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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 focus es 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 narrati ves 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 practice s.
Background
The World Health Organisation (WHO) declares that
health is “A state of complete physical, me ntal and social
well-being and not merely the absence of disease or infir-
mity “[1]. However, creating health-oriented rather than ill-
ness-oriented services has proved rather more difficult
than the clarity of this declaration would suggest. Efforts to
generate a science of illness have been very successful, with
shared taxonomies to identify types of illness, established
and validated interventions to treat and manage these iden-
tified illnesses, and clinical guidelines and quality standards
available to increase efficiency and equity. These successes
have not been mirrored by equivalent advances in applying
the science of well-being within health services. The typical
health worker will know a lot about treating illness, and far
less about promoting well-being.
In this article we u se me ntal health services as an
exemplar of the issue, and explore h ow mental health
services could more effectively promote well-being. Our
central argument is that mental health workers will
need new approaches to assessment and treatment if the
goal is promoting well-being rather than treating illness.
Well-being is becoming a central f ocus of international
policy, e.g. Canada [2] and the United Kingdom [3]. In
the same way that tertiary prevention is an important
health promotion strategy, well-being is possible for
people experiencing mental illness.
We will discuss two new emerging areas of knowledge
which are highly complementary, and provide a
* Correspondence: m.slade@iop.kcl.ac.uk
Health Service and Population Research Department (Box P029), Institute of
Psychiatry, King’s College London, Denmark Hill, London, SE5 8AF UK
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© 2010 Slade; licen see BioMed Centra l Ltd. This is an Open Access ar ticle distributed un der the terms of the Creative Commons
Attribu tion License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted u se, distribution, an d reproduction in
any me dium, provided the original work is prop erly cited.
counter-balance to the traditional focus of mental health
services on deficit amelioration. We will identify how
they link (and differ), and then explor e t heir implica-
tions for mental health workers. Specifically, we will
argue that assessment and treatment o f the individual
will need to change if the goal is promoting well-being
rather than treating illness, and that there are also
broader challenges for mental health professionals to
become more outward-looking in their view of their
role, and to construct their job as more than working
with individuals. We will conclude that a focus o n
improving social inclusion, becoming social activists
who challenge stigma and discrimination, and promot-
ing societal well-being m ay need to become the norm
rather than the exception for mental health professionals
in the 21
st
Century.
Discussion
The WHO declarati on about mental heal th is also clear:
it is “a state of well-being in which the individual rea-
lizes his or her own abilities, can cope with the normal
stresses of life, can work productively and fruitfully, and
is able to make a contribution to his or her community “
[1]. A relative lack o f workforce skills in promoting
well-being is particularly important in mental health ser-
vices, since mental disorders directly impact on personal
identity and ability to maintain social roles.
This distinction between mental illness and mental
health is empirically validated, with only modest correla-
tions between measures of depression and measures of
psychological well-being, ranging from -0.40 to -0.55
[4,5]. A more statistically robust approach is a confirma-
tory factor model, which showed that the latent factors
of mental health and mental illness in a US sample (n =
3,032) correlated at 0.53, indicating that only one quar-
ter of the variance between measures of mental i llness
and mental health is shared [6].
Why is this distinction important? Because it points to
the need for mental health professionals to support both
the reduction of mental illness and the improvement o f
mental health. This will involve the development of
further skills in the workforce. These skills will be based
on two new areas of knowledge, each of which have
emerged as distinct scientific areas of enquiry only in
the past two decades.
New area of knowledge 1: Recovery
People personally affected by mental illness have
become increasingly vocal in communicating both what
their life is like with the mental illness and what helps
in moving beyond the role of a patient with mental i ll-
ness. Early accou nts were written by individual pioneers
[7-12]. These brave, and sometimes oppositional and
challenging, voices provide eco logically valid pointers to
what recovery looks and feels like from the inside. Once
individual stories were more v isible, compilations and
syntheses of these accounts began to emerge from
around the (especially Anglophone) world, e.g.from
Australia [13], New Zealand [14-17], Scotland [18,19],
the USA [12,20,21] and England [22,23]. The under-
standing of recovery which has emerged from these
accounts emphasises the centrality of hope, identity,
meaning and personal responsibility [13,24,25]. We will
refer to this consumer-based understanding of recovery
as personal recovery, to reflect its individually defined
and experienced nature [26]. This contrasts with tradi-
tional clinical imperatives - which we will refer to as
clinical recovery- which emphasise the in variant impor-
tance of symptomatology, social functioning, relapse
prevention and risk management. To note, this distinc-
tion has been referred to by other writers as recovery
“from” versus recovery “in” [27]; clinical recovery versus
social recovery [28]; s cientific versus consumer models
of recovery [29]; and service-based recovery versus user-
based recovery [30].
Opinions in th e consumer literature about recovery
are wide-ranging, and cannot be uniformly charac-
terised. This multiplicity of per spectives in it self has a
lesson for mental health services - no o ne approac h
works for, or ‘fits’, everyone. There is no right way for a
person to recover. Eliciting idiographic knowledge -
understanding of s ubjective phenomema - is an impor-
tant clinical skill. Nonetheless, some themes emerge. A
first clear point of divergence from t he clinical per spec-
tive is that recovery is seen as a journey into life , not an
outcome to be arrived at: “re covery i s not a bout ‘ getting
rid’ of problems. It is about seeing people beyond their
problems - their abiliti es, possibilities, interests and
dreams - and recovering the socia l rol es and relation-
ships that give life value and meaning “ [31].
