Hedonia (i.e., emotional well-being)
1. Positive affect: Cheerful, interested in life, in good spirits, happy, calm and peaceful, full of life
2. Avowed quality of life: Mostly or highly satisfied with life overall or in domains of life
Positive psychological functioning (i.e., psychological well-being)
3. Self acceptance: Holds positive attitudes toward self, acknowledges, likes most parts of personality
4. Personal growth: Seeks challenge, has insight into own potential, feels a sense of continued development
5. Purpose in life: Finds own life has a direction and meaning
6. Environmental mastery: Exercises ability to select, manage, and mold personal environs to suit needs
7. Autonomy: Is guided by own, socially accepted, internal standards and values
8. Positive relations with others: Has, or can form, warm, trusting personal relationships
Positive social functioning (i.e., social well-being)
9. Social acceptance: Holds positive attitudes toward, acknowledges, and is accepting of human differences
10. Social actualization: Believes people, groups, and society have potential and can evolve or grow positively
11. Social contribution: Sees own daily activities as useful to and valued by society and others
12. Social coherence: Interest in society and social life and finds them meaningful and somewhat intelligible
13. Social integration: A sense of belonging to, and comfort and support from, a community
Positive mental health is a core construct for mental health promotion (Barry 2009) and the salutogenic paradigm (Antonovsky 1979) because it requires the study and implementation of the causes of good health in order to prevent disease and promote recovery. Until recently, positive mental health was defined and measured piecemeal, with a focus on specific and often only emotional aspects of well-being rather than including positive functioning in life (Zubrick and Kovess-Masfety 2005). There is a growing consensus on the heuristic value of hedonic and eudaimonic well-being for further developing knowledge about positive aspects of mental health (Barry 2009). Here, the mental health continuum long (Keyes 2002) and short (Keyes 2006a) forms are used not only as a guide to build new instruments for—but also as a measure of—positive mental health, such as the Warwick-Edinburgh Mental Well-being Scale (Tennant et al. 2007).
Another important distinction between mental health promotion and mental illness treatment concerns the complete state model of mental health (Keyes 2005a, 2007). Such a distinction has been represented in the scientific literature for more than half a century (Jahoda 1958; World Health Organization 1948) and posits that mental health is not only the absence of mental illness but also the presence of subjective well-being. More recently, the availability of a research methodology for assessing states of complete mental health has provided specific criteria for combining indicators of mental illness and positive mental health (i.e., subjective well-being). This was developed and used to study the model of complete mental health, which is also called the two (or the dual) continua model (Keyes 2005a, 2007).
Since the mid-1980s, persons with psychiatric disabilities have highlighted that it was possible to recover from mental illness, here corresponding to the achievement of a full and meaningful life in spite of enduring psychiatric symptoms or impairments. Consistent with this view, phenomenological and other qualitative approaches (Silverstein and Bellack 2008), and numerous personal accounts (e.g., Ridgway 2001; Spaniol and Koehler 1994), have provided a better understanding of personal and environmental factors that hinder or facilitate recovery, as well as valuable insight about key dimensions (e.g., hope, empowerment, positive sense of identity) and phases underlying this experience (Onken et al. 2007). The voices of persons with psychiatric disabilities are thus viewed as the royal road to advance knowledge on recovery, and the acquisition and use of experiential knowledge (e.g., critical analysis of personal experiences) is especially targeted in peer support interventions (Mead et al. 2001).
A large number of researchers and clinicians have endorsed consumers’ viewpoints on recovery. Provencher (2002), for instance, has defined recovery as the transcendence of symptoms, functional limitations, and social handicaps attached to mental illness, from which emerges a new sense of existence, the performance of meaningful roles in society, and a better sense of well-being and quality of life. However, consumers’ definition of recovery has challenged a more traditional view of this phenomenon that is still largely represented in the scientific community, which conceives of recovery through the lens of the disease and focuses on the extent, or the level, of remission from mental illness (Silverstein and Bellack 2008). In this vein, several long-term follow-up studies have reported significant improvement in psychiatric symptoms and deficits—or even complete recovery—from schizophrenia over time, in contrast to the deteriorating course that is typically assumed for this disorder (Calabrese and Corrigan 2005).
