London I love you: mental health and cities
People living in cities are taking part in one of the most exciting experiments ever in human living but that doesn’t mean it’s fair
The Following is the text of a speech given by Mark Brown on 15th May 2018 to the Pint of Science Event ‘London I Love You But You’re Bringing Me Down’ in Whitechapel, London
According to the United Nations Department of Economic and Social Affairs, by 2050 66% of the global population will live in cities, many of which will not be designed in any overall sense. I’m not a scientist. But I am someone who cares deeply about mental health and cares deeply about cities. And cares deeply about London.
Cities like London stand as the greatest achievement of the constantly overlapping fabric of dreams and desires and nightmares and hopes of the millions of people who live there, the millions who came before them and the millions that will come after. Cities are our understanding of how humans relate to each other under particular forms of social organisation made concrete, sometimes literally. We have a tendency to see cities as the driver of mental health difficulty; the great unnatural hives of human degradation, the juxtaposition of dark satanic mills and green and pleasant land.
I think it’s a bit more complicated than that.
Maids cycling; false binaries
In 1993, Conservative Prime Minister John Major in possibly his most famous speech made it sound like the quintessential british experience was a suburban one, a smaller town one. The speech to the Conservative Group for Europe on 22nd April 1993 listed things that would be forever British: “Fifty years from now Britain will still be the country of long shadows on county grounds, warm beer, invincible green suburbs, dog lovers and pools fillers and — as George Orwell said — “old maids bicycling to Holy Communion through the morning mist”
Except that isn’t what George Orwell said. In ‘England Your England’ written in 1941 at the height of the blitz, Orwell actually wrote of a very much less sedate world, one that included cities as well as towns and villages, noise as well as calm, a much more urban world. Orwell wrote:
“The diversity of it, the chaos! The clatter of clogs in the Lancashire mill towns, the to-and-fro of the lorries on the Great North Road, the queues outside the Labour Exchanges, the rattle of pin-tables in the Soho pubs, the old maids biking to Holy Communion through the mists of the autumn morning — all these are not only fragments, but characteristic fragments, of the English scene.”
Somehow in a space of decades, and through a conservative filter, Orwell’s words about the political and economic realities of the modern world and the world of cities and towns had become gummed into a comforting celebration of a non urban Britain. Cities, somehow, shifted to being places of horrible necessity rather than the pinnacle of our collective dreams.
When engaged in thinking about mental health and cities we’re often engaged in such a false binary. The useful comparison is not between city and countryside; between London and a sleepy village. Those comparisons don’t tell us anything we can actually do anything about because they don’t really tell us anything about experiences of London or any other massive city. The real comparison, if there is one to be made, is between good experiences of the city which give us what we need to be what we want to be and bad experiences of the city that rob us of the things we need to be our best.
A day in the life
Between 2014 and 2015 I did a project called A Day in the Life. On four calendar days across the year, one each season, we asked people who experience mental health difficulties to write anonymous blogs answering the questions
‘What was your day like? What made your mental health better and what made it worse?.
All of the blogs were eventually published at dayinthelifemh.org.uk/.
There were 872 individual days published, amounting to maybe a quarter of a million words worth of everyday life experienced with mental health difficulty. There were days where nothing much happened, days where people experienced the worst day of their life in hospital, days where people did things that made them feel a sense of wellbeing and days where they didn’t. No one had done a crowdsourcing project like that in mental health before.
The project was funded by Public Health England, and part of the idea was this approach would help to build provisional knowledge, hints and hunches, that might be followed up by later public health research into how the wellbeing of people who already experience mental health difficulties might be improved. Each blog was up to 700 words and those submitting were asked to submit metadata along with their upload. We weren’t interested in tracking individual people’s wellbeing but in making a snapshot of life on a given day. At the end, along with the Centre for Mental Health, we did a very simple content analysis, having developed a set of indicators against which to code each upload. This, along with metadata like age, gender, which mental health diagnosis was closest to their experiences, whether mental health was someone’s primary disability, where they lived in the country and what kind of place they lived, we hoped would let us tell very simple stories about what this massive stack of qualitative data might tell us.
