Mental Health Promotion
To this point in the report, the emphasis has been on decreasing risk factors and increasing protective factors with the ultimate goal of reducing numbers of new cases of mental disorders. But “health ” is not simply the absence of disease. Indeed, recent reports (Mechanic, 1991, 1986) indicate that people have a much broader concept of health that includes successful physical and psychosocial functioning and encompasses spiritual growth. For example, answers to the common question, “In general, would you say your health is excellent, good, fair, poor, or bad?” actually encompass comprehensive and integrated concepts of health. The responses to such subjective assessments of health status not only tend to be given within a holistic frame of reference that may not sharply distinguish between physical and psychological aspects of the respondent's health (Eastwood, 1975), but also go beyond the presence or absence of disease. They tend to incorporate appraisals that relate to the development and sustenance of the concept of self—including individual competence, activity, and self-efficacy (Mechanic and Hansell, 1987).
The importance of this more complex view of health, for programmatic as well as theoretical purposes, is underscored by a strong link between the subjective assessment of health status and many health measures, including mortality (Idler, 1992; Ware, 1986). Specifically,
This chapter is based in part on a commissioned paper by N. Dinges, available as indicated in Appendix D.
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,
1991; Stokols, 1991; Travis and Ryan, 1988; Ardell, 1986). Substantial resources—public as well as private—are currently being expended in the attempt to promote mental health. The expenditures are almost certainly large, perhaps similar in extent to the prevention research and service programs reviewed elsewhere in this report, but there has been no accounting. Programs, many of which are cited below, exist in schools, health service organizations, businesses, industries, and municipal governments. Other, perhaps not so apparent, examples can be found in religion, recreation, and physical exercise, all of which can be used to enhance mental well-being. The enthusiasm of commitment to such activities is infectious; personal testimony in regard to success abounds. Yet careful, rigorous examination of the efficacy, let alone the effectiveness, of these activities and of their associated costs and benefits has not yet been conducted. Thus the development of a scientific body of knowledge in regard to mental health promotive interventions represents a truly pioneering labor. Toward this end, the committee offers a review of the field as a foundation on which to build and raises a number of questions as a blueprint for progress.
Chapter 1 describes several of the problems involved in identifying, defining, and classifying mental disorders. There is, unfortunately, even less clarity about and little common nomenclature for discussing mental health and well-being. The reasons for this discrepancy are intriguing and include socioeconomic (Starr, 1980) as well as cultural (Kleinman, 1988; Manson, Tatum, and Dinges, 1982) factors. Although deserving fuller study, such analysis is beyond the immediate purview of this chapter. However, scholars have attempted to define this domain.
One of the major theoretical forerunners of the contemporary literature on psychological well-being is found in work on the dimensions of positive mental health and the related concept of happiness (Bradburn, 1969; Jahoda, 1958). The initial writings focused on the individual traits that were thought to define the mentally healthy person (Heath, 1977; Jahoda, 1958), which evolved from enumeration of core characteristics to more complex schemas that attempted to describe similarities in the dimensions that characterize well-functioning individuals, families, groups, and organizations (Adler, 1982). The original concepts of positive mental health and psychological well-being have further evolved to include the closely related constructs of competence, self-efficacy, and individual empowerment (Bandura, 1992, 1991; Sternberg and Kolligian, 1990; Swift and Levin, 1987). A recurrent element of such
schemas has been the concept of self-esteem and its variants. Although this concept is prominently associated with the psychology of the self, other disciplines have also examined its role in their attempts to explain a wide range of human activities that are relevant to mental health promotion.
Goldschmidt (1974) asserted that humans are preprogrammed to be essentially concerned with the maintenance and furtherance of a positive self-image, reinforcing other theorists who previously had pointed out that the concept of self lies at the very center of humankind's symbolic system. Thus “normal” individuals in “normal” communities act to enhance the quality of the symbolic self, even though the actions required for this purpose may vary considerably from culture to culture. The most pertinent point about this theoretical position is that the social institutions of a given culture must provide means to maintain and promote the self-symbols of its members at the same time that these institutions must ensure their own basic survival. Taken by itself, the concept of “culture” is inadequate because it lacks a theory of motivation to account for cultural behavior. The concept of the self-image, when combined with cultural behavior, provides just such a motivating concept.
