The personal, social and environmental factors that determine mental health and mental illness are clustered conceptually in the literature around three main themes:

  1. Structural level factors including living environments, housing, employment, transport etc.;
  2. Community level factors including a sense of belonging and social support;
  3. Individual level factors – the ability to manage thoughts or feelings, to manage life, emotional resilience and the ability to cope with stressful or adverse circumstances.

(Barry & Jenkins, 2007; WHO, 2005).

This unit focuses largely on the third area of the individual. The aim of this unit is to introduce the concepts of wellness and positive psychology and to identify wellness strategies that mental health nurses may implement in their practice in addition to identifying challenges to working within a wellness paradigm. At completion of this unit the learner should be able to:

  • Identify the main tenets of Wellness;
  • Explain the key concepts of resilience, positive psychology, flourishing and languishing;
  • Identify the characteristics of ‘Positive Mental Health’;
  • Explain the ‘two continuua’ model of mental health and mental illness;
  • Identify key factors which impact on wellness across the lifespan;
  • Describe some wellness strategies that can be incorporated into mental health nursing practice;
  • Identify individual and organizational challenges for mental health nurses when working within a Wellness paradigm.

Before commencing this unit, take some time to think about the following reflective questions:

  • What do you believe are the key factors which influence an individual's wellness?
  • What wellness strategies (formal or informal) do you use to maintain your wellness?
  • How do you think you might help service users improve their self-efficacy and ultimately improve wellness?

Wellness as a paradigm and a mental health promotion approach has gained in popularity in the field of public mental health (Magyary, 2002) . Effective mental health promotion is now recognised as being based on a positive, non-pathologised approach to mental health that focuses on strengths and resilience building (Lahtinen et al, 2005). This is part of a move away from a traditional medical perspective in which only ‘illness’ was emphasised, towards a more holistic health care model in which ‘wellness’ and ‘wellbeing’ are also highlighted. Wellness is defined as a deliberate process which requires a person to become aware of and make choices for a more satisfying lifestyle leading to improved health (Swarbrick et al, 2009). Included within this lifestyle is a balance of healthy habits which focus on nutrition, sleep, exercise, supportive relationships, participation in meaningful activity and avoiding self-destructive behaviour Swarbrick et al, 2009, Swarbrick & Moosvi, 2010.

In the mental health literature, the concept of wellness is often closely tied to that of recovery for individuals with existing mental health difficulties and while both concepts are closely aligned the concept of wellness is one that has much to offer those who have never experienced a mental health problem. The central focus of wellness is on health, with an emphasis on individuals’ strengths and abilities and their personal responsibility to manage their mental (and physical) health Swarbrick, 2006. Within the wellness perspective, an individual is empowered to manage stressors and difficult situations proactively and is encouraged to self-monitor their own health behaviour. Wellness is not a popular trend, but rather a philosophy that embraces a way of living that helps all people enjoy a more satisfying, productive, and happy life Swarbrick & Moosvi, 2010.

Read this paper by Swarbrick (2006) which gives an overview of the comparison between the wellness approach and the traditional medical model. Reflect on your current practice and:

  1. Think about whether you work within a wellness approach and/or within the traditional medical model approach.

  2. Identify elements of your practice that are wellness orientated and those (if any) that remain more medically orientated.

Interlinked with the concept of wellness is the field of ‘positive psychology’ which introduces us to the terms of ‘flourishing’ and 'languishing'. Positive psychology will be explained and the key terms of flourishing and languishing will be defined as will the term 'resilience' which is an important concept within the wellness paradigm.

Positive psychology: a field of psychology heavily influenced by the work of Seligman & Csikszentmihalyi (2000:5). In their words:

“Positive psychology at the subjective level is about valued subjective experiences: well-being, contentment and satisfaction (in the past); hope and optimism (for the future); and flow and happiness (in the present). At the individual level, it is about positive individual traits: the capacity for love and vocation, courage, interpersonal skill, aesthetic sensibility, perseverance, forgiveness, originality, future mindedness, spirituality, high talent and wisdom. At the group level, it is about civic virtues, and the institutions that move individual towards better citizenship; responsibility, nurturance, altruism, civility, moderation, tolerance and work ethic.”