Distinct conceptions of recovery may be viewed as desirable and as providing enriching perspectives and stimulating multidisciplinary work in order to better understand this phenomenon. However, such diversity remains problematic until theoretical approaches are developed to clearly address how they can complement each other. Potential attempts to resolve this issue may reduce ongoing tensions, encourage a dialogue, and foster collaboration among proponents, whereas neglect of this issue may perpetuate the confusion that prevails about recovery and may possibly carry the risk of decreased interest in the delivery of recovery-oriented services over the long run. What has been overlooked so far has been the fact that those proposed conceptions of recovery rely on distinct approaches of mental health: the search and engagement in a pleasant and fulfilling life in alignment with the salutogenic vision and the alleviation of mental illness outcomes with the pathogenic vision. This stresses the relevance of theoretical approaches that bring together mental illness and positive mental health.
This chapter proposes that the study and process of recovery from mental illness can be augmented by adopting the model of complete mental health. The first part presents a brief overview of Keyes’ model. Current definitions of recovery are then reexamined based on their underlying conceptions of mental health. Third, recovery is redefined as a complete mental health experience, relying on two complementary processes and outcomes, restoration from mental illness, and optimization of positive mental health. An emphasis is placed on outcomes, which are viewed as pathways to complete mental health over the recovery process. Finally, some concluding remarks are made about how the complete view of mental health recovery extends previous conceptions, and some future directions for research in order to advance knowledge in this area are proposed.
Complete Mental Health
Positive mental health, like mental illness, is a syndrome of symptoms that consist of an individual’s subjective well-being. Previous research on subjective well-being (Keyes 2005b; Ryan and Deci 2001) yielded latent factors that are the converse of the cluster of symptoms used in the DSM-IV-TR (American Psychiatric Association 2000) to diagnose major depressive episode (MDE). Depression requires symptoms of anhedonia, and positive mental health consists of symptoms of hedonia, or emotional well-being; depression consists of symptoms of malfunctioning, and positive mental health consists of symptoms of eudaimonia, or positive functioning.
Table 13.1 presents clusters of symptoms of positive mental health, and the diagnosis of states of positive mental health is modeled after the DSM-III-R approach to diagnosing MDE. In order to be diagnosed as flourishing in life, individuals must exhibit high levels (every day or almost every day during the past 2 weeks) on at least one measure of hedonic well-being and high levels on at least six measures of positive functioning. Individuals who exhibit low levels (never or once or twice during the past 2 weeks) on at least one measure of hedonic well-being and low levels on at least six measures of positive functioning are diagnosed as languishing in life. Adults who are moderately mentally healthy do not fit the criteria for either flourishing or languishing in life. A continuous assessment sums up all measures of positive mental health, and conclusions have not varied between the categorical and the continuous assessment of positive mental health.
The following findings come from papers using the 1995 Midlife in the United States (MIDUS) survey, a random-digit-dialing sample of noninstitutionalized English-speaking adults between the ages of 25 and 74 living in the 48 contiguous states. The MIDUS used DSM-IV-TR (APA 2000) criteria to diagnose four mental disorders (i.e., major depressive episode, panic, generalized anxiety, and alcohol dependence) using the Composite International Diagnostic Interview Short Form (CIDI-SF) scales. Four separate summary measures served as indicators of mental illness, operationalized as the number of symptoms of major depressive episode, generalized anxiety, panic disorder, and alcohol dependence. Three scales served as indicators of positive mental health: the summed scale of emotional well-being (i.e., single item of satisfaction with life + a six-item scale of positive affect), the summed scale of psychological well-being (i.e., Ryff’s six scales summed together), and the summed scale of social well-being (i.e., Keyes’ five scales summed together).
Confirmatory factor analysis was used to test the complete state model of mental health. The single factor model hypothesizes that the measures of mental health and mental illness reflect a single latent factor, support for which would indicate that the absence of mental illness implies the presence of mental health. The two-factor model hypothesizes that the measures of mental illness represent the latent factor of mental health that is distinct from, but correlated with, the latent factor of mental illness that is represented by the measures of mental illness. The data strongly supported the two-factor model (Keyes 2005a), and the two continua model has been recently confirmed in US adolescents (Keyes 2009b).
Across studies, the latent factor of mental illness correlates with the latent factor of mental health (r = −.55). Although level of good mental health tends to increase as mental illness symptoms decrease, the association is moderate. Data support the argument that the absence of mental illness does not imply the presence of mental health; too, the presence of mental illness does not imply the absence of some level of mental health. Complete mental health is a state in which individuals are free of mental illness and are flourishing. Of course, flourishing may sometimes occur with an episode of mental illness, and moderate mental health and languishing can occur both with and without a mental illness.
