It seems obvious that our wellbeing influences our mental health; but recent debates in public health have complicated this view. Mark Brown explores where this debate came from and what it means for mental health
‘A little bit of what you fancy does you good’ would appear, on the face of it, to be an uncontentious idea. ‘If I do things that will make me happier,’ we might say, ‘surely, I’m less likely to become unwell and experience mental health difficulties?’, but is it true?
Anything from having a cup of tea to meditation to throwing a stick for the dog might affect our sense of wellbeing positively. For something so concerned with making life the best it can be, there is a surprising amount of discord around the idea of mental wellbeing. Wellbeing, though, has unexpectedly turned out to be a surprisingly contentious idea. And the idea that wellbeing (or its lack) and mental illness are connected has recently proven to be even more so.
In an extension of the idea that an ‘apple a day which keeps the doctor away’, Mindapples, a project originated by social entrepreneur Andy Gibson, takes forward the idea of five-a-day for mental health. What began in 2008 online has grown into a series of workshops and training sessions. When you encounter Andy or one of his colleagues you’ll be asked it to take a card in the shape of an apple and write on each a thing that you do in your life to look after your mental wellbeing. If you’re lucky, you’ll get to stick your apples on the six-foot high Mindapples tree and share what makes you feel better with others. Writing for The Guardian in 2012, Gibson explained that he conceived Mindapples to “encourage people to think positively about the health of their minds. I wanted to create a campaign that did for mental health what the five-a-day campaign has done for physical health: to make taking care of our minds a normal, natural thing for all of us… public health has a bad reputation for telling people how to live. That doesn’t work for mental health. It’s too personal, and in any case the evidence suggests taking prescribed actions to boost our wellbeing doesn’t really work.”
Mental health and wellbeing
Many of us are familiar with the idea that we should eat five portions of fruit and vegetables a day to remain healthy. We’re mainly aware of it because, deep in the bowels of government, someone decided that we should know about it. When Mindapples launched it was riding a wellbeing wave. In the first decade of the 21st century before global austerity arrived European governments were turning increasingly toward the idea that the prosperity of nations depended on more than Gross Domestic Product. No new mental health drugs were in the pipeline, so prevention seemed to be better than cure. Wellbeing was in and this time there was going to be an evidence base for it.
In October 2008, the Government Office for Science published the results of a two year Foresight review future-scanning exercise into mental wellbeing. The report Mental capital and wellbeing: making the most of ourselves in the 21st century suggested that as mental health conditions were rising it was vital that action was taken to attempt to reduce their severity and their cost to the public purse. The report proposed that “achieving a small change in the average level of wellbeing across the population would produce a large decrease in the percentage with mental disorder.” If everyone looked after their mental wellbeing, the report suggested, then fewer people would develop treatable mental health difficulties.
As part of the review, thinktank The New Economics Foundation (nef) were commissioned to develop an equivalent of ‘five fruit and vegetables a day’ for wellbeing; an easy, catchy but science-based set of things that individuals could do to promote or safeguard their own mental health and which public sector agencies could promote. These were: connect with people around you; be (physically) active; take notice of the world and people around you and find time for reflection; keep learning; and give your time and support to something that helps someone else.
The Foresight review also stated that wellbeing is influenced by the circumstances of your life. Beyond strengthening individual’s wellbeing, it also suggested strengthening communities so that people could better support each other; reducing structural barriers such as poverty, discrimination and inequalities, increasing access to good-quality employment and housing; and improving where we live and the things around us.
The hypothesis of the Foresight review was that focus on general wellbeing could ‘pull the curve of the normal distribution’, meaning that if more people had lives with greater wellbeing these people would have greater stores of social capital, less outside stresses and more satisfaction with life meaning that mental health difficulty would be less likely to manifest with with severity requiring long-term treatment and support. In essence, if more people had better lives then the incidence of poor mental health would be reduced.
Action for Happiness is campaign to promote individual action to create greater happiness and wellbeing. It has on its board a number of the luminaries of the pre-austerity wellbeing field including Lord Richard Layard, credited with making the case for greater government investment in talking therapies through Improving Access to Psychological Therapies, and Nic Marks, leader of nef’s wellbeing work. According to Action for Happiness: “Although our genes influence about 50% of the variation in our personal happiness, our circumstances (like income and environment) affect only about 10%. As much as 40% is accounted for by our daily activities and the conscious choices we make. So the good news is that our actions really can make a difference.”
