Mental health and mental illness: the Complete State Model
In terms of a therapeutic framework, the CSM provides a way in which clinicians can organize and interpret an individual’s cognitive, behavioral, and emotional functioning, and then translate aspects of these into objectives for therapy. Moreover, the CSM of mental health suggests that the objective of strategies to promote mental health must be to build those psychological strengths that can then shift people from poorer states of functioning (i.e., languishing, struggling, or floundering) toward a sustainable state of flourishing in life.
The cognitive process of hope is an example of a positive psychological strength that can be employed as a mechanism to move young people toward a sustainable state of flourishing in life. According to Snyder’s Hope Theory (Snyder et al. 1991), hopeful thinking consists of three elements: goal setting, pathways thinking, and agency thinking. Goals provide the anchor for the mental action sequences that are generated by successful hopeful thinking (Snyder 1994). Pathways and agency thinking are suggested to continually affect, and be affected by, each other during the goal pursuit process (Snyder 2000). Pathways thinking reflect an individual’s capacity to conceptualize one or more avenues in order to arrive at a desired goal, while agency thinking reflects an individual’s ability to initiate and sustain movement along a chosen pathway in order to reach that goal (Snyder et al. 1991). Successful hopeful thinking thus enables an individual to set goals, develop strategies to achieve those goals, and build and sustain the motivation to execute those strategies (Cheavens et al. 2006; Snyder et al. 1991). Hopeful thinking begins as children start to think about themselves and their goal pursuits (Snyder 2000). However, it is only upon reaching adolescence that an individual is suggested to have all the necessary cognitive resources required for successful hopeful thinking in all areas of life. According to Seifert et al. (2000), the development of formal operational thought enables a young person to emphasize the possible rather than the actual, reason systematically, and combine ideas skillfully. Relating this to hopeful thinking, it may be only during adolescence that young people can begin to envisage future goals, conceive possible and practical ways to obtain these, and envisage the practical benefits of goal pursuit in all aspects of their lives.
There is considerable evidence that high levels of hope promote physical and psychological health (Herth 1990; Nekolaichuk et al. 1999). When conceptualized cognitively, people high in hope—compared to those low in hope—not only believe that they can generate but actually generate more pathways to goals, sustain more energy to pursue goals, and view goal blockages merely as temporary setbacks (Snyder et al. 1991), even when faced with adversity (Cheavens 2000). In comparison, people low in hope set fewer goals, are more tenuous in their pursuit, are unlikely to produce alternative routes, and may view blockages as demoralizing (Snyder 2002). Thus, just as a generalized expectancy for failure can cause and sustain mental illness, it may be said that a generalized expectancy for goal success can promote mental health and protect against mental illness (Cheavens 2000). Furthermore, as hopeful thinking elicits emotion, people high in hope are suggested to experience enduring and positive emotions that are, in turn, accompanied by a zest for the pursuit of goals. This is in contrast to people low in hope, who are suggested to experience negative emotions accompanied by a lethargic attitude toward the pursuit of goals (Snyder 2002). Thus, the presence of high levels of hope appears to activate a positive upward spiral of functioning that better equips people with the skills and resources needed to overcome challenges and obtain a state of flourishing in life, while the presence of low levels of hope does not.
In terms of mental health promotion, this suggests that when faced with a challenging situation or a goal blockage, those low in hope may experience stress, which over time, elicits negative emotions. However, those high in hope will have the resources needed to redirect goal pursuit and alleviate any initial or subsequent stress that arises (Snyder 2002). There is evidence, moreover, that differences in hope levels have both short- and long-term effects. For example, compared to young people low in hope, young people high in hope report increased levels of physical and psychological functioning (Cheavens et al. 2006; Snyder et al. 2000, 1991), and the presence of high levels of psychological strengths when young is linked to positive mental health outcomes in adulthood (Arehart-Treichel 2006).
The Broaden and Build Theory of Positive Emotions
Fredrickson’s Broaden and Build Theory of positive emotions (1998, 2002, 2008) states that the continued experience of positive emotions acts to broaden an individual’s momentary thought–action responses (i.e., increase the range of responses available in a situation), build their enduring personal resources, and help people to cope more effectively with adversity (Fredrickson and Branigan 2005; Fredrickson and Joiner 2002; Fredrickson and Losada 2005; Fredrickson et al. 2003). Thus, while the experience of negative emotions may narrow the range of responses available in a situation and may also carry immediate adaptive benefits (i.e., fight or flight), the experience of positive emotions may widen the array of responses available and may carry indirect and long-term adaptive benefits. For example, joy creates the urge to play, push boundaries, be creative in one’s activities, and expand involvement in life, while interest creates the urge to explore, learn, experience new things, and expand the self (Fredrickson 2002). Thus, in contrast to the experience of negative emotions that, if prolonged, may lead to depression, anxiety, aggression, and health-risk behavior, the experience of positive emotions has indirect and long-term adaptive benefits because these emotions help to develop the psychological strengths and positive resources an individual needs in order to reach and sustain a state of flourishing in life (Fredrickson 2002; Fredrickson and Joiner 2002).