The importance of self-esteem maintenance and enhancement has achieved a broad disciplinary acceptance as a unifying concept, helping explain behaviors intended to attain psychological well-being. This desire to sustain self-esteem may partly explain why humans perceive it as a threat to be defined as an object (Kelman, 1975), and thus this motive may be the source of efforts in contemporary empowerment movements. Obviously, such movements owe much to the self-actualization principles of the past decades of humanistic psychology. Contemporary theorists have expanded these earlier views to a conceptual framework of self-esteem as a cultural construction (Solomon, Greenberg, and Pyszczynski, 1991). However conceived, there is little doubt that self-esteem has attained considerable importance in the thinking that informs mental health promotion efforts (Mecca, Smelser, and Vasconcellos, 1989).
Although the motives of self-esteem and mastery have been at the forefront of these developments, other concepts have appeared and received fleeting attention, only to disappear for lack of sufficient empirical verification or perhaps for lack of theoretical credibility. For example, the notion of trauma/stress conversion—which refers to the transformation of a painful, distressing, or shocking experience into one that induces strength and resiliency (Finkel and Jacobsen, 1977; Finkel, 1975, 1974)—enjoyed a brief exposure before being overwhelmed by the
apparently more theoretically compelling complexities described in the literature on the stress-coping process. The idea that successfully coping with an objectively traumatic event could lead to personality strengths continues to have some appeal and is included in some models of the stress-coping process (IOM, 1982; see also the commissioned paper by Glynn, Mueser, and Herbert, available as indicated in Appendix D). But the potential for positive outcomes has been overlooked while attention has focused on negative effects (Zautra and Sandier, 1983).
Even less well received, if not actively scorned by many mental health professionals, have been proponents of the “transformative” health movement (Walsh, 1992; Grof and Grof, 1989; Tart, 1989, 1975; Wilber, Engler, and Brown, 1986; Walsh and Shapiro, 1983; Ferguson, 1980; Walsh and Vaughan, 1980), who have written extensively from a humanistic and “transpersonal ” psychology perspective. This movement emphasizes the holistic nature of the human condition and sees it as inextricably rooted in social context. Its proponents argue that, by systematically focusing attention on the interplay of spiritual, physical, and psychological dimensions of everyday life experience, individuals can recast their sense of self, to the benefit of themselves and others.
Other theoretical contributions have focused on less sweeping, but nonetheless important, aspects of what seems to be an unlimited human need to think well of oneself by whatever means are available. The New Age forms that this need sometimes takes today can mask the perennial essential human striving that underlies it. Whether mundane or transcendent in purpose, the concept of self-esteem remains at the core of cultural behavior and manifests itself according to prevailing norms of the day. Contemporary forms of mental health promotion are thus now beginning to converge with spiritually oriented, transpersonal wellness movements (Murphy, 1992; McGuire, 1988).
Societies and their respective cultures vary in their ability to provide institutionalized means for preserving and enhancing the self-images and cultural identities of their members. Several theorists have pointed to the inherent interdependence of humans in finding an effective, socially adaptive fit between social structure and environmental demands. For example, Mechanic (1974) assessed the literature on personal coping abilities. He concluded that adaptation is widely perceived as being dependent on the ability of individuals to develop personal mastery over their environment. In Mechanic' s view, this position was contradicted by the evidence for the interdependence of people in finding group solutions to socioenvironmental problems.
