Slade BMC Health Services Research 2010, 10:26

http://www.biomedcentral.com/1472-6963/10/26

DEBATE Open Access

Mental illness and well-being: the central

importance of positive psychology and recovery
approaches
Mike Slade*

Abstract
Background: A new evidence base is emerging, which focuses on well-being. This makes it possible for health
services to orientate around promoting well-being as well as treating illness, and so to make a reality of the long-
standing rhetoric that health is more than the absence of illness. The aim of this paper is to support the re-
orientation of health services around promoting well-being. Mental health services are used as an example to
illustrate the new knowledge skills which will be needed by health professionals.
Discussion: New forms of evidence give a triangulated understanding about the promotion of well-being in
mental health services. The academic discipline of positive psychology is developing evidence-based interventions
to improve well-being. This complements the results emerging from synthesising narratives about recovery from
mental illness, which provide ecologically valid insights into the processes by which people experiencing mental
illness can develop a purposeful and meaningful life. The implications for health professionals are explored. In
relation to working with individuals, more emphasis on the person’s own goals and strengths will be needed, with
integration of interventions which promote well-being into routine clinical practice. In addition, a more societally-
focussed role for professionals is envisaged, in which a central part of the job is to influence local and national
policies and practices that impact on well-being.
Summary: If health services are to give primacy to increasing well-being, rather than to treating illness, then
health workers need new approaches to working with individuals. For mental health services, this will involve the
incorporation of emerging knowledge from recovery and from positive psychology into education and training for
all mental health professionals, and changes to some long-established working practices.

Background the science of well-being within health services. The typical

The World Health Organisation (WHO) declares that health worker will know a lot about treating illness, and far
health is “A state of complete physical, mental and social less about promoting well-being.
well-being and not merely the absence of disease or infir- In this article we use mental health services as an
mity “[1]. However, creating health-oriented rather than ill- exemplar of the issue, and explore how mental health
ness-oriented services has proved rather more difficult services could more effectively promote well-being. Our
than the clarity of this declaration would suggest. Efforts to central argument is that mental health workers will
generate a science of illness have been very successful, with need new approaches to assessment and treatment if the
shared taxonomies to identify types of illness, established goal is promoting well-being rather than treating illness.
and validated interventions to treat and manage these iden- Well-being is becoming a central focus of international
tified illnesses, and clinical guidelines and quality standards policy, e.g. Canada [2] and the United Kingdom [3]. In
available to increase efficiency and equity. These successes the same way that tertiary prevention is an important
have not been mirrored by equivalent advances in applying health promotion strategy, well-being is possible for
people experiencing mental illness.
* Correspondence: m.slade@iop.kcl.ac.uk We will discuss two new emerging areas of knowledge
Health Service and Population Research Department (Box P029), Institute of
Psychiatry, King’s College London, Denmark Hill, London, SE5 8AF UK
which are highly complementary, and provide a

© 2010 Slade; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
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counter-balance to the traditional focus of mental health what recovery looks and feels like from the inside. Once
services on deficit amelioration. We will identify how individual stories were more visible, compilations and
they link (and differ), and then explore their implica- syntheses of these accounts began to emerge from
tions for mental health workers. Specifically, we will around the (especially Anglophone) world, e.g. from
argue that assessment and treatment of the individual Australia [13], New Zealand [14-17], Scotland [18,19],
will need to change if the goal is promoting well-being the USA [12,20,21] and England [22,23]. The under-
rather than treating illness, and that there are also standing of recovery which has emerged from these
broader challenges for mental health professionals to accounts emphasises the centrality of hope, identity,
become more outward-looking in their view of their meaning and personal responsibility [13,24,25]. We will
role, and to construct their job as more than working refer to this consumer-based understanding of recovery
with individuals. We will conclude that a focus on as personal recovery, to reflect its individually defined
improving social inclusion, becoming social activists and experienced nature [26]. This contrasts with tradi-
who challenge stigma and discrimination, and promot- tional clinical imperatives - which we will refer to as
ing societal well-being may need to become the norm clinical recovery- which emphasise the invariant impor-
rather than the exception for mental health professionals tance of symptomatology, social functioning, relapse
in the 21st Century. prevention and risk management. To note, this distinc-
tion has been referred to by other writers as recovery
Discussion “from” versus recovery “in” [27]; clinical recovery versus
The WHO declaration about mental health is also clear: social recovery [28]; scientific versus consumer models
it is “a state of well-being in which the individual rea- of recovery [29]; and service-based recovery versus user-
lizes his or her own abilities, can cope with the normal based recovery [30].
stresses of life, can work productively and fruitfully, and Opinions in the consumer literature about recovery
is able to make a contribution to his or her community “ are wide-ranging, and cannot be uniformly charac-
[1]. A relative lack of workforce skills in promoting terised. This multiplicity of perspectives in itself has a
well-being is particularly important in mental health ser- lesson for mental health services - no one approach
vices, since mental disorders directly impact on personal works for, or ‘fits’, everyone. There is no right way for a
identity and ability to maintain social roles. person to recover. Eliciting idiographic knowledge -
This distinction between mental illness and mental understanding of subjective phenomema - is an impor-
health is empirically validated, with only modest correla- tant clinical skill. Nonetheless, some themes emerge. A
tions between measures of depression and measures of first clear point of divergence from the clinical perspec-
psychological well-being, ranging from -0.40 to -0.55 tive is that recovery is seen as a journey into life, not an
[4,5]. A more statistically robust approach is a confirma- outcome to be arrived at: “recovery is not about ‘getting
tory factor model, which showed that the latent factors rid’ of problems. It is about seeing people beyond their
of mental health and mental illness in a US sample (n = problems - their abilities, possibilities, interests and
3,032) correlated at 0.53, indicating that only one quar- dreams - and recovering the social roles and relation-
ter of the variance between measures of mental illness ships that give life value and meaning “ [31].
