YOUNG PEOPLE, SOCIO-ECONOMIC PROCESSES, AND YOUTH MENTAL HEALTH PROMOTION by Shari Laliberte B.Sc.N. University of Victoria, 1996 M.N. University of Calgary, 2002 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Nursing) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) August 2015 © Shari Laliberte, 2015 ii Abstract Little is known regarding current relational dynamics among young people, their mental health, and socio-economic processes and implications for mental health promotion initiatives. Social praxis, underpinned by a Hegelian-Marxist historical-dialectical perspective was used to deepen understanding regarding ways that young people’s socio-economic environments are influencing their mental health, their processes of seeking to realize their mental health, and mental health promotion from a socio-economic perspective. The experiences of 30 diverse young people between the ages of 15 and 28 years were explored and compared to ways that socio-economic determinants of mental health are addressed within provincial mental health policy. There were four central findings in this study. First, participant reflections indicated eight inter-related mental health needs as having relevance in this current socio-economic context. Second, needs and affective experiences are important sites for deepening understanding regarding the inter-relation between young people’s mental health and socio-economic processes. Participant reflections illustrate the relational nature of mental health. They show how mental health is a phenomenon that emerges from the inter-relation between young people and the socio-economic processes that young people participate in within their day-to-day lives. Affective states indicate the degree to which a young person’s mental health needs are met, and play an inter-related role with socio-economic processes in influencing young people’s engagement in socio-economic processes as they seek to realize their needs. Third, there are several key ways that individualistic, wealth-oriented capitalist socio-economic practices and processes threaten young people’s mental health needs across the socio-economic spectrum. Fourth, young people’s control over realizing their mental health needs is limited by the ways they are oriented to seeking realization of their mental health within the inner and inter-personal contexts of their lives, despite the important role that socio-economic processes play in enabling their needs. A close reading of mental health policies shows their positioning in support of capitalist socio-economic processes. This limits the potential of mental health promotion in supporting synergistic relations between young people and socio-economic processes in realizing young people’s mental health. Based on insights gained from this study, I propose multi-level approaches for future praxis-oriented mental health promotion initiatives. iii Preface I drew insights from the field of continental philosophy and specifically Hegelian-Marxist scholarship to inform the approach to social praxis within this research. The purpose of this research was to explore relational dynamics among young people, their mental health, and socio-economic processes and implications for mental health nursing care and health promotion initiatives. UBC Behavioral Research Ethics Review Board Approval: Addressing socio-economic determinants in health promotion initiatives: A dialectical inquiry into the relationship between socio-economic factors and youth mental health and wellbeing Approval Certificate #: H11–01321 iv Table of Contents Abstract ..................................................................................................................................... ii  Preface ...................................................................................................................................... iii  Table of Contents ..................................................................................................................... iv  List of Tables ......................................................................................................................... viii  List of Figures ........................................................................................................................... ix  Acknowledgements ................................................................................................................... x  Chapter 1: Introduction ........................................................................................................... 1  Gaps in Knowledge ................................................................................................................ 8  Research Objectives Guiding this Study .............................................................................. 10  Organization of Thesis ......................................................................................................... 11  Chapter Two: Review of Current Knowledge ...................................................................... 14  Introduction .......................................................................................................................... 14  Perceived Socio-Economic Status and Mental Health and Substance Use .......................... 15  Employment Status .............................................................................................................. 19  Neighborhood-level Socio-Economic Disadvantage ........................................................... 22  Gaps in Previous Research and Objectives Guiding this Study ........................................... 32  Chapter Three: Research Design and Implementation ....................................................... 36  Historical-Dialectical Ontology ........................................................................................... 37  Research Methodology: Social Praxis ................................................................................. 42  The Research Process ........................................................................................................... 47  Phase I: Critical dialogue sessions and participatory documentary photography ......... 48  Recruitment for engagement in first dialogue session ................................................ 48  Introduction to research participants .......................................................................... 50  Recruitment of participants within second dialogue session and participatory documentary photography .......................................................................................... 53  Collecting data to explore young people’s views and experiences: Dialogue sessions and participatory documentary photography .............................................................. 54  Data analysis ............................................................................................................... 59  Phase II: Meta-critical analysis of young people’s critical reflections in relation to mental health policy documents ...................................................................................... 60  Data collection: Retrieval of B.C. Mental health policy documents .......................... 60  Data analysis ............................................................................................................... 62  Conceptual terms used for presenting findings from phases I and II of data analysis ... 67   v Data quality: Validity criteria for judging the quality of agentic knowledge produced from this study ................................................................................................................. 68  Reflexivity .................................................................................................................. 69  Process and outcome validity ..................................................................................... 73  Ethical considerations ..................................................................................................... 76  Seeking informed consent ........................................................................................... 76  Confidentiality ............................................................................................................ 80  Honorariums ............................................................................................................... 81  Minimizing the risks of psychological distress .......................................................... 82  Conclusion ............................................................................................................................ 83  Chapter Four: Dialectical Relations Among Young People, Mental Health, and Socio-Economic Processes ................................................................................................................ 84  Introduction .......................................................................................................................... 84  Young People’s Mental Health Needs ................................................................................. 85  Eight Inter-Related Needs for Enabling Young People’s Mental Health in Their Day-to-Day Lives ............................................................................................................................. 88  1. Physical survival, health and comfort ......................................................................... 88  2. Authentic social connections ....................................................................................... 91  3. Self-worth and self-determination ............................................................................... 94  4. Self- and socio-environmental realization ................................................................... 97  5. Learning and responsive education ........................................................................... 100  6. Inspiration and perspective in life ............................................................................. 104  7. Balance in life ............................................................................................................ 106  8. Need for a secure future ............................................................................................ 108  Inter-Relation of Young People’s Mental Health and Socio-Economic Processes ........... 109  Affective States as Barometer of Need Realization ........................................................... 110  Inter-Relation of Socio-Economic Processes and Affective States in Need Realization Processes ............................................................................................................................ 112  Comparison to Policy Documents ...................................................................................... 114  Chapter Five: Contradiction Between Young People’s Mental Health Needs and Wealth-Oriented Socio-Economics ...................................................................................... 119  Introduction ........................................................................................................................ 119  Monetized, Individualistic, Wealth-Oriented Production and Distribution Processes and Young People’s Mental Health Needs ............................................................................... 119  The need for survival and self and socio-environmental realization within context of capitalist socio-economic processes .............................................................................. 121  Employment experiences .......................................................................................... 121  Gambling for money through panhandling and entrepreneurship ............................ 127  Increasing the odds for a secure income through higher learning ............................ 129  Increasing cost of living within wealth-oriented free markets ................................. 130  The need for a secure future and inspiration in the context of endless economic growth132  The need for self-worth, self-realization, and authentic social connections in context of wealth-oriented notions of success and beauty ............................................................. 135   vi Media and advertising ............................................................................................... 137  Social media .............................................................................................................. 140  Schools and parental pressure ................................................................................... 141  The need for social connections in context of the monetization of recreation (social life) and economic inequities ................................................................................................ 145  Comparison to Policy Documents ...................................................................................... 148  Chapter Six: Orienting Young People Inward To Seek Realization Of Their Needs Within The Inner And Inter-Personal Contexts Of Their Lives ...................................... 156  Introduction ........................................................................................................................ 156  Pragmatic Struggle: Orienting Young People Inward Through Material, Ideological and Social Dynamics that Evoke Insecurity, Hopelessness, and Shame .................................. 157  Insecurity ....................................................................................................................... 159  Hopelessness .................................................................................................................. 161  Shame ............................................................................................................................ 171  Seeking Realization of Mental Health Within Inner and Inter-Personal Contexts of Young People’s Lives .................................................................................................................... 174  Individual-level strategies ............................................................................................. 174  Actions with friends and family ..................................................................................... 178  Comparison to Policy Documents ...................................................................................... 182  Chapter Seven: Discussion and Implications ..................................................................... 190  Introduction ........................................................................................................................ 190  Summary of Findings From This Study ............................................................................. 191  Mental health needs within current socio-economic contexts ....................................... 192  Relational dynamics among young people, mental health, and socio-economic processes ........................................................................................................................ 194  Contradictions between capitalist socio-economic dynamics and young people’s mental health needs ................................................................................................................... 197  Individualism and mental health ............................................................................... 199  Wealth-oriented socio-economics and mental health ............................................... 201  Young peoples’ contradictory response patterns .......................................................... 204  Opportunities for Social Praxis Within Future Mental Health Promotion Initiatives ........ 209  Limitations of this Study .................................................................................................... 220  Conclusion .......................................................................................................................... 222  References .............................................................................................................................. 224  Appendix A: Recruitment Process ...................................................................................... 254  Appendix B: Recruitment Documents ................................................................................ 256  Appendix B1: Information Letter ....................................................................................... 257  Appendix B2: Recruitment Poster ..................................................................................... 261  Appendix B3: Recruitment Brochure ................................................................................. 262   vii Appendix C: Demographic Survey Form ........................................................................... 263  Appendix D: Participants’ Demographic Information ..................................................... 270  Appendix E: Guide for Facilitating Small Group (Individual) Dialogue Sessions ......... 277  Appendix F: Informed Consent Forms ............................................................................... 281  Appendix F1: Informed Consent Form for Phase I and II ................................................. 282  Appendix F2: Adapted Informed Consent Form for Young People Who Were Homeless293  Appendix F3: Informed Consent Forms for Participatory Documentary Photography Process ................................................................................................................................ 304  Appendix G: Handouts for Research Participants ............................................................ 312  Appendix G1: Know Your Rights as a Research Participant Handout .............................. 313  Appendix G2: Child and Youth Mental Health Services Handout .................................... 315  Appendix H: Training Guide for Documentary Photography ......................................... 317   viii List of Tables Table 3.1   Participants’ self-reported financial situation ................................................ 51  Table 3.2   Participants’ self-reported health status ......................................................... 52  Table 3.3   Participants’ overall wellbeing ........................................................................ 52  Table 3.4   First dialogue questions .................................................................................... 55   ix List of Figures Figure 3.1   Dialogue sessions sequence. .............................................................................. 59   x Acknowledgements With deep gratitude, I write: To the young people who participated in this study: This work would not have been possible had you not shared your knowledge and experiences so openly with me. I hope I have done justice to your visions and voices for a better world for young people. I look forward to your feedback on this work and to working with you and allies in building a better world for young minds. To my academic supervisor, Colleen Varcoe, I have learned so much from you-from your metaphors, distinctions, sharing of your own experiences with critical research, your questions, and feedback. You are the kind of mentor I have come to aspire to be like- one who works from both her head and heart and whom walks her talk with her students. I am eternally grateful for your humor, wisdom, and patience, which supported my growth not only academically, but also personally. To my committee: Joy Johnson, I will never forget our first committee meeting and how you set a context of teamwork in this process. I also deeply appreciated your feedback and critical questions that deepened my evolving analysis. Kathy Teghtsoonian, I was continually grateful for your thought provoking questions and feedback. I also deeply appreciated your metaphors and distinctions, which were so helpful to me in understanding the nuances of qualitative data analysis. To Tina Thornton, amazing editor from Australia, thank-you for catching the last of those long-winded sentences of mine, for transforming the dissertation into UBC format, and being on call with formatting to help me in meeting final deadlines. Justin Love and Elizabeth Rivero, in your work as research assistants on this project: thank-you for your work engaging some of the young people who participated in this study and for tracking down digital cameras. Deep appreciation also goes to the following funding sources for this work: The Canadian Institutes of Health Research, Doctoral Research Award; Wil Evon McCreery Memorial Prize Research Award; Irene Goldstone HIV/AIDS and Social Justice Graduate Scholarship; Lyle Creelman Endowment Fund, UBC School of Nursing grant; and UBC Four Year Fellowship. Finally, thank-you to the examining committee for their helpful comments and feedback: Geertje Boschma, Shauna Butterwick & Denise Drevdahl. To my family, friends, mentors and colleagues: Mom, your enduring strength and depth of compassion have always been a deep source of inspiration to me in my life and in this work. Tom, thank-you for always playing devil’s advocate and your belief in me. My beautiful sisters, Tammy and Allison, your passionate love of life and the beautiful spirits you have brought (and are bringing) into this world, along with the young people of this world, were my greatest inspiration in this work. Peter Prontzos and Glenn Deefholts, you’ve become the dear older brothers I never had. Our philosophers’ cafes continually inspired me in this work. Peter, I’m also grateful for your suggestion to use the notion of self-determination to capture one of the themes in this work and your generous stream of emails with reports that aligned with this work, some of which have found their way into this report. Dima Alansari, for your depth of wisdom, our friendship, and the inspiration and sense of solidarity I experienced in hearing about your art-making, community-building projects. Viviane Josewski and Constance Bos, for your amazing friendship and sharing your beautiful hearts and minds with me on walks with our furry four xi legged friends. Jennifer Pullin, for your integrity in all that you do and your incredible support from across the country in my recovery from surgery mid-way through studies. Cedar, for the hours you waited by my side with your loving presence. My director and colleagues at Vancouver Community College, Kathy Fukuyama, Dee Duncan, Margery Hawkins, Meridy Black, and Caroline Brunt, I am eternally grateful to your flexibility with my workload in the final stages of writing and your ongoing encouragement to ‘get er’ done.’ Your passion for pushing the bounds in nursing education was also a deep source of inspiration for me. Susan Duncan, for cheering me onto this academic path and your enduring support and belief in me. You have also been the kind of mentor I aspire to be like, in head and heart, in your policy advocacy work and your work in public health nursing education. Lorraine Wright, for your continuing influence on my thinking, from introducing me to Maturana and Varela to your guidance to look up up up! –in seeing the pattern that connects our lives. Deborah Littman, for your tireless work and all that I am learning from you in relational organizing, including a few of the questions that I used in this work to engage young people in dialogue. xii Joseph Laliberte (1946–2012) Dad~ I dedicate this to you…for teaching me about the importance of our connection to land and that we’re all in this together 1 Chapter 1: Introduction Epidemiological data indicate that up to 20% of children and adolescents suffer from disabling mental illnesses (Belfer, 2008, p. 26). Depression is the leading cause of disability for young people between 10 and 19 years of age and suicide is the third leading cause of death among adolescents worldwide (World Health Organization, 2014). Research has drawn attention to the important role that the environment plays in shaping patterns of child and youth mental health (CYMH) and distress (Butler-Jones, 2011; Hanvey et al., 2006; Health Canada, 1999, 2004; Joseph, 1999; Smythe, 2007; Strohschein, 2005; Weiss & Landrigan, 2000; World Health Organization, 2002). Based on the 2002 Health Behavior in School Age Children (HBSC) cross national survey, the most powerful social determinants of young people’s physical and emotional health include gender, family affluence, school conditions and the influence of peers on risk taking (Boyce, 2004, p. xvii; Health Canada, 2004, p. 8). Of these determinants, Health Canada (1999) has recognized poverty “as the single most significant determinant of a child’s level of health” (Evans & Stoddart cited p. 4). The Chief Public Health Officer of Canada has reported previous work that has shown that “of 27 factors identified as having an impact on child development, up to 80% were seen to improve as family income increases” (Butler-Jones, 2009, p. 30). Previous research underscores the important influence of socio-economic factors on child and youth mental health (CYMH).1 Findings are complex and at times unexpected, however, in relation to adolescent mental health. Reiss (2013) conducted a systematic review of 55 studies and found that children and youth who were of lower socio-economic status were two to three times more likely to develop mental health problems. Reiss further found that of individual-level socio-economic factors, an “overall correlation between at least one marker of socio-economic status and mental health problems was proven in 52 studies from a total of 23 countries” (Reiss, 2013, pp. 25–26). Similar to preceding work (West, 1997), Reiss found a decreased strength in 1 I have used the term “youth” to be consistent with the use of this term in previous empirical literature. However, in response to the recognition of the importance of expanding use of the term “youth” to include those within their twenties (Furstenberg, 2008; Hicki, 2011), I have used the term “young people” throughout the remainder of this report to be inclusive of the range of young people that I invited to participate in this study who were between the ages of 13 and 30. 2 association between socio-economic status and youth mental health compared to children. This supports a review by West who reported several studies that found no relationship between a young person’s socio-economic status and mental health and distress. Researchers hypothesized that use of parental indicators of socio-economic status may not adequately capture young people’s experiences of their socio-economic context (Goodman et al., 2001; Goodman, Huang, Schafer-Kalkhoff, & Adler, 2007; Hamilton, Noh, & Adlaf, 2009). Subsequent work has thus explored young people’s perceptions of their socio-economic status (versus parental reports of socio-economic status) and found more consistent, albeit complex associations between perceived socio-economic status and young people’s mental health and substance use. For example, while some studies have found a strong association between perceived socio-economic status and indicators of youth mental health (Hamilton et al., 2009; Koivusilta, Rimpela, & Kautiainen, 2006; Piko & Fitzpatrick, 2001, 2007), other studies have produced contrasting results. In the context of shaming experiences, middle perceived socio-economic status has been found to have a protective effect on young people’s mental health compared to lower and upper perceived socio-economic status groups (Aslund, Leppert, Starrin, & Nilsson, 2009). Another study found that youth who rated themselves as middle perceived socio-economic status were at greater risk of poorer mental health outcomes compared to lower and upper perceived socio-economic status youth (Varga, Piko, & Fitzpatrick, 2014). There have also been unexpected findings in studies exploring the relationship between perceived socio-economic status and substance use. For example, Piko and Fitzpatrick (2007) found that young people evaluating themselves as lower and lower-middle class had a lower likelihood of reporting drinking and marijuana use. This finding is similar to some studies that have shown that young people of upper socio-economic status backgrounds are also vulnerable to greater levels of distress and behavioural challenges (e.g. Luthar & Latendresse, 2005). Complex findings have also been found in studies exploring the relationship between unemployment experiences and neighbourhood social disadvantage (NSD) and young people’s mental health outcomes. Unemployment has been associated with both positive mental health outcomes (Hagquist & Starrin, 1996) and negative mental health outcomes (Allen, 2014; Fryer, 1997; Hagquist & Starrin, 1996; Hammarstrom, 1994; Kieselbach, 2003). Some studies have found that unemployment experiences are mediated by social integration, unemployment benefits and economic deprivation (Hammer, 2000). Neighbourhood disadvantage has been 3 directly associated with young people’s mental health in some studies (Aneshensel & Sucoff, 1996; Dupere, Leventhal, & Lacourse, 2009) and not directly associated with mental health in other studies (Brenner, Bauermeister, & Zimmerman, 2011; Drukker, Kaplan, Schneiders, Feron, & van Os, 2006). This includes unexpected results in studies that have found associations between NSD and lower rates of alcohol and marijuana use and reduced effects of deviant peers on adolescent substance use (Snedker, Herting, & Walton, 2009). While one study showed a similar decreased association between inequities and substance use for 15-year-old youth compared to 11–13 year-old youth (Elgar, Roberts, Parry-Langdon, & Boyce, 2005), other studies have found positive associations between economic inequities and adolescent mental health. Goodman, Huang, Wade and Kahn (2003) found that lower household income, lower average school income, and greater (within) school-level income inequality were significantly associated with depressive symptoms. While Drukker et al. (2006) found that indicators of NSD were not associated with change in general health or mental health over a two-year period, they did find that exposure to greater disparity between individual level socio-economic status and NSD (e.g. high socio-economic status youth living in deprived neighborhoods) negatively impacted young people’s self-esteem and satisfaction. While inconsistencies and unexpected findings exist across this body of quantitative studies, qualitative studies exploring young people’s views regarding the meaning and determinants of mental health emphasize the importance of socio-economic factors such as employment for young people’s mental health. Furthermore, youth views studies2 extend previous empirical work by drawing attention to the importance of several socio-economic factors, several of which have not been explored in previous quantitative studies. These factors include: money, financial security and access to material resources (Harden et al., 2001; Oliver et al., 2008); worries about the ways that certain social locations are discriminated against by future employers (Leadbeater et al., 2008); school work load pressures (Oliver et al.), school performance, the ability to attend college or vocational school (Gampetro, Wojciechowski, & Amer, 2012) and availability of funds to pay for post-secondary educational programs (Leadbeater et al.); environmental pollution (Harden et al.; Oliver et al.), the built environment, 2 Note that I included a few studies that explored youth’s views of health and wellbeing generally (in addition to mental health) 4 green space, public transportation (Ott, Rosenberger, McBride, & Woodcox, 2011), food and clothing (Gampetro et al., 2012); finding balance in life (White & Wyn, 2008); and corporate media and advertising in relation to young people’s self-worth (Stasiulis, 2002). Importantly, despite the attention that young people have brought to the influence of broader socio-economic, or structural factors in relation to young people’s mental health, mental health promotion intervention studies primarily focus on addressing intra and inter-personal factors at the local community level. A previous comparison of youth views studies to youth mental health promotion intervention research (between 1990 and 2000) shows a discrepancy between the attention that young people have brought to the importance of structural factors3 in relation to their mental health and the lack of attention to addressing structural factors in intervention studies (Harden et al., 2001; Oliver et al., 2008). Harden et al. compared high quality mental health promotion intervention studies to youth views studies. They found that socio-economic determinants of mental health were identified by youth in 10 (of 12) qualitative studies exploring young people’s views of the determinants of mental health.4 However, of the high quality systematic reviews (N=7) and outcome evaluations (N=47) that were included in their in depth review, no evaluated interventions addressed the concerns identified by young people regarding the material and physical circumstances of young people’s day-to-day lives (Harden et al.; Oliver et al.). More broadly, in Harden et al.’s exploration of trends across 345 studies that included a mixture of outcome and process evaluations, non-intervention research, and systematic reviews, they found that only 32% of these studies addressed broader societal (i.e. socio-cultural and structural) factors.5 Most of the previous studies addressed individual level factors (psychological) (34%) and interpersonal and family factors (30%) (Harden et al.). 3 Harden et al. 2001 use the notion of structural factors to refer to material aspects of young people’s lives such as their employment, income, access to resources, built and natural environments 4 For their more in depth review, they selected qualitative studies that sought to explore young people’s views regarding the meaning and determinants of mental health as a central focus of the study (as opposed to situating young people’s views within a particular theoretical or analytic framework or use of survey methods with pre-selected questions) 5 In Harden et al.’s (2001) report “society barriers and facilitators refer to the wider social world in which individuals and communities reside. These have been broken down into ‘socio-cultural’ factors referring to social and cultural identities (e.g. experiencing or overcoming discrimination on the grounds of sex or ethnicity) and ‘structural factors’ which cover those arising from the environmental, political, financial and legal context of individuals and communities (e.g. material resources, employment)” (p. 22). 5 This lack of attention to addressing broader structural factors has also been found across regional health authorities in Canada. Within the Canadian health policy context, MacNeil (2012) conducted a cross-jurisdictional scan of all Canadian health region websites exploring interventions addressing social determinants of health, health equity and structural-level interventions.6 Based on his review of 2200 interventions, MacNeil found that 25% of interventions addressed equity and of these, 16% were structural in nature. Most interventions relied on direct interventions at the 1:1 level (e.g. bringing health services to underserved communities). Interventions providing fiscal support for citizens or formalized policies addressing environmental factors such as regulation were less common than individual level supports. Within the fields of mental health nursing, there is a longstanding trend towards theorizing and practicing health promotion at individual and interpersonal levels from a biomedical perspective. In analyzing trends in the British Journal of Nursing between 1992-2002, Ashmore, Cutcliffe and Collier (2002) suggested that an ongoing issue in the mental health nursing literature at that time was the “‘humanistic-biological’ debate“ (p. 504) in which tensions emerged between those who theorized and approached mental health from a cognitive-behavioral perspective informed by insights from the physical sciences, and those aligned with Nightingale’s axiom that “nurses do not heal anyone, nurses place people in the best position possible in order to let nature heal them” (p. 504). Despite recognition of the importance of understanding and promoting mental health at both micro (individual, interpersonal level) and macro (socio-cultural/political-economic/environmental) systemic levels, it has been argued that a micro-systemic perspective of mental health has dominated contemporary mental health nursing practice (e.g. Crowe 2000a/b). This hasn’t changed with more recent work exploring the barriers and supports to population level health promoting nursing practice, which has identified several barriers to addressing the broader social determinants of health in nursing practice (Cohen, 2006) and inter-disciplinary health promotion practice more broadly (Raphael, Curry-Stevens & Bryant, 2008). 6 MacNeil defined structural interventions as “those which address health outcomes not on a case by case basis, but across larger populations” (p. vi). 6 B.C. British Columbia (B.C.), the context of this study, is a useful case example of the tendency to promote mental health at the individual level. Although it was acknowledged within the 2003 B.C. Child and Youth Mental Health Plan that “community capacity development is critical” and that “children’s environments can have a significant influence on their development and mental health” (B.C. Ministry of Children and Family Development, 2003, p. 13), policies and programs were oriented primarily along individual lines with the implementation of province-wide cognitive–behavioral therapy prevention programming and individually focused counseling services (A. Berland Inc., 2008). This tendency to focus on individual level supports for young people within the most recent 10-year mental health and substance use policy has continued (B.C. Ministry of Health Services & B.C. Ministry of Children and Family Development, 2010). This tendency to individualize mental health programming is concerning in the context of broader cut backs to financial supports and social programs that have taken place in B.C. over the past decade. In the midst of the B.C. CYMH planning process in 2003, the B.C. government eliminated several programs that affect broader determinants of CYMH. As Liberals took office in 2002 several cut backs were made in women’s resource programs, child-care, housing, legal aid, apprenticeship-training programs including changes to minimum wage (Butterwick, Frisby, & Kolpakova, 2003; CBC News, 2009a, 2009b, 2009c; Early Learning and Child Care Research Unit, 2007a, 2007b; Laanela, 2009; Mazereeuw, 2009; Morrow, Hankivsky, & Varcoe, 2004). Changes to the B.C. Employment Standards Act eliminated the requirement for employers to obtain a permit to employ children between the ages of 12 and 14 and removed the role of the Employment Standards Branch in predetermining the suitability of worksites for child employees, thereby shifting responsibility to parents and children for ensuring safe worksites (Luke, 2009). Reported childhood injury claims increased significantly compared to years prior to the enactment of this law (Luke). Interviews and focus groups with 129 young people in B.C. found that 19% of them missed classes due to work; 46% reported being too tired and/or not having enough time to complete their homework, and/or participate appropriately in school because of too much work; and 16% reported having dropped out of school due to their work schedule and/or financial need (Montani & Perry, 2013). Most recently, B.C. has been identified as having the highest child poverty rates across Canada and the only province without a poverty reduction strategy (First Call: BC Child and Youth Advocacy Coalition, 2013; Ivanova, 2009). 7 B.C. has also been identified as having the worst levels of economic inequalities across Canadian provinces (MacLeod, 2014).  More broadly, poverty and economic inequities have continued to rise. From 1980 to 2003, Canada’s child poverty rate7 remained high at 13.3% (UNICEF Innocenti Research Centre, 2012). Internationally, Canada ranked 24th out of 35 wealthy developed nations in child poverty rates in 2009 (Adamson, 2012). Analysts have drawn attention to the historic growth of economic inequities over the past 30 years and associated health gradients (Harvey, 2008). For example, the Canadian Centre for Policy Alternatives-Manitoba office (2010) reports that Census data show that the richest 20 percent of Canadians obtained median earnings increases of 16.4 percent whereas the poorest 20 per cent had a 20.6 percent drop in earnings since 1980. World wide, almost half of the world’s wealth is owned by one percent of the population with the richest 85 people owning the same wealth as the bottom half of the world's population (OXFAM, 2014). This context has been referred to variously as late- or post-modernity or late capitalism (Chouliaraki & Fairclough, 1990; Harvey, 1990), neoliberal capitalism (Harvey, 2005) and American Corporate Capitalism (Kasser, Cohn, Kanner & Ryan, 2007). Several challenging trends have been documented in relation to young people within this broader economic context. Employment trends are toward flexibilization within the broader labor market in which labor has been casualized and labor protection policies deregulated (Harvey, 2005). Young people are disproportionately affected, including higher rates of unemployment compared to other age groups. In 2012, the unemployment rate for Canadian young people between 15 and 24 years of age was 14.3% compared to 6% for workers aged 25–54 and 55 and older (Bernard, 2013). While forming 16% of the labor market, Canadian young people between 15 and 24 years-of-age faced 50% of the job losses in the last recession (O’Rourke, 2012). In 2012, summer jobs were at their lowest since 1977 thus making it difficult to save for the costs associated with higher education and housing (O’Rourke). Of the available employment, the majority of jobs are part-time without benefits or career prospects (O’Rourke). The significant rise in tuition fees and student loans challenge young people’s access to education and ability to prepare themselves for their life’s work and career goals. The cost of a year’s tuition rose by 174% in British Columbia between 1991 and 2007; the average student 7 The limitations of the term “child poverty” are recognized within this report. It is understood that child poverty is inclusive of their families. 8 loan debt for Canadian students is between CDN$20,000 and $30,000 (except for Quebec at CDN$14,000) (O’Rourke, 2012). In 2012, the total cost of a 4-year degree for those not living at home was CDN$78,817 and over CDN$30,000 for a 2-year college program with the average student taking 14 years to pay off their student loans (O’Rourke). According to a Statistics Canada survey of post-secondary graduates in 2001, 52% of full-time 20–24-year-old students relied on employment to pay for tuition, while over 25% cited income from employment as the main way they pay for tuition (Canadian Federation of Students, 2013a). Of students who cease their post-secondary studies early, 36% cited financial reasons (Canadian Federation of Students, 2013b). Student debt challenges students’ ability to engage in their fields of study and to develop their careers. For example, with the need to repay loans young people struggle to engage in career-related volunteer experience to develop skills for their chosen field of study (Canadian Federation of Students, 2013a). Recent contextual dynamics in which this study was situated include movements such as the Occupy Movement and the Quebec Student Movement. The 2012 Quebec Student Movement focused on advocating for quality and accessible education, which was framed as being under threat due to the expansion of neoliberal economic policies within the post-secondary educational context (Ayotte-Thompson & Freeman, 2012). Broader movements against neoliberal economic policies include the Anti-globalization protests such as the World Trade Organization (WTO) protests in Seattle in 2001 and most recently the Occupy Movement (Roberts, 2015). The Occupy Movement began in 2011 with demonstrations occurring in 95 cities in 82 countries and across more than 600 communities in the United States (Roberts). Through the use of key slogans such as “we are the 99%,” this movement focused on challenging the growth of economic inequities, the expansion of neoliberal economic policies (Roberts) and austerity measures that were implemented after the 2008 financial crash (Mizen, 2015). Gaps in Knowledge There are complex findings in previous empirical work and a discrepancy between the attention that young people have brought to the importance of socio-economic factors to their mental health and a lack of attention to addressing socio-economic factors in health promotion intervention research and policy. More work is thus needed to deepen understanding regarding relationships among young people, their mental health and socio-economic environments and 9 implications for health promotion initiatives. More specifically, knowledge regarding the relationship between socio-economic factors and youth mental health and implications for youth mental health promotion is limited in three key ways. First, pre-selected socio-economic factors that have been studied in relation to youth mental health within quantitative studies only partially addresses the many socio-economic factors that young people have identified as important influences on their mental health in youth views studies. Furthermore, quantitative studies do not enable a deeper exploration of the complex and dynamic interrelationship of diverse aspects of socio-economic life in relation to young people’s mental health. Second, while qualitative studies exploring youth views have identified several socio-economic factors that impact young people’s mental health, they have not explored how aspects of socio-economic life affect young people’s mental health. Third, of previous youth mental health promotion intervention studies, the majority of studies focus on addressing inner and inter-personal factors with a lack of attention to addressing constraining aspects of socio-economic life in relation to young people’s mental health. These limitations in previous empirical literature suggest the importance of deepening understanding regarding relationships among young people, their mental health, and various aspects of socio-economic life, as well as identifying directions for future mental health promotion initiatives in ways that take into account broader structural (socio-economic) factors. Importantly, research exploring ways that health promotion initiatives can address broader socio-economic factors in relation to young people’s mental health needs to be done with attention to dominant and taken for granted ways of understanding mental health and mental health promotion that may limit possibilities for promoting mental health. Previous analytic work has drawn attention to the contested (and political) nature of concepts such as “mental health,” “mental health promotion,” and “socio-economic factors” (Bambra, Fox, & Scott-Samuel, 2005). Coppock and Hopton (2000) have shown that there is a lack of “a universally accepted theory of mental health and distress” (p. 176). Previous work has drawn attention to how mental health policies and programs are increasingly underpinned by a neoliberal (individualistic) perspective, which is reflected within the development of programs that focus on individual levels factors and that decontextualize mental health and distress (Carpenter, 2000; Donald, 2001; Moncrieff, 2006; Ramon, 2008; Teghtsoonian, 2009; Timimi, 2005, 2010). Western, biomedical approaches to child psychiatric care have been critiqued for their tendency to decontextualize and then to commercialize distress (Timimi, 2005, 2010). This has occurred through the application of 10 biomedical diagnostic and treatment approaches that obscure the influence of broader political, economic and socio-cultural trends on young people’s mental health (Timimi, 2005, 2010). It is thus important to develop knowledge in a way that brings continual attention to taken-for-granted assumptions. Research Objectives Guiding this Study This study sought to deepen understanding regarding current and evolving relational dynamics among young people, mental health, and their socio-economic environments and implications for mental health promotion initiatives. In order to address the limitations of previous quantitative studies that have missed researching socio-economic factors identified as important by young people within youth views studies, and in order to ensure that recommendations for youth mental health promotion initiatives are responsive to young people’s needs and experiences, this approach to inquiry was grounded within young people’s lived experiences. In order to address the limitations of previous quantitative studies to deepening understanding of the complex, co-evolving and dynamic nature of socio-economic life in relation to mental health, and in order to address the dominance of individualistic perspectives within mental health promotion research, policy and practice, this approach to inquiry was relational and reflexive in nature. Explored more fully in Chapter three, this study was underpinned by a Hegelian-Marxist historical-dialectical perspective, which draws attention to exploring relationships as a fundamental unit of analysis in the inquiry process. Relationships are understood to be historical in nature, and thus co-evolving and dynamic. Relational dynamics among multiple aspects of socio-economic life, including the relationships between aspects of actual existing socio-economic life and the dominant and evolving ideas and ways of understanding socio-economic life are a central focus of inquiry. Reflexive inquiry draws attention to the inter-relationship between ideas and relationships in material life, scrutinizing the influence of dominant ideas and ways of understanding not only in relation to the foci of research, but also within the inquiry process itself. In this study I viewed mental health, the socio-economic environment, and mental health promotion as political concepts (Bambra, Fox & Scott-Samuel, 2005). I assumed that notions of mental health/promotion and socio-economic determinants of mental health within mental health policies would be reflective of dominant assumptions. I thus explored young people’s views and 11 experiences of how their socio-economic environments affected their mental health in relation to how notions of mental health/promotion and socio-economic determinants of mental health were discursively taken up in mental health policy. This served to not only deepen understanding of current relational dynamics among young people, their mental health and aspects of their socio-economic environment, but also to deepen analysis of the positioning of mental health policy in relation to young people and the broader socio-economic environment. This helped to inform insights regarding ways to orient mental health promotion initiatives to address constraining aspects of socio-economic life for young people’s mental health and to build on previous health promotion work. This study was guided by the following objectives: 1. To deepen understanding regarding ways that young people’s current socio-economic environments are influencing their mental health and young people’s processes of realizing their mental health. 2. Identify opportunities for developing mental health promotion initiatives in ways that address current socio-economic dynamics that are constraining young people’s mental health. Organization of Thesis Within this report, I start in chapter two by presenting a more detailed review of the empirical literature exploring the relationship between socio-economic factors in relation to young people’s mental health. I highlight gaps in previous research that informed the direction of this research project. I also present insights from previous analytic work that has highlighted dominant assumptions that underpin notions of mental health/promotion in ways that draw attention away from the influence of broader contextual factors. This literature shows the contested nature of notions of mental health and socio-economics and served to justify my use of a praxis-oriented approach to inquiry, underpinned by a Hegelian-Marxist historical-dialectical perspective. 12 In Chapter Three, I present the ontological and epistemological perspectives that informed the approach to inquiry in this study. I provide an overview of the Hegelian-Marxist historical-dialectical perspective that informed my positioning of this research as a process of social praxis, and which informed my relational and reflexive approach to inquiry. This perspective was important for guiding my analysis of relational dynamics among young people, their mental health and aspects of their socio-economic environment to inform the identification of possibilities for future praxis-oriented mental health promotion initiatives oriented to addressing constraining aspects of socio-economic life for young people’s mental health. I then provide an overview of the process of social praxis undertaken in this study, which occurred in two phases. Within the first phase, I engaged thirty diverse young people between the ages of 15 and 28 years of age in audio-recorded individual, dyadic or small group dialogue sessions. Sixteen of these young people were then engaged in second dialogue sessions at which preliminary themes from analysis of the first sessions were discussed and their perspectives on opportunities for change explored. Of this second group of participants, seven were engaged in participatory documentary photography to explore their experiences of the relationship between socio-economic life and young people’s mental health and opportunities for change. Within the second phase I engaged in a process of meta-critique in which I compared participant’s experiences to the ways that notions of mental health/promotion and socio-economic determinants of mental health are discursively taken up and addressed in two sets of British Columbia provincial policy documents. I explored how mental health policy is positioned in relation to young people and broader socio-economic processes in order to identify ways of building on existing work to address constraining aspects of socio-economic life for young people’s mental health. I conclude this chapter by defining concepts that supported my presentation of findings in this study. In Chapters Four, Five and Six I present analyses of the data in relation to the retrieved policy documents. Specifically, in Chapter Four I focus on the ways that young people’s mental health needs and affective states are two key sites for deepening understanding regarding relationships among young people, their mental health and socio-economic processes. This chapter draws attention to the mutual dependency between young people and their socio-economic environments in processes of realizing young people’s mental health needs. 13 In Chapter Five, I present an analysis of the ways that socio-economic dynamics contradicted participants’ mental health needs. I show how, within young people’s economic contexts in which mental health resources have been monetized, two central and inter-related capitalist socio-economic dynamics challenged participants’ mental health needs in several key ways. These included first, individualistic production and distribution processes; and second, practices oriented to fostering capital (wealth) creation and accumulation. These capitalist dynamics challenged participants’ mental health needs across socio-economic positions, or approaches to seeking income, and within their positioning as consumers. In Chapter Six, I describe participants’ patterns of response to the contradictory dynamics presented in Chapter Five and show the ways that young people are oriented inward toward seeking realization of their mental health needs within their inner and inter-personal lives, despite the ways that socio-economic processes fundamentally mediated their ability to realize their mental health needs. Within the concluding sections of each of these three findings chapters, I present a comparison of these findings with a close reading of provincial policy documents. I highlight the positioning of mental health policies and programs in relation to young people and socio-economic processes. I demonstrate how, within the policy documents young people are positioned to enable capitalist socio-economic processes at the same time that these processes threaten young people’s mental health needs. I show how this prioritization of capitalist socio-economic processes undermines the stated goals of the mental health policies. I conclude in Chapter Seven by comparing findings within this study to other empirical work. I explore how insights from this study help to deepen understanding of inconsistencies in previous empirical work. I propose multi-level, inter-sectoral approaches for future praxis-oriented mental health promotion initiatives focused on promoting a fuller realization of young people’s mental health. 14 Chapter Two: Review of Current Knowledge Introduction While the importance of socio-economic factors to child and youth mental health is incontrovertible, further research is needed to deepen understanding regarding relationships among young people, their mental health, and socio-economic factors in light of complex findings in previous research. Between 1990 and 2012, Reiss (2013) conducted a systematic review of 79 publications comprising 55 cross-sectional, longitudinal and cohort studies of children and adolescents between the ages of 4 and 18 years of age with samples that ranged from 88 to 40,592 participants (M=3974). Within this review of individual-level socio-economic factors, an “overall correlation between at least one marker of socio-economic status and mental health problems was proven in 52 studies from a total of 23 countries” (Reiss, pp. 25–26). Household income and low parental education were the strongest predictors of children and adolescents’ mental health problems compared to other socio-economic indicators such as parental unemployment or low occupational status (Reiss). Similar to previous studies (West, 1997), Reiss found that while socio-economic status was associated with mental health in all age groups, socio-economic disadvantage was more strongly associated with mental health problems in younger children than it was in those 12 years of age and older. Reiss’s finding regarding the decreased strength in association between socio-economic status and youth mental health (compared to children) supports a previous review by West (1997) who reported that several studies found no relationship between a young person’s socio-economic status and mental health and distress. In making sense of these inconsistencies West argued that there are unique dynamics inherent to adolescence, such as peer and school culture that “equalizes” class differences once seen in childhood and that re-emerge into adulthood. Researchers have hypothesized that use of parental indicators of socio-economic status may not adequately capture young people’s experiences of their socio-economic context (Goodman et al., 2001; Goodman et al., 2007; Hamilton et al., 2009). Subsequent studies thus explored young people’s perceptions of their socio-economic status (versus parental reports of socio-economic status) and found more consistent, albeit complex associations between perceived status and young people’s mental health and substance use patterns. I thus extended Reiss’s beginning 15 review of studies exploring youth’s perceived socio-economic status with studies that explicitly sought to examine the relationship between perceived socio-economic status and mental health, as well as the relationship between young people’s employment and unemployment status (versus their parents’ occupational status) and mental health outcomes. As Reiss’s review did not include group-based socio-economic factors, I also reviewed studies that explored young people’s neighbourhood contexts and levels of economic inequities in relation to mental health. In searching for relevant studies, I cross-referenced search terms for young people, socio-economic factors and mental health within CINAHL and Academic Search Complete databases. For young people, I inputted ‘youth/adolescent/young people’; for socio-economic factors, I inputted: ‘socio-economic’, ‘inequity’, ‘neighbourhood disadvantage’. In seeking studies that explored mental health in a positive sense, I used the search terms ‘mental health’ and related terms of ‘wellbeing’, ‘mental flourishing’, ‘mental fitness’. As most studies continue to focus on mental distress, I also included these studies in this review. Furthermore, I included studies involving young people between the ages of 13 and 24 years in acknowledgment of the complex developmental transitions that young people face (Hickie, 2011) and their extended time in post-secondary school, delays in leaving the parental home, and delays in marriage and childbearing (Furstenberg, 2008). Perceived Socio-Economic Status and Mental Health and Substance Use Young people’s perceived socio-economic status has a complex and not fully understood influence in relationship to mental health and substance use. In contrast to parental—or what some refer to as “objective” socio-economic indicators that include parental income, occupational, and educational status—perceived socio-economic status includes young people’s perception of either their own social and economic position compared with peers in their school context and/or their family’s social and economic position as compared to other community members in social life. Studies comparing perceived socio-economic status to objective indicators found perceived status to be a stronger predictor of mental health outcomes (Koivusilta et al., 2006; Piko & Fitzpatrick, 2001, 2007) with this relationship being unmediated by other socio-demographic variables. Hamilton et al.’s (2009) cross-sectional Canadian study using a student drug survey data of seventh to twelfth grade students (N=7726) found that 16 adolescents with lower perceived financial status8 were associated with greater emotional distress, while adjusting for age, gender, household characteristics and parental education. These associations between perceived socio-economic status and mental health are in tension, however, with unexpected findings in relation to substance use. Similar to Reiss’s (2013) review, which shows inconsistencies in associations between various socio-economic factors and internalizing and externalizing mental health symptoms,9 inconsistencies have been found in the relationship between perceived socio-economic status and substance use. Piko and Fitzpatrick (2007) found that young people evaluating themselves as lower and lower-middle class had a lower likelihood of reporting drinking and marijuana use. Hamilton et al. (2009) reported age effects in which hazardous and harmful drinking was lower in early adolescence among youth of higher perceived financial status. However, by mid-adolescence the harmful drinking of those with higher perceived financial status surpassed that of young people with average or below average perceived financial status. The likelihood of drug use among young people with above-average perceived financial status increased with age at a much faster rate than those with below-average perceived financial status. Using area-based measures of socio-economic status, Luthar and Latendresse (2005) also found this increased strength of association between higher socio-economic status and substance use, as well as emotional distress. They found higher substance use and higher emotional distress among higher income youth (living in the suburbs) compared to lower income youth (living in the inner city). Within the first of three cohort studies, they found that upper-class, suburban high-school students reported significantly higher anxiety, somewhat higher depression, and significantly higher use of cigarettes, alcohol, marijuana, and hard drugs than young people in the inner city; suburban youth’s substance use was also higher than national norms. Furthermore, girls in the suburbs were three times more likely to report clinically significant signs of depression in comparison to normative samples in the U.S. context. In their third cohort study, 8 As an example of how perceived socio-economic status was evaluated, Hamilton et al.’s (2009) study assessed perceived financial status by asking young people: “ ‘How would you describe your family’s financial situation?’” Response options included: “Well above average average/somewhat above average/about average/somewhat below average/well below-average” (p. 1529). 9 For example, from Reiss’s (2013) review: a number of studies reported a stronger association between low SES and externalizing disorders than between low SES and internalizing disorders. In contrast, representative studies from the U.S. and the Netherlands reported a stronger association between low SES and internalizing compared to externalizing disorders. Two studies found no association between low SES and internalizating and externalizing disorders. One study from New Zealand found a significant association between family SES and anxiety but not depression. 17 popular suburban seventh grade youth had significantly higher levels of substance use. Finally, Luthar and Latendresse showed how “youth at the socio-economic extremes were more similar than different” (p. 51). On returning to their cohort I data to explore overt forms of rebellion, they found distinct sub-groups of young people among both lower- and upper- income youth who manifested multiple behaviour problems (e.g. substance use, delinquency, lack of interest in academics) and significantly lower than average grades. Further exploring the sub-group of suburban youth, they found that “twenty percent of these students showed persistently high substance use across time” and that “across all three assessments, [higher income youth] showed relatively high levels of depression and physiologically manifest anxiety (e.g. nausea, difficulty breathing), and poor grades and negative teacher ratings” (Luthar & Latendresse, p. 51). In their study of 445 adolescents (14-18 years of age), while Tur, Puig, Pons and Benito (2003) found that the mother’s educational level was negatively associated with alcohol consumption, they also found that “adolescents from occupational upper class parents were positively and significantly related to alcohol consumption” (p. 243). These unexpected findings are similar to other studies. Varga, Piko and Fitzpatrick (2014) found that subjective socio-economic status was the most influential indicator of youth mental health (compared to objective measures). However, middle-class youth had the highest risk of low mental wellbeing compared to lower and higher-class youth. Aslund, Peppert, Starrin and Nilsson (2009) found that if shaming experiences were present, participants who perceived their family’s wealth and social standing (compared to others in society) as both high and low were at increased risk for depression, whereas medium status seemed to have a protective function. In contrast, the lowest perceived status in comparison to one’s peers had the highest elevated risk for depression. The role of gender in mediating the relationship between both parental- and youth-perceived socio-economic factors and mental health is complex. Reiss’s (2013) review found “no consistent gender patterns” across studies reviewed (p. 27). Piko and Fitzpatrick (2001) found that while gender was significantly correlated with all psychosocial health variables, gender was not a confounder in the relationship between self-assessed socio-economic status and psychosocial health. Hamilton et al. (2009) reported that gender was not a significant moderator of the association between perceived financial status and emotional distress, nor was there a gendered effect for alcohol or drug use. In a cross-sectional study of two groups (11–13 years of 18 age; 14–16 years of age) of youth (n=830) Hutton, Nyholm, Nygren and Svedberg (2014) found that self-rated mental health was associated with the total Family Affluence Score (FAS) (material goods such as car ownership, taking holidays, number of computers) for boys only in both age groups, with no association between total FAS for girls and mental health. By contrast, girls’ mental health was only associated at the item level: not having one’s own bedroom was significantly protective of mental health and having none to one family holiday was significantly associated with worse mental health. Other studies have yielded unexpected findings regarding the influence of racial/ethnic background on the relationship between young people’s perceived socio-economic status and mental health. In their longitudinal study of 1179 non-Hispanic Black and White young people from their seventh to twelfth grade, Goodman, Huang, Schafer-Kalkhoff and Adler (2007) found that race and objective socio-economic measures (parental education and family household income before taxes) did not further affect how low perceived socio-economic status predicted self-rated health. Their cross-sectional and longitudinal analyses also indicated that Black teens from families with low parent education had higher perceived family socio-economic status than White teens from similarly (low) educated families, whereas White teens from highly educated families had higher perceived family socio-economic status than Black teens from highly educated families. Overall, several inconsistencies are found across these studies. While perceived socio-economic status was found to be a strong predictor (compared to objective measures) of youth mental health in ways unmediated by race and gender, complexities were found in relation to substance use patterns in which young people with upper socio-economic status had higher substance use. These studies coincide with other studies, which also found that upper-class young people experience higher levels of emotional distress and behavioural challenges (Luthar & Lattendresse, 2005). Complex findings include studies that found that while one’s middle income status was protective of mental health when faced with social shame (Aslund et al., 2009) it was also harmful to one’s mental health (Varga et al., 2014). These inconsistent findings suggest there may be additional experiences within young people’s socio-economic environments that may influence their mental health experiences. In context of growing economic inequities and challenging employment experiences faced by young people, as discussed previously, it is also important to consider the influence of young people’s direct 19 participation in the labour force along with group-based socio-economic measures that explore levels of economic inequities and neighbourhood social disadvantage on young people’s mental health. Employment Status Studies exploring young people’s employment status and mental health outcomes draw further attention to the complex relationships among socio-economic factors and young people’s mental health. Previous research has explored the relationship between mental health and various dimensions of the work environment such as hours of work, level of decision-making power, skill building in relation to young people’s future career goals, and work stress. Mortimer, Harvey and Staff’s (2002) review of previous studies revealed mixed findings in relation to number of work hours and mental health. Some studies found associations between longer work hours and unhealthy lifestyles—such as less sleep and exercise, skipping breakfast and greater use of alcohol, cigarettes and illicit drugs, minor delinquency and school misconduct (Mortimer, Harvey, & Staff, 2002). Others found no relationship between work hours and self-esteem, efficacy and depressed affect (Mortimer et al.). Job stressors and early decision-making autonomy have been associated with increased distress for adolescent boys, with the acquisition of useful skills on the job decreasing male depressive affect (Mortimer et al.). Work stress and being held responsible for things beyond one’s control have been associated with increased depressed mood for females (Mortimer et al.). Skill building at work has been associated with greater quality relationships with parents and peers for boys, with positive experiences at the workplace appearing to support adolescent resilience when faced with strain in families and tensions between parents and adolescents (Mortimer et al.). Studies have also found that when work is relevant to young people’s futures, work intensity was less associated with negative mental health outcomes (Mortimer et al.). In their own longitudinal exploration of the relationship between work, school, and mental health among 7,700 young people, Mortimer et al. (2002) found that extrinsic rewards such as having enough money to spend time with friends were associated with wellbeing in the last year of high school, and that wage satisfaction or perceived good pay was predictive of increased wellbeing and reduced depressive affect. Employed students who believed work was compatible with school (i.e. work contributes to education and vice versa) experienced less 20 depressive affect in the twelfth grade. Early work stressors were found to have lasting effects on depressed affect with overly stressful/demanding work being associated with depressed affect four years after high school. Unexpectedly, and in contrast to a previous study that found that young people employed in jobs with which they were dissatisfied were as badly off as unemployed peers (Winefield, Tiggemann, Winefield & Goldney, 1993 cited in Fryer, 1997), Mortimer et al. found no association between intrinsic rewards (learning new things on job) and wellbeing or depressive affect in twelfth grade. Studies have reported both positive and negative mental health experiences in relation to situations of unemployment. Some studies have found associations between unemployment and psychological distress (Fryer, 1997; Hammarstrom, 1994). Reviews of empirical work report associations between unemployment and minor psychological disorders, increased physiological illness (particularly for girls), increased health care consumption, and increased tobacco consumption and illicit drug use (Hammarstrom, 1994) and depression, lower life satisfaction, increased alcohol consumption, civil unrest, and increased crime (Allen, 2014). Long-term unemployment has been associated with increased physical and psychological symptoms, smoking habits and use of cannabis for young people across gender, increased systolic blood pressure and increased crime rates among long-term unemployed boys (Hammarstrom, 1994), increased alcohol use for unemployed men (Hagquist & Starrin, 1996; Hammarstrom, 1994) and increased smoking for females (Hagquist & Starrin). In their study of the mental health effects of unemployment, Hagquist and Starrin found that out of 81 unemployed young people under the age of 25, every fourth unemployed male and every second unemployed female’s mental health worsened when they became unemployed. Unemployed youth have described their experience of unemployment as “boring and marked by idleness and inactivity” evoking fear and nervousness about the future (Hagquist & Starrin, p. 219; Kieselbach, 2003); challenging to one’s self-esteem and confidence and evoking restlessness, anxiety and a sense of social isolation (Hagquist & Starrin); including loneliness, and feelings of depression (Kieselbach). Conversely, some young people have experienced unemployment situations positively. In contrast to their finding that unemployment was associated with mental distress, Hagquist and Starrin (1996) also found that for 10% of the unemployed participants, unemployment was experienced positively and another 10% associated unemployment with both positive and negative experiences. Positive experiences included: opening up new possibilities and 21 opportunities that otherwise would not have been considered and enabling more time for friends and family, walking and cycling, volunteering in community, and having time for one’s children (Hagquist & Starrin). Research has shown that unemployment is mediated by several factors, such as level of social support from friends, family and one’s community, varying attitudes and beliefs regarding work and one’s level of external locus of control (Hammarstrom, 1994), and income supports such as unemployment benefits and access to employment training programs. Hammer’s (2000) comparison of the effects of unemployment on young people’s mental health across five Nordic countries (N=8000) found that social exclusion was not necessarily an outcome for unemployed youth. Social integration, levels of unemployment benefits, and economic deprivation were more strongly associated with mental health symptoms than one’s unemployment status (Hammer). Previous studies have shown how social support from family, friends and community, including less ‘victim blaming’ attitudes, is associated with diminishing the negative effects of unemployment (Hammarstrom, 1994). Kieselbach’s (2003) research with unemployed youth across three Northern European countries found that factors that decreased risk for social exclusion included youth with higher qualifications, relative financial security, and youth who were supported by their social environment while seeking work (i.e. financial, social, and institutional supports). Benefits from governmental institutions and supports from family and friends were associated with higher self-esteem (Kiesebach). Employment training programs have been associated with promoting self-confidence, giving young people somewhere to go, learning new things, and enabling work experience that young people associated with being good for the future and fun (Hagquist & Starrin, 1996). Comparing unemployed youth to those in youth employment training programs, Hagquiest and Starrin found that nervousness and anxiety were five times higher among unemployed women compared to female trainees and that 50% of unemployed men experienced higher anxiety than trainees. They also found that restlessness was more than twice as prevalent for women, and almost twice as prevalent for males who were unemployed as compared to female and male youth trainees. They reported improved states of health and mental health when unemployed youth transitioned to training programs. However, Hagquist and Starrin also reported that some youth trainees expressed negative experiences of youth training programs such as being exposed to real work situations and feeling like they were 22 observers, and feeling exploited and used with their engagement in free labour (Hagquist & Starrin). Overall, these studies offer contrasting perspectives in relation to the benefits and challenges of both employment and unemployment situations for young people’s mental health. Unemployment has been associated with both positive and negative experiences that are mediated by levels of social integration and income supports. While earlier studies have indicated potentially beneficial aspects of employment to young people’s mental health, these studies are limited in number and findings are inconsistent. There are significant gaps in this body of research. Despite Mortimer et al.’s (2002) finding regarding the long-term impact of stressful and demanding work on young people’s depressive affect for up to four years after high school, there has been no more in-depth follow-up research exploring young people’s experiences of their employment situations in relation to their mental health. Furthermore, there has not been explicit attention given to exploring the meaning of employment and employment experiences in relation to young people’s mental health in context of current educational and labour market trends.10 This is particularly important considering the challenging socio-economic trends for young people discussed previously. Neighbourhood socio-economic disadvantage, which in some studies includes the rates of unemployment at the community level, is another socio-economic dimension that has been explored in relation to young people’s mental health. Neighborhood-level Socio-Economic Disadvantage A central question addressed in studies exploring group-based socio-economic indicators has been whether neighbourhood social disadvantage (NSD) has a direct relationship with young people’s mental health, or an indirect relationship, being mediated by other risk and protective factors. Some studies have found a direct relationship, uninfluenced by confounding variables, 10 For example, in context of challenging socio-economic trends, there is a lack of attention to exploring meaningful employment in relation to mental health outcomes in previous research exploring the relationship between dimensions of employment and health and mental health outcomes. This is evident within previous reviews of this literature for the World Health Organization Commission on the Social Determinants of Health (Employment Conditions Knowledge Network, 2007) and in relation to informing policies oriented to supporting young people who are “not in employment, education or training (NEET)” in the UK (Allen, 2014). 