Wolfgang Rutz 2012

Person Centred Public Health Promotion Risk – and Protective Factors Contributing to Mental Health and Wellbeing
An Overview and a Plea

by Wolfgang Rutz, MD, PhD, Professor of Social Psychiatry Stockholm / Coburg

Summary

The health definition of the United Nations (UN) and the World Health Organisation (WHO) has traditionally focused on individual health as a human right, defined not only by the absence of symptoms, disorder and disease but also including in the definition a state of continuous and balanced mental- and physical wellbeing (1). To day increasingly holistic approaches integrate even physical, mental, psychosocial and existential factors and focus as well on salutogenesis and resilience as even happiness (2). Recently, an increasing movement on person centred diagnosis, treatment and “people focused” public mental health promotion  has started and is gaining world wide importance, not only concentrating  on individual persons, but even “people”, namely groups and populations at risk (3).

During the last decades WHO has summarized the global research evidence regarding mental health and mental wellbeing and defined the following determinants of health as necessary to keep healthy and to avoid  illness (4):

1)   A state of control: Not to be helpless, to be in charge of and execute mastery in one’s own life.

2)   A sense of existential cohesion and meaning: To feel involved in an over individual context of meaning and sense and to find individual and feasible ways to live according to this feeling.

3)   A feeling of social connectedness: To feel socially connected and related, to experience the feeling to be needed and have others to get supported by when needing help, to have someone to care for and  to be cared for.

4)   A feeling of “caseness” - being a person and identity by one’s own:  This involves feelings of integrity, identity, dignity, getting respected and the absence of alienation.

Here, diagnostic and person centred public health and community approaches, focussing on regions or populations at risk, have to investigate and elucidate these four dimensions for each person or population at risk by their own.

In this article the often complex patterns of specific vulnerabilities will be shown, specific assets and strengths as well as specific etiological causalities  analyzed and some of different populations individual salutogen or pathogen health consequences  described – in order to get an underlying basis for actions and interventions on a demographic level.

Thus, the four domains of health promotion and diseases treatment will be elucidated: Self control, existential cohesion, social significance as well as personal and cultural identity. According to the UN and the WHO they have to be applied as a universal human right of all individuals and populations in a society. They will be exemplified by specific protective as well as noxic factors, adapted to the different needs of people at risk, as e.g. age groups, genders, minorities, disabled persons, immigrants and others.                                                        

Key Words

Public Health, Health Promotion, Public Mental Health, Person Centred Medicine, Person
Centred Health Promotion, Psychiatry for the Person, Community Based Mental
Health, Social Psychiatry, Societal Psychiatry, Mental Health Impact Analysis,
Mental Health Accountancy, Human Ecology

Introduction

A useful argument for getting momentum in political and health promotional efforts is, that as well the UN as the WHO repeatedly have declared that not only the right to health and treatment, but even the access to the above described health determinating  prerequisites of  health have to be considered as a  “Human Right” (5).

A European Perspective

Experiences from European countries in heavy societal transition during the last decades, where especially in eastern Europe dramatic changes in future and social perspectives - gender roles, professional identities, social and family cohesion -of value systems and in ethical norms could be found. These examples have shown that there is a nearby stereotypically repeated reactive pattern of mortality and morbidity, characterizing societies and countries in heavy transition. A societal or “community syndrome” appears, often with seismographic rapidity and
reagibility, characterizing societies and populations in stress and consisting of depression, aggression, violence, high suicide figures, self-destructive life styles, abuse, but also physically  cardio -  and cerebro-vascular morbidity and mortality. It even expresses itself in increasing figures of homicides, accidents and other death by external causes (6).

These patterns show as well a gender specificity, where non compliance and non help seeking patterns specially dramatize the situation for the male parts of the population. They show also that interventions, e.g. supporting efforts  through crisis centres have to be stratified and designed in a way that makes them not only available but also accessible and acceptable for the populations that are mostly at risk, e.g. Russian industrial workers, unemployed youngsters in Scandinavia or Baltic fisherman and farmers (7).

European Risk Populations

Health promotion, service - design and - provision as well as the efforts to facilitate recovery and rehabilitation have to be adapted to the specific religious, cultural and demographic peculiarities of different risk populations.

Experiences from the last decades show that e.g. farmers in Ireland, elderly men in the Portuguese region of Alentejo, young people especially young men in Finland  and the United Kingdom as well as young women in Scandinavia are such risk populations. Others are indigenous people in Greenland as well as immigrants in Denmark and asylum seekers in Sweden. Over all there is a gender specificity, whereby most often a male gender is an additional risk factor – due to help avoiding, abuse and an alexithymic incapacity to show weakness and ask for help in time.