The Hope Activation Cycle
Drawing together elements from the three concepts described above, it therefore follows that the ability to successfully hope provides the experiences that are capable of shifting young people from poorer states of mental health toward sustainable states of positive mental health (i.e., flourishing in life). High levels of hope, according to Fig. 2.2, result in the activation of a positive upward spiral in which increases in goal success lead to increases in the experience of positive emotion (e.g., happiness). This positive emotion, in turn, increases momentary thought–actions and builds enduring personal resources (e.g., resilience), buffers against the onset of mental illness (e.g., depression), activates health-promoting behavior (e.g., physical exercise), and ultimately leads to a state of flourishing in life. However, low levels of hope may lead to a state of languishing, struggling, or floundering in life. Low levels of hope, according to the model, may or may not result in the activation of a negative downward spiral. Nonetheless, the inability to successfully hope may leave an individual susceptible to mental illness.
The Hope activation cycle
The model depicted in Fig. 2.2 combines two related but increasingly disparate fields of investigation that have dominated research on well-being. The hedonic approach, traditionally aligned with positive psychology, conceptualizes well-being as a state with high levels of positive affect, low levels of negative affect, and a high degree of life satisfaction (i.e., subjective or short-term well-being; Boskovic and Jengic 2008). The eudaimonic approach, traditionally aligned with positive mental health, conceptualizes well-being as the processes that lead to the sustained fulfillment and/or realization of an individual’s full potential (i.e., psychological or long-term well-being; Boskovic and Jengic 2008; Keyes et al. 2002). Ryan and Deci (2001), however, suggest that well-being is best conceptualized as incorporating elements of both the hedonic and eudaimonic approaches.
Consistent with this, Keyes et al. (2002) have empirically confirmed that subjective well-being and psychological well-being are related and are not mutually exclusive concepts. In line with this, the proposed model (Fig. 2.2) similarly assumes that feeling good in the short term (i.e., via increased levels of hope and the upward spiral of positive emotions that follow) may ultimately build the psychological resources needed to live well in the long term and provide clinicians with a mechanism to increase the mental health of young people.
The ability to successfully hope, an exemplar of a psychological strength, is an important element of mental health because it provides a young person with the skills and resources needed to reach and sustain an optimum state of mental health. This implies that psychological strengths, such as hope, can be developed to increase levels of mental health and prevent or reduce symptoms of mental illness. There is a counter argument, namely, that a baseline or genetically determined set point exists to which the symptoms of positive functioning always return following any short-term increases (Headey and Wearing 1992; Kahneman et al. 1999). The hedonic treadmill, as this effect has been coined, suggests that any attempt to increase an individual’s positive affect is futile, even though levels may fluctuate, as no sustained increase can ever be achieved (Brickman and Campbell 1971; Headey 2006; Headey and Wearing 1992). In contrast, research from a positive psychological perspective has indicated that (a) levels of life satisfaction can and do change over time (Fujita and Diener 2005); (b) strategies that focus on developing hopeful thinking increase subjective well-being and decrease the symptoms of mental illness (Cheavens et al. 2006); and (c) as goals change or are changed with time, a focus on goals may avoid the hedonic treadmill and ensure that increases in positive affect do not become routine, but remain a source of positive uplift (King 2008). This supports the assumptions that levels of hope—a future goal-orientated process—can be increased, and moreover, that developing hope may be an important new mental health strategies focus that is complementary to, and may be more effective than, the current focus on alleviating mental illness.
Research in Australia from a Complete Mental Health Perspective
Numerous studies in the United States have conceptualized mental health within a positive framework and reported its prevalence and relationship to various physical, social, and behavioral outcomes (Cheavens et al. 2006; Fredrickson and Branigan 2005; Fredrickson and Joiner 2002; Irving et al. 1998; Keyes 2004, 2005b, 2006; Lopez et al. 2000; Snyder 2002; Snyder et al. 1991). Excluding the research described below, very little research has adopted this focus in Australia, and none have operationalized the CSM of mental health (Keyes and Lopez 2002). Most Australian research has focused on the identification (Sawyer et al. 2000), prevalence (Boyd et al. 2000), and prevention of mental illness (Barrett et al. 2006; Lowry-Webster et al. 2001; Shochet et al. 2001), which was presumed to indirectly report mental health. Our own research aimed to expand this focus and thus to contribute to knowledge in the area of mental health from a positive psychological perspective, extending the platform from which positive mental health strategies can be developed and launched to meet the mental health needs of young Australians.