and mental health is shared [6]. Many definitions of recovery have been proposed by
Why is this distinction important? Because it points to those who are experiencing it [8,18]. We will use the
the need for mental health professionals to support both most widely-cited definition that “recovery is a deeply
the reduction of mental illness and the improvement of personal, unique process of changing one’s attitudes,
mental health. This will involve the development of values, feelings, goals, skills, and/or roles. It is a way of
further skills in the workforce. These skills will be based living a satisfying, hopeful, and contributing life even
on two new areas of knowledge, each of which have within the limitations caused by illness. Recovery involves
emerged as distinct scientific areas of enquiry only in the development of new meaning and purpose in one’s
the past two decades. life as one grows beyond the catastrophic effects of men-
tal illness “ [32]. It is consistent with the less widely-
New area of knowledge 1: Recovery cited but more succinct definition that recovery involves
People personally affected by mental illness have “the establishment of a fulfilling, meaningful life and a
become increasingly vocal in communicating both what positive sense of identity founded on hopefulness and self
their life is like with the mental illness and what helps determination “ [13].
in moving beyond the role of a patient with mental ill- One implication of these definitions is that personal
ness. Early accounts were written by individual pioneers recovery is an individual process. Just as there is no one
[7-12]. These brave, and sometimes oppositional and right way to do or experience recovery, so also what
challenging, voices provide ecologically valid pointers to helps an individual at one time in their life may not
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help them at another. If mental health services are to be provided by the Complete State Model of Mental Health
focussed on promoting personal recovery, then this [42], proposed by Corey Keyes, and shown in Figure 1.
means there cannot be a single recovery model for ser- This model identifies two dimensions. Mental illness
vices. This is a profound point, and challenging to estab- lies on a spectrum, from absent to present. Well-being
lished concepts such as clinical guidelines, evidence- also lies on a spectrum, from low to high.
based practice and care pathways. A recurring feature in This conceptual framework easily maps on to the
recovery narratives is the individual engaging or re- themes emerging in the recovery literature. A perennial
engaging in their life, on the basis of their own goals question about recovery is “How can you be recovered
and strengths, and finding meaning and purpose if you still have the mental illness?”. Whatever answers
through constructing or reclaiming a valued identity and are given, they can be only partial answers since the
social roles. All of this points to well-being rather than term recovery is an illness term. By contrast, access to
treatment of illness. There is now a scientific discipline mental health is open to all. This provides an alternative
- positive psychology - devoted to the promotion of frame of understanding for recovery [26]:
well-being.
Personal recovery involves working towards better
New area of knowledge 2: Positive Psychology mental health, regardless of the presence of mental
Positive psychology is the science of what is needed for illness
a good life. This is not a new focus - proposing qualities
needed for a good life is an activity dating back to Aris- People with mental illness who are in recovery are
totle’s investigation of eudaimonia, and builds on semi- those who are actively engaged in working away from
nal work in the last Century by Antonovsky [33], Rogers Floundering (through hope-supporting relationships)
[34] and Maslow [35]. But the emergence of a scientific and Languishing (by developing a positive identity), and
discipline in this area is a modern phenomenon. Martin towards Struggling (through Framing and self-managing
Seligman, often identified along with Mihaly Csikszent- the mental illness) and Flourishing (by developing
mihalyi as the founders of the discipline, suggests a defi- valued social roles).
nition [36]: This concept of mental health has been operationa-
lised into 13 dimensions, across the domains of emo-
The field of positive psychology at the subjective level tional well-being, psychological well-being and social
is about valued subjective experiences: well-being, well-being [6,43]. These dimensions have been empiri-
contentment, and satisfaction (in the past); hope and cally validated [4,44], and are shown in Additional file 1.
optimism (for the future); and flow and happiness (in Like mental illness, the concept of mental health can
the present). be expressed as a constellation of factors. Using the
At the individual level, it is about positive individual same diagnostic framework as DSM uses for major
traits: the capacity for love and vocation, courage, depression, the condition of Flourishing is defined as
interpersonal skill, aesthetic sensibility, perseverance, requiring high levels in Dimensions 1 (Positive affect) or
forgiveness, originality, future mindedness, spiritual- 2 (Avowed quality of life) to be present, along with high
ity, high talent, and wisdom. levels on at least 6 of the 11 dimensions of positive
At the group level, it is about the civic virtues and functioning (Dimensions 3 to 13). Similarly, to be diag-
the institutions that move individuals toward better nosed as Languishing, individuals must exhibit low
citizenship: responsibility, nurturance, altruism, civi- levels on one of the emotional well-being dimensions,
lity, moderation, tolerance, and work ethic. and low levels on 6 of the remaining 11 dimensions.