Many definitions of recovery have been proposed by
those who are experiencing it [8,18]. We will use the
most widely-cited definition that “recovery is a deeply
personal, unique process of changing one ’s attitudes,
values, feelings, goal s, skill s, and/or roles. It is a way of
living a sa tisfying, h opeful, and con tributing life even
within the limitations caused by illness. Recovery involves
the development of new meaning and purpose in one’s
life as one grows beyond the catastrop hic effects of men-
tal illness “ [32].Itisconsistentwiththelesswidely-
cited but more succinct definition that recovery involves
“the establishment of a fulfilling, meaningful life and a
positive sense of identity founded on hopefulness and self
determination “ [13].
One implication of these definitionsisthatpersonal
recovery is an individual process. Just as there is no one
right way to do or experience recovery, so also what
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
focussed on promoting personal rec overy, then this
means there cannot be a s ingle recovery model for ser-
vices. This is a profound point, and challenging to estab-
lished concepts such as clinical guidelines, evidence-
based practice and care pathways. A recurring feature in
recovery narratives is the individual engaging or re-
engaging in their life, on the basis of their own goals
and strengths, and finding meaning and purpose
through constructing or reclaiming a valued identity and
social roles. A ll of this points to w ell-bein g rathe r tha n
treatment of illness. There is now a scientific discipline
- positive psychology - devoted to the promotion of
well-being.
New area of knowledge 2: Positive Psychology
Positive psychology is the science of what is needed for
a good life. This is not a new focus - proposing qualities
needed for a good life is an activity dating back to A ris-
totle’s investigation of eudaimonia, and builds on semi-
nal work in the last Century by Antonovsky [33], Rogers
[34] and Maslow [35]. But the emergence of a scientific
discipline in this area is a modern phenomenon. Mart in
Seligman, often identified along with Mihaly Csikszent-
mihalyi as the founde rs of the discipline, suggests a defi-
nition [36]:
The field of positiv e psychology at the subjective level
is about valued subjective experiences: well-being,
contentment, and satisfaction (in the past); hope and
optimism (for the future); and flow and happiness (in
the present).
At the individual level, it is about positive individual
traits: the capacity for l ove and vocati on, cou rage,
interpersonal skill, aesthetic sensibility, perseverance,
forgiveness, originality, future mindedness, spiritual-
ity, high talent, and wisdom.
At the group level, it is about the civic virtues and
the institutions that move individuals toward better
citizenship: responsibili ty, nurturance, al truism, civi-
lity, moderation, tolerance, and work ethic.
Research centres are developing internationally (e.g.
http://positivepsychologyaustralia.org, http://cappeu.com,
http://centreforconfidence.co.uk). Academic compilations
of the emerging empirical evidence [37,38] and accessible
introductions to the theory [39,40] and its applications
[41] are becoming available. Findings from positive psy-
chology are important to mental health services because
its focus on a good life is as relevant to people with men-
tal illness as to people without mental illness.
One key advance is in relation to empirical investiga-
tion of mental health. A conceptual framework is
provided by the Complete State Model of Mental Health
[42], proposed by Corey Keyes, and shown in Figure 1.
This model identifies t wo dimensions. Mental illness
lies on a spectrum, from absent to present. Well-being
also lies on a spectrum, from low to high.
This conceptual framework easily maps on to the
themes emerging in the recovery literature. A perennial
question about recovery is “How can you be recovered
if you still have the mental illness?”.Whateveranswers
are given, they can be only partial answers since the
term recovery is an illness term. By contrast, access to
mental health is open to all. This provides an alternative
frame of understanding for recovery [26]:
Personal recovery involves working towards better
mental health, regardless of t he presenc e of me ntal
illness
People with mental illness who are i n recovery are
those who are a ctively engaged i n working away from
Floundering (through hope-supporting relationships)
and Languishing (by developing a positive identity), and
towards Struggling (through Framing and self-ma naging
the mental illness) and Flourishing (by developing
valued social roles).
This concept of mental health has been operationa-
lised into 13 dimensions, across the domains of emo-
tional well-being, psychological well-being and social
well-being [6,43]. The se d imensions have be en emp iri-
cally validated [4,44], and are shown in Additional file 1.
Like mental illness, the concept of mental health can
be expressed as a constellation of factors. Using the
same diagnostic framework as DSM uses for major
depression, the condition of Flourishing is defined as
requiring high levels in Dim ensions 1 (Positive affect) or
2 (Avowed quality of life) to be present, along with high
levels on at least 6 of the 11 dimensions of positive
functioning (Dimensions 3 to 13). Similarly, to be diag-
nosed as Languishing, individuals must exhibit low
levels on one of the emotional well-being dimensions,
and low levels on 6 of the remaining 11 dimensions.
Adults who are neither flourishing nor languish ing are
said to be moderately mentally healthy. Finally, complete
mental health is defined as the absence of mental illness
and the presence of flourishing.
What is the prevalence of mental health, using these
definitions? A cross -sectional a ssessment in the US
population [43] (n = 3,032) is shown in Table 1.
A similar US study of youth (n = 1,234) found 6% of
12 to 14 year olds Languishing, 45.2% with Moderate
Mental Health, and 48.8% Flourishing, with respective
proportions of 5.6%, 54.5% and 39.9% in 15 to 18 year
olds [45].
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These results have two profound implications. First,
careful consideration should be given to the balance
between research into mental illness and mental health.
Among US adults with no mental illness, one in 1 0 are
languishing and less than 2 in 10 are flourishing. The
implicit expectation that research into mental illness
will promote mental well-being is neither empirically
justified nor a cost-free assumption - the opportunity
costs for an illness-dominated research agenda may be
high. For example, Flourishing is aligned with concepts
such as self-righting, self-efficacy and mastery as charac-
teristics which crit ically impact on the ability to self-
manage. As Keyes puts it [6]:
In particular, is languishing a diathesis for, and is
flourishing a protective factor against, the onset and
recurrence of mental illness? Conceptually, one can
think of mental health as the continuum at the top
of the cliff where most individuals reside. Flourishing
individuals are at the healthiest and therefore farth-
est distance from the edge of this cliff; languishing
places individuals very near the edge o f the c liff.