This perspective has been more recently elaborated by Antonovsky (1987, 1979) in positing the concept of “salutogenesis.” (It is perhaps an
indication of the dominating conceptual framework of pathogenesis that new terms have to be coined to describe a presumably qualitatively different health status on the positive end of the spectrum.) Antonovsky 's salutogenic orientation grew out of his own background in traditional public health, but it came to be focused on the origins of and sustaining conditions for health rather than the etiology of illness. He proposed the concept of “generalized resistance resources” as the basis of health and included among such resources any phenomenon that was effective in combating a wide variety of stressors. Although such resources are easy to identify in the abstract (e.g., social supports, money, and ego strength), Antonovsky sought to specify the common elements of the dynamic process by which such resources promoted healthy functioning. He posited a “sense of coherence ” as the organizing concept, defined as
a global orientation that expresses the extent to which one has a pervasive, enduring, though dynamic, feeling of confidence that one 's internal and external environments are predictable and that there is a high probability that things will work out as well as can reasonably be expected. (Antonovsky, 1979, p. xiii)
Antonovsky's subsequent work has extended the model to examine the empirical support for and the heuristic value of adopting the salutogenic perspective (Antonovsky, 1987). It is consistent with notions of communal coping (David, 1979) that come from quite different theoretical and empirical origins. Likewise, there are clear parallels to the moral or behavioral codes that serve as the central themes for organizing life in other segments of our society. Consider, for example, the concept of sa' a naghai bik'e hozhq, or simply hozhq, in the Navajo world view:
Kluckhohn (1968) identified hozhq as the central idea in Navajo religious thinking. But it is not something that occurs only in ritual song and prayer, it is referred to frequently in everyday speech. A Navajo uses this concept to express his happiness, his health, the beauty of his land, and the harmony of his relations with others. It is used in reminding people to be careful and deliberate, and when he says good-bye to someone leaving, he will say hozhqqgo naninaa doo “may you walk or go about according to hozhq.” (Witherspoon, 1977, p. 47)
Sa' a naghai bik'e hozhq encompasses the notions of connectedness, reciprocity, balance, and completeness that underlie contextually oriented views of human health and well-being (Stokols, 1987; Farella, 1984; Moos, 1979; Sandner, 1979). As a subsequent section of this chapter suggests, many contemporary mental health promotion activities in the United States can be construed as expressions of attempts to
achieve a “sense of coherence,” irrespective of the conceptual schema that informs the particular approach.
HEALTH PROMOTION PROGRAMS
The concepts described above have guided the development of the content, process, and outcome criteria of the various mental health promotion programs. The committee has chosen from among these programs some examples that illustrate the range and diversity of these activities on the contemporary scene, but has made no attempt to evaluate these programs according to any more stringent criteria.
The best current, single source of mental health promotion literature is contained in the annotated bibliography prepared by Trickett, Dahiyat, and Selby (in press). However, the mental health promotion literature constitutes a minute portion of the entire bibliography, only 22 of 1,326 references, and Trickett's definition of mental health promotion was not especially clear. He focused on articles “dealing with mental health education as a preventive strategy . . . and preventive interventions intended to promote varied aspects of mental and physical health” (Trickett et al., in press). About half of the 22 articles focused on preventing illnesses. This is itself a statement about the relative attention that has been given to mental health promotion.
The mental health promotion examples cited by Trickett range from those that focus on the acquisition of health-enhancing habits (Albino, 1984) to specific intervention programs in child and maternal health (Groves, Leeson, and Slovine, 1989; Peters, 1988; Bronstein, 1984; Chamberlain, 1984). These include efforts across the developmental life span (Re, Noble, and Howard, 1990) targeting issues specific not only to youth but also to older adults (Leventhal, Prohaska, and Hirschman, 1985; Gioiella, 1983). A large portion of the literature reviewed by Trickett and his colleagues reveals that, regardless of focus, social resources are a critical element in most promotive endeavors (Kulbok, 1985), especially insofar as natural support groups can form the basis for promoting desirable behaviors and empowering individuals (Albino and Tedesco, 1987; Mechanic, 1985).
Supporting and strengthening family functioning is, of course, a focal issue in many mental health promotion efforts (Duffy, 1988; Bowman, 1983), which reinforces earlier views of the critical role of the family in providing the foundation for healthy child, adolescent, and adult functioning (David, 1979). However, echoing Bradburn's earlier empirical research on the structure of individual well-being, Dunst, Trivette, and Thompson (1991) found that the prevention of poor outcomes could
not be equated with the strengthening of family functioning, and that the absence of individual problems did not necessarily indicate the presence of positive family functioning.