Adults who are neither flourishing nor languishing are
Research centres are developing internationally (e.g. said to be moderately mentally healthy. Finally, complete
http://positivepsychologyaustralia.org, http://cappeu.com, mental health is defined as the absence of mental illness
http://centreforconfidence.co.uk). Academic compilations and the presence of flourishing.
of the emerging empirical evidence [37,38] and accessible What is the prevalence of mental health, using these
introductions to the theory [39,40] and its applications definitions? A cross-sectional assessment in the US
[41] are becoming available. Findings from positive psy- population [43] (n = 3,032) is shown in Table 1.
chology are important to mental health services because A similar US study of youth (n = 1,234) found 6% of
its focus on a good life is as relevant to people with men- 12 to 14 year olds Languishing, 45.2% with Moderate
tal illness as to people without mental illness. Mental Health, and 48.8% Flourishing, with respective
One key advance is in relation to empirical investiga- proportions of 5.6%, 54.5% and 39.9% in 15 to 18 year
tion of mental health. A conceptual framework is olds [45].
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Figure 1 Complete State Model of Mental Health.

These results have two profound implications. First, recurrence of mental illness? Conceptually, one can
careful consideration should be given to the balance think of mental health as the continuum at the top
between research into mental illness and mental health. of the cliff where most individuals reside. Flourishing
Among US adults with no mental illness, one in 10 are individuals are at the healthiest and therefore farth-
languishing and less than 2 in 10 are flourishing. The est distance from the edge of this cliff; languishing
implicit expectation that research into mental illness places individuals very near the edge of the cliff.
will promote mental well-being is neither empirically Hence, languishing may act as a diathesis that is
justified nor a cost-free assumption - the opportunity activated by stressors that push individuals off the
costs for an illness-dominated research agenda may be cliff and into mental illness(p. 547)
high. For example, Flourishing is aligned with concepts
such as self-righting, self-efficacy and mastery as charac- There is empirical support for this proposition. One
teristics which critically impact on the ability to self- validated approach involves training for optimism, by
manage. As Keyes puts it [6]: modifying the three components of explanatory style
(permanence, pervasiveness, personalisation) through
In particular, is languishing a diathesis for, and is transforming negative thinking into positive cognitive
flourishing a protective factor against, the onset and processes that promote flexible thoughts and resilience.

Table 1 Prevalence of mental health and mental illness

Condition Prevalence (%)
Mental Illness and Languishing 7
Mental Illness and Moderately Mentally Healthy 15
Mental Illness and Flourishing 1
Languishing (and no mental illness) 10
Moderate Mental Health (and no mental illness) 51
Complete Mental Health (Flourishing, no mental illness) 17
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A study involving 70 children at high risk of depres- b) Clear proximal (short-term) goals and immediate
sion showed that this technique reduced depressive feedback on progress
symptomatology and lowered incidence rates at 2-year They define being in flow as:
follow-up [46]. In a mental health service context,
there is also emerging evidence that positive life events the subjective experience of engaging just-manageable
are important protective factors [47]. A study of 260 challenges by tackling a series of goals, continuously
people with severe mental illness showed that an processing feedback about progress, and adjusting
increasing ability to engage in pleasurable activities action based on this feedback (p. 90)
leads to the ability to regulate depressive symptoms to
the point where they did not impact on identity by In terms of flow, a good life is one that involves com-
eroding self-esteem [48]. plete absorption in what one does.
The second implication is that it is possible to be Flow is an important concept for mental health pro-
moderately mentally healthy, or even flourishing, despite fessionals to understand, since it is the structural oppo-
the presence of ongoing mental illness. In other words, site of positive emotion. Flow is a subjective experience,
personal recovery is possible even in the presence of but unlike positive emotions it is not defined by feelings.
current symptoms. Cook and Jonikas label this process Rather, it results from doing activities we like. Indeed,
as thriving, in which individuals rebuild lives with quali- 80% of people report that when in flow, feelings and
ties better than before their difficulties began [49]. Inter- thinking are temporarily blocked [53]. This means that
ventions which support the individual in moving feeling good is not always necessary for a good life.
towards mental health may be as important as interven- Consequently, an automatic focus on taking away
tions which address the mental illness. experiences of unhappiness (such as symptoms of
Positive psychology is specifically relevant to perso- depression) may be counter-productive. It is possible to
nal recovery. Factors identified by consumers as experience authentic happiness by living a meaningful
important for their recovery include hope, spirituality, life that comes through full engagement. This of course
empowerment, connection, purpose, self-identity, has implications for how mental health services work -
symptom management and stigma [30]. All but symp- the aim may not be to help the person to feel better,
tom management are almost entirely absent from pro- but to re-engage in their life. What this means for men-
fessional training [50]. An influential framework, and tal health services is that a central challenge is support-
one which could underpin the training of mental ing reasonable goal-setting and goal-striving. These
health professionals, is Seligman’s theory of Authentic goals need to be:
Happiness [51,52]. This identifies different types of 1. Personally relevant, rather than meeting the needs of
good life: staff
1. The Pleasant Life, which consists in having as There may of course be other reasons for staff-based
much positive emotion as possible and learning the care planning, but care plans focussed on clinical risk,
skills to prolong and intensify pleasures medication compliance, relapse prevention and symp-
2. The Engaged Life, which consists in knowing your tom reduction will not promote personal recovery
character (highest) strengths and recrafting your work, 2. The right level of challenge
love, friendship, play and parenting to use them as The concept of a reasonable goal captures the balance
much as possible in setting goals which are neither too easy (leading to
3. The Meaningful Life, which consists in using your boredom and distraction) nor too difficult (leading to
character strengths to belong to and serve something anxiety and heightened self-awareness). A good life is
that you believe is larger than just your self not achieved by simply lowering expectations, as com-
4. The Achieving Life, which is a life dedicated to mentators from both left-wing politics (who want more
achieving for the sake of achievement. justice) and right-wing politics (who want more excel-
This framework points to the possibility of different lence) have noted [54]. But nor is it achieved by raising
types of good life - which means that a range of expectations too high - recovery should be a journey,
approaches to promoting well-being are needed. For not a tread-mill.
