A Salutogenic Mental Health Model: Flourishing as a Metaphor for Good Mental Health

Abstract

This chapter focuses on a salutogenic understanding of mental health based on the work of Corey Keyes. He is dedicated to research and analysis of mental health as subjective well-being, where mental health is seen from an insider perspective. Flourishing is the pinnacle of good mental health, according to Keyes. He describes how mental health is constituted by an affective state and psychological and social functioning, and how we can measure mental health by the Mental Health Continuum—Short Form (MHC-SF) questionnaire. Further, I elaborate on Keyes’ two continua model of mental health and mental illness , a highly useful model in the health care context, showing that the absence of mental illness does not translate into the presence of mental health. You can also read about how lived experiences of former patients support Keyes dual model of mental health and mental illness. This model makes it clear that people can perceive they have good mental health even with mental illness, as well as people with perceived poor or low mental health can be without any mental disorder. The cumulative evidence for seeing mental disorder and mental health function along two different continua, central mental health concepts, and research significant for health promotion are elaborated in this chapter.

Full text

47
© The Author(s) 2021
G. Haugan, M. Eriksson (eds.), Health Promotion in Health Care – Vital Theories and Research,
https://doi.org/10.1007/978-3-030-63135-2_5
A Salutogenic Mental Health
Model: Flourishing asaMetaphor
forGood Mental Health
NinaHelenMjøsund
Abstract
This chapter focuses on a salutogenic under-
standing of mental health based on the work of
Corey Keyes. He is dedicated to research and
analysis of mental health as subjective well-
being, where mental health is seen from an
insider perspective. Flourishing is the pinna-
cle of good mental health, according to Keyes.
He describes how mental health is constituted
by an affective state and psychological and
social functioning, and how we can measure
mental health by the Mental Health
Continuum—Short Form (MHC-SF) question-
naire. Further, I elaborate on Keyes’ two con-
tinua model of mental health and mental
illness, a highly useful model in the health
care context, showing that the absence of
mental illness does not translate into the pres-
ence of mental health. You can also read about
how lived experiences of former patients sup-
port Keyes dual model of mental health and
mental illness. This model makes it clear that
people can perceive they have good mental
health even with mental illness, as well as
people with perceived poor or low mental
health can be without any mental disorder.
The cumulative evidence for seeing mental
disorder and mental health function along two
different continua, central mental health con-
cepts, and research signicant for health pro-
motion are elaborated in this chapter.
Keywords
Mental health · Mental health promotion ·
Flourishing · Mental health continuum short
form · MHC-SF · Two continua model
Salutogenesis · Complete mental health
Positive mental health · Well-being
5.1 Introduction
This chapter is about mental health. Mental
health is explained from a salutogenic perspec-
tive. This is an asset- and resource-oriented
approach, which is explained with Corey Keyes’
theoretical model of mental health [1–3], where
mental health is understood as the presence of
feelings and functioning, and not the absent of
illness. The two continua model of mental health
[3, 4] contributes to an understanding of mental
health relevant in health care services by incorpo-
rating knowledge about diseases (pathogenesis)
and complements this with the knowledge about
health and well-being (salutogenesis).
N. H. Mjøsund (*)
Division of Mental Health and Addiction, Department
of Mental Health Research and Development, Vestre
Viken Hospital Trust, Drammen, Norway
e-mail: nina.helen.mjosund@vestreviken.no
5

48
Years ago, WHO [5] introduced a denition of
health praised as well as criticized from many
perspectives. However, it can be seen as a deni-
tion including situations a person is eager to
achieve and situations a person is eager to avoid.
“Health is a state of complete physical, mental
and social well-being and not merely the absence
of disease and inrmity” ([5], p.1). Health has
different meanings to different people. Green and
Tones [6] say it so strikingly:
…health is one of those abstract words, like love
and beauty, that mean different things to different
people. However, we can condently say that
health is, and has always been, a signicant value
in people’s lives ([6], p.8).
To focus on mental health by separating it
from health in its totality might be articial due
to the risk of losing the sight of health’s complex-
ity and composition. Mjøsund etal. [7] argue that
perceived mental health, and physical, emotional,
social, and spiritual aspects of health reciprocally
inuence each other. It seems that the phenome-
non of mental health is especially fragile from
being separated from the totality of health.
However, a conscious theoretical attention to one
of the aspects of health while remembering its
connectedness to the other aspects might facili-
tate a deeper understanding and more targeted
clinical intervention to promote it.
In a society with a dominant awareness on ill-
ness and disease prevention, people need useful
knowledge to care for and promote their mental
health, as well as physical, spiritual, and social
health. Academics and scholars need theories and
models to study mental health, and health profes-
sionals and health promoters need an extensive
knowledge base to perform evidence-based inter-
ventions for quality enhancement in clinical
practices. Scientists claim to adapt a pragmatic
approach accepting various conceptualizations of
health because it remains unlikely that we arrive
at consensus on a health denition for health pro-
motion research [8].
Findings from lived experiences of inpatient
care in the project Positive Mental Health—From
What to How [9] shed light on some elements of
the mental health and Keyes’ dual model of men-
tal health [2]. In this qualitative research project,
the meanings of mental health and mental health
promotion were explored from the perspective of
persons with former and recent patient experi-
ences [7].
5.2 Mental Health
Nearly two decades ago, Corey Keyes, PhD in
sociology [1], suggested to operationalize mental
health as a syndrome of symptoms of positive
feelings and positive functioning in life. Mental
health is about an individual’s subjective well-
being; the individuals’ perceptions and evalua-
tions of their own lives in terms of their affective
state, and their psychological and social function-
ing [1]. Inspired by salutogenesis, mental health
is viewed as the presence of positive states of
human capacities and functioning in cognition,
affect, and behavior [3].
Hence, the more dominant view of mental
health as the absence of psychopathology was
questioned by Keyes [3]. While still holding this
view, Keyes needed to employ the DSM-3 [10]
approach as a theoretical guide for the conceptu-
alization and the determination of the mental
health categories and the diagnosis of mental
health [1]. These terms, more often used in diag-
nosing mental disorders, rather than health, were
used with a conscious aim [1, 4, 11]. Keyes
chooses to utilize DSM-3, its established reputa-
tion and familiarity, as a tool aiming to place the
domain of mental health on equal footing with
mental illness [1]. The measurement of mental
health was done in the same way as psychiatrist
measures common mental disorders, as for exam-
ple a major depressive episode [12]. The con-
cepts (syndromes, symptoms, and diagnosis) are
familiar for nurses and for multidisciplinary pro-
fessionals in health care services, as well as for
patients and their relatives, which is a pedagogic
benecial when health promotion models and
theories are used to guide interventions in clinical
practice.
Mjøsund [9] contributes to the knowledge
base of health promotion by investigating expe-
riences of mental health among persons with
mental disorders. This study explored how
N. H. Mjøsund

