563247 research-article2015
RSH0010.1177/1757913914563247Current topics & opinionsCurrent topics & opinions
Current Topic & Opinion
Collective Wellbeing in Public Mental Health Understanding wellbeing through subjective scales leads to underestimations of the significance of inequalities due to their simplistic nature. Here, Lee Knifton, Reader and Co-Director of the Centre for Health Policy at the University of Strathclyde, argues for a broader and more progressive notion of ‘collective wellbeing’ drawing upon learning from human rights, citizenship and capabilities approaches. “I will not cease from mental fight”1
expectations and social norms – that one must be able ‘to appear in public without shame’ The importance of relative poverty was clear in Smith’s Wealth of Nations where ‘no society can surely be flourishing and happy of which by far the greater parts of the numbers are poor and miserable’. The overwhelming importance of entwined themes of shame, poverty and inequalities have been articulated and developed in recent decades across academic disciplines but perhaps most notable by sociologist Peter Townsend’s3 work on stratification and the relative nature of poverty.
Imagine, for a moment, that we are back to the era of Blake’s ‘dark satanic mills’ and seeking to make some sense of the industrial deprivations, poverty and injustices that those subject to these conditions were experiencing. Our likely response would be one of compassion, moral outrage and righteous anger. The wellbeing of the people would be a tremendous concern. We might see this in material terms of freedoms from hunger, industrial injury, contaminated water, shelter, disease and healthcare. And we might also see this in social dimensions such as freedom from loneliness, violence and abuse, or freedom to protest and organise, have time to Contemporary individual nurture social relationships, to experience wellbeing a life of dignity and equality, and to live in However the contemporary wellbeing society without shame. Such material and agenda in UK public health has taken a social dimensions are of course contex- different route. Wellbeing is an essentially tual, varying according to the conditions contested concept4 and a broad term. and norms of society in which The dominant way of one lives and also within socidealing with this has eties according to gender, been to conceptualise the two interrace and so on. wellbeing in terms of an related issues As an academic and individual’s reported of relative practitioner in contemporary deprivation and state of mind, rather Glasgow, also working in than as a collective shame get to global health inequalities, I experience or in social the heart of believe that the two interterms. Friedli5 describes mental health related issues of relative a psychologising of and wellbeing. deprivation and shame get mental health and to the heart of mental health wellbeing – influenced and wellbeing. Of course by positive psychology. this is not new. Sen2 elegantly describes This notion of wellbeing certainly fits with the more neo-liberal political climate of the how the oft mis-quoted Scot Adam United States and United Kingdom that Smith was clear that a person’s poverty has dominated since the early 1980s. It must be understood in relative terms also makes for fairly unchallenging related to wider society’s incomes,
24 Perspectives in Public Health l January 2015 Vol 135 No 1
academic research: if wellbeing in a society is merely the accumulated wellbeing of the individuals in it, then our response to understanding it is to develop ‘snapshot’ self-report scales that attempt to gain insights into people’s states of mind, ‘count’ the aggregated ‘scores’ and then attempt to correlate them with selected socio-demographic variables. Such scales do have value. But as a profound way of understanding wellbeing in a society, they are problematic. One issue is political – it sets out a frame of reference for wellbeing which underplays the notion of collective or social wellbeing as a construct. By this I mean that issues such as the connectedness, fairness, loneliness, violence of a society should not be subsumed into individual selfreports – we will return to this. But there are other problems too. Many of these scales conflate wellbeing, happiness and life satisfaction. This is especially problematic when you add in research/er effects. Most people who are poor or multiply deprived do not know the social realities and extent to which they are disadvantaged – the basic unfairness of the society of which they are a citizen. We have to consistently be aware that what we might be finding from these scales is an artefact of the questions. One might report satisfaction or happiness with life if you are unaware of the extent to which you are marginalised. Or might report satisfaction if you have reconciled yourself to the realities of your situation and feel that you can’t change it. Indeed if you maintained a resentment and righteous anger at this social injustice, you might score badly. If we instead asked people about satisfaction and happiness by comparing the life they live now with the one they dreamed of for themselves, or children, we might get very different results. In essence, I suggest that this approach leads to a distortion of social wellbeing by underplaying inequalities and injustice.