example, the positive psychology literature has 3. Proximal rather than distal
addressed the question of how to lead an engaged life. Short-term goals provide more opportunity to become
A key emergent concept is flow, which requires two engrossed in the experience, and make engaged goal-
conditions [53]: striving more likely
a) Perceived challenges that stretch (i.e. neither over- 4. Structured so that feedback is immediate and authentic
match nor under-utilise) existing skills - a sense that It is this immediate feedback loop that promotes full
one is engaging challenges at the level of one’s capacities attentional awareness on the challenge
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One approach to increasing well-being is therefore to equivalent to “weakness and damage” and should not
support personally-relevant goal-setting and goal-striving preclude a focus on what is healthy. The benefits of
activity. The Collaborative Recovery Model emphasises positive psychology might be even greater for people
key recovery values of autonomy and self-determination with severe psychiatric disabilities than for those
[55], and builds on an established evidence base around without such impairments. (p. 121)
personal goal-setting and goal-striving [56]. Preliminary
evaluations of CRM are positive, showing improvements A second point of divergence is methodological. Pro-
in staff attitudes (e.g. hopefulness) and knowledge [57]. ponents of the recovery approach have focussed on
A 10-site randomised controlled trial across three Aus- developing position statements [67], consensus state-
tralian states is underway. ments [68], frameworks [69], guidelines [70], and other
Future-oriented goal-setting is not the only approach, action- and change-oriented approaches. This has been
and some traditions emphasise being over becoming: “so more successful at influencing policy than positive psy-
we never live, but we hope to live; and as we are always chology. The relatively small amount of empirical recov-
preparing to be happy, it is inevitable we should never be ery research has in general used inductive methods,
so“ [58] (p. 87). A second approach to increasing well- such as collating and synthesising narratives. This is
being is to pay more attention to spiritual development consistent with an emphasis on individual meaning and
and healing [59]: “The healing process not only incorpo- experience, since grouping the responses of participants
rates a new way of living with and controlling symptoms, necessarily reduces the granularity of analysis. However,
but also an increasing adeptness of navigating social the consequence is difficulty in making the intellectual
realms to overcome stigmatizing and discriminatory social- case to clinicians with influence to change the mental
structural beliefs and practices. Re-authoring hinges on health system, who tend to value nomothetic group-
reclaiming a positive self-concept.” (p. 14). Healing as a level evidence.
spiritual activity [60], the role of moral experience [61], By contrast, positive psychology is unequivocally
the role of community rather than individualism [62], the based on empirical research, and unlike recovery-
place of religion in mental health services [63] and focussed research has not avoided the use of nomo-
approaches to supporting spirituality [64] are all contribu- thetic approaches, even to assess complex constructs
tors to well-being. such as meaning of life [71]. Indeed, it has been criti-
cised for under-use of qualitative methods [72]. This
Parallels between positive psychology and recovery scientific orientation has led to an emphasis on con-
There are parallels between the position of recovery ceptual clarity, the use of scientific methods, and con-
ideas in the mental health system and the position of vergence on overarching theories [51]. The result is an
positive psychology in the family of psychology disci- academically credible scientific discipline [37], whose
plines [65]. Some points of convergence are shown in evidence is based on robust scientific methodologies
Additional File 2. [73]. It has not, however, yet been highly influential in
Two points of divergence can be identified [65]. First, international policy.
the positive psychology focus has explicitly been on bal- Why has there not been a greater rapprochement
ancing the preoccupations of clinical psychology by dis- between these two, apparently compatible, groups? This
tancing from the “study of pathology, weakness, and may be because of their differing aims [65] - one is “an
damage“ [36]. Most empirical research has therefore intellectual movement, led by prominent academic psy-
involved people with either no mental illness or with chologists, that challenges the dominance of “negative
mild to moderate common mental disorders such as psychology”, whereas the other is “a grassroots movement
depression and anxiety. An implicit, and sometimes of the disenfranchised that has placed itself apart from
explicit [66], dichotomous assumption is that healthy the human service professions, the academy, and the
people will benefit from positive psychology, whereas empirical research tradition“ (p. 121).
people with mental illness will continue to require A second reason may be the name of the discipline.
‘negative’ psychology. There is no evidence for this Positioning it as a branch of psychology invokes unhelp-
assumption, and indeed the convergence of narratives ful tribal loyalties - it suggests a relevance to psycholo-
from people with mental illness around key positive psy- gists but not other types of researchers or professionals.
chology themes (e.g. meaning, agency, empowerment, The oppositional perspective of some positive psycholo-
hope and resilience) suggests that the opposite may be gists reinforces this divergence [74]. The name is mis-
true. As Resnick and Rosenheck put it [65]: leading - well-being is a potential focus for many
disciplines. Anthropologists would help us understand
Proponents of the recovery model would instead the association between social systems and well-being.