Fast forward through five years of austerity and one change of government. An early feature of David Cameron’s time in office had been discussion of the wellbeing and happiness of the nation.
When the reorganisation of the the NHS came into effect on April 1st 2013 as a result of the Health and Social Care Act, along with a number of other bodies Public Health England’s Mental Health and Wellbeing directorate came into existence charged with the job of thinking about the mental health and wellbeing of the public. Building on the work of the Foresight report, for them wellbeing is “a dynamic process that gives people a sense of how their lives are going, through the interaction between their circumstances, activities and social, emotional and psychological resources or ‘mental capital’.” Public health duties were also reassigned in to local councils, who have always had at the heart of their duty the promotion of the wellbeing of the people who live and work in their area.
Upsetting the applecart
On 9th of September this year the Chief Medical Officer (CMO) for England Dame Sally Davies upset the applecart by publishing her annual report. Her topic this year was public mental health, looking at the ways in which the available evidence could be best used to improve the mental health of people in England. Davies says she refuses to take a “leap of faith” and recommend wellbeing programmes without the evidence to support them. She advises that work to promote mental wellbeing should not be paid for out of funds for the treatment or prevention of mental illness or the promotion of mental health. While supporting evidence-based programmes to act upon things like bullying, violence, employment difficulties and similar the CMO’s report also states that there is no evidence that promotion of wellbeing, through things such as the Five Ways to Wellbeing has any effect on the amount of people currently experiencing mental illness.
The definition of mental health promotion in the CMOs report is adapted from the World Health organisation: “Mental health promotion activities imply the creation of individual, social and environmental conditions that enable optimal psychological and psychophysiological development.”
For her, mental health promotion is about having systems and knowledge in place that get people to treatment early for mental illness, helping people to self managing their existing conditions and tackling things that evidence says leads to mental illness which crosses over with preventing things like bullying, better parenting, reducing problematic drug and alcohol use, reducing violence in families and acting on other risk factors for the development of mental illness.
In her introduction to the report Davies says: “I conclude that our approach to this subject should no longer be framed in terms of ‘well-being’. I do not refer here to the concept of ‘well-being’ more generally as it applies more broadly across the business of Government or indeed to ‘health’ more generally. I welcome the consideration of the wider determinants of health in policy making. I reiterate that I refer here to the concept of well-being as relates only to mental health.
“After reviewing the evidence I conclude that well-being does not have a sufficiently robust evidence base commensurate with the level of attention and funding it currently receives in public mental health at national and local government level. Well-being, as a field within mental health, has not evidenced an acceptable definition or set of metrics. It is unclear how concepts and measures that do exist relate to populations with mental illness.”
Davies specifically targets the hypothesis contained in the Foresight review, setting mental health needs against overall population wellbeing: “Contrary to popular belief, there is no good evidence I can find that well-being interventions are effective in primary prevention of mental illness, or can ‘shift the normal distribution curve’ described by Rose and hypothesised by the Foresight report in 2008. The result is that the public health needs of approximately 1 in 4 of the population who have a mental illness, 75% of whom receive no treatment, risk being side-lined in the enthusiastic pursuit of a policy agenda that is running ahead of the evidence.”
She goes on to say: “If we take the lead from the WHO and frame the subject as ‘mental health promotion’, ‘mental illness prevention’ and ‘treatment and rehabilitation’, then it becomes immediately apparent that we already have a good deal of evidence supporting a public health approach to mental health, and that effective and cost- effective interventions should be the priority.”
The report states that while wellbeing promised much and features in many government policies, including the current national strategy for England’s mental health No Health Without Mental Health, definitions of wellbeing differ and it is something difficult to measure.
The report caused consternation for those in public mental health, signalling for some a return to heavily medical models of mental health focusing on illness rather than health. Some questioned it was too early to state that the evidence wasn’t there for wellbeing. Others questioned whether political and policy perspectives might be shifting in the face of austerity-era policies. Others were disappointed that the agenda was moving away from changing policy and challenging inequality.