The next part of this chapter describes and summarizes the outcomes from our recent research program exploring the effective measurement of a CSM in Australian youth and the relationships between the cognitive asset of hope, complete mental health, and health-risk behaviors in young Australians.
Objectives of Research and Sample
Our research has three broad objectives. First, we have strived to describe the status of mental health in young Australians according to the four states outlined in the CSM of mental health (Keyes and Lopez 2002), to examine the relationship of these states to health-risk and health-promoting behavior, and to provide an example of how multiple measures can be combined to diagnose young people as flourishing, languishing, struggling, or floundering in life. Second, we have explored the possibility that the cognitive process of hope—used as an exemplar of a psychological strength—may predict mental health in young Australians better than mental illness does and thereby support the argument for shifting the primary focus of health promotion toward building an individual’s strengths.
Finally, we have attempted to establish normative scores for the Adult Hope Scale (AHS; Snyder et al. 1991) in a young Australian population. The AHS is an effective outcome measure that allows clinicians to assess an individual’s hope levels and/or the effectiveness of therapeutic interventions. It was purported, however, that the AHS also has the potential to be used as an initial resource to identify young Australians who differ from the developmental norm in terms of their hope scores and, where appropriate, to guide interventions to help those in need of reaching and sustaining a state of flourishing in life.
The South Australian Youth Mental Health Survey (SAYMHS)
The SAYMHS was a predominantly online survey designed to collect indicators of positive and negative functioning from young people throughout rural and metropolitan South Australia (N = 3,913; refer to Table 2.1). This age range was chosen to coincide with the ages during which a young person attends secondary school in Australia (years 8–12) and to make the results comparable to previous Australian research examining mental health in this population (Sawyer et al. 2000). The SAYMHS consists of five well-validated measures chosen to operationalize the CSM of mental health (Keyes and Lopez 2002), as well as demographic questions used to gather information on factors known to be associated with mental health, and questions on health-risk (smoking cigarettes and alcohol consumption) and health-promoting behavior (e.g., adequate sleep and exercise). The measures included were (a) the AHS (Snyder et al. 1991), (b) the Satisfaction with Life Scale (SWLS; Diener et al. 1985), (c) the Psychological Well-Being Scale (PWBS; Ryff 1989), (d) the Social Well-Being Scale (SWBS; Keyes 1998), and (e) the Depression Anxiety Stress Scale 21 (DASS-21; Lovibond and Lovibond 1995).
Age and gender distribution of sample from SAYMHS (58% from metropolitan areas)
Male n (%)
Female n (%)
Details of the power analysis, sampling method, scale selection, and procedures followed during the SAYMHS have been published elsewhere (Venning et al. 2009, 2011a) but are briefly outlined below. Data collection took place in early 2007. In total, 129 schools were approached to participate (i.e., every secondary school in South Australia listed either with the Department of Education and Children’s Services or listed in the 2005 Annual Report of the Advisory Committee on Non-Government Schools in South Australia that had a student population over 100 was approached). Data were recorded from 41 of the 129 schools canvassed, and while it was not possible under our funding constraints to obtain a stratified random sample, our data were drawn from schools that covered a wide geographical area and broad socioeconomic spectrum. Parental consent and student assent were gained before data collection began. Data were collected electronically from 38 schools (n = 3,315; no missing values) and manually from three (n = 598). Two approaches were taken to missing data collected via the manual version of the survey: if one or more of the measures were left completely blank, the entire data set for that individual was excluded; and if isolated missing values existed, mean imputation was used. No significant differences were found between the scores of participants who completed the online or the manual version of the survey, so data were merged for all analyses.
Outcomes of Research
Our first objective was to identify the prevalence and distribution of flourishing, languishing, struggling, and floundering in life in young South Australians, and to investigate the association of these states to health-risk behavior in order to better inform the development and targeting of mental health strategies. Data were drawn from the SAYMHS and combined to classify young people according to these diagnostic groups on the basis of their combined scores on the PWBS, SWBS, SWLS, and DASS-21. Results indicated that 42% of young people sampled were flourishing in life, 5% were languishing, 36% were struggling, and 17% were floundering in life. Therefore, contrary to what had been previously reported in Smart and Sanson’s (2005) study (i.e., that 80% of young Australians have “good” mental health), these results suggest that <50% of young South Australians are flourishing in life.
In addition, flourishing in life was associated with more health-promoting and less health-risk behavior, while floundering in life was associated with more health-risk and less health-promoting behavior. There were, moreover, gender and regional differences in the uptake of health-risk or health-promoting behavior according to CMH states. Table 2.2 provides a description of the health behavior according to CMH states. Results have been reported in more detail elsewhere (Venning et al. 2012).
Health behavior of sample from SAYMHS (N = 3,913) within Complete Mental Health States
Exercise per week
Sleep per night
Flourishing (n = 1,639) (%)
Languishing (n = 202) (%)
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