Mental Health and Wellbeing - A blog entry
Mental health is much in the news these days, and in some of these stories a shift in emphasis can be discerned.
In the past mental health stories were mostly negative, reporting the rare instances where someone with a mental illness has caused a problem for others, or the suicides or drug overdoses of famous people. These can be misleading because people with mental illness are much more likely to suffer harm at the hands of others than they are to cause it. Such stories give the impression that mental illness is rare when it is actually very common and don’t convey the fluctuating nature of mental health. They give the impression that what is important about mental health is illness.
Just occasionally nowadays stories are printed about mental wellbeing, the positive end of the mental health spectrum where people feel good about being alive and function well at home, at work in their communities and in society more generally. Their relationships with others are life enhancing; they know how to handle conflict constructively; and they are resilient in the face of problems and the inevitable life events.
Most of us have known times like this, but few would say that they were common. Our mental health fluctuates with good times and bad, but the relentless time pressures and high expectations that have become a normal way of life get in the way of feeling good and functioning at our best.
Mental wellbeing is the state of mind where not only are we most able to learn new things and master new skills, it is also the one where the body operates optimally. In this state the immune system can eliminate ‘foreign’ things like bacteria, viruses and cancer cells and does not launch the self-attacks that characterise many chronic illnesses. The body’s regeneration and repair mechanisms work well as do the cardiovascular, digestive and respiratory systems.
Several different academic disciplines - psychology, child health, management - have researched the impact of focusing on the positive and drawn the general conclusion that ‘what you pay attention to is what you get more of’. So a greater focus on the positive end of the mental health spectrum in our media and in our everyday lives would benefit us all.
To do this we need to find a way of slowing down and making time to notice what we value, what makes us feel good. Then we know what we need to do more of. Ways of slowing down like mindfulness and meditation, yoga and tai chi are becoming more and more popular. Their popularity is a measure of the way they are able to help, but they are not necessarily for everyone.
Simple things like going for a walk, especially in green spaces, or a run; singing or making music; gardening; creative arts - all these are well known to have a positive effect on our state of mind, but in the rush of our 21st century lives we have let these activities go to the wall. Studies are now beginning to confirm what many people already know, that what they eat affects how they feel. Healthy diets rich in fruit and vegetables and the essential fatty acids found in fish, nuts and seeds, with little sugar, meat or deep fried foods support mental as well as physical health. Cigarettes, alcohol and drugs can offer short term benefits but also depress mental health in the longer term.
Improving mental health therefore means changing how we live. That means both changing something in ourselves and also changing the environment so that it is less toxic for mental health. Changing how we live is not easy.
As people who have given up smoking, or drinking to excess, taken up more exercise or cut back on sugar know, our short term solutions are addictive. And so it turns out is being overly busy, living in our heads, chasing wealth or status and workaholism more generally. The latter cut us off from others and from understanding their needs, and cut us off from our bodies and their needs, so we can fail to notice the destructive effects of rushing about all the time
The extent to which the changes should be environmental/societal or down to the individual is hotly debated in the field of public mental health where I work. But the answer, as is so often the case, is not ‘either/or’, but ‘both/and’. Individuals need to work on resetting the set point in their neurological systems where the stress response is triggered.
This set point is established very early on in life, in infancy and depends on the emotional and relational environment into which they are born. Infants who are lucky enough to be born into families where levels of stress are low and parents levels of mental wellbeing high are programmed for resilience. But the set point can be altered in later life, either by the experience of trauma in which case the point is lowered or by the experience of calm, safety and supportive relationships as in the various activities described above.
As people work on themselves they become more able to regulate their neurological systems and because this has an effect on their relationships with others this changes their environment and ultimately changes communities and societies. They feel good more of the time and are more resilient.
But those of us with low set points to begin with can need help to get started and this means workplaces and schools that are less toxic; more support for parenting and family life; better environments, better governance and social support systems. And it means that the services like health, education and social care employ people who are trained to help and support others begin the resetting process.
All these things are starting to happen, even in these times of austerity, as more and more people - individuals, service providers and policy makers - start to understand the agenda. For the changes to be widely appreciated, we need a media that wants to enhance and extend the shift in emphasis from the negative to the positive and to give us more stories of success.
The Warwick-Edinburgh Mental Well-being Scale, called WEMWBS for short, is supporting policies and practice to improve mental health. Over the ten years since it was developed, this short self-completion questionnaire has become very popular in the UK and further afield, and translations have appeared in most of the European and Scandinavian languages as well as Chinese, Bengali Urdu and many others.