49
mental health was perceived by former patients
[7], and the experiences of mental health pro-
motion efforts in an inpatient setting [13]. The
methodology Interpretative Phenomenological
Analysis [14] was applied on 12 in-depth inter-
views. Apart from the participants, an advisory
team of ve research advisors either with a
diagnosis or related to a family member with
severe mental illness was involved at all stages
of the research process as part of the extensive
service user involvement applied in the project
[15, 16].
5.2.1 Mental Health asaSyndrome
ofSymptoms
Keyes [1] operationalizes mental health as a syn-
drome of symptoms, based on an evaluation or
declaration that individuals make about their
lives. The syndrome of symptoms of positive
feelings and positive functioning in life included
psychological, social, and emotional well-being
[1], make up the family tree of mental health,
which is portrayed in Fig.5.1.
How you are feeling about life includes (1)
emotional well-being—and how you are func-
tioning is about, (2) psychological well-being,
and (3) social well-being. The division of subjec-
tive well-being consists in this way of two com-
patible traditions: the Hedonic tradition, focusing
on the individual’s feelings toward life, and the
Eudaimonic tradition that equates mental health
with how human potential, when cultivated,
results in functioning well in life [3, 17].
Emotional well-being consists of perceptions of
happiness, interest in life, and satisfaction with
life [18]. Where happiness is about spontaneous
reection on pleasant and unpleasant affects in
one’s immediate experience, the life satisfaction
represents a more long-term assessments of one’s
life [2]. The Hedonic approach equals emotional
well-being as it frames happiness as positive
emotions and represent the opinion that a good
life is about feeling good or experiencing more
moments of good feelings [12]. In contrast to the
emotional well-being, psychological well-being
is about the individual’s self-report about the
quality with which they are functioning [2].
Psychological and social well-being are rooted in
Family Tree of Mental Health
Positive Feeling Positive Functioning
I - Me
Emotional Well-Being Psychological Well-Being Social Well-Being
We - Us
Happiness
Satisfaction
Interest in Life
Self-Acceptance
Positive Relations with Others
Personal Growth
Purpose in Life
Environmental Mastery
Autonomy
Social Acceptance
Social Integration
Social Growth
Social Contribution
Social Coherence
Fig. 5.1 The family tree of mental health. (Reproduced with permission from a lecture given by C.Keyes in Drammen,
Norway, 13th of December 2010)
5 A Salutogenic Mental Health Model: Flourishing asaMetaphor forGood Mental Health

50
the Eudaimonic tradition which claims that hap-
piness is about striving toward excellence and
positive functioning, both individually and as a
member of the society [2]. Eudaimonia frames
happiness as a way of doing things in the world
and represents the opinion that a good life is
about how well individuals cultivate their abili-
ties to function well or to do good in the world
[12]. Psychological well-being is conceptualized
as a private phenomenon that is focused on the
challenges encountered by the individual; it is
about how well an individual functions in life
[12]. Social well-being represents a more public
experience related to the individual social tasks
in their social structures and communities [2].
Social well-being is about how well an individual
is functioning as a citizen and a member of a
community [12]. An important distinction
between psychological and social well-being is
that the former represents how people view them-
selves functioning as “I” and “Me,” while the lat-
ter represents how people view themselves
functioning as “We” and “Us” [17].
The level of mental health is indicated when
a set of symptoms of emotional well-being com-
bined with symptoms of psychological and
social well-being at a specic level are present
for a specied duration [1, 2]. This constellation
of symptoms coincides with the individual’s
internal and subjective judgment of their affec-
tive state and their psychological and social
functioning.
5.2.2 Mental Health:
FromLanguishing
toFlourishing
Mental health can be conceptualized along a con-
tinuum and subdivided into three conditions or
levels: languishing, moderate, and ourishing
mental health [1]. To be ourishing is to be lled
with positive emotions and to be functioning well
psychologically and socially. Flourishing has
emerged to be a term describing the optimal state
of mental health [19]. Languishing is to be men-
tally unhealthy, which is experienced as being
stuck, stagnant, or that life lacks interest and
engagement [2]. Further, languishing can be
described as emptiness and lack of progress, the
feeling of a quiet despair that parallels accounts
of life as hollow, empty, a shell, or a void.
Individuals diagnosed as neither ourishing nor
languishing are considered to have moderate
mental health [1]. To be diagnosed as having
ourishing, moderate or languishing mental
health, three dimensions or symptoms of emo-
tional well-being, six of psychological well-
being, and ve dimensions of social well-being
are assessed [18]. A state of mental health is
indicated when a set of symptoms at a specic
level are present or absent for a specied dura-
tion, and they coincide with distinctive cognitive
and social functioning [1].
5.2.3 Measuring Mental Health:
TheMental Health Continuum
Short Form
The self-administered questionnaire Mental
Health Continuum—Short Form (MHC-SF) was
developed to assess mental health based on indi-
viduals’ responses to structured scales measuring
the presence or absence of positive effects (hap-
piness, interest in life, and satisfaction), and
functioning in life, which includes the measure-
ment of the two dimensions: psychological well-
being and social well-being [1, 18]. Psychological
well-being is characterized by the presence of
intrapersonal reections of one’s adjustment to
and outlook on life and consists of six dimen-
sions: self-acceptance, positive relations with
others, personal growth, purpose in life, environ-
mental mastery, and autonomy. Social well-being
epitomizes the more public and social criteria
and consists of social coherence, social actualiza-
tion, social integration, social acceptance, and
social contribution [17]. Individuals who are
ourishing or languishing must exhibit, respec-
tively, high or low levels on at least seven or more
of the dimensions [1]. Keyes [18] explains:
To be diagnosed with ourishing mental health,
individuals must experience ‘every day’ or ‘almost
every day’ at least one of the three signs of hedonic
wellbeing and at least six of the eleven signs of
N. H. Mjøsund