With regard to states of positive mental health, languishing adults reported the highest prevalence of any of the four mental disorders, as well as the highest prevalence of two or more mental disorders during the past year. In contrast, flourishing individuals reported the lowest prevalence of any of the four 12-month mental disorders or their comorbidity. Compared with languishing or flourishing, moderately mentally healthy adults were at intermediate risk of any of the mental disorders, or two or more mental disorders, during the past year. The modest correlation between the latent continua reflects the tendency for the risk of mental illness to increase as mental health decreases. For example, the 12-month risk of major depressive episode was over five times greater for languishing than flourishing adults.
In addition, previous findings on Keyes’ model revealed that level of mental health differentiated the level of functioning for those with, and for those free of, a mental disorder. Of the 77% MIDUS adults free of any of the four mental disorders, the 16.6% who were flourishing functioned better than the 50.6% with moderate mental health: those who were flourishing reported the fewest workdays missed, the fewest workdays cutback by one-half, the lowest rate of cardiovascular disease, the lowest level of health limitations of activities of daily living, the fewest chronic physical conditions at all ages, the lowest healthcare use (medical visits, hospitalizations, and medications), and the highest levels of psychosocial functioning. In terms of psychosocial functioning, this meant that completely mentally healthy adults reported the lowest level of perceived helplessness, the highest level of knowing what they want from life, the highest level of self-reported resilience (e.g., that they try to learn from adversities), and the highest level of intimacy (e.g., that they have very close relationships with family and friends). Using the same criterion measures, the 9.8% who were languishing and free of mental disorder functioned worse than adults with moderate mental health (Keyes 2007). Of the 23% MIDUS adults with at least one of the four mental disorders, the 1.5% who were flourishing functioned better than the 14.5% who had moderate mental health and who, in turn, functioned better than the 7.0% who were languishing. In other words, level of mental health differentiates levels of impairment and disability, even among adults who have had a mental illness in the past year; just over two-thirds of adults with a mental disorder in the past year had at least moderate or flourishing mental health. In short, previous research on Keyes’ model has provided evidence that anything less than complete mental health results in increased impairment and disability (Keyes 2007).
Recovery from Mental Illness
Over the last two decades, recovery has become the overarching aim of mental health services systems in many countries: Australia, New Zealand, England, Scotland, and the United States, to name a few (Slade et al. 2008). Current definitions of recovery, as a process and as an outcome, are now revisited in light of their underlying conceptions of mental health.
A Pathogenic View of Recovery
As mentioned before, the vision of recovery as an outcome corresponds to the traditional or clinical view of this phenomenon and falls under the umbrella of scientific-oriented definitions (Silverstein and Bellack 2008). Outcomes of recovery here are defined from a pathogenic perspective which views mental health as improvements in typical indicators of mental illness, such as psychiatric symptoms and impairments in cognitive, role, and social functioning. However, there is still an ongoing debate about the requirements for declaring someone recovered. Some authors (Andreasen et al. 2005) have proposed that the full remission of symptoms and the return to premorbid levels of function are necessary, whereas others (Liberman and Kopelowicz 2005; Torgalsboen 2005) have suggested that partial remission of symptoms and role restoration that are sustained over two consecutive years are sufficient.
The pathogenic view of recovery is also represented in the literature that focuses on key dimensions, or process elements, that are involved in the minimization of mental illness and that have been particularly documented in consumer-oriented definitions (Silverstein and Bellack 2008). More specifically, this side of the recovery experience targets the building of protective factors against relapse, functional deterioration, and handicap, which has been traditionally addressed in the field psychiatric rehabilitation (Anthony et al. 2002). Those protective elements refer to personal and environmental resources that contribute to the reduction of mental illness and its negative social consequences (e.g., stigma, discrimination). At the individual level, they involve the restoration of skills that had been altered by the illness and the learning of illness management strategies, such as strategies for preventing relapse or coping with enduring symptoms, as well as advocacy skills for getting needed services (Mueser et al. 2006; Salyers et al. 2009). At the environmental level, they include the provision of accommodations for supporting the performance of social roles, such as parents, students, or workers (e.g., later start times or flexible break times as work adjustments). They also rely on the use of community interventions for restoring civil rights and reducing barriers to social exclusion, such as educating potential employers and other members of the community about mental illness (Corrigan et al. 2008). In addition, several subjective changes take place throughout this process, such as the development of a positive identity based on restored abilities (Brown and Kandirikirira 2007), a renewed sense of hope for better prevention of illness relapses, or the development of a sense of empowerment, which encompasses increased self-efficacy in coping with mental illness, active participation in the planning of individualized services (Adams and Drake 2006; Drake et al. 2009), and advocacy for defending rights as consumers (Onken et al. 2007). In short, the building of protective factors against mental illness and their related subjective processes are aligned with a pathogenic view of recovery and with the use of mental illness indicators as outcomes.