Of the order of 100 people a month now register to use the scale to evaluate local projects, conduct surveys or monitor the effects of policy or environmental change.
The scale’s development was funded by NHS Health Scotland. Following devolution the Scottish Government started to take an interest in mental health and wellbeing, and recognised the need for policy makers and service providers to know whether what they were doing was or was not helpful in this regard. To do that they needed a reliable measure. NHS Health Scotland and the University of Edinburgh were partners with Warwick in the scale’s development and evaluation. And one of the conditions for providing funding was that the scale could never be sold.
Scotland was the first country formally to recognise the need to address mental wellbeing as well as mental illness. There were many scales addressing mental illness which were used to evaluate interventions in psychiatry and estimate the extent of mental illness in the population. And correlation between WEMWBS and some of these scales, like for example the well-known GHQ-12 and the CES-D which measures depression, is quite high.
So the question ‘why was it necessary to develop WEMWBS?’ needs to be asked. Practitioners and public respond to this question saying it makes a lot of difference to be asked how well they are doing at good things, like confidence and optimism, rather than how badly they are doing in bad things like feeling anxious or pessimistic. And the 14 questions in the WEMWBS scale are all about positive aspects of mental health, whereas most mental illness questionnaires focus on the negative.
Simply focusing on the positive has been shown to make a difference in therapeutic approaches like solution-focused therapy and practices like asset-based community development. There is something about registering how much you are getting right that makes what you are not getting right more palatable.
In terms of evaluation the instrument you use to measure change declares something about the goals of the project or programme. Using WEMWBS declares that the project intends to help participants develop good attributes and feelings. Using a mental illness questionnaire declares that the project is most interested in preventing illness. The latter is not a bad thing; indeed it is one of the effects of promoting mental wellbeing; but because illness can be viewed as a financial and social burden and because it carries stigma, prevention starts from the premise that what you have is bad and this can cast a shadow over projects and programmes.
The nature of mental wellbeing and even its name have been quite extensively debated. Some authorities, particularly the World Health Organsation, refer to positive mental health, a pretty much synonymous concept, but one that seems to be less readily understood by the general public. In the US the term wellness may be used in the place of wellbeing.
Debates about the nature of mental wellbeing date back millennia to the Greek philosophers and beyond to the great spiritual traditions of the East. More recently in the West, psychologists and social scientists have contributed to discussions. The debates range around the relative importance of feeling good – the hedonic component often operationalised simply as happiness or life satisfaction – and functioning well – the eudaimonic components like relationship skills, being able to focus on what is right, having a sense of capacity to influence things, being able to act autonomously.
The extent to which populations feel these things can depend on their governments and social circumstances, but within populations individuals vary systematically in their capacity to function in this way. The two aspects, feeling good and functioning well, are related because functioning well usually leads to greater happiness and feeling good makes it more possible to grow learn and develop these positive attributes. Almost all authorities now agree that mental wellbeing comprises both aspects.
The fourteen questions in WEMWBS cover the key aspects of feeling good and functioning well in roughly equal measure. Since WEMWBS was developed a small number of other scales have appeared with slightly different emphases, some much longer than WEMWBS.
The appearance of these scales, particularly WEMWBS, has enabled researchers to investigate what influences mental wellbeing and they have found that this can be rather different from the things which influence mental illness. The latter is highly associated with poverty, unemployment and lack of educational achievement. The correlation with the upper end of the spectrum is not nearly so clear cut. There doesn’t seem to be much evidence that educational achievement or money predispose you to mental wellbeing, and employment can work both ways depending on the nature of the work.
WEMWBS is enabling researchers to discover the things that promote mental wellbeing and so enable an ‘evidence-base’ to be assembled. High on the list of things that work in this way are programmes to support healthy lifestyles - eating well and taking exercise - because the health of the mind and body are closely related.
Programmes that support parenting and enable parents to parent effectively and more harmoniously improve parents’ mental wellbeing as well as helping children. Counselling programmes, mindfulness programmes, singing, gardening, walking, volunteering and many more activities are being shown to be helpful.
Many of these are things the general public already appreciate and incorporate into their daily lives. But for too many of us, the time to do what we enjoy and helps us stay sane gets eroded. WEMWBS is enabling researchers to show that governments, employers, schools, universities and families that allow these activities to be eroded damage the health of their citizens, employees, students and children.
By Professor Sarah Stewart-Brown