51
positive functioning during the past month.
Individuals who exhibit low levels (i.e., ‘never’ or
‘once or twice’ during the past month) on at least
one measure of hedonic wellbeing and low levels
on at least six measures of positive functioning are
diagnosed with languishing mental health.
Individuals who are neither ourishing nor lan-
guishing are diagnosed with moderate mental
health ([18], p.1).
The MHC-SF is constructed to be interpreted
by both a continuous scoring, sum 0–70, and a
categorical diagnosis of ourishing, moderate
mental health or languishing. The questionnaire
has been translated to many languages and applied
in different cultures across many continents, such
as Europe [20], Africa [17], Australia [21], South-
America [22], North-America [23, 24], and Asia
[25, 26]. Recently, the structure and application
were evaluated for cross-cultural studies, involv-
ing 38 nations [27]. The MHC-SF shows good
internal reliability, consistency, and convergent
and discriminant validity in respondents between
the age of 18 and 87 years [20] and across the
lifespan [28]. The MHC-SF is claimed to be valid
and reliable for monitoring well-being in student
groups [29], as well as in both clinical (affective
disorders) and nonclinical groups [30]. Moreover,
the MHC-SF has also been used as the outcome in
intervention studies [31, 32].
5.2.4 Flourishing: ThePinnacle
ofGood Mental Health
The term ourishing gives associations to some-
thing we want to achieve, a state where we are
thriving, growing, and unfolding, and I have
vitality, energy, and strength. The concept of
ourishing has mostly been used in the eld of
positive psychology and sociology. Although
the concept is considered to be relevant in nurs-
ing practice and research, it is still virtually
absent in the nursing literature [19]. According
to Keyes, ourishing is the pinnacle of good
mental health; he chose to use the term ourish-
ing to be clear that he was talking about mental
health and not merely the absence of mental ill-
ness [12]. An evolutionary concept analysis of
ourishing claimed that ourishing is still an
immature concept, however with a growing evi-
dence of ourishing as a district concept [19].
This concept analysis was based on four com-
mon conceptual frameworks of ourishing. The
framework with most information available and
most cited was presented by Keyes [1].
Additionally, the frameworks of Diener and
Diener etal. [33, 34], Huppert and So [35], and
Seligman [36] were included in this concept
analysis [19]. The authors request further multi-
disciplinary research to establish standard oper-
ational and conceptual denitions and to develop
effective interventions [19].
5.2.5 Perceived Mental Health:
ADynamic Movement
onaContinuum
Former inpatients described mental health as an
ever-present aspect of life; moreover, mental
health was perceived as a dynamic phenomenon,
a constantly ongoing movement, or process like
walking up or down a staircase [7]. The move-
ment was affected by experiences in the emo-
tional, physical, social, and spiritual domains of
life and accompanied by a sense of energy.
Figure5.2 shows that mental health is expressed
both verbally and by body language, and in
everyday life, mental health was experienced as a
sense of energy and as increased or decreased
well-being [7].
It is interesting that the participants living with
the consequences of severe mental disorders were
not talking about the absence of illness, pathologi-
cal conditions, and disorder symptoms when they
described their perception of mental health and
mental health promotion [7]. The salutogenic
understanding of Keyes [3] claiming that mental
health is the presence of feelings and functioning,
a state of human capacities, was supported by how
the participants perceived mental health.
The understanding of mental health as a pro-
cess and movement, like walking up or down a
spiral staircase—equivalent to a continuum—is
previously conrmed by a study of young people
[37]. Talking about the experience of being in dif-
ferent positions on the mental health staircase,
5 A Salutogenic Mental Health Model: Flourishing asaMetaphor forGood Mental Health

52
the exploration of the participants’ accounts and
their descriptions clearly indicated a vertical
movement in accordance with Keyes’ [1] contin-
uum of mental health. The perception of the phe-
nomenon of mental health as an ever present
aspect of life, a part of being human [7], is of
signicance. Mental health was perceived as a
quality of daily life, not characterized by quanti-
tative entities such as numbers, but rather as good
or bad, up or down, poor or strong. Mental health
being experienced as constantly present in life
and a part of being could be a contradiction to the
early work of Keyes, when he described ourish-
ing as the presence of mental health and
languishing as absence of mental health [1].
More recently, [3, 12, 38] languishing is denoted
as the absence of positive mental health or “the
lowest level of mental health” [39]. Based on the
participants’ way of speaking about the position
“low in the staircase” [7], and Keyes’ description
of high, moderate, and low mental health, Fig.5.3
visualizes the levels of mental health.
V
i
t
a
l
i
t
y
P
h
y
s
i
c
a
l
E
m
o
t
i
o
n
a
l
S
p
i
r
i
t
u
a
l
S
o
c
i
a
l
F
a
t
i
g
u
e
I’m great
I’m fine
I’m down
S
e
n
s
e
o
f
e
n
e
r
g
y
S
e
n
s
e
o
f
e
n
e
r
g
y
© 2017 Nina Helen Mjøsund
Fig. 5.2 Perceived mental health. (Reproduced with per-
mission from Mjøsund NH.Positive mental health—from
what to how. A study in the specialized mental health care
service. Trondheim: Norwegian University of Science and
Technology, Faculty of Medicine and Health Sciences,
Department of Public Health and Nursing; 2017)
I’m great
I’m fine
I’m down
Mjøsund Keyes
High
Flourishing
= presence of good
mental health
Languishing
= presence of good
mental health
Moderate
mental health
Low
© Nina Helen Mjøsund 2021
Fig. 5.3 Mental health as moving up and down a staircase—equivalent to Keyes’ continuum of mental health
N. H. Mjøsund