Hence, languishing may act as a diathesis that is
activated by stressors that p ush individuals off the
cliff and into mental illness(p. 547)
There is empirical suppo rt fo r this proposition. One
validated approach involves training for optimism, by
modifying the three components of explanato ry style
(permanence, pervasiveness, personalisation) through
transforming negative thinking into positive cognitive
processes t hat 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
Figure 1 Complete State Model of Mental Health.
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A study involving 70 children at high risk of depres-
sion showed that this technique reduced depressive
symptomatology and lowered incidence rates at 2 -year
follow-up [46]. In a mental health service context,
there is also emerging evidence that positive life events
are important protective factors [47]. A study of 260
people with severe mental illness showed that an
increasing ability to engage in pleasurable activities
leads to the ability to regulate dep ressive symptoms to
thepointwheretheydidnotimpactonidentityby
eroding self-esteem [48].
Thesecondimplicationisthatitispossibletobe
moderately menta lly healthy, or even flourishing, despite
the presence of ongoing mental illness. In other words,
personal recovery is possible even in the presence of
current symptoms. Cook and J onikas label t his process
as thriving, in which individuals rebuild lives with quali-
ties better than before their difficulties began [49]. Inter-
ventions which support the individual in moving
towards mental health may be as important as interven-
tions which address the mental illness.
Positive psychology is specifically relevant to perso-
nal recovery. Factors identified by consumers as
important for their recovery include hope, spir ituality,
empowerment, connection, purpose, self-identity,
symptom management and st igma [30]. All but symp-
tom management are almost entirely absent from pro-
fessional training [50]. A n influential framework, and
one which could underpin the training of mental
health professionals, is Seligman’s theory of Authentic
Happiness [51,52]. T his ide ntifies different types of
good life:
1. The Plea sant Life, which consists in having as
much positive emotion as p ossible a nd learning the
skills to prolong and intensify pleasures
2. The Engaged Life, which consists in knowing y our
character (highest) strengths and recrafting your work,
love, friendship, play and parenting to use them as
much as possible
3. The Meaningful Life, which consists in using your
character strengths to belong to and serve something
that you believe is larger than just your self
4. Th e Achievi ng Life , which is a life dedicated to
achieving for the sake of achievement.
This framework points to the possibility of different
types of good life - which means that a range of
approaches to pro moting well-being are needed. For
example, the positive psychology literature has
addressed the question of how to lead an engaged life.
A key emergent concept is flow, which requires two
conditions [53]:
a) Perceived chal lenges tha t stretc h (i.e. neither over-
match nor under-utilise) existing skills - a sense that
one is engaging challenges at the level of one’s capacities
b) Clear proximal (short-term) goals and immediate
feedback on progress
They define being in flow as:
the subjective e xperience of engaging just-manageable
challenges by tackling a series of goals, continuo usly
processing feedback about progress, and adjusting
action based on this feedback (p. 90)
In terms of flow, a good l ife is one that involves com-
plete absorption in what one does.
Flow is an important concept for mental health pro-
fessionals to understand, s ince it is the structural oppo-
site of positive emotion. Flow is a subjective experience,
but unlike positive emotions it is not defined by feelings.
Rather, it results from doing activities we like. Indeed,
80% of people report that when in flow, feelings and
thinking are temporarily blocked [53]. This means that
feeling good is not always necessary for a good life.
Consequently, an automatic focus on taking away
experiences of unhappiness (such as symptoms of
depression) may be counter-productive. It is possible to
experience authentic happiness by living a meaningful
life that comes through full engagement. This of course
has implications for how mental health services work -
the aim may not be to help the person to feel better,
but to re-engage in their life. What this means for men-
tal health services is that a central challenge is support-
ing reasonable goal-setting and goal-striving. These
goals need to be:
1. Personally relevant, rather than meeting the needs of
staff
There may of course be other reasons for s taff-based
care planning, but care plans focussed on clinical risk,
medication compliance, relapse prevention and symp-
tom reduction will not promote personal recovery
2. The right level of challenge
The concept of a reasonable goal captures the balance
in setting goals which are neither too easy (leading to
boredom and distraction) nor t oo difficult (leading to
anxiety and heightened self-awareness). A good life is
not achieved by simply lowering expectations, as com-
mentators from both left-wing politics (who want more
justice) and right-wing politics (who want more excel-
lence) hav e noted [54]. But nor is it achieved by raising
expectations too high - recovery should be a journey,
not a tread-mill.
3. Proximal rather than distal
Short-term goals provide more opportunity to become
engrossed in the experience, and make engaged goal-
striving more likely
4. Structured so that feedback is immediate and authentic
It is this immediate feedb ack loop that promotes full
attentional awareness on the challenge
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One approach to increasing well-being is therefore to
support personally-relevant goal-setting and goal-striving
activity. The Col laborative Recovery Model emphasises
key recovery values of autonomy and self-determination
[55], and builds on an established evidence base around
personal goal-setting and goal-striving [56]. Preliminary
evaluations of CRM are positive, showing improvements
in staff attitudes (e.g. hopefulness) and knowledge [57].
A 10-site randomised controlled trial across thre e Aus-
tralian states is underway.
Future-oriented goal-setting is not the only approach,
and some traditions emphasise being over becoming: “so
we never live, but w e hope to live; and as w e are always
preparing to be happy, it is inevitable we should never be
so“ [58] (p. 87). A second approach to increasing well-
being is to pay more attention to spiritual development
and healing [59]: “Th e healing process not only incorpo-
rates a new way of living with and controlling symptoms,
but also an increasing adeptness of navigating social
realms to overcome stigmatizing and discriminatory social-
structural beliefs and practices. Re-authoring hinges on
reclaiming a positive self-concept.” (p.14).Healingasa
spiritual activity [60], the role of moral experience [61],
the role of community rather than individualism [62], the
place of religion in mental health services [63] and
approaches to supporting spirituality [64] are all contribu-
tors to well-being.