23 while others have not. Dupere, Leventhal and Lacourse’s (2009) longitudinal study, which followed 2776 children from the age of 8 to 18 years of age through six cycles of data collection found that living in a poor neighbourhood was directly associated with both suicidal thoughts and suicide attempts for adolescents. The odds of reporting suicidal thoughts was two times higher among those who lived in poor neighbourhoods compared to those who did not, and the odds of attempting suicide was four times higher in poor compared to non-poor neighbourhoods while controlling for other risk factors. Neighbourhood poverty had a significant independent effect on youth suicidal thoughts in which its association with suicidal thoughts was not attributable to individual and family vulnerabilities and youth risk factors (Dupere et al.). Aneshensel and Sucoff (1996) studied a community sample of 807 adolescents in Los Angeles. Using regression analysis, they found that of the structural aspects of neighbourhood contexts (median household income, percentage of population below poverty line, percentage of labour force in professional or executive or management level occupations) and youth’s subjective experience of their neighbourhood (the presence of ambient hazards such as graffiti, crime, violence, drug use and dealing; and social cohesion which was seen as essential to controlling the impact of ambient hazards), ambient hazards was the sole factor related to all dimensions of mental health evaluated. The more threatening the neighbourhood was, the more common were the symptoms of depression, anxiety, oppositional defiant disorder, and conduct disorder symptoms. Among the structural neighbourhood factors, conduct disorder was common among the low socio-economic status cluster and oppositional defiant disorder symptoms were common among the middle and affluent clusters. This bears some similarity to previous studies on perceived socio-economic status and substance use and Luthar and Lattendesse’s (2005) unexpected finding that more challenging behaviours were found among higher income youth. In contrast, Brenner, Bauermeister and Zimmerman’s (2011) study of 711 urban high school youth via multilevel modelling found that NSD was not directly associated with adolescent alcohol use (while accounting for risk and protective factors such as peer and parental substance use, and social support and prosocial activities). This lack of support for the neighbourhood disorganization theory or a direct relationship between NSD and health outcomes was also the case in earlier studies exploring the effects of NSD on health outcomes such as violence and delinquency (Brenner et al. 2011). More recently, Drukker et al.’s (2006) longitudinal study of 475 youth living in 36 neighbourhoods through a baseline and a follow-up 24 survey 2–3 years later found that neighbourhood factors did not predict changes in general health or mental health in the period of transition from late childhood to early adolescence. Studies of NSD have also produced unexpected (opposing) results. For example, Drukker et al. (2006) found a positive association between NSD and self-esteem in youth of lower educated parents and a negative association between NSD and self-esteem in youth of higher educated parents (which wasn’t statistically significant). This contrary finding was also shown in Snedker, Hertin and Walton’s (2009) study, which drew from previous survey data and drug use prevention intervention studies for 2,006 youth. They found that youth living in economically disadvantaged areas had lower rates of alcohol and marijuana use and, furthermore, NSD was associated with reduced effects of deviant peers on adolescent substance use. In support of West’s (1997) equalization hypothesis, Drukker et el.’s (2006) baseline measurement (at 11 years of age) showed associations between neighbourhood factors and general health and mental health, but not at follow-up 2-3 years later. The researchers hypothesized that this likely was due to children spending most of their time in their neighbourhoods, compared to youth who may have greater freedom to go outside their neighbourhood to a different school and/or neighbourhood context. Studies have also explored whether factors such as social cohesion mediate the relationship between NSD and young people’s mental health, and conversely, whether NSD mediates the relationship between inter-personal factors and youth mental health outcomes. Exploring the role that inter-personal factors play in mediating the relationship between NSD and mental health outcomes, Drukker et al’s (2006) study further found that the positive association between NSD and self-esteem in youth of lower educated parents and a negative association between NSD and self-esteem in youth of higher educated parents was stronger in neighbourhoods low in social cohesion and trust. In contrast, other studies did not find interactive effects of social processes such as social support mediating the relationship between NSD and mental health. McMahon, Felix and Nagarajan’s (2011) longitudinal cross-sectional study of 85 students who completed a pre- and post- survey in grades 6 and 8 from two Chicago public schools explored the stress-buffering effects of social support. They used hierarchical regression to test main effects and stress-buffering models of social support on neighbourhood stressors in relation to global self-worth in context of NSD. They found no evidence for the stress-buffering hypothesis of social support; 25 that is, social support did not buffer the effects of NSD on youths’ sense of self-worth. Similarly, Brenner, Zimmerman, Bauermesiter and Caldwell (2013) did not find a buffering effect of social support in relation to NSD and young people’s cortisol levels. In contrast to studies that explored whether inter-personal factors mediate the relationship between NSD and young people’s mental health outcomes, studies have explored whether NSD influences the relationship between individual and inter-personal factors and young people’s mental health outcomes. Brenner et al. (2013) used a subsample (N=163) of young people from the sixth wave in a longitudinal study of 850 youth to explore whether NSD influences the relationship between perceived stress and type of coping on young people’s cortisol levels. They found that “both high effort coping and perceived stress were dependent on the level of NSD in their effect on cortisol reactivity” (p. 801). Put another way, the relationship between coping and perceived stress and cortisol were moderated by the degree of NSD. Other studies have drawn attention to the influence of the discrepancy between a young person’s family socio-economic status and that of their neighbourhood as influential on mental health outcomes. Within Drukker et al.’s (2006) study, while they found that none of the indicators of NSD were associated with change in general health or mental health over a two-year period, they did find that exposure to greater disparity between individual level socio-economic status and NSD (i.e. high socio-economic status youth living in deprived neighborhoods) negatively impacted young people’s self-esteem and satisfaction. This finding points to the final dimension I considered in this review, that of economic inequities.Economic Inequities School and national levels of economic inequities have been associated with young people’s mental health outcomes. A study by Goodman, Huang, Wade and Kahn (2003) explored the relationship between the socio-economic context of the school environment and adolescent depressive symptoms independent of household income. Their cross-sectional, multivariate linear/multilevel regression analysis of 13,235 young people in grades 7 through to 12 from 132 schools found that lower household income, lower average school income and greater (within) school-level income inequality were significantly associated with depressive symptoms. At the national level across 34 countries in Europe and North America, Elgar, Roberts, Parry-Langdon and Boyce (2005) conducted a cross-sectional study of 162,305 adolescents (aged 11, 13, 15) from 5,998 schools using the international Health Behavior in School-Aged 26 children data. Elgar et al. (2005) explored the relationship between country-level income inequality (UN Development program) and young people’s health (including mental health indicators) and found that countries with high-level inequality reported greater drinking for 11 and 13-year-olds, but not 15-year-olds while controlling for sex, family affluence and country wealth. The 11-year-olds were found to report greater levels of drunkenness for highly unequal countries compared to low national inequality. Due et al. (2009)11 used the same dataset as Elgar et al. (2005) and found (in support of previous research) that adolescents of greater socio-economic disadvantage are at higher risk of being victims of bullying. They also found that: international differences in prevalence of exposure to bullying were not associated with the economic level of the country (gross national income) or the school, but wide disparities in affluence at a school and large economic inequalities (as measured by the Gini coefficient) at the national level were associated with an increased prevalence of exposure to bullying. (p. 907) Overall, this review of studies exploring various individual and group level socio-economic factors in relation to young people’s mental health has shown that perceived socio-economic status measures tend to be more consistent than objective (parental) indicators in measuring the association between socio-economic status and young people’s mental health. Findings from studies that have explored the relationship between perceived socio-economic status and young people’s mental health outcome are complex, however. Two studies produced contrasting results with one showing that, in the context of shaming experiences, middle perceived socio-economic status had a protective effect compared to lower and upper perceived socio-economic status groups; whereas another study found that youth who rated themselves as middle perceived socio-economic status were at greater risk of poorer mental health outcomes compared to lower and upper perceived socio-economic status youth. Findings are also unexpected in relation to substance use, in which young people with higher perceived socio-economic status have reported greater levels of substance use. This finding is similar to some studies that have shown that young people of upper socio-economic status backgrounds are also vulnerable to greater levels of distress and behavioural challenges and experience vulnerabilities as has been found in previous studies showing vulnerabilities for lower income young people. 11 Due et al. (2009) did not explore inequities in relation to young people’s mental health per se. This study is included in this review, however, due to the strong associations between bullying and young people’s mental health for both victims and perpetrators of bullying (see Kim & Leventhal, 2008). 27 In relation to young people’s employment experiences, studies have begun to explore various dimensions of employment in relation to young people’s mental health, but they are limited. Studies exploring the impact of unemployment on young people’s mental health outcomes have found both positive and negative experiences associated with unemployment. Studies have also found that mental health outcomes in relation to unemployment experiences depend on the level of social integration and income supports or level of economic deprivation. In relation to studies exploring associations between neighbourhood disadvantage and young people’s mental health, studies have shown that in some cases NSD is directly associated with mental health outcomes whereas others have not found a direct association. Opposing findings have also been found whereby young people from NSD have better mental health outcomes such as higher self-esteem and lower rates of alcohol and marijuana use and reduced effects of deviant peers on adolescent behavior. Studies have also shown that in some cases social factors mediate the relationship between NSD and mental health outcomes and others have not found this interactive effect. One study found that NSD mediates the relationship between perceived stress and coping style and cortisol levels. Finally, studies have found positive associations between greater levels of economic inequities and poorer mental health outcomes. Overall, these studies affirm the important, albeit complex relationship between socio-economic factors and young people’s mental health. A central limitation of quantitative methods is their inability to explore complex relational dynamics between young people and socio-economic processes. Quantitative studies are also limited in terms of pre-selecting socio-economic factors that lack attention to young people’s lived experiences. Young people’s experiences offer insights into relevant dimensions of current and evolving socio-economic dynamics for young people’s mental health that have been neglected in previous quantitative studies. Qualitative studies exploring the meaning and determinants of mental health from young people’s perspectives have identified several socio-economic factors not explored in quantitative studies examining the relationship between socio-economic factors and young people’s mental health outcomes. In these youth views studies, young people have expressed concerns about environmental pollution (Harden et al. 2001; Oliver et al. 2008), the built environment, and green space, as well as concerns regarding their access to key resources such as public transportation, grocery stores, 28 and safe physical environments, neighbourhood and school amenities and health care (Ott et al., 2011)12 which has included the need for a stable home (Oliver et al.). Young people have suggested that a lack of material resources that prevents them from getting on with daily tasks of life and engaging in leisure activities is a barrier to mental health (Oliver et al. 2008). Young people have identified their schooling experiences including school performance and an ability to attend college or vocational school as influential to their mental health (Gampetro et al., 2012). Young people have expressed difficulties with studying, coping with academic pressure, and in particular, fears about academic failure (Gallagher & Miller, 1996). They have identified the stress of exams and having too heavy a workload in school that eats into free and leisure time (Harden et al., 2001; Oliver et al., 2008) and challenges associated with finding balance in life into late adolescent years (White & Wyn, 2008) as threats to their mental health. Furthermore, young people have identified having enough funds for post-secondary schooling as influential. Young people in state care transitioning into adulthood have identified worries associated with not having enough money to pay bills and to finish high school or to pay for post-secondary schooling (Leadbeater et al., 2008).13 Young people in state care have explained that once leaving care, “all of [one’s] time and earnings [go] towards rent, food and bills” leaving little left for costs associated with school (Leadbeater et al., p. 13). Young people have also expressed their need for financial security. Within their experiences as consumers who participate in paying for food and clothing to offset family expenses, young people have expressed worries about financial independence (Gampetro et al., 2012). Young people have explained that they need to work to contribute to family income and to support oneself and thus have identified family finances as a factor that affects their health (Ott et al., 2011). Young people have explained that having to work to support family finances has contributed to young people’s stress with balancing time to make healthy meals and meet their needs (Ott et al.). Young people who were nearing completion of high school have expressed worries about long-term future goals and the ability to make a living (Gampetro et al. 12 Note that this focus group study explored young people’s views of the meaning of health generally. 13 Note that both Leadbeater et al. (2008) and White and Wyn’s (2008) work discuss young people’s wellbeing more broadly. Furthermore, Leadbeater et al.’s study focused more broadly on what factors shape young people’s experiences as they transition into adulthood. 29 2012) and making decisions about employment (Gallagher & Miller, 1996; Oliver et al., 2008). Young people have expressed concerns about choosing and finding a job and worries about finances and money (Gallagher & Miller) and they have expressed worries about the ways that certain social locations are discriminated against by future employers (Harden et al., 2001; Leadbeater et al., 2008; Oliver et al., 2008). Young people have expressed concerns about their social location as youth where young people have “described their experiences of watching adults watch them in public places . . . [seeing this] gaze as a specter of apathy, condemnation and anger” which have evoked feelings of fear, being unwanted and invisible in community life (Leadbeater et al., p. 14). More broadly, young people have identified restrictions on young people’s freedom due to societal attitudes, structure and police, and their powerlessness when adults make decisions for them as barriers to mental health (Harden et al., 2001; Oliver et al., 2008). Young people have expressed a need to be heard on all levels of decision-making from state policies to local programs and inter-personal interactions (Ott et al., 2011). Young people have also identified not feeling in control as a barrier to mental health (Oliver et al.). In other work, young people have associated their wellbeing with the ways that they relate to valued consumer goods, which are shaped by peer pressure and peer hierarchies (Morrow, 2001). More generally, international young people’s activists have expressed concerns about the ways that the “socialization of children in affluent countries by corporations and the media [encourage young people] to evaluate their self-worth in terms of clothing labels and electronic toys” (Stasiulis, 2002, pp. 290–291). These qualitative studies offer important insights into socio-economic factors that are relevant to young people’s mental health that have not been addressed in previous quantitative studies. Because these factors were identified in studies looking generally at what aspects of young people’s lives affect their mental health, a more in depth exploration of how these aspects of socio-economic life affect young people’s mental health and implications for mental health promotion programming is needed. Importantly, further work is needed to identify implications for youth mental health promotion initiatives that are oriented to addressing the ways that socio-economic dynamics constrain young people’s mental health. Previous work has shown discrepancies between youth 30 views studies that highlight the importance of broader structural factors and mental health promotion intervention research and policy that lacks an attention to addressing structural factors. A previous comparison of youth views studies to youth mental health promotion intervention research (between 1990 and 2000) shows a discrepancy between the attention that young people have brought to the importance of structural factors14 in relation to their mental health and the lack of attention to addressing structural factors in intervention studies (Harden et al., 2001; Oliver et al., 2008). Harden et al. compared mental health promotion intervention studies to youth views studies. They found that socio-economic determinants of mental health were identified by youth in 10 (of 12) qualitative studies exploring young people’s views of the determinants of mental health.15 However, of the high quality systematic reviews (N=7) and outcome evaluations (N=47) that were included in their in depth review, no evaluated interventions addressed the concerns identified by young people regarding the material and physical circumstances of young people’s day-to-day lives (Harden et al.; Oliver et al.). More broadly, in Harden et al.’s exploration of trends across 345 studies that included a mixture of outcome and process evaluations, non-intervention research, and systematic reviews, they found that only 32% of these studies addressed broader societal (socio-economic and socio-cultural) factors. This tendency to develop individual and inter-personal level health promotion interventions is also reflected within Canadian health programming. Within the Canadian health policy context, MacNeil (2012) conducted a cross-jurisdictional scan of all Canadian health region websites exploring interventions addressing social determinants of health, equity and structural-level interventions16. Based on his review of 2200 interventions, MacNeil found that 25% of interventions addressed equity and of these, 16% were structural in nature. Most interventions relied on direct interventions at the 1:1 level (e.g. bringing health services to 14 Harden et al. 2001 use the notion of structural factors to refer to material (e.g. access to resources, built and natural environments) dimensions of young people’s lives. Examples of structural interventions include: “increasing access to resources or services, environmental modification and legislation or regulation” (Oliver et al., 2008, p. 777). 15 For their more rigorous review, Harden et al. (2001) selected qualitative studies that sought to explore young people’s views regarding the meaning and determinants of mental health as a central focus of the study (as opposed to situating young people’s views within a particular theoretical or analytic framework or use of survey methods with pre-selected questions) 16 MacNeil (2012) defines structural interventions as including: “those which address health outcomes not on a case by case basis, but across larger populations” (p. vi) 31 underserved communities). Interventions providing fiscal support for citizens or through formalized policies addressing environmental factors such as regulation were less common than individual level supports. As mentioned previously, this primary focus on promoting health at the individual and inter-personal level is also reflected within B.C. mental health policy. Furthermore, similar to the tendency to develop health promotion programming in individualistic ways, recommendations made within previous quantitative studies tend to be individualistic in nature despite their focus on exploring the relationship between socio-economic factors and young people’s mental health. For example, based on research exploring the relationship between perceived SES and young people’s mental health, Frojd et al. (2006) and Hamilton et al. (2009) highlighted the psychological meaning attached to young people’s life situations. Frojd et al. suggested that while adolescent perception of financial difficulties is probably associated with the objective financial situation of the family, it may also be an indicator of the psychological meaning attached to the situation and should thus be considered a possible risk factor for adolescent maladjustment in clinical practice (Frojd et al., 2006). Frojd et al. suggested that: social and healthcare professionals working with families should consider the financial difficulties in the family as a possible risk factor for maladjustment in the offspring. Possible ways of preventing maladjustment are discussions of the psychological meaning of economic hardship (helping the adolescent to see his/her situation in a new way, reducing feelings of inferiority or shame) and giving the adolescent tools to cope with situations arising as a consequence of financial difficulties (conflicts with parents, conflicts between parents and difficulties in socializing with peers). (p. 547) These recommendations lack attention to balancing care at the individual and interpersonal level with attention to addressing socio-economic factors that influence young people’s mental health. Furthermore, while several recommendations have been made within the broader social determinants of health literature regarding ways to address various social determinants of health (including that of employment, income and economic inequities, for example), and while there is an abundance of evidence regarding interventions (Marmot & Allen, 2014), understanding what interventions are relevant to young people with attention to current and evolving socio-economic dynamics requires more in depth exploration of young people’s views. 32 Gaps in Previous Research and Objectives Guiding this Study Overall, across the studies reviewed the nature of the relationship among aspects of socio-economic life in relation to young people’s mental health remains unclear. Specifically, there is little understanding of relational dynamics among young people’s mental health and various aspects of socio-economic life. This includes a lack of understanding regarding how to translate more nuanced understandings of these complex relationships into mental health promotion initiatives oriented to addressing aspects of socio-economic life that constrain young people’s mental health. Qualitative work has drawn attention to concerns raised by young people about structural determinants of mental health. Empirical findings affirm the important albeit complex role that socio-economic factors play in young people’s mental health. Together these bodies of literature suggest the importance of exploring the relationships among young people’s mental health and socio-economic factors from a broader relational perspective. The dominance of individual and inter-personal approaches to CYMH prevention/promotion programming and their incongruence with young people’s attention to structural factors (Oliver et al., 2008) suggests the importance of exploring opportunities for addressing constraining socio-economic determinants of young people’s mental health in health promotion initiatives from the perspective of young people. More specifically, this lack of attention to addressing socio-economic factors in young people’s mental health promotion programming is likely due to several factors, including the lack of a broader relational understanding of socio-economic life and young people’s mental health. Quantitative studies are limited in their ability to deepen understanding regarding the complex and dynamic interrelationship of diverse aspects of socio-economic life in relation to young people’s mental health. Qualitative studies exploring youth views have begun to identify additional socio-economic factors, but have not explored how aspects of socio-economic life affect young people’s mental health and implications for mental health promotion initiatives. Causal models underpinning theories of the relationships among socio-economic factors and health have several limitations for giving clear directions regarding health promotion initiatives. A causal model is reflected in debates regarding which factors are most salient, with neo-materialists putting material and structural conditions of people’s lives at the centre of explanations of health inequities in contrast to others putting psychosocial mechanisms and 33 specifically the negative emotional impact of living in an unequal society at the centre of explanations of health inequities (Crinson & Yuill, 2008). A causal model is also reflected in polarizing debates regarding the direction of the causal relationship between health and wealth. Some argue that people who are ill drift into situations of poverty and thus ill health is the cause of health inequities. Others argue that income inequality is either directly causal or indirectly causal (in being a marker of broader social inequalities) of poor health (Marmot, Allen, & Goldblatt, 2010). This “linear model of causality” in which cause-and-effect relationships are assumed, lacks attention to “emergence and contingency . . . and the complexity of human agency and social structural interaction within an open society” (Crinson & Yuill, p. 467). This causal-linear perspective is constraining in that it results in ideological stalemates in theoretical and empirical explorations of the nature of relationships among social determinants of health and health outcomes and proposed solutions. Furthermore, quantitative studies underpinned by realist and idealist ontologies are limited in that they assume the possibility of developing truth claims regarding ‘socio-economic factors’ and ‘mental health.’ This perspective is problematic in that it does not consider the dynamic, interrelated, co-evolving nature of aspects of socio-economic life and young people’s mental health. This perspective does not address how conceptions of mental health and socio-economic factors are rooted in social and cultural values and shaped by dominant and evolving assumptions regarding human nature and social change. These concepts are contested and political in nature. Their definitions are shaped by evolving power relations and shape how young people’s mental health is promoted in community life (Bambra et al., 2005). The contestation of these terms is reflected in analytic work that has questioned taken-for-granted assumptions underpinning notions of mental health and mental health promotion within the health promotion and mental health policy and practice literature. Based on a review of critical perspectives in mental health, Coppock and Hopton (2000) draw attention to the lack of “a universally accepted theory of mental health and distress” (p. 176) and argue that there is a “hierarchy of ideologies, which seems to privilege discourses which incorporate biological psychiatry over all competing discourses” (p. 165). In the case of theorizing mental health, the majority of works construct mental health as being an ability to cope or adapt to environmental stressors at the individual level and the ability to be productive in the larger economic environment (For example, McDougall, 2006; Mohr, 2006; Townsend, 2006; World Health 34 Organization, 2004). Analyses have variously shown the dominance of Western cultural, patriarchal, individualistic, bio-medical/psychiatric, middle-class, and liberal/neoliberal discourses inherent to notions of mental health and distress in mental health practice (Coppock & Hopton, 2000; Crowe, 2000a, 2000b; Ferguson, 2007; Rose, 1999; Stavropoulos, 2008; Teghtsoonian, 2009; Timimi, 2005, 2010). Barriers to addressing social determinants of health in policy and practice has been attributed to the continued dominance of quantitative and individualistic approaches to researching health and determinants of health that are depoliticized and the dominance of liberal ideological values such as individualism in Western culture (Raphael, Curry-Stevens, & Bryant, 2008). As argued by Bambra et al. (2005), health is a political concept “because its social determinants are amenable to political interventions and thereby dependent on political action” and “because power is exercised over [health] as part of a wider social and political system. Changing this system requires political awareness and political struggle” (pp. 187–188). It is thus important to build on previous work in making transparent the underlying assumptions and values that are operating within notions of health/mental health. This includes addressing the attention that young people have brought to the importance of addressing structural factors in relation to mental health and calls that have been made within nursing and interdisciplinary health disciplines for addressing the socio-environmental determinants of health (E.g. Baum, 2007; Hawe, 2009; Marmot, Friel, Bell, Houweling, & Taylor, 2008; Raphael, 2010; Reutter & Kushner, 2010). I thus drew on a praxis-oriented approach to inquiry, underpinned by a Hegelian-Marxist historical-dialectical perspective that enabled an exploration of socio-economic life in relation to young people’s mental health and implications for mental health promotion initiatives. In order to ensure that insights and recommendations were responsive to young people’s needs and experiences, this approach to inquiry was grounded within young people’s lived experiences. It was also reflexive in nature, attending explicitly to the political and co-evolving, contested nature of the notions of mental health and socio-economic factors. In this study I viewed both mental health and socio-economic environment as political concepts (Bambra et al., 2005). I explored young people’s views and experiences on how their socio-economic environments affected their mental health in relation to dominant ways of understanding and addressing socio-economic determinants of mental health within mental health policy. This helped to inform 35 insights regarding ways to build on existing health promotion work in ways that address constraining aspects of socio-economic life for young people’s mental health. This study was guided by the following objectives: 1. To deepen understanding regarding ways that young people’s current socio-economic environments are influencing their mental health and young people’s processes of realizing their mental health. 2. Identify opportunities for developing mental health promotion initiatives in ways that address current socio-economic dynamics that are constraining young people’s mental health. 36 Chapter Three: Research Design and Implementation Critical qualitative research methods are a means of exploring relationships among broader social, political and economic dynamics and the day-to-day life and health experiences of people (Cook, 2005; Raphael et al., 2001). Political-economic and dialectical perspectives are important to deepening understanding about these relationships in ways that prevent “ideological dichotomies” (Robertson & Minkler, 1994, p. 298) between macro- versus micro- level factors that affect health (Raphael & Bryant, 2006; Raphael et al., 2001; Robertson & Minkler). Labonte, Polanyi, Muhajarine, McIntosh, & Williams (2005) argue for the importance of research specifically focused on understanding the relationships among aspects of socio-economic life and health in order to guide diverse political and social actors—such as health workers, community-based organizations, employers, government policy makers, and politicians—in developing policies that transform the socio-economic conditions that lead to ill health. Furthermore, better understanding of these relationships will support the selection and development of theories of society and social change that can be taken up in critical health promotion research, policy and practice (Labonte et al., 2005). I thus used a praxis-oriented approach to inquiry, underpinned by a Hegelian-Marxist dialectical and historical perspective (Bologh, 1979; Choat, 2010; Harvey, 1996; Hill, 2009; Lather, 1986; Lefebvre, 1969; Marcuse, 1960; Ollman, 1976, 2003) to address the objectives guiding this study. Bologh (1979) describes Marx’s research method as a form of “dialectical phenomenology” that supports a relational analysis of mental states, political and economic systems, language and knowledge. This relational approach to inquiry assumes that aspects of socio-economic life are dynamic, co-evolving, historical in nature, and not always self-evident within evolving language and conceptual systems. A central goal of this approach to inquiry is to deepen understanding regarding relational and ideational dynamics to identify opportunities for ethical and socially just socio-economic change (Bonefeld, 2012; Harvey, 1996; Lather, 1986; Ollman, 2003) that, in the case of this research, is supportive of young people’s mental health. I start by providing an overview of the historical-dialectical ontology that supported my relational approach to inquiry in this study. I then provide an overview of the process of social 37 praxis that informed my approach to data collection and analysis and, more specifically, the research process. Historical-Dialectical Ontology In support of my relational approach to inquiry within this study, I drew upon insights from the field of Western Marxism (Choat, 2010; Feenberg, 2014; Kellner, 2005), and more specifically Hegelian-Marxist scholarship (Hill, 2009) that has interpreted Marx’s approach to inquiry from a historical–dialectical perspective (Bologh, 1979; Feenberg, 2014; Feenberg & Leiss, 2007; Harvey, 1996; Hill, 2009; Lefebvre, 1969; Marcuse, 1960; Ollman, 2003). This approach to inquiry is focused on exploring relations as a fundamental unit of analysis (Harvey, 1996; Ollman, 1976, 2003) and offers a “fundamentally non-reductive way of viewing the world” (Hill, 2009, p. 609). Put another way: a historical dialectical approach to inquiry is relational inquiry. I have thus used the terms dialectical (encompassing historical) and relational interchangeably in this report. Two overarching sets of assumptions supported my approach to relational inquiry within this study. The first set of assumptions within this historical–dialectical perspective centre around the notion that aspects of socio-economic life are inter-related with, and co-constitutive of, each other and with the whole system of which they are a part. Parts of a system are assumed to encompass relations that contain within themselves the very interactions to which they belong (Bologh, 1979; Hill, 2009; Ollman, 1976, 2003). Furthermore, a dialectical view holds that while autonomous in nature, parts and wholes also co-constitute each other within socio-economic life (Bologh; Harvey, 1996; Hill, 2009; Ollman, 1976, 2003). This means that parts of a system are both internally autonomous and “identical” in that each part is a necessary condition for the other and thus is conceived as a part of the other (Ollman, 2003). For example, while people are free and function as independent autonomous agents within a market economy, they are also fundamentally dependent on the market in realizing income and resources from exchange relations (Harvey, 2010, 2014). Attention is thus brought simultaneously to the “part” (e.g. an entrepreneur) and the process of which it is a part (e.g. exchange relations within markets) (Bologh; Hill; Harvey; Ollman, 2003). In moving beyond tendencies in social research to stop at exploring similarities and differences between parts (e.g. thematic analysis), a central focus of dialectical inquiry is to explore not only the ways that parts are similar and different to each 38 other, but also to explore the ways that their identities include the relationships with other parts of the system of which they are a part (Ollman, 2003). This perspective helped me to explore young people’s lived experiences of their socio-economic environments while maintaining a simultaneous attention to socio-economic processes in which young people participate. This perspective also helped me to resist dominant, linear, and taken-for-granted ways of conceiving notions of mental health and socio-economics within this inquiry process. For example, instead of dividing research participants into income levels or socio-economic positions (e.g. capital and labor) and explaining their mental health experiences and needs within those categories, I sought to explore inter-relations among young people, their mental health experiences, needs, response patterns, and socio-economic processes and level of access to resources, while keeping an open mind to additional ways of understanding their experiences. I sought to understand the relationship between young people and the socio-economic processes of which they are an inter-related part. From this perspective, I further explored how young people are both influenced by and influencing socio-economic processes that they are part of within their day-to-day lives. This was important to deepen understanding regarding how relational dynamics among young people and socio-economic processes were influencing young people’s attempts to realize their mental health and specifically, their level of influence and control in meeting their mental health needs. Drawing on both Marx and Adorno’s work, Bonefeld (2012) argues that “agency” and “structure” and “subject” and “object” are not separate, but connected through social practice. This social practice includes evolving language and meaning systems oriented to understanding and coordinating social practice with other people to meet needs and goals within the broader world of which practice is an inter-related part (Lefebvre, 1969). For example, as new needs and goals arise out of evolving production systems (and the new technologies and commodities that are produced), new ideas and language are needed to coordinate social relations in meeting evolving needs and goals. Both Marx’s dialectics (Ollman, 2003) and Adorno’s negative dialectics “hold that however much the objective world has autonomized itself from the acting individuals, it remains a form of human practice” (Marx quoted in Bonefeld, 2012, p. 129). With this focus on practice, there is no “essence” of subjects and objects; “essence is ‘society as the unity of object and subject,’ however much the subject is degraded to a foundational means of the object that it forms” (Bonefeld, p. 128). With this in mind, I paid attention to research 39 participants’ descriptions of how, for example, commodities such as name-brand clothing and IPhones shaped and influenced their mental health and, in turn, how they sought to meet their mental health needs within this material context. I also explored how young people were being positioned and positioning themselves within socio-economic processes in relation to their processes of seeking to realize their mental health needs. More broadly, I explored young people’s experiences in relation to mental health policies and assumed that while social structures (and processes) such as a mental health system, and the economic system with which it is inter-related, may appear as separate structures and permanences, they are inter-related with, and extensions of, the co-evolving social processes and practices that constitute them. This understanding set the stage for examining the positioning of mental health policies and programs in relation to young people and broad socio-economic processes. This understanding of the nature of socio-economic life formed part of the lens through which I analyzed possible opportunities for developing future mental health promotion initiatives. The other lens was that of contradictions. The second set of assumptions within this historical–dialectical perspective centre around the notion that contradictions are important sites for analyzing opportunities for social change. From this perspective, moments of socio-economic life are considered to be heterogeneous in nature through their dynamic inter-relation with other moments of socio-economic life over time (Harvey, 1996).17 A moment within socio-economic processes can be internally contradictory within itself as well as in contradictory relationship with other moments in socio-economic life. Contradictions can arise when internally related aspects of a moment (through its relations with other moments) or relational dynamics between moments hold oppositional needs, goals, interests, values, positions, ideas, desires and/or directions. For example, conflicts and tensions emerge within relationships among different social positions and respective needs, goals, values, and interests. With our embeddedness within this complex and contested social terrain of ideas and relational dynamics, we too can experience contradictory internal experiences. An example from this study entailed how young people both resisted what they referred to as “capitalist brainwashing” at the same time as they sought the very products being advertised to meet their 17 Harvey uses the notion of “moments” to reflect this relational perspective on aspects of socio-economic life that are assumed to be temporal and historical in nature, as well as inter-related with other moments of socio-economic life in dynamic ways. The notion of moments signals the impermanent and dynamic nature of socio-economic life such that there are endless possibilities for change that occurs at various points in time and contexts (Harvey, 1996). 40 need for social inclusion. These contradictory dynamics are considered to be the most important relations for dialectical analysis in that it is assumed that they are key sites for transformative social change (Harvey, 1996; Ollman, 2003). Understanding these contradictory dynamics from a dialectical perspective is important to enable insights into relational power dynamics and opportunities for systemic change that, in the case of this research, is supportive of young people’s mental health. Importantly, contradictions include direct conflictual dynamics, as well as a mutual dependency between moments of socio-economic life (Bologh, 1979). A contradiction is a divergent “tense form [or relation] because the side that is repressed is in conflict with its other side and there is a suppression of one side to allow the other side to realize itself” (Bologh, p. 69). A contradiction also includes an alliance and mutual dependency between conflictual moments in that each part is a necessary condition for the other’s existence. Put another way, contradiction “refers to the incompatible development of different [moments] within the same relation [i.e.] between [moments] that are also dependent on each other” (Ollman, 2003, p. 17). From this dialectical view (as opposed to the Aristotelian view in which two statements are held to be completely at odds so that one cannot be true) a contradiction is assumed to “arise when two seemingly opposed forces are simultaneously present within a particular situation, an entity, a process or event” (Harvey, 2014, p. 1) and thus are mutually dependent upon one another. Analysis of the conflictual and interdependent nature of contradictory relations in socio-economic life offers a lens for identifying opportunities for systemic change. Within my analysis of contradictory dynamics faced by young people within this study, this awareness of the mutual and divergent aspects of a contradictory dynamic enabled me to consider solutions that are oriented to enabling the realization of both sides of a contradictory dynamic in ways that attend to “different sides of [the] contradiction . . . at the same time, and [to] grasp the ways that processes actually interpenetrate . . . as their mutual dependence evolves” (Ollman, 2003, p. 18). This was important to avoid mutual interactions from being mistaken for causality (with the tendency to focus on one side of the contradiction to a greater degree than the other) (Ollman, 2003) and, in turn, one-sided solutions that do not address the inter-dependent elements of a contradictory dynamic. An example of this kind of analysis can be applied to a living wage policy, which has been identified as a key strategy for ensuring access to income as a determinant of health within 41 the field of public health (e.g. Public Health Association of British Columbia, 2014). While a living wage can alleviate the struggle for labourers to meet their needs for a period of time by increasing access to money and thus needed resources or commodities, this solution contradicts the drive for profits within private production processes. As increased wages result in loss to profit margins, the price of commodities must increase, which then contradicts the solution of increasing wages in the first place. Conversely, the increased focus on maximizing profit margins inherent to neoliberal economic policies and practices results in increasing precarious and low-wage work followed by the challenge in realizing profits in markets where there is no longer an effective demand (Harvey, 2005, 2014). Analysis of this contradictory dynamic shows the mutual dependency of capital and labour. Labour is dependent on production to access money to meet needs, and capital is dependent on labour in production and, in free markets, as consumers to actualize profits. Solutions thus need to be developed from an understanding of both the root conflict and mutual dependency between, in the case of this example, labor and capital in production and distribution processes. These insights apply to youth mental health promotion in that promoting young people’s socio-economic wellbeing cannot be achieved through simple, one-sided solutions. In addition to the contradictory dynamics that can arise within material life, Marx and subsequent Hegelian-Marxist scholars drew attention to the contradictory dynamics that can arise between material reality and evolving conceptions of this reality (Adorno & Horkheimer cited in Crotty, 1998; Feenberg, 2014; Feenberg & Leiss, 2007; Hill, 2009; Kellner, 2005; Levebvre, 1969; Marcuse, 1960). They variously critiqued the ways that capitalist logic and scientific knowledge and subsequent concepts, theories and abstractions present seemingly static truths about the world that contradict the dynamic and co-evolving, relational nature of life and how these “truths” can strengthen existing power dynamics and limit opportunities for change. A central and dual aspect of Marx’s analytic work included analyzing not only relational dynamics within actual existing socio-economic life, but also analyzing the ways that concepts and constructs are taken up in limiting and constricted ways that mask broader social relations that are operating in social life (Bologh; Hill; Harvey; Ollman, 2003). For example, Marx showed the ways that wage labour presents a façade of mutual exchange when in reality the wages exchanged for labour power and surplus profits are not equivalent in private production processes (Ollman, 1976). Marx “devoted significant critical energies to an intensive re- 42 examination of the way in which economic abstractions distort the internal relations that actually exist between human beings” (Hill, p. 613). The notion of reification is used to draw attention to how certain ways of conceptualizing aspects of socio-economic life (e.g. subjectivity, social and material relations) can distort a more expansive understanding of actual existing and complex relational dynamics (Feenberg). Further, Marx and subsequent thinkers drew attention to how reified notions limit the potential of human beings and their capacity for critical thought, imagination and action in relation to actualizing evolving goals and needs (Hill). These reified forms of rationality negate the dialectical view of human nature, which Hegelian-Marxist scholars assumed was historical in nature (Hill; Lefebvre). This means that we, as human beings, are continually seeking to understand (and conceptualize, abstract) the world and address needs in relation to a world that we both change, are changed by, and respond to in a co-evolving way (Feenberg & Leiss; Hill; Lefebvre; Ollman, 1976). This contradictory dynamic between reality and conceptions of reality can occur within daily social and cultural practices, as well as within knowledge development processes. These concerns regarding reified reality emerged from Marx’s critique of how philosophy (and modern rationality) had evolved to be disconnected from reality and his argument for the importance of starting with day-to-day life experiences and using our senses as theoreticians in praxis-oriented inquiry (Hill, 2009; Lefebvre, 1969). The philosophy of praxis that informed my approach to inquiry was enlightened by these critiques of the reifying practices inherent in dominant forms of rationality, and the historical-dialectical ontological perspective that emerged from these critiques. Research Methodology: Social Praxis I drew upon a Hegelian-Marxist philosophy of praxis to inform my approach to data collection and analysis in this study in which I explored young people’s mental health needs within the context of their day-to-day life experiences. I examined participants’ experiences and perspectives regarding the ways that aspects of socio-economic life affected their mental health and their approaches in seeking to realize their mental health needs in relation to dominant conceptions of mental health and approaches to promoting mental health. This philosophy of praxis also supported my reflexive approach to inquiry. 43 Referred to as “meta-critical” in nature by Feenberg (2014),18 Marx’s approach to praxis-oriented inquiry includes an iterative two-step process of first, analyzing relational dynamics and second, identifying solutions that have potential for resolving contradictory dynamics within material and social life (Feenberg). The first step of relational analysis entails exploring lived experience and relational dynamics within socio-economic life. This includes analyzing language and conceptions of reality in relation to actual existing socio-economic life both in terms of a) the ways that dominant understanding of, in the case of this research “mental health/promotion” and “socio-economic determinants of youth mental health” contradict reality and in turn limit possibilities for meeting young people’s mental health needs; and b) the potential ways that dominant understandings and assumptions in socio-economic life may hinder insights gained within the research process itself. In relation to the potential influence of dominant ideas within the research process, Hegel, Marx and subsequent Marxist scholars acknowledged the necessity and challenge of critique (inquiry) from within the conceptual systems of thought that mediate our knowledge of reality. Hegel’s critique of Kant’s ahistorical categories of understanding and Hegel’s marrying of “epistemology with ontology” within his arguments that “thought could never exist as a stand- alone entity from the subject from whom it emanated” brought a “historical-dialectical vantage point” to philosophy (Hill, p. 607). From this perspective, pre-existing suppositions are rigorously critiqued (Hill). Furthermore “given that the only knowledge we can ever have of the external world is mediated by what Hegel calls ‘formations of consciousness’, which constitute mere interpolations of reality, reality is always only ‘known’ through a fixative process of ‘abstraction’” (cited in Hill, p. 608). From this view, Hill argues that: We are only ever able to gain a semblance of reality, this being a mere representation or a mediated impression of what lies beyond our human and historically situated field of vision. Knowledge can only ever be knowledge of 18 Feenberg (2014) uses the notion “meta-critical” to distinguish Marx’s “non-reductive social theory of knowledge” (p.12) based on his critique of the metaphysical and idealist-normative aspects of previous philosophy. Feenberg argues that Marx’s approach to inquiry is meta-critical in nature in that a dual attention is brought to analyzing two domains of contradictions that are resolved through social practice: First, the contradictions that occur in existing material-social reality and second, the contradictions that occur between ideas-abstractions and material-social life. Attention is brought to abstractions as “relative states” and to comparing these abstractions to concrete reality. Concepts are held as relative and evolving states of understanding the world, which may contradict the realities of that world. By increasing awareness of the contradictions between ideas and reality, opportunities open for new ways of being and becoming through social practice. 44 ‘appearances’ by this view. Far from our reasoning therefore being braced by timeless and eternal truths, it becomes a very human and historical entity as a result. (Hill, p. 608) For Marx, this necessitated a “skeptical self-comprehension” (Hill, p. 608) resulting in the need for a continual questioning of knowledge claims and their influence on relational dynamics and social practices that then shape human thought, experiences, needs, and evolving understandings and knowledge claims in an iterative way (Hill; Ollman, 2003). For Adorno, this required a form of “immanent critique,” a form of phenomenological critique from within the complex relational and ideational dynamics that are at play within evolving socio-economic dynamics (Adorno cited in Crotty, 1998). A central feature of this approach to inquiry is thus the simultaneous exploration of relations among moments of actual existing socio-economic dynamics and the relation between conceptions of reality and actual existing socio-economic dynamics (Ollman, 1976, 2003) both as the object of inquiry and within the inquiry process itself. I thus attended to material and ideational dynamics that were influencing young people’s mental health and their attempts to realize their mental health, as well as my own assumptions shaping my approach to inquiry. Hill (2009) describes this praxis-based approach to inquiry as an audit of dominant ideas and normative accounts of reality with real life experience. This is based on the assumption that ideas are in dialectical relationship with social relations over time in ways that both reveal and conceal aspects of reality, social relations and power dynamics (Bologh, 1979; Lefebvre, 1969; Marcuse 1960; Ollman, 2003). A central focus of relational analysis is to explore the ways that dominant ideas and ways of making sense of reality may present seeming truths and permanences in social relations and institutional forms in order to show how these ideas obscure oppressive and unjust relations and limit potential (Harvey, 1996) of, in the case of this research, young people’s mental health and wellbeing. Abstractions are analyzed in relation to how they contradict the dynamic and co-evolving, relational nature of life and thus possibilities for change (Harvey). Marcuse (1960) argued that dialectical thinking is negative thinking in that it must negate the established social “facts” so that their emancipatory potential may be realized. An example of this contradictory dynamic from this research includes the ways that research participants expressed yearning to engage in meaningful work that contributed to their communities, at the same time that many of them held dominant assumptions that people would not be “incentivized” to work if they were not paid. 45 From this new approach to rationality in which concepts (and human nature) are not read normatively, but dialectically and historically (Hill, 2009), the second step of this approach to relational inquiry is that of solution building in ways that are informed by a deeper understanding of relational dynamics. From this perspective, relational dynamics are explored and concepts are deconstructed in order to enable potential openings for new ways of understanding and being in the world. From this historical view of human nature and social change, Marx argued that the forms of human being’s powers and capacities are endless and “have as many possibilities as there are ages and classes in human history” (Ollman, 1976, pp. 87–88) and thus there are open possibilities and solutions for meeting evolving needs. This is partly based on Marx’s critique of the ways that history was depicted as an external force operating upon people and to which people must passively submit and forfeit their autonomy in determining their future (Hill). Instead, he projected a meta-view, or “onto-formative” (Hill, p. 606) view of human nature with a central focus on people’s abilities to reflect, create, set goals, and act in a world that people change and in turn are changed by and “a thoroughly humanized and dialectical view of history that advances human purposive activity as the motor force of cultural evolution and progress” (Hill, p. 609). I applied this process of solution building within this study by a) engaging young people in critical reflections on the research objectives guiding this study while being attentive to their mental health needs, and b) analyzing contradictory dynamics between dominant ways of understanding mental health/promotion and participant’s lived experiences. Importantly, I recognized that within this process of immanent or reflexive inquiry, a central goal is to build ethical and moral choices within a contested terrain of constructed knowledges (Harvey, 1996). The goal of analysis is to “find a plausible and adequate basis for the foundational beliefs that make interpretation and political action meaningful, creative and possible” (Harvey, 1996, p. 2). According to Harvey (1996), “the exploration of potentialities for change, for self-realization, for the construction of new collective identities and social orders, new totalities (e.g. social ecosystems) and the like is a fundamental motif in Marxian dialectical thinking” (p. 56). Knowing what ideas and actions to prioritize in the context of complex and contradictory dynamics within co-evolving material and ideational moments of socio-economic life is a fundamental challenge in praxis-oriented inquiry. My analysis of solutions thus focused both on addressing socio-economic dynamics that were constraining young people’s ability to realize 46 mental health in their day-to-day lives and, more broadly, opportunities for developing mental health promotion initiatives in ways that address contradictory dynamics that constrain young people’s mental health needs in this contemporary socio-economic context. Importantly, instead of producing normative truth claims, this approach to inquiry is oriented to producing a “constellation” of ideas and calls to action (Adorno cited in Crotty, p. 135) that are open to ongoing praxis that is, in the case of this research, oriented to meeting young people’s evolving needs and goals (Levebvre, 1969). I thus sought to identify multi-level opportunities for future praxis-oriented youth mental health promotion initiatives that are responsive to current relational dynamics that constrain young people’s mental health. Overall, I applied this praxis-based approach to inquiry across two phases within this study. First, I engaged 30 diverse young people between the ages of 15 and 28 years from an urban context. Within two series of dialogue sessions and the use of participatory documentary photography, I explored participants’ experiences and perspectives regarding the ways that their socio-economic environments were influencing both their own and fellow young people’s mental health. This included exploring the ways that participants were seeking to meet their mental health needs in their day-to-day lives. Furthermore, in agreement with Marx’s recognition of the creative and imaginative powers of people (Hill), and the central importance of goals and aims in processes of praxis, whereby praxis “involves tactics and strategy . . . [and] no activity without an aim in view, no act without a program” (Lefebvre, 1969, pp. 54–55), I engaged young people to share their recommendations for socio-economic change oriented to supporting young people’s mental health. I also explored their critical reflections on barriers and supports to change. Based on the assumption that mental health policy reflects dominant and privileged ways of understanding and promoting mental health and to identify implications for mental health promotion initiatives, I compared insights gained from dialogue sessions with young people to the ways that mental health and socio-economic determinants of mental health are discursively taken up within two sets of provincial mental health policy documents within the second phase of this study. More specifically, I compared the ways that notions of mental health and socio-economic determinants of mental health are taken up within these policy documents to the lived experiences of participants in this study. I analyzed the ways that mental health/promotion and socio-economic determinants of mental health are understood within current mental health policy 47 and how mental health policy is positioned in relation to young people and broader socio-economic processes. I explored how common sense notions of mental health and socio-economic determinants of mental health within these policy documents both support and/or gloss over, or deny potentialities for promoting mental health in young people’s day-to-day lives. This analysis was important to understand the relational context of young people’s lives and to deconstruct taken-for-granted assumptions regarding mental health/promotion and social determinants of mental health. It was also important to explore the responsiveness of mental health policies and proposed programs in addressing socio-economic dynamics that constrain young people’s mental health and to identify implications for future mental health promotion initiatives. In essence, I applied this reflexive, relational-dialectical (meta-critical), and solution-oriented approach to inquiry by examining the meaning of “mental health” and “socio-economic determinants of mental health” (Bologh, 1979) as taken up in two sets of provincial mental health policy documents by subjecting these notions to the “scrutiny and rigorous audit based on real world experience” (Hill, 2009, p. 608) of young people. In context of previous arguments that this critical approach to praxis is best taken up within settings, by those most affected (Kemmis, 2010) and within iterative spirals of critical reflection, learning, action and evaluation (Kemmis, 2010; Stringer & Genat, 2004), I considered this to be a process of social praxis. I assumed that the setting of focus is the broader, contemporary socio-economic environment of diverse young people, their allies, and mental health programs. I sought to develop insights regarding the relational terrain of young people’s lives and possibilities for promoting mental health that can be the source of further dialogue and action within the broader community. Within this research, while I recognized the benefits of engaging research participants within group dialogue, I also recognized the importance of ensuring that these diverse young people felt safe in sharing their views and experiences and thus gave them the option of how they wanted to meet with me. This resulted in a mixture of mostly individual meetings and some dyadic and small group dialogue sessions with 30 diverse young people. This necessitated my engagement in analyzing patterns across dialogue sessions. The Research Process Within the first phase of this study, I used methods of data collection from the fields of critical pedagogy (Friere, 1970; McLaren, 2001; Tones, 2005) and photovoice (Wallerstein, 48 1987; Wang, 1999; Wang & Burris, 1997; Wang, Kun Yi, Wen Tao, & Carovano, 1998) to explore young people’s lived experiences of their socio-economic environments and their recommendations for change oriented to supporting young people’s mental health. In the second phase of this study, I engaged in a meta-critical analysis of all data collected, including retrieved policy documents, to address the research objectives guiding this study. Phase I: Critical dialogue sessions and participatory documentary photography The first phase occurred over a period of 17 months and involved recruiting young people from diverse social locations to participate in two sets of dialogue sessions and participatory documentary photography. Recruitment for engagement in first dialogue session Informed by standpoint theory19 (Swigonski, 1994), I sought to engage diverse research participants to ensure that varied experiences of socio-economic processes were represented. Guided by previous empirical and analytic work exploring the nature of socio-economic status/class and social stratification (Berkman & Macintyre, 1997; Crompton & Scott, 2005; Devine & Savage, 2005; Liberatos, Link, & Kelsey, 1988; Lynch & Kaplan, 2000; Raphael et al., 2005) I sought diversity in level of income and perceived socio-economic status, employment status, levels of education, housing situation, as well as positioning in relation to ownership of capital/production systems and level of political voice/activism ranging from non-participation through to engagement in youth-led activist/advocacy organizations. Engagement of research participants and data collection occurred from July 2012 to December 2013. I utilized four approaches to invite young people between the ages of 13 and 30 to participate (Appendix A). First, I posted recruitment posters and brochures, which included links to Facebook and Twitter pages, along central city street bulletin boards (Appendix B). 19 Having initially been informed by Marxist analysis of the conditions of the working classes, this term, “standpoint” is used within Feminist standpoint theory to enable analysis of the inter-relation of social locations and positions in society (Swigonski, 1994). Standpoint has been defined as “a position in society” (Swigonski, p. 390). I have used this term standpoint interchangeably with “position/positioning” to refer to one’s participation within socio-economic processes and the perspective that comes from this positioning. 49 Second, I emailed 24 community centres and six neighbourhood houses within the Vancouver catchment area requesting permission to post posters and brochures on their community bulletin boards and to be connected to their youth coordinators; I also offered to present the research project to youth groups. This resulted in presentations to two youth employment preparation programs for two neighbourhood houses and posters distributed to five community centres and one neighbourhood house, with one neighbourhood house distributing the brochures to their youth group. Third, I emailed, phoned and presented the project to various youth-serving non-profit organizations and left brochures to distribute to their members. This included: representatives of an agency offering supports to youth who were homeless; the youth engagement coordinator of provincially based child and youth mental health services located within Vancouver; two youth advisors for a provincially based child and youth mental health advocacy group who referred me to a university-based peer support group; a provincially based youth-led advocacy group focused on addressing social and environmental issues facing youth; the B.C. First Call Child and Youth Advocacy Coalition; and the Director of Clubs for the Boys and Girls Clubs of South Coast B.C. The contact from the service for youth who were homeless arranged for me to come and present on the project to their interested youth.20 Finally, at the end of each dialogue session, I gave brochures to research participants and offered them the option of inviting their friends or other young people whom they thought might be interested in participating. I also distributed brochures to a few young people I encountered on local transit and among my professional network of faculty and nursing students. This led me to offer presentations to two groups of young people at different community centres: an immigrant youth group and a youth leadership group. In determining inclusion criteria, I had initially extended the traditional upper age limit of 18 from previous definitions of youth/adolescence to 24 years of age. This decision was informed by the “widespread recognition as early as the 1970s that the timetable for growing up was slowing” (Furstenberg, 2008, p. 2). This has arisen from the extension of time in post- 20 I further discuss the steps I took to address the vulnerability that this group of youth face in the ethics section of this report. 50 secondary school, delays in leaving the parental home and delays in marriage and childbearing (Furstenburg) and with how the “developmental period from 12–25 years is characterized by multiple biological, neurodevelopmental, education and social transitions” (Hickie, 2011, p. 65). With feedback from the first group of young people to whom I had presented, and a couple of youth leaders and a member from the youth-led advocacy group, I learned that this upper limit of 24 years of age was too low. I learned that several Vancouver-based youth programs extended the upper age limit to 30 years of age, which for one program aligned with federal youth employment program guidelines offered through Service Canada. I followed their guidance and sought to recruit young people between the ages of 13 and 30. This enabled exploration of young people’s experiences within secondary and post-secondary educational programs and employment situations. To optimize diversity, I invited young people to fill out an adapted demographic survey form from the National Longitudinal Survey of Children and Youth (Statistics Canada, 2009) at the start of their first dialogue session (Appendix C). After 12 young people had been recruited, two 4th-year Bachelor of Science in Nursing (B.Sc.N.) health promotion practicum students from Vancouver Community College joined me as research assistants. We collated the demographic profile of this initial sample and noted a lack of representation of young people who perceived their socio-economic status as being “somewhat above average” and “well above average” and those whose families owned their own homes. The research assistants thus distributed approximately 35 brochures to young people at cafes and convenience stores near private and public schools in the West side and South-West Vancouver to increase the likelihood of recruiting participants with greater economic resources. Introduction to research participants This recruitment process resulted in a sample of 30 diverse research participants between the ages of 15 and 28 years. Their self-identified gender included: 15 males, 14 females, one non-response.21 Participants reported various socio-economic experiences. I highlight some of 21 Note that one non-response was due to my neglect to bring the demographic form to the dialogue session with one participant. I thus followed up via email to arrange to have the form filled out but this participant did not respond to my email. 51 these experiences here and refer the reader to Appendix D for information regarding participants’ level of personal and parental education, type of home ownership and length of residency. Participants also reported varying health- and wellness-related experiences and diverse self-identified ethnic backgrounds. Participants reported their family’s financial situation, as shown in Table 3.1. Table 3.1 Participants’ self-reported financial situation Description Number of responses Well above average 0 Somewhat above average 7 About average 13 Somewhat below average 4 Well below average 4 Response missing 2 Total 30 Your family has a hard time getting enough money for food, clothing, and basic living costs 4 Your family has just enough money for food, clothing and basic living costs 13 Your family has few problems buying what your family needs 4 Your family has no problem buying what your family needs and is able to buy special things 8 Response missing 1 Total 30 In relation to employment status, at the time of their participation 12 were employed and 17 were not, with one non-response. Within the previous 12 months there were 20 who had worked for pay, 8 had not with two non-responses. Three reported that they had run their own business in the past 12 months, 1 had indicated that they had “sold stuff on E-bay,” 1 indicated that they had “sort of” run their own business in the previous 12 months; 23 had not; and there were two non-responses. Among the 24 who identified when they had started working for pay the range was 10–25 years of age, with six working for pay at age 14 and under; 8 between the ages of 14 and 15; and the remaining 10 at age 16 or over. In relation to political participation, participants were asked if they had ever voted in an election. Eighteen had voted in school-related elections; of the 16 who were eligible to vote, two had voted municipally, 3 provincially, and five federally. When asked if they had ever 52 participated in a community-based decision-making process that influenced the participants’ life and that of other members in their neighbourhood/community, 13 indicated that they had, 15 indicated that they had not, and two made no response. Participants’ reported overall health status and wellbeing are shown in tables 3.2 and 3.3. Table 3.2 Participants’ self-reported health status Descriptor Number of responses Excellent 3 Very good 12 Good 8 Fair 5 Poor 1 Non-response 1 Total 30 Table 3.3 Participants’ overall wellbeing Descriptor Number of responses Happy and interested in life 13 Somewhat happy 11 Somewhat unhappy 6 Unhappy with little interest in life 2 So unhappy that life is not worthwhile 0 Non-response 2 Total 30 Importantly, of those who indicated that they were “happy and interested in life”, two participants also indicated being “somewhat unhappy.” Of those indicating feeling “somewhat happy”, two indicated also being “somewhat unhappy.” More specifically, three participants indicated experiencing more than one category. One participant indicated experiencing: “happy and interested in life,” “somewhat happy” and “somewhat unhappy”; one participant indicated experiencing both “happy and interested in life” and “somewhat unhappy.” One participant selected both “somewhat happy” and “somewhat unhappy.” Overall, 17 indicated being somewhat happy, somewhat unhappy, or unhappy and 11 indicated being happy and interested in life with two nonresponses. 53 When asked if research participants had ever been formally diagnosed with a physical or mental health challenge, 11 indicated yes, 17 indicated no, 1 indicated that they did not know, and one did not respond. Of those who indicated that they had been diagnosed with a health challenge, they reported the following diagnoses: four reported that they had been diagnosed with depression; one reported a diagnosis of anxiety; one was diagnosed with dyslexia; and four participants indicated that they had been diagnosed with multiple health challenges. As listed by each participant, these multiple health challenges included: "scoliosis, chronic pain, depression and social anxiety"; “obsessive compulsive disorder, anxiety, attention deficit disorder-attention deficit hyperactivity disorder"; “dissociation, low blood pressure"; "attention deficit hyperactivity disorder, psychosis." Recruitment of participants within second dialogue session and participatory documentary photography I used the contact information provided by research participants in their informed consent forms to invite them to participate in a second dialogue session to provide feedback on my initial thematic analysis of the qualitative data. Of these 30 young people, 29 indicated an interest in meeting for a second dialogue session to provide feedback on the preliminary findings and to share more specific recommendations. Twenty-six young people (and one “maybe” depending on time) indicated interest in participating in the use of documentary photography to further explore young people’s experiences after the second dialogue sessions. After conducting an initial thematic analysis of the data, I followed up via email, text and phone calls (depending on participant’s preference) to invite the interested 29 young people to a second dialogue session. Of these, 14 young people engaged in the second dialogue sessions across 9 follow-up meetings. Two members responded to the email indicating their interest in learning about the findings via the use of Dropbox and suggested that they would like to share their feedback via email. I thus shared the findings via a Power Point presentation and narration of the preliminary themes via Dropbox with them and they participated that way. This resulted in a total of 16 young people who shared feedback on the initial findings across 9 interviews and two sets of email exchanges. For the remaining 13 young people who did not participate in the second dialogue sessions: 8 did not respond to my emails or phone calls and one person’s phone 54 number was out of service for a total of nine nonresponses. Three participants requested the preliminary findings via email/Dropbox, but did not respond to my email; 1 had moved and had also expressed interest to share feedback via email, but did not respond to my email. Finally, of the young people who participated in the second dialogue sessions, 11 expressed interest in the documentary photography process and ten joined individual or group training sessions in the use of photography as a data collection method (depending on their preference). One young person expressed interest but her family had moved to an outlying area of Vancouver and she did not feel comfortable commuting. Of the ten who participated in the training, 3 did not respond to follow-up texts/emails; 7 followed through with the documentary photography process. Consequently, 6 participants engaged in 5 dialogue sessions and one shared photos and feedback via email. Young people were given the choice of where to meet and I met them in coffee shops, community centres, neighbourhood houses, and their homes. I also gave young people the choice to meet individually or with peers in dialogue sessions in order to create safety in exploring diverse, and at times politically incorrect perspectives that might not be shared in a group context (Thorne, 2008). Collecting data to explore young people’s views and experiences: Dialogue sessions and participatory documentary photography In keeping with my methodology, I used a participatory approach to engage participants in sharing their reflections within the first phase of the data collection process. Within the first dialogue session, I asked seven open-ended questions (Fontana & Frey, 2005) (see Table 3.4) and used “generative words” (Freire cited in Crotty, 1998, p. 148), problem posing questions (Friere, 1970) and circular difference questions (from the field of family therapy) (Brown, 1997) to engage participants in reflecting on their experiences and to explore possibilities for promoting mental health from young people’s perspectives. According to Ollman (2003), Marx’s dialectical approach to inquiry entails starting with the whole, the system, or as much of it as one understands, and then proceeds to an examination of the part to see where it fits and how it functions, leading eventually to a fuller understanding of the whole. (p. 14) 55 I started by asking participants how they saw the world today and how the world as it is today affected them so that I could facilitate reflections upon their broader environments.22 This was important for being responsive to participants’ experiences, current needs and goals (Lather, 1986). I took the participants’ lead in this process. If there was an aspect of their socio-economic environment that was of central concern for them, I stayed focused on exploring that and only moved to the next questions if the participant felt that they had shared what they had wanted to in relation to that issue. With the use of generative words (Freire cited in Crotty, 1998), I then explored more specifically participants’ first thoughts and experiences associated with the notions of “mental health” and “socio-economics”, “socio-economic system” (or “money” if they did not know what socio-economics meant) in order to explore their meanings of these aspects of their lives, and their experiences of the relationship between their socio-economic environment and their mental health and wellbeing. Table 3.4 First dialogue questions As a lead into the dialogue, I asked: “Why are you interested in this project ‘Money and Young Minds’?” 1. How would you describe the world as it is today? 2. How does the world as it is today affect you? Your relationships with your friends/family/community? 3. What is “mental health”? 4. What is “socio-economics/socio-economic factors” “money”? 5. Do you think that there a relationship between “money”/“socio-economics” and youth mental health? If so, what is the relationship? How would you describe this relationship from your own experience? 6. How might we change the world/socio-economic environment to make it more supportive of young minds? 7. What recommendations do you have for mental health programs/supports in our community to address your concerns? In order to explore participants’ recommendations for mental health promotion initiatives, I initially invited them to reflect on how they would change the world and socio- 22 I’d like to acknowledge that I learned about these open ended questions from a leadership training session that was lead by Deborah Littman, Lead Organizer from the Metro Vancouver Alliance in which they presented their approach to relational organizing based on Saul Alinsky’s work. 56 economic environment to make it more supportive of young minds. If they struggled, I asked them a miracle question, “if you had a magic wand and could change the world to make it more supportive of your mental health, how would you change it?” (Cited in Wright & Leahey, 2005). For those that struggled and in response to those that expressed fear that they would be “wrong” in their answers, I encouraged them to speak from their own personal experiences and perspectives and invited some of them to brainstorm ideas aloud. I later asked how the changes they recommended could be implemented. I then asked more specifically about how to promote young people’s mental health from both within and beyond our formal mental health system. If they struggled in answering this question, I shared my background as a children’s mental health nurse and previous research with young people that raised concerns for me about the influence of broader socio-economic factors such as income and poverty on young people’s mental health and wellbeing. I asked them to consider how mental health professionals and communities might work together in addressing these broader socio-economic factors and referred back to the concerns that each participant had identified in the earlier part of our meeting. For a guide to the small group dialogue sessions, which included a list of follow up (probing) questions that I prepared to support me in inviting research participants to reflect on aspects of their socio-economic environments in relation to their mental health, refer to Appendix E.23 After completing the first dialogue sessions, I conducted a preliminary qualitative analysis of participants’ critical reflections and presented these initial findings to 16 participants in the second dialogue sessions. I used power point to present the preliminary themes and read quotes that coincided with preliminary themes. This presentation included: young people’s reflections on aspects of socio-economic life that they described generally and in relation to their mental health; the initial themes pertaining to socio-economic needs for young people’s mental health; and participants’ recommendations for improving their “world” and socio-economic environment and promoting young people’s mental health and wellbeing. I then asked participants to reflect on what aspects of socio-economic life affected them most and to elaborate on how these aspects affected their mental health and wellbeing and whether they had any further recommendations. If they struggled to share ideas that addressed challenging socio- 23 I also used these probing questions for individual meetings with participants 57 economic dynamics, I engaged more interactively with them and shared recommendations that were made by fellow research participants and two examples of economic and labour policy options for their consideration.24 These policy options included a guaranteed annual income policy to address their expressed need to have their basic needs met (e.g. food, housing) and the example of cooperatively run businesses as an option in addressing their need for greater control over their work activities. Posing these examples evoked critical reflection and, at times, lively debate both within each dialogue session and across dialogue sessions as participants responded to the reflections of other participants that I had shared from the preliminary thematic analysis. I then engaged participants in analyzing “where the agency lies” (Harvey, 1996) to consider ways of fostering social change that could address their recommendations. This entailed exploring their views and experiences of barriers and supports to their own agency and broader change oriented to addressing their concerns and recommendations. Research participants looked at the PowerPoint slide of aspects of their socio-economic environment that were identified within the first dialogue sessions.25 They then reflected on what aspects of the system they thought would produce the greatest potential for systemic change and shared their thoughts on how to facilitate this change. I concluded by asking if they had any other general recommendations and then invited them to join a participatory documentary photography process to further explore their experiences in their day-to-day lives. Within my use of documentary photography as a method of photo-elicitation, I applied methods from photovoice, which has been used to engage young people in participatory inquiry in previous studies. Photovoice is a participatory action research method developed by Carolyn Wang and colleagues in order to engage community members in visually documenting and analyzing assets and barriers to health with the aim of addressing determinants of health 24 Note that an exception to this practice occurred for the young people who preferred to have the findings presented to them via Drop Box. For those participants I audio-recorded my presentation to them in which I read key quotes alongside the preliminary themes that were presented in the power point slides. I also mentioned the GAI and cooperative economic policy as examples of policies oriented to changing socio-economic processes. 25 Moments of socio-economic life that were presented in a series of thought bubbles in the power point slide included: social relationships including class/status (i.e. “rich” “poor” people); societal progress; neighborhood; community services (E.g. education, health, transportation); resources (food, housing); media and advertising; employment, jobs, income; economic system; impact of economic system on societal values; government and policies; pace of change; technology. 