Promoting Positive Mental Health: Theoretical Frameworks for Practice

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Advancing the Implementation of Best Practice in
Mental Health Promotion Professor Margaret Barry
Department of Health Promotion National
University of Ireland, Galway Ollscoil na
hÉireann, Gaillimh
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Introduction

• Mental health is fundamental to good health,
  wellbeing and quality of life
• resource for everyday life which enables us to
  manage our lives successfully
• Importance of promoting mental health in its own
  right, as well as its role in reducing the risks
  of mental ill-health
• Demand for effective mental health promotion
  strategies - raise the standard of mental health
  promoting policy and practices worldwide

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Overview

• What do we know about effective mental health
  promotion?
• Applying the existing knowledge base concerning
  mental health promotion and its effectiveness
• what makes mental health promotion programmes
  work?
• translate from research into effective programme
  implementation
• Evidence-based principles of effective practice
• Implications for future development of practice
  and policy

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Effective Mental Health Promotion

• WHO Reports (2004/5)
• Promoting Mental Health Concepts, Emerging
  Evidence, Practice.
• Prevention of Mental Disorders Effective
  Interventions and Policy Options.
• - clarify concepts of promotion and prevention
• - review the evidence of effectiveness
• - public health policy and practice implications
• Cost-effectiveness of mental health promotion and
  prevention (Friedli and Parsonage, 2007)
• Knapp et al., 2008 - mental health economics

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IUHPE Special Issue, 2005there is sufficient
knowledge to move evidence into practice

• Jané-Llopis, E., Barry, M.M., Hosman, C. and
  Patel, V. (Eds.) (2005) The Evidence of Mental
  Health Promotion Effectiveness
• Momentum for mental health promotion
• Review of the international evidence base on
  effectiveness
• Principles of successful programme implementation
  and adoption
• Determinants - poverty and gender in a global
  society
• Why governments should promote mental health
• Integration into health promotion and public
  health

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Promotion and Prevention

• Mental health promotion
• focus on positive mental health and quality of
  life across populations
• building strengths, competencies and resources
• Prevention of mental disorders
• concern with specific disorders - reducing
  incidence, prevalence or seriousness of a
  targeted problem
• mortality, morbidity and risk behaviours

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Standard treatment for known disorders
Case identification
Indicated
Compliance with long-term treatment
Selective
After-care (including rehabilitation)
Strategies for promoting well-being quality
of life
Universal
Competence
Empowerment
Resilience
Supportive Environments
Barry, M.M. (2001) International Journal of
Mental Health Promotion, 3(1) 25-34.
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Positive concepts of mental healththe absence of
mental ill-health does not equal mental health

• Mental health and mental disorder - continuum or
  separate entities?
• Conceptualisations of positive mental health
  (Keyes, 2002 Huppert, 2005 Ryff et al., 2006)
• Hedonic - subjective well-being and life
  satisfaction
• Eudaimonic - positive functioning, engagement,
  fulfilment and social wellbeing
• Population approach - distribution of mental
  health and mental disorder across the population
• Mental health as an integral part of health and
  wellbeing (Lancet series on Global Mental Health
  2007)

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Current definitions of mental healthmore than
the absence of mental illness

• Mental health may be defined as
• a state of emotional and social well-being in
  which the individual realises his or her own
  abilities, can manage the normal stresses of
  life, can work effectively, and is able to play a
  role in his or her community (WHO, 1999)
• Mental health is the embodiment of social,
  emotional and spiritual wellbeing .. provides
  individuals with the vitality necessary for
  active learning, to achieve goals and to interact
  with one another in ways that are respectful and
  just (VicHealth, 2005)

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Aspects of Well-being

• Emotional well-being - affect/feeling
• Psychological well-being - positive functioning
• Physical well-being - physical health and fitness
• Social well-being - relations with others and
  society
• Spiritual well-being - meaning and purpose in
  life

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Positive mental health

• Barry and Friedli (2008) - review of the
  determinants of positive mental health for the UK
  Governments Foresight Project on Mental Capital
  and Wellbeing
• few studies have focused on analysing the
  determinants of positive mental health among
  whole populations
• existing evidence is drawn from epidemiological
  studies of mental disorders and interventions
  studies
• Measuring positive mental health (Kovess-Masfety
  et al., 2005)
• Sense of Coherence scale (Antonovsky, 1993)
• Affectometer 2 scale (Kammann Flett ,1983)
• Warwick Edinburgh Mental Wellbeing scale (Tennant
  et al., 2006)
• Energy and Vitality Index (SF-36)
• Keyes (2002, 2005) -suite of measures

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The Emergence of Positive Psychology

• The scientific study of the strengths and
  virtues that enable individuals and communities
  to thrive (Positive Psychology Centre,
  University of Pennsylvania, 2007)
• Psychological aspects of what makes life worth
  living - optimism, love, emotional intelligence,
  hope, wisdom, creativity, humour
• Focus on happiness - positive emotion, engagement
  and meaning
• - how we establish meaningful social relations,
  and our ability to find coherence and deeper
  meaning in our lives

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Positive Psychology

• Writings of Seligman, Peterson, Csikszentmihalyi,
  Zautra, Synder et al.
• Seligman - 3 pillars of positive psychology
• Positive subjective experiences
• Positive individual characteristics (strengths
  and virtues)
• Positive institutions and communities
• Is happiness the appropriate construct?
• Link up with a positive sociology and positive
  economics?

