ALL WELL IN THE WELFARE STATE? All well in the welfare state? Welfare, well-being and the politics of happiness NordWel Studies in Historical Welfare State Research 5 edited by carl marklund marklun d (ed. ) All w ell in the welfa re state ? e aim of this volume is to analyze how the recent attention to subjective well-being and happiness may affect welfare state policies, looking at both Nordic and international experiences. While the Nordic welfare states typically score well in rankings of happiness, the volume asks whether all is well in the welfare state. Rather than assessing whether happiness research manages to capture the multiple factors which underpin subjective well-being, the contributions probe the relationship between the general discourse on subjective well-being and the welfare policies designed to support those members of society who are in greatest need. ISSN 1799-4691 ISBN 978-952-10-8306-8 N ordW el NordWel Studies in Historical Welfare State Research 5 All well in the welfare state? Welfare, well-being and the politics of happiness Edited by Carl Marklund NORDIC CENTRE OF EXCELLENCE NORDWEL Helsinki 2013 e Nordic Centre of Excellence NordWel (e Nordic Welfare State – Historical Foundations and Future Challenges) is a multidisciplinary, cross-national research project and network of eight partner units in the Nordic universities. It is a part of NordForsk’s Nordic Centre of Excellence Programme on Welfare (2007–2012). NordWel is hosted by the Department of Political and Eco- nomic Studies at the University of Helsinki. e mission of NordWel is to deepen our under- standing of the development of the Nordic welfare state in order to foster the research-based discus- sion on Nordic societies and their future. is involves the establishment of a highly-integrated Nordic research platform within international welfare research. e NordWel Studies in Historical Welfare State Research series provides a publishing forum, par- ticularly for volumes elaborated on the basis of the NordWel seminars and conferences. is is a peer- reviewed publication. Contact: NCoE NordWel Department of Political and Economic Studies Section of Social Science History P.O.Box 54 (Snellmaninkatu 14A) FIN-00014 University of Helsinki http://blogs.helsinki./nord-wel/ Director: Pauli Kettunen, Department of Political and Economic Studies, University of Helsinki Vice-Director: Klaus Petersen, Centre for Welfare State Research, University of Southern Denmark Coordinator: Heidi Haggrén, Department of Political and Economic Studies, University of Helsinki Titles in this series include: 1 Workfare and welfare state legitimacy Edited by Helena Blomberg and Nanna Kildal 2 Welfare citizenship and welfare nationalism Edited by Andrzej Marcin Suszycki 3 Migrations and welfare states: Policies, discourses and institutions Edited by Heidi Vad Jønsson, Elizabeth Onasch, Saara Pellander and Mats Wickström 4 Education, state and citizenship Edited by Mette Buchardt, Pirjo Markkola and Heli Valtonen 5 All well in the welfare state? Welfare, well- being and the politics of happiness Edited by Carl Marklund 6 Retrenchment or renewal? Welfare states in times of economic crisis Edited by Guðmundur Jónsson and Kolbeinn Stefánsson Cover: Katriina Rosavaara Layout: Graanen Suunnittelu Timo Jaakola Oy Copy-editing: Heidi Haggrén Printed in Finland by Bookwell Oy, Jyväskylä 2013 NordWel Studies in Historical Welfare State Research 5 ISBN 978-952-10-8306-9 (paperback) ISBN 978-952-10-8984-8 (PDF) ISSN 1799-4691 7 12 26 55 82 103 Contents Preface   Introduction   Social inequalities in health and well-being – A review of research and the case of Israel   Happy without reason? Mental illness and the ‘right’ to happiness in Sweden    Who needs mental health services? Mental health care planning and the image of the service user in Finland     Happy without money of their own? On the reasons for teenagers’ participation in paid work – e case of Iceland       135 168 206 Somewhere over the high seas there is a land of my dreams – Happiness and life satisfaction among immigrants in Europe   Public health and solidarity – How to succeed in the population-based prevention of alcohol problems     e return of happiness – the end of utopia? Rankings of subjective well-being and the politics of happiness   List of Contributors   Preface   I went to a happiness conference, researchers looked very unhappy.1 e search for happiness has been there for very many years. In the old times Greek philosophers discussed, for example, what constituted the good life and how it could be achieved. e American Declaration of Independence from 1776 saw happiness as important for society and individuals, and the same can also be seen in the French constitution from 1793.2 Societies have thus historically, as well as today, shown an interest in how to ensure a good, prosperous and happy life. Recent years have further seen a dramatic increased interest in the search for an understanding of what happiness is as well as what might pro- mote both individual and societal happiness. A whole new brand of research across traditional disciplines within social science has tried to cast light over what happiness is, whether we can measure happiness, and if we can com- pare happiness across societies. e search for and use of indicators related to happiness and well-being has also its roots in a growing awareness that economic measures, such as GDP and GDP per inhabitant, although being objective in themselves, do not properly include the impact of economic development on, for example, the environment. Robert Kennedy is quoted as having said: ‘It measures ev- erything, in short, except that which makes life worthwhile’. In the same vein it has been argued, that there is a need to ‘shi emphasis from measuring 1 Taleb, Nassim Nicholas (2010) e Tale of Procrustes. London: Penguin, 24. 2 Greve, Bent (2012) Happiness. London: Routledge.    economic production to measuring people’s well-being’.3 e international economic organization OECD has at the same time increased its focus on non-economic factors including publication of data related to the How’s Life?-project. Many countries have also embarked upon how to nd infor- mation to supplement the more traditional economic types of measurement. e same has been done by many and very dierent kind of think tanks around the world. In general the quest for happiness and ways to measure and understand conditions for the good life and good society has increased. It is thus timely to ask, as the title of this book does, is ‘all well in the welfare state’? Especially in the Nordic welfare states, oen portrayed as the happiest nations around the globe, this question is an important one. How can it be, I have oen been asked in Denmark, that the Danish oen come out as one of the happiest people in the world when we have so many sui- cides, people suering from depression, and stress-related diseases? Can we really mark ourselves as a happy nation when so many are outside the labour market or in other ways excluded from societal development? e simple, but naturally not fully sucient answer is, that an average of many happy people does not mean that all people are happy at all times. We know that well-being also depends on changes over life time and people losing one of their beloved (wife, husband, partner, family member, children etcetera) will, for example, have times when they are not happy. Having had a hard time looking for a job and being rejected many times is not the best starting point for being a happy person. Happiness also changes over the life-cycle – typically happy as very young and as elderly (oen with dierent kinds of arguments), as less happy during the hard working years establish- ing families and with diculties to balance work and family life. erefore it is also obvious that not all is well for all – at least not all the time, as pointed out by Carl Marklund in the introductory chapter of this volume. Still, this also raises the question of whether it is possible to ensure that most people most of the time have conditions and options – or set of capabilities, in Am- artya Sen’s view – to pursue the good and happy life. 3 Stiglitz, Joseph E., Sen, Amartya & Fitoussi, Jean-Paul (2009) Report by the Commission on the Measurement of Economic Performance and Social Progress. Paris: Commission on the Measurement of Economic Performance and Social Progress, 12.   By looking into various issues and concerns of dierent groups in the welfare state, this book thus supplements existing knowledge and broadens the perspective on how and to what extent all actually is well and how the search for happiness is both an individual and societal issue. However, by raising issues related to the absence of happiness (unhappiness) in the rst three chapters, health and mental illness as central aspects of modern wel- fare states are emphasized. is further underlines how the focus on being a ‘normal’ citizen might inuence the well-being of others in society. e risk is that happiness will be mainly for those fullling the ambition of the mod- ern welfare states and who are, in the active life years, gainfully employed on the labour market. is should remind us that modern welfare states also have tendencies of social exclusion. e relation between health and societal development, including well- being has been known for a long time. However, recent focus on the impact on societies of inequality of health has highlighted that society might help in ensuring a better life for all citizens, and that societal focus on how to ensure better health for the individual may not only have an impact on inequality and daily living standard, but also on the general well-being and happiness in societies. is also implies a focus on not only physical diseases, but also on mental health. Likewise a focus on prevention of substance abuse, as dis- cussed in the chapter by Pekka Sulkunen and Trygve Ugland, is an indicator of an important area for welfare states having an ambition to ensure welfare for its citizens. It is sometimes argued that a smile can be infectious. is might also be the case for happiness, for as is shown in Olli Kangas’ chapter, immigrants are happier in happy nations. Naturally, there might be dierences depend- ing on where you are moving. Southern European men seem happier in the Nordic countries, more so than Southern European women. Still, as written by Kangas: ‘Happy immigrants live in happy countries’. ey have also a larger degree of trust. It might be that the institutional and structural fea- tures of the Nordic welfare states imply that the citizens are having, at least for the clear majority, a good life.    Studies of happy nations oen focus on adults and overlook the children and young persons. In her chapter, Margrét Einarsdottir focuses on young persons in Iceland, many of whom want to have money of their own, as this will imply a better well-being. is again highlights that, in accordance with Richard Easterlin’s position, money matters at least until a certain level, and that comparison among individuals have an impact on the degree of happi- ness. Even for young persons, work can be an important part of life, as this makes it possible to live life like their peers do. Furthermore, it may serve as a very early indication that work has become a still more central part of the Nordic welfare states way of life. e balance between work and family life, between work and free time, and the balance between included or excluded in modern societies are thus an important issue for the happiness of nations. is is also the issue of the last chapter in the book, which discusses whether in principle individual is- sues of subjective happiness can be made part of political debate and politi- cal decision making. It thus also raises the issue whether there is an emerg- ing global politics of happiness that attempts to combine our knowledge in very diverse areas – such as economic growth, equality, health, and environ- ment, etcetera. A further question concerns the criteria by which to distinguish between dierent policies and to choose between dierent projects. Even in the rich Nordic countries, there is a constant quest for economic eciency and need to prioritize between dierent policy goals. e question of how to balance a perspective on happiness with a perspective of ecient use of resources is thus still open for debate. Just one example to illustrate: From an economic perspective more police in the street will be a waste of money, but for ensur- ing an increasing level of personal security and thereby possibly increased level of happiness this could be an important issue. Conicts on how to prioritize in the welfare state have thus not been solved with the increased interest in what makes us happy. Neither can we ensure that the quest for happiness will not imply a further division in so- ciety between those who are well and those who are not. However, the in- creased focus on happiness has made us more aware that even if money   matters, money is not the whole story of a good life. By bringing to the fore these issues the welfare state will no longer only seek to provide material goods and income security, but presumably also adopt a broader role for social inclusion with a new focus on more subjective and individual needs. At the same time, the welfare state has to respect that individual lives are lived dierently and that there is an individual right to choose a lifestyle t- ting the individual. e welfare state’s role revolves to a large degree around setting the framework. is also implies a role for the welfare state in ensur- ing capabilities for individuals to make choices, and to be active in society’s development. In this way this book, by questioning whether all is well in the welfare states, contributes a new perspective while at the same time continuing in the tradition of welfare research, emphasizing the importance to also keep the focus on the vulnerable and those in need. References Greve, Bent (2012) Happiness. London: Routledge. Stiglitz, Joseph E., Sen, Amartya & Fitoussi, Jean-Paul (2009) Report by the Commission on the Measurement of Economic Performance and Social Progress. Paris: Commission on the Measurement of Economic Performance and Social Progress. Taleb, Nassim Nicholas (2010) e Bed of Procrustes. London: Penguin.    Introduction C M Introduction From having been treated with considerable scepticism by politicians and scholars alike during much of the post-war era, happiness has recently won renewed actuality in public debate, both as a target of scientic enquiry as well as an explicit concept in public policy evaluations.1 While individual well-being has long been closely connected with prosperity, high material standards of life, and good physical health – in short, welfare – recent in- terest has increasingly turned towards the role of various non-economical factors in promoting healthy living, psychological well-being, quality of life, and subjective happiness on the societal level. is renewed attention has, among other things, manifested itself in a recent surge of international rankings which aim to measure the level of quality of life, satisfaction with life, and subjective well-being (SWB) – as distinct from objective well-being (OWB) – within and across dierent so- cieties.2 Recently, ‘satisfaction with life’ has been added to traditional mea- sures, such as Gross Domestic Product (GDP), according to which dierent societies are being compared and evaluated. Other examples include the Human Development Index (HDI), the Satisfaction with Life Index (SLI), the Gallup World Poll (GWP), the World Values Survey (WVS), the Euro- pean Values Survey (EVS), and the European Social Survey (ESS). 1 is scepticism has been the norm in Western Europe and North America, while explicit notions of happiness have continued to play a decidedly political function in East Asian as well as South East Asian politics. 2 Costanza, Robert et al. (2007) ‘Quality of Life: An Approach Integrating Opportunities, Human Needs, and Subjective Well-Being’. Ecological Economics, Vol. 61, Issues 2–3, 267–276.   e enthusiastic media reception of these new rankings and their eager appropriation by governments as well as intergovernmental and international non-governmental organizations around the world warrants the growing in- terest and global importance of non-economic and immaterial factors for hu- man well-being, in advanced welfare states as well as in developing countries. Partly, this renewed attention follows from advances in scientic re- search, not only in psychology and psychiatry, where the commonsensical inverse of happiness, depression, has long been the object of concern, but also in the natural sciences and the social sciences more broadly. Partly, it has been promoted by a long-standing commercial interest in ‘life coaching’, ‘self-help’, and psychotherapy. In both these aspects, it primarily addresses the preconditions for individual happiness and well-being. Certainly, images and notions of individual happiness have long been employed for advertising purposes, at least since the emergence of mass consumption from the late nineteenth century and onwards. e fullment of desires, needs, and wants through the consumption of various products and services have fused into a cultural mix of social norms, signiers, and symbols of pleasure, satisfaction, and personal success that the individual may subscribe to or resist at dierent points in life.3 Recent research appears to conrm the importance of consumption and ‘shopping’ for satisfaction with life.4 Yet, this commercial appropriation of happiness has been criticized for reproducing ‘false needs’ by generating a kind of ‘treadmill syndrome’, whereby consumers are conditioned to crave for the next experience, product, or service but rarely achieving the desired satisfaction. is may generate economic growth, critics assert, but does not necessarily lead to societal progress, personal development, or, for that mat- ter, individual happiness.5 3 Kellner, Douglas (1983) ‘Critical eory, Commodities, and the Consumer Society’. eory, Culture, and Society, Vol. 1, No. 3, 66–84. 4 Roos, John Magnus (ed.) (2012) Konsumtionsrapporten 2012. Göteborg: Centrum för konsumtions- vetenskap, Handelshögskolan vid Göteborgs universitet. 5 Slater, Don (1997) ‘Consumer Culture and the Politics of Need’. In Nava, Mica, Blake, Andrew, MacRury, Iain & Richards, Barry (eds) Buy is Book: Contemporary Issues in Advertising and Consumption. London: Routledge; Bruni, Luigino & Porta, Pier Luigi (eds) (2007) Handbook on the Economics of Happiness Cheltenham: Edward Elgar; Dahlén, Micael (2008) Nextopia – Livet, lyckan och pengarna i förväntningssamhället. Stockholm: Volante förlag.    In the early 1970s, Richard Easterlin, American economist and happi- ness research pioneer, pinpointed the subjective and relative character of the income–happiness nexus, claiming that: “[i]n all societies, more money for the individual typically means more individual happiness. However, raising the incomes of all does not increase the happiness of all. [...] e resolution of this para- dox lies in the relative nature of welfare judgments. Individuals as- sess their material well-being, not in terms of the absolute amount of goods they have, but relative to a social norm of what goods they ought to have.”6 e attention upon individual happiness as distinct from societal hap- piness has also been criticized for supporting a materialistic and market- oriented approach towards life, which may primarily serve commercial in- terests and hence support ‘neoliberal’ biopolitics.7 More recent critics have also claimed that the commercialization of the moral imperative for the individual to achieve happiness, however dened, underpins the existing socio-economic order, channelling the proverbial ‘pursuit of happiness’ into competition between atomized individuals, rather than promoting collec- tive eort towards solving common problems and pursuing common values in society at large.8 6 Easterlin, Richard (1973) ‘Does Money Buy Happiness?’ e Public Interest, Vol. 30, 4; see also Easterlin, Richard (1974) ‘Does Economic Growth Improve the Human Lot?’ In David, Paul A. & Reder, Melvin Warren (eds) Nations and Households in Economic Growth: Essays in Honor of Moses Abramovitz. New York: Academic Press, 89–125. 7 Lasch, Christoper (1978) e Culture of Narcissism: American Life in an Age of Diminishing Expecta- tions. New York: Norton; Rimke, Heidi Marie (2000) ‘Governing Citizens rough Self-Help Litera- ture’. Cultural Studies, Vol. 14, No. 1, 61–78; Moskowitz, Eva S. (2001) In erapy We Trust: America’s Obsessions with Self-Fullment. Baltimore: John Hopkins University Press; Hazelden, Rebecca (2003) ‘Love Yourself: e Relationship of the Self with Itself in Popular Self-Help Texts’. Journal of Sociol- ogy, Vol. 39, No. 4, 413–428; McGee, Micki (2005) Self-Help, Inc. Makeover Culture in American Life. Oxford: Oxford University Press; Rose, Nikolas (1989) Governing the Soul: e Shaping of the Private Self. London: Routledge; Rose, Nikolas (1996) Inventing Our Selves: Psychology, Power and Person- hood. New York: Cambridge University Press; Foucault, Michel (2004) Security, Territory, Population. Lectures at the Collège de France, 1977–1978. New York: Palgrave Macmillan. 8 Ahmed, Sara (2010) e Promise of Happiness. Chapel Hill: Duke University Press; Ehrenreich, Barbara (2009) Bright-Sided: How the Relentless Promotion of Positive inking Has Undermined America. New York: Metropolitan Books/Henry Holt & Company.   According to this critique, the booming market for self-help literature, life coaching, and the subsequent commodication of psychology and psychotherapy reinforces the image of self-governing and self-regulating ‘rational economic man’ as the ideal human being. is personality type supposedly copes individually with adverse circumstances either through adaptation, competition, or therapy, rather than through voicing protest or political engagement. ereby, critics assert, the ideal type of rational eco- nomic man may serve to marginalize or even replace the ideal of the socially embedded and politically active citizen. e rise of ‘the happiness agenda’ or ‘the happiness industry’ has thus been interpreted as a commercial-cultural symptom of the neoliberal economic order.9 But the renewed interest in happiness has also followed from a possibly more ‘progressive’ (as distinct from neoliberal) interest in alternative ways of assessing policy outcomes as well as providing a more fair ground for the comparison of dierent societies than the straitjacket of GDP and the mono- dimensional focus upon economic growth as the primary goal.10 Here, the concern with SWB is rather connected with socio-economic equality, life chances, social integration, and ecological and social sustainability.11 e emerging eld of happiness economics has served as a channel of communication between the distinct academic elds of social statistics and happiness research as it seeks to quantify and measure subjective well-being while analyzing its relationship to measures of competitiveness, growth, and prosperity.12 is concern has become more acute in the wake of the recent recession, as nancially strapped governments point to ‘austerity policies’ 9 Ahmed 2010; Burnett, Simon (2011) e Happiness Agenda: A Modern Obsession. Basingstoke: Palgrave Macmillan. 10 Gandelman, Néstor & Hernández-Murillo, Rubén (2009) ‘e Impact of Ination and Unemploy- ment on Subjective Personal and Country Evaluations’. Federal Reserve Bank of St. Louis Review, Vol. 91, No. 3, 107−126. 11 Sen, Amartya (1993) ‘Capability and Well-being’. In Nussbaum, Martha & Sen, Amartya (eds) e Quality of Life. Oxford: Clarendon Press, 30−53; Dahrendorf, Ralf (1979) Life Chances: Approaches to Social and Political eory. London: Weidenfeld and Nicolson. 12 Ahmed 2010; Abdallah, Saamah, ompson, Sam & Marks, Nic (2008) ‘Estimating Worldwide Life Satisfaction’. Ecological Economics, Vol. 65, No. 1, 35–47; Oswald, Andrew (1999) ‘A Non-Technical Introduction to the Economics of Happiness’. Online. Available HTTP: (accessed October 2012); Powdthavee, Nattavudh (2007) ‘Economics of Happiness: A Review of Literature and Applications’.­Chulalongkorn Journal of Economics, Vol. 19, No. 1, 51–73.   € and ‘suciency economy’ as a way of coping with weaker economic growth, rather than questioning the focus upon economic growth. As of yet, the ndings of happiness economics remain inconclusive. Some studies suggest real GDP at purchase power parity (PPP) per capita aect happiness positively.13 Other studies show little or no correlation between absolute and relative income levels and SWB, positing the existence of a ‘sa- tiation point’ in the range between USD 15 000–20 000 GDP (PPP), beyond which wealthier countries register no further increase in SWB.14 Recently, for example, Angus Deaton has used Gallup polls to show that the current nancial crisis has had little veriable impact upon the SWB of Americans, despite widespread public perceptions to the contrary.15 In a related vein, it has been suggested that SWB is rather determined by personality traits than by external circumstances. According to some observers, this would seem to indicate that there is an individual ‘happiness set point’ to which people tend to return to aer both positive and negative experiences.16 ese divergent results of happiness research render eventual policy im- plications of this emerging discipline dicult to assess. Some members of the research community have been reluctant to make policy recommenda- tions before the complex links between income, wealth, leisure, freedom of choice, and welfare policies and their impact upon SWB have been more fully explored. American lawyer Derek Bok has recently questioned wheth- er the research results could warrant a new politics of happiness, claiming 13 Discussing the link between income and well-being, Betsey Stevenson and Justin Wolfers argue that ‘several interesting variants of the question could be asked—such as whether it is GDP, broader measures of economic development, or alternatively, changes in output or in productivity that drive happiness’, but note that ‘[u]nfortunately, we lack the statistical power to resolve these questions’. Hence, they concentrate their study on the GDP–SWB relationship. See Stevenson, Betsey & Wolf- ers, Justin (2008) ‘Economic Growth and Subjective Well-Being: Reassessing the Easterlin Paradox’. NBER Working Paper No. 14282. Online. Available HTTP: (accessed October 2012) 14 For recent discussions, see Layard, Richard (2005) Happiness: Lessons From A New Science. London: Penguin; Layard, Richard (2012) ‘Mental Health: e New Frontier for the Welfare State’. Online. Available HTTP: (accessed October 2012); Layard, Richard, Mayraz, Guy & Nickell, Stephen John (2008) ‘e Marginal Utility of Income’. Journal of Public Economics, Vol. 92, Issues 8–9, 1846–1857; Stevenson & Wolfers 2008. 15 Deaton, Angus (2011) ‘e Financial Crisis and the Well-being of Americans’. Oxford Economic Papers, Vol. 64, No. 1, 1–26. 16 Bruni & Porta 2007.   that the welfare state shows a low impact upon SWB.17 Nevertheless, Bok supports an expansion of welfare state commitments in the USA with a view of improving quality of life and SWB. Other researchers have more explicitly supported the government policy of maximizing SWB with regard to spe- cic policy areas, such as employment policies and psychological therapy, as well as public policy more generally. In a typical statement, one of the most vocal proponents for a new politics of happiness, British economist Richard Layard, has argued that a government’s role should be to increase happiness and reduce misery and that ‘well-being and mental health need to be the new frontier for the welfare state’.18 Given the inconclusiveness of the research, however, it remains uncertain exactly what kind of policies would constitute such a ‘new frontier’. Happiness, well-being, and the (Nordic) welfare state So far, the Nordic countries have scored well in comparative statistics on SWB. e Danes, for example, were ranked rst on happiness according to the Gallup World Poll 2005–2011, followed by the Finns, the Norwegians, and the Dutch.19 Similarly, in the OECD’s Better Life Index of 2012 Norway, Sweden, and Denmark came out among the top ve.20 While the rankings in themselves do not explain the underlying causes, the Nordic model of welfare, with its focus upon collective and universal social security, has typically been seen as a key factor for these favourable results. is notion has a tradition, too, as the Nordic countries have for a long time been presented as utopian ‘happy democracies’ where freedom and welfare have been successfully combined.21 17 Bok, Derek (2010) e Politics of Happiness: What Government Can Learn from the New Research on Well-Being. Princeton: Princeton University Press. 18 Layard 2012. 19 For a discussion of earlier scores, see Greve, Bent (ed.) (2010) Happiness and Social Policy in Europe. Cheltenham: Edgar Elgar; Helliwell, John F., Layard, Richard & Sachs, Jerey D. (eds) (2012) World Happiness Report. New York: e Earth Institute, Columbia University. 20 Organisation for Economic Co-operation and Development (OECD) (2012) ‘Better Life Index’. Online. Available HTTP: (accessed October 2012) 21 See for example Tingsten, Herbert (1966) Från idéer till idyll: Den lyckliga demokratien. Stockholm: Bokförlaget PAN/Norstedts.    As the global nancial crisis has forced national governments to adopt austerity policies and cut public spending, welfare state supporters across the world point to the success of Nordic countries in these rankings, un- derlining the role of social policies in promoting growth and stability in the midst of recession.22 Admittedly, the Nordic score in terms of SWB may simply reect performance on a number of traditional parameters – such as GDP per capita, growth, competitiveness, market freedom, productivity, as well as social equality (Gini), healthcare, safety, and public trust – which are usually also taken into account in various rankings of SWB. Yet, it is becom- ing more widely acknowledged that social policy may have a direct positive inuence on SWB, not only through providing for economic growth and creativity, but also through ensuring redistribution, social security, and so- cial equality.23 In short, the welfare state may be a decisive factor for ‘Nordic happiness’.24 Yet, all is not necessarily well in the Nordic welfare states – at least not for all, and certainly not all of the time. For example, mental disorders are reportedly on the rise in all Nordic societies.25 e increasing prevalence of stress symptoms and mental illness stands in a complex relation to recent shis in the scope and means of social benets and social security more generally, in the Nordic countries as well as elsewhere.26 International stud- ies have shown that mental distress has become a more common reason for early retirement since the early 1980s and onwards, especially among young adults.27 At the same time, socio-economic gaps are also reported as widen- ing in the Nordic welfare states. 22 Marklund, Carl (forthcoming 2013) ‘A Swedish Norden or a Nordic Sweden? Image Politics During the Cold War’. In Jonas Harvard & Peter Stadius (eds) Communicating the North: Media Structures and Images in the Making of the Nordic Region. Farnham: Ashgate. 23 Saari, Juho (2012) Onnellisuuspolitiikka – Kohti sosiaalisesti kestävää Suomea. Helsinki: Kalevi Sorsa Säätiö; Wilkinson, Richard G. & Pickett, Kate (2009) e Spirit Level – Why More Equal Societies Almost Always Do Better. London: Penguin. 24 Greve 2010; Saari 2012. 25 Olofsson, Jonas & Östh, John (2011) Förtidspensionering av unga. En fråga om utsortering eer utbildningsnivå och socioekonomisk bakgrund? Underlagsrapport till den parlamentariska socialförsäk- ringsutredningen. Stockholm: Parlamentariska socialförsäkringsutredningen. 26 See for example OECD (2011) Sick on the Job? Myths and Realities about Mental Health and Work. Paris: OECD Publishing; OECD­(2013) Mental Health and Work: Sweden. Paris: OECD Publishing. 27 Olofsson & Östh 2011.   Traditionally, universalist welfare policies do not only provide a basic so- cial security for all. ey also seek to help people through transitory periods of diculty in life. But what happens in the trade-o between the needs of those with transitory problems and the needs of those who risk permanent problems? In response to this query, this book brings together social scientists and historians in a discussion of how these emerging trends interrelate with one another. e volume is based on some of the contributions presented at the conference ‘All well in the welfare state? Mental well-being and the politics of happiness’ at the Department of Economic and Political Studies at the University of Helsinki in the autumn of 2011, which was a part of the ac- tivities of the Nordic Centre of Excellence: e Nordic Welfare State – His- torical Foundations and Future Challenges, NordWel. e conference was organized by one of its theme groups: ‘e Normative Charges of Work: e Labour Market and the Welfare State’. e contributions focus upon two dierent aspects of the relationship between SWB on the one hand and welfare on the other hand. If a given soci- ety’s ‘quality’ can be assessed by its attitude towards and the assistance it pro- vides its most sensitive members, it rst becomes of interest to ask what the recent attention to SWB may mean for those who are the least likely to pos- sess the economical and social means that are ‘normally’ expected to enhance either OWB or SWB. It is by no means self-evident who may, at times, belong to these groups. But given the demonstrably unequal access to life chances, likely groups may include the physically ill and the mentally disabled as well as substance abusers. Also children, elderly, immigrants, and the unemployed may face similar challenges. e question is whether the SWB of these groups is strengthened or obscured by the new interest in the happiness of society as a whole, with its concomitant focus upon the needs of the majority, e.g. the gainfully employed and economically more secure members of society. Second, the contributions also address the relationship between eco- nomic and non-economic factors, between OWB and SWB, and between welfare and well-being for perceived life satisfaction. e links between in- come, wealth, and work on the one hand and social relations, stress, and    safety on the other hand, as well as physical health and mental health, are not only complex in their own right. Post-materialist and progressive discourses on happiness are increasingly merging with neoliberal discourses on liberty and self-actualization, posing new and complex challenges to welfare states, not only in the Nordic countries, but in other welfare states as well. Overview of the book As Varda Soskolne shows in her chapter, advances in medicine and social policy have led to major improvements in health and to extended life ex- pectancy globally, aecting SWB positively. But Soskolne asks whether this occurs in all sections of society. In Israel, health inequalities have widened since the 1990s, in parallel with an increase in income inequalities and a shi from welfare state policies to more neoliberal policies, including the priva- tization of the healthcare sector and the transfer of more health and welfare services to NGOs and private companies. Soskolne shows that socioeco- nomic status (SES) correlates with rising inequalities in health, probing the extent to which the psychosocial environment may explain these inequali- ties. Soskolne notes that the interventions and policies aimed at ‘closing the gap’ between dierent socio-economic groups is not yet fully covered in the scientic literature, conrming the notion that the relationship between happiness research and welfare state policies remains uncertain. In her chapter, Katarina Piuva shows how ‘normality’ has become an expected precondition for health and happiness in Sweden: While the men- tally ill are supposed to be integrated into society at large, they are also to be viewed as if they paradoxically did not have any specic needs. Normality, in its turn, is closely connected with performance in various social activities, including work. As ‘health’ is increasingly dened as ability to work through the concept of ‘employability’, Piuva concludes that implicit understandings of normality may serve as an obstacle to the social integration of the severely mentally ill. In other words, the principles of normality that have become the ideology of social integration may turn out to be a demand on the in- dividual to live a life just like ‘everybody else’ – a demand which may have been the cause of the discomfort to begin with.   e dehospitalization movement exemplies an attempt to close the gap between the well-being of the mentally ill and the majority population. In their chapter, Anna Alanko and Carl Marklund show how mental health care planning in Finland has adapted to the international trend towards de- hospitalization, partly in the interest of increased cost-eciency, but also with the SWB of the mentally ill in mind. However, as the categories of mental illness continue to expand, so does the demand for inpatient treat- ment rise in parallel with the demands for more outpatient treatment. Ris- ing mental problems, especially among the young, can be interpreted as a sign of decreasing SWB and higher stress in society, running the risk of putting further strain on the already limited resources available for those in the most need of special care. While some groups in society may thus require protection from the de- mands of ‘normal’ life in order to achieve SWB, other groups may instead increase their well-being as a result of being exposed to precisely these chal- lenges and rewards. In her contribution, Margrét Einarsdóttir looks at the relationship between part-time work and SWB among teenagers in Iceland. In particular, she tracks the sensitive balance between the independence and autonomy that follows from being gainfully employed and the risks and de- mands being posed by work. Einarsdóttir notes that monetary reasons are not necessarily the determining cause for teenagers’ work in Iceland, but that work ethics, independence, autonomy, socialization, and enjoyment play key roles, too. Her ndings underline that teenagers, even in a welfare state under considerable economic strain, typically enter the job market pri- marily to enact a consumer identity, which in its turn aects teenage percep- tions of the relationship between work, income, and happiness. Einarsdóttir’s study deals with part-time work, but points to the rela- tionship between permanent (un)employment and SWB. Most studies show that involuntary unemployment is as strongly related to negative SWB as leisure is linked to positive SWB. Nordic welfare states have re- cently been grappling with the problem of rising unemployment in par- ticular groups whose social inclusion and protection is sometimes seen as an onerous cost, in what amounts to a criticism of the welfare state and its    ability to provide not only jobs but also well-being for all. According to this criticism, governmental policies should singularly focus on creating jobs rather than social protection. In his chapter, Olli Kangas compares the well-being of immigrants in dierent European countries, noting that immigrants report the highest levels of SWB in the countries which have the most generous welfare policies, thus challenging the arguments of the welfare-state critics. In their chapter, Pekka Sulkunen and Trygve Ugland address the rela- tionship between substance abuse, abuse control, and SWB by comparing French and Nordic policies against the backdrop of emerging common EU policy goals. While alcohol policy aims to improve not only public health and reduce health care spending, but also to further the well-being of the population in general, there is also a tension between the duty to further the well-being of those who are the least likely to conform to societal norms about happiness without infringing upon the independence and identity of the individual person. If welfare policies then may then have direct implica- tions for individual as well as societal well-being, it also becomes impor- tant to consider under what conditions well-being and happiness should or should not be made the target of political agency. In the closing chapter, Carl Marklund looks at the emerging rankings of dierent societies with regard to SWB. Noting that the generation of scien- tic knowledge oen constitutes the rst step towards the establishment of a new policy eld, the chapter discusses how these new rankings may aect welfare-state policy making. However, the inclusion of these categories into global rankings appears to play a soothing rather than spurring function, conrming that the rising interest in happiness has not, at least not just yet, been explicitly politicized. Yet, given the way in which the discussions on happiness activate criti- cal tensions in contemporary society, of material welfare versus subjective well-being, prosperity versus sustainability, and state responsibility versus individual responsibility, the public discourse on happiness may well de- velop into a critical site of political contest in the near future. Due to the in- conclusive status of happiness research, however, the political consequences   of this possible ‘new frontier’ in welfare state policies can just as well serve to expand the responsibility of the welfare state as it may further limit the reach of politics, pointing to the responsibility of the individual for his/her own happiness. Conclusions e high score of the Nordic welfare states in the rankings of happiness could possibly indicate that the welfare state – originally concerned with the universal provision of basic social benets while providing additional social support to those most in need – already makes a substantial contribution to SWB. Is all well in the welfare state, then? e contributions to this book point in two possibly diverging directions when addressing this question. On the one hand, acknowledging the risks posed by mental as well as material sources of stress, a continued commit- ment to welfare state universalism could take on responsibility for the over- all happiness and well-being of the population, representing a kind of ‘poli- tics of happiness’ reaching beyond the concerns of material welfare. SWB could thereby become another public good, alongside the more customary objectives of welfare policy. On the other hand, several tendencies in contemporary society point towards the greater medicalization of various social conditions, while stress and discomfort are reportedly on the rise due to the high demands of work and pressures in social life, potentially expanding the number of people who report dissatisfaction and low SWB as well as mental ill health. Here, the renewed attention to SWB could possibly signal the advent of a negative ‘politics against unhappiness’ – as distinct from a positive politics of happi- ness which would be more concerned with the need for individual therapy than the reduction of collective risk. Either way, the arrival of SWB on the political agenda activates the dual duty of the welfare state to not only answer to the basic social demands of the population at large, even when these expand beyond basic provisions and social services, but to continue to extend assistance and care to those in the most need.    References Abdallah, Saamah, ompson, Sam & Marks, Nic (2008) ‘Estimating Worldwide Life Satis- faction’. Ecological Economics, Vol. 65, No. 1, 35–47. Ahmed, Sara (2010) e Promise of Happiness. Chapel Hill: Duke University Press. Bok, Derek (2010) e Politics of Happiness: What Government Can Learn from the New Research on Well-Being. Princeton: Princeton University Press. Bruni, Luigino & Porta, Pier Luigi (eds) (2007) Handbook on the Economics of Happiness Cheltenham: Edward Elgar. Burnett, Simon (2011) e Happiness Agenda: A Modern Obsession. Basingstoke: Palgrave Macmillan. Costanza, Robert et al. (2007) ‘Quality of Life: An Approach Integrating Opportunities, Human Needs, and Subjective Well-Being’. Ecological Economics, Vol. 61, Issues 2–3, 267–276. Dahlén, Micael (2008) Nextopia – Livet, lyckan och pengarna i förväntningssamhället. Stock- holm: Volante förlag. Dahrendorf, Ralf (1979) Life Chances: Approaches to Social and Political eory. London: Weidenfeld and Nicolson. Deaton, Angus (2011) ‘e Financial Crisis and the Well-being of Americans’. Oxford Economic Papers, Vol. 64, No. 1, 1–26. Easterlin, Richard (1973) ‘Does Money Buy Happiness?’ e Public Interest, Vol. 30, 3–10. Easterlin, Richard (1974) ‘Does Economic Growth Improve the Human Lot?’ In David, Paul A. & Reder, Melvin Warren (eds) Nations and Households in Economic Growth: Essays in Honor of Moses Abramovitz. New York: Academic Press, 89–125. Ehrenreich, Barbara (2009) Bright-Sided: How the Relentless Promotion of Positive inking Has Undermined America. New York: Metropolitan Books/Henry Holt & Company. Foucault, Michel (2004) Security, Territory, Population. Lectures at the Collège de France, 1977–1978. New York: Palgrave Macmillan. Gandelman, Néstor & Hernández-Murillo, Rubén (2009) ‘e Impact of Ination and Unemployment on Subjective Personal and Country Evaluations’. Federal Reserve Bank of St. Louis Review, Vol. 91, No. 3, 107−126. Greve, Bent (ed.) (2010) Happiness and Social Policy in Europe. Cheltenham: Edgar Elgar. Hazelden, Rebecca (2003) ‘Love Yourself: e Relationship of the Self with Itself in Popular Self-Help Texts’. Journal of Sociology, Vol. 39, No. 4, 413–428. Helliwell, John F., Layard, Richard & Sachs, Jerey D. (eds) (2012) World Happiness Report. New York: e Earth Institute, Columbia University. Kellner, Douglas (1983) ‘Critical eory, Commodities, and the Consumer Society’. eory, Culture, and Society, Vol. 1, No. 3, 66–84. Lasch, Christoper (1978) e Culture of Narcissism: American Life in an Age of Diminishing Expectations. New York: Norton. Layard, Richard (2005) Happiness: Lessons From A New Science. London: Penguin. Layard, Richard (2012) ‘Mental Health: e New Frontier for the Welfare State’. Online. Available HTTP: (accessed October 2012) Layard, Richard, Mayraz, Guy & Nickell, Stephen John (2008) ‘e Marginal Utility of Income’. Journal of Public Economics, Vol. 92, Issues 8–9, 1846–1857.   Marklund, Carl (forthcoming 2013) ‘A Swedish Norden or a Nordic Sweden? Image Politics During the Cold War’. In Jonas Harvard & Peter Stadius (eds) Communicating the North: Media Structures and Images in the Making of the Nordic Region. Farnham: Ashgate. McGee, Micki (2005) Self-Help, Inc. Makeover Culture in American Life. Oxford: Oxford University Press. Moskowitz, Eva S. (2001) In erapy We Trust: America’s Obsessions with Self-Fullment. Baltimore: John Hopkins University Press. OECD (Organisation for Economic Co-operation and Development) (2011) Sick on the Job? Myths and Realities about Mental Health and Work. 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(2012) Konsumtionsrapporten 2012. Göteborg: Centrum för kon- sumtionsvetenskap, Handelshögskolan vid Göteborgs universitet. Rose, Nikolas (1989) Governing the Soul: e Shaping of the Private Self. London: Routledge. Rose, Nikolas (1996) Inventing Our Selves: Psychology, Power and Personhood. New York: Cambridge University Press. Saari, Juho (2012) Onnellisuuspolitiikka – Kohti sosiaalisesti kestävää Suomea. Helsinki: Kalevi Sorsa Säätiö. Sen, Amartya (1993) ‘Capability and Well-being’. In Nussbaum, Martha & Sen, Amartya (eds) e Quality of Life. Oxford: Clarendon Press, 30−53. Slater, Don (1997) ‘Consumer Culture and the Politics of Need’. In Nava, Mica, Blake, Andrew, MacRury, Iain & Richards, Barry (eds) Buy is Book: Contemporary Issues in Advertising and Consumption. London: Routledge. Stevenson, Betsey & Wolfers, Justin (2008) ‘Economic Growth and Subjective Well-Being: Reassessing the Easterlin Paradox’. NBER Working Paper No. 14282. Online. 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A substantial and rapidly growing literature has in recent decades provided consistent evidence that although the advances in medicine and improvements in standard of living have contributed to overall better health and extended life expectancy, signicant dierences in health exist between social groups. e Commission on Social Determinants of Health (CSDH) of the World Health Organization (WHO) states that inequalities in health arise because of inequalities in society – in the conditions in which people are born, grow, live, work, and age.1 e most important determinants of health inequalities are those that produce stratication within society, namely the structural determinants such as the distribution of wealth and income, or gender or ethnic discrimination rooted in the context of the society. Another issue that has attracted attention from health and social sci- entists in diverse elds in recent decades is the concept of well-being. e changing demography and ageing of the population in many countries has brought to the fore a focus on quality of life and subjective well-being. e WHO denes health very broadly as a multidimensional construct, ‘a state of complete physical, mental, and social well-being and not merely the absence 1 Commission on Social Determinants of Health (CSDH) (2008) Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. Final report. Geneva: World Health Organization.      -  of disease or inrmity’.2 e approach to measuring health, beyond that of the traditional morbidity and mortality data, has thus been broadened, but the measurements of well-being are contested, because the concept remains ambiguous and ill-dened.3 Researchers oen use a multiplicity of terms that sometimes seem to be synonymous and at other times rather dier- ent, such as positive emotions, subjective well-being, life satisfaction, hap- piness, and quality of life. e most commonly used conceptualization of well-being focuses only on psychological aspects and dierentiates between global judgments of life satisfaction and feelings.4 Based on evidence of the association of well-being with health, this conceptualization elucidates the convergence of health and well-being in the scientic literature and in health policy.5 In addition, well-being is relevant to the health inequalities agenda, because recognition that well-being is an appropriate measure of what people value in life, makes it a popular topic for public health policies and interventions aimed at reducing health inequalities. A more detailed denition of well-being and evidence of inequalities in well-being together with a focus on health inequalities are necessary for a fuller understanding of the complex causes of inequalities at global or local levels.6 is chapter aims to expand this understanding by reviewing the deni- tions and the scope of social inequalities in physical health and well-being, and the major underlying explanatory mechanisms of these inequalities. Rooted in the social determinants of health framework, this chapter focuses mainly on socioeconomic status (SES), dened mainly by income, educa- tion or occupation, as a major social feature of health and well-being in- equalities. People with a higher socioeconomic position in society have a greater array of life chances and more opportunities to lead a ourishing life 2 World Health Organization (WHO) (1946) Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19–22 June, 1946. Online. Available HTTP: (accessed September 2011) 3 Carlisle, Sandra & Hanlon, Phil (2008) ‘“Well-being” as a Focus for Public Health? A Critique and Defence’. Critical Public Health, Vol. 18, 263–270. 4 Diener, Ed (2000) ‘Subjective Well-Being: e Science of Happiness and a Proposal for a National Index’. American Psychologist, Vol. 55, Issue 1, 34–43. 5 Diener, Ed & Chan, Micaela Y. (2011) ‘Happy People Live Longer: Subjective Well-Being Contrib- utes to Health and Longevity’. Applied Psychology: Health and Well-Being, Vol. 3, Issue 1, 1–43. 6 Carlisle & Hanlon 2008.    and have better health. Furthermore, these topics are elaborated by a review of the Israeli context in order to demonstrate how they are expressed at a specic local level, yet representing the broader issues of health inequalities and the well-being agenda and their relationship to the welfare state. In the last decades, the universal/citizenship-based policy of Israel’s welfare system was trimmed, and a more explicitly neoliberal and non-universal welfare approach took eect.7 Although one cannot ignore the problems unique to Israel, above all the political conict with the Arab world and the substan- tial national security expenditures, the retrenching welfare state is subject to many of the same pressures and discontents as are other societies in Europe and North America. e welfare policy shis and the subsequent increase in social inequality are relevant when we seek to study the way in which SES af- fect health and well-being. Finally, the chapter suggests several implications of this review for further research while analysing policies that contribute to and are necessary for tackling health inequalities. Israel: General background and social inequalities Israel, established in 1948, has a population of 7.7 million: 76 per cent are Jews, 20 per cent Arabs (86 per cent of whom are Muslims), and the rest are Druze and other groups.8 e immigration of Jews is central to Israel’s development, with major waves arriving in the 1950s and 1960s. A more recent large wave of close to one million immigrants arrived in the 1990s from the former Soviet Union. By now, 28 per cent of the Jewish popula- tion is foreign-born.9 ese gures represent the multi-ethnic and multi- cultural characteristics of Israeli society and its major social divisions. e major and most salient ri is between Jews and Arabs, constantly aected by the Israeli-Palestinian conict. e Israeli Arabs, who are native-born, became a minority in 1948 and found themselves in a subordinate posi- 7 Gamliel-Yehoshua, Haya & Vanhuysse, Pieter (2010) ‘e Pro-Elderly Bias of Social Policies in Israel: A Historical-Institutional Account’. Social Policy & Administration, Vol. 44, No. 6, 708–726. 8 Israel Central Bureau of Statistics (2011a) Statistical Abstract of Israel 2010. Jerusalem: Central Bureau of Statistics. Online. Available HTTP: (accessed July 2012) 9 Israel Central Bureau of Statistics 2011a.      -  tion to the Jewish population, politically, socially and economically. ey have lower education, income, occupational and standard-of-living levels than their fellow Jewish citizens. e Jewish population is also characterized by an ethnic cleavage between those of European or American (Ashkenazi) origin and those originating from North African or Middle Eastern/Asian countries (Sephardi origin). e latter group has been subordinate to the former in many socio-economic indicators – education, income and occu- pational status.10 Israel, as one of the Mediterranean group of welfare states, was origi- nally inuenced by the Beveridgean legacy in which social protection pro- grammes are funded through general tax revenues, including, for example, the introduction of residual safety-net programmes for the poor in 1980.11 Since the mid-1990s, however, the welfare regime characterized by uni- versalism and comprehensive risk coverage has shied towards a market- oriented economy.12 Policies aimed at retrenching the welfare state became more apparent with the signicant reduction of most benets, in conjunc- tion with cutbacks or spending freezes on many programmes, in keeping with the stated aim of reducing government expenditure. is more explic- itly neoliberal and non-universal welfare approach took eect particularly aer Benjamin Netanyahu rst became a prime minister in 1996 and when he became nance minister in 2002, and has le an indelible mark on wel- fare in the country.13 A further non-progressive policy of reducing tax rates was introduced, the benets of which have accrued to those in the highest income deciles.14 us, the direct eect of government policy on the levels of poverty and inequality through social welfare allowances and direct taxes 10 Semyonov, Moshe & Lewin-Epstein, Noah (2011) ‘Wealth Inequality: Ethnic Disparities in Israeli Society’. Social Forces, Vol. 99, 935–959. 11 Gal, John (2010) ‘Is ere an Extended Family of Mediterranean Welfare States?’ Journal of European Social Policy, Vol. 20, Issue 1, 283–300. 12 Zambon, Alessio, Boyce, Will, Cois, Ester, Currie, Candace, Lemma, Patrizia, Dalmasso, Paola, Borraccino, Alberto & Cavallo, Franco (2006) ‘Do Welfare Regimes Mediate the Eect of Socio- economic Position on Health in Adolescence? A Cross-National Comparison in Europe, North America, and Israel’. International Journal of Health Services, Vol. 36, Issue 2, 309–329. 13 Gamliel-Yehoshua & Vanhuysse (2010). 14 Bank of Israel (2011) Bank of Israel, Annual Report, 2011. Chapter 8: Welfare Policy Issues. Online. Available HTTP: (accessed July 2012)    has weakened. In the past decade, the incidence of poverty in individuals increased from 21.1 per cent in 2002 to 24.4 per cent in 2010, and the in- come gap (the average gap between the poverty line and the income of poor persons) increased from 29.7 per cent to 35.8 per cent during these years.15 Poverty rates parallel ethnic and social division in the population, with rates reaching close to 57 per cent among Israeli Arabs and ultra-Orthodox Jews, populations that are characterized by large families, low educational level and low employment rates.16 e above mentioned policy changes in Israel are reected in the increase in inequality levels measured by the Gini coef- cient (a standard measure of income inequality that ranges from zero to one, the higher the coecient the greater the inequality): from 0.32 in the 1980s to 0.38 in the late 2000s, ranking third in inequality among OECD countries.17 e ratio of the average income of the richest 10 per cent of the population to that of the poorest 10 per cent is 9 to 1 in the OECD countries; it is much lower in the Nordic countries, but reaches 14 to 1 in Israel.18 One of the eects of these growing social inequalities in Israeli society is reected in health status inequalities and in utilization of health services, despite the fact that the right to health is fundamental in Israel. e Israeli health system has traditionally oered universal health care administered by four health maintenance organizations (HMOs) that were initially set up by the country’s labour unions before the establishment of the state in 1948. However, persons not in the workforce were usually uninsured. Since January 1995, under the provisions of the National Health Insurance Law, all permanent residents are insured and are entitled to health services in accordance with the principles of justice, equality, and mutual support. However, the Israeli health system is far from being able to adhere to these principles. Although a basic basket of medical services is provided under the Law, health inequalities persist between the major social divisions in Israeli 15 Bank of Israel 2011. 16 Bank of Israel 2011. 17 Organisation for Economic Co-operation and Development (OECD) (2011a) Growing Income In- equality in OECD Countries: What Drives It and How Can Policy Tackle It? Online. Available HTTP: (accessed October 2011) 18 OECD 2011a.      -  society, between those with high and low SES levels, between central and peripheral areas, and between the Jewish majority and the Arab minority.19 In order to fully understand these dierences in the Israeli context, the fol- lowing sections review the general evidence of the denition and scope of inequalities in health and well-being globally and their explanatory vari- ables, followed by the evidence in Israel. Socioeconomic inequalities in health Health inequalities refer to the dierence in health status between social groups that is not only unnecessary and avoidable, but is also considered unfair and unjust.20 Although the term health inequities has been used in recent years to emphasize the injustice of the dierence in health status, I use the term health inequalities, which emphasizes the unequal distribution of health, and is oen used interchangeably with the term health disparities in the American literature. SES inequalities are most commonly measured as dierences in income, education, occupation or household assets at the individual level, and as per capita gross domestic product (GDP) at com- munity, regional or national levels. e importance of poverty has been recognized as a major social factor of health since the 19th century when it was recognized as a determinant of infectious disease – e.g. Rudolf Virchow’s conclusion that poor sanita- tion, ignorance of basic hygiene, lack of education, and near starvation were the root problems of a typhus epidemic.21 e more recent awareness of the eects of these factors on non-communicable diseases, on general health status and on mortality, has generated compelling evidence that lower SES 19 Chernichovsky, Dov (2011) ‘e Healthcare System’. In Ben-David, Dan (ed.) State of the Nation Re- port – Society, Economy and Policy 2010. Jerusalem: Taub Center for Social Policy Studies. [Hebrew] 20 Adler, Nancy E. & Stewart, Judith (2010) ‘Health Disparities across the Lifespan: Meaning, Methods, and Mechanisms’. Annals of the New York Academy of Sciences, Vol. 1186, 5–23. 