argue that the existence of “pathology” is not Geneticists will create designer-baby dilemmas when
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they can select embryos which are more likely to be 1. Deficiencies and undermining characteristics of the
happy. Sociology could investigate how the meaning of person
well-being is constructed and identify influences on its 2. Strengths and assets of the person
evolution. What are the neuroanatomical correlates of 3. Lacks and destructive factors in the environment
resilience? What philosophical perspective is associated 4. Resource and opportunities in the environment
with maximum well-being? Can we teach children com- Traditional clinical assessment practice - exemplified
passion? The field is far larger than the name implies, by the mental state assessment - focuses almost exclu-
and highly cross-disciplinary. A less loaded name for the sively on dimension 1. This focus has arisen for several
discipline would be helpful, either a neologism (positol- reasons. First, multi-dimensional assessment is hard
ogy?) or a more neutral term such as positive well- work. Each dimension is dynamic and changing, and
being. inter-dependent in complex ways. Holding this com-
This divergence is impoverishing for both groups. The plexity is intellectually demanding, and requires a ten-
concordance between the fundamental aims of recovery tative stance and openness to changing understanding.
in mental illness and of positive psychology suggests It is much easier and in some ways more rewarding to
valuable lessons may be learned in both directions. For be the clinical expert, who can summarise the pro-
recovery, the development of a clinically credible evi- blems of the person (i.e. dimension 1) with a pithy
dence base, including randomised controlled trial evi- piece of professional language. This issue will reduce
dence, has potential to be an important pathway to with the development of a shared taxonomy and lan-
transforming mental health services. The preponderance guage for dimensions 2 to 4. This is beginning to
of good ideas and relative paucity of evaluative research emerge. For example, the concept of character
has been highlighted as a key problem in getting recov- strengths has been disaggregated into six core virtues
ery-focussed practice into everyday mental health prac- of wisdom, courage, humanity, justice, temperance and
tice [75]. Whilst there are tensions between the values transcendence [81]. Similarly, positive affect has been
of evidence-based mental health and recovery [76], disaggregated into Joviality (e.g. cheerful, happy, enthu-
there is no fundamental incompatibility [77]. For exam- siastic), Self-Assurance (e.g. confident, strong, daring)
ple, the use of an invariant primary outcome for all par- and Attentiveness (e.g. alert, concentrating, deter-
ticipants in a clinical trial does not capture the mined) [82].
individual nature of recovery, and innovative approaches Second, the expectation in the mental health system
to individualising clinical end-point measurement are that it is the person who is going to be treated inevitably
now being evaluated in the REFOCUS Study http:// leads to a focus of attention on the individual. This of
researchintorecovery.com. Similarly, the need of profes- course is a consequence of clinical (and patient) beliefs
sionals for a conceptual framework to understand about what the job is, and doesn’t have to be the case.
recovery which does not become a ‘model’ showing the Third, the clinician’s illusion means that professionals
‘right’ way to recovery is addressed in the Personal don’t see people as often when they are coping [83], so
Recovery Framework which gives primacy to identity they gain the false impression they cannot cope or self-
over illness [78]. right.
For positive psychology, the incorporation of the cen- Finally, the questions asked impose a structure on the
tral recovery focus on the individual and their differing dialogue, and influences content. The highly practised
ways of seeing the world (including giving primacy to deficits-focussed discourse of taking a psychiatric history
familial or cultural affiliation over personal identity) will systematically identifies all the deficient, inexplicable,
address criticisms that it is ethnocentric (being based different and abnormal qualities and experiences of the
mainly on US research) and overly concerned with the person. This focus on deficits (and the other Ds: diffi-
experience of individuals rather than groups [78,79]. culties, disappointment, diagnosis, disease, disability, dis-
Additionally, if there are ways in which people with empowerment, disenfranchisement, demoralisation,
mental illness are outliers (e.g. in having a relatively low dysfunction) reinforces an illness identity, and the per-
ratio of protective to risk factors), then excluding them son disappears. Up close, nobody is normal: a deficit-
from consideration makes the development of generali- focussed discourse will always elicit confirmatory evi-
sable theories more difficult. dence for an illness-saturated view of the person.
An alternative approach is possible [84]. In assess-
Implications for mental health assessment practices ment, this involves a greater emphasis on the indivi-
How can a person with mental illness be assessed if the dual’s goals and strengths, an approach which has been
clinical goal is to promote well-being? Clinical assess- developed and evaluated in the Strengths Model [85].
ment should focus on four dimensions [80]: Other approaches which emphasise well-being over
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deficits in assessment processes are person-centred plan- the quick-fix of a magic pharmacological or psychologi-
ning [86,87] and Wellness Recovery Action Planning cal bullet. Just as becoming a top-class violinist requires
[88]. What these have in common is an assumption that 10,000 hours of practice with a competent teacher [95],
it is more productive to focus on what the person wants so too mindfulness needs to become a way of life if it is
in their life and what they can do towards their own to transform identity. It involves changing habits:
goals than on what the professional thinks is in the per-
son’s best interests and on what the person cannot do. • enhancing meta-cognitive awareness by noticing
what one is thinking about
Interventions in mental health services to promote well- • developing the ability to urge-surf by noticing but
being not being caught up in rising cognitions
What interventions increase levels of well-being or • developing cognitive fluidity - taking habits from
amplify existing strengths? one space and using in another (e.g. using meta-
phors: thoughts as passing cars; thoughts as clouds;
Cognitive behavioural therapy (CBT) hare brain, tortoise mind)
This psychological intervention will be familiar to most • paying attention to a wider range of the available
clinical readers, so no introduction will be given. Com- percept or experiences
petently-provided CBT is aligned with many elements of
promoting recovery and personal well-being: a focus on The pay-off in terms of well-being is high. Mindfulness
personally-valued rather than service-valued goals; has the potential to lead to a reconstructed, more complex
responsibility for change lies with the patient not the identity, in which self and thought are separated. Develop-
therapist; the development of meta-cognitive awareness ment of a watching self gives a different means of respond-
- an awareness of thoughts being distinct from self - ing to and working on experiences of mental illness.
