several studies that have controlled for other risk factors have observed large differences in mortality over significant follow-up periods between those individuals who rated their subjective health status as excellent and those who rated it as poor (Idler and Kasl, 1991; Idler and Angel, 1990; Kaplan and Camacho, 1983; Mossey and Shapiro, 1982). If such assessments can predict something as basic as survival, then future preventive intervention efforts cannot afford to ignore the multidimensional nature of health, especially in terms that move beyond an exclusive concern with disease models and an artificial dichotomy between physical and psychological health.

With this expanded concept of health in mind, the present chapter embarks on a different line of inquiry from that pursued earlier in the report. Here the focus on pathology and the attendant risk-oriented approaches to preventive intervention momentarily is set aside, and the discussion turns instead to the state of the art of research and intervention specific to promoting mental health. As explained in Chapter 2, mental health promotion activities are offered to individuals, groups, or large populations to enhance competence, self-esteem, and a sense of well-being rather than to intervene to prevent psychological or social problems or mental disorders.

In many respects, the goals of decreasing risk and increasing protection in the disease-oriented model and the goals of promoting mental health are not mutually exclusive, either in practice or in outcome. There is also overlap in the techniques used to achieve these goals. For example, cognitive and behavioral interventions frequently are employed to prevent depression by reducing anger, regulating anxiety, and increasing positive cognitions (Lewinsohn, Hoberman, and Clarke, 1989; Muñoz, Ying, Armas, Chan, and Gurza, 1987). Likewise, the same cognitive and behavioral techniques may characterize attempts to enhance personal harmony and well-being (Walsh, 1992; da Silva, 1990). Consequently, it sometimes may be difficult to distinguish the pursuit of prevention from the pursuit of promotion; moreover, achieving one can result in the other. However, there are enormous differences, conceptually and philosophically, between these two goal orientations that must be recognized. Such differences have far-reaching implications for how people talk about these endeavors, why they participate in them, what they expect to gain, and the manner and extent to which they are willing to support them.

Mental health promotion represents the logical extension of the intervention spectrum depicted in Figure 2.1, yet it remains separate, outside of the illness model. It encompasses matters of individual as well as collective well-being and optimal states of wellness (Chopra,



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