21 Reese, David M. (1998) ‘Fundamentals – Rudolf Virchow and Modern Medicine’. Western Journal of Medicine, Vol. 169, 105–108.    is associated with higher mortality rates and poorer health.22 Typically, the age-adjusted risk of death for those at the lowest socioeconomic level is two or three times as high as that of the highest level.23 e magnitude of the inequalities is stronger for mortality than for morbidity and varies between countries. For example, among European countries, relative inequalities in mortality between men with the lowest and the highest level of education were just under two in Sweden and in England and Wales, and were four or higher in Hungary, the Czech Republic, and Poland; on the other hand, the relative inequalities in the prevalence of poor self-assessed health were 1.2 in Germany and about 1.7 in Portugal.24 It is important to note that these trends have been observed not only for the general population but also within age sub-populations. e rate of reporting their children as being in fair/poor health was almost twice as high among families in the bottom 25th income percentile compared with those in the 75th income percen- tile.25 Similarly, health inequalities persist even among the oldest-old (85 years of age or older) but the evidence is less consistent and is confounded by signicant methodological issues.26 Dierences are found not only between those in the extreme SES catego- ries. Consistent evidence from various countries shows that there is a social gradient of mortality and morbidity: each step one moves up the social lad- 22 Lantz, Paula M., House, James S., Mero, Richard P. & Williams, David R. (2005) ‘Stress, Life Events, and Socioeconomic Disparities In Health: Results from the Americans’ Changing Life Study’. Journal of Health and Social Behavior, Vol. 46, Issue 3, 274–288; Mackenbach, Johan P., Stirbu, Irina, Ros- kam, Albert-Jan R., Schaap, Maartje M., Menvielle, Gwen, Leinsalu, Mall & Kunst, Anton E. (2008) ‘Socioeconomic Inequalities in Health in 22 European Countries’. New England Journal of Medicine, Vol. 358, Issue 23, 2468–2481; van Oort, Floor V. A., van Lenthe, Frank J. & Mackenbach, Johan P. (2005) ‘Material, Psychosocial, and Behavioural Factors in the Explanation of Educational Inequali- ties in Mortality in the Netherlands’. Journal of Epidemiology & Community Health, Vol. 59, 214–220. 23 Phelan, Jo C., Link, Bruce G. & Teranifer, Parisa (2010) ‘Social Conditions as Fundamental Causes of Health Inequalities: eory, Evidence, and Policy Implications’. Journal of Health and Social Behav- ior, Vol. 51, Suppl., S28–S40. 24 Mackenbach et al. 2008. 25 Chen, Edith, Martin, Andrew D & Matthews, Karen A (2004) ‘Why Socioeconomic Status Aects e Health Of Children: A Psychosocial Perspective’. Current Directions in Psychological Science, Vol. 13, 112–115. 26 Guilley, Edith, Bopp, Matthias, Faeh, David & Paccaud, Fred (2010) ‘Socioeconomic Gradients in Mortality in the Oldest old: A Review’. Archive of Gerontology and Geriatrics, Vol. 51, Issue 3, e37– e40.      -  der, the better one’s health.27 Moreover, an important issue is the evidence that socioeconomic inequalities in health in various Western countries per- sist or have widened despite various programmes aimed at reducing them.28 However, the mechanisms responsible for these health inequalities are still being debated. SES inequalities in health in Israel Signicant dierences in health between the major social divisions in the population have been consistently reported. For instance, dierences in life expectancy at birth between Jews and Arabs persist. Among men, life ex- pectancy was 80.4 and 76.8 years for Jews and Arabs respectively, and 83.7 and 81.0 years among women, respectively.29 Infant mortality rates, which declined to 4 per 1000 live births in 2010, have declined more steeply among Arabs during the last decades, but are still double the rate among Jews.30 General measures of morbidity, for example self-rated health (SRH), are poorer and the rate of disabilities higher among Arabs than among Jews.31 It is important to note, however, that a comparison between Arab and Jewish residents found no dierences in health status between the two populations in localities with a low socio-economic standing, although they persisted in middle and higher status localities.32 Similarly, dierences in mortality were found between sub-groups of the Jewish population, e.g. higher mortality rates among those of North-African origin, but the dierence disappeared 27 Siegrist, Johannes & Marmot, Michael (2004) ‘Health Inequalities and the Psychosocial Environ- ment – Two Scientic Challenges’. Social Science and Medicine, Vol. 58, 1463–1473. 28 Davey-Smith, George, Dorling, Danny, Mitchell, Richard & Shaw, Mary (2002) ‘Health Inequalities in Britain: Continuing Increases Up to the End of the 20th Century’. Journal of Epidemiology and Community Health, Vol. 56, Issue 6, 434–435; Mackenbach, Johan P., Bos, Vivian, Andersen, Otto, Cardano, Mario, Costa, Giuseppe, Harding, Seeromanie, Reid Alison, Hemström, Örjan, Valkonen, Tapani & Kunst, Anton E., (2003) ‘Widening Socioeconomic Inequalities in Mortality in Six Western European Countries’. International Journal of Epidemiology, Vol. 32, Issue 5, 830–837. 29 Israel Central Bureau of Statistics 2011a. 30 Israel Central Bureau of Statistics 2011a. 31 Israel Ministry of Health (2010a) Tackling Health Inequality. Jerusalem: Ministry of Health. [He- brew] 32 Shemesh, Annarosa A., Nacamulli Levi, Diana, Horowitz, Pamela & Averbuch, Emma (2011) Health Gaps and Social Periphery. Jerusalem: Ministry of Health. [Hebrew]    completely when SES measures were taken into account.33 ese ndings suggest that health dierences between Jews and Arabs or by ethnic origin within the Jewish population are confounded by SES (see details above in the introduction). In line with the focus of this chapter on SES inequali- ties in health, evidence is provided of the SES inequalities in health within the Arab or the Jewish population, using data from national representative samples. Within the Jewish population, signicant SES inequalities presenting a clear social gradient from those at the lowest to those at higher levels were found in adult mortality rates,34 as well as in infant mortality as measured by the mother’s educational level or by the socioeconomic community score of the place of residence.35 Likewise, inequalities were observed in regard to morbidity, measured by SRH or limiting longstanding illness (LLI). For example, the odds for those with low vs. high education (age and gender adjusted) were more than four for fair/poor SRH, and about two for LLI in the Jewish population.36 Similar ndings were observed within the Arab population: the respective odds ratios were close to four for fair/poor SRH, and about 2.5 for LLI.37 ere is also evidence that health inequalities have widened in the past two decades. One example is a study comparing adult mortality rates in two cohorts (early 1980s and mid-1990s) within the Jewish population. Special attention was given to avoiding biases due to distributional changes across 33 Jae, Dena, H, Neumark, Yehuday, D, Eisenbach, Zvi & Manor, Orly (2008) ‘Educational Inequalities in Mortality Among Israeli Jews: Changes over Time in a Dynamic Population’. Health and Place, Vol. 14, 287–298. 34 Manor, Orly, Eisenbach, Zvi, Peritz, Eric & Friedlander, Yehiel (1999) ‘Mortality Dierentials Among Israeli Men’. American Journal of Public Health, Vol. 89, 1807–1813; Manor, Orly, Eisenbach, Zvi, Israeli, Avraham & Friedlander, Yehiel (2000) ‘Mortality Dierentials Among Israeli Women: e Israel Longitudinal Mortality Study’. Social Science and Medicine, Vol. 51, 1175–1188. 35 Israel Ministry of Health 2010a. 36 Soskolne, Varda & Manor, Orly (2010) ‘Health Inequalities in Israel: Explanatory Factors of Socio- economic Inequalities in Self-Rated Health and Limiting Longstanding Illness’. Health & Place, Vol. 16, 242–251. 37 Daoud, Nihaya, Soskolne, Varda & Manor, Orly (2009a) ‘Educational Inequalities in Self-Rated Health within the Arab Minority in Israel: Explanatory Factors’. European Journal of Public Health, Vol. 19, Issue 5, 477–483; Daoud, Nihaya, Soskolne, Varda & Manor, Orly (2009b) ‘Examining Cul- tural, Psychosocial, Community and Behavioral Factors in Relationship to Socioeconomic Inequali- ties in Limiting Longstanding Illness Among the Arab Minority in Israel’. Journal of Epidemiology and Community Health, Vol. 63, 351–358.      -  socioeconomic groupings, and transformations within social structures that occur over time (such as mass immigration from the former Soviet Union to Israel in the early 1990s). Using a composite household amenities variable as a measure of asset-based wealth to represent the social hierarchy unique to each cohort, and dividing the second cohort into stable residents and re- cent immigrants, widening inequalities were observed in overall mortality: odds ratios for overall mortality for those at the lower level compared with those at the highest level of wealth among stable residents grew from 1.34 to 1.44 among men and from 1.30 to 1.42 among women.38 In an additional analysis, the risk of mortality from cardiovascular disease among women with low vs. high levels of education increased from two to ve times over these two study periods.39 Other data show that disparities in infant mortal- ity between those born to mothers with lowest vs. highest educational level increased from a relative risk of 3.5 in 1993–1996 to 4.6 in 2000–2002.40 Explanatory models of SES inequalities in health Several approaches to revealing the underlying mechanisms and the ex- planatory factors of SES inequalities in health have been proposed over the years.41 e material factors approach suggests that individual income and material living conditions have a direct inuence on health. e health behaviours approach views dierences in life-style behaviours, such as in smoking, dietary habits, physical activity or alcohol consumption as major factors of dierences in health. e life-course approach argues that early- life SES eects, such as poverty and limited environmental resources aect the health in childhood and are carried into adulthood along with cumu- lative SES inequalities in health. e psychosocial environment approach suggests that material factors or health behaviours alone are insucient for explaining SES inequalities in health; individual psychosocial factors (for 38 Jae, Dena H. & Manor, Orly (2009) ‘Assessing Changes in Mortality Inequalities in Israel Using a Period-Specic Measure of Socioeconomic Position, 1983–92 and 1995–2004’. European Journal of Public Health, Vol. 19, Issue 2, 175–177. 39 Jae et al. 2008. 40 Israel Ministry of Health (2005) Health in Israel, 2005. Jerusalem: Ministry of Health. 41 Bartley, Mel (2004) Health Inequality. An Introduction to eories, Concepts and Methods. Cam- bridge: Polity.   € example, life events, lack of social support, working conditions) or com- munity factors such as neighbourhood characteristics, community socio- economic level, and social capital are mediating pathways that link SES to health-related behaviours and biological response.42 While there may be dis- agreement about the specic approach, there is consensus that social posi- tion is linked to health via complex multilevel (individual and macro-level) pathways of diverse factors.43 e explanatory power of the factors refers to their statistical power in mediating the association between SES and health, or in other words, in reducing the SES inequalities in health. Individual-level explanatory variables e factors and their power in explaining health inequalities may dier ac- cording to the health outcome selected. For example, material variables are the most signicant explanatory variables when mortality rates are used as an outcome measure.44 In contrast, psychosocial factors45 or physical work- ing conditions46 are signicant explanatory factors of SES inequalities in health when self-rated health (SRH) is used as the outcome measure. ese examples should not be taken as contradictory, but rather as an indication of the complexity of the underlying mechanisms of the SES inequalities in health. is understanding as well as the persistence of SES inequalities in overall health in recent decades47 provide evidence to the theory of funda- mental causes of the SES association with health,48 which states that a) SES is 42 Kawachi, Ichiro, Kennedy, Bruce P., Lochner, Kimberly & Protow-Stith, Deborah (1997) ‘Social Capital, Income Inequality, and Mortality’. American Journal of Public Health, Vol. 87, 1492–1498; Marmot, Michael & Wilkinson, Richard G. (2001) ‘Psychosocial and Material Pathways in the Relation Between Income and Health: A Response to Lynch et al’. British Medical Journal, Vol. 322, 1233–1236. 43 Singh-Manoux, A., Macleod, J. & Davey, S. (2003) ‘Psychosocial Factors and Public Health’. Journal of Epidemiology and Community Health, Vol. 57, No. 8, 553–556. 44 van Oort et al. 2005. 45 Molarius, Anu, Berglund, Kenneth, Eriksson, Charli, Lambe, Mats, Nordström, Eva, Eriksson, Hans G. & Feldman, Inna (2007) ‘Socioeconomic Conditions, Lifestyle Factors, and Self-Rated Health Among Men and Women in Sweden’. European Journal of Public Health, Vol. 17, Issue 2, 125–133. 46 Kaikkonen, Risto, Rahkonen, Ossi, Lallukka, Tea & Lahelma, Eero (2009) ‘Physical and Psychoso- cial Working Conditions as Explanations for Occupational Class Inequalities in Self-Rated Health’. European Journal of Public Health, Vol. 19, Issue 5, 458–463. 47 Phelan, Link & Teranifer 2010. 48 Link, Bruce G. & Phelan, Jo C. (1995) ‘Social Conditions as Fundamental Causes of Disease’. Journal of Health and Social Behavior, Special No., 80–94.      -  related to multiple disease outcomes via multiple psychosocial, behavioural and biological risk factors, and b) that the deployment of resources plays a critical role in the association between SES and health (thus supporting the combination of the above mentioned explanatory models). However, they also argue that c) SES maintains an association with disease over time even when intervening mechanisms change, because the risk factors are re- placed by new ones. For example, behavioural risk factors such as smoking replaced old ones such as poor sanitary conditions. is argument suggests that when new knowledge is produced or new technologies developed, those at a higher SES level adopt it in ways that benet their health, thus maintaining their health advantage over those at lower SES levels. In Israel, two studies have shown the contribution of individual mate- rial and psychosocial variables as explanatory factors of SES inequalities in health. Adjusting for various individual and community psychosocial vari- ables and health behaviours, the educational inequalities in SRH and in LLI were substantially reduced and became non-signicant in the Arab popula- tion.49 In the Jewish population these intervening variables fully explained the educational inequalities in LLI but only partially in SRH, suggesting that other variables mediate this association.50 Societal-level explanatory variables Additional approaches suggest that beyond the above mentioned individu- al-level characteristics, macro-level societal factors are signicant explana- tory variables of health inequalities. Richard G. Wilkinson claims that the more unequal a society’s rate of inequality, the worse its health, and that socioeconomic inequality aects psychosocial factors such as social rela- tions, low social status, family functioning, and stress, thereby impacting on health.51 For every 0.05 increase in the Gini coecient, mortality increased by 7.8 per cent, with an estimated 1.5 million excess deaths each year in 30 49 Daoud, Soskolne & Manor 2009a; Daoud, Soskolne & Manor 2009b. 50 Soskolne & Manor 2010. 51 Wilkinson, Richard G. (2005) e Impact of Inequality: How to Make Sick Societies Healthier. New York: e New Press.    OECD countries.52 e evidence in Israel does not, as yet, support this as- sociation; although Israel ranks third highest in the rate of social inequality (Gini coecient) among OECD countries, life expectancy is higher than the average for OECD countries.53 is could be the result of the presence of a retrenched, yet high quality public health-care system in Israel. Another societal measure is welfare state regime. Based on evidence that morbidity and mortality rates in Scandinavian countries (welfare state regime types that oer universalism, comparatively generous replacement rates, and extensive welfare services) were lower than in other welfare state regimes, the expectation was that health inequalities would also be the smallest; yet, the ndings showed otherwise.54 Bismarckian and Southern regimes fairly consistently exhibited smaller educational inequalities in health than Scandinavian regimes across most age groups. In Israel, the evidence of widening gaps in health could partially reect the changes in welfare policy in Israel since the late 1990s. Although Israel enjoys high-quality medicine, the health-care system suers from major funding and organizational problems. While all Israelis are required to reg- ister with one of the HMOs to be entitled to a basic government-funded health-care package, the National Health Insurance Law permitted HMOs to create supplementary medical insurance that Israelis could purchase, al- lowing them greater access to aordable private care. Some 80 per cent of Israelis now hold supplementary medical insurance (of which only 55 per cent is via the HMOs and the rest is commercial) that covers a portion of private care. Furthermore, the government pays for 59 per cent of Israeli health-care expenditures, the lowest share among developed countries that provide universal health care, and a sharp decrease from close to 70 per cent in the mid-1990s.55 National expenditure on health as a percentage of the 52 Pickett, Kate E. & Wilkinson, Richard G. (2009) ‘Greater Equality and Better Health’. British Medical Journal, Vol. 339, 1154–1155. 53 OECD 2011a. 54 Bambra, Clare, Netuveli, Gopalakrishnan & Eikemo, Terje A. (2010) ‘Welfare State Regime Life Courses: e Development of Western European Welfare State Regimes and Age-Related Patterns of Educational Inequalities in Self-Reported Health’. International Journal of Health Services, Vol. 40, Issue 3, 399–420. 55 Chernichovsky 2011.      -  gross national product (GDP) in 2009 was 7.6 per cent in Israel compared with 10 per cent in Sweden, 9.8 per cent in the UK, and 8.7 per cent in Aus- tralia.56 is situation has created a shi towards private medicine, which fewer people can aord, while the public hospitals (almost all the hospitals in Is- rael) and community health-care services suer from shrinking budgets. Indeed, inequality in access to health services has been increasing. People at lower income levels report greater diculties in obtaining access to medical care than those at a higher income level.57 ese ndings at the individual level were further supported by evidence at the community level. e avail- ability of specialty care physicians is 5–10 times lower, and the hospital beds ratio per 1000 residents is about two times lower in localities of low SES status or in the periphery.58 ese conditions led to a ve-month doctors’ strike in Israel in 2011, the demands being not only an increase in wages and a decrease in working hours, but also a substantial shi in budget allocations in order to rescue the public medical system. During the strike, a prominent Israeli journalist described the situation: “Suddenly, people are realising that without a strong public sector there is no strong economy. Health care is an instructive example... e Finance Ministry did not appreciate the rare Israeli achievement of the health-care system. Its ocials wanted America. So they re- duced expenses, lowered costs and encouraged privatization. ey subjected the health system to market forces. e treasury’s privatis- ers ignored the fact that the basic conditions that enable and justify a market economy do not exist in the health system. e result has been devastating.”59 56 Israel Central Bureau of Statistics (2011b) CBS Statistical Abstract of Israel 2011. National Expen- diture on Health, International Comparisons. Online. Available HTTP: (accessed March 2012) 57 Gross, Revital, Bramli-Greenberg, Shuly & Waitzberg, Ruth (2009) Public Opinion on the Level of Service and Performance of the Healthcare System in 2007 and in Comparison With Previous Years. Jerusalem: Myers-JDC-Brookdale Institute. 58 Israel Ministry of Health 2010a. 59 Shavit, A. (2011) ‘Health Care in the Privatized Lane’. Haaretz, 10 March 2011. Online. Avail- able HTTP: (accessed October 2011)    e central role of the state in widening SES inequalities in health is regarded as destroying the fundamental right to health. e Association for Civil Rights in Israel (ACRI) claims that consecutive Israeli governments have shirked their social and economic responsibilities, and the deteriora- tion in the scale and quality of services provided by the health system has actually resulted in two health systems that dier substantially in quality – one for the rich and the other for the poor.60 Well-being and health In the following sections a more detailed denition of well-being and evi- dence of SES inequalities in well-being is elaborated in order to arrive at a better informed use of well-being targets in the health inequalities agenda. e conceptualization of well-being is broad and without a single, ac- cepted denition. In health and epidemiological studies, well-being focuses on assets in functioning, including positive emotions and psychological re- sources, the absence of negative emotions, and satisfaction with life, full- ment and positive functioning.61 However, the other common measure, that of health-related quality of life (HRQOL), includes some of these compo- nents in its denition as ‘an individual’s or group’s perceived physical and mental health over time’, yet it generally focuses on decits in functioning, e.g. pain, negative aect.62 e ambiguity of the concept is thus oen based on the dierences be- tween measures that include physical health as one of the components of well-being, and those that view well-being as more a subjective psychologi- cal concept, separate from health. e Gallup Well-being Index is an average of six sub-indexes of life evaluation, physical health, emotional health, work environment, health behaviours and access to basic necessities.63 In contrast, 60 ACRI (Association for Civil Rights in Israel) (2011) e Right to Health. Association for Civil Rights in Israel. Online. Available HTPP: (accessed August 2011) 61 CDC (Centers for Disease Control) (2001) Well-being Concepts. Online. Available HTTP: (accessed March 2012) 62 CDC (Centers for Disease Control) (2000) Measuring Healthy Days: Population Assessment of Health-Related Quality of Life. CDC Monographs. Atlanta: Centers for Disease Control and Preven- tion. 63 Gallup-Healthways (2011) e Gallup – Healthways Index of Well-being. Online. Available HTTP: (accessed August 2011)      -  the most commonly used conceptualization of well-being focuses only on the psychological aspects and makes the distinction of dening it as global judgments of life satisfaction and of feelings, ranging from depression to joy.64 Subjective well-being should, therefore, dierentiate between two con- cepts that are oen confounded: emotional well-being, which refers to the emotional quality of an individual’s everyday experience, the frequency and intensity of experiences of joy, stress, sadness, anger, and aection; and life evaluation, which refers to the thoughts people have about their life when they think about it.65 Studies have conrmed the validity of this division between the aective and the cognitive dimension dimensions of subjective well-being, concluding that well-being is not an unidimensional construct.66 Findings from prospective studies demonstrate the inuence of subjec- tive well-being, especially in the form of positive aect, on health and lon- gevity in healthy populations, as well as in some samples of patients living with a chronic disease.67 Cross-sectional studies show that life satisfaction and positive and negative aectivity is signicantly related to perceived health.68 However, this association may be bi-directional: health status is strongly linked to life satisfaction.69 Less is known about the scope of SES inequalities in well-being, as well as whether well-being plays an important role as a potential explanatory variable of SES inequalities in physical health. 64 Diener 2000. 65 Kahneman, Daniel & Deaton, Angus (2010) ‘High Income Improves Evaluation of Life But Not Emotional Well-Being’. Proceedings of the National Academy of Sciences, Vol. 107, Issue 38, 16489–16493. 66 Kahneman, Daniel & Krueger, Alan, B. (2006) ‘Developments in the Measurement of Subjective Well-Being’. Journal of Economic Perspectives, Vol. 20, Issue 1, 3–24; Watson, Dorothy, Pichler, Flo- rian & Wallace, Clare (2010) Second European Quality of Life Survey: Subjective Well-Being in Europe. Luxembourg: Oce for Ocial Publications of the European Communities. 67 Diener & Chan 2011. 68 Cloninger, C. Robert & Zohar, Ada, D. (2011) ‘Personality and the Perception of Health and Happi- ness’. Journal of Aective Disorders, Vol. 128, 24–32. 69 OECD (2011b) How’s Life? Measuring Well-being. Chapter 12. Subjective Well-being. Online. Avail- able HTTP: (accessed July 2012)    SES inequalities in well-being Although few studies have examined SES inequalities in well-being, their ndings show a similar pattern to that of SES inequalities in health. Yet, the association of SES (measure by income) with well-being was found to vary by the nature of the well-being dimension: the slope was much steeper for life evaluation than for measures of feeling (positive aect and [no] nega- tive feelings), suggesting milder income inequalities for the emotional di- mensions of well-being than for the (cognitive) life evaluation.70 Similar, but more specic results among American respondents showed that people’s life evaluations rise steadily with income, but that the emotional dimensions of well-being are fully satiated at an annual income of about $75 000; above this level there was no improvement whatsoever in any of the three measures of emotional well-being. Moreover, the association diers within the emo- tional dimension: the strength of the association of income is greater with negative measures (‘not blue’ aect, and stress free) than for positive aect.71 Similarly, satiation points were found in educational inequalities in life satisfaction, happiness and emotional well-being in the European Quality of Life Survey. People with low levels of education had signicantly lower levels of subjective well-being than those who had completed secondary- level education. ere was, however, no additional benet to subjective well-being from education beyond secondary level when income and living standard are controlled.72 Data on mediating factors that may explain the SES inequalities in well- being are relatively limited. One study found dierent mediators of the as- sociation between income and the life evaluation and emotional dimensions of well-being. e strongest mediation between income and life evaluation was satisfaction with a material factor (standard of living), while social psychological prosperity was a more signicant mediator for feelings.73 A 70 Diener, Ed, Ng, Weiting, Harter, James & Arora, Raksha (2010) ‘Wealth and Happiness Across the World: Material Prosperity Predicts Life Evaluation, Whereas Psychosocial Prosperity Predicts Posi- tive Feeling’. Journal of Personality and Social Psychology, Vol. 99, 52–61. 71 Kahneman & Deaton 2010. 72 Watson, Pichler & Wallace 2010. 73 Diener, Ng, Harter & Arora 2010.      -  community-level study demonstrated that the negative association between societal income inequality and individual-level happiness was explained by perceived fairness and general trust.74 Additionally, while the income in- equalities in the positive measure of emotional well-being were fully ex- plained by the inclusion of explanatory variables, the association of income with negative feelings remained signicant.75 Others have also demonstrat- ed that in addition to income level, explanatory factors of positive aect dif- fer from those of negative aect and are usually weaker or non-signicant,76 echoing Leo Tolstoy’s famous quote: ‘Happy families are all alike; every un- happy family is unhappy in its own way.’77 Although this chapter adopts the convergence of health and well-being, one may still question whether subjective well-being is an explanatory fac- tor of SES inequalities in physical health. e evidence is sparse. One direc- tion rests on the indication that positive aect may have distinctive biologi- cal correlates that can benet health, and that positive aect is associated with protective psychosocial factors, thus suggesting that positive aect may be part of a broader prole of psychosocial resilience that reduces the risk of adverse physical health outcomes.78 In fact, positive and negative states pro- duce independent eects on health when controlling for the other.79 Other evidence from a meta-analysis showed that negative measures slightly more strongly predicted short-term health outcomes, whereas positive well-being slightly more strongly predicted long-term health outcomes.80 ese nd- ings may indicate the potential role of well-being in explaining physical health inequalities. 74 Oishi, Shigehiro, Kesebir, Selin & Diener, Ed (2011) ‘Income Inequality and Happiness’. Psychological Science, Vol. 22, Issue 9, 1095–1100. 75 Diener, Ng, Harter & Arora 2010. 76 Katz, Ruth (2009) ‘Intergenerational Family Relations and Subjective Well-Being in Old Age: A Cross-National Study’. European Journal of Ageing, Vol. 6, Issue 2, 79–90. 77 Tolstoy, Leo (2000 [1873]) Anna Karenina. London: Allen Lane/Penguin. 78 Steptoe, Andrew, Dockray, Samantha & Wardle, Jane (2009) ‘Positive Aect and Psychobiological Processes Relevant to Health’. Journal of Personality, Vol. 77, Issue 6, 1747–1776. 79 Steptoe, Dockray & Wardle 2009. 80 Howell, Ryan T., Kern, Margaret L. & Lyubomirsky, Sonja (2007) ‘Health Benets: Meta-Analytically Determining the Impact of Well-Being on Objective Health Outcomes’. Health Psychology Review, Vol. 1, Issue 1, 83–136.    SES inequalities in well-being in Israel In the OECD survey of well-being, Israelis rate life satisfaction at 7.4 (on a scale from 0 to 10), which is higher than the OECD average of 6.7, thus ranking Israel eighth out of 36 countries.81 is result is surprising as it stood in contrast to the grading of Israel’s positive aect balance which was much lower than the OECD average. While in most OECD countries, people re- ported experiencing more positive than negative aect, reaching an average of eighty per cent for all OECD countries but only 69 per cent in Israel.82 e contradiction between the levels of the two dimensions of well-being in Israel can be explained by the fact that they are inuenced in dierent ways by social indicators. Whereas positive aect is only weakly associated with income, life satisfaction is strongly inuenced by income: the bottom 20 per cent of the Israeli population has a level of 6.6 in life satisfaction, while this score reaches 8.0 for the top 20 per cent.83 Additional data supports these ndings showing that income is signicantly associated with the cognitive dimensions of well-being (quality of life and life satisfaction), but not with the aective dimension (depression).84 ese inequalities in life satisfaction provide additional evidence for the consequences of the societal changes and the situation of the health-care system in Israel as described above. ey shed additional light on the cir- cumstances of the growing social inequalities, the increasing proportion of economically deprived people, and the feeling among many working people that their earnings do not enable them to aord basic necessities. In fact, these factors were fertile ground and a major catalyst for the outbreak of the nation-wide social protests in Israel that continued throughout the summer months of 2011. e protests were initiated by mainly middle-class people against the signicant rise in the cost of living, unaordable public housing, rising food, fuel and basic amenity prices, as well as increasing privatization of the public education system and health services. ousands of people 81 OECD 2011b. 82 OECD 2011b. 83 OECD 2011b. 84 Amit, Karin & Litwin, Howard (2010) ‘e Subjective Well-Being of Immigrants Aged 50 and Older in Israel’. Social Indicators Research, Vol. 98, 89–104.      -  camped in the country’s squares, and hundreds of thousands from all social strata took to the streets clamouring ‘the people demand social justice’. Aer weeks of demonstrations, Prime Minister Benjamin Netanyahu appointed a committee to pinpoint the grievances and propose solutions to Israel’s socioeconomic problems (Trajtenberg Committee). e Committee’s rec- ommendations were submitted to the government within two months and were perceived to be benecial for the ‘hard-working middle classes’, but faced strong political opposition inside the government; instead of adopt- ing all the recommendations, an approach of gradual implementation was eventually adopted and only one recommendation has been implemented. By winter the movement seemed to be dead, but protests resumed in June 2012 because nothing happened, and prices increased.85 us one may ex- pect even lower levels of positive aect than those detailed above. Two recent studies highlight the role of well-being as an explanatory fac- tor of SES inequalities in health in Israel. One study demonstrated that when vigour, a dimension of emotional well-being (positive aect) was included in the nal regression analysis, educational inequalities in overall mortality became non-signicant.86 Similarly, another study showed that the associa- tion between education and SRH among middle-aged people becomes non- signicant when life satisfaction and negative feeling (depression) measures are included in the nal step of the hierarchical regression analysis.87 ese are important contributions to advancing scientic knowledge on the role of well-being in explaining SES inequalities in health. 85 For more details see Alimi, Eitan Y. (2012) ‘“Occupy Israel:” A Tale of Startling Success and Hopeful Failure’. Social Movement Studies: Journal of Social, Cultural and Political Protest, Vol. 3–4, No. 11, 1–6. 86 Shirom, Arie, Toker, Sharon, Jacobson, Orit & Balicer, Ran D. (2010) ‘Feeling Vigorous and the Risks of All-Cause Mortality, Ischemic Heart Disease, and Diabetes: A 20-year Follow-Up of Healthy Employees’. Psychosomatic Medicine, Vol. 72, 727–733. 87 Iecovitch, Esther & Cwikel, Julie (2010) ‘e Relationship between Well-Being and Self-Rated Health among Middle-Aged and Older Women in Israel’. Clinical Gerontologist, Vol. 33, Issue 4, 255–269.   € Conclusions and implications e evidence of SES inequalities in physical health outcomes is highly con- sistent and convincing. It is generally understood that a complex, multi- level array of material, psychosocial, behavioural, societal and policy fac- tors, as well as biological mechanisms, intervene in mediate the association between SES and health. Yet, further research is necessary to elucidate these explanatory pathways, in particular, the way biological mechanisms interact with psychosocial and behavioural factors. is review also shows that the increasing interest in well-being has pro- duced important information, clarifying the concept and validating its two dimensions. Furthermore, the evidence of SES inequalities in well-being, although in need of further research, has produced clear indication that SES inequalities in life evaluations dier from those in the emotional dimen- sion of well-being. In particular, the preliminary evidence regarding SES inequalities in positive vs. negative measures of emotional well-being di- mension call for further research directed at disentangling those that ex- plain inequalities in negative as against positive measures. Such an approach may lead to understanding of mediating protective factors that contribute to positive emotions rather than mainly risk factors for negative emotions and may redirect future interventions aimed at reducing inequalities in well-being to focus on these positive factors. Additionally, regarding the role of well-being as an explanatory variable of SES inequalities in health, this review shows that the evidence is still limited. Prospective studies of life course approaches are necessary in order to assess whether well-being di- mensions are determinants, and if so in what way, of the SES inequalities in physical health and mortality. Yet, the preliminary data is sucient to show the relevance of well-being for the health inequalities agenda as it elucidates dierent approaches to interventions aimed at reducing SES inequalities in health. e Israeli case study highlights not only the widening SES inequali- ties in health, similar to those in several other countries, but also the com- plexity of the multilevel explanatory factors of SES inequalities in health. Supporting the social determinants of health approach, research ndings      -  indicate that individual-level psychosocial factors are explanatory factors of SES inequalities in health. In addition, the Israeli case demonstrates the role of societal-level factors for health inequalities. Welfare policy changes and growing social inequality in recent decades have exerted their inuence on SES inequalities in health, beyond the eects of individual-level dierences. At the same time, evidence on life satisfaction and emotional dimensions of well-being is sparse and somewhat contradictory, and no long-term in- formation on changes over time or assessments of the underlying macro- and micro-level explanatory mechanisms of SES inequalities in well-being. Greater eort is required in order to better understand what well-being means for Israelis and, as in other societies, its potential role as an explana- tory factor of SES inequalities in physical health. Additionally, the Israeli data showed that the explanatory power of psychosocial and behavioural factors of the SES inequalities in health within the Jewish or the Arab popu- lations diers. No data on ethnic dierences in well-being, or dierences in SES inequalities in well-being and changes over time with the retrenching welfare state are available. is evidence is essential for Israel and implies that research on SES inequalities in health and well-being within dierent cultural, ethnic or racial sub-populations, as well as comparative studies of dierent welfare regimes is a priority in order to provide a basis for evi- dence-based interventions for many societies. Implications for practice and policy e complexity of the mechanisms explaining SES inequalities in health and well-being, and the evidence that the underlying explanatory factors are oen replaced by new ones, may lead professionals and policy makers to abandon all hope that health inequalities can be reduced. is, of course, is not the case. Eorts can be made to address the underlying causes, the risk factors, so that the core causes of fundamental factors are tackled.88 is re- quires concerted eorts at all levels: local, regional, and governmental. Data on SES inequalities in well-being as well as the potential role of well-being in 88 Phelan, Link & Teranifer 2010.    explaining health inequalities may subsequently adopt a dierent approach to interventions by addressing mediating protective factors, rather than only risk factors. For example, interventions aimed at enhancing life satisfaction and positive aect among socio-economically deprived sub-populations may lead to reduction of inequalities in physical health. It should also be clear that changes are not the sole responsibility of health-care professionals and health policy makers, but rather of many sec- tors of society. It is evident that reducing economic, educational or occupa- tional inequalities will ultimately aect inequalities in health. Nevertheless, several implications for practice within the health-care system arise from this review. Above all, in all settings, health-care workers should be aware of the magnitude of SES inequalities in health and the factors explaining them, so that they routinely inquire about them and make decisions about appropriate care. Health promotion programmes, whether for primary or secondary prevention, should be creative in not only tackling the underly- ing factors of health inequalities, but also include interventions to enhance subjective well-being. Whatever interventions are planned, they will not be successful without political will. e reduction of these inequalities demands coherent policy responses across sectors and across countries, and a rm political commit- ment by all parties. is idea requires ‘governance for health’, namely, the pursuit of health as integral to well-being through both a ‘whole of govern- ment’ and a ‘whole of society’ approach.89 Clearly dened goals of reducing SES inequalities in health and well-being need to be dened and routinely monitored. is means that specic measures of subjective well-being, if not already in use, should be incorporated into on-going surveys. Additionally, evaluation research of interventions and of policy changes is imperative. e eorts aimed at reducing health inequalities are still in their infancy in Israel. Only recently, in 2010, the Ministry of Health responded to the accumulation of research ndings regarding the scope of health inequalities in Israel, and to reports and recommendations issued by the Israel Medical 89 WHO (World Health Organization) (2011) Governance for Health in the 21st Century: A Study Conducted for the WHO Regional Oce for Europe. Copenhagen: WHO Regional Oce for Europe.      -  Association,90 and decided to include the reduction of health inequalities as one of the Ministry’s major multi-year goals.91 It was the culmination of pressures from prominent Israeli public health professionals, as well as the impact of the WHO CSDH report. Although this does reect political will, the initial activities of a special unit in the Ministry have been limited, mainly directed at reducing co-payments by economically deprived popu- lations.92 e consistent social gradient in health suggests that although it is tempting to focus limited resources on those most in need, everyone should be targeted. e social protests in Israel have highlighted the plight of the middle class in many life domains, including health. us, if the focus is on the worst-o, what would happen to those just above the bottom, or at the median, who have worse health than those above them? In consequence, a far greater eort to reduce inequalities is required, not a separate health agenda, but action across the whole of society. is is likely to work only if a more integrated approach is adopted, one that links closely to wider social inequalities in the society in order to avert the con- tinued consequences of the neoliberal policy in health care. Despite other enormous problems being faced by Israeli society, above all political and security issues, the health of the nation needs to be more equally distributed. At a national policy level, this requires recognition by the government that reducing health inequalities is a national priority, to be achieved by coordi- nated actions of health, education, labour, housing and welfare ministries. Better understanding of the explanatory factors of inequalities in health and in well-being is needed as a basis for designing evidence-informed pro- grammes at national and local levels either by universalist welfare policies or by particularist ones, such as progressive payment programmes. In Israel’s ethnically and culturally highly diverse society, the explanatory factors of SES inequalities in health may be dierent across population groups and over the lifecycle. Policies aimed at reducing the SES inequalities in health 90 Israel Medical Association (2008) Inequality in Health in Israel. Ramat-Gan: Israel Medical Associa- tion. 91 Israel Ministry of Health (2010b) Health Policy Main Goals 2011–2014. Online. Available HTTP: (accessed March 2012) [Hebrew] 92 Israel Ministry of Health 2010a.    may therefore easily be ineective in some populations. erefore, involve- ment of stakeholders and sub-populations in each locality will assure that ‘bottom-up’ together with ‘top-down’ planning of programmes may nd ef- fective ways to help distributing health more equally. is is particularly rel- evant now. e Israeli social protest of 2011 has not (yet?) resulted in policy changes but has propelled an important shi in public and media discourse, forcing the government to take the public voice into consideration more seriously than before. References ACRI (Association for Civil Rights in Israel) (2011) e Right to Health. Association for Civil Rights in Israel. Online. 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In the eld of social research about mental illness and mental disability, happiness – or rather the absence of happiness – is a well-known theme. In view of this fact, it may appear sur- prising that mental health issues have until recently only rarely been seen on the international political agenda. In 2007, a document published by the World Health Organization (WHO) stated that: Mental health may be the most neglected public health issue. In much of Europe it remains a taboo to discuss the challenges that mental health raises for governments, societies, and particularly for people with mental health problems themselves.1 Mental health is seldom in the focus of political discourses on health. Yet, happiness cannot be measured without an idea about unhappiness at the other end of the scale, as its hidden opposite. Knowledge about happi- ness and health is always a concern for the political administration. Health and happiness is a tempting goal that concerns both the individual and the whole of society; a goal which can be traced through modern public health history. e recently formulated concept of happiness is in some respects 1 Klein, Judith (2007) ‘Foreword’. In Knapp, Martin, Mc Daid, David, Mossialos, Elias & ornicro, Graham (eds) Mental Health Policy and Practice across Europe: e Future Direction of Mental Health Care. Maidenhead: Open University Press, xxii.   € very similar to earlier articulations of positive mental health.2 It is the same mix of psychology, politics and social science, characteristic for the welfare society guided by the ideals of reason. In the post-war period from 1945 un- til the early 1970s, the Human Relations School and the concept of ‘mental hygiene’ carried the message of happiness, relying on ‘mental health’ and especially ‘positive mental health’ as the main concepts.3 Public health policies regarding mental health can be split into two as- pects: rst, to prevent mental illness in the population; and second, to man- age the care of the severely mentally ill. e concept that combines those two aspects is ‘normality’. Prevention is about keeping the population in good health in order to promote ‘normal’ mental health. e care of the mentally ill is about taking care of people who are considered as deviant in that respect. Normality, however, is a dicult concept to grasp; it is seldom explic- itly described, yet it is oen implicitly assumed as the opposite to deviant behaviour.4 Furthermore, it is almost impossible to distinguish denitions of mental health from denitions of normality. When normality is dened, the three following meanings are expressed: the statistical meaning, e.g. the most common, ‘like everybody else’, the ideal meaning or moral notions about how it should be, and the medical meaning, which implies no health problems, e.g. no deviations from an expected state of health.5 e general understanding of normality usually consists of a mix of the three aspects. Of course, the common understanding of normality trans- 2 For a recent conceptualization of happiness, see Pacek, Alexander & Radcli, Benjamin (2008) ‘As- sessing the Welfare State: e Politics of Happiness‘. Perspectives on Politics, Vol. 6, Issue 2, 267–277; for positive mental health, see Jahoda, Marie (1958) Current Concepts of Mental Health. New York: Basic Books. 3 Mayo, Elton (1943) e Social Problems of an Industrial Civilization. Boston: Harward Business School; Mindus, Erland (1969) Arbete och mental hälsa. Stockholm: Folksam/Tiden; omson, Mathew (1995) ‘Mental Hygiene as an International Movement’. In Weindling, Peter (ed.) Interna- tional Health Organizations and Movements. Cambridge: Cambridge University Press. 4 Hacking, Ian (1991) e Taming of Chance. Cambridge: Cambridge University Press; Tengland, Per-Anders (2001) Mental Health. A Philosophical Analysis. Dordrecht: Kluwer Academic Publish- ers; Piuva, Katarina (2005) Normalitetens gränser. En studie av den mentalhygieniska rörelsen under 1900-talet. Stockholm: Stockholm University. 5 Jahoda’s division of the normality concept is twofold as she distinguishes between the statistical and the normative ideal. Tideman, Magnus (2000) Normalisering och kategorisering: Om handikappide- ologi och välfärdspolitik i teori och praktik för personer med utvecklingsstörning. Lund: Studentlittera- tur; Piuva 2005, 56–60; Jahoda 1958, 18–21.        ‘’      forms over time, as demands of health and quality of life expectations change. What is considered normal is the result of cultural and political negotia- tions. Over time, various values, such as autonomy and integrity, have been added to the understanding of normality. ese values are also connected to the ethics of welfare. Furthermore, these values work in two directions; as a top-down demand on self-reliant citizens, citizens’ and as bottom-up expectations of individual freedom and a minimum of governance by state authorities. e mentally ill, especially those with severe mental illness, of- ten end up with long-term inability to work and to maintain economical self-support. is also entails a lifelong dependency on medical and social services, thereby jeopardizing the contract of autonomy between the welfare state and the individual. e aim of this chapter is to discuss the problems surrounding the con- cept of happiness in relation to mental illness. It explores how dierent un- derstandings of normality aect expectations of happiness. First, the chap- ter turns to the two main ocial investigations about mental health care in Sweden during the second half of the twentieth century. e exploration is undertaken with a focus on how mental illness is connected to the health and happiness of the whole population. Second, mental health policy is dis- cussed in terms of practical social work. How are happiness and normal life conditions rendered by the social service administration and how do social interventions aect the autonomy and integrity of the severely mentally ill and their families? Finally, the chapter reects on the social integration of the severely mentally ill. e politics of mental illness, normality and happiness Institutionalization and deinstitutionalization of the mentally ill Mental care as we understand it in the history of welfare in Western Europe can be briey summarized as consisting of two periods. e rst period of institutionalization refers to the expansion of in-hospital care from the early nineteenth century to the mid-twentieth. e second period covers the clos- ing of the mental hospitals starting from the end of the Second World War    and the policy of integrating people with severe mental illness. e period of institutionalization resulted in a professionalization of care in more orga- nized settings.6 e former care of the mentally ill undertaken by the local communities was oen inferior to the standards of health care, a condition that repeatedly caused severe criticism from ocial inspections and inves- tigations.7 Historical sources describe the community-based care that the mentally ill had to endure in Scandinavia during the nineteenth and early twentieth century as being terrible.8 Patients were described as work house or poor house inmates.9 e period of deinstitutionalization aer the Sec- ond World War is closely connected to the development of the welfare states in Europe. e development of medical care and the political concerns about public health contributed to the integration of the severely mentally ill in national social security plans. However, this was merely an organizational and administrative integration, despite the 1950s and 1960s being an era of institutional growth. Most European countries, with the notable exception of the UK and Ireland, increased the number of hospital beds in mental care during these two decades. During the 1970s, the deinstitutionalization process aimed for the social integration of the mentally ill. is period of on-going integration is charac- terized by the expansion of community-care systems. State mental hospitals were replaced by smaller nursing homes and housing facilities in commu- nity settings. Ocial statistics reect a decline of beds in state psychiatric hospitals from the end of the 1970s. In Sweden, for example, the number of state hospital beds in psychiatric care declined from 75 per cent of all psy- 6 Qvarsell, Roger (1982) Ordning och behandling. Psykiatri och sinnessjukvård i Sverige under 1800-ta- lets första häl. Umeå: University of Umeå. 7 Piuva, Katarina (2010) ‘e Meaning of Normality. e Controversy About the Mental Health Campaign in Sweden 1969’. Scandinavian Journal of History, Vol. 35, Issue 2, 198–216. 8 Community-based services concerning the severely mentally ill in the cities meant poor houses and mad houses. In rural areas the poor, including the handicapped and severely mentally ill without economical resources, were adapted to the system of rotehjon, a kind of ambulating care between estates and farms. According to ocial investigations, the mentally ill considered as being dangerous or otherwise unruly were locked up in wooden cages or chained in stalls. 9 Berge, Anders (2007) Sjukvårdens underklass: Sjukvården i den kommunala fattigvården 1910–1950. Umeå: Borea; Shorter, Edward (2007) ‘e Historical Development of Mental Health Services in Europe’. In Knapp, Martin, McDaid, David, Mossialos, Elias & ornicro, Graham (eds) Mental Health Services and Practices Across Europe. Future Directions of Mental Health Care. Maidenhead: Open University Press.        ‘’      chiatric beds to 0 per cent between the years 1972 and 2001.10 However, statistics of this kind do not present an entirely clear picture of the actual development of mental health care during this time. Taking Sweden as an example, the decline in the number of hospital beds repre- sents the closing down of old-fashioned state hospitals. In-hospital care was still conducted by municipalities, community-based nursing homes and by an increasing number of private entrepreneurs to this day. erefore, it is worth noting that the widespread periodization of mental health care as two ‘eras’, as presented above, is rather rough and simplied. In addition, re- search about the social integration of the mentally ill shows a recent trend of ‘reinstitutionalization’.11 Nevertheless, institutionalization and deinstitu- tionalization were the two common public policies in the West European countries, even if the reality always turned out to be more complex. De- spite the general tendency of successive political decisions, connement, community-oriented care and family-oriented care have always co-existed as parallel systems. e ocial investigations on the development of the mental-health pol- icy in Sweden reveal the same patterns of deinstitutionalization, followed by a policy of integration, as in all the European welfare states, although the ex- pansion of state managed in-hospital care in Sweden was late in comparison to Europe. is period of expansion during the rst decades of the twentieth century was rapid, just as the deinstitutionalization during the last 20 years of the same century has been swi.12 10 Shorter 2007, 24–25. 11 Priebe, Stefan, Badesconyi, Alli, Fioritti, Angelo, Hansson, Lars, Kilian, Reinhold, Torres-Gonzales, Fransisco, Turner, Trevor & Wiersma, Durk (2005) ‘Reinstitutionalization in Mental Health Care: Comparison of Data on Service Provision from Six European Countries’. British Medical Journal, Vol. 330, 123–126. 12 Piuva 2010, 200.   € In between two regimes of mental health care: e ‘caring state’ versus the ‘autonomous citizen’ e two most important ocial investigations about mental health care in Sweden were written in 1958 and in 1992, respectively.13 As historical docu- ments, they are of great interest as time-bound indicators of how mental ill- ness, mental health and normality have been related to the happiness of the population during the two periods of welfare state policies. e titles of the investigations display two dierent purposes, adjusted to the welfare agen- das of the time. Irrespective of the time they were written, however, both these ocial texts about mental care and social services struggle to integrate the target group into the welfare society. When reading SOU 1958:38, it becomes clear that the intentions with regard to mental health care were to expand, modernize, and reorganize the treatment of the mentally ill in an ‘up-to-date fashion’. e concept of mental hygiene, representing the latest trends of preventive care and the development of out-hospital care in Western Europe and the US, was ad- justed to in-hospital care in the Swedish context. e investigation made a considerable eort in describing how the physical surroundings should be shaped in order to look as normal as possible. According to the plans for the new mental hospitals, there would be libraries, hair-dressers, and shops in addition to the traditional wards. Attention was also paid to the out-door surroundings. e plans also outlined large recreation grounds as well as ar- eas for sport and other activities. As the severely mentally ill were excluded from normal social conditions during the period of welfare reforms that characterized Swedish social policy during the post-war period until the middle of the 1970s, the ambition was to ‘normalize’ the inner milieu at the institutions. It might be said that patients were included into the welfare program by this modernization of care but still physically excluded from the ‘normal’ society. is rapid expansion of in-hospital care, which continued until the early 1960s, belonged to the welfare reform programme of Sweden. e di- 13 SOU 1958:38. Mentalsjukvården – Planering och organisation. Stockholm: Fritzes; SOU 1992:73. Välfärd och valfrihet. Stockholm: Fritzes.        ‘’     € mension of inclusion in the excluded sphere implied that the mentally ill also had their share of material welfare. Although the expansion of mental health care during the 1950s and 1960s belonged to the Swedish welfare programme, little is known about whether the expansion improved the life conditions for the mentally ill. It is certain, however, that the expansion led to a large increase in the number of psy-professionals being trained, who later became involved in the modernization of mental health care. e political decisions in the Western societies about deinstitutionaliza- tion have been made for a range of reasons, mostly related to the well-being of service recipients and concerns about the quality of care. A number of factors coincided and became an advantage for the shi: 1. e use of new drugs which enabled independent living for a large number of the mentally ill. 2. A transformation of costs from the governmental state level to the local political level. 3. Claims from user organizations together with an increasing public criticism about the quality of care at the large mental hospitals. Economic and humanitarian motives coincided in the claims for a de- institutionalization of mental health care. is political consensus on both the le and the right facilitated the process of deinstitutionalization.14 Aer the deinstitutionalization at the close of the twentieth century, a new situ- ation emerged. In the 1990s, the welfare politics in Sweden began to waver between two welfare regimes. e state’s responsibility for the welfare of the population as a collective was reduced in favour of a more liberal agenda founded on the individual’s position in society. e titling of SOU 1992:73 – Välfärd och valfrihet [Welfare and Freedom of Choice] – signals the com- mittee’s attempt to mediate between the ethos of the traditional welfare state and the ethos of freedom of choice, as two key concepts of modern welfare policy. e psychiatric care and the social services to the severely mentally ill became, through the Psychiatric Health Care Reform in 1995, integrated 14 Krieg, Randall (2001) ‘An Interdisciplinary Look at the Deinstitutionalization of the Mentally Ill’. e Social Science Journal, Vol. 38, Issue 3, 367–380.   € within the concept of a new public health policy, individual freedom of choice and risk minimization.15 e ambition was to increase the patients’ inuence and to promote out-hospital care. e coordination of care and service became the responsibility of the social service administration as a step in the direction of realizing these ambitions. e Psychiatric Health Care Reform sought to enrol the mentally ill into the new regime of the or- ganization of the welfare state: the regime of the ‘autonomous citizen’. e normalization of living conditions and the goal of a ‘better life’ were formulated in similar ways both in 1958 and in 1992. A dierence, however, can be found in how normality was interpreted in the texts. Normal living conditions for the severely mentally ill in the 1950s implied an institution- alized high standard of mental care at the same level as somatic care. In 1992, normal living conditions for the severely mentally ill instead implied personal autonomy and integrity, in short, in a normal life outside the walls of the institutions. In the former investigation, happiness was connected to normal conditions for any patient in medical care. e latter investigation emphasized happiness in terms of equal living conditions to any person in society at large. A normal life is equal to have the same life conditions as everybody else.16 is shi of meaning is essential, as it marks the political ambition to include the mentally ill in the disability discourse, a policy that is emphasizing the individual rights to be included into the society. In between normality and deviance Who is normal, then, and who is not? e following part of this chapter is an eort to describe how the investigations handled denitions of men- tal illness, mental health and normality. ese denitions were central for the implementations of the reforms and for the living conditions and hence the happiness and the well-being of the severely mentally ill. Estimating the 15 e proposals of SOU 1992:73 were transformed to a suggestion of implementation in the Govern- mental Proposition 1993/94:128. Psykiskt stördas villkor; see also Petersen, Alan & Lupton, Deborah (1996) e New Public Health. Self and Health in the Age of Risk. London: Sage; Rose, Nicholas (1999) Powers of Freedom: Reframing Political ought. Cambridge: Cambridge University Press. 16 Brusén, Peter & Hydén, Lars-Christer (2000) Ett liv som andra: Livsvillkor för personer med funktion- shinder. Lund: Studentlitteratur.        ‘’     € number of severely mentally ill people in the population has been a govern- mental activity in Sweden since 1901.17 In the early years, an investigation came to the result that there were 17 300 individuals needing in-hospital mental care, i.e. 0.34 per cent of the Swedish population. e calculations continued during the twentieth century, chiey with the aim of calculating the need of beds, doctors and sta in the mental hospitals. e investigation of 1958 calculated the need of hospital beds to 0.05 per cent of the population.18 In only a few years, the number of patients had risen to 0.45 per cent of the population.19 In fact, the ocial investigation in the 1950s had proposed deinstitutionalization as a solution. Yet, this pro- posal to minimize the in-hospital care was not realized; instead Sweden held the top-position in Europe, regarding the number of patients in mental care, for at least ten years. e number of beds within mental hospitals peaked in 1962 when Sweden had the highest number of patients in mental hospitals in Europe.20 Both the investigation of 1958 and the investigation of 1992 struggled to dene the target group in a way that would make mental illness and normali- ty concordant with the suggested changes. Both investigations presented cal- culations about the prevalence of mental illness in the whole population. In addition, the investigation of 1958 made estimations of hospital beds, while the investigation of 1992 calculated how many of the mentally ill persons suf- fered from long-term illness equal to a disability (handicap). In 1958 the cal- culations were made in order to motivate the expansion of preventive mental health and the education of sta in out-hospital care, while the calculations in 1992 aimed to estimate how many individuals that would have legal rights to special social services. In both cases, severe mental illness (schizophrenia) is presented in relation to milder ill-health. Due to the lack of exact data, the calculations were based on earlier investigations, research articles, and statistics compiled from case records and the use of hospital beds. 17 Medicinalstyrelsen [Swedish Royal Medical Board] (1903) Medicinalstyrelsens underdåniga berättelse angående sinnessjukvården i riket för år 1901. Stockholm: P.A. Norstedt & Söner. 18 SOU 1958:38. 19 Sjöström, Bengt (1992) Kliniken tar över dårskapen. Göteborg: Daidalos. ‚ƒ „„ …†‚ patients in hospital care, e.g. ‡ˆ…,„ per ‰ƒƒ ƒƒƒ inhabitants. Sjöström ‰ŠŠ‚, ‰‡.   € e calculations of the prevalence of schizophrenia are quite similar at the dierent points in time. In the calculation of hospital beds, the investiga- tion from 1958 did not propose an increase; on the contrary, only 0.05 per cent of the population was expected to need in-hospital care. e proposal concerning in-hospital care in 1958 was about replacing the old mental hos- pitals with more modern clinical care in close connection to somatic health care, a proposal that contributed to a normalization of mental health care. In reality, however, the old mental hospital remained for a rather long time alongside the new clinics and the newly-built psychiatric hospitals. e most striking dierence between the calculations in 1958 and 1992 is the assumption about the prevalence of milder forms of mental ill-health. e investigation from 1958 came to the conclusion that as much as 40 per cent of the total population suered from milder psychiatric illness. e corresponding estimation of milder mental ill-health went down to 13 per cent in 1992. e reason behind this is probably that the aspect of preven- tion was no longer an issue of high priority in 1992. In 1958 though, the mental hygiene doctrine permeated the scientic eld of psychiatry. e ocial investigation of 1958 argued that milder mental ill-health was very common and an expansion of out-door psychiatric care would decrease the need of in-hospital care. is argument is also the reason for the proposal of the investigation to increase the education of psychiatrists, psychologists, mental hospital nurses and psychiatric social workers. e task of the inves- tigation in 1992 was more limited; to dene and describe the needs of the severely mentally ill entitled to special services from the community. e investigation of 1958 presented the spectrum of mental illness as a continuum with milder ill-health at one end and severe mental illness (schizophrenia) at the other. In 1958 the concept of mental hygiene included the whole population and, as such, the resources of mental health care ex- panded with the aim of preventing an increase of severe mental illness. With reference to the WHO, the argument was that preventive mental health will ‘take the health of all citizens to the highest possible level’.21 In the conclud- 21 WHO (World Health Organization) (1951) Mental Health: Report on the Second Session of the Expert Committee. Geneva: World Health Organization.        ‘’     € ing chapter of the investigation – programmatically entitled e View of Mental Hygiene Must Permeate the Whole Society – a declaration is made: “…so must Mental Hygiene clean up the mental environment, e.g. reveal and revise prejudices and delusions that enable generation af- ter generation to continue to create unhappy and inhibited individu- als, which generates social disorder.”22 is statement is directed to the health of the whole population. As such, it is far from the principles about normality and autonomy of the investiga- tion of 1992. It also represents the ethics of the former ‘caring state’, a wel- fare policy against unhappiness in society at large distinct from the present politics of happiness where the right to autonomy and self-management is emphasized. Between illness and disability e issue in 1992 was, by contrast, to add severe mental illness to the disabil- ity concept, which meant that people with disabilities should have the right to normal living conditions concerning accommodation, economy and ac- cess to social activities. is would require special care and individual solu- 22 SOU 1958:38. Table 1. Calculations of prevalence and need of care within the adult population in Sweden (in per cent) Calculations 1958 Calculations 1992 Milder ill-health 30–40 13.0 Schizophrenia 0.72 0.5 In need of in-hospital care 1958 0.05 -- Long-term illness/Handicap 1992 -- 0.6 Source: SOU 1958:38; SOU 1992:73.   €€ tions according to dierent needs. erefore the investigation had to distin- guish between individuals in need of special care and individuals without the need of special care. It was not about the health of the whole population, but about nding a denition for the group within the group of severe men- tal illness who were entitled to special support from social services, a social status that can serve as a ticket to autonomy and integrity. Medical reasons are still present in the categorization, but the group-specic problems of so- cial autonomy are underlined. e following excerpts are examples from the investigation that illustrate how the authors struggled with the denitions of the new social status of the ex-patient: 1. Long-term illness that has caused impairment. 2. Residual symptoms from psychosis or schizophrenia. 3. Brain injury caused by psychosis. 4. Problems of daily life equal to a handicap. e idea of normalization in the 1990s was a two-step operation; rst, through identity within the disability concept, and second, through entitle- ment to the legislative right to normal living conditions. In conclusion, the policy of the Psychiatric Health Care Reform in 1995 which followed upon the investigation of 1992 was to match the living conditions of those with a severe mental illness with the living conditions of people with learning disabilities, in order to include the target group into the disability discourse. e idea of severe mental illness as a handicap or a disability can be con- sidered either as a language modernization, as an attempt to come around the rhetoric of ‘chronic illnesses’ or – at its best – as a change of citizenship status, from being a long-term patient, lacking any possibilities of social in- clusion, to a position of autonomy. In the investigation of 1992, the situation of the former patient status is painted in dark colours, as well as the life at institutions which is singularly described in negative terms. Underlining this critical impression, the report reprinted a picture of how a building that belonged to Säter Hospital was torn down with dynamite. e message is clear; away from institutions and forward to social inclusion. As the policy turned away from concerns surrounding the mental health        ‘’     € of the whole population, severe mental illness no longer remained the worst scenario on a continuum, but something quite distinct from ‘normality’. However, the problems of applying the generalized denitions of disability to individual people remained for practitioners to solve. Where should the line drawn; who suers from severe mental illness, and who ts into the def- inition that includes impairment? What happens if a person recovers from mental illness? Does that person still have the special social rights that a dis- abled person is entitled to? What about conditions that are uctuating over time? According to the evaluations of the Psychiatric Health Care reform of 1995 it seems dicult to grasp the meaning of psychiatric impairment and thus the meaning of disability. According to the evaluations of the reform, only 10 per cent of the estimated number of people (2600 out of estimated 20 000–40 000 individuals) have been assessed as being disabled in accor- dance with the intentions of the reform.23 e debate about the reform as a failure has continued over the years, although there is no consensus about the causes behind the problems.24 In conclusion, the benevolent aim of the investigation in 1992 has turned into an obstacle for the implementation of the reform as the social services to the severely mentally ill have become stuck between the concepts of illness and disability. A normal and happy life? Assessing the needs, happiness and well-being of the mentally ill For the severely mentally ill, happiness has become a question about needs and how those needs are met by social services and medical care. e politi- cal goal of a normalization of living conditions has called for some kind of agreement upon the understanding of the requirements for a normal life. 23 Socialstyrelsen [National Board of Health and Welfare] (1998) Reformens första tusen dagar. Årsrap- port för psykiatrireformen. Rapp.1998:4; Socialstyrelsen [National Board of Health and Welfare] (1999) Välfärd och valfrihet? Slutrapport från utvärderingen av 1995 års psykiatrireform. Socialsty- relsen följer upp och utvärderar 1999:1; Socialstyrelsen [National Board of Health and Welfare] & Länsstyrelserna [County Administrative Boards of Sweden] (2005) Kommunernas insatser för personer med psykiska funktionshinder. Slutrapport från en nationell tillsyn 2002–2004. Vällingby: Elanders Gotab. 24 Dencker, Jonas & Wåhlinder, Jan (2004) ‘Psykiatrireformen ett misslyckande för en stor grupp vårdsökande’. Läkartidningen, Vol. 101, Issue 5, 398.   € In order to determining who has the right to special care and special social interventions, experts and scientists have developed an array of instruments to assess the needs of the severely mentally ill.25 ese tools for assessment emanate from standards of care (what the social services and psychiatric care is supposed to deliver) and from standards of needs (what the target group is supposed to need). International research and follow-ups of the deinstitutionalization of psychiatric care show that the social inclusion of the severely mentally ill is problematic and there are also variations among countries concerning care standards and how needs are met with social ser- vices.26 Naturally, a wide variety of results are obtained depending on the research questions, on the diverse issues of the dierent elds of research and on which persons are included in the study. Also, the increasing devel- opment of assessment tools belongs to the evidence-based practice (EBP). It oers an opportunity to measure happiness as a kind of objective well- being, grounded on the presumption that met needs of social services and medical care are required to gain happiness. Considering the mentally ill, the needs being measured are connected to what a disabled person is sup- posed to need in order to live a normal life. On the basis of the problems discussed above, a survey was carried out in a region near Stockholm between the years 2008 to 2010.27 e aim was to investigate the extent that the needs of the mentally ill were met by medical and social services in the region. e construction of the survey, a tool for needs assessment, was based on the expectations of the quality of care and social support that was formulated in the Psychiatric Health Care reform of 1995 with respect to the aim of the normalization of living conditions of 25 Including for example the Camberwell Assessment of Needs (CAN), Need of Social Service Ques- tionnaire (NSSQ), Bangor Assessment of Need Prole (BANP). Recently, a number of assessment tools in the Swedish language, concordant to the Swedish Social Law legislation, have also been launched. 26 Kovess-Masféty, Vivianne, Wiersma, Durk, Xavier, Miguel, de Almeida, José Mel Caldas, Carta, Mauro G., Dubuis, Jacques, Lacalmontie, Elisabeth, Pellet, Jacques, Roelandt, Jean Luc, Torres- Gonzalez, Francisco, Kustner, Berta Moreno & Walsh, Dermont (2006) ‘Needs for Care Among Patients with Schizophrenia in Six European Countries’. Clinical Practice and Epidemiology in Mental Health, Vol. 2, Issue 22. Online. Available HTTP: (accessed July 2012) 27 Åberg, Martin & Piuva, Katarina (2010) Kartläggning av behov och insatser för personer med psykiska funktionsnedsättningar inom Nordvästkommunerna. Sollentuna: FoU – Nordväst.        ‘’     € people with severe mental illness, e.g. needs met concerning housing, op- portunities to work and study, economical resources and access to medical care and social services. e survey was distributed to social service sta and user organizations. Unsurprisingly, the results showed major gaps between needs and needs met. Briey, the younger group in the survey (18–29 years) was underrepresented in the investigation. In addition, very few within the younger population received disability pension or other benets from the social insurance system. Instead, social allowance, the minimum standard of economic support distributed by the social services, was a common source of income among the youngest. For some reason, the middle-aged persons (40–65 years) were overrepresented in the material. Furthermore, social in- terventions were not directed to people with drug- and alcohol dependency. Irrespective of age, severe mental illness meant exclusion from the labour market. Lastly, the needs of elderly people with mental disabilities were not well-known by the social services. What information about the fullment of the political goal of the Psy- chiatric Health Care Reform do we get from this information? How does it conform to the political ambition of a ‘life like everybody else’? is goal of normalization was to be implemented by the tools of the disability politics, i.e. to give compensation for the impairment and the social services admin- istration was given the responsibility to dene the target group, to explore their needs and thereaer decide on the interventions that would lead to the political goal of normalization (a life like everybody else). Concerning the youngest, the results indicated major problems to even identify the entitled individuals. Consequently, there are major problems concerning the task to decide on which social services that would increase the possibilities to live a normal life. Besides young age, persons with drug- and alcohol problems were at high risk of not having access to services that supports normal liv- ing conditions. e oldest group could not be identied at all by the social services, which meant that the knowledge about their disabilities and needs of medical care and social services was highly limited. However, the persons between 40 and 65 years seemed to have received adequate services in rela- tion to the politics of normalization. e results were discussed in several    settings with professionals from the social services and members from user organizations, as the researchers wanted well-informed reections on the outcome. When the reform was implemented in 1995, all identied patients in psychiatric care were transferred from psychiatric care to the social services, where they still remain. is can explain the overrepresentation of people aged 40–65 years. Day centres for the long-term mentally ill were also trans- ferred directly to the municipalities. Over the years, with a few exceptions, little has changed within those day centres. Younger people, regardless of illness or disability, have dierent demands for activities. eir claims are about the possibilities to study and possibilities to nd job placements. Ad- ditionally, the dismantling of preventive activities, both regarding psychiat- ric care and social services, leads to a situation in which younger people do not receive adequate and timely help. Both professionals and members of the user organizations agreed on the lack of coordination between psychiat- ric care, drug- and alcohol treatment and the social services. Improvements have been made as a result of the engagement of case managers, but there are still claims for an expansion of case managers. Almost all cases of the el- derly with severe mental illness were reported from the psychiatric care. e lack of knowledge about elderly people with mental illness within the social services was explained by the internal organization of the community care. Usually, the sections of elderly care in the municipalities did not cooperate with the sections responsible for social psychiatry. To conclude, the assessment of needs and decisions on social rights made by the social administration are so complex and the requirement of ‘proving’ one’s disability are so high, that the important ten years aer entry into adult life passes by before the person eventually qualies for the special interventions directed to persons with disabilities. A possible consequence of this could be that the number of adult people with severe social problems and disabilities caused by mental illness may expand in the future.        ‘’      A normal and happy family e second study, on which this discussion about the implementation of mental health policies and its relation to the happiness and well-being of the mentally ill is based, focuses on a pilot study comprizing 16 interviews with mothers to adult children with severe mental illness.28 e interview- ees were accessed through the user organizations, Riksförbundet för Social och Mental Hälsa [e National Association for Social and Mental Health, RSMH] and Schizofreniförbundet [e Schizophrenia Association]. ese interviews present perspectives on happiness and normality as narrated by individuals with close experience of mental illness and mental health care. Including these perspectives in research is novel as the lifelong responsi- bility and caring experiences of the family members have generally been neglected in Swedish welfare policy and research.29 Traditionally, research on mental illness and its consequences for family members has tended to focus on the increasing care burden. As a consequence, mental illness has been studied as a phenomenon causing major stress in the family, nally resulting in dysfunctional family relations. Moreover, previous research has commonly regarded the cause of mental illness as likely to be found in fam- ily life in general and in the relationship between the mother and the child in particular.30 is pathological understanding of families and mothers of children suering from mental illnesses has come under critical assessment in more recent studies. Most families endure whatever stress that might fol- low with a child suering from mental illness. Also, most families adapt successfully to the situation and become important actors in processes of recovery.31 28 Piuva, Katarina & Brodin, Helene (forthcoming) ‘En familj som alla andra? Mödrar till vuxna barn med psykiska funktionsnedsättningar berättar om sina erfarenheter’. In Karlsson, Lis-Bodil, Ran- takeisu, Ulla & Kuusela, Kirsti (eds) Marginalisering i socialt arbete. Lund: Studentlitteratur. 29 Jeppsson Grassman, Eva, Whitaker, Anna & Taghizadeh Larsson, Annika (2009) ‘Family as Failure. e Role of Informal Help Givers to Disabled People in Sweden’. Scandinavian Journal of Disability Research, Vol. 11, Issue 1, 35–49. 30 Syrén, Susanne (2010) Det outsagda och ohörsammade lidandet. Tillvaron för personer med långvarig psykossjukdom och deras närstående. Växjö: Växjö University. 31 Schön, Ulla-Karin, Denhov, Anne & Topor, Alain (2009) ‘Social Relationship as a Decisive Factor in Recovering From Severe Mental Illness’. International Journal of Social Psychiatry, Vol. 55, Issue 4, 336–347.    e method of research was adapted to the life-story perspective, as we wanted to encourage personal narratives. e main ndings from the in- terviews were the overall theme of resistance to social exclusion in the life stories. e oldest mothers, through lifelong relations to professional care- givers, had experiences from both regimes of welfare politics in Sweden, e.g. the period of in-hospital mental care that was practised until the late 1970s, as well as the process of deinstitutionalization during the end of the century. In many respects, the narratives illustrated the problems connected to the politics of happiness and normalization, not the least with regard to the or- ganization of everyday life and economy, both being important for how you experience personal autonomy and integrity. e normal everyday life Regarding the quality of care and social service, all of the interviewees agreed that much has improved since the 1960s and 1970s, when the experiences of families and relatives were systematically rejected. e present commu- nity-based services, including housing, contact persons and case managers were seen as positive resources. However, the experiences of the policies of normalization also contained some lessons. Having access to an apartment connected to social services might also include a set of principles of normal life, such as standards of ‘normal furnishing’, expectations of normal hob- bies and normal destinations for one’s travels. Normalization was also about social rules, for instance that adult persons normally visit their parents on Sundays, not anytime they like. is ‘regime of reason’ made the parents feel incapacitated and their adult children feel underage. e principle of normality that guides the social services implies that people with functional disabilities due to severe mental illness should have the opportunity to live as other citizens, but this positive aim is sometimes applied as a template according to which disabled people should live their lives. us, in reality, the ‘principle of normalcy’ might come out as forced moral values based on what the social services and the social workers think constitutes a good life.        ‘’      Autonomy and economy Although reports repeatedly point to the fact that mental illness and func- tional disabilities due to severe mental illness generate poverty and economic marginalization,32 the nancial situation for adults with mental issues seems to be a non-issue, judging from the interviews. Mental illness is one of the most common reasons for a disability pension in Sweden and many of the recipients, as most have not been gainfully employed, are only entitled to the lowest levels of benets from the Swedish social insurance. e mothers be- ing interviewed conrmed this situation. e families and the mothers had oen had to help their adult children with money. In addition, the mothers have assisted by sorting out the jungle of bureaucratic rules, certicates and paperwork that are needed in order for their children to receive the benets they are entitled to. e mothers also described how their children had been living for years on end at the lowest levels of social allowance as they have been unable to approach the psychiatrists and clinics they needed to visit in order to receive benets from the National Insurance System. e overall conclusion of this pilot study was that – contrary to the norms of able-bodiness, which frames mental illness as “abnormal” and as a reason for lifelong unhappiness – the mothers described how they and their adult children had managed to integrate mental illness in their ordinary life. e neglected economy of the severely mentally ill was rather surprising. Help from the social services meant that the mentally ill children were en- titled to resources in natura so to speak. eir incomes, either as social al- lowances or benets from the Social Insurance System were so low that they never had enough money to make plans for the nearest future or to pay for something ‘extra’ beyond covering the most minimal expenditure. In the long run, insolvency also had consequences for the family nancial situa- tion. at long term mental illness causes economic concerns or even pov- 32 Bülow, Per (2004) Aer the Mental Hospital – A Study in the Wake of the Deinstitutionalization of Psychiatric Care. Linköping University; Riksförsäkringsverket [Swedish National Social Insurance Board] (2004) Sjukdomar som orsakat pensionering. Rapport 2004:3; Statistiska centralbyån [Statis- tics Sweden] (2003) Levnadsförhållanden för personer med funktionshinder 1988−1999. Stockholm: Statistiska centralbyån; SOU 2006:100. Ambition och ansvar. Stockholm: Fritzes.    erty is a well-known fact.33 e narratives of the mothers added the experi- ences of the consequences of poverty in a lifelong perspective, pinpointing also how poverty may inuence family relations and, hence, the well-being and happiness of the mentally ill. Happy without reason? e issue of this chapter was to discuss the problems surrounding the con- cept of happiness in relation to mental illness, a discussion that necessarily has to relate to the concept of normality and its time bound and vacillat- ing meaning. e two most important ocial investigations about mental health care in the aer war period in Sweden were initially the focus of this investigation. e rst ocial investigation mirrored the policies of the ‘car- ing state’ as the welfare policies concerning mental health in the 1950s and 1960s, was to reduce the genesis of the illness and mental hygiene was the route. At the end of the twentieth century, when the second investigation was undertaken, normal living conditions were presented as the solution that would increase the quality of life for the severely mentally ill. e latter investigation struggled to integrate the severe mentally ill into an ethos of welfare which emphasized individual autonomy. To be normal, e.g. to have the “right to ‘normal’ living conditions” include individual autonomy, integ- rity and opportunities to make one’s own choices in life. In a broad meaning, these are the same values that are connected to the concept of happiness, which are highly ranked values in our age of reason. e same values turn out to be almost everything that is regarded as the opposite to mental illness. Despite the broad consensus about the problems of the concepts of nor- mality, mental health and positive mental health, they are oen implicitly rendered as simply the absence of mental ill-health, thus indicating a state of normality. In 1958, Marie Jahoda, for example devised a list of character- istics which were present in the majority of people who were regarded as mentally healthy, though she notes that is an inherent problem that the ideal norm of normality is similar to positive mental health. ese characteristics 33 SOU 2006:100.        ‘’      include high self-esteem, personal growth, the ability to cope with stress, autonomy in the sense of self-regulation, a sense of reality orientation, the ability of empathy and the ability to environmental mastery.34 Aer 1958, critical investigations about the concept of ‘mental illness’ have been in fo- cus within the social sciences. Per-Anders Tengland’s reections on the con- cept of ‘mental health’ in 2001 represents a return to a discussion that have been absent for quite a long time. e problems that we have to deal with when discussing happiness and mental illness are strongly connected to the three-dimensional meaning of normality: the statistical, the ideal and the medical meaning. ‘Positive mental health’ and thus the ideal meaning of normality is very close to the values of happiness, but not close to the concept of normality that permeates the Swedish Psychiatric Health Care Reform, which relies on the statistical meaning of normality as being the most typical life circumstances.35 To fol- low this line of argument would lead to the conclusion that the mentally ill have the right to expect the same amount of happiness as the average citizen (but not more?). In addition, the moral dimension of this kind of normality can cause frustration. Family members, in this case the mothers, tells us that the ideals of ‘a normal life’ can be converted into demands. If following the medical dimension of the normality concept, mental illness (deviant from mental health) means among other things, loss of self-control, loss of ability to master the environment and loss of reality orientation, just the opposite qualities to mental health and normality presented by Jahoda in 1958. Para- doxically, the social practice of normality, concerning the mentally ill, has turned out to be a requirement that the presumptive patient has lost control, otherwise the individual is not entitled to the social rights that come with the denitions of disability. Irrespective of time and rhetoric, a borderline between expectations of happiness for normal citizens as distinct from people suering from long- term mental illness, is being drawn. Implementing this practice of separation 34 Jahoda 1958, 22–64; Tengland 2001, 35–49; Nordenfeldt, Lennart (1997) ‘e Stoic Conception of Mental Disorder: e Case of Cicero’. Philosophy, Psychiatry & Psychology, Vol. 4, Issue 4, 285–291. 35 Tideman 2000; Piuva 2005, 56–58.   € when it comes down to administration, more precisely the administration of social rights, is problematic. Again, the crucial concepts of normality, illness and disability are dependent on cultural values and hence dicult to measure. is may be one reason why the concept of ‘needs’ has returned together with the evidence-based practice (EBP) within social work. is is ‘safe territory’ as we can rely on knowledge about social problems and on the traditional goals of welfare policies, assuming that the increase of welfare is of crucial impor- tance for subjective well-being, e.g. that happiness is a function of welfare.36 From the survey about needs and unmet needs and the interviews dis- cussed earlier in this chapter, we can conclude that the severe mentally ill are unfavoured concerning economy, access to medical care and social services. is is merely the same conclusion as evaluations of the Psychiatric Health Care Reform have told us before. e present discussion adds the conceptu- al dimension. Several inherent paradoxes are active and generate sometimes unintended and frequently counter-productive consequences. ere are considerable problems connected to the administration of welfare (needs met) when the categorization of the individuals is ambiguous. In addition, the practice of categorization is also connected to ethical problems. For ex- ample, if a person is unemployed as many of the mentally ill are, the contract between the autonomous individual and the state is severed. Autonomy is strongly connected to access to work and money of one’s own – something which the severely mentally ill rarely have. It is the work (the employment) that generates the possibilities to normality and happiness. In the recent World Happiness Report mental health is identied as ‘the biggest single factor aecting happiness in any country’.37 At the same time, however, the report tells us that the opportunities for treatment are limited in the advanced societies and even more limited in poorer countries. is ‘happiness paradox’ is also true regarding social policy of mental health. e 36 For this discussion, see Sumner, Leonard Wayne (1996) Welfare, Happiness, and Ethics. Oxford: Clar- endon Press; Frey, Bruno & Stutzer, Alois (2002) ‘Happiness, Economy and Institutions’. Economic Journal, Vol. 110, Issue 466, 918–938. 37 Helliwell, John, Layard, Richard & Sachs, Jerey (2012) World Happiness Report. New York: Earth Institute, Columbia University. Online. Available HTTP: (accessed July 2012)        ‘’      universal state did not solve the problem of mental illness by addressing the whole population. In all probability, it is not likely that the neoliberal welfare state will solve it either. e idea of solving problems belongs to the utopian dimension. e more pragmatic questions deal with what kind of problems follows from dierent policies of mental health. e problems that emerged from the universal welfare policy – the caring state – can roughly be sum- marized as an ‘isolation-trap’. e intentions to include the mentally ill into the social community by strengthening their position as patients with access to high quality mental care, turned out to exclude them from ‘normal’ soci- ety. e neoliberal ethos of the responsible citizen – the autonomous indi- vidual – will cause another kind of problems concerning mental health care. e question: who has the right to treatment (in order to be normal and thus happy?) will of course generate new problems. Where is the line to be drawn between the mentally ill that are entitled to get help and those that are not? Several contributions to this volume describe happiness as a returning phenomenon in the social sciences and social policy. e ‘return’ can also be applied to the eld of mental health. Today when the care of the severely mentally ill is a task for social science and social work, there is reason to believe that the question of happiness and mental health will be expressed more explicitly. Happiness with the meaning of ‘positive mental health’ has so far dwelled within the elds of social psychology and social medicine during the post-war period. Instead, mental illness and abnormal social be- havior, with the qualities of being social problems, have been issues of social research for quite a long time. e top-down scientic interpretations of happy citizens is becoming increasingly challenged by a bottom-up interpretation of subjective well-be- ing. In the eld of mental health, this concerns taking into account the men- tal health service users’ own perceptions of the services provided and their eects upon their well-being. Happiness, as it is used in the social sciences today,38 is oen understood as a kind of evaluation of welfare policies, a measure of how content the citizens are concerning the state’s ability to pro- 38 See for example Rothstein, Bo (2010) ‘Happiness and the Welfare State’. Social Research, Vol. 77, Issue 2, 1–28.    vide safety, freedom, democracy and possibilities of pleasure. Is this bottom- up perspective true for the severely mentally ill? Do we expect happiness and well-being on the same conditions as other citizens when it concerns people with severe mental illness? Do we ask people with severe mental ill- ness (schizophrenia, bipolar illness, personality disorders and other severe conditions of ill-health) if they are healthy and happy? When the doctor or the social worker asks ‘Is everything all right, do you feel well?’ the implicit meaning is oen ‘Are you free from symptoms, do the voices disturb you? Are you satised with your medicine dose?’ It is more unlikely (though pos- sible) that professional agents ask if the person is satised with his or her life circumstances, if he or she is able to cope with illness/disability, or perhaps does not mind the illness at all. Certainly, this chapter provides no solution to this landscape of para- doxical questions. But it is hoped that it can contribute to problematize the underlying cultural assumptions about citizenship, happiness and so- cial conditions for individuals with severe mental illness. e discourses of health and happiness can be considered as aspects of ‘the broken dialogue’ with mental illness, or the broken dialogue with deviance from what we consider as normal.39 When we talk about ‘populations’ and ‘expectations’, the severely mentally ill are oen being disregarded – owing to their status of being abnormal, unusual and therefore not representative. e challeng- ing questions for the future are about the ability to foresee obstacles and to present the uncomfortable questions. Are all individual choices the same as good choices? Will it be possible to ask for help without proving a personal incapability to understand that help is needed? In conclusion, the discussion presented here has sought to show that the singular focus upon individual freedom may, in the context of well-being of the mentally ill, run the risk of turning into new forms of social exclusion, instead of the social inclusion all contemporary mental health policy strives for. 39 Foucault, Michael (2006 [1964]) Madness and Civilization. A History of Insanity in the Age of Reason. London: Routledge.        ‘’      References Åberg, Martin & Katarina Piuva (2010) Kartläggning av behov och insatser för personer med psykiska funktionsnedsättningar inom Nordvästkommunerna. Arbetsrapport. Sollen- tuna: FoU – Nordväst. Berge, Anders (2007) Sjukvårdens underklass: Sjukvården i den kommunala fattigvården 1910–1950. Umeå: Borea. Brusén, Peter & Lars-Christer Hydén (2000) Ett liv som andra: Livsvillkor för personer med funktionshinder. Lund: Studentlitteratur. 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Göteborg: Daidalos.        ‘’      Statistiska centralbyån [Statistics Sweden] (2003) Levnadsförhållanden för personer med funktionshinder 1988−1999. Stockholm: Statistiska centralbyån. Sumner, Leonard Wayne (1996) Welfare, Happiness, and Ethics. Oxford: Clarendon Press. Syrén, Susanne (2010) Det outsagda och ohörsammade lidandet. Tillvaron för personer med långvarig psykossjukdom och deras närstående. Växjö: Växjö University. Tengland, Per-Anders (2001) Mental Health. A Philosophical Analysis. Dordrecht: Kluwer Academic Publishers. omson, Mathew (1995) ‘Mental Hygiene as an International Movement’. In Weindling, Peter (ed.) International Health Organizations and Movements. Cambridge: Cambrid- ge University Press. Tideman, Magnus (2000) Normalisering och kategorisering: om handikappideologi och välfärdspolitik i teori och praktik för personer med utvecklingsstörning. Lund: Student- litteratur. World Health Organization (1951) Mental Health: Report on the Second Session of the Expert Committee. Geneva: World Health Organization.       Who needs mental health services? Mental health care planning and the image of the service user in Finland     Introduction Internationally, mental health policy has undergone important changes in the last decades, just as welfare policies in general.1 A central element in mental health care planning has been the ambition to reduce or to avoid psychiatric hospital care through so-called psychiatric dehospitalization.2 e criticism of the potentially negative eects of psychiatric hospital treat- ment – not only with regard to patients’ recovery, but also for patients’ indi- vidual well-being and sense of self-determination while in treatment – dates back to the late nineteenth century. As a broader international movement towards policy change, however, dehospitalization only became inuential aer the Second World War.3 1 By ‘mental health policy’ we refer to both the society’s eorts in mental health promotion and in the prevention and treatment of mental health problems. In addition, we distinguish between ‘mental health care’, which encompasses all activities in the eld and ‘mental health services’, which we use to refer to service provision. Cf. Pilgrim, David (2009) Key Concepts in Mental Health. London: Sage. 2 e term ‘deinstutitionalization’ can also be used in the same meaning, even though it may be criti- cized for neglecting the institutions that remain in mental health care. See for example Helén, Ilpo, Hämäläinen, Pertti & Metteri, Anna (2011) ‘Komplekseja ja katkoksia – psykiatrian hajaantuminen suomalaiseen sosiaalivointivaltioon’. In Helén, Ilpo (ed) (2011) Reformin pirstaleet. Mielenterveys- politiikka hyvinvointivaltion jälkeen. Tampere: Vastapaino. 3 Castel, Robert, Castel, Françoise & Lovell, Anne (eds) (1982) e Psychiatric Society. New York: Columbia University Press; Barham, Peter (1997) Closing the Asylum: e Mental Patient in Modern Society. London: Penguin; Grob, Gerald (1991) From Asylum to Community: Mental Health Policy in Modern America. Princeton: Princeton University Press; Scull, Andrew (1984) Decarceration. Com- munity Treatment and the Deviant – A Radical View. Cambridge: Polity Press.       Dehospitalization has been seen as a result of several dierent phenom- ena.4 Some scholars have stressed the eect of the advances in psychiatry, es- pecially in pharmacological treatment and the development of antipsychotic chlorpromazine in the early 1950s.5 Others have argued that the harmful eects of psychiatric hospital treatment as presented by proponents of criti- cal psychiatry and social psychiatry have played a decisive role.6 It has also been suggested that economic factors may have worked in favour of dehos- pitalization in dierent ways.7 Lastly, it has been observed that ‘psychiatriza- tion’ – the spreading of psychiatry beyond the connes of the hospital and into everyday life – has contributed to dehospitalization by making mental health matters a normal aspect of life for many people.8 As in most industrialized countries, dehospitalization has inuenced Finnish mental health policy. However, Finland was a latecomer: While de- hospitalization had elsewhere already started aer the Second World War, in Finland the psychiatric hospital capacity was still perceived as insucient during the 1950s and 1960s. Opposition against institutional treatment and related civil rights violations was voiced in Finland from the 1960s and on- wards.9 Yet, the number of psychiatric hospital beds continued to grow until the late 1970s, when dehospitalization took o.10 Finnish dehospitalization 4 e classication of dierent histories presented here is inuenced by the work of Enric Novella, but his classication is not followed as such. Novella, Enric J. (2008) ‘eoretical Accounts on Deinstitu- tionalization and the Reform of Mental Health Services: A Critical Review’. Medicine, Healthcare and Philosophy, Vol. 11, Issue 3, 303–314. 5 Shorter, Edward (1997) A History of Psychiatry: From the Era of the Asylum to the Age of Prozac. New York: John Wiley; Grob 1991. 6 Salo, Markku (1996) Sietämisestä solidaarisuuteen. Mielisairaalareformit Suomessa ja Italiassa. Tam- pere: Vastapaino. 7 Scull 1984; Novella 2008. 8 Rose, Nikolas (2006) ‘Disorders Without Borders? e Expanding Scope of Psychiatric Practice’. BioSocieties, Vol. 1, Issue 4, 465–484; Hautamäki, Lotta, Helén, Ilpo & Kanula, Saara (2011) ‘Mie- lenterveyden hoidon lääkkeellistyminen Suomessa’. In Helén, Ilpo (ed.) (2011) Reformin pirstaleet. Mielenterveyspolitiikka hyvinvointivaltion jälkeen. Tampere: Vastapaino; Castel, Castel & Lovell 1982; Helén, Hämäläinen & Metteri 2011. 9 e so-called ‘November movement’ was founded in 1967, partly inspired by the works of sociolo- gist Erving Goman and his analysis of the negative eects of hospital treatment. Niemelä, Anna (2003) Laitoksista hallittuun vapauteen: Marraskuun liikkeen poikkeava, sosiaalinen kansalaisuus ja hallintarationaalisuus. Unpublished master’s thesis. Helsinki: University of Helsinki; Honkala, Kaisa (2011) ‘YK:n ihmisoikeudet vankiloihin!’: Marraskuun liikkeen suomalaisen kontrollipolitiikan kritiikki 1967–1972. Unpublished master’s thesis. Helsinki: University of Helsinki; Salo 1996. 10 Hyvönen, Juha (2008) Suomen psykiatrinen hoitojärjestelmä 1990-luvulla historian jatkumon näkökulmasta. Kuopio: Kuopio University Publications; Eskola, Jarkko (2007) ‘Mielenterveystyö ja yhteiskunnan muutos’. In Eskola, Jarkko & Karila, Antti (eds) Mielekäs Suomi. Näkökulmia mie- lenterveystyöhön. Helsinki: Edita, 14–44; Tiitta, Allan (2009) Collegium Medicum. Lääkintöhallitus 1878–1991. Helsinki: National Institute for Welfare and Health.       policy primarily emerged from within the health administration rather than from advocacy groups and ‘radicals’ as in for example Italy.11 Dehospitaliza- tion in Finland was also rapid and dramatic. During the period discussed in this chapter, from the late 1970s until the late 2000s, the number of psychiat- ric hospital beds in relation to the population can be estimated to have fallen by approximately four hs.12 is shi has generated considerable criticism over the years, and is has oen been argued that the reduction of the psychiatric hospital beds has not been compensated with a sucient amount of outpatient care.13 Most of the criticism has emphasized the diculties of implementing the dehospitaliza- tion reform under the economic and social crisis in the 1990s.14 e Finnish welfare system has changed remarkably during the period and the shi has been conceptualized as a move from an expansive to post-expansive welfare state.15 Previous studies on diverse social and health care elds have pointed out that the emphasis and demand for the citizen’s autonomy have increased along with these changes.16 11 Salo 1996. 12 e highest number recorded in Finnish ocial statistics is 19 866 beds in 1976. While the exact number of annual hospital beds has not been recorded since 1995, the ocial statistics are using an estimate based on the number of annual treatment days in psychiatric hospitals divided by the amount of days in a certain year. is gure was 4272 in 2009. Koskinen, Riitta (1994) Tervey- denhuolto: katsaus väestön terveyteen, terveyspalvelujen käyttöön ja resursseihin. Helsinki: Stakes; Forsström, Jari & Pelanteri, Simo (2011) Psykiatrian erikoisalan laitoshoito. Helsinki: National Institute for Welfare and Health. 13 Helén, Hämäläinen & Metteri 2011; Karlsson, Nina & Wahlbeck, Kristian (2011) ‘Finland. Från reformintention till praxis. Mentalvårdens utveckling i Finland eer år 1990’. In Lindqvist, Rafael, Bengtsson, Steen, Fredén, Lars, Larsen, Frode, Rosenberg, David, Ruud, Torleif & Wahlbeck, Kris- tian (2011) Från reformintention till praxis. Hur reformer inom psykiatri och socialtjänst översatts till konkret stöd i Norden. Gothenburg: e Nordic School of Public Health, 65–100. 14 Öhman, Kaisa (2003) Mielenterveystyön reformi ja mielenterveyspotilaan sosiaalinen kansalaisuus. Unpublished master’s thesis. Helsinki: University of Helsinki; Eskola 2007; Hyvönen 2008; Helén, Hämäläinen & Metteri 2011. 15 Julkunen, Raija (2001) Suunnanmuutos. 1990-luvun sosiaalipoliittinen reformi Suomessa. Tampere: Vastapaino. 16 Helén, Ilpo (2011) ‘Asiakaslähtöisyys: eli miten mielenterveystyön ajatus epäpolitisoitui’. In Helén, Ilpo (ed.) (2011) Reformin pirstaleet. Mielenterveyspolitiikka hyvinvointivaltion jälkeen. Tampere: Vastapaino, 153–181; Helén, Ilpo & Jauho, Mikko (2003) ‘Terveyskansalaisuus ja elämän politiikka’. In Helén, Ilpo & Jauho, Mikko (eds) Kansalaisuus ja kansanterveys. Helsinki: Gaudeamus, 13–32; Leppo, Anna & Perälä, Riikka (2009) ‘User Involvement in Finland: e Hybrid of Control and Emancipation’. Journal of Health Organization and Management, Vol. 23, Issue 3, 359–371; Kananen, Johannes (2013) ‘e Procedural Openness of Nordic Welfare State Restructuring’. In Götz, Norbert & Marklund, Carl (eds) e Promise of Openness. Leiden: Brill; Outinen, Sami (2012) ‘Labour Mar- ket Activation in Finland in the 1990s: Workfare Reforms and Labour Market Flexibilisation’. Local Economy, Vol. 27, Issue 5–6, 629–636; Ollila, Eeva & Koivusalo, Meri (2009) ‘Hyvinvointipalvelusta liiketoiminnaksi – terveydenhuollon parantamisen tärkeät valinnat’. In Koivusalo, Meri, Alanko, Anna & Ollila, Eeva (eds) Kansalaisesta kuluttajaksi. Markkinat ja muutos terveydenhuollossa. Hel- sinki: Gaudeamus, 21–47.       While it has been shown that the shortcomings of the Finnish mental health care cannot be explained with the cost cuts during the economic cri- sis of the 1990s, a puzzle has only partly been solved. Simultaneously with the dehospitalization, the supply of outpatient mental health care has mul- tiplied, but Finnish mental health care is still oen considered inadequate.17 Why does it seem that the overall demand for mental health services has expanded – rather than been satised – with the increasing supply of outpa- tient mental health services? is chapter aims to nd out to what degree Finnish mental health care planning has contributed to this ambiguity. e research questions are two- fold: First, what have been the key aims and proposals of Finnish mental health care planning between 1977 and 2009? Second, what is the image of the service user and which abilities and responsibilities have been assigned to the service users in the plans? e chapter focusses on the planning of mental health policy during the period of the policy of dehospitalization starting from the late 1970s and continuing until 2009. e chapter analyses the most important planning documents published between 1977 and 2009 that discuss Finnish mental health care on a general level, without focusing on a specic problem, diag- nosis, or patient group. While the plans also relate to the mental health care of children and elderly people, the present analysis concentrates upon the discussions about the mental health care of those in working age. e anal- ysed plans are altogether seven. ey have been produced by four dierent projects that have been working under the auspices of the Finnish Ministry of Social Aairs and Health (hereaer, MSAH). While the earlier studies have emphasized a break between the planning of the dehospitalization during the 1970s and the 1980s, and the implemen- tation of dehospitalization from the 1990s onwards, this chapter identies a continuum. e analysis shows that during the whole period starting from the 1970s the plans contain what may be called revolving aims, i.e. objec- tives that were repeated in all the plans. e expression of the revolving 17 Helén, Hämäläinen & Metteri 2011.      € aim is inspired by the notion of the ‘revolving door patient’ to denote a per- son who is repeatedly admitted to psychiatric hospital care.18 e revolving aims identied in the analysis range from reducing supposedly excessive psychiatric hospital or ‘inpatient’ treatment, to increasing the availability of outpatient treatment; from enhancing the possibilities of the aŒicted in taking part in working life to ensuring mental health care service users an equal position with other citizens in need of care; and from following the ex- ample of other countries that have been considered forerunners with regard to mental care to even surpassing international pioneers. In addition, all the plans discuss the need to dene the target groups of mental health care and mental health policy. However, also a break within the planning is identied: the target group rst expands in each of the plans. Second, the image of the ideal service user transforms in the documents, little by little, from a mentally ill or aŒicted person in need of care to an autonomous individual with the ability to iden- tify his or her own needs and to take care of him- or herself, and ensure his or her own well-being. e shiing target groups and changing images of the ideal service user as identied in this study are both likely to aect the scope of mental health care in various ways, even if the overall aims remain largely the same. e transition from ‘need’ of care to ‘autonomy’ does not only have an impact on the quantity and quality of services provided. It may also aect who is entitled to care and who is not. e National Board of Health working group In 1977, a working group set up by the Finnish National Board of Health (hereaer, NBOH) published a planning document in which Finnish men- tal health care planning was connected with the dehospitalization trend un- derway internationally.19 e NBOH working group was chaired by Medical 18 Shaw, Ian (2004) ‘Doctors, “Dirty Work” Patients, and “Revolving Doors”’. Qualitative Health Re- search, Vol. 14, Issue 8, 1032–1045. 19 e plan was signed by 17 members, although ve additional people were listed that had also taken part in its writing. e group reported having heard 11 experts and having sent hearing requests to 70 professional or civic organizations, of which 50 responded. National Board of Health (NBOH) (1977) Psykiatrisen terveydenhuollon kehittäminen. Psykiatrisen terveydenhuollon kehittämisohjelma 1977–1986. Helsinki: National Board of Health.       Counsellor Raimo Miettinen, a psychiatrist by profession.20 e working group noted that Finland’s volume of psychiatric hospital treatment was high by international standards and that the number of psychiatric hospital beds was ‘among the highest in the world’.21 e NBOH working group con- cluded that the risk of ‘hospitalism’, the undesirable eects of hospital care, called for the need to develop outpatient treatment as an alternative: “e possibility to receive psychiatric hospital treatment in recent years has been safeguarded for everyone who necessitates it. Along- side the rapid development of hospital treatment, the development of outpatient treatment has been slower than hoped for. […] Far too little attention has been paid to the many disadvantages of long-term hospital treatment. Every hospital treatment separates and alien- ates the aŒicted person from his/her normal environment – family, friends, workplace – and gives an exceptional character to the illness. Especially long-term hospital treatment raises detrimental attitudes towards the mentally ill, increases the tendency to isolation and pro- motes hospitalism.”22 Outpatient care was proposed as a means of assisting the patients in getting ‘back to society’, thereby helping them to gain the same status as other citizens.23 Amending the Mental Illness Act of 1952 was suggested as a way of allowing for the establishment of boarding houses and ‘semi-open treatment’.24 e NBOH working group also highlighted the importance of employment. While rehabilitation to wage work was discussed, sheltered work was considered the most suitable form of rehabilitation. Noting that the then current legislation allowed for the treatment of ‘the mentally ill’ without their consent, unlike the physically ill, the working group suggest- ed removing this dierence from the legislation as a way of giving mental 20 Miettinen was born in 1929. Huovinen, Pentti, et al. (1970) Kuka kukin on: henkilötietoja nykypolven suomalaisista. Helsinki: Otava. 21 In 1977, the number of hospital beds, 19 853, was close to that of the peak year 1976. NBOH 1977, 8–9. 22 NBOH 1977, 31–32. 23 NBOH 1977, 18. 24 Mielisairaslaki [Mental Illness Act] 187/1952; NBOH 1977, 18.       health patients equal status with other citizens.25 e NBOH working group also justied its positions by pointing out that similar reforms had been un- dertaken in Sweden and the UK. e NBOH working group also pointed out the need for mental illness prevention at large. According to the working group, ‘general social mental health work’ should be taken into account when planning the mental health care of the whole population.26 Yet, ‘psychiatric health care’ was still iden- tied as a ‘specialist level psychiatric function within the public sector’.27 A major problem here was that a signicant group of patients which did ‘not belong to psychiatric health care’ remained within the psychiatric care system.28 While the overall aim was to reduce psychiatric hospital care, the working group considered some of the ‘ill’ to be inevitably in need of hos- pital treatment.29 In improving the eld, a key measure would be to remove the patients that were considered not to ‘belong’ to psychiatric health care, including the elderly, the mentally disabled as well as the substance abus- ers, from the psychiatric hospitals.30 e NBOH working group concluded that psychiatric health care would improve if the resources were focussed on those in the most need of psychiatric services, i.e. the mentally ill or af- icted. e Committee for Mental Health Work e NBOH working group’s proposals contributed to the amendment of the Mental Illness Act in 1978. Partly as a result of legislative changes and the policy recommendations of the NBOH, the reducing of the psychiatric hos- pital beds continued in the early 1980s.31 Also the revision of Finnish men- tal health care continued. In 1984, the Committee for Mental Health Work 25 is has been partly responded to in the amendments of the legislation but the possibility of using involuntary treatment has not been removed. Mäkelä, Jari (2008) Houruinhoitoasetuksesta mielenterveyslakiin. Mielisairaanhoidon ja erityisesti tahdosta riippumattoman hoidon lainsäädännön muutokset vuosina 1840–1991. Unpublished master’s thesis. Joensuu: University of Joensuu; NBOH 1977, 18. 26 NBOH 1977, 5–7. 27 NBOH 1977, 7. 28 NBOH 1977, 41. 29 NBOH 1977, 35. 30 NBOH 1977, 41. 31 At the time of publishing the report in 1984, the amount was 17 534. Koskinen 1994.       (hereaer, CMHW or the Committee) published a new plan for Finnish mental health work, as part of its report.32 Partly made up of the same indi- viduals as the earlier NBOH working group, the CMHW was also chaired by a psychiatrist, Professor Yrjö Alanen.33 Like its predecessor, the CMHW saw a need for counteracting excessive hospital treatment, referring among other things to the results of the Finnish national schizophrenia project of 1981–1987:34 “Even if the annual accumulation of the long-term patients is slow, a small stream grows into a sea, because the exit is slow. Some of the patients have been in treatment more than half a century. [...] In a way, the hospital is ‘pregnant’ with future long-term patients.”35 e CMHW argued that increasing the supply of outpatient treatment would make it possible to reduce the number of psychiatric hospital beds by half.36 e Committee also argued that at least ve times more opportuni- ties for sheltered work would be needed.37 At the same time, the CMHW reasoned that the resources in the mental health sector were lagging behind the rest of the economy. Given the economic growth and continuous expan- sion of the welfare state during the 1980s, the CMHW considered it justi- able to increase the resources directed to mental health at the same rate as the annual growth of GNP, at least if the goal of achieving parity between mental health service users and other citizens should be met.38 Also this time, the need to reduce the number of psychiatric hospital beds was ratio- 32 ere was some member turnover in the committee, but the document was nally signed by 24 persons. e committee heard 157 experts in the process. Committee for Mental Health Work (CMHW) (1984a, b, c) Mielenterveystyön komitean mietintö. Helsinki: Ministry of Social Aairs and Health. 33 A supporter of the Social Democratic Party, Alanen was born in 1927. Tarkka, Jukka (1986) Kuka kukin on: henkilötietoja nykypolven suomalaisista. Helsinki: Otava. 34 NBOH (1981) Skitsofrenian tutkimus-, hoito-, ja kuntoutustyön valtakunnallinen kehittämisohjelma. Helsinki: National Board of Health. 35 CMHW (1984a) Mielenterveystyön komitean mietintö I. Mielenterveystyön kehittämisen perustelut. Helsinki: Ministry of Social Aairs and Health, 175. 36 e suggested reduction was reached already in 1991. CMHV (1984b) Mielenterveystyön komitean mietintö II. Mietinnön tiivistelmä ja komitean ehdotukset. Helsinki: Ministry of Social Aairs and Health, 180; Koskinen 1994. 37 CMHW 1984a, 154. 38 CMHW 1984b, 194; cf. Julkunen 2001.       nalized with reference to international experiences. Aer having noted that only Ireland had more psychiatric hospital beds per capita, the Committee pointed to Sweden, Norway, Denmark, Iceland, Italy, the Soviet Union, the UK, and the US as examples of outpatient service-based systems.39 Yet, not all of those countries provided good examples, the CMHW ob- served. In the US, resources had been diverted from institutional treatment without establishing an alternative care system. As a consequence, patients had been ‘le without treatment and sometimes even abandoned’.40 How- ever, the Committee expected that the welfare state would prevent such ad- verse outcomes from dehospitalization in Finland.41 Most importantly, the CMHW suggested that a new law should be dra- ed using a new legislative nomenclature, pointing to ‘mental health’ rather than ‘mental illness’ as the target of policy reform. Despite some dierences between the Committee’s initial suggestions and the Mental Health Act ad- opted in 1991, the new legislation added a novel emphasis on the mental health of all citizens, and not only those suering from or having a risk of mental health disorder.42 As the CMHW sought to dene the target population, it also noted that many patients in the hospitals could not be considered to be in need of psy- chiatric hospital treatment.43 At the same time, and in contrast to the NBOH working group, the CMHW did not distinguish between psychiatric care and other mental health work and included general living circumstances in its analysis.44 In response to this broader stance, the CMHW did not only focus on the work of psychiatrist specialists exclusively, but referred to many other health and social care professions as relevant to mental health care work, such as medical doctors, psychologists, nurses and social workers. Perhaps 39 CMHW 1984a, 9, 325–364. 40 CMHW 1984a, 361. 41 CMHW 1984a, 364. 42 It was not the rst time this nomenclature was suggested, but the previous proposal of a mental health act of a committee in 1964 had failed. Mielenterveyslaki [Mental Health Act] 1116/1990; Hyvönen 2008, 211. 43 CMHW 1984b, 190–192. 44 Helén, Hämäläinen & Metteri 2011; Öhman 2003.       as a result of this wider interpretation of the scope of mental health care professions, the Committee expressed the need to outline some restrictions, stating that ‘the work of lawyers and construction engineers is no longer professional mental health work’.45 Following this broader outlook, the CMHW considered mental health problems to be very frequent in the population at large, citing a report which stated that only ‘a third of the population were completely healthy’.46 As a result, the Committee gave the slightly paradoxical recommendation that the number of hospital beds should be reduced, while at the same time claiming that the need for psychiatric services, including hospital services, was greater than the supply.47 In the end, the CMHW apparently expected that its suggestions for a shi from mental illness care to mental health work and a renewal of the legislation would guarantee the economic and social prerequisites for the enhanced mental wellbeing of the population at large. e patients were thought to be in need of support in order to be able to cope with the new freedom that would result from the prescribed dehospitalization. In the words of the Committee, ‘adding freedom demands adding more personnel. e locks should be replaced with human relationships.’48 Meaningful Life(!) By the mid-1990s, the process of reducing the number of hospital beds had already been underway for two decades.49 However, by the time the Men- tal Health Act of 1991 came into eect, Finland was facing deep recession. e subsequent administrative and budgetary restructuring of the Finnish welfare state during the early 1990s spelled trouble for mental health care, necessitating a renewed overview of policies.50 45 CMHW 1984a, 44. 46 CMHW 1984a, 171. 47 CMHW 1984a, 199. 48 CMHW 1984a, 87. 49 In the beginning of the process leading to the establishment of the Meaningful Life!-project, the estimated number of hospital beds was 6232. Nenonen, Mikko, Pelanteri, Simo & Rasilainen, Jouni (2000) Mielenterveyden häiriöiden hoito Suomessa 1978–1998. Helsinki: Stakes. 50 For a discussion of broader reforms in the context of the 1990s recession in Finland, see for example Sulkunen, Pekka (2006) ‘Projektiyhteiskunta ja uusi yhteiskuntasopimus’. In Rantala, Kati & Sulkunen, Pekka (eds) Projektiyhteiskunnan kääntöpuolia. Helsinki: Gaudeamus, 17–32; Julkunen 2001; Eskola 2007; Hyvönen 2008; Öhman 2003.       In 1996, the task of reviewing Finnish mental health care planning was given to Vappu Taipale’s one-person committee.51 Taipale’s work resulted in a memorandum entitled Meaningful Life.52 Taipale concluded that by 1996, Finnish dehospitalization had shied from ‘controlled change to uncon- trolled shutdown’.53 e reduction of the number of hospital beds had been even faster than planned, resulting in a situation where there were more patients than adequate spaces in the hospital wards.54 Taipale’s work was later expanded into a broader project, also known as Meaningful Life, but distinguished from Taipale’s memorandum by the addition of an exclamation mark to the project name. e Meaningful Life!- project delivered a number of reports which proposed further developing outpatient treatment as a way to remedy the negative eects of uncontrolled dehospitalization.55 While these suggestions turned against excessive hos- pital treatment, just as the NBOH and the CMHW had done before, the Meaningful Life!-project took an even stronger interest in international comparisons than either of these projects, noting that similar problems re- sulting from dehospitalization could be detected abroad.56 In her preceding memorandum, Taipale had even suggested that the challenges which con- fronted mental health planners internationally could provide an opportuni- ty for Finnish mental health care to establish itself as a pioneer in the eld.57 51 Born in 1940, Vappu Taipale, MD, a supporter of the Social Democratic Party and a participant in the so-called November movement (cf. footnote 9 above) in the late 1960s and early 1970s, had been a member of the CMHW in 1981–1982 and Minister for Social Aairs and Health in 1982–1984. In 1996, she was Director General of the Finnish National Research and Development Centre for Welfare and Health (STAKES). Rantala, Risto (1998) Kuka kukin on: henkilötietoja nykypolven suomalaisista. Helsinki: Otava. 52 e memorandum was based on hearings of 100 mental health care experts and citizens who were not individualized in the document. Taipale, Vappu (1996) Mielekäs elämä. Sosiaali- ja terveysministeriön työryhmämuistioita. Helsinki: Ministry of Social Aairs and Health. 53 Taipale 1996, 16. 54 Taipale 1996, 17. 55 According to the nal report of the project, 35 publications were published under the auspices of the project. Among them was so-called ‘grey literature’, polytechnic school theses, abstracts in conference proceedings, and public disseminations. In addition to Taipale’s report, three publica- tions of the Meaningful Life!-project have been selected for analysis here: MSAH (1997) Mielekäs elämä! -ohjelman esisuunnitelma: työryhmän muistio. Helsinki: Ministry of Social Aairs and Health; MSAH (2000) Mielekäs elämä: mielenterveyspalvelujen kehittämissuositukset. Helsinki: Ministry of Social Aairs and Health; Immonen, Tuula, Kiikkala, Irma & Ahonen, Juha (eds) (2003) Mielekäs elämä! -ohjelman loppuraportti. Helsinki: Ministry of Social Aairs and Health. 56 Taipale 1996, 13. 57 Taipale 1996, 11–12.       During the early 1990s, Finland experienced high unemployment rates due to recession, causing social exclusion and social problems as well as straining the resources of the welfare state. Paradoxically, the unemploy- ment security policy during the crisis increasingly emphasized the individu- al’s responsibility for making one’s living from wage work.58 In the beginning of the Meaningful Life!-project in 1996, the project still focused on develop- ing employment for people suering from mental health problems within sheltered work.59 Tellingly, by time the project came to an end in 2003, the emphasis had shied towards wage work.60 From the very beginning, the Meaningful Life!-project openly acknowl- edged the adverse social position of users of mental health care services compared to other citizens, noting that the shortcomings were ‘worse in mental health care than in any other sector’.61 A report published in 2000 stated that ‘[t]he mental health patients have not been guaranteed the same rights to good treatment according to their needs as other patient groups’, despite all earlier eorts to ensure parity in this regard.62 e images of the service user ranged in the publications of the Meaningful Life!-project from ‘mental health patients’ who should be protected from being abandoned in consequence of the dehospitalization policy to ‘rehabilitees’ who would mainly be responsible for their own rehabilitation.63 Yet, the need for sup- port to the latter was still to be taken into account: “In a patient-oriented operations model, the patients’ own responsi- bility for care should be supported. is must not, however, lead to failing to treat the patients that are severely disturbed or lack initia- tive; the treating professional must be active both in relation to the patient and the patient’s social network.”64 58 Outinen 2012; Kananen 2013. 59 Taipale 1996, 22. 60 Immonen, Ahonen & Kiikkala 2003, 93. 61 Taipale 1996, 46. 62 MSAH 2000, 7. 63 Taipale 1996; MSAH 2000, 10. 64 MSAH 2000, 12.       In line with the broadening of both the concept of mental health care as well as its intended target groups, the Meaningful Life!-project took an interest in ‘the meaningful life’ of all citizens, despite the fact that the project had originally started out from the need to focus on those suering from severe mental disorders.65 At the close of the project, mental ‘health care’ in terms of ‘service provision’ played a minor role, while widening ‘the under- standing of the wide nature of mental health care’ was seen as a core achieve- ment of the project.66 Mind 2009 In spring 2004 – only a year aer the Meaningful Life!-project had deliv- ered its nal report – a motion suggesting a new national mental health programme was presented in the Finnish Parliament. Initiated by Kirsi Ojansuu, an MP representing the Finnish Green League, the motion won exceptionally broad support, being signed by 106 of the 200 Members of Parliament. While the motion did not refer to the work of the Meaningful Life!-project, it revoked many of the concerns which had served as a starting point for the project in 1996, in particular by emphasizing the shortcomings of mental health care and addressing the imperfect implementation of the dehospitalization policy during the 1990s recession.67 In response to the broad political support for policy reform, the MSAH appointed the Mind 2009 working group in 2007, chaired by MSAH Assis- tant Director of Department, Master of Laws (trained on the bench) Marja- Liisa Partanen. e proposals of the Mind 2009 working group were pub- lished in 2009.68 At the time of writing, the plan is still being implemented.69 65 Taipale 1996, 41–42. 66 Immonen, Ahonen & Kiikkala 2003, 85. 67 Kansallinen mielenterveysohjelma [National Mental Health Programme] TPA 36/2004 vp. 68 e Mind 2009 working group had 14 members and organized six hearing events. MSAH [Ministry of Social Aairs and Health] (2009) Mielenterveys- ja päihdesuunnitelma. Mieli 2009 työryhmän ehdotuksen mielenterveys- ja päihdetyön kehittämiseksi vuoteen 2015. Helsinki: Ministry of Social Aairs and Health. 69 For an investigation on the implementation of the plan, see Kuussaari, Kristiina & Partanen, Airi (2010) ‘Administrative Challenges in the Finnish Alcohol and Drug Treatment System’. Nordic Studies on Alcohol and Drugs, Vol. 27, Issue 6, 667–684; Stenius, Kerstin, Kekki, Tuula, Kuussaari, Kristiina & Partanen, Airi (2012) ‘Päihde- ja mielenterveyspalveluiden integraatio – kirjava käytäntö Suomen kunnissa’. Yhteiskuntapolitiikka, Vol. 77, Issue 2, 167–175.       Again, the unequal position of mental health care service users was highlighted as a fundamental problem and the Mind 2009 working group argued in favour of treating the problems of mental health care service us- ers and substance abusers with the same diligence as the health problems of any other patient group. e lack of parity in the treatment of these groups was presented as a cause for both discrimination and stigmatization. But it was also suggested that this problem could be tackled with the education of care providers and decision-makers as well as by integrating mental health care with other forms of health and social care, in particular substance abuse care. While the plan published by the Mind 2009 working group has mostly been discussed with regard to its proposal to co-ordinate mental health care and substance abuse care, many of its other suggestions were similar to earli- er recommendations.70 For example, even though the number of psychiatric hospital beds had been considerably reduced in the preceding decades, the working group still regarded excessive hospital treatment as a major prob- lem: “e development of community care has played a secondary role, and there is a disproportionate focus on institutional treatment in mental health care and substance abuse care costs.”71 In this context, the Mind 2009 working group also identied the com- paratively high degree of involuntary psychiatric treatment in Finland as a specic problem. e high prevalence of involuntary treatment was seen as a specic problem by the Mind 2009 working group, which addressed those in need for mental health services in terms of ‘clients’ or ‘service us- ers’.72 e Mind 2009 working group envisioned the ideal service users as ac- tive clients, in need of strengthening their status, self-determination rights 70 Kuussaari & Partanen 2010. 71 MSAH (2010) Plan for Mental Health and Substance Abuse Work. Proposals of the Mieli 2009 Work- ing Group to Develop Mental Health and Substance Abuse Work Until 2015. Helsinki: Ministry of Social Aairs and Health, 9. 72 e original word in the Finnish version is asiakas, usually translated as ‘client’ but in the ocial translation this is translated as ‘service user’. MSAH 2009; MSAH 2010.      € and communities as well as improving their livelihood, while putting pres- sure on the mental health services to become more exible. In so doing, the working group apparently expected clients or service users to primarily rely upon their ‘own resources’.73 e role of ‘peer support’ and ‘user ex- perts’, was accentuated, and the opinion of the service user was to be taken into account even in the context of coercive measures.74 In line with this, the group also suggested a ‘psychiatric advance directive’ to be agreed upon when a person’s health status can be considered stable enough to allow for self-determination.75 Like the earlier plans and policy reviews, the Mind 2009 working group placed strong emphasis on working ability. e growing numbers of peo- ple who could not work due to mental health problems was seen as a main challenge.76 In response, the working group suggested that more attention should be paid to those in danger of losing their working capacity.77 is in turn lead the working group to emphasize the need for dening and, like both the CMHW and the Meaningful Life!-project, widening, the target population. e suggestion of the Mind 2009 working group was to integrate the problems to be addressed by mental health care and those to be taken care of through substance abuse care.78 e working group motivated this suggestion by pointing to the increase of simultaneous mental health and substance problems as well as the increased rate of alcohol-related deaths among the working-age population. Since the group with ‘dual diagnosis’ was growing, all the treatment in both sectors should ideally be planned and coordinated together.79 It may seem self-evident that psychiatric care should be planned in order to ensure that those in need get the required treatment. In the parliamentary 73 MSAH 2010, 10. 74 MSAH 2010, 18. 75 MSAH 2010, 19. 76 However, at the same time, another working group focussing on inability to work was created. MSAH (2011) MASTO-hankkeen (2008–2011) loppuraportti. Masennusperäisen työkyvyttömyyden vähentämiseen tähtäävän hankkeen toiminta ja ehdotukset. Helsinki: Ministry of Social Aairs and Health. 77 MSAH 2010, 41–42. 78 For discussion on the implementation of this aim, see Partanen & Kuussaari 2010; Stenius, Kekki, Kuussaari & Partanen 2012. 79 MSAH 2010.       motion of 2004, the central problem had been the lack of mental health ser- vices for those in need. Yet, as the Mind 2009 working group worked away on this problem, the working group nally settled on the need to reduce psychiatric hospital care and to support the target group’s autonomy as the central problem. By the end of the early 2000s, then, the notion of a need of mental health services, especially psychiatric hospital services, had largely withered away from the discussions. Conclusion: Who needs mental health services? Six distinct aspirations or aims tend to reverberate in the planning of the Finnish mental health care throughout the period between 1977 and 2009. All the plans have called for the need to limit excessive hospital treatment; to increase outpatient care in dierent forms; to promote mental health ser- vice users’ participation in working life; to ensure equality between mental health service users and other citizens; to provide mental health services in line with, or even surpassing, international standards; and to delineate the target group of the services. e recurrence of these aspirations has been so regular that they could well be considered revolving aims. If the other aims have then been remarkably stable over time, there was a more visible shi regarding the groups of persons that are to be included under the purview of mental health services. ese vacillations expanded the scope of individuals and issues discussed within the planning of mental health discourse. e need to provide services for the ‘right’ target group has also activated conicting aims in mental health planning. As the selection of target groups vary somewhat from plan to plan, the proposals may have had a certain impact upon the practice of mental health policy while the stated aims have remained largely the same over time. As the target group expanded, the plans may well have further fuelled the demand for more mental health services.80 e question of the target group also activated the issue of how the abili- ties, needs, and responsibilities of the service users were to be understood 80 Helén, Hämäläinen & Metteri 2011; Vilhelmsson, Andreas, Svensson, Tommy & Meeuwisse, Anna (2011) ‘Mental Ill Health, Public Health and Medicalization’. Public Health Ethics, Vol. 4, Issue 3, 207–217.       and cared for. A gradual change took place from ensuring the care of those most in need in the late 1970s, via support to rehabilitation and the mental health of the broader population as a whole in the 1980s and the 1990s, to reinforcing the mental health of the autonomous citizen in the early 2000s. Even though the widening of relevant target groups means that more and more citizens can be discussed within the sphere of mental health, the changing image from the ‘mentally ill’ person in need of mental care to the autonomous citizen requesting mental health services may add a new tangent to the context of planning mental health services as well as social services more generally; a decreasing emphasis on the need for services in favour of individual demands may also reect a decrease in the public re- sponsibility in providing for services. is emphasis on autonomy may be connected with Pekka Sulkunen’s conceptualization of the conict between autonomy and intimacy, ask- ing whether this emphasis on autonomy is wholly benecial if it leads to avoiding interventions and, in this case, the reduction of service provision. Sulkunen has argued that the emphasis on autonomy may lead to the pos- sible loss of dignity and marginalization of those unable to practise their sovereignty in the expected ways.81 ere may also be certain risks and counterproductive eects from expecting – or even demanding – ‘normal’ behaviour from those suering from mental health problems, as noted by Katarina Piuva.82 In a similar vein, Ilpo Helén has identied the risk that the attention to autonomy may lose track of that which was bothering the patient to begin with: An individual’s mental health problems may exactly relate to the person’s diculties in taking responsibility for his or her own well-being.83 To conclude, the results presented in this chapter may help to explain why Finnish mental health care has constantly been perceived as inadequate 81 Sulkunen, Pekka (2009) e Saturated Society: Governing Risk and Lifestyles in Consumer Culture. London: Sage; Sulkunen, Pekka (2011) ‘Autonomy Against Intimacy: On the Problem of Governing Lifestyle-related Risks’. Telos, Vol. 156, 99–112. 82 Piuva, Katarina (2005) Normalitetens gränser. En studie av 1900-talets mentalhygieniska diskurser. Stockholm: Institute for Social Work. 83 Helén 2011.       in recent decades. e reason is not only that the welfare state has changed, but also that the planning of mental health care has changed. Two new phe- nomena emerged in the state-level mental health plans: psychiatrization, understood as the problematization of the mental health of a widening population, and an increased emphasis on autonomy. e concurrence of these two developments helps to explain why the demand for mental health services has grown simultaneously, but faster, than the supply of services. In other words, the state-level planning of mental health care seems to have contributed to the impossibility of fullling the demand for mental health services in today’s Finland. 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MSAH [Ministry of Social Aairs and Health] (2010) Plan for Mental Health and Substance Abuse Work. Proposals of the Mieli 2009 Working Group to Develop Mental Health and Substance Abuse Work Until 2015. Helsinki: Ministry of Social Aairs and Health.       MSAH [Ministry of Social Aairs and Health] (2011) MASTO-hankkeen (2008–2011) lop- puraportti. Masennusperäisen työkyvyttömyyden vähentämiseen tähtäävän hankkeen toiminta ja ehdotukset. Helsinki: Ministry of Social Aairs and Health. Mustonen, Minna (2010) ‘Tästä aidasta nää ei voi enää mennä ylitte.’ Pro Lapinlahti -liik- keen yhteiskunnallinen mobilisaatio. Unpublished master’s thesis. Tampere: University of Tampere. NBOH [National Board of Health] (1977) Psykiatrisen terveydenhuollon kehittäminen. Psy- kiatrisen terveydenhuollon kehittämisohjelma 1977–1986. Helsinki: National Board of Health. NBOH [National Board of Health] (1981) Skitsofrenian tutkimus-, hoito-, ja kuntoutustyön valtakunnallinen kehittämisohjelma. Helsinki: National Board of Health. Nenonen, Mikko, Pelanteri, Simo & Rasilainen, Jouni (2000) Mielenterveyden häiriöiden hoito Suomessa 1978–1998. Helsinki: Stakes. Niemelä, Anna (2003) Laitoksista hallittuun vapauteen: Marraskuun liikkeen poikkeava, sosiaalinen kansalaisuus ja hallintarationaalisuus. Unpublished master’s thesis. Hel- sinki: University of Helsinki. Novella, Enric J. (2008) ‘eoretical Accounts on Deinstitutionalization and the Reform of Mental Health Services. A Critical Review’. Medicine, Healthcare and Philosophy, Vol. 11, Issue 3, 303–314. Öhman, Kaisa (2003) Mielenterveystyön reformi ja mielenterveyspotilaan sosiaalinen kansa- laisuus. Unpublished master’s thesis. Helsinki: University of Helsinki. Ollila, Eeva & Koivusalo, Meri (2009) ‘Hyvinvointipalvelusta liiketoiminnaksi – terve- ydenhuollon parantamisen tärkeät valinnat’. In Koivusalo, Meri, Alanko, Anna & Ollila, Eeva (eds) Kansalaisesta kuluttajaksi. Markkinat ja muutos terveydenhuollossa. Helsinki: Gaudeamus, 21–47. Outinen, Sami (2012) ‘Labour Market Activation in Finland in the 1990s: Workfare Re- forms and Labour Market Flexibilisation’. Local Economy, Vol. 27, Issue 5–6, 629–636. Pilgrim, David (2009) Key Concepts in Mental Health. 2nd edition. London: Sage. Piuva, Katarina (2005) Normalitetens gränser. En studie av 1900-talets mentalhygieniska diskurser. Stockholm: Institute for Social Work. Rantala, Risto (1998) Kuka kukin on: henkilötietoja nykypolven suomalaisista. Helsinki: Otava. Rose, Nikolas (2006) ‘Disorders Without Borders? e Expanding Scope of Psychiatric Practice’. BioSocieties, Vol. 1, Issue 4, 465–484. Salo, Markku (1996) Sietämisestä solidaarisuuteen. Mielisairaalareformit Suomessa ja Italias- sa. Tampere: Vastapaino. Scull, Andrew (1984) Decarceration. Community Treatment and the Deviant – A Radical View. 2nd edition. Cambridge: Polity Press. Shorter, Edward (1997) A History of Psychiatry. From the Era of the Asylum to the Age of Prozac. New York: John Wiley. Stenius, Kerstin, Kekki, Tuula, Kuussaari, Kristiina & Partanen, Airi (2012) ‘Päihde- ja mie- lenterveyspalveluiden integraatio – kirjava käytäntö Suomen kunnissa’. Yhteiskunta- politiikka, Vol. 77, Issue 2, 167–175. Sulkunen, Pekka (2006) ‘Projektiyhteiskunta ja uusi yhteiskuntasopimus’. In Rantala, Kati & Sulkunen, Pekka (eds) Projektiyhteiskunnan kääntöpuolia. Helsinki: Gaudeamus, 17–32. Sulkunen, Pekka (2009) e Saturated Society: Governing Risk and Lifestyles in Consumer Culture. London: Sage.       Sulkunen, Pekka (2011) ‘Autonomy Against Intimacy: On the Problem of Governing Lifestyle-Related Risks’. Telos, Vol. 156, 99–112. Taipale, Vappu (1996) Mielekäs elämä. Sosiaali- ja terveysministeriön työryhmämuistioita. Helsinki: Ministry of Social Aairs and Health. Tarkka, Jukka (1986) Kuka kukin on: henkilötietoja nykypolven suomalaisista. Helsinki: Otava. Tiitta, Allan (2009) Collegium Medicum. Lääkintöhallitus 1878–1991. Helsinki: National Institute for Welfare and Health. Vilhelmsson, Andreas, Svensson, Tommy & Meeuwisse, Anna (2011) ‘Mental Ill Health, Public Health and Medicalization’. Public Health Ethics, Vol. 4, Issue 3, 207–217.        Happy without money of their own? On the reasons for teenagers’ participation in paid work – e case of Iceland       Introduction In Western societies, children and teenagers are placed outside the economy and the sphere of production, but within the sphere of reproduction, i.e. the home and the school. is situation means that the age-group is supposed to passively receive economic resources from their adult guardians, and, hence, depend on them economically.1 Jens Qvortrup has argued that this arrangement is ahistorical and that in pre-industrial times children were placed within the economy and expected to do their part of the work from an early age.2 In the wake of industrialization, new ideas about the nature of children changed this expectation. Childhood was increasingly romanti- cized and seen as a state of some kind of heavenly innocence, where work had no place. A proper and happy childhood came to be conceived of as almost the opposite of adulthood: ‘If adults were burdened with responsi- bilities, children should be carefree. If adults worked, children should not work’.3 Emphasis was placed on all children being entitled to experience this 1 James, Allison, Jenks, Chris & Prout, Alan (1998) eorizing Childhood. Cambridge: Polity Press; Qvortrup, Jens (1995) ‘From Useful to Useful: e Historical Continuity of Children’s Constructive Participation’. Sociological Studies of Children, Vol. 7, 49–79; Qvortrup, Jens (2001) ‘School-work, Paid Work and the Changing Obligations of Childhood’. In Mizen, Phillip, Pole, Christopher & Bolton, Angela (eds) Hidden Hands: International Perspectives on Children’s Work and Labour. Lon- don: RoutledgeFalmer, 91–107. 2 Qvortrup 1995. 3 Cunningham, Hugh (1995) Children & Childhood in Western Society Since 1500. London and New York: Longman, 160.    kind of childhood, it was feared that if they had to work and toil, their child- hood would be an unhappy one, and it was even argued that by working, children simply lost their childhood.4 It is in accordance with this romantic construction of childhood to argue that, instead of undertaking work, children should spend their time play- ing and galloping around in nature. Nevertheless, the upsurge of bourgeois thinking and its domestic ideal during industrialization, as well as the de- mand from the new industry for an educated labour force, soon associated children with the home and the school, where they should spend their time in education and be protected and provided for by adults.5 To begin with, these new ideas of how children should spend their time were not uncontroversial and elicited strong debate. In the long run, how- ever, advocators of children spending their time at school instead of work gained the upper hand, and the placement of children within the sphere of reproduction was sanctied by legislation on child labour and compulsory education.6 Needless to say, child labour laws and laws on compulsory edu- cation were passed all around the industrialized world, and are still in exis- tence. Moreover, the placement of children within the sphere of reproduc- tion has been further sanctied, and universalized, by the United Nations Convention on the Rights of the Child (UNCRC) recognizing children’s special rights to education, protection and provision. Taken further, these special rights of children include the right not to work.7 4 Cunningham 1995; Hendrick, Harry (1997) ‘Constructions and Reconstructions of British Child- hood: An Interpretative Survey, 1800 to the Present’. In James, Allison & Prout, Alan (eds) Con- structing and Reconstructing Childhood: Contemporary Issues in the Sociological Study of Childhood. London, Philadelphia: RoutledgeFalmer, 34–62. 5 Cunningham 1995. 6 Cunningham 1995; de Coninck-Smith, Ning (1997) ‘e Struggle for the Child’s Time – At All Times: School and Children’s Work in Town and Country in Denmark from 1900 to the 1960s’. In de Coninck-Smith, Ning, Sandin, Bengt & Schrumpf, Ellen (eds) Industrious Children: Work and Child- hood in the Nordic Countries 1850–1990. Odense: Odense University Press, 129–159; Sandin, Bengt (1997) ‘“In the Large Factory Towns:” Child Labour Legislation, Child Labour and School Compul- sion’. In de Coninck-Smith, Ning, Sandin, Bengt & Schrumpf, Ellen (eds) Industrious Children: Work and Childhood in the Nordic Contries 1850–1990. Odense: Odense University Press, 17–46. 7 Weston, Burns H. & Teerink, Mark B. (2005) Rethinking Child Labor: A Multidimensional Human Rights Problem. In Weston, Burns H. (ed.) Child Labor and Human Rights: Making Children Matter. Boulder, CO: Lynne Rienner Publishers, xv–xxv.        Indeed, it has been a general belief that the Western World – the Nordic welfare states included – has succeeded in its eort of securing children the right not to work, and, hence, nowadays child work is usually associated with ‘old days and distant skies’, as the Norwegian sociologist Anne Sol- berg puts it.8 Also, their happiness and well-being is believed to be secured through the absence of work, and, hence, that their subjective well-being can be harmed by them undertaking any paid work.9 Employment of chil- dren and teenagers of any kind has, therefore, been problematized whereas various kinds of unpaid activities of the age-group – such as play, education and organized leisure activities – are believed to enhance their subjective well-being.10 Recently, the construction of a work-free childhood, and its vision of children as passive receivers, whether in the social, political or economic sense, has been challenged, however. Partly, this challenge comes from in- ternational law, as the UNCRC not only recognizes children’s special rights to education, protection and provision, but also their right to participation in society. It has been argued that children’s right of participation includes their right to work.11 Partly, this challenge is, however, academic. Within the disciplinary eld of childhood studies it is, therefore, recognized that children are active social agents in the present, and the recognition reaches all spheres of society, including the political and the economic.12 e recog- nition of children being economic agents in the present has not only yielded 8 Solberg, Anne (1994) Negotiating Childhood: Empirical Investigations and Textual Representations of Children’s Work and Everyday Life. Stockholm: Nordic Institute for Studies in Urban and Regional Planning, 19; see also McKechnie, Jim & Hobbs, Sandy (1999) ‘Child Labour: e View from the North.’ Childhood, Vol. 6, No. 1, 89–100. 9 Mortimer, Jeylan T. (2003) Working and Growing Up in America. Cambridge, Massachusetts: Har- vard University Press. 10 James, Jenks & Prout 1998. 11 Karl Hanson and Arne Vandaele point out that the right to work is twofold, as it includes both the right to employment and rights in work. e argument that the participation articles of the UNCRC involve the right to work has also been raised by Madeleine Leonard. See Hanson, Karl & Vandaele, Arne (2003) ‘Working Children and International Labour Law: A Critical Analysis’. e Interna- tional Journal of Children’s Rights, Vol. 11, 73–146; Leonard, Madeleine (2004) ‘Children’s Views on Children’s Right to Work’. Childhood, Vol. 11, No. 1, 45–61. 12 James, Allison & Prout, Alan (eds) (1990) Constructing and Reconstructing Childhood: Contemporary Issues in the Sociological Study of Childhood. London: e Falmer Press; Qvortrup, Jens, Corsaro, William A. & Honing, Michael-Sebastian (eds) (2009) e Palgrave Handbood of Childhood Studies. Basingstoke and New York: Palgrave Macmillan.   € the argument that most children’s daily activities – including their educa- tion – have some economic value, despite society usually not recognizing that value (at least not in the present),13 but also reveals that children under the age of 18 commonly undertake various kind of paid and unpaid work.14 For example, ndings from the UK,15 the US,16 as well as from the Nor- dic countries,17 all show that it is not uncommon for the young generation in these countries to undertake paid work. As the vast majority of the age group goes to school, and are indeed obliged to do so until they reach 16, it should not come as a surprise, however, that the work is usually exible part-time work and oen informal.18 e recognition of children’s and young people’s participation within the sphere of production sheds a light on the tension that can exists in their live between the (material) well-being the participation provides and the (subjective) well-being that the absence for work might provide. A step toward understanding the tension is to explore why the young generation undertakes paid work. e aim of this chapter is to seek some answers to that question from the perspective of childhood studies which argues both for children being social agents and worthy of study in their own right.19 Childhood studies have many Nordic advocators,20 but the question on the reasons behind child and teenage work is, nevertheless, under-researched in the Nordic contexts. In this chapter the question will be put in a Nordic con- text, however, by presenting ndings of a doctoral research on paid work of 13–17-year-old Icelanders. Both qualitative and quantitative methods were 13 Qvortrup 1995. 14 See for example Liebel, Manfred (2004) A Will of eir Own: Cross-Cultural Perspectives on Working Children. London & New York: Zed Books; Mizen, Phillip, Pole, Christopher & Bolton, Angela (eds) (2001b) Hidden Hands: International Perspectives on Children’s Work and Labour. London: Rout- ledgeFalmer; Mortimer 2003. 15 McKechnie & Hobbs 1999, 92. 16 Mortimer 2003. 17 Rafnsdóttir, Guðbjörg Linda (1999) Barn- och ungdomsarbete i Norden. Copenhagen: Nordic Coun- cil of Ministers. 18 Einarsdóttir, Margrét (forthcoming) Paid Work of Icelandic Children and Teenagers: Emphasis on Protection from Work or Rights In Work? Unpublished doctoral thesis. Reykjavík: University of Iceland. 19 James & Prout 1990; Qvortrup, Corsaro & Honing 2009. 20 See for example the Norwegian and Finnish sociologists Anne Solberg and Leena Alanen cited elsewhere in this chapter. An example of Nordic childhood studies can also be found in Brembeck, Helene, Johansson, Barbro & Kampmann, Jan (eds) (2004) Beyond the Competent Child: Exploring Contemporary Childhoods in the Nordic Welfare Societies. Roskilde: Roskilde University Press.        applied in the research and the teenagers were asked why they undertake paid work, how they spend their income, as well as how they evaluate that spending. In addition to the ndings on those child-centred questions, nd- ings on the association between paid work of young Icelanders and eco- nomic status of parents will be illustrated. Child and teenage work and economic deprivation of parents If viewed from the perspective of the construction of a work-free childhood, a reasonable answer to the question why children and teenagers in aŒuent societies undertake paid work could be that they only do so out of economic hardship, and hence, that the work is associated with economic deprivation of parents. is possibility has been addressed in some British and Ameri- can research.21 Findings from those British and American studies indicate that participation in paid work is not restricted to children from poor fami- lies.22 us, the research of Sue Middleton and Julia Loumidis has shown that British children in single parent families were less likely to hold a paid job than their counterparts living with two parents.23 Jeylan T. Mortimer draws the conclusion from ndings of American studies that most teenage workers in America are not poor.24 In fact, employed youth come dispropor- tionately from middle class families.25 Nevertheless, there are indicators of children from economically disadvantaged families working longer hours than children from aŒuent families, and of the importance of the child’s in- 21 However, as far as I know, it has not yet been researched in the Nordic context. 22 Hobbs, Sandy & McKechnie, Jim (1997) Child Employment in Britain. Edinburgh: e Stationery Oce; Middleton, Sue & Loumidis, Julia (2001) ‘Young People, Poverty and Part time Work’. In Mizen, Phillip, Pole, Christopher & Bolton, Angela (eds) Hidden Hands: International Perspectives on Chilren’s Work and Labour. London: Routledge Falmer Press, 24–36; Morrow, Virginia (1994) ‘Re- sponsible Children? Aspects of Children’s Work and Employment Outside School in Contemporary UK’. In Mayall, Berry (ed.) Children’s Childhoods Observed and Experienced. London & Washington, D.C.: Falmer Press, 128 143; Mortimer 2003; Schoenhals, Mark, Tienda, Marta & Schneider, Barbara (1998) ‘e Educational and Personal Consequences of Adolescent Employment’. Social Forces, Vol. 77, No. 2, 723–762. 23 Middleton & Loumidis 2001. 24 Mortimer 2003. 25 Mortimer 2003, 115.    come for poorer households.26 us, the research ndings of Middleton and Loumidis revealed that the average earnings of children from disadvantage families were three times greater as a share of family income (6 per cent) than those of young people from better o families (2 per cent). e authors point out that ‘[t]hese dierences are small in percentage terms but could be of great importance to the living standards of poorer families’.27 Commodied childhood and the social meaning of consumption e empirical fact of child and teenage work not being restricted to children from poor families suggests that the work might be connected to increasing materialism in Western societies and an upturn of the consumer society. Research that has looked into what child and teenage workers spend their income on corroborates the answer, at least at rst sight. us, research nd- ings reveal that only a small minority of Western child and teenage work- ers spend their money on things can be classied as absolute necessities, or contribute directly to their household.28 However, those ndings also shed a light on how debatable the question of the boundaries between necessities and luxuries is. us, are fashion clothes – items young workers sometimes spend their earnings on – necessities because they are clothes, or luxuries because they are fashion? What about toiletries and savings for the future as well as another items young workers in some instances spend their income on? 26 Marsh, Herbert W. & Kleitman, Sabina (2005) ‘Consequences of Employment During High School: Character Building, Subversion of Academic Goals, or a reshold?’ American Educational Research Journal, Vol. 42, No. 2, 331–369; Middleton & Loumidis 2001; Schoenhals, Tienda & Schneider 1998. 27 Middleton & Loumidis 2001, 31. 28 Einarsdóttir, Margrét (2004) Bara eitthvað sem krakkar gera til þess að vinna sér inn pening: Sjónar- horn blaðburðarbarna á vinnu sína sett í stærra sögulegt og félagslegt samhengi. Unpublished master’s thesis. Reykjavík: University of Iceland; Howieson, Cathy, McKechnie, Jim & Semple, Sheila (2006) e Nature and Implications of the Part-time Employment of Secondary Schools Pupils. Edinburgh: Scottish Executive Social Research, e Department of Enterprise, Transport and Lifelong Learning; Ingenhorst, Heinz (2001) ‘Child Labour in the Federal Republic of Germany’. In Mizen, Phillip, Pole, Christopher & Bolton, Angela (eds) Hidden Hands: International Perspectives on Children’s Work and Labour. London: RoutledgeFalmer, 139–148; Mizen, Phillip, Pole, Christopher & Bolton, Angela (2001a) ‘Why Be a School Age Worker?’ In Mizen, Phillip, Pole, Christopher & Bolton, Angela (eds) Hidden Hands: International Perspectives on Children’s Work and Labour. London: RoutledgeFalmer, 37–54; Mortimer 2003.        An attempt is oen made in political and academic discussion to dene the line between necessities and luxuries in either relative or absolute terms, but ‘[a]ll in all, a standard of living, whether an absolute or a relative one, is always based on a subjective evaluation’.29 Such subjective evaluation of what is a necessity and what is not has been salient in academic discussion on the spending patterns of child and teenage workers. In their writing on part- time work of American high school students in the 1980s, Ellen Greenberg- er and Laurence D. Steinberg, for example, set their own absolute criteria for necessities when they argue that the work of students, whose work is not motivated by their parents’ economic hardship, is a ‘luxury youth employ- ment’ as well as when they argue that the young workers’ spending on things like clothing, stereo equipment, music, movies, recreation, hobbies, and car expenses is ‘discretionary spending’.30 Phillip Mizen, Christopher Pole, and Angela Bolton, on the other hand, view similar spending of British school- age workers as necessities in the consumer society they live in:31 [T]he decision to work cannot be viewed as the simple choice to con- sume but rather represents a necessary act on the part of many chil- dren if they are to merely participate in many of the ‘normal’ routines of childhood. It is no longer the case that children’s and teenagers’ leisure activities are mostly free. On the contrary, their leisure has been reconstituted into new and increasingly commodied forms dictated by the market, whose only entry requirement is the pos- session of money. For those children for whom money is something dicult to come by, the search for some sort of wage is one of the few viable alternatives.32 29 Sturluson, Jón Þór, Eydal, Guðný, & Ólafsson, Andrés Júlíus (2011) Íslensk neysluviðmið. Reykjavík: Velferðarráðuneyti, 5. 30 Greenberger, Ellen & Steinberg, Laurence D. (1986) When Teenagers Work: e Psycological and Social Costs of Adolesent Employment. New York: Basic Boooks, 74, 75. 31 Mizen, Phillip, Pole, Christopher & Bolton, Angela (1999) ‘School Age Workers: e Paid Employ- ment of Children in Britain’. Work, Employment and Society, Vol. 13, No. 3, 423–438; Mizen, Pole & Bolton 2001a. 32 Mizen, Pole & Bolton 1999, 433.    e argument of ‘commodied childhood’ brings up the theory of the social meaning of consumption; not only has it been theorized that con- sumption of activities and goods is embedded in the social in general, but also that the consumption may be especially important in the social life of teenagers.33 Research that has looked into the social and symbolic meaning of teenagers’ consumption of goods like brand clothes and makeup conrm the theory.34 Moreover, Elin Olsson’s study shows that among Swedish teen- agers (aged 10–18) economic resources, both in terms of the resources of the household and the teen’s own resources, are positively associated with social relations of peers.35 Nevertheless, in the research, the young people own economic resources were not directly linked to an income of their own, but simply dened as accessibility to cash. e standpoint of children e importance that consumption can have in the life of the young gen- eration suggests the possibility of evaluating the spending from the view- point of child and teenage workers themselves, as does the child-centred argument of childhood studies.36 Jeylan T. Mortimer heads in that direc- tion when she points out that teenagers’ denitions of ‘discretionary spend- ing’ may vary considerably from adults’ denitions of the concept. She puts her argument forward in the context of the question of car ownership and argues that: ‘whereas car ownership on the part of an adolescent may be considered, from an adult standpoint, as a discretionary item, the situation may be perceived quite dierently by a teenager who needs the car to go to school, to attend various social activities, and to get to work’.37 In her writing 33 Piacentini, Maria & Mailer, Greig (2004) ‘Symbolic Consumption in Teenagers’ Clothing Choices’. Journal of Consumer Behaviour, Vol. 3, No. 3, 251–262; Olsson, Elin (2007) ‘e Economic Side of Social Relations: Household Poverty, Adolescents’ Own Resources and Peer Relations’. European Sociological Review, Vol. 23, No. 4, 471–485. 34 Piacentini & Mailer 2004; Gentina, Elodie, Palan, Kay M. & Fosse-Gomez, Marie-Hélène (2012) ‘e Practice of Using Makeup: A Consumption Ritual of Adolescent Girls’. Journal of Consumer Behaviour, Vol. 11, No. 2, 115–123. 35 Olsson 2007. 36 Alanen, Leena (1994) ‘Gender and Generation: Feminism and the “Child Question”’. In Qvortrup, Jens, Bardy, Marjatta, Sgritta, Giovanni & Witersberger, Helmut (eds), Childhood Matters: Social eory, Practice and Politics. Aldershot: Avebury, 27–42; James & Prout 1990. 37 Mortimer 2003, 118.        on part-time work of American high school students, however, Mortimer does not present any ndings on how the young workers themselves evalu- ate their spending, and it remains dicult to assess how Western child and teenage workers evaluate their spending. Western child and teenage workers have, however, been questioned on why they undertake paid work (though, once again, the subject is under-re- searched in the Nordic context, to my best knowledge). e ndings indicate that the money the young workers earn is the main reason for the work.38 ese ndings corroborate that there is some connection between child and teenage work and a ‘commodied childhood’, but, notably, these ndings also reveal that the monetary reasons are not the only reasons children and teenagers give to explain why they participate in paid work.39 us, employ- ment and career opportunities (including gaining work experience),40 so- cializing and having fun,41 as well as independence,42 have been recognized as motivating children and teenagers to undertake paid work. It is worth noticing that research ndings indicate interplay between the monetary reasons and the independence reasons; it being the independent income of paid work that enables the young workers to take a step towards their au- tonomy.43 us, Mizen, Pole, and Bolton draw the conclusion from their re- search among British school-age workers that earning money increased the young workers ‘spending power’ as the money enabled them to buy things their parents disapproved of, such as cigarettes, alcohol, and makeup, and that the power ‘brought with it a discernible shi in relations with parents and family’.44 38 Einarsdóttir 2004; Howieson, McKechnie & Semple 2006; Ingenhorst 2001; Mizen, Pole & Bolton 2001a; Mortimer 2003. 39 Besen, Yasemin (2006) ‘Exploitation or Fun? e Lived Experience of Teenage Employment in Suburban America’. Journal of Contemporary Ethnography, Vol. 35, No. 3, 319–340; Einarsdóttir 2004; Howieson, McKechnie & Semple 2006; Hungerland, Beatrice, Liebel, Manfred, Liesecke, Anja & Wihstutz, Anna (2007) ‘Paths To Participatory Autonomy: e Meanings of Work for Children in Germany’. Childhood, Vol. 14, No. 2, 257–277; Mizen, Pole & Bolton 2001a. 40 Howieson, McKechnie & Semple 2006; Hungerland, Liebel, Liesecke & Wihstutz 2007; Mortimer 2003. 41 Besen 2006; Hungerland, Liebel, Liesecke & Wihstutz 2007; Mizen, Pole & Bolton 2001a. 42 Einarsdóttir 2004; Howieson, McKechnie & Semple 2006; Hungerland, Liebel, Liesecke & Wihstutz 2007; Mizen, Pole & Bolton 2001a. 43 Hungerland, Liebel, Liesecke & Wihstutz 2007; Mizen, Pole & Bolton 2001a. 44 Mizen, Pole & Bolton 2001a, 44–45.    Methods e aim of the research presented here is to analyze why children and teen- agers undertake paid work despite their acknowledged right not to work in a Nordic context by exploring the reasons behind paid work of Icelan- dic children and teenagers. Despite Iceland being one of the Nordic coun- tries, the country deviates from the other Nordic countries in some aspects. e country had no compulsory school system until the beginning of the twentieth century and school summer holidays were relatively long.45 Ólöf Garðarsdóttir puts the long summer holidays in context with an annual need of the country’s main industry in the twentieth century, i.e. the sh in- dustry, of a reserve army, and argues that this need fuelled a positive attitude towards child and teenage work in the country.46 Indeed, participation in summer work is exceptionally common in Iceland; the research of Guðbjörg Linda Rafnsdóttir’s research from the late 1990s has shown that 92 per cent of 13–17-year-old Icelanders undertook paid summer work compared to 70 per cent of their Danish, 42 per cent of their Norwegian and Finnish, and 35 per cent of their Swedish counterparts.47 On the other hand, the research also revealed that the prevalence of term-time work was not exceptional in Iceland, and indeed much lower than in Denmark (but on a par with Nor- way and Finland). Also, term-time work of Icelandic students is commonly problematized.48 erefore, I infer that child and teenage work in Iceland does not dier in essence to child and teenage work in the other Nordic countries. e data presented in this chapter originates in my doctoral research on paid work of young Icelanders, aged 13–17. e research design and the conduct of the research were based on two methodological approaches, 45 More than three months, but shortened to circa nine weeks in elementary school at the beginning of this century. 46 Garðarsdóttir, Ólöf (1997) ‘Working Children in Urban Iceland 1930–1990’. In de Coninck-Smith, Ning, Sandin, Bengt & Schrumpf, Ellen (eds) Industrious Children: Work and Childhood in the Nordic Countries 1850–1990. Odense: Odense University Press, 160–185. 47 Rafnsdóttir 1999. 48 Ólafsson, Hannes Í., Þorgeirsdóttir, Björk & Gíslason, Garðar (2006) Vinna framhaldsskólanema með námi: Könnun gerð í þremur framhaldsskólum á höfðuðborgarsvæðinu vorið 2005. Online. Available HTTP: (accessed August 2012); Sigurðardóttir, Guðríður & Karlsson, Þorlákur (1991) Göfgar vinna með námi? Niðurstöður rannsóknar á þáttum tengdum vetrarvinnu framhaldsskólanema. Reykjavík: Rannsóknarstofnun uppeldis- og menntamála.        rstly, the approach of research with children, and secondly, the approach of mixed methods research. e approach of research with children is the methodological counterpart of childhood studies, and in addition to the premises of children and young people holding social agency, its frames of reference include the involvement (participation) of young people in the research; the suitability of the research methods; as well as an awareness of ethical issues within child research.49 e approach of mixed methods research is, on the other hand, based on the pragmatic stance of the research questions determining the methods, not vice versa.50 As the questions of the doctoral research that is presented here called upon both qualitative and quantitative methods both types of data was collected. e quantitative part of the research constituted of a comprehensive sur- vey on child and youth work. Together the sample constituted of 2000 Ice- landers aged 13–17, randomly selected from the Icelandic Register of Per- sons. Totally, 952 young people responded, thus, the response rate was 48.8 per cent. e qualitative part of the research constitute on the other hand, of group interviews with around forty 13–18 years old Icelandic teenagers, of both sexes, and with various social and economic background, who all had at least some experience of paid work. e group of the interviews were relatively small, between two and ve young people participated in each, and the participants in each group knew each other beforehand, in some instances they were close friends, in other instances class or school mates. e research was conducted during the peak of the 2000s economic boom in Iceland, and enquired, on the one hand, on paid work during the summer of 2007, and, on the other hand, on term–time work during the school year of 2007–2008. 49 See for example Alderson, Perscilla & Morrow, Virginia (2004) Ethics, Social Research and Consulting with Children and Young People. Barkingside: Barnardo’s; Christensen, Pia & James, Allison (2008) Research with Children: Perspectives and Practices. New York and London: Routledge. 50 See for example Johnson, R. Burke & Onwuegbuzie, Anthony J. (2004) ‘Mixed Methods Research: A Research Paradigm Whose Time Has Come’. Educational Researcher, Vol. 33, No. 7, 14–26; Tashak- kori, Abbas & Teddlie, Charles (eds) (2003) Handbook of Mixed Methods In Social & Behaviorial Research. ousand Oaks, CA: Sage Publication.    Advocators of the mixed methods research disagree on whether the mix- ing should occur at all stages of the research process, only at the last stage of interpretation of the data and the writing of the result, or somewhere be- tween.51 In this research the argument of Janice M. Morse ‘that each method must be complete in itself; that is, all methods used must meet appropriate criteria for rigor’, and that the mixing should therefore only be conducted at the last stage of the research was taken into account.52 Hence, the quantita- tive and the qualitative data were analysed separately, and the ndings only mixed during the stage of writing. Because of the commonality of summer work in Iceland the main fo- cus of the results presented below is on why some Icelandic children and teenagers undertake term-time work, and what they spend their term-time earning on. Findings from both the qualitative and the quantitative part of the research are discussed. Results In total, 49 per cent of the respondents of the survey reported participating in paid term-time work during the school year 2007–2008; thereof 29 per cent reported being in regular employment and 20 per cent working irregu- larly. More than half of the term-time workers reported holding a term-time job in the retail sector. In total, 84 per cent of the respondents reported working during the summer of 2007, most commonly in the work-schools run by most municipalities in Iceland. e respondents who reported par- ticipating in term-time work were asked why they worked during term- time. e participants of the group interviews were also asked why they participate in paid work. e ndings of these quantitative and qualitative enquires are presented below. 51 Johnson, R. Burke, Onwuegbuzie, Anthony J. & Turner, Lisa A. (2007) ‘Toward a Denition of Mixed Methods Research’. Journal of Mixed Methods Research, Vol. 1, No. 2, 112–133. 52 Morse, Janice M. (1991) ‘Approaches to Quantitative-Qualitative Methodological Triangulation’. Nursing Research, Vol. 40, No. 2, 120–123.        e reasons behind term-time work of Icelandic teenagers e results on the question regarding why respondents of the quantitative research participate in term-time work are presented in Table 1. e ques- tion was asked in a multiple choice format; i.e. each respondent could mark more than one option. e results head in the same direction as other re- search ndings on the issue, and reveal the importance of monetary rea- sons for child and teenage work. erefore, the vast majority, or 86 per cent, reported that they had a term-time job because they wanted to earn some money. e results illustrated in Table 1 are also in accordance with other re- search results regarding that, whereas monetary reasons are the key reasons behind child and teenage work, they are nevertheless not the only reasons. erefore, a third of the respondents mark the option ‘to gain work experi- ence for the future’, one out of three reported working to be able to get things their parents were not willing, or not able, to provide, and a quarter reported having term-time work because they wanted to have enough to do. Gender dierence is only prominent in the option of ‘saving for expensive things’. us, while half of the boys work to be able to save for expensive things, this is the case for only one out of four girls. e dierence is statistically signicant.53 ‘Just the money’ Findings from the group interviews concur with the results of the quantita- tive part of the research regarding the fact that monetary reasons are the main reason for working. us, the vast majority of the participants of the group interviews answered the question regarding why they work during the school year, with remarks like ‘it’s the money’, ‘just the money’, and ‘just because I needed the money’. ese answers are reminiscent of the answers I received in some former research on the subject, both in relation to the money being the most common answer, as well as in relation to the adverb ‘just’ frequently being added in the answer.54 53 χ2(1)=4.28, p<.05 54 ‘Just’ is a translation of the Icelandic work ‘bara’. I got answers like ‘bara peningurinn’, ‘út af þvi, bara, mig vantaði pening’, and ‘bara aukapeningurinn’. Einarsdóttir 2004.   € ‘To have something to do’ Also, the ndings of the group interviews head in the same direction as the results of the survey regarding the possibility of other reasons than the monetary one motivating term-time work of Icelandic teenagers. us, both work ethics and independence emerged as important themes in the analysis of the interview, although, notably, a concern about future work experience did not. ese reasons were, nevertheless, seldom the rst reasons brought up by the participants when asked why they participated in term-time work, but rather a further explanation of the nancial reason. is becomes clear in the answer of Valdemar. He gave his answer aer my rearmation of the monetary reasons being the only reason for working, and, emphasized the requisite for being industrious: ...I would just nd it rather awkward not to be working anywhere, to be doing nothing. Just, when you come home from school, just go home and do nothing. Table 1. Reasons for term-time work of Icelandic teenagers (in per cent). Reason Percentage To earn some money 86 To save for something expensive (i.e. computer, travel abroad) 43 To gain some work experience for the future 33 To get or do things my parents are not willing, or not able, to provide for 30 To have enough to do 25 My parents think I should work 16 To have as much spending money as my peers 15 Wanted to try how it is to work during term-time 10 Because everyone else works during term-time 2 Other reasons 11 Total 271 N: 411        Emphasis on being industrious appears in the account of some other participants of the group interviews and one girl even argued that she rst and foremost works during term-time because she ‘doesn’t have anything better to do’. ‘It’s terribly boring asking your mum for money’ e group interviews reveal that some of the participants, especially the younger ones, are more or less dependent on their family nancially, and may, therefore, be perceived as being economic recipients, rather than eco- nomic providers. us, the accounts of some of the participants who were still in compulsory education reveal that not only were they dependent on their parents and/or other family members in relation to food and shel- ter, but also more or less in relation to savings and money for spending. None reported receiving ‘pocket money’ from their parents, but quite a few recounted that they ‘just own money’. My enquiry into the origin of that money revealed that a part of it might be income from odd jobs, like occa- sional babysitting, but it could also be a birthday gi and/or savings from an amount of money a parent has given the child with the purpose of spending it on food in school, on school journeys, etcetera. e accounts of other participants of the group interviews, especially the older ones, reveal, on the other hand, that at some point the economic equilibrium between the generations is disturbed. e young individuals begin taking on the role of an economic provider, and their journey into economic independence begins. It is worth noting that, not only did this independence surface in some of the participants emphasizing that they wanted to decide by themselves what to do and what to buy, but also, and more commonly, in the participants emphasizing that they did not want to be a burden on their parents. e perception, that at some stage in the life course it is not proper for an individual to ask the parents for money for spending anymore, and, con- sequently, that the individual needs some income of his/her own appeared as an important theme in the group interviews. e perception is apparent in this discussion between two 17-year-old girls:    Erla: But, you know, I think that just no one wants to ask her mum for money, it is just... Bára:...yes... Erla: ... it is just wrong, or, you know. Bára: Just hopeless. Erla: Not when you have become old enough to be able to work. Bára: You know, you could get away with it when you were younger because it is so ‘smallish’, but now, when you are older and you are asking about 3000 krona to go to a disco, no, you don’t do that. Erla: Yea, exactly. e group interviews reveal more instances of participants describing their unease, or unwillingness, to ask their parents for money. ey appear in comments like ‘I don’t want to ask my mum for some money’ and ‘I think it’s terribly boring asking your mum for some money’. Some participants used stronger words than ‘ask for’, and, instead, talked about ‘begging for money’ or ‘mooching money’ from their parents.55 One participant even lik- ened teenagers that do not take up a term-time job to parasites. e other participants of that particular group interview did not oppose his words. ‘Fun kids’ Socializing and fun did not appear as an important motivation of the par- ticipants to take up a job. Nevertheless, the analysis of the group interviews reveals that the young Icelanders do not consider socializing and fun as un- important. Indeed, the ndings of the group interviews reveal that it is im- portant for many of them not to be bored, and that socializing with friends, or other people they nd amusing, and having fun are strongly connected. e connection between having fun and socializing with friends has been identied in other research.56 When I asked Sigrún, who works in a super- market, whether she considers it important that the supermarket is mostly occupied with teenagers, she replied: ‘it is more fun’, and her friend Ugla continues: 55 e Icelandic words used here were ‘biðja’, ‘belta’, and ‘sníkja’. 56 Besen 2006; Hungerland, Liebel, Liesecke & Wihstutz 2007.        Ugla: Of course, if you are just working alone with old ladies, or grown up women, it would just be like oh no! Margrét: Boring? Ugla: Yea. e group interviews provide examples of the importance of socializing and fun aecting both the decision to carry on in a job they have started, and the decision where to apply for a job at a time of a great supply of part- time jobs. Þórður, for example, found his supermarket job boring to begin with, and states that he only stayed in the job because his friend worked there too. When the friend quit, a girl from school started working in the supermarket and gave Þórður some company. at and the fact that he had also got used to the job reduced the boredom. Similarly, Embla got a sum- mer job in a supermarket and could have stayed there aer the school start- ed but decided not to: It was just that I didn’t nd it that much fun working in the super- market, because there were so many old people working there. ere was no one of my age that I could talk to (laughter). She decided to apply for a term-time job in a kiosk where most of the sta was her age, and got that job. e spending patterns of Icelandic term-time workers e research results presented in Table 2 reveal that it is most common for 13–17-year-old Icelandic term-time workers to use their term-time income as ‘pocket money’. More than two thirds of the term-time workers marked that option. Also, slightly less than half of the term-time workers use their income to ‘save for certain expensive things, i.e. a computer, bicycle or to travel abroad’. Both options could be classied as ‘discretional spending’, e.g. if one accepts the denition of Greenberger and Steinberg that spending that can be classied as part of a commodied childhood is ‘discretional’.57 57 Greenberger & Steinberg 1986.    However, the results do not indicate that the young workers only spend their income on certain trivial things. Slightly less than three quarters spend their money on clothes for themselves, more than half saves for the future, and a h uses their income to buy schoolbooks. A tenth of the term-time workers reported paying for expenses related to organized leisure activities, slightly less than a tenth reported buying food for the household, and 7 per cent reported paying their school fees. A small fraction of the term-time workers, or 1.5 per cent, reported using their income to pay an allowance to their parents. Gender dierence is notable in relation to both saving for expensive things and purchasing clothes. e dierence is statistically signicant in both instances.58 e gender dierence in terms of purchasing clothes is particularly salient. Whilst 73 per cent of the girls reported using their term-time income to buy clothes for themselves, only 43 per cent of the boys 58 Purchasing clothes: χ2(1)=32.62, p<.01. Saving for an expensive thing: χ2(1)=4.60, p<.05. Table 2. How Icelandic teenagers spend their term-time income (in per cent). Spending Percentage Pocket money (i.e. to pay for sweets, pizza, movies) 68 Buy clothes for myself 63 Save for the future 54 Save for a certain expensive thing (i.e. a computer, travel) 45 Pay for schoolbooks 19 Pay for organized leisure activities 10 Buy food for the home 9 Pay school fees 7 Pay an allowance to my parent(s) 2 Other 8 Total 285 N: 389        did so. e boys are, on the other hand, more likely to use their term-time income to save for expensive things than the girls. e dierence is, though, not as salient as before, or 52 per cent compared to 41 per cent. e age dierence in relation to the expenses as illustrated in Figure 1, of which all can be classied as necessities, is worth further attention. e gure shows that it is exceptional for the 13-year-olds to use their income to pay for leisure activities, schoolbooks, school fees, and/or to buy food for the home, but that the commonality of paying for those expenses grows with age, although the steepness of the growth varies. us, 45 per cent of the 17-year-olds use their term-time work to pay for school books, 21 per cent to buy food for the home, 19 per cent to pay for school fees, and 16 per cent to pay for organized leisure activities. e age dierence in rela- tion to school books and school fees can, at least partly, be explained by the fact that, in Iceland, upper-secondary students have to buy their textbooks and pay a small fee to their school, whereas compulsory students have not. For the youngest term-time workers to use their income to buy clothes for themselves is not as uncommon as for them to use it on other necessities; 32 per cent report doing so, but the frequency of the expense rises rapidly with age and has reached 72 per cent in the oldest year. In all instances, the age dierence is statistically signicant. ese ndings on the growing participation of young workers in pur- chasing necessities as their age rises are compatible with the ndings of the group interview, presented above, on the interplay between young people undertaking paid work on the one hand and gaining independence on the other. ‘Just something’ Group interviews are not a very suitable for collecting information on in- dividual spending as they do not allow for a detailed mapping of every par- ticipant’s behaviour. In the case of the present study, the mapping became even more dicult as the participants’ incomes varied considerably; some had only earned relatively low amounts during the summer (less than 50 000 ISK), while others ranged from having no or an irregular income during the    school year to having a relatively high and regular income all year around (more than 50 000 ISK per month during term-time added to the summer income). Nevertheless, the analysis of the group interviews of the present research provides some relevant results on the issue. e group interviews do not provide detailed answers on how the par- ticipants spend the part of their income that turned into ‘pocket money’. us, in many instances a direct enquiry of mine on the subject provoked unclear answers like ‘just something’ and ‘just to have some money during the winter’. Nevertheless, the inference can be made from the interviews that young Icelanders use at least part of their income on things like lunch at school, eating out, going to the cinema, the mall, and/or a disco. Figure 1. Percentage of Icelandic term-time workers spending their income on certain necessities, in relation to age. 80 70 60 50 40 30 20 10 0 17-year- olds 16-year- olds 15-year- olds 14-year- olds 13-year- olds % Figure 1. Percentage of Icelandic term-time workers spending their income on certain necessities, in relation to age. Organised leisure activities Clothes for myself Food for the home School fees School books        e car e data provides more detailed information on other spending patterns than the data dealing with ephemeral recreational activities. us, the nd- ings from the qualitative research head in the same direction as the result of the survey and reveal that it is common for Icelandic teenagers to save for certain expensive things. e group interviews gave, therefore, examples of young workers saving for both a computer and to travel abroad. Surpris- ingly, however, by far the most common purpose of these savings was for a car. Moreover, the 17-year-old age limit for a driving licence meant that among the oldest participants, this car-saving had turned into a spending, as some of them had already bought a car. Interestingly, the group interviews gave more than one example of young Icelanders that had bought a car sev- eral months before they turned 17. e ndings reveal that driving and car- ownership entail more expenses than just the purchasing of the car itself. erefore, a few of the participants mentioned that they needed money to pay for driving lessons and a driving licence, and ‘of course that costs a lot’, others said that they needed money to pay for the petrol, and a few had bought a more expensive car than their savings allowed for, and were at the time of the interview, therefore, paying o a loan. Interestingly, none men- tioned paying for the insurance of the car and the annual car tax in Iceland. Possibly, it is a common habit of Icelandic parents to pay the insurance of their child’s car. e commonality of car ownership and car expenses among the partici- pants of the group interviews elicit the question as to whether this spend- ing is a discretionary luxury or not. e majority of the participants of the group interviews would not have given a positive answer to the question. erefore, many of the participants, especially the ones living either in the suburbs of Reykjavík or outside the capital area, argued that it was dicult to do anything without a car, and gave several examples of their daily activi- ties being encumbered by the long distances and limited service of public transport in Iceland. ese examples included both school attendance and organized sport activities. is argument concurs with Mortimer’s argu- ment regarding the fact that many American teenagers probably do not    agree that their car expenses are discretional.59 Long distances and a limited public transport service are also features of American society, and in that respect Icelandic and American teenagers probably have more in common than Icelandic and many European teenagers.60 ‘Always buying everything myself ’ e ndings of the group interviews reveal, like the results of the survey, that it is not uncommon for Icelandic teenagers to use part of their income on things that are reasonable to dene as necessities. Firstly, the majority of the participants reported buying clothes for themselves. eir accounts reveal, however, that it diers whether they only buy clothes they fancy or all the clothes they need. erefore, Kristín reported mainly using her earnings on ‘food and clothes’, although only fast food and food in school, and all the clothes she needs unless: Kristín: ...the money is gone. Yes, also if I need something, a coat or something, then my mum buys it. Margrét: Yes, so your parents buy the more expensive clothes, shoes, and so on? Kristín: Yes, and these extra things that I need but don’t bother buy- ing myself. e friends Erla and Bára, on the other hand, bought nearly all the clothes they need themselves. ey only got clothes from their parents on special occasions, i.e. as a birthday or Christmas present or if their mothers wanted to show their aection to their daughter by inviting her to go shop- ping. Secondly, a minority of the participants reported paying for some other necessities than clothes. erefore, there were instances of term-time work- ers paying for at least some of the expenses related to their organized lei- sure activities, and moreover, of term-time workers reporting ‘always pay- 59 Mortimer 2003. 60 Moreover, Reykjavík, the capital of Iceland, is a relatively new city, mostly constructed since the Second World War, and designed for cars rather than pedestrians.        ing everything for myself ’. ese workers argued that in addition to ‘pocket money’ they paid for all their clothes, for books they needed for school, for school fees as well as for food for the household if they bought the grocer- ies themselves: ‘You know, if you go by yourself to the grocery shop then you pay for the food with your own money’. ese groups of teenagers also argued that if they wanted something special for dinner then they had to pay for it themselves. Notably, though, none of the participants of the group interviews reported paying for their own housing. To control one’s spending by saving Some of the participants of the group interviews described that they were not able to save their earnings, and that they did not really know what they spent their income on. e money they earn somehow just ‘goes in one hand and out of the other’. On the other hand, other participants reported saving almost all, or at least some part, of their earnings. Saving with the purpose of purchasing a certain expensive thing has already been mentioned, but the group interviews also gave several examples of young Icelandic workers that put part of their earnings into a future fund and/or controlled their spending by saving. e examples of 14-year-old Ásbjörn and 17-year-old eódór il- lustrate this. Ásbjörn has a regular term-time job and can earn a substantial amount each month. With the help of his mother, he controls how he spends his earnings through dierent kinds of savings opportunities: I got maybe 45 000 [ISK] for the last month, then 10 000 goes into a bank account, and my mum puts maybe 20 000 into a future fund, and then something onto the debit card. e 10 000-per-month-saving was earmarked for the purchase of a car and the amount which was put onto the debit card account was for daily use. eódór has had a regular income for several years, and has controlled his spending in a similar way, though without any help from his parents. For some years he put a certain amount every mouth into a ‘car fund’ that enabled him to buy his rst car at the age of 16. At the time of the interview he had exchanged that car for a more expensive one.   € ‘Just some extra needs’? e ndings of the group interviews not only reveal variations with regard to the way the participants use their income on necessities; they also re- veal the dierent views of the participants towards the needs of teenagers. erefore, some of the term-time workers argued that they needed the in- come because ‘it is not possible to do anything here unless you pay for it’. ese young workers agreed with the argument of Mizen, Pole, and Bolton of a commodied childhood, albeit not being familiar with the academic discourse.61 However, the opinion was also expressed by some of the par- ticipants that most of the things the term-time workers used their earnings on were only some unnecessary ‘extra needs’, as this discussion in one of the group interviews sheds light on: Margrét: Do you want to add something to the research that I have not enquired about yet? Something you think I should have asked you about? Ísak: No, or maybe just that you don’t need to work during term-time if you don’t want to. Kristín: You need to, anyway. Ísak: No, I mean, you buy clothes [he is addressing Kristín], and he buys a car [he is addressing the other boy participating in the in- terview]. I own nothing, I mean, of course I own some clothes, you see, just because I worked during the summer, something easy. But you don’t need to work during term-time. Unless you intend to buy lunch in every lunch break in school and buy a car instead of taking the bus. Findings of the quantitative part of the research on why some Icelandic teenagers choose not to undertake a term-time work, not presented in detail here, head in the same direction as these qualitative ndings, and reveal that a part of Icelandic teenagers decide not to work during term-time because they do not have the time and/or rather want to concentrate on their studies. 61 Mizen, Pole & Bolton 1999.        Association with educational status of parents In former research on the association between the extent of child and youth work and the socioeconomic status of parents, dierent indicators of the so- cioeconomic status (SES) of the parents have been applied.62 Here, the sum- mation of education of both the mother and father is used as an indicator of the SES of parents. us, the respondents were classied into three groups: of both parents who have only nished primary education; of both parents with tertiary education; and of other combinations of parents’ education (one with primary education, the other with secondary education, one with primary and the other with tertiary education, etcetera). e association of parental education with three indicators of employment status was ana- lysed: with participation of summer work; with the level of employment in term-time work; and with the purchasing of certain necessities. Firstly, the result shows that children of parents with tertiary education are less likely to participate in summer work than the children of parents with a lesser education, but that the association disappears amongst the young people who have nished their compulsory education aer control- ling for age. In other words, the results indicate that it is more common for children of parents with a tertiary education to be older when they start working during the summer than it is for children of parents with a lesser education. Secondly, the results reveal that pupils of parents with a tertiary educa- tion are less likely to undertake term-time work than pupils of parents with a lesser education; that those children of parents with a tertiary education who undertake term-time work are less likely to be in intensive (>12 hours per week) and regular term-time work than their counterparts of parents with a lesser education, and that the association persists aer controlling for age. irdly, the results reveal that children of parents with a tertiary educa- tion are less likely to spend their term-time income on two or more of the following necessities: schoolbooks, school fees, food for the household; and 62 Inter alia family form and income support, parental education and family income, and economic level of school areas. Middleton & Loumidis 2001; Mortimer 2003; Morrow 1994.    allowances to their parents, than children of parents with a lesser education. is result must, however, be taken with the precaution that the association disappears aer controlling for age. Interestingly, the results do not indicate any association of the educational status of parents with purchasing of cloth- ing, nor with paying for organized leisure activities. A possible explanation of the research not indicating any association between purchasing of cloth- ing and educational status of parents is that it did not discriminate between dierent types of clothing. It is, therefore, possible that children of worse-o parents prefer to spend their income on practical clothing than better-o children. e non-association with paying for organized leisure activities is not as easily explained. Conclusion In modern Western societies childhood has been seen as a period without work and responsibility, and hence a period of dependency; in other words as the opposite of adulthood. It has been feared that if children take on adult responsibilities, such as work, their childhood will be an unhappy one and their (subjective) well-being will be at risk.63 is construction of a work- free childhood has been further sanctied in legislation on child labour and compulsory education. Moreover, the construction has been universalized in the UNCRC provisions on children’s rights to protection, provision, and education as well as the derivate right not to work.64 It has been a general belief that this arrangement and its placement of children outside the sphere of production has made child work a thing of the past and hence the well- being of children secured in developed societies.65 However, research on the prevalence of paid work in this part of the world does not support the belief of child and teenage work being a phenomenon of the past in Western soci- eties. It reveals the commonality of children and teenagers undertaking paid work, although the work is usually part-time, exible, and oen informal.66 Participation of Icelandic youths in paid work is sometimes thought to 63 Cunningham 1995. 64 Weston & Teerink 2005. 65 McKechnie & Hobbs 1999. 66 Einarsdóttir forthcoming.        be exceptionally high. Research on the extent of paid work of Nordic teenag- ers conrms that the participation of young Icelanders is, indeed, exception- ally high regarding summer work, but also that their undertaking of work does not stand out when it comes to term-time work.67 But why do Western children and teenagers undertake paid work, de- spite they supposedly having the right not to? A feasible answer from the perspective of the discourse of a work-free childhood is that the work is restricted to those with parents in economic hardship. e connection be- tween child and teenage work and economic deprivation of parents is un- der-researched in the Nordic contexts, but existing American research nd- ings indicate that young American workers disproportionately come from middle class families.68 e association between educational status of par- ents and paid work of Icelandic teenagers was also examined in the research presented here. ese ndings do not concur with the ndings of American studies, but indicate a negative association between educational status of parents and teenage work, and, hence, indicates a connection between child and teenage work and economic deprivation of parents. Nevertheless, be- fore more nite conclusions are made, the association need further exami- nation, not only in the Icelandic context but in the Nordic context as well. Likewise, more examination is needed regarding the connection between child and teenage work and the upturn of consumerism in Western societ- ies. e social meaning of consumption has been recognized, and there is empirical evidence of consumption playing a special role in the social life of teenagers.69 Also, British researchers argue for a connection between child and teenage work and the emergence of a ‘commodied childhood’ in the UK, but their research reveals that school-age workers in the UK use their income to consume the products, services, or experiences that are required as part of commodied childhood.70 However, the discussion on consumption and materialism brings forth the debate as to where the line between absolute and relative poverty, be- 67 Rafnsdóttir 1999. 68 Mortimer 2003. 69 Piacentini & Mailer 2004. 70 Mizen, Pole & Bolton 1999; Mizen, Pole & Bolton 2001a.    tween necessities and luxuries, lies. In a recent report on the Icelandic stan- dard of living, it is pointed out that a standard of living is always based on subjective evaluation.71 One possibility of evaluating the spending patterns of young workers is therefore to view it from the standpoint of the young people themselves. is approach has guided the present research, as the young Icelanders who participated in it were asked about their evaluation of their spending as well as why they undertake paid term-time work. e ndings revealed that Icelandic teenagers do not deviate from their counterparts in other Western countries regarding the money they earn by their work as being the main reason behind the work. Importantly, the re- search also shows that the young workers commonly spend their income on things some would dene as discretionary luxury – even on a car. Many of the participants would not use this evaluation, but considered such spend- ing as a necessity in the life of (Icelandic) teenager. e ndings also reveal that it is not uncommon for Icelandic teenagers, especially the older ones, to spend their income on things that most would classify as necessities, i.e. school-related items and food. I conclude from my ndings that having and spending money of their own is an important part of the young people’s journey towards autonomy and independence from parents, including from the parents’ economic sta- tus. us, many of the participants stated that at a certain age it is not proper to ‘beg your mum for money’ any longer, and some emphasized that they did not want to be a burden on their parents. However, my ndings also reveal that the young generation is not a homogeneous group, but have dif- ferent views on how much spending money a young person needs to have in order to be able to participate in normal teenage life. us, some do not regard consumption that important factor in their social life, and choose not to work during term-time but focus on their education and leisure time activities instead. is choice brings up the question about the tension that exist in the life of children and teenagers between their (material) well-being that paid 71 Sturluson, Eydal & Ólafsson 2011.        work can provide and their (subjective) well-being gained though their ab- sence of work. ere has been a tendency within the Western construction of a work-free childhood to ignore the existence of such a tension, but to the extent that this tension has been acknowledged, a one-way solution has been suggested: Child and teenage work has been seen as problematic and, hence, it has been suggested that it would be in the best interest of the young generation not to work. However, the empirical fact of the commonality of child and teenage work in Western societies cannot be ignored and neither can the viewpoints of young people that, for one reason or another, undertake paid work and earn their own money. eir work and their income can enrich not only their material but also their social and psychological well-being, and the question must be raised if more emphasis should be placed on the right of the young generation right to work – meaning not only the right to employ- ment but also rights in work (decent work condition, decent pay, etcetera) than at present.72 Simultaneously, it must be considered that increasing em- phasis on children and teenagers having the right to work, might involve the danger of the young generation losing their right not to work, and the ad- vantages and protection that this right can (or at least should) bring to them. References Alanen, Leena (1994) ‘Gender and Generation: Feminism and the “Child Question”’. In Qvortrup, Jens, Bardy, Marjatta, Sgritta, Giovanni & Witersberger, Helmut (eds), Childhood Matters: Social eory, Practice and Politics. Aldershot: Avebury, 27–42. Alderson, Perscilla & Morrow, Virginia (2004) Ethics, Social Research and Consulting with Children and Young People. Barkingside: Barnardo’s. Besen, Yasemin (2006) ‘Exploitation or Fun? e Lived Experience of Teenage Employment in Suburban America’. Journal of Contemporary Ethnography, Vol. 35, No. 3, 319–340. Brembeck, Helene, Johansson, Barbro & Kampmann, Jan (eds) (2004) Beyond the Com- petent Child: Exploring Contemporary Childhoods in the Nordic Welfare Societies. Roskilde: Roskilde University Press. 72 Hanson & Vandaele 2003.    Christensen, Pia & James, Allison (2008) Research with Children: Perspectives and Practices. New York and London: Routledge. Cunningham, Hugh (1995) Children & Childhood in Western Society Since 1500. London and New York: Longman. de Coninck-Smith, Ning (1997) ‘e Struggle for the Child’s Time – At All Times: School and Children’s Work in Town and Country in Denmark from 1900 to the 1960s’. In de Coninck-Smith, Ning, Sandin, Bengt & Schrumpf, Ellen (eds) Industrious Children: Work and Childhood in the Nordic Countries 1850–1990. Odense: Odense University Press, 129–159. Einarsdóttir, Margrét (2004) Bara eitthvað sem krakkar gera til þess að vinna sér inn pening: Sjónarhorn blaðburðarbarna á vinnu sína sett í stærra sögulegt og félagslegt samhengi. Unpublished master’s thesis. Reykjavík: University of Iceland. Einarsdóttir, Margrét (forthcoming) Paid Work of Icelandic Children and Teenagers: Emphasis on Protection from Work or Rights In Work? Unpublished doctoral thesis. Reykjavík: University of Iceland. Garðarsdóttir, Ólöf (1997) ‘Working Children in Urban Iceland 1930–1990’. In de Coninck- Smith, Ning, Sandin, Bengt & Schrumpf, Ellen (eds) Industrious Children: Work and Childhood in the Nordic Countries 1850–1990. Odense: Odense University Press, 160–185. Gentina, Elodie, Palan, Kay M. & Fosse-Gomez, Marie-Hélène (2012) ‘e Practice of Using Makeup: A Consumption Ritual of Adolescent Girls’. Journal of Consumer Behaviour, Vol. 11, No. 2, 115–123. Greenberger, Ellen & Steinberg, Laurence D. (1986) When Teenagers Work: e Psycological and Social Costs of Adolesent Employment. New York: Basic Boooks. Hanson, Karl & Vandaele, Arne (2003) ‘Working Children and International Labour Law: A Critical Analysis’. e International Journal of Children’s Rights, Vol. 11, 73–146. Hendrick, Harry (1997) ‘Constructions and Reconstructions of British Childhood: An Interpretative Survey, 1800 to the Present’. In James, Allison & Prout, Alan (eds) Constructing and Reconstructing Childhood: Contemporary Issues in the Sociological Study of Childhood. London and Philadelphia: RoutledgeFalmer, 34–62. Hobbs, Sandy & McKechnie, Jim (1997) Child Employment in Britain. Edinburgh: e Stationery Oce. Howieson, Cathy, McKechnie, Jim & Semple, Sheila (2006) e Nature and Implications of the Part-time Employment of Secondary Schools Pupils. Edinburgh: Scottish Executive Social Research, e Department of Enterprise, Transport and Lifelong Learning. Hungerland, Beatrice, Liebel, Manfred, Liesecke, Anja & Wihstutz, Anna (2007) ‘Paths To Participatory Autonomy: e Meanings of Work for Children in Germany’. Child- hood, Vol. 14, No. 2, 257–277. Ingenhorst, Heinz (2001) ‘Child Labour in the Federal Republic of Germany’. In Mizen, Phillip, Pole, Christopher & Bolton, Angela (eds) Hidden Hands: International Perspectives on Children’s Work and Labour. London: RoutledgeFalmer, 139–148. James, Allison, Jenks, Chris & Prout, Alan (1998) eorizing Childhood. Cambridge: Polity Press. James, Allison & Prout, Alan (eds) (1990) Constructing and Reconstructing Childhood: Con- temporary Issues in the Sociological Study of Childhood. London: Falmer Press. Johnson, R. Burke & Onwuegbuzie, Anthony J. (2004) ‘Mixed Methods Research: A Research Paradigm Whose Time Has Come’. Educational Researcher, Vol. 33, No. 7, 14–26.        Johnson, R. Burke, Onwuegbuzie, Anthony J. & Turner, Lisa A. (2007) ‘Toward a Denition of Mixed Methods Research’. Journal of Mixed Methods Research, Vol. 1, No. 2, 112–133. Leonard, Madeleine (2004) ‘Children’s Views on Children’s Right to Work’. Childhood, Vol. 11, No. 1, 45–61. Liebel, Manfred (2004) A Will of eir Own: Cross-Cultural Perspectives on Working Children. London & New York: Zed Books. Marsh, Herbert W. & Kleitman, Sabina (2005) ‘Consequences of Employment During High School: Character Building, Subversion of Academic Goals, or a reshold?’ Ameri- can Educational Research Journal, Vol. 42, No. 2, 331–369 Mayall, Berry (2000) ‘Conversations with Children: Working with Generational Issues’. In Christensen, Pia & James, Allison (eds) Research with Children: Perspectives and Practices. London & New York: Falmer Press, 120–135. McKechnie, Jim & Hobbs, Sandy (1999) ‘Child Labour: e View from the North.’ Child- hood, Vol. 6, No. 1, 89–100. Middleton, Sue & Loumidis, Julia (2001) ‘Young People, Poverty and Part-time Work’. In Mizen, Phillip, Pole, Christopher & Bolton, Angela (eds) Hidden Hands: International Perspectives on Chilren’s Work and Labour. London: RoutledgeFalmer, 24–36. Mizen, Phillip, Pole, Christopher & Bolton, Angela (1999) ‘School Age Workers: e Paid Employment of Children in Britain’. Work, Employment and Society, Vol. 13, No. 3, 423–438. Mizen, Phillip, Pole, Christopher & Bolton, Angela (2001a) ‘Why Be a School Age Worker?’ In Mizen, Phillip, Pole, Christopher & Bolton, Angela (eds) Hidden Hands: Interna- tional Perspectives on Children’s Work and Labour. London: RoutledgeFalmer, 37–54. Mizen, Phillip, Pole, Christopher & Bolton, Angela (eds) (2001b) Hidden Hands: Internatio- nal Perspectives on Children’s Work and Labour. London: RoutledgeFalmer. Morrow, Virginia (1994) ‘Responsible Children? Aspects of Children’s Work and Emp- loyment Outside School in Contemporary UK’. In Mayall, Berry (ed.) Children’s Childhoods Observed and Experienced. London & Washington, D.C.: Falmer Press, 128–143. Morse, Janice M. (1991) ‘Approaches to Quantitative-Qualitative Methodological Triangu- lation’. Nursing Research, Vol. 40, No. 2, 120–123. Mortimer, Jeylan T. (2003) Working and Growing up in America. Cambridge, Massachu- setts: Harvard University Press. Olsson, Elin (2007) ‘e Economic Side of Social Relations: Household Poverty, Adoles- cents’ Own Resources and Peer Relations’. European Sociological Review, Vol. 23, No. 4, 471–485. Ólafsson, Hannes Í., Þorgeirsdóttir, Björk & Gíslason, Garðar (2006) Vinna framhaldsskó- lanema með námi: Könnun gerð í þremur framhaldsskólum á höfðuðborgarsvæðinu vorið 2005. Online. Available HTTP: (accessed August 2012) Piacentini, Maria & Mailer, Greig (2004) ‘Symbolic Consumption in Teenagers’ Clothing Choices’. Journal of Consumer Behaviour, Vol. 3, No. 3, 251–262. Qvortrup, Jens (1995) ‘From Useful to Useful: e Historical Continuity of Children’s Constructive Participation’. Sociological Studies of Children, Vol. 7, 49–79. Qvortrup, Jens (2001) ‘School-work, Paid Work and the Changing Obligations of Child- hood’. In Mizen, Phillip, Pole, Christopher & Bolton, Angela (eds) Hidden Hands: International Perspectives on Children’s Work and Labour. London: RoutledgeFalmer, 91–107.    Qvortrup, Jens, Corsaro, William A. & Honing, Michael-Sebastian (eds) (2009) e Palgra- ve Handbood of Childhood Studies. Basingstoke and New York: Palgrave Macmillan. Rafnsdóttir, Guðbjörg Linda (1999) Barn- och ungdomsarbete i Norden. Copenhagen: Nordic Council of Ministers. Sandin, Bengt (1997) ‘“In the Large Factory Towns:” Child Labour Legislation, Child Labour and School Compulsion’. In de Coninck-Smith, Ning, Sandin, Bengt & Schrumpf, Ellen (eds) Industrious Children: Work and Childhood in the Nordic Cont- ries 1850–1990. Odense: Odense University Press, 17–46. Schoenhals, Mark, Tienda, Marta & Schneider, Barbara (1998) ‘e Educational and Perso- nal Consequences of Adolescent Employment’. Social Forces, Vol. 77, No. 2, 723–762. Sigurðardóttir, Guðríður & Karlsson, Þorlákur (1991) Göfgar vinna með námi? Niðurstöður rannsóknar á þáttum tengdum vetrarvinnu framhaldsskólanema. Reykjavík: Rannsók- narstofnun uppeldis- og menntamála. Solberg, Anne (1994) Negotiating Childhood: Empirical Investigations and Textual Represen- tations of Children’s Work and Everyday Life. Stockholm: Nordic Institute for Studies in Urban and Regional Planning. Sturluson, Jón Þór, Eydal, Guðný, & Ólafsson, Andrés Júlíus (2011) Íslensk neysluviðmið. Reykjavík: Velferðarráðuneyti. Tashakkori, Abbas & Teddlie, Charles (eds) (2003) Handbook of Mixed Methods In Social & Behaviorial Research. ousand Oaks, CA: Sage Publication. Weston, Burns H. & Teerink, Mark B. (2005) Rethinking Child Labor: A Multidimentional Human Rights Problems. In Weston, Burns H. (ed.) Child Labor and Human Rights: Making Children Matter. Boulder, CO: Lynne Rienner Publishers.              Somewhere over the high seas there is a land of my dreams – Happiness and life satisfac- tion among immigrants in Europe1   Introduction e history of Homo sapiens is a history of constant movement. If we are creationists and believe in the Bible, the rst emigrants forced out of their home were Adam and Eve. ose two ancestors of ours, expelled from their garden as such, were the start of the future trajectories for humankind that – according to evolutionists – has moved from Olduvai Gorge to the highest peak of Terra del Fuego to the banks of Bering Strait. Sometimes moves have been motivated by the search for a better life or a sheer desire for adventure and excitement. Sometimes moves are forced by violent armies or extreme poverty, hunger, disease and threat of premature death. Worldwide, there are by now about 220 million people living outside their own country. Out of those movers, some 50 million reside within the boundaries of the Eu- ropean Union (EU), of which 30 million come from outside the EU and 20 million have their country of origin in some other EU member state. 1 e title of the paper is inspired by the most famous and melancholic Finnish tango written and composed by Unto Mononen in 1955. e lyrics of the tango tell about a desire to move overseas to a happy country of fairytales. us, the allusions in the title t very well to my former position as an H. C. Andersen Professor in the happy country of Denmark. I became interested in the happiness of immigrants while working as H.C. Andersen Professor at the Centre of Welfare State Research, Uni- versity of Southern Denmark. My Danish colleague Klaus Petersen once asked me whether a Finn becomes happier when moving to Denmark, the country that is oen depicted to be the happiest country in the world. is study is a humble attempt to answer Klaus’s inquiry. I want to thank Wim van Oorschot and other participants of the ISA RC-19 annual meeting in Oslo for their valuable comments on the rst dra of the article.   € A common procedure in welfare research is to trace dierences between welfare states and welfare regimes. Following Gøsta Esping-Andersen’s seminal work, social scientists have clustered countries according to social policy institutions. Initially, three separate models of welfare capitalism existed: the Social Democratic (Nordic/Scandinavian), the Liberal (Anglo- Saxon) and the Conservative (Continental/Central European).2 Later, two other models were added to the list: the South-European and Post-Socialist.3 Welfare state models are a handy tool for social scientists to use to ex- plain almost all social phenomena when applied to regimes in dierent do- mains: e.g. the incidence of poverty and social exclusion, employment and unemployment, gender equality and woman-friendliness, dominance and privilege, birth and death, health and sickness, opinions and attitudes etcet- era.4 e aim of this chapter is to expand the eld of application and take a look at happiness and life-satisfaction among those 50 million or so immi- grants that have their new homes in Europe. e views of happiness and its importance to social research vary.5 Some critical analysts argue that happiness is an individually generated state of mind, i.e. a subjective feeling and hence not a real thing. As such, it is not a proper object for scientic inquiry. However, psychologists, armed with fan- cy brain probing devices, have discovered that happiness is a specic kind of electric activity in the frontal part of the brain. us, happiness obviously is a real and scientically measurable thing. From the social science point of view, the key question to ask pertains to the kind of phenomena that cause 2 Esping-Andersen, Gøsta (1990) ree Worlds of Welfare Capitalism. Cambridge: Polity Press. 3 For a more detailed discussion on welfare state models and their characteristics, see Castles, Francis, Leibfried, Stephan, Lewis, Jane, Obinger, Herbert & Pierson, Christopher (eds) (2010) e Oxford Handbook of the Welfare State. Oxford: Oxford University Press. 4 For overviews on the research eld, see for example Leira, Arnlaug (2002) Working Parents and the Welfare State. Cambridge: Cambridge University Press; Ferrarini, Tommy (2006) Families, States and Labour Markets. Institutions, Causes and Consequences of Family Policy in Post-War Welfare States. Cheltenham: Edward Elgar; Wilkinson, Richard G. & Pickett, Kate (2008) ‘Income Inequality and Socioeconomic Gradients in Mortality’. American Journal of Public Health, Vol. 98, No. 4, 699–704; Cooke, Lynn Prince (2011) Gender-Class Equality in Political Economies. New York & London: Routledge; Kvist, Jon, Fritzell, Johan, Hvinden, Björn & Kangas, Olli (eds) (2012) Changing Social Equality: e Nordic Welfare Model in the 21st Century. Bristol: Policy Press; Svallfors, Stefan (ed.) (2012) Contested Welfare States. Welfare Attitudes in Europe and Beyond. Stanford: Stanford Univer- sity Press. 5 Layard, Richard (2006) Happiness. Lessons from a New Science. London: Penguin Books; Saari, Juho (2012) Onnellisuuspolitiikka. Helsinki: Kalevi Sorsa Säätiö.              those positive electric waves in the brain. As there are plenty of reasons to explain happiness and misery, it is little wonder that a growing plethora of competing explanations exist pertaining to the preconditions for a happy life. ere are also a growing number of studies on immigrants and their hap- piness. For example, the academic journal Social Indicators Research launched a special issue on the subjective well-being of immigrants in Europe.6 From our point of view, the intriguing question deals with the extent to which, if any, that the level of life-satisfaction and happiness of immigrants varies between the ve dierent welfare state regimes. We ask whether there are systematic dierences between the welfare states and welfare regimes and how immigrants coming from dierent regimes evaluate their happiness in their new surroundings. What is the role of the prosperity of the country of residence? How important are other contextual factors such as income dis- tribution and the level of social protection? What about gender dierences between regimes? Given the discussion of the woman-friendly welfare state, we could for example expect that the Nordic countries, in particular, should contribute towards life-satisfaction among female migrants. How strongly do the individual characteristics of immigrants – age, gender, health, in- come, employment status and social networks aect their life-satisfaction? We are also interested to know whether relationships between explanatory variables and happiness vary between dierent welfare state regimes. e structure of the chapter is as follows. e next section depicts a broader theoretical frame of reference that this study is linked to. ereaer, a section on previous studies in the eld is presented, which also species more detailed research tasks. is is then followed by a section dealing with the data and methods used. e section entitled Happy immigrants live in happy countries presents the main analyses and empirical ndings, and the nal section discusses the results obtained. 6 Clark, Andrew, Sauger, Nicholas & Senik, Claudia (2009) ‘Welfare, Well-Being and Immigration in Europe: Evidence from the European Social Survey’. Social Indicators Research, Vol. 91, No. 3, 299–426; see also Eurostat (2011) Migrants in Europe: A Statistical Portrait of the First and Second Generation. Luxembourg: Eurostat; Senik, Claudia (2011) The French Unhappiness Puzzle: e Cultural Dimension of Happiness. Paris: Paris School of Economics.    General starting points: Individualistic and collectivistic ap- proaches to happiness Happiness has made a phenomenal entry into the high chambers of scien- tic inquiry. So social scientists are not the only ones to be thrilled about studying happiness today; hard-core economists and natural scientists are so as well.7 Needless to say, the search for happiness takes place in dier- ent domains and by dierent methods depending on the discipline of the scholar. While a psychologist would search for signs of happiness in the dorso- lateral prefrontal cortex of the brain, using electroencephalogram and posi- tron emission tomography,8 a social scientist would apply surveys and ask people how happy they feel. Although the approaches may seem very distant from each other, it has been shown that there is also a close correspond- ence between electrical activities in the le front of the brain – indicating happiness – and people’s own opinion of their state of mind.9 Whereas the psychologist tries to trace electrical waves, the issue for the social scientist is to discover the societal contexts and conditions that actually cause that positive electrical brain activity in the rst place. e possible link between an individual’s physiological status, social po- sition and the characteristics of the society he/she lives in has been widely discussed by epidemiologists, and the conclusion has been that social fac- tors – income, employment, our position in social hierarchy, social relations, 7 Veenhoven, Ruut (1984) Conditions of Happiness. Dortrecht: Riedel; Veenhoven, Ruut (2002) ‘Why Social Policy Needs Subjective Indicators’ Social Indicators Research, Vol. 58, Issue 1, 33–45; Layard, Richard (2006) Happiness. Lessons from a New Science. London: Penguin Books; Bok, Derek (2010) e Politics of Happiness – What Governments Can Learn from the New Research on Well-Being. Princeton: Princeton University Press; Saari 2012; see also the contribution by Carl Marklund in this volume. 8 Davidson, Richard D. (2004) ‘Wellbeing and Aective Style Neural Substrates and Bio behavioural Correlates’. Philosophical Transactions of the Royal Society B: Biological Sciences, Vol. 359, 1395–1411. 9 Layard 2006, 11–21.              etcetera – are of importance for our health.10 Whereas an advantageous po- sition in society has a multiplier eect leading to better education, better income and health, as well as to a longer and happier life, in a disadvanta- geous position harmful things tend to accumulate: low educational attain- ment, low income, health problems, lower experienced happiness, and life expectancy that is years behind that of people in better positions in society. Within social sciences and between political camps there are substantial dierences in the interpretations of the social prerequisites of misery and happiness. With some simplication, we can distinguish two main sets of explanations – and a vast grey area between them – that have bearing for this study. First, in the individualistic perspective, happiness is deeply re- garded as an individual phenomenon that is achieved by individuals them- selves. As such, individual freedom is set into focus, which also dictates the subsequent role of the national state and sets limits for state actions. In this approach, which originates with the ideas of classical liberals, the state is seen to exercise its jurisdiction through coercion that is oensive to peo- ple’s autonomy. For example, the government levies taxes, which cuts into people’s personal resources and limits their personal freedom and thus their possibilities to choose. Liberty begins where the state ends; liberty is only realizable in the private sphere, not in the area of public policy.11 In order to maximize liberty, and hence to trigger individual happiness, the activities and tasks of the state should be limited. For example, when it comes to eco- nomic growth and prosperity, oen regarded as the best determinants for a happy life, the most important issue is to create growth and a high Gross Domestic Product (GDP), whereas the distribution of prosperity is second- ary. People are happy if they live in a rich country regardless of the inequal- 10 Marmot, Michael (1996) ‘e Social Pattern of Health and Disease’. In Blane, David, Brunner, Eric & Wilkinson, Richard G. (eds) Health and Social Organizations. London: Routledge, 42–67; Marmot, Michael (2002) ‘e Inuence of Income on Health: Views of an Epidemiologist’. Health Aairs, Vol. 21, No. 1, 31–46; Kawachi, Ichiro & Kennedy, Bruce P. (2006) e Health of Nations: Why Inequality Is Harmful to Your Health. New York: New Press; Wilkinson, Richard G. & Pickett, Kate (2009) e Spirit Level. Why Greater Equality Makes Societies Stronger. New York, Berlin & London: Blooms- bury Press; Bachans, Mona (2011) Gender Policy and Gender Equality in Public Health Perspective. Stockholm: Karolinska Institutet. 11 Hayek, Friedrich (1960) e Constitution of Liberty. London: Routledge; Nozick, Robert (1979) Anarchy, State and Utopia. Oxford: Blackwell.    ity concerning how the wealth in the country is distributed. is kind of political attitude supposedly underpins right-wing welfare thinking and in particular the social policy making in the US. e second view is more collectivistic. Here, the interpretation of human beings, their happiness and other conditions of living are dened contextu- ally, in relation to the prevailing standards in the society where they live. In contrast to the individualist approach, the collectivist tradition also pays attention to distributional issues: not only is the level of prosperity impor- tant, even more important is how evenly prosperity is distributed. Equality is better for everyone, as Richard G. Wilkinson and Kate Pickett argue in an inuential book, entitled e Spirit Level.12 e overarching theme of the collectivist tradition deals with the re- sources and possibilities society oers to its members. is idea has been an explicit starting point in the Nordic welfare state studies and the very same idea is making a new entry in the clothing of the new social invest- ment welfare state.13 e main idea has been to measure welfare with the help of the resources individuals have at their disposal. For example, in the Swedish level of living surveys, well-being was measured on nine compo- nents: health, employment, economic resources, knowledge and education, social integration, housing and neighbourhood, security of life and prop- erty, recreation and culture as well as political resources.14 e crucial point deals with the extent to which people have command over resources, while not that much attention was paid to subjective well-being. In his compara- tive project, Erik Allardt partially utilized the Swedish approach but shied focus more towards the level of need-satisfaction described by the catch- 12 Wilkinson & Pickett 2009. 13 Allardt, Erik (1975) Att ha, att älska, att vara. Om välfärd i Norden. Lund: Argos; Allardt, Erik (1993) ‘Having, Loving and Being: An Alternative to the Swedish Model of Welfare Research’. In Nussbaum, Martha & Sen, Amartya (eds) e Quality of Life. Oxford: Clarendon Press, 88–94; Ringen, Stein (1987) e Possibility of Politics. Oxford: e Clarendon Press; Erikson, Robert & Uusitalo, Hannu (1987) ‘e Scandinavian Approach to Welfare Research’. In Erikson, Robert, Hansen Erik-Jørgen, Ringen, Stein & Uusitalo, Hannu (eds) e Scandinavian Model. Welfare State and Welfare Research. Armonk, New York & London: M.E. Sharpe, 177–193; and, more recently, Morel, Nathalie, Palme, Joakim & Palier, Bruno (eds) (2011) Towards A Social Investment Welfare State? Ideas, Policies and Challenges. Bristol: Policy Press. 14 Johansson, Sten (1970) Om levnadsnivåundersökningen. Stockholm: Allmänna förlaget; Johansson, Sten (1979) Mot en teori om social rapportering. Stockholm: Institutet för social forskning.              words having, loving and being.15 Having relates to material resources, loving pertains to an individual’s social relations, and being refers to self-realization and self-esteem. Despite dierences in emphasis, the overarching theme in the Nordic approach is the very wide concept of welfare which includes the quality of life aspect. is approach has some conceptual linkages to Amartya Sen’s interpretation of the capabilities of individuals to full their own potential.16 According to this brand of social philosophy, when debating welfare we al- ways have to take into consideration the ability to function, i.e. we should be able to make conscious life choices that we are capable of realizing. Making conscious choices is a fundament for human well-being and happiness and the very idea dates back to Aristotle’s Ethics.17 Quite naturally, dierences in the philosophical interpretation of human society lead to diverging views on how to measure well-being and its pre- requisites. If everyone is the architect of his or her own fortune, there is no point in studying societal factors as determinants of happiness. It is enough to only scrutinize individual factors. At the other end of the continuum, attention is paid to the quality of the welfare state, the capacities and poten- tialities that the state oers to its citizens. e grey zone between disciplines and philosophical orientations is huge due to the deep divide in the main philosophical approaches on the role of the welfare state as a facilitator or inhibitor of happiness among human beings.18 e aim of the next section is to cursorily summarize previous research in the eld and take a step away from the high spheres of social philosophy towards the more mundane and concrete research questions of this chapter. 15 Allardt 1975; Allardt 1993. 16 Sen, Amartya (1992) Inequality Re-examined. Oxford: Oxford University Press; Sen, Amartya (1993) “Capability and Well-being’. In Nussbaum, Martha & Sen, Amartya (eds) e Quality of Life. Oxford: Clarendon Press, 30–53; Sen, Amartya (2010) e Idea of Justice. London: Penguin Books. 17 Aristotle (1955) Ethics. London: Penguin Books. 18 For a mental map of dierent approaches, see Saari 2012, 19.    Previous studies and research questions e old adage states that it is better to be healthy and wealthy than sick and poor. ere is an undeniable common sense truth in this: in most societies people are happier if they are healthy and have money than if they were poor and in ill-health. No doubt, health is good for happiness but it has also been shown that positive emotions are good for health.19 Positive feel- ings improve blood chemistry and have benecial eects on health.20 In this context, the concept of social capital, despite its ambiguity, has proved to be useful and has lots of explanatory power to health outcomes. Linkages exist between physical health and social capital, which are measured as trust in other people (individual trust) and trust in institutions (institutional trust). It is strongly argued that the relationship between the individual’s health and trust is a causal one.21 Social capital is good for society as a whole and makes it function well and prosper.22 While the degree of social capital is tied to certain macro characteristics of the state: non-corrupt, eective, guaranteeing equality of possibilities etcetera.23 At the micro level, social capital also places impor- tance on the individual’s own micro networks. As suggested by Erik Allardt, the term ‘loving’ reveals that the quality of social relations is of crucial im- portance for our well-being and happiness.24 Social support gained from our fellows helps us to muddle through periods of low mood and misery. All this suggests that when analysing happiness it is important, in addition to health 19 Danner, Deborah, Snowdon, David & Friesen, Wallace (2001) ‘Positive Emotions in Early Life and Longevity: Findings from the Nun Study’. Journal of Personality and Social Psychology, Vol. 80, No 5, 804–813. 20 Davidson, Richard D. (2000) ‘Aective Style, Psychopathology, and Resilience: Brain Mechanisms and Plasticity’. American Psychologist, Vol. 55, No 11, 1196–1214; Davidson 2004. 21 For a detailed discussion on the issue, see for example Hyyppä, Markku T. & Mäki, Juhani (2001) ‘Individual-Level Relationships between Social Capital and Self-Rated Health in a Bilingual Com- munity’. Preventive Medicine Vol. 32, Issue 2, 148–155; Kawachi, Ichiro, Subramanian, S. V. & Kim, Daniel (2008) Social Capital and Health. New York: Springer. 22 Putnam, Robert (1993): Making Democracy Work. Princeton: Princeton University Press; Putnam, Robert (2000): Bowling Alone: e Collapse and Revival of American Community. New York: Simon & Schuster; Whiteley, Paul (2000) ‘Economic Growth and Social Capital’. Political Studies, Vol. 48, 443–466. 23 Rothstein, Bo (1998) Just Institutions Matter. e Moral and Political Logic of the Universal Welfare State. Cambridge: Cambridge University Press; Rothstein, Bo (2003) Sociala fällor och tillitens prob- lem. Stockholm: SNS. 24 Allardt 1975; Allardt 1993.              and wealth indicators, to include explanatory variables pertaining to vari- ous social factors. In our study, we shall operate on the two forms of social capital (trust in people and trust in institutions) and social relations (if the respondent has intimate friends or not). More specically, in this study we will ask if the impact of bad health on the happiness of immigrants is the same in dierent welfare state regimes of residence. Here, the hypothesis is that in all regimes bad health has a detri- mental eect upon happiness, but the eect may be weaker in those welfare states that have extensive social policy programmes to cushion the immedi- ate detrimental economic eects of sickness. On the basis of previous studies, we expect positive and signicant link- ages between social trust and happiness. And if it is as Bo Rothstein argues that just institutions matter, immigrants, regardless of their origin, should display high levels of trust in those types of countries that are labelled as just, i.e. where natives also have high levels of trust in each other and in their institutions.25 A contamination from the context is also hypothesized: the Nordic countries occupy the top positions in the non-corrupt state lists.26 Previous studies have shown that both forms of social capital, i.e. trust in individuals and trust in institutions, are very high in the Nordic countries.27 erefore, should the contamination take place, immigrants (regardless their origin) in the Nordic countries will display higher levels of social capi- tal than immigrants in the other countries. When it comes to the impact of income upon health and happiness, there are two sets of explanations, absolute and relative. e rst one emphasizes the impact of the absolute sum of money. is means that the level of GDP is the most important thing. Residents, be they natives or immigrants, are happier in wealthy countries: the richer, the happier. At the individual level, the absolute view states that the poor have bad health because of a lack of 25 Rothstein 1998. 