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Mental Health and Wellbeing

Jon Fieldhouse; Katrina Bannigan

INTRODUCTION

HEALTH AND WELLBEING

Wellbeing and health have been bound together conceptually since the World Health Organization (WHO) defined health as ‘a state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity’ (WHO 1948). This definition ambitiously proposed a holistic concept of health and wellbeing, established wide parameters for considering what constitutes human health, and recognized socioeconomic factors as the legitimate concern of health services (Barry and Yuill 2012). However, the WHO definition has been criticized for its impracticality and for appearing to correspond more to happiness than health. Huber et al. (2011) suggest it is no longer fit for purpose because it does not accommodate the fact that ageing with chronic illness is increasing worldwide. They propose shifting the emphasis towards seeing health as a person’s capacity to adapt and self-manage in the face of social, physical, and emotional challenges, with fulfilment and a sense of wellbeing. This offers a dynamic view of health that has much in common with resilience, which is the capacity to maintain and restore one’s equilibrium through coping and social connectedness. (Resilience is also discussed in the context of the emotional health and wellbeing of children and young people, in Ch. 25.) Huber et al. (2011) describe a person’s sense of coherence as a crucial factor in their health; seeing this as a capacity for coping, recovering from stress, and ultimately for experiencing wellbeing.

The word ‘complete’ in the WHO definition also attracts criticism, on several counts. Not only is it deemed impracticable because it is not measurable, but also because it would result in much of the world’s population being classified as unhealthy most of the time. Furthermore, it is suggested that the WHO definition has unintentionally contributed to the medicalization of society by supporting the tendencies of the medical profession and pharmaceutical industry to diagnose and treat conditions not previously defined as health problems (Huber et al. 2011). While the WHO’s definition of health highlighted the importance of wellbeing, it also instigated the entanglement of health with wellbeing. One unfortunate outcome of this has been the tradition that health is the exclusive preserve of biomedicine, and is objective; while wellbeing is about subjective emotional and psychological states (McNaught 2011). This has caused confusion. For example, Spiegel (1998) noted how health is often mistakenly assumed to be the necessary precondition for wellbeing;

Making a similar point, Lawton-Smith (Head of Policy for the UK’s Mental Health Foundation) ponders the relationship between wellbeing and mental health;

So, while the term wellbeing is widely used in health and social care, it remains largely unexamined in its own right and poorly understood as a consequence. Significantly, perhaps, there is no consensus on how to write it: wellbeing, well-being and well being are all used. What follows is an exploration of wellbeing in relation to contemporary mental health practice, with an emphasis on social perspectives and an awareness of the increasing inclusion of wellbeing in mental health and social policy.

Defining Wellbeing

The coupling of wellbeing and health is now a feature of everyday language (McNaught 2011). The Oxford English Dictionary (2013) defines wellbeing as ‘the state of being or doing well in life; happy, healthy, or prosperous condition; moral or physical welfare (of a person or community)’. It is interesting, from an occupational perspective, to note the conjunction of ‘being’ and ‘doing’ and the fact that wellbeing is considered to be both a personal and societal phenomenon. However, attempts to define and explore wellbeing more deeply – so it can be used more reliably within health and social care practice – reveal wellbeing to be a complex, confusing and contested topic. The search for a generally accepted definition of such an elastic concept has been described as ‘frustrating and fruitless’ (McNaught 2011, p. 10).

The International Classification of Functioning, Disability and Health has defined wellbeing as ‘a general term encompassing the total universe of life domains including physical, mental and social aspects (education, employment, environment, etc.) that make up what can be called a ‘good life’’ (WHO 2001a). While this definition highlights wellbeing’s complex nature, it also reinforces its elasticity.