Copyright © Royal Society for Public Health 2015 SAGE Publications Downloaded from rsh.sagepub.com at UNIV OF ILLINOIS URBANA on March 16, 2015 ISSN 1757-9139 DOI: 10.1177/1757913914563247
Current Topic & Opinion This is clearly morally significant, but does it really matter on a practical level? I will argue so. First, the psychologising of wellbeing risks dampening down calls for public and social policies that are more redistributive and socially just. Although interestingly some research at panEuropean level highlights that if you focus less on maximising happiness and more on ‘minimising misery’ then the social gradients are much starker, and the direction for redistribution much clearer.8 Second, it leads to adoption of policies and programmes that are contentious. One example is the surge in interest in asset based approaches to promote wellbeing in communities. Unlike many from a critical perspective, I think that these are important. But only if they are seen as part of a wider solution – still best articulated in the Ottawa Charter as empowering individuals, families and communities while addressing the social determinants of health.9 This relates to the ideas of Friere, McKnight and others and it is about recognising power and injustice and the struggle of communities, and about collective action at many levels. However, Friedli5 offers a compelling critique of how many people are currently using asset based approaches across the United Kingdom – they focus narrowly upon ‘positive’ outcomes and tend to limit the scope to community citizens taking action to increase wellbeing. This definition tends to exclude collective action such as unionisation to protect employee rights, campaigns to change policies or protest movements. If the public health community instead sees wellbeing in more social justice terms, a more inclusive model of asset based (or community development) approaches could ensue. A second example is the national roll out of the ‘increasing access to psychological therapies’ initiative. This is basically mass cognitive behavioural therapy (CBT) for those who have levels of mental health problems, mental distress or unhappiness. These problems occur across society but are concentrated among the poor. And at one level, we can see this as responding to expressed need. However, some of the motivations behind this are essentially
about getting more people into work and therefore being ‘productive’ citizens who would cost the government less. This is a ‘win-win’ to some, but when we stand back and consider this, it begins to get a bit more uncomfortable. Why are we getting people to reframe their social situations without changing people’s social situations? When we add to this the orchestrated media demonisation of the ‘idle’ poor often directly linking this to mental health problems, it is more uncomfortable still. We can argue that the focus should instead be upon prevention and social realities: minimising economic inequalities and maximising social protection programmes, which correlate much more strongly to broad health outcomes.10,11
Collective wellbeing All of this leads back to Blake, and the echoes of history across continents. And to reflect upon the recent coverage of the suicide of Xu Lizhi, a migrant worker in China, whose death might just have been another footnote – a rural migrant to the city factories whose dreams fade under the hardship of poverty, extreme working and living conditions, precarious living, alienation and inequality. Except like Blake he was also a poet. And his work has begun to gain international attention – speaking to, and for, the deprived.12 The global processes of re/ de-industrialisation might have inevitability, but the ways in which they are managed and regulated to maintain the wellbeing of communities do not. We might find it laughable to suggest we offer mass CBT to ‘those’ masses of people living such difficult lives in unequal circumstances in low and middle income countries. It is clear from the outside that wellbeing would be about enhancing rights; improving the material factors of
income, housing, nutrition; about reducing extreme stress and pressure; and providing the opportunity for creativity, expression and to live a life of dignity without shame. And yet in our society, we rarely question this despite our tremendous economic and health inequalities. More simply it can be seen in public health terms as moving from acceptance and amelioration, to a view of collective wellbeing that is about ‘prevention’ through social justice policies and concepts. Public health can be bold and reconnect with it’s radical and reforming past. It should be at the vanguard of developing a distinct field of collective wellbeing that stress equity over utilitarian notions of overall improvements in wellbeing. There are important bodies of critical work on wellbeing that indicate a need for a broader conceptualisation of wellbeing beyond individualism, and not simply considered through the lens of poverty. Harris et al.’s6 