26 Transparency International. Online. Available HTTP: 27 Scheepers, Peer, Grotenhuis, Manfred Te & Gelissen, John (2002) ‘Welfare States and Dimensions of Social Capital’. European Societies, Vol. 4, No. 2, 185–207; Fridberg, Torben & Kangas, Olli (2008) ‘Social Capital’. In Ervasti, Heikki, Fridberg, Torben, Hjerm, Mikael & Ringdal, Krister (eds) Nordic Social Attitudes In A European Perspective. Cheltenham: Edward Elgar, 65–85.    money; they do not have the same possibilities to healthy nutrition as the better os. us, it is absolute poverty that is detrimental for health and ill-health in turn hollows out prerequisites for happiness. e proponents of the relative interpretation argue that in addition to the absolute mate- rial conditions, there are numerous behavioural factors that are harmful to health, and most importantly, the suppressed position of the poor causes stress and other forms of psychosomatic strains, which, in a gradual manner, permanently weaken the health and reduce mental well-being. It is argued that large income dierences are harmful for both health and happiness and the negative eects cannot be attributed to dierences between the absolute level of wealth of the country and how wealthy the people themselves are. Also in very aŒuent societies inequality has corrosive eects.28 If this state- ment is true, we should nd happier people in countries with more equal income distribution. Previous research has shown that employment is not only a source of income, but an important factor aecting our well-being. Beginning from the classical Marienthal studies, there are a vast number of studies proving the negative eects of unemployment.29 ese eects are not only negative in terms of income, but also aect our self-esteem, being is strongly built on our status in the labour markets. We can expect to nd a strong negative association between unemployment and happiness, regardless of the immi- grant’s country of origin or country of residence. As discussed in the previous section, the collectivist approach to welfare adheres to a large welfare state and as a rule, in this brand of thinking, the Nordic model is set as a bench mark and an ideal towards which all other countries should strive. Indeed, the goals of the modern Nordic welfare model reach further than the goal of alleviating poverty for the deserving needy. ere is no doubt that the Nordic countries do try to tackle poverty and insure against income loss, but they also address a wider range of so- 28 Wilkinson, Richard G. & Pickett, Kate (2006) ‘Income Inequality and Population Health: A Review and Explanation of the Evidence’. Social Science and Medicine, Vol. 62, No. 7, 1768–1784; Wilkinson & Pickett 2008; Wilkinson & Pickett 2009; Kawachi & Kennedy 2006. 29 Jahoda, Marie, Lazarsfeld, Paul E. & Zeisel, Hans (2002 [1933]) Marienthal. e Sociography of an Unemployed Community. New Brunswick: Transaction Publishers.              cial inequalities.30 e goal is not only to provide people with an amount of money they can live o, but also to provide them with the opportunities to become full members of the society they are living in through their own ef- forts, primarily in the labour market. e view echoes Amartya Sen’s ideas. Lots of heated debate has taken place as to whether the Nordic welfare state is woman-friendly or not. An abundance of evidence from research, however, shows that this indeed is the case – the Nordic way of employment policies, organizing social services and other social policy programmes do facilitate gender equality.31 However, there are also more critical voices argu- ing that under the equality surface, there are still substantial gender inequali- ties and in the Nordic hemisphere women are more severely hampered by glass-ceilings than in the Liberal countries. Moreover, the segregation into male and female employment sectors is strict.32 It is not the task of this study to evaluate the correctness of these arguments as such. In this study we only want to see whether there is a linkage between immigrants’ happiness and the level of gender equality prevailing in the country of residence, and whether that linkage is positive or negative. We expect to nd a positive association. One important pre-requisite for human well-being is feeling safe and free from discrimination. Immigrants may be objects of discrimination and even open hatred from the side of the native population which, needless to say, will increase feelings of insecurity. ese negative encounters are linked 30 Nelson, Kenneth (2003) Fighting Poverty: Comparative Studies on Social Insurance, Means-tested Benets and Income Redistribution. Stockholm: Swedish Institute for Social Research. 31 Korpi, Walter (2000) ‘Faces of Inequality: Gender, Class and Patterns of Inequality in Dierent Types of Welfare States’. Social Politics, Vol. 7, No. 2, 127–191; Korpi, Walter, Ferrarini, Tommy & Englund, Stefan (2011) ‘Women’s Opportunities Under Dierent Family Policy Constellations: Gender, Glass and Inequality Tradeos in Western Countries Re-examined’. Stockholm: Swedish Institute for Social Research. Online. Available HTTP: (accessed August 2012); Leira 2002; Meager, Gabriella & Szebehely, Marta (2012) ‘Equality in the Social Service State: Nordic Child Care Models in Comparative Perspective’. In Kvist, Jon, Fritzell, Johan, Hvinden, Björn & Kangas, Olli (eds) Changing Social Equality: e Nordic Welfare Model in the 21st Century. Bristol: Policy Press, 89–117. 32 Mandel, Hadas & Semyenov, Moshe (2006) ‘A Welfare State Paradox: State Interventions and Women’s Employment Opportunities in 22 Countries’. American Journal of Sociology, Vol. 111, No. 6, 1910–1949; Mandel, Hadas & Shalev, Michael (2009) ‘How Welfare States Shape the Gender Pay Gap: A eoretical and Comparative Analysis’. Social Forces, Vol. 87, No. 4, 1873–1912; Datta-Gupta, Nabanita, Smith, Nina & Verner, Mette (2008) ‘e Impact of Nordic Countries’ Family Friendly Policies, Employment, Wages, and Children’. Review of the Economics of the Household, Vol. 6, No. 1, 65–89.   € to a reduced well-being. Happy immigrants live in countries with low levels of discrimination. Data and methods e data used in this study are derived from the European Social Survey (ESS). Since 2002, an ESS has been carried out at two-year intervals.33 e latest year of observation used in this study was 2010. e size of the cross- sectional data varies from the low 579 in Iceland (2004) to the sample size of 3032 in Germany in 2010. As a rule, bi-annual national samples vary from 1500 to 2000. In the individual waves, the number of immigrants in most countries is too low and insucient for reliable statistical analyses. In order to obtain more reliable estimates, we pooled the data for dierent years, i.e. we merged data for 2002, 2004, 2006, 2008 and 2010. In the pooled le thus obtained, there are a total of 228 621 respondents from 33 countries. From the merged data le we excluded those countries that had less than 50 im- migrant respondents. Also Israel and Turkey were excluded. e collapsed data contain 17 837 observations on immigrants in 28 countries. e small- est sample is from Bulgaria (50 observations) and the largest one, the Swiss sample, contains as many as 1886 immigrants. Immigrant status is attached to each respondent born outside the country of residence. Since we are here interested in those who have moved into a country, we do not include sec- ond or third generation immigrants in the sample. In principle there are two indicators for subjective well-being in the ESS. e rst one is directly targeted for measuring happiness: ‘how happy would you say you are?’ e respondents could express their happiness on a con- tinuous scale that runs from 0 ‘extremely unhappy’ to 10 ‘extremely happy’. e ESS also contains a question relating to life satisfaction: ‘how satised are you with your life as a whole nowadays?’ e response alternatives were analogous to the happiness question. 0 indicates extreme dissatisfaction, while 10 indicates the highest possible level of satisfaction with one’s life. We can assume that while happiness is more limited a concept and measures 33 For a closer description, see European Social Survey. Online. Available HTTP: (accessed August 2012)              a mental state of mind, satisfaction with life comes closer to traditional wel- fare studies and reects more broadly the respondents’ satisfaction with the actual circumstances in which they are living. Figure 1 constitutes a preamble to the subsequent, more detailed study. As can be seen, the Nordic countries, together with Switzerland, top the league when the questions on happiness or the more general dimension of life satis- faction, are concerned. At the other end of the continuum we nd – perhaps not that surprisingly – the Post-Socialist countries and poorer Southern Eu- ropean countries displaying signicantly lower levels of happiness. e cor- respondence between the two variables is very high. At the individual level, the correlation coecient (r) is .70**, and at the aggregate country level, it is as high as .98***. Correlations are almost exactly the same if we look at the 8 7 6 5 4 3 2 Figure 3. Happiness, gender, regime of birth and the regime of residence in Europe. Figure 1. Happiness and life satisfaction. Source: European Social Survey. Happines s Life satisfaction R2 Linear=0,912 post-soc south-e anglo central-e nordic other post- soc south- e anglo center- e nordic Regime of birth Regime of residence WOMEN Estim at ed ma rg inal mean s 8 7 6 5 4 3 2 post- soc south- e anglo center- e nordic Regime of residence MEN Estim at ed ma rg inal mean s 9,0 8,0 7,0 6,0 5,0 5,0 6,0 7,0 8,0 9,0 TUR HUN POR EST POL FRA SLO LAT SLK RUS ROM ITA CRO CZ GRE DEN SWI SWE LUX AUT GER SPAGB ISR CYP IRE BEL FINNOR NL UK R SL K SLO SW E RU S PO R PO L NO R NLLAT LUX IR E HU N CRO GR E UKFRA FI N SPA ES T DE N GE R CZ E CYP SW I BU L BE L AUT Figure 1. Happiness and life satisfaction. Source: European Social Survey.    native population or immigrants separately. A preliminary conclusion of this rst inspection is that happy and satised immigrants are found in countries where the natives, too, are happy and satised (see Figure 2). To gain a more robust measure for subjective well-being, we merged the two variables and constructed an additive index ((happiness + life satisfac- tion)/2). e new variable also varies between the low 0 (very unhappy) and high 10 (very happy). For the sake of simplicity we call the additive index ‘happiness’. As indicated above, in welfare research it is a common practice to clus- ter countries in welfare state regimes reecting the underpinning rationale and institutional characteristics in national social policy solutions. On the basis of this family resemblance countries of residence are here grouped into ve welfare clusters: e Post-Socialist regime (Bulgaria, Croatia, Czech Republic, Estonia, Hungary, Latvia, Poland, Russia, Slovenia, Slovakia and Ukraine); the Southern European regime (Cyprus, Greece, Portugal and Spain); the Anglo regime (Ireland and the UK); the Central European regime (Austria, Belgium, France, Germany, Luxembourg, Netherlands and Swit- zerland) and the Nordic cluster (Denmark, Finland, Norway and Sweden).34 When classifying the regime of birth, a sixth regime ‘Other’ has been added to catch all those respondents coming from countries outside the Eu- ropean hemisphere (also Turkey and Israel, that are included in the ESS, are classied as ‘others’).35 ese clusters will be used, on the one hand, to evalu- ate how happy immigrants emigrating from dierent welfare regimes are, and on the other, the regimes of residence will be used when analysing how explanatory factors perform in various contextual settings. e background characteristics of the regimes are depicted in Appendix Table A1. Before proceeding further, a few words about the methods applied are warranted. When describing and discussing the construction of variables, we preliminarily make references to the relative importance of our key vari- 34 Iceland (a country that displays a very high level of happiness) was le out of the analysis because of the insucient number of immigrant respondents. 35 Design weight is used in regression models when operating with countries, while data are weighted by population weight when analysing data regime-wise. For clustering countries, see Castles, Leib- fried, Lewis, Obinger & Pierson 2010.              ables. is importance is measured by multilevel models where we have included the country and the variable in question into the analyses. Ap- plication of this kind of multilevel modelling provides us with possibilities to preliminarily evaluate the magnitude of the variance that the variable in question explains within and between countries. e coecients are given in Appendix Table A2 and are occasionally discussed in the text. Social capital is measured by two dimensions. e rst dimension per- tains to individual trust and is a combination of three separate statements: ‘Most people can be trusted or you can’t be too careful.’ ‘Most people try to take advantage of you, or try to be fair.’ ‘Most of the time people are helpful or mostly looking out for themselves.’ Respondents could give their answers in a continuum where 0 indicated the lowest trust and 10 the highest. With the help of principal component analysis the three questions were collapsed into one dimension (analysis re- sulted in one component) ‘personal trust’ that consists of factor loadings of those three questions. e second dimension ‘institutional trust’ is as well a combined factor of three questions on trust in the country’s parliament, trust in the legal system of the country and trust in the police. e scale was the same (0 to 10) as in previous questions, and also here factor analysis was used to get one indicator. e higher the value, the stronger the trust. Both factors perform very well. While personal trust explains 30 per cent of the within country and almost 10 per cent of the variation between countries, trust in national institutions explains more than 40 per cent of the variation in happi- ness within a country and some 10 per cent of the between country variance (Appendix Table A2). Preliminarily we can conclude that trust is a very im- portant precondition for happiness and just institutions matter.36 Indeed, the macro-level correlation between the non-corrupt index and trust in people is 0,82** and trust in national institutions as high as 0,86**. One can discuss whether social capital is a personal characteristic attached to an individual or whether it is a country level factor that should be linked to the quality of the state. Here we have treated social capital as an individual level variable. 36 Rothstein 1998; Rothstein 2003.    e quality of social relations is based on a question pertaining to whether a respondent has a close person with whom to discuss intimate and personal matters. e variable is dichotomous (0 = has a close person/s; 1 = does not have a close person/s). Respondents’ experiences on discrimina- tion are asked dichotomously (‘Are you a member of a group discriminated against in this country?’). Two other subjective welfare indicators, i.e. health status and feeling safe were dichotomized. We recoded the health status into ‘Bad health’, value 1 consisting of the original alternatives ‘very bad’ and ‘bad’ and ‘fair’, whereas ‘good’ and ‘very good’ were assigned a value 0. e same kind of procedure was applied to feeling safe. e ESS asked whether the respondent feels safe when walking alone aer dark in a local area. ‘Very unsafe’ and ‘unsafe’ responses were grouped into ‘Feeling unsafe’ (value = 1) and the rest got the value 0. Unfortunately, income data in the ESS are not ideal: income is catego- rized into 10 income groups, and in richer countries into 12. However, the groups do provide some possibilities to evaluate the economic position of the respondent. As such, the original variable is a categorical measure of a household’s absolute income level. As can be seen in Appendix Table A2, the variable is a powerful explanatory factor both when it comes to the within country variance (between individuals living in the same country) or to the variance between countries (variances explained are 18 per cent and 6 per cent, respectively). By recoding the original income variable it is possible to rank households according to their income and to use those rankings as proxies of nationally organized deciles, quintiles or quartiles. Here we grouped the respondents into quartiles to obtain more observations in each quartile. Although the relative placing of the individual is of importance, the eect of the absolute level seems to be stronger (Appendix Table A2). However, instead of abso- lute income levels we use quartiles in regression models, and aer the indi- vidual level factors are controlled for, we regress country dummies against national GDP per capita data which are an indicator of the overall level of prosperity of the country.              In addition, we include a third income variable into the analyses. e ESS also asks the respondents to provide their own perception on their present income. Answers were reanalysed into a new dichotomous variable called ‘economic diculties’. Value 1 was given to all those who said that they have diculties in coping on their incomes, and those with no prob- lems getting on were assigned a value 0. Preliminarily, one can already say that the subjective experience of economic diculties, together with self- evaluated health, is one of the most important explanatory factors for hap- piness. Indeed, experiences on economic hardship explain as much as 45 per cent of variations in happiness within countries and 10 per cent between countries. For the health problems, the corresponding shares of explanation are almost as high (Appendix Table A2). e variables discussed above all pertain to individual level characteris- tics and they have a close correspondence to the variables used in the Nordic level of living surveys. In order to take into consideration contextual factors, we include a number of country level variables. To complement analyses of the signicance of monetary living conditions, GDP per capita (in Euros modied by Purchasing Power Parities in 2006 prices) is included. e GDP is used as a general measure of the prosperity of the country. As discussed above, it may be worthwhile to include some country-level indicators on so- cial inequalities. erefore, the Gini coecient, social security spending as a percentage of the GDP (indicating the state involvement in guaranteeing so- cial protection to residents),37 relative poverty rate (60 per cent poverty line) and Gender Inequality Index (GII) are used as contextual variables against which OLS-regression coecients of country dummies are projected. If we are to believe Wilkinson and Pickett, a negative correlation (aer control- ling for individual level variables) between happiness and inequality can be expected. Correspondingly, there should be a negative linkage between the GII and happiness, whereas the happiness and prosperity of nations should 37 Eurostat. Expenditure on Social Protection as % GDP. Online. Available HTTP: (accessed August 2012)    go hand in hand.38 In subsequent analyses, regression models are used for the total sample of all immigrants and regime-wise subsamples to see if there are dierences in how the explanatory variables listed in Appendix Table A2 perform in dierent welfare state settings. From the regression model on the total im- migrant sample we derive coecients for each country (countries are in- cluded into the models as dummies). Using Sweden (that many analysts re- gard as the welfare state) as a reference, a positive regression coecient for a country indicates a greater level of happiness in the country in question and a negative value a lower level of happiness than in Sweden when individual level characteristics are controlled for. Finally, the country coecients are depicted against the most important country-level variables to see if there are connections at the macro level. We visualize interactions between hap- piness, gender, regime of origin, regime of residence and some other key variables by plots from univariate linear models (LM) which are handy de- vices to present rather complicated two and three level interactions in easily interpretable and understandable graphs. Happy immigrants live in happy countries Previous studies have shown that the level of happiness is lower among im- migrants than native residents.39 Although there are numerous interesting reasons for that, the issue falls outside the scope of this study. Here we only take a cursory glance over the situation. In Figure 2, the levels of happiness are portrayed separately for immigrants and for the native population. e main story of the graph is that happy immigrants tend to live in countries with happy natives and most probably the same factors inhibit or generate happiness among both natives and immigrants. e overall level of happi- 38 Indicators are for the year 2006 which is in the middle of our observation period. A better strategy would have been to take an average for the entire observation period. However, all the indicators used here are rather sticky and changes in them are slow. erefore, the choice to use the 2006 values instead of averages for 2002–2010 does not aect the results. Data are taken from United Nations Development Programme (UNDP). Going Beyond GDP, UNDP Proposes Human Development Measure of Sustainability. Online. Available HTTP: (accessed August 2012) 39 Senik 2011.              ness is high in Denmark, Switzerland and Finland followed by Norway and Sweden. In these countries also the immigrants say that they are happy. Also Ireland and Austria, together with the Low Countries – Belgium, Luxem- bourg, and the Netherlands – are happy countries, but dierences between natives and immigrants are substantial, comparatively speaking. Table 1 gives a summary of the importance of each individual explana- tory variable when the other variables are controlled for. e two indicators of social trust are statistically signicant in all country-settings, as expected. Whereas unemployment, bad health and experienced economic problems are also signicant regardless of the regime, the importance of the other variables depends on the sample of countries. For example, income quartile is signicant in the total sample, in Post-Socialist countries and in Central Europe, but not signicant in the other regimes. Correspondingly, while having no friends and experiences of discrimination are important in the Southern European regime, they play no major role in the Anglo regime. When it comes to the origin of the immigrants, those who emigrated from 9,0 8,0 7,0 6,0 5,0 4,0 Figure 2. Happiness (combined happiness and life satisfaction) among natives and immigrants in Europe. born in the country immigrant UK R SL K SLO SW E RU S PO R PO L NO R NLLAT LUX IR E HU N CRO GR E UKFRA FI N SPA ES T DE N GE R CZ E CYP SW I BU L BE L AUT Figure 2. Happiness (combined happiness and life satisfaction) among natives and immigrants in Europe.    a Post-Socialist country into some other Post-Socialist country are signi- cantly less happy than the non-European immigrants. Whereas Central- European emigrants seem to be happy in another Continental country or in South Europe, they are not that happy if their destination happens to be the Anglo regime. In relation to non-European immigrants, the Anglo movers are happiest in a Southern European country. Our interim conclusion so far could be that there are some regime-de- pendent dierences in the explanatory power of the whole model – as indi- cated in the Adjuster R squared – and while some variables (health, expe- rienced economic diculties, unemployment and social capital) are robust to welfare regimes, some other variables (e.g. gender, age, income quartile, feeling unsafe, and regime of origin) are more context sensitive. On average, although the level of happiness is the highest in the Nor- dic hemisphere, the picture is much more thrilling than simply that. Table 1 showed that immigrants coming from the same regime of origin dis- play dierent levels of happiness depending on their regime of residence. In Figure 3 – which is a result from LM models where other variables are controlled for – we have visualized three-way interactions, i.e. regime of residence*regime of origin*gender. Based on this, some interesting regime and gender patterns appear. Whereas Southern European males express low levels of satisfaction in the Anglo countries, they are satised in the North, as are other Northeners and men from Eastern Europe. Female immigrants from the Nordic regime express the highest levels of happiness in the An- glo countries, Southern European women are not that happy in the Nordic countries, and Eastern European and non-European female immigrants are happy in the South. A number of cultural and language factors may contribute to these re- sults. As can be seen in Appendix Table A1, while the share of non-Europe- an immigrants is the largest in Anglo and Southern European regimes, the share of Nordic immigrants is the largest in the Nordic hemisphere and im- migrants in the Post-Socialist countries tend to have moved in from another post-socialist country or from outside Europe. ese factors may have some ramications for the level of happiness among immigrants. Due to lingual              All countries Post Socialist South Anglo Central Europe Nordic Constant 8,247*** 7,827*** 9,708*** 8,105*** 7,852*** 8,604*** Gender 0,096** 0,155** -0,196* 0,070 0,234*** 0,079 Age -0,038*** -0,032** -0,068*** -0,036** -0,045 -0,058** Age squared/1000 0,402*** 0,282 0,613*** 0,494*** 0,453*** 0,658** Economic diculties -1,001*** -1,090*** -0,842*** -1,041*** -0,977*** -0,769*** Quartile 0,050*** 0,178*** 0,018 0,009 .139*** 0,076 Bad health -0,684*** -0,612*** -0,474*** -0,534*** -0,611*** -0,666*** Unemployed -0,402*** -0,702*** -0,288* -0,640*** -0,301*** -0,504* No friends -0,533*** -0,777*** -0,851*** -0,205 -0,607*** -0,789*** Feeling unsafe -0,092** -0,474*** -0,058 -0,229** 0,088 -0,241 Discrimination -0,317*** -0,345*** -0,614*** -0,291** -0,248*** -0,265 Trust in people 0,306*** 0,273*** 0,221*** 0,331*** 0,270*** 0,417*** Trust in institutions 0,381*** 0,370*** 0,227*** 0,355*** 0,370*** 0,248*** Regime of origin (non-European = reference) Post-socialist -0,196*** -0,340*** 0,006 -0,279 -0,029 -0,094 Southern 0,157* 0,613 0,053 -0,398* 0,158 -0,283 Anglo 0,230*** -0,263 0,787** -0,91 0,352 -0,081 Central Europe 0,208*** -0,084 0,288* -0,280* 0,277*** 0,083 Nordic 0,201** 0,614 0,215 1,111 0,176 0,038 Adj. R squared 0,305 0,302 0,222 0,258 0,247 0,228 Note: age squared was divided by 1000 in order to make coecient visible. Table 1. Unstandardized OLS regression coecients for happiness in dierent welfare state regime settings.   € resemblances, those moving within Scandinavia understand each other (the Finns are an exception) as do the Irish moving to Britain and vice versa. Many Central European movers belong to a same lingual group (French or German). When it comes to the impact of language, we can assume that the English-speaking countries are in the best position. Since English is to- day’s lingua franca and immigrants already speak English when they enter the country be it Britain or Ireland, and British or Irish emigrants are also understood in their new country of residence as well. Many other countries, belonging to a group of smaller, more isolated languages, say Finland or Hungary, face bigger language-related problems with people moving in as do the Finns and Hungarians when moving out from their home countries. A closer analysis on the impact of language and culture falls beyond the scope of this study. We can also visualize some other interactions that are concealed behind the regression coecients in Table 1. In principle, we could again control for other variables and inspect how happiness varies when we move from non-unemployed to unemployed, from healthy to sick persons and from better-os to those who have problems in getting on with their present in- come. e story from all of these graphs would be more or less the same: in all the regimes bad conditions signicantly hollow out happiness and the Figure 3. Happiness, gender, regime of birth and the regime of resi- dence in Europe. 8 7 6 5 4 3 2 Figure 3. Happiness, gender, regime of birth and the regime of residence in Europe. Post-soc South E Anglo Central E Nordic Other Post- soc South E Anglo Central E Nordic Post- soc South E Anglo Central E Nordic Regime of birth Regime of residence WOMEN Estim at ed ma rg inal mean s 8 7 6 5 4 3 2 Regime of residence MEN Estim at ed ma rg inal mean s              hollowing out eect is the biggest in the Post-Socialist regime, while the eect is not that steep in the Nordic countries and in the Southern Euro- pean regimes. at kind of visualization is presented in the upper le-hand panel in Figure 4. Instead of presenting similar plots for economic hard- ship and unemployment, we focus on the interaction between origin and health (upper right-hand panel). While there were no dierences between the Nordic and Southern European countries when we analysed the regime of residence, the regime of origin inspection shows that immigrants origi- nating from the Nordic countries have, in comparison to other immigrants, higher levels of happiness depending on whether they are sick or not. e lowest level of satisfaction and the deepest hollowing out eects are found in the Post-Socialist countries. Figure 4 also contains a graphical presentation of the relationships be- tween social capital (institutional trust in the lower le-hand panel), regime of origin and the regime of residence. ese two graphs show how the level of social capital – one of the most important explanatory factors of hap- piness – varies between various immigrant groups in dierent destination clusters. Immigrants, whatever their origin, trust in the Nordic institutions. It is intriguing that while the Nordic immigrants display high levels of trust in other people (the right-hand panel) regardless of their regime of resi- dence, the level of the Northeners’ trust in institutions vary depending on the regime of residence. ese results indicate that there is a kind of con- tamination eect from ‘just’ institutions.40 Now it is time to take a look at the country level variables and try to see whether we can nd any relationship between happiness and a number of macro level indicators (due to space considerations we do not graphically present results for all macro level inspections). Mimicking a simple two- stage approach, the rationale in Figure 5 is that aer controlling for the key individual level variables we can project regression coecients for country dummies obtained in the rst equation in Table 1, and assume that if, for example, the Gender Inequality Index (GII) is somehow related to female 40 Rothstein 1998.    happiness, that should be revealed when we regress country dummy coef- cients on GII, as done in the upper le-hand panel. e correlation between GII and country coecients is strong (-0,75** for women that are portrayed in the graph and -0,69** for males) and al- though it will shrink if we omit the Post-Socialist countries, it still remains signicant (r = -0,48). e result gives qualied support for the ideas of the 1,0 0,5 0,0 -0,5 -1,0 -1,5 Figure 4. Interactions between happiness, bad health and regime of residence (upper left-hand panel) and regime of origin (upper right-hand panel) and interactions between levels of social capital (lower left-hand panel: trust in institutions; and lower right-hand panel: trust in people). Post-soc South E Anglo Central E Nordic Other Post- soc South E Anglo Central E Nordic Post- soc South E Anglo Central E Nordic Regime of birth Regime of residence Estim at ed ma rg inal mean s 1,0 0,5 0,0 -0,5 -1,0 -1,5 Regime of residence Estim at ed ma rg inal mean s 7,0 6,5 6,0 5,5 5,0 Good Bad Health condition Estim at ed ma rg inal mean s 7,0 6,5 6,0 5,5 5,0 Good Bad Health condition Estim at ed ma rg inal mean s Figure 4. Interactions between happiness, bad health and regime of residence (upper left-hand panel) and regime of origin (upper right-hand panel) and interactions between levels of social capital (lower left-hand panel: trust in institutions; and lower right-hand panel: trust in people).              woman-friendly welfare state – that also seems to make men happier.41 is simple inspection gives rather strong support to the ideas that some coun- tries and clusters of countries may be more women-friendly than others. e other correlations also run in the expected direction but they are substantially smaller and the relationships will be further reduced by the omission of the poorer countries. e correlation between social spending and happiness goes down from 0,38* to insignicant -0,10 if the Post-So- cialist regime is omitted. ere seems to be slight support for Wilkinson’s and Pickett’s kind of arguments. e lower right-hand panel depicts the re- lationship between income inequality and happiness (r = -.59**) but this re- lationship is also sensitive to the inclusion or omission of the Post-Socialist countries. While the correlation coecients between happiness and relative income poverty are -0,39* for the total sample and -0,22 for West Europe, the measure of material deprivation, i.e. an index constructed by Eurostat to measure the lack of necessities, yields a much higher coecient in all samples (r = -0,69** for all countries and -0,52* for the richer countries, the pictures of poverty are not displayed here). e correlation between country coecients and GDP per capita is modest but nevertheless it gives qualied support for the ‘absolutist’ views – there is a tendency that happiness and national wealth are linked to each other. e results were fortied in multilevel analyses. GDP per capita and material deprivation appeared to be mutually exclusive in regression models. If material deprivation and GDP were simultaneously included in the mod- els, the material deprivation variable became signicant and down-played the importance of GDP (sig. = ,259). However, if the deprivation index was omitted, GDP got signicance (sig. = ,002) as well as non-corrupt state (sig. = ,000), gender inequality (sig. = ,000) and social security spending (,039). It is important to pinpoint that at the national level all the variables used here are linked to each other: countries that spend much on social security display low levels of poverty, income inequality and inequalities between genders. Consequently, they are the least corrupt states and all these features are important macro-level ingredients for a happy life. 41 Cf. Bachans 2011.   € Figure 5. Unstandardized coecients for country dummies (individual level characteristics controlled for) depicted against some country level characteristics. Figure 5. Unstandardized coecients for country dummies (individual level characteristics controlled for) depicted against some country level characteristics. Cou n tr y c oecie nt s, W omen ( Sw eden=0 ) Gender inequality index R2 Linear=0,562 0,5 0,0 -0,5 -1,0 -1,5 -2,0 0,0 0,1 0,2 0,3 0,4 HUN HUN POR SLO SLO POR POR POR EST EST POL POL POL CRO POL FRA FRA FRA FRA SLO LAT LAT LAT LAT SLK SLO SLKRUS RUS RUS RUS EST EST SLK SLK HUN HUN UKR UKR BUL BUL BUL BUL CRO CRO CRO CZ CZ CZ CZ GRE GRE GRE GRE DEN DEN DEN DEN SWI SWI SWISWE SWE SWE SWE SWELUX LUX LUX LUX AUT AUT AUT AUT GER GER GER GER SPA SPA SPA SPA GB GB GB GB CYP CYP CYP CYP IRE IRE IRE IRE BEL BEL BEL BEL FIN FIN FIN FIN NOR NOR NOR NOR NL NL NL NL Cou n tr y c oecie nts ( Sw eden=0 ) Social spending, % of GDP R2 Linear=0,147 0,5 0,0 -0,5 -1,0 -1,5 10 15 20 25 3530 Cou n tr y c oecie nts ( Sw eden=0 ) GPD per capita (euros) R2 Linear=0,243 0,5 0,0 -0,5 -1,0 -1,5 0,0 20 000 40 000 60 000 80 000 Cou n tr y c oecie nts ( Sw eden=0 ) Income inequality (GINI*100) spending, % of GDP R2 Linear=0,348 0,5 0,0 -0,5 -1,0 -1,5 25 30 35 40 45             € Conclusions e aim of this chapter was to analyse happiness among immigrants living in the European hemisphere. We used the basic ideological underpinnings of the Nordic welfare state as its platform. e goal of social policy making in Scandinavia has been to oer residents a wide set of possibilities to master their own lives. e idea has links to Amartya Sen’s philosophical thinking on capabilities. Everyone has to be oered a wide set of capabilities in order to be able to more or less fully participate in the life of the surrounding society. In the Nordic level of living studies, capabilities have been in the disguise of resources that individuals can command to master their lives. e idea has been that if there are sucient resources they will produce high levels of material well-being which in turn produce satisfaction and hap- piness. Having, loving and being are at high levels in the Nordic countries. us, whereas the state in the Nordic discourse has been seen as a facili- tator for a good and happy life, in liberal Hayek-inspired thinking the state is oen regarded as a malevolent and alien force, depriving the individual of freedom and hence, circumscribing individual happiness. In this brand of thinking, distributional issues are not seen as being that important. e most important thing is to increase the level of material welfare, which is also the best guarantee for happiness. In the collectivist tradition, much em- phasis is laid on relative dierences, and huge relative dierences are seen as being harmful not only to the worst-os but to everyone. Our humble results perhaps point more to the collectivist tradition: the happiest and most satised immigrants were found in countries with large and ecient welfare states and, comparatively speaking, small income and other social dierences. Such social conditions create institutional settings that gen- erate and fortify trust or social capital, if you like. However, there was a strong indication that the absolute income level is important as well, and the impact, no doubt, is the strongest among those who are living in economic scarcity. In addition to experienced economic problems, bad health and unemployment appeared to be associated with lower levels of happiness. But the strength of that negative association varied between welfare state regimes. Also the im- portance of other explanatory variables was to some extent context-bound.   € Earlier studies have shown that the most important determinant of hap- piness and a good life is the degree of social capital the individuals have. at is very much true for immigrants, too. ose who have high levels of social capital display high levels of happiness as well. is perhaps is not that novel a nding. e novelty in our study is in the inspection of vari- ous interactions between the backgrounds of immigrants and their country and welfare regimes of residence. For example, when it comes to the Nordic emigrants, i.e. those who have emigrated from their own country, they seem to have a higher level of social capital, and hence, they seem to be happier than emigrants/immigrants from other regimes. Furthermore, the Nordic immigrants tend to maintain their trust in people wherever they reside, but their level of trust in institutions changes depending on their country of residence. 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New York, Berlin & London: Bloomsbury Press.   €€ Post-Socialist South Europe Anglo Central Europe Nordic Happiness (mean / st.dev*.) 5,50/2,28 7,06/1,82 7,22/1,77 6,98/1,96 7,68/1,76 Individual characteristics Gender; share of women (%) 58,8 50,6 52,5 53,4 54,0 Age (mean / st.dev.) 51,8/18,1 38,3/14,1 44,2/17,4 43,8/16,6 46,3/17,4 Economic diculties (%) 64,6 38,9 21,7 26,9 16,0 Unemployed (%) 4,5 13,3 5,5 8,8 6,8 Bad health (%) 69,0 26,1 23,3 35,1 26,7 No intimate friend (%) 15,3 10,1 9,8 9,9 10,0 Feeling unsafe (%) 48,2 20,7 33,5 25,8 19,3 Discrimination (%) 11,4 20,2 16,3 17,2 15,3 Trust in persons (mean / st.dev.) -0,45/1,1 -,23/0,9 -0,14/0,9 -0,03/0,9 0,48/0,9 Trust in national institutions (mean / st.dev.) -0,88/1,0 0,01/0,9 0,11/0,9 0,97/0,9 0,42/0,9 Regime of origin (%) Non-European (%) 46,9 69,1 67,7 53,0 49,7 Post-socialist (%) 49,1 12,8 7,5 20,9 12,6 South Europe (%) 0,1 3,2 4,2 12,4 1,6 Anglo (%) 0,1 2,6 10,3 1,7 2,7 Central Europe (%) 3,8 11,7 9,4 11,5 8,3 Nordic (%) 0,1 0,7 0,9 0,5 25,1 Country level data Gini coecient / st.dev. 37,8/5,02 33,0/2,21 33,82/0,75 29,8/2,84 25,0/2,57 Poverty (%) / st.dev 19,3/6,2 18,2/1,2 17,8/1,5 13,8/1,4 12,0/0,9 GDP per capita (2006) /st.dev. 11750/4212 27259/2853 35118/667 33739/3758 38580/5590 Gender Inequality Index / st.dev. 0,31/0,05 0,13/0,01 0,20/0,01 0,09/0,02 0,07/0,01 Social spending (% of GDP) / st.dev. 15,0/4,2 22,9/2,1 22,9/3,7 27,7/3,1 27,4/3,2 Non-corrupt state index/st.dev. 5,0/1,7 5,9/1,0 8,1/0,6 8,3/0,6 9,2/0,3 * standard deviation; Gender Inequality Index (GII) is a composite measure reecting equality achievements between genders in three dimensions: health, empowerment and labour market. e higher the value the larger the gender disparity. World-wide the GII values vary from the low 0,05 in Sweden to 0,7 in Sierra Leone. e non-corrupt state index varies from 10 = very clean to 0 = highly corrupt. In 2006 the world-wide variation was from the high 9,6 in Finland to the low 1,6 in Chad. APPENDIX 1 Table A1. Summary characteristics of immigrants in dierent welfare state regimes.             € Variable Variance explained within countries Variance explained between countries Gender 0,0 0,1 Age 3,5 0,3 Economic diculties 44,9 10,0 Income (quartile) 10,4 5,1 Income (absolute) 17,6 6,1 Bad health 39,3 9,9 Unemployed 0,1 1,8 No intimate friend 6,8 2,6 Feeling unsafe 13,5 1,4 Discrimination 0,3 1,4 Trust in people 30,1 7,8 Trust in national institutions 43,9 9,3 Regime of origin 11,0 0,6 Table A2. Within country and between country variance explained by individual explanatory variables; multilevel model including the country and the variable in question (in per cent).      € Public health and solidarity – How to succeed in the population-based prevention of alcohol problems     Introduction Traditional welfare state research has aimed to explain levels and distribu- tions of objective well-being in terms of services and equality policies. Even recent interest in subjective indicators of well-being by economists such as Joseph Stiglitz, Amartya Sen and Jean-Paul Fitoussi have looked at them from the perspective of risks posed by structural, external factors.1 Much less attention has been paid to a second type of risk, namely that produced directly by consumption. We can call this internal risk.2 Our own desires and choices are threats against which we must protect ourselves. e facts are well known. In developed countries, the ve most important causes of the total health burden are tobacco, blood pressure, alcohol, cholesterol and overweight, all related to lifestyle. Across the whole world, including the developing countries, the most important factors are otherwise the same but include underweight, unsafe sex, and unsafe water; in other words indica- 1 Stiglitz, Joseph E., Sen, Amartya & Fitoussi, Jean-Paul (2009) Report by the Commission on the Measurement of Economic Performance and Social Progress. Paris: Commission on the Measurement of Economic Performance and Social Progress. 2 Sulkunen, Pekka (2011) ‘Autonomy Against Intimacy: On the Problem of Governing Lifestyle-Relat- ed Risks’. Telos, Vol. 156, 99–112.     € tors of extreme inequality of resources appear at the top of the list.3 ese risks, too, are the making of human societies, not of nature itself. Once we observe this, we also observe how poor the track record of health and welfare policy is in this area. is incapacity is a recent phe- nomenon. History is full of examples of society successfully controlling the consumption and desires of individuals, including sexuality, media culture, food, drugs, and alcohol. Alcohol control has in fact had been one of the rst areas of social policy exercised by the emerging nation states in the late nineteenth and early twentieth centuries. Severe measures, including prohi- bitions, individual rationing systems, state monopolies, high taxes to keep prices up, restrictions on selling hours, and outlets have been used through- out the industrialized world. In the individualized modern society today, such measures are incom- patible with the dominant principles of justication of the social order, which include the freedom of consumers to follow their preferences, and the freedom of the market to satisfy them. Total prohibitions or controls targeted at problem users or specic risk groups – on the basis of particu- laristic criteria such as ethnicity, gender, or class – would be experienced as violations of equity norms and requirements of self-responsibility. Alcohol policy has a history of evolution from rigorous state-imposed controls towards increasing freedom of the market and the consumer in most industrialized countries since the turn of the twentieth century. is evolution has been accompanied by increasing consumption and by grow- ing rates of harm to health and society. A balance between freedom and harm has been sought by dierent means, for example trying to modify be- haviour towards less risky drinking patterns, but most of the attempts have either failed or been experienced as excessively normative and biased to fa- vour the dominant middle class (male) culture. 3 World Health Organization (WHO) (2002) World Health Report. Geneva: World Health Orga- nization; Babor, T. F., Caetano, R., Casswell, S., Edwards, G., Giesbrecht, N., Graham, K., Grube, J., Gruenewald, P., Hill, L., Holder, H., Homel, R., Osterberg, E., Rehm, J., Room, R. & Rossow, I. (2003) Alcohol: No Ordinary Commodity – Research and Public Policy. Oxford and London: Oxford University Press.       e Total Consumption Model e Total Consumption Model (TCM) has been a solution that satises both sides of the balance, at least in theory. According to this model, even moder- ate drinkers inuence the prevalence of alcohol problems in any population, because they are the vast majority, and problems like accidents, petty crime and violence sometimes occur in relatively controlled drinking occasions. But even chronic health problems typically associated with long-term heavy drinking co-vary with moderate consumption. It is very dicult to reduce heavy use without also aecting moderate drinking, as the distribution of alcohol use has been observed to be very stable across populations and over time. e model recommends universal preventive measures to regulate the average consumption, such as price increases and availability restrictions, instead of measures directed at persons at high risk. Such measures increase the cost of alcohol in terms of time and money, but leave the choice to the consumers, and equally to all consumer groups. is model has served as a leading policy doctrine among experts in the area of public health and alcohol for several decades. It has been the guide- line of the European Alcohol Action Plans since 1993, and it has been vali- dated and elaborated on several occasions since it was introduced almost 40 years ago.4 However, its implementation in actual policy-making has been rare. Business interests, the diculty of justifying restrictive availability and tax measures, and the low esteem of public health interests in comparison to economic and scal interests, have been obstacles to its implementation. e dierences in how countries utilize and implement the ndings of the TCM can partially be explained as depending on the temperance history and drinking patterns of the country in question. Although all the Nordic countries have had similar drinking patterns, strong temperance move- ments, and severely state-regulated alcohol markets, only Sweden, and to some extent Norway, have applied the TCM for any signicant period of time. is chapter will show that there are also positive preconditions, em- 4 Bruun, Kettil, Edwards, Grith, Lumio, Martti, Mäkelä, Klaus, Pan, Lynn, Popham, Robert E., Room, Robin, Schmidt, Wolfgang, Skog, Ole-Jørgen, Sulkunen, Pekka & Österberg, Esa (1975) Alcohol Control Policies in a Public Health Perspective. Helsinki: e Finnish Foundation for Alcohol Studies.      bedded in the TCM itself, for its application in actual policy. ey are less connected to alcohol-related harm, drinking cultures and even to temper- ance traditions than to the mode of governance. e model presupposes a policy-maker governing a delimited population, individual consumer au- tonomy, and a strong link between expertise and health policy. is chapter will analyse four cases, comparing France with three Nor- dic countries, Finland, Norway and Sweden, where attempts to frame alco- hol policy as a restriction of total consumption in a population have been successful, at least for a while; more so in Sweden and France than in the other two cases. Two factors are likely to explain this: early medicalization of the alcohol problem, and a strong appeal to social solidarity by advocates of this policy. e more research-based applications of the model in Norway and Finland, by comparison, have not gained strong popular support, but for opposite reasons. In Norway, the temperance tradition has continued in almost all political parties and been associated with nationalism as the country has otherwise been integrated to the global world. Technocratic ep- idemiological arguments were not very much needed. In Finland, the tem- perance movement had become incapacitated as a stake-holder in alcohol policy at the moment when the public health argument was most needed. e analysis of Norway, Sweden and Finland presented in this chapter is based on several studies already published. e French case is based on our original research, including press material, ocial documents and per- sonal interviews of key participants in the policy process. is research has never before been published, and therefore it is oered here to the reader in greater detail than the Nordic cases. Background: Alcohol policy and the temperance issue With regard to alcoholic beverages, the TCM implies political restrictions on the free market and consumer choice. erefore it would seem natural to assume that temperance history and the strong presence of socialist po- litical parties would explain its implementation in some countries, whereas countries with less prominent anti-alcohol traditions and dominant market- liberal political attitudes would be less inclined to accept it as the alcohol       policy guideline. e cultural traditions of alcohol use, the political role of women, the Protestant religion and the dominance of the rural population are all related to the temperance history of the late nineteenth and early twentieth century. erefore, one would assume that these factors should also be relevant determinants of whether the TCM will gain popular ac- ceptance or not.5 At a closer look, however, the relationships between these background factors and alcohol policy are very complex. In countries where the socialist working-class parties carried the anti-alcohol ag until the rst decades of the twentieth century, the alcohol policy regimes remained more restrictive of the market and consumer freedom than in countries where the socialist platform dismissed the alcohol issue early on. is holds, for example, for comparisons between Belgium and Germany or France, between Scotland and England, and between the other Nordic countries and Denmark, the second of these pairs of comparison having been more liberal in their alco- hol policy regimes than the rst, in which the socialist parties maintained the alcohol issue on their agendas longer. However, in the period aer the Second World War, when alcohol regimes gradually became liberalized in the Nordic countries, the alcohol issue became politicized along the le- right dimension only for a very short period of time; and again inconsist- ently, in the 1970s. en socialist parties accepted stronger state regulations than liberal or conservative parties, which labelled TCM-oriented alcohol policy as a ‘socialist plot’, for example in Finland.6 Temperance history is related to Protestantism in an interesting way. Anglo-American Protestant movements associated with Calvinism (Meth- odism, Baptism) are especially critical of drinking, which partly explains why the strongly Lutheran Denmark has had a less alcohol-critical policy 5 Johansson, Lennart (2000) ‘Sources of the Nordic Solutions’. In Sulkunen, Pekka, Sutton, Caroline, Tigerstedt, Christoer & Warpenius, Katariina (eds) Broken Spirits: Power and Ideas in Nordic Alco- hol Control. Helsinki: Nordic Council for Alcohol and Drug Research (NAD), 17–43. 6 Anttila, Anu-Hanna & Sulkunen, Pekka (2001) ‘e Inammable Alcohol Issue: Alcohol Policy Argumentation in the Programs of Political Parties in Finland, Norway and Sweden from the 1960s to the 1990s’. Contemporary Drug Problems, Vol. 28, 49–86.      tradition than Sweden and Norway.7 In the post-war decades the rural dry option was adopted mostly in regions where these churches have been prominent.8 Yet many examples can be given of countries where religion does not seem to play a role, such as Catholic Poland with a relatively strong temperance tradition, and – for this chapter most relevant – the Catholic but ocially non-religious state of France, where the TCM has played an impor- tant role. France is also a case in point concerning women’s political roles, as they gained voting rights in national elections only in 1945. As to the prominence of the rural population, the early temperance movements that in the late nineteenth and early twentieth century repre- sented the avant-garde of modern ideals of individual autonomy gradually became conservative rural traditionalists9. In most Western countries, anti- alcohol attitudes have therefore become associated with moral conserva- tism. Again, however, the post-war alcohol policy history is contradictory. For example, in Finland the rural population was larger than in the other Nordic countries, yet alcohol policy liberalization was more radical than in Sweden or Norway. In Norway, on the other hand, earlier dry rural areas had started to strive for o-licenses and restaurants for competitive reasons.10 Drinking patterns are even less consistently related to the implementa- tion of the TCM than religion, politics, women’s political rights or the size of the rural population. Finland, with a high rate of arrests for drunkenness, and the UK with a high rate of binge drinking, are examples where restric- tive alcohol policies could be expected to appear, compared to milder drink- ing patterns in Sweden or France. Instead, both the UK and Finland have been reluctant to adopt the TCM and the market regulations that it implies, compared to Sweden and France. 7 Eriksen, Sidsel (1993) ‘Drunken Danes and Sober Swedes? Religious Revivalism and the Temper- ance Movements as Keys to Danish and Swedish Folk Cultures’. In Stråth, Bo (ed.) Language and the Construction of Class Identities. e Struggle for Discursive Power in Social Organisation: Scandinavia and Germany aer 1800. Gothenburg: Gothenburg University, 55–94. 8 Johansson 2000; Andersen, Jan (2000) ‘Municipalities Between the State and the People’. In Sulkunen, Pekka, Sutton, Caroline, Tigerstedt, Christoer & Warpenius, Katariina (eds) Broken Spirits: Power and Ideas in Nordic Alcohol Control. Helsinki: Nordic Council for Alcohol and Drug Research (NAD), 183–197. 9 Sulkunen, Pekka & Warpenius, Katariina (2000) ‘Reforming the Self and the Other: e Temperance Movement and the Duality of Modern Subjectivity’. Critical Public Health, Vol. 10, No. 4, 423–438. 10 Andersen 2000.       Overall, the match between the usual background factors of temperance history and the application of the TCM is poor. In an earlier article we have shown one reason for this.11 e emergence of the TCM as an alcohol policy guideline was not at all an ospring of temperance politics; it was an anti- dote to its moralistic undertones and normativity. In the mind of its early developer, Professor Kettil Bruun, TCM-based alcohol policy increases the cost of alcohol in time and money to the consumers but leaves it up to them to make decisions on their consumption, given the known risks to health, wealth and welfare. Policy was to avoid individual discrimination and other moral stands, and to treat all individuals in the same way, neutrally. To get a better view of the preconditions for successful applications of the TCM we need to take a look at the kind of policy approach it represents in the eld of lifestyle-related risk prevention. Biopolitics and the pastoral welfare state e total consumption framework was invented in France by the demogra- pher Sully Ledermann in the 1950s. e context was the extraordinary loss of male lives in and between the two world wars. He argued that the biggest factor of the high mortality rate was not war but the very high consumption of alcohol in France. Ledermann proposed that the distribution of alcohol consumption is skewed and has a relatively constant form. erefore, when the average consumption rate in a population increases, also the number and consumption level of problem drinkers, and consequently the preva- lence of drinking problems, will increase even more. erefore, the objec- tive of alcohol policy should be to regulate the total consumption of a popu- lation, by means of taxation, by regulating opening hours and by controlling the network of outlets for alcoholic beverages. Ledermann’s work was almost forgotten for over a decade, but it was rediscovered by Canadian researchers in the 1960s, and later in other coun- 11 Sulkunen, Pekka & Warsell, Leena (2012) ‘Universalism Against Particularism. Kettil Bruun and the Ideological Background of the Total Consumption Model’. Nordic Studies On Alcohol And Drugs, Vol. 29, 217–232.      tries.12 e Nordic countries became involved in this research for immedi- ate policy reasons. Alcohol consumption was increasing and health care and alcoholism treatment systems were unprepared for the mounting problems and costs incurred to the public. e approach found its way back to France in the late 1980s in the context of the Évin Law (passed in 1990). e Euro- pean Regional Oce of the World Health Organization in Copenhagen be- came instrumental in diusing the message to policy makers across Europe. e population argument is a continuation of a long historical develop- ment in which the life of the population became the object of state power in modern societies. As Michel Foucault has argued, the modern process shis the emphasis of power to the size of the population, its health, hygiene, sexuality and mental tness, instead of disciplining deviant or rebellious in- dividuals.13 Increasingly also civilized manners and ways of thinking were conceived as products of good government. e populations of national so- cieties were not only the objects of national states; they were also the source of the states’ sovereignty. e people, le peuple, das Volk, folket, kansa, was thought to act on itself through the institutions of parliamentary politics that were expected to reect not only the people’s needs but also its common will. Nation states are societies with geographic boundaries, independent political institutions, a more or less shared culture – and a population. Ideologically the TCM represents the type of governance that Michel Foucault has described with the metaphor ‘pastoral power’.14 Pastoral authority, the shepherd, knows the herd and its needs, leads it from one meadow to another, and cares for the lost sheep. It is an inclusive and uni- versalistic form of power that assumes a high degree of solidarity among the members of the ock. ese metaphors perfectly describe the welfare state until the last third of the twentieth century because they stress that the function of social policy was, besides the well-being of the population, the 12 de Lint, Jan & Schmidt, Wolfgang (1971) ‘Consumption Averages and Alcoholism Prevalence: A Brief Review of Epidemiological Investigations’. British Journal of Addiction, Vol. 66, 97–107; Popham, Robert (1970) ‘Indirect Methods of Alcoholism Prevalence Estimation: A Critical Evalua- tion’. In Popham, Robert (ed.) Alcohol and Alcoholism. Toronto: University of Toronto Press. 13 Foucault, Michel (1976) Histoire de la sexualité 1. La volonté de savoir. Paris: Gallimard; Foucault, Michel (1991) ‘Governmentality’. In Burchell, Graham, Gordon, Colin & Miller, Peter (eds) e Foucault Eect. Chicago: University of Chicago Press, 87–104. 