In putting together the indicators we didn’t really know what we might find in this massive stack of everyday life, so we created indicators that we thought might be present or which might, when combined with each other, tell us something about the lives of people with mental health difficulty.
What we found was this: the theme recognised in the greatest number of analysed days was experience of mental health services, whether this was positive or negative.
The second most frequently mentioned area was work contribution, covering the feeling. That work had contributed either negatively or positively to the sense of wellbeing of the person living with mental health difficulty on the day in question. The third most mentioned area was home life — stability, security, routine — the sense of home as a safe environment in which to live. The fourth was friend support, the ability and opportunity to talk to and gain support from friends. Fifth was sense of purpose in life or its absence.
The three most commonly mentioned positive wellbeing indicators are friend support, home life and sense of purpose. These were closely followed by positive experiences of mental health services, positive experiences at work, and hobbies.
The three most common negative wellbeing indicators were experiences of mental health services, poor or unsatisfying sleep and the physical health of the individual writing.
Of those days with included metadata about location, 224 came from people who lived in cities, 257 came from people who lived in towns and 106 came from people who lived in villages or other rural locations. We had an indicator about the environment in which people lived. It didn’t come up very much. We weren’t looking at people’s levels of wellbeing, remember, but what they mentioned in relation to their wellbeing on a given day. When people wrote, they didn’t really talk about their direct environment as a thing which directly the affected them. This surprised us.
Just what is public mental health?
In some ways, 2014/15 was a high water mark for the Five ways to Wellbeing approach to mental wellbeing, what we thought we might see was influenced by them. The five ways to wellbeing, for those that aren’t aware, are
- connect.
- be active.
- take notice.
- keep learning.
- give.
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 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.” As part of the review, thinktank The New Economics Foundation were commissioned to develop an equivalent of ‘five fruit and vegetables a day’ for wellbeing.
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.
This was a call both for individual action, but was also aimed at public health approaches to creating the conditions for mental health. Make London a better place to be and people will be less unwell. If we could find the equivalent of great structural health improvers like Joseph Bazelgette’s London sewers of the mid 19th century, then we could begin at an infrastructure level to engineer out poor mental health by raising the mental health of everyone. The public good and the private good would be as one.
When the reorganisation of the the NHS came into effect on April 1st 2013 as a result of the Health and Social Care Act, public health duties were reassigned 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. Public Health England came into existence to help.
Everything’s a therapy nowadays!
Then came a bombshell. On 9th of September 2014 the Chief Medical Officer (CMO) for England Dame Sally Davies upset the applecart by publishing her annual report. Her topic 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 specifically targeted 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’ 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.”
This was significant for two reasons. The first was that it placed local authorities, already unsure about public mental health into an even greater position of uncertainty. Local authorities are comfortable with bricks and mortar problems, responsible for an area and the people in it. The second was that it at first damaged the idea that environment and social organisation, the stuff of cities, was a great determinant in mental health and then created conditions where interventions based on environment attempted to massively up their game in providing evidence of mental health benefits.
Wellbeing had provided a happy halfway house where it was possible to argue that things like parks, cycle lanes, civic amenities and noise reduction were for the overall civic good and that they were also vital for people’s sense of wellbeing. Suddenly, the race for evidence of such things directly impacting mental health became a stampede as austerity continued to eat them up like Japanese movie monster taking great bites out of the landscape of people’s lives.
Suddenly parks were ecotherapy. Libraries were bibliotherapy. Telling people about cool stuff they might find nice to do was social prescribing. Suddenly, the race was on to find the winning evidence for public spending on what might previously have been taken as read.
Wellbeing and the urban environment
I recently reviewed a paper ‘Urban Mind: Using Smartphone Technologies to Investigate the Impact of Nature on Mental Well-Being in Real Time’ (Bakolis et al, 2018) for The Mental Elf, an amazing site where a variety of people try to summarise the most interesting and relevant mental health research.