edited book offers ideas about wellbeing, in both historical and contemporary terms, which explore issues related to gender. And much of my own community-based participatory research builds on such critical perspectives, for example, with citizens with mental health issues in multiply deprived areas of Glasgow, we found wellbeing to be determined by relationships and status with family, loved ones and friends – but that this was enabled or diminished by poverty and lack of basic resources and services. Further work with ethnic minority communities highlighted how disadvantaged social circumstances including shame, racism, fear, poverty and opportunity shape mental wellbeing. This work also challenges the idea of a simple dual continuum separating positive mental health and illness as issues such as anxiety and depression were frequently seen instead as a response to life’s challenges.7 There are a number of ways in which we can understand and advance this position, but the work of Amartya Sen13 and his building of the capabilities approach, especially as it related to human rights, is both a compelling and
January 2015 Vol 135 No 1 l Perspectives in Public Health 25 Downloaded from rsh.sagepub.com at UNIV OF ILLINOIS URBANA on March 16, 2015
Current Topic & Opinion the challenges centre unifying frame for further on developing What a research and action. What a measures of collective capabilities capabilities approach can do approach can do wellbeing, then areas is to enable us to reconcile such as loneliness are is to enable us the two dimensions of social to reconcile the useful candidates14 as wellbeing and human rights of two dimensions are areas that have structure (including material of social poverty) and agency been carefully outlined wellbeing and (empowerment to live a life of by The Oxford Poverty human rights dignity without shame in one’s and Human community). Many others Development Initiative have built on these ideas in (OPHI)15 being poverty the field of health inequalities, and I argue itself (and perhaps especially child for its application in mental wellbeing. If poverty) but also dimensions such as
empowerment, safety, social isolation, humiliation and shame and quality of work. And we need a recognition of the significance to wellbeing of multiple marginalisation including gender,6 race, sexuality and disability. More recently, people are applying a capabilities lens to outcomes work with people with mental health problems16 and linking this to human rights and citizenship theory.17 I conclude by arguing that power, citizenship, capabilities and human rights are the territory for a renewed public health approach to collective wellbeing.
References 1. 2.
3. 4.
5.
6.
7.
Blake W. And did those feet in ancient times, 1808. Sen A. Adam Smith and the contemporary world. Erasmus Journal for Philosophy and Economics 2010; 3(1): 50–67. Townsend P. Poverty in the United Kingdom. Harmondsworth: Penguin Books, 1979. Gallie WB. Essentially contested concepts. Proceedings of the Aristotelian Society 1956; 56: 167–98. Friedli L. What we’ve tried, hasn’t worked: The politics of assets based public health. Critical Public Health 2013; 23(2): 131–45. Harris B, Galvez N, Machado H. (eds). Gender and Wellbeing in Europe: Historical and Contemporary Perspectives. Surrey: Ashgate, 2009. Knifton L. Understanding and addressing the stigma of mental ill-health with ethnic minority
communities. Health Sociology Review 2012; 21(3): 287–98. 8. Lelkes O. Minimising misery: A new strategy for public policies instead of maximising happiness. Social Indicators Research 2013; 114(1): 121–37. 9. World Health Organization (WHO). Ottawa Charter for Health Promotion. Geneva: WHO, 1986. 10. Marmot M. Fair Society, Healthy Lives: Strategic Review of Health Inequalities in England Post-2010. London: Marmot Review, 2010. 1. Pickett KE, Wilkinson RG. Inequality: An under1 acknowledged source of mental illness and distress. British Journal of Psychiatry 2010; 197(6): 426–8. 12. Lizhi X. Poetry. Available online at: http:// libcom.org/blog/xulizhi-foxconn-suicide-poetry (Last accessed November 2014).
26 Perspectives in Public Health l January 2015 Vol 135 No 1 Downloaded from rsh.sagepub.com at UNIV OF ILLINOIS URBANA on March 16, 2015
13. Sen A. Human rights and capabilities. Journal of Human Development 2005; 6(2): 151–66. 14. Collins AB, Wrigley J. Can a Neighbourhood Approach to Loneliness Contribute to People’s Well-Being? York: Joseph Rowntree Foundation, 2014. 15. Oxford Poverty and Human Development Initiative (OPHI), Oxford University, 2014. Available online at: http://www.ophi.org.uk/ research/missing-dimensions/ (Last accessed November 2014). 16. Simon J, Anand P, Gray A, Rugkasa J, Yeeles K, Burns T. Operationalising the capability approach for outcome measurement in mental health research. Social Science & Medicine 2013; 98: 187–96. 17. Rowe M, Pelletier JF. Citizenship a response to the marginalization of people with mental illnesses. Forensic Psychology Practice 2012; 12(4): 366–81.