58 (Wallerstein, 1987; Wang, 1999; Wang & Burris, 1997; Wang et al., 1998). Photovoice extends Paulo Freire’s method of problem-posing education by inviting community members to use photography to document, interpret and present their surrounding environment (Strack, Magill, & McDonagh, 2004; Wang & Burris, 1997). I started by engaging participants in photovoice training sessions where I provided an overview of the consent process, basics of camera operation, and safety issues in taking photographs in the community setting.26 Within the photovoice training sessions I posed the open-ended questions from the first dialogue sessions and invited research participants to use cameras to take photos within their own day-to-day lives in order to further explore these questions and anything else they wanted to photograph.27 Participants were given note pads and offered the option of making notes of what they were aiming to depict in taking their photos and then engaged in a follow-up meeting to share their photos. I adapted the SHOWD tool from Wallerstein’s (1987) further development of this participatory data analysis tool for youth that was originally developed by Wang et al. (1998). When exploring photos with participants, I asked them to reflect on the following questions: • S=What do you SEE in your picture? (What is happening in this picture? What stands out the most for you in this photo?) • HO=HOW does this help us to understand young people’s mental health and what affects young people’s mental health? • W=WHY does this situation, concern or strength exist? (if appropriate) • D=What can we DO about it? Do you have further recommendations for supporting young people’s mental health in our community? I held five dialogue sessions with six young people, and one participant who shared photos and reflections via email for a total of seven responses. In sum, 22 initial dialogue sessions were held with 30 young people in a mixture of individual, dyadic and small group sessions. For the second dialogue sessions, 16 young people participated to further explore the initial findings from the first interviews and provided feedback across 9 follow-up meetings and two emails. I then engaged 7 of these young people to further 26 I describe this process in more depth in the ethical considerations section of this report. 27 A more detailed description of this process is offered in the ethical considerations section of this report. 59 explore their experiences through the use of photovoice. All meetings were audio-recorded and professionally transcribed to support data analysis. I reviewed all transcripts alongside audio-recordings in order to ensure accuracy of transcription. Figure 3.1 Dialogue sessions sequence. Data analysis Upon completion of the first dialogue sessions with 30 young people, I conducted a qualitative analysis of participants’ reflections. Drawing on Thorne’s (2008) overview of qualitative data analysis, I explored patterns within each individual transcript and across transcripts of dialogue sessions as a whole. I started by synthesizing the common and divergent patterns across dialogue session transcripts. This included developing a MSWord document and categorizing patterns and themes that were similar. I then conducted a second analysis with the use of HyperResearch software (Researchware) and specifically sought to explore contrasting and divergent themes compared to the initial themes I had identified. While doing so, I kept memos of potential themes, while also highlighting exemplar and contrasting perspectives. I also noted questions that came up for me in terms of understanding the relationships between the First Dialogues: 22 meetings with 30 young people Second Dialogues: 9 meetings and 2 emails with 16 young people Photo Dialogues: 5 meetings with 6 young people 1 email from one young Photovoice training with 10 60 ideas and experiences that young people were sharing in relation to the research objectives guiding this study. I presented themes from this initial qualitative analysis to research participants in the second dialogue sessions. Phase II: Meta-critical analysis of young people’s critical reflections in relation to mental health policy documents In order to address the research objectives guiding this study, I compared insights gained from the first phase of this study to two sets of provincial mental health policy documents that were developed to guide mental health promotion across the full continuum of care in British Columbia. I assumed that these policy documents would reflect dominant (privileged) understandings and practices in addressing mental health. Data collection: Retrieval of B.C. Mental health policy documents The policy documents included first, the B.C. 10-Year Mental Health and Substance Use Plan and second, the Core Public Health Functions for B.C. Model Core Program Paper: Mental Health Promotion and Mental Disorders Prevention. In order to consider how socio-economic determinants of health were addressed within this goal of mental health promotion and mental disorders prevention, I also reviewed the main objectives and outcome indicators of inter-related core public health goals and programs within B.C.’s Guiding Framework for Public Health (BC Ministry of Health, 2013). The B.C. 10-Year Mental Health and Substance Use Plan policy was developed by the B.C. Ministry of Health Services and the B.C. Ministry of Children and Family Development to guide the development and implementation of mental health and substance use programs, services and initiatives in British Columbia (B.C. Ministry of Health Services (BCMHS) & B.C. Ministry of Children and Family Development (BCMCFD), 2010). One of the stated goals of this policy document is to expand the previously dominant focus on treatment of mental illness to include a focus on upstream approaches that focus on mental health promotion and prevention programs (BCMHS & BCMCFD, 2010). A previously developed 5-year child and youth mental health plan in 2003 (BCMCFD, 2003) has been integrated within and updated within this 10-Year plan. 61 Included within this plan is also guidance from the Core Public Health Functions for B.C. Model Core Program Paper: Mental Health Promotion and Mental Disorders Prevention. This core public health functions document was developed by the B.C. Health Authorities (BCHA) and (then) B.C. Healthy Living and Sport (BCMHLS) (now Ministry of Health) to guide the development of core public health functions focused on prevention of mental illness and promotion of mental health as part of the broader Core Public Health Functions process across the province (BCHA & BCMHLS, 2009). This document is framed as a vision for future mental health prevention and promotion based on current evidence. Within this document it is recognized that not all of the stated plans will have been implemented. The goal of the document is to guide development of a performance improvement process to “move the public health system in B.C. towards evidence-based best practice” in mental health promotion and prevention (BCHA & BCMHLS, 2009, preamble). This goal is part of seven core public health goals within the B.C. Framework for Public Health (B.C. Ministry of Health, 2013). There have been three follow-up reports on the 10-Year mental health and substance use plan, two in 2011 and one in 2012 reporting on the programs, services, and initiatives that have been implemented from proposed plans. The following B.C. mental health policy documents were thus retrieved for analysis: 1. Healthy Minds, Healthy People A Ten-Year Plan to Address Mental Health and Substance Use in British Columbia (BCMHS & BCMCFD, 2010) and follow-up reports: • Healthy Minds, Healthy People A Ten-Year Plan to address Mental Health and Substance Use in British Columbia Monitoring Progress First Annual Report 2011 (BCMHS & BCMCFD, 2011a) • Healthy Minds, Healthy People A Ten-Year Plan to address Mental Health and Substance Use in British Columbia Monitoring Progress First Annual Report 2011 Supplementary Document (BCMHS & BCMCFD, 2011b) • Healthy Minds, Healthy People A Ten-Year Plan to address Mental Health and Substance Use in British Columbia Monitoring Progress 2012 Annual Report (BCMHS & BCMCFD, 2012) 62 2. Core Public Health Functions for B.C. Model Core Program Paper: Mental Health Promotion and Mental Disorders Prevention (BCHA & BCMHLS, 2009). This includes a report on school health promotion (Morrison & Kirby, 2010) and inter-related core public health program documents. I reviewed the core mental health promotion and mental disorders prevention document in depth pertaining to the data analysis plan. I reviewed inter-related public health functions documents specifically in relation to how social determinants of health were taken up within these documents: • Promote, Protect, Prevent: Our Health Begins Here (B.C. Ministry of Health, 2013) • Model Core Program Paper: Healthy Communities (BCHA & B.C. Ministry of Health, 2007) • Model Core Program Paper: Food Security (B.C. Ministry of Health, 2014) Data analysis I analyzed the data in two stages. As mentioned previously, upon completion of the first dialogue sessions with 30 young people, I completed a qualitative analysis of participants’ reflections. In the second phase, I engaged in a meta-critical analysis of all data (demographic data, transcripts from first and second dialogue sessions, photo-elicitation data, and the two guiding B.C. mental health and substance use policy documents and the B.C. Framework for public health) with support of the ontological framework discussed earlier. In the first step of this second phase, I used thematic analysis and mind mapping to analyze transcripts from the first and second dialogue sessions and photo-elicitation meetings. In this process, I explored common and divergent patterns in the ways that participants described the relationship between “money/socio-economics” and “mental health.” I considered the ways that young people were being positioned, as well as positioning themselves, within socio-economic processes to meet their mental health needs. This attention to needs was important in identifying the ways that socio-economic dynamics faced by young people within their socio-economic environments contradicted their mental health needs (Lefebvre, 1969). During analysis of participants’ recommendations for change and their critical reflections on barriers and supports to change, I both recognized their capacity to identify needs and goals for informing future action and the importance of analyzing how dominant ideas may be 63 influencing their recommendations. For example, participants’ reflections on the relationship between their socio-economic environments and their mental health underscored several mental health needs such as the need for physical survival and the need for a secure future. One participant emphasized the importance of engaging young people in entrepreneurship as a way of promoting young people’s mental health. Analysis of how participants sought to meet their mental health needs showed, however, that private, individualistic production processes such as entrepreneurship contradicted participants’ needs in several core ways. For example, participants who pursued entrepreneurial activities in their attempts to seek income to access resources to enable their need for survival faced several barriers, such as the struggle to obtain start-up funds and the challenge of securing an ongoing income stream within free markets. More broadly, participants’ reflections showed how young people’s lives are situated within fundamentally insecure socio-economic processes that create several barriers not only to meeting their mental health needs, but also limiting their control over meeting their mental health needs in significant ways. This relational analysis enabled me to consider the influence of dominant ideas in relation to participants’ experiences and to develop insights into the potential role that nurses can play in supporting young people to address contradictory dynamics that constrain their mental health. To support this relational analysis of young people and their socio-economic environments and opportunities for change from young people’s perspectives I used the following analytic questions to guide my analysis of dialogue transcripts: • How do young people variously describe how socio-economic moments affect young people’s mental health? • How do young people variously describe how socio-economic moments constrain young people’s mental health? What dynamics within their socio-economic environments challenge their mental health needs? • How are young people positioned within the socio-economic processes that they have described? How are young people positioning themselves within these socio-economic processes in terms of enabling/promoting their own mental health and addressing their mental health needs? 64 • How does this positioning influence young people’s mental health? How does this positioning variously influence young people’s needs and their ability to meet their needs? • How do young people respond to their positioning? How do they seek to meet their mental health needs? • How are dominant ideas operating within young people’s reflections? What ways of understanding and promoting mental health are missing from participants’ reflections and my own attempt to capture patterns within their reflections? • What are participants’ recommendations for enabling young people’s mental health? What are their views regarding change that is supportive of young minds? What do these recommendations suggest about their needs and contradictory dynamics? • If there are contradictory dynamics operating, what are the opposing elements in these dynamics? What is the underlying common element and mutual dependency? How can this common element be used to inform change initiatives? • What are barriers/supports to young people’s action in meeting their mental health needs and change more broadly? • “Where’s the agency” (Harvey, 1996) in shifting contradictory dynamics in ways that could enable actualizing common needs across diverse social standpoints/positions? I then compared participants’ views to the ways that notions of mental health/promotion and socio-economic determinants of mental health were being taken up within the mental health policy documents. This subjecting of the notions of mental health/promotion and socio-economic determinants of mental health within the policy documents to the “scrutiny and rigorous audit based on real world experience” (Hill, 2009, p. 608) of study participants was important in revealing contradictory dynamics that exist between common sense truth claims and dominant ways of understanding mental health/promotion and young people’s mental health needs and experiences. Understanding these contradictory dynamics between dominant, common sense ideas and the realities of young people’s lives thus enabled deeper insights into the ways that mental health policies were being positioned in relation to recipients of mental health care and broader socio-economic processes and opportunities for change. 65 In order to support my close reading of the policy documents in relation to participants’ experiences, I drew guidance from elements of Gramscian rhetorical analysis (Zompetti, 1997, 2012) and critical rhetorical analysis (Winton, 2013) to explore discursive practices within the policy documents. Rhetorical analysis, as a form of critical policy analysis, provides a “method for identifying how arguments are constructed to persuade audiences to accept and support particular constructions of reality, truth and courses of action” (Winton, p. 161). Aligned with the philosophy of praxis presented earlier, rhetorical analysis assumes that “knowledge of [discursive] strategies can be used to understand why particular policy solutions are supported by groups with conflicting goals and values, to question the version of reality proposed by policy, to imagine other possibilities, and as grounds for political action” (Winton, p. 159). Exploration of discursive practices within these policies in relation to insights gained from the first phase of this study was important in showing the role and function of textual practices within these policies and, more broadly, how mental health policies and programs are positioned in relation to young people and young people’s socio-economic environments. The main focus of my close reading of the policy documents was to identify how dominant notions of mental health/promotion may limit possibilities for mental health promotion work oriented to enabling young people’s mental health needs within this current socio-economic environment. More specifically, in applying this process of auditing the dominant ideas within the policy documents in relation to insights gained from the first phase of this study, I extended the analysis of participants’ reflections with a close reading of the selected mental health policy documents. I started by drawing out key statements in relation to the definitions and conceptions of “mental health”, “socio-economic determinants of mental health”, and “mental health promotion” within goal statements and proposed programs and accountability criteria (performance targets and outcome indicators). I then thematized these statements to explore underlying assumptions. I compared insights gained from the first phase of this study and the analysis of all transcripts, to the ways notions of mental health/promotion and socio-economic determinants of mental health were being framed within the policy documents. I explored the ways that young people and these mental health policy documents were being positioned in relation to each other and to broader socio-economic processes. I explored how conceptions of mental health and approaches to addressing socio-economic determinants of mental health were being framed and normalized in 66 these documents and how discursive practices perpetuated dominant conceptions of mental health/promotion (Winton, 2013; Zompetti, 1997, 2012). In this process, I saw the mental health policy documents as potentially playing a role in perpetuating hegemony, which is defined as the process whereby consent is generated for dominant power relations through the use of images, representations and ideas that create a “common sense” that normalizes existing material and social relations (Zompetti, 2012). Key sites for these consent-building practices are socializing institutions such as education and mental health systems. To this end, I sought to analyze the commonsense and scientific ways that mental health/promotion is understood and abstracted within current policy in order to show the ways that mental health policy and practice both supports and/or glosses over and denies potentialities that exist for promoting mental health in young people’s day-to-day lives and broader socio-economic processes. I explored the ways that mental health promotion initiatives could build on insights gained about participants’ mental health needs and the contradictory dynamics they faced within their day-to-day lives. I also considered how mental health promotion initiatives could support young people in gaining greater control over the ways that moments of socio-economic life were challenging their mental health needs. I used the following analytic questions to guide this analysis: • What is the stated purpose of the mental health policy documents? • How is mental health defined? • How are outcomes evaluated? What are proposed accountability measures? • What is the positioning (function) of mental health policy in relation to socio-economic processes? • Within mental health policy: How are young people positioned within/in relation to mental health policy and programs? How are mental health policies positioned in relation to young people and their mental health? • What are proposed strategies for addressing socio-economic determinants of mental health? o How does mental health policy address young people’s socio-economic needs? 67 o How are constraints to young people’s mental health addressed within proposed strategies within the mental health policy documents? o How is mental health policy positioned in relation to these constraints to young people’s mental health and wellbeing? • If notions of mental health/promotion within the policy documents are limiting young people’s mental health needs, how are these notions maintained? How do discursive practices operate within mental health policies to maintain coherences/notions of mental health/maintain permanences that gloss over contradictions? • What are possible opportunities for mental health promotion initiatives to be developed in ways that: o support young people in gaining increased influence and control over aspects of their socio-economic environment that affect their mental health? o address aspects of socio-economic life that young people identified as constraining their mental health and wellbeing? o seize opportunities for shifting contradictory dynamics within young people’s socio-economic environments in ways that could enable actualizing young people’s socio-economic needs? With the use of these analytic questions, I used a mixture of a second-level thematic analysis with the use of HyperResearch software and mind mapping to explore themes and relational dynamics. I did not analyze the photos that young people took in the photovoice process and used them primarily as a way of engaging young people to reflect on their experiences. Conceptual terms used for presenting findings from phases I and II of data analysis In alignment with the historical-dialectical ontology within this praxis-oriented approach to inquiry and in order to support my presentation of the findings from this study, I use a few key terms to highlight relational dynamics explored in both phases of data analysis. I use the notion “material dynamics” to refer to the more structured social processes and practices, including the 68 material outcomes of these processes that participants described experiencing such as forms of production and distribution of resources, including technologies and commodities. I use the notion “social dynamics” to refer to the social positions and patterns of social relations that participants described experiencing, assuming, and observing within their communities; this included relational patterns such as socio-economic inequities, competition, individualism, and social distrust. This also included the ways that participants were being positioned (e.g. as students, consumers) and positioning themselves (e.g. as political consumers). At times, I use the notion “ideological” to bring an explicit focus and attention to dominant ideas, systems of meanings, and social norms that were reflected within participant reflections and the policy documents. Furthermore, I used the notion “dynamic” to refer to the social, ideological and/or material forms, as reflected in existing practices and processes, that were evident within participant descriptions of their experiences of the relationships among aspects of their socio-economic environments and their own and fellow young people’s mental health. Data quality: Validity criteria for judging the quality of agentic knowledge produced from this study As mentioned previously, this analysis and approach to inquiry was not intended to produce truth claims about a world that is assumed to be external to an observer. The intention was to identify a constellation of insights and potential actions that contribute to an ongoing social praxis that is oriented to co-creating healthy environments for young people’s mental health, with particular attention to the role of mental health promotion initiatives in this process. As I have argued previously, in light of the dominant approaches to promoting mental health at the individual and interpersonal levels and despite the attention that studies of the views of youth and other recent studies have brought to the importance of broader socio-economic factors, there were two central aims of this study. The first aim was to explore young people’s experiences of the ways that their socio-economic environments affect their mental health from a more open-ended perspective (compared to the dominance of quantitative methods used in previous studies). The second aim was to critically examine young people’s experiences in relation to the ways that notions of mental health/promotion and socio-economic determinants of mental health are taken up in two sets of provincial policy documents—as public statements that I assumed reflect dominant meanings of mental health and current accepted practices for promoting mental health. 69 My intention in doing so was to generate emancipatory knowledge in terms of liberating young people and their allies from “dependencies on myth, superstition, custom, tradition, ideology and irrationality” (Kemmis, 2010, p. 12) that could be operating within these current ways of understanding and living mental health/promotion. This included seeking to open up possibilities for addressing the ways that socio-economic dynamics are constraining young people’s mental health and wellbeing within mental health promotion initiatives. In recognition of the embeddedness of this research process within complex relational and ideational dynamics, and the impossibility of separating myself and the research participants from the public and common languaging systems of which we are an inter-related part (Habermas cited in Kemmis, 2010) and thus the necessity of immanent critique (Adorno cited in Crotty, 1998), I engaged in reflexivity within all stages of this research project. To enable judgment as to the relevance of theoretical insights from this study to young peoples’ lives and opportunities for youth mental health promotion initiatives, I applied process and outcome validity (Anderson & Herr, 1999; Oolbekkink-Marchand, van der Steen, & Nijveldt, 2014). This was important to enable future users of this research to deconstruct the process of knowledge production within this study and to judge the relevance of findings from this study for diverse contexts and settings. It was also important to enable future users of this research to take insights from this study to inform responsive praxis-oriented mental health promotion in other contexts. Reflexivity To address the ways that settling too quickly on potentially narrow abstractions could limit alternative understandings of social relations and possibilities for social change (Ollman, 2003), I sought to bring an ongoing reflexivity to the ways that prior concepts and categories could obscure my evolving understanding in this study. Reflexivity is an approach within the field of critical qualitative research that has been variously defined (Pillow, 2003). I have taken reflexivity to refer to “a deconstructive exercise for locating the intersections of author, other, text and world and for penetrating” the inquiry process itself (Macbeth, 2001 quoted in Pillow, p. 179). I have further taken representation to refer to the process of knowledge production in which new meaning and ways of understanding are rendered through the use of language (Cloyes, 2006). 70 Reflexive practices have been used to foster the validity and legitimacy of knowledge produced and to account for how researchers interact with and impact the research process (Pillow, 2003). Various methods have been used such as reflexive journaling or field notes, forms of textual reflexivity (e.g. questioning voice in text, using different writing and representational styles such as play, literary story or multivoiced text where no interpretations are privileged and the research text remains open-ended), and the use of participatory engagement of research participants within all stages of the research process (to validate the “truth” claims of researchers) (Pillow). In her review of previous approaches to the use of reflexivity in critical qualitative research, Pillow identifies two limitations. The first of these limitations relates to the complexity of the subject, including varying levels of conscious awareness of one’s assumptions, and in turn the challenges in gaining awareness of the researcher’s assumptions. Second, Pillow questions the ways that research participants are engaged in all phases of the research process to ensure adequate representation of research participants’ voices (as an attempt at ensuring validity). She argues that these forms of “member checking” practices can at times further entrench power dynamics where research participants in reality are used to legitimize, reassure, affirm and validate the researcher’s position and thereby solidify the power of the researcher and “truth claims” in the knowledge development process. Pillow (2003) advises against giving up on reflexivity altogether or allowing a kind of “paralyzed reflexivity” (cited p. 187) and recommends the importance of engaging in “reflexivities of discomfort” (p. 187). This formed a key way of positioning myself and this research in a politics of uncertainty to ensure that the constellation of ideas and proposed practices that have come from this study are accountable to “complexity and multiplicity, becoming and difference” (Lather, 2012, p. 1024). I engaged in reflexivity, or mindfulness awareness, intrapersonally and interpersonally (Hartrick-Doane & Varcoe, 2015) in the moments of my interactions with research participants and within the data analysis process. As I interacted with young people in the dialogue sessions, I strove to pay attention to my positioning as a child and youth mental health nurse, nurse educator, and researcher committed to social and environmental justice and equity. I sought to attend to my way of relating with participants. This included attending to my assumptions and first impressions in meeting participants and how my way of being was influencing their engagement in the dialogue sessions. I invited the participants to join me in this reflexive space. For example, I was transparent about my intention in wanting to understand their personal 71 experiences and perspectives. I shared this as my rationale for not sharing my views on the open-ended questions that I posed to them in the first dialogue sessions. When participants shared that they did not have “expertise” or know much about the questions I had asked them, I told them that from my perspective there was not a “right answer” and that my main curiosity was in learning more about their personal experiences in relation to the research questions. When I was analyzing the research data, I engaged in mindfulness awareness and used reflexive notes to increase my awareness of what hypotheses and assumptions I was making. While recognizing the impossibility of full awareness of all of my working assumptions, this was important in striving to guard against imposing prior theoretical assumptions on the data (Lather, 1986). Within my reflexive notes, I noted questions that arose for me, and noted aspects of the data that challenged my analysis to increase awareness of my evolving assumptions. I also used mind maps to explore the relationships within the data. I kept iterations of the drafts of my analysis to increase awareness of my evolving working assumptions and to ensure that important meaning was not lost. In applying these approaches to reflexivity, I observed my internal experience, noticing what resonated with my experience and paying attention to and coding specifically for contrasting experiences to what I had initially identified as key themes and relationships in the data. For example, in earlier stages of analysis, I had assumed that young people need direct control over resources to meet their need for survival such as having ownership and control over one’s labour and housing. I then read the transcripts looking for contrasting experiences to this assumption and explored one young female’s expressed openness to renting from her landlord “who was nice to her.” I considered her additional comment in which she noted how expensive her rent was and I explored this in relation to other participants’ expressed worries about the increasing cost of living. I removed my initial inclusion of the need for ownership over resources such as housing within the category “self-determination” and situated this female youth’s contrasting experience of being open to renting from a landlord within the category of “the need for survival, health and comfort,” which then opens up additional options beyond the private ownership of property to social provisions that ensure access to important resources such as food and housing. Furthermore, I only used examples pertaining to the need for control over one’s labour (versus ownership of resources such as housing) within the category of “self- 72 determination” which was a common theme across participant reflections on their work experiences. I sought to maintain mindfulness of my internal experiences (and assumptions) in my process of developing themes and codes. For example, I noticed how I initially tended to categorize participant recommendations as “progressive” versus “status quo” recommendations. Examples of their “progressive” recommendations included notions of reclaiming the commons, which resonated with my assumption regarding the importance of collective approaches to supporting young people’s mental health. When one of the participants recommended the importance of developing mental health programs that are focused on changing young people’s thoughts, I noticed myself categorizing this as being reflective of dominant individualistic approaches to enabling mental health. To challenge my assumptions, I considered mental health promotion initiatives at individual, small group, and societal levels and explored their relationship with each other. I also posed questions to myself to challenge the themes I was identifying such as the notion of “self-realization.” For this theme I wondered about the implication of all young people “doing what they love.” This was in part triggered by one participants’ argument that not all young people should do what they love and his sense that we, as a society, need to consider what will “progress humanity forward.” Along with the reflections of other participants who expressed a need to see societal progress and environmental protection, I subsumed this initial category of self-realization within a broader category of “self and socio-environmental realization” to reflect the dual need for engaging in meaningful, rewarding work-live activities that actualize young people’s interests and capacities in ways that also contribute to their communities. This included participants’ expressed need to live in communities that are committed to addressing needs over profits. I also paid attention to how I wanted participants to answer my questions in the dialogue sessions. For example, when one participant reflected on how he was o.k. engaging in his love of music outside of his formal work context, I noticed how I wanted him to express a need to engage in work that was directly related to his love of music. This helped me to appreciate how I initially assumed that engaging in meaningful work activities could only be done within a formal employment context. As I continued to read through the transcripts, I gained appreciation for the need for employment that pays a living wage in response to other participants who described their experiences of “working to go to work” within low wage jobs and thus not having time outside of their formal work context to engage in life 73 activities that were rewarding and meaningful to them. I thus described their need for “self-realization” as including the need to engage in meaningful work and/or life activities to encompass young people who expressed a need for engaging in meaningful work within formal employment and those who expressed openness to engaging in meaningful life activities outside of the formal work context. Overall, I noticed how my initial assumptions were influenced by Marxist scholarship such as the work of David Harvey (2015) who has analyzed the contradictions within capitalist economic systems. In response to my committee’s caution to avoid imposing theory onto the data within an initial iteration of analysis, I sought to read the transcripts with more openness. After guidance from my supervisor, I explored how participants were describing the relationships among socio-economic processes, young people, and their mental health in a more open way. In doing so, I gained new insights into relational dynamics that young people are facing within this current socio-economic environment. For example, I gained greater appreciation for the challenges that young people across the socio-economic spectrum experience within capitalist socio-economic processes. Process and outcome validity In applying these reflexive practices, I also brought a dual attention to the method and content of knowledge production (McLaren, 2001, p. 122; Pillow, 2003). In doing so, I sought to ensure process and outcome validity (Anderson & Herr, 1999; Oolbekkink-Marchand et al., 2014). To foster process validity, and specifically to enable the deconstruction of my approach to inquiry that informed the findings in this research for future users of this work (Loutzenheiser, 2007; Pillow, 2003), I sought “not to get the politics out of research” but “to get the politics out of hiding” (Tesh quoted in Labonte et al., 2005, p. 14). In doing so, I have sought to make underlying assumptions and methods of inquiry that I used to frame reality transparent in this research report. A central goal of my application of process validity has been to provide enough detail of working assumptions and methods that I used in this research process in order to enable future users to deconstruct the process of knowledge production within this study. Outcome validity (Anderson & Herr, 1999; Oolbekink-Marchland et al., 2014) focuses on ensuring the development of valid knowledge claims that support the development of responsive 74 action initiatives. In seeking to ensure that findings are responsive to the complexity that was reflected within participants’ diversity and the contradictory relational dynamics that were explored in this study, I drew on two types of outcome validity, namely dialogic and catalytic validity. I applied these sub-forms of validity in order to ensure that a) I was not objectifying participants within this research process, and b) that the constellation of insights and proposed practices that were generated from within this study could inform responsive praxis-oriented mental health promotion initiatives across contexts into the future. In applying dialogic validity, as a form of preliminary check on the relevance and usefulness of findings, I submitted my initial analysis to the scrutiny of participants in earlier stages of this research (Lather, 1986). I also shared my evolving analysis with my supervisory committee. I shared the final findings with research participants and gave them the option of sharing confidential, formal response statements to the findings that I have included in the appendices as a continuation of the dialogue that will be ongoing following this dissertation (Lather, 1986). I have also engaged in informal dialogue with peers, young people, and community groups where I presented the findings for critical discussion of the method and findings of this research (Anderson & Herr, 1999; Oolbekink-Marchland et al., 2014). Finally, I have developed an online blog to present findings from this research project and used Facebook and Twitter pages to disseminate this blog. Within the blog, I have sought feedback from the broader community of young people and their allies (including mental health professionals and advocacy groups) via discussion threads. Preliminary evidence of the resonance and relevance of these findings is reflected within the formal statements of research participants from this study in the appendices and this blog. One limitation to ensuring dialogic validity was that fewer young people participated in the second dialogue session and the photovoice process within the first phase of this study as well as the meta-critical analysis that I had conducted within the second phase of this study. More participation would have enabled further feedback and, ideally, group discussion and collective analysis of study findings. As mentioned previously, in order to create a safe environment for participants to share their views, I gave them the choice regarding how they would like to meet with me. Most of them chose to meet individually and/or in small dyads or small groups with their friends. Only half of the participants were available to participate in the 75 second dialogue sessions and less than one third in the photovoice process. My inability to submit my evolving analysis to the critical scrutiny of all participants through all stages of this study limits the potential responsiveness of my final analysis and recommendations to their diversity of experiences and perspectives. Catalytic validity “represents the degree to which the research process reorients, focuses, and energizes participants toward knowing reality in order to transform it . . .” (Lather quoted Pillow, 2003, p. 187). More specifically, this aspect of validity draws attention to whether groups of people that have an interest in this research topic reach an expanded understanding of the relational terrain of young people’s lives and whether transformation of knowledge and, eventually, action on the part of young people and their allies has occurred as a result of the research (Anderson & Herr, 1999; Oolbekink-Marchland et al., 2014). A key way that I applied this form of validity was to situate this dissertation in a politics of desire and imagination where I not only sought to expand understanding regarding the challenging socio-economic dynamics that are constraining young people’s mental health, but also to explore implications for mental health promotion initiatives. I explored implications in relation to the ways that mental health promotion initiatives can support young people within existing socio-economic processes as well as implications for the ways that mental health promotion initiatives can support the transformation of contradictory socio-economic dynamics that constrain young people’s mental health. To this dual end, I engaged participants in this study to a) consider how mental health promotion initiatives can support young people in realizing their mental health needs to the degree possible within current constraining socio-economic dynamics and b) I engaged participants in actively imagining “what kind of world would be more supportive of young minds” and engaging them to brainstorm possible ways of reorganizing socio-economic environments in ways that are more supportive of young people’s mental health. Finally, to guard against projecting my own revolutionary fantasies onto young people by reifying them as heroes, and the group primarily responsible for social change (Fine & Burns, 2003), I extended the critical reflections and analysis that participants offered within the first phase of this study with my own meta-critical analysis of data within the second phase of this study. This was oriented to identifying implications for mental health promotion initiatives. In doing so, I recognized the importance of distributing the burden of organizing for socio- 76 economic change among diverse actors (Wang & Redwood-Jones, 2001). I compared participants’ views to the mental health policy documents and explored implications for mental health promotion initiatives. This was important in developing a constellation of insights and proposed strategies for supporting change. This included identifying multi-level opportunities for promoting young people’s mental health—such as attention to the potential advocacy and activist roles that mental health nurses and other health care actors can take in addressing ways that socio-economic dynamics constrain young people’s mental health and their control over realizing their mental health needs. I highlighted several possibilities for mental health promotion initiatives that could be the focus of ongoing social praxis by multi-level actors with a shared responsibility for promoting young people’s mental health. Ethical considerations As per Tri-Council guidelines for ethical research involving human subjects in Canada, I received ethics review board approval from the UBC Behavioral Research Ethics Board (Certificate #: H11–01321) prior to conducting this study. These guidelines, along with previous analytic and empirical literature, offered support in addressing several ethical issues throughout this study, including the importance of respecting autonomy by seeking informed consent from young people—including mature minors, confidentiality, and the use of honorariums in ways that would prevent coercion in the recruitment of research participants. Seeking informed consent Guided by B.C. legislation and previous research on young people’s participation and consent in research, I used three sets of guidelines in seeking informed consent from young people that depended on their age and level of involvement with their parents, caregivers, or legal guardians. For all participants, I presented and distributed to participants informed consent forms and a handout detailing their rights as research participants (Bruzesse & Fisher, 2003) (Appendices F and G), providing extra copies for them to share with their social networks so they could seek feedback from their friends and family (Gallager et al., 2010; Lambert & Glacken, 2011). I ensured that potentially interested young people took a minimum of 48 hours to review the consent forms prior to setting up informed consent meetings with them. This occurred in a few ways. For young people who were 18 years of age or older, I distributed copies 77 of the informed consent form at the end of presentations (or via email if I met them in the community) for them to review prior to their first interview. We then arranged an interview time and completed the informed consent form at the beginning of the interview. For young people in the care of a parent, caregiver or legal guardian, I gave them two copies of the consent form—one for them and one for their caregiver, along with hand outs on their rights as research participants and mental health counselling supports, to review prior to arranging a meeting with them and their parents, caregivers, or legal guardians at a place chosen by the young people. In my meeting with young people and their caregivers, I went over the consent form and explained their rights as research participants and invited their questions. I answered their questions they had prior to inviting both the parent and young person to sign the informed consent form. This is consistent with previous work that has shown that rights comprehension improves after being offered a “brief rights lesson” (Bruzesse & Fisher). I then arranged for a follow-up interview with the young person at a place of their choosing. I treated seven young people as mature minors within this study based on the mature minor doctrine used in medical care. This doctrine “emphasizes the capacity of the chid to make informed decisions rather than considering only the age of the child. Such minors are considered to have the same competency as competent adults and can provide a free and informed consent to research” (Avard, Samuel, Black, Griener & Knoppers, 2011, p. 33). Participants who were less than 18 years of age were allowed to consent on their own behalf if a) they did not feel comfortable with their parents/legal guardian’s awareness of their participation in this research; and b) if they were able to demonstrate their understanding of the purpose of the research project, their rights as research participants, the nature of their involvement, and risks and benefits of participating in this research. These young people offered the following rationale that I accepted for treating them as mature minors: • One 17-year-old was living on his own while going to university • Four young people (aged 15–17 years of age) wanted to participate but on the condition that I not bother their busy parents 78 • Two young people were dating and both staying at the female’s home (the male no longer had regular contact with his parents); they did not want me to go to their home and were not open to me arranging to meet the female’s parents in the community. For these mature minors, I implemented the informed consent procedure as mentioned previously. I also sought to determine their comprehension by having the young person repeat back their understanding of the information provided in the informed consent form including their rights as research participants (Lambert & Glacken, 2011) prior to obtaining their consent. More specifically, prior to obtaining their signature on the informed consent form, I asked them to repeat back to me: who I was, the meaning of research to them, the purpose of this research project, their rights as research participants, and the risks and benefits of being part of this study including the limitations to confidentiality, and how their information (research data) will be used and confidentiality maintained. I audio-recorded their responses for documentation purposes. All of these young people demonstrated understanding of these aspects of the research process, in some cases needing minor clarification. They were aware that they could ask questions to clarify aspects of the research process as they engaged in it. I emphasized that they could change their minds about participation in this study while keeping their honorarium. In applying these procedures, I sought to respect young people’s varying levels of development and varying experience levels with the research process (Broome, Richards, & Hall, 2001). This approach was also aligned with previous research that has found that young people who were 14 years of age and older comprehend “the purpose and nature of the research, research risks and benefits, and the voluntary nature of participation and confidentiality” (Bruzesse & Fisher, 2003, p. 20).28 Finally, this process is in accordance with B.C. legislation whereby, according to the B.C. Infants Act, children under the age of 19 may consent to health care on their own behalf if the health care provider (in this case the researcher) deems the child capable of understanding the 28 More specifically, Bruzesse & Fisher (2003) found that comprehension of the purpose and nature of the research, research risks and benefits, the voluntary nature of participation and confidentiality was evident across age groups (8-10 years of age; 9-13 years of age; 14-17 years of age; 17-26 years of age) with the two youngest groups (between 8-13 years of age) not fully understanding the right to withdraw. 79 nature of the health care received and risks and benefits. According to the B.C. Health Care (Consent) and Care Facility (Admission) Act, health care includes participation in health care research. In addressing the vulnerabilities of young people attending a community service for young people who were homeless, I worked with the agency director who offered to share the brochures with their youth and to arrange an information session with those interested. The director expressed concerns about youth who were homeless being given the honorarium and expressed a preference for providing gift certificates to London Drugs as done by previous UBC researchers. I respected this decision and followed their guidance by seeking ethics approval to tailor the honorarium procedure to this group of young people. For one young person who was living with her Spanish-speaking grandmother, I had the consent form professionally translated by B.C. Language Service and sent a copy for the young person to share with her grandmother prior to our meeting. I then arranged for an informed consent meeting with this grandmother and a Vancouver Community College (VCC) undergraduate nursing student who spoke Spanish to interpret for me during the meeting. The second aspect of informed consent was implemented within the photovoice process. Two types of consent were obtained in addition to the initial consent to participate (Wang & Redwood-Jones, 2001). The first type of consent focused on obtaining permission to take photos of young people’s friends, family, and community members for the purpose of sharing and discussing these photos, either with the researcher or in group meetings. The second type of consent ensured that the person who was photographed gave permission for pictures to be published or used to disseminate findings (Wang & Redwood-Jones). Participants were shown how to obtain consent for photography prior to taking their photos of community members. Participants were also educated about issues pertaining to the use of cameras in ways that ensured their safety (Strack et al., 2004; Wang & Redwood-Jones), which included being given my contact information and cell phone number in case they needed support while taking photos in the community setting. Research participants were also educated about the importance of maintaining confidentiality in terms of photos shared and ideas exchanged in team meetings. 80 This education about the consent process and the importance of confidentiality occurred within a photovoice training session with myself and a volunteer photographer. Young people were oriented to the meaning of collaborative research and the photovoice process via a short documentary of a youth photovoice project in Hamilton Ontario (PhotovoiceHamilton, 2008). They were then given research kits that included their own digital cameras, note pads to keep track of their thoughts as they took the photos, portfolios to keep their images and consent forms for community members that they may take photos of (to give permission for their photo to be shared and discussed in the research group meetings) (Strack et al., 2004; Wang & Redwood-Jones, 2001) (Appendix H). For community members who were 17 years of age or less, parental/guardian consent was required for their photos to be taken and used for discussions in follow-up social media/small group interviews and for dissemination purposes. However, no photos of people were taken so this type of informed consent was not needed. Confidentiality Confidentiality was ensured in three different ways. First, as part of the initial introduction to small group interviews, research participants were encouraged to protect the privacy of fellow research participants in the group interviews by not sharing the identity of young people outside of the group interview context. The risk of one’s name being disclosed by fellow research participants in group meetings was identified as a risk in the informed consent process and young people were also made aware of the limits to confidentiality in situations of suicide risk and/or child abuse and public health reporting practices regarding communicable diseases. The second way that I ensured confidentiality was by removing and separating identifying information from demographic survey forms and keeping these forms in a separate filing cabinet from the one in which I locked the remaining survey forms of young people’s responses during the data analysis process. I created codes for the transcripts and replaced the research participant’s names with their own chosen pseudonyms within the transcripts. Codes for transcripts included the interview number and the count of the young people who had been interviewed (i.e. for the first interview the identification number was 1–2 to acknowledge that it was the first interview with two research participants). I kept all files in a locked filing cabinet 81 and in a password-protected computer. The third set of procedures that I implemented occurred in relation to file sharing with transcriptionists. I initially used a USB port to share audio files with the first transcriptionist hired for this research project and she sent me password-protected transcripts via email. In my work with a second transcriptionist for 10 interviews I texted her just prior to dropping audio files into a Dropbox account that she accessed immediately to save files and then I deleted them from the Dropbox account immediately upon her confirmation of receipt of the audio files. These transcriptionists then sent me password-protected transcripts via email. In relation to addressing the limits to confidentiality, I had one young person’s parent decline their child’s involvement in the photovoice project when I shared the limits in relation to issues of child abuse. Out of concern for the wellbeing of this young person I consulted with her friend’s parent (who lived in the same housing complex) and after doing so realized that I had breached confidentiality in this case. I thus reported this to the UBC Behavior Research Ethics Review Board (BREB). Furthermore, in response to the young people who had requested to share their feedback via email, I supported them in doing so. In reviewing the ethics protocols in the process of writing this report I further considered the threats to their confidentiality by sharing their feedback via email. As per UBC guidelines on the use of digital communication methods in research data collection processes, I followed up with them to encourage them to delete their email to me in the sent folders of their email system and deleted these emails within my UBC email to protect their confidentiality. For participants who wanted to review the findings from the Drop Box account, I deleted the files of the preliminary findings within the Drop Box account upon confirmation that participants reviewed these files. Transcriptionists, the volunteer photographer, and research assistants signed professional confidentiality forms prior to their involvement in this project. Honorariums In order to acknowledge the time that research participants dedicated to this inquiry process and to balance the risks of offering honorariums to young people who were vulnerable in relation to their varied socio-economic circumstances and developmental levels, I implemented a few steps to prevent coercion. I had originally planned to offer an explanation of the honorariums after the informed consent had been obtained in order to minimize coercion. However, upon 82 receipt of feedback from youth group leaders that young people were quite aware of the research process and expected compensation for the time that they gave in order to contribute to research projects, I sought ethics review board approval to alter this procedure. Upon receiving approval from the UBC BREB, I included this information in the main informed consent forms. I also gave honorariums to young people at the beginning of each individual or group meeting and shared a reminder that they were free to discontinue engagement in the research process at any time and that this would not affect their honorarium. Honorariums of CA$25.00 per meeting were provided to research participants who participated in the first and second dialogue sessions, or shared their feedback via email. For those that participated within the participatory photography process, I provided them a digital camera and photography kit for their honorarium. I also provided snacks at all meetings. Minimizing the risks of psychological distress In order to minimize the potential risk of participants experiencing psychological distress in response to their participation in this research project, I provided a list of child and youth mental health (and a phone number for mental health services for youth 18 years of age and older) supports and resources along with the informed consent forms and the overview of research participants rights (see Appendix Gii). I had one young person email me about a month after her meeting with me requesting information on a university-based peer support group that I had mentioned to her as part of my recruitment process. I provided this information to her via email as per her request. I also had one participant who had expressed distress via text messages to me in response to his ongoing challenge in finding employment and starting his own business. In response, I referred him to employment preparation programs, a business development coaching program, a mental health counselling program, and disability supports to help him to access welfare supports. He continued to struggle in accessing supports. Upon his permission and his written consent to release information about his situation, which included the potential of having dyslexia, I contacted his business development coach from Work B.C. and advocated on his behalf to gain access to psychological testing to assess his needs. 83 Conclusion Overall, I engaged participants in a process of social praxis within the first phase of this study and then used a process of meta-critique to analyze their experiences from a relational perspective. This resulted in several insights into relational dynamics among young people, their mental health, and their socio-economic environments. Insights were gained regarding young people’s mental health needs within this current and evolving socio-economic context and challenging socio-economic dynamics that challenged these needs as participants sought to realize their mental health in their day-to-day lives. A comparison of participant experiences within the first phase of this study to a close reading of the policy documents also yielded important insights regarding the positioning of mental health policies in relation to young people and their broader socio-economic environment. 84 Chapter Four: Dialectical Relations Among Young People, Mental Health, and Socio-Economic Processes Introduction Findings from this study deepen understanding regarding current relational dynamics among young people, mental health, and socio-economic processes. Participants’ explanations of the meaning of mental health and how their socio-economic environments affected their own and fellow young people’s mental health emphasized eight inter-related mental health needs. These needs include: the foundational need for physical survival, health and comfort; the need for authentic social connections; the need for a core sense of self-worth and self-determination; the need for self and socio-environmental realization; the need for learning and access to responsive education; the need for balance in life; the need for inspiration and perspective in life; and the need for a secure future. These needs were both elements of participants’ inner mental health experience and were enabled by socio-economic processes to which participants were integral. That is, participants participated in the very processes that enabled and constrained their needs. For example, the need for learning and responsive education was described as both a need internal to young people, and as a process in their socio-economic environments that enabled this need. Authentic social connections were described as both a mental health need, but also as a social process of which young people were an inherent part. Participants also described mental health needs as being inter-related with each other in that when one need was met, other needs were enabled. For example, authentic social connections whereby people are valued for each person’s diversity were described as enabling young people’s need for self-worth and self-determination in that a) young people felt valued for their uniqueness; and b) young people felt safer to be themselves. The inter-relation between participants’ mental health needs and their socio-economic environments was also reflected in participants’ affective experiences. Affective states indicated the degree to which participants’ mental health needs were met. Affective states also played a key and inter-related role with socio-economic processes in influencing participants’ ability to realize their mental health needs. When participants’ needs were met and they experienced 85 positive affects, they described being further motivated, energized and able to participate more fully in socio-economic life. When participants’ needs were threatened and they experienced distress, they struggled in various ways to participate in socio-economic life in their attempts to meet their mental health needs. Within this chapter, I present common needs that were identified within participants’ reflections on the meaning of mental health, as well as their explanations regarding relational dynamics among aspects of their socio-economic environments and young people’s mental health. I present how participants’ needs and affective states are important sites for showing the relational nature of mental health. I present how mental health needs are both internal to young people’s experience and are created and enabled by socio-economic processes within which young people participate. Participant reflections further illustrate how affective experiences are influenced by the degree to which young people’s needs were met and in turn influence their ability to participate in socio-economic processes in processes of seeking to realize their mental health needs. I highlight how participants across diverse socio-economic positions and access to economic resources struggled to experience a full realization of their mental health needs. Finally, in order to contextualize these findings and to support my analysis of the positioning of mental health policy in relation to young people and broader socio-economic processes, I conclude this chapter (and subsequent chapters) by contrasting insights gained from participant reflections with a close reading of two provincial mental health policies and relevant sections of inter-related public health functions documents within B.C.’s Guiding Framework for Public Health. Young People’s Mental Health Needs Money affects everything. Money affects where you live, how you grow up as a child, what you get exposed to, what you become afraid of, what you become confident with. It creates a setting in your head. Money. Of course not money like the dollar sign, but money like what it gives you. Money, like your lack of money and what that gives up. And of course, it affects everything, right? It affects what school you go to. It affects how your family does. It affects how your parents feel. That affects you a lot, too ‘cause you learn from your parents, of course, right? It affects your friends. I mean, if my friends have problems it affects me because I’m their friend, right? I always want what’s best for my friends and vice versa . . . It affects everything, I think. And all that 86 affects your growth and what kind of person . . . like, the potential of your being. (Cassie, 15-year-old female)29 Research participants’ reflections on the meaning of mental health and their explanations regarding how their socio-economic environments affected their own and fellow young people’s mental health emphasize eight inter-related mental health needs that are inter-related with current socio-economic processes. Common mental health needs were evident within participants’ descriptions of what money enabled access to. Mental health needs were also reflected within a key theme whereby participants emphasized that money and wealth are not what is ultimately important to their mental health. They identified other needs that are important for mental health beyond money. Participants described money in relation to young people’s mental health in two ways. First, participants associated money with enabling freedom from worry to pay for resources to meet one’s need for physical survival (e.g. food, clothing, housing), to do what one wants such as exploring and learning about the world, accessing formal educational programs to support their learning, following one’s dreams, creatively expressing oneself, and engaging in work–life activities that are inspiring and of interest to young people in ways that benefit their communities. The freedom that participants imagined from having money included enabling young people time to “to breathe” [Derrick, 20-year-old male], rest, relax, and to consider what is important in life. Money was also associated with freedom to spend time with friends in various leisure activities with participants suggesting that social activities and “social outlets are intrinsic to human nature and make you feel better” (Antony, 24-year-old male) and promote a sense of fun and enjoyment. Second, while one participant declared his love for money and shared how he liked to spend time in a central city space because it was “fast-moving . . . [and] feels like there is money dripping off the walls,” most participants emphasized the importance of not getting caught up with a central focus on money. Several participants emphasized that it was a “misconception that if [one] has money, they’ll be happy” (Derrick, 20-year-old male). Having too much money was associated with being “too money driven” and situations where parents are “battling over money 29 In order to protect research participants’ anonymity pseudonyms are used when referring to young people. Participants were invited to select their own pseudonyms. 87 in a divorce” (French, 17-year-old male) and/or have little time for their children. One participant shared his observations of his wealthier friends: “their parents are quite wealthy and like their parents make three, four times what my parents make and then they just buy the kids nice stuff but they don’t spend any time with them” (Andrew, 19-year-old male). Being rich was also associated with “losing touch with reality” (Derrick, 20-year-old male) and “being the target of other people” resulting in one having to “watch one’s back” (Group interview; Haden, 17 year old male). Several participants emphasized that money and material goods were not what ultimately mattered to them and their mental health. They drew a distinction between having money and having a good personality and emphasized that who a person is, is more important than money. They highlighted the importance of health and social connections to mental health arguing that “if you’re in love with an object . . . that isn’t healthy mentally” (Group interview). Participants emphasized that money cannot protect one from sadness that can come from life events such as illness, giving the example of Steve Jobs and his cancer. They compared Eastern and Western cultures and assumed that people in Eastern countries are happier in that there are more social connections and less exposure to media and corporate advertising, technology and commodities like iPhones and computers. The majority of participants suggested that “being rich” did not automatically equate to being happy and suggested that needs were foundational to enabling mental health, whereas wants often worsened mental health. For example, participants suggested that getting caught up in materialistic and wealth-oriented notions of success constrained their mental health by tying their self-worth to status-based commodities. Jonathan (17-year-old male) explained how money cannot buy happiness, but can buy stability, which can lead to happiness. Haden expressed a similar sentiment suggesting that there isn’t a “full link with happiness” and money “just [provides] ease of mind” (17-year-old male). Money came into one’s awareness if one had either too much or too little money. Andrea (19-year-old female) explained that she did not think about money much with not having to worry about it in her context of having most of her needs met. Andrew framed the distinction between needs and wants with the notion of “threshold” - I think money is only important up to like a certain point like a threshold like where you can afford to sustain a decent standard of living where you’re not living on the street and you can feed yourself. Like to have basic amenities. 88 But past a certain point I don’t think it’s necessary and it just feeds on itself like greed. (19-year-old male) Participants identified other needs including their need for physical survival, authentic social connections and having perspective on what is important in life as fundamentally important to their mental health. Eight Inter-Related Needs for Enabling Young People’s Mental Health in Their Day-to-Day Lives Participants offered explanations about what money enabled access to; they described what was ultimately important for young people’s mental health (beyond money), and they offered proposed theories about the nature of the relationship between their socio-economic environments and young people’s mental health more broadly. These reflections, along with their exploration of the meaning of mental health, emphasized eight inter-related mental health needs within their current socio-economic environments. Participants’ accounts of their experiences emphasize how young people’s need for physical survival, health, and comfort is foundational to enabling freedom to actualize young people’s remaining inter-related mental health needs. Their experiences illustrate how these mental health needs are inter-related with and work synergistically with each other. The realization of one need enabled the realization of other needs. Broader socio-economic processes played important roles in enabling these mental health needs within participants’ home, school, community, and built and natural environments. 1. Physical survival, health and comfort The first need that participants identified as foundationally important for young people’s mental health was their need for physical survival, health and comfort. Participants explained that having money enabled freedom from worry about meeting one’s basic needs for survival, health and comfort and imagined that this would enable them to meet their remaining mental health needs with less stress and pressure. Sometimes I wonder if money didn’t exist like how much happier people would be because you’re not wondering, ‘am I going to make rent? Do I have money for food? Do I have money for new shoes because my old ones are shit?’ (Natalie, 19-year-old female) 89 I just don’t want my life to be I feel like I worry about money so much, I want to have that freedom where I can focus on the things that I want to do instead of just trying to get by all the time, I think that’s what bothers me the most . . . I feel like my life revolves more around money woes than what I actually want to do with my life. (Mindmatters, 25-year-old female) Participants identified the following basic needs for survival, health and comfort: healthy organic food, water, clothing, health services, hygiene products, transportation, and housing that is safe and has “comfort at home [including] temperature, electricity, heat [and] fans” (Haden, 17-year-old male). Some participants considered access to counselling a basic need that they could not afford. Participants expressed various forms of distress when their needs for survival were threatened. For example, one participant explained that due to “some stupid technicalities with the social assistance system here I basically had almost no income for a while this summer. I lost fifteen pounds from not eating, was constantly stressed out, I still haven’t recovered that at all.” In an email, he shared: It’s impossible to be in a good mental state if you don’t have food, water and shelter. These are the three most basic rights, and they amount to nothing more than the right to live, which shouldn’t be something anyone has to pay for. If you don’t have food, water and shelter, you will die. This is such a simple concept. No one should have to pay someone else for the privilege of not dying. That’s not the same as saying that people shouldn’t have to work for these things, as long as they’re able, but if anyone is lacking in these areas, that lack should be made up. Instantly, without question. (Antony, 24-year-old male) Several participants described how physical health was inter-related with mental health and emphasized how “you’ve got to balance both right? They’re connected, they’re not two different things” (Da Dragon, 19-year-old male). Participants explained that ensuring basic needs for survival and physical health, such as access to healthy food, enabled the biochemical conditions for mental health. Like with money I’d able to eat properly and be able to get the exact chemicals that makes me happy so, benefit a mental health process. I’d definitely be physically healthier than I am now . . . mental and physical wellbeing they’re tied in together-they both feed off each other, so having healthy organic food. (Sarah, 21-year-old female) 90 Interactively, mental health was seen as enabling physical health: “when you’re happy and you live relatively almost stress free or not all, well life with not a lot of stress, then your body reciprocates that” (Da Dragon, 19-year-old male). Several participants highlighted housing as an essential need that addresses their need for survival, comfort, and other inter-related mental health needs, including their needs for social connections and learning. Participants made the distinction between “housing” and “home” and explained that housing was about having a place to live and a home was where one belonged (Cassie, 15-year-old female). In addition to safe and comfortable housing as a basic need for physical survival and comfort, participants emphasized that the location of housing is important. Housing that is near vibrant social settings was associated with helping young people to feel calmer, connected with others, and happy with being more easily able to connect with other people. Housing that is quiet, near schools, and that includes supportive people was identified as a place to study and learn. French expressed that for him, housing and where one lives was “the number one factor” and a “giant giant determinant of your . . . mental health and your education . . . because you spend so much time in your house” (French, 17-year-old male). In describing a photo that Jonathan took a picture of the location of his home, he shared: It has everything. And it’s in the centre of the city so you access everything, too. I think it keeps me happy, because seeing people wanting to come. It’s like: ‘Oh, I’m so lucky to be living here.’ Say I meet a new person. I’ll just be like: ‘Oh, I live in [central city].’ It’s easier to access, therefore it’s easier to meet people and bring them over . . . it eases interactions. (17-year-old male) The need for comfort was also evident within participant reflections in which they shared how they used money to purchase items like alcohol and cigarettes to support social connections and to bring them comfort when they were stressed. I only had about fifty dollars personal a month and whether it be wanting to have a beer with my friends or buying a pack of cigarettes, I really had to sacrifice there, which then stresses you out more because it’s something . . . that helps brings you a little bit of comfort and suddenly, you know, you can’t afford that stuff. (Mandie, 27-year-old female) The complex relationship between this need for comfort and young people’s mental health was evident across participant reflections with a couple of participants expressing 91 ambivalence in relation to this experience of comfort. They expressed their concerns with how “capitalism brainwashes [people] by giving [them] the conveniences . . . and comforts of capitalist technology” (Da Dragon, 19-year-old male), which was viewed as a key barrier to social change oriented to enabling their mental health needs. More broadly, the complexity of distinguishing a need versus a want was evident in participant reflections. Participant reflections illustrate how commodities at times function as both a need and want simultaneously in that accessing certain commodities enables other non-monetary needs. Participant reflections further show how young people’s needs are both used to sell products at the same time as being shaped by the products being produced. For example, several participants suggested that the production of new technologies like cell phones have become essential to enabling communication and social connections (a core need), but suggested that the “latest IPhone” is not necessary. They explained how media and advertising work in concert with social comparison dynamics (people’s tendency to compare oneself to others) to associate the consumption of commodities to self-worth and social prestige, thereby creating strong wants in order to meet other non-monetary needs such as social inclusion and connections. Several participants described their experiences of corporate advertising and ongoing production of commodities in their environments that worked in concert with social comparison dynamics to shape what are considered needs. This dynamic helps to understand the complexity of participants’ descriptions of how they at times sought unneeded products to meet other mental health needs such as the need for social connection, while at other times resisted buying these products to assert their need for self-worth and self-determination. As explored more fully in chapter’s five and six, participants described how basing one’s self-worth on status-based commodities (e.g. latest iphone, brand name clothes) negatively affected one’s self-worth and need for authentic social connections. This resulted in various approaches to resisting these dynamics and/or seeking to protect participants’ mental health from social comparison dynamics and the attachment of one’s self-worth to status-based commodities. 2. Authentic social connections Participants stressed the importance of social connections for their mental health and wellbeing. This included their connections with friends, family, and their community, which 92 several participants explained were irreplaceable and more important than money and various commodities. Similar to Andrew’s notion of “threshold” (19 year old male) and as a further example of the distinction that participants made between needs and wants, a group of young people emphasized the importance of one’s family over various commodities like iphones, which they described as being “just extra, just make you feel better. You can have like a phone it can break, you can buy another one but you can’t have your family twice like you will never have two families” (Debbie, 16-year-old female, group interview). I think your cultural upbringing big time, also your relationships—whether it be with parents, other family, if you have a boyfriend, girlfriend . . . I think we all know that you can live in an okay place, have a really shitty relationship and be super depressed but be making lots of money. (Mandie, 27-year-old female) Other factors the biggest one is probably my relationships with people around me. If things are going well then I feel happy and if they’re not, I feel unhappy, I think that’s pretty universal. (Antony, 24-year-old male) Several participants described experiencing social comparison dynamics which included “comparisons that people make between themselves and other people” (Colin, 19 year-old male) and “keeping up to a certain image” (Mindmatters, 25 year-old female). This also included seeking access to money and various commodities (e.g. designer clothes, cars, and status-based commodities such as a Louis Viton purse, fancy watches, Iphones) which affected the degree to which they felt “good,” “adequate” and “valued.” Participants expressed their sense that the “clothes we buy with money affects how other people see us” (Andrea, 19 year-old female) and how they “judge you” (Pablo, 15 year-old male). Denis shared his view that this tendency to compare oneself to others is part of human nature: “it’s not their fault because if somebody has something their friend would want it, it’s human nature. It’s not necessarily jealousy they would just question themselves ‘well why don’t I have it, I can ask my parents.’ (19 year-old male). In response to social comparison dynamics and social judgements in their environments that threatened their self-worth and sense of belonging, participants emphasized the importance of authentic social connections. Authentic social connections were characterized by relationships in which people are valued for their diverse uniqueness, and connect based on our common humanity. In reflecting on the social judgments and distrust that he observed in his environment, Da Dragon (19-year-old male) pondered “when have we humans stopped being human beings?” 93 Participants expressed their need to be seen, valued, “admired” (Donald, 28-year-old male), and appreciated for one’s uniqueness equally while appreciating common experiences of suffering and vulnerability among fellow human beings. When asked what their biggest worries were, a group of young people between 16 and 18 years of age identified broader social judgments and social comparison dynamics as their biggest concern and called for a common sense of our humanity. Yana: I think people just don’t treat you equally . . . Like some people think that they deserve to be treated less for some hot reason. I don’t know why and some people just think that they deserve to be treated better than others. But in reality you’re all the same people like sure you guys look different, you guys are all different obviously in your own way but you all have a heart, you all have a nose, you have eyes, you have ears . . . we’re all different but the same. (16-year-old female) Anna: Like just having mutual respect and consideration of others . . . like just unite as a species or as human beings instead of just being cruel to each other. (16-year-old female) Brenda: Some people are born without a leg, it doesn’t mean they’re not the same—they’re still a human being, they’re still alive. They still have a soul like they’re all the same. Like I think if we stop worrying about the money and electronics and ‘oh, I have more than you do, you don’t have this, you don’t have that,’ I think it would be a way better thing to do. (16-year-old female, group interview) Participants suggested that authentic social connections play a central role in affecting young people’s level of happiness, sense of belonging, and self-worth. Supportive friends were also described as playing a key role in shaping one’s thoughts, emotions and activities. Show me your friends and I’ll show you your future. You are the sum total of your five closest friends. And that’s income, relationships, whatever, mental health, health body-wise. Do you hang around fit people? You’re going to be fit . . . If you go out to eat with friends and they’re ordering foods that aren’t exactly 100% healthy, it makes a big difference. So friends . . . goes along with mental health. Because you could have a friend being like: ‘Yeah, they did diagnose you with that and you might not make it.’ But you could have an opposite friend being like: ‘Who cares? They diagnosed you with that? Let’s fight it!’ It makes a world of difference. (Donald, 18-year-old male) Underscoring the importance of authentic social connections and being valued for one’s uniqueness, participants offered ideas for promoting greater levels of social inclusion and social equality, within both their schooling and neighbourhood environments. Participants 94 recommended having programs in schools that support the valuing of diversity and that encourage young people to work together across peer groups. In response to Anna sharing about how she had met her best friend this way, a group of participants suggested having days in schools where everyone is mixed up, working on projects with a common goal (e.g. drama groups) so they are encouraged to break up cliques and are enabled to get to know other diverse young people with which they normally would not connect. Participants also recommended the importance of developing more community centres for diverse people of all ages to connect and to talk openly without judgment and shame about their lives and challenges. Youth centres were also seen as an option for enabling young people to spend time with diverse peers and across economic differences. Inter-related with participants’ need for authentic social connections was the need for a strong grounding in one’s self-worth and self-determination. Participants explained how feeling connected and valued for one’s uniqueness supported one’s self-worth and sense of belonging. When invited to consider how living in a social context in which people were valued for diversity would impact mental health, participants imagined that young people would experience greater safety and freedom to be themselves. Anna (16-year-old female) shared, “I think you wouldn’t be afraid to be yourself . . . you’d be happy to voice your opinion instead of holding it.” 3. Self-worth and self-determination Within participants’ definitions of mental health and their contemplations about how to protect their mental health from the effects of challenging social dynamics, participants identified the importance of having a core sense of self-worth and self-determination. Having a core sense of self-worth included being “happy with who [one] is . . . comfortable in [one’s] own skin . . . self-esteem through your own power” (Da Dragon, 19-year-old male) and being at peace with oneself. Self-worth was associated with being less influenced by money and challenging wealth-oriented trends. Based on her observations of peers in her school and their varied levels of access to money, Andrea (19-year-old female) suggested that young people are more influenced by “status, arrogance . . . and the trend and money” when they have “low self-esteem . . . and aren’t stable.” 95 Inter-related with participants’ need for self-worth, was their need for self-determination, or control over one’s thoughts and actions. Within a few participants’ definitions of mental health and descriptions of what was ultimately important to their mental health beyond money, they explained that control over one’s thoughts and being able to re-focus or “occupy” (Derrick, 20-year-old male) one’s mind was important to enabling mental health. This need for control over one’s thoughts included how one reacts to situations faced in one’s life and “taking responsibility for circumstances that one has control over” (Andrew, 19-year-old male) including “taking ownership” (Mindmatters, 25-year-old female) of one’s life and finding one’s place in what many participants described as a complex and fast-changing world. Self-worth and self-determination were inter-related experiences. For some participants, self-determination included the importance of self-awareness and integrity in knowing and living one’s values, ethics and principles. Participants also suggested that having a strong grounding in one’s values and sense of self-worth was associated with giving oneself direction and focus in one’s life. . . . knowing your own values and making sure that your life and your decisions reflect those values. Like I feel like the minute you stop giving importance to the things that matter to you it’s just a downward spiral. So knowing your values and being accepting of other people’s values and how they differ from yours. (Mindmatters, 25-year-old female) This self-direction was challenged, however, by socialization processes within young people’s environments, over which most participants described having little control, such as being exposed to advertisements in their day-to-day lives. Participants thus also emphasized the need for having control over the impact of social trends and messaging on oneself and that “other people’s perception doesn’t have to [become one’s] reality” (Donald, 28-year-old male). One intervention that some participants recommended to help young people to increase their control over the influence of harmful messaging within media and advertising was critical media literacy programming. These participants recommended that this programming be focused on increasing their awareness of how harmful messages are constructed and ways of controlling their influence on young people’s self-worth. The first thing that came to mind [when asked what mental health is] was being able to control thoughts. Let’s say you’re dating and you’re hoping to 96 see the other person and they either, one: got busy, or two: bailed. However, as a human mind—you know those thoughts can easily spiral down into saying: ‘Oh, maybe they’re out with another person, or maybe they don’t like me. Oh, we had such a great night last night . . . how come they don’t want to see me again? Is it because I’m fat, or I’m too skinny? I’m not muscular? My teeth?’ You know, whatever it is. We start to have a really downward spiral very, very quickly because we’re really critical on ourselves, even though it doesn’t seem like that because no one really knows 100% of our thoughts. And I think that is exactly how depression starts to happen. Is because mainstream media . . . There’s so many re-affirmations . . . confirmations from other outside sources besides themselves, so they start to believe that it’s true. (Donald, 28-year-old male) In response to the initial findings and one young person’s suggestion that having control over one’s mind was “not caring what others think,” other participants emphasized the inter-relationship between self-worth and social connections. Participants suggested that caring what others think is important in order to connect with them, but that a person still needs to be able to control the influence of other people and harmful social trends on oneself in order to stay grounded in one’s values and ethics. Not caring what others think of me . . .? I am not sure if I totally agree with that part. Because if you want to interact with people, you . . . need to care what they think of you . . . Say you do whatever you want, but whatever you want is actually socially immoral. Like, say you like killing cats or whatever, and you just kill cats every day and you don’t care what people think of you . . . I don’t know if that’s a good thing. I think being happy with who I am is good. Be self-aware. Know about yourself. Know my values, which is also know about myself. Have control over my thoughts is good. (Haden, 17-year-old male) Participants also emphasized how social relations play a role in the development of one’s sense of self and, in turn, self-worth. Denis suggested that not caring what other people think is a contradiction and explained, “we are getting an understanding of our self, in part, from others. Therefore, you cannot realize that you are unique unless you care about what others think” (20-year-old male). Being grounded in one’s sense of self-worth was also described as being inter-related with the need for self-realization, or discovering and realizing one’s unique strengths, capacities and purpose or contribution to one’s community. Inter-relatedly, self-realization was associated with supporting young people’s self-worth and self-determination in response to the pressures 97 they experienced within social trends. Mandie (27-year-old female) suggested that young people who had meaningful work likely would not feel as pressured to conform to idealized notions of beauty in commercials. Da Dragon explained that broader social pressures did not ultimately matter to him as long as he was “alive and able to contribute and pay back [his] parents [and] contribute to human beings” (19-year-old male). 4. Self- and socio-environmental realization This close relationship among the needs for self-worth, self-determination and self-realization was further reflected in participants’ descriptions of how part of discovering their unique sense of self entailed discovering their unique purpose, strengths, interests and capacities. I have used the notion of self-realization to reflect how participants variously suggested that having a sense of “meaning and purpose” (Denis, 20-year-old male) in one’s life, doing what one loves and is “inspired” by (Donald, 28-year-old male) and “passionate” about (Antony, 24-year-old male), and “creatively expressing oneself” (French, 17-year-old male) and “doing something that one is good at” (Andrew, 19-year-old male) is important to young people’s mental health. Participants emphasized the importance of “knowing [one’s] potential” (Andrew, 19-year-old male) and actualizing one’s capacities and strengths. Participants expressed the importance of contributing to community, “inspiring others and leaving a legacy” (Donald, 28-year-old male), and “being ‘someone useful in the world, someone who can help others and someone that people actually like’” (Prinda, 15-year-old female). In order to be mentally well I think you need to feel happy—that means that your needs and wants are satisfied to a certain extent . . . you need to have an occupation is one of the things I find very important. You need to work or study and have some kind of a purpose you want to achieve . . . to know what you want to do and to realize that there is a purpose for your life big or small. (Denis, 20-year-old male) Definitely when I’m engaged in doing something I’m passionate about which for me would be music or writing, I really enjoy writing. And I feel less well definitely if I’m, well in the past when I was in school that was a big thing for me that stressed me out and upset me. And more recently most jobs that I’ve had. (Antony, 24-year-old male) Participants’ need to contribute to their communities and their worries about the lack of societal progress and the state of their natural environments highlighted their inter-related need 98 for socio-environmental realization. I have used the notion of socio-environmental realization to reflect participants’ worries about the progress of society and the state of their natural environments and their need to see social evolution and practices that protect their natural environments. Participants stressed their concerns with various aspects of their broader social and natural environments that included: materialism, inequalities, poverty, homelessness, farmed salmon, the use of coltan in cell phones from the Congo, pollution, colonialism, lack of fair trade, endless production and consumption, population growth, and competition over resources. Several participants identified the importance of societal progress focused on community needs (versus money) and environmental sustainability in order to give them a sense of hope for their future and a sense that their governments and communities care about them. Consistent with these worries, participants identified initiatives such as permaculture and the 100-mile diet as important to sustaining their environments into the future. I’m committed to the idea that we need to move our progress forward . . . I mean I might be overly idealistic and naïve here . . . but there’s so many materialistic people that so what if you die with a million dollars what’s going to happen to it, it’s not yours anymore . . . it doesn’t matter. And the thing that scares me the most sometimes is that imagine a huge meteorite coming towards earth and killing every human . . . it would make me think that we’re no better than dinosaurs, we haven’t achieved anything whatsoever. (Denis, 20-year-old male) So seeing communities like Quebec where they have strong social services and people actually care. I mean the protests for the . . . Tuition? Yeah it’s like amazing and they have all this funding for the arts and for their culture it makes me not want to live in Vancouver, I’d rather live in Quebec . . . because they care about these kinds of things and they have more community. (French, 17-year-old male) Across different dialogue sessions, participants explained how they wanted governments to invest in welfare, housing, transit, and health care—instead of malls and highways—and explained how this makes them feel listened to and cared for. Yeah like it’s nice because if you break a leg they don’t cost you for the ambulance . . . they fix you and then you’re good. You don’t have to worry about paying . . . I don’t know if it’s actually because they care but that’s what it feels like, like that’s good because it feels like they actually care, they don’t care about the money. (Yana, 16-year-old female, group interview) 99 While participants identified work as one potential context for enabling their self-realization, they explained that formal work isn’t the only context for enabling self- and socio-environmental realization. However, to engage in meaningful life activities outside of the work context, employment that pays wages to meet basic needs is needed. Explored more fully in Chapter Five, having to work several low wage jobs and/or long hours of low wage work to meet basic needs resulted in not having time to engage in meaningful activities outside of the work context. The need for having control over one’s working life was thus emphasized. This reflected the inter-relation between self and socio-environmental realization and self-determination. It also illustrated participants’ need for self-determination not only over their inner experiences, but their work-life activities. In extension of participants’ need for self-determination, several participants expressed needing control over their work activities. They expressed frustration with how working for someone else limited their freedom to engage in work that enabled them to express their creativity and capacities. Several participants highlighted the power dynamic between an owner and worker in a business and, while a couple of participants expressed being “okay” working for a “nice boss,” several participants expressed their need to work in a context where they have influence over the focus and direction of their work. Donald, who was striving for freedom to realize his passions and “to live a life of inspiration,” expressed his need to have control over his work and saw that as achievable through entrepreneurship. Time off . . . I chose sales for one reason: freedom. Sales is not about time. It’s about results. And so that’s the reason I chose sales, because I could do things in a compressed time, get the results and then be able to stay home. But by having a boss, they just want you to work no matter what. Being your own boss, you can compress time and it’s more of a rebellious thing. You know not having someone tell you ‘—you can go for lunch now, you can take your breaks now. Now you can be home.’ ‘Oh hey—can you work tomorrow?’ ‘No I can’t work.’ ‘Oh actually I need you to work.’ It’s not ‘can you work’—it’s all nice at first. They change and are like ‘no you have to work.’ You know so that goes along with having a boss. Versus being your own boss: I want to work, I get to work. Those languages are very different. Versus I have to work. (28-year-old male) Having control over one’s work was inter-related with enabling one’s self-realization. Control over one’s work was associated with increased freedom to do what one wants; having a sense of goal orientation, aspiration and motivation; and a sense of inspiration in doing 100 something that one wants to do. Participants further associated control over one’s work with freedom in being able to do much more than working for other people. More broadly, having control over one’s life and having a sense of independence was described as “mentally very rewarding” (Mandie, 27-year-old female) and creating pride and happiness. I think it would be positively, it would be goal oriented knowing that I have to do this and stuff like that, it would be a sense of inspiration knowing what you’re doing, wanting to do it, not just sitting there in a rut. (Derrick, 20-year-old male) I see being your own boss is an achievement it’s kind of one of those things where you’re always working under somebody and there might be a time when you get up to par with that person that is your boss and whatever. And you branch off and do your own stuff . . . If you have your own company, you can do so much more. (Sarah, 21-year-old female) Another central and inter-related mental health need was participants’ need to learn about themselves and their environments. The need for learning and responsive education was inter-related with participants’ need for self-determination in terms of increasing their options and choices in life. Learning and responsive education was also inter-related with self-worth and self-realization. When participants did not have a positive sense of self-worth, or a sense of their interests and passions, this negatively affected their ability to engage in learning. For example, Isabella described how, in not having a sense of her passions and interests, she did not have the motivation to study and learn in school. She shared: I don’t know what I want to be. I think that’s another reason why I am not motivated. It’s because I don’t know what I want to be, so I don’t know where to start. I don’t know what I have to focus on, so I think that’s another big thing [that affects my mental health]. (16-year-old female) 5. Learning and responsive education Within participants’ reflections on the various freedoms that money enables, they shared their need to learn about themselves and their environments. Participants variously expressed wanting to go to school, to travel, explore the world, and “experience different walks of life” (Mindmatters, 25-year-old female), to learn about various cultures and languages, and to learn about the universe and how it works. Participants emphasized the importance of learning how to think critically and to meet their needs and to care for their mental health, not only individually, 101 but in relation to the ways that their socio-economic environments affect their mental health. Consistent with a “holistic and developmental conception of education” in which “learning occurs in many different forums, including work and family life” (White & Wyn, 2008, p. 153), participants described education and learning as including both formal and informal learning contexts (e.g. one’s home and living situation, friends, community centres and media, internet) and explained how they are learning about themselves, their communities and their world in all of these contexts. Learning was described as shaping young people’s growth, character development, potential and increasing one’s options in life such as increasing the “scale of choice of their occupation” (Denis, 20-year-old male). Participants explained how education “affect[s young people’s] capacity to think and their potential” (Cassie, 15-year-old female). A good education was associated with developing problem-solving skills; meeting one’s needs and learning how to care for oneself and one’s mental health; discovering, exploring and developing one’s unique strengths and capacities; and preparing young people to support their communities and increasing their career choices. A central emphasis across participants’ reflections on their formal educational experiences was the need for support in developing their unique and evolving interests and capacities. Several participants were concerned about the way that educational experiences were not tailored to their interests and needs. Rigid and structured educational programming was described as decreasing the joy of learning, challenging self-worth, “soul crushing,” and increasing the risk for suicide when rigid and high academic standards did not match young people’s unique strengths, abilities, learning styles and interests. Participants emphasized the importance of responsive education in which curriculum is flexible and tailored to young people’s learning styles and evolving interests, capacities, and passions. I think the biggest thing would be to help people discover what they’re passionate about . . . Children need to be given the freedom to focus on the fields they’re interested in. A mandatory curriculum is the worst idea in the history of worst ideas. Every child is so dramatically different, and has different interests and strengths. Our school system ignores all of that. It’s tyrannical. I think I told you that I dropped out of school when I was quite young. I never suffered as intensely as I did in school. Being made to sit for six hours and complete lessons that I had no interest in was soul crushing. I was so intensely miserable. I thought about suicide constantly starting from when I 102 was five or six years old, and this depression vanished when I left school several years later and I realized that there wasn’t anything wrong with me. School made a grey hole out of my childhood. (Antony, 24-year-old male) The schooling system, something needs to be done it, it’s archaic . . . since I’ve turned eighteen and started working . . . I came to the realization that I wasn’t the idiot that I thought I was going through school because . . . like my reading level has always been high and my math . . . but just paying attention in school and the format, the way they presented it didn’t work for me. I couldn’t do it. Skipped classes, never there . . . And I excel at a lot of things in my work [construction] that I can’t do without large amounts of training or schooling that weren’t really accessible to me. (Murphy, 25-year-old male) Participants expressed their need for greater flexibility in academic programming, matching teaching styles to learning styles and enabling alternative learning experiences such as work experience in exchange for course credit. While some participants emphasized the importance of continuing to have core courses, they agreed with other participants who recommended exposing young people to a variety of courses earlier in their schooling and providing “cafeteria style” (Da Dragon, 19-year-old male) flexibility in terms of what, when and how fast they take courses guided by their evolving interests, capacities, and longer term career goals. Tailoring grading and courses to young people’s career goals was associated with preventing young people from wasting their lives studying for courses they do not need. Prinda suggested that young people should only be graded on courses they will actually use in preparing them for university or future jobs- Yes—because to become a doctor takes so long. Already as it is I’m going to lose a lot of my life studying . . . After you graduate it’s like a new beginning for you. It’s like you didn’t do anything. Because these things you learn they don’t help you when you go to university . . . It would be better to start everything at grade 8. So we don’t have to study that much . . . They are forcing us to take courses that we don’t really need. Like physical education—why do we need to take a course? We could just go outside and have fun. We don’t need to take a course. (15-year-old female) Tailoring education to young people’s evolving interests was associated with increasing young people’s passion for learning. My parents taught me to read before I went to kindergarten. It was a whole new world for me. When I went to school, I would read novels in class, and 103 have them taken away from me and be forced to go over kindergarten spellers with the rest of the class. I was forced to write out a sentence five hundred times until I got it between the lines, instead of writing my thoughts or feelings. Children cannot be forced into a curriculum. It’s Satanic. Certainly my experience was worse than average, but every child is forced to study things they have no interest in, and will never put to use. For many children it kills the desire to learn, and makes them hate school. Education needs to be completely overhauled. (Antony, 24-year-old male) In addition to their need for responsive education, participants expressed their need for supports that directly connect them to meaningful work upon graduation in order to enable their needs for survival and self- and socio-environmental realization. Several participants expressed their fear of graduating and not knowing how to connect to meaningful employment and to establish financial security. Participants also recognized that graduating from education programs did not guarantee work within one’s field of study. Participants emphasized the importance of “cradling and caressing” (Cassie, 15-year-old female) young minds within and beyond high school in order to support young people to engage in meaningful work and life activities after formal educational experiences. While Graduate Transitions30 programs were identified as supporting young people as they transition from high school into community and guiding young people in decisions regarding work and/or post-secondary opportunities, participants also emphasized the need to further tailor these programs to young people’s needs. A couple of participants described graduate transitions programs as stressful and taking up so much time beyond their course work that they did not know what day it was. They questioned the value of engaging in volunteer work and self-exploratory activities that did not directly develop skills that were aligned with their career goals. In response, these participants recommended the need to tailor graduate transitions programs more fully to young people’s interests and capacities and to offer direct and ongoing supports as young people transition to post-secondary education programs and/or meaningful work upon graduation from public schooling programs. 30 Within B.C. curriculum, Graduate Transitions is a mandatory course and must be completed in order to graduate for all B.C. secondary school students who are enrolled in Grades 10, 11 or 12 as of September 1, 2007. Within this course, students must demonstrate that they have met the following requirements: personal health, which entails maintaining a personal health plan including the engagement in at least 80 hours of moderate to rigorous physical activity in addition to PE 10; community connections, which includes 30 hours of volunteer experience; and career and life, which includes the development of a transition plan. 104 Explored more fully later, a barrier to enabling young people to access post-secondary educational programs was the cost of post-secondary education. Being caught working in cycles of low-wage work to meet basic needs for survival or struggling to find summer employment prevented these participants from accessing post-secondary programs. Some participants thus expressed the need for free education and/or reduced tuition to enable access to post-secondary educational programs. I think when you have the money that’s fine, when you don’t, it’s like you feel hopeless. You know and to be in like the top ten percent of my graduating class and to not be able to afford to go to university it’s like what kind of society is this? Like we obviously do not support the education system very well. (French, 17-year-old male) Importantly, having one’s basic needs met for survival was identified as foundational to enabling time and space to study and learn in one’s life. Haden reflected, “who needs education if you can’t survive? Once you can survive, then you can start getting an education and you can start thinking about what you want to do in the future” (17-year-old male). Having freedom from worry about one’s basic needs was also associated with enabling young people time to appreciate the beauty of their surroundings and to gain perspective in life. 6. Inspiration and perspective in life In addition to their need to engage in inspiring work–life activities, participants expressed needing inspiration and perspective in their lives more broadly. Participants shared how seeing beauty within both their built and natural environments evoked an experience of awe, appreciation, happiness, hope and “eased troubles and hardships” (Cassie, 15-year-old female). This included the need to be surrounded by clean, “green” (Jonathan, 17-year-old male) and “aesthetically” pleasing neighbourhoods (Denis, 20-year-old male) and/or to see beauty in their natural environments (Anna, 17-year-old female) for both themselves and their future children (Jacob, 18-year-old male). Denis shared that the reason he chose to stay in one of the youth shelters when he could not afford to pay his rent was “because it’s close to the seawall and if I have time I can just look at the sea” (19-year-old male). Jonathan took a photo of the view of his neighbourhood from his balcony to show the importance of green spaces for his happiness (17-year-old male). Comparing his country of origin to his current surroundings, he shared “I don’t 105 think I would have been as happy because it’s concrete everywhere, at least in my city. Yeah, I’m lucky to be surrounded by green” (17-year-old male). You’re a product of your environment because I’ve lived in some really shady places and been . . . super depressed and just not in the best state, you know. And then as compared to where I live now, I’m feeling good like I like my surroundings, you know, so I would say that my mental health is a lot better . . . I mean your housing . . . and not just your housing like your physical house that you live in but where that house is located, where you live like the city, definitely—just like your total surroundings. [Holding her arms in a circle]—the physical space around you. (Mandie, 27-year-old female) I was just taking pictures of how crappy my neighbourhood is, like the pavement and everything is so the same. And then I just thought it was cool because you look at the buildings and how old and ugly they are, and then you look up into the sky and it’s so pretty and the silhouette of the trees . . . what I was trying to capture here in these pictures was even though it’s really ugly and old and ghetto, there is still beauty . . . it’s sort of that mentality of seeing beauty in even the smallest things. And if you can find those kinds of things, maybe it’s a little easier to find like, hey, ‘life is beautiful.’ It’s not just all these troubles and hardships, but there are things that make up for it, just small things. (Cassie, 15-year-old female) Participants also needed perspective in their lives. As described previously, a central theme across most participants’ reflections on how their socio-economic environments affected their own and fellow young people’s mental health was a broader analysis of what was ultimately important for young people’s mental health beyond money and status-based goods. Furthermore, in addition to the appreciation and happiness that the beauty of nature evoked for some participants, nature was also described as enabling one to gain perspective in life. Well, the moon and the stars, right? It’s always put it in perspective, you know, how tiny we are? I live in this big environment, but within this earth, outside of this environment there’s an even larger environment and space and all of that, right? So I always like to look up and just look at the stars and think about what’s out there. And it lets me know that this environment, it’s not the only environment that exists. There’s more. (Jonathan, 17-year-old male) The need for perspective in one’s life was also evident within participants’ reflections on their experiences of free time. Moments of freedom from worrying about money were described as “giv[ing one’s] mind room to breathe and take in more” (Derrick, 19-year-old male). Conversely, participants who struggled to find free time expressed sadness with not having time to gain perspective in their life and in relation to important life events. Mindmatters described 106 how she did not have time to grieve her sister’s suicide and emphasized the importance of free time to enable young people to come to terms with important life events such as the loss of a family member. Everything seems to be moving faster and . . . Not even just faster but even the way of like obviously technology—it’s become such a focus—like that affects the way you think and like physiologically . . . and it feels like a lot of just trying to keep up sometimes. I’ll be completely honest—I’ve struggled with mental health issues and I don’t want to get too into it but I lost a sister to suicide [crying]. It does affect you like it’s impossible for it not to affect you so it’s like just trying to be a part of the normal world, it gets overwhelming especially when it forces you to think about what’s important and still like push through that and keep on going—like that’s expected of you [crying]. I feel like it really does force me to think about the things that were important and you have that in the forefront of your mind and you still have to do all these mundane things- like busy yourself [crying]. (25-year-old female) Within participants’ reflections on the challenge of finding free time to gain perspective in their lives, they emphasized more broadly their need for a dynamic balance among work–life activities, free time, rest, relaxation and leisure and play, and the present and future. The inter-relation of participants’ mental health needs was further evident within their reflections on the need for this balance. 7. Balance in life Although none of the young people in this study experienced an enduring sense of financial security, when participants experienced periodic moments of accessing money and/or having access to and control over resources in order to meet their basic needs, they described having more time and space to be able to relax, to feel peace, and to take care of themselves. Participants suggested that a balance among work–life activities with free time, rest, relaxation and leisure was needed to promote mental health. This need for balance also included balancing inter-related mental health needs. Like others, French’s definition of mental health included the need for balancing mental health needs and finding a balance among work and educational activities with free time for social connections and relaxation. 107 It is physical, personal and social wellbeing—it includes so many aspects like your biological health, biochemical balance in brain; social aspect is important—if you feel isolated this will affect your mental health; it’s really hard to define . . . For me personally mental health means being financially stable, if I have a strong social structure, if I’m happy with my education, and I’m happy with social relationships, if I have a good work–life–school balance. If I feel like I’m eating properly and I’m active not only socially, politically but also physically I think it’s, it’s like the magical balance between life and stress and relaxation and just trying to figure everything out. (French, 17-year-old male) The need for balance among participants’ inter-related mental health needs was further reflected in participants’ contrasting views on leisure. While some participants explained that having money that enabled them time to engage in enjoyable activities with one’s friends and family promoted a sense of fun and enjoyment in their lives, a couple of participants expressed concerns with having too much of a focus on recreation and leisure, which threatened their need for socio-environmental realization. Similar to Da Dragon’s reflections on how the way that people are “brainwashed [by the] conveniences of modern technology” is a core barrier to social change, Denis shared his concerns with the lack of societal progress which he attributed to the dominant focus on “entertainment and the entertainment industry.” Denis suggested that this dominant focus, combined with the lack of promotion of critical thought in schooling experiences, contributed to people being “mentally fat” (19 year-old male). The need for balance also included other dimensions of young people’s lives, including finding a balance among technology and nature and the time dimensions of one’s life. In sharing his definition of mental health, Barry reflected- Maybe balance between technology and nature, and you know, old and new and even the in-between . . . just a good balance between everything. You know people say forget the past, and some people say ignore the future like just ignore what will come, it will come. Some people say, you know, live in the present. I believe that you should have a balance between all three. (15-year-old male) This need to find balance among technology and nature and the past, present and future of young people’s lives reflected a final key and inter-related theme pertaining to young people’s mental health: the need for security into their future. 108 8. Need for a secure future A final central theme across participants’ reflections entailed their need for a secure future. Participants expressed this need in two ways. First, they wanted to know that they would have financial security into their future in order to meet their needs and for some, to take care of their ageing parents. Second, participants worried about the state of their natural environments and implications for their future. A few participants shared their concerns about the endless production and consumption, or “buying and dumping” (Jacob, 18-year-old male) practices that threatened their natural environments. Several participants shared their concerns about population growth, the scarcity of resources and increased competition for these resources into their future. Not being able to see a future in which one had meaningful and/or secure work was described as evoking fear, anxiety, depression, and hopelessness. Not having meaningful work into one’s future resulted in “youth [not] have anything to look forward to” (Jonathan, 17-year-old male). When asked if there as anything that she found stressful in her life, Andrea shared: My future . . . I worry because I don’t know what is there yet. I want to be financially independent and I don’t know if I have the ability to and then I don’t know if I have the ability to be independent and being able to aid my parents. I feel like I should like pay them back something, and I don’t even know if I can take care of myself. (Andrea, 19-year-old female) I like to know what I have to do and what’s going to happen in the future. I’m not bad with change. I think change is good it’s needed, but uncertain changes that are very rapid they kind of shock you, and doesn’t put me in good mental health . . . it’s balance and knowing what’s going to happen. I think just, where I’m going to live? Education wise-‘am I going to keep going to school, am I going to have to work, do I want to do coop, do I want to go on exchange? Am I going to graduate in four years or five years? (French, 17-year-old male) The inter-relation of the need for a secure future and one’s education and learning was reflected within Denis’s reflections on how education enabled “more decisions about [one’s] future, and [one’] surroundings and [one’s] life in general” (Denis, 20-year-old male). 109 Inter-Relation of Young People’s Mental Health and Socio-Economic Processes Overall, despite the fact that not one of the participants had their mental health needs fully met, their reflections on having met their needs to varying degrees emphasized how these needs are inter-related. Furthermore, participant reflections illustrate how, when young people’s mental health needs are enabled through socio-economic processes, young people are supported to engage in socio-economic processes in synergistic ways in processes of realizing young people’s mental health. At the heart of participants’ reflections was the need for physical survival, health and comfort. This foundational need was described as enabling freedom to explore and learn about their environments and to discover and develop their own strengths and capacities in processes of self- and socio-environmental realization. This included freedom to explore and develop their sense of self-worth, including getting clear on their own values and what is of ultimate importance to them in their lives, and freedom from focusing on themselves in order to support other people and to contribute to community life. Several participants expressed yearning to live in a world where they did not have to worry about money in order to survive and imagined that this would free them to meet their other inter-related mental health needs such as exploring and developing their interests and capacities in ways that contribute to community life and connecting with others in more authentic ways. It would be so great, you know, to be able to have, to live in the sense that, you know, you don’t have to stress about rent because, your things are paid for. You don’t have a landlord that will come at the end of the month and kick you out if you don’t pay. I guess just the sense of greater community and more connectedness to each other and actually like caring, you know, just out of the goodness of your heart rather than, you know, for profit. (Mandie, 27-year-old female) I think that if you don’t have to worry about money, you have . . . that gate’s gone and then you can think of things outside of the gate . . . since I don’t have to worry about myself, I can think of other people. And that’s really clichéd, but I think it’s true. If you don’t have to worry about yourself, you’re in a better position to help other people who aren’t like you. I mean, if you don’t have to worry about anything, why do you need to be greedy? Why do you need to be selfish? You have everything you need. . . . in my opinion if I didn’t have to worry about myself I could worry about other people. (Cassie, 15-year-old female) 110 Analysis of the inter-relation between participants’ needs and their affective experiences further illustrates the inter-dependent relationship between young people and socio-economic processes in realizing their needs. Within this relationship, young people depend on socio-economic processes to enable their needs, and when their needs are met, they are more able to participate in socio-economic processes in seeking to realize their mental health needs. An important site for understanding this dialectical relationship is that of young people’s affective experiences. Affective States as Barometer of Need Realization A central theme within research participants’ accounts of how their socio-economic environments affected their own and fellow young people’s mental health entailed the ways that socio-economic experiences shaped participants’ affective states. Participants’ reflections on how socio-economic processes affected their mental health illustrate how affective states act as a barometer, indicating the degree to which one’s needs are realized. When socio-economic processes enabled participants’ needs, participants described experiencing positive affects. When socio-economic processes threatened their mental health needs, participants described experiencing emotional and bodily states of distress. Affective experiences, in response to the degree that participants’ needs were met, in turn influenced participants’ ability to participate in socio-economic life. When participants’ needs were met and they experienced positive affects, they described being further motivated, energized and able to participate more fully in socio-economic life. When participants’ needs were threatened and they experienced distress, they struggled variously to participate in socio-economic life in seeking to meet their mental health needs. In order to methodically explore participants’ affective experiences in relation to their socio-economic experiences, I categorized their affective states. In doing so, I drew upon Panksepp’s (2008, 2011) distinctions between primary affective states including: emotional feeling states (fear, sadness, depression), sensory affects (sensation, pain, pleasure) and interoceptive affects (general bodily feelings such as exhilaration, nausea, fatigue). I then compared participants’ affective experiences in relation to their socio-economic experiences. 111 When participants had enough money and/or were able to access resources in order to meet their mental health needs to certain degrees and/or imagined what life would be like if they did not need to worry about money, they variously described experiencing (or anticipating an experience of) the following emotional feeling states: enjoyment, fun, “ease of mind,” “peace of mind,” happiness, hopeful, “fulfils your pride” and the following interoceptive affects: feeling calm, relaxed, and “better.” When participants did not have enough money to meet their needs, or worried about meeting their needs into the future, they described experiencing various states of emotional and interoceptive distress. Emotional distress included feeling: fear, sadness, depression, anxiety, scared, down, frustration, anger, misery, shame and embarrassment (for low-income young people), guilt and frustration (for higher income young people), not happy, and hopeless and “not caring anymore.” Interoceptive distress included experiences of feeling unwell, stress, pressure, fatigue, insomnia, nausea, vomiting, headaches, “feeling physically sick,” tearful, tiresome and a “chronic wear and tear of stress.” Participants also described experiencing worries and suicidal thoughts and/or hearing about peers who had attempted or committed suicide when their needs were threatened. It [money/socio-economic environment] totally affects your mental health it’s like if you have to panhandle every single day for that same slice of pizza . . . I mean it’s just affects your peace of mind, like did you eat today? What do you have to do for that money? Things like that. If you’re not working it’s a lot more difficult to live, it affects your mental health more knowing that you’re just going to be drinking simple water, having your shelter to sleep, the stress it creates, the anxiety it creates. (Derrick, 19-year-old male) If one of your needs are not being met whether it be, you know, food wise, love wise, shelter wise, you know, you’re going to be stressed and that’s gonna affect your mental wellbeing . . . when I moved out I realized just how strongly money affects an individual and when it came time to, you know, buy groceries . . . if I went hungry for a day or two like just how stressing . . . not sleeping and not eating properly. I just know personally that when I feel I don’t have enough money or when my rent comes into question that it seriously will make me ill to the point of nausea, vomiting, headaches, insomnia like you wouldn’t believe. [Mandie, 27-year-old female] Participants’ mental health needs were continually in tension with each other as they struggled to meet all of their needs. Some needs were compromised to meet other needs, 112 resulting in mixed emotions. For example, Mandie expressed feeling proud and happy when she moved out on her own and experienced a sense of independence and self-determination, but then faced stress with the insecurities she faced in meeting her basic need for survival. She shared, But holy shit, mentally did it take its toll because, you know, I’d never realized what it was like to pay rent every month and, you know, bills having to be due and it was like wow, what a wake-up . . . I realized just how strongly money affects an individual and when it came time to buy groceries, you know, for the first time in my life I had to say, ‘I only have thirty bucks and I’ve got to make this food last six days.’ (27-year-old female) Haden (17-year-old male) shared how joining a youth advisory group to a community-based science education centre was “pretty fun,” made him “happy” in “making decisions and being creative,” and “[feeling] good having some power in things that [he was] passionate about,” but he also expressed how it was “stressful” “because [he had] to balance it with homework and homework ties in with [his] grades . . . [where he then had] to stay up really late.” More generally, participants described needing to prioritize survival and, to this end, needing to focus on accessing income over realizing inter-related mental health needs. Inter-Relation of Socio-Economic Processes and Affective States in Need Realization Processes Influenced by the degree to which participants’ needs were met in their day-to-day lives, affective experiences in turn influenced their ability to participate in socio-economic life in seeking to realize their needs. Positive affective states in response to meeting one’s needs enabled participants to engage in socio-economic life more fully. Participants explained that when they were happy and at peace, they were “more outgoing, being more happy, being more wanting to be social not wanting to be withdrawn because you’re super stressed about money, money, money” (Mandie, 28-year-old). Experiencing a sense of “aspiration” when engaged in meaningful work that one was passionate about was associated with increasing one’s happiness and motivation to continue to engage in meaningful work. Overall, as participants yearned to have their basic needs met for survival and considered what it would be like to be free from worry about money, they imagined having greater freedom to engage in socio-economic life more authentically through the engagement in work-life activities that are intrinsically rewarding. 113 Conversely, participants associated emotional distress with contributing to and worsening vicious cycles of struggle in their attempts to access money and needed resources to meet their needs. These participants described how threatened needs evoked emotional distress such as depression, anxiety, and hopelessness, which then decreased their energy and motivation and made it hard for them to keep going. Sarah described her struggle to find employment: One of those cycles where you get that first bit of depression and it starts going down when you realize that there are a few things that haven’t been working when you’re working your hardest . . . I job search and I try to look on Craig’s list to try to find work. Also I’m on disability as well. I hate being on welfare it’s kind of painful—look for jobs, get no callbacks—nothing . . . I do get depression and I do get it bad so it’s kind of hard for me to put myself out there walking store to store or like just do my emails three times each day and not get any response. And just seeing people having responses to like when I hand them my resume it just cycles into depression, anxiety. (21-year-old female) Derrick described his experience of chronic unemployment and the toll on his life: Yeah, I mean that’s the problem because they’re putting everyone on idle and the crime rate goes up because they knock kids down for that long a time, still trying, eventually just getting tired of it all . . . and you stop giving a shit about what you intend to do, wind up in jail multiple times, crime rate goes up, it’s not helping anyone . . . And its annoying, its tiresome, for me it makes you more violent towards getting the money, if I’m not working it’s like I don’t really care anymore, I want to risk a lot more thinking I’m so tired of the same thing like a rut. (Derrick, 21-year-old male) Participants’ reflections show how enabling their inter-related mental health needs is foundational to enabling their participation within socio-economic processes in synergistic ways. Derrick’s reflections show the vicious cycle of struggle that young people face when unemployed and homeless. His recommendations for a flexible job bank illustrates how socio-economic processes that enable needs are foundational to enabling one’s participation within socio-economic life; or in the case of his example, one’s ability to participate in the process of searching for and applying for employment. Yes, it’s hard for sure because you never know where you’re going to sleep . . . like a regular job you get paid two weeks later but yet you’re on the street—that doesn’t help you feed yourself, it doesn’t help you take care of yourself and where are you going to sleep? You can wind up anywhere based on those 114 basic needs to live so how are you supposed to keep a job? . . . There should be some sort of twenty-four hour building where you can go and sign your name . . . ‘hey, we need a dishwasher here this day and this day’ . . . Possible jobs that they could utilize instead of having to panhandle or squeegee or rob people, as long as you go to the building, sign up, within the next seventy-two hours you can have a job placement and then it would be like a trial with whoever you want to work for . . . and then boom you have a job instead of doing the arbitrary like hand in your resume task . . . give them just a sheer chance just do it as a trial and you can get paid that same day if the place likes you then hire them. (Derrick, 20-year-old male with Sarah, 21-year-old female agreeing in a joint dialogue session) Denis’s struggle to access education highlights how having a secure income and housing is foundational to enabling learning. He described how he had once had full-time work at $15.00 per hour within an environmental consulting firm over two summers and how, when he lost that job, he was unable to find full-time summer work. He thus needed to seek part-time work during his academic studies. He worked for companies that had a pool of workers and distributed inconsistent hours to employees. He moved four times in two years when he did not get enough hours at his work to pay his rent and eventually ended up living in a youth shelter and discontinuing his studies, despite previous career planning indicating that he “had” to go to university. He explained that it “wasn’t an easy path for me” and “I didn’t do well because I had to worry about my housing, being able to pay rent, buying food and things like that” (Denis, 20-year-old male). While some participants described experiencing depression and anxiety that worsened their struggle to meet their needs, other participants described being energized by anger and frustration when their mental health needs were threatened. This motivated them to change their approach to meeting their needs and/or to resist aspects of their socio-economic environments that threatened their needs. However, they faced fundamental challenges to these alternative approaches to meeting their needs when faced with challenging socio-economic dynamics. Comparison to Policy Documents A close reading of the 10-Year Plan (BCMHS & BCMCFD, 2010), follow-up reports (BCMHS & BCMCFD, 2011a, 2011b; 2012) and the Mental Health Promotion and Mental Disorders Prevention document (BCHA & BCMHLS, 2009; Morrison & Kirby, 2010) in relation to the mental health needs identified by participants shows several areas of alignment between 115 participants’ expressed mental health needs and the conceptions of mental health and social determinants of health in the policy documents. Definitions of mental health and proposed initiatives within these documents partially align with participants’ expressed need for self- and socio-environmental realization. This includes definitions of mental health such as enabling people to “realize [one’s] own abilities . . . to experience life as meaningful and to be creative” (BCMHS & BCMCFD, 2010, p. 2), to “live fulfilling lives” (BCMHS & BCMCFD, 2010, p. 3), to realize one’s strengths (Morrison & Kirby, 2010), to achieve “one’s potential and independence” (in reference to people with mental illness) (BCMHS & BCMCFD, 2010, p. 31), and to contribute to one’s community (BCMHS & BCMCFD, 2010, p. 2). The proposed plans for cognitive (BCMHS & BCMCFD, 2011a, 2011b, 2012; BCMHS & BCMCFD, 2010), cognitive–behavioural, social competence skill building (BCHA & BCHLS, 2009), socio-emotional learning (Morrison & Kirby, 2010) and self-regulation skills (BCMHS & BCMCFD, 2010) in part align with research participants’ expressed need for self-determination, or self-responsibility and control over their thoughts and actions and their need for social connections. The proposed development of “positive body image programs for girls and boys through media literacy prevention programs to prevent or reduce eating disorders and obesity” (BCHA & BCMHLS, 2009, pp. iv, 29–31) are also aligned, in part, with participants’ recommendation for critical media literacy to increase their control over the influence of harmful social trends and messaging on their self-worth. Proposed changes to public schooling practices align both with participants’ expressed needs for social connections that value diversity and their needs for self-realization, learning, and responsive education. The proposed development of comprehensive and “ecological” school health initiatives guided by the Joint Consortium for School Health Report Schools as a Setting for Promoting Positive Mental Health: Better Practices and Perspectives (BCMHS & BCMCFD, 2011b, p. 11; Morrison & Kirby, 2010) and the development of Neighbourhood Learning Centres align with participants’ expressed need for social connections that value diversity. In alignment with participants’ recommendations for fostering social connections, proposed school health initiatives include the development of school-based cultures that value diversity. Examples of proposed practices to promote the valuing of diversity include: the setting up of classrooms to foster engagement of regular dialogue across diverse groups; the fostering of 116 learning new languages; and cooperative learning models with “heterogeneous” groups of children and youth, including the development of school policies that “ensure learning opportunities are provided which help students learn about, appreciate and celebrate differences among people” (Morrison & Kirby, 2010, p. 37). This also includes the proposed development of Neighbourhood Learning Centres that respond to local community needs by co-locating “schools, sports organizations, non-profit organizations and social activities under one roof” (p. 4) in order to create “inviting places where people of all ages can access education, community services, health care, recreation, and cultural opportunities seven days a week, twelve months a year” (BCMHS & BCMCFD, 2011a, pp. 7–8). The proposed guidelines within the Joint Consortium School Health (JCSH) Schools as Settings for Promoting Mental Health (Morrison & Kirby, 2010) document also aligns with participants’ expressed needs for self-realization and learning and responsive education. Specifically, participants’ needs for self-realization and responsive education are aligned with recommendations to adopt strength, interest, and autonomy-based learning approaches. This includes recommendations to “explore with students areas of strength, interest and potential . . . to personalize learning for students and enhance their engagement in education and relationships” (Morrison & Kirby, 2010, p. 65); and to “adapt teaching methods to accommodate individual learning preferences and needs . . . [including] differentiated instruction, universal design approaches, the use of multiple teaching and assessment processes, applied learning experiences, mentorship opportunities, project work and cooperative learning activities” (Morrison & Kirby, p. 66). An additional recommendation is to “adopt teaching approaches that support autonomy, for example, by minimizing control, listening to and validating student perspectives, and creating opportunities for children to experience choice and autonomy within planned learning activities” (Morrison & Kirby, p. 66). While these recommendations seem to imply adaptation of student interests within existing curriculum (versus enabling young people more control over designing personalized curriculum), the background literature review within this document more fully aligns with participant’s expressed needs for self-realization and responsive education. For example, strength-based learning is conceptualized as focusing on young people’s “interests, what gives them a sense of accomplishment, and explores their choices, dreams, and aspirations for the 117 present and future” (Morrison & Kirby, 2010, p. 30). Additionally, it is proposed that interests and strengths be used as “potential content theme areas for the development of specific curriculum strategies . . . developing independent study projects on particular areas of interest for individual students or small groups . . . linking students with school or community mentors who have specialized knowledge or skills related to areas of student interests or strength . . . providing opportunities for students to demonstrate or celebrate areas of strength or interest through special events, performances or presentations . . . planning special lessons, field trips or initiatives that incorporate theme areas relevant to important student relationships, accomplishments or goals” (Morrison & Kirby, p. 31). “Autonomy supportive practices” are based on self-determination theory and conceptualized as “linking students’ interests, preferences and strengths with learning content and instructional activities” and “creating opportunities for students to design their own approaches for working” (Morrison & Kirby, p. 29). Explored more fully within chapters six and seven, there is not a clear positioning of emotions as a site for exploring the relationship between socio-economic processes and mental health needs. Furthermore, with the exception of the Food Security program (BC Ministry of Health, 2014) proposed mental health promotion initiatives are not directly oriented to transforming socio-economic processes (beyond public schooling systems) in ways that enable young people’s foundational need for survival and inter-related needs such as self-realization (in community life), self-determination, inspiration and perspective in life, balance in life, and a secure future. This is despite the dual recognition of the importance of promoting healthy choices and “creating healthy communities”, “health-promoting environments” (BC Ministry of Health, 2013; BCHA & B.C. Ministry of Health, 2007, p. i) and “modifying the broader social and economic environments that influence mental health” (BCHA & MHLS, 2009, p. 71) in these documents. Overall, the importance of addressing “upstream” (BCMHS & BCMCFD, 2011b, p. 7), “protective factors” (BCMHS & BCMCFD, 2010, p. 20), and “social determinants of health” including the “creat[ion of] supportive community environments” (BCHA & BCMHLS, 2009, pp. 5) that include “healthy municipalities, health care facilities, workplaces and schools” (BCHA & BCMHLS, 2009 p. 17), “creating environments in which the healthy choice is the 118 easy choice” (BCMHS & BCMCFD, 2010, p. 13), and “supporting the development of healthy public policy” (BCHA & BCMHLS, 2009, p. 8) are recognized within the policy documents. However, as presented within Chapters five and six, these policy documents are positioned in ways that align with and support capitalist socio-economic dynamics that contradict young people’s mental health needs in several important ways. 119 Chapter Five: Contradiction Between Young People’s Mental Health Needs and Wealth-Oriented Socio-Economics Introduction In this chapter, I present an analysis of the ways that socio-economic dynamics contradicted participants’ mental health needs. I present how, within young people’s economic context in which mental health resources have been monetized, two central and inter-related capitalist31 socio-economic dynamics challenged participants’ mental health needs in several key ways. These included first, individualistic (private) production and distribution processes; and second, practices oriented to fostering capital (wealth) creation and accumulation. These capitalist dynamics challenged participants’ mental health needs across socio-economic positions, or approaches to seeking income, and within their positioning as consumers. Within this chapter, I start by presenting an overview of participant reflections on the challenging socio-economic dynamics that they experienced. I then present the various ways that capitalist economic dynamics challenged participant’s mental health needs. I conclude by comparing participant descriptions of the ways that these wealth-oriented socio-economic dynamics challenged their mental health needs to the ways that social determinants of health are addressed within the policy documents. Monetized, Individualistic, Wealth-Oriented Production and Distribution Processes and Young People’s Mental Health Needs I think as a society we’ve created money more as a dependent. Without it you can’t do anything until you make money. But you can’t get money until you find something [employment]. It’s depressing that we rely on an invisible currency to run our basic needs . . . And then when you don’t have money or you get laid off and you have that 6 months off and you’re not working, you’re screwed because then they don’t hire you because you were homeless. And then we’re stuck in that day-to-day thing and you have to scrounge up money just to eat. (Sarah, 21-year-old female) 31 I am using this term to refer to economic processes that are oriented to generating privately owned profits beyond the initial investments and costs of production (Harvey, 2010). 120 If I had to put the problem with our economic system into a nutshell, it would be that basic necessities are not a right. They are controlled by an elite who parcel them out for profit. I don’t understand why people don’t revolt against this system. It’s horrific. Everyone seems to be sleepwalking. With a few friends, I could construct a house in a month. Why do we have to work eight hours a day, for twenty years, in order to have enough money to make a down payment on a house? Because land is privately owned. I don’t know how that ever happened. It’s mind-boggling. How can someone own the land we walk on, the air we breathe, the water we drink? . . . There’s no hope for a system in which people can own the earth. There’s no hope for a system in which the necessities of life are sold for profit, and withheld from some. (Antony, 24-year-old male) Several participants expressed deep frustration and hopelessness with being forced to meet their basic needs through the use of money in a context in which they lacked fundamental control over access to money. Participants’ described facing challenges in their varied attempts to obtain money in order to access resources to meet their needs. Their reflections show a monetized socio-economic environment in which money is positioned as an intermediary between young people and accessing resources to meet their needs. Within context of this monetized environment, participant reflections variously illustrate two central and inter-related capitalist dynamics that threatened their ability to meet their mental health needs. The first dynamic was the individualistic, or privatized nature of production and distribution processes, which left participants with little control over access to resources. This dynamic was evident within participants’ descriptions of how, within their socio-economic environment, everyone was focused on “looking out for oneself.” Participants expressed frustration with how they were oriented inward to seeking their own financial security, which prevented them from working with others to ensure universal access to resources for everyone. This dynamic was also evident within participants’ reflections on the fundamental insecurities they faced in their socio-economic environment, which was characterized in the following way: “insecurity is the backbone of the whole structure” (Derrick, 19 year-old male) and in which accessing money was described as ultimately random and arbitrary. The second dynamic included the various ways that profit was maximized within private production processes and the ways that the need for a secure source of income to survive within this monetized system drove economic growth. The necessity of seeking an ongoing and expanding income stream was supported through the ongoing production of commodities and advertising to ensure continual sales. These two inter-related dynamics challenged participant’s mental health needs in several ways across diverse 121 socio-economic positions, or approaches to seeking income, and within participants’ positioning as consumers. The need for survival and self and socio-environmental realization within context of capitalist socio-economic processes A major theme within participants’ explanations of how socio-economic processes affected their own and fellow young people’s mental health entailed the struggle to seek a secure income to access resources for their survival and to engage in meaningful work or life activities. Participants described the benefits and limitations of waged labour, or employment experiences, in contrast to other ways of seeking money such as through panhandling, entrepreneurship, and struggling to access higher education in the hopes of increasing one’s chances of obtaining a good paying job (and secure income). Regardless of their approach to seeking a secure income to meet their foundational need for survival and their approach to engaging in meaningful work or life activities to meet their need for self and socio-environmental realization, participants faced several key challenges within monetized, individualistic, and wealth-oriented socio-economic processes. Employment experiences Participants described employment in relation to their need for a secure income to meet their needs for survival and inter-related mental health needs such as self and socio-environmental realization. While a few participants recognized that they could engage in meaningful life activities outside of the work context, most participants emphasized work as an important context for enabling self- and socio-environmental realization. They suggested that work was more than a means of survival—they saw it as a form of self-expression. Denis drew a distinction between work and income and suggested that work is a way of expressing one’s identity, and income is about meeting one’s needs. So having employment is again one of the ways for people to express their, you know, express their individuality, their need of self-expression and fulfillment. While income is a whole different thing that helps meet other needs of socio-economic factors. (20-year-old male) 122 Barriers  to  seeking  a  secure  income  In relation to their need for a secure income, participants faced several challenging practices that threatened secure access to employment and thus income to meet their foundational need for survival. A central dynamic that participants described as preventing their access to secure waged labour was the drive for profits through wage-suppression strategies within private production processes. Wage-suppression strategies included hiring part-time and temporary workers to avoid higher wages and the cost of health and other benefits, outsourcing in search of lower waged labour, and the use of technology to displace workers in order to avoid the cost of labour. Wage-suppression strategies resulted in low-wage, precarious work opportunities or unemployment at the same time that participants faced an increasing cost of living. Insecure employment and an insecure future evoked various forms of emotional distress such as anxiety and depression, fear, stress, depression, hopelessness, and anxiety. Participants expressed frustration with low-waged labour and unemployment situations, and, if they were unemployed, their struggle to apply and/or qualify for state welfare supports. Why are there people who become depressed? Young people become depressed, they see no future, they know that if their grandparents were working hard and doing well, their parents doing the exact same thing and doing worse and themselves going on the exact same path what do they expect? That’s the reason I think many people are depressed and stressful and anxious . . . People are not guaranteed a job for life because no company would make a commitment to that, they’re afraid for their future . . . In the modern business world that’s not efficient . . . there are so many graduates, bright people that it’s easier to fire a worker who’s been working there for a year or two, find a new one who can do his job just as well, paying the starting rate, save money. Contract work is becoming more and more common so even if you work in an office it doesn’t mean you have secured employment even if you have the required skills and do your job beyond a hundred percent- try to make additional commitments, it’s the global economy . . . So if at a certain point an individual finds themselves happy it doesn’t mean that their future is secure. If you’re working hard it doesn’t mean that things are going to be good in the future for your kids, for your grandkids. (Denis, 20-year-old male) Participants were also frustrated with how accessing money seemed ultimately arbitrary. They described processes of hiring workers from a mass pool of workers and expressed frustration with not having work experience in order to access employment as a youth. Participants in this study expressed wanting to work but not having control over the employment 123 opportunities that were available nor control over being hired. Reflecting a certain level of awareness of the high levels of unemployment and the lack of control that workers have over being hired for employment, Derrick argued for the need for secure access to employment. He attributed the main problem of insecure access to employment for young people to the resume system that privileges those with work experience. In expressing his frustration with the resume system, Derrick (20-year-old male) explained, “It doesn’t give a fair chance to other youth that are on the street that do want to work but may not have the skills but want to learn them” (20 year-old male). In order to enable secure access to employment, Derrick recommended replacing the resume system with a job bank where workers can trial work to show that they are capable. In describing this job bank, he shared Possible jobs, opportunities, that, they could utilize instead of having to panhandle or squeegee or rob people they could, as long as you go to the building, sign up, within the next seventy-two hours you can have a job placement…And then it would be like a trial with whoever you want to work for…and then boom you have a job instead of doing the arbitrary hand in your resume task which really doesn’t work, there’s only twenty other resumes that will be handed in and you. If you as a person are capable of doing that specific job in mind then that person should get it rather than the robotic prince out a thousand, which is just stupid. (20 year old male) Derrick’s reflections are similar to other participants who expressed their openness to work to meet their needs, yet in many instances they did not have opportunities to work or their only option was low-wage, part-time work. Their reflections illustrate the lack of control they have over accessing employment within their current socio-economic environment. I think the basic necessities of life such as rent and food should not be something that are optional . . . well not that you shouldn’t have to work for them but that sometimes there isn’t the option of working for them and that is really messed up in my opinion. (Antony, 24-year-old male) Chronic unemployment challenged multiple mental health needs including the need for survival, self-realization, and social connections. Facing two years of unemployment despite his ongoing work search and a four-month employment preparation program, John visually documented the effects of chronic unemployment on his mental health. This included experiencing chronic worry and stress, insomnia, depression, suicidal thoughts, and acute stress 124 when receiving repeated calls from the federal student loan department regarding unpaid student loans. John took a photo of his bedroom and living room to show his insomnia and superimposed the notion of “emptiness” on the photo to reflect his loneliness in not having social connections through work, or the funds to afford engagement in social life and to engage in further training to work in his field of interest (web design). Barriers  to  engaging  in  meaningful  work–life  activities  Inter-related with the struggle to access a secure income through employment was the struggle to engage in meaningful work-life activities. Participants who saw work as a context for enabling self-realization emphasized that work is one key way for expressing one’s capacities and strengths. Completing an education program and then not being able to engage in meaningful work that enables the creative expression of one’s unique abilities, capacities and passions, which several participants recognized as a reality for many young people, was considered a “waste of a life” (Group interview). Employment was associated with “regulating one’s mind” and keeping young minds “focused” (Derrick, 20-year-old male). However, for some participants if the young person did not find the job meaningful or inspiring, or the job did not actualize their capacities, creativity and/or interests, employment evoked emotional distress. In further support of young people’s need for self-realization and inspiration, “menial” and “boring” jobs (Antony, 24-year-old male) were described as resulting in frustration, depression, sadness and a sense of hopelessness. I think there’s definitely a connection [between socio-economics and mental health] . . . Most of my friends actually are in similar positions . . . the general pattern is the same: they have a job, it’s menial, they don’t like it, they have a brilliant mind at least in my opinion or great artistic talent and are stuck making sandwiches or something. They quit, they have to get another [menial job] eventually . . . I think frustration is the biggest result. Well one of my friends is supposedly clinically depressed she was diagnosed with depression. I don’t think it’s anything wrong with her mind but just that there’s no situation or place for her and her own set of talents. (Antony, 24-year-old male) A dynamic that prevented access to meaningful work for participants was the nature of wealth-oriented free labor markets. Participants who saw work as a key context for enabling self-realization drew attention to the lack of available jobs that enable an expression of one’s creativity and unique capacities. Profit-maximizing social technologies such as divisions of labor 125 were described as narrowing the scope of skills that a young person could learn within available employment. This dynamic, coupled with wage-suppression practices, prevented secure access to meaningful employment opportunities that realized participants’ abilities in ways that enabled them to give back to their communities. The mismatch between profit-oriented priorities and young people’s need for self-realization through employment was particularly acute for young people with diverse talents and interests not well aligned with the market place. French (17-year-old male) expressed frustration with the lack of funding for arts and cultural programs in his community and the “lack of equality between the artistic . . . and normal community . . . [where] we have to be business people and scientists if we want to make a decent living.” Antony expressed his frustration with the lack of employment opportunities for musicians. Okay, the biggest problem for me and the jobs I’ve had is that what I’m good at and passionate about there isn’t really a market for. I think I’m a good musician—I’ve been playing music for a very long time. When I played in Mexico on the streets I would make sometimes two hundred pesos in an hour, which is the equivalent of close to twenty dollars. Here on a bad day sometimes you can play for two hours and make two dollars . . . I think everywhere but especially in Canada there’s not much emphasis on the arts at all and that’s my theory. (Antony, 24-year-old male) Participants described meaningful work opportunities not only in relation to the engagement in creative and inspiring activities such as the arts and humanities, but also in relation to the development of diverse skills within work oriented to directly meeting basic needs such as food and housing for oneself and one’s community. A few participants suggested that part of the reason that waged labour feels less meaningful is due to a) the ways that they are forced to work menial jobs to access money for resources to meet their basic needs and, more broadly, b) the ways that work has been narrowed in scope within practices of division of labour. These participants explained that working directly to meet one’s basic needs, as well developing a diversity of skills in meeting these needs, would be more meaningful and rewarding for them and enable them to feel like they were contributing to their communities more directly. I used to have grandparents on the farm and I felt that I totally deserved the food that they gave me because I worked almost 18 hours a day on their farm and like I actually worked on something that benefited not only me but the environment, the people I’m helping. It feels better than holding a piece of 126 plastic—‘this might not be my money but here you go’—it doesn’t feel so true like ‘ahh I finally did it.’ (Sarah, 21-year-old female) In our economic system, there is a huge disconnect between your necessities and what you do for work. People need food and shelter, for example, but they don’t participate in growing food, or building houses. They don’t know how to do these things. Instead they perform a repetitive, menial task, in an office perhaps, or a construction site. They receive tokens for their work (money), which can then be exchanged for food and shelter. They are completely dependent on ‘the powers that be’ for these tokens. The whole system is utterly bizarre when I think about it. I find it incredibly frustrating that I have to perform a task that I’m unsuited to, in exchange for tokens that are worth less and less every year (I’m sure I’m not the only person who’s mentioned that the cost of living has quadrupled in my lifetime, while the minimum wage has scarcely budged) in order to eat. I would rather belong to a community in which everyone took part in the food production and the construction of houses, for example. It would be so much more interesting to be actively engaged in so many different areas, instead of forced do to one repetitive task for a pittance. (Antony, 24-year-old male) Social technologies, such as the division of labour and resulting narrowly skilled jobs to access money to meet needs, alienated young people from their work experiences, themselves and other people. Natalie shared similar reflections to other participants who expressed yearning for freedom from worry about meeting their needs for survival so that they could follow their passions and dreams and engage in social life in more authentic ways. She emphasized the importance of finding ways to remove money as an intermediary to meeting one’s needs in order to enable the freedom to engage in intrinsically rewarding work-life activities that meet community needs. This was also associated with enabling social connections in community life. I think really most people’s main stress comes from not being able to pay their bills or working their ass off at a job they don’t like to get just the smallest reward. And it makes you bitter towards other people, you know? Like even people you don’t know, like if you have a bad day at work and you’re saying to yourself ‘I’m working this fucking job that I don’t even like to get me nowhere why am I doing this?’ And you’re taking the train home and anyone who looks at you the wrong way and you’re like ‘what are you looking at and you’re rude to everybody because you’re pissed off at the job you have.’ And if we didn’t have money around and you aren’t working that shitty job to get the small rewards you’re not pissed off at other people, you’re happy as shit because you’re working a job that you love and you’re not worried about your bills. So it’s like ‘hey how are you?’ You know? Talk to everybody . . . I just think it makes it easier for you to be happy and want to interact with other people. (Natalie, 19-year-old female) 127 Although work was identified as a key way of expressing one’s capacities and giving back to community for some participants, a few participants recognized that work was not the only way to engage in life activities that they were passionate about and/or felt to be meaningful (e.g. playing music). However, having to work several low-wage jobs and long hours of low-wage work to meet one’s basic needs for survival resulted in not having time to a) engage in educational programs to develop one’s capacities for engaging in meaningful and inspiring work into the future and/or b) not having time to engage in meaningful activities outside of the work context. . . . it is just pay cheque to pay cheque—you’re getting enough money just to pay your bills. The drywall was contract, the landscaping was like hourly so you got paid but it’s still, you’re just, you’re living off a pay cheque till you get your next pay cheque to live off a pay cheque. It’s almost like you’re working to go to work and it’s a frustrating and self-defeating thing. I know a lot of guys who left work to go sell drugs because at least they can make money and do whatever they wanted all day instead of doing this. (Murphy, 25-year-old male) Gambling for money through panhandling and entrepreneurship In contrast to participants who pursued waged labour, other participants sought income through panhandling and entrepreneurial activities. Participants’ descriptions of panhandling and entrepreneurial approaches to seeking income reflected some parallel experiences and dynamics. Both participants who sought money through panhandling and entrepreneurship associated these methods of seeking income with adventure and the potential of gaining great amounts of money. Furthermore, participants expressed hope that these methods of seeking income would enable greater freedom to enable self and socio-environmental realization. In describing his experiences of panhandling, Derrick (19-year-old male) stressed that he would never want to work for the “corporate shield” and wanted to work for himself, to be his own boss, and to be “goal oriented” with “a sense of inspiration knowing what you’re doing, wanting to do it” (19 year-old male). In relation to his hope of making great amounts of money, Derrick described how “When you panhandle and do odd jobs there is no system for it so you could make . . . that ten dollars in an hour but it’s not predetermined . . . which is great because you never know what you’re going to get.” Donald (28-year-old male), who pursued entrepreneurship, imagined that he could make “millions” and “leverage [labour time]” to maximize profits and in turn, freedom to engage in 128 meaningful and inspiring life activities. However, similar to waged workers, young people using these approaches to seeking income faced fundamental insecurities of their own which evoked chronic stress and anxiety. Participants who sought to initiate their own businesses described challenges to starting a business and then securing ongoing sales and subsequent income streams. They identified the challenges of accessing property and start-up funds such as government small business grants and accessing programs to learn about how to start a business. Murphy (25-year-old male), who wanted to start his own business, obtained student loans to start a business degree program that was a requirement for accessing a government start-up grant. However, the business certificate from the private college he had attended was not recognized by the federal government, which resulted in the loss of access to these funds while incurring student loan debt. John (27-year-old male) explained that he could not qualify for a Work B.C. business development program because he had been in an employment preparation program in the previous five years of his application. This was despite not being able to find work over the past two years and having to live with his mother, to which he described as “insane.” Once starting a business, the challenge of maintaining sales and an income stream became a source of insecurity. This included the challenge of affording the costs associated with renting or leasing property for one’s business and meeting government regulations including costs associated with relevant fees and licenses. Participants also described the need to maintain relationships with business partners and employees, the challenge of engaging and maintaining clients, and the ongoing threat of being put out of business within broader competitive dynamics where “it’s hard for a small business to be successful when it is competing with a bigger business” (Jacob, 18-year-old male). At the end of the day, though, once I close a deal I’m done. That means that I can’t go back to them in terms of getting another sale. There is no reoccurring sale . . . There is no money in terms of a yearly membership or something like that, so what happens is I close a deal . . . I have a stellar month and next month I start at zero. So what that means is if I take off six months to a year at a time, I have no money coming in. (Donald, 28-year-old male) . . . mostly it’s funding, because in order to start my business I need a workspace, like office, right? And then I need equipment and supplies and 129 money, which I don’t have. And I can’t get clients—like, I advertise on Craigslist, right? (John, 27-year-old male) Increasing the odds for a secure income through higher learning In addition to the paths of waged labour, panhandling, or entrepreneurship to seek income, another way that participants sought a secure income was through the pursuit of post-secondary education. Participants with various levels of access to resources described experiencing social pressures and concerns about financial security that focused on striving to access post-secondary educational programs to increase their chances of securing income through good paying jobs. The tension between participants’ need for a secure income and their need for self-realization was illustrated in their reflections on how they felt pressured to give up their primary passions, interests and engagement in meaningful work to seek high paying jobs. These participants described spending their time competing for access post-secondary educational opportunities and then struggling to keep up with their workload with little time for social connections and to do what they love. Younger participants described experiencing pressure and anxiety in relation to getting good grade point average (GPA) standing in high school. They strove to access advanced academic programs in high school (e.g. Venture, International Baccalaureate college) and took summer courses and engaged in volunteer work in the hopes of increasing their chances of getting into competitive universities. Similar to low-wage workers who had little time to pursue interests beyond long hours of low-wage work, older participants with scholarships described the pressures of maintaining their GPA standing and having little time for their own interests, free time, and social connections beyond their academic studies. These pressures and insecurities were described as being faced by all participants to varying degrees regardless of income. French, a 17-year-old who was living on his own, and who was in a French immersion program at a university with scholarships and access to free tuition (as his mother worked at the university), described how this economic “pressure cooker” negatively affected his mental health. I think about money every day; I think about how I will pay my rent; I think about how I will afford to have a decent life after school. All of my worries stem from the central issue of not having enough money. This has caused me to re-think my learning path in order to seek a career that I will learn to like, rather than one which I would naturally find fulfilling. In terms of mental health, this means that I focus on being a competitive student, cutting the time 130 for things that help me enjoy life and which promote mental health such as my artistic practice, spending time with my significant other, relaxing with friends, practising mindfulness, and giving back to my community. I need to focus on getting the highest grades, being involved on campus, having the best job experience, and knowing all of the right people. That’s a pressure cooker environment that I have to go through, just so that I can get a good job to live a decent life. The irony of the whole situation is, despite my basic needs being met or exceeded in the end, by obtaining a top job, I will just be continuing the cycle of neoliberal domination of the working class. (17-year-old male) Colin, a 19-year-old male with stable support from his parents who enabled his access resources such as housing, described how financial considerations, and his need for a secure income for survival superseded his ability to realize his inter-related needs for self and socio-environmental realization. Well I don’t know like even some of my friends they’re like ‘oh I want to be a doctor’ and I’m like ‘well do you like genuinely like helping people is that why you’re going to be a doctor?’—but I can tell that’s not really what they’re in it for and I’ve even had some of them say ‘well it’s good money’ and everything right? I feel people should be doing what they want to do and then be good at it and be happy with their lives because you can’t really make up for your pathetic existence by buying, you know, like the next new toy. And, you know, it’s kind of a balance right because there were things that I might have pursued instead of commerce if I really didn’t care at all about future income and my future welfare and everything. But because the way society is set up . . . you need money like money is the key to everything. (Colin, 19-year-old male) Participants recognized that they faced fundamental insecurities in seeking income as well as meaningful work. They recognized that even if they were successful in completing post-secondary education programs, they were not guaranteed a job in their field of study. Increasing cost of living within wealth-oriented free markets The challenges faced within all approaches to seeking a secure income were magnified by the increasing cost of living that several participants identified as their biggest worry. The increasing cost of living was described as a key threat to accessing resources to meet participants’ mental health needs. Living in Vancouver that I probably won’t be able to support myself when I grow up. The cost of living is ridiculous here like food wise it’s okay I guess 131 groceries but I mean buying a house, it’s just crazy . . . that would be my main worry not being able to support myself. (Andrew, 19-year-old male) The positioning of key resources such as housing within private property relations and the role that profit-oriented market dynamics played in increasing the cost of living created significant and unpredictable insecurities in relation to participants’ access to resources, and thus their ability to meet their mental health needs. Colin described how the speculative housing market that threatened his need for secure housing and social connections: One thing really disheartening about the system right now is the more money you have the easier it is to make money too. So it makes it very hard for people down below . . . specifically for me like my parents can’t get a mortgage on a house because we don’t have like real estate has like skyrocketed in Vancouver so if we could even get a house and then resell it you’d make so much money you make like a hundred thousand dollars to three hundred thousand dollars like even more than that. And because my family never jumped on the bandwagon and bought a house we’ve been renting . . . if you don’t have a house to begin with then you can’t buy another house and you can’t buy another house and keep making money . . . my friend is like ‘oh yeah like we bought this house and like we’re selling it and making this much money.’ (19 year-old male) He explained how he and his family lost the rental home he had grown up in when their landlord “suddenly” chose to sell, leaving them in a housing and rental market with inflated prices that they could not afford. He explained that this loss was “tough on [his] whole family . . . [and] caused some conflict with [his] parents” with both he and his parents feeling a loss of control and “really sad” with how they “all had attachments” to that home and their neighbours. Like other participants in this study, he and his parents thus needed to move to an outlying area where housing prices were lower, which challenged his need to remain connected to his neighbourhood community. Overall, participants described experiencing several challenges in their processes of seeking a secure income and meaningful work and/or life activities to enable their needs for survival and self and socio-environmental realization. Participants were acutely aware of their precarious state, and the effects of that state on their wellbeing. Participants described how profit-oriented tactics such as wage-suppression practices, outsourcing, and labor-displacing technologies challenged their need for a secure income. Participants’ who sought to meet their need for self-realization through employment were challenged by profit-oriented divisions of 132 labor within free markets, which limited the availability of meaningful job opportunities. Conversely, participants who sought to meet their need for self-realization outside of the employment context, were challenged when caught working low wage work in cycles of survival to meet their basic needs and thus did not have time outside of the employment context to engage in meaningful life activities. In summary, monetized, individualistic, and wealth-oriented socio-economic processes not only posed challenges for participants from the position of labor, but also for participants who sought income through entrepreneurship, or starting up their own businesses. Participants who wanted to develop their own businesses identified several barriers to their entry into the business cycle and then maintaining an ongoing income stream. In some key ways, their experiences paralleled those who were homeless and whom sought income and self-realization through panhandling. These insecurities and challenges in meeting inter-related needs were also faced by those who were striving to access post-secondary programs in the hopes of increasing their chances of securing good paying jobs. The core dynamic of wealth creation and profit maximization within private production and distribution processes also created challenges for participants’ need for a secure future and their need for self-worth and authentic social connections. The need for a secure future and inspiration in the context of endless economic growth Everything is changing. [Neighbourhood] is. They are going to knock everything down and then rebuild the mall and then rebuild apartments and everything. And they are planning, on [street name], to put more stores around there to make it more civilized. And there used to be a gas station there, but I am pretty sure they are building another apartment there. And everything is just changing. I don’t really like it because it’s going so fast and I still have those memories of what it was before . . . our generation is watching everything change so quickly I guess we’re not really that used to it . . . I feel like since we’re running out of room for houses and everything, which is kind of sad, and we’re overpopulating, I feel like everything is going to turn into New York. And I don’t want it to because I’ve been to New York and the air was not as great as here and I just don’t want to see it change like that. But my mom says one day it will be like that. (Aubrey, 15-year-old female) Participants expressed worries about the threats that the ongoing production and consumption of commodities are posing to their natural environments and to their need for a secure future. Several participants expressed worries about population growth and increasing 133 competition for resources. Participants recognized that a central goal of producing ongoing commodities (and the advertising to encourage consumption) was to make profits. Jacob took a photo of a garbage can with “capital” on it and shared: I found this really ironic—a garbage can that has ‘Capital’ on it . . . I’m guessing that’s a company’s name—but the idea of Capital . . . And the best part is that it was right beside an abandoned shopping cart . . . I mean the idea of capital. Capitalism. How it’s kind of: buy-dump, buy-dump, buy-dump, right? That’s kind of the thing. You buy something, then when it’s obsolete, you dump it! And you need to keep that process going. It’s actually interesting a lot with computers, where they go obsolete by just one thing. One little piece in the computer—that’s the only thing that needs to be replaced for the computer to be perfect. But that company will say: No, dump it. (Jacob, 18-year-old male) Participants’ associated this growth with pollution and expressed their concerns regarding the threats to their natural environments and future access to resources. Jacob shared a photo of construction and shared about his inter-related worry about the increasing price of housing and the association between increasing development and increasing pollution, I was thinking construction. Actually, a couple of things came to my head . . . 1) construction; like more buildings, less things we’ll be able to afford, right? I also thought about all the pollution that that is going to cause, right? To have empty buildings. Because right behind them, there is a bunch of buildings that are completely empty as well. All the Olympic Village . . .? For some participants pollution threatened their need for inspiration through connecting with the beauty of nature. In describing a photo that she took of a bush behind a fence, Anna reflected on the threats to her need to see beauty in the world. This is the beauty of the world getting stuck in chains. It sums up the entire picture. Because the thing is the world does have a lot of beauty, it does. But the things that people do destroy it. Like, completely. Pollution . . . if we had a picture of how the world was before so much pollution happened, it’d probably be so much different. This kind of scares me, because we ain’t that green! . . . They should try because we don’t know if the world can actually be destroyed by pollution. We don’t know. But who wants to live in a world where there’s no plants? Where there’s no trees? That’s disgusting—like, have you guys seen the Hunger Games? You see where they live? I never, ever in my life want to 134 live in a place like that. (17-year-old female in small group interview with two other participants)32 Explored more fully in chapter six, participants’ distress in response to threats to their natural environments was also evident in the ways that they described blocking out aspects of their environments that worried them (e.g. farmed salmon) and their recommendations for environmentally sustainable practices such as the 100-mile diet and permaculture. These dynamics of economic growth were described as being inter-related with an increased sense of the pace of change, which lessened time for social connections. Several participants expressed feeling “pressured” and overwhelmed by the “increasing pace of change” in their socio-economic environments. They variously attributed the increasing pace of change to: ongoing production of new commodities (e.g. Iphones) and technologies (e.g. online social media); the pressure to keep up with information and new social media platforms; and the need to seek money to meet one’s basic needs for survival, or, as Natalie put it—being in a rush to get to their jobs “for fear of getting their asses fired” (19-year-old female). Haden (17-year-old male) suggested that people are “racing against life” in the pursuit of “making money to make a living to survive.” This struggle to seek a secure income and to keep up with the latest commodities and evolving social media technologies were associated with increasing isolation, and creating less time for family and friends. At times, participants felt that no one was listening to young people. This was the case particularly for young people who had parents who were working low-wage work where parents considered free time to be “time [that parents aren’t] making money” (Cassie, 15-year-old female). Parents caught up in social media sites themselves were associated with creating a sense that no one was listening to young people (Group interview). Mindmatters (25-year-old female) and Molly (25-year-old female) suggested that this increasing isolation plays a key role in increasing the risk for suicide among young people. These dynamics of endless growth through production and consumption were also described as being inter-related with social dynamics. Jacob shared that one of the main drivers for consumption is to buy products that enable one to fit in with one’s peers: 32 Note this participant turned 17 in between her first and second interview. 135 Because if you think about it, the idea of having the newest thing is the way we live by. The way school goes by, where a lot of times you’re being measured by what you have. That whole social status in school, where ‘I got the new iPhone,’ or ‘I got the new android,’ where there are kids that don’t, that can’t have the phone. It’s hard for them, right? But high school is that environment where you need to have the stuff to be part of the group. And to be part of the group is mental health . . . (19 year-old male). This need to fit in with one’s peers was shaped by broader socialization processes that generated dominant wealth-oriented notions of success and beauty in participant’s socio-cultural environments, which challenged participants’ needs for self-worth, self-realization, and authentic social connections. The need for self-worth, self-realization, and authentic social connections in context of wealth-oriented notions of success and beauty Participants described socialization processes that promoted and strengthened wealth-oriented notions of success as undermining their mental health. Participants suggested that wealth-oriented and material notions of success were a central part of the “capitalist brain wash” (Da Dragon, 19-year-old male) in which success is attributed to having wealth and people are judged based on their ownership of status-based commodities. Participants explained how wealth-oriented notions of success negatively affected young people’s self-worth, peer relationships, and their need for self-realization. Participants described comparing themselves to notions of “perfection” that were reflected within media and advertising, which represented “middle-class” or “upper-class” people. Central norms and social expectations that were reflected within participants’ descriptions of the wealth orientation of their socio-economic environment included the need to be confident, independent, financially successful, and to have status-based jobs and/or commodities that signaled one’s worth to self and amongst peers and within one’s community. Participants suggested that the drive to make money, “to be the 1%” (Haden, 17-year-old male), and the ways that social status is attributed to what one has versus who one is (Mindmatters, 25 year-old female), are central norms driving consumption and patterns of individualism and competition within their social contexts. In this day and age the way that we were brought up and how money is attributed to success. And success, you know, you get the prestige you get the attention . . . we measure each other’s worth by successes by what we have, the 136 materials right? Like ‘[name] over there has a nice car I wish I had a nice car like that.’ And that’s where it adds to competitiveness too so now we’re in a culture of pretty much money equals the power which equals the respect. Oh I see that right now we’re so entrenched in this capitalist brain wash. (Da Dragon, 19-year-old male) Wealth-oriented notions of success were also described as being inter-related with racialized and gendered notions of beauty. Through advertisements and media like they advertise perfect lives and celebrities are put on this pedestal. Well they’re human as well, they probably have their own problems to deal with . . . especially with physiques . . . like men are supposed to be big and muscular and then women are supposed to be really slim and always have perfect skin. (Andrew, 19-year-old male) I always see people trying to be the upper class . . . If you smoke, you’ll be cool. If you smoke, you’ll be rich. I don’t know. It’s always a false advertising. Because richer looks cooler because you can afford anything. Like, look at vodka commercials, beer commercials. It’s always the young, handsome, white male in the suit. And he looks rich and he’s in a huge penthouse or whatever. If you drink this, you’ll become like him. (Haden, 17-year-old male) Participant reflections illustrated three main contexts that generated and strengthened wealth-oriented notions of success, including that of media and advertising, social media, and competitive schooling environments strengthened by parental pressure. Participants recognized that a central goal of advertising was to encourage consumption and ongoing sales and profits, and suggested that a central goal of teachers and parents was to encourage young people to succeed in their schooling in order to increase their chances of securing good paying and/or socially prestigious jobs. Participants recognized that their teachers and parents had good intentions in terms of seeking a secure income stream for young people, or as Cassie (15-year-old female) put it in relation to parents: “hav[ing] to focus about money and be stressed out all the time because [they are] trying to look out for [their] family.” However, being socialized within these dominant notions of success threatened their self-worth, their need for self-realization, and authentic social connections. This included feeling stigmatized and judged when they did not look “corporate” enough (Sarah, 20-year-old female) when applying for jobs and interacting with others in day-to-day life. A few participants suggested that young people should just focus on changing their minds and not care about these materialistic values. Several participants, however, described facing 137 powerful socialization processes that oriented them and their peers towards basing their self-worth on wealth-oriented notions of success. Furthermore, just changing their minds and not caring about money was challenged by the pragmatic reality that money was needed to access resources for their survival in their monetized economic context. Participants further drew attention to the ways that young people are socialized to need money to enjoy time with their friends and the ways that social life has been increasingly monetized in which people need money to participate in social and recreational activities. In this context, economic inequities were described as further challenging connections among peers with varied levels of access to income, creating varied forms of emotional distress for both low- and higher income young people. Media and advertising Participants identified media (e.g. television, computers, video games) and advertising as key spaces in which wealth-oriented notions of success are generated. Advertising was seen by participants as functioning to promote profit through depictions of wealth-oriented notions of success, which worked in concert with social comparison dynamics to promote consumption at the expense of young peoples’ self-worth. Participants suggested that “if advertisers cared about young people, they’d tell them to be themselves” (Group interview). Participants described how media and advertising narrowed the valuing of diversity within peer and broader school and community cultures. Several participants talked about the “brainwashing” of such messaging that affected the way they define beauty and success and, in turn, the ways that they view and judge themselves and each other. Participants described the influence of advertising on self-worth as being inter-related with social comparison dynamics, competition, and patterns of inclusion and exclusion within peer networks. Their plan is to make children want it so that their parents will get it . . . So that they can sell their products. And let’s say that product is a big hype at school, right? That affects children a lot . . . it’s sort of like if you have this then you’re in, and if you don’t you’re not. (Cassie, 15-year-old female) Participant’s self-worth was described as being shaped by comparison of self to the notions of success and gendered beauty depicted in media (“the perfect person”) and then in relation to peers. If young people fit the media depicted ideal—either in relation to their level of 138 gender-based beauty and/or ability to purchase status-based commodities associated with upper-class ideals (e.g. “fancy watches, or iPhones”)—they described feeling greater self-worth and anticipating and/or experiencing more inclusion in peer networks. If they did not match this ideal, they described feeling lower self-worth or “feeling like shit” (Yana, 16-year-old female). When participants did not achieve these norms, they described experiencing stress and fear of being excluded from their peer groups. Donald suggested that young people between 5 and 20 years of age are particularly influenced by these media messages and explained “society is just projecting Barbie dolls and Ken dolls and the perfect body and the perfect relationship and the perfect careers. When people don’t stand up to it . . . it’s a lot to do with self-worth” (Donald, 28-year-old male). Aubrey: Media is really big because you know how people say: ‘You have to look a certain way and everything.’ Isabella: Or like: ‘Buy this product and then you’ll be like this!’ Aubrey: It’s really difficult to live up to that picture. Because we don’t want to change who we are. Isabella: Yeah, it’s plastered everywhere. If you look at the billboards and posters. Aubrey: It’s sad. A person sees at least 400 advertisements a day. And we can’t do anything about it. And we just don’t want to be like that, but since society says you have to look like this, it somehow changes everybody’s minds to say: ‘Oh, you have to look like this.’ Isabella: Especially when you see it every day, you start to believe it . . . I try not to care, but sometimes you do because it’s just all around you. Everywhere you look, on TV, magazines, just everywhere. Aubrey: You try so hard not to think that you’re not pretty or that you’re not ugly or so different from everybody else. But it’s just hard to not think that. (15 and 16-year-old females) . . . let’s say for a girl who is really insecure about herself . . . she sees a really popular girl wearing a TNA33 sweater or just a load of people in the school, just in general, popular, non-popular, just everyone wearing a TNA sweater. It doesn’t have to be black; it doesn’t have to be the same kind. It’s just from TNA and you know it. You see it, you know it. So you’re kind of like, without 33 TNA is a brand of clothing sold in Aritzia fashion boutiques across North America. 139 yourself really realizing it you’re kinda like: ‘You know what? I kinda want a TNA sweater. I kinda need a sweater . . . I’m just going to go get one at TNA.’ You kind of make an excuse to cover the fact that you’re just trying to fit in. So you buy the sweater, and in your own mind you kinda think that everyone else is thinking . . . you kinda feel like you’re making a name for yourself and everyone is like: ‘Oh, she has a TNA sweater? She must be cool.’ (Anna, 16-year-old female) Dominant wealth and gendered notions of success, which were associated with being able to attract potential dates, evoked additional stress and worry for young people as they sought intimate relationships. Participants described how females were expected to be confident, wealthy and beautiful and males were expected to be confident, wealthy and strong. . . . like confidence and self-esteem is always key but then not everyone is blessed with great confidence or self-esteem right or, or wealth because I have been to like clubs and decked out . . . I’m wearing like black and I just polish my bling so that it stands out some more. And, you know, when women see that they’re like ‘oh he has money’ and then just like talk to me more . . . (Da Dragon, 19 year-old male) While participants thought that biological and genetic drives influenced perceptions of beauty to a certain degree, they also suggested that media and advertising strengthened certain notions of beauty. Dominant notions of success and beauty in relation to what young people considered attractive in seeking an intimate partner evoked mixed feelings. This included disagreement with these notions of beauty mixed with worry, fear and, felt pressure to achieve these ideals in the hopes of attracting an intimate partner. Aubrey: We’re also worried about being single forever. Well for me, I’m not sure about her! We’re worried that what if nobody actually finds you attractive? Because people just look at you for your looks first. And then if you don’t look that great to them then (makes dismissive noise) whatever! Isabella: For example, if you’re in a room and you’re looking for a boyfriend or a girlfriend, if there’s a room full of girls and guys you’re not going to choose the one with the best personality. Obviously you’re going to gravitate towards the one that’s the best looking to you. Aubrey: And I totally wish that it wasn’t true. (15 and 16-year-old females) Well because what contributes to stress too is because when people think of success money and by money it’s how I can get like an S O, a significant other right? It’s like ‘oh, if I don’t have money how can I flaunt my wealth to get her 140 like to be interested in me right’ because I don’t want to be Joe Blow or average right?’ (Da Dragon, 19-year-old male) These expectations and the challenges that they posed to young people’s self-worth and peer relationships were further strengthened by social media. Social media Participants’ reflections illustrate how social media has become a key context for reinforcing wealth-oriented notions of success and, in turn, further challenging young people’s mental health. Social comparison dynamics were strengthened within online platforms in which young people post images and narratives about their lives, which enabled social judgments and comparisons among peers. Anna (17-year-old female) took a picture of her cell phone and the various social media platform sites, which she described as having the power to “destroy your self-esteem.” Other participants described how social media is “addicting.” Brenda (16-year-old female) explained how, “At first the internet was cool because you could look up everywhere in the world, and it was fun. And then it just got really addicting. It’s kind of like a drug . . . because it is bad for you, actually.” Participants described social media as a platform for “put[ting] forward the best image of [one]self” (Mindmatters, 25-year-old female) and a space for “gossip” (Anna, 17-year-old). My friends are so obsessed with gossip that if they don’t have their phone they get kind of like ‘Oh, I need my phone; I need to know what’s going on; I need to know who’s who, who’s wearing this,’ and I feel like sometimes we need to let go of all this technology. (Aubrey: 15-year-old female) The internet was also described as a space for criticizing or bullying with impunity, with a destructive impact on young people’s self-worth, to the point of bringing young people, like Amanda Todd,34 to the point of suicide. Consistent with these worries, participants recommended helping help young people to have greater control over the negative effects of media and corporate advertising through critical media literacy programs. 34 Amanda Todd committed suicide at the age of 15 in response to cyberbullying and sexual exploitation. Prior to her death, she posted a video to YouTube sharing about her experiences of being blackmailed into exposing her breasts on webcam, bullied and physically assaulted (CBC, Fifth Estate). 141 Schools and parental pressure How does the world affect me today? Well, I think a lot of it has to do with education and realizing the competitiveness of the world, realizing that I’m surrounded by crazy keener kids who are going to be extremely well educated and like the workforce is going to be extremely competitive and that’s one of the major things that the world is influencing. So it makes me want to try and be as competitive as possible, you know, try and get the best education I can, try and be as active and involved as I can. (French, 17-year-old male) And if I don’t do good [in school], I’m going to become homeless. I’m going to have to beg people in the street for money. That’s what my parents always tell me: ‘Oh, you’re going to end up in the street, homeless, begging for money.’ (Isabella, 16-year-old female) Schooling experiences backed by parental pressure comprised another central domain of young people’s lives that strengthened wealth-oriented notions of success and thus challenged mental health. Schooling systems were described as the initial grounds for fostering competition. Younger participants reflected on messages they received from their teachers that a main goal of schooling was to obtain work upon graduation and they described pressures experienced from parents to seek “good grade[s which] equals good post-secondary” (Jacob, 18-year-old male) to increase their chances of obtaining good paying jobs, financial security and/or social status. Money, success, happiness, it’s all concreted into each other now, you know, by the system that we have . . . school system which raises your competition against each other. For example, my friends in engineering [refers to big university], they’re like ‘it’s just so competitive’ right? And school has taught them that ‘and you have a better job then you can make more money.’ The more money, you can go to places, travel, afford things that you normally couldn’t without that job right? And that’s where success comes in too because we measure each other’s worth by successes, by what we have, the materials right? Like [name] over there has a nice car I wish I had a nice car like that. And that’s where it adds to competitiveness too so now we’re in a culture of pretty much money equals the power which equals the respect. (Da Dragon, 19-year-old male) Participants described how competitive dynamics in schooling challenged their self-worth and peer relationships. They expressed concerns with the dominant focus on grades and graduating to get good paying jobs to the neglect of focusing on mental health and peer relationships. Cassie had been accepted in an advanced academic program in her high school with encouragement from her mother. While recognizing the importance of accessing money to 142 avoid suffering, she drew attention to the complexities of learning for young people and emphasized the importance of focusing on young people’s experiences with relationships and other aspects of their lives that impact their mental health. Like participants who described how their need to seek income for their survival superseded other inter-related mental health needs, Cassie’s reflections illustrate a theme amongst school age youth in this study whom described how parents’ focus on encouraging young people to do well in school to increase their chances of seeking a secure job upon graduation oftentimes superseded their attention to other mental health needs. I think adults are a little narrow-minded about that. Let’s say you’re in high school. Your parents want straight A’s. Okay? For some reason straight A’s is going to get you somewhere. It’s going to get you to be that doctor, right? You need straight A’s. Not for you, but for me, right? They don’t realize that it’s not that simple, getting an A. ‘Do your work.’ That’s not very simple either. I could do my work, but I could still not do well in my work. I could still screw up and that could change an 86, which is an A, to an 82, which is a B, but no—it’s not an A. They want an A . . . They’re so fixated on ‘get an A’, but they don’t care about the process. I don’t get that. If you’re not learning or if you’re really struggling, they don’t care. They just want that A, for some reason. Well, I’m not saying like you shouldn’t focus on money, because without money you’re going to suffer, right? But you should be more focused on the things surrounding us. Parents need to be more aware of what their children are going through and how they feel about that. It could be easy to say: ‘Your boyfriend dumped you? Get over it.’ No, you don’t understand. Maybe things in between that. Oh, God, in between. Everything is in between that. There’s things . . . what you get exposed to changes how you think of things in life. (Cassie, 15-year-old female) A central emphasis on grades and GPA standing in high school created significant pressure for young people in this study and was inter-related with social comparison and competitive dynamics. These dynamics were described as severely challenging for young people’s mental health, both threatening their self-worth and, in some cases, bringing young people to the point of suicide. Jacob, Anna, and Cassie described how young people in their school assume a hierarchy between regular and advanced academic program students. They expressed their frustration that a young person who gets a better grade, or is in an advanced academic program, is viewed as better than other young people in their school. Advanced academic programs were described as being “really competitive” with young people who receive better marks feeling “superior” (Cassie, 15-year-old female). They explained how students judge 143 each other based on who made it on the honour role. Similar to other participants, they drew attention to the pressure young people are under from their parents to get good grades. They gave examples of young people who were too afraid to tell their parents about their grades, in one case a youth who committed suicide out of fear that her parents could not cope with her getting a C. You know what’s sad, too? Because I was in acting class, right? And there was this one international student who wanted to be in that class, and when she called her house to be like, ‘Hey, I am going to take this class,’ her parents said, ‘No, you cannot.’ And then she had to take an extra academic course, and it was just too much for her. So she got, I don’t know, I think she got a C in one of the courses. She actually hung herself because she knew that if she told her parents they would just be devastated. (Jacob, 18-year-old male) Participants explained how in some situations competing and seeking access to post-secondary educational opportunities and scholarships resulted in distrust among peers and careful decision-making regarding whether to tell peers about scholarship opportunities or not. Haden explained, “and I am also competing with my peers so I never talk to them about scholarships . . . I wouldn’t tell them unless they’re my best friends as it’s so competitive” (Haden, 17-year-old male). Participants described how competitive dynamics at times influence good people to give wrong answers to peers to improve one’s chances of doing better on exams and accessing scholarships and post-secondary educational programs. Really it’s really just a type of capitalist system you know, where you’re just reaping off others and, you know, competitiveness even like, even in high school it was always competitive like the smart people they’d purposely give you the wrong answer right? I have a good number of friends who are trying to get into med school and engineering. They’re like it’s just brutal, it’s just butt rape. And I was like wow, and like even them—they’re good people and they’re like ‘even we have to give the wrong answers’ and stuff too right, just to like screw them over . . . And it’s just, it’s just hard to comprehend that. (Da Dragon, 19-year-old male) Participants described how competitive dynamics left little time for social connections and developing social skills. Participants explained that for many, struggling to compete and succeed in school took up so much time that they had little left for enjoying life and sharing time with friends. These competitive dynamics were also described as leaving little time for social interactions, which prevented the development of good communication skills to support one’s participation in employment settings as well as developing relationships with other people. 144 Unless you have a very good footing in that competition you’ll just end up like being stressed, again looking at my friends who are trying to go to med school or engineering-they have next to nothing in the social life department. (Da Dragon, 19-year-old male) In addition to the ways that participants sought post-secondary education to increase their chances of accessing a secure job (and income), wealth-oriented notions of success influenced young people’s decision-making regarding their educational and career paths in seeking social status and social inclusion. Participants described how they were socialized to seek self-worth and social status through accessing high status jobs and status-based commodities, which challenged their need for authentic self-worth, social connections and self-realization. Parental and social pressures to access high-income and status-based career paths were in tension with participants’ needs for authentic self-worth and their need for meaningful work and/or life activities that realized their unique capacities and interests. False expectations that moving up socio and economic class will make you happy or make your life ten times better . . . [comes from] media, movies, could be video games too . . . Parents too . . . [makes reference to his ethnic background] like I know its stereotypical but a lot of my friends too like their parents always want them to be some type of professional because that makes money and then they can brag to their friends and life will be so much better once you get there. I mean just getting into [names university] is like a prestigious goal which I don’t really like that term but some parents like to brag to other parents like ‘oh my son got into [names university], my son is a lawyer’ and it’s just face like, be proud and arrogant. I think that could just be a product of the western like media value like just outward success I mean if he’s a lawyer and he’s about to commit suicide I don’t think that’s very successful. (Andrew, 19-year-old male) I feel sometimes society has the wrong idea about what it is, what we’re meant to do, like kind of people are kind of caught in the capitalist ideal that like ‘oh I got to make all this money so I can buy all these things’ but really people have to sit back and, you know, just look back and say like ‘oh well I should also be enjoying my life and I should be like finding a career that I’m gonna enjoy and have a fun time doing.’ And, you know, and that way they’ll be able to make the most difference in the world. (Colin, 19-year-old male) Participants described how they had little control over their exposure to socialization processes that strengthened wealth-oriented notions of success. This context, along with their need for money in order to participate in social activities, created challenges for their self-worth and developing social connections across economic differences. 145 The need for social connections in context of the monetization of recreation (social life) and economic inequities Participants described the inter-related way that the monetization of recreational activities and economic inequities evoked varied forms of distress for participants with differing levels of access to economic resources within their attempts to seek social connections. Several participants shared their observations of economic inequities across their peer groups, neighbourhoods across Vancouver, and for participants who travelled, across countries. A couple of participants expressed concerns with the ways that recreational, leisure and play activities have been monetized. They challenged the assumption that money was needed to enjoy time with friends and drew attention to how they had been socialized to assume that they need money to engage in activities with friends. They reminisced about times in their childhood in which they played “in the dirt” (Mandie, 27-year-old female) or played tag with friends and described how they were socialized to engage in activities that required money once entering their adolescent years. Social comparison dynamics, combined with parental and societal pressures to “mature” and “be an adult” (Da Dragon, 19-year-old male) resulted in felt pressure to engage in these activities in order to fit in with peers. Because, you know, as you grow older some stuff you really can’t do anymore for a social life. Okay like I’m still down to play four-corner soccer and just kid stuff like tag and whatever, you know, it’s fun, it gets you moving . . . and you’re just bonding with friends right? But as you grow older . . . other people would just look at you weird like ‘you’re grown ass adults we have standards . . . social norms that we expect you to conform to,’ you know? And if you look at it the school system, the way our parents raise us, most of the time that’s how they expect us to conform and ‘act our age.’ So it just can be like ‘hey [name] do you want to go and play cops and robbers or whatever?’ you know? He’s like ‘no man, why don’t we just go to the gym and work out?’ (Da Dragon, 19-year-old male) Within this context of monetized recreation and leisure activities, and, more broadly, dominant wealth-oriented notions of success within their socio-economic environments, participants with varied levels of economic resources felt emotional distress when trying to connect across economic differences. Participants described experiencing various forms of distress, depending on their level of access to income and resources, when they tried to engage with peers in social activities that cost money. While social connections were identified as more 146 important than money, having money was associated with enabling one to do things in social life. Several participants emphasized that, “you need money to do everything” (Aubrey, 15-year-old female) and “if you don’t have money you can’t be my friend (Brenda, 16-year-old female) because “everything costs money” (Anna, 16-year-old female). Yeah money, if you want to go out with your friends, you need money. If you want to go to a movie you need money, if you want to go out on a date you need money, girls don’t like it when they have to pay for you. [Laughs] Some don’t mind, once in a while, okay, but if it becomes like a constant thing they get really annoyed. (John, 27-year-old male) Isabella: Everything requires money now. Like when we want to do something fun, everything is money: the movies to the pool, if you want to go to the mall or just grab a bite to eat, taking the Skytrain, the bus. Just anything you want to do to have fun, it requires money. Aubrey: And it’s just difficult sometimes, that you can’t do what you want to do because of money. And sometimes we just want to go out and have fun, right? But we can’t because we don’t have the money for it. I mean, we want to go to indoor beach volleyball or something and it’s like $15 per person. We just really don’t have that kind of money right now. Isabella: Money goes by really fast . . . And food. Food is a very big one. Aubrey: Yeah, food for us. We always go eat as a big group and it just brings everyone together. (Aubrey, 15-year-old female; Isabella 16-year-old female) Lower income participants variously expressed frustration, anger, embarrassment and fear of being excluded when they did not have enough money to purchase status-based commodities and/or to participate in activities with peers who had money. You always want to be part of things and to be included. I mean, in a lot of situations that does mean you need money. And if you don’t have money, what can you do? You don’t want to go and be like: ‘Oh, I don’t have money.’ Right? That’s really embarrassing. Especially if there are people who do have that kind of money, right? You don’t want to be that outsider that, you know, isn’t as, say, ‘blessed’ as other people . . . And even if there’s people who are nice enough to not [judge you], it’s sort of like if you don’t have it—‘Oh, you’re not in this.’ But you can’t be in it, therefore you won’t be able to experience things. I mean, what materialistic thing in this world cannot be bought? (Cassie, 15-year-old) Conversely, young people with greater levels of income expressed feeling guilt when they had more than their peers and described how they avoided talking about money and 147 activities that required income when they spent time with peers who had fewer economic resources. Participants with greater economic resources also expressed frustration with not being able to do things with their low-income peers who could not afford to participate in activities that required money. Their empathy for lower income peers was evident in the dialogue sessions whereby one of the members who had more income offered to buy a bike for another lower income research participant who had shared how she could not afford transit or to buy a bike while living on her caregiver’s low fixed income and in response to her challenge to find employment as a youth with little work experience. It adds to guilt as far as like my economic standing goes because I understand that we’re somewhat above average because we do have a lot of expendable income. I have pretty much everything I would like to have . . . And I’m thankful for that but I also feel really guilty for that because I see people in Vancouver that have a hard time even going to a public school . . . I try not to involve money or things that cost money, you know, I try not to mention money, it’s mostly just about me and my friends, you know. You know if we play basketball . . . we don’t talk about what shoes we’re wearing or what basketball shorts we have on, we just play basketball. (Barry, 15-year-old male) Lower income participants shared their observations of how higher income young people will either flaunt their economic wealth in seeking approval and attention from peers or will hide their economic wealth in not wanting to stand out from peers. In response to these challenging dynamics, participants suggested that community and youth centres were important to enabling young people to engage with each other in social life across economic differences. One participant shared how he avoided spending time with young people of differing incomes to avoid these dynamics. Personally, I have never been able to maintain a friendship with a rich person, and I don’t think it’s because of any bias on my part. I have struck up friendships with rich people before, but invariably they will invite me to do something that seems completely normal to them, such as skiing or snowboarding, or boating, and I won’t be able to go because it costs too much. Or we will go out and they will choose a place to go for dinner and drinks, and when we arrive I can’t afford anything. Alternatively, I will take them to a dive like the [pub], and they will be super awkward, if not obviously frightened, and imagine that everyone who speaks to them wants to mug them . . . Some wealthier young people might be perfectly nice, and willing to befriend anyone, but they live in a different world and do different things. They have no 148 idea how other people live, and it’s an obstacle to connecting with them. (Antony, 24-year-old male) Overall, participant reflections draw attention to a central contradiction between capitalist socio-economic dynamics and young people’s mental health needs. These dynamics were described as challenging participants’ mental health needs in several ways. Participants’ positioning within individualistic profit-oriented production and distribution processes created insecure access to income and resources across socio-economic positions. Increasing divisions of labour alienated young people from themselves and others in community life through the production of narrowly focused, menial work that they were dependent upon to access money and resources for their survival. Working several low wages jobs resulted in vicious cycles of “working to go to work” to meet one’s need for survival, which left little time for engaging in meaningful activities beyond the work context and realizing other inter-related mental health needs. Participants simultaneously faced an increasing cost of resources and expressed worries and concerns about the state of their natural environments and access to resources into the future. Across all levels of access to income and resources, participants struggled to protect their self-worth and relationships from wealth-oriented messaging and struggled to connect with peers across economic differences in a context where social life was monetized and hence, required access to money in order to engage with others in key aspects of community life. Comparison to Policy Documents These contradictory dynamics are mirrored within the policy documents. As described within chapter four, proposed definitions of mental health and programs within the policy documents partially align with participants’ expressed mental health needs. However, the overarching goals of the policy documents not only do not focus on enabling access to resources for survival and other inter-related mental health needs (i.e. social determinants of health) as a universal and foundational mental health promotion strategy, but position mental health programs in ways that support economic growth. One of the central goals within the policy documents is to foster economic growth and prosperity. Analysis of the policy documents in relation to participant reflections shows how, within the contradiction between capitalist socio-economic dynamics and young people’s mental health, both mental health programs and young people (as recipients of proposed programs and mental health promotion initiatives) are 149 positioned to support capitalist dynamics within the mental health policy documents. This positioning is evident within the stated goals and outcomes of proposed programs. This positioning is also evident in relation to the ways that proposed programming is oriented towards cost reduction and the ways that recipients of mental health programming are positioned as workers in support of production and capital accumulation processes. Goals and arguments (rationale) for the proposed programs and initiatives within the policy documents that reflect a clear position in support of economic growth include the following statements: 1) within the framing of childhood early intervention and prevention programs as “set[ting] the course for a healthy, fulfilling and productive life . . . [in order to provide] personal, social and economic returns” (BCMHS & BCMCFD, 2010, p. 3); 2) within arguments made regarding the importance of efficiently using mental health and substance use supports and services in order to ensure that “everyone involved in promoting the healthy social and emotional development of British Columbians can maximize their investments and yield long-term positive outcomes and economic gains for individuals, businesses and government” (BCMHS & BCMCFD, 2010, p. 2); 3) within the milestones (overarching outcome indicators) which reflect the way that mental health is positioned in support of businesses: “Good mental health contributes to improvements in social interactions and effective functioning, and is fundamental to the resilience of individuals, families, communities and businesses” (BCMHS & BCMCFD, 2010, p.7). The emphasis on securing economic gains is also reflected in arguments regarding the importance of preventing lost productivity gains within the corporate sector and broader economy: “The indirect costs of mental illness and/or substance use are also significant. A recent Canadian study has suggested that mental illness costs the Canadian economy $51 billion annually in lost productivity. B.C.’s proportional share of this burden would be more than $6.6 billion each year. Indirect costs of lost productivity related to alcohol use alone are estimated at $1.1 billion.” (BCMHS & BCMCFD, 2010, p. 2) 150 “The Global Business and Economic Roundtable on Addiction and Mental Health (GBERAMH) estimates workplace mental disorders and sub-clinical mental health problems in Canada annually result in $33 billion in lost industrial production.” (BCHA & BCMHLS, 2009, p. 73) There are two central ways that B.C. mental health policy is oriented to supporting economic gains as reflected within goal statements, proposed programs and initiatives, and performance targets and outcome indicators. The first entails the focus on cutting costs in the public sector. The second entails the positioning of recipients of mental health care as workers in order to prevent lost productivity and in turn enable economic gains within the private sector. The focus on cost constraints is reflective of neoliberal practices, which position state apparatuses in support of capital accumulation processes through cuts to social programs and fiscal policies such as corporate tax breaks (Harvey, 2005) among other “class-determined public policies” (Navarro, 2007, p. 53) including: “(a) deregulation of labor markets; (b) deregulation of financial markets; (c) deregulation of commerce in goods and services; (d) reduction of social public expenditures; (e) privatization of services; (f) promotion of individualism and consumerism; (g) development of a theoretical narrative and discourse that pays rhetorical homage to the markets, but masks a clear alliance between transnationals and the state in which they are based; (h) promotion of an anti-interventionist discourse, that is in clear conflict with the actual increased state interventionism, to promote the interests of the dominant classes and the economic units- the transnationals- that foster their interests” (Navarro, p. 53). The focus on cost constraint within the policy documents coincides with the documented reduction of corporate taxes in B.C. over the past decade (Ivanova & Klein, 2013; Lee, Ivanova, & Klein, 2011). Aligned with individualistic private production and distribution processes, cost cutting is done, in part- through the development of self-help and self-management tools. Development of self-help and peer-based supports are identified as less costly options to support people with mild to moderate mental health challenges: “It is clear that aligning the existing community capacity to identify and address problems earlier is essential to reduce suffering and avoid more costly hospital or residential specialized services later on . . . Low-intensity interventions for people with mental health problems provide a means of serving a greater number of people. These interventions, which include self-help tools and supported self-help programs such as the Bounce Back or First Link programs, offer cost-effective forms of help that can be accessed directly or delivered by personnel who are not necessarily mental health specialists . . . 151 By 2015, over 50,000 British Columbians will have access to Bounce Back, a program designed to help people cope with mild to moderate symptoms of depression though education materials and phone support.” (BCMHS and BCMCFD, 2010, p. 29–30) This includes the development of self-management tools such as the Dealing with Depression program for youth deleted rest of sentence speaking to supporting families program (BCMHS & BCMCFD, 2011a, pp. 32–33). Although inter-sectoral work is identified as important in addressing social determinants of health (SDOH) that are influenced by public policies beyond the health sector within these documents, inter-sectoral work within the mental health policy documents is primarily oriented towards minimizing the costs of service provision. The main ways that collaborative work across sectors is taken up is a) to tailor and wrap existing services around people with mental illness more efficiently (e.g. through shared care models, integrated models of service delivery) and b) to reduce costs associated with other services. Examples of this inter-sectoral approach to cost cutting are the Homelessness Intervention Project and the Community Assistance Program. The Homelessness Intervention Project, which is administered by Housing Matters B.C., aims to “help those in the greatest need, including those living with mental illness and/or problematic substance use, with access to safe, affordable housing” (BCMHS & BCMCFD, 2010, p. 5). The Community Assistance Program “seeks to help the most vulnerable income assistance clients improve their quality of life and connect with services in their communities [with a focus on] develop[ing] positive life skills and connect[ing individuals] with mental health, housing, substance dependence treatment, legal aid and family services” (BCMHS & BCMCFD, 2010, p. 5). These programs are framed as saving money as follows: “Providing adequate housing support is cost effective. An adult with severe substance use and/or mental illness who is homeless or lives on the street costs the public system in excess of $55,000 per year – the provision of adequate housing and supports is estimated to reduce this cost to $37,000 per year” (BCMHS & BCMCFD, 2010, p. 34). While important for those with mental health challenges, and in particular, in terms of addressing the ways that stigma and discrimination threatens their access to key determinants such housing, education, and employment (which is recognized within these policy documents), 152 initiatives that enable direct access to resources such as housing are not considered a primary prevention or universal mental health promotion strategy. This is despite several arguments made throughout these documents regarding the importance of addressing SDOH such as “employment and income, social support, education, housing and health services” (BCMHS and BCMCFD, 2010, p. 12) including the proposed commitment to “enhance health promotion efforts across the lifespan, with particular emphasis on addressing determinants of health” (BCMHS & BCMCFD, 2011b, p. 30). This includes reference to previous consultation feedback received from youth whom “highlighted the importance of addressing fundamental needs such as food, shelter and recreational opportunities” (BCMHS and BCMCFD, 2010, p. 9). Furthermore, while there are several references to the importance of SDOH within these documents there are no outcome indicators that track the universal provision of key resources for young people’s foundational need for survival, and in turn, mental health. There are several recommendations for inter-sectoral strategies, including the definition of mental health promotion that focuses on both skill building and “modifying the broader social and economic environments that influence mental health” (BCHA & BCMHLS, 2009, p. 71). However, with the exception of the food security (core public health) program which calls for “increase[d] food security and decrease[d]food security for all citizens in the province” (BC Ministry of Health, 2014, p. iii)35, there are no performance targets nor outcome indicators that focus on tracking changes to the broader socio-economic environment in ways that enable young people’s foundational need for access to resources for their survival. With the exception of tracking “increased adolescent school connectedness” (BCHA & BCMHLS, 2009, p. 79), there is also a lack of attention to shifting economic and labour policies that enable inter-related mental health needs such as self- and socio-environmental realization and self-determination. Missing from these policy documents are outcome indicators that track levels of access to resources such as education, housing, and work that realizes young people’s unique capacities in ways that contribute to their communities and that enable self-determination. For example, direct 35 Within the B.C. core public health functions framework, the Food Security program core public is inter-related with the Mental Health Promotion and Mental Illness prevention goal reviewed within this study (i.e. BCHA & BCMHLS, 2009). While accepting the broader “globally competitive” (B.C. Ministry of Health, 2014, p. 9) free market economy, the food security policy document includes the argument for the importance of advocating for universal access to food in B.C. through inter-sectoral strategies and “leadership and advocacy to advance food security” (B.C. Ministry of Health, 2014, p. 32). 153 provisions ensuring young people’s access to post-secondary programs and/or entry into living wage jobs that help them to realize their strengths and capacities upon graduation from public schooling systems and cooperative economic policies that promote greater self-determination in the workplace are not tracked. Attention to partnering with, for example, the B.C. Ministries of Finance, Advanced Education, Agriculture, Forests, Lands and Natural Resources, Jobs, Tourism and Skill Training, Environment, Social Development and Social Innovation, Technology, Innovation and Citizen’s Services, and relevant federal departments is not outlined. There is a neglect of attention to enabling young people’s input in developing broader economic policies that influence the kinds of industries that are supported and in turn, kinds of employment created, and economic and monetary policies that shape distribution of resources. These options are not listed as proposed inter-sectoral strategies, performance targets, nor outcome indicators within the mental health policy documents and the healthy communities core program document. While intersectoral work partially addresses employee mental health through workplace-based mental health promotion and prevention programming, this strategy is contradicted by the second way that the B.C. mental health policies are oriented to supporting wealth-oriented economics. In this case, recipients of mental health care are centrally positioned as workers in order to prevent lost productivity and in turn economic gains. Proposed mental health programs are oriented to minimizing mental health symptoms and developing people’s socio-emotional and cognitive-behavioral skills in order to support “economic participation” (BCHA & BCMHLS, 2009, pp. 75,76) with the aim of preventing “lost productivity” associated with mental illness and substance use (BCMHS & BCMCFD, 2010, p. 2). Recipients of mental health policies and programs are thus positioned as serving employers and productivity gains while one of the primary functions of mental health policies and programs is to produce, reproduce and rehabilitate workers. To this end, inter-sectoral collaboration is used to extend socio-emotional skill building and prevention programs to employment settings. Within the employment setting, “collaborat[ion] with employers and unions to develop and implement workplace supports such as self-care resources, opportunities for early identification of problems” (BCMHS & BCMCFD, 2010, p. 23) and “back-to-work strategies” (BCMHS & BCMCFD, 2010, p. 24) are proposed. This includes the development of “job skills training that incorporate social support, job search 154 skills, motivation and coping skills for those who become unemployed” (BCHA & BCMHLS, 2009, p.33). Among the outcome measures within the 10 Year Plan, economic participation is listed as a central outcome (BCHA & BCMHLS, p 75–76). Economic participation is measured by “reduction in absence from the workplace due to mental ill-health” and a reduction in number of workdays lost per year per worker (BCHA & BCMHLS, p. 78). This focus on serving market driven employment is made further clear by the absence of programming and/or inter-sectoral work oriented to supporting economic democracy and the development of meaningful employment opportunities that “realize [people’s] abilities” (BCMHS & BCMCFD, 2010, p. 2) and increase people’s control in the work place. This is despite reference to previous research that shows the relationship between low job control and high job demands and mental distress in the 10 Year Plan (BCMHS & BCMCFD, 2010, p. 22). Within proposed workplace programs such as the GuardingMinds@Work that aim to promote psychologically healthy workplaces, contradictory goals are proposed. “Psycho-social” indicators of healthy workplaces that include the need for “involvement & influence” in workplace decision-making processes, “workload management” and “balance” between “the demands of work, family and personal life” (Centre for Applied Research in Mental Health and Addiction, 2014) contradict hierarchical decision-making structures. These goals are further contradicted within the private business sector and the need to maximize profits within broader competitive wealth-oriented dynamics as discussed previously. More broadly, although participants’ concerns regarding the sustainability of their natural environments for their future access to resources (in relation to their need for a secure future) are not explicitly addressed in the mental health policy documents, they are addressed within the inter-related environmental health goal within B.C.’s guiding framework for public health (BC Ministry of Health, 2013). Within the environmental health goal, it is recognized that there are “significant new challenges-such as the public health impacts from climate change” . . . and “ resource depletion, pollution, animal health and species extinction” (Ministry of Health, 2013, p. 39). However, while a “robust health surveillance system” that includes “laboratory analysis to measure environmental, biological and chemical contaminants in water, food, air, land and the human population . . . in [order to track and analyze contaminants in order to assess policy and document improvements]” (Ministry of Health, 2013, p. 40) is important, there is no attention to 155 the threats that wealth-oriented economics poses to environmental sustainability as raised by the young people in this study. For example, there is a lack of attention to addressing participants’ expressed concerns regarding the impact of endless “buying and dumping” on the sustainability of their environments. Instead, the orientation to enabling wealth creation is reflected not only within the mental health policy documents in which one of the goals is to prevent “billions” in “lost industrial production” due to “mental disorders and sub-clinical mental health problems” in the workplace (BCHA & BCMHLS, 2009, p. 73), but also the overarching objectives of B.C.’s Guiding Framework for Public Health, which is to cut costs and promote productivity, economic growth, and prosperity: The public health system helps shift the focus towards upstream solutions to increase the level of health and wellness experienced by British Columbians. This overarching aim is an important task, not only to address the consequences and costs of ill health, but also to bring about significant benefits to individuals and communities and foster economic growth, productivity and prosperity. Public health is one component of a larger strategy to help bend the cost curve, and actions need to occur within and outside the health system to affect sustainable change. (BC Ministry of Health, 2013, p. 5) Overall, these policies emphasize the importance of addressing SDOH while positioning young people and mental health programs in support of capital accumulation processes. Within these documents, there is a clear acceptance of and normalization of broader wealth-oriented economic processes in which mental health promotion and prevention programs are positioned as enabling and protecting productivity and economic gains (BCMHS & BCMCFD, 2010, pages 2, 3, 6). Aligned with private individualistic production processes, proposed mental health initiatives are oriented along individual lines placing primary responsibility for realizing mental health at the individual level. This dominance of individual level approaches to realizing mental health was reflected within participant descriptions of how they sought to realize their mental health needs within their day-to-day lives. Their descriptions illustrate the ways that broader socio-economic dynamics orient them inward, to their inner and inter-personal lives, in seeking to realize their mental health. 156 Chapter Six: Orienting Young People Inward To Seek Realization Of Their Needs Within The Inner And Inter-Personal Contexts Of Their Lives There’s societal influences like I feel when I was really young my mind was really a lot more creative, a lot more, you know, it could go off in different directions but now after growing up especially going through education and everything, I feel like my way of thinking is a lot more closed . . . it’s ideas like ‘oh well, I’ve got to look out for myself, I’ve got to make money and stuff’ those are actual thoughts that I’m having because of what society has imprinted in our minds through media, popular culture . . . and how all your friends are . . . I mean it’s also probably more like responsibilities that have come to me too that take your mind away from other stuff but it kind of sucks. (Colin, 19 year-old male) Introduction Within this chapter, I extend the analysis presented in Chapter Five by illustrating how young people’s control over their mental health needs is limited by the ways that they are positioned and oriented to seeking realization of their mental health within the micro context of their lives, despite the important role that socio-economic processes play in enabling young people to meet their needs. A key finding within this study is that not one young person, regardless of their diverse socio-economic positions described experiencing a full realization of their mental health needs. Participants described struggling to meet their needs to varying degrees, which depended on their varied and unpredictable levels of access to resources. Most participants described taking a stance of pragmatic struggle, which was underpinned by three experiences that oriented young people inward to seeking realization of their mental health needs within the inner and inter-personal contexts of their lives. These experiences included that of insecurity, hopelessness, and shame, which were evoked by material, social and ideological dynamics within participants’ socio-economic environments. In this context, participants described using a variety of cognitive strategies and ways of working with friends and family to seek realization of their mental health needs to varying degrees depending on their varied and insecure access to resources. These approaches included trying to change their thinking and ways 157 of being to survive the fundamental insecurities they faced and the ways they worked creatively with friends and family to enable access to resources through, for example, rationing resources. Within this chapter, I start by presenting ways that inter-related material, ideological, and social dynamics oriented participants inward to their inner and inter-personal lives to seek realization of their mental health needs. I then present participants’ response patterns and, specifically, the ways that participants sought to realize their mental health within the inner and inter-personal contexts of their lives. I highlight a contradictory tension between individual and communal approaches to realizing mental health needs that was evident in participants’ reflections. Participants’ attempts to realize their mental health needs in their day-to-day lives contradicted their relational descriptions of their mental health needs and their recommendations for socio-economic change oriented to supporting young people’s mental health needs. I conclude with a further comparison of young people’s response patterns to proposed interventions and mental health promotion initiatives and performance targets and outcome indicators, within the policy documents. This comparison shows more clearly how, within the broader contradiction between capitalist economic dynamics and young people’s mental health, mental health policies support capitalist processes through individualistic programming. Pragmatic Struggle: Orienting Young People Inward Through Material, Ideological and Social Dynamics that Evoke Insecurity, Hopelessness, and Shame Participant reflections on the ways that they sought to realize their mental health needs along with their recommendations for socio-economic change and reflections on barriers to socio-economic change reflected a dominant pattern of pragmatic struggle which was underpinned by three experiences that oriented young people inward to seeking realization of their mental health needs within the inner and inter-personal contexts of their lives. These experiences included that of insecurity, hopelessness, and shame, which were shaped by inter-related material, social and ideological dynamics within participants’ socio-economic environments. I have used the notion of pragmatic struggle to reflect the ways that most participants described going along with existing capitalist socio-economic processes despite the ways that capitalist dynamics threatened participants’ mental health needs. Within context of insecure 158 capitalist socio-economic processes and a pervasive sense of hopelessness, participants expressed their sense that they had to participate in current socio-economic processes in order to increase their chances of having a decent life. When faced with tensions between their mental health needs, the majority of participants tended to prioritize their needs for social inclusion and financial security for survival over inter-related mental health needs. To varying degrees, participants sought to actualize wealth-oriented notions of success to seek social inclusion and they engaged in competitive dynamics in order to better their own financial situations. They went along with broader social trends while trying to be kind to people they interacted with in their day-to-day lives to the extent possible, while disagreeing with the broader wealth orientation of their socio-economic environments. I believe that our current economic system has the greatest impact on my life . . . As a student and worker, I find myself caught in a trap between accepting the current economic system or trying to challenge our oppressive economic regime. I’ve slowly come to the realization that it is easier to accept the system, and use it to the best of your advantage. (French, 17-year-old male) As it is now I don’t like the world but I have to be here so, you know, I’ve got to roll with the punches I guess you can say. But I guess just, you know, waking up every day and, you know, going to work and just trying to be kind to others and stuff helps me. But, yeah, definitely I’m not a huge fan of the monetary system. (Mandie, 27-year-old female) Just there’s frustration I guess like because I don’t want to get caught into it but then at the same time I have to otherwise I’m going to have like a really shitty life probably so, yeah . . . You kind of have to just go with the flow even if you’re not really happy with what’s going on but at least you can like go and talk about it like this . . . like I don’t know, I feel like people are just trying to gain money for their own personal like benefit and like their family, for the benefit of their family but not so much for like the benefit of society as a whole. And so I don’t know that’s kind of a sad thing but that’s the way the system is kind of set up right now. (Colin, 19-year-old male) This pragmatic stance was underpinned by experiences of insecurity, hopelessness, and shame, which were shaped by material, social and ideological dynamics within participants’ socio-economic environments. 