53
Mjøsund etal. [7] claim that a sense of energy
was a salient marker of perceived mental health.
The sense of energy inuenced experiences of
mental health in the emotional, physical, spiri-
tual, and relational domains of life. The feeling of
energy was proportional with the position on the
staircase; while low or down on the staircase, the
sense of energy was described as “like starting a
shaky engine with a at battery.” The participants
described how this lack of mental and physical
energy was associated with difculties initiating
and completing any activities [7]. This is in line
with Keyes’ [1] descriptions of ourishing
including the presence of enthusiasm, aliveness,
vitality, and an interest in life, associated with a
sense of energy. Lack of energy and motivation
as a result of mental disorders has been identied
by patients as a barrier to integrating healthy life-
styles [40]. An assessment of the sense of energy,
in collaboration with the patient, might form the
basis for interventions aiming to “push or pull”
into an activity or advising rest. Both the inter-
ventions have been described by Lerdal [41]. The
sense of energy should be investigated more in
depth and its relationship with mental health and
mental disorders needs further research in order
to inform the health promotion knowledge base.
The use of lay language in order to break
down barriers between stakeholders in health
promotion and health care is encouraged [42].
Having dialogs about taking a step or moving in
the staircase of mental health is one way of oper-
ationalizing mental health into lay language for
all people. Visualizing theoretical models might
increase the possibility to grasp the content, as
well as the usefulness in clinical practice can be
promoted. Illustrations might enhance insight
and shared understanding that is signicant in
health promotion initiatives aiming to increase
empowerment (Figs.5.1, 5.2, 5.3 and 5.4).
5.3 The Two Continua Model
The two continua model includes the presence of
human capacities and functioning as well as the
assessment of disease or inrmity [3, 4]. The
contemporary dominant perspective in mental
health care is on treating diseases and illness.
Therefore, theories, models, and concepts which
can help to facilitate mental health promotion are
required. The dual continua model includes
related but distinct dimensions of both mental
health and mental illness [11, 28, 43, 44]. The
illustration of the two continua model of health
(Fig.5.4.) reproduced from Keyes [3] visualizes
the conceptualized denition of health along the
vertical line and the continuum of mental illness
along the horizontal line.
This dual model of mental health and mental
illness goes well with WHO’s [5] denition of
health and is particular signicant for health
professionals in health care settings. The classi-
cal myth of Asclepius, the God of Medicine, and
his two daughters Hygeia and Panacea gave rise
to complementary concepts and approaches to
health. The daughters represents two different
points of view enlightening the distinction
between the denitions of health and illness [6].
The daughter Hygeia represented a salutogenic
approach symbolizing the virtue of wise living
and well-being. Salutogenesis comes from the
Latin word “salus” which means health and is
considered as a state of human capacities and
functioning. Health is the natural order of
things, a positive attribute to which human
beings are entitled if they govern their life
wisely. Panacea represented the pathogenic
approach, which considers health as the absence
of disease and illness [3].
With Hygeia and Panacea in mind, it becomes
clear that it is possible to have good mental health
even with mental illness, and one can have poor
or low mental health without mental illness. This
concurs with accounts from persons living with
mental disorders [7]. In the eld of recovery, the
inuence of positive mental health has been stud-
ied in a sample of persons with mood and anxiety
disorders [45] and individuals during recovery
from drug and alcohol problems [46]. Moreover,
the absence of mental illness does not equal the
presence of mental health and revealing that the
causes of mental health are often distinct from
those understood as the causes for mental illness
[43], and the conditions that protect against men-
tal disorders do not automatically promote the
5 A Salutogenic Mental Health Model: Flourishing asaMetaphor forGood Mental Health

54
presence of positive mental health [3]. There
seems to be cumulating evidence that mental dis-
orders and mental health function along two dif-
ferent continua that are only moderately
interrelated [4, 20, 28].
There is a growing interest for studying the
relationship between mental health and mental
illness in various environments, including work
settings and psychosocial work conditions [47].
MHC-SF has been found to be valid and reliable
for monitoring well-being in both clinical
(patients with affective disorders) and nonclinical
samples [30]. The prevalence of ourishing
among individuals with schizophrenia spectrum
disorders has been studied in Hong Kong [48].
Psychiatric outpatients with major mental illness
have lower rates of well-being compared to con-
trols, although about one-third is seen to be our-
ishing [49]. Screening of levels of mental health
complements mental disorders screening in the
prediction of suicidal behavior and impairment
of academic performance among college students
[50]. High level of mental health seems to protect
against the onset of mental disorders (mood, anx-
iety, and substance abuse disorders) [51] or func-
tion as a resilience resource [52]. A study
examined the presence and correlates of well-
being measured by MHC-SF and psychopathol-
ogy in a sample of female patients with eating
disorders, as well as the level of mental health
HIGH MENTAL HEALTH
LOW MENTAL HEALTH
LOW
MENTAL
ILLNESS
HIGH
MENTAL
ILLNESS
Flourishing &
Mental Illness Flourishing
Moderate
Mental Health &
Mental Illness
Languishing &
Mental Illness Languishing
Moderate
Mental Health
Fig. 5.4 The dual-continua model. (Reproduced with
permission from Keyes CLM. Mental Health as a
Complete State: How the Salutogenic Perspective
Completes the Picture. In: Bauer GF, Hämmig O, editors.
Bridging Occupational, Organizational and Public Health:
A Transdisciplinary Approach. London: Springer; 2014.
p.179–92)
N. H. Mjøsund