RSH0010.1177/1757913914563247Current topics & opinionsCurrent topics & opinions
Current Topic & Opinion
Collective Wellbeing in Public Mental Health Understanding wellbeing through subjective scales leads to underestimations of the significance of inequalities due to their simplistic nature. Here, Lee Knifton, Reader and Co-Director of the Centre for Health Policy at the University of Strathclyde, argues for a broader and more progressive notion of ‘collective wellbeing’ drawing upon learning from human rights, citizenship and capabilities approaches. “I will not cease from mental fight”1
expectations and social norms – that one must be able ‘to appear in public without shame’ The importance of relative poverty was clear in Smith’s Wealth of Nations where ‘no society can surely be flourishing and happy of which by far the greater parts of the numbers are poor and miserable’. The overwhelming importance of entwined themes of shame, poverty and inequalities have been articulated and developed in recent decades across academic disciplines but perhaps most notable by sociologist Peter Townsend’s3 work on stratification and the relative nature of poverty.
Imagine, for a moment, that we are back to the era of Blake’s ‘dark satanic mills’ and seeking to make some sense of the industrial deprivations, poverty and injustices that those subject to these conditions were experiencing. Our likely response would be one of compassion, moral outrage and righteous anger. The wellbeing of the people would be a tremendous concern. We might see this in material terms of freedoms from hunger, industrial injury, contaminated water, shelter, disease and healthcare. And we might also see this in social dimensions such as freedom from loneliness, violence and abuse, or freedom to protest and organise, have time to Contemporary individual nurture social relationships, to experience wellbeing a life of dignity and equality, and to live in However the contemporary wellbeing society without shame. Such material and agenda in UK public health has taken a social dimensions are of course contex- different route. Wellbeing is an essentially tual, varying according to the conditions contested concept4 and a broad term. and norms of society in which The dominant way of one lives and also within socidealing with this has eties according to gender, been to conceptualise the two interrace and so on. wellbeing in terms of an related issues As an academic and individual’s reported of relative practitioner in contemporary deprivation and state of mind, rather Glasgow, also working in than as a collective shame get to global health inequalities, I experience or in social the heart of believe that the two interterms. Friedli5 describes mental health related issues of relative a psychologising of and wellbeing. deprivation and shame get mental health and to the heart of mental health wellbeing – influenced and wellbeing. Of course by positive psychology. this is not new. Sen2 elegantly describes This notion of wellbeing certainly fits with the more neo-liberal political climate of the how the oft mis-quoted Scot Adam United States and United Kingdom that Smith was clear that a person’s poverty has dominated since the early 1980s. It must be understood in relative terms also makes for fairly unchallenging related to wider society’s incomes,
24 Perspectives in Public Health l January 2015 Vol 135 No 1
academic research: if wellbeing in a society is merely the accumulated wellbeing of the individuals in it, then our response to understanding it is to develop ‘snapshot’ self-report scales that attempt to gain insights into people’s states of mind, ‘count’ the aggregated ‘scores’ and then attempt to correlate them with selected socio-demographic variables. Such scales do have value. But as a profound way of understanding wellbeing in a society, they are problematic. One issue is political – it sets out a frame of reference for wellbeing which underplays the notion of collective or social wellbeing as a construct. By this I mean that issues such as the connectedness, fairness, loneliness, violence of a society should not be subsumed into individual selfreports – we will return to this. But there are other problems too. Many of these scales conflate wellbeing, happiness and life satisfaction. This is especially problematic when you add in research/er effects. Most people who are poor or multiply deprived do not know the social realities and extent to which they are disadvantaged – the basic unfairness of the society of which they are a citizen. We have to consistently be aware that what we might be finding from these scales is an artefact of the questions. One might report satisfaction or happiness with life if you are unaware of the extent to which you are marginalised. Or might report satisfaction if you have reconciled yourself to the realities of your situation and feel that you can’t change it. Indeed if you maintained a resentment and righteous anger at this social injustice, you might score badly. If we instead asked people about satisfaction and happiness by comparing the life they live now with the one they dreamed of for themselves, or children, we might get very different results. In essence, I suggest that this approach leads to a distortion of social wellbeing by underplaying inequalities and injustice.