which creates the context in which a positive identity Developing habits of greater occupation of the available
can flourish, despite the presence of ongoing symptoms attention reduces rumination and increases being in the
of mental illness; enhancing self-management skills and moment - the flow concept we discussed earlier [96]:
reinforcing interdependence and independence rather
than dependence, leading to sustained gains after the ...by increasing the amount of time a person spends
end of the formal therapy; and an emphasis on home- thinking grateful and calming thoughts, there is sim-
work, reality testing and learning opportunities which all ply less time to think upsetting and ‘’unhelpful’’
contribute to keeping the person in their life during thoughts. Assuming that attention is a zero-sum
therapy. If unhappiness is caused by a mismatch game, the most efficient way to reduce negative and
between self and ideal-self images, then CBT has the increase positive thoughts and emotions may be to
potential to focus on the environmental reality as much focus on increasing the positive.(p. 28)
as the personal interpretation of experience. This points
to a wider role for professionals, a point we will return Overall, the personal qualities cultivated through
to. Recent approaches to CBT explicitly focus on build- mindfulness practice are nonjudging, nonstriving, accep-
ing strengths and resilience [89]. tance, patience, trust, openness, letting go, gentleness,
generosity, empathy, gratitude and lovingkindness [97] -
Mindfulness qualities which are highly relevant to the personal recov-
Meditation is “a family of techniques which have in com- ery journey of people with mental illness.
mon a conscious attempt to focus attention in a non-
analytical way, and an attempt not to dwell on discur- Narrative psychology
sive, ruminative thought“ [90]. Teaching meditation to A further clinical approach emerges from a sub-disci-
members of the public increases self-reported happiness pline called narrative psychology, which investigates the
and well-being, changes which are corroborated by heal- value of translating emotional experiences into words.
thier EEG readings, heart rates and flu immunity [91]. This brings together insights from three strands of
Meditation has been applied to mental health issues, research (primarily from European and American cul-
such as anger [92] and - in the form of mindfulness- tures) [98]:
based cognitive therapy (MBCT) - depression [93]. 1. Inhibition - not talking about emotional trauma is
Mindfulness, like prayer [94], is a form of meditation unhealthy
which involves attending non-judgmentally to all stimuli 2. Cognitive - development of a self-narrative allows
in the internal and external environment but to avoid closure
getting caught up in (i.e. ruminating on) any particular 3. Social dynamics - keeping a secret detaches one
stimulus. Mindfulness requires a different mind-set to from society.
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One approach involves asking people to write about (or balance a focus on individual deficit with a focus on indivi-
in other ways generate an account of) their experiences, as dual capability, since this leaves unchallenged the clinical
a means of making sense of their own story. The most belief that treatment is something you do first, after which
beneficial story content includes placing the story in a the person gets on with their own life. This is highlighted
context appropriate to its purpose, the transformation of a as an unhelpful approach in the accounts from people
bad experience into a good outcome, and the imposition who write about their recovery from mental illness. For
of a coherent structure [99]. Developing stories about example, Rachel Perkins notes [105]:
growth, dealing with difficult life events and personal
redemption all contribute to a positive narrative identity Mental health problems are not a full time job - we
[100]. Empirical evidence suggests that this approach is have lives to lead. Any services, or treatments, or
particularly beneficial for groups who, as a whole, are not interventions, or supports must be judged in these
as open about their emotions: men [101], people with high terms - how much they allow us to lead the lives we
hostility [102], and people with alexythimia [103]. wish to lead.

Positive Psychotherapy
An approach which brings together several of these Societal implications
methods is positive psychotherapy (PPT) [104]. The We therefore now raise some potential implications of
focus in PPT is on increasing positive emotion, positive psychology for the job of the mental health pro-
engagement and meaning. For example, groups for fessional at the social, rather than individual, level. This
depression undertake a series of weekly exercises. is underpinned by an emerging understanding of the
Week 1 (Using Your Strengths) involves using the importance of relationships and connection for indivi-
Values in Action Inventory of Strengths [81] to assess dual and social well-being. For example, an international
your top five strengths, and think of ways to use those consortium of 450 academics has recently produced
strengths more in your everyday life. Week 2 (Three reports about determinants and influences on well-being
Good Things/Blessings) involved writing down three [106]. This important document has been summarised
good things every evening that happened today, and by the New Economics Foundation http://www.neweco-
why you think they happened. Week 3 (Obituary/Bio- nomics.org as Five Ways To Wellbeing: Connect (to
graphy) involves imagining that you have passed away others, individually and in communities); Be active;
after living a fruitful and satisfying life, and writing an Take notice (of the world); Keep learning; and Give (e.g.
essay summarising what you would most like to be smile, volunteer, join in). It is no coincidence that these
remembered for. Week 4 (Gratitude Visit) involves are all outward-looking recommendations, more about
thinking of someone to whom you are very grateful, engaging in and living life to the full than sorting out
but whom you have never properly thanked, compos- any internal or intrapsychic disturbances. Stigma and
ing a letter to them describing your gratitude, and discrimination stop people with mental illness from
reading it to the person by phone or in person. Week exercising their full rights as citizens and meeting their
5 (Active/Constructive Responding) involves reacting human needs for connection [107]. Therefore, the role
in a visibly positive and enthusiastic way to good news of the mental health professional should be about chal-
from someone else at least once a day. Week 6 lenging stigma and creating well-being-promoting socie-
(Savouring) involves once a day taking the time to ties as well as treating illness.