The work of Spivack and Shure (1974; Shure and Spivack, 1978) on interpersonal, cognitive problem-solving deserves to be included among mental health promotion efforts, especially since it has gained relatively broad acceptance in school-based efforts to promote self-esteem and prosocial behavior (Groves et al., 1989). This program, “I Can Problem Solve: An Interpersonal Cognitive Problem-Solving Program, ” is included as an illustrative preventive intervention research program in Chapter 7 and is an example of how the same program may serve both preventive and promotive functions. The recent studies of resilient youth (Wyman, Cowen, Work, and Parker, 1991; Parker, Cowen, Work, and Wyman, 1990; Work, Cowen, Parker, and Wyman, 1990; Cowen and Work, 1988) also serve as examples of mental health promotion, as do the various studies of resilience and invulnerability (Beardslee, 1989; Garmezy, 1985; Werner and Smith, 1982).
Still other examples of mental health promotion present a more complex array of human activities from which to draw and a considerably greater challenge in terms of categorization. Because these are not typically oriented to scientific validation, it can be difficult to trace a clear line from their theoretical underpinnings to the methods used and the outcome criteria by which results might be judged. Just as Kleinman (1984) described the heterogeneity of indigenous systems of healing, so too can the myriad of human activities that may be motivated by mental health promotion efforts be seen as local forms of expression in a wide range of contexts.
One of the best places to look for examples of such mental health promotion efforts is among the diverse settings that provide some form of nonprofessional “healing,” a term that is becoming widely embraced as a metaphor for less stigmatized, more participatory, holistic, and positively oriented approaches to addressing the (dis-)order of the human condition. It commonly is assumed that such practices are sought by those desperately grasping for a solution to a terminal illness after having exhausted the resources of professional biomedicine or by those lacking the motivation or discipline to comply with a medically prescribed regimen. This, however, is a misconception (Eisenberg, Kessler, Foster, Norlock, Calkins, and Delbanco, 1993). McGuire found that although a few adherents had participated in ritual healing practices as a last resort, most were attracted by a larger system of beliefs of which health-illness concerns were only a part. “For most adherents, therefore, the use of alternative healing typically involves a totally different definition of medical reality, an
alternative etiology of illness, and a specific theory of health, deviance, and healing power” (McGuire, 1988, p. 5).
Equally important, McGuire's research did not support the rather common misconception that alternative healing practices and the systems of belief that informed such practices were characteristic of rural, poorly educated, lower-class persons, or that such practices had waned with increasing social mobility. Rather, her study demonstrated that alternative healing had considerable appeal to well-educated, economically secure, middle- and upper-middle-class residents of suburban communities.
A similar conclusion probably can be drawn with respect to the consumers of contemporary mental health promotion activities. Indeed, the “meaning-making” functions—that is, the communication of a structure for perceiving and assigning significance to people, places, and events—of participation in these practices may have many mental-health-promoting effects. This is perhaps what Antonovsky (1987, 1979) had in mind when he referred to the ability to maintain high levels of health by translating difficult, complex bombardment by environmental stimuli into a meaningful whole that provides a sense of coherence. Such concepts clearly go beyond those contained in the models of competence, positive mental health, and self-efficacy reviewed above.