Copyright © Royal Society for Public Health 2015 SAGE Publications Downloaded from rsh.sagepub.com at UNIV OF ILLINOIS URBANA on March 16, 2015 ISSN 1757-9139 DOI: 10.1177/1757913914563247
Current Topic & Opinion This is clearly morally significant, but does it really matter on a practical level? I will argue so. First, the psychologising of wellbeing risks dampening down calls for public and social policies that are more redistributive and socially just. Although interestingly some research at panEuropean level highlights that if you focus less on maximising happiness and more on ‘minimising misery’ then the social gradients are much starker, and the direction for redistribution much clearer.8 Second, it leads to adoption of policies and programmes that are contentious. One example is the surge in interest in asset based approaches to promote wellbeing in communities. Unlike many from a critical perspective, I think that these are important. But only if they are seen as part of a wider solution – still best articulated in the Ottawa Charter as empowering individuals, families and communities while addressing the social determinants of health.9 This relates to the ideas of Friere, McKnight and others and it is about recognising power and injustice and the struggle of communities, and about collective action at many levels. However, Friedli5 offers a compelling critique of how many people are currently using asset based approaches across the United Kingdom – they focus narrowly upon ‘positive’ outcomes and tend to limit the scope to community citizens taking action to increase wellbeing. This definition tends to exclude collective action such as unionisation to protect employee rights, campaigns to change policies or protest movements. If the public health community instead sees wellbeing in more social justice terms, a more inclusive model of asset based (or community development) approaches could ensue. A second example is the national roll out of the ‘increasing access to psychological therapies’ initiative. This is basically mass cognitive behavioural therapy (CBT) for those who have levels of mental health problems, mental distress or unhappiness. These problems occur across society but are concentrated among the poor. And at one level, we can see this as responding to expressed need. However, some of the motivations behind this are essentially
about getting more people into work and therefore being ‘productive’ citizens who would cost the government less. This is a ‘win-win’ to some, but when we stand back and consider this, it begins to get a bit more uncomfortable. Why are we getting people to reframe their social situations without changing people’s social situations? When we add to this the orchestrated media demonisation of the ‘idle’ poor often directly linking this to mental health problems, it is more uncomfortable still. We can argue that the focus should instead be upon prevention and social realities: minimising economic inequalities and maximising social protection programmes, which correlate much more strongly to broad health outcomes.10,11
Collective wellbeing All of this leads back to Blake, and the echoes of history across continents. And to reflect upon the recent coverage of the suicide of Xu Lizhi, a migrant worker in China, whose death might just have been another footnote – a rural migrant to the city factories whose dreams fade under the hardship of poverty, extreme working and living conditions, precarious living, alienation and inequality. Except like Blake he was also a poet. And his work has begun to gain international attention – speaking to, and for, the deprived.12 The global processes of re/ de-industrialisation might have inevitability, but the ways in which they are managed and regulated to maintain the wellbeing of communities do not. We might find it laughable to suggest we offer mass CBT to ‘those’ masses of people living such difficult lives in unequal circumstances in low and middle income countries. It is clear from the outside that wellbeing would be about enhancing rights; improving the material factors of
income, housing, nutrition; about reducing extreme stress and pressure; and providing the opportunity for creativity, expression and to live a life of dignity without shame. And yet in our society, we rarely question this despite our tremendous economic and health inequalities. More simply it can be seen in public health terms as moving from acceptance and amelioration, to a view of collective wellbeing that is about ‘prevention’ through social justice policies and concepts. Public health can be bold and reconnect with it’s radical and reforming past. It should be at the vanguard of developing a distinct field of collective wellbeing that stress equity over utilitarian notions of overall improvements in wellbeing. There are important bodies of critical work on wellbeing that indicate a need for a broader conceptualisation of wellbeing beyond individualism, and not simply considered through the lens of poverty. Harris et al.’s6 