A Salutogenic Perspective of Recovery
In addition to the pathogenic view, consumer-oriented definitions emphasize another side of the recovery experience in which the pursuit of positive emotions (e.g., happiness, life satisfaction) and the engagement in fulfilling activities are highlighted despite the presence of mental illness. Positive mental health is at the center of this view of recovery and underlies a salutogenic conception of mental health, although never recognized as such. The dimensions of flourishing (see Table 13.1) are used as a framework to propose linkages between recovery and positive mental health, drawing on three lines of literature.
First, qualitative research and personal accounts (Ridgway 2001; Spaniol and Koehler 1994) call attention to consumers’ experiences and aspirations that are aligned with positive mental health (see Table 13.1). Brown and Kandirikirira (2007), for instance, found that persons in recovery require and strive for a positive identity, which reflects self-acceptance. Individuals also said they require and seek to engage in meaningful activities and to develop positive relationships with other people and with their environments, which reflect purpose in life, positive relations with others, and social acceptance. Narratives of persons in recovery also reveal their need and aspiration for living in communities where they are seen as more than their illness and where their contributions are valued, which are signs of positive mental health called social integration and social contribution. Persons in recovery also need and strive to manage their lives, stay healthy, and be resilient to setbacks, which reflect environmental mastery and, to some extent, autonomy (i.e., confidence to express personal opinions, needs).
Several dimensions of positive mental health are indeed targeted in recovery interventions. Consistent with hedonic well-being, having pleasure, fun, and happiness in life through involvement in leisure and social activities is promoted in supported socialization (Davidson et al. 2003, 2004, 2006). With regard to positive functioning, psychological well-being is enhanced in a self-development program (Oades 2008) and other treatment programs, for example, Well-Being Therapy (WBT) (Fava and Ruini 2003) for persons with recurrent depression or functional Cognitive Behavioural Therapy (fCBT) (Cather et al. 2005) for those with schizophrenia. In line with social well-being, peer support encourages those individuals who want to contribute to social changes and to engage in pro-social behaviors, such as using political strategies to increase access to resources (e.g., housing, paid work) (Mead et al. 2001). In this vein, capabilities approaches (Nussbaum 2000; Sen 1999) are increasingly used as guides to promote measures of social inclusion, such as securing access to participatory structures in local organizations in order to join collective efforts oriented toward the welfare of the whole community (Ware et al. 2007).
Finally, several dimensions that are assessed in recovery instruments strongly resemble the dimensions of subjective well-being that make up the assessment and diagnosis of positive mental health. For instance, subjective quality of life, as indexed by life satisfaction, reflects hedonic well-being and has been widely used in clinical practice and evaluation research. The Recovery Assessment Scale (Corrigan et al. 2004) is a self-report questionnaire that is widely used and relies on five dimensions—personal confidence and hope, willingness to ask for help, goal and success orientation, reliance on others, and no domination by symptoms—which all somewhat overlap with purpose in life, environmental mastery, autonomy, and positive relations with others. The RAS reflects psychological well-being, for the most part (see Table 13.1), and is even stronger for post-traumatic growth. This latter concept refers to positive shifts in personality schema and assumptive worlds following significant life crises (e.g., bereavement, chronic disability) (Tedeschi et al. 1998) and captures the process of thriving in recovery or becoming better off than before mental illness (Onken et al. 2007). The three dimensions of post-traumatic growth overlap with those of psychological well-being: changes in philosophy are aligned with the dimensions of purpose in life and with autonomy; changes in perceptions reflect those of environmental mastery, personal growth, and self-acceptance; and changes in relationships mirror the dimension of positive relationships with others (see Table 13.1). In this vein, the evaluation of psychological well-being (Ryff and Singer 1996) has been particularly recommended for tracking changes in growth in longitudinal studies (Joseph and Linley 2008). However, it should be emphasized that flourishing implies thriving and also directs attention to other meaningful experiences, such as positive emotions and a sense of fulfillment in social life. Finally, a special focus has been recently placed on the need for a better understanding of changes in self-experience over the recovery process, and the Scale to Assess Narrative Coherence (STAND) (Lysaker et al. 2006) has been developed to measure the extent of a coherent story about self-experience based on personal narratives of persons with schizophrenia. Four specific dimensions of self-experience are evaluated, namely, social worth, connectedness with others, agency, and illness conception. Social worth concerns a positive view about oneself in private and public life, reflecting the dimensions of self-acceptance and social contribution. Connectedness with others refers to a fulfilling and intimate relationship with at least one person, in line with the dimension of positive relationships with others. Agency corresponds to the perceived ability to affect one’s own destiny and to engage meaningfully with others and reflects the dimensions of mastery and positive relationships with others. Finally, illness conception refers to the ability to address and face diverse personal challenges, including those related to the management of schizophrenia, and overlaps with the dimensions of mastery and personal growth. Those four aspects of self-experience are thus aligned with several dimensions of positive functioning (see Table 13.1).