159 Insecurity Participants’ position of pragmatic struggle was in part underpinned by the fundamental insecurities that they faced within their socio-economic environments. Participants who both agreed and disagreed with the broader wealth orientation of their socio-economic environments highlighted the fundamentally insecure nature of their socio-economic environments. This insecurity was described as focusing participants on looking out for their own financial interests, despite their desire to engage more authentically and freely in giving back to their communities through meaningful work and/or life activities. While the majority of participants explained that the wealth orientation of their environments was unhealthy for young people’s mental health, there were a few participants who expressed agreement with the focus of their economic environment. However, they also expressed ambivalence highlighting the fundamental insecurities that they and fellow young people face in seeking to realize their mental health needs within existing socio-economic processes. Donald expressed, “I do have a love for money” and shared his view that his socio-economic context was like a poker game and people needed to “play the cards they are dealt…and to do what they can do with what they are dealt with” (Donald, 28-year-old male). Aligned with dominant individualistic ideas, he assumed that as long as one worked hard enough, one would increase one’s chances of reaching one’s financial goals. Yet he also shared his sense of the broader insecure nature of his economic context in which he strove to seek money through entrepreneurship. In describing the insecure and unpredictable nature of his economic environment, he shared, “do you know what the funny thing is? That there has been a depression, or like a very slow economic time, almost every 10-12, 15 years for the past 100 years. But yet every time that it happens it’s like this is new. It’s not new! It’s just the exact same thing what happened in the 80’s, 90’s 2000’s” (28 year old male). He further reflected on the insecure nature of his post-industrial economic environment describing how the insecurities that he and his peers faced were his rationale for turning to entrepreneurship. In describing why he was interested in participating in this study he shared, I’m still young, but… I find that it’s (money) more important than ever because…to be very frank, the way that we’re taught is very industrial. Back in like the 1930’s, 1940’s, it was always ‘go to school and get a job and go work for a company’ and that was because there was a big boom then. There was a lot of steel companies and things like that, just a lot of industrial growth 160 at that time in North America and the world, and of course parents going through that depression and most people not learning outside of what they’ve learned from their parents, their aunts, their uncles, and so it’s just gotten taught on and on and now here we are. I still think that it’s being taught, but I don’t think that it’s the way to go in terms of statements of like: ‘Oh, it’s too expensive here in Vancouver, how are we going to be able to afford a house when we get out of school’…those type of statements make me realize that, how is anyone ever going to do that if I’m hearing it from these types of people? So that’s why I got very interested…I’m an entrepreneur and I like, hopefully, inspiring others to take a similar path and so when I hear about money and youth and world economics, it piques my interest. (28-year-old male) Similarly, Jonathan shared his sense that he had many more opportunities after arriving in Canada with his family as refugees. He described seeking financial security and success for himself through higher education. In describing the meaning of socio-economics, he expressed his sense that getting an education increases one’s chances of seeking wealth and security and enables a virtuous cycle of success,   …the economy like commerce that kind of thing like water as a necessity-water leads to healthy life, healthy life leads to a stable life leads to an education, education leads to a job. And then you can keep doing that cycle because then…it allows for socio economic growth if everyone is able to grow like that. Once you’re healthy enough to have an education and you educate yourself, get a job, that leads to the economy and obviously that helps not only the country grow but your family’s, not reputation, but history like much more healthier because you’re stable, you have some sort of income right? And that cycle just keeps happening and eventually your family…it’s not struggling to get by right? Like they have a history of success right. (17-year-old male) Yet he also reflected on the insecurities that young people face in their processes of seeking a secure income through education: “Like before you’d usually get a job with a bachelor’s like in really anything…I wasn’t living in that era but from what I’ve heard from my friends like well not friends, my teachers and stuff like they’re ‘like, oh yeah, it was much easier, much less pressure back then’” (17 year old male). This insecurity was also reflected within participants’ descriptions of their attempts to resist aspects of their wealth-oriented environment with which they disagreed. To varying degrees, at various times, and across contexts, participants described periodically resisting wealth-oriented dynamics with which they disagreed and that threatened their mental health 161 needs. In contrast to times that sadness, depression and hopelessness decreased participants’ energy and motivation, anger and frustration energized and mobilized them to resist wealth-oriented dynamics. For example, they described avoiding buying status-based items (to avoid attaching their self worth to commodities) or changing their thoughts and approaches to seeking an income stream. Participants’ forms of resisting, however, necessarily took place within the insecure socio-economic processes that they were resisting. For example, participants described how their frustration with the inequities and exploitation that they observed within their socio-economic environments focused them on being political consumers. A couple of these participants assumed that “every decision is a political decision” and “the personal is political” (French, 17-year-old male; Mandie, 27-year-old female). As political consumers, they saw every purchase as a vote and sought to engage in conscious consumption practices oriented to supporting products they believed in, such as fair trade and/or organic products and products that supported sustainability. Participants’ abilities to engage in conscious consumption was challenged, however, by broader capitalist dynamics that produced insecure incomes and increasing costs. And another thing is like what impacts me is, sure it would be wonderful to be vegan and live on a vegan commune and make my own clothes but that’s not an option. I see the inequalities and I want to do something but I can’t afford a two hundred dollar shirt. I’d rather go to H&M and buy one for twenty dollars. I see all these inequalities and I want to do something but we’re so limited because we’re in such a capitalist society and everything is based off money. (French, 17-year-old male) Hopelessness This pragmatic stance was also underpinned by a pervasive sense of hopelessness. Participants expressed dominant pessimistic assumptions regarding human nature and the possibility of social change, which evoked hopelessness for broader social change. This, coupled with their insecure socio-economic contexts, focused participants on engaging in current socio-economic processes to increase their chances of having a decent life, despite not agreeing with the dominant wealth orientation of their socio-economic environments. Participants’ sense of hopelessness was evident in two ways: first within their expressions of dominant assumptions regarding human nature and social change and second in their reflections on barriers to social change. 162 Participant reflections on each other’s recommendations for social change, and the idea of a Guaranteed Annual Income (GAI) and cooperative economics (for those who struggled to identify system level solutions), entailed dominant views regarding human nature and social change. In contradiction to participants’ relational descriptions of their mental health needs and their recommendations for broader socio-economic change, participants expressed individualistic and pessimistic assumptions regarding human nature and social change. These assumptions evoked a core sense of social distrust and hopelessness regarding the possibility for collective social change oriented to enabling universal access to resources for mental health. In further support of participants’ relational descriptions of their mental health needs described in Chapter Four, participants offered several recommendations for socio-economic change focused on increasing collective access to resources. Some participants recommended the need for subsidized housing and a living wage. Several participants reflected their awareness of the role of government in the distribution of resources and recommended shifts in government funding priorities. This included, for example, redistributive tax policies and a shift in focus from funding military equipment to funding public goods (e.g. food, housing, education, health care, counseling). Participants called for more investments in social welfare and community services such as expanding transit services, making bus tickets less expensive, funding mental health counseling, and funding schools to decrease class sizes. This was particularly important for young people who were unemployed, underemployed, or working low-wage work and who struggled to meet their basic needs. Several participants identified initiatives oriented to ensuring universal access to resources to meet young peoples’ foundational need for survival. These initiatives included: drafting people to take a year out of their lives to work on housing and making housing free for everyone;36 putting a cap on the prices of needed resources such as organic food (not fast food); and promoting cooperative housing. A few young people, while prefacing their reflections by suggesting that their ideas were likely “unrealistic” imagined removing the monetary system or creating a world with as much money as anyone needs to meet needs. These participants imagined reclaiming the 36 This was proposed as a contrast to military drafts. 163 commons by organizing production and distribution of resources in ways that enable the free and reciprocal exchange of resources in communities. Being kind of influenced by the Zeitgeist movie . . . they gave an example of a commune world where, say I was really good at gardening and you’re really good at baking and I love bread and you want some fresh vegetables. I’ll give you some of my vegetables if you give me a loaf of bread and everyone is smiling. And obviously there’s way more aspects, between policing and healthcare and all that but I just think that if we could ever reach that point where there isn’t a monetary system and people using their skills and knowledge for bettering human life rather than for profit there would be a huge change . . . I think that not only would people feel better because you’re doing something out of the goodness of your heart and also with the intent your needs will be met. But, making your skills, your needs, everything always available. So, you’re not doing it for profit, you know, ‘do better than Joe Blow’- you’re doing it because you want to survive and you’d rather live in harmony than the whole competitive-‘look what I got blah, blah, blah’ that kind of thing (Mandie, 27-year-old female) I remember a couple of months ago watching a comedian do a stand up and his name is Lois C K and he was joking about how it would be funny if God was to come down to earth and see everybody using money to buy food and buy clothing and buy houses and he said God would come down here and go ‘what are you doing like what’s money? What are jobs? Just eat what’s on the ground! I left you all this food and I left you all these trees, build your houses,’ You know? Like ‘why are you working for money when you have all this stuff?’ And it made me think he’s right, you know? Like millions of years ago there probably wasn’t money. I mean we just ate what was growing on the trees, growing out of the ground, we just cut down trees and chopped up wood and built our own houses . . . (Natalie, 19-year-old female) In contradiction to participants’ relational descriptions of their mental health needs and these recommendations for socio-economic change, participants expressed pessimistic and individualistic views regarding human nature and social change. Individualistic and pessimistic views of human nature entailed the assumption that humans are selfish and greedy, and thus primarily oriented to looking out for one’s interests. Pessimistic views of social change entailed the notion that economic growth was an inevitable feature of their socio-economic environments and that broader social change was impossible. These individualistic and pessimistic views were apparent within participants’ reflections on what they observed within their socio-economic environments generally, and within their responses 164 to each other’s recommendations for enabling universal access to resources to meet young people’s need for survival and a guaranteed annual income policy. When describing their environments, participants variously expressed feeling sadness, frustration, anger, fear, being disheartened, and being “affected positively or negatively by other people’s experiences (and] preventable misery . . . like poverty” (Antony, 24-year-old male) and other challenging socio-economic issues such as economic inequities and threats to their natural environments. When asked if there was anything to be done about the issues that concerned them, most participants expressed hopelessness. Several participants expressed a sense that people are selfish and greedy and that the system is just the way it is and there is nothing that young people can do to change it. When asked how to prevent his observed “preventable miseries,” Antony shared, “I don’t think it will be ever but I mean the obvious one is lack of greed” (24-year-old male). Haden shared, “For humans, no matter what we just keep populating and we destroy everything around us which is not in balance in nature . . . humans are more like viruses . . .”(Haden, 17-year-old male). French shared his sense that there is no alternative to capitalist economics: “money drives us . . . we always have to grow no matter what it doesn’t matter if we’re in a recession we have to grow” (French, 17-year-old male). More broadly, several participants expressed a sense of social distrust when describing their socio-economic environments in relation to mental health. In addition to their descriptions of the ways that people are in a rush and focused on seeking their own financial security, participants described observing and experiencing social distrust as inter-related with competition in which people use each other to better their own situations. Although participants noted the good and supportive people in their own lives, when describing their broader communities, participants described challenging social relations reflected by a “loss of our humanity.” Participants shared their observations of how everyone is “self-centered” “in their own bubble” “competitive” “judgmental” “cruel” and where in a capitalist system . . . we see everyone as potential stepping stones, a means to some unknown end . . . everyone is out for their own gain or . . . if people decide to work together that’s because they all have other secret agendas that mutually benefits them right? Its more like it’s no longer what is right, what is wrong, it’s more what will benefit me more right now? (Da Dragon, 19-year-old male) 165 The idea of a GAI policy and participant recommendations pertaining to enabling universal access to resources evoked participants’ consideration of the nature of people’s participation within socio-economic processes, including what engages and incentivizes people. In response to the idea of a GAI policy and participants’ recommendations for universal access to resources through collaborative production and distribution processes and/or the removal of the monetary system, other participants expressed their distrust that people would contribute to community life and to use available resources to meet their needs. For example, in considering how a world where he did not need to worry about money would affect him, Colin shared the importance of having a purpose and contributing to society, but expressed his worry that not all people would contribute in meaningful ways. I find that some people might not have the right idea even though they think they do but, yeah, I’m going to leave it there just because I want to stay PC (politically correct) . . . Like some people find the meaning in their lives is to like work and do something that they’re like loving and if people didn’t have to worry about working then maybe they’d search for other reasons for why they’re living their life and that those reasons might not like be the very best ones for the benefit of society as a whole. (Colin, 19 year-old male) Jacob imagined that a GAI policy would enable people to engage in work because they wanted to and to have more time for social connections. Yet he also expressed his worry that not everyone would use their guaranteed income to meet their basic needs asking, “now, my only question is, they would get enough money for that, but would some of them use it for that?” (18-year-old male). Denis expressed his distrust in people by suggesting that, “the more opportunistic ones would steal from others, the more lazy . . . If we make everyone equal, then everybody is just going to steal from everybody” (20-year-old male). Individualistic and pessimistic views of human nature were in contradictory tension with participants’ expressed mental health needs. In contradiction to how participants expressed yearning to engage in inspiring and intrinsically meaningful work and/or life activities that contribute to their communities, several participants expressed their assumptions that people are selfish and only motivated and incentivized by money and thus cannot be trusted. In response to the idea of a GAI policy, and, in contradiction to his expressed need for having meaning and purpose in his life, Denis shared “being comfortable is very dangerous. Because once you become comfortable, you don’t want to do anything . . . I mean, if they were given the means to survival, they have no reason to move . . . to earn 166 more money” (20-year-old male). After imaging herself taking time off to watch TV for a year, Prinda went on to express the importance of learning and knowledge development and for socio-environmental realization- If I have the money I’m not going to study. You know, you would stay home and then you’d watch movies and do whatever you want, but then you’re going to get tired of it. And then you’re going to regret it after . . . Maybe for like a year it’s fine not to do anything and just do whatever you want, but after that you shouldn’t. Because no one is going to know anything. It’s just going to be people walking around doing nothing . . . so the world wouldn’t get better. (Prinda, 15-year-old female) These dominant ideas evoked a sense of pessimism and hopelessness regarding the possibility for social change oriented to enabling young people’s mental health needs. Participants’ sense of hopelessness for broader social change was also evident within their reflections on barriers to social change oriented to enabling universal access to resources to meet young people’s mental health needs. Participants identified a range of barriers. When invited to share recommendations for socio-economic change oriented to enabling access to resources to meet their needs, several participants expressed their sense of hopelessness in light of the power of upper-class groups who they referred to variously as “the 1%” “the rich people” and “business people.” This accorded with participants’ distrust in their governments. Several participants expressed their sense that a) governments were plutocratic in nature and functioned primarily to enable capital accumulation processes and to serve upper-class interests and b) “the rich” wouldn’t want to give up their power, prestige and acquired living standards to share wealth. The role of government was attributed to “keeping the economy going” through “job creation and getting people to buy and consume” (Donald, 28-year-old male; Jacob, 18-year-old male). Tax policies such as the Harmonized Sales Tax (HST) were interpreted as evidence that governments serve those who already have money, adding to their sense of hopelessness. Events such as the robo-call scandal in the 2013 Canadian federal election led participants to question the intentions of political leaders and whether they were focused on promoting the public good or acquiring power (Cassie, 15-year-old female). Governments were described variously as “being intoxicated with getting money,” (Anna, 16-year-old female]; “legalized organized crime” (Jacob with group of youth 15–17-year-olds); “maintaining the 167 status quo” (Da Dragon, 19-year-old male); “corrupt” (John, 27-year-old male]; a “puppet of the rich” (Haden, 27-year-old male); “power-prime ministers are going to be the end of our world” (Cassie, 15-year-old female); “the only difference between our politicians in the West compared to those in developing countries is they can hide their corruption” (Group interview). Participants expressed hopelessness that change was possible because of growing economic inequities and their sense that governments serve upper-class interests. Seeing so many homeless people led participants to question whether taxes were really serving people (Anna, 17-year-old female and Jacob, 18-year-old male). In response to hearing about Colin, who had lost his home and whose family could not afford to buy in Vancouver, in a follow-up interview Haden reflected: Holy crap. You know but that’s life though. There’s the 1% that owns the world and then there’s everyone else that works for them. It’s crazy. Obviously, it’s unfair, but I don’t know. There’s nothing we can do about it. We can only assassinate them, that’s it. Interviewer: Well, that’s one of the goals of this research, to look at ways we can resist and change the system to make it more fair. Haden: No, there’s no way. The only way that can happen is if 99% of the world is holding torches and pitchforks. No, seriously. There’s no way. Yeah, just a metaphor. The thing is, people aren’t even aware of this, like in South America and Africa they don’t even know what is going on . . . Nothing should have money anymore. Just, the world is so messed up, I don’t know. I can’t think of a solution. I was just trying to think of me putting money into research and technology, but then . . . I don’t know. There is nothing that will solve the economic situation . . . We need to spend money into helping other countries to industrialize and then once every country is industrialized, then there will be less problems in the world. But the thing is, the countries that are rich and can make that happen, don’t want that to happen because then their power will go away. So there is no solution (17 year-old male) Louie: The problem is that some people are happy that we’re not equal. Let’s say if we will be happy if we will be equal, but some people won’t. I mean I don’t know presidents of some countries, they don’t want the world to be the same because they will be the same too and they won’t have that power or money or that kind of stuff so they don’t want that because it’s not for them. Brenda: Because . . . like rich people they always want to be better than everybody else. It seems like they don’t want to be equal . . . because right now they’re rich, yeah, they have everything they want. They have a high standard, everybody looks up to them and if everyone is equal they won’t . . . 168 Anna: They won’t feel important. Louie: I have everything so I don’t care about the other. Jacob: See like this is the thing: they want to be better and greater and they’re so focused on that that they don’t realize how well off they are compared to other people. (Group interview 16–18-year-old young people) In further support of participants’ expressed need for a secure future, participants were worried and distressed about the lack of commitment and leadership on the part of political leaders to taking steps to change the system in ways that enable access to key resources such as housing into their future. Participants also expressed worries with what they observed as ongoing cuts to important health and social programs such as counseling and recreational programs. These funding cuts evoked worries in relation to their secure access to these resources. What worries me is that right now, our future leaders or future decision makers they’re all trapped in the system right? They’re all comfortable with it . . . They’re all raised in this traditional system and they’re raised with the mentality that we’ve got to continue this system . . . I’m worried about that because if it continues like this not a lot of people will be happy and especially if, you know, because I think about it like everyone becomes a first world country shit a lot of things will be expensive, information, population, just going overboard and that makes it even harder. It’s just like, you know, like trying to buy a house in Vancouver right? Everyone wants a house so that house is expensive and because to make it fair that it’s expensive so that only those who can afford it get it. But then those who really need it, they can’t afford it, they’re on their own. (Da Dragon, 19-year-old male) Participants also expressed a sense of powerlessness in democratic processes, which they suggested privileged higher income people. Those who could vote suggested that it didn’t really matter if they voted “because the votes are already kind of pre-organized . . . because the people with money get to make that decision” (Mandie, 27-year-old female). Participants’ sense of powerlessness in democratic processes was also attributed to their lack of political voice as young people. Participants expressed frustration with their lack of formal political voice, not only in electoral processes for young people below the age of 18, but also in relation to the stigma that young people face in their broader communities and their sense that political leaders do not take young people’s ideas seriously. 169 Frustrating, frustrating that even though I feel like I understand most of these causes better than most voting people yet I’m not allowed to vote. Being a seventeen-year-old, I see all these people who don’t even understand how the political system works sometimes. It’s extremely frustrating. And I want to make all these changes but, you know, especially looking at the government it’s like if seventeen-year olds can understand these concepts why can’t you with a PhD? (Laughing) It makes me want to make changes but it’s super frustrating, ridiculously frustrating. (French, 17-year-old male) More broadly, participants’ expressed a sense of the insignificance of their individual lives in influencing broader social change. Mandie shared, “But, as far as government, the economic system, I kind of feel like such a small pea that I don’t really feel like I make a huge difference” (27-year-old female). Denis shared, “I probably don’t find my personal life as important, significant because we just passed seven billion humans on this earth. And one person at this point doesn’t make much of a difference unless they can be a great person” (Denis, 20-year-old male). Da Dragon attributed the lack of incentive for social change to the conveniences of capitalist technology. When asked to clarify what he meant by his use of the term “capitalism” and where he learned it from, Da Dragon explained that he has always been interested in learning about “how our society works which lead me to capitalism, then capitalism sort of led me to more of my philosopher aspects of life” and eventually “Karl Marx.” He shared his disagreement with Marx’s prediction that people would “rise up” to change the system and explained, . . . some of Marxist stuff like where he says that the proletarians will, you know, rise up and I’m like ‘no its not.’ Because right now capitalism is a much more profitable system that works and it brainwashes people by giving you like the conveniences of technology right? (19-year-old male) A lack of understanding of how broader political-economic systems work and how to influence change was identified as a barrier to social change. While a few participants expressed confidence in their understanding of dynamics within their broader socio-economic environments, several participants expressed their lack of understanding of how their political economic systems operate and ways to influence change as a key barrier to change. Participants noted a similar lack of understanding among others in their communities and a lack of interest in learning about their socio-economic context among their peers. Participants shared that they had 170 little understanding of where products were made and under what conditions (e.g. child labor) including the pricing of products (e.g. rent, housing, food), how to purchase major products such as housing (and what a mortgage is), and the tax system. Jonathan (16-year-old male) thought his peers were generally not interested in learning about socio-economic issues. A few participants identified that they lacked content on how the political-economic system works beyond learning about personal budgeting, how to financially invest, and marketing. French expressed his frustration with peers who did not understand the implications of their buying practices and having received 30 minutes of content on voting. A lot of it is was just seeing the ignorance with my classmates and I don’t want to be rude but just seeing how dumb some people are not realizing the things that they’re doing. I think especially being at (name of his high school) people came from money so they expected everything to be perfect . . . they didn’t care what those things had to go through in order to be produced. Money just buys you everything so they didn’t take the time to realize what they were doing . . . Like people especially with social media . . . Or even like donating money but if you’re not really active in the cause or like you’ll see a lot of hypocritical people too post stuff, you know, and people don’t realize what they’re posting. Like they’ll post something about We Day or Free the Children but they don’t realize that by supporting causes like that it can be viewed as a good thing on the outside but they don’t realize the implications of being in a third world country and having this whole white dominance, the whole colonization. (French, 17-year-old male) Some participants were reluctant to make recommendations for broader social change because they did not understand how their socio-economic system works. They thought economic systems were too complex to know what to do and thus suggested doing nothing. In response to these barriers, some participants emphasized the importance of engaging young people in socio-political action through educating young people about how their political economic system works and ways to influence decisions at the policy level. Within the second dialogue sessions most participants identified “government and policy” as the aspect of their socio-economic environment that had the greatest potential and leverage for promoting change. They recommended targeting government decision-making processes, which they suggested was a key site of power in their environments. Participants emphasized the importance of mobilizing the “99%,” which Haden suggested as including “more like the 97%” to counter the plutocratic nature of governments and class-based power dynamics. For a couple of participants, a tool that was considered to hold potential power was that of social media for mobilizing people, combined 171 with education oriented not only towards young people, but those with power. In contrast, one participant cautioned against the use of social media suggesting that it prevents people from getting actively engaged in direct social action. These recommendations were challenged, however, by participants’ varied struggles to meet their need for survival and social inclusion which left little time for realizing inter-related mental health needs and engagement in socio-political activities. In addition to the ways that their experiences of insecurities and hopelessness oriented participants inward to seeking realization of their mental health needs, participants also described how experiences of shame oriented them inward. Shame The third experience that participants described, which oriented them inward in seeking to alleviate affective distress was that of shame. Participant reflections illustrate ways that dominant individualistic wealth-oriented notions of success worked in concert with social judgments and shame in silencing public expressions of affective distress. Participants described experiencing and/or observing expressions of social judgments in response to expressions of affective distress in their communities, which evoked shame. Participants’ descriptions further illustrated how wealth-oriented notions of success were individualistic in nature, in which people are expected to be “perfect,” self-reliant, and in which “confidence is beautiful.” These dominant ideas played a central role in shaping how emotions were addressed in individualistic ways within their communities. . . . everything is based around money, everyone wants to go into business and science because they can get a career so they can have money. And everyone is also focused around this idea that we have to have a perfect life, we can’t have difficulties, we can’t have problems. If we do, we have to hide them because that’s not acceptable. Everyone wants to go to (a prestigious business school) and marry a rich guy, have a perfect house in (a suburb), ‘I’ll be a professor, you can be a doctor, we’ll raise awesome kids, it will be wonderful’ and that works sometimes . . . But ninety-nine percent of families are not perfect . . . (French, 17-year-old living on his own) Dominant individualistic wealth-oriented notions of success were reflected within participants’ descriptions of how emotions were addressed within their peer and community contexts. Participants expressed the dominant idea that people should deal with their problems on 172 their own and that admitting emotional distress and insecurity was considered a sign of weakness in a context where people were expected to be independent and confident. In describing her feeling of insecurity and shame with being “chubbier” and thus not being able to wear what other young people are wearing, Aubrey expressed her reluctance to share her insecurity. She described how insecurity was seen as a form of “weakness” and “making a person an easy target” of other’s judgment in a context where “confidence is beautiful” and “people think less of you…when they see that you’re insecure.” Isabella: I don’t really want to talk about it because I feel like if you tell this to people they kind of look down on you because everyone thinks confidence is beautiful, right? But then once you let everyone know they’re like: ‘No, you should be yourself!’ People say don’t be like that but you just can’t, right? . . . You don’t want people to know you’re insecure . . . So that’s why no one tells people these things . . . And when they see that you’re insecure they think less of you. (16-year-old female) Aubrey: Only our closest friends. I only tell Isabella how I really feel, and my mom. My sister knows too, but they are the only people that I tell because I trust them. (Aubrey, 15-year-old female) Participants expressed a sense of guilt and shame in asking for help in a context of being expected to be independent. For young people in school, this inter-related with their fear of being socially excluded for being different. During extremely, extremely hard times, I have reached out, like ‘you know, mum I really need help’ and, you know, you get that help but I think for me, I feel guilty, you know, I feel like a very sense of shame that I cannot care for myself at that present time. (Mandie, 27-year-old female) I remember, because I didn’t try hard in school in elementary, right? In Grade 8, I was put into a Skills program and since I was still not getting the greatest grades the teacher said to me: ‘Oh, maybe it’s because you’re mentally challenged’ . . . and I refused to believe it because I don’t want to be mentally challenged. Because I know how society cuts you off because you’re mentally challenged and I was really scared, but I just didn’t really tell anybody about it. But I was just so scared and I refused to believe it . . . And then they tried to make me think that going to Skills wasn’t a really big deal, but I felt really embarrassed and ashamed. I didn’t tell anybody that I was in Skills. So whenever class started, I would just zoom in and before the bell rang I would zoom out. Because I didn’t want anybody to see me and anybody to look down on me . . . I was so ashamed because I didn’t want to be excluded. (Aubrey, 15-year-old female) 173 An aspect of individualistic approaches to managing distress was the placement of blame on the individual, despite the influence of family and community dynamics that evoked distress. Participants reflected on how distress evoked by difficult life circumstances, such as child abuse and strong emotions such as anger evoked by aspects of their environment with which they disagreed (e.g. animal cruelty), were stigmatized and silenced. Participants described experiencing a lack of empathy among peers (Anna, 16-year-old within group interview). Anna and her peers gave the example of how young people in their school judged Amanda Todd thinking “oh it’s stupid why would she do that like just shut up” or judged other young people who expressed feelings like Amanda Todd, telling them to “go and kill yourself like Amanda Todd.” This included blaming young people for their distress- I think a lot of kids in that, in schools have a lot of anger that they can’t take out so when they get the chance to they just kind of like go out and you can’t do anything about it because you don’t know what they’re going through and it’s not like a lot of people listen so they can’t talk about it. And then people blame them for being like angry but the thing is . . . like for people who have bad, bad problems at home like let’s say they’re getting beat but it’s not like people listen to them either so they can’t really talk about it . . . They’re afraid to voice their opinions and emotions because they’re getting judged. So everyone is forced to just be quiet they can’t say anything. (Anna 16-year-old female in group interview) Wealth-oriented material dynamics strengthened dominant individualistic approaches to alleviating distress. As mentioned previously, several participants suggested that the lack of time to listen and seek to understand people was due, in part, to the increasing pace of change, the dominant focus on seeking access to money to survive, and the influence of evolving online technologies such as social media. In response to these material, social and ideological dynamics, and in particular, in their attempts to avoid experiencing social shame in response to their affective distress, participants focused on seeking emotional support from their most trusted of friends and family members in the private spheres of their lives. Overall, material, ideological and social dynamics oriented participants inward, to their inner and inter-personal lives to seek realization of their mental health needs. Individualistic and wealth-oriented socio-economic processes created fundamental insecurities for participants who described being focused on seeking their own financial security. Individualistic and pessimistic assumptions regarding human nature and social change, along with participants’ reflections on barriers to social change, evoked a pervasive 174 sense of hopelessness for collective action oriented to enabling young people’s mental health needs. Dominant individualistic wealth-oriented notions of success shaped approaches to alleviating emotional distress within community life, which focused participants on seeking support from their most trusted of friends and family members in order to avoid social shame. Within this context, participants described using a range of mental strategies and actions both at the individual and inter-personal level to seek realization of their needs to varying degrees depending on their unpredictable access to resources. Seeking Realization of Mental Health Within Inner and Inter-Personal Contexts of Young People’s Lives Participants described using a variety of strategies to protect and enable their mental health to varying degrees within the inner and inter-personal contexts of their lives. This included a variety of individual and inter-personal level cognitive-mental and action-based strategies. Individual-level strategies Participants described using a range of individual-level cognitive strategies to protect and enable their mental health. These strategies included asserting their self-determination, re-framing their thoughts to alleviate distress that arose in response to insecure wealth-oriented dynamics, and strategies more oriented to protecting their mental health by blocking out aspects of their environments that were distressing. In some cases, participant descriptions of their cognitive strategies seemed to reflect an expression of their self-determination over their thoughts, inner experiences, and behaviors. A few participants described how they actively sought to resist basing their self-worth on wealth-oriented notions of success by refusing to purchase status-based commodities. Mindmatters described how she avoided buying products with corporate labels to resist the association of her self-worth with labeled products to fit in with her peers (25-year-old female). Positioning himself as a smart consumer, Jonathan explained how having taken film camps and watched several critical documentaries, along with his parent’s coaching, helped him to be more aware of how advertising works (17-year-old male). 175 Similar to the ways that some participants positioned themselves as political consumers to resist aspects of their environments with which they disagreed, other participants described avoiding wealth-oriented dynamics in ways more focused on protecting their mental health. This entailed avoiding exposing oneself to advertisements to prevent one’s own sense of beauty and success from being influenced by the “brainwash” of commercials. For example, Jacob described how he avoided advertisements by decreasing the amount of time he spent watching television and social media, and instead spent time with diverse people in community centres (18-year-old male). In other cases, participants’ strategies seemed to reflect an alignment of their way of thinking with dominant capitalist processes in order to protect themselves from distress evoked by insecure access to resources for their survival. Across approaches to seeking income such as panhandling and entrepreneurship, these participants re-framed their insecure contexts as “abundant” and full of possibilities (such as the potential of making great amounts of money) and internally coached themselves to strengthen their willpower and inner strength. Derrick used the notion of “wear and tear” to reflect the chronic stress he experienced both in relation to his own situation of homelessness and what he imagined would be chronically stressful in working a full-time job. He reframed his homeless situation as exhilarating and himself as strong in the face of an insane existence. When you panhandle and do odd jobs there is no system for it so you could make, it’s a possibility for you to make that ten dollars in an hour but it’s not predetermined, it’s not already scribed in stone it’s like you might, you might not. Yeah that uncertainty is like the backbone of the whole structure. Which is great because you never know what you’re going to get, I’ve had times when I’ve gotten all sorts of awesome things . . . and I gain a lot more things that normal people wouldn’t even know existed in the real world but it’s great, you get fucked on that shit and you love it. And it’s not even drugs it’s just activities alone. Panhandling, busking, flying a sign, squeegee, you know, there’s plenty of ways to get money, really robberies sometimes is a nice option to do especially if the person is drunk, asleep and stupid. You either fight it or you just get fucked off it and when I say get fucked off it, it’s just like why don’t you just go insane and love the idea or the whole concept of it. . . Just maintain that strong willpower, you’ve got to go for as long as it takes, I’ve been doing it for years now, it’s insane but it’s great. Weather can sometimes be a problem -you just have to get a tent, you just can’t be soft you just have to know what the fuck you’re doing. So but then again I mean the whole wear and tear that whole nine to five everyday thing I couldn’t do it I’d 176 rather get the money that I’ve made, the two hundred dollars daily random base so a lot of time it’s like I’d rather do that and doing pretty much bum fuck all than having to do something for a society that’s just a farce really is what it is. (Derrick 20-year-old male) In direct parallel to Derrick’s goal of seeking freedom for self-determination and self-realization through panhandling, Donald described turning to entrepreneurship to seek his freedom. Similar to Derrick’s attempt to empower himself in response to the insecurities he faced within his use of panhandling to seek income, Donald explained how he controlled his thoughts to cope with the uncertainties of entrepreneurship. Donald emphasized the importance of recognizing that “entrepreneurship of course is not a free ride or anything like that. It takes a lot of hard work. Generally minimum 3–5 years.” He explained how important it is to have “positive self-talk” to avoid the potential downward spiral and self-doubt that can arise in response to unsuccessful sales. . . . I control my world, and so I really believe in that. And I think that’s why a lot people quit sales, is because they start . . . they hear all these huge numbers upfront, first of all, like: ‘Yeah, I made X amount of dollars in X amount of time’ and they come in and they don’t really do the work. That’s number one. But they expect to have the results. So I think those are the self-talk I did have, and of course I still have it. I just tell myself not to have it. Thoughts leads to feelings and feelings lead to actions and then action leads to results. But it all starts with the thoughts. It’s very easy to hang up the phone and you just received a rejection to say, to have these downward spiraling thoughts: ‘Am I cut out for this? Is this product even good? Am I selling a crap, a shit, a crappy product? Maybe I can’t sell? Maybe I’m not good enough. Maybe I can’t do this.’ And you start to have these self-doubts, which then they start to say: ‘Oh, I’m not going to make this next call; I’m just going to go on Facebook. I’m just going to do this.’ And then the day goes by and it just happens over a while and then they say: ‘I’m not cut out for this.’ Versus on the flip side, saying, you know, some people get really excited when they get a ‘no’ because they know a ‘no’ is worth X amount of dollars because every ‘no’ leads closer to a ‘yes’. Or like: ‘Okay, good. I got my tenth ‘no’ out of the way because I know the next one is coming. The next ‘yes’ is coming.’ So it totally depends on thoughts. (Donald, 28-year-old male) In managing fears and frustrations in response to social comparison dynamics and the threats that these dynamics posed to one’s self-worth and need for social inclusion in the context of economic inequities, low-income participants re-framed economic inequities they faced in two ways. Low-income participants described easing their distress by bringing humor to their comparisons of themselves with peers with more income. Conversely, they 177 consciously compared themselves to people with less than themselves in order to help themselves to appreciate what they have. This appreciation in their own lives also included seeking to consciously focus on their non-material values (e.g. friends, family). That’s our way of coping with it . . . you have to make the best out of your situation so you’re not making fun of rich people obviously, but you kind of make a joke of it. You know like if they have like three IPhones you’re like ‘stupid rich kid.’ (Debbie, 16 year-old female) In contrast to these approaches to re-framing one’s insecure situation and threats to self-worth in the context of economic inequities and social comparison dynamics, several participants sought to protect their mental health by blocking out and consciously not thinking about broader socio-economic dynamics that concerned them. This involved efforts to not think about these aspects of their environments and consciously changing their thoughts. When describing how the “chaotic world where everyone is rushing” affects her, Natalie shared, “I don’t really let it affect me, I just kind of go with the flow, and just kind of block out anything that’s very negative” (19-year-old female). Andrew expressed his concerns about issues like pollution from factory farming, which he described having learned “produces more pollution than all cars in the world,” and his sense of the pervasive and harmful influences of his socioeconomic environment. Andrew described his decision to focus on his own life and what he can control in order to protect his mental health. He saw depression as a response to how “material things are meaningless” and the ways that corporate advertising perpetuates “idealizations” and “perfect lives” with “celebrities being put on pedestals.” In response, he described how people try to avoid depression through “purposeful ignorance.” I see purposeful ignorance to issues like avoidance of issues because there are a lot of issues that are quite alarming if you were to actually delve into them but people would rather not think about them or not hear about them because they might aggravate- like it might make them feel bad about themselves and who wants to feel bad about themselves? But sometimes I feel like there’s some things that I can’t directly control and its better not to worry about them because sometimes it affects my mental health adversely . . .. (Andrew, 19-year-old male) Da Dragon explained how, given his limited control, he re-focused his worries about his future back to the present context of his life: 178 I do think of money often but then when I think about it I also think ‘well what can I do now?’ Because what I’m thinking is I want to get a good job, make money . . . save money so that I can take care of my parents when they can’t really work anymore. Do I have enough money to start a family if ever right? You think far into the future right because you don’t know what the future will be right? And that’s why I try to draw myself back and be like, ‘okay, what can I do now?’ And, you know, sometimes I over think far into the future and I do stress myself out, you know, grow some strands of grey . . . other than that I just live in the moment, I just go on auto pilot. (Da Dragon, 19-year-old male) Participants also used substances and video gaming to sooth and/or re-direct their attention away from their painful emotions to manage the emotional distress, chronic stress, and “wear and tear” that arose from insecure financial situations and related threats to their mental health. Well I’m not consumerist by any means but it’s just nice little leisurely activities, it’s nice in this fucked up world people created themselves. Hey LCD- just came out with killer video games somewhat down the line and people make craft beers, make alcohol kind of they, make alcohol for a reason. Life sucks for a lot of people so they drink to have that feeling that you want to have this paid vacation or a back injury forty ounces of __ and you feel the same that chemicals released in the body, those endorphins that are released. Like, yeah, life sucks but everything is good for the moment. (Derrick, 20-year-old male) Mandie said that using drugs was a way she could control her emotional distress in the context of not having control over broader economic stressors that affected her mental health. I was depressed, it was my own form of happiness that I felt that I could still have a little control over which, you know, having control of your own life is mentally very rewarding. But if you feel you don’t have that you’re like shooting your foot. So just going through hard times and knowing that the power of money can build you up, it can break you down but just physically and mentally having to live through that. (Mandie, 27-year-old female) Actions with friends and family Participants also worked with friends and family members to enable and protect their mental health to varying degrees depending on their unpredictable access to resources. Participants worked with their friends and family in seeking to meet their basic survival needs and to alleviate the negative impact of corporate advertising and wealth-oriented notions of success on their self-worth. 179 Participants described a variety ways that they worked with friends and family to enable access to resources for survival. This included: renting a one-bedroom apartment for three family members and not telling their landlord to avoid being evicted; having additional family members move in (e.g. grandmother) to help with the cost of rent and/or living with friends; having extended family members take on child care so parents could work; and engaging in illegal activities if unable to find work. Participants also described various ways of prioritizing how money was spent while living on a tight budget, which included: prioritizing pet food over one’s own food needs; prioritizing paying for rent and then going to food banks for food; and prioritizing the needs of younger children/siblings over older sibling’s needs with the assumption that the older youth could work to help meet their needs. Anna explained how, in order to afford rent for three family members, her family told their landlord that there were only two members in their family. Me and my grandma and my brother, but we couldn’t tell them that we were living with my brother because then they were going to force us to get two rooms . . . Me and my brother share the bed. My niece, we only babysit her sometimes, but when we are babysitting her my brother will usually just sleep over at a friend’s house and she’ll sleep with me on the bed. Or I’ll sleep on the couch and my grandma will sleep with the baby. Because I don’t like sleeping with the baby. (Anna, 17-year-old female) Describing how he had lost 15 pounds during his struggle to find regular employment over several months, Antony explained how he stayed with friends and relied on food banks: When I first came back (to Canada] I had a place to live because my friends already had this house so I’d already arranged to move in with them. I didn’t spend a cent on food for many months. I went to the food bank. I found that the food bank only gave you enough food for three days out of each week. (Antony, 24-year-old male) In contexts of having limited access to resources, participants expressed their sensitivity to asking caregivers for items and described how their families prioritized needs. In describing how she lived on her grandmother’s fixed budget, Anna shared how she avoided asking her grandmother for money for social events and how her grandmother prioritized her needs over her brother’s needs: Well, it’s really stressful because if you want to do something you don’t like asking for money because you know that it’s needed for something way more 180 important, but at the same time it is—people think that it isn’t—but it is actually healthy to go out and enjoy yourself because if you’re never enjoying yourself you’re just going to be stressing all the time. And, I don’t know, you get really cranky and it’s just not good . . . Like, this [computer] is actually what I do most of the time, but it’s stressful too, because when you’re in a room with the same person for almost ever, you want to rip each other’s throats out, so there are times where you need to get out of the house but there’s nowhere to go . . . And [my grandmother] puts my needs before my brother’s because my brother is 22 years old, so his needs are more like he should get a job and do some of his needs on his own, whereas mine—I have to focus on school. So she puts my needs as a priority. My brother doesn’t get mad about it at all. He understands. Sometimes he even does my needs too. Sometimes he’ll get me whatever, pads or tampons, if I need it. (Anna, 17-year-old female) In response to having no access to employment, some participants engaged in illegal work, or “survivor crime” (Savelsberg & Martin-Giles, 2008) among other odd jobs. Murphy shared how, when he left home at the age of 14 and needed income a temp company37 connected him to a demolition company for work. He worked for the demolition company and was eventually fired when they realized that he was under the age of 18. He explained how, “after the demolition company fired me I went back to temp companies just doing odd jobs here and there . . . I’d work there for three weeks and then they wouldn’t need anybody anymore kind of thing.” He eventually found a full-time job with full benefits, but then lost that job after six months of employment, when it was outsourced to India. When invited to share about his criminal record (that prevented him from being able to travel to India) he shared, I have a lot of anger issues and I knew a lot of people who were selling drugs and stuff like that and I never really got into the whole drug scene . . . but I’m a big guy and intimidating so I did a lot of protection or collecting money especially when I was super broke. So . . . after the demolition company fired me . . . I was pretty much just making my money off whatever people would pay me for doing whatever. (Murphy, 25-year-old male) Participants described how they learned how to protect their self-worth from harmful social comparison dynamics in social media and in response to online bullying. They also described working with close friends and family to protect their self-worth from harmful messages within corporate advertising. Anna observed the effects of social media on her older 37 This refers to a “temp agency,” which supplies “temp workers” (employees) to a third-party client (employer) (Longhurst, 2014) 181 siblings and learned how to not personalize negative messages for herself by “build[ing] a wall” between herself and others. In describing her observations of the effects of negative messaging from social media on her older siblings, Anna shared: I don’t consider myself the strongest person in the world . . . but like, if someone were to call me a name, I’m actually not bothered by it at all. I’ve grown up in a home where they actually raised me to learn how to deal with it. Because I have a brother and a sister—and they are both older than I am—and they both went through hell. So because I am the youngest, I would actually call myself lucky because I had the privilege of seeing how they went through it and they would cry, they would get depressed. They went through so much trouble, and then I actually had the privilege to learn from watching them . . . For me, myself, I think I have a pretty good wall. It’s not like a wall that I am shielding myself from everything, it’s more like just a wall that keeps me protected. (Anna, 17-year-old female) Participants sought support from their close and trusted friends and family to protect their self-worth from the harmful messages of corporate advertising. Isabella shared how she and her close friends will “remind each other that you’re perfect the way you are; you shouldn’t change yourself for anybody or anything” (16-year-old female). Finally, in context of economic inequities and in order to prevent oneself from being subject to negative social judgments, lower income participants described hiding their low-income status. Explaining what it’s like being poor, Pablo shared how his sister helped him to dress in “nicer” clothes to enable his social inclusion with peers: It’s not a good feeling it’s like you feel down and you don’t have what other people have. You don’t really have the same friends like we’re all the poor people and all the rich people. In my grade everyone is rich except for me, I guess it’s the way that like my sisters made me grow up like I have clothes that are nice looking so it makes me fit in with them. Like I don’t like wearing raggedy clothes, they just wear like brand name stuff. . . Because people judge you (15-year-old male) Overall, participants engaged in a range of strategies to enable and protect their mental health to varying degrees within existing socio-economic processes with family and close friends for support. This tendency to seek realization of their mental health needs within the inner and inter-personal levels of their lives contradicted their relational descriptions of their mental health needs and participant recommendations for broader socio-economic change oriented to enabling their mental health needs. This contradictory tension between individual and communal 182 approaches to enabling mental health, and the predominance of individual level approaches to seeking realization of mental health was mirrored within the policy documents. Comparison to Policy Documents My final review of the policy documents focused on comparing participants’ response patterns to proposed mental health promotion and prevention initiatives, including performance targets and outcome indicators within the policy documents. I included a close reading of two mental health prevention program documents: the B.C. My Friends Youth Skills for Life program (BCMCFD, ND) and an online depression toolkit for young people, entitled, “Dealing with Depression Antidepressant Skills for Teens” (Bilsker, Gilbert, Worling, & Garland, n.d.) to explore more specifically how young people are guided to enable their mental health. I explored these documents as samples of how socio-emotional skills programs are being applied. While I recognize that they do not reflect the ways that these programs are taken up in actual practice, I assumed that they offer a useful perspective of how these programs are being applied in principle. This comparison of the policy documents to participants’ response patterns further extends the analysis presented in Chapter Five by showing how individualistic programs work to one-sidedly place primary responsibility for young people’s mental health on young people themselves and, in turn, draw attention away from the equally important role that socio-economic processes play in enabling young people’s mental health needs. Within the inter-dependent relationship between young people and socio-economic processes there is a clear focus on changing young people and their individual strategies versus changing socio-economic processes. This one-sided (individualistic) approach to mental health promotion and prevention does not address the inter-dependent relationship between young people and socio-economic processes in realizing young people’s mental health needs and, in turn, young people’s ability to engage in socio-economic processes in thriving ways, as presented in Chapter Four. Similar to the contradictory tension between individual and communal approaches to enabling mental health that is reflected within participants’ relational descriptions of their mental health needs and their recommendations for socio-economic change and their inwardly focused response patterns, there is a dual attention to individual and communal strategies within the 183 policy documents. Arguments are made for the dual importance of promoting healthy environments and healthy choices within the mental health policy documents. Mental health promotion initiatives are framed as needing to foster both “cultures and create environments” (BCMHS & BCMCFD, 2010, p. 13) and “modif[y] broader social and economic environments that influence mental health” (BCHA & BCMHLS, 2009, p. 71) and “creating environments” (BCMHS & BCMCFD, 2010, p. 13) in ways that “the healthy choice is the easy choice” (BCMHS & BCMCFD, 2010, p. 13). The principle of ensuring environmental supports in order to enable healthier choices is aligned with insights gained within this study regarding the dialectical nature of the relationship between young people’s mental health and their socio-economic environments. Yet the primary emphasis within proposed mental health promotion and prevention initiatives is on the promotion of healthy choices, skills, functioning, productivity, and the minimization of mental health symptoms and substance use at the individual level. With the partial exceptions within the policy documents that are aligned with participants’ expressed needs (as discussed in Chapter Four), there is a lack of equal attention to ensuring that socio-economic processes are developed in ways that support healthy choices. For young people, central mental health promotion and prevention intervention programs are based on individually oriented cognitive–behavioral therapy principles. Examples include the B.C. FRIENDS for Life Program (BCMHS & BCMCFD, p. 15; BCHA & BCMHLS, 2009, p. 8), which is a “school based cognitive-behavioral program to prevent anxiety, depression and suicide” (BCHA & BCMHLS, 2009) and the “Dealing with Depression Antidepressant Skills for Teens” (Bilsker et al., ND), which is an online cognitive-behaviorally based self-help tool for managing mild to moderate depression posted on the Ministry website. Guidance in managing affective distress within these programs focuses primarily on changing young peoples’ thoughts and actions at the individual level to alleviate and/or to prevent distress. Within the Dealing with Depression toolkit, while situational stressors are recognized as one of five parts of a young person’s life that causes depression38 (Bilsker et al., 2005, p. 5), the central focus is on changing young people’s thoughts and actions at the individual and inter-personal level. Case examples are offered in this tool kit for guiding young people in the application of cognitive–behavioural principles to manage distress. One of the case 38 The other causal factors listed include: thoughts, actions, emotions, and one’s physical state. 184 examples used in the depression toolkit reflects the concerns raised by participants in this study regarding the negative impact of wealth-oriented notions of success, their competitive schooling environments, and insecure access to post-secondary education programs on their mental health. This case example is entitled “The Perfect Girl.” In this case example, a 16-year-old female faces getting 78% on a math exam in context of being determined to do well in school because she dreamt of becoming a scientist, and knew how much competition there is for university science programs . . . and had a perfectionistic approach, always expecting herself to do things to the highest standard. (Bilsker et al., 2005, p. 25) The guidance focuses primarily on changing the girl’s unrealistic thoughts about herself and her abilities with no attention to exploring how her distress is a site for gaining insights into the relationship between socio-economic processes and young people’s mental health needs as was illustrated by participant reflections within this study. Instead, there is a central focus on developing “antidepressant skills” (p. 11) that focus on promoting “realistic thoughts” (p. 26) and changing the young person’s actions at the individual level including, for example: relaxation strategies; diet; exercise; and the engagement in enjoyable activities, and, for more serious forms of distress, seeking professional help and possibly medications. While important for fostering control over one’s thoughts and actions (as participants emphasized as important in this study), the lack of equal attention to engaging young people in critically examining not only how their moods are influenced by their own thoughts and actions, but also their broader socio-economic environment misses opportunities for helping young people to have greater control over socio-economic dynamics that challenge their mental health needs. This central orientation to changing young people’s thoughts and actions at the individual level is also reflected within the updated guidelines for the “My Friends Youth Skills for Life” program (BCMCFD, ND). In this program, the acronym FRIENDS stands for key themes that are explored through group-based learning activities including: F=Feelings; R=Remember to relax; I=inner helpful thoughts; E=Explore solutions and coping; N=Now reward yourself; D=Do it everyday; S=Stay strong inside (p. 34). Learning activities focus on: • building empathy skills through learning about verbal and non-verbal communication skills and self-regulation and soothing skills; and communication skills • friendship skills training 185 • relaxation and mindfulness skills • attention training focused on changing negative thoughts to positive thoughts and focusing on positive aspects of one’s environment • coping skills for school work and study and situational stressors; and problem-solving skills • peacemaking skills which include learning about bullying and dealing with bullying and conflict styles and conflict resolution strategies in relation to parent- teen conflict situations • and a running theme throughout all sessions focused on fostering “healthy daily habits” including being thankful and grateful each night before bed within daily gratitude journaling; eating healthy and exercising; being active outdoors; and getting enough sleep and rest with a reference to adolescent’s need for 9.2 hours of sleep per night (p. 4–5). While environmental constraints are touched upon in this document, young people are oriented inward. Recommended coping skills focus on increasing young peoples’ awareness of inner thoughts and feelings and to “realize that some ways of thinking will help them cope better than others” with students learning “knowledge and practice in the skills for changing negative, unhelpful thoughts to positive, helpful thoughts . . . in order to reduce their level of anxiety and fear” (p. 17). Similar to how participants in this study described changing their thoughts in ways that enabled them to cope with the insecurities of their environments by focusing on “abundance,” young people in the Friends program are encouraged to change their thoughts to “green” (positive) thoughts, to engage in “positive self-talk” (p. 15), and to use their “attention flashlight” to focus their attention in ways that focus on the positive aspects of situations they face (p. 18). Aspects of the situations they face include: “intrapersonal, interpersonal and environmental” (p. 18). Rationale for this focus on changing negative thoughts to positive thoughts includes: people who are prone to anxiety, depression or anger are more likely to have negative attention biases, and to selectively (and automatically) pay more attention to perceived threats in situations, creating a negative feedback loop and ongoing patterns of unhelpful thinking styles. By training children to repetitively and consciously focus their attention on the positive aspects of situations, this can help them to develop the ‘habit’ of thinking in helpful, positive, optimistic ways rather than unhelpful, negative ways. (p. 4) 186 A further example of the process of recognizing socio-economic stressors but recommending individual level solutions is reflected in this FRIENDS program guide. The multiple and competing expectations that young people face such as “school, extra-curricular activities, homework, friends, family, chores, and social media” (p. 5) are recognized within one of the sessions. Instead of inviting young people to critically analyze the increasing and competing demands that young people face in their day-to-day lives and how broader socio-economic dynamics are contributing to those demands, young people are encouraged to “find quiet time for relaxation” and to engage in “mindfulness activities” (p. 5). Furthermore, in the final sessions of the Friends program, young people are encouraged to engage in volunteer activities to give back to their communities which further adds to the multiple and competing demands that young people are facing in their processes of seeking access to post-secondary programs and/or secure jobs. Interestingly, in contrast to the participant reflections in this study that illustrate how the expectations to be confident and not show signs of weakness (such as one’s insecurities) are aligned with individualistic wealth-oriented notions of success, updates to this program include a shift from exploring self-esteem to promoting “confidence” (p. 10). Outcome indicators within the mental health policy documents more broadly reflect the primary focus on skills and coping at the individual level. Examples of individual level outcome indicators within prevention and promotion programs include: “effective functioning” (BCMHS & BCMCFD, 2010, p. 7); “social competence” (BCMHS & BCMCFD, 2010, p. 7); “cognitive, social and self-regulation skills for . . . children and youth” (BCMHS & BCMCFD, 2010, p. 13); “social-emotional, cognitive development, and resilience in children, youth and families” (BCMHS & BCMCFD, 2010, p. 14); “anxiety and social-emotional skill building” (BCMHS & BCMCFD, 2010, p. 15); “reduced rates of depression and anxiety among youth” (BCHA & BCMHLS, 2009, p. 77); “rates of mood disorders among youth” (BCHA & BCMHLS, 2009, p. 79). While proposed school mental health promotion programs align with participants’ need for authentic social connections through the cultivation of school cultures that value diversity and, to a certain extent, address their need for self-realization and responsive education (through more tailored and responsive curriculum) (as mentioned in Chapter Four), the primary outcomes for school health promotion initiatives include: “lifelong skills, attitudes and healthy behaviors” (BCMHS & BCMCFD, 2010, p. 14) and other individual-level indicators such as: decreased smoking during pregnancy and training parents in the Friends program (BCMHS & BCMCFD, 187 2010, p. 15) and decreased binge drinking, delayed onset of tobacco, alcohol and cannabis; and preventing harms associated with substance use (BCMHS & BCMCFD, 2010, p. 17). This does not include tracking outcomes such as the school cultural environment and degree to which curriculum has been tailored to young people’s interests and capacities. While un/employment trends are tracked in other government departments (e.g. Provincial Health Services Authority, n.d.), there is a lack of attention to tracking numbers of young people who secure employment tailored to their unique capacities after schooling in which their needs for self-realization and self-determination are realized. These systems-level indicators are further not addressed in the inter-related public health goal of promoting healthy communities and proposed outcome indicators for monitoring, surveillance and evaluation in relation to healthy school environments (BCHA & BC Ministry of Health, 2007, p. 26). Overall, the central focus of the mental health policy documents is to address mental health at the individual level, which is positioned as contributing to “improvements in . . . communities and businesses” (BCMHS & BCMCFD, 2010, p. 7) without an equal attention to cultivating socio-economic processes that enable young people’s mental health needs and, in turn, their ability to engage in socio-economic processes in synergistic ways. In my comparison of ideological dynamics as reflected within participants’ reflections to discursive practices within the policy documents, there seems to be a parallel pessimism regarding the ability to influence broader community factors outside of the health sector and, in turn, a pragmatic stance of focusing on individual and local community level strategies. This forms the underlying logic within the dominant and one-sided focus on individual and local community level strategies within not only the mental health policy documents, but also the Healthy Communities Core Public Health Framework. In the healthy communities paper “it is recognized that in many instances, the health authorities will have relatively little influence or control over healthy communities indicators” (BCHA & BC Ministry of Health, 2007, p. 21). The outcome indicators for surveillance and monitoring are thus limited. With the exceptions of the following indicators: “number of communities that have food security policies/plans”, “percentage of urban parks” and “environmentally sustainable/green health care policies” within the health system (BCHA & BC Ministry of Health, 2007, p. 26-27), there is no explicit attention to addressing social determinants of health within the proposed outcome indictors for 188 surveillance and monitoring.39 This pragmatic logic is also reflected within the Mental Health Promotion and Mental Disorders prevention document in which the development of individual skill-building is argued to be a key moderating factor between environmental risk factors and mental health. The Mental Health Promotion and Mental Disorders prevention document lists several socio-economic risk factors such as “poverty, overcrowded living situations, community violence, chaotic neighborhoods . . . unemployment, low income, limited education, stressful working conditions that threaten mental health” (BCHA & BCMHLS, 2009, p. 4). The argument is then made that “protective factors” including “prenatal nutrition and avoidance of harmful substance use during pregnancy, positive engagement with family, friends and communities, and optimum levels of cognitive functioning and emotional self-regulation” . . . “moderate and mediate the effects of risk factors” (BCHA & BCMHLS, 2009, p. 4). Stated later in this document, “social and emotional competence and social inclusion” are framed as “protective factors that enable young people to recognize and manage their own emotions, appreciate the perspective of others and establish positive relationships.” These goals are then framed as “contribut[ing] to resiliency and the ability to cope with adversity and deal effectively with the demands and stresses of life” (BCHA & BCMHLS, 2009, p. 14). This pragmatic and individualistic logic is also reflected in statements such as this one in the Depression Toolkit: “research has shown that some people who develop depression have experienced an unusual amount of stress, conflict or loss before the depression. So, helping a person to deal more effectively with life problems should help to prevent depression” (Bilsker et al., n.d., p. 28). Furthermore, similar to how some of the young people recommended social movement building and action to counter the class-based power dynamics they sensed and observed within their socio-economic environments, “building ‘political’ commitment to the process throughout the community, including decision makers, the grassroots and special interests” (B.C. Ministry of Health, 2007, p. i) and “advocating for healthy public policies that would contribute to healthier communities” (BCHA & BCMHLS, 2009, p. 13; BCHA & BC Ministry of Health, 2007, p. i) 39 While the importance of monitoring and addressing SDOH is recognized in the Healthy Communities program document, the proposed outcome indicators and performance targets track local solutions. This includes indicators such as: local capacity building and local “healthy community plans via collaboration with “local governments” and “facilitate[ing] collaboration between local governments and other key groups on health issues” (BCHA & BC Ministry of Health, 2007,p. 23). These indicators lack an explicit attention to tracking vertical partnerships with provincial and federal level economic and education departments in collaborative policy development oriented to ensuring adequate resources to enable access to social determinants of health. 189 are identified as “fundamental” for achieving progress and successful outcomes in the programs for promoting mental health (BC Ministry of Health, 2013, p. i). However, performance measures and outcome indicators are focused at the individual and local levels with a lack of attention to monitoring health care providers’ level of engagement in policy advocacy and socio-political action oriented to influencing inter-sectoral and multi-level policies. While advocacy is a proposed role of health care providers at the regional health authority level and a list of recommendations for both regional health authorities (e.g. creating healthy workplaces within the health care system itself) and other sectors are offered in order to support health care worker advocacy work (BCHA & BC Ministry of Health, 2007, p. 13; BCHA & BCMHLS, 2009, p. 13, p. 22-24), there are no outcome indicators tracking the level of advocacy, as has been done within the Food security program (BC Ministry of Health, 2014, p. 32). Nor are there performance targets or proposed programs that are oriented to developing capacity of health care providers to engage in advocacy and socio-political action in ways that are influential. Overall, aligned with private individualistic production processes, proposed mental health initiatives are one-sided and oriented along individual lines thereby placing primary responsibility for realizing mental health at the individual level. Comparison of how participants sought to realize their mental health needs to proposed mental health promotion initiatives, and outcome indictors within the policy documents, illustrate the ways that broader socio-economic dynamics, backed by mental health programming, are one-sided in supporting young people to realize their mental health at the individual level. This is without equal attention to ensuring that socio-economic processes enable young people to participate in ways that enable their foundational need for survival and inter-related mental health needs. Overall, proposed mental health programs and outcome measures do not explicitly address participants’ identified needs for: a) meaningful and intrinsically rewarding work-life activities as a way of enabling their self- and societal realization upon graduation from public and post-secondary education programs; b) control over work and life activities; c) a secure future; d) balance in life; and foundationally e) young people’s need for survival through the direct and universal provision of key resources such as income and housing in the present and future contexts of their lives. Aligned with individualistic production processes, proposed mental health initiatives are oriented along individual lines placing primary responsibility for realizing mental health at the individual level. 