55
compared with the general population [53]. Less
research has been done in treatment settings and
hospitals; however, one study provides evidence
for the psychometric properties of the MHC-SF
in a primary care youth mental health setting, and
they claim that the MHC-SF’s three-factor struc-
ture is valid for use in mental health care [54].
Health promotion in health care should take a
holistic approach, also anchored in the WHO’s
[5] denition of health, meaning the salutogenic
orientation complementing the pathogenic
orientation in contemporary health care services.
I claim that the two continuum model provides
theoretical tools which are useful in the develop-
ment of health promotion interventions in the
health care context; this model is equalizing
treatment and care of disorders and the promo-
tion of health. Having the dual continua model in
mind, the protection of mental health is not to be
confused with protections against mental disor-
ders. I would like to emphasize the differentiation
between the protection of mental health (some-
thing positive) and the protection against mental
illness (something negative). The perception of
what is positive or negative depends on the con-
text and culture and might differ from one person
to another. However, in this chapter, the terms
positive and negative are used simply to illustrate
the difference in purpose. In clinical practice of
health disciplines such as nursing, it is relevant to
have theoretical models to guide in customizing
the care to the individual situation of the person.
Patients and health care providers may utilize this
framework to focus on the mental illness status,
as well as the persons’ level of mental health
[44]. Keyes’ conceptual framework maps on to
themes emerging from narratives about recovery
from mental illness [55] and can be a model to
bridge mental illness with positive mental health
in processes of recovery [56].
The ndings presented by Mjøsund etal. [7]
give support to the promotion and protection of
mental health as described in the two continua
model [2], which brings the continuum of mental
illness and the continuum of mental health into
the same picture (Fig.5.4). This corresponds to
the experiences presented by the participants and
interpretation of their accounts led to an under-
standing of an everyday life where they perceived
illness and health as intertwined, but also dis-
similar [7]. They have been diagnosed with a
mental disorder, but they are not their diagnosis,
life is also mental health and well-being. The rec-
ognition of the duality of mental health and men-
tal illness require major changes for current
clinical practice in health care dominated by the
pathogenic approach. Health promotion and
mental health promotion should have a more
dominant position in today’s health care systems.
Complementing health promotion and the protec-
tion of good mental health with treatment and
prevention against disorder and illness should be
given equal consciousness and resources based
on the evidence base. In the words of Keyes,
“…what lowers the bad does not necessarily
increase the good” (Personal communication on
12th of July 2015).
5.4 Flourishing: Signicant
inSalutogenic Mental Health
Promotion
Some perspectives on the opportunities and pros-
pects for a further salutogenic development of
mental health promotion in the health care might
be relevant. In line with Keyes [3], I claim that
research using absence of illness as an outcome
as well as mental health promotion interventions
with a purpose to restore health understood as
absent of illness or to protect against disease are
wrongly labeled as salutogenic. Even the father
of the term salutogenesis, Aaron Antonovsky [57,
58], might be understood as inuenced by this
way of thinking in some of his writings. In my
view, this is the main difference between
Antonovsky’s salutogenic model of health and
Keyes’ dual continua model of mental health.
Antonovsky gives a conceptual denition of the
health ease/dis-ease continuum as a multifaceted
state or condition of the human organism:
A person’s location at a given point in time, on this
continuum, can be described by the person’s par-
ticular prole on four facets: pain (felt by the indi-
vidual), functional limitations (felt by the
individual), prognostic implications (dened by
5 A Salutogenic Mental Health Model: Flourishing asaMetaphor forGood Mental Health

56
health authorities) and action implication (seen by
such authorities as required) ([58], p.65).
This denition of health leads us to recognize
a person’s location on the healthy end of contin-
uum, when these negative facets are missing.
Based on this, I claim that Antonovsky did not
dene health as something present or positive,
rather the absence of something negative. This is
in line with Antonovsky’s own remark:
The health ease / dis-ease, or breakdown, contin-
uum as presented here essentially seems to formu-
late the most desirable health category in negative
terms; an absence of pain, no functional limitation,
and so forth ([58], p.67).
In a later paper from 1985, however,
Antonovsky dened mental health as somewhat
more than the absence of something negative:
Mental health, as I conceive it, refers to the loca-
tion, at any point in the life cycle, of a person on a
continuum which ranges from excruciating emo-
tional pain and total psychological malfunctioning
at one extreme to a full, vibrant sense of psycho-
logical wellbeing at the other ([59], p.274).
A salutogenic orientation will focus on the
achievement of successful coping, which facili-
tates movement toward that end of the mental
health continuum which is a vibrant sense of psy-
chological well-being. Antonovsky proposed rel-
evant issues and questions to be answered by
health promoters. Understanding how people
move from the use of unconscious psychological
defence mechanism toward the use of conscious
coping mechanisms is where the emphasis lies,
from rigidity in a defensive structure to the capac-
ity for constant and creative inner readjustment
and growth, from a waste of emotional energy
toward its productive use, from emotional suffer-
ing toward joy, from narcissism toward giving of
oneself, and from exploitation of others toward
reciprocal interaction [59].
However, it is important to underline that the
salutogenic orientation is much more than the
salutogenic model of health [60]. Eriksson ([60],
p. 103) suggests to use the metaphor of an
umbrella to underline that salutogenesis is more
than Antonovsky’s salutogenic model of health.
Salutogenesis is an umbrella concept of theories
and concepts about assets for health and well-
being, including salutogenic elements and dimen-
sions [61]. The editors of The Handbook of
Salutogenesis discuss possible futures of the
salutogenic orientation, and Georg Bauer states:
If we narrowly follow Antonovsky’s conceptual-
ization, salutogenesis is about coping with miser-
able life situations or about “surviving the toxic
river of life”- leaving little space for looking at the
bright side of life. Applying salutogenesis to posi-
tive health development- or joyful swimming in
the river of life- is urgently needed ([60], p.442).
5.5 Conclusion
In summary, I claim that Keyes’ model of mental
health is an important contribution to the saluto-
genic orientation and the knowledge base of
health promotion. In this model, mental health is
dened by the presence of subjective well-being
[1], which is in line with the lived experiences of
former patients, who perceived mental health as
an ever-present aspect of life [7]. Keyes has also
given important contribution to the health promo-
tion eld by his two continua model of mental
health and mental illness in the same context.
Splitting the phenomenon of mental health and
the phenomenon of mental illness into two sepa-
rate, although related, phenomena is a meaning-
ful and useful way of understanding health and
illness for patients, relatives, and health care pro-
fessionals in the context of health care services.
Take Home Messages
• Mental health is an ever-present aspect of life.
• Mental health is about subjective well-being;
the individuals’ perceptions and evaluations
of their own lives in terms of their emotional
state and their psychological and social
functioning.
• Flourishing, as a term, describes the optimal
state of mental health.
• Mental Health Continuum—Short Form
(MHC-SF) is a structured scale that can quan-
tify mental health.
• The two continua model of mental health and
mental illness includes the presence of human
N. H. Mjøsund