The cultural sensitive diversities in these groups demand apparently different approaches in health promotion, primary prevention and salutogenic resilience increasing efforts.

The European Union (EU) and the WHO have since the WHO ministerial conference on Mental Health in 2005 in Helsinki strongly focused on
the different need to be met in the different courses of life – adolescence, the working age of males and females as well as demands to be met in higher age, again often with specific differences in men and women (8).

Unemployed people with a responsibility for family provision, people experiencing the very risky phase of job insecurity, people by stigma reasons keeping away from medical, psychiatric and social services – they all have different needs to be met in adaptation to their specific vulnerabilities and sensitivities.

A Paradigm Shift

To cope with these problems, we need in public health and salutogenic action a widened focus on not only disorder and diseases, but also function, resilience and wellbeing. A re-focusing from therapy to prevention and promotion, a widening of efforts avoiding risk factors to those even offering protective factors and facilitating strength, resilience, health and happiness promotion seems essential.

There is even a challenge to establish and support structures on creating political awareness and capacity building, by educational programs and information to decision makers and political structures. There is a need for creating regular structures not only to asses economical investments, progresses and failures but also to demand from organisations and enterprises a regular health accountancy - in a similar and as self clear way as it is done for economy.

A today already vivid discussion and awareness about the need to consider environmental aspects in political and health relevant action must be widened to include the mental environment concerning both mental health causes as mental health consequences for the exposed and afflicted population.

Today mental health professionals have often abdicated from their political responsibility to interfere and interact with political and societal discussions and developments. Therefore it seems to be a moral obligation for experts in these fields to take action to enable responsible leaders and structures to make the right decisions respectful to and inevitable for human person’s basic needs (9).

Concretely

Some examples can be given:
                                                                                                                                
- Evidence is overwhelming that income gaps in societies are one of the most pathogenic social factors in a society (10).

-We know that job insecurity is leading to deteriorated mental health indicated by increasing suicide figures and that over debt phenomena in big populations are an important suicidogenic factor.                                             

- We know that value changes, the secularized questioning of religious and/ or moral values (11)  and value migration is one
of the main factors burdening  immigrants, together with identity losses and societal changes.

- We know that the imbalance between responsibility and influence, the gap between control and demand is one of the most important pathogenic factors in working life – directly related to dysfunction, illness, abuse and suicide. It indicates  crucial losses of participation- all challenges that relatively easily and concretely can be met if the decision makers will and ambition is there (12).

- We also can see that often people already molested by a much too heavy working load get still more work to cope with, and those suffering badly by unemployment and the insignificance and marginalisation linked to that get still less to do, feeling invaluable and superfluous (13).

Some possible solutions can be programs on participation on working places, of integrating and respecting the value transitions experienced by immigrants, of respecting identity and dignity in the activities, programs and centres of insurance companies, working agencies and supportive social- or health institutions as well as to make political decisions minimizing income gaps and the unjust and contraproductive distribution of work.

Research

There is a wide range of research relevant to the promotion of mental health and mental resilience that already exists and has to be utilized and implemented. That research elucidates wellbeing, and happiness, positive psychology and health promoting psychiatry, neuropsychiatric evidence on serotonin, nor epinephrine, endorphins, dopamine and other brain metabolisms, their interaction and their implications
for human wellbeing and human’s capacity to tackle life, its events and stresses. Research on environment and health interaction, on genomes and epigenomics is clarifying and explaining that stressful mental environmental factors not only afflict present generations, but risk to find their way even into persons  genomic hereditary settings, thus influencing the health of future  generations (14).

We today also know a lot about ethological mechanisms regulating and creating both vulnerability but also resilience in individuals and groups, and we get increasingly aware of the importance of spiritual and existential factors when it comes to health promotion and salutogenesis (15).

A New Psychiatric Awareness

There is a traditional conceptualisation of “Healthy Choices”, often used in WHO, other societal and political efforts and generally in health promotional discussions. Hereby the focus was often directed to choices to be made by the individual, regarding lifestyles, nutrition, physical exercises or patterns of alcohol consumption etc. (16).

Today there is a need to widen this conceptualisation in two directions.

1. To include the responsibility of political and other decision makers regarding the mental health and access to health determinants of peoples and population directly influenced by and sometimes sacrificed by their decision-making and policies.