Parallels between positive psychology and recovery
There are parallels between the position of recovery
ideas in the mental health system and the position of
positive psychology in the family of psychology disci-
plines [ 65]. Some points of conve rgence a re shown in
Additional File 2.
Two points of divergen ce can be identified [65]. Fi rst,
the positive psychology focus has explicitly been on bal-
ancing the preoccupations of clinical psychology by dis-
tancing from the “study of pathology, weakness, and
damage“ [36]. Most empirical research has therefore
involved people with either no mental illness or with
mild to moderate common mental disorders such as
depression and anxiety. An implicit, and sometimes
explicit [66], dichotomous assumption is that healthy
people will benefit from positive psychology, whereas
people with mental illness will continue to require
‘ne gative’ psychology. There is no evidence for this
assumption, an d indeed the convergen ce of narratives
from people with mental illness around key positive psy-
chology themes (e.g. meaning, agency, empowerment,
hope and r esilience) sugges ts that the opposite may be
true. As Resnick and Rosenheck put it [65]:
Proponents of the recovery model would instead
argue that the existence of “ pathology” is not
equivalent to “weakness and damage” and should not
preclude a focus on what is healthy. The benefits of
positive psychology might be even greater for people
with severe psychiatric disabilities than for those
without such impairments. (p. 121)
A second point of divergence is methodological. Pro-
ponents of the re covery approach have focussed on
developing position statements [67], consensus state-
ments [68], frameworks [69],guidelines[70],andother
action- and change-oriented approaches. This has been
more successful at influencing policy t han positive psy-
chology. The relatively small amount of empirical recov-
ery research has in gene ral u sed ind uctive methods,
such as collating and synthesising narratives. This is
consistent with an emphasis on individual meaning and
experience, since grouping the responses of participants
necessarily reduces the granularity of analysis. Howev er,
the consequence is difficulty in making the intellectual
case to clinicians with influence to change the mental
health system, who tend to value nomothetic group-
level evidence.
By contrast, positive psychology is unequivocally
based on empirical research, and unlike recovery-
focussed research has not avoided the use of nomo-
thetic approaches, even to assess complex constructs
such as meaning of lif e [71]. Indeed, it has been criti-
cised for under-use of qualitative methods [72]. This
scientific orientation has led to an emphasis on con-
ceptual clarity, the use of scientific methods, and c on-
vergence on overarching theories [51]. T he result is an
academically credible scientific discipline [37], whose
evidence is based on robust scientific m ethodologies
[73]. It has not, however, yet been highly influential in
international policy.
Why has there not been a greater rapprochement
between these two, apparently compatible, groups? This
may be because of their differing aims [65] - one is “an
intellectual movement, led by prominent academic psy-
chologists, that challenges the dominance of “ negative
psychology”, whereas the other is “a grassroots movement
of the disenfranchised that has placed itself apart from
thehumanserviceprofessions,theacademy,andthe
empirical research tradition“ (p. 121).
A second reason may be the name of the disci pline.
Positioning it as a branch of psychology invokes unhelp-
ful tribal loyalties - it suggests a relevance to psycholo-
gists but not other types of researche rs or professionals.
The oppositional perspective of some positive psycho lo-
gists reinforces this divergence [74]. The name is mis-
leading - well-being is a potential focus for many
disciplines. Anthropologists would help us understand
the association between social systems and well-being.
Geneticists will create designer-baby dilemmas when
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they can select embryos which are more likely to be
happy. Sociology could investigate how the meaning of
well-being is constructed and identify influences on its
evolution. What are the neuroanatomical correlates of
resilience? What philosophical perspective is associated
with maximum well-being? Can we teach children com-
passion? The field is far larger than the name implies,
and highly cross-disciplinary. A less loaded name for the
discipline w ould be helpful, either a neologism (positol-
ogy?) or a more neutral term such as positive well-
being.
This divergence is impoverishing for both groups. The
conc ordance betwe en t he fundamental ai ms of recovery
in mental illness and of positive psychology suggests
valuable lessons may be learned in both directions. For
recovery, the development of a clinically credible evi-
dence base, including randomised controlled trial evi-
dence, has potential to be an important pathway to
transforming mental health services. The preponderance
of good ideas and relative paucity of evaluative research
has been highlighted as a key problem in getting recov-
ery-focussed practice into everyday mental health prac-
tice [75]. Whilst there are tensions between the values
of ev idence-based ment al health and recovery [76],
there is no fundamental incompatibility [77]. For exam-
ple, the use of an invariant primary outcome for all par-
ticipants in a clinical trial does not capture the
individual nature of recovery, and innovative approaches
to individualising clinical end-point measurement are
now being evaluated in the REFOCUS S tudy http://
researchintorecovery.com. Similarly, the need of profes-
sionals for a conceptual framework to understand
recovery which does not become a ‘model’ showing the
‘right’ way to recovery is addressed in the Personal
Recovery Framework which gives primacy to identity
over illness [78].
For positive psychology, the incorporation of th e cen-
tral recovery focus on the individual and their differing
ways of seeing the world (including giving primacy to
familial or cultural affiliat ion over personal identity) will
address c riticisms t hat it is ethnocentric (being based
mainly on US research) and overly concerned with the
experience of individuals rather than groups [78,79].
Additionally, if there are ways in which people with
mental illness are outliers (e.g. in having a relatively low
ratio of protective to risk f actors), then excluding them
from consideration makes the development of generali-
sable theories more difficult.