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Economics of happiness

• Richard Layard (2005)- Happiness Lessons from a
  New Science?
• Income and happiness - no direct correlation
• Relative income - hedonic treadmill
• Economic growth produces many unwanted
  side-effects - diminishing returns (Sustainable
  Development Commission, 2003)
• Rethinking economic policy - how the economy
  affects our well-being
• Object of public policy - maximising the sum of
  human well-being?
• Policy making centred on economic growth or
  well-being?

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A policy focus on well-being

• What would politics look like if promoting
  peoples well-being was one of the governments
  main aims?
• New Economics Foundation - A Well-being Manifesto
  for a Flourishing Society
• Measure what matters - set of national well-being
  audits
• Well-being economy - employment, meaningful work
  and environmental taxation
• Reclaim our time
• Education system that promotes flourishing
• Health service that promotes complete health
• Invest in the early years and parenting
• Discourage materialism and promote authentic
  advertising
• Strengthen active citizenship social well-being
  and civil society
• Integration of social, economic and ecological
  policies

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• Adopting a Mental Health Promotion Approach

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A process view of mental health

• Mental health is fundamental to good health,
  well-being and quality of life
• a resource for everyday life which enables us to
  manage our lives successfully
• not a static entity - dynamic equilibrium
• contributes to the functioning of individuals,
  families, communities and society
• influenced by the broader determinants of health
• importance of promoting positive mental health in
  its own right

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Mental Health Foundation

• Mental health promotion works to enable
  individuals, whanau, organisations and
  communities to improve and sustain their mental
  health and realise their full potential.

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The importance of mental healththere is no
health without mental health

• Mental health promotion - socio-ecological model
• Builds on the basic concepts and principles of
  health promotion
• Mental health promotion concepts are positive,
  dynamic and empowering - focus on enhancing the
  strengths and competencies of individuals,
  communities and society
• Multidisciplinary - theories and methods

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Health Promotion action areas Build healthy
public policy Create supportive
environments Reorient health services Strengthen
community action Develop personal
skill combined into Health Promotion
strategies
Systems Policies environmentorganisationcom
munityperson Systems scale
Health Promotion Model (WHO Ottawa Charter) The
process of enabling people to increase control
over their health and the determinants of health
micro - macro
Health Promotion Principles (participation,
empowerment, equity)
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Determinants of mental health

• Healthy structures - economic, political, social
  and cultural framework for developing and
  maintaining positive mental health
• Citizenship - social support, sense of social
  integration and inclusion
• Emotional Resilience - self-esteem, coping , life
  skills, sense of control

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Generic principles of mental health promotion

• Adopt a socio-ecological approach
• Bring about change at the level of the
  individual, the family, social group/community
  and broader society
• Programmes need to be able to influence the
  enduring environments in which the individual,
  family, group or community is functioning
• The importance of supportive environments or
  settings
• - homes, schools, workplaces, communities, health
  services

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Generic principles of mental health promotion

• Embracing an empowerment philosophy
• engage the active participation of programme
  participants
• build on existing strengths and skills of the
  programme participants
• enhance their sense of control over their lives
• address systems of socialisation and control
  (poverty, social injustice, discrimination)
• Multilevel construct - role of mediating
  structures

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Generic principles of mental health promotion

• Engaging in Consultation and Collaboration
• Partnership working and participation at all
  stages
• Hauf and Bond (2002) - community-based
  collaboration
• Promotes greater ownership
• Facilitates capacity building
• Supports development of inter-sectoral structures
• Improves chances of sustainability

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Generic principles of mental health promotion

• Addressing Social Equity
• Social inequalities in the distribution of mental
  health problems - markers of social disadvantage
  are all associated with poorer mental health
  (Melzer et al., 2004 Prince et al., 2007)
• Mental health is both a consequence of and
  contributor to health inequalities
• Multi-sectoral initiatives tackling sources of
  disadvantage and inequalities for poor and
  marginalised groups
• education, standards of living, employment,
  childcare, community supports, discrimination,
  social exclusion

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• Evidence of Effectiveness

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Evidence Reviews

• Mrazek and Haggerty (1994) - systematic review
  Institute of Medicine Report Reducing Risks for
  Mental Disorders Frontiers for Preventive
  Intervention Research.
• Durlak Wells (1997) - meta-analytic review
• American Journal of Community Psychology
  25(2),115-152
• Tilford et al. (1997) Effectiveness of Mental
  Health Promotion Interventions A Review. HEA
  (UK)
• IUHPE Report (1999) The Evidence of Health
  Promotion Effectiveness, Chapter 3
• Friedli (2003) Making it Effective A guide to
  evidence based mental health promotion.
  Mentality, UK