190 Chapter Seven: Discussion and Implications Introduction This study draws attention to several ways that capitalist socio-economic dynamics challenge young people’s mental health across socio-economic positions (approaches to seeking income), levels of economic resources, and within their positioning as consumers. Findings from the broader relational analysis offered within this study help to explain some of the inconsistent, unexpected and contradictory findings within previous research that has explored the relationship between various individual and group level socio-economic factors and young people’s mental health. Insights from this study emphasize the importance of developing multi-level health promotion initiatives in which nurses and inter-disciplinary health care professionals work not only to support young people at the individual and inter-personal levels of their lives, but also to engage in policy advocacy and socio-political action oriented to changing wealth-oriented material, social, and ideological dynamics that challenge young people’s mental health and limit young people’s control in meeting their mental health needs. The importance of this multi-level health promotion is exemplified by a comparison of provincial mental health policy documents to participant reflections in this study. This comparison of policy to young people’s lived experience of their socio-economic environments from a meta-critical perspective shows how mental health programs not only do not address socio-economic determinants as a universal mental health promotion strategy, but position mental health programs (and inter-sectoral strategies) in ways that support capitalist dynamics. Instead of resolving the contradictory relationship between individualistic and wealth-oriented dynamics and young peoples’ mental health needs, these policies position young people in support of capitalist dynamics that challenge young people’s ability to engage in socio-economic processes to realize their mental health needs in synergistic ways. While there is an accumulation of analytic literature (supported by previous empirical work) arguing for the importance of addressing the impact of broader socio-economic dynamics on young people’s mental health, there has been little intervention research and few mental health promotion initiatives developed to this end. I thus conclude by proposing possibilities for future multi-level praxis-oriented mental health promotion research and practice. I orient these possibilities in two ways: first, in ways that are focused on supporting 191 young people within existing socio-economic processes; and second, in ways that are focused on transforming the contradictory relationship between capitalist socio-economic processes and young people’s mental health in ways that enable realization of young people’s inter-related mental health needs. Within this concluding chapter, I start by providing a summary of the findings while contrasting them to the broader empirical literature. I then discuss the positioning of mental health policies in relation to young people and their broader socio-economic environment. I conclude by identifying implications for future mental health promotion policy, research, and practice. Summary of Findings From This Study There are four central findings from this study that deepen understanding regarding the ways that current socio-economic dynamics affect diverse young people’s mental health. The first finding draws attention to eight inter-related mental health needs that are relevant within this contemporary socio-economic environment for young people. These needs were evident within participants’ reflections on the meaning of mental health and the relationship between their socio-economic environment and their own and fellow young people’s mental health. The second finding draws attention to how these mental health needs and young people’s affective states are two key sites for deepening understanding regarding relational dynamics among young people, their mental health, and socio-economic processes. Furthermore, this finding draws attention to the mutual dependency between young people and their socio-economic environments in processes of realizing young people’s mental health needs. The third main finding draws attention to the ways that capitalist socio-economic processes contradict young people’s mental health needs and limit their control in realizing their mental health needs. Participant reflections highlight how the very needs that are enabled by money within young people’s socio-economic environments are simultaneously threatened by two inter-related capitalist dynamics. These dynamics included first, individualistic (private) production and distribution processes; and second, practices oriented to fostering capital (wealth) creation and accumulation. The fourth key finding draws attention to how material, ideological, and social dynamics orient young people inward, to their inner and inter-personal lives to seek realization 192 of their mental health needs, despite the ways that socio-economic processes play integral roles in mediating young people’s ability to realize their mental health needs. Mental health needs within current socio-economic contexts The first key finding within this study highlights eight inter-related mental health needs that are important for young people’s mental health within current socio-economic environments. These mental health needs were evident within a central theme whereby participants emphasized that money and wealth are not what is ultimately important to their mental health. The majority of participants suggested that “being rich” did not automatically equate to being happy and suggested that needs were foundational to enabling mental health, whereas wants that were driven by materialistic and wealth-oriented values and social norms constrained their mental health. Similar to previous research that has shown a “sweet spot” of 37,000 per year (adjusted for Purchasing Power Parity adjusted GDP per capita) within the United Kingdom, in which life satisfaction levels peak at 37,000 and dip with levels of income beyond 37,000 (Proto & Rustichini, 2013), participants in this study argued that it’s a misconception that having money automatically enables mental health. Participants used the notion of “threshold” to emphasize that having one’s basic needs met were foundational to mental health. Participant reflections on the meaning of mental health and how their socio-economic environments affect their own and fellow young people’s mental health emphasized eight inter-related mental health needs. These needs include: the foundational need for physical survival, health and comfort; the need for authentic social connections; the need for a core sense of self-worth and self-determination; the need for self and socio-environmental realization; the need for learning and responsive education; the need for inspiration and perspective in life; the need for balance in life; and the need for a secure future. Several of the needs that participants emphasized as important to their own and fellow young people’s mental health within this study are aligned with previous research. Participant reflections within this study illustrate the foundational importance of ensuring access to resources for young people’s survival to enabling inter-related mental health needs. Participants also emphasized the inter-relation between physical and mental health. They explained that having access to key resources for survival such as healthy food is foundational to enabling 193 physical health and, in turn, inter-related mental health needs. This finding aligns with previous youth views studies that have underscored the importance of having access to material resources “to participate in leisure activities . . . and to get on with the tasks of everyday life” (Harden et al. 2001; Oliver et al., 2008 p. 780). Similar to previous work in which young people emphasized the importance of having a comfortable home (Shucksmith et al.), within this study, comfort was described as being inter-related with having one’s basic needs for survival met such as having a warm, safe, home. Aligned with the remaining inter-related mental health needs that were identified within this study, previous research draws attention to the importance of: social support, friendships, social inclusion and connectedness (Shucksmith et al. 2009) including close friendships that offer emotional support (Oliver et al. 2008); school connectedness (Murnaghan, Morrison, Laurence, & Bell, 2014); neighbourhood environments in terms of ambient hazards (Aneshensel & Sucoff, 1996), level of cleanliness, safety, well kept green spaces, well-built buildings and infrastructure in one’s community (Ott et al., 2011; Watson & Douglas, 2012); the importance of meaningful work (Cited in Fryer, 1997), contributing to one’s community (van Dyke & Elias, 2007) and having a meaningful role in one’s community (Paxton, Valois, Huebner, & Drane, 2006); the need for solitary past times and leisure and fun (Harden et al. 2001; Oliver et al.); the need for a sense of identity (Shuksmith et al.) and self-worth (Harden et al.; Oliver et al.; Shucksmith et al.); the need for self-determination both in terms of having control over one’s own choices (Shucksmith et al.) and in relation to self-mastery in one’s life and having influence over conditions in one’s community and society at large (Caputo, 2003). Similar to previous youth views studies in which young people have expressed a need to feel in control (Oliver et al.) and to be heard on all levels of decision-making from state policies to local programs and inter-personal interactions (Ott et al., 2011), within this study research participants expressed their need for self-determination and control over not only themselves but also their work-life activities. Similar to participants in this study who expressed a need for having control over their work-life activities, previous research has shown the importance of having control over one’s work (Employment Conditions Knowledge Network, 2007; European Communities, 2008). Similar to the need for access to secure housing which was reflected in the distress that was experienced by participants in this study in their loss of rental homes and their inability to buy a home within the same neighborhood due to high prices in context of speculative housing market dynamics, previous work shows that private renters appear to be more vulnerable than 194 home purchasers to the mental health effects of unaffordable housing (Mason, Baker, Blakely, & Bentley, 2013). Finally, similar to and in extension of previous work that highlights young people’s worries about their future security in terms of their ability to make a living (Gampetro et al. 2012), young people in this study expressed a need for a secure future, not only financially, but also in relation to their need for a sustainable environment. In extension of previous work that has found an association between young people’s educational level and mental health outcomes (Havas, Bosma, Spreeuwenberg, & Feron, 2010), findings in this study emphasize learning as a mental health need and the importance of access to responsive education. Interestingly, participants’ expressed need for social connections and the need for more responsive education that is tailored to their evolving interests and capacities within this study aligns with recommendations made by young people in a previous photovoice study exploring the meaning and determinants of mental health in which young people recommended less time in formal education to enable more time to connect with peers and to explore the world beyond the school setting (Laliberte & York, 2010). Finally, the need for balance between work and rest, relaxation, leisure and play that has been identified in previous research is expanded within this study with an emphasis on also having balance among: work and school and rest, relaxation, leisure and play, as well as the past, present, and future, and a balance between technology and the needs of nature. Relational dynamics among young people, mental health, and socio-economic processes The second finding within this study deepens understanding regarding the dialectical (relational) nature of mental health. This study illustrates how young people depend on socio-economic processes to enable their needs, and how, to the degree that their needs are met, young people are enabled to participate in socio-economic processes that in turn mutually strengthen socio-economic processes and realization of young people’s mental health. This is similar to Brenner et al.’s (2013) findings of inter-active relationships among neighborhood stressors, level of neighborhood disadvantage, young people’s perception of stress, coping style, and physiological outcomes such as cortisol levels. It is also similar to previous work exploring young people’s views on the meaning and determinants of mental health in which young people have emphasized “a holistic view of mental health stressing the ways in which different aspects 195 of their lives worked together to influence it” (Shucksmith et al., 2009, p. ix) and in which young people have emphasized that “mind describes your whole life” (Laliberte & York, 2010). Two key sites for understanding relational dynamics among young people, their mental health, and socio-economic processes, and that show the dialectical (inter-dependent) relationship between young people and socio-economic processes in processes of realizing their mental health needs, are young people’s needs and affective experiences. In contrast to previous studies that have treated young people and their mental health separately from individual level and group level socio-economic factors, findings from this study illustrate how mental health is a phenomenon that emerges from the inter-relation between young people and the socio-economic processes that young people participate in within their day-to-day lives. That is, participants participated in the very socio-economic processes that enabled and constrained their mental health needs. To the degree that their needs are met young people are supported to participate within socio-economic life. For example, the need for learning and responsive education was described as both a need internal to young people and as a socio-economic process they participated within that enabled this need; participants’ engagement in learning experiences within community centres and educational programs both met their need for learning and enabled them to build knowledge and skills to participate in socio-economic life. Authentic social connections were described as both a mental health need, but also a social process of which young people were an inherent part. Mental health needs were also described as being inter-related with each other in that the realization of one need enabled the realization of other needs. For example, authentic social connections whereby people are valued for each person’s diversity were described as enabling young people’s need for self-worth and self-determination in that a) young people felt valued for their uniqueness; and b) young people felt safer to be themselves. The inter-relatedness of these needs is reflected in recent studies. For example, van der Wel and Halvorsen’s (2014) study affirms the inter-relation among the need for survival and other inter-related mental health needs such as the need for self and socio-environmental realization, and the need to engage in meaningful work-life activities. Their study shows how across 18 European countries, increased social spending on welfare benefits increased employment commitment and motivation to work. Another example is Vuolo, Mortimer and 196 Staff’s (2014) study, which shows how steady paid work during high school supports young people in their school to work transition. This finding is similar to a central theme within this study in which participants expressed yearning to be free from worry about meeting their basic survival needs in order to engage in meaningful work and/or life activities that give back to their communities. Participants described how freedom from worry about meeting their needs for survival would motivate and enable them to give back to their communities in more authentic ways. Furthermore, engaging in meaningful work that enabled young people to express their unique capacities was described as evoking a sense of “aspiration” and increasing the young person’s happiness and motivation to continue to engage in work. This finding is also aligned with a meta-analysis of predictors of individual level innovation at work in which previous studies have shown that intrinsic motivation has a stronger association with innovation than extrinsic motivation (Hammond, Neff, Farr, Schwall, & Zhao, 2011).40 In further showing the inter-relation between self-determination and self-realization, Hammond et al. report findings that show associations between work environments that structure jobs to enable individuals’ greater discretion in how and when they do their work and greater levels of innovative performance of employees. Conversely, Savelsberg and Martin-Giles’ (2008) exploration of Australian youth’s experience of homeless and labour market policies shows how, when young people are struggling to survive, they are unable to engage in socio-economic life. Their work illustrates how youth who were homeless faced “ a combination of unstable accommodation, diminished mental and physical health, drug use, limited education and skills (which) made participation in paid employment virtually impossible” (p. 22). Another site for understanding the relationship between young people and their socio-economic environments is their affective states. This study shows how affective states are an intermediary between young people and their socio-economic environments. Within this study, affective states indicated the degree to which participants’ mental health needs were met and played a key and inter-related role with socio-economic processes in influencing participants’ engagement in socio-economic processes in seeking to realize their mental health needs. When participants’ needs were met and they experienced positive affects, they described being further 40 Note that they also found that extrinsic motivation was associated with innovation to a lesser degree than intrinsic motivation. 197 motivated, energized, and able to participate more fully in socio-economic life. When participants’ needs were threatened and they experienced distress, they struggled in various ways to participate in socio-economic life in their attempts to meet their mental health needs. This included young people who lost energy and motivation with depression, anxiety, and hopelessness that was evoked in situations of chronic unemployment and homelessness and young people who felt depressed in “boring” and “menial” jobs. This also included young people whose anger and frustration energized and mobilized them to change their thoughts and attitudes about their life situation, to try a new path to seeking income, or to resist wealth-oriented dynamics with which they disagreed and that were threatening their values and needs. This is similar to previous research exploring the reasons that young people engage in socio-political action and which has shown the ways that emotions provide an “intelligent commentary” on the level of one’s wellbeing, which shapes young people’s engagement in actions oriented to seeking to meet their needs, including the engagement in socio-political action (Mizen, 2015). However, while anger mobilized participants to action in addressing their needs, capitalist dynamics positioned them in ways that placed severe limits over their control in meeting these needs. Contradictions between capitalist socio-economic dynamics and young people’s mental health needs A third key finding in this study deepens understanding regarding the ways that capitalist socio-economic dynamics contradict young people’s mental health by illustrating how the very needs that are enabled by money within young people’s monetized socio-economic environments are simultaneously threatened by capitalist dynamics. Two central and inter-related capitalist socio-economic dynamics challenged participants’ mental health needs in several ways. Within context of a monetized economic environment in which money is needed to access resources (including funded public resources), these capitalist dynamics included first, individualistic production and distribution processes; and second, practices and processes oriented to fostering capital (wealth) creation and accumulation. These dynamics threatened young people’s secure access to resources and created several challenges for participants’ mental health needs to varying degrees and in various ways depending on their socio-economic position, or approach to seeking income, their unpredictable access to resources, and within their positioning as consumers. Similar to epidemiological work that has found that only 20% of a representative 198 sample of people between 25 to 74 years of age in the US experienced mental ‘flourishing’ (Keyes, 2010) not one young person in this study, regardless of their diverse socio-economic positions and access to economic resources, described experiencing a full realization of their mental health needs. Instead, participant reflections illustrate how they faced ongoing tensions among their mental health needs, having to compromise certain needs in order to meet other needs. In response, participants experienced varied, and in some cases chronic forms of distress as they struggled to meet their mental health needs depending on their unpredictable access to resources. These findings align with empirical and analytic work that has explored the influence of dimensions of contemporary socio-economic environments in relation to mental health and wellbeing. Analytic and empirical work has explored the influence of cultural dimensions of modern Western cultures (Eckersley, 2006, 2011), goal and value conflicts inherent to American Corporate Capitalism (ACC)41 (Kasser, Cohn, Kanner, & Ryan, 2007) and facets of modern American society (Schwartz, 2000) on health and wellbeing. Three inter-related socio-cultural dimensions explored within these ways of framing contemporary socio-economic environments are that of individualism (Eckersley, 2006, 2011; Kasser et al., Schwartz), materialism (Eckersley, 2006, 2011; Kasser et al., Schwartz) and competition (Kasser et al.). The notions of materialism and individualism are similar to my use of wealth-oriented notions of success to describe how participants were challenged by what they referred to as the “capitalist brainwash” which included central norms and social expectations regarding the need to be confident, independent, financially successful, and to have status-based jobs and/or commodities that signalled one’s worth amongst peers and within one’s community. Materialism has been defined as attaching importance or priority to money and possessions (Eckersley, 2006) and reflecting goals of wealth, fame or image (Kasser et al.). A related notion is that of “affluenza,” which has been defined as “placing a high value on acquiring money and possessions, looking good in the eyes of others and wanting to be famous” (James quoted in Ferguson, 2007). Distinguished from autonomy, or having a solid grounding in oneself while remaining inter-dependent with others, 41 For an elaboration of their definition of ACC, refer to their article in which they provide an overview of the core institutional and ideological features of this economic system, which, based on previous analytic and empirical work, they argue is a dominant form of capitalism in the world today (Kasser et al., 2007). Their argument is supported by recent analytic work (Panitch & Gindin, 2012). 199 individualism has been defined as not being dependent on or influenced by others (Eckersley, 2006) and a social dynamic “which holds that people’s main duty is to make the most of themselves and to be as successful as possible, ‘a struggle of each against all’” (Children’s Society in Britain partially quoted in Eckersley, 2011, p. 10). The inter-relationships among materialism, individualism and social competition is reflected in Kasser et al.’s characterization of the central values, goals and practices inherent to the institutions and ideologies of American Corporate Capitalism, which they argue is the dominant form of capitalist economics globally. These goals, values, and practices include “values based in self-interest, a strong desire for financial success, high levels of consumption, and interpersonal styles based on competition” (Kasser et al., p. 3). Individualism and mental health The finding in this study regarding the contradictory relationship between individualistic production and distribution processes and young people’s foundational need for secure access to resources to enable survival and in turn inter-related mental health needs, is aligned with analytic work that has drawn attention to the contradictory nature of contemporary notions of freedom (choice) in free markets where “the reality of freedom differs from its ideal” (Eckersley, 2006, p. 254). This analytic work has drawn attention to the contradictory nature of individualism within late modern, free market capitalist systems which have, on the one hand, produced greater levels of expectations for choice, freedom, and control, and on the other hand, produced increased economic insecurity and economic inequities (Eckersley, 2006; Schwartz, 2000). This analytic work is similar to the finding in this study regarding the stress, insecurities and threats to mental health needs that research participants from all socio-economic positions faced within individualistic private production and distribution processes. This included young people who sought the freedom that they assumed would come from entrepreneurial activities and whom were met with the reality (and insecurity) of their dependence on money and fellow people (clients/consumers) in generating and maintaining an ongoing income stream. It also included participants who described their attempts to seek a secure income through employment and whom were met with wealth-oriented wage suppression practices that decreased their wages and produced insecure, part-time work, or, within context of labor (wage) displacing technologies-unemployment. Eckersely (2006) draws on empirical work to argue that while freedom and 200 individual choice have been associated with wellbeing, in the current context of individualism in which people are increasingly positioned independently, or as being self-reliant, individualism has also been associated with a heightened sense of risk, uncertainty and insecurity; a lack of clear frames of reference; (and) a rise in personal expectations coupled with the perception that the onus of success lies with the individual despite the continuing importance of social disadvantage and privilege. (Eckersley, 2006, p. 254) Empirical and analytic work has focused on the cultural dimensions of individualism in relation to young people’s mental health and wellbeing. Eckersley and Dear (2002) explored the association between cultural indicators of individualism and socio-economic status (SES) and male and female suicide rates for young people between 15–24 years of age, cross nationally.42 They found a strong positive correlation between young male’s suicide rates and subjective measures of health, optimism, and several indices of individualism including personal freedom and control, individualisation, individual effort, trust, and individualistic values (with opportunity to choose not being associated) (Eckersley & Dear). Comparison of individualistic versus collectivist values and group dynamics have also been explored in relation to outcomes such as life satisfaction. Santo, Bukowski, Stella-Lopez, Carmago and Mayman (2013) found that adolescents in peer groups that reported higher levels of collectivism have a stronger association between social competence and general self-worth compared to individually oriented peer groups. More recently, a study by Karamanoli, Fousiani and Sakalaki (2014) of adult participants found that preference for non-cooperative economic strategies (versus pro-social/cooperative strategies) are associated with less optimism, lower perceived self-efficacy, and less positive emotions. Inter-related with the threats that individualism has for mental health is that of economic inequities. Previous empirical work is aligned with the finding in this study regarding the challenges of economic inequities for young people’s need for social connections in the context of monetized social and recreational activities and wealth-oriented notions of success. These dynamics combined with inter-personal social comparison dynamics position young people as needing status-based commodities to enable social inclusion. Likely Wilkinson and Pickett’s 42 Countries compared include: New Zealand, Finland, Norway, Switzerland, Canada, Australia, USA, Ireland, Austria, Sweden, France, Denmark, Germany, England, Japan, Netherlands, Spain, Italy, Portugal, Greece 201 (2010) work is the most comprehensive examination of the challenges of economic inequities and mental health and social relations. Their review, in addition to more recent empirical work, highlights the need for social connection and inclusion by showing associations between social cooperation and activation of the reward centres of the brain (Rilling et al., 2002; Stallen & Sanfey, 2013; Wilkinson & Pickett, 2010) and associations between social exclusion and activation of the pain centres of the brain (Eisenberger, Jarcho, Lieberman, & Naliboff, 2006; Eisenberger & Lieberman, 2004; Wilkinson & Pickett, 2010). This includes studies that have shown that just observing social exclusion results in the same activation of pain circuits of the brain (Novembre, Zanon, & Silani, 2015). This study extends their work by showing how young people want to connect across economic differences but experience varied forms of distress in doing so with their varied access to money being a key barrier to engaging in similar activities that cost money. In attempting to connect across economic differences, participants expressed distress across varied levels of access to economic resources. Those of lower income experienced shame, embarrassment, and fear of being excluded. Those with more resources felt guilt and frustration with the challenge of engaging in activities that their lower income peers could not afford. An important insight in this study shows how higher income participants avoided talking about money and resources when interacting with lower income peers to protect their connection with them. This is similar to a previous study that has shown that children as young as two years of age will, once figuring out how to access a treat from a puzzle box, avoid seeking the treat when they are in front of their untrained peers who haven’t learned the puzzle to seek the treat yet (Haun, Rekers, & Tomasello, 2014). Wealth-oriented socio-economics and mental health The second and inter-related capitalist dynamic that challenged young people’s mental health within this study is wealth creation. Similar to the challenges that participants in this study described in relation to wealth-oriented notions of success for their self-worth and peer relationships, previous psychological studies (across age groupings) have explored indices of materialism and reported challenging mental health outcomes. Materialism has been associated with dissatisfaction, depression, anxiety, anger, isolation, and alienation (Eckersley, 2006). From his review of previous psychological studies across age groups, Eckersley (2006) reports that: 202 People for whom ‘extrinsic goals’ such as seeking fame, fortune and glamour are a priority in life experience more anxiety and depression and lower overall wellbeing than people oriented towards ‘intrinsic goals’ of close relationships, self-knowledge and personal growth, and contributing to the community. (Eckersley, 2006, p. 253) In their review of psychological studies exploring the influence of features of ACC beliefs, values, and practices on aspects of psychological health, Kasser et al. (2007) report findings that show the harmful effects of ACC to peoples’ social connections, self-worth, and autonomy. They report findings from studies that have found associations between a greater focus on extrinsic goals such as financial success, image and popularity, and shorter, more conflictual relationships, and lower quality relationships amongst friends and families. They report studies showing how people who are more oriented towards materialistic values are less empathic and less cooperative. In relation to self-worth, similar to the attention that participants in this study brought to their sense that their value is judged based on what they have and do versus who they are in their socio-economic environments, Kasser et al. highlight how within the context of ACC, one’s self-worth is judged based on one’s level of financial success and number and quality of possessions. Similar to the descriptions of the messaging that participants in this study described facing within media and advertising and how this messaging worked in concert with school, parental pressure and social comparison dynamics to threaten participants’ need for authentic self-worth and peer connections, Kasser et al. draw attention to the core messaging within media that “wealth=success” (p. 12). They draw attention to the use of the dynamic of social comparison to sell products via the “cognitive script: ‘you lack the product being advertised. The cool, happy, good-looking, successful, sexy person in our ad does have the product. If you want to be like this person, you should buy this product’” (p. 13). In this context, Kasser et al. report a review of studies that show associations between idealized messages about financial success in advertisements and people’s self-evaluations. While arguing that more research is needed, they suggest that the practices within ACC promote a form of fragile or contingent and extrinsic self-esteem in which one’s self-worth is dependent on external praise and circumstances. In relation to autonomy, Kasser et al. report that, informed by self-determination theory “research shows that extrinsic, materialistic goals are typically pursued for more controlled and less autonomous reasons . . . (such as guilt, anxiety, or external coercion and the promise of rewards)” (p. 14). Studies exploring these dynamics in relation to young people’s mental health align with 203 research participants’ descriptions of the harms that school-based competitive dynamics and parental pressures and expectations to actualize wealth-oriented notions of success had for their mental health. Empirical work has shown how children with very “high perfectionistic strivings (those who saw achievement failures as personal failures) had relatively high depression, anxiety and substance use, as did those who indicated that their parents overemphasized their accomplishments, valuing them disproportionately more than their personal character” (cited in Luthar & Latendresse, 2005, p. 50). More recent work has shown how young people from Western cultures experience significantly more body surveillance, body shame, and appearance control beliefs in response to media and peer pressure compared to Eastern cultures (Kahumoku et al., 2011). Exposure to luxury advertisements has been associated with greater expectations of social rejection in subsequent ambiguous social interactions (Jiang, Gao, Huang, DeWall, & Zhou, 2014). Previous work has also associated higher levels of materialism with higher risk taking behaviours (Auerbach et al., 2010) and a modest association with liking school less and poorer school performance (Goldberg, Gorn, Peracchio, & Bamossy, 2003). In addition to the ways that wealth creation practices such as wage suppression in private production processes created insecurities in seeking secure access to income and in turn resources for participants in this study, wealth creation also challenged participants’ need for a secure future. Participants’ concerns regarding the security of their future in terms of the impact that ongoing production and consumption and pollution are having on the sustainability of their environments and future access to resources, are similar to concerns that young people have identified in relation to environmental pollution (Oliver et al., 2008) and climate change (Laliberte & York, 2010) in youth views studies. This aligns with recent work that has identified the risks that climate change is posing not only to physical health, but also mental health with preliminary “evidence . . . indicating that impacts may be felt at both the individual and community levels, with mental health outcomes ranging from psychological distress, depression and anxiety, to increased addictions and suicide rates” (Bourque & Cunsolo Willox, 2014, p. 415). Participants’ descriptions of how they sought to protect their mental health by consciously not thinking about aspects of their broader environments that threaten the sustainability of their natural environments is similar to analytic work within the field of environmental psychology and the argument that people are very aware of the various threats to their environment and are 204 “in despair” over it, but are too “psychologically paralyzed by the barrage of mind bending misinformation to respond” (Pipher, 2012, 2013 cited in Alexander & Shelton, 2014, p. 495). Overall, the key findings from this study regarding the contradiction between capitalist socio-economic dynamics and young people’s mental health supports attention that analysts have brought to the contradictory nature of wealth-oriented (i.e. individualistic, materialistic and competitive) ideologies and practices within contemporary socio-economic environments and mental health and wellbeing. Stavropoulos has referred to this contradictory dynamic as a “disjuncture between the individualist ‘ideals’ of liberalism and the relational reality of our lives’” (quoted in Eckersley, 2011, p.10). Eckersley (2006) refers to it as a form of cultural fraud in which the “promotion of images and ideals of ‘the good life’ that serve the economy . . . do not meet psychological needs, nor reflect social realities” (p. 256). Young peoples’ contradictory response patterns Within this contradictory context, a fourth key finding from this study entails how young people are positioned to respond in contradictory ways within their processes of seeking to realize their mental health needs. This study shows how despite the central role that broader socio-economic processes have in mediating young people’s mental health needs, young people are positioned and oriented in ways that limit their control over influencing these dynamics in order to enable their mental health needs. This study shows how experiences of insecurity, hopelessness and shame evoked by material, ideological and social dynamics orient young people inward, to their own private inner and inter-personal lives to seek realization of their mental health needs, rather than engage with changing broader socio-economic processes that constrain their mental health needs. With limited control over harmful wealth-oriented socio-economic processes, participants in this study turned inward to their own lives, blocking out aspects of their broader socio-economic environment in order to protect their mental health. This included framing their experiences in ways that aligned with wealth-oriented processes to empower themselves in the context of the fundamental insecurities they faced. This resembles previous data in Savelsberg and Martin-Giles’ (2008) work, which reflects the process of reframing the fear and terror of living in homeless situations with a form of radical acceptance: In the end . . . I remember one time just sitting there and I started having anxiety attack and shaking . . . I could not stop shaking and like it happened a 205 lot . . . and I remember just thinking like every single thing like breathing exercises and things to stop it and I was really like . . . the noise was incredible just like my feet hittin’ the ground and my whole body convulsing and shaking and I was just thinking about the last five years this has been happening and I’ve lived in absolute petrified fear for five years . . . I’ve had enough . . . I want it to happen . . . I want these people to come here and hurt me now . . . I just accepted it and all of a sudden it was like snap . . . I went from convulsing to just calm as . . . and one day just accepted I’d rather die today than live another day in fear . . . that’s so true . . . there’s no point in livin’ . . . it’s so much worse livin’ in fear than facing your fear . . . that was the biggest lesson I ever learnt . . . (Martin-Giles 2006, quoted in Savelsberg & Martin-Giles’ 2008, p. 60) Research participants from this study also worked with friends and family members to meet their basic need for survival and inter-related mental health needs to varying degrees depending on their unpredictable access to resources. In this context, when participants had no alternatives to earn money to meet their need for survival, they engaged in what Saveslberg and Martin-Giles (2008) have referred to as “survivor crime.” This tendency to focus on individual and inter-personal level approaches to enabling their mental health despite participants’ descriptions of how socio-economic processes fundamentally mediated their mental health needs, is similar to previous work. In their study exploring lay views of the meaning, determinants and approaches to enabling one’s mental health amongst 101 non clinical community members, Rogers and Pilgrim (1997) found that most respondents emphasized social causes of mental distress such as life events (family problems) with financial difficulties, employment stress and unemployment being cited as the most frequent examples, with biological and genetic causation being assigned a secondary role (Rogers & Pilgrim). Like most of the participants in this study who expressed a sense of hopelessness for broader system change, participants in Rogers and Pilgrim’s study generally considered that they had little control over external constraints and stressors, so they focused on their own conscious actions. These strategies included: self-reliance, striving for autonomy, finding time and space to be alone, consumption of chocolates, alcohol and cigarettes, and cognitive strategies which focused upon moral obligations and personal responsibility. More recent sociological work has shown how, in response to uncertain labor market trends, young people place increasing emphasis on engagement in leisure activities and personal relationships versus attaching their identities to secure career trajectories (White & Wyn, 2008). 206 While some participants in this study described resisting aspects of their broader wealth-oriented environment with which they disagreed, they necessarily participated in the very contradictory processes that they were resisting. This included purchasing fair trade or “green” products that were marketed as promoting environmental sustainability at the same time that these products contributed to the production of waste that created worries for participants about the sustainability of their environments into their future. It also included their inability to afford fair trade products. This orientation inward to one’s life was further strengthened by material, ideological and social dynamics within participants’ socio-economic environments. Aligned with individualistic wealth-oriented notions of success, participants described the social shame they experienced or observed in response to expressions of emotional distress in their communities. Expressions of distress or insecurity were associated with being “weak” and making young people the target of social shame and/or bullying, which in turn silenced young people. This social stigma and reluctance to express distress within one’s community was also reflected in Rogers and Pilgrim’s (1997) study in which they found that people assigned a secondary role to “relational approaches” to enabling one’s mental health such as turning towards social support networks for support and health care professionals due to cultural assumptions regarding privacy (Rogers & Pilgrim). The fundamental insecurities that participants faced in seeking a secure income, combined with pessimistic assumptions regarding human nature and social change, and several key barriers that participants identified in relation to social change evoked a pervasive sense of hopelessness for collective change amongst participants in this study. These dynamics oriented young people inward to “looking out for oneself” and one’s own financial security. In the midst of this complexity, some participants emphasized the importance of social action to address plutocratic power dynamics as a major barrier to socio-economic change and a source of their hopelessness and powerlessness. This call to engaging young people in socio-political action, however, was challenged by most participants’ descriptions of their lack of understanding of how their political economic systems work and their lack of free time as they struggled to meet their basic need for survival and inter-related mental health needs to varying degrees at the individual and inter-personal levels of their lives. This in turn, limited their opportunities in (and control over) influencing policies and initiatives that shape socio-economic processes. 207 Findings from this study help to deepen understanding regarding some of the inconsistent and unexpected findings in previous studies exploring the relationship between individual and group level socio-economic factors and young people’s mental health. For example, the ways that wealth-oriented notions of success threaten young people’s need for authentic self-worth and social connections helps to deepen understanding regarding the distress that young people from upper socio-economic backgrounds might be experiencing. In contrast to previous hypotheses of the unexpected association between higher income youth or youth with higher educated parents and higher substance use as being due to families with greater financial resources (and thus greater access to substances) or more liberal attitudes (Piko & Fitzpatrick 2007), this study extends Luthar and Lattendresse’s (2005) suggestion that young people may use substances as a form of self-medication in contexts of high social pressures by showing, as one participant in this study explained, how young people use substances as a means of controlling their distress in a context of having little control over the ways that socio-economic dynamics threaten their mental health needs. Findings from this study expand the ways that previous studies narrowly define mental health as an experience internal to young people health (and separate from socio-economic processes) by showing the inter-relation among young people, their mental health needs, and socio-economic processes. This study draws attention to the ways that mental health needs are both internal to young people and also part of the socio-economic processes of which young people are an integral part. Furthermore, affective experiences (and levels of distress) play a key and inter-related role with socio-economic processes in influencing young people’s engagement in socio-economic life as they seek to realize their mental health needs. This finding helps to deepen understanding of previous research that has produced contradictory and unexpected outcomes. For example, findings from the current study helps to explain previous work that has found both positive and negative experiences associated with unemployment (Hagquist & Starrin 1996) in that a young person’s experience of unemployment depends on the ways that different needs are variously threatened and enabled. For example, other factors such as one’s level of economic security and access to resources for one’s survival can shape one’s experiences of unemployment by enabling, for example, one’s foundational need for survival. A further example is reflected in Hammer’s (2000) study which unexpectedly found that for unemployed youth across five countries social support amongst friends and family was weakly related to 208 mental health whereas social isolation was strongly associated with poor mental health. Findings from this study regarding participants’ need for self and socio-environmental realization support Hammer’s hypothesis that young people also need to have a meaningful role in society beyond the peer and family context or, as he put it: “the experience of social isolation as unemployed may have more to do with not taking an active part in society through employment than lack of social contact with family and friends” (p. 58). Inter-related needs that have been identified within this study also help to explain unexpected findings in studies such as Aslund et al. (2009) in which youth who were of middle perceived income status were protected compared to both low and upper perceived socio-economic status youth. This study suggests that low income youth’s need for survival may be threatened with lack of access to income and resources, and both youth of lower income and upper class backgrounds may experience threats to their sense of self-worth and need for social connections in contexts of wealth oriented notions of success, competitive academic pressures and social comparison dynamics. This research also helps to deepen understanding regarding the context of concerns raised by young people in studies of youth’s views. For example young people’s description of schools as being like cages and prisons and their expressed concerns about stress related to the pressures of school work, to succeed, and to fit everything into an increasingly busy schedule (Shucksmith et al, 2009; White & Wyn, 2008) and the stress of having too heavy a workload that eats into free time (Oliver et al., 2008), aligns with the pressures that participants described facing in this study. This study deepens understanding regarding how individualistic wealth-oriented capitalist dynamics contribute to competitive dynamics within young people’s schooling environments. This includes the pressures that young people face from parents and teachers to seek an education to increase their chances of seeking a secure job (and income) within insecure individualistic and wealth-oriented production and distribution processes. Furthermore, young people’s expressed concerns about the boredom with their schooling experiences identified in previous studies (Oliver et al.) perhaps is further understood by the reflections offered by participants within this study who expressed deep frustrations with rigid programming not aligned with their evolving passions, interests, capacities, and learning styles. These experiences were described as “soul crushing” and killing the desire to learn in this study. 209 These insights suggest the importance of expanding the focus of empirical work, which has focused on studying individual and group level socio-economic factors in relation to mental health. Future empirical work needs to explore the relationships among dominant wealth-oriented material, ideological and social dynamics, young people, and their mental health needs. Insights from this study also suggest the importance of expanding beyond individual and inter-personal level solutions to include examination of multi-level, inter-sectoral mental health promotion initiatives oriented to enabling the needs that participants in this study highlighted as particularly relevant. Opportunities for Social Praxis Within Future Mental Health Promotion Initiatives A comparison of participants’ reflections to discursive dynamics within the provincial mental health policy documents shows how the contradictory dynamics that young people face within their socio-economic environments are mirrored within the policy documents. On the one hand, proposed definitions, objectives and some proposed programs within these policies recognize the central role that socio-economic factors play in enabling the realization of mental health. On the other hand, overarching goals of the policy documents and proposed mental health programs not only do not address socio-economic determinants of health as a universal mental health promotion strategy, but position mental health programs in ways that support capitalist dynamics. One of the central goals within the policy documents is to foster economic growth and prosperity through the promotion of economic participation of recipients of mental health programs and prevention of lost productivity for businesses. This one-sided approach to mental health promotion does not address the mutual inter-dependence of young people and socio-economic processes and the ways that capitalist dynamics undermine young people’s mental health and control over meeting their mental health needs, and in turn, young people’s ability to engage in community and economic life. More specifically, analysis of the policy documents reflects how, within the contradiction between capitalist socio-economic dynamics and young people’s mental health, young people are positioned to serve wealth-oriented dynamics in ways that contradict their mental health needs. Proposed mental health promotion initiatives (and individualistically oriented recommendations made within previous empirical literature) one-sidedly address the inter-relationship between socio-economic environments and young people’s mental health. This one-sided focus includes managing distress and symptoms in order to 210 promote young people’s participation in wealth-oriented economic processes while neglecting attention to how these same processes fundamentally challenge young people’s mental health needs, including limiting their control over meeting their mental health needs. The individualistic ways that programming is developed and the ways that programming is oriented to enabling productivity within the broader economic environment positions mental health policies and programs in ways that support the very capitalistic dynamics that threaten young people’s mental health needs. These programs further strengthen the ways that material, social and ideological dynamics within young people’s environments orient young people inward to seeking realization of their mental health needs in ways that contradict the relational nature of their mental health needs. In order to resolve this core contradictory dynamic within existing mental health practice, and, more generally, to foster synergistic relations between young people and socio-economic processes in realizing young people’s mental health needs, the scope of mental health nursing and interdisciplinary health promotion practice needs to be expanded. Health promotion practice needs to harness the information young people’s affective states provide regarding the ways that their socio-economic environments mediate their mental health needs. Therapeutic work within mental health programs needs to expand the dominant focus on assessing and intervening to address young people’s affective distress within their interpersonal and local community contexts to include action that addresses the ways that broader socio-economic dynamics challenge young people’s mental health needs. This can be done at multiple levels spanning 1:1 therapeutic work, small group, policy advocacy, and socio-political action. Therapeutic practice models that are underpinned by a social model of health and health promotion such as Relational Inquiry (Hartrick-Doane and Varcoe, 2015), Just Therapy (Waldegrave, 2000; Waldegrave & Tamasese, 1994) and the Ottawa Charter of Health Promotion (WHO, Canadian Public Health Association (CPHA) & Health and Welfare Canada, 1986) are important foundations to nursing and interdisciplinary work. These social models of health and health promotion emphasize the importance of deepening understanding of and intervening to address the ways that broader material, social and ideological factors are influencing, in the case of this research, young people’s mental health. Building on previous work that has shown the important role that emotions play in human reasoning by signalling threats to one’s wellbeing and values (Mizen, 2015; Sayer cited in 211 Mizen), nurses need to explore young people’s distress within the multi-layered contexts of their lives in order to inform action oriented to promoting young people’s mental health. Within front line health promotion work, nurses need to seek to understand young people’s distress not only in relation to their inter-personal lives, but also in relation to broader socio-economic dynamics. Social models of health promotion can guide nurses in understanding and promoting health at multiple levels. A central focus of these approaches to therapeutic work is exploring the meaning of people’s lives and exploring and addressing factors that shape their control over their health and healing experiences (Hartrick-Doane and Varcoe, 2015; Waldegrave, 2000; Waldegrave & Tamasese, 1994; WHO, CHPA & Health and Welfare Canada, 1986). For example, nurses working across contexts of health care can normalize the struggles and challenges that young people are facing in relation to challenging socio-economic dynamics and work with young people to manage their immediate affective distress. These models of practice also guide nurses to, for example, draw upon information from the field of political economy regarding broader youth labour market trends and to use this information to help young people to understand their affective distress within this broader context. When understood within this broader context, young people’s distress can be used to inform action amongst young people and their allies including nurses. For example, young people’s affective distress can signal nurses to explore broader socio-economic dynamics that are threatening young people’s mental health needs and to explore young people’s recommendations for alternative socio-economic forms and processes that would better support their mental health needs. This in turn can inform nurses’ advocacy and socio-political action oriented to promoting alternative economic forms in collaboration with young people to the degree that they are able to participate. Importantly, individually focused nursing practice needs to be complemented with group-based health promotion work that inter-relates with socio-political action such as community organizing and/or policy advocacy work. For example, within the Just Therapy model, 50% of the family therapists’ role is allotted to front line family therapy work and 50% is allotted to the engagement in community development and policy advocacy work, which are assumed to mutually inform each other (Waldegrave, Personal Communication, 2002). This is aligned with the historical roots of public health nurses whom engaged in health promotion at the individual level as well as advocacy and community organizing oriented to addressing socio-political and economic determinants of health (Duncan, Leipart & Mill, 1999). Overall, this research suggests 212 the importance of expanding the scope of nursing practice by reclaiming our traditional advocacy role in ways that are responsive to current and evolving socio-economic dynamics. This includes the need to further develop existing inter-disciplinary and inter-sectoral health promotion programs in ways that help young people to manage their immediate distress as well as enabling young people’s access to resources within this current socio-economic environment (to the degree possible) and working to transform capitalist socio-economic dynamics in ways that ensure young people’s universal access to resources that enable inter-related mental health needs. In terms of increasing young people’s access to resources within this current socio-economic context, programs like the Nurse-Family Partnership program, which focuses on connecting first time young mothers to diverse health, social and economic resources to support the healthy development of their baby (Smyth & Anderson, 2014) could be adapted within youth mental health promotion programs. To this end, nurses need to develop an ongoing awareness of existing socio-economic resources such as social housing, democratic schooling options, employment preparation and food access programs to refer young people. Informed by young people’s inter-related mental health needs such as their need for self-worth, authentic social connections, learning, self-determination, and self and socio-environmental realization, nurses can work in collaboration with interdisciplinary and inter-sectoral partners in developing universally based, primary prevention, multi-level inter-sectoral health promotion initiatives. An important setting for this health promotion work is public schools in collaboration with civil society groups. The concerns that participants in this study raised regarding their competitive schooling environments is reflected in several reports on the increased pressures that young people are facing in their educational programs and in seeking work upon graduation. For example, participants’ affective distress evoked by wealth oriented notions of success, backed by competitive schooling environments and parental pressure is similar to reports of the high rates of mental distress amongst post-secondary students which has been attributed to “academic demands, social pressures, parents’ expectations, and a looming recognition of a tough job market awaiting [young people]” (Lanau, 2012, p. 56). A U.S. based National College Health Assessment survey of 79,266 students across 140 post-secondary institutions has reported that of these students: 46.4% “felt things were hopeless”; 86.4% “felt overwhelmed by all you had to do”; 82.1% “felt exhausted (not from physical activity)”; 54% 213 “felt overwhelming anxiety”; 32.6% “felt so depressed that it was difficulty to function”; and 8.1% reported “seriously considering suicide” (American College Health Association, 2014a, 2014b).43 Furthermore, previous work has demonstrated that the “post 1970’s generation . . . is the first generation in industrialized countries to enter a world in which post-secondary employment is not taken for granted” and “employment is precarious [where] individuals are less and less able to rely on established pathways and structures to establish their livelihood” (cited in White & Wyn, 2008, p. 149). It is also aligned with work in Canada that has shown that 24.6% of young people holding a university degree are employed in jobs that don’t require a university education (Certified General Accountants Association of Canada, 2012) and that one in three young people between 25 and 29 years of age have moved into low skilled occupations after graduation (O’Rourke, 2012). Nurses thus need to work with interdisciplinary and inter-sectoral partners to develop multi-level and inter-sectoral health promotion initiatives that support young people’s learning in ways that link them directly to meaningful work-life activities that enable self-determination. Neighborhood Learning Centres within B.C. mental health policy offer opportune possibilities for developing partnerships between mental health programs, public educational programs, and civil society groups. Within this context, socio-emotional learning programs could be developed in ways that support young people to explore their identity, values, unique strengths, interests and capacities in ways that inform individualized curriculum planning and that link young people to meaningful work or post-secondary schooling upon graduation from public educational programs. It is also important to develop these health promotion initiatives in ways that create opportunities for young people to work in collaboration with nurses and community groups to directly influence relevant inter-sectoral policies such as primary and secondary level education, advanced education, and economic and labour policies. Insights gained from this study show the unique contribution that young people can bring to informing such policies. For example, the attention that participants in this study brought to the importance of engaging in meaningful work-life activities that contribute to their communities and natural environments is not addressed in current conceptions of “quality jobs” in previous reports exploring labour market 43 These percentages are similar to a 2011 survey of University of Alberta students in 2011 (Lanau, 2011) 214 trends. While participants’ expressed need for having control and self-determination in their work-life activities is partially addressed in research reviews and policy reports addressing employment as a determinant of health (e.g. Allen, 2014; Employment Conditions Knowledge Network, 2008), there is no attention to addressing the need for the development of meaningful work opportunities for young people that enable them to contribute to their communities in order to support their need for self and socio-environmental realization. Furthermore, while previous reports on the general decline in quality employment define quality of employment in terms of the level of pay and permanent full-time status in part addresses participants’ need for secure access to resources, current notions of quality employment lack attention to enabling the expression of young people’s unique capacities in ways that contribute to their community (e.g. Blatchford, 2015; Citizens for Public Justice, 2013; Grant, 2013; Grant, Curry & Kennedy, 2015; International Labour Organization, 2015; Tal, 2015). Nurses thus need to explore ways of linking young people’s voices to inter-sectoral policies such as education, labour and industry policies that shape young people’s schooling experiences and their transition into work-life activities upon their graduation in ways that enable their inter-related mental health needs. In addressing participants’ concerns about their lack of understanding of how their political-economic system works and ways to influence change, nurses can work in collaboration with political-economists to develop critical economic literacy programming which can be offered within group based mental health promotion initiatives. This is important in light of the long-standing attention brought to the lack of economic literacy amongst high school students (Walstad & Soper, 1988) and attention brought to the ideological bias in existing economic literacy programming. Within the high school context, attention has been brought to the bias towards laissez fair and Keynesian interventionist economic policies (Nelson & Sheffrin, 1991) and the corporatization and commercialization of existing financial literacy curriculum (Sukarieh & Tannock, 2009).44 In context of the growth of economic inequities, recent calls have been made for the better integration of economic literacy programming in high schools (Rogers, 2014). Furthermore, engagement of young people in socio-political activities oriented to advocating for policy changes could be integrated within existing health promotion 44 Note that university students across 19 countries are drawing attention to the bias towards neo-classical and free market economic theories within undergraduate economics programs and arguing for the need to include alternative views such as Marxist, Keynesian and heterodox economic perspectives (Inman, 2013a, 2013b, 2014). 215 programming. For example, group based health promotion work could be developed in ways that support existing youth movement building efforts such as mass student demonstrations regarding tuition fees (e.g. Bousquet, 2012). This is supported by research that has shown that participation in community organizing and political action has positive mental health outcomes (Klar & Kasser, 2009). In relation to addressing the harmful effects of wealth-oriented notions of success on young people’s self worth and peer relationships, nurses can work with partners to further develop critical medial literacy programs. While work has been done to develop critical media literacy programs in existing mental health programs, further work is needed to explore ways of preventing young people’s exposure to advertisements that induce unrealistic notions of success. This is important considering participants’ descriptions of how difficult it was to avoid internalizing media messages once exposed to them and their lack of control over their exposure to these images in their day-to-day lives. Research has shown that exposure to media and advertising has pervasive influences on mental health. For example, Kasser et al. (2007) report studies that have shown how “the socializing institutions of ACC’s ideology (such as) contemporary media, with its many messages glorifying consumption and wealth, is associated with greater concern with financial success and a stronger consumer orientation” (p. 6) and that subtle exposure to business related objects (e.g. briefcases and board room tables) has been show to increase competitive cognitions and behaviours. Alternative approaches to protecting young people from these harmful messages has spanned changing the size of models in advertisements to critically examining the role that corporate advertising plays in shaping cultural values and using consumer activism and political protest to shape the role of advertising in communities. In extension of critical media literacy programming which seeks to develop young people’s capacity as critical consumers, work has been done to evaluate the influence of content information labels (to present simple and factual information about the underweight status of thin media models and normal weight) and warning labels (a simple warning about the risk of being exposed to the thin-ideal) on body image (Veldhuis, Konijn, & Seidell, 2014). Velduis et al. found that a simple information label that included the weight status of a thin model was associated with less negative body perceptions in adolescent girls compared to warning labels or images only. Research has also explored the impact of changing the size of models in advertisements. Recent studies have examined the 216 influence of exposing young people to advertising conditions with both unrealistic and more realistic body weights of models. For example, Diedrichs and Lee (2011) explored the influence of three advertisement conditions (no model, thin models and average sized models) on advertising effectiveness and body image for 171 women and 120 men. They found that both male and female research subjects rated averaged sized models to be as equally effective as thin models in the effectiveness of the advertisement. They also found that for women who had average and high levels of internalisation of cultural beauty ideals, exposure to average-size female models was associated with a significantly more positive body image state in comparison to exposure to thin models. For men who reported high levels of internalisation, exposure to average-size models was also associated with a more positive body image state in comparison to viewing thin models. In a study by Halliwell, Dittmar and Howe (2005) of young women with eating disorders, they found that exposure to average weighted models resulted in lower levels of body focused anxiety. More broadly, analytic work has examined the role that corporate media and advertising plays in shaping community values and perpetuating unsustainable consumption. Analysts have called for a critical examination of the role that corporate advertising plays in shaping community values. They have emphasized the importance of consumer action and political protest in orienting media and advertising in ways that contribute to alternative futures based on alternative economic models to the dominance of growth and market led economic models (Ciochetto, 2011). Ciochetto also argues for the examination of new ways of funding media in order to prevent the reliance on advertising as a primary form of funding media. Aligned with this attention to broader socio-economic dynamics and their influence on key socializing institutions such as media, nurses need to balance their health promotion work at the individual and small group level with collaborative work with interdisciplinary, inter-sectoral, and civil society partners in building movements that transform capitalist socio-economic processes in ways that prioritize young people’s needs over profits. Findings from this study offer preliminary insights into socio-economic policies for which nurses can advocate and explore in future research. Policies that ensure unconditional universal access to resources that enable young people’s foundational need for survival are worthy of consideration as a universal mental health promotion strategy. An example of this kind of policy is a guaranteed annual income (GAI) policy that ensures a base level of income to enable young people to meet their basic needs and to ensure a basic standard of living. This policy addresses one of the central 217 findings in this study regarding the ways that ensuring young people’s survival and physical health enables inter-related mental health needs such as young people’s need for learning and education. For example, research on the outcomes of the guaranteed annual income experiment in Daughan Manitoba between 1974–1979 shows how a basic income policy resulted in greater numbers of young people staying in school longer (Forget, 2011). More broadly, research has shown a decrease in hospitalization rates for mental health and accidental injuries in Daughan compared to similar sized cities (Forget). Policies that ensure a guaranteed income and/or access to basic resources for survival are particularly important considering analytic and empirical work that has shown the increasing rates of unemployment and precarious employment not only for young people but people generally (Artner, 2013; International Labour Organization, 2015). Similar to analytic work showing the role that profit-maximizing technologies within private production processes play in increasing unemployment generally (Gorz, 1989; Gorz cited in Harvey, 2014), Artner argues that youth unemployment needs to be understood within the broader context of growing unemployment. Based on her analysis of European Union statistical data on youth unemployment trends in comparison to broader labour market trends, Artner stresses that the underlying reason behind the disengagement and exclusion from society of an increasing part of young people is the generally high unemployment. There have never been so many people without a job in Europe as there are today. Since 2009, in the EU15 the level of unemployment has been higher than it was at its peak after WWII at 22.3 million (11.5%) in March 2013.” (p. 197) In disagreement with the dominant theory that youth unemployment is due to a “structural mismatch between their skills and the demand of the market,” Artner (2013) argues that unemployment for both youth and adults is part of a wider trend of profit driven automation and displacement of workers. She thus argues for exploring alternative economic policies such as a guaranteed income. Importantly, nurses need to balance advocacy for a GAI policy with advocating for the continued development and funding of public services that address common needs. This is supported by previous analyses of GAI policies that have drawn attention to their threat to continued funding of state programs and services (Young & Mulvale, 2009). Nurses’ advocacy for healthy economic policies also needs to consider the dynamics of 218 continued economic growth that drive the practices and processes that threaten young people’s mental health needs and, more specifically- that create economic inequities and the consolidation of social (class) power and, in turn, a sense of hopelessness for young people in relation to the possibility for social change. To this end, nurses need to consider monetary policies that are oriented to developing a means of exchange (i.e. money) that facilitates the circulation of goods and services but that limits or excludes the capacity of private individuals to accumulate money as a form of social power (Harvey, 2014). Socio-economic growth also needs to be “de-coupl(ed) from environmental degradation” in fostering environmental sustainability (Hertwich et al., 2010, p. 9) in order to address the threats that economic growth poses to the security of young people’s environments and access to resources into their future. Importantly, Wilkinson and Pickett (2010) draw attention to the inter-relationship between levels of national economic equity and environmental protection policies showing, for example, that countries with lower levels of inequity have a higher level of recycling policies. This suggests the potential that advocating for economic equity not only addresses young people’s need for more inclusive communities, but also their need for a secure and sustainable future. More broadly, further work in nursing research is needed to explore ways of overcoming barriers to the engagement of nurses in policy advocacy and socio-political action. Previous work has identified individual, organizational and extra-organizational barriers to population focused health promoting nursing practice (Cohen, 2006). A review of previous work by Roden and Jarvis (2012) draws attention to several barriers to health promoting nursing practice informed by a broader conception of health and health promotion as outlined in the Ottawa Charter of Health Promotion. These barriers include: insufficient educational preparation for nurses’ health promotion role; limited resources including inadequate staffing and limited time; shorter hospital stays; no clear policies or lack of intent to engage politically on the part of nurses; a lack of conceptual framework and epistemological position to support a clear understanding of health promotion; and a lack of a sense of the potential of what health promotion can achieve (Roden & Jarvis). In their own study of pediatric nurses in Australia, Roden and Jarvis found that while pediatric nurses recognized the importance of socio-political action such as lobbying their members of parliament to advocate for healthy public policies, they were frustrated with the ways that they are limited due to increasing workloads and less time and resources. Roden and Jarvis emphasize the lack of education about health promotion practice as a key barrier for 219 nurses. In their exploration of how six case study primary health care (PHC) centres in an Australian context are addressing social determinants of health (SDOH) and the barriers in doing so, Baum, Legge, Freeman, Lawless, Labonte and Jolley (2014) identified the following barriers: broader political shifts to prioritizing chronic disease management and prevention using behavioural models within health policies and programs; a continued biomedical focus within health departments which leaves little room to respond to broader SDOH; vertical governance structures and funding priorities; the tensions between addressing immediate clinical needs and taking action on underlying determinants; PHC providers’ sense of their lack of control over broader social factors; and the discourse on SDOH which “itemizes a number of conditions (mimicking behavioural epidemiology and its list of specific risk factors) rather than presenting a more unified political analysis of how these conditions are linked” (p. 11); and the political tensions that PHC providers face when challenging existing power dynamics in their role as advocates. Such barriers imply several possible interventions that need development and evaluation in relation to enabling nurses’ full scope of health promoting practice. This includes the need to develop and evaluate curriculum and practicums within nursing education programs that are oriented to educating nurses about ways to assess and intervene in addressing the influence of broader socio-economic determinants of, in the case of this research, young people’s mental health; the need to develop organizational supports to enable nurses to engage in working at the community and policy advocacy level (Cohen, 2006) such as the expansion of nursing job descriptions in ways that enable time and resources to engage in community development and socio-political action. Importantly, more research is needed to inform how nurses can navigate the context of current mental health policies that are positioned in ways that strengthen wealth-oriented economic processes and plutocratic state decision-making processes (Gilens & Page, 2014, p. 21).45 This includes the contradictory nature of nursing work in which nurses are dependent on incomes for their own financial security which can result in reluctance to engage in socio-political action that challenges existing power dynamics that threaten their job security. 45 For example, a study of US Senate decisions by Gilens & Page (2014) showed how US policy decision makers are biased towards economic elite and business interests with average citizens’ preferences having “essentially zero estimated impact upon policy change” (p. 21) with the use of multivariate analyses. 220 Exploration of the role of professional practice associations in addressing the dual contradictory dynamic between capitalist socio-economic processes and young people’s mental health needs and the contradictory tensions within mental health policies and programs (and nurses’ work within these programs) may be one option for future research. Furthermore, in order to inform nurses’ policy advocacy oriented to transforming capitalist socio-economic dynamics, interdisciplinary research that explores the influence of dimensions of alternative economic forms compared to dimensions of capitalist economic processes in relation to young people’s mental health needs is needed. Building on Wilkinson and Pickett’s (2010) analysis there are several possibilities for future research and policy advocacy. Alternative economic forms including steady state, cooperative, local, and commons based economies are worthy of further exploration. Commons based economics align with not only the participants in this study that advocated for ensuring universal access to key resources for survival but also other youth activists that have called for reclaiming the commons (Baker, 2015). As these alternative economic forms exist to varying degrees, future research could contrast young people’s experiences of these alternative economic forms with mainstream capitalist socio-economic processes. For example, young people’s mental health needs could be explored in relation to their experiences of working within a cooperatively run business in which decision-making processes and profits are shared compared to working in a private for profit firm. Finally, as is exemplified within this study, social praxis, underpinned by a historical-dialectical ontological framework offers a useful epistemological framework for analyzing the complex and inter-related aspects of socio-economic life in relation to young people’s mental health. In turn, a deeper understanding of current and evolving relational dynamics offers promise in informing coherent health promotion strategies that address contradictory dynamics that threaten young people’s mental health needs. Limitations of this Study There are a few limitations to this study. As mentioned, in seeking to ensure that research participants felt safe to share their experiences within the dialogue sessions, I gave them the choice as to how they wanted to meet with me and other research participants. This resulted in a mixture of individual, dyadic and small group meetings with young people that participated 221 within this study, which limited their engagement in the research process and analysis of data. While I sought to enable participants to engage with each other more actively through the offering of online discussion spaces and meeting on a weekly basis at a local community centre to discuss photos and share their experiences, participants did not accept this invitation. Furthermore, with the exception of periodically sharing about a GAI policy and cooperative economic forms (when participants struggled to identify structurally-based recommendations), I chose not to share about alternative economic forms for discussion in order to minimize my own influence on participants’ responses. While these approaches to data collection supported exploring participants’ lived experiences across social differences, they also limited the depth of engagement of participants within the process of social praxis used within this study. Another limitation entailed the lack of engagement of nurses and interdisciplinary mental health professionals within the process of social praxis used in this study. This potentially limits insights gained regarding opportunities to build on existing mental health promotion efforts in ways that are responsive to current shifts and trends within evolving mental health promotion initiatives. Furthermore, this study engaged young people within an urban and sub-urban context. Thus some insights may not be relevant to other rural and remote urban settings. Importantly, I would like to recognize that the argument made within this study regarding the ways that all young people are struggling across socio-economic positions to realize their inter-related mental health needs is in no way meant to gloss over the degrees of vulnerability and struggle experienced by young people across socio-economic situations. For example, young people whom are homeless and facing the immediate threats to their survival are clearly more immediately vulnerable compared to those with more resources. While young people with more resources struggled in similar ways to meet their need for survival, compromising their need for self and socio-environmental realization through seeking access to post-secondary programs that would increase their chances of seeking secure income streams into their future, it is important to recognize the varying degrees of immediate threats to survival that the participants variously faced within their insecure and unpredictable access to resources in this current economic context. 222 Conclusion In conclusion, this study used a critical qualitative approach to explore the relationship between socio-economic environments and young people’s mental health with particular attention to identifying opportunities for health promotion oriented to addressing young people’s current mental health needs. Thirty diverse young people between the ages of 15 and 28 years of age were engaged within the first phase of a process of social praxis to explore their experiences of the relationship between socio-economic processes and young people’s mental health and opportunities for change. Participant reflections were then compared with a close reading of two sets of provincial mental health policy documents to explore how mental health policy is positioned in relation to young people and broader socio-economic processes and to identify ways of building on existing work to address constraining aspects of socio-economic life for young people’s mental health. Findings from this study deepen understanding regarding the dialectical nature of relationships among young people, mental health, and socio-economic processes, and, within these relationships, a core contradiction between capitalist socio-economic processes and young people’s mental health. Eight inter-related needs were emphasized within participant reflections including the foundational need for physical survival, health and comfort; the need for authentic social connections; the need for a core sense of self-worth and self-determination; the need for self and socio-environmental realization; the need for learning and responsive education; the need for balance in life; the need for inspiration and perspective in life; and the need for a secure future. Two key sites for understanding the relationships among young people, mental health and socio-economic processes, are young people’s needs and their affective states. Affective states indicated the degree to which participants’ mental health needs were met or not and played a key and inter-related role with socio-economic processes in shaping young people’s abilities to participate in socio-economic life as they sought to realize their mental health needs. This inter-dependency between young people and socio-economic processes is disrupted, however, by a central contradiction between capitalist socio-economic dynamics and young people’s mental health needs, and in turn, their ability to engage in socio-economic life. In this context, mental health policies position mental health programs in support of economic growth in 223 ways that do not address the inter-dependence of young people and socio-economic processes, and do not address how capitalist dynamics undermine young people’s mental health. This in turn limits the potential of mental health promotion programs to enable young people’s mental health, and in turn their ability to engage in socio-economic processes in sustainable and synergistic ways. Importantly, not one young person in this study, regardless of their diverse socio-economic positions and varied access to economic resources, described experiencing a full realization of their mental health needs. Instead, participants faced ongoing tensions between their mental health needs, having to compromise certain needs in order to meet other needs. In response, participants experienced varied, and in some cases chronic, forms of distress as they struggled to meet their mental health needs which left little time to engage in action oriented to changing policies that shape the ways that socio-economic processes fundamentally mediate young people’s mental health. This study implies the importance of multi-level, inter-sectoral mental health promotion initiatives. Young people’s affective states offer a key site for deepening our understanding regarding the ways that their socio-economic environments are affecting their mental health. Young people’s affective states, along with insights from the field of critical political economy, offer important information in informing multi-level action oriented to both enabling young people’s access to resources within existing socio-economic processes and transforming capitalist socio-economic processes in ways that enable a fuller realization of young people’s mental health needs. A central priority is the need for policy advocacy and socio-political action oriented to enabling young people’s access to resources for their survival as a universal mental health promotion strategy. This would support young people in realizing inter-related mental health needs in ways that enable them to participate within socio-economic life in more authentic and synergistic ways into the future.224 References A. Berland Inc. (2008). A review of child and youth mental health services in B.C. Following implementation of the 2003 child and youth mental health plan. 