enjoy something that you usually hurry through, writ-
ing write down what you did, how you did it differ- Mental health professionals can improve social inclusion
ently, and how it felt compared to when you rush Supporting people using mental health services from
through it. These exercises are intended to amplify accessing normal citizenship entitlements is a central (i.
components of Authentic Happiness [51]. Randomised e. not an optional extra) part of the job. We illustrate
controlled trials of group PPT with mild to moderately this in relation to employment.
depressed students (n = 40) and individual PPT with If a single outcome measure had to be chosen to
severely depressed mental health clients (n = 46) both capture recovery, there would be a case to make that it
showed gains in symptom reduction and happiness, should be employment status. Not because of a value
with moderate to large effect sizes and improvement about economic productivity, but because work has so
sustained at one-year follow-up [104]. many associated benefits. There is now a strong evi-
We have considered some approaches to focussing more dence base that Individual Placement and Support
on strengths, goals and preferences. However, if mental (IPS) approaches which support the person to find
health services are to fully support recovery and promote and maintain mainstream employment are better
well-being, it may not be enough to simply counter- than training the person up in separate sheltered
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employment schemes in preparation for mainstream on where the work takes place), Things (focussing on
work [108,109]. Mental health professionals can equipment needed to do the job) or Activities (focussing
increase the access of service users to the valued social on the work tasks). For people with physical disability,
role of work by supporting the development of accommodation needs tend to relate to Places and
employment schemes [110]. Things. This is what employers are used to. In mental
One specific work opportunity is within mental health illness, People issues are often the central issue. Employ-
services. These are often large employers - the National ers need educating about how these interpersonal needs
Health Service in the UK is the largest employer in Eur- can be tended to, which might include [108]:
ope. However, health services have a history of poor • addressing concentration problems by having a qui-
recruitment and retention approaches to attracting peo- eter work place with fewer distractions rather than
ple with declared mental illness to work for them [31]. an open-plan office
(Of course, many people working in these services have • the need to have some time away from other
an undisclosed history of mental illness.) This is a workers
wasted opportunity, and reinforces stigmatising us-and- • enhanced supervision to give feedback and guidance
them beliefs in the work-force. Actively encouraging on job performance
applications from people who have used mental health • allowing the use of headphones to block out dis-
services for all posts, and positively discriminating tracting noise (including hearing voices)
between applicants with the same skill level in favour of • flexibility in working hours, e.g. to attend clinical
people with a history of mental illness are two relevant appointments or work when less impaired by
approaches. They directly challenge “the common ten- medication
dency in human service organisations to see workers as • mentor scheme for on-site orientation and support
either health and strong and the donors of care, or as • the need to talk to a supporter (e.g. a job coach)
weak and vulnerable recipients“ [108]. during a lunch break
There are other ways in which mental health profes- • clear job description for people who find ambiguity
sionals and teams can improve social inclusion. A and uncertainty difficult
common experience of workers in the mental health • prior discussion about how leave due to illness will
system is frustration - a sense that these ideas about be managed, e.g. allowing the use of accrued paid
social inclusion, employment and social roles are all and unpaid leave
well and good, but impossible to implement within the • relocation of marginal job functions which are dis-
existing constraints. But resources can become avail- turbing to the individual
able by spending allocated money differently. This is Alongside this direct contribution to improving social
the approach used by The Village http://www.mhavil- inclusion, well-being focussed mental health profes-
lage.org, a mental health service in inner-city Los sionals of the future will also have a contribution to
Angeles working with homeless and severely mentally make to policy.
ill clients. The service decided to undergo a ‘fiscal
paradigm shift’, by spending money to promote well- Mental health professionals can increase societal well-
ness and recovery (especially by creating pathways being
back into employment) rather than promote stability If a new knowledge base around well-being is integrated
and maintenance. This involved transforming from by mental health professionals into their practice, then
being an organisation which spent most of its allocated this creates opportunities to influence social and politi-
money on acute hospitalisation (28%), long-term care cal priorities. The position power and status of the role
(23%) and out-patient therapy (23%) to one spending allow authoritative communication with the aim of
on individualised case management (41%), work (25%) influencing society and increasing wellbeing both for the
and community integration (12%) [111]. Hospitalisa- general population and specifically for people with
tions and living in institutional residence are markedly experience of mental illness. A few examples will illus-
reduced for members attending the Village [112], trate this re-orientation.
allowing the money saved to be re-invested in work- Does money bring happiness? Above a certain level
supporting services. (estimated by Richard Layard as US$20,000pa [54]), the
A further contribution from the clinician can be edu- answer is no - relative wealth is more of an influence on
cating local employers about their legal duties under happiness than absolute wealth [113]. A salary of
relevant discrimination legislation and about reasonable $50,000 where average salaries are $25,000 is preferred
work-place adjustments for people with mental to a salary of $100,000 where the average is $250,000
illness. The accommodations can relate to People [114]. If social comparison influences well-being, what
(focussing on interpersonal challenges), Places (focussing are the implications for policy? For example, do social
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structures such as gated communities and private with happiness [124,125]. Using a scale from 10 (no
schools harm us all? Contrary to intuition, those within happiness) to 100 (total happiness), the fall in happiness
the enclave aren’t any happier because they are no weal- associated with separation (compared with marriage) is
thier than their comparison group, and those outside 8 points, with unemployment or poor health is 6 points,
have a visibly wealthier reference group. with personal freedom is 5 points, with saying no to
Television is a powerful influence, both because it “God is important in my life” (personal values) is 3.5
encourages social comparison and because of its innate points, with a national increase of 10% in unemploy-
effects. Researchers have observed consistently adverse ment is 3 points, and with a drop in family income by a
changes following the introduction of television into third is 2 points.