Implications for mental health assessment practices
How can a person with mental illness be as sess ed if the
clinical goal is to promote well-being? Clinical assess-
ment should focus on four dimensions [80]:
1. Deficiencies and undermining characteristics of the
person
2. Strengths and assets of the person
3. Lacks and destructive factors in the environment
4. Resource and opportunities in the environment
Traditional clinical assessment practice - exemplified
by the mental state assessment - focuses almost exclu-
sively on dimension 1. This focus has arisen for several
reasons. First, multi-dimensional assessment is hard
work. Each dimension is dynamic and changing, and
inter-dependent in complex ways. Holding this com-
plexity is intellectually demanding, and requires a ten-
tative stance and openness to changing understanding.
It is much easier and in some ways more rewarding to
be the clinical expert, who can summarise the pro-
blems of the perso n ( i.e. dimension 1) with a pithy
piece of professional language. This issue will reduce
with the development of a shared taxonomy and lan-
guage for dimensions 2 to 4. This is beginning to
emerge. For example, the concept of character
strengths has been disaggregated into six core virtues
of wisdom, courage, humanity, justice, temperance and
transcendence [81]. Similarly, positive affect has been
disaggregated into Joviality (e.g . cheerful, happy, enthu-
siastic), Self-Assurance (e.g. confident, strong, daring)
and Attentiveness (e.g.alert,concentrating,deter-
mined) [82].
Second, the expectation in the mental health system
that it is the person who is going to be treated inevitably
leads to a focus of attention on the individual. This o f
course is a consequence of clinical (and patient) beliefs
about what the job is, and doesn’t have to be the case.
Third, the clinician’s illusion means that professionals
don’t see people as often when they are coping [83], so
they gain the false impression they cannot cope or self-
right.
Finally, the questions asked impose a structure on the
dialogue, and influences content. The highly practised
deficits-focussed discourse of taking a psychiatric history
systematically identifies all the deficient, inexplicable,
different and abnormal qualities and experiences of the
person. This focus on deficits (and the other Ds: diffi-
culties, disappointment, diagnosis, disease, disability, dis-
empowerment, disenfranchisement, demoralisation,
dysfunction) reinforces an il lness identit y, and the per-
son disappears. Up close, nobody is normal: a deficit-
focussed discourse will always elicit confirmatory evi-
dence for an illness-saturated view of the person.
An alternative approach is possible [84]. In assess-
ment, t his involves a greater emphasis on the indivi-
dual’s goals and strengths, an approach which has been
developed and evaluated in the Str engths Model [85].
Other approaches which emphasise well-being over
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deficits in assessment processes are person-centred plan-
ning [86,87] and Wellness Recovery Action Planning
[88]. What these have in common is an assumption that
it is more productive to focus on what the person wants
in their life and what they can do towards their own
goals than on what the professional thinks is in the per-
son’s best interests and on what the person cannot do.
Interventions in mental health services to promote well-
being
What interventions increase levels of well-being or
amplify existing strengths?
Cognitive behavioural therapy (CBT)
This psychological intervention will be familiar to most
clinical readers, so no introduction will be given. Com-
petently-provided CBT is aligned with many elements of
promoting recovery and personal well-being: a focus on
personally-valued rather than service-valued goals;
responsibility for change lies with the patient not the
therapist; the development of meta-cognitive awareness
- an awareness of thoughts being distinct from self -
which creates the context in which a positive identity
can flouris h, despite the pres ence of ongoing s ymptoms
of mental illnes s; enhancing self-management skills and
reinforcing interdependence and independence rather
than dependence, leading to sustained gains after the
end of the formal therapy; and an emphasis on home-
work, reality testing and learning opportunities which all
contribute to keeping the person in their life during
therapy. If unhappiness is caused by a mismatch
between self and ideal-self images, then CBT has the
potential to focus on the environmental reality as much
as the personal interpretation of experience. This points
to a wider role for professionals, a point we will return
to. Recent approaches to CBT exp licitly focus on build-
ing strengths and resilience [89].
Mindfulness
Meditation is “a family of techniques which have in com-
mon a conscious attempt to focus attention in a non-
analytical way, and an attempt not to dwell on discur-
sive, ruminative thought“ [90]. Teaching meditation to
membe rs of the publi c increases self-reported happiness
and well-being, changes which are corroborated by heal-
thier EEG readings, heart rates and flu immunity [91].
Meditation has been applied to mental health issues,
such as anger [92] and - in the form of mindfulness-
based cognitive therapy (MBCT) - depression [93].
Mindfulness, like prayer [94], is a form of meditation
which involves attending non-judgmentally to all stimuli
in the internal and external environment but to avoid
getting caught up in (i.e. ruminatin g o n) an y part icular
stimulus. Mindfulness requires a different mind-set to
the quick-fix of a magi c pha rmacological or psycho logi-
cal bullet. Just as becoming a top-class vio linist requires
10,000 hours of practice with a competent teacher [95],
so too mindfulness needs to become a way of life if it is
to transform identity. It involves changing habits:
• enhancing meta-cognitive awareness by noticing
what one is thinking about
• developing the ability to urge-surf by noticing but
not being caught up in rising cognitions
• developing cognitive fluidity - taking habits from
one space and using in another (e.g. using meta-
phors: thoughts as passing cars; thoughts as clouds;
hare brain, tortoise mind)
• paying attention to a wider range of the available
percept or experiences
The pay -off in terms of well-being is high. Mindfulness
has the potential to lead to a reconstructed, more complex
identity, in which self and thought are separated. Develop-
ment of a watching self gives a different means of respond-
ing to and working on experiences of mental illness.