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Culture, Theory & Critique, 53(3), 365–382. doi: 10.1080/14735784.2012.721628 254 Appendix A: Recruitment Process Date Method of Recruitment Implementation August-September 2012 Recruitment posters and brochures posted to central city street community bulletin boards No response August 2012–March 2013 Emailed 24 community centres and six neighborhood houses within the Vancouver catchment area with request to post posters/brochures to bulletin boards and/or present to youth groups Posters/brochures posted to 5 community centre bulletin boards and 1 neighborhood house by front desk staff Poster/brochures distributed to youth from 1 community centre and 1 neighborhood house by youth coordinators I presented to 2 employment prep programs via Neighborhood Houses September 2013–April 2014 Emailed/phoned select leaders from youth-serving organizations to share posters/brochures for them to share with their youth populations along with offer to present to youth groups Met with: youth engagement coordinator of provincially based child and youth mental health services located within Vancouver; two youth advisors for a provincially based child and youth mental health advocacy group who referred me to a university-based peer support group leader who shared posters/brochures with their young people I met with and presented to a four youth from an agency providing services to young people who were homeless A youth-led advocacy group focused on addressing social and environmental issues facing young people emailed the brochures to 172 of their members Director of Clubs for the Boys and Girls Clubs of South Coast B.C. forwarded my email and brochure to program leaders Presented the project to the B.C. First Call Child and Youth Advocacy Coalition monthly meeting on September 12th 2012 and left brochures for coalition partners to share with interested youth Sp Peer to peer recruitment At the end of each interview, I 255 Date Method of Recruitment Implementation anned entire data collection phase and word of mouth gave brochures to research participants and invited them to invite friends or other young people whom they thought might be interested in participating and distributed brochures to a few young people that I encountered on local transit and through word of mouth I presented to two more youth groups via community centres: an immigrant youth group and a youth leadership group 256 Appendix B: Recruitment Documents 257 Appendix B1: Information Letter INTRODUCING A ONE YEAR RESEARCH STUDY THAT AIMS TO EXPLORE THE RELATIONSHIP BETWEEN SOCIO-ECONOMIC FACTORS AND YOUTH MENTAL HEALTH AND WELL-BEING Study Title: Addressing socio-economic determinants in health promotion initiatives: A dialectical inquiry into the relationship between socio-economic factors and youth mental health and wellbeing Study Purpose: The purpose of this study is to inform health promotion programming that aims to address broad social determinants of youth mental health and wellbeing Research Team: Colleen Varcoe R.N., Ph.D. Shari Laliberte R.N., M.N. Ph.D. student UBC School of Nursing Joy Johnson R.N., Ph.D. Kathy Teghtsoonian Ph.D. Funded by: School of Nursing, University of British Columbia Lyle Creelman Endowment Fund WHAT IS THIS RESEARCH STUDY ABOUT? The primary goal of this research study is to explore youth’s ideas on how socio-economic factors (e.g. money/finances, jobs/employment) affect youth mental health and well-being. Our hope is that by better understanding youth views on the ways that socio-economic factors affect youth mental health and well-being, we will be better able to develop health promotion initiatives that address social, political and economic determinants of youth mental health and wellbeing. There are two main goals of this study: • To explore youth views regarding how socio-economic factors (e.g. money/finance, jobs/employment) affect youth mental health and wellbeing 258 • To explore ways that health promotion initiatives can help to address youth’s concerns and worries about socio-economic factors (e.g. money/finances, jobs/employment) WHO IS INVITED TO PARTICIPATE IN THIS STUDY? Diverse young people between the ages of 14 and 30 years old. HOW MIGHT I BECOME INVOLVED IN THIS STUDY? If you are a youth/young adult who lives in Vancouver and surrounding area and are between the ages of 14 and 30, you are invited to consider whether you would like to be part of this study. If you decide that you would like to be involved in this study, you will first be invited to meet with the researcher to learn more about this research project. You will be informed about: • the goals of this research • who is conducting this research • the phases of this study and what participation will entail • the risks and benefits of participating in this study • how the information will be used from this research • your rights as a research participant You will be given a hand out with this information to review yourself. If you would like and with your permission-this information can also be sent to your parent/caregiver/guardian. If you would still like to be part of this research study, you will be invited to contact the researcher to set up your first interview. At this interview, the researcher will explore your understanding of this research and your rights as a research participant and clarify any questions you might have. If the researcher feels confident that you understand this research, you will be invited to sign the consent form and then to meet with the researcher individually or with a small group of other youth. Periodically the researcher will check in with you to ensure that you understand the research process and your rights as a research participant. You will be reminded that you are free to discontinue participation within this study at any time. 259 As a research participant, you will meet with the researcher for an individual or group interview about what you think affects youth mental health and well-being. You will then be asked whether you would like to join a second phase of this study in which you will be trained in the basics of documentary photography (with other research participants). You will be invited to take photographs that show what affects your mental health and wellbeing in your day-to-day life. Once the researcher has interviewed all 25–30 youth in this study, attempts will be made to include as many youth in this photography process as is possible with available resources. If more youth express interest than the researcher can accommodate, youth’s names will be drawn from a hat to ensure fairness. In this second phase of this project, you will then be invited to either meet individually with the researcher, to join other research participants in a small group interview, or to meet the researcher and other youth online in a private social media platform (similar to Facebook-but private) to share your photos and to explain what you see in your photos. The researcher will analyze the information that you and fellow research participants provide within the bigger community context. The researcher will share this information with you and research participants to get your ideas on how health promotion initiatives can help to address youth’s worries about socio-economic factors that are challenging to youth mental health. TIMETABLE OF RESEARCH PHASES PHASE I July 2012-September 2012 Recruitment of youth research participants PHASE II Ongoing sampling/recruitment and data collection: • September to November 2012: Individual and small group interviews • November 2012:Documentary photography training • January to June/July 2013 Documentary photographic work PHASE III: July to October 2013 Summary of findings PHASE IV: Exploration of how findings can inform policies and programs (August 2013-November 2013) 260 If you would like to be involved in this study, please contact: Shari Laliberte, primary research facilitator Taking part in this study is voluntary. If you choose to volunteer, you can change your mind about participating at any time. You are free to discontinue participation in this study at any time. If you are experiencing any worries/concerns that come up for you as a result of being part of this research project, you are encouraged to contact one of the agencies on the attached handout for support. 261 • Do you ever worry about money or school pressures and your future education? Do you work to make money? How is it connecting with others and being heard by leaders in your community? • Are you from Vancouver and between the ages o f 13 and 30? • Are you inte rested in he lp ing to s tudy how soc io-economics (e .g . money, jobs , po l i t i ca l vo ice , schoo l , soc ia l connect ions) a f fects youth menta l hea l th and wel lbeing? • This s tudy w i l l use crea t i ve approaches such as photography • I f you ’re inte rested, g rab a brochure and cons ider part ic ipa t ing in th is research s tudy and f ind ou t more on: Facebook: “Money” and Young Minds Research Pro ject Twi t ter : YoungMindsResearch Appendix B2: Recruitment Poster Brian Powell 262 Appendix B3: Recruitment Brochure 263 Appendix C: Demographic Survey Form Demographic Survey Form Addressing socio-economic determinants in health promotion: A dialectical inquiry into the relationship between socio-economic factors and youth mental health and wellbeing DEMOGRAPHIC SURVEY FORM Hello, You are being invited to fill out this survey form in order to help the researchers of this research project to learn about your social characteristics (demographic information). Filling out this survey form is completely voluntary. You are free to not answer questions in this form. You are free to change your mind at any point and we will shred this survey form should you change your mind in filling it out in order to protect your privacy. The information provided in this survey will help to ensure that a diversity of experiences is included in this study. In order to ensure confidentiality, the researcher will remove your name/address on this first page of this form and may report some of your demographic (social characteristics) information that you report on pages 2-5 in future research reports. Name: ___________________________________ Date of Birth: ________________ Age: _________ Address: _________________________________ Phone number: ___________________________ Email: ___________________________________ Interview number: _____________________ Pseudonym (to protect confidentiality in research report): ______________________________ Your age:__________ Your Birth date:____________________ Month/Day/Year 264 What gender do you most closely identify with (e.g. male, female, trans, inter-sex): _________________ Do you have children? Yes No If so, how many children do you have and what are their ages? ___________________________________________________________________ Your Living Situation Who do you currently live with (identify whether they are friends/family/legal guardians)? You do not need to put their name down. Please note what kind of relationship the person is to you (e.g. friend, parent/legal guardian, sibling, legal guardian, professional caregiver, pet) Age of the person What type of housing do you live in? You rent suite in house You rent an apartment You rent a mobile home You own your own mobile home You own your own single house You own your own duplex You own your own apartment You live in an institution (e.g. a group home, supported housing unit) You live in a hotel; rooming house You live in a camp You live in the street Other (specify)________________ 265 How long have you lived in your current housing situation? Less than 6 months Less than 1 year Less than 2 years 3 to 5 years 5 to 10 years More than 10 years Regarding your family of origin: What is the highest level of education that your parent(s)/caregiver(s)/guardian(s) has ever attained (think about both parents/caregivers and report on the one with the higher education level)? No schooling Some elementary (1–7 years) Completed elementary school Some secondary Completed secondary school Some trade, technical, vocational school, or business college Some community college Some university Diploma or certificate from trade, technical, or vocational school, or business college Diploma or certificate from a community college or university Bachelor or undergraduate degree Master’s degree Doctoral Degree How would you describe your family’s financial situation? Well above average Somewhat above average About average Somewhat below average Well below average Which of the following statements best describes your family financial situation: Your family has a hard time getting enough money for food, clothing, and basic living costs 266 Your family has just enough money for food, clothing and basic living costs Your family has few problems buying what your family needs Your family has no problem buying what your family needs and is able to buy special things Your Relationship Status: What sexual orientation do you most closely identify (e.g. heterosexual, homo-sexual, bi, straight, two-spirited): ___________________________________ If you are of the dating age or older, what is your intimate relationship status? Single, never married Married Living common-law Widowed Separated Divorced Intimate relationship with a boyfriend Intimate relationship with a girlfriend Other (specify): __________________________ Are you presently in school? Yes No If so, what grade level are you attending presently? _________ What type of school do you attend? Is it: Public school? Catholic school, publicly funded? Private school Alternate school (e.g. publically funded special education, store front) Not in school Taught at home (home schooled) Trade, technical, vocational school, or business college Community college University You have completed: High school diploma High school equivalent (e.g. GED) Some trade, technical, vocational school, or business college Some community college Some university Completed diploma or certificate from trade, technical, or vocational school, or business college Completed diploma or certificate from a community college or university 267 Completed bachelor or undergraduate degree Completed master’s degree Completed doctoral degree Other:_______________________ Your Income/Employment/Job Situation Are you currently employed? Yes No Have you worked for pay or profit at any time in the past 12 months? Yes No What age did you start to work for pay? _______________ Have you run your own business at any time in the past 12 months? Yes No If so, during the past 12 months, what was your total personal income from wages, salaries, profits (before deductions)? $________________________________________ Your experiences with community decision making: Have you ever voted in the following elections: School elections (e.g. school council; student union elections) Municipal Provincial Federal Have you ever participated in a community-based decision-making process that influences your own life and that of other members in your neighborhood/community? Yes No Your Overall Health and Wellbeing In general, would you say your health is: Excellent Very good Good Fair Poor 268 In general, would you describe yourself as being usually: Happy and interested in life Somewhat happy Somewhat unhappy Unhappy with little interest in life So unhappy that life is not worthwhile Have you ever been formally diagnosed with a physical or mental health challenge? Yes No If so, what diagnosis were you given?________________________________________ Did you agree with this diagnosis? Yes No If you disagreed, why did you disagree? _______________________________________________________________ Your Cultural/ethnic background: What is your citizenship status: Canadian citizen Landed immigrant Other: ___________________ If you immigrated to Canada, what year did you immigrate to Canada? ________________ What language is primarily spoken in your home? English French Cantonese Spanish Italian Farsi Cree Other: _______________________ 269 What ethnicity(ies) do you most closely identify with? ___________________________________________________________________ Thank-you 270 Appendix D: Participants’ Demographic Information Housing Situation What type of housing do you live in? Type of housing Number of responses Rent room in house/rent house 13 Own house 4 Duplex rent 1 Duplex own 0 Rent apartment 5 Own apartment 1 Lives in apartment (own/rent-unknown) 4 Street 1 Youth shelter 1 Response missing 1 Total 31* *Note one youth answered twice: owns own apartment and is also renting apartment How long have you lived in your current housing situation? Duration Number of responses Less than 6 months 7 Less than 1 year 4 Less than 2 years 7 3 to 5 years 3 5 to 10 years 3 More than 10 years 5 Response missing 1 Total 30 271 Education Parental education: What is the highest level of education that your parent(s)/caregiver(s)/guardian(s) has ever attained (think about both parents/caregivers and report on the one with the higher education level)? Education level achieved by parents Number of responses Some secondary 2 Completed secondary school 6 Some trade, technical, vocational school, or business college 1 Some community college 2 Some university 1 Diploma or certificate from trade, technical, or vocational school, or business college 1 Diploma or certificate from a community college or university 2 Bachelor or undergraduate degree 9 Master’s degree 1 Doctoral Degree 3 Response missing 2 Total 30 Research Participants’ Education: Are you presently in school? School attendance Number of responses Yes 18 No 11 Non response 1 Total 30 272 If so, what grade level are you attending presently? Grade level of schooling Number of responses Grade 9 - Public school 2 Grade 10 – Public school 4 Grade 11 Public school 4 Grade 12 Public school 2 Alternative 1 2nd year college (after attending private school) 1 1st year university 3 Not currently in school 11 Response missing 2 Total 30 *Note that of one of the young people was not in school, they noted that they were in an employment preparation program Type of school that research participant has attended: School type Number of responses Public school 12 Catholic, publicly funded 0 Private school 0 Alternative school (publicly funded, special education) 1 Taught at home 0 Trade, technical, vocational school, or business college 0 Community college 0 University 5 Not in school currently 11 Non response 1 Total 30 Note: 1 who was currently in university noted that they went to private school in past 1 not currently in school noted that they went to public school and some college in past 273 2 not currently in school noted that they went to public school in past Research participant has completed (check all that apply): Education level achieved Number of responses High school diploma 9 High school equivalent (e.g. GED) 1 Some trade, technical, vocational school, or business college 0 Some community college 3 Some university 1 Completed diploma or certificate from trade, technical, or vocational school, or business college 2 Completed diploma or certificate from a community college or university 1 Completed bachelor or undergraduate degree 0 Completed master’s degree 0 Completed doctoral Degree 0 Some high school 1 Currently in process- high school 12 Currently in process-alternative school 1 Currently in process-university 4 Response missing 1 274 Sexual orientation and relationship status What sexual orientation do you most closely identify (e.g. heterosexual, homo-sexual, bi, straight, two-spirited): Sexual orientation Number of responses Heterosexual 11 Straight 13 Homo-sexual 1 Bi 1 Two spirited 1 Unidentified 1 Response missing 2 Total 30 If you are of the dating age or older, what is your intimate relationship status? Relationship status Number of responses Single, never married 19 Married 0 Living common-law 1 Widowed 0 Separated 0 Divorced 0 Intimate relationship with a boyfriend 4 Intimate relationship with a girlfriend 3 Other- Intimate relationship with everyone (boyfriend and girlfriend) 1 Response missing 2 Total 30 275 Cultural Background Citizenship status: Citizenship Number of responses Canadian citizen 20 Landed immigrant 3 Dual-citizen 2 Permanent Resident 2 Other: Diplomat 1 Other: Tourist 1 Non-response 1 Total 30 What language is primarily spoken in your home? (more than one response accepted) Language spoken Number of responses English 16 Bilingual English/French 1 Cantonese 2 Spanish 5 Farsi 1 Russian 1 Hungarian 1 Mandarin 1 Tagalog 1 Vietnamese 1 276 What ethnicity(ies) do you most closely identify with? Ethnicity Number of responses Canadian 1 Canada/Cuba/Panama 1 Russian 1 Native 1 Caucasian/First Nations 1 Chinese 3 Hispanic 2 Irish 1 Filipino/Asian/American 1 Caucasian 3 German 1 Mexican 1 South American/Hispanic 1 Vietnamese 1 Iranian 1 American/Texan/Mexican/Ohio/Italian/German/Native American 1 Latin American, Hispanic, Latino 1 Aboriginal 1 Nisga’a 1 Japanese Indonesian 1 Dad: German, French, Irish, Scottish but I identify with Canadian 1 Canadian, Vietnamese, Human, Earthling, Meatbag 1 277 Appendix E: Guide for Facilitating Small Group (Individual) Dialogue Sessions 1. Introduction to group process: Researcher will introduce the research project and the research student. The research student will introduce group norms to guide the small group interviews: • People have common and unique experiences thus there might be some agreement and some differences in ideas and experiences that are shared-this is o.k. • It’s o.k. to disagree and have different ideas and experiences • The goal of this discussion is to enable everyone to have a turn to share their ideas/experiences and to enable you all to explore ideas/experiences together in a conversation. Thus we will at times take turns sharing ideas and at times we will have space to have a dialogue where people can share their ideas together in dialogue/conversation with each other. • If a member feels distressed at any point, I will be available to meet with the you after the meeting to debrief and ensure resources are available • If members have ideas and experiences that they don’t feel comfortable sharing in the group meeting, they can request to meet with me individually in a follow up individual meeting • It is strongly encouraged that the ideas/experiences that are shared in this meeting are private and thus everyone is encouraged to only share about their own experiences with friends/family outside of this group. Please do not share information about other members in this group beyond this group. There is one exception: if members share information that makes the researcher concerned about the safety of research participants, the researcher may need to report this information to helping professionals (e.g. child welfare, mental health counselors) to ensure the safety of research participants. 2. Introduction of research participants: Start with a round of introductions. Invite participants to share their names and what interested them about this research project. 78 3. The following sets of questions will be offered and participants will be invited to take their turns sharing their ideas. The researcher will facilitate group discussion ensuring that each participant has a turn to share and enabling participants to comment on each other’s reflections. START WITH OPEN ENDED QUESTIONS FIRST: 1. How would you describe our world as it is today? 2. How does the world as it is today affect you? Your relationships with your friends/family? And your community? 3. I’m going to say some words and I’m wondering if you can share what thoughts come to your mind in hearing them? The words are: “Mental health.” What does “mental health” mean to you? If they associate mental health with mental illness, ask: I’m going to invite you to now think about this in relation to your “wellbeing.” How would you know if you are “mentally healthy”? 4. What is “socio-economics/ socio-economic factors”? If they don’t know, ask: what does the term “finance” “money” “income” mean to you? 5. Do you think that there a relationship between “money”/“socio-economics” (use the youth’s terms) and youth mental health? If so, what is the relationship? How would you describe this relationship from your own experience? Put another way (if they don’t respond): Does “money” or “finances” or “income” (using youth’s language) affect your mental health and wellbeing? If so, in what ways does money/finances/income affect your life, mental health and wellbeing? How does it affect your relationships with others? 6. Solutions: “How might we change the world/socio-economic environment to make it more supportive of young minds? 7. What recommendations do you have for mental health programs/supports in our community to address your concerns? o Probing questions: a) MENTAL HEALTH SYSTEM: a. Can you share what you know about our current mental health system? b. What recommendations do you have for improving how we support young people’s mental health? 79 b) SOCIO-ECONOMIC CHANGE: a. How else might our communities work together to address the your identified concerns? (e.g. lack of money, economic inequities, unemployment, educational pressures etc.) b. What do you think the world should look like? How might we move from the world as it is to a world as you think it should be? c. If you had a magic wand and could change the world to make it more supportive of your mental health/young people’s mental health, how would you change it? FOLLOW UP/PROBING QUESTIONS: Guided by the young person’s reflections on aspects of their socio-economic contexts, the research student will ask follow up questions to invite them to further elaborate. Examples of aspects of socio-economic life that might be explored further include: • Educational experiences/career planning o How has your schooling affected your life? o Did/do you like/dislike school? Why/why not? o Was there anything that you wanted to learn, but didn’t in school? o What changes would you make to your schooling to make it more supportive of your mental health? • Employment/job experiences; production processes o How did you get their first/current job? o What do you like/dislike about their job? o How did you decide to apply for their first job? /decide that you needed to work? o What encouraged you to stay/leave your job? o Do you like working? o If money wasn’t an issue, meaning you had more than enough money, what would you do with your time? How would you spend your time? Would you work? If so, what job would you do? • Access to material goods, consumer goods o What kinds of things do you buy with your money? 80 o Why do you buy the things you do? o How do these products affect your mental health? • Institutions e.g. community resources/services o How does this service/community resource support/challenge your mental health? • Levels of economic equity amongst peers, school, community members o How has this (equality/inequality) affected you? And your relationships with others? • Access to political decision making processes/structures/political voice o How did you get involved in these kinds of decision-making processes? o How did these decision-making processes affect your mental health? o What was your experience like? Did you feel heard and respected? Why/why not? 281 Appendix F: Informed Consent Forms 82 Appendix F1: Informed Consent Form for Phase I and II T H E U N I V E R S I T Y O F B R I T I S H C O L U M B I A School of Nursing T201- 2211 Wesbrook Mall Vancouver, B.C. Canada V6T 2B5 Tel: (604) 822–7417 Fax: (604) 822–7466 Consent form for Youth Research Participants for Phase I and II CONSENT FORM: YOUTH/YOUNG ADULT BETWEEN 13 YEARS AND 30 YEARS OF AGE Study Title: Addressing socio-economic determinants in health promotion initiatives: A dialectical inquiry into the relationship between socio-economic factors and youth mental health and wellbeing Research Team: Colleen Varcoe R.N., Ph.D. Shari Laliberte R.N., M.N. Ph.D. (c)-Ph.D. research student UBC School of Nursing Joy Johnson R.N., Ph.D. Kathy Teghtsoonian Ph.D. Allison Penko-voluntary community photographer: www.alipenko.com Funded by: School of Nursing, University of British Columbia (Lyle Creelman Endowment Fund) 83 INVITATION AND PURPOSE OF THIS STUDY: You, _________________________ (insert young person’s name) are being invited to participate in this study. One key goal of this research study is to explore young people’s views on what affects their mental health and wellbeing and then to explore young people’s views on what can be done to address their concerns about socio-economic factors that negatively affect youth mental health and wellbeing. This form, along with the verbal explanation provided by the Ph.D. research student, is meant to explain the purpose of this research project, along with the risks and benefits of participating in this study to you. This is so that you can decide whether you would like to participate in this study. If you sign this form, you are giving your permission/consent to participate in this study. However, by signing this form, you are FREE to change your mind and withdraw from this study at any point with no negative consequences to yourself as a result. YOUR RIGHTS AS A RESEARCH PARTICIPANT RIGHT TO INFORMATION ABOUT THIS RESEARCH PROJECT You have the right to know about what this research project is about. You have the right to ask questions about any aspect of this research process that you don’t understand or would like more information about. You can call or email the Ph.D. research student with your questions anytime. For example, you have the right to know: • What the purpose of this research project is • Who is facilitating this research project • The risks and benefits of participating in this study (if you don’t understand-ask) • The study procedures and methods (e.g. what information will be gathered, how information is gathered) • Where and how your information will be used 84 RIGHT TO REFUSE ANSWERING QUESTIONS AND/OR TO STOP PARTICIPATING IN THIS PROJECT You have the right to refuse to answer any questions that are asked of you in this project; for example-you don’t have to answer questions asked of you in the interview and you don’t have to answer all of the questions in the demographic survey form. You have the right to stop your participation in this research project at any time. You also have the right to tell the Ph.D. research student that you would not like the information that you have provided to be included in the study findings. DESCRIPTION OF THE RESEARCH PROJECT RESEARCH PROCESS Making sure that participating in this research project is right for you After getting information about this research study from the Ph.D. research student, you are encouraged to review this consent form and take your time in deciding whether you would like to join as a research participant in this project. If you would like to be part of this study, you are invited to contact the Ph.D. research student (Shari Laliberte) to arrange a meeting to go over this consent form and then to arrange an individual or small group interview. You will be encouraged to identify a place that you would like to meet with the Ph.D. research student that is comfortable to you. Phase I of study: Meeting the Ph.D. research student for an individual interview or a small group interview In this interview, you will be invited to first share your understanding of this research project and your rights. You will be invited to ask any questions you might have in order to ensure that you fully understand the nature of this research project, the risks associated with participating in this study, and your rights as a research participant. If the Ph.D. research student is confident that you understand what is involved in participating in this research project and your rights, you will then be asked to sign this consent form and to fill out a demographic survey form (see attached copy). After you sign the consent form, you will be invited to meet with the Ph.D. research student either individually or within a small group of other youth (4–6 youth) to share what you think affects youth mental health and wellbeing. 85 About a month after your interview, you will be contacted and invited to review a summary of the preliminary findings of this research project. You will be invited to join the Ph.D. research student either in person-individually, or with a small group of same age peers; or you can join the Ph.D. research student and peers in an online social media platform (like Facebook-but private) to review the findings. You will be asked for your ideas about how our community can address youth’s worries about youth mental health and wellbeing. Phase II of study: Learning about photovoice After your interview with the Ph.D. research student, you will then be asked whether you would like to join a second phase of this study in which you will be trained in the basics of documentary photography (with other youth research participants). You will be invited to take photographs that show what affects your mental health and wellbeing in your day-to-day life. Once the Ph.D. research student has interviewed all 30 youth in this study, attempts will be made to include as many youth in this photography process as is possible with available resources. If more youth express interest than the Ph.D. research student can accommodate, your name will be added, along with other youth’s names to a hat and names will be drawn from a hat to ensure fairness. Those who are selected will be contacted to join this second phase of this research study. In this phase, you will join other young people for four hours to learn about a method of research called “photovoice” which has been adapted to this research project. Photovoice is a research method that involves engaging youth to take photos to show what affects their mental health and wellbeing. In your photovoice training session, you will learn: • The basics of camera operation (e.g. how to turn the camera on; how to take photos; how to download photos onto a computer and composition) • How to take photos in a way that ensures your safety and respects the privacy of yourself and community members. • How to obtain consent from your friends/family and/or community members to ensure that they are o.k. with you using their images in the next steps of this research project. 86 Going out to take photos and sharing your photos with the Ph.D. research student individually or with fellow youth who are involved in this research project If you do not have a camera of your own, you will be given a digital camera and invited to take this camera with you to photograph what affects your mental health and wellbeing in your day-to-day life. The research facilitator (Shari) will be available to support you if you have any questions and/or need support in the photovoice process (e.g. the Ph.D. research student will provide a cell phone number that you can call anytime you have questions). Once you have taken some photos, you will be invited to share your photos. In order to respect your privacy and your comfort level, you will be given a few options for sharing your photos. You can: • Meet individually with the Ph.D. research student • Meet with a group of 4–6 fellow research participants who are approximately the same age • Join the Ph.D. research student and same age research participants in an online social media platform (similar to Facebook-but private) • Meet with other youth who share similar experiences (e.g. other females or males) Making sense of your photos and ideas The Ph.D. research student will gather your photos and summarize the information that you and other research participants share. The Ph.D. research student will explore your ideas and experiences in the context of broader public policies that are related to your day-to-day experiences. The Ph.D. research student will share this information with yourself and other research participants and seek your input in exploring ways to address socio-economic factors that negatively affect youth mental health and wellbeing. Time required to participate in this study You will be invited to volunteer your time to participate in this study. The total time that you might be involved in this study depends on how you would like to be involved. If you would like to meet with the Ph.D. research student once for an individual interview, the time required will take approximately 4–6 hours. If you would like to be involved in both the individual interview and the photovoice process, the time required will take approximately 27 hours. 87 POTENTIAL HARMS, DISCOMFORTS, INCONVENIENCES There are some potential harms and discomforts that may arise in this research project: • Being involved in this study may evoke concerns and worries about experiencing stigma in being part of this study which is focused on exploring factors that affect mental health. • There is the possibility that you (or other young people in this study) may become emotionally or psychologically distressed in reflecting on distressing experiences and/or in hearing the experiences shared by other young people in the small group meetings or social media platform. You will be given a hand out with a list of community resources that you can call if you are in need of support (see attached document). Individual and group interviews will be facilitated by a research facilitator who has past clinical experience in supporting children and youth with mental health concerns. Should you or another young person experience distress or discomfort, you will be offered the opportunity to meet with the research facilitator individually and will be offered ideas of what kinds of community agencies are available for further support. • In exploring mental health issues, there is also the potential that disclosures of thoughts of suicide/self harm, infectious disease and child abuse may occur. If you share any information that makes the Ph.D. research student concerned about your safety, or the safety of other people, the Ph.D. research student is obligated to take steps to ensure your and other’s safety. For example, if a research participant (under age of 18) shares that they are experiencing child abuse, the Ph.D. research student is obligated to report this to a child welfare agency. BENEFITS OF PARTICIPATING IN THIS STUDY • This experience may be informative and, perhaps, promote a sense of purpose and meaning in your life. By sharing about your experiences in order to help generate knowledge that will be used to help other young people, you may experience a sense of reward in being part of this project. • For some people, sharing about one’s own life experiences can also be experienced as therapeutic. You may also gain new knowledge and skills as a result of being part of this research process (e.g. learning about research processes, learning about photography). 88 • Being part of this study will potentially result in meeting people that you share common interests with and thus result in greater social support and new friends. REIMBURSEMENT FOR PARTICIPATING IN THIS STUDY CDB$25.00 will be given at the beginning of the individual or small group interview Juice and granola bars will be available for individual interviews. Juice and pizza will be provided at small group interviews. Please tell us if you have any food allergies/sensitivities that will be considered: ________________________________________________________________________ CONFIDENTIALITY AND DISSEMINATION OF FINDINGS Individual and group interviews will be audio-taped and transcribed to assist the Ph.D. research student in summarizing and sharing the findings of this study. Information that is collected from this study will be kept in a locked filing cabinet for up to 5 years after this study. All research data/information will then be shredded. Group members/research participants will be requested to ensure your confidentiality, however- this cannot be guaranteed. If you choose to engage in the social media platform the information that you share could be shown to other people by fellow research participants. Web security features will be put in place to prevent other youth from copying and sharing your photos and written reflections. You will be invited to use a pseudonym (a different name from your real name) and to consider what photos you upload when you interact on the social media platform in order to protect your confidentiality to the extent possible. If there are photos and thoughts you would like to keep private from the social media platform, but you would like these photos/ideas to be shared in this research project, you will be invited to share your photos and your thoughts privately with the Ph.D. research student in an individual meeting. Photos will only be shared if you and/or community members have signed a photo release consent form. Specifically, for youth under the age of 18, they will be required to have parental/caregiver/legal guardian consent (unless youth have met with the Ph.D. research student to ensure that they fully understand the nature/risks associated with sharing photos from this 89 research project). For youth and adults older than 18 years of age, they will be required to provide consent on their own behalf. At the end of your interview, you will be asked if you would like to be notified of the findings from this research project and whether you would like to receive updates about plans for sharing findings from this research with other community groups/members. SIGNATURES For the research project entitled, “Addressing socio-economic determinants in health promotion: A dialectical inquiry into the relationship between socio-economic factors and youth mental health and wellbeing,” I certify that I understand: • The purpose of this research project • My rights as a research participant in this research project • The procedures to be used in this research project • The risks and benefits to participating in this research project • How the information that I share will be used from this research project My preferences (please check off the relevant boxes to indicate your preferences for how you would like to participate in this study): Phase I of study: I would like to meet with the Ph.D. research student for: • Individual interview • Group interview with 4–6 other young people I would be interested in participating in a meeting about 1 month after my individual or small group interview in order to meet with the Ph.D. research student to learn about the findings from the first phase of this study and to share my views on how youth’s concerns about youth mental health and wellbeing could be helped.  Yes  No 90 If I selected yes: I would like to learn about these findings in the following ways: • Newsletter sent to: o My email o My mailing address OR o Private online social media platform (like Facebook but private) I would like to share my views on the findings in the following way: • In person: o Meet individually with the Ph.D. research student o Join a small group of other youth • Online: o Meet individually (e.g. through a separate email function) o Small group (e.g. join the Ph.D. research student and a small group of youth in a separate private chat room of web media platform like facebook but private) Phase II of study: I would be interested in participating in the second phase of this project which entails joining other youth to take photos that explore the relationship between socio-economic factors and youth mental health and wellbeing Yes No IF YES, I would like to share my photos and talk about my photos: o Individually with the Ph.D. research student o With a small group of youth to share my photos and ongoing reflections in person o Private online social media environment (like facebook but private) 91 Learning about study findings: I would like to be updated about the findings from this research project and I am o.k. with the Ph.D. research student contacting me via my phone number or email Yes No I would like to be updated about plans for sharing findings from this project with other community leaders/groups: Yes No I have received a copy of this information/consent form Yes If I have questions or would like to register a complaint that I might have about this project, I may contact any of the people on the attached contact list. HONORARIUM: I am aware that I will also be given CDN$25.00 honorarium to acknowledge my time dedicated to this project. I am also aware that after I have received this $25.00, I am free to change my mind and to withdraw from this research project at any time and I will be able to keep the $25.00 honorarium. I am aware that I can change my mind about this decision to participate in this research project at any time throughout the research project and that this will not negatively impact me in doing so. Signature of youth/young person: __________________Date: _____________________ Name of youth/young person (please print):_________________________________ Date of birth: _______________________________ Age: ________ Address:________________________________________________________________ _______________________________________________________________________ Phone number and email: __________________________________________________ 92 If under 18 years of age: Signature of parent/legal guardian: _________________Date: _____________________ Print name: __________________________________ Investigator and/or Delegate’s Signature______________________Date_____________ If you have questions about this project and/or would like to express concerns you may have with this project, you make contact the Ph.D. research student: Shari Laliberte R.N., Ph.D. (c)-PhD research student UBC School of Nursing T201 2211 Westbrook Mall Vancouver, B.C. V6T 2B5 You may also contact the PhD research student’s supervisor: Dr. Colleen Varcoe UBC School of Nursing If you have questions and/or concerns about your rights as a research participant, you may contact: Research Subject Information Line UBC Office of Research Services Please see attached handout for a list of possible resources you might want to contact for emotional support. 93 Appendix F2: Adapted Informed Consent Form for Young People Who Were Homeless T H E U N I V E R S I T Y O F B R I T I S H C O L U M B I A School of Nursing T201- 2211 Wesbrook Mall Vancouver, B.C. Canada V6T 2B5 Tel: (604) 822–7417 Fax: (604) 822–7466 Consent form for Youth Research Participants for Phase I and II CONSENT FORM: YOUTH/YOUNG ADULT BETWEEN 13 YEARS AND 30 YEARS OF AGE Study Title: Addressing socio-economic determinants in health promotion initiatives: A dialectical inquiry into the relationship between socio-economic factors and youth mental health and wellbeing Research Team: Colleen Varcoe R.N., Ph.D. Shari Laliberte R.N., M.N. Ph.D. (c) UBC School of Nursing Joy Johnson R.N., Ph.D. Kathy Teghtsoonian Ph.D. Funded by: School of Nursing, University of British Columbia (Lyle Creelman Endowment Fund) 94 INVITATION AND PURPOSE OF THIS STUDY: You, _________________________ (insert young person’s name) are being invited to participate in this study. One key goal of this research study is to explore young people’s views on what affects their mental health and wellbeing and then to explore young people’s views on what can be done to address their concerns about socio-economic factors that negatively affect youth mental health and wellbeing. This form, along with the verbal explanation provided by the researcher, is meant to explain the purpose of this research project, along with the risks and benefits of participating in this study to you. This is so that you can decide whether you would like to participate in this study. If you sign this form, you are giving your permission/consent to participate in this study. However, by signing this form, you are FREE to change your mind and withdraw from this study at any point with no negative consequences to yourself as a result. YOUR RIGHTS AS A RESEARCH PARTICIPANT RIGHT TO INFORMATION ABOUT THIS RESEARCH PROJECT You have the right to know about what this research project is about. You have the right to ask questions about any aspect of this research process that you don’t understand or would like more information about. You can call or email the researcher with your questions anytime. For example, you have the right to know: • What the purpose of this research project is • Who is facilitating this research project • The risks and benefits of participating in this study (if you don’t understand-ask) • The study procedures and methods (e.g. what information will be gathered, how information is gathered) • Where and how your information will be used 95 RIGHT TO REFUSE ANSWERING QUESTIONS AND/OR TO STOP PARTICIPATING IN THIS PROJECT You have the right to refuse to answer any questions that are asked of you in this project; for example-you don’t have to answer questions asked of you in the interview and you don’t have to answer all of the questions in the demographic survey form. You have the right to stop your participation in this research project at any time. You also have the right to tell the researcher that you would not like the information that you have provided to be included in the study findings. DESCRIPTION OF THE RESEARCH PROJECT RESEARCH PROCESS Making sure that participating in this research project is right for you After getting information about this research study from the researcher, you are encouraged to review this consent form and take your time in deciding whether you would like to join as a research participant in this project. If you would like to be part of this study, you are invited to contact the researcher (Shari Laliberte) to arrange an individual or small group interview. You will be encouraged to identify a place that you would like to meet with the researcher that is comfortable to you. Phase I of study: Meeting the researcher for an individual interview or a small group interview In this interview, you will be invited to first share your understanding of this research project and your rights. You will be invited to ask any questions you might have in order to ensure that you fully understand the nature of this research project, the risks associated with participating in this study, and your rights as a research participant. If the researcher is confident that you understand what is involved in participating in this research project and your rights, you will then be asked to sign this consent form and to fill out a demographic survey form (see attached copy). After you sign the consent form, you will be invited to meet with the researcher either individually or within a small group of other youth (4–6 youth) to share what you think affects youth mental health and wellbeing. 96 About a month after your interview, you will be contacted and invited to review a summary of the preliminary findings of this research project. You will be invited to join the researcher either in person-individually, or with a small group of same age peers; or you can join the researcher and peers in an online social media platform (like Facebook-but private) to review the findings. You will be asked for your ideas about how our community can address young people’s worries about youth mental health and wellbeing. Phase II of study: Learning about photovoice After your interview with the researcher, you will then be asked whether you would like to join a second phase of this study in which you will be trained in the basics of documentary photography (with other youth research participants). You will be invited to take photographs that show what affects your mental health and wellbeing in your day-to-day life. Once the researcher has interviewed all 30 youth in this study, attempts will be made to include as many youth in this photography process as is possible with available resources. If more youth express interest than the researcher can accommodate, your name will be added, along with other youth’s names to a hat and names will be drawn from a hat to ensure fairness. Those who are selected will be contacted to join this second phase of this research study. In this phase, you will join other young people for four hours to learn about a method of research called “photovoice” which has been adapted to this research project. Photovoice is a research method that involves engaging youth to take photos to show what affects their mental health and wellbeing. In your photovoice training session, you will learn: • The basics of camera operation (e.g. how to turn the camera on; how to take photos; how to download photos onto a computer and composition) • How to take photos in a way that ensures your safety and respects the privacy of yourself and community members. • How to obtain consent from your friends/family and/or community members to ensure that they are o.k. with you using their images in the next steps of this research project. 97 Going out to take photos and sharing your photos with the researcher individually or with fellow youth who are involved in this research project If you do not have a camera of your own, you will be given a used digital camera and invited to take this camera with you to photograph what affects your mental health and wellbeing in your day-to-day life. The research facilitator (Shari) will be available to support you if you have any questions and/or need support in the photovoice process (e.g. the researcher will provide a cell phone number that you can call anytime you have questions). Once you have taken some photos, you will be invited to share your photos. In order to respect your privacy and your comfort level, you will be given a few options for sharing your photos. You can: • Meet individually with the researcher • Meet with a group of 4–6 fellow research participants who are approximately the same age • Join the researcher and same age research participants in an online social media platform (similar to Facebook-but private) • Meet with other youth who share similar experiences (e.g. other females or males) Making sense of your photos and ideas The researcher will gather your photos and summarize the information that you and other research participants share. The researcher will explore your ideas and experiences in the context of broader public policies that are related to your day-to-day experiences. The researcher will share this information with yourself and other research participants and seek your input in exploring ways to address socio-economic factors that negatively affect youth mental health and wellbeing. Time required to participate in this study You will be invited to volunteer your time to participate in this study. The total time that you might be involved in this study depends on how you would like to be involved. If you would like to meet with the researcher once for an individual interview, the time required will take approximately 4–6 hours. If you would like to be involved in both the individual interview and the photovoice process, the time required will take approximately 27 hours. 98 POTENTIAL HARMS, DISCOMFORTS, INCONVENIENCES There are some potential harms and discomforts that may arise in this research project: • Being involved in this study may evoke concerns and worries about experiencing stigma in being part of this study which is focused on exploring factors that affect mental health. • There is the possibility that you (or other young people in this study) may become emotionally or psychologically distressed in reflecting on distressing experiences and/or in hearing the experiences shared by other young people in the small group meetings or social media platform. You will be given a hand out with a list of community resources that you can call if you are in need of support (see attached document). Individual and group interviews will be facilitated by a research facilitator who has past clinical experience in supporting children and youth with mental health concerns. Should you or another young person experience distress or discomfort, you will be offered the opportunity to meet with the research facilitator individually and will be offered ideas of what kinds of community agencies are available for further support. • In exploring mental health issues, there is also the potential that disclosures of thoughts of suicide/self harm, infectious disease and child abuse may occur. If you share any information that makes the researcher concerned about your safety, or the safety of other people, the researcher is obligated to take steps to ensure your and other’s safety. For example, if a research participate (under age of 18) shares that they are experiencing child abuse, the researcher is obligated to report this to a child welfare agency. BENEFITS OF PARTICIPATING IN THIS STUDY • This experience may be informative and, perhaps, promote a sense of purpose and meaning in your life. By sharing about your experiences in order to help generate knowledge that will be used to help other young people, you may experience a sense of reward in being part of this project. 99 • For some people, sharing about one’s own life experiences can also be experienced as therapeutic. You may also gain new knowledge and skills as a result of being part of this research process (e.g. learning about research processes, learning about photography). • Being part of this study will potentially result in meeting people that you share common interests with and thus result in greater social support and new friends. REIMBURSEMENT FOR PARTICIPATING IN THIS STUDY A CDN$25.00 gift certificate to London Drugs will be given at the beginning of the individual interview Juice and granola bars will be available for individual interviews. Juice and pizza will be provided at small group interviews. Please tell us if you have any food allergies/sensitivities that will be considered: ________________________________________________________________________ CONFIDENTIALITY AND DISSEMINATION OF FINDINGS Individual and group interviews will be audio-taped and transcribed to assist the researcher in summarizing and sharing the findings of this study. Information that is collected from this study will be kept in a locked filing cabinet for up to 5 years after this study. All research data/information will then be shredded. Group members/research participants will be requested to ensure your confidentiality, however- this cannot be guaranteed. If you choose to engage in the social media platform the information that you share could be shown to other people by fellow research participants. Web security features will be put in place to prevent other youth from copying and sharing your photos and written reflections. You will be invited to use a pseudonym (a different name from your real name) and to consider what photos you upload when you interact on the social media platform in order to protect your confidentiality to the extent possible. If there are photos and 00 thoughts you would like to keep private from the social media platform, but you would like these photos/ideas to be shared in this research project, you will be invited to share your photos and your thoughts privately with the researcher in an individual meeting. Photos will only be shared if you and/or community members have signed a photo release consent form. Specifically, for youth under the age of 18, they will be required to have parental/caregiver/legal guardian consent (unless youth have met with the researcher to ensure that they fully understand the nature/risks associated with sharing photos from this research project). For youth and adults older than 18 years of age, they will be required to provide consent on their own behalf. At the end of your interview, you will be asked if you would like to be notified of the findings from this research project and whether you would like to receive updates about plans for sharing findings from this research with other community groups/members. SIGNATURES For the research project entitled, “Addressing socio-economic determinants in health promotion: A dialectical inquiry into the relationship between socio-economic factors and youth mental health and wellbeing,” I certify that I understand: o The purpose of this research project o My rights as a research participant in this research project o The procedures to be used in this research project o The risks and benefits to participating in this research project o How the information that I share will be used from this research project My preferences (please check off the relevant boxes to indicate your preferences for how you would like to participate in this study): 01 Phase I of study: I would like to meet with the researcher for: o Individual interview o Group interview with 4–6 other young people I would be interested in participating in a meeting about 1 month after my individual or small group interview in order to meet with the researcher to learn about the findings from the first phase of this study and to share my views on how youth’s concerns about youth mental health and wellbeing could be helped.  Yes  No If I selected yes: I would like to learn about these findings in the following ways: o Newsletter sent to:  My email  My mailing address OR o Private online social media platform (like Facebook but private) I would like to share my views on the findings in the following way: • In person: • Meet individually with the researcher • Join a small group of other youth • Online: • Meet individually (e.g. through a separate email function) • Small group (e.g. join the researcher and a small group of youth in a separate private chat room of web media platform like Facebook but private) 02 Phase II of study: I would be interested in participating in the second phase of this project which entails joining other youth to take photos that explore the relationship between socio-economic factors and youth mental health and wellbeing Yes No IF YES, I would like to share my photos and talk about my photos: • Individually with the researcher • With a small group of youth to share my photos and ongoing reflections in person • Private online social media environment (like Facebook but private). Learning about study findings: I would like to be updated about the findings from this research project and I am o.k. with the researcher contacting me via my phone number or email Yes No I would like to be updated about plans for sharing findings from this project with other community leaders/groups: Yes No I have received a copy of this information/consent form Yes If I have questions or would like to register a complaint that I might have about this project, I may contact any of the people on the attached contact list. HONORARIUM: I am aware that I will also be given CDN$25.00 gift certificate to London Drugs to acknowledge my time dedicated to this project. I am also aware that after I have received this $25.00 gift certificate, I am free to change my mind and to withdraw from this research project at any time and I will be able to keep the $25.00 gift certificate. I am aware that I can change my mind about this decision to participate in this research project at any time throughout the research project and that this will not negatively impact me in doing so. 03 Signature of youth/young person: __________________Date: _____________________ Name of youth/young person (please print):_________________________________ Date of birth: _______________________________ Age: ________ Address:____________________________________________________________ ___________________________________________________________________ Phone number and email: _______________________________________________ Investigator and/or Delegate’s Signature__________________Date________________ If you have questions about this project and/or would like to express concerns you may have with this project, you make contact the researcher: Shari Laliberte R.N., Ph.D. (c) You may also contact the researcher’s supervisor: Dr. Colleen Varcoe If you have questions and/or concerns about your rights as a research participant, you may contact: Research Subject Information Line UBC Office of Research Services Please see attached handout for a list of possible resources you might want to contact for emotional support 304 Appendix F3: Informed Consent Forms for Participatory Documentary Photography Process 3-PAGE PHOTO RELEASE FORM FOR PEOPLE 18 YEARS AND OLDER You are being requested to give permission for your photograph to be taken in order to facilitate discussions amongst youth/young people about the mental health issues and needs of youth in our community. This is part of a Ph.D. Dissertation Research Project at UBC within the School of Nursing. The title of this research project is, “Addressing socio-economic determinants of health in health promotion initiatives: A dialectical inquiry into the relationship between socio-economic factors and youth mental health and wellbeing.” Youth photographers have been invited to take photos of people, events, things, places and/or activities in our community that relate to the experience of “money” and young minds. The purpose of this study is to: to explore youth perspectives on the nature of the relationship between socio-economic factors and youth mental health and ways that we can develop health promotion initiatives that promote youth mental health and wellbeing in our community. You are being requested to give permission for your photograph taken for the following reason (s): OPTION ONE: Your photograph may be taken in order to facilitate discussions amongst youth/young people (who are part of this study) about youth mental health and wellbeing. This photo may be shown to the research facilitator-Ph.D. student of this research project (Shari Laliberte), a community volunteer- James Heinrich Graphic/Web Designer, volunteer community photographer, Allison Penko http://alipenko.com/ and fellow young people in small group interviews where youth will share their photos with each other and share what they see in their photos. OPTION TWO: Your photograph may be shared in the process of disseminating findings from this research study to health care leaders, policy makers and health care 05 professionals and community members who are interested in developing programs and services that support youth mental health and wellbeing.  By signing this consent form, you are indicating that you are aware that the youth/young person who took your child’s photo will be given a copy of this photo and a copy of this photo will be kept in the research facilitator’s research (home) office throughout this research project and the primary investigator’s office at the University of British Columbia (UBC) for up to five years after this project ends (until January 2016). By signing this consent form, you are also indicating your awareness of potential risks and benefits associated with the use of your photo: Risks: • I am aware that as this research project is focused on exploring mental health issues, there may be stigma attached to images portrayed in photos • I am aware that the researchers cannot guarantee that youth photographers will not share photos beyond the research project (as they will be given a copy of their photos) Benefits: • I am aware that I may experience a sense of meaning and purpose in having my photo used to further knowledge and understanding about youth wellbeing which in turn will be used to inform the development of mental health promotion policies and programs that seek to support youth mental health and wellbeing 06 DECLARATION OF CONSENT TO BE PHOTOGRAPHED AND PHOTO TO BE RELEASED FOR USE IN THIS STUDY: I hereby agree to have my photograph taken and used for the following purposes (please initial the boxes indicating which ways you are giving consent for your photo(s) to be used in this research project): I give consent for my photo to be used to facilitate discussions amongst youth/young people (who are part of this study) about youth mental health and wellbeing. This photo may be shown to the Ph.D. research student of this research project (Shari Laliberte), a research assistant, and fellow young people in small group interviews (i.e. in person or on a social media website) where youth will share their photos with each other and share what they see in their photos. I give consent for my photo to be shared in the process of disseminating (sharing) findings from this research study to health care leaders, policy makers and health care professionals and community members who are interested in developing programs and services that support youth mental health and wellbeing. I give consent for my photo to be shared in the process of disseminating findings from this research study to health care leaders, policy makers and health care professionals and community members who are interested in developing programs and services that support youth mental health and wellbeing. HOWEVER, I would like my face to be blurred (with photo-editing software) to minimize the chance of identifying my identity. I am aware that other aspects of the image may enable people to identify me, and I am willing to take this risk. I have received a copy of this consent form and am aware that if I have any questions or would like to register a complaint related to this research project, I may contact any person on the attached sheet. I am aware that I can change my mind about this decision about sharing my photo in this research project. I have been given the contact name/number of the research facilitator-Ph.D. research student (Shari Laliberte) and am aware that I can contact her to 07 request for my photo to be removed from use in this project. I am aware that if I do not contact the research facilitator/Ph.D. research student in time, there is a chance that my photo may have been distributed before changing my mind. I am also aware that sharing my photo is within my control unless required by law. The legal obligation to share information from photos beyond this research project includes a number of circumstances, such as suspected child abuse and infectious disease, expression of suicidal ideas, where research documents are ordered to be produced by a court of law and where researchers are obliged to report to the appropriate authorities. Signature of person: ___________________________________________ Name of person (please print):_________________________________ Date______________________________ Investigator and/or Delegate’s Signature________________Date___________________ If you would like to be notified about the research findings, please provide your contact information: Address: _______________________Email:_________________Phone Number:_______________________ If you have questions about this project and/or would like to express concerns you may have with this project, you make contact the Ph.D. research student or her supervisor: Shari Laliberte R.N., Ph.D. (c) Dr. Colleen Varcoe If you have questions and/or concerns about this research study, you may contact: Research Subject Information Line UBC Office of Research Services 308 3-PAGE PARENT/CAREGIVER/LEGAL GUARDIAN PHOTO RELEASE FORM FOR CHILDREN/YOUTH WHO ARE 17 YEARS OF AGE OR YOUNGER You are being requested to give permission for your child/youth to have their photograph taken in order to facilitate discussions amongst youth/young people about the mental health issues and needs of youth in our community. This is part of a Ph.D. Dissertation Research Project at UBC within the School of Nursing. The title of this research project is, “Addressing socio-economic determinants of health in health promotion initiatives: A dialectical inquiry into the relationship between socio-economic factors and youth mental health and wellbeing.” Youth photographers have been invited to take photos of people, events, things, places and/or activities in our community that relate to the experience of “money” and young minds. The purpose of this study is to: to explore youth perspectives on the nature of the relationship between socio-economic factors and youth mental health and ways that we can develop health promotion initiatives that promote youth mental health and wellbeing in our community. You are being requested to give permission for your child/youth to have his/her photograph taken for the following reason (s): OPTION ONE: Your child/youth’s photo may be taken in order to facilitate discussions amongst youth/young people (who are part of this study) about youth mental health and wellbeing. This photo may be shown to the research facilitator-Ph.D. student of this research project (Shari Laliberte), a community volunteer- James Heinrich Graphic/Web Designer, volunteer community photographer, Allison Penko http://alipenko.com/ and fellow young people in small group interviews where youth will share their photos with each other and share what they see in their photos. OPTION TWO: Your child/youth’s photo may be shared in the process of disseminating findings from this research study to health care leaders, policy makers and health care professionals and community members who are interested in developing programs and services that support youth mental health and wellbeing. 309  By signing this consent form, you are indicating that you are aware that the youth/young person who took your child’s photo will be given a copy of this photo and a copy of this photo will be kept in the research facilitator’s research (home) office throughout this research project and the primary investigator’s office at the University of British Columbia (UBC) for up to five years after this project ends (until January 2016). By signing this consent form, you are also indicating your awareness of potential risks and benefits associated with the use of your child/youth’s photo: Risks: • I am aware that as this research project is focused on exploring mental health issues, there may be stigma attached to images portrayed in photos • I am aware that the researchers cannot guarantee that youth photographers will not share photos beyond the research project (as they will be given a copy of their photos) Benefits: • I am aware that my child/youth may experience a sense of meaning and purpose in having his/her • I am aware that photos are used to further knowledge and understanding about youth mental health which in turn will be used to inform the development of mental health promotion policies and programs that seek to support youth mental health and wellbeing DECLARATION OF PARENTAL/CAREGIVER/LEGAL GUARDIAN CONSENT FOR CHILD/YOUTH TO BE PHOTOGRAPHED AND THE PHOTO TO BE RELEASED FOR USE IN THIS STUDY: I hereby agree to have ___________________________ (insert your child/youth’s name) photograph taken and used for the following purposes (please initial the boxes indicating which ways you are giving consent for your child/youth’s photo(s) to be used in this research project): To be used to facilitate discussions amongst youth/young people (who are part of this study) about youth mental health and wellbeing. This photo may be shown to the research 310 facilitator of this research project (Shari Laliberte), a research assistant, and fellow young people in small group interviews where youth will share their photos with each other and share what they see in their photos. To be shared with health care leaders, policy makers and health care professionals and community members who are interested in developing programs and services that support youth mental health and wellbeing. To be shared in the process of sharing findings from this research study to health care leaders, policy makers and health care professionals and community members who are interested in developing programs and services that support youth mental health and wellbeing. HOWEVER, I would like my child/youth’s face to be blurred (with photo-editing software) to minimize the chance of identifying his/her identity. I am aware that other aspects of the image may enable people to identify my child/youth, and I am willing to take this risk. I have received a copy of this consent form and am aware that if I have any questions or would like to register a complaint related to this research project, I may contact any person on the attached sheet. I am aware that I can change my mind about this decision about sharing my child/youth’s photo in this research project. I have been given the contact name/number of the research facilitator-Ph.D. student (Shari Laliberte) and am aware that I can contact her to request for my child/youth’s photo to be removed from use in this project. I am aware that if I do not contact the research facilitator in time, there is a chance that my child/youth’s photo may have been distributed before changing my mind. I am also aware that sharing my child/youth’s photo is within my control unless required by law. The legal obligation to share information from photos beyond this research project includes a number of circumstances, such as suspected child abuse and infectious disease, expression of suicidal ideas, where research documents are ordered to be produced by a court of law and where researchers are obliged to report to the appropriate authorities. Signature of child/youth in the photograph indicating his/her assent: __________________________ 311 Name of child/youth in the photograph (please print): ___________________________________ Signature of parent/caregiver/legal guardian indicating consent: _________________________________ Name of parent/caregiver/legal guardian (please print):_________________________________ Date______________________________ Investigator and/or Delegate’s Signature________________Date___________________ If you would like to be notified about the research findings, please provide your contact information: Address: ________________________________Email:_______________Phone Number:__________________ If you have questions about this project and/or would like to express concerns you may have with this project, you make contact the primary investigator: Shari Laliberte R.N., Ph.D. (c) Dr. Colleen Varcoe If you have questions and/or concerns about this research study, you may contact: Research Subject Information Line UBC Office of Research Services 312 Appendix G: Handouts for Research Participants 313 Appendix G1: Know Your Rights as a Research Participant Handout (K. Chabot, personal communication, 2012) 314 315 Appendix G2: Child and Youth Mental Health Services Handout 316 317 Appendix H: Training Guide for Documentary Photography Outline for Documentary Photography Training Session 1. Introductions: invite to share name and why interested in this project 2. Shari to re-cap where we are at in the process of the research study/explain that we are now entering into the second phase where we are adapting photovoice to engage young people to further explore the following research questions: a. Describe what our “socio-economic environment” is from the perspective of young people: what is “socio-economics”; how would young people describe the “world as it is today” b. How does our socio-economic environment affect young people’s mental health/minds? c. What aspects of our socio-economic environment are young people most worried/concerned about? d. How can we improve our socio-economic environment to support young minds? What kinds of mental health promotion initiatives in our community might we implement to address young people’s concerns and promote their mental health and wellbeing? e. GROUP BRAINSTORM: Shari will put up slide to show the summary of the main ideas shared in describing our socio-economic environment today and put up a big sheet of paper and invite youth to start to brainstorm how these aspects of our environment relate to each other and to young minds. Young people will then be invited to go out and document how these aspects of their environment affect their mental health and wellbeing Share trailer to Born into Brothels (explain how this was how I was introduced to documentary photography/photovoice as a way to give people voice in our community): http://www.youtube.com/watch?v=AODZ6k8LgEI 318 Share this overview of Hamilton Youth Photovoice Project: http://www.youtube.com/watch?v=shrFa2c305g Explain that we will integrate these photos into the interview data from the individual interviews and then eventually within a website that James will be helping to develop and future photo exhibits, publications/conferences. 3. Provide an overview of the principles of conducting research a. Minimizing harm and a person’s right to make decisions about their life: i. Explain that we want to be sensitive to the stigma surrounding “mental health” in our community and make sure that people have a choice as to whether they want to be involved in this project or not and to take the risks of perhaps being judged/mis-judged by being involved in this project ii. Explain that by being documentary photographers they will hold some power in how they represent the people in our community. Invite them to be sensitive to this and to attempt to be as transparent as possible with the people they are taking photos of and to try to not mis-represent people when they are taking their photos (e.g. avoid putting someone in a false light in taking their photo). They can ensure that they are sharing power by making sure the person who they take the photo of is aware of the purpose of this project and why their photo is being taken and the options they have of how their photo can be used in this project. There are three ways their photo can be used: 1. Privately-for us to use in our group discussion in September; 2. For sharing findings from this research with our community; 3. Sharing findings from this study with the option of having their face blurred with photo-editing software. iii. Explain that Shari will be on call for them if they would like coaching/support in taking their photos in community-they can text/call Shari any time b. Ensuring confidentiality i. Explain that we want to make sure that people have the right to maintain their confidentiality and to give their permission for us to take their photos. Distribute the photo release forms and explain the photo-release forms and the options that people can sign up to in being photographed for this project 319 ii. Shari and Ali to role play the process of getting a photo-release form signed (e.g. for children under age; a person who doesn’t want their photo taken) 1. Explain that youth will need to explain the purpose of the project; options for how one’s photo can be used; and make sure that they have the person sign a copy for Shari and that they give the person a copy of the release form which includes a link to our facebook page in case they want to learn more about the project c. Ensuring youth photographer’s safety i. Encourage the youth to be careful about their surroundings when out taking photos; invite them to be sensitive to people’s comfort level in having their photo taken and to not put themselves at risk to take photos for this project ii. Invite them to call me and I can be with them to take photos if they don’t feel safe 4. Hand out the cameras and kits a. Camera-set up date/time function on camera b. Note pad (to make notes of what they were trying to depict in the photograph to remind them when they come back to share the photos; encourage them to note the photo number/date and time that they took the photo and what research question they were trying to answer) c. USB port device and memory card: explain the options for downloading their photos d. Photo release forms and brochures for this research project 5. Ali to provide an overview of how to use the cameras and some basic tips in taking photos a. E.g. encourage patience. Invite the youth to wait a bit after they get the photo release form signed to enable the person to forget about the photography process and engage in their live spontaneously again. 6. Dissemination of findings: a. Shari to share how we might share photos in future publications, photo exhibits 320 b. James to share his idea of developing a website to share the photos/findings from this research project and engage more youth in exploring how our socio-economic environment affects young minds and how we can promote youth mental health 7. Walk around community to start taking photos