new communities. In Bhutan, this was followed by Can these seven identified influences be used by
increased family break-up, crime and drug-taking, along- mental health services to directly increase happiness,
side reduced parent-child conversation [115]. In Canada, rather than continuing with attempts to reduce unhap-
social life, participation in sports and level of creativity piness? This will involve meeting three challenges.
were all negatively impacted [116]. Homicide rates go First, traditional professional training only focuses on
up after televised heavyweight fights [117], and suicide one of these seven influences: health. Second, interven-
rates increase after on-screen portrayals [118]. Televi- tions to promote health which increase personal free-
sion content leads to an inflated estimate of adultery dom and are concordant with personal values will
and crime rates [119], and negative self-appraisal [120]. increase happiness more than those which impinge on
Given the average Briton watches 25 hours of television personal freedom or which deny or discount personal
per week [121] - with similar levels in the US [54] - value. This will require clinical decision-making to
what does this imply for media regulation? focus as much on values and freedom as on interven-
When making a social comparison, the reference tion effectiveness - echoing the call for ethics before
group influences well-being: Olympic bronze medal win- technology by Bracken and Thomas [126]. Third, most
ners (who compare themselves with people missing out influences on happiness are social rather than intrap-
on a medal) are happier than Silver medal winners (who sychic, yet most mental health interventions are at the
compare themselves with the victor) [122]. For mental level of the individual. Overall, this is not to argue for
health, this may mean that anti-stigma campaigns more centralised control per se, but rather to highlight
focussed on promoting mental health literacy and iden- that this knowledge should be more visible in public
tifying when to seek professional help actually increase debate, so that both social policy and individual
negative social comparisons and reduce well-being. choices are informed by our best scientific understand-
High-profile people talking about their own experiences ing of contributors to well-being.
are better at reducing the social distance and difference We finish on an optimistic note. One reason for raising
experienced by people with mental illness [107]. some of these implications is to highlight their relative
In contrast to salary, 4 weeks holiday when others absence from sociopolitical debate. Although there is
have 8 weeks is preferred over 2 weeks when others good evidence that being happy and cheerful is associated
have 1 week [114]. Would a national policy of compul- with improved brain chemistry, blood pressure and heart
sory flexible working arrangements (e.g. annualised rate [127,128], and with living longer [129], this kind of
hours) reduce work-related stress and consequent men- evidence does not yet feature prominently in public
tal illness? More generally, the fact that people who win debate. If skilled professionals with an interest in promot-
Oscars live longer than unsuccessful nominees [123] ing well-being don’t point out that a high turnover of
may point to the importance of achievement for longev- local residents create communities which are less cohe-
ity. If we want people to live longer, should we focus on sive [130] and more violent [131] then who will inject
developing community-level opportunities for participa- this information into social policy? This opens up inno-
tion, connection and mastery? Should services for parti- vative environmental approaches to fostering well-being,
cularly marginalised groups, such as people with mental like the simple act of closing most points of entry to a
illness, put some of their resources towards celebrating housing estate which led to an increased sense of com-
and amplifying success? munity and a 25% reduction in mental illness rates [132].
What are the sources of happiness? The Big Seven Similarly, the pernicious effects of a societal value that
influences on happiness explain 80% of the variance in we must make the most of everything is becoming clear.
happiness: Family relationships, Financial situation, People who constantly worry about missing opportunities
Work, Community and friends, Health, Personal free- - so-called hyper-optimisers - have more regrets, make
dom and Personal values [54]. The effects on happiness more social comparisons and are less happy than people
of problems in each domain have been estimated, on who are happy with what is good enough [133]. An
the basis of international surveys of factors associated empirically-informed policy-making approach would
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recognise the toxic consequences for well-being of socie- health services, user involvement in and influence on mental health services,
staff-patient agreement on need, and contributing to the development of
ties which encourage unfavourable social comparison, clinically useable outcome measures, including the Camberwell Assessment
continuous reoptimisation to make the best of every of Need and the Threshold Assessment Grid. He has written over 120
opportunity, and living for the future rather than savour- academic articles and seven books, including Slade M (2009) Personal
recovery and mental illness, Cambridge: Cambridge University Press. He is
ing the present. keen to disseminate an understanding of recovery to the field through free-
Research into mental illness proceeds apace. Advances to-download booklets, such as Shepherd G, Boardman J, Slade M (2008)
in understanding are being generated by genetic, geno- Making Recovery a Reality, London: Sainsbury Centre for Mental Health
(downloadable from http://www.scmh.org.uk) and Slade M (2009) 100 ways
mic, proteomic, psychological and epidemiological stu- to supportrecovery, London: Rethink (downloadable from http://www.rethink.
dies, among other disciplines. These advances are to be org). He has acquired over £7 m of grant funding, including a £2 m NIHR
welcomed, and should continue to inform clinical prac- Programme Grant for Applied Research for the five-year REFOCUS study to
develop a recovery focus in adult mental services in England.
tice. The challenge is to also integrate and apply the evi-
dence base around well-being, so that mental health Competing interests
professionals of the future inform social policy as well The author declares that they have no competing interests.
as treating mental illness. Received: 18 February 2009
Accepted: 26 January 2010 Published: 26 January 2010
Summary
• Two new sources of knowledge are now available to References
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