The project Urban Mind, carried out by King’s College London, along with landscape architects J&L Gibbons and art foundation Nomad projects, tracked 108 people for one week, measuring their location, their exposure to natural features in the built environment and their momentary wellbeing via a smartphone app.
Participant were prompted by the app to record what they could see (e.g. Can you see trees? Can you hear birds singing? Do you feel in contact with nature?) and to also take a photograph to document their location. The app also relayed Global Positioning Satellite (GPS) data to locate them precisely. Each Ecological Momentary assessment gave participants 30 minutes to complete the assessment steps until the assessment was logged as complete or incomplete. Data was stored on the device and uploaded later if the device was not connected to the internet at the time of the assessment.
This data was combined with demographic, socioeconomic and wellbeing (Warwick Edinburgh Well-Being Scale) data collected from each subject. Also collected was a measurement of the individual’s trait impulsivity. This trait impulsivity was regarded by the authors as “a psychological measure of one’s tendency to behave with little forethought or consideration of the consequences, which is indicative of a higher risk of developing mental-health issues, flagging associations between impulsivity and addictive disorders; attention-deficit hyperactivity disorder; antisocial personality disorder and bipolar disorder”.
The study found that there was a significant positive association between momentary wellbeing and being outdoors; seeing trees; hearing birds singing; and feeling in contact with nature. An association between seeing or hearing running water was only present in those who responded to more than 66 percent of the assessments. The research also found positive ‘lag effects’ where the positive effect on momentary wellbeing was carried over from one assessment to the next, which on average took place 2 hours and 25 minutes later.
The study found that there was a greater significant interaction between the effects of being outdoors, seeing trees, hearing birdsong and feeling in contact with nature and momentary wellbeing for those with higher trait impulsivity than those with lower trait impulsivity.
The authors concluded: “These findings provide empirical support for the notion that short-term exposure to specific natural features has measurable beneficial effects on mental well-being…that these beneficial effects could still be observed even if the participant was no longer outdoors and no longer had access to nature… The effects of being outdoors, seeing trees, seeing the sky, hearing birds singing, and feeling in contact with nature on momentary mental well-being were greater in people with higher levels of impulsivity.”
In short they concluded, from a small self reporting sample, that seeing a bit of nature, even if it was a tree made people who felt a bit wound up feel calmer.
The paper was not looking to suggest that a walk in the park is the perfect cure for what ails you, or that birdsong is a tonic to the soul. The authors are attempting to build the argument for the pro-wellbeing possibilities of the designed urban environment as a public health concern. It was looking for a relationship between wellbeing over time and urban environments that include elements of nature.
Generation Rent: The crisis of social reproduction is killing our cities and making us lonely
It is impossible to escape from the political realities of social and economic organisation. I recently wrote a piece on the loneliness of generation rent for Prospect, based on findings from the Office of National Statistics. Younger people who rent report feeling lonely more often than older people who are settled and live in homes they own. To give an idea of scale, 46 percent of people aged 25 to 34 rent from a private landlord. Using data taken from the 2016 to 2017 Community Life Survey, the ONS identified three groups of people as being most at risk of loneliness: widowed older homeowners living alone with long-term health conditions; unmarried, middle-agers with long-term health conditions and younger renters with little trust and sense of belonging to their area. In 2016 to 2017 five percent of adults in England said they were lonely “often” or “always”. Women said they felt lonely more often than men.
The researchers found 61 percent of young renters aged between 16 and 34 reported they felt lonely occasionally or more frequently, compared with 46 percent of the overall sample. They were likely to be in paid work and, while they identified their marital status as single, just over half were cohabiting. Only 25 percent of them felt they could trust their neighbours; 70 percent of them lived in the 50 percent of most deprived areas or neighbourhoods and 55 percent said they belonged to their neighbourhood ‘not very strongly’ or ‘not at all’.