Mental health promotion activities are common throughout many cultures. Among Native Americans, for example, the sweat lodge ritual can be and often is used by relatively well-functioning persons. The cultural practice in this case involves the sweat lodge purification ritual (Inipi Onikare), which is regarded as a “serious and sacred occasion in which spiritual insights, personal growth, and physical and emotional healing may take place. The purpose of purification is experienced on numerous levels of awareness, including the physical, psychological, social, and spiritual” (Wilson, 1988, p. 44). Many symbolic aspects of the physical construction of the sweat lodge and the various objects are part of the ritual (Brown, 1971). Of more direct relevance here are the psychological effects attributed to the ritual process, which includes a physically close circular arrangement of participants to increase unity and bonding, individual prayers involving self-disclosure of personal concerns and needs, as well as the needs and concerns of others, and the “opening” of the Four Doors through a cycle of prayers (actual opening of the sweat lodge door with change in heat and light conditions), which is controlled by the medicine person, who works to lead the group to
see more fully the symbolic nature of the ritual as a paradigm of life's central struggles. The juxtaposition of darkness and light may then take on deeper symbolic values as the paradigms of life versus death; insight versus ignorance;
growth versus stagnation; hope versus despair; relief versus suffering; renewal versus stasis; connection versus separation; communality versus aloneness, and will versus resignation. (Wilson, 1988, p. 54)
Wilson provides an explanation of the psychobiological aspects of altered states of consciousness that have commonly been observed and measured during the ritual and of the shifts in hemispheric dominance of the brain that are part of the altered states of consciousness commonly produced by ritual participation. Other aspects of the ritual are designed to promote a sense of the continuity of the community and the continuity of the individual in the culture. The conclusion of the ritual is typically accompanied by a number of positive psychological outcomes, including a sense of emotional release and a feeling of renewal and inner strength. Clearly, for many people, participation in the church and related religious activities serves similar purposes and offers comparable benefits. These benefits have been particularly well-documented for African-Americans (Neighbors, 1990; Dressler, 1987, 1985; Maypole and Anderson, 1987; Neighbors, Jackson, Bowman, and Gurin, 1983).
Another example of a contemporary form of mental health promotion can be found in groups combining Eastern meditation practices such as Zen, transcendental meditation, and yoga, and tenets of the human potential movement that have gained increasing popularity in many parts of the country. According to McGuire (1988), Eastern meditation practices in the United States trace their historical roots to the latter part of the nineteenth century but did not receive much public recognition until they were popularized through press coverage beginning in the 1960s and 1970s. Their increasing popularity was brought about in part by the growth of the self-realization goals of the human potential movement, whose adherents subsequently turned to Eastern spirituality for their longer-term development. McGuire noted as well that many Eastern spiritual forms have attracted not only the stereotypical countercultural youth but also middle-aged, established, and educated persons. Because the membership of Eastern meditation groups and the human potential movement appears to overlap considerably, McGuire treats them as one in her systematic examination of their core elements.
Ideal concepts of health and wellness are a prominent element of such groups, which emphasize balance among physical, psychological, and spiritual levels of the individual, as well as energy, flexibility, and self-awareness (Goleman and Epstein, 1983). They emphasize a holistic view of these elements in interaction and use such concepts in both literal and metaphorical ways to refer to both physical and spiritual well-being. Thus they emphasize a life-style characterized by balance in
all spheres of life, seeking moderation and avoiding excess as a means of achieving a state of optimal balance. Life-style choices are a prominent feature of the means by which the desired state of well-being can be attained. These choices extend to larger social, environmental, political, and economic issues in an attempt to address real causes and not just the symptoms of imbalanced states.
The source of health, as well as of overall well-being, is conceived of as a universal life force that is more spiritual than mechanistic. This force provides the basic energy required for states of physical and spiritual well-being, and many of the practices of the groups are oriented to adjusting such energies into a harmonious flow. Eclecticism characterizes the choice of healing and health practices in both individual and group form. Meditation, massage, yoga, and dance therapy might be among the simultaneous or serial choices of health-oriented practices to bring about purification or promote balance and personal growth.
The element of flexibility as a criterion of well-being is fundamental for judging the beneficial outcomes of the belief system and life-style choices of adherents to Eastern meditation and the human potential movement. Practice, technique, beliefs, and methods of managing one 's life are not given eternal validity but are rather viewed as appropriate for a particular time, place, and problem that at some point no longer applies. Thus the impermanence of both physical and psychological substance are considered the natural state, and self-awareness and self-responsibility are key requirements of general well-being. A generalized faith in the expectation that usefulness of whatever practice one is employing also characterizes this approach. Hence, being part of the “flow” without fully understanding or being able to control it is considered an important corollary of the generalized expectation of beneficial outcomes.
There are striking parallels between the beliefs and practices of Eastern meditation and human potential adherents derived from non-Western cultures and those articulated in the more formalized conceptual framework of generalized resistance resources and sense of coherence proposed by Antonovsky (1987, 1979). In Csikszentmihalyi's (1990) examination of the psychology of optimal experience, he depicted both as related to “flow” as the organizing concept.