14 Foucault 1991, 87–104.      € consolidation of social order by treating all citizens in the same way. In the welfare state literature this is called the universality principle. To succeed, such an approach cares for the population while leaving it to individuals themselves to weigh their pleasures against the risks. However, two further conditions must be met. First, there must be a centralized state that represents the generalized interest of the population in terms of the commonly accepted good, in this case the health, well-being and security of the population, instead of only particular interests or values of particular groups. is centralized power must draw its legitimacy from the will of the people, expressed through parliamentary elections. Second, it must be based on transparent scientic evidence to prove that it works, and it must have measurable objectives to demonstrate that it attains the goals set for it. e second requirement implies that the TCM is justied on the basis of expert knowledge. No one individual, from his or her own experience, can judge whether price increases actually have an impact on alcohol-related harm rates in the population, even if personal evidence on individuals’ reactions is available to everyone. is must be demonstrated with statistical knowl- edge. Even less can individuals observe from their own experience how the consumption-harm relation can be expected to react when policy measures are implemented. is requires expert knowledge about the regularities of the consumption distribution, risk functions and methods of aggregating the burden of harm, not only in one population but across several popula- tions in time and place. In the next two sub-sections we shall examine how these preconditions were met, rst in the three Nordic countries Norway, Sweden and Finland, and then in France. e Nordic cases e total consumption model landed in a fertile soil in the Nordic coun- tries with their state alcohol monopolies, not only because of the increasing alcohol-related problems but also for general ideological reasons related to the societal context. e Nordic welfare states were in the process of con- solidation, albeit Finland was somewhat behind the others. Welfare states, especially in the Nordic context, were national projects that continued the      nation-building process of the late nineteenth and early twentieth century.15 Nordic alcohol policy in the mid-twentieth century was a prime example of the gradual shi from discipline to concerns about the health and welfare of the population.16 Rigorous state control of drinking by the state has been relaxed in three waves. e rst occurred in the 1950s and can be called the civilizing wave, with increasing consumption levels and a gradually liberal- izing availability policy. e second was the wave of welfare state liberalism, and the total consumption approach became part of that approach in the 1970s and 1980s. e increasing availability of alcohol from both o- and on-premise outlets was frozen in all countries, and although political con- cern was expressed about rising alcohol problems, otherwise the policy re- actions varied between them. e third occurred as a consequence of the evolving new consumer society in the ‘crazy decade’ of the 1980s, when non-socialist coalition governments were in power, the monetary market was liberalized, public services were outsourced and credit-based consump- tion boomed.17 Also alcohol markets were liberalized, and this turn became a challenge to the total consumption approach. On-premise availability increased drastically. Moreover, the state-owned o-licences (monopoly stores in eect) increased in number and were modernized, wine columns started to appear in the printed media, beer societies were founded, and all three countries faced the need to adjust their alcohol policy systems in light of European Union (EU) rules. However, each country reacted dierently in terms of implementing this new policy.18 e dominant idea of the rst wave of liberalization was that since prohi- bitions did not work, drinking behaviour should be civilized and controlled by individuals themselves autonomously. e civilizing discourse was lib- 15 Sulkunen, Pekka (2009) e Saturated Society. Governing Lifestyles and Risks in Consumer Culture. London: Sage, ch. 4. 16 Mäkelä, Klaus & Viikari, Matti (1977) ‘Notes on Alcohol and the State’. Acta Sociologica, Vol. 20, 155–179. 17 Mjøset, Lars (2011) ‘Nordic Political Economy aer Financial Deregulation: Banking Crises, Eco- nomic Experts and the Role of Neoliberalism’. In Mjøset, Lars (ed) e Nordic Varieties of Capitalism. Bingley: Emerald Books, 365–420. 18 Sulkunen, Pekka (2000) ‘e Liberal Arguments’. In Sulkunen, Pekka, Sutton, Caroline, Tigerstedt, Christoer & Warpenius, Katariina (eds) Broken Spirits: Power and Ideas in Nordic Alcohol Control. Helsinki: NAD-Publication, 72–90.       eral in the sense that it purported to replace the polarity of drinking versus abstinence by more nuanced images of alcohol use, borrowed from Euro- pean, especially French bourgeois culture. To achieve this, alcoholic bever- ages should be allowed in the legal market, but under supervision by state monopolies and other government control agencies. e main motivation of the policy was the fear of the drunken worker.19 e viina, renat or bren- nevin (distilled white grain spirits) was the drink of intoxication, revolt and uproar as well as the cause of social misery, especially grave on the family and its welfare that depended on the man’s reliability and sense of respon- sibility (skötsamhet in Swedish). It was believed that if working-men would drink wine instead of spirits, the drinking pattern and the sociability around it would also become tamed according to the self-controlling bourgeois model. e monopolies gave advice on the proper way of serving drinks, informed the customers about the origins and characteristics of dierent ‘wine cultures’ and favoured ‘mild’ beverages in their pricing policies. Consequently, availability restrictions were gradually lied in the Nordic countries, which culminated in the licensed sale of medium beer in grocery stores in Sweden and Finland in 1966 and 1969 respectively. Furthermore, age limits for buying alcoholic beverages were lowered in all three Nordic countries. is reinforced the increasing long-term trend in alcohol con- sumption that could be observed throughout the Western world. is trend was widely believed to be a natural consequence of modernization that al- cohol policy could not prevent without perverse eects.20 In the Nordic countries serving regulations, selling practices and the in- dividual controls exercised over problem drinkers were selective and unfair towards the working class, the rural population and women.21 e second wave of liberalization of the 1970s in Nordic alcohol policy incorporated 19 Peltonen, Matti (1991) ‘Kieli vai kulttuuri? Väittely suomalaisesta viinapäästä keväällä 1948’. Alko- holipolitiikka, Vol. 56, 8–25. 20 Sulkunen, Pekka (1983) ‘Alcohol Consumption and the Transformation of Living Conditions. A Comparative Study’. In Smart, Reginald G. (ed.) Research Advances in Alcohol and Drug Problems, Vol. 7. London: Plenum Publishing Corporation, 247–297; Sulkunen, Sutton, Tigerstedt & Warpe- nius 2000. 21 Järvinen, Margareta (1991) ‘Kontrollerade kontrollörer – Kvinnor, män och alkohol’. Nordisk alko- holtidskri, Vol. 8, 143–152; Peltonen 1991.      the total consumption approach as a reaction to such biases but also as a continuation of the civilizing policy. Although the TCM reacted against the rising overall consumption level and its harmful consequences (and was therefore a backlash movement as regards market and consumer freedom), it was ideologically liberal as it reacted against the discriminating and ineq- uitable methods of the civilizing policy that still carried strong disciplinary overtones. It stressed solidarity and the need to sacrice part of the consum- ers’ freedom and convenience even among moderate drinkers for the benet of the public good. In contrast, the third wave of liberalization of Nordic alcohol policy from the early 1980s onwards emphasizes the romantic ethos of individual dier- ence and happiness. It gives priority to individuals’ desires over social needs. It became dominant later, when restrictions of the marketplace were again relaxed and a series of price and tax cuts began. Sweden e start of the rst liberal wave in Sweden culminated in the discontinua- tion of the Bratt system in 1955. Paradoxically, this was considered a victory for the conservative temperance movement, which considered the system of personal monthly quotas to be a permissive alternative to total prohibition, and felt that the referendum of 1922 was a defeat for their cause.22 e Bratt system, even aer its repeal, continued to have the support of the alcohol liberals, arguing that the personal allowance was, from the point of view of educating the Swedish people, much better than the personal control that replaced it, with blacklists, checks at purchase and other individual con- trols.23 For the temperance folk, the repeal of the Bratt system was a double- edged sword. e consumption level increased rapidly, and a substantial tax increase was implemented as a counter-measure in 1957. Already at this point the Swedish temperance movement saw the reduction of total con- 22 Bruun, Kettil (1985) ‘Maktens centrum – centraladministrationen’. In Bruun, Kettil & Frånberg, Per (eds) Den svenska supen. En historia om brännvin, Bratt och byråkrati. Stockholm: Prisma, 74–114. 23 Sulkunen 2000, 74.       sumption as the best policy line,24 and still in the wake of new liberalization measures the argument was that ‘misusers are recruited from among mod- erate consumers – therefore zero consumption is best’.25 Although divisions between conservative and more lenient wings of the temperance lobby – those close to the labour unions and students – were tense, the common ground was rm: less is better. e last move of the rst liberal wave in Nordic alcohol policy was again led by Sweden with its medium beer reform of 1965. Allowing medium- strength beer to be sold outside the monopoly in ordinary grocery stores was of course a controversial idea, but the justications used to support it were strongly consensual. e civilizing alcohol policy that aimed to achieve a society without alcohol-related harm was felt to be discriminating against the working class, rural people, women, youth and minorities. e number of blacklisted people went up to 20 000, and however neutral the selection mechanisms appeared on the surface, the actual sales practices in the mo- nopoly were not. On the eve of the reform, a media storm was raised by the Torvald Nilsson case. He was a construction worker who wanted to buy seven bottles of vodka in working clothes. He was given two bottles of wine. e next day he dressed up in a jacket, white shirt and a tie: no ques- tions were asked about his vodka bottles. e justication of the reform was unanimously solidarity and equality rst, reducing alcohol-related harm second.26 A number of adverse consequences followed, notably an increase in the consumption level. e government appointed an expert committee, whose report was an amalgam of the continued civilizing harm-reductionism (‘de- glorifying alcohol’) and a set of proposals to keep consumption low.27 Al- though in this sense it was a backlash against the rst wave of liberalization, the ideological principles of justication remained liberal and within the 24 Tigerstedt, Christoer (2000) ‘Discipline and Public Health’. In Sulkunen, Pekka, Sutton, Caroline, Tigerstedt, Christoer & Warpenius, Katariina (eds) Broken Spirits: Power and Ideas in Nordic Alco- hol Control. Helsinki: Nordic Council for Alcohol and Drug Research (NAD), 135–152. 25 Sulkunen 2000, 74. 26 Sulkunen 2000, 76. 27 SOU 1974:92. Alkoholpolitik: betänkande. Stockholm: Liber Förlag/Allmänna förlaget.      pastoral regime of power. It employed measures of inclusion and solidarity that aimed at the whole population, not bad individuals.28 From 1977 rules tightened for sales hours and alcohol serving in theatres and concerts, the number of monopoly shops was frozen, the medium-beer was repealed, and an advertising ban on alcoholic beverages was passed. From 1980 onwards expert reports commissioned by the government declared the TCM as the ocial doctrine, repeated in later reports and pre- liminary work for legislation:29 ‘e total consumption model needs to be theoretically developed and completed as a foundation for a comprehensive alcohol policy. e principal goal is to reduce total consumption’.30 Like in Norway, the argument relied on both universalism and solidarity. Govern- ment reports in 1991 insisted that alcohol-related harm aect not only alco- holics but ‘all of us’. e question is about caring for our fellow citizens, and the more Swedish people drink, the more harm will be caused to the whole society. Even the contagion argument proposed by researchers was used:31 If moderate drinkers increase their consumption, the excessive users will nd themselves in more situations where alcohol is used and therefore increase their consumption.32 In contrast to the earlier doctrine dominant in socialist discourse, attributing alcohol problems to bad social conditions – the so- called symptom theory that saw drinking-related misery only as a side eect of poverty and dissatisfaction – the causal connection was now made clear: at the alcohol question should be placed within a social context does not mean that it is just an expression for dissatisfying social conditions. Alcohol plays therewith an independent role in creat- 28 Tigerstedt 2000, 104. 29 Samordningsorganet för alkoholfrågor (SAMO) (1980) Om alkoholpolitiken. Förslag från Samord- ningsorganet för alkoholfrågor. Stockholm: Liber Förlag/Allmänna förlaget; Sutton, Caroline (1998) Swedish Alcohol Discourse. Constructions of a Social Problem. Uppsala: Studia Sociologica Upsalien- sia, 45, 100. 30 SOU 1994:24. Svensk alkoholpolitik – en strategi för framtiden. Stockholm: Fritzes; quoted in Tiger- stedt 2000, 105. 31 Sulkunen, Pekka (1976) ‘Drinking Patterns and the Level of Alcohol Consumption: An International Overview’. In Gibbins, Robert J., Israel, Yedy, Kalant, Harold, Popham, Robert E., Schmidt, Wolfgang & Smart, Reginald G. (eds) Research Advances in Alcohol and Drug Problems, Vol. 3. New York: John Wiley & Sons; Skog, Ole-Jørgen (1985) ‘e Collectivity of Drinking Cultures: A eory of the Distribution of Alcohol Consumption’. British Journal of Addiction, Vol. 81, Issue 3, 83–99. 32 Sutton 1998, 104–119.       ing and exacerbating problems. Heavy consumption of alcohol is far from always a symptom of poor social integration.33 Two factors concerning the actors in the Swedish case deserve special attention. First, the alcohol monopoly Systembolaget itself very prominently promoted the TCM. From about 1988 onwards it published several bro- chures for its customers on the importance of public retail monopoly and availability restrictions. One of them was titled: Why Must We Suer for the Sake of a Few Alcoholics, and Seventeen Other Questions. One of these ar- gued in a straightforward manner: ‘e more alcohol that is sold, the more Swedish people lose…’.34 e man behind this policy was Systembolaget’s Director General (1982– 1999) Gabriel Romanus, a liberal (Folkpartiet) Member of Parliament, former Minister of Social Aairs, and an ardent supporter of restrictive al- cohol policy, also internationally well-known in this role. e Liberal Party in Sweden has traditionally been the most active in temperance politics, and the fact that its representative was chosen to serve in the key position in the alcohol control system is a strong indication of the national concern about alcohol as a social and health problem. One reason why the principal com- mercial outlet for alcoholic beverages could take such a position against its own business interests was that Systembolaget only controlled retail sales, not wholesale or production. Its control policy position was a reaction to the liberal trend against state monopolies: it underlined the special and prob- lematic nature of alcohol as a consumer item, and thus the importance of public control over its distribution. e second factor that helped Sweden to adopt and maintain a strong adherence to the TCM was the role of researchers. e state commissions of 1974, 1980 and 1994 were manned not only by medical scientists but by epidemiologists, sociologists, a criminologist, and academic researchers of social work and social policy.35 Evidence for the TCM itself cannot be ob- 33 SAMO 1980, 10, 29; quoted in Sutton 1998, 105. 34 Sutton 1998, 105. 35 Sutton 1998, 112–113.      served without statistical studies, and to be convincing, aggregate informa- tion of alcohol’s harm and cost to the whole society is necessary. e tenacity of the Swedish policy is further stressed by the fact that both Social Democrats and Conservative Governments have supported it, and therefore the Swedish alcohol policy has had strong parliamentary support. Even the third wave of alcohol policy liberalism, with radical romantic over- tones stressing consumers’ freedom and ‘modernization’ since the mid-1980s did not succeed in shattering the state-control of the market that the TCM implies.36 e Swedish adjustment of alcohol regulations to comply with EU rules occasioned by the European Economic Area (EEA) Agreement from 1994, and full EU membership from 1995 was conservative, minimizing the necessary changes despite challenges against the monopoly system.37 Norway Norwegian alcohol researchers were among the rst in the world to redis- cover ‘the Ledermann curve’. As early as 1972 elements of the TCM were introduced in a governmental report and it has had a dominant role in pub- lic policy documents ever since.38 However, it is widely believed that the model had little impact on actual policies, only the justication changed.39 In a governmental report from 1987, Norwegian alcohol policy is justied in the following way: We know progressively more about the harmful health and social ef- fects of alcohol – not only for the heavy consumers, but for each and every consumer and for the society as a whole. We should therefore much more than before direct the attention towards the collective consequences viewed from a public health perspective.40 36 Sulkunen 2000, 84–85. 37 Ugland, Trygve (2000) ‘European Integration and the Corrupting Gaps of the Systems’. In Sulkunen, Pekka, Sutton, Caroline, Tigerstedt, Christoer & Warpenius, Katariina (eds) Broken Spirits: Power and Ideas in Nordic Alcohol Control. Helsinki: Nordic Council for Alcohol and Drug Research (NAD), 185–198. 38 Hauge, Ragnar (1998) Norsk alkohollovgivning gjennom 1000 år. Oslo: Rusmiddelsdirektoratet, 238–239. 39 Hauge 1998, 239. 40 Our translation. Sosialdepartementet [Ministry of Social Aairs] (1987) Stortingsmelding nr 17 (1987–1987) Alkohol og folkehelse. Oslo: Sosialdepartementet, 5–6.       One inuential view is that Norwegian alcohol policy has always been based on the principle of solidarity even before the TCM was introduced, because of the strong presence of the temperance movement.41 In contrast to Finland and Sweden, Norway had a kind of civilizing wine policy in place already during the ‘prohibition’ that only involved spirits and fortied wine. To illustrate the more pragmatic attitude towards beer and table wine, the state alcohol monopoly – Vinmonopolet – was established by a parliamentary decision in 1922, in the midst of the prohibition period between 1919 and 1926. However, the same concern about alcohol problems that was felt in Finland and Sweden during the second backlash wave of liberalism, led to an advertising ban in 1975. On the other hand, no major response to the rising consumer culture during the third wave of liberalization occurred, until tax reforms and the adjustments to EU legislation in connection with Norway’s adoption of the EEA Agreement in 1994. However, these changes aroused little political fervour. e negotiations between Norway and the EU concerning the retail monopoly were cautious on both sides; to question Vinmonoplet’s role as protector of public health and social welfare would have issued negative signals to an already EU-sceptic population that was thinking in terms of national sovereignty and self-determination versus EU domination.42 e widely accepted interpretation of researchers is that Norwegian al- cohol policy has been strongly inuenced by the nationalistic temperance movement and its presence across the political spectrum, the exception being the utmost neo-liberal right within Høyre and the populist Frem- skrittspartiet.43 e expert doctrine represented by the TCM has however been, albeit strongly supported by the research community, far less impor- tant than in Sweden as a guideline in actual policy-making. Also, the liber- alization that took place in Norway was gradual rather than abrupt like in 41 Brofoss, Knut (1996) ‘Alkoholpolitikken i Norge’. In Pedersen, Willy & Waal, Helge (eds) Rusmidler og veivalg. Oslo: Cappelen Akademisk Forlag, 34–38. 42 Ugland 2000, 129. 43 Hauge, Ragnar (1986) Alkoholpolitikken i Norge. Oslo: Statens Edruskapsdirektorat; Hauge 1998; Tigerstedt 2000, 105; Sulkunen 2000, 86.      Sweden and Finland. is incremental logic is illustrated by the fact that, despite numerous amendments, the Alcohol Act of 1927, which was estab- lished immediately aer prohibition, remained in eect until 1989, when a new comprehensive Alcohol Act was adopted. Finland Finnish researchers started to work on the TCM as a reaction to an alcohol policy crisis created by the rst, civilizing wave of alcohol policy liberali- zation.44 Following Sweden’s example, medium beer was released from the state monopoly to grocery stores in 1969. In addition, rural municipalities were allowed to have restaurants and monopoly stores in their area (with the consent of the local council), public drunkenness was decriminalized, advertising rules were relaxed and some other minor reforms were imple- mented. e consequent rise in the consumption level, from a little over two to almost six litres of 100 per cent alcohol per capita within a few years sur- prised everyone. Beer gradually became a national drink, instead of vodka; wine consumption stayed at a low level, but unruly behaviour in the streets increased, arrests for drunkenness did not go down and many other harm indicators showed alarming trends. e response among the research community was to turn to the TCM. With some trouble the management of the monopoly, as well as the minis- tries controlling it, were convinced of the need to control the total consump- tion; the number of outlets was frozen, price increases (moderate) were implemented, the advertising ban was introduced in 1975, and in general, attitudes towards alcohol liberalism became more critical. About 70 rural communities withdrew their consent to sell medium beer in their area.45 A new state committee was commissioned to make a long-term plan, led by Heikki Koski, Director General of the monopoly, Alko.46 is com- mittee was the only one in Finland who explicitly drew on the TCM as the theoretical guideline for its proposals. ey included price increases, lower- 44 Sulkunen & Warsell 2012. 45 Sulkunen 2000, 84. 46 Alkoholikomitea [Alcohol Committee] (1978) Alkoholikomitean mietintö. Helsinki: Valtion paina- tuskeskus.      € ing the alcohol content of beers (there were three classes: ‘mild’ beer below 2.25 per cent vol., medium beer below 4.7 per cent, and strong up to 5.2 per cent), maintaining the ban on advertising, freezing the number of outlets and some other minor measures. None of these were implemented – the third wave of alcohol liberalism was already setting in, together with the turf of deregulating the credit market and the consequent consumption boom.47 e alcohol policy climate was increasingly opposed to regulation, starting from the media and gradually turning into popular opinion and also policy. e opinion favouring the release of wine from the monopoly went up from a quarter to two thirds 1984–1996, the consumption level went up from 7.9 to 9.5 litres in 1985–1990, the number of fully-licensed bars and restaurants went up from 1585 to 4274 in 1980–1997, monopoly shops were modernized, and advertising was reintroduced in 1995.48 e EU nego- tiations resulted in a drastic reorganization of the monopoly, which now retained only its retail functions, separated from production, imports and wholesale. Medium beer was allowed in kiosks and service stations, at sports occasions, regulations on serving alcohol as well as selling hours were re- laxed. e sale of ‘wine’ from factory outlets was allowed.49 Many of these changes in excess of the legal EU requirements were made directly in the parliament, without preparatory work, in a spirit of revolutionary freedom following the victorious referendum to join the EU, which for supporters meant modernization, cosmopolitism, and a nal blow to Russo-friendly foreign policy. Aer these events, the TCM has hardly been mentioned in governmental policy programmes. Comparison between Sweden, Norway and Finland e overall picture is that alcohol policy changes in Norway have been gradual and perhaps even less politicized than in Sweden and Finland. Swe- den has experimented with reforms both ways, Finland going consistently 47 Vartiainen, Juhana (2011) ‘e Finnish Model of Economic and Social Policy – From Cold War Primitive Accumulation to Generational Conicts’. In Mjøset, Lars (ed.) e Nordic Varieties of Capitalism. Bingley: Emerald Books, 53–88. 48 Sulkunen 2000, 87. 49 Ugland 2000.      towards a free market. e TCM has been and still is an important policy guideline in Sweden but relevant only in Finnish and Norwegian alcohol research, not in policy. Two related factors seem to explain the dierences. First, the role of the temperance movement had almost disappeared in Finland at the mo- ment when the welfare-state based TCM was introduced. e movement was incorporated into political parties and lost autonomy as a stake-holder in specic alcohol policy issues. It took more than 10 years before the re- maining bodies of temperance organizations realised that the TCM might serve their cause, but then it was too late. is is important, because the Finnish power structure is very dominated by corporatist bodies rather than the parliamentary institutions. e employers, labour unions, the Finnish Bank, together with the sitting government, have played decisive roles in economic and social policy. In contrast, lifestyle policies in general have not had a strong stake-holder structure at the national level. Issues around alco- hol policy have either been subsumed to other policy concerns such as state nances, western orientation in foreign policy, and other fragmented policy interests such as the media and sports on advertising and sponsoring; de- centralized production, imports and wholesale interests; and the food retail structure based on two major chains covering over 80 per cent of the total turnover. e alcohol monopoly has lost its role as a central national actor and the research expertise it once had at its disposal in the policy eld has been removed and decentralized. e contrast with Norway is interesting. Whereas in Finland, the public health lobby in the alcohol issue was weakest when it was most needed in the middle of ‘the crazy 1980s’, the temperance movement has remained an active stake-holder role in Norway within the party structure itself. Weak majority coalitions, even minority governments during a long period of 1986–1997 were unwilling to rock the boat, especially as the alcohol policy issue was closely connected with the EU membership question that divided all major parties.50 us there has been less need for using the TCM as a 50 Mjøset, Lars & Cappelen, Ådne (2011) ‘e Integration of the Norwegian Oil Economy into the World Economy’. In Mjøset, Lars (ed.) e Nordic Varieties of Capitalism. Bingley: Emerald Books.       policy guideline to support the restrictions to the overall mild liberaliza- tion trend domestically. e increasing number of outlets, especially in rural areas, has resulted from local competitive interests, not from political deci- sions at the national level. However, the Norwegian temperance movement is still very active in its promotion of the TCM internationally. For instance, the Norwegian Policy Network on Alcohol and Drugs (ACTIS) – which re- placed the Norwegian Temperance Alliance (Avholdsfolkets Landsråd) when it was dissolved in 2003 – has maintained a permanent lobby oce in Brus- sels since 1995, due to the strong impacts of the EU integration process on Norwegian alcohol policies.51 Sweden, therefore, is the only Nordic country where the TCM has actu- ally served signicant policy goals. Two factors stand out as explanations for this. First, the temperance movement, also spread across the political spectrum, has maintained its stake-holder role at national level politics. Secondly, the alcohol policy debate has remained in parliamentary hands at the national level, infused with independent expert knowledge through the political state committees that actually participate in the formulation of policy. An important feature of this expertise is that it has largely been represented by the medical, epidemiological and social science community in the policy-making bodies and activities. For example, in the 1980s about every third medical doctor signed a petition to re-introduce the rationing system in order to reduce alcohol-related harm and keep the consumption level in control.52 e French case If the TCM has been dicult to implement in the Nordic countries with strong temperance traditions, unruly drinking patterns, and a centralized welfare state exercising pastoral power over the population, it might be even less likely that a country like France with a much longer history of daily alcohol consumption, an immense alcohol and serving industry and an in- 51 Ugland, Trygve (2011) Alcohol on the European Union’s Political Agenda: Getting O the Policy Roller- Coaster? Oslo: Norwegian Institute for Alcohol and Drug Research. 52 Tigerstedt 2000, 98–99.      dividualistic, state-sceptic culture, would adopt such an approach to care for the well-being of its citizens. In circumstances where the availability of alco- hol is very high and it is present everywhere, it might be expected to be very dicult to demonstrate that policy can have an impact on consumption, and, even more dicult to convince consumers that it can reduce harm. Nevertheless, in September 2001 the French Minister for Health, Ber- nard Kouchner, presented a new alcohol action plan, based on the idea that a reduction in the total consumption of alcohol is required if alcohol-related problems should be minimized. is policy document was not unique. It reects and redenes a long public health tradition in the French alcohol policy arena. As is well known, the epidemiological basis of the total con- sumption framework was originally laid in France in the 1950s in the work of the epidemiologist and demographer, Sully Ledermann.53 Since then, it has repeatedly been oated as the policy argument in alcohol control ef- forts, disappearing occasionally only to surface again. Minister Kouchner’s policy paper continues the legislation pressed through the parliament in 1989–1991 by Claude Évin, then Minister for Social aairs. e so-called Loi Évin, the Évin Law, marked the most radical restrictive reform in alcohol and tobacco policy in Western Europe in the second half of the twentieth century, aiming at a quasi-total prohibition of advertisement and sponsor- ing, and introducing serious cuts in the availability of these products, espe- cially for young people. e law created an enormous public debate in the media from the preliminary stages of the legislative process until the evalua- tion report of 1999, which declared that the law was a legal failure and needs to be rewritten completely.54 Still the law continues to be implemented, with possibly reinforcing eects on a development in which alcohol consumption has been declining and awareness of alcohol-related risks increasing for over a half-century. 53 Ledermann, Sully (1956) Alcool, alcoolisme, alcoolisation. Institut national d’études démographiques. Paris: Presses universitaires de France. 54 Commission nationale d’évaluation (1999) Evaluation de la Loi Évin. Paris: Commission nationale d’évaluation.       e historical background Although still amongst the leading alcohol consumers in the world, the level of consumption by the French has declined since the 1950s. is was also the period when the rst initiatives to control the consumption were taken at the political level. During his short period as Prime Minister (June 1954–February 1955), Pierre Mendès-France introduced more than 20 de- crees and proposals related to the objective of reducing the production and consumption of alcohol in the French society. For instance, his government proposed new restrictions in relation to the bouilleur de cru system, a set of scal measures to encourage production of sugar instead of alcohol, and regulations to favour milk in relation to wine. A government bill to rein- state a ban on the advertising of pastis and whisky was presented to the Parliament, as was a proposal to ban the sale of aperitifs between ve and 10 o’clock in the morning.55 Perhaps most important in the long run, Mendès-France established the High Committee for the Study and Information on Alcoholism (Haut Comité d’Etudes et d’Information sur l’Alcoolisme) with Robert Debré as its president in 1955. is committee was an agency of the Prime Minister, and its main tasks were to provide information on alcohol-related problems, to fund research and to provide initiatives in order to reduce alcohol abuse in society. All in all, the Mendès-France actions represented a comprehensive ap- proach towards the ght against alcoholism in France. Although most of his proposals were defeated, the attention concerning alcohol related prob- lems was raised, and this attention was institutionalized through the High Committee for the Study and Information on Alcoholism. Public aware- ness about the risks related to alcohol use increased and has ever since been an important factor in the historical decline in alcohol consumption in France.56 55 Prestwich, Patricia E. (1988) Drink and the Politics of Social Reform: Antialcoholism in France Since 1870. Palo Alto, CA: e Society for the Promotion of Science and Scholarship. 56 Sulkunen, Pekka (1989) ‘Drinking in France 1965–1979. An Analysis of Household Consumption Data’. British Journal of Addiction, Vol. 84, No. 1, 61–72; Aigrain, Pierre, Boulet, Daniel, Lambert, Jean L. & Laporte, Jean P. (1991) La consummation du vin en France en 1990. Montpellier: INRA.      Despite these initiatives, the public health interest in relation to alcohol did not manage to make a consistent and continuous impact in the French society, as the economic and market interests seemed to dominate the arena during the next decade. However, the public health interests never disap- peared completely, and their balance with commercial and economic inter- ests has been unstable. e Minister for Social aairs, Maurice Schumann, expressed his opinion on the subject in 1968, when he claimed that ‘alcohol- ism is the worst and most poorly fought of all our social diseases [éaux]’. Legislation allowing random breath testing in trac in the early 1970s was the most important – and probably eective – consequence of this concern.57 e public health point of view became more visible again during the 1980s. On request from President Giscard d’Estaing, Professor Jean Bernard presented a new report on alcohol prevention, education and treatment in 1980. Since a total ban on alcohol advertising at that time was not a viable option, the legislation that was proposed merely intended to regulate alco- hol advertising in a manner that had already been implemented on tobacco a few years earlier. e Évin Law Law no. 91–32 of 10 January 1991 is the ocial name of what has become known as the Évin Law. Its objective is to reduce the harm related to tobacco and alcohol in society. e Évin Law focuses on advertising and sponsoring, education, as well as the supply side in relation to tobacco and alcohol prod- ucts. Its background documentation refers explicitly to the need to reduce alcohol consumption among the whole population. e law has been in eect since 1 January 1993. It prohibits direct or in- direct advertising of alcoholic drinks on television and cinema, in stadiums, public and private sports grounds, swimming pools, competition arenas and all areas used by youth associations or for education. Advertising was au- thorized in the original law on radio only within certain specied time slots, on billboards or notices only in zones of production. Advertising is permit- 57 Prestwich 1988.       ted, however, within sales outlets and in the press, except for publications aimed at young people. e content of the advertising messages is strictly limited to product information concerning the alcohol content, origin, the categorization (de- nomination), ingredients, the name and address of the producer, the agents and distributors, modalities of merchandizing (packaging etcetera), and the manner in which it is supposed to be consumed (mode de consommation).58 Specically, the permitted announcements must not include any encour- agement to minors. It is forbidden to give, distribute or send documents or objects naming an alcoholic drink to those under age. Lastly, advertisements for alcoholic drinks must include a health warning stating that alcohol abuse is dangerous to health. A specic aim of the legislation was to avoid the possibilities of indirect advertising that had been extensively used under previous legal restrictions. Sponsoring involving advertisements for tobacco and alcohol products was completely banned, which violated serious interests in mass media sports, especially soccer and Formula 1 racing, but was felt necessary because of the widespread use of indirect advertisement before. In the controversy, the alcohol lobby argued that tobacco and alcohol should not be combined in the same law since the nature of the problem is completely dierent in the two cases. e wine lobby attempted to exclude French quality wines (appellation d’origine controlée – AOC) from the law.59 e negotiations that ensued introduced a number of compromises and minor amendments in the law that later proved fatal to its intent. Also, a number of issues were to be ruled by the ministry later on by decrees, which also proved to be a problem for the implementation of the law. e advertis- ing industry announced that the limits of the law would be pushed as far as the letter would allow as regards the content of the regulations.60 58 Haut Comité d’études et d’information sur l’alcoolisme (1990) Actualités, No. 3–4. 59 Sénat. Compte rendu ocial, No. 60, 12 October (1990). Assemblée Nationale. Seconde session ordi- naire de 1989–1990 (92e séance). Compte rendu integral, 2867. 60 Bureau de Vérication de la Publicité. 16 April 1992.      e campaign From the point of view of this chapter, the process that led to the adoption of the law was even more interesting than the outcome. e initiative came from ve prestigious professors of medicine, Gérard Dubois, Claude Got, François Grémy, Albert Hirsch and Maurice Tubiana. eir campaign was carefully planned, and the outcome has been presented as the rst lobby vic- tory within the public health sector in France.61 e background of their initiative can be traced back to 1984, when the High Committee for the Study and Information on Alcoholism presented a proposal for a ban on the advertising of alcoholic drinks directed towards adolescents. However, possible restrictions on alcohol advertising were challenged by the new media situation. As a response to pressure from the new commercial television channels, the restrictions of beer advertising were relaxed in 1985 and again in 1986. en Prime Minister Jacques Chi- rac announced that although alcohol advertising could be banned in public television by an administrative decision, a ban in the commercial TV chan- nels would require a new law.62 In 1987, this initiative was formalized in a new law (Loi no 87–588 30 July 1987), oen referred to as the Loi Barzach aer the then Minister for Health, Michèle Barzach, herself a medical doctor by training. is law banned alcohol advertising on TV for the rst time in France, but made an exception for beer. Because beer advertising was still allowed, the ve professors were not content with this law, arguing that the ‘dangerousness of alcohol does not depend on the amount of water that surrounds it’. Professors Dubois and Got were at that time members of the High Committee for the Study and In- formation on Alcoholism. Claude Got le the High Committee as a protest, which received considerable attention in the media. Together with Grémy, Hirsch and Tubiana they decided to launch a campaign to get a new and more restrictive law on alcohol advertising. e medical professional socie- ties, the deans of medical faculties and important personalities among the medical professions including some Nobel Prize winners joined in to make 61 Personal interview with Gérard Dubois on 12 October 1992. 62 Personal interview with Laurence Nart (Direction générale de la santé) on 9 October 1992.       it known to the Minister for Health that alcohol is still the number one public health problem in France.63 is was done in the form of a petition that also included a subscription to collect money for paid advertising on the issue.64 When Claude Got was commissioned to prepare a new policy paper on the prevention of AIDS in 1988, he decided with his close colleagues to also address public health issues that were regarded as even more important, namely trac accidents, smoking and alcoholism.65 e process towards the Évin Law picked up speed in 1989, when the ve professors were commis- sioned to prepare a white paper on these three issues by the Minister for Social aairs, Claude Évin. In this paper, they raised the need for rmer ac- tions in order to reduce the harm resulting from alcohol consumption. eir proposal for the new legislation included a wide range of public health is- sues: screening for certain cancers, reducing the number of trac fatalities, and excessive use of psychotropic drugs, which is high in France. e Minister for Social Aairs accepted the proposals from the ve pro- fessors on tobacco and alcohol, and decided to present a new law before the Parliament in May 1990. e new law was presented using the procedure of urgency. Aer a very intensive debate on alcohol – the legislation con- cerning tobacco was less controversial – the law was passed by the National Assembly on 27 June 1990, and with some modications by the Senate on 16 October the same year. e Senate, however, excluded the restrictions on alcohol advertising. e revised text then went back both to the National Assembly and the Senate, where the nal text was adopted in December 1990 and became law in January 1991. In the Assembly, the Socialist Party voted in corpore for the legislation presented by the socialist minister, but in the Senate the socialists were rst opposed. e communists were against the legislation throughout the process, whereas the bourgeois parties were divided. Despite the amendments that were adopted in this process, the nal legislation was for the most part in line with the proposal of the ve profes- sors. 63 Personal interview with G. Dubois on 12 October 1992. Active support was given by the internation- ally reknown and prestigious professor of haematology and cancerology Jean Bernard, Member of the Academie de France and Academie des sciences. Le Monde, 18 April 1990. 64 Personal interview with G. Dubois, 12 October 1992. 65 Personal interview with Claude Got on 29 October 1992.      An important part of the campaign was an article bearing the title ‘No to a ministry of disease!’ that appeared in Le Monde the day aer the white paper was published.66 e authors claimed that ‘the government should not hesitate in implementing a public health policy, and not delay measures that have a general interest and the support from the majority of the population and of the politicians’. e media approach was combined with active lob- bying in the political arena. An opinion poll commissioned in 1989 by the Catholic newspaper La Croix l’Événement that opened their columns to the campaign showed that 69 percent of the population supported a ban on to- bacco advertising, and 61 per cent supported a ban on alcohol advertising.67 e total consumption framework was central in the argumentation of the ve professors, and a number of references were made to the work of Ledermann in the background material, as well as in the document pre- pared by the Ministry of Social Aairs to introduce the legislation to the public.68 e universalism of the population argument was an important part of the campaign. e restrictions on advertising and availability that they proposed in the name of the public good concern everyone in the same way. It is important that especially the media to which all are exposed re- gardless of their will should be free of advertising. A further aspect of the universalism is the solidarity argument involved. e professors published a second article just before the bill was presented to the Assembly, writing that: e 100 million premature deaths caused by alcohol and tobacco are not randomly distributed. e life expectancy of a manual worker at the age of 35 is eight years less than his male counterpart belonging to the upper middle class. ese inequalities are largely explained by the superior capacity to manage alcohol- and tobacco-related risks 66 Dubois, Gérard, Got, Claude, Hirsch, Albert, Grémy, François & Tubiana, Maurice (1989) ‘Non au Ministere de la Maladie!’. Le Monde, 15 Nov. 67 Dubois, Gérard, Got, Claude, Grémy, François, Hirsch, Albert & Tubiana, Maurice (1990) ‘L’état est en retard sur l’opinion’. La Croix l’Événement. 10 Jan. 68 Ministère de la Santé et de la Protection sociale [Ministry of Social Aairs] (1989) L’action politique dans le domaine de la santé publique et de la prévention. Propositions de Gérard Dubois, Claude Got, François Grémy, Albert Hirsch et Maurice Tubiana. Paris: Ministère de la Santé et de la Protection sociale.      € by social groups that are in a favourable familial and educational en- vironment.69 In their public articles, the professors employed the rhetorical format of the pending narrative, placing themselves on the side of the public good against the threatening private interests. e scene is set, the characters of the plot are positioned, the task of the protagonist is dened, but the solu- tion of the story is pending70 – and depending on the support of the public: the readers.71 However, they also wanted to get around the political elite, resorting to the classical method of French intellectual movements since the Dreyfus Aair – the petition:72 e group prepared, we had an idea, and since we had the support of the Nobelists etc., we said, yes, let’s make a petition to the people: destroy the politicians! e politicians are intermediaries, elected by the people. When you turn directly to the people, you ignore the politicians, which is for them the most disagreeable thing. So we made an appeal to people in Le Monde asking them to subscribe and to send us money.73 e new and strange aspect of this self-denition is not that intellectuals represent themselves as vanguards of the people; what is striking is that this time the vanguards did not come from the margins of intellectual life – the literary circles and the artists, but from what according to Pierrre Bourdieu’s analysis is the most legitimate centre of the intellectual eld.74 But the margins were against. A group of social workers who were at the time in the process of establishing their own national network of ‘alcoolo- 69 Dubois, Gérard, Got, Claude, Hirsch, Albert, Grémy, François & Tubiana, Maurice (1990) ‘Un hon- neur pour notre démocratie’. Le Monde, 29 Mar. 70 A pending narrative is a semiotic structure where the setting of the story is ready, with threats, objectives, and heroes, but the narrative does not unfold to the end, as if the solution would depend on the support of the audience. Pending narratives are typically used in persuasive texts such as editorials. 71 Sulkunen, Pekka & Törrönen, Jukka (1997) ‘e Production of Values: e Concept of Modality in Textual Discourse Analysis’. Semiotica, Vol. 113, Issue 1/2, 43–69. 72 Ory, Pascal & Sirinelli, Jean-François (1986) Les intellectuels en France de l’Aaire Dreyfus à nos jours. Paris: Armand Colin. 73 Personal interview with G. Dubois on 9 October 1992. 74 Bourdieu, Pierre (1986) Homo Academicus. Cambridge: Cambridge University Press.      gists’ as a counterbalance to the medically dominated and temperance-ali- ated treatment community, decided to rally with the industry and the media that opposed the law.75 ey considered the initiative to be hypocritical, and argued that it was paternalistic to attack the advertising and availability of alcohol, while the real issues of poverty, exclusion and education were not addressed. e working class and ordinary people should be educated and given the opportunity to appreciate wine and to avoid the risks of alcohol- ism.76 e group calls itself Alcoologie plurielle and publishes a review bear- ing that name. e review and other activities of the group are supported nancially by the French distilling industry, but it is also signicant that the ‘pluralism’ of the group contrasts with the traditional medically-oriented French anti-alcoholism movement Association Nationale de Prévention de l’Alcoolisme (ANPA) and its commitment to total abstinence in treatment. Alcoologie plurielle collaborates closely with ex-drinkers’ associations but is in favour or moderation rather than abstinence. e group argued that the Évin Law is scape-goating the producers, the advertising industry and the drinkers, and is not based on rm evidence on the impact advertising has on drinking problems; rather, it represents neo-prohibitionism. Instead, alcohol advertising should be taxed to support treatment institutions and self-help organizations. Emphasis should be placed on regional rather than national structures and institutions.77 In sum, the Évin Law was a victory for the public health lobby over the alcohol and advertising industries, and France has adopted the most restric- tive legislation on alcohol advertising in the EU. Like the beverage laws that were adopted by the Mendès-France government (Code de Boissons), the public health interests had won a more or less unexpected victory. e cam- paign fought by the ve professors of medicine was crucial in this process, infused with references to the values of the modern welfare state: universal- ism, solidarity and justice as well as science and health. 75 A counter ‘manifest’ was signed and published in July 1990 by the Breton regional activist G. Caro and by P. Zolotare, together with a number of psychiatrists, treatment personnel and some social scientists. 76 Personal interview with P. Zolotare on 15 October 1992. 77 ‘Loi Évin – le débat se poursuit’. Alcoologie Plurielle, No. 9. Nov. 1990, 6–13.       Attacks and resilience e Évin Law has been highly controversial throughout its existence, and its implementation has been systematically maimed not only by the alcoholic beverage industries, but, to an even higher degree, by advertising and the media. One of its immediate eects has been to deprive the press of about one h of its advertising revenue.78 With respect to alcohol, the controversies over the Évin Law have led to a number of important modications following lobbying pressures. e legislation has been watered down in relation to alcohol advertising, distri- bution and sponsoring. e evaluation, much delayed from what was in- tended, argued that the law is excessively ambiguous and leads to a waste of resources in continuous court cases on what is and what is not allowed in alcohol advertising. e initiative by Health Minister Kouchner – himself a medical doctor and co-founder of Médecins Sans Frontières (MSF) – in 2001 was a decisive step towards consolidating the Évin law, suggesting that the established ob- jective of promoting ‘moderate alcohol consumption’ should be replaced by ‘low alcohol consumption’. e argument is based on the recommendations of the WHO and scientic literature. It claims that the idea of moderate drinking has to be abandoned because this notion allows individuals to de- ne for themselves what is moderate drinking. ese individual denitions are said to be too oen above what is epidemiologically dened as low risk. e traditional focus on problem drinkers must be replaced by a ‘new focus’ on speeding up the process of reducing the total consumption and on heavy drinking occasions. And furthermore: To speak to the total population in order to reduce the total consumption does not mean to address an abstract population but to put into place means which are aimed at dierent seg- ments of population and its dierent consumption patterns.79 e Évin Law is assumed to play a key role in connection with this new strategy, and the ambition is to strengthen the law. It is claimed that the ideas behind the Évin Law are good, but it has not worked practice. e 78 Dorozynski, Alain (1995) ‘France Dilutes Tobacco and Alcohol Advertising Ban’. British Medical Journal, Vol. 310, Issue 6985, 962. 79 Stratégie d’action alcool. Stratégie d’action alcool: Intensier la prévention et le traitement des prob- lèmes de santé liés à la consommation d’alcool. Paris: Direction générale de la Santé, 2001.      response to the evaluation report of October 1999, which underlined the incoherence between the legislative dispositions and the present regulations were to strengthen the law by eliminating the number of exceptions in the area of publicity within sports, as well in the elds of culture and science.80 e arguments presented in favour of the Évin Law not only rely on the TCM but, even more interestingly, closely resemble the rhetoric of Pastoral power, especially the principles of universalism and solidarity. e essential factor in its success was that it was backed by the expert authority of the medical community. e medical community has always been in an im- portant role in promoting that awareness, ever since the foundation of the French association against the abuse of alcohol in 1872. Like in Sweden the ‘medicalization’ of the problem did not rst and foremost concern treatment but prevention. In France, the focus of attention was placed especially on the bouilleurs de cru (traditional distillers) and the cheap alcohol that they made available to the people.81 e Évin Law successfully maintained the health promotion image of a restrictive alcohol policy by combining alcohol and tobacco. e Évin Law marks, however, an important change in the French de- bate over alcohol. In the earlier phases of its history, this conict has been very complex politically. e medical profession has not been prone to turn towards socialism, not even in the social democratic sense. Neither has the socialist party and even less the French communist party been unanimous in its support of a public health-oriented alcohol policy. On the contrary, the socialists have had a stronghold in the viticulture regions, and consequently their attitudes towards restrictive attempts have tended to be negative. e process around the Évin Law has markedly changed this. Like in the Nordic countries, alcohol policy has become a le-right political issue only in the course of the last quarter of the twentieth century. is may make it even more vulnerable to political tides than before. 80 Stratégie d’action alcool 2001. 81 Nourrisson, Didier (1987) Alcoolisme et antialcoolisme en France sous la Troisième République. Vol. 2. Paris: Haut Comité d’études et d’information sur l’alcoolisme.       Conclusions e comparisons we have made in this chapter concerning the Total Con- sumption Model in alcohol policy demonstrate that the viability of the public health approach in lifestyle regulation policy depends not only on epidemiological arguments per se but on the match between the social phi- losophy in which it is formulated and the political context in which it is applied. e public health concern in the alcohol question has for long been severe in France, and it was strongly surfacing in the Nordic countries in the crazy 1980s, when consumption levels were already high and rising still. Yet the TCM gained force only in France and Sweden, among the countries studied in this chapter. In Norway it was strong among researchers but less needed in policy implementation, since the anti-alcohol attitudes continued to be built into the political apparatus, amalgamated with the EU issue. In Finland, the corporatist power structure has tended to downplay the promi- nence of lifestyle regulation policy at the expense of economic and interest- based social policy concerns. e parliamentary political structure has been weak, leaving the alcohol eld open to particular interest lobbies precisely when the public health argument was most needed. Even the parliament was carried away by the liberal gusto of the crazy 1980s, when it passed the reforms of the alcohol regime to adapt it to the EU-membership in 1994. e population argument is part of the ‘bio-political’ discourse that has been characteristic of modern national societies in the course of the twenti- eth century. e responsibility of the state has been not only to correct devi- ant individuals but to place emphasis on the public good, the well-being of the population, solidarity, and the values of rational and scientically-based central planning. In the French case, the attractiveness of the population ar- gument and its success in justifying the initial formulations of the Évin Law was based on two of its properties. Firstly, it holds an expert position – only research can provide the necessary evidence on the relationship between the number of deaths and the consumption of alcohol in the population. Sec- ondly, it appeals by its universalism, and by the argument of solidarity that it implies. It applies to every citizen in the same way by restricting the choice itself, and only makes an argument about the consequences of drinking at      the population level rather than against indulging in the pleasures of drink- ing by individuals. Both of these values are well adapted to contemporary modern and pluralistic societies, where it would be very dicult to agree on whose drinking and what kind of drinking should be permitted or rejected, and where the calculation of risks rather than guarding over behaviour is the proper role of experts. But the comparisons also show that these two aspects of the epidemio- logical argument are also its weaknesses. e statistical relationship between total consumption and the prevalence of problems is not obvious to the public, and evokes the issue of trust in a world impregnated with suspicion for hidden agendas. e struggle against total consumption is never only a technical matter but always also involves priorities, and some priorities necessarily imply a sacrice of others. Pastoral power implies the notion of the public good and its priority over private gain. e idea of the public good can only be enforced if it is made to appear as the will of the nation through parliamentary processes, and the population becomes not only the object of governmental power but also its source. e temperance history at the turn of the century therefore does not explain the success of prioritizing public health in this matter, unlike the liberalism of the Finnish case, and the determination of the French policy show. Rather, it seems to matter to what extent public health experts and advocates are able to join forces at the national level in the central institutions of parliamentary power. e fragmentation of the Finnish corporatist stake-holder structure and the par- liamentary structure in Sweden and France are extreme points on a scale. e similarities between France and Sweden documented in this chapter can also be identied in their relationships with the EU. It has for instance been illustrated how the French and Swedish governments have actively supported each other in discussions and disputes over alcohol policy ques- tions at the EU-level.82 Our analysis shows that the conditions for the successful use of the TCM are unique, precarious and probably exceptions, rather than the rule in the contemporary world. On the other hand, French public health policy shows 82 Ugland, Trygve (2003) ‘A Case of Strange Bedfellows in the EU: An Institutional Perspective on the French-Swedish Cooperation on Alcohol Control’. Scandinavian Political Studies, Vol. 26, No. 3, 269–286.       