As I wrote: “The economics of actually having a life are a desperate balancing act between the affordability of rent, the cost of travel, possible earnings and the desperate hope for, perhaps one day, enough left over to save for a place of one’s own. It is a lucky person who finds affordable housing close to a job that makes them enough money to have spare time to make new friends, find new lovers and to actually explore what the local community might offer.
“The organisation of economic life shapes social life. Feminist Nancy Fraser refers to the current phase of capitalism as being characterised by a crisis of social reproduction, where the demands of social and economic life make it impossible to maintain the social capacities such as having and raising kids, caring for friends and family, maintaining households and broader communities, and sustaining social connections that are vital for us to be able to continue as people.”
Exactly the kinds of things the people who took part in A Day in Life mentioned as influencing their wellbeing positively, they were telling us about the condition of their lives as influenced by the environment around them. Only estate agents and social climbers really talk about the pros and cons of their area. Families talk about a place for the kids to play up to the age where their kids find their own places. The discussion of life in the city and the fabric of the city itself become impossible to extricate from each other. We want to leave ‘our London’ not the London we might have if things were different.
‘Make Slums Great Again’
The promotion of cities that promote wellbeing requires the interaction of regulation, capital, investment and political will. This is an uphill struggle. The UK is generally agreed to be experiencing a housing crisis. In cities, the effects of income inequality and the erosion of social housing have created high density modern developments where the experience of the built environment is often governed by the amount of money you have.
The global future of cities is unlikely to conform to the particularly British dream of the Garden City or to the suburban dream beloved of a global middle class. In reality, without action the future of cities is closer to being ‘Make Slums Great Again.’ The majority of the world’s population lives in poverty; a condition that is unlikely to be rectified by the increasing concentration of people in cities.
In his 2006 book ‘Planet of Slums’ Mike Davis estimates that there are over 200,000 unplanned urban environments across the world which “rather than being made out of glass and steel as envisioned by earlier generations of urbanists, are instead largely constructed out of crude brick, straw, recycled plastic, cement blocks and scrap wood.” According to Davis: “Residents of slums, while only 6% of the city population of the developed countries, constitute a staggering 78.2% of urbanites in the least-developed countries.” Such unplanned, piecemeal urbanisation solved the problem of somewhere to live, but not necessarily somewhere to feel alive.
According to Davis, China added more people to its cities in the 1980s than all of Europe including Russia did in the whole of the 19th Century. The new humans, the products of the crisis of social reproduction, will live under pressures that make it unlikely that our traditional ideas of the good life, of health, vitality, social life and joy will be achievable for the many.
London is glorious and it should be our playground
The city, of which London is one of the largest, represents a grand stage upon which our lives are lived out. It is not a question of what is available in the abstract but a question of what what social and economic restraints allow us to access. Urban living is a human experience in itself, a novel, constantly changing historic present. We live with the things we make. Like scar tissue, cities reflect what we cannot escape and what we have lived through in the past. In a city like London, the good life is not about the attainment of individuals. Anyone with enough capital can have their own slice of heaven.
A London that helps to support our mental health will be a London that is built by political will. Evidence about how cities affect our mental health must not be a bystander to making a city for all, it must be a guide. People who live in London are not people who have failed to achieve rural arcadia: we’re people taking part in one of the most exciting experiments ever in human living. Who you are and where and how you live is defined by factors often beyond your direct control.
I cannot alone make this city safe for all women to enjoy the freedom to wander and explore. I cannot alone remove the effect of historic injustice that places those who are most discriminated against in areas most missed by the tide of money. I cannot alone change the cycle where shit mental health means you end up poor and in shit housing and where poor and shit housing and environment means our mental health suffers. It is not inevitable that cities make our mental health worse; it is a collective political choice to accept that they do.
What we choose for our cities depends on what and who we think is important. London is glorious and it’s up to us all to make it glorious for everyone.
@markoneinfour