Positive psychology is not only the absence of mental distress, but also the presence of positive psychological resources such as hedonic or subjective well-being (positive affect, life satisfaction, happiness) and eudaimonic well-being (self-acceptance, positive relations, purpose in life) (Blakeman & Ford, 2012).

Read the following article by Slade (2010) for a heightened understanding of the interconnectedness of positive psychology and mental health recovery.Identify the points of convergence and divergence between positive psychology and mental health recovery.

Positive psychology centers have been established in many countries worldwide which provide users with further information about wellness resources. Included are positive psychology centers in:

• The US: The Positive Psychology Centre in Pennslyvania headed up by Dr Martin Seligman.

• The UK: The Center for Confidence and Well-Being

• Australia: Wellbeing Australia

Perform a search in your own country to determine if there is a positive psychology center which might provide you with up to date research and activities in the field and provide you with a resource to signpost service users to for further information.

Flourishing and languishing: These terms are commonly used within the field of positive psychology. Flourishing is understood as the presence of mental health while languishing is considered to be the absence of mental health. To be flourishing is to have high levels of mental well-being, to be filled with positive emotion and to be functioning well psychologically and emotionally (Keyes, 2002). Conversely, those with incomplete mental health are languishing in life with low well-being where languishing may be conceived of as emptiness and stagnation (Keyes, 2002). Those who are not languishing or flourishing are considered to be in moderate mental health (Westerhof & Keyes, 2010). Keyes (2002) conceptualised flourishing and languishing to exist on opposite ends of a mental health continuum (see later in this unit).

Click here for a further discussion of the concept of well-being and flourishing by Dr Martin Seligman. Founder and Director of the Centre for Positive Psychology, University of Pennsylvania.

Resilience: The concept of resilience – the capacity to cope with adversity and to avoid breakdown or diverse health problems when confronted with stressors – is closely linked to the work of Rutter (1985). Resilience is not a fixed attribute but rather a balance between the mechanisms and processes of protection and vulnerability. In practical terms, resiliency helps people to cope with life’s challenges and gives them a sense of mastery and control over their life (Kobau et al, 2011). A number of protective factors have been found to increase a person’s resilience and ability to cope with adversity. While some of these protective factors are static (e.g. gender), many are not (e.g. learned optimism, problem-solving, social support) and are therefore amenable to intervention hence the large number of public health programmes internationally which aim to improve resilience among participants in varied settings and across the lifespan (Kobau et al, 2011).

Watch this TEDx Talk on resilience (with a particular emphasis on young people) by Dr Maria Kukhareva. Reflect on.

Read this seminal paper on Resilience in the face of adversity by Rutter (1985). Reflect on.

The concept of well-being and positive mental health has been much studied in the academic and popular psychology literature and various components have been identified. For the purpose of this unit, positive mental health is divided into three main areas; 1. Emotional well-being, 2. Psychological well-being and 3. Social functioning. The following table identifies some of the components of each aspect of positive mental health drawing on the work of Ryff, (1989); Ryff and Keyes, (1995); Keyes, (1998) and Westerhof & Keyes, (2010).

Emotional (hedonic) Well-being Psychological (eudiamonic) Well-being Social Well-being
Happiness Satisfaction Interest in life Self-acceptance : a positive and acceptant attitude towards aspects of self in past and present; Positive relations with others: having satisfying personal relationships in which empathy and intimacy are expressed; Personal growth: the insight into one’s own potential for self-development; Purpose in life: goals and beliefs that affirm a sense of direction and meaning in life; Environmental mastery: the capability to manage the complex environment according to one’s own needs; Autonomy: self-direction as guided by one’s own socially accepted internal standards. Social coherence: the ability to make meaning of what is happening in society; Social acceptance: a positive attitude towards others while acknowledging their differences; Social actualization: the belief that the community has potential and can evolve positively; Social contribution: the feeling that one’s activities contribute to and are valued by society; Social integration: a sense of belonging to a community.