The reemergence of such concepts, which appear to have long histories and broad cross-cultural recognition, leads to the issue of the rediscovery of fundamental aspects of psychological well-being that can inform mental health promotion. A common misconception is that such belief systems espouse some unattainable utopian ideal of mental health that has little relation to everyday existence. To the contrary, such belief
systems are oriented to understanding how human beings manage to find positive meaning and identity-sustaining experiences as they go about coping with life's adversities (da Silva, 1990). Over 20 years ago, Bradburn (1969) empirically demonstrated in studies with humans that a subjective sense of psychological well-being consisted of a balance of positive and negative emotions, not just positive ones.
Most of the intervention strategies discussed to this point have been individually rather than collectively oriented in design and implementation. There is, in addition, an emerging emphasis on linking individual-focused, small-group/organizational, and community approaches to mental health promotion (Fawcett, Paine, Francisco, and Vliet, 1993; Hawkins and Catalano, 1992; Weiss, 1991; Braithwaite and Lythcott, 1989; Winett, King, and Altman, 1989; Green and Raeburn, 1988; McLeroy, Bibeau, Steckler, and Glanz, 1988; Green, 1986). This perspective assumes that the healthfulness of a situation and the well-being of its participants are influenced by the diverse interplay among biological, psychological, and social factors. It also assumes that the effectiveness of any health promotion activity can be enhanced through the coordination of individual and group action at different levels: family members who attempt to improve their health practices, corporate managers who shape organizational health policies, and public health officials who supervise community health services (Green and Kreuter, 1990; Winett et al., 1989; Pelletier, 1984). This particular perspective has encouraged promotive policies and community interventions at municipal, regional, national, and even international levels.
For instance, Toward a State of Esteem (California Department of Education, 1990), a legislatively mandated review, outlines a comprehensive plan for engineering massive increases in self-esteem and personal as well as social responsibility. Such change is advocated across private and public sectors, targeted simultaneously at individuals, families, schools, neighborhoods, business, and government, through a wide variety of means. Examples include nurturing and family life programs for teenage parents (Family Development Resources, Inc., Adolescent Family Life Programs), as well as specialized training for foster care and institutional staff to promote personal and social responsibility among their wards (Sacramento County Foster Parent Training Program). Other examples are in-service and credentialing requirements for educators that emphasize self-esteem enhancement skills (Action Education, Annual California Self-Esteem Conference), real-life skills curricula (College Readiness Program, Partnership Academy Program), and parent-school collaboration in education (Project Self-Esteem, New Parents as Teachers Project). Still other examples include community
partnerships in after-school projects that promote constructive, prosocial experiences and serve as alternatives to activities that may place youth at risk of delinquency and violence (Urban Youth Lock-In, Stop-Gap Theatre); peer-support groups that foster learning, self-confidence, and motivation among welfare recipients (GAIN, GOALS Program); and strategies that positively reinforce employee responsibility in the work place (New Ways to Work). A basic theme is simultaneous, coordinated action across these different domains.
Recent examples of intercity and cross-national cooperation in mental health promotion include the World Health Organization's (WHO) Healthy Cities Project (World Health Organization, 1988, 1986, 1984; Ashton, Grey, Barnard, 1986; Hancock and Duhl, 1985). Recognizing that healthy cities continually create and improve physical and social environments conducive to their residents' well-being, WHO orchestrates, through technical assistance and resource materials, the development and implementation of citywide health plans. Healthy Cities Indiana (Flynn and Rider, 1991) represents the U.S. counterpart, in which Indiana University, the state public health association, six Indiana cities, and the W.K. Kellogg Foundation have combined their efforts to bring about planned change to improve community life. Other communities are rapidly adopting similar plans, such as the Healthy Communities Initiative, a cooperative venture between the National Civic League and the U.S. Public Health Service. Specific examples include the Kansas Initiative, involving the Wesley Foundation and an array of citizen as well as institutional participants (Fawcett et al., 1993), and the Colorado Healthy Communities Initiative, which employs community and agency coalitions, supported by the Colorado Trust. As is evident, these endeavors frequently engender significant investment by private as well as public sponsors. The Municipal Foreign Policy Movement has provided a similar forum for intercity development of legislation in health promotion and environmental protection (Agran, 1989; Shuman, 1986). Regardless of the particular form such enterprises take, all value citizen action in, mutual investment toward, and shared responsibility for promoting health, well-being, and positive life-styles.
