Mental Health Promotion
What it is and why it matters
There are many different definitions and models of mental health promotion. These are influenced by different concepts of mental health and mental illness and by different traditions and cultures across the EU.
Mental health
Achieving a shared definition of what constitutes positive mental health or mental well-being remains a challenge in Europe. Most definitions of mental health used by health and other professionals draw on the definition of health drawn up by the World Health Organisation in 1948 and the 1986 Ottowa Charter for health promotion:
Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.
Health is a resource for everyday life, not the object of living. It is a positive concept emphasizing social and personal resources as well as physical capabilities.
(Ottawa Charter for Health Promotion WHO, Geneva, 1986)
There is general agreement that mental health is more than an absence of mental illness.
“mental health is the emotional and spiritual resilience which allows us to enjoy life and to survive pain, disappointment and sadness. It is a positive sense of well-being and an underlying belief in our own, and others’ dignity and worth.”
- (Health Education Authority (1997) Mental health promotion: a quality framework London: HEA)
The definition of mental health as a ‘positive sense of well-being’ challenges the idea that mental health is the opposite of mental illness. For example, someone with a diagnosis of schizophrenia might feel supported, at ease and optimistic. They might be coping well with life and enjoying a high level of well-being. Equally, many people who are not clinically diagnosed have a poor sense of well-being.
In a number of key EU/WHO policy documents, mental health is usually defined in terms of its benefits:
Positive mental health is “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community”.
- (WHO 2004 Promoting mental health : concepts, emerging evidence, practice : summary report - a report from the World Health Organization, Department of Mental Health and Substance Abuse in collaboration with the Victorian Health Promotion Foundation and the University of Melbourne“that mental health and mental well-being are fundamental to the quality of life and productivity of individuals, families, communities and nations, enabling people to experience life as meaningful and to be creative and active citizens. We believe that the primary aim of mental health activity is to enhance people’s well-being and functioning by focusing on their strengths and resources, reinforcing resilience and enhancing protective external factors.”
“it is a global public good; it is an integral part of the health and well-being of the citizens of Europe and a fundamental human right; it is a prerequisite for a viable, socially responsible and productive Europe as envisaged by the Lisbon strategy; it enhances social cohesion and social capital and improves safety in the living environment."
- (Integrating mental health promotion interventions into countries’ policies, practice and mental health care system (the IMHPA Project) Final Report to the European Commission DG SANCO/G October 25th 2005)
Some further examples of different definitions and debates about all aspects of mental health can be seen on www.wellontheweb.org
Mental health promotion
Currently, the main debates about mental health promotion concern the importance of achieving a balance between action to prevent mental health problems and action to promote mental health for all and the most effective ways of demonstrating the benefits of promoting mental health.
Putting Mental Health on the European Agenda (1998-2000), coordinated by STAKES, Finland, advocated strongly “the need to shift the focus of mental health to a comprehensive population approach including mental health promotion and prevention of mental ill-health. A public health approach to mental health within the European context is important because of the vital contribution made by mental health to the well-being of populations, and to the enhancement of their human, social and economic capital. It is therefore of utmost importance that mental health and its promotion is closely integrated with all public health strategies. The value of mental health needs to be recognised throughout Europe and across all levels and all sectors of society.”
“Positive mental health cannot be gained by treating mental disorders alone. For example, providing the most effective evidence based treatment for one half of all people with depression would only reduce the current burden of depression by less than one quarter.
On the other hand, evidence demonstrates that mental health promotion and mental disorder prevention can lead to health, social and economic gain, increases in social inclusion and economic productivity, reductions in the risks for mental and behavioural disorders and decreased social welfare and health costs”.(Prevention of mental disorders : effective interventions and policy options : summary report - a report of the World Health Organization Dept. of Mental Health and Substance Abuse ; in collaboration with the Prevention Research Centre of the Universities of Nijmegen and Maastricht )
“mental health activities capable of improving the well-being of the whole population, preventing mental health problems and enhancing the inclusion and functioning of people experiencing mental health problems.”