The mental health/illness and the flourishing/languishing continues:

There are problems with the positioning of mental health and mental illness at two opposing ends of a continuum which infers that the opposite of mental illness is mental health and vice versa. Problems include that many people who do not have a mental illness do not function well and do not feel mentally healthy; those who are not depressed are not necessarily happy Keyes (2005). It is suggested therefore that many people do not fit into the ‘one-dimensional illness-health continuum’ (Westerhof & Keyes, 2010). For this reason, a two-continua model of mental health is proposed by Keyes (2005) and (Westerhof & Keyes, 2010). Within this model the concepts of mental health and mental illness are related yet distinct. One continuum places flourishing and languishing on opposite poles while the other places mental illness and the absence of mental illness at opposite poles. In this diagram, the vertical continuum represents the presence or absence of mental health; those who are flourishing are mentally healthy while those who are languishing are not. Mental health is viewed as a complete state and not just the absence of mental illness. The horizontal continuum reflects the presence or absence of mental illness. The inter-relatedness of these two continuua is clear. As can be seen in the diagram, for a proportion of people with a mental illness, it is possible to be moderately mentally healthy. Similarly, a proportion of those who are languishing do not have a mental health problem thereby supporting the two continuua model (Westerhof & Keyes, 2010).

The positioning of mental health (flourishing) on a continuum helps to visualize and reflect on our own position on this continuum and is a tool that can utilized with service users. Daily challenges in addition to static factors challenge our mental health and our resilience and therefore our positioning on the continuum. By watching where we are on the this continuum and putting in place strategies to increase wellness we can help to keep ourselves towards the ‘flourishing’ end of this continuum. Factors which positively influence our position on the mental health continuum include healthy habits such as nutrition, sleep and exercise; supportive relationships; participation in meaningful activity and avoiding self-destructive behaviour. Later in this unit a number of wellness strategies will be identified which can be incorporated into your practice.

There are many determinants of mental health in addition to mental health promotion activities which are common across the lifespan and not specific to any particular age group. Conversely however, there are also a number of factors which pose a challenge to wellness and mental health at specific stages in the lifespan. Consequently, this section will briefly identify some challenges to mental health and wellness across the lifespan.

Before reading on in this unit, identify what you believe might impact on mental health and wellness across the lifespan in:

Click here to connect to a recent Australian literature review on increasing student well-being in schools.

Wellness and the related concept of positive psychology, with its focus on well-being and ‘flourishing’ (Boiler et al, 2013) are just as relevant to those with mental health problems as to those without. As previously identified, it is possible to be moderately mentally healthy or even flourishing in the presence of an on-going mental health problem (Slade, 2010). Whether working in a primary, secondary or tertiary mental health promoting capacity, mental health nurses can utilize evidence-based wellness tools to increase mental health self-efficacy and self-management of wellbeing in the people they work with. The following are examples of some wellness tools which can be implemented into mental health nursing practice:

Identifying stress and responding to triggers: Stress affects everybody at different times in our lives and to varying degrees. A little stress is required to keep motivated and prevent becoming bored. However excess stress and a maladaptive response to it can cause significant difficulties for many people. Signs and symptoms of stress can impact all areas of wellbeing including physical, emotional, behavioural and cognitive areas in varied ways. Identifying stress triggers enables individuals to make changes to minimise exposure to these triggers or to minimize their effect on the individual by changing the stress response. One of the most common ways of dealing with stress is to use calming techniques such as meditation and mindfulness. More detailed information on mindfulness is presented below in the next section.

Click on this link to a video which focuses on stress and bringing calm to our lives by using mindfulness. (Source - Suicide or Survive).

Watch this TEDTalk which presents an alternative view of how to think about stress and your stress response.

Meditation and mindfulness. A number of studies have explored the effects of mindfulness on mood and have shown it to lower emotional volatility (Arch and Craske, 2006), reduce perceived stress (Chang et al, 2004, Klatt et al, 2009), reduce symptoms of anxiety and depression (Cavanagh et al, 2013), reduce ruminating and habitual worrying (Verplanken & Fisher, 2013), enhance positive states of mind (Chang et al, 2004), and improve sleep (Klatt et al, 2009). Mindfulness exercises can be incorporated into everyday life and can be a helpful technique that can be used by mental health nurses with service users.

Have a look at this Ted Talk outlining the importance of mindfulness and in particular how to ‘do’ mindfulness in 10-minute sessions.

Click on the following link which will talk you through how to take a mindfulness minute which is a technique that you may practice with the people you work with.

For a more detailed understanding of mindfulness and its origins click on the link to access a lecture by Prof Mark Williams on the Science of Mindfulness.