edited book offers ideas about wellbeing, in both historical and contemporary terms, which explore issues related to gender. And much of my own community-based participatory research builds on such critical perspectives, for example, with citizens with mental health issues in multiply deprived areas of Glasgow, we found wellbeing to be determined by relationships and status with family, loved ones and friends – but that this was enabled or diminished by poverty and lack of basic resources and services. Further work with ethnic minority communities highlighted how disadvantaged social circumstances including shame, racism, fear, poverty and opportunity shape mental wellbeing. This work also challenges the idea of a simple dual continuum separating positive mental health and illness as issues such as anxiety and depression were frequently seen instead as a response to life’s challenges.7 There are a number of ways in which we can understand and advance this position, but the work of Amartya Sen13 and his building of the capabilities approach, especially as it related to human rights, is both a compelling and
January 2015 Vol 135 No 1 l Perspectives in Public Health 25 Downloaded from rsh.sagepub.com at UNIV OF ILLINOIS URBANA on March 16, 2015
Current Topic & Opinion the challenges centre unifying frame for further on developing What a research and action. What a measures of collective capabilities capabilities approach can do approach can do wellbeing, then areas is to enable us to reconcile such as loneliness are is to enable us the two dimensions of social to reconcile the useful candidates14 as wellbeing and human rights of two dimensions are areas that have structure (including material of social poverty) and agency been carefully outlined wellbeing and (empowerment to live a life of by The Oxford Poverty human rights dignity without shame in one’s and Human community). Many others Development Initiative have built on these ideas in (OPHI)15 being poverty the field of health inequalities, and I argue itself (and perhaps especially child for its application in mental wellbeing. If poverty) but also dimensions such as
empowerment, safety, social isolation, humiliation and shame and quality of work. And we need a recognition of the significance to wellbeing of multiple marginalisation including gender,6 race, sexuality and disability. More recently, people are applying a capabilities lens to outcomes work with people with mental health problems16 and linking this to human rights and citizenship theory.17 I conclude by arguing that power, citizenship, capabilities and human rights are the territory for a renewed public health approach to collective wellbeing.
References 1. 2.
3. 4.
5.
6.
7.
Blake W. And did those feet in ancient times, 1808. Sen A. Adam Smith and the contemporary world. Erasmus Journal for Philosophy and Economics 2010; 3(1): 50–67. Townsend P. Poverty in the United Kingdom. Harmondsworth: Penguin Books, 1979. Gallie WB. Essentially contested concepts. Proceedings of the Aristotelian Society 1956; 56: 167–98. Friedli L. What we’ve tried, hasn’t worked: The politics of assets based public health. Critical Public Health 2013; 23(2): 131–45. Harris B, Galvez N, Machado H. (eds). Gender and Wellbeing in Europe: Historical and Contemporary Perspectives. Surrey: Ashgate, 2009. Knifton L. Understanding and addressing the stigma of mental ill-health with ethnic minority
communities. Health Sociology Review 2012; 21(3): 287–98. 8. Lelkes O. Minimising misery: A new strategy for public policies instead of maximising happiness. Social Indicators Research 2013; 114(1): 121–37. 9. World Health Organization (WHO). Ottawa Charter for Health Promotion. Geneva: WHO, 1986. 10. Marmot M. Fair Society, Healthy Lives: Strategic Review of Health Inequalities in England Post-2010. London: Marmot Review, 2010. 1. Pickett KE, Wilkinson RG. Inequality: An under1 acknowledged source of mental illness and distress. British Journal of Psychiatry 2010; 197(6): 426–8. 12. Lizhi X. Poetry. Available online at: http:// libcom.org/blog/xulizhi-foxconn-suicide-poetry (Last accessed November 2014).
26 Perspectives in Public Health l January 2015 Vol 135 No 1 Downloaded from rsh.sagepub.com at UNIV OF ILLINOIS URBANA on March 16, 2015
13. Sen A. Human rights and capabilities. Journal of Human Development 2005; 6(2): 151–66. 14. Collins AB, Wrigley J. Can a Neighbourhood Approach to Loneliness Contribute to People’s Well-Being? York: Joseph Rowntree Foundation, 2014. 15. Oxford Poverty and Human Development Initiative (OPHI), Oxford University, 2014. Available online at: http://www.ophi.org.uk/ research/missing-dimensions/ (Last accessed November 2014). 16. Simon J, Anand P, Gray A, Rugkasa J, Yeeles K, Burns T. Operationalising the capability approach for outcome measurement in mental health research. Social Science & Medicine 2013; 98: 187–96. 17. Rowe M, Pelletier JF. Citizenship a response to the marginalization of people with mental illnesses. Forensic Psychology Practice 2012; 12(4): 366–81.