57
capacities and functioning as well as the
assessment of disease or inrmity.
• Based on the understanding of mental health
and mental illness as two continua, it is possi-
ble to have good mental health with mental
illness and have poor or low mental health
without mental illness.
• The absence of mental illness does not equal
the presence of mental health, substantiating
that the causes of mental health are often dis-
tinct processes from those understood as the
risks for mental illness and disorder.
• There is cumulating evidence that mental
illness and mental health function along two
different continua with only moderate
correlation.
• The evidence-based salutogenic models of
mental health and the two continua model of
mental health and mental illness made by
Corey Keyes are signicant knowledge for
health promotion.
Acknowledgments The author would like to thank
Vestre Viken Hospital Trust, Department of Mental Health
Research and Development for making it possible to write
this chapter. Magnus Lien Mjøsund, thank you for review-
ing the language and for assisting in ne-tuning of the
gures.
References
1. Keyes CLM.The mental health continuum: from lan-
guishing to ourishing in life. J Health Soc Behav.
2002;43(2):207–22.
2. Keyes CLM. Promoting and Protecting positive
Mental health: early and often throughout the lifes-
pan. In: Keyes CLM, editor. Mental well-being: inter-
national contributions to the study of positive mental
health. Dordrecht: Springer; 2013. p.3–28.
3. Keyes CLM.Mental health as a complete state: how
the Salutogenic perspective completes the picture. In:
Bauer GF, Hämmig O, editors. Bridging occupational,
organizational and public health: a transdisciplinary
approach. London: Springer; 2014. p.179–92.
4. Keyes CLM. Mental illness and/or mental health?
Investigating axioms of the complete state model of
health. J Consult Clin Psychol. 2005;73(3):539–48.
https://doi.org/10.1037/0022-006X.73.3.539.
5. WHO. WHO denition of Health. Preamble to the
Constitution of the World Health Organization as
adopted by the International Health Conference,
NewYork, 19–22 June, 1946; signed on 22 July 1946
by the representatives of 61 States and entered into
force on 7 April 1948. ed: Ofcial Records of the
World Health Organization, no. 2, p.100; 1946.
6. Green J, Tones K. Health promotion: planning and
strategies. Los Angeles: Sage; 2010.
7. Mjøsund NH, Eriksson M, Norheim I, Keyes CLM,
Espnes GA, Vinje HF. Mental health as perceived
by persons with mental disorders—an interpretative
phenomenological study. Int J Ment Health Promot.
2015;17(4):215–33. https://doi.org/10.1080/1462373
0.2015.1039329.
8. Mittelmark MB, Bull T. The salutogenic model
of health in health promotion research. Glob
Health Promot. 2013;20(2):30–8. https://doi.
org/10.1177/1757975913486684.
9. Mjøsund NH. Positive mental health—from what to
how. A study in the specialized mental healthcare ser-
vice. Trondheim: Norwegian University of Science
and Technology, Faculty of Medicine and Health
Sciences, Department of Public Health and Nursing;
2017.
10. American Psychiatric Association. Diagnostic and
Statistical Manual of Mental Disorders 3rd ed.
Washington, DC: American Psyciatric Assocition.
1987.
11. Keyes CLM.Promoting and protecting mental health
as ourishing: a complementary strategy for improving
national mental health. Am Psychol. 2007;62(2):95–
108. https://doi.org/10.1037/0003-066X.62.2.95.
12. Keyes CLM.Why ourishing? In: Harward DW, edi-
tor. Well-being and higher education. A strategy for
change and the realization of education’s greater pur-
pose. Washington, DC: Bridging Theory to Practice;
2016. p.8.
13. Mjøsund NH, Eriksson M, Espnes GA, Vinje
HF. Reorienting Norwegian mental healthcare ser-
vices: listen to patients’ learning appetite. Health
Promot Int. 2018;day012:11. https://doi.org/10.1093/
heapro/day012.
14. Smith JA, Flowers P, Larkin M. Interpretative phe-
nomenological analysis: theory, method and research.
London: Sage; 2009.
15. Mjøsund NH, Eriksson M, Espnes GA, Haaland-
Øverby M, Jensen SL, Norheim I, et al. Service
user involvement enhanced the research quality
in a study using interpretative phenomenological
analysis: the power of multiple perspectives. J Adv
Nurs. 2017;73(1):265–78. https://doi.org/10.1111/
jan.13093.
16. Mjøsund NH, Eriksson M, Haaland-Øverby M, Jensen
SL, Kjus S, Norheim I, etal. Salutogenic service user
involvement in nursing research: a case study. J Adv
Nurs. 2018;74(9):2145–56. https://doi.org/10.1111/
jan.13708.
17. Keyes CLM, Wissing M, Potgieter JP, Temane M,
Kruger A, Van Rooy S. Evaluation of the men-
tal health continuum-short form (MHC-SF) in
setswana- speaking south Africans. Clin Psychol
Psychother. 2008;15(3):181–92. https://doi.
org/10.1002/cpp.572.
5 A Salutogenic Mental Health Model: Flourishing asaMetaphor forGood Mental Health