The Wheel of life. The ‘Wheel of Life’ is a simple tool which encourages users to score each of nine areas of their life out of 100. Areas scored include work, health, family and finance. Taking the time to reflect and score each area helps participants to identify those areas of life that require development to maintain a sense of wellbeing. It can be used over time to compare how things are now to how they were before action was taken and can therefore be used as a tool to motivate and encourage users to make the changes necessary to achieve a higher satisfaction with life. Having completed ‘The Wheel of Life’, participants are then encouraged to select one area at a time to set short, medium and long-term goals.

Click to watch a video explaining ‘The Wheel of Life’ in addition to locating with worksheets for ‘The Wheel of Life’ which you can then use with service users. (Source: Suicide or Survive).

Holistic goal setting. Goal setting is a commonly used tool in mental health as emphasising the person’s own goals and strengths is needed to improve well-being (Slade 2010). Goal-setting forms a central part of mental health self-management as setting clear and specific goals can be highly motivational and can help to mobilise individual resources (Egan 2014). In addition, goals provide incentives for people to search for strategies to accomplish them (Egan 2014). Using the ‘Wheel of Life’ users can identify specific goals and further break them down to elements that can be achieved in the short, medium and long term.

Changing negative thinking. What someone thinks has a significant impact on their wellness and how they feel. Another wellness strategy which may be used in mental health practice is to work with people to challenge and change their thinking. This is not simply putting a positive spin on negative events but rather is about seeing events realistically. There is a marked effort to move away from negative thinking patterns like catastophising to more realistic evaluations of events and thinking in a more balanced and flexible way.

Watch this video on 'changing your thinking' which takes the learner though the key issues including automatic thoughts, assumptions, and core beliefs. This webpage also contains worksheets which can be used in mental health practice to identify the processes behind our thinking (e.g. 1. What is the thought, 2. Is it true, 3. Is it logical, 4. Is it helpful 5. Identifying a more helpful way of thinking). this also links to a wellness workshop which demonstrates how you can change your thinking and ‘think your way to wellness’.

For further information on negative thinking, have a look at this Ted Talk on 'getting stuck in the negatives'.

Despite a large body of literature supporting the potential of a wellness focus and wellness interventions in improving outcomes for service users, there are some challenges to implementing a wellness focus within mental health care. Mental health nurses have traditionally worked within the medical model of care focusing their attention on treatment and symptom/illness reduction (Blakeman & Ford, 2012; Slade, 2010; Magyary, 2002). Having wellness and positive psychology as a core component of mental health promotion requires a distinct paradigmatic shift. It requires a new way of thinking about preparation and education for mental health professionals including nurses and will require a change in how they practice if primacy is to be given to increasing well-being rather that to treating illness (Slade, 2010); Health services, and the workers within them, need to be reoriented with a shift on emphasis to health being a shared responsibility among individuals, community groups, health professionals, health service institutions and governments (Jane-Lopis et al., 2005). There is a need to create health-orientated rather than illness-orientated services.

Challenges to working within a wellness perspective:

• The dominance of the medical model remains a difficulty when striving to develop and support a holistic care plan grounded in the tenets of wellness and positive psychology.

• Working from a wellness focused perspective requires a change in mind-set in addition to a change in practice.

• Despite the prominence of well-being in mental health promotion policies, there can be a difficulty in accessing services that promote well-being (Owens et al, 2010).

• Supporting service users to undertake activity, learning, social connections etc. can be expensive, anxiety-provoking and time-consuming for all concerned (Blakeman & Ford, 2012).

• Although the literature suggests that service users are open to learning the skills required to promote well-being and positive psychology, there is a learning curve here. This is particularly so for those service users who have essentially been a passive recipient of care and treatment within the parameters of the medical model (through no fault of their own). Not only is a paradigm shift required for nurses and other mental health professionals, but also for some service users for whom these are new concepts.

• Nurses cannot work within the well-being and positive psychology realm in isolation from other mental health professionals; instead, it requires a multi-disciplinary team approach with buy-in from each discipline within that team.

Read the following discussion paper by Wand (2013) which argues for a positioning of mental health nursing within the paradigm of positive health.

Reflect on the following questions:

  • What structural challenges do you think exist in your area of work to working within a wellness orientated paradigm?
  • What individual challenges do you think exist which militate against working from a wellness perspective?
  • Identify how you might overcome both structural and individual challenges.