GAPS IN OUR KNOWLEDGE
The current level of knowledge about the mental health promotion activities that are occurring in this country is sparse. Gaps in knowledge include a wide variety of topics that could be addressed in a research agenda.
A useful body of theory exists as one component in the knowledge base for mental health promotion activities. Several lines of inquiry might prove especially fruitful in expanding our understanding. What is the motivation for psychological well-being, and what are the conditions under which it emerges? How many dimensions are necessary for a complete accounting of the variations in psychological well-being? Do the different forms of alternative mental health promotion noted above reflect significant needs that have not been met by other mental health interventions? Do promotion efforts arise from attempts to counteract the social stigma that frequently accompanies the onset of disease in an individual? Does the pursuit of wellness, holism, empowerment, and a sense of coherence reflect the need for buffers against the social loss involved in the illness experience (Kleinman, 1984)? Perhaps our attention has been so focused on psychopathology that we have missed the significance of the tremendous grass-roots efforts that are being expended in the pursuit of psychological well-being.
McGuire's (1988) analysis of the new individualism involved in urban ritual healing suggests that conventional, institutional forms of healing may be losing their effectiveness in providing means for maintaining and furthering self-esteem. Did conventional healing ever provide sufficient avenues for pursuit of the positive self-symbol, or were such avenues limited to the fortunate few? Perhaps mental health practitioners and researchers have failed to understand that lay definitions of psychological well-being are at variance with professional views, just as medical practitioners have long operated with different explanatory models of physical disease from those of their patients (Kleinman, 1980). Perhaps it is time to consider how the psychological, biosocial, cultural, and spiritual dimensions intersect in contemporary definitions of psychological well-being and mental health promotion.
Cultural variations in mental health promotion activities and the ways in which specific cultural practices might inform mental health promotion might prove to be particularly significant areas of inquiry. Do alternative forms of mental health promotion serve different sectors of society or subcultures of the mass culture? What determines a person's choice of mental health promotion resources, and how does being placed in a devalued social role affect such choices (as may occur with subcultural group members)? Has the multicultural nature of our society been a significant factor in the emergence of diverse modes of mental health promotion?
A closely related issue concerns the extent of simultaneous use of different methods of mental health promotion. Options from conventional and alternative systems are sometimes presented as polar choices
requiring allegiance to one or the other orientation. But individuals often choose more than one option, as in participation in workplace wellness programs during the week and ritual healing practices on the weekend. Individuals' simultaneous use of different methods may be an expression of their self-determination and may reflect goal-oriented striving to incorporate new sources of information to promote self-esteem.
The types, forms, scope, frequency, and location of mental health promotion activities are poorly understood. How many people participate in mental health promotion activities? Of what kind? What are their sociodemographic characteristics, particularly with respect to subcultural variation and geographic location? Where are mental health promotion activities occurring, and where else could they be implemented? Schools and work sites are obviously prime locations, but perhaps there are many other venues the potential of which has been underestimated, such as churches, neighborhoods, and cities. How are these activities organized, and who uses them? Much contemporary mental health promotion activity appears to emanate from religious and spiritual beliefs that historically have not been available for empirical study in the United States. Can such activities now be studied?
A critical issue concerns how to determine the actual outcomes of participation in different potential mental health promotion activities. What criteria are to be used in evaluating the outcomes of these activities? This question goes directly to the issue of the impacts of conventional and alternative forms of mental health promotion. Is one or the other superior in outcomes for specific groups of individuals? Is a combination of involvements more effective for long-term psychological well-being? If alternative methods yield promotive benefits, how do they produce such effects? Do they achieve outcomes different from or similar to those of more conventional methods? Not much is known about the harm some mental health promotion activities might cause. What potential adverse effects are there? Are particular forms of mental health promotion likely to cause harm? Are specific groups of individuals more at risk?
