PSYC11412: Foundations in Mental Health and Distress The role of life circumstances in mental health Dr Ming Wai Wan SENSITIVE TOPICS • These lectures will inevitably explore sensitive topics that can be emotional/triggering (e.g. examples of life experiences that some individuals might regards as painful or traumatic • Some individuals might feel that the content of this lecture “hits home” • Please ensure that you do what works best for you in terms of looking after your well-being, e.g. take a 5-minutes break; familiarise yourself with the lecture material beforehand etc. • Feel free to approach me, your academic advisor/year tutor, or the University’s well-being services (e.g. Counselling Service and Mental health services https://www.counsellingservice.manchester.ac.uk). Overview • Whether, how, and which kinds of stressful/traumatising life experiences impact on mental health • An overview of the research and the limitations • Whether structural factors, such as discrimination and inequality, affect mental health • Can adverse life experiences be positive for mental health? Are there protective factors? problem with the term ‘traumatic’ we’re not always sure if the specific individual is traumatised or they’ve just experienced an event that is commonly inducing trauma Adverse (or potentially traumatising) life experiences • Most of us experience have experience of 1+ ‘potentially traumatising’ life experiences (PTEs): • 90% of older US adults (mean 60 years) (Ogle et al., 2013) • 81% of Dutch adults (De Vries & Olff, 2009) • 70% based on combined samples from 24 countries using the World Mental Health Survey (N = >68k) • And 30.5% had 4+ PTEs (Benjet et al., 2015) • PTEs can lead to post-traumatic stress in the immediate aftermath of the event • But most people exposed to stressful – even traumatic – events do not develop a mental disorder but the likelihood is increased Estimated % who develop PTSD following… Severe beating / physical assault 31.9% Stabbing or shooting 15.4% Estimated % who had depression following… Losing spouse later in life 13% Adverse experiences increase risk of MH difficulties • Major stressful life events prospectively predict depressed affect, anxiety and fear • This in turn raises risk of depression (Gotlib & Joorman, 2010; Hammen, 2016). • Individuals with depression are at 2.5 - 9.4x as likely to have experienced a major stressful life event before the first onset of depression (Kendler et al., 2000; Slavich & Irwin, 2014). correlation between major stressful life events & first onset of depression can’t say that it’s a cause!!! (depression might have happened anyway even w/out the event • PTSD by definition is a mental disorder that arises from a traumatic life experience by default PTSD requires an identifieble stressor “i’ve experienced trauma” referes to an experience of a typically traumatising event Events Frequently used terms: • Adverse life experiences • Negative / stressful life events • Traumatic experience / ‘trauma’ (more accurately a ‘potentially traumatising event’ General definition: A group of events that are typically extremely stressful or negative if experienced or witnessed, which are Known to be physically / psychologically threatening to self (or loved ones) While all these can be traumatising, they do not necessarily lead to psychological trauma Adverse childhood experiences (ACES – when in childhood) predictor of physical/mental health worse ACES ~= worse physical/mental health General definition: (Psychological) trauma (‘traumatised’): A general term referring to an emotional (& physiological) response to an intensively distressing event/s, which can have lasting mental, emotional, physical and social impacts What is trauma? Impact of self ‘i’m traumatised’ experiencing the aftereffect following a potentially traumatising event Post-traumatic stress disorder (PTSD): A DSM diagnosis not a DSM diagnosis, but people are fighting it to be Developmental trauma: Childhood trauma (usually repeated/prolonged) characterised by various forms of dysregulation (affective, behavioural, attentional, physiological), but often does not fit the PTSD criteria based on the defined stressor(s) (low or no recollection); neither are there some PTSD symptoms; e.g. flashbacks (Van der Kolk, 2005) Stressors, PTEs and mental health difficulties • (Potentially) traumatising experiences are more likely to develop into mental health difficulties are (on average) more likely to develop when traumatic experiences are: more likely to develop MH difficulties following a traumatic interpersonal experience rather than experiencing a natural disaster • Repeated/multiple or prolonged; when ”escape” is difficult or impossible • Interpersonal (they involve people close to the person or