58
18. Atlanta: Brief description of the mental health contin-
uum short form (MHC-SF) [database on the Internet].
2009. https://www.aacu.org/sites/default/les/MHC-
SFEnglish.pdf. Accessed 25 Oct 2019.
19. Agenor C, Conner N, Aroian K.Flourishing: an evo-
lutionary concept analysis. Issues Ment Health Nurs.
2017;38(11):915–23. https://doi.org/10.1080/016128
40.2017.1355945.
20. Lamers SM, Westerhof GJ, Bohlmeijer ET, ten
Klooster PM, Keyes CLM.Evaluating the psychomet-
ric properties of the mental health continuum-short
form (MHC-SF). J Clin Psychol. 2011;67(1):99–110.
https://doi.org/10.1002/jclp.20741.
21. Hides L, Quinn C, Stoyanov S, Cockshaw W, Mitchell
T, Kavanagh DJ. Is the mental wellbeing of young
Australians best represented by a single, multidimen-
sional or bifactor model? Psychiatry Res. 2016;241:1–
7. https://doi.org/10.1016/j.psychres.2016.04.077.
22. Lupano Perugini ML, de la Iglesia G, Castro Solano
A, Keyes CLM.The Mental Health Continuum-short
form (MHC-SF) in the Argentinean context: con-
rmatory factor analysis and measurement invari-
ance. Eur J Psychol. 2017;13(1):93–108. https://doi.
org/10.5964/ejop.v13i1.1163.
23. Orpana H, Vachon J, Dykxhoorn J, Jayaraman
G.Measuring positive mental health in Canada: con-
struct validation of the Mental Health Continuum-
short form. Health Promot Chronic Dis Prev Can.
2017;37(4):123–30. https://doi.org/10.24095/
hpcdp.37.4.03.
24. Gallagher MW, Lopez SJ, Preacher KJ. The
hierarchical structure of well-being. J
Pers. 2009;77(4):1025–50. https://doi.
org/10.1111/j.1467-6494.2009.00573.x.
25. Guo C, Tomson G, Guo J, Li X, Keller C, Söderqvist
F. Psychometric evaluation of the Mental Health
Continuum-short form (MHC-SF) in Chinese ado-
lescents—a methodological study. Health Qual Life
Outcomes. 2015;13(1):198. https://doi.org/10.1186/
s12955-015-0394-2.
26. Rogoza R, Truong Thi KH, Różycka-Tran J, Piotrowski
J, Żemojtel-Piotrowska M.Psychometric properties of
the MHC-SF: an integration of the existing measure-
ment approaches. J Clin Psychol. 2018;74(10):1742–
58. https://doi.org/10.1002/jclp.22626.
27. Żemojtel-Piotrowska M, Piotrowski JP, Osin EN,
Cieciuch J, Adams BG, Ardi R, et al. The mental
health continuum-short form: the structure and appli-
cation for cross-cultural studies—a 38 nation study.
J Clin Psychol. 2018;74(6):1034–52. https://doi.
org/10.1002/jclp.22570.
28. Westerhof GJ, Keyes CLM. Mental Illness and
Mental health: the two continua model across the
lifespan. J Adult Dev. 2010;17(2):110–9. https://doi.
org/10.1007/s10804-009-9082-y.
29. Johnson BA, Riley JB.Psychosocial impacts on col-
lege students providing mental health peer support. J
Am Coll Health. 2019:1–5. https://doi.org/10.1080/0
7448481.2019.1660351.
30. Ferentinos P, Yotsidi V, Porichi E, Douzenis A,
Papageorgiou C, Stalikas A.Well-being in patients
with affective disorders compared to nonclinical
participants: a multi-model evaluation of the Mental
Health Continuum-short form. J Clin Psychol.
2019;75(9):1585–612. https://doi.org/10.1002/
jclp.22780.
31. Fledderus M, Bohlmeijer ET, Smit F, Westerhof
GJ.Mental health promotion as a new goal in public
mental health care: a randomized controlled trial of
an intervention enhancing psychological exibility.
Am J Public Health. 2010;100(12):2372. https://doi.
org/10.2105/AJPH.2010.196196.
32. Santini ZI, Meilstrup C, Hinrichsen C, Nielsen L,
Koyanagi A, Krokstad S, etal. Formal volunteer activ-
ity and psychological Flourishing in Scandinavia: nd-
ings from two cross- sectional rounds of the European
social survey. Soc Curr. 2018;6(4):2329496518815868.
https://doi.org/10.1177/2329496518815868.
33. Diener E.The science of Well-being: the collected
works of Ed Diener. Social indicators research series
37. NewYork: Springer Science & Business Media;
2009.
34. Diener E, Wirtz D, Tov W, Kim-Prieto C, Choi DW,
Oishi S, etal. New Well-being measures: short scales
to assess ourishing and positive and negative feel-
ings. Soc Indic Res. 2010;97(2):143–56. https://doi.
org/10.1007/s11205-009-9493-y.
35. Huppert FA, So TTC. Flourishing across Europe:
application of a new conceptual framework for den-
ing well-being. Soc Indic Res. 2013;110(3):837–61.
https://doi.org/10.1007/s11205-011-9966-7.
36. Kobau R, Seligman MEP, Peterson C, Diener E,
Zack MM, Chapman D, et al. Mental health pro-
motion in public health: perspectives and strate-
gies from positive psychology. Am J Public Health.
2011;101(8):e1–9. https://doi.org/10.1177/10253823
050120020103x.
37. Shucksmith J, Spratt J, Philip K, McNaughton R.A
critical review of the literature on children and young
people’s views of the factors that inuence their men-
tal health. Edinburgh: NHS Health Scotland; 2009.
38. Keyes CLM. Mental well-being: international con-
tributions to the study of positive mental health.
Dordrecht: Springer; 2013.
39. Iasiello M, van Agteren J, Keyes CLM, Cochrane
EM.Positive mental health as a predictor of recovery
from mental illness. J Affect Disord. 2019;251:227–
30. https://doi.org/10.1016/j.jad.2019.03.065.
40. Verhaeghe N, De Maeseneer J, Maes L, Van
Heeringen C, Annemans L.Health promotion in men-
tal health care: perceptions from patients and mental
health nurses. J Clin Nurs. 2013;22:1569–78. https://
doi.org/10.1111/jocn.12076.
41. Lerdal A.A concept analysis of energy. Its meaning
in the lives of three individuals with chronic illness.
Scand J Caring Sci. 1998;12(1):3–10.
42. International Health Promotion Hospitals and Health
Services. The New Haven recommendations on part-
nering with patients, families and citizens to enhance
performance and quality in health promoting hos-
pitals and health services clinical. Health Promot.
2016;6(1):1–15.
N. H. Mjøsund