In summary, personal and environmental changes contributing to the improvement of psychiatric symptoms and illness impairments represent an important side of recovery and underlie a pathogenic view of this experience. A salutogenic perspective is also represented, as other transformations target the achievement of optimal levels of emotional well-being and positive functioning. The ability to function well in a life, toward which one also feels good, is the sine qua non of good mental health (i.e., flourishing) and, therefore, of complete recovery.
Recovery of Complete Mental Health
The two continua model (Keyes 2007) incorporates the pathogenic and salutogenic perspectives into a unitary, complete view of recovery. Here, this experience is redefined as two complementary processes and outcomes: restoration from mental illness and optimization of positive mental health. Keyes’s model underscores the need to better understand and intervene in factors and conditions that help persons, with and without mental illness, to flourish in life. Several of them have been previously discussed as key elements related to the pathogenic and salutogenic views of recovery, respectively, underlying the processes of restoration and optimization. A brief overview of strategies for promoting those two processes is now presented.
Through restoration, persons in recovery take steps to manage, and make the most of, the limitations imposed by mental illness. At the individual level, peer and psychiatric rehabilitation interventions (Copeland 2000; Corrigan et al. 2008; Drake et al. 2005) may provide support for the development of illness management skills, the reduction of deficits in a variety of domains (e.g., cognitive, social, and role functioning), and the restoration of roles, including those performed in normative settings. At the environmental level, strategies are oriented toward the alleviation of stress in the family (e.g., reduction of expressed emotions) and other milieus (e.g., provision of work accommodations) (Becker and Drake 2005; Glynn et al. 2006). In addition, other interventions are provided for decreasing stigma and discriminatory behaviors within surrounding environments and the general population (Corrigan and Gelb 2006; Corrigan et al. 2005).
Through optimization, persons in recovery take steps to move up the continuum of positive mental health. As previously mentioned, this may involve the use of supported socialization (Davidson et al. 2004), WBT (Fava and Ruini 2003) or fCBT (Cather et al. 2005) for enhancing positive emotions or positive functioning. Building on personal strengths represents another strategy for promoting positive mental health. For instance, a self-report measure has been developed to assess a series of character strengths that are classified into six broad virtues: wisdom and knowledge (e.g., love of learning), courage (e.g., perseverance), humanity (e.g., kindness), justice (e.g., citizenship), temperance (e.g., self-control), and transcendence (e.g., spirituality) (Peterson and Seligman 2004). This survey instrument has been used as a tool for helping people with severe mental illness to identify their top five character strengths, also called signature strengths. Such activity was perceived as enjoyable and as having contributed to an increase in a sense of pride and self-esteem in participants (Resnick and Rosenheck 2006). At the environmental level, optimization strategies are oriented toward the provision of support for interpersonal flourishing (Ryff and Singer 2000), which includes opportunities to develop intimate and reciprocal relationships (Mead et al. 2001; Ware et al. 2007). Actions directed at community development are also undertaken to promote social inclusion. They entail initiatives for encouraging civic and social participation, such as those that increase access to participatory structures within mental health and nonmental health organizations (Ware et al. 2007). Other community-level interventions aim to reduce poverty and to improve access to basic resources (e.g., education, employment, affordable housing), such as those documented in the field of mental health promotion (Barry 2009). It is also worthwhile to mention the Strengths Model (Rapp and Goscha 2006)—a case management program targeting the maximization of personal and environmental strengths—and its potential efficacy for enhancing positive mental health.