Developing habits of greater occupation of the available
attention reduc es rumination and increases being in the
moment - the flow concept we discussed earlier [96]:
...by increasing the amount of time a person sp ends
thinking grateful and calming thoughts, there is sim-
ply less time to think upsetting and ‘’un helpful’’
thoughts. Assuming that attention is a zero-sum
game, the most efficient way to reduce negative and
increase positive thoughts and emoti ons may be to
focus on increasing the positive.(p. 28)
Overall, the personal qualities cultivated through
mindfulness practice are nonjud ging, nonstriving, accep-
tance, patience, trust, openness, letting go, gentleness,
generosity, empathy, gratitude and lovingkindness [97] -
qualities which are highly relevant to the personal recov-
ery journey of people with mental illness.
Narrative psychology
A further clinical approach emerges from a sub-disci-
pline called narrative psychology, which investigates the
value of translating emotional experiences into words.
This brings together insights fro m three strands of
research (primarily from European and American cul-
tures) [98]:
1. Inhibition - no t talking abo ut emotional trauma i s
unhealthy
2. Cognitive - devel opment of a self-narrative allows
closure
3. Socia l dynamics - keeping a secret detache s one
from society.
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One approach involves asking people to write about (or
in other ways generate an account of) their experiences, as
a means of making sense of their own story. The most
beneficial story content includes placing the story in a
context appropriate to its purpose, the transformation of a
bad experience int o a good o utcome, and the imposition
of a coherent structure [99]. Developing stories about
growth, dealing with difficult life events and p ersonal
redemption all c ontribute to a positive narrative identity
[100]. Empirical evidence suggests that this approach is
particularly beneficial for groups who, as a whole, are not
as open about their emotions: men [101], people with high
hostility [102], and people with alexythimia [103].
Positive Psychotherapy
An approach which brings together several of these
methods is positive psychotherapy (PPT) [104]. The
focus in PPT is on increasing positive emotion,
engagement and meaning. For example, groups for
depression undertake a series of weekly exercises.
Week 1 (Using Your Strengths) involves using the
Values in Action Inventory of Strengths [81] to assess
your top five strengths, and think of ways to use those
strengths more in your everyday life. Week 2 (Three
Good Things/Blessings) involved writing down three
good things every evening that happened today, and
whyyouthinktheyhappened.Week3(Obituary/Bio-
graphy) involves imagining that you have passed away
after living a fruitful an d satisf ying life, and writing an
essay summarising what you would most like to be
remembered for. Week 4 (Gratitude Visit) involves
thinking of someone to whom y ou are very grateful,
but whom you have never properly thanked, compos-
ing a letter to them describing your gratitude, and
reading it to the person by phone or in person. Week
5(Active/ConstructiveResponding) involves reacting
in a visibly po sitive and enthusiast ic way to go od news
from someone else at least once a day. Week 6
(Savouring)involvesonceadaytakingthetimeto
enjoy something that you usually hurry through, writ-
ing write down what you d id, how you did it differ-
ently, and how it felt compared to when you rush
through it. These exercises are intended to amplify
components of Auth entic Happiness [51]. Randomi sed
controlled trials o f g roup PPT with mild to moderately
depressed students (n = 40) and individual PPT with
severely depressed mental health clients (n = 46) both
showed gains in symptom reduction and happiness,
with moderate to large effect sizes and improvement
sustained at one-year follow-up [104].
We have considered some approaches to focussing more
on strengths, goals and preferences. However, if mental
health services are to fully support recovery and promote
well-being, it may not be enough to simply counter-
balance a focus on individual deficit with a focus on indivi-
dual capability, since this leaves unchallenged the cl inical
belief that treatment is something you do first, after which
the person gets on with their own life. This is highlighted
as an unhelpful approach in the accounts from people
who wr ite about their recovery from mental illness. For
example, Rachel Perkins notes [105]:
Mental health problems are not a full time job - we
have lives to lead. Any services, or treatments, or
interventions, or supports must be judged in these
terms - how much they allow us to lead the lives we
wish to lead.
Societal implications
We therefore now raise some potential implications of
positive psychology for the job of the mental health pro-
fessional at the social, r ather than individual, level. This
is underpinned by an emerging understanding of the
importance of relationships and connection for indivi-
dual and social well-being. For example, an international
consortium of 450 academics has recently produced
reports about determinant s and influences on well-being
[106]. This important document has been summa rised
by the New Economics Foundation http://www.new eco-
nomics.org as Five Ways To Wellbeing: Connect (to
others, individually and in communities); Be a ctive;
Take notice (of the world); Keep learning; and Give (e.g.
smile, vo lunteer, join in). It is no coincidence that these
are all outw ard-looking recommen dations, more about
engaging in and living life to the full than sorting out
any internal or intrapsychic disturbances. Stigma and
discrimination stop people with mental illness from
exercising their full rights as citizens a nd meeting their
human needs for connection [107]. Therefore, the role
of the mental health professional should be about chal-
lenging stigma and creating well- being-promoting socie-
ties as well as treating illness.
Mental health professionals can improve social inclusion
Supporting people using mental health services from
accessing normal ci tizenship entitlement s is a central (i.
e. not an optional extra) part of the job. We illustrate
this in relation to employment.
If a single outcome measure had to be chosen to
capture recovery, there would be a case to make t hat it
should be employment status. Not because of a value
about economic productivity, but because work has so
many associated benefits. There is now a strong evi-
dence base that Individual Placement and Support
(IPS) approaches which support the person to find
and maintain mainstream employment are better
than training the person up in separate sheltered
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employment schemes in preparation for mainstream
work [108,109]. Mental health professionals can
increase the access of service users to the valued social
role of work by supporting the development of
employment schemes [110].
One spec ific work opportunity is within mental health
services. These are often large employers - the N ational
Health Serv ice in the UK is the largest employer in Eur-
ope. However, health services have a history of poor
recruitment and retention approaches to attracting peo-
ple with declared mental illness to work for them [31].
