Mental health and wellbeing

Formulating a clear and concise definition of mental health and indicators of its measurement is a continual challenge for researchers and affiliated mental health services. The definitions of mental health and related concepts have been contested over time (Christodoulou et al., 2011). The many criticisms of the existing definitions are combined with the added difficulty of various definitions based on culture or ethnicity (Christodoulou et al., 2011; MacDonald, 2006; Vaillant, 2012; WHO, 2004a). Such debates have often led to the postulation of multiple and, often, opposing perspectives (Grinde, 2012). In the academic literature and in educational policy circles, debate has also arisen about the nature of the construct of ‘positive mental health’ or, as it is also referred to, ‘mental wellbeing’ (Adi, Killoran et al., 2007; Christodoulou et al., 2011, p. 5). The following definitions, concerning mental health, mental health disorders, mental health problems and wellbeing, outline the meanings that have been adopted for the current research.

2.1.2.1 Mental health

The WHO (2004a) sees positive mental health as a unified state that allows individuals to realise their abilities, cope with the normal stresses of life, work prolifically and make a contribution to their community. The ability to form mutually satisfying and enduring relationships is also widely recognised as another important component of mental health (WHO, 2002). Arnold and Janssen-Breen (2006) recognise health as not only including wellbeing but also characteristics such as a

balanced state, growth functionality, transcendence and empowerment, demonstrating the complexity of the concept. In addition, Suldo and Shaffer (2008) define mental health as a complete state of being, consisting of positive factors such as life satisfaction, self-acceptance and social contribution rather than simply the absence of illness or disorder. Kazdin (1993) also maintains that mental health encompasses optimal functioning or wellbeing in psychological and social domains, as well as the absence of psychosocial dysfunction. This is also well exemplified by the definition of health accepted by Australia’s Indigenous culture: ‘health is not just the physical health wellbeing of the individual but the social, emotional, and cultural wellbeing of the whole community. This is a whole-of-life view and it also includes the cyclical concept of life-death-life’ (Australian Health Ministers’ Advisory Council, 2004, p.

4). The Australian Aboriginal concept of positive mental health (with reference to social inclusion) noted by Kovess-Masferty, Murray and Gureje (2005) is also significant for its broad, holistic perspective.

The UK Mental Health Foundation (2001) review highlights the nature and importance of positive mental health. Its definition of mental health, which encompasses aspects of both emotional wellbeing and social functioning, utilises the term wellbeing and stresses the equal importance of a holistic perspective. Essential to the current research, this definition has been adopted to inform the theory, practice and evaluation of the mental health and wellbeing school-based intervention programme.

2.1.2.2 Mental health disorders and illness

Historically, mental health has been simplistically defined in the health literature as the absence of mental illness (Maddux, 2002; Wells et al., 2003). Traditional mental health diagnosis is similarly defined by the presence or absence of internalising (e.g., depression, anxiety) or externalising disorders (e.g., conduct disorder or associated symptoms). The most universally used diagnostic system that provides common language and standard criteria for the classification of mental disorders, field communication and the standardisation of research is the Diagnostic and Statistical Manual of Mental Disorders (DSM). The first DSM (American Psychiatric Association, 1952) was based on the medical model that viewed behavioural and emotional problems as ‘mental disease’. Previously, the emphasis of mental health

was on the presence or absence of psychopathology as a way to diagnose individuals.

Additionally it has been embedded in psychological and behavioural characteristics (Fischer, 2012).

During the interwar years, subsequent editions of the DSM followed, emphasising a somatic viewpoint.⁶ These were of limited diagnostic utility as they offered relatively broad categorisations of mental disorders (Kawa & Giordano, 2012). Mental illness was seen as a term applied to people with a diagnosed mental disorder. Following this time, the conceptualisation of psychopathology largely shifted from recognising mental conditions as distinct from mental health, to considering mental health and illness on a continuum of variable severity (Double, 2002). The second DSM (American Psychiatric Association, 1968) was also more closely aligned to the WHO classification schemes (Double, 2002). DSM (1952) and DSM (1968) thus represented a shift towards a more clinical mind-set and making general distinctions between psychotic and non-psychotic conditions (Fischer, 2012).

However, DSM-III (American Psychiatric Association, 1980) signalled a change in approach. While the DSM (1952) and DSM (1968) had used comparisons to prototypical descriptions for diagnosis, DSM-III (1980) used checklists of features, considerably enhancing diagnostic reliability. Being the first to define mental disorder, DSM-III (1980) was also extremely important in legitimising psychiatry as a medical specialty (Zimmerman & Spitzer, 2005). The focus of mental health was then primarily centred on the presence of illness and problems within social relationships and the environment (American Psychiatric Association, 2000). These adjustments coincided with changes in the wider social context, including both World Wars, and changes in the medical and psychiatry fields, including the establishment of the WHO, and an increased awareness of differences in health needs of children, adolescents and adults (Fischer, 2012).