In her review and critique of the use of wellbeing in the professional discourse across occupational therapy and occupational science, Aldrich (2011) noted a large discrepancy between the number of sources that used wellbeing (or well being or wellbeing), as a keyword and the number of sources that also provided a definition of the term. She concluded that wellbeing was widely seen as a standardized concept that needed no definition because it was universal. However, she saw no evidence to support this claim of universality. Instead, the diversity of definitions suggested that the term is used inconsistently and uncritically (Aldrich 2011). Indeed, it sometimes seems to be used as a ‘linguistic flourish’ (McNaught 2011, p. 8). For example, in various contexts it has been used as a concrete noun (where wellbeing is a distinct entity that can be improved or threatened), or as an adjective or qualifier for another noun (as in ‘wellbeing outcomes’). It may be seen as something specific to particular groups (as in ‘children’s wellbeing’ or ‘employees’ wellbeing’) or as an ‘extender’ to a set of other qualities, somehow bringing them together, (as in ‘x, y, and wellbeing’) (Ereaut and Wright 2008).

It is possible that our intuitive sense of what wellbeing might mean confounds our attempts to clearly articulate what it is. Ereaut and Wright (2008) argue that, as a social construct, wellbeing cannot have a fixed meaning;

They also note that wellbeing is ‘up for grabs’; being hotly contested, and accorded particular significance. For example, the UK government’s mental health outcomes strategy states that ‘more people of all ages and backgrounds will have better wellbeing and good mental health’ (DH 2011, p. 6). Like the previous government (DH 2009), it defines wellbeing as:

Agreeing how to define wellbeing may create problems when, as Aldrich (2011) notes, our use of the term implies judgements and assumptions about what it ought to be. For occupational therapists, whose person-centredness arguably has wellbeing as the ultimate goal of intervention (Hammell 2008; Pentland and MacColl 2009), these value judgements must be consciously acknowledged if occupational therapy is to be truly person-centred, culturally sensitive and inclusive. It would therefore be advantageous for occupational therapists to be able to describe more clearly what wellbeing means to them. There are two strategies for stabilising meaning; overt definition, and discursive usage aiming to give a term greater currency and hence understanding (Ereaut and Wright 2008). This chapter adopts the latter approach.

WELLBEING AND MENTAL HEALTH

The WHO (2001b) has defined mental health as ‘a state of wellbeing 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’. In order to appreciate the resonance of wellbeing as a concept within mental health practice, this chapter now presents a variety of perspectives of wellbeing, concluding with specifically occupational perspective of it. This encompasses the different viewpoints through its holism, and offers a basis for incorporating wellbeing into occupational therapists’ professional reasoning and practice. Wellbeing has historically been explored from two distinct, yet complementary traditions; a sociological viewpoint, focusing on social capital, and a psychological one, focusing on mental capital (Pilgrim 2009).

Wellbeing and Social Capital

The sociological viewpoint conceptualizes wellbeing as a relational, not a solitary, experience; one that reflects our interdependence within our family, friends and neighbourhood networks. The importance to a person’s mental health of their social connectedness has long been recognized within mental health practice but it has proved to be challenging for service providers to reliably incorporate it as a resource in their care planning with individuals (Morgan and Swann 2004).

McKenzie and Harpham (2006) suggest it is difficult to draw a clear distinction between the comparatively well-researched concepts of social support and social networks, and the concept of social capital. Wilcock (2006, citing Nutbeam 1998) offers the following definitions: social support is the assistance available to individuals and groups from within communities that can provide a buffer against adverse life events and living conditions, and be a positive resource for enhancing quality of life; social networks are the relations between individuals that may provide access to, or mobilization of, social support; and social capital is the degree of social cohesion which exists in communities. Putnam (1993) defines social capital as participation in community networks, the sense of belonging, solidarity and equality derived from that participation, and the norms of reciprocity and trust that emerge between co-participants. Social capital is, therefore, about people and populations ‘having opportunities to participate in society and enact their rights of citizenship in everyday life’ (Whiteford and Pereira 2012, p. 188). It can be seen as a process and an outcome; the means by which people are enabled to participate, as well as the fact of participation (Whiteford and Pereira 2012). Putnam (1993) suggests that social capital can not only strengthen the ties of people who know each other but makes for a more receptive or inclusive society, capable of bringing together people who previously did not know each other. Social capital is, therefore, a property of groups rather than of individuals, whereas social networks are a more discrete feature of individuals’ day-to-day lives. Social inclusion is discussed further in Chs. 23 and 24, which focus on community settings and older people, respectively.