We simply do not understand the full range of the phenomena involved in mental health promotion and certainly lack the evidence to reject alternative sources as useless. Kleinman (1984) suggested that no policies be advanced that might control nonprofessional indigenous healers in the United States until research could demonstrate if such activities were beneficial or counterproductive to the nation 's health. An analogous position probably is advisable with respect to the complexities involved in the measurement of the myriad forms of potential mental health promotion activities engaged in by the U.S. public.
Mechanic (1991) has taken a similar position with regard to research on the sources of health and disease, which vary widely in a given community. Referring to researching the idea of health in broad terms, he comments: “Definition and measurement is central to the challenge, but to allow the easily measurable to guide our definitions of what is important and our research efforts would be exceedingly foolish ” (p. 32).
A related issue concerns the criteria by which costs and benefits are calculated. The social and economic costs and benefits of conventional mental health promotion activities figure prominently in any research agenda. Are alternative mental health promotion efforts more socially acceptable and cost-effective than those provided through conventional means? If workplace wellness programs can demonstrate positive cost-effectiveness, may there be equal or greater benefits involved for those who participate in alternative mental health promotion, or some combination of the two?
People in our society are deeply committed to health promotion pursuits, expending enormous resources to attain happiness and dignity. Success often has been equivocal, certainly uneven, and the ideas of mental health promotion are to some extent culture-bound. Nonetheless, this endeavor—the promotion of mental health and well-being—will continue. Hence it behooves us to proceed thoughtfully and with care on a research agenda regarding these activities.
FINDINGS AND LEADS
Health, wellness, zest, resilience, self-efficacy, empowerment, order, balance, harmony, integrity, energy, flexibility, a sense of coherence: each represents some facet of an underlying human experience that is desirable, satisfying, perhaps even necessary. In the quest to understand and ultimately attempt to prevent suffering, it is important to not lose sight of another, equally powerful imperative, that is, the need to nurture positive regard for one's self and the world around us. There appear to be many ways of accomplishing this goal of promotion of mental health; clearly, each entails more than seeking freedom from disease or ailment.
Research on mental health promotion, defined as distinct from enhancement of protective factors within an illness model, may be a difficult concept for some to accept. In part, this may reflect a tension between expressing an openness to new ways of thinking about mental health on the one hand, and attempting to be scientifically rigorous and skeptical on the other. An analogous tension in the physical illness field
was partially resolved in 1992 when the National Institutes of Health established an Office of Unconventional Medical Practices—later renamed the Office of Alternative Medicine—and began systematically to explore such interventions. The decision to use federal support to determine the effectiveness of unconventional medical practices was controversial and momentous. It was an acknowledgment of the wide application of such practices and an openness to their potential usefulness.
Traditional mind-body dichotomies are alternative ways of understanding the same phenomenon. The concept of health promotion has begun to integrate these perspectives.
In Chapter 7, a small, but growing body of scientific evidence could be cited in regard to the efficacy of interventions for decreasing risk factors and enhancing protective factors with an ultimate goal of preventing mental disorders. No comparable corpus of knowledge is available with respect to mental health promotion. The current level of understanding about the potential contribution of conventional and alternative approaches to the goals of mental health promotion is sparse.
Current public and private expenditures to promote mental health are substantial. They are perhaps similar to the amounts spent on prevention research and service programs reviewed elsewhere in this report. Because we know little about the outcomes from promotion activities, it would be useful to assess them scientifically. A research agenda could begin by cataloging mental health promotion activities across the life course and crafting outcome criteria that could be used in rigorous evaluations down the road.
Enthusiasm for the health promotion movement should not interfere with a willingness to evaluate potential harm from such activities. For example, although mental health promotion activities do not use an illness model, persons with severe mental disorders may seek out such activities, viewing them as alternatives to standard treatment. Ethical issues such as this will be paramount in any attempts to bring methodological rigor to the mental health promotion field.
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