59
43. Keyes CLM, Dhingra SS, Simoes EJ. Change in
level of positive mental health as a predictor of
future risk of mental illness. Am J Public Health.
2010;100(12):2366–71. https://doi.org/10.2105/
AJPH.2010.192245.
44. Keyes CLM. The next steps in the promotion and
protection of positive mental health. Can J Nurs Res.
2010;42(3):17–28.
45. Schotanus-Dijkstra M, Keyes CLM, de Graaf R, ten
Have M.Recovery from mood and anxiety disorders:
the inuence of positive mental health. J Affect
Disord. 2019;252:107–13. https://doi.org/10.1016/j.
jad.2019.04.051.
46. McGafn BJ, Deane FP, Kelly PJ, Ciarrochi
J. Flourishing, languishing and moderate mental
health: prevalence and change in mental health during
recovery from drug and alcohol problems. Addict Res
Theor. 2015;23(5):351–60. https://doi.org/10.3109/16
066359.2015.1019346.
47. Fan JK, Mustard C, Smith PM.Psychosocial work
conditions and mental health: examining differences
across mental illness and well-being outcomes. Ann
Work Expos Health. 2019;63(5):546–59. https://doi.
org/10.1093/annweh/wxz028.
48. Chan RCH, Mak WWS, Chio FHN, Tong
ACY. Flourishing with psychosis: a prospective
examination on the interactions between clinical,
functional, and personal recovery processes on well-
being among individuals with schizophrenia spectrum
disorders. Schizophr Bull. 2018;44:778–86. https://
doi.org/10.1093/schbul/sbx120.
49. Stanga V, Turrina C, Valsecchi P, Sacchetti E, Vita
A. Well-being in patients with schizophrenia, mood
and personality disorders attending psychiatric ser-
vices in the community. A controlled study. Compr
Psychiatry. 2019;91:1–5. https://doi.org/10.1016/j.
comppsych.2019.02.001.
50. Keyes CLM, Eisenberg D, Perry GS, Dube SR,
Kroenke K, Dhingra SS. The relationship of level
of positive mental health with current mental disor-
ders in predicting suicidal behavior and academic
impairment in college students. J Am Coll Health.
2012;60(2):126–33. https://doi.org/10.1080/0744848
1.2011.608393.
51. Schotanus-Dijkstra M, ten Have M, Lamers SMA, de
Graaf R, Bohlmeijer ET.The longitudinal relationship
between ourishing mental health and incident mood,
anxiety and substance use disorders. Eur J Public
Health. 2017;27(3):563–8. https://doi.org/10.1093/
eurpub/ckw202.
52. Trompetter HR, de Kleine E, Bohlmeijer ET. Why
does positive mental health buffer against psychopa-
thology? An exploratory study on self-compassion as
a resilience mechanism and adaptive emotion regu-
lation strategy. Cogn Ther Res. 2017;41(3):459–68.
https://doi.org/10.1007/s10608-016-9774-0.
53. de Vos JA, Radstaak M, Bohlmeijer ET, Westerhof
GJ.Having an eating disorder and still being able to
ourish? Examination of pathological symptoms and
well-being as two continua of mental health in a clini-
cal sample. Front Psychol. 2018;9:2145. https://doi.
org/10.3389/fpsyg.2018.02145.
54. Donnelly A, O’Reilly A, Dolphin L, O’Keeffe L,
Moore J. Measuring the performance of the Mental
health continuum-short form (MHC-SF) in a pri-
mary care youth mental health service. Ir J Psychol
Med. 2019;36(3):201–5. https://doi.org/10.1017/
ipm.2018.55.
55. Slade M. Mental illness and well-being: the central
importance of positive psychology and recovery
approaches. BMC Health Serv Res. 2010;10(1):26.
https://doi.org/10.1186/1472-6963-10-26.
56. Provencher HL, Keyes CLM.Complete mental health
recovery: bridging mental illness with positive men-
tal health. J Public Ment Health. 2011;10(1):57–69.
https://doi.org/10.1108/17465721111134556.
57. Antonovsky A.Unraveling the mystery of health: how
people manage stress and stay well. San Francisco:
Jossey-Bass; 1987.
58. Antonovsky A. Health, stress, and coping. San
Francisco: Jossey-Bass; 1979.
59. Antonovsky A. The life cycle, mental health and
the sense of coherence. Isr J Psychiatry Relat Sci.
1985;22(4):273–80.
60. Mittelmark MB, Sagy S, Eriksson M, Bauer GF,
Pelikan JM, Lindström B, et al. The handbook
of Salutogenesis. Cham: Springer International
Publishing AG; 2017.
61. Lindström B, Eriksson M.The Hitchhiker’s guide to
salutogenesis: salutogenic pathways to health promo-
tion. Helsinki: Folkhälsan; 2010.
Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License
(http://creativecommons.org/licenses/by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in
any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license and indicate if changes were made.
The images or other third party material in this chapter are included in the chapter's Creative Commons license,
unless indicated otherwise in a credit line to the material. If material is not included in the chapter's Creative Commons
license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to
obtain permission directly from the copyright holder.
5 A Salutogenic Mental Health Model: Flourishing asaMetaphor forGood Mental Health