Of the report Dr John Middleton, Vice President for the Faculty of Public Health, said: “The CMO’s very comprehensive report makes some important and powerful recommendations, many of which FPH thoroughly endorses. It is important that health and social care commissioners, public health practitioners, clinical commissioning groups and local authorities realise that her report looked at wellbeing in the context of mental health. The conclusions do not apply to the considerable role mental wellbeing plays in the promotion of physical health and the prevention of unhealthy lifestyles and physical disease.”
Paul Farmer, chief executive of national mental health charity Mind sounded a similar note: “Our own research into ‘ecotherapy’ initiatives such as gardening or outdoor exercise shows the impact that general wellbeing programmes can have but we agree that the evidence-base for wellbeing services isn’t as strong as it ought to be. This, for us, is another example of how far mental health lags behind physical health. We have come to understand a great deal over many years about preventing heart disease and stroke, with robust evidence that underpins a national public health programme. We need to see the same sort of investment for research into the impact of public mental health programmes.”
In a blog post public health professional Mark Gamsu pointed out that the medical nature of the CMOs discussion of wellbeing avoids looking at inequality, meaning wider social determinants of mental ill-health are missed, turning the mental health focus back to mental illness services and away from the potential of public policy to affect people’s mental health: “This is primarily a clinical report (not surprising with approximately 90% of the authors being medics) the wider social conditions that people live in receive insufficient attention. Frankly, given the evidence that the bottom quintile are more than twice as likely to be at risk of mental illness than the top quintile this is more than a small omission – this is very poor – not good use of the evidence.”
Confusion or clarity?
In October this year Mind published the results of a series of Freedom of Information Act (FOI) requests to local authorities in England that found that they on average spend 1.36 percent of their public health budgets on mental health prevention. Mind stated: “The total annual spend by local authorities on preventing physical health problems is considerable, including increasing physical activity (£76m), anti-obesity (£108m), smoking cessation (£160m) and sexual health initiatives (£671m). Mind’s research indicates that the equivalent spend for preventing mental health problems is a fraction of this, at less than £40m. When reporting on spend for different public health priorities, local authorities file public mental health under ‘Miscellaneous’.
“Responses from many areas also painted a picture of enormous confusion about what local public health teams should do to help prevent people becoming mentally unwell. In others, it was clear that public health teams didn’t know it was part of their responsibility in the first place.”
Reasonably, some have questioned whether it was too early to state that the evidence wasn’t there for wellbeing and its interaction with mental health and mental illness . Others have questioned whether political and policy perspectives might be shifting in the face of austerity-era policies. It’s possible to see the CMOs report as a kind of back-to-basics approach centering public mental health in the provision of services rather than in the modification of policy.
There is, of course, a difference between what we ‘know’, what we can prove and what we are happy for taxes to spent upon. While it may feel ever more important that we do what we can to look after our own mental health in the face of difficult times, it seems that, at least in some quarters, the tide is shifting away from the idea that anyone can advise on a set formula to help us to do so. For some, including people with mental health difficulties fed up with being told to ‘go for a run’ or to ‘take up a hobby’ this may be a relief but for others it will feel like a re-medicalisation of mental health.
While it may be true that many wellbeing for mental health projects have lacked a strong evidence of impact, it seems there is potential to throw babies and bathwater into the same re-medicalisation of focus. There has been little work to date focusing on the wellbeing of people with mental health difficulties. The arena of wellbeing has been a place to begin this work, even if it has not yet hit its stride. While the CMO may be correct in her assertions they do not suggest a path forwards for understanding and developing services that will make life with a mental health difficulty better; an area that inevitably leads us away from medicine and into the realm of politics, economics and social organisation.
It is notable that the CMOs report is very favourable towards Time to Change and anti-stigma work in general; seemingly supporting an idea that people who experience mental health difficulties will become a population indivisible from those without mental health difficulties given a reduced level of stigma, timely treatment and strong prevention work.
Simply looking at mental health in terms of diseases, cures and preventions may take focus away from the role that policy and government has in helping create the conditions for people with mental health difficulties and those without to have a good, fulfilling and enjoyable life.
This is a much extended version of an article that was commissioned by BBC Ouch which appeared on 8th October 2014 under the title ‘Does wellbeing improve your mental health?
Mark Brown is development director of Social Spider CIC. He is @markoneinfour on twitter