This sociological perspective is a broad one. Participation and inclusion are viewed against the backdrop of factors, such as social class, gender, ethnicity, place of living, health-related behaviours, and the degree of choice an individual or family has regarding education, work and play (Barry and Yuill 2012). People’s innate drive to connect with others is acknowledged along with the importance of equal access to shared resources to enable people to do this. This relates to occupational justice (see Chs. 3, 13 and 29), which raises ‘concerns about the unfairness of some people flourishing in what they do, whereas other people are leading unhealthy, empty, marginalized, or dangerous lives’ (Stadnyk et al. 2010, p. 330). It also reflects Hammell’s (2008) view that, because it is often unattainable in conditions of oppression and poverty, wellbeing is a political notion tied to human rights.

Wellbeing and Mental Capital

The term mental wellbeing describes how mental capital contributes to society. It is defined as;

This definition echoes Huber et al.’s (2011) perspective on health described earlier. The emphasis on wellbeing as something derived from doing is also significant. The psychological perspective of wellbeing places less emphasis on relationships, focusing on what is personally derived and internalized by the individual (Pilgrim 2009). Individualization and internalization finds expression in contemporary notions of positive psychology or ‘happiness science’ (Seligman & Csikszentmihalyi 2000). This perspective views the personal search for meaning as the impulse for self-actualization, echoing the Aristotelian principle of eudaimonia, or human flourishing (Carson and Gordon 2010). This is often described in terms such as belonging, resilience, hope, spirituality, self-efficacy, self-esteem, self-acceptance, flow, happiness, autonomy, purpose and meaning (see Glossary for all terms; Chs. 17 and 20 for discussion about flow; Ch. 16 for explanations of self-efficacy and self-esteem). These concepts highlight the connection between wellbeing and personal recovery (Slade and Davidson 2011). Recovery-oriented practice (discussed further in Chs. 6, 11 and 23) emphasizes these personal values. They are important because pursuing personal life goals without excessive frustration may be essential to self-efficacy, identity and wellbeing. Living within a wider society, therefore, means it is the mutual respect for personal identity that makes these goals achievable for individuals. In this sense, wellbeing is still dependent on reciprocal, or two-way, relationships (see also Box 2-1).

From this brief overview of social capital and mental capital, it can be seen that an understanding of wellbeing requires an appreciation of human life as it is lived in relationship to others. It is not determined simply by factors within the intra-personal domain.

Pilgrim (2009) suggests that somewhere between these contrasting social capital and mental capital views of wellbeing lies a strong interdisciplinary consensus on the importance of relationships, and it is this which is of great interest in mental health. A middle position integrates subjective, internal states and observable measurable social conditions, related to deprivation for example. It unites personal subjective experience with broader sociological or societal issues. In other words, wellbeing can be seen wholly as something that is not simply about social experience, nor purely as a psychological state. It is not ‘either/or’, but both; a psychosocial phenomenon.

For example, the feeling of belonging that a person gets from participating in the life of their community has been termed cognitive social capital because it has become internalized by them. This is distinguished from structural social capital, which is the availability of networks and relationships in a given area. Cognitive social capital is a reliable predictor of wellbeing while structural social capital may not be; particularly if a person is living in the same street as other people but leads a separate, excluded life (McKenzie and Harpham 2006).

Promoting social inclusion could therefore be understood in terms of converting structural social capital into cognitive social capital; accessing the opportunities that are ‘out there’ and transforming that capital into an intrapersonal sense of belonging, which is a vital dimension of wellbeing and quality of life (Chan et al. 2005).

Supporting this process requires collaboration between mental health services and mainstream community agencies (Fieldhouse 2012). This brings together different stakeholders with their contrasting notions of wellbeing; some health-orientated, others orientated to citizenship (Bates 2010). A psychosocial definition of wellbeing is helpful in this context:

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An Intersectional Approach to Inequity Working on the Margins: Occupational Therapy and Social Inclusion Community Practice Life Skills Professional Accountability Play

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