(Of course, many people working in these services have
an undisclosed history of mental illness.) This is a
wasted opportunity, and reinforces stigmatising us-and-
them beliefs in the work-force. Actively encouraging
applications from people who have used mental health
services for all posts, and positively discriminating
between applicants with the same skill level in favour of
people with a history of mental illness are two relevant
approaches. T hey directly challenge “the common ten-
dency in human service organisations to see workers as
either health and strong and t he don ors o f care, or as
weak and vulnerable recipients“ [108].
There are other ways in which mental health profes-
sionals and teams can improve social inclusion. A
common experience of workers in the mental health
system is frustration - a sense that these ideas about
social inclusion, employment and social roles are all
well and good, but impossible to implement within the
existing constraints. But resources can become a vail-
able by spending allocated money differently. This is
the approach used by The Village http://www.mhavil-
lage.org, a mental health service in inner-city Los
Angeles working with homeless and severely mentally
ill clients. The service decided to undergo a ‘fiscal
paradigm shift’, by spending money to promote well-
ness and recovery (especially by creating pathways
back into employment) rather than promote stability
and maintenance. This involved transforming from
being an organisation which spent most of its allocated
money on acute hospitalisation (28%), long-term care
(23%) and out-patient therapy (23%) to one spending
on individualised case management (41%), work (25%)
and community integration (12%) [111]. Hospitalisa-
tions and living in institutional residence are markedly
reduced for members attending the Village [112],
allowing the money saved to be re-invested in work-
supporting services.
A further contribution from the clinician can be edu-
cating l ocal employers about their l egal duties under
relevant discrimination legislation and about reasonable
work-place adjustments for people with mental
illness. The accommodations can relate to People
(focussing on interpersonal challenges), Places (focussing
on where the work takes place), Things (focussing on
equipment needed to do the job) or Activities (focussing
on the work tasks). For people with physical disability,
accommodation needs tend to relate to Places and
Things. This is what employers are used to. In mental
illness, People issues are often the central issue. Employ-
ers need educ ating about how the se interpersonal needs
can be tended to, which might include [108]:
• addressing concentration problems by having a qui-
eter work plac e with fewer distractions rather than
an open-plan office
• the need to have so me time away from other
workers
• enh anced supervision to give feedback and guidance
on job performance
• allowing the use of headphones to block out dis-
tracting noise (including hearing voices)
• flexibil ity in working hours, e.g.toattendclinical
appointments or work when less impaired b y
medication
• mentor scheme for on-site orientation and support
• the need to talk to a supporter (e.g.ajobcoach)
during a lunch break
• clear job description for people who find ambiguity
and uncertainty difficult
• prior discussion about how leave due to illness will
be managed, e.g. allowing the use of accrued paid
and unpaid leave
• relocation of marginal job functions which are dis-
turbing to the individual
Alongside this direct contribution to improving social
inclusion, well-being focussed mental health profes-
sionals of the future will also have a contribution to
make to policy.
Mental health professionals can increase societal well-
being
If a new knowledge base around well-being is integrated
by mental health professionals into their practice, then
this creates opportunities to influence social and politi-
cal priorities. The position power and status of the r ole
allow authoritative communication with the aim of
influencing society and increasing wellbeing both for the
general population and specifically for people with
experience of mental illness. A few examples will illus-
trate this re-orientation.
Does money bring happiness? Above a certain level
(estimated by Richard Layard as US$20,000pa [54]), the
answer is no - relative wealth is more of an influence on
happiness than absolute wealth [113]. A salary o f
$50,000 where average salaries are $25,000 is preferred
to a salary of $100,000 where the average i s $250,000
[114]. If social comparison influences well- being, what
are the implications for policy? For example, do social
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structures such as gated communities and private
schools harm us all? Contrary to intuiti on, those within
the enclave aren’t any happier because they are no weal-
thier than their comparison group, and those outside
have a visibly wealthier reference group.
Television is a powerful influence, both because it
encourages social comparison and because of its innate
effects. Researchers have observed consistently adverse
changes following the introduction of t elevision into
new communities. In Bhutan, this was followed by
increased family break-up, crime and drug-taking, along-
side reduced parent-child conversation [115]. In Canada,
social life, participation in sports and level of creativity
were all negatively impacted [116]. Homicide rates go
up after televised heavyweight fights [117], and suicide
rates increase after on-screen portrayals [118]. Televi-
sion content leads to an inflated estimate of adultery
and crime rates [119], and negative self-appraisal [120].
Given the aver age Briton watches 25 hours of televisio n
per week [121] - with similar levels in the US [54] -
what does this imply for media regulation?
When making a social comparison, the reference
group influences well-being: Olympic bronze medal win-
ners (who compare themselves with people missing out
on a medal) are happier than Silver medal winners (who
compare themselves with the victor) [122]. For mental
health, this m ay mean that anti-stigma campaigns
focussed on promoting mental heal th lite racy and iden-
tifying when to seek professional help actually increase
negative so cial comparisons and reduce well-bein g.
High-profile people talking about their own experiences
are better at reducing the social distance and difference
experienced by people with mental illness [107].
In contrast to salary, 4 weeks holiday when others
have 8 weeks i s preferred over 2 weeks when others
have 1 week [114]. Would a national policy of compul-
sory flexible working arrangements (e.g.annualised
hours) reduce wo rk-r elated stress and consequent men-
tal illness? More generally, the fa ct that people who win
Oscars live longer than unsuccessful nominees [123]
may point to the importance of achievement for longev-
ity. If we want people to live longer, should we focus on
developing community-level opportunities for participa-
tion, connection and mastery? Should services fo r parti-
cularly marginalised groups, such as people with mental
illness, put some of their reso urces towards celebrating
and amplifying success?