2.  To reassure that policies and decisions should be the object of an impact analysis being offered by human ecological expertise regarding peoples basic human needs, given that control and mastery, the sense of cohesion and over individual meaning in life, identity status and
dignity as well as social connectedness and significance are the essential psychosocial prerequisites of health. (17).

Especially in the present situation of globalisation, profit maximisation, growth fetishism, consumism, share holder values, social transition, value migration, secularisation and the at time being predominantly instrumental view on humanity - all questioned and discussed today by many -  these analyses are badly needed. They should be done as consequently, self clear and necessarily as the ecological analyses regarding the climate and the external environment that in fact are in place today.

There are not only environmental and climatic consequences and catastrophes to be aware of, there are even “mental tsunamis” to be avoided in times where the individual human being all too often gets neglected (18).

Here a new role for psychiatric and mental health professionals can be recognized – to provide human ecological and mental ecological expertise to politicians, other leaders, democratic structures, in offering analysis, describing consequences and, thus, being catalyst and warning signal in order to reassure a further human ecological and democratical development.

Societal Consequences of Societies Posttraumatic Stress – a Lesson

Even other societal phenomena underline the actual importance of mental health promotion on an aggregated societal level, especially in times being  characterised by transition, value changes, societal turmoil’s, de- identification phenomena as well as dehumanisation.

There are wellbeing societies, who easily can realize the tolerance, the pluralism, the acceptance for people with deviant behaviour that characterizes the democratic pluralistic capital of a country.

In contrast, experiences from the posttraumatic societies in the Balkan region after the internal conflicts and warfare’s during the 90ies show clearly that societies and their people in crisis get regressive in a way we can recognize from individual psychopathology.

Intolerance, scape-gouting and the marginalisation of deviant minorities appears, together with a regressive black and white thinking, “we and them”, “people who are not for us are against us” etc. This can lead to public demands for simple solutions, together with a regressive and nostalgic longing after a strong leader, law and order, fundamentalistic ideologies and lastly totalitarian structures.

Experience from internal conflicts due to terrorism in Spain, Ireland and recently the Arabic countries confirm these risks.

These experiences show, that the democratic potential of a society, the resistance against totalitarism , the capacity for democracy rebuilding, reconciliation efforts and even re-humanisation after times of materialistic instrumentalisation clearly is linked to the degree and quality of mental health in a population (19).

It becomes evident that we -  in a  time where increasing social problems are threatening society and humanity and authoritative economical sociological and political experts warn for pre-revolutionary movements -  strongly should focus on the promotion of societal mental health in order to strengthen the democratic potential as the kings’ way to find constructive and evolutionary solutions and to avoid revolutionary
destruction or violence.

Outlook

There is today a need to respect and recognize the interfaces of modern mental health sciences. Anthropology, sociology, religious sciences, political sciences, neuropsychology and social psychiatry are linked together and need complex judgements as well as creative, constructive attitudes towards  complexity. There is a demand for an interdisciplinary responsibility taking with focus on the “conditio humana” we know so much about.

For this we need even a new evidence conceptualisation, respecting the need both for humanistic qualitative evidence and subjective experience as well as quantitative positivistic science, interacting with and presupposing each other.

As human beings are dynamically exposed to both, we need both approaches to create complex person centred health promotion in order to be able to take the political and humanistic responsibility laid on us and to cope with a risky reality.

At present, first positive signs appear. Some states and their experts introduce mechanisms of measuring growth not only in economic terms but even in terms of measuring wellbeing, solidarity and equality.  Other societies, as the Kingdom of Bhutan, following the example of the USAs and the German constitution and assisted by the London School of Economics, introduce   spiritual “happiness” as a constitutional right of every citizen (20).

One of the most ardent motivations for the personal promotion of health and well being comes from Octavio Paz, poet, humanist, diplomat and Nobel prize winner. He said in 1963

What sets the world in motion is the interplay of differences, their attractions and repulsions. Life is plurality, death is uniformity. By suppressing differences and peculiarities, by eliminating different civilisations and cultures, progress weakens life and favours death. The idea of a single civilisation for everyone, implicit in the cult of progress and technique, impoverishes and mutilates us (21).

Or as Bertrand Russell put it after Hiroshima;

We appeal as human beings to human beings. Remember your humanity and forget the rest. If you can do so, the way is open for a new society. If you cannot, there lies before you the risk of universal death (22).

  

References by the author