercy, Butchart, Bellis et al, 2014

Effect of chronic stress in childhood

Compared to those with no ACEs, those 4+ ACEs were:

3.7x ↑ to be currently receiving treatment for mental illness

6.1x ↑ to have ever received treatment for mental illness

9.5 ↑ to have ever felt suicidal or self-harmed

Relationship between ACEs and mental illness

0%

10%

20%

30%

40%

50%

60%

70%

Lifetime mental illness Current mental illness Felt suicidal or self-

harmed

0 ACEs 1 ACE 2-3 ACEs 4+ ACEs64%23%

30%9%39%6%

What is resilience?

The ability to

• Bounce back from adversity

• Work through challenges

• Overcome obstacles

• WHO Health 2020 defines resilience as:

“ The dynamic process of adapting well and responding individually or collectively in the

face of challenging circumstances, economic crisis, psychological stress, trauma, tragedy,

threats, and other significant sources of stress. It can be described as an ability to

withstand, to cope or to recover from the effects of such circumstances and the process

of identifying assets and enabling factors…”

Breaking the cycle – Building Resilience

Social capital (individual level) reflects an individual’s relationships and connections with others, including:

• Positive relationships, along with a sense of meaning and accomplishment, are of real importance to resilience and a lack of positive relationships can lead to vulnerability.

• Family cohesion, warm and emotionally responsive care-giving, and parent-child relationships are important for the development of emotional and cognitive regulation and secure attachment

• Social relationships and engagement in community life are important for individual resilience and can affect mental wellbeing. Relationships give people a profound sense of emotional security. Social support may be linked with increased use of active coping mechanisms such as problem-solving, and increased feelings of belonging and solidarity encouraging healthy coping behaviours, such as emotional regulation.

• • Community support such as peer networks, and supportive environments such as schools are assets for resilience .

Individual and Community Resilience Report (Davies A, et al 2019) Mental capital, Wellbeing and Social Capital

Professor Mark A. BellisDirector of Policy Research & Development, Public Health Wales

Does Resilience Trump ACEs?Results from the Welsh ACEs and Resilience Survey

ACEs and Resilience

The Resilience Research Centre Adult Resilience Measure (RRC-ARM), Wales, 2017 The Resilience Research Centre Adult Resilience Measure (RRC-ARM), Wales, 2017, Hughes, Bellis et al 2018

Always Available Adult

Getting an

education was

important to me

I had people I looked up toI enjoyed

my community’s

cultures and

traditions

My parents, caregivers knew a lot about

me

I had opportunities to develop

skills to help me succeed

in life

I tried to finish activities that I started

I felt I belonged in my school

I knew where to go in my community

to get help

My family would

stand by me during difficult times

I was treated fairly in

my community

I was able to solve problems without harming

myself or others

Always Available

Adult

Culturally Connected

Guide your destiny and

overcome Hardship

Manage your behaviour and emotions

Welsh ACE and Resilience Study (Prof Karen Hughes et al)

• 2497 18-69 year olds surveyed in 2017 (2005 national sample, 492 boost)

Trusted adult relationship

While you were growing up, before the age of 18, was there an adult in your life who you could trust and talk to about any personal problems?

With four or more ACEscurrent mental illness was

• 28% in those without a trusted adult relationship

• 20% in those who sometimes had one

• 19% in those who always had a trusted relationship

If

Developmental trauma is a biological process managed through our human connections

(Dr Christopher Blodgett 2017)

then

Every positive, attuned interaction with a trustworthy other can help to rewire the brain (Perry, 2008)

• Schizophrenia – Studies in Finland of those adopted at birth (Tienari P.et al, 2003, American J. Psychiatry)

• ‘Unhealthy rearing environment’ defined as highly critical, conflictual and exhibiting overinvolvement, boundary problems, or high expressed emotion

• Among adoptees with a high genetic risk and an unhealthy rearing environment, 36% developed a psychotic disorder, while only 6% of those with high genetic risk reared in a healthy environment developed psychosis. Among adoptees with low genetic risk, the family environment did not contribute to the risk for psychosis.

Protective effect of relationships to those with serious mental illness

0

5

10

15

20

25

30

35

40

45

50

55

1 2 3 4 5

% w

ith low

ment

al w

ell-b

ein

g

Increasing Poverty ->

Mental well-beingACEs and AAA (Always Available Adult) Status

Percentages are calculated using estimated marginal means function and are adjusted through logistic regression modelling for confounding from other variables in the model Bellis et al. BMC Psychiatry, 2017, 17:110 DOI 10.1186/s12888-017-1260-z

≥4 ACEs, Not always trusted adult ≥4 ACEs, Always trusted adult

0 ACEs, Not always trusted adult

0 ACEs, Always trusted adult

Financial security and Current Mental Illness

0%

10%

20%

30%

40%

50%

0 ACEs 1 ACE 2-3 ACEs 4+ ACEs

One month or less

>1 month to 1 year

>1 year to <5 years

5 years plus

Longer perceived financial security was associated with lower levels of current mental illness across all ACE levels

Perceived length of financial security

35%

11%

Effects of scarcity on mental wellbeing and functioning

• Tunnelling (narrowing of broad band width)

• Horizon shortening (“myopia”)

• Borrowing

• Insensitivity to horizon & its costs

• Distraction

• Depletion, ErrorShafir et al 2012

So ACEs and scarcity additive in decreasing processing and regulation

Psychology of Scarcity

• “The combination of social, economic, environmental, cultural, and political

conditions identified by individuals and their communities as essential for them to flourish and fulfil their potential.’ (Wiseman and Brasher 2008, pg 358).

• People are part of more than one community and may identify with a community at work; in school or education; with others of similar characteristics or interests as well as where they live.

• community wellbeing is something greater than the sum of a community’s individual members, but this extra 'something' is hard to describe. (What Works Wellbeing, 2017)

Wiseman J and Brasher K (2008) Community wellbeing in an unwell world: Trends, challenges, and possibilities. Journal of Public Health Policy 29(3), 353–66

What Works Wellbeing, 2017, What is Community Wellbeing? Conceptual review

Community Wellbeing

• Human capital: e.g. innate and acquired personal attributes including skills and

education, capacity and local knowledge.

• Social capital (community level): e.g. the extent of social networks and connections within a community, effectiveness of local community and voluntary organisations (support, participation), and resources of public, private and third sector organisations that are available to support a community. Bonds, Bridges and Links

• Includes cultural capital: e.g. worldview, values, norms, sense of identity,and political capital

• Physical/built capital: e.g. physical infrastructure including homes and roads, access to amenities.

• Natural/environmental capital: e.g. access to green and blue space, availability and use of natural resources.

• Financial or economic capital :e.g. income, wealth, access to resources, civic and social enterprises.

Factors contributing to Community Resilience (Davies A. et al 2019)

Components of Mental Wellbeing (Mably S. et al 2019)

• Social connectedness, Participation, Belonging

• Lack of exclusion/discrimination/victimisation – having a voice

• Having access without anxiety to basic necessities such as food,water, shelter, clothing, medical care

• Having purposeful activity – work/other ability to contribute

• Liberty - Freedom from fear of expression, freedom to travel, explore, to be ‘you’

• Hope for the future – Social security, predictability, Peace

• Resilience to life’s insults - illness, ageing, loss

Ingredients for Positive Mental Health ?

Stigma-free, Psychologically-literate and supportive individuals, families, schools, workplaces, communities, society that recognise most elements of mental health as a spectrum of response based on experiences and assets/gaps from childhood to adulthood, linked to;