What are the sources of happiness? The Big Seven
influences on happiness explain 80% of the variance in
happiness: Family relationships, Financial situation,
Work, Community and friends, Health, Personal free-
dom and Personal values [54]. The eff ects on happiness
of problems in each domain have been estimated, on
the basis of international s urveys of factors associated
with happiness [124,125]. Using a scale from 10 (no
happiness) to 100 (total happiness), the fall in happiness
associated with separation (compared with marriage) is
8 points, with unemployment or poor health is 6 points,
with personal freedom is 5 points, with s aying no to
“God i s important in my life” (personal values) is 3.5
points, with a national increase of 10% in unemploy-
ment is 3 points, and with a drop in fam ily income by a
third is 2 points.
Can these seven identified influences be used by
mental health services to directly increase happiness,
rather than continuing with attempts to reduce unhap-
piness? This will involve meeting three challenges.
First, traditional professional training only focuses on
one of these seven influences: health. Second, interven-
tions to promote health which increase personal free-
dom and are concordant with personal values will
increase happiness more than those which impinge on
personal freedom or which deny or discount personal
value. This will require clinical decision-making to
focus as much on value s a nd freedom as on interven-
tion effectiveness - echoing the call for ethics before
technology by Bracken and Thomas [126]. Third, most
influences on happiness are social rather than intrap-
sychic, yet most mental health interventions are at the
level of the indi vidual. Overall, this is not to argue for
more centralised control per se, but rather to highlight
that this knowledge should be more visible in public
debate, so that both social policy and individual
choices are informed by our best sc ientific understand-
ing of contributors to well-being.
We finish on an optimistic note. One reason for raising
some of these implications is to highlight their relative
absence from sociopolitical debate. Although there is
good evidence that being happy and cheerful is associated
with improved brain chemistry, blood pressure and he art
rate [127,128], and with living longer [129], this kind o f
evidence does not yet feature prominently in public
debate. If skilled professionals with an interest in promot-
ing well-be ing d on’tpointoutthatahighturnoverof
local residents create communities which are less cohe-
sive [130] and more violen t [131] then who will inje ct
this information into social policy? This opens up inno-
vative environmental approaches to fostering well-being,
like the simple act of closing most points of entry to a
housing estate which led to an increased sense of com-
munity and a 25% reduction in mental illness rates [132].
Similarly, the pernicious effects of a societal value that
we must make the most of everything is becoming clear.
People who constantly worry about missing opportunities
- so-called hyper-optimisers - have more regrets, make
more social comparisons and are less happy than people
who are happy with what is good enough [133]. An
empirically-informed polic y-making approach would
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recognise the toxic co nseque nces for wel l-bei ng of socie-
ties which encourage unfavourable social comparison,
continuous reoptimisation to make the best of ever y
oppor tunity , and living for the future rather than savour-
ing the present.
Research into mental illness proceeds apace. Advances
in understanding are being generated by gene tic, geno-
mic, proteomic, psychological and epidemiological stu-
dies, among other disciplines. These advances are to be
welcomed, and should cont inue to inform clin ical prac-
tice. The challenge is to also integrate and apply the evi-
dence base around well-being, so that mental health
professionals of the future inform social policy as well
as treating mental illness.
Summary
• Two new sources of knowledge are now available to
mental health professionals: collated syntheses of narra-
tives of recovery from mental illness, and empirical evi-
dence about well-being from the academic discipline of
positive psychology
• These two sources are highly complementary, and
provide a counter-balance to the traditional focus of
mental health services on deficit amelioration
• Assessment and treatment of the individual will need
to change if the goal is promoting well-being rather than
treating illness
• There are also broader challe nges for mental health
professionals to bec ome more outward-looking in their
view of their role, and to construct their job as more
than working with individuals
• A focus on improving social inclusion, becoming
social activists who challenge stigma and discrimin ation,
and promoting societal well-being may need to become
the norm rather than the exception for mental health
professionals in the 21
st
Century.
Additional file 1: Operationalisation, definition and examples of
three domains of mental health. Table showing operationalisation,
definition and examples of three domains of mental health.
Click here for file
[ http://www.biomedcentral.com/content/supplementary/1472-6963-10-
26-S1.DOC ]
Additional file 2: Points of convergence between recovery in
mental illness and positive psychology. Table showing points of
convergence between recovery in mental illness and positive
psychology.
Click here for file
[ http://www.biomedcentral.com/content/supplementary/1472-6963-10-
26-S2.DOC ]
Author’s information
Dr Mike Slade is a Reader in Mental Health Services Research at the Institute
of Psychiatry, and a consultant clinical psychologist in rehabilitation with
South London and Maudsley Mental Health NHS Foundation Trust. Mike’ s
main research interests are recovery-focussed and outcome-focussed mental
health services, user involvement in and influence on mental health services,
staff-patient agreement on need, and contributing to the development of
clinically useable outcome measures, including the Camberwell Assessment
of Need and the Threshold Assessment Grid. He has written over 120
academic articles and seven books, including Slade M (2009) Personal
recovery and mental illness, Cambridge: Cambridge University Press. He is
keen to disseminate an understanding of recovery to the field through free-
to-download booklets, such as Shepherd G, Boardman J, Slade M (2008)
Making Recovery a Reality, London: Sainsbury Centre for Mental Health
(downloadable from http://www.scmh.org.uk) and Slade M (2009) 100 ways
to supportrecovery, London: Rethink (downloadable from http://www.rethink.
org). He has acquired over £7 m of grant funding, including a £2 m NIHR
Programme Grant for Applied Research for the five-year REFOCUS study to
develop a recovery focus in adult mental services in England.
Competing interests
The author declares that they have no competing interests.
Received: 18 February 2009
Accepted: 26 Jan uary 2010 Published: 26 January 2010
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Cite this article as: Slade: Mental illness and well-being: the central
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