Nurturing mental health and wellbeing early in life produces benefits that will continue to pay off for young people, their families, and their communities across the entire course of their lives. Current approaches to mental health typically lack an integrated understanding of the pressures and challenges that young people face. They struggle to address disparities, and often fail to reach marginalized populations.
Changing the narrative around mental health to consider the interconnection of self, society, and space can help to unify diverse stakeholders to support the mental health and wellbeing of emerging generations. At CitiesRISE, we advocate for a concept of mental health that clarifies these three dimensions.
At the core of the various factors that influence a person’s wellbeing is an individual “self,” who is experiencing a complex and unique journey. Parts of this journey can be observed or described to others, but it takes place beneath the surface and links the attitudes, thoughts, and behaviors of an individual to a vast constellation of past experiences and future aspirations. Studies of positive psychology, positive mental health, and recovery approaches to mental illness provide important insights into the role of the individual “self” in mental health and wellbeing.
Recovery approaches draw from the lived experiences of people with mental illness to form insight on the processes they use to develop purposeful and meaningful lives, understanding that what works for someone at one point in life might not work for another person, or even for the same person at another point in time. In contrast to medical models, which focus on pathology, deficits, and dependency, recovery approaches focus on building hope, self-determination, self-management, empowerment, advocacy, inclusion, and freedom from stigma and discrimination.
Research surrounding recovery approaches indicates the importance of shifting the focus from treatment of illness to supporting the person experiencing the illness to engage with life on the basis of their own strengths and goals. This holistic, person-centered approach also aligns with growing understanding about the role of spirituality in recovery processes.
Evidence surrounding the social determinants of mental health has clearly established that society plays a strong role in driving risk and protective factors. Specifically, social inequalities have been linked to risk factors for many common mental health disorders, with disadvantaged populations suffering disproportionately. Social factors associated with mental health include income, employment, financial strain, socio-economic status, education levels, gender, ethnicity, and presence of social support networks.
Society also influences the mental health of individuals in a variety of ways across the life course. In childhood, mental health is affected by caregiving behaviors, education, and the living conditions of the family and neighborhood in which a person grows up. Adolescents exposed to chronic poverty are at increased risk of developing mental health problems such as depression, and more likely to engage in risky behaviors such as substance abuse, early sexual activity, and criminal acts.
Early adulthood is a time of particular vulnerability, when lack of access to regular, good quality employment increases the risk of mental health issues. This can trigger a cycle of risk, as the symptoms of mental ill-health can further impede a person’s ability to navigate social norms and structures, making it all the more difficult to gain employment, education, training, and a secure livelihood.
Parenthood can heighten the impact of inequalities, insecure livelihoods, and other social determinants of mental health, particularly for people who have children during adolescence and early adulthood. Chronic stress raises the risk of mental health problems, such as depression, and can interfere with parents’ ability to nurture healthy cognitive and emotional development in their children, perpetuating intergenerational cycles of disadvantage and risk of mental ill-health.
In later adulthood, cycles of risk triggered by inequalities experienced earlier in life can continue to compound and also impact upon future generations. Strong social relationships can help protect and maintain mental health, but when society places differing expectations on people based on gender, race, or age then social relationships can also produce added responsibilities, strain, and stress for certain groups.
Based on these dynamics, there is a clear need for action beyond clinical responses by mental health professionals, and the evidence points to the importance of addressing risk factors in society, such as poverty and inequalities, that restrict access to employment, education, and secure livelihoods.
Research also reinforces the importance of studying how social policies and institutions can better support positive mental health and optimal functioning, which remains a significant gap in knowledge and practice.
The spatial dimension of mental health encompasses the interplay of social and physical environments that form the setting for a person’s life journey. This includes a person’s connection to place and community, including their access to healthy natural and built environments.
Social spaces that have been identified as particularly important include workplaces and educational settings. Having a secure place to live is fundamental to wellbeing. Poor housing quality is linked to psychological distress, while cleanliness, comfort, and safety of housing have been found to reduce stress levels and promote self-worth. Studies of social determinants have also established strong links between mental ill-health and neighborhood conditions such as socioeconomic makeup, geographical distribution of housing, built environments, and ethnic composition.
The presence of open spaces and public facilities such as community centers, cafés, green spaces, and children’s play areas have also been identified as important for wellbeing. In addition, access to green spaces generates lasting positive impacts on mental wellbeing, while interaction with nature has been found to improve multiple aspects of mental health (such as cognitive functioning, mood, and emotional wellbeing), reduce psychological distress and mediate risk factors for some types of mental illness.
Finally, global environmental security is also important to take into account, as people – particularly young people – increasingly report feelings of anxiety, guilt, and hopelessness related to issues such as COVID-19.
Increased cooperation between mental health experts and the keepers of social, built, and natural spaces has great potential for expanding knowledge and awareness of how to support the spatial dimension of mental health and wellbeing.
Advocating for mental health systems reform
Mental health conditions are currently the leading cause of disability in young people across all world regions, a situation that is expected to cost over US $16 trillion in lost economic output by 2030. There is a high probability that the medium and long term impact of the COVID-19 crisis will exponentially increase this figure. Unfortunately, only a small fraction of government health spending is typically dedicated to mental health domestically, and global development assistance for mental health has never exceeded 1% of health spending worldwide. A major shift is crucial.
There is a growing consensus among global mental health experts that cross-sectoral approaches are needed to achieve large-scale systems change. The three dimensions model has important implications for how we approach mental health system reform. It means a shift away from the current emphasis on medical models of treating mental illness, towards a more holistic vision of supporting the life journey of all individuals.
This reinforces the importance of proportionate universalism, as advocated by the World Health Organization (WHO), meaning approaches to reach entire populations, with extra support for the people most in need. One way of accomplishing this is to develop strategies for providing at least the three levels of support highlighted here. This requires bringing people who do not normally interact together to form coordinated and cooperative responses.