Key elements of mental well-being
There have been a number of attempts to define the different elements or dimensions of well-being and to identify scales that can measure mental well-being, as distinct from scales that measure mental illness.
Keyes makes the following distinction:
- Positive feelings (subjective well-being) ‘hedonic’
- Positive functioning (engagement and fulfilment) ‘eudaimonic’
Keyes, CLM. (2002) The mental health continuum: from languishing to flourishing in life. J Health Soc Res 43:207-22
This recognises that positive feelings (e.g. happiness) are not a sufficient indicator of mental well-being and vice versa, positive functioning may co exist with feeling unhappy.
Keyes describes the combination of positive feelings and positive functioning as ‘flourishing’. Using data from the US, he found the following:
17% flourishing
54% moderately mentally healthy
11% languishing (pre-clinical)
18% mentally ill
Huppert, using the Keyes model, applies the work of Rose (1992) to argue for a population approach to improving mental health, by shifting the whole population in a positive direction. Figure 1 shows that by reducing the mean number of psychological symptoms in the population, many more individuals would cross the threshold for flourishing. A small shift in the mean of symptoms or risk factors would result in a decrease in the number of people in the languishing and mental illness tail of the distribution. The problem with this model is that it suggests that people living with a diagnosis cannot, by definition, be flourishing – a view that has been challenged.
Huppert, F, Baylis, N and B Keverne (eds) (2005) The Science of Wellbeing.
Oxford: OUP.
Broadly then, mental health and wellbeing may cover the following domains:
- Subjective well-being/life satisfaction
- Personal and social relationships
- Occupation (personal development, employment and other activity)
- Engagement/participation in community
(Hird, Susan (2003) What is Wellbeing? A brief review of current literature and concepts NHS Scotland)
The proposed European Social Survey (ESS third wave) well-being module aims to extend the measurement of well-being to capture key elements of these domains in several ways:
- It adopts a definition of well-being which incorporates not only how people feel, i.e. hedonic aspects of well-being such as pleasure, enjoyment, satisfaction, but also how people function, i.e. eudaimonic aspects of well-being, such as competency, interest or engagement, meaning or purpose in life.
- It gives equal emphasis to personal well-being and to inter-personal or social well-being.
Promoting mental well-being
In practical terms then, mental health promotion aims to promote thoughts, feelings and activities that strengthen well-being in individuals, as well as securing conditions at a community and structural level that are conducive to positive mental health. The following ‘positive steps’ for achieving and maintaining positive mental health have been described as the ‘five fruit and vegetables of mental health’:
- keeping physically active
- eating well
- drinking in moderation
- valuing yourself and others
- talking about your feelings
- keeping in touch with friends and loved ones
- caring for others
- getting involved and making a contribution
- learning new skills
- doing something creative
- taking a break
- asking for help
(NIMHE (2005) Making it possible: improving mental health and well-being in England)
Put another way, the following are the emotional and cognitive protective factors for mental well-being:
- agency/locus of control
- capacity to learn, grow and develop
- feeling loved, trusted, understood, valued
- interest in life
- autonomy
- self-acceptance and self-esteem
- optimism and hopefulness
- resilience/problem solving
Measuring mental health and public mental health indicators
There are currently a number of national and EC funded projects concerned with identifying indicators that could form a basis for measuring mental health and well-being (for an overview of the issues see Parkinson J (2006) Establishing a Core set of Sustainable National Mental Health and Well-being Indicators for Scotland Journal of Public Mental Health 5.1).
This is a significant development for the following reasons:
- most national and European data on mental health currently concerns incidence and prevalence of mental illness e.g. surveys of psychiatric morbidity
- evaluation of the effectiveness of mental health promotion will require indicators that capture mental health and well-being outcomes, as well as indicators which reflect prevention
Further information on the development of mental health indicators includes:
STAKES (2001) Minimum data set of European mental health indicators. Proposed set of mental health indicators; definitions, description and sources. Helsinki: National Research and Development Centre for Welfare and Health (STAKES).
STAKES (2005) Mental Health Information and Determinants for the European Level (MINDFUL): Interim technical implementation report.MINDFUL website