Positive mental health is a key asset and resource for population well-being and the long-term social and economic prosperity of society (Barry, 2009). Historically, mental health nurses have focused on symptom reduction and as a result relatively little attention was paid to what makes people happy. However, every mental health practitioner needs to be familiar with the concept of ‘well-being’ if they are to succeed in the mental health climate of the years to come.

Blakeman, P. & Ford, L. (2012) Working in the real world: a review of sociological concepts of health and well-being and their relation to modern mental health nursing. Journal of Psychiatric and Mental Health Nursing, 19, 482-491.

Boiler, L., Haverman, M., Westerhof, G.J., Riper, H., Smit, F. & Bohlmeijer, E. (2013) Positive psychology interventions: a meta-analysis of randomized controlled studies. BMC Public Health, 13, 119.

Cavanagh, K., Strauss, C., Cicconi, F., Griffiths, N., Wyper, A. and Jones, F. (2013) A randomised controlled trial of a brief online mindfulness-based intervention. Behaviour Research and Therapy 51(9), 573–578.

Csikszentmihalyi, M. & Seligman, M.E.P. (2000) Positive Psychology: An Introduction. American Psychologist, 55(1), 5-14.

Egan G. (2014) The Skilled Helper: A Problem-Management and opportunity Development Approach to Helping. Brooks/Cole Cengage Learning. USA.

Jane-Lopis, E., Barry, M., Hosman, C. & Vikram, P. (2005) Mental health promotion works: a review. Promotion and Education, 12:9.

Keyes, C.L.M. (2002) The Mental Health Continuum: From Languishing to Flourishing in Life. Journal of Health and Social Behavior, Vol. 43, (2), 207-222.

Keyes, C.L.M. (2005) Mental Illness and/or Mental Health? Investigating Axioms of the Complete State Model of Health. Journal of Consulting and Clinical Psychology, 73(3), 539-548.

Kobau, R., Seligma, M.E.P., Peterson, C., Diener, E., Zack, M.M., Chapman, D. & Thompson, W. (2011) Mental Health Promotion in Public Health: Perspectives and Strategies From Positive Psychology. American Journal of Public Health, 101 (8), e1-e9.

Lahtinen, E., Joubert, N., Raeburn, J., & Jenkins, R. (2005). Strategies for Promoting the Mental Health of Populations. In H. Herrman, S. Saxena, & R. Moodie (Eds.), Promoting Mental Health: Concepts, Emerging Evidence, Practice (pp. 226-242). Geneva: World Health Organization.

Magyary, D. (2002) Positive mental health: A turn of the century perspective. Issues in mental health nursing, 23:331-349.

Owens, C., Crone, D., Kilgour, L. & El Ansari, W. (2010) The place and promotion of well-being in mental health services: a qualitative investigation. Journal of Psychiatric and Mental Health Nursing, 17, 1-8.

Rutter, M. (1985) Resilience in the face of adversity. British Journal of Psychiatry, 147, 598-611.

Slade, M. (2010) Mental illness and well-being: the central importance of positive psychology and the recovery approaches. BMC Health Services Research, 10:26.

Swarbrick M. (2006) A wellness approach. Psychiatric Rehabilitation Journal 29(4), 311-314.

Swarbrick M. & Moosvi, K.V. (2010) Wellness: A practice for our lives and work. Journal of Psychosocial Nursing and Mental Health Services 48(7), 1-3.

Swarbrick M., Roe D., Yudof J. and Zisman Y. (2009) Participant perceptions of a peer wellness and recovery education program. Occupational Therapy in Mental Health 25(3-4), 312-324.

Verplanken B. and Fisher N. (2013) Habitual worrying and benefits of mindfulness. Mindfulness. Available here.

Wand, T. (2013) Positioning mental health nursing practice within a positive health paradigm. International Journal of Mental Health Nursing. 22, 116-124.

Westerhof, G.J. & Keyes, C.L.M. (2010) Mental Illness and Mental Health: The Two Continua Model Across the Lifespan. Journal of Adult Development, 17, 110-119.

World Health Organization (2005) Promoting Mental Health: Concepts, Emerging Evidence, Practice. WHO, Geneva.

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