meaningful others) • Happen at critical developmental stages (childhood, adolescence and ‘life transitions’) • Stress proliferation theory/effects (Pearlin, 1981; LeBlanc et al., 2015) • A stressor/set of stressors expand or develop within and beyond a situation • Result in new stressors (that were not originally present) • Thus, early stressors in life may increase risk to mental health difficulties via the proliferation of further stressors • Mothers’ own adverse childhood experiences were associated with child mental health difficulties at 5 years, mediated by maternal depression and attachment difficulties (anxiety/avoidance) (Cooke et al., 2019) – Suggests that trauma can have indirect intergenerational effects on mental health mother’s ACEs —> metarnal depression —> child attachment insecurity —> child MH difficulties How common are Adverse Childhood Experiences (ACES)? • ACES are studied by asking adults about how often they had various negative childhood experiences • High prevalence of at least 1 ACE: 47% British adults; 50% Korean adults, 25% Swedish adults • 8% of UK adults have experienced 4+ ACEs • Much higher rates of 1+ ACEs in Low and Middle Income Countries (LMIC) • E.g. 90/77% young Malawian men/women, >80% Brazilian adolescents, 75% in Philippines and China • Research shows that girls tend to experience more ACES than boys and different types of ACE. ACEs and common mental health difficulties Systematic reviews and meta-analyses found a strong association between the number of ACEs and risk of ‘common’ mental health difficulties in a dose-response relationship: Merrick et al.’s (2017) Californian study (N = 7465) found a dose-response (graded) relationship between number of ACEs and depressed affect Adjusted odds ratios (i.e. Increased odds/risk) Anxiety Self-harm Suicidality Drug use Alcohol use Mental health related behaviour Psychosis Borderline personality disorder Bipolar disorder Number of ACEs were associated with other common mental health difficulties… (Merrick et al. 2017) On average, people exposed to childhood adversities are 3x more likely to develop psychosis (Varese et al., 2012) Up to a third of cases of psychosis could be attributable to the impact of childhood adversities (Varese et al., 2012) Those exposed to 5 types of childhood trauma: 53x more likely to have experienced psychosis (Shevlin et al., 2007) ACEs and mental health • Regarding types of ACE, emotional abuse may be particularly - self report destructive to mental health. 36% partly due to co-occurrence with other types of abuse/maltreatment • Meta-analysis of 97 studies by Palmer-Klaus et al. (2015) found: • Bipolar disorder: 4 times more likely than non-clinical controls to report childhood emotional abuse • Borderline personality disorder:14x more likely than controls to report childhood adversities; 38x more likely to report childhood emotional abuse • Merrick et al. (2017): The strongest effect of any single ACE on outcomes measured was emotional abuse on attempted suicide (5.6 times increased risk) • Biggest predictors of negative affect (not a diagnosis) are mental disorder in household, emotional neglect and emotional abuse How do adverse experiences affect our mental health? Adverse life experiences How we perceive / appraise the negative situation is more important than the objective situation whether it becomes part of self identity (e.g. shame) and relates how we view/relate to others (e.g. trust) All inter-related Cognitive and Emotional -Emotional dysregulation -Negative beliefs about self, others and the world - Sense of threat -‘Maladaptive’ thinking styles (rumination, suppression) There is research evidence supporting each of these processes Physiological Behavioural -Stress effects on neuroendocrine system (e.g. HPA axis) -Long-lasting neurobiological changes e.g. heightened stress sensitivity - Health-harming behaviours as a way of coping (alcohol, drug use, self-harm) social - Difficulties in relationships - Other behaviours as way of coping e.g. being aggressive struggling to regulate your stress responses Increased risk of a range of mental health difficulties loosing trust for others indirect impacts: e.g. drinking alcohol as a way of coping may influence our relationships with drienf/family asking adults who recollect/report on their childhood experiences often might be underreported due to memory/no desire to share private experiences Research limitations Negative life events from a structural (sociological) perspective • The way society is structured contributes to mental health difficulties through: opportunities & rewarads for different • Social inequality unequal social positions or statues within a group or society • Poverty (or socioeconomic disadvantage) • Discrimination (e.g. racism, transphobia, homophobia) • Discrimination: Unfair treatment or negative attitudes towards categories of people (based on age, gender, race/ethnicity, religion, disability, sexual orientation etc.) • Not always overt; often ‘subtle’ but damaging forms of singling out members (e.g. limiting access to social resources) Negative life events from a structural (sociological) perspective • Individuals belonging to ‘minorities’ have elevated mental health risks: evidence suggests role of discrimination • Ethnic minorities & psychosis risk (24 studies; Pearce et al., 2019) • Not explained by immigration • Young homeless people who report more discrimination report more psychological distress/suicidal ideation (Narendorf et al., 2022) • Reasons for discrimination include housing status, sexual orientation, juvenile justice involvement • Across Europe (N = 40k), those belonging to more minoritised ‘categories’ have more depressive symptoms • Effect stronger in Eastern & Southern European countries; Alvarez-Galvez & Rojas-Garcia, 2019) • Thus, increasing evidence suggesting a role of discrimination • But discrimination itself is not in most stressful/negative life event measures Poverty and social inequality • Poverty and social inequality (i.e. unequal opportunities and rewards for different social positions or statuses within a group or society) are associated with mental health, both within a nation and between countries • Extent of within-country wealth and social inequality correlates with the incidence of many mental health issues (see graph) • Levels of psychotic disorders are 9 times higher in people in the lowest fifth income households compared to the highest. The relationship between lifetime adverse life events & mental health Wisbech Carstensen et al. 2020 • Danish study (N > 7000) asked adults about a wide range of lifetime negative life events (including stress, violence, bereavement, serious injury) and emotional distress in the last week Key findings: • A dose-response relationship: As adverse events accumulated (especially 9+ events), emotional distress increased • Slight ‘U-curve’ supports a small resilience effect: low levels of adverse events more protective than no adverse life events None • Seery et al. (2011) found a larger resilience effect for ALEs and post-traumatic stress symptoms / global distress Protective (resilience) characteristics & buffering effects Positive life experiences and relationships across the lifespan can buffer or counteract the impact of life adversities (i.e. resilience / protective factors) Goal orientation Confidence, academic aspiration, life satisfaction Social support Sleep Having the support of an adult, family cohesion, perceived emotional support, access to social support, social resources (Only one study out of those reviewed studied this) Cognition and cognitive strategies Greater perceived selfefficacy/control, less negative affectivity, Less rumination • Older adults: Life satisfaction and social support important; young people: goals, attachment & IQ • For marginalised groups, the protective role of community / neighbourhood support is important Alleviating mental health difficulties after challenging life experiences • Access to ‘corrective experiences’ can help survivors even after developing mental health problems as a result to life challenges • Adverse life experiences that threaten our lives and social role, and how we make meaning out of those events, can particularly affect mental health • Re-processing this experience in a safe environment can help individuals to move on. • Trauma-informed care encourages mental health professionals to assume that all individuals who access mental health services might have experienced important adverse life events Therapeutic relationship as source of social and emotional support Therapist as a model of self-compassion Therapist to encourage adaptive coping and health-promoting behaviours Therapist to help retrain cognitions Conclusions • Most adverse life events do not result mental health difficulties, but risk is increased, especially if repeated/chronic, interpersonal (esp emotional abuse), or happen at life transitions / early in life • Traumatic experience impacts on our emotions, cognitions, behaviours, relationships and neurobiology • ACES are associated with a wide range of mental health difficulties and maladaptive behaviours in a dose-response (graded) relationship • Negative life experiences may disproportionately happen in certain sections of society, resulting from how our society is organised structurally • When working with individuals in distress, provision of ‘corrective’ experience and protective factors help to boost psychological resilience and prevent, reduce and alleviate mental health difficulties