that there is no absolute reason why the values of solidarity and the public good could not stand up to private interests and individualism even today, but there is no guarantee of their success either. References Aigrain, Pierre, Boulet, Daniel, Lambert, Jean L. & Laporte, Jean P. (1991) La consummati- on du vin en France en 1990. Montpellier: INRA. 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In Pedersen, Willy & Waal, Helge (eds) Rusmidler og veivalg. Oslo: Cappelen Akademisk Forlag, 34–38. Bourdieu, Pierre (1986) Homo Academicus. Cambridge: Cambridge University Press. Bruun, Kettil (1985) ‘Maktens centrum – centraladministrationen’. In Bruun, Kettil & Frånberg, Per (eds) Den svenska supen. En historia om brännvin, Bratt och byråkrati. Stockholm: Prisma, 74–114. Bruun, Kettil, Edwards, Grith, Lumio, Martti, Mäkelä, Klaus, Pan, Lynn, Popham, Robert E., Room, Robin, Schmidt, Wolfgang, Skog, Ole-Jørgen, Sulkunen, Pekka & Öster- berg, Esa (1975) Alcohol Control Policies in a Public Health Perspective. Helsinki: e Finnish Foundation for Alcohol Studies. Bureau de Vérication de la Publicité. 16 April 1992. Commission nationale d’évaluation (1999) Evaluation de la Loi Évin. Paris: Commission nationale d’évaluation. de Lint, Jan & Schmidt, Wolfgang (1971) ‘Consumption Averages and Alcoholism Preva- lence: A Brief Review of Epidemiological Investigations’. 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In Sulkunen, Pekka, Sutton, Caroline, Tigerstedt, Christoer & Warpenius, Katariina (eds) Broken Spirits: Power and Ideas in Nordic Alcohol Control. Helsinki: NAD-Publication, 72–90. Sulkunen, Pekka (2009) e Saturated Society. Governing Lifestyles and Risks in Consumer Culture. London: Sage. Sulkunen, Pekka (2011) ‘Autonomy Against Intimacy: On the Problem of Governing Lifestyle-Related Risks’. Telos, Vol. 156, 99–112. Sulkunen, Pekka, Sutton, Caroline, Tigerstedt, Christoer & Warpenius, Katariina (eds) (2000) Broken Spirits: Power and Ideas in Nordic Alcohol Control. Helsinki: Nordic Council for Alcohol and Drug Research (NAD). Sulkunen, Pekka & Törrönen, Jukka (1997) ‘e Production of Values: e Concept of Modality in Textual Discourse Analysis’. Semiotica, Vol. 113, Issue 1/2, 43–69. Sulkunen, Pekka & Warpenius, Katariina (2000) ‘Reforming the Self and the Other: e Temperance Movement and the Duality of Modern Subjectivity’. Critical Public Health, Vol. 10, No. 4, 423–438. Sulkunen, Pekka & Warsell, Leena (2012) ‘Universalism Against Particularism. Kettil Bruun and the Ideological Background of the Total Consumption Model’. Nordic Studies On Alcohol And Drugs, Vol. 29, 217–232. Sutton, Caroline (1998) Swedish Alcohol Discourse. Constructions of a Social Problem. Upp- sala: Studia Sociologica Upsaliensia. Tigerstedt, Christoer (2000) ‘Discipline and Public Health’. In Sulkunen, Pekka, Sutton, Caroline, Tigerstedt, Christoer & Warpenius, Katariina (eds) Broken Spirits: Power and Ideas in Nordic Alcohol Control. Helsinki: Nordic Council for Alcohol and Drug Research (NAD), 135–152.      Ugland, Trygve (2000) ‘European Integration and the Corrupting Gaps of the Systems’. In Sulkunen, Pekka, Sutton, Caroline, Tigerstedt, Christoer & Warpenius, Katariina (eds) Broken Spirits: Power and Ideas in Nordic Alcohol Control. Helsinki: Nordic Council for Alcohol and Drug Research (NAD), 185–198. Ugland, Trygve (2003) ‘A Case of Strange Bedfellows in the EU: An Institutional Perspec- tive on the French-Swedish Cooperation on Alcohol Control’. Scandinavian Political Studies, Vol. 26, No. 3, 269–286. Ugland, Trygve (2011) Alcohol on the European Union’s Political Agenda: Getting O the Policy Roller-Coaster? Oslo: Norwegian Institute for Alcohol and Drug Research. Vartiainen, Juhana (2011) ‘e Finnish Model of Economic and Social Policy – From Cold War Primitive Accumulation to Generational Conicts’. In Mjøset, Lars (ed.) e Nordic Varieties of Capitalism. Bingley: Emerald Books, 53–88. WHO (World Health Organization) (2002) World Health Report. Geneva: World Health Organization.   € e return of happiness – the end of utopia? Rankings of subjective well-being and the politics of happiness1   Introduction In July 2011, the General Assembly of the United Nations unanimously ad- opted Resolution 65/309. Entitled ‘Happiness: towards a holistic approach to development’, the Resolution recognized ‘the need for a more inclusive, equitable and balanced approach to economic growth’ with the aim of pro- moting ‘sustainable development, poverty eradication, happiness and well- being of all peoples’ in line with the Millennium Development Goals. Mem- ber States were invited to elaborate measures that can better capture the importance of the pursuit of happiness and well-being with a view to guide future public policy. e Resolution also called upon Members States as well as regional and international organizations to develop new indicators and to share information on these at upcoming sessions of the UN General As- sembly.2 Following the aims spelled out in the Resolution, the world’s rst World Happiness Report was released in early April 2012. Commissioned by the ‘United Nations Conference on Happiness’ – also a global rst – the report begins by noting that ‘happier countries tend to be richer countries’. Ac- cording to the report, the happiest countries in the world are clustered in 1 e author wishes to thank Anna Alanko, Nicholas Aylott, Inga Brandell, Yonhyok Choe, Pauli Ket- tunen, Klaus Petersen, Hannele Sauli, Varda Soskolne, Michael Kuur Sørensen, and Jaakko Turunen for valuable comments and critique on an earlier dra of this chapter. 2 United Nations (2011) Resolution 65/309. Online. Available HTTP: (accessed October 2012)     –      Northern Europe, with Denmark, Norway, Finland, and the Netherlands at the top. e least happy countries are all in Sub-Saharan Africa, with Togo, Benin, Central African Republic, and Sierra Leone registering the lowest self-reported happiness.3 But it is not just wealth that makes people happy, the report underlines: Political freedom, strong social networks, and absence of corruption are – if taken together – more important factors than income in explaining well-being dierences between the top and bottom countries, according to the authors. At the individual level, good mental and physical health, job security, and stable families are crucial, as well as having ‘someone to count on’.4 ‘Behaving well’ makes people happier, too. In addition, the report also tracks dierences between dierent groups with regard to happiness. In advanced countries, for example, women are generally happier than men, while the situation is more mixed in poorer countries. Happiness is lowest in middle age. e report con- rms that mental health is the biggest single factor aecting happiness in any country. Yet, only a quarter of mentally ill people get treatment for their con- dition in advanced countries and still fewer in poorer countries.5 On average, the report states, the world has become ‘a little happier in the last 30 years’. However, as living standards rise, self-reported happiness has increased in some countries, but not in others.6 Apparently, happiness does not rise in tandem with economic growth.7 Several recent studies suggest that aŒuence and wealth has a tendency to generate new sets of problems which are detrimental to self-reported happiness.8 is observation has also been connected with the widespread notion that wealthy Westerners have become relatively unhappier throughout the past half century.9 3 Helliwell, John F., Layard, Richard & Sachs, Jerey D. (eds) (2012) World Happiness Report. New York: e Earth Institute, Columbia University. 4 See also Marmot, Michael & Wilkinson, Richard (eds) (2003) Social Determinants of Health: e Solid Facts. Copenhagen: WHO Regional Oce for Europe. 5 Helliwell, Layard & Sachs 2012, 74. 6 Frey, Bruno S. & Stutzer, Alois (2002) ‘What Can Economists Learn from Happiness Research?’ Jour- nal of Economic Literature, Vol. 40, No. 2, 402–435. 7 Layard, Richard (2005) Happiness: Lessons From A New Science. London: Penguin. 8 Oer, Avner (2006) e Challenge of Auence. Oxford: Oxford University Press; Lane, Robert E. (2001) e Loss of Happiness in Market Democracies. New Haven: Yale University Press; James, Oliver (1998) Britain On the Couch: Why We Are Unhappier Compared to 1950 Despite Being Richer. London: Arrow Books. 9 James 1998; Simonson, Nisse (2008) Varför mår vi så dåligt när vi har det så bra? Stockholm: Brom- bergs; Eriksen, omas Hylland (2008) Storeulvsyndromet: Jakten på lykken i overodssamfunnet. Aschehoug & Co.    While increasing income thus has a direct and positive impact upon self-reported happiness in poor countries, the correlation is weaker in rich countries, as growth itself appears to generate problems of adaptation and adjustment. us, economic growth and level of income does not neces- sarily improve self-reported happiness, as rst scientically observed by American economist Richard Easterlin.10 e so-called ‘Easterlin paradox’ observes that richer individuals may be happier than poorer persons at any particular time, but that society as a whole does not become happier as it becomes richer. e most common explanation for the Easterlin paradox is that people compare themselves to others: When the economy as a whole improves, individuals’ relative status remains unchanged as those who gain the most quickly adapt to their new higher income while the gains may not have been evenly shared.11 Yet another aspect of the paradoxical relationship between income, wealth, and happiness is identied by the authors of the World Happiness Report. ey observe that various ‘societal factors’ may have ‘counteracted any benets felt from the higher incomes’, noting that ‘[u]ncertainties and anxieties are high, social and economic inequalities have widened con- siderably, social trust is in decline, and condence in government is at an all-time low’.12 By inference, social policies that target the improvement of social conditions and generate social equality – or a less competitive work culture and excluding labour market, one may add – may thus have a posi- tive impact upon self-reported happiness, which in turn can have positive eects upon the economy.13 Happiness is thus not necessarily a primarily private aair, but something which is inextricably linked with economical, political, and social structures 10 Easterlin, Richard (1974) ‘Does Economic Growth Improve the Human Lot?’ In David, Paul A. & Reder, Melvin Warren (eds) Nations and Households in Economic Growth: Essays in Honor of Moses Abramovitz. New York: Academic Press, 89–125; Easterlin, Richard (1995) ‘Will Raising the Incomes of All Increase the Happiness of All?’. Journal of Economic Behavior and Organization, Vol. 27, 35–47. 11 Helliwell, Layard & Sachs 2012. 12 Helliwell, Layard & Sachs 2012. 13 Greve, Bent (ed.) (2010) Happiness and Social Policy in Europe. Cheltenham: Edgar Elgar; Saari, Juho (2012) Onnellisuuspolitiikka – Kohti sosiaalisesti kestävää Suomea. Helsinki: Kalevi Sorsa Säätiö; Wilkinson, Richard G. & Pickett, Kate (2009) e Spirit Level – Why More Equal Societies Almost Always Do Better. London: Penguin.     –      and hence, human agency. But the Easterlin paradox is not unanimously ac- cepted by happiness researchers, and the complex relation between income, wealth, and happiness as delineated in the World Happiness Report remains at the core of contest in contemporary happiness research.14 Taking this observation as its point of departure, this chapter analyzes the ‘return’ of happiness in public debate, looking at the tension between happiness as an (il)legitimate goal of politics and happiness as an (ir)rele- vant study object of science. It rst looks at how happiness was marginalized as a political and scientic category in Western public discourse aer the Second World War. It then analyzes its initially slow return from the 1970s and onwards to today’s dramatically rising interest in happiness rankings by international organizations and national governments alike. While there is an emerging literature on the business appropriation of happiness, its scientic-cum-political utilization has not yet been analyzed in any greater detail. With a few exceptions, most studies have been prima- rily been concerned with the quality of the scientic evidence presented in support of the claims to measure what scholars call ‘subjective well-being’ (SWB).15 By contrast, this chapter does not discuss the methods and results of these rankings, most of which are easily accessible and subject to lively de- bate among social statisticians.16 Instead, it asks why these rankings are be- ing produced to begin with and what they may entail for public policy. 14 Most notably, it has been criticized by Ruut Veenhoven, whose statistics show a strong correlation between happiness and income, both on the societal and the individual level, see Veenhoven, Ruut (2008) World Database of Happiness: Continuous Register of Scientic Research on Subjective Appre- ciation of Life. Rotterdam: Erasmus University; Gasper, Des (2007) ‘Uncounted or Illusory Blessings? Competing Responses to the Easterlin, Easterbrook and Schwartz Paradoxes of Well-Being’. Journal of International Development, Special Issue: Human Security, Well-Being And Sustainability, Vol. 19, Issue 4, 473–492. 15 Dolan, Paul, Peasgood, Tessa & White, Mathew (2008) ‘Do We Really Know What Makes Us Happy? A Review of the Economic Literature on the Factors Associated With Subjective Well Being’. Journal of Economic Psychology, Vol. 29, 94–122; in, Neil (2012) Social Happiness: eory Into Policy and Practice. Bristol: e Policy Press. 16 For a comprehensive overview of dierent rankings of happiness and SWB and their dierent means and ends, see European Communities (2009) Beyond GDP—Measuring Progress, True Wealth and the Well-being of Nations. Luxembourg: Oce for Ocial Publications of the European Communi- ties. Online. Available HTTP: (accessed October 2012)    Scepticism towards happiness While the recent concern with well-being has generated high-prole initia- tives of governments and international organizations alike, scientic inter- est in measuring happiness is not new. Early and largely theoretical eorts to quantify happiness were made by enlightenment philosophers and utilitar- ian liberals, perhaps most notably evidenced by Jeremy Bentham’s concept of the ‘felicic calculus’.17 Nevertheless, in bringing the explicit concept of happiness back into the scope of global governance, the World Happiness Report marks a new depar- ture from a long tradition of scepticism towards happiness in the social sci- ences. Western social sciences have largely viewed happiness as emotional, personal, and highly subjective.18 Hence, social scientists tended to regard it as either irrelevant or found alternative ways of conceptualizing it. When used – although sparingly, as noted by Easterlin19 – it was most oen as a vague analogy to ‘welfare’ in welfare economics, primarily in theoretical discussions of the dierence between ‘wealth’ and ‘welfare’.20 Yet, the subject matter of happiness – the match between needs and hu- man satisfaction – never ceased to be of interest to social scientists. But that interest had to be channelled through proxy concepts such as well-being, satisfaction with life, and quality of life. Partly, this purging seems to have been the result of the success and inuence of American behaviourism on modern psychology and social science. With its insistence upon only re- searching those phenomena which can be empirically observed – i.e. actions and behaviour of humans and conditions of environment and heredity – behaviourism had by the mid-1950s established a rm consensus on social ‘cause and eect’ and psychological ‘stimulus and response’ as the preferred paradigm of Western social science. 17 Bentham, Jeremy (1907 [1780/1789]) An Introduction to the Principles of Morals and Legislation. Oxford: Clarendon Press. 18 McMahon, Darrin M. (2006) Happiness: A History. New York: Atlantic Monthly Press. 19 Easterlin 1974. 20 Pigou, Arthur Cecil (1912) Wealth and Welfare. London: Macmillan; Little, I. M. D. (1950) A Critique of Welfare Economics. London & New York: Clarendon Press; Mishan, E. J. (1968) ‘Welfare Economics’. In International Encyclopedia of the Social Sciences, Vol. 16. New York: Macmillan, 504–512; Eckaus, Richard S. (1972) Basic Economics. Boston: Little, Brown.     –      In so doing, behaviourism also bypassed the problem of subjectivity of (dis)satisfaction by deploying an objective standard of (dis)satisfaction through the concept of ‘needs’, e.g. Abraham Maslow’s ‘hierarchy of needs’ with physiological needs at the bottom, followed by needs for safety, love, esteem, and ‘self-actualization’ on the top. Since happiness could not be tied to any particular set of cause and eect or stimulus and response it could neither be empirically connected with the fullment of concrete needs nor be observed experimentally. us, the category of happiness thus remained something of a ‘blind spot’ for modern social science until methods for pub- lic opinion polling were being more widely applied by social psychologists in the 1960s. In an early eort to address the scientic blindness vis-à-vis human hap- piness, American public opinion scholar Hadley Cantril collected data in 1957–1963 from 14 countries – both capitalist and communist societies, rich and poor – asking open-ended questions about what people want out of life and what they would need for their lives to be completely happy.21 Despite the vast socio-economic and cultural disparities among the countries, peo- ple’s responses were strikingly similar, ranking level of living, happy family life, personal and family health, work, emotional stability, personal worth, and self-discipline as the most important factors, in that order. According to Cantril’s ndings, factors such as war, civil rights, political liberties, and social equality, mattered less, but this did not mean that respondents valued these factors less. It only meant that the interviewees tended to regard these factors as largely exogenous.22 Another example of explicit social science interest in happiness dates from a collaborative Nordic sociological project in the early 1970s, where subjective happiness was directly connected with material welfare and in- cluded in the questionnaires used for sampling perceptions of welfare in 21 e 14 nations included in the original study cover Brazil, Cuba, Dominican Republic, Egypt, India, Israel, Japan, Nigeria, the Philippines, Panama, Poland, the United States, West Germany, and Yugoslavia. e study employed a ‘Self-Anchoring Striving Scale’, asking the respondent to dene hopes and fears for self and the nation. Cantril, Hadley (1965) e Pattern of Human Concerns. New Brunswick, Rutgers University Press. 22 Easterlin, Richard (2004) ‘e Economics of Happiness’. Daedalus, Vol. 133, Issue 2, 26–33.    the Nordic countries. Yet, the study used the abstract, existential, and hence rather depersonalized question of whether the respondent nds that ‘Life is happy’, the answer to which need not necessarily tell the researcher much about the actual SWB of the respondent.23 Despite these early attempts at approaching explicit notions of happi- ness scientically, ‘satisfaction with life’ proved the most popular analytical category throughout the 1960s and 1970s. Part of its appeal rested in its connection to then current theories on ‘development’, largely understood as the fullment of material needs, commensurate with ‘objective well-being’ (OWB) and oen treated as synonymous with ‘standard of living’.24 However, as standard of living gradually evolved into a rhetorical weap- on in the Cold War struggle between capitalism and communism, alterna- tive and supposedly more neutral concepts such as ‘quality of life’ had to be developed. Quality of life proved politically attractive, as most clearly indi- cated by US President Richard Nixon’s state of the union address in January 1970 and the Quality of Life review process as established in October 1971. e political appropriation of this concept clearly reected the shi from ‘materialist’ to ‘post-materialist’ values which could be registered through- out the politically tumultuous and economically insecure 1970s.25 Rankings of happiness Over the past decade, however, the explicit concept of ‘happiness’ has begun to reappear more frequently in scholarly literature and university textbooks across a number of disciplines, alongside the expanding and progressively more inclusive concept of ‘well-being’.26 While academic interest in develop- ing statistical methods for conducting surveys and rankings of SWB found a platform in the journal Social Indicators Research, founded in 1974, e Journal of Happiness Studies has since 2000 catered for the more specic 23 Allardt, Erik (1975) Att ha, att älska, att vara: Om välfärd i Norden. Lund: Argos. 24 Gasper, Des (2005) ‘Subjective and Objective Well-Being in Relation to Economic Inputs: Puzzles and Responses’. Review of Social Economy, Vol. 63, Issue 2, 177–206. 25 Inglehart, Ronald (1977) e Silent Revolution. Princeton: Princeton University Press. 26 Huppert, Felicia & Linley, P. Alex (eds) (2011) Happiness and Well-being: Critical Concepts in Psy- chology. New York: Routledge.     –      interest in the subject matter of happiness. Today, ‘happiness research’ has been established as an independent eld of multidisciplinary academic re- search, including economics, psychology, sociology, and management stud- ies.27 Alongside the development of the academic discipline, one of the most high-level initiatives has been undertaken by the Organisation for Econom- ic Cooperation and Development (OECD) from the beginning of the 2000s. Using substantive analysis and surveys, the OECD has sought to address the limits of ocial statistics in measuring the progress of societies’ mate- rial living conditions, quality of life and sustainability. In 2001, the OECD launched its so-called Better Life Initiative to this end.28 In 2011, the Better Life Initiative released a report entitled How’s Life? Measuring Well-being as part of its ongoing work to promote ‘Better Policies for Better Lives’.29 Together with the launching of the so-called ‘Your Better Life Index’, the release of the report has been widely noted in the media as a step towards going ‘beyond GNP’ by measuring and valuing ‘happiness’ as an independ- ent social objective alongside the more traditional economic measures ac- cording to which societies are usually ranked.30 In a related undertaking, the OECD-sponsored Global Project on ‘Measuring the Progress of Societies’ seeks to develop progress indicators as well as to create a community work- ing together to determine how to measure the well-being of societies. To ensure legitimacy and authority, it includes representatives of NGOs, gov- ernments, and researchers worldwide. e OECD World Forum in Istanbul in June 2007 made the ‘Measuring and Fostering the Progress of Societies’ its core topic: 27 Layard 2005; Martin, Paul (2005) Making Happy People: e Nature of Happiness and its Origins in Childhood. London: Fourth Estate. 28 Organisation for Economic Co-operation and Development (OECD) (2011) ‘Better Life Initiative: Measuring Well-being and Progress’. Online. Available HTTP: (accessed October 2012) 29 OECD (2011) How’s Life? Measuring Well-being. Online. Available HTTP: (ac- cessed October 2012) 30 OECD (2012) ‘Better Life Index’. Online. Available HTTP: (accessed October 2012)    Is life getting better? Are our societies making progress? Indeed, what does ‘progress’ mean to the world’s citizens? For a good portion of the 20th century there was an implicit assumption that economic growth was synonymous with progress: an assumption that a grow- ing GDP meant life must be getting better.­But we now recognise that it isn’t quite as simple as that. Access to accurate information is vital when we come to judge our politicians and hold them accountable. But access to a comprehensive and intelligible portrait of that most important of questions – whether or not life has got and is likely to get better – is lacking in many societies.31 At the World Forum, the Istanbul Declaration was signed by representa- tives of the European Commission, the OECD, the Organisation of the Is- lamic Conference, the United Nations, the United Nations Development Programme and the World Bank. e Declaration states that: A culture of evidence-based decision making has to be promoted at all levels, to increase the welfare of societies. And in the ‘information age’, welfare depends in part on transparent and accountable public policy making. e availability of statistical indicators of economic, social, and environmental outcomes and their dissemination to citi- zens can contribute to promoting good governance and the improve- ment of democratic processes. It can strengthen citizens’ capacity to inuence the goals of the societies they live in through debate and consensus building, and increase the accountability of public poli- cies.32 Noting that ‘[o]cial statistics are a key “public good” that foster the progress of societies’, the Declaration ‘urge[s] statistical oces, public and private organizations, and academic experts to work alongside representa- tives of their communities to produce high-quality, facts-based information 31 OECD­(2008) Statistics, Knowledge and Policy 2007: Measuring and Fostering the Progress of Societies. Paris: OECD Publishing. 32 Istanbul Declaration (2007) Online. Available HTTP: (accessed October 2012)     –      that can be used by all of society to form a shared view of societal well-being and its evolution over time’.33 In November 2007, this largely OECD-driven quest for ‘a shared view of societal well-being’ resulted in a conference in the European Parliament in Brussels on the topic ‘Beyond GDP – Measuring progress, true wealth, and the well-being of nations’, jointly organized by the European Commission, European Parliament, Club of Rome, WWF and OECD.34 e conference sought to initiate the selection and inclusion of various new indexes pur- porting to measure happiness and well-being in ocial statistics, providing a ‘Virtual Indicator Exhibition’ where some 20 complementing and compet- ing indexes were presented. In gathering the authors of these indexes, it also provided a platform for a general discussion on the political applicability of these measures, i.e. for making and shaping policy initiatives. At the conference, a basic dividing line emerged between those who view these new measures as a complement to GDP and those who argue that these measures should also contribute to a shi in (inter)national policy objectives, away from promoting free market liberalism in favour of global equality, justice, and welfare. Neither side turns openly against the order of priority held by the other. Instead, the debate is focused on the degree to which ‘societal well-being’ or ‘happiness’ can at all be measured with any accuracy. While the policy implications remain rather underdeveloped in these discussions, the evidence presented by both sides appear to support a link between happiness and welfare policies, as long as the latter are ad- equately provided for.35 rough evaluation of policy outcomes and peer pressure, the OECD has been instrumental in promoting policy diusion and norm entrepre- 33 Istanbul Declaration 2007. 34 European Communities (2009), Beyond GDP—Measuring Progress, True Wealth and the Well-being of Nations. Luxembourg: Oce for Ocial Publications of the European Communities. Online Available HTTP: (accessed October 2012); see also Costanza, Robert, Hart, Maureen, Posner, Stephen & Talberth, John (2009) Beyond GDP: e Need for New Measures of Progress. Boston: e Frederick S. Pardee Center for the Study of the Longer-Range Future. 35 e argument can be found in a more developed form in Frey, Bruno S. & Stutzer, Alois (2007) ‘Should National Happiness Be Maximized?’ Institute for Empirical Research in Economics University of Zurich Working Paper, No. 306. Online. Available HTTP: (accessed October 2012)   € neurship in a wide variety of dierent policy areas.36 Since 2008 and on- wards, its advocacy for including happiness in ocial statistics appears to win ground internationally. In the USA, for example, similar ideas have been expressed by advisers of President Barack Obama’s administration. In their 2008 book Nudge: How to Improve Decisions About Wealth, Health, and Happiness, economist Richard H. aler and lawyer Cass R. Sunstein (until August 2012 head of the US Government’s Oce of Information and Regulatory Aairs, OIRA) argue that individuals are frequently led astray from making the decisions which would improve their SWB by following the wrong cues. A measure of ‘libertarian paternalism’ – which is distinct from paternalism according to aler and Sunstein in that it does not pro- hibit, but rather attempt to ‘nudge’ people’s decisions in certain, presumably favourable directions – can, the authors suggest, improve general levels of happiness by reframing the ‘choice architecture’ of a given society.37 In December 2011, a panel of experts in psychology and economics – including Daniel Kahneman, psychologist and Nobel laureate in econom- ics and prolic writer on the topic of well-being and ‘hedonic psychology’ – began convening in Washington D.C. to try to dene reliable measures of SWB.38 e panel enjoys the explicit support of President Obama’s chief economic adviser and chair of the Council of Economic Advisers, Alan B. Krueger, who has previously proposed a method for generating a national statistic covering ‘the ow of emotional experience during daily activities’.39 Mainly funded by the US Department of Health and Human Services and organized by the non-prot National Academies, the panel has been 36 Recent examples where the OECD has inuenced member state policies include anti-corruption, educational policy, investment policy, labour market policy, and tax policy. 37 aler, Richard H. & Sunstein, Cass R. (2008) Nudge: Improving Decisions about Health, Wealth, and Happiness. New Haven: Yale University Press; see also Sunstein, Cass R. (2010) Law and Happiness. Chicago: University of Chicago Press. 38 Kahneman, Daniel, Wakker, Peter P. & Sarin, Rakesh (1997). ‘Back to Bentham? Explorations of Ex- perienced Utility’. e Quarterly Journal of Economics, Vol. 112, No. 2, 375–406; Kahneman, Daniel, Diener, Ed & Schwartz, Norbert (eds) (1999) Well-Being: e Foundations of Hedonic Psychology. New York: Russel Sage Foundation; Whoriskey, Peter (2012) ‘If you’re happy and you know it ... let the government know’. e Washington Post. Online. Available HTTP: (accessed October 2012) 39 Krueger, Alan B. & Kahneman, Daniel (2006) ‘Developments in the Measurement of Subjective Well-Being’. Journal of Economic Perspectives, Vol. 20, No. 1, 3–24.     –      promoting the message that a more accurate measure of happiness is a helpful tool for evaluating the success or failure of a range of government policies. As such, it could help analyze citizen preferences and government policy priorities with regard to trade-os between health benets, educa- tion, employment, and higher income levels, besides probing the complex and changing relationships between these human needs and policy goals. It might also detect extremes of inequality or imbalances in how people divide their time between work and leisure. If deemed reliable, the measures under development by the panel could become part of ocial US statistics, includ- ing that of the US Census Bureau and the Bureau of Economic Analysis. If so, the USA­would become ‘the latest country to clamber aboard a happiness bandwagon’, as noted by e Economist.40 e happiness discourse is by no means reserved by ‘progressive’ ac- tors such as the current US administration. Conservatives on both sides of the Atlantic, have also been keen to appropriate the happiness discourse. In 2008, former French President Nicholas Sarkozy convened a commission, consisting of Joseph Stiglitz, Amartya Sen, and Jean-Paul Fitoussi, stating that ‘time is ripe for our measurement system to shi emphasis from meas- uring economic production to measuring people’s well-being’. e Commis- sion on the Measurement of Economic Performance and Social Progress – also known as the Stiglitz-Sen-Fitoussi Commission – concluded in Sep- tember 2009 that a broad range of measures and indicators about people’s well-being and societal progress should be used alongside more standard economic measures such as GDP.41 In 2009, the­French government started publishing its­own happiness indicator, in line with OECD recommenda- tions. In 2011, also the British Coalition Government began surveys, asking respondents ‘Overall, how happy did you feel yesterday?’ and ‘Overall, how satised are you with your life nowadays?’ More specically, the connection 40 ‘Happiness – No Longer the Dismal Science?’ e Economist. 6 April 2012. Online. Available HTTP: (accessed October 2012) 41 Stiglitz, Joseph E., Sen, Amartya & Fitoussi, Jean-Paul (2009) Report by the Commission on the Measurement of Economic Performance and Social Progress. Paris: Commission on the Measurement of Economic Performance and Social Progress.    between happiness and sustainability has been underlined by a UK govern- ment initiative entitled the Sustainable Development Commission (SDC). In cooperation with Earthscan, the SDC proposed ways in which to refocus public policy in line with the principle of ‘prosperity without growth’. is interpretation could favour an increased attention to sustainability and an emphasis upon ‘downshiing’ or ‘descaling’ the economy.42 e SDC was set up by the Labour Government in June 2000 as a non-departmental pub- lic body responsible for advising the government on sustainable develop- ment and related issues. e SDC was closed by the Coalition Government in March 2011, but its reports have since been cited favourably by British Prime Minister David Cameron, noting ‘it’s time we focused not just on GDP but on GWB – general well-being’. Along similar lines, British econo- mist Richard Layard has argued that General National Happiness (GNH) could positively complement GDP.43 In addition to these governmental initiatives, there have also been nu- merous attempts at measuring SWB launched by universities, research in- stitutions, think tanks, and NGOs. While these rankings usually either pool together variables which are already measured by traditional indexes or rely upon interviews and surveys where the informants state their own percep- tion of their SWB, they are oen represented in the media as claiming to chart happiness. As such, they signal a new type of interest in SWB which goes a long way towards ‘rehabilitating’ the concept of happiness in public debate. For example, the reference objects of these rankings have recently shied from various qualied and limited notions ‘perceived’ quality of life or ‘self-reported’ or ‘avowed’ happiness to make direct and explicit refer- ences to happiness. Paradoxes of happiness While these rankings all factor in non-material concerns, the authors of these indexes usually do not claim that these new measures should replace 42 Jackson, Tim (2009) Prosperity without Growth. Economics for a Finite Planet. London: Earthscan. 43 e modern formulation of the idea of GNH nds its origin in a conservative context, having rst been proposed by the King of Bhutan in 1972, see Ura, Karma & Galay, Karma (eds) (2004) Gross National Happiness and Development. imphu: e Centre for Bhutan Studies; Layard 2005.     –      the traditional economical measures which have dominated the assessment of societies. Instead, the addition of social factors through the notion of SWB should simply prevent it from becoming solely deducible from eco- nomic and material factors.44 But how much importance should be give to the one or the other? Is it possible to weigh these factors against one another in an accurate manner? And are they really distinct from one another, aer all? A number of dierent paradoxes or tensions emerge when the concept of happiness is introduced as a parameter for assessing socio-economic con- ditions as well as policy outcomes. Progressives highlight that the societies which tend to register the high- est levels of SWB are characterized by a high level of economic equality and social security, as exemplied by the Nordic countries.45 Indeed, several sur- veys report the Danes as being the most satised.46 Several studies have sug- gested that the universalistic welfare state has been a decisive factor for the high levels of SWB and public trust recorded in the Nordic countries.47 is would apparently favour a universalistic welfare state of the Nordic model which combines economic growth with social redistribution, in addition to placing a strong focus upon democracy and sustainability. ese interpretations have troubled self-designated neoliberal observers for a variety of reasons. First, there is scepticism regarding the inclusion of rankings of SWB in the work of various international organizations. Second, there has been a neoliberally-slanted criticism which claims that the notion of legitimate needs could imply a limiting of free choice in consumption and 44 Diener, Ed & Seligman, Martin E. P. (2004) ‘Beyond Money—Towards and Economy of Wellbeing’. Psychological Science in the Public Interest, Vol. 5, No. 1, 1–31; Costanza, Robert, Fisher, Brendan, Ali, Saleem, Beer, Caroline, Bond, Lynne, Boemans, Roelof, Danigelis, Nicholas L., Dickinson, Jennifer, Elliott, Carolyn, Farley, Joshua, Gayer, Diane Elliott, Glenn, Linda MacDonald, Hudspeth, omas, Mahoney, Dennis, McCahill, Laurence, McIntosh, Barbara, Reed, Brian, Rizvi, S. Abu Turab, Rizzo, Donna M., Simpatico, omas & Snapp, Robert (2007) ‘Quality of Life: An Approach Integrating Opportunities, Human Needs, and Subjective Well-Being’. Ecological Economics, Vol. 61, Issues 2–3, 267–276; Brown, Kirk & Kasser, Tim (2005) ‘Are Psychological and Ecological Well- Being Compatible? e Role of Values, Mindfulness and Lifestyle’. Social Indicators Research, Vol. 74, No. 2, 349–369; Abdallah, Saamah, ompson, Sam & Marks, Nic (2008) ‘Estimating Worldwide Life Satisfaction’. Ecological Economics, Vol. 65, No. 1, 35–47. 45 Wilkinson & Pickett 2009. 46 Greve 2010. 47 Rothstein, Bo (2011) ‘Social tillit, lycka, korruption och välfärdsstat’. In Holmberg, Sören, Weibull, Lennart & Oscarsson, Per (eds) Lycksalighetens ö. Göteborg: SOM-institutet, 65–84.    production and hence an infringement upon the free market forces. ird, there is a tendency to question the link between the welfare state and hap- piness on the one hand and the link between sustainability and happiness on the other. e criticism has unfolded in two dierent directions in response to the progressive challenge posed by the new happiness discourse to free market liberalism. One direction has actually ‘joined the choir’. Legatum Institute, for example, a think tank based in Washington D.C., has pointed out that the contemporary policies of the Nordic welfare states which generate fa- vourable ratings for the Nordics are just as liberal and economy-oriented as the policies of those societies which score worse. e dierence lies in the determination and skill by which Nordic governments have implemented necessary reforms in the welfare systems, thus saving the welfare state while reframing the ‘Nordic model’ of the past into a new ‘Nordic Way’ of the fu- ture which has recently won the praise of liberal newspaper e Economist.48 Another concern has been the accuracy of the measures. Neoliberal crit- ics frequently criticize the evidence provided by happiness researchers. In 2007, the same year as the OECD launched its ‘Beyond GNP’ conference, researchers associated with the Cato Institute, another Washington-based think tank, argued that the data provided by happiness researchers show that ‘neither higher rates of government redistribution nor lower levels of income inequality make us happier, whereas high levels of economic free- dom and high average incomes are among the strongest correlates of SWB’.49 e problem rests with the diverging interpretation of the causal mecha- nisms behind the weak correlations that the rankings point to: Not only is happiness research troubled by competing methodologies and conicting research objectives, neoliberal critics and other sceptics argue. Happiness itself does not appear as ‘a simple empirical phenomenon but a cultural and 48 ‘e Next Supermodel: Politicians from both Right and Le Could Learn from the Nordic Coun- tries’. e Economist. 2 Feb. 2013. Online. Available HTTP: (accessed February 2013) 49 Wilkinson, Will (2007) ‘In Pursuit of Happiness Research: Is It Reliable? What Does It Imply for Policy?’ Policy Analysis, No. 590, 2–41. Online. Available HTTP: (accessed October 2012)     –      historical moving target’, dened dierently by dierent individuals at dif- ferent points in life – indeed, a central argument of liberal critics of the wel- fare state for a long time. Politics or rhetorics of happiness? Happiness research has this far failed to establish a singular ‘shared view of societal well-being’ as called for by the OECD. e question is whether the rather natural and seemingly neutral quest for such a shared view could translate from rhetorics into politics, and what kind of politics that would be. e dierences between dierent factors in explaining happiness and SWB appear marginal in most rankings. is observation has lead social psychologists to launch the ‘set-point theory’ according to which most peo- ple have a stable level of SWB, to which they return aer various positive as well as negative experiences. is individual set-point is supposedly more determined by personality than income, wealth, health, or equality. If SWB is mostly determined by factors beyond the reach of politics or even human agency, it would follow that public policy with the aim of improving happi- ness would carry little hope of actually increasing SWB, just as the so-called ‘bell curve paradox’ would rule out the aggregated eects of education on overall levels of intelligence in a given society. A set-point theory of happi- ness would thus rather support a neoliberal interpretation than a welfare state interpretation of public policy.50 But if we accept the correlation between happiness and the welfare state as evidenced by the high rankings for the Nordic societies, the possibility of a politics of happiness would seem clear enough: It would simply be a question of providing for the basic social goods (education, employment, empowerment, and environmental protection) on a universal basis through the means of public participation to secure the possibility for as many as possible to independently pursue their own ideas of how to achieve happi- 50 Bruni, Luigino & Porta, Pier Luigi (eds) (2007) Handbook on the Economics of Happiness Chelten- ham: Edward Elgar; Easterlin 2004; Inglehart, Ronald & Klingemann, Hans-Dieter (2000) Genes, Culture and Happiness. Boston: MIT Press.    ness.51 It would then be a rather basic and very practical question of setting up systems of social care which as far as possible address social conditions which are known to correlate with unhappiness and deteriorating mental health, rather than some utopian attempt at downscaling the economy or to ‘maximize happiness’ for all through some ambitious scheme of ‘social engineering’. However, it must also be observed that the universalism of the welfare state may produce potential tensions, too. e principle of universalism se- cures some measure of equality which translates into public trust and SWB as well as legitimacy of the welfare state. To be able to aord this universal- ism, however, the welfare state requires a rather high level of productivity to allow for a comparatively high level of both private and public consumption. is means that a substantial source of stress and dissatisfaction will likely remain inbuilt into the system.52 e levels of stress among the employed, well-integrated, and more or less well-paid middle classes are reportedly on the rise, not only in the West generally, but in the Nordic countries, too. is generates growing demands for mental health care and crowding out scarce resources for those who al- ready suer from unemployment, poverty, social exclusion, and/or mental problems – whose well-being in turn is imperilled by the rising require- ments for employability.53 If the happiness discourse would be embraced by the universalistic welfare state, the latter would also need to accommodate the rather dierent needs of both these groups. Medical denitions would become even more important than they are today. Where do we draw the line between the happiness which should be the concern of the individual and the unhappiness which should be the concern of society as a whole? is issue is complicated by the suggestion that the welfare state – in the Nordic countries as well as elsewhere – is undergoing a transformation 51 See discussion in European Communities (2009); Frey & Stutzer 2007. 52 Bunting, Madeleine (2005) Willing Slaves: How the Overwork Culture is Ruining Our Lives. London: Harper. 53 For a discussion, see Fallov, Mia Arp (2011) ‘Constructing the Capacity of Employability, and the Government of Inclusion’. In Blomberg, Helena & Kildal, Nanna (eds) Workfare and Welfare State Legitimacy. Helsinki: Nordic Centre of Excellence NordWel, 125–160.     –      towards a more neoliberal mode of governance by gradually and piece by piece abandoning the principle of universalism, so that it becomes a ques- tion of interpretation whether the eventual success of the Nordic welfare model is rather the result of whatever traditional welfare state is le or fol- lows from the competition state reforms, which, according to some, may spell the end of traditional welfare policies.54 e increasing attention to the immaterial factors for happiness and SWB unfold in parallel with the current economic recession. e ‘soer’ measures of economic and social performance of societies do indeed seem to reect some of the post-materialist values which have become more widely accepted during the last decades, in Western Europe, the USA, and increasingly also in Southeast Asia. It would be politically sound for both conservative and progressive politicians to rhetorically embrace more post- materialist values in a time of crisis, while retaining a focus upon traditional economic policy goals in actual policies, just as Nixon once sought to chan- nel counter-culture sentiments in the USA during the high-tide of radical- ism in the early 1970s while conducting relatively traditional economic poli- cies. Assuming that the Easterlin paradox holds some truth, governmental interest in SWB may then increase when economic gures point downward or when income disparity is on the rise. Similar rhetorics have, for exam- ple, been utilized by various South East Asian governments, notably by the Chinese Government invoking the concept of xiaokang [‘basic well-being’] during the rapid growth of the 1990s or by the ai Government in the wake of the Asian nancial crisis in 1997, as citizens were ecouraged to focus on ‘suciency economy’ and to moderate their consumption rather than to expect increased governmental relief or press for an expansion of welfare programmes in times of need.55 54 Blomberg, Helena & Kildal, Nanna (eds) (2011) Workfare and Welfare State Legitimacy. Helsinki: Nordic Centre of Excellence NordWel; Heiskala, Risto & Kantola, Anu (2010) ‘Vallan uudet ideat: hyvinvointivaltion huomasta valmentajavaltion valvontaan’. In Pietikäinen, Petteri (ed.) Valta Suomessa. Helsinki: Gaudeamus, 124–148. 55 Noy, Darren (2011) ‘ailand’s Suciency Economy: Origins and Comparisons with Other Systems of Religious Economics’. Social Compass, Vol. 58, No. 4, 593–610.    e inclusion of happiness and SWB by conservative governments and traditionally free-trade-oriented international organizations can also chan- nel public criticism away from economic failure, rising income disparity, and welfare state retrenchment. So it has been suggested that former French President Sarkozy’s embracing of the new happiness agenda was designated to compensate for criticism in the context of the lowering of the French credit rating in 2011. In any case, the conservative appropriation of the hap- piness discourse is not very likely to herald massively increased government spending on public goods. Conclusion e new rankings of happiness have had some political impact, as witnessed by the high-level interest from the UN and the OECD as well as national governments. e close relationship between political agency and scientic knowledge production, especially the political function of statistics is well- known: Numbers, rankings, and scientic veriable knowledge have long been considered a precondition for the turning of various social problems into targets of evidence-based policy making (EBP).56 But, as of yet, this in- terest remains on the level of political rhetoric. Even if the social statisticians working with ocial statistics may perceive an increased pressure from gov- ernments and international organizations to conform to the new norms, a pressure which can be said to be ‘political’, the happiness discourse appears rather ‘under-politicized’ for now. Yet, the popular reception of rankings and measures has actualized an essentially political struggle between dierent interpretations of happiness rankings and research. rough its vague and non-committal character, the happiness discourse can be bent for dierent political purposes. For some, the happiness discourse can be used as an argument for the expansion of the welfare state to also include more qualitative social services with more ambitious aims in terms of health and happiness. For others, it can be used 56 Piironen, Ossi & Erkkilä, Tero (2009) ‘Politics and Numbers: e Iron Cage of Governance Indica- tors’. In Cox III, R. W. (ed.) Ethics and Integrity in Public Administration. Armonk, N.Y.: M.E. Sharpe, 125–145.     –      to drive home the point that we are all individually responsible for our own happiness. Still others may use the happiness discourse to promote an envi- ronmentalist agenda of descaling, downsizing, redistribution, and extended regulation of the nancial markets in the interest of sustainability. It may perhaps seem paradoxical that happiness returns as a political concern at a point in time when politics is widely thought to have been re- placed by the market and public policy-making is supposedly supplanted by ‘post-political regulation’.57 e idea that individual happiness can be mea- sured is strangely familiar with the idea that individual happiness could, for all of its complexity, be made into a political objective in its own right – in- deed, a most utopian idea in itself. is would appear even more puzzling, since utopian or visionary ideas are supposedly in short supply today, both on the le as well as on the right.58 Proponents argue that there is a demand for better measurements due to the rather natural interest in ascertaining a better balance between OWB and SWB – between economical and social concerns – when evaluating policy eects and designing new policy measures. At the same time, the causality between various policies and the reported SWB in a partcular so- ciety remains elusive at best, national social statisticians warn, beyond the subjective character of happiness to begin with. Yet, the way in which the goal of individual happiness is articulated ties in with societal well-being is an important issue if we are interested in how the limits of politics are being changed and re-negotiated under conditions of globalization, post-modern values, and post-political regulation.59 For now, it remains a question for debate whether the rising interest in 57 For a discussion of the concept of ‘post-political regulation’, see Garsten, Christina & Jacobsson, Kerstin (2013) ‘Post-Political Regulation: So Power and Post-Political Visions in Global Governance’. Critical Sociology. Online. Available HTTP: (accessed February 2013) 58 For the notion of ‘end of utopia’, see successive discussions in Marcuse, Herbert (1970) ‘e End of Utopia’. In Marcuse, Herbert, Five Lectures: Psychoanalysis, Politics, and Utopia. Boston: Beacon Press, 62–82; Habermas, Jürgen (1986) ‘e New Obscurity: e Crisis of the Welfare State and the Exhaustion of Utopian Energies’. Philosophy and Social Criticism, Vol. 11, No. 2, 1–18; Bauman, Zyg- munt (1999) In Search of Politics. Cambridge: Polity; Berghahn, Klaus L. (2008) ‘e End of Utopia?’ Telos, No. 143, 171–180. 59 Cf. Inglehart, Ronald (1997) Modernization and Postmodernization: Cultural, Economic, and Political Change in 43 Societies. Princeton: Princeton University Press.   € happiness will be politicized and, if so, to what degree and with what con- sequences. A rst political implication is that these rankings do not only answer to a perceived need for knowledge, but also contribute to sustain and expand this need. is need will either be lled by ‘pseudo-science’ marginalizing ocial statistics, or ocial statistics will have to adapt to the demand, even if ocial social statisticians may be wary and skeptical of po- litical pressure to expand the scope of their discipline. Indeed, identifying, measuring, and ranking performance is not only a way of generating better knowledge about social conditions and policy out- comes with a view of improving both. It is also a means of communicating a message to the electorate and to shape public opinion. Rankings, even if they do not necessarily herald a new start for welfare state policies, do signal at least a symbolic response on the part of international and national policy- making elites to widespread popular concerns with life satisfaction, health, and environment beyond the scope of individual economy. Second, it may today simply not be possible for politicians to focus sin- gularly on economic growth as the primary policy objective, despite the cur- rent crisis. Cynics may remark that this would be rather tting, since market performance is more volatile and appears less susceptible to political control now than in the past. It would hence be unwise for politicians to make them- selves too dependent upon economical performance as the single most im- portant parameter of policy evaluation. Novel concerns with ‘so issues’ can be used to oset growing dissatisfaction with faltering economic policies and demonstrable weakness of politics. Nordic countries, for example, rank nicely in the statistics, while social inequalities are on the rise, indicating that overall perfomance may be good even if the least privileged members of society fare ill or do not share the benets of stability and growth. A third political implication, or rather symptom, is that the concern with rankings corresponds to the ‘evacuation of politics’ in evidence in contem- porary governance in a multitude of policy elds, such as care, education, and unemployment policies.60 Overarching social conicts and party po- 60 See for example discussions on neoliberal governance in educational policies in Giroux, Henry A. (2008) Against the Terror of Neoliberalism: Beyond the Politics of Greed. Boulder: Paradigm.     –      litical contests are reduced as economic and social problems are isolated into targets for specialized policy administration.61 In the ‘political void’ that is le, global non-political organizations increasingly take up the role of visionaries, norm-entrepreneurs, and policy promoters, exactly through producing and disseminating new knowledge, new standards, and new best practices in a general movement towards post-political regulation. For all of its concern with accountability and transparency, it is of interest to note how post-political governance is tasking itself with yet more complex policy goals, identifying categories that, strictly speaking, cannot be as accurately and unambiguously quantied, compared, and evaluated as the traditional policy goals of work, security, justice, growth, and equality. is raises the question whether contemporary discourses on happiness will serve to expand the duties of public policy to include more immaterial notions of welfare or to limit the reach of politics, further pointing to the responsibility of the individual for her own happiness. Due to this tension in the recent attention to happiness, the primary political importance of the recent rankings of SWB does not seem to concern their eventual ability to actually measure happiness but rather to rhetorically challenge the primacy of economy as the single most important basis for public policy and to un- derscore the social component of economic performance. As such, it answers to a utopian drive in an era of utopian exhaustion. It is paradoxical, as the increased political and scientic interest in the vague and causally under-determined phenomenon of happiness can go in two directions: It may either divert attention away from the economy in order to further strengthen its grips on our public policies, or – quite on the contrary – further emphasize the need for alternative, non-monetary yardsticks by which to assess the well-being in the contemporary welfare state. 61 For a discussion, see Mair, Peter (2000) ‘Partyless Democracy? Solving the Paradox of New Labour?’. 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In 2008–2009 she worked as the coordinator of Nord- Wel, and in 2005–2008 in the Finnish National and Development Centre for Welfare and Health, STAKES, in projects discussing healthcare reforms.       is a doctoral student in Sociology at the University of Iceland. She has previously held a NCoE NordWel mobility fellowship at the University of Helsinki. Her research focus on paid work of children and teenagers in Iceland from the perspective of childhood studies and address- es the questions of how childhood is constructed in Western societies; of children’s rights to both protection and participation and how those rights eects their welfare; as well as of children’s social and economic agency.   is Professor in Social Science at the Department of Society and Globalisation at the University of Roskilde, Denmark. He has published es- pecially about social and labour market policy, and nancing of the wel- fare states oen in a comparative perspective. Recently he has also been re- searching the relationship between happiness and welfare and welfare states.   is Research Director at Kela, the Social Insurance Institution of Finland. Previously he has been professor at the University of Turku, the Danish Institute for Social Research in Copenhagen and the University of Southern Denmark. His research interests revolve around comparative po- litical economy of the welfare state in terms of causes and consequences.    is a post-doctoral researcher at the Centre for Baltic and­ Eastern European Studies (CBEES) at Södertörn University, Sweden. He is also aliated with the Centre for Nordic Studies (CENS) and Network for European Studies (NES), both at University of Helsinki, Finland. His re- search interests concern communication studies, social science expertise, social planning and the Nordic welfare state model.    is Assistant Professor of Social Work at the Department of Social Work, Stockholm University, Sweden. Her major elds of research concern the contemporary history of psychiatric care and social work.   is Associate Professor of Social Work at Bar-Ilan Univer- sity, Israel. Her major research interests concern various aspects of social, psychological and behavioural factors in health and illness, among them socio-economic inequalities in health in the general population and among the elderly in Israel.   is Professor of Sociology at University of Helsinki and Senior Research Fellow at the Helsinki Collegium for Advanced Studies. His research interests are addictions, public sector research, power, and social theory.   is Associate Professor of Politics and International Stud- ies at Bishop’s University, Canada. His research interests lie in the elds of comparative public policy, with a focus on European Union (EU) politics. All well in the welfare state? Welfare, well-being and the politics of happiness NordWel Studies in Historical Welfare State Research 5 edited by carl marklund marklun d (ed. ) All w ell in the welfa re state ? e aim of this volume is to analyze how the recent attention to subjective well-being and happiness may affect welfare state policies, looking at both Nordic and international experiences. While the Nordic welfare states typically score well in rankings of happiness, the volume asks whether all is well in the welfare state. Rather than assessing whether happiness research manages to capture the multiple factors which underpin subjective well-being, the contributions probe the relationship between the general discourse on subjective well-being and the welfare policies designed to support those members of society who are in greatest need. ISSN 1799-4691 ISBN 978-952-10-8306-8 N ordW el ISBN 978-952-10-8306-9 (paperback) ISBN 978-952-10-8984-8 (PDF) ISSN 1799-4691