This evolution of the DSM also resulted in: (1) a theoretical shift in the conceptualisation of mental disorders; (2) the development of the multi-axial diagnostic system; (3) the inclusion of new disorders and the expansion of previously

6 Relating to or affecting the body, distinguished from a body part, the mind or the environment;

corporeal or physical (American Heritage, 2003).

defined disorders; (4) a ‘lateral’ reorganisation of disorders into discrete, broad categories that entailed merging a number of disorders and eliminating others; and (5) a shift that reinforced the descriptive, somatic orientation in all subsequent DSMs.

Particularly pertinent is Rogler’s (1997) analysis, which highlighted this progression and its subsequent inclusion throughout almost all of mental health practice, education and training to date. These changes had influence on practices, public attitudes and mental health interventions. For example, previous research on adolescent psychological functioning focused on a negative, symptom-based definition of mental health. Under this conceptualisation, if an adolescent did not meet the criteria for a particular disorder, he or she was considered subclinical and no intervention would follow, ignoring positive factors and markers of wellbeing. These revisions have aided the notion that mental health is more than the absence of illness.

Recent revisions of the DSM (American Psychiatric Association, 1994, 2000, 2013) have utilised a multi-axial approach. The most recent revision, DSM-5 (2013), makes use of results from neuroscience in order to more directly address the connections between psychiatry and the rest of medicine, with the aim of facilitating a clearer dialogue between mental health professionals and their medical colleagues outside of psychiatry (Kupfer & Regier, 2011). This makes it possible for mental health services and interventions to be oriented around promoting wellbeing as well as treating illness (Slade, 2010). This evolution points to the need for mental health professionals and researchers to support both the reduction of mental illness and the improvement of mental health. In the current study, the term mental illness refers to a number of diagnosable disorders that significantly interfere with an individual’s cognitive, emotional or social abilities. Mental health problems will be used to refer to the full range of mental health issues, including mental distress that may not be based on current psychiatric or medial models.

2.1.2.3 Wellbeing

In recent decades, agencies have envisaged mental health as encompassing emotional health and wellbeing (Weare & Markham, 2005) and emotional and social competence (Department for Education and Skills, 2001; Weare, 2000; WHO, 2010).

This paradigm shift is seen in the more comprehensive conceptualisation of mental health that includes markers of wellbeing (Diener, 2000; Seligman &

Csikszentmihalyi, 2000). Recent research suggests that an absence of psycho-pathology does not equate with complete mental health and that wellbeing and psychopathology are not at opposite poles of the same continuum (Keyes, 2006). This shift calls for a focus on examining indicators of prevention and positive psychology.

Offering a psychometric point of view, some researchers suggest that the construct of mental wellbeing is independent of the construct of mental illness (Adi, Killoran et al., 2007). Two distinct perspectives on mental wellbeing are currently presented in the academic literature: the hedonic perspective, which focuses on the subjective experience of happiness and life satisfaction, and the eudaimonic perspective, which focuses on psychological functioning and self-realisation (Adi, Killoran et al., 2007;

Ryan & Deci, 2001; Westerhof & Keyes, 2010). The components of emotional and social wellbeing during adolescence that have been well researched include: pro-social behaviour, healthy peer relationships and self-esteem (Weare, 2000). All of these perspectives have informed distinct bodies of research in positive mental health and have since been translated to contemporary psychology (Deci & Ryan, 2008).

This has clear implications for this current project, including topics and elements covered in the programme (see Chapter 4).

Due to the paucity of instruments relating to the study of mental wellbeing, the concept is often operationalised as the absence of mental health problems (Adi, Killoran et al., 2007), despite the term mental wellbeing being capable of subsuming autonomy, emotional regulation, resilience, self-efficacy and self-esteem (Fraillon, 2004). Nevertheless, current research indicates that both mental wellbeing and mental illness may represent separate but correlated dimensions of health (Adi, Killoran et al., 2007; Westerhof & Keyes, 2010). This has resulted in a shift towards recognising the benefits of the promotion of mental health and wellbeing and prevention of mental health problems.

The definition of wellbeing used in the current research has been influenced by three different, but related, constructs comprising of life satisfaction, positive affect and negative affect (Diener, 2000). Life satisfaction refers to both global and domain-specific (school, family, friends) judgments of one’s life. Positive affect involves experiencing pleasant emotions and moods, such as interested, proud and delighted.

Negative affect involves experiencing unpleasant emotions and moods, for example,

lonely, sad and frightened. Therefore, in the current research, wellbeing refers to:

individuals’ cognitive faculties, that is, their anxiety, stress or other negative emotions; and their social interaction, that is, their ability to engage in relationships and their interactions with others, along with their ability to function in society and meet the demands of everyday life.