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Conclusions from Evidence Reviews

• Effective interventions have been identified
  which promote the mental health of the population
  at large and those known to be at risk of mental
  health problems (Tilford et al., 1997)
• IUHPE Report (1999) The Evidence of Health
  Promotion Effectiveness.
• mental health promotion programmes not only
  improve mental health and quality of life but
  also reduce the risk for mental disorder
• lasting positive effect on functioning in
  multiple domains
• clusters of risk and protective factors -
  cost-effective
• strategies - effective across diverse groups and
  across the lifespan

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IUHPE Special Issue, 2005 Mental Health
Promotion Works A Review

• Draws on different sources of evidence
• - systematic reviews, process evaluations, grey
  literature
• - case studies from high, middle and low-income
  countries
• Reviews the evidence of effectiveness in terms of
  health, social and economic impacts
• - interventions across key settings - home,
  school, community, workplace and health services
• Positive outcomes across multiple areas of health
  and social functioning
• Sufficient knowledge to move evidence into
  practice

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Research Principles of Efficacy What makes
mental health promotion effective?Eva
Jané-Llopis and Margaret Barry - IUHPE Special
Issue, 2005

• Adoption and implementation of evidence-based
  interventions - efficacy and effectiveness
• Evidence-based principles underpinning programme
  success
• sound theoretical and research base
• clarifying key goals and objectives
• programme provider training and support
• evaluation and high quality research methods
• infrastructural support from management
• programme fidelity versus reinvention
• transferability across countries and cultures

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Characteristics of successful programmes (Barry
Jenkins, 2006)

• Programme development based on underpinning
  theory, research principles of efficacy and needs
  assessment
• A focused and targeted approach to programme
  planning, implementation and evaluation
• Address a range of protective and risk factors

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Characteristics of successful programmes (Barry
Jenkins, 2006)

• Adopt a competence enhancement approach and an
  implementation process that is empowering,
  collaborative and participatory, carried out in
  partnership with key stakeholders
• Employ a combination of intervention methods
  operating at different levels

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Characteristics of successful programmes (Barry
Jenkins, 2006)

• Comprehensive approaches that intervene at a
  number of different time periods rather than once
  off
• Include the provision of training and support
  mechanisms that will ensure high quality
  implementation and sustainability

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Theoretical base of effective programmes

• Clear articulation of programme theory
• Attachment theory
• Self-efficacy
• Resilience
• Stress and coping
• Social support
• Social learning theory
• Organizational theory

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Theoretical base of effective programmes

• Causative and prescriptive theories (Chen,1998)
• Causative theories - mechanisms underpinning the
  intervention
• Prescriptive theories - dynamic process of change
  
• JOBS depression prevention programme (Vinokur,
  Price Schul, 1995)
• - causative theory based on models of stress and
  coping
• - prescriptive theory based on active learning
  and building of self-efficacy
• Adoption of the JOBS programme in Ireland (Barry
  et al., 2007 Journal of Public Mental Health)

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Needs Assessment

• Tailored to the needs of the participants and the
  local setting - ecological fit
• Age, gender and culturally sensitive programmes
• Example Lara et al. (1997, 2003) - adapting a
  depression prevention programme for women in
  Mexico city
• Balancing programme fidelity and adapting to
  local needs
• Rural Mental Health Project (Barry et al., 2005)

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Focused approach to programme planning,
implementation and evaluation

• Example Communities that Care initiative
  (Hawkins et al., 2002)
• Readiness phase - capacities and barriers
• Involving the community - organizational
  structure
• Compiling a community baseline profile
• Developing a comprehensive action plan
• Implementation and evaluation of the plan

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Competence enhancement approach

• Promotion of resourcefulness and generic coping
  and competence skills
• Greenberg et al (2001) promoting alternative
  thinking strategies (PATHS)
• Kellam et al (1994) Good Behaviour Game
• Gillham et al (1995) Penn Resiliency programme
• Resourceful Adolescent programme (Shochet et al,
  2001)
• Depression prevention mood management (Munoz,
  1997 Clarke et al. 1995)

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Competence enhancement approach

• Implementation approach that is empowering,
  collaborative and participatory
• Programme Examples
• Community Mothers Programme (Johnson et al.,
  2000 Molloy, 2002) - parent empowerment
• Widow-to-Widow peer support programme (Silverman,
  1986, 1988) - mutual help
• Patel et al. (2005) - poverty, gender equality,
  violence, literacy - community development and
  economic empowerment

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Address a range of protective and risk factors

• High/Scope Perry Preschool Programme (Schweinhart
  et al., 2005) - intellectual and social
  development in 3-4 year olds from disadvantaged
  backgrounds
• Cognitive and social co-operation skills
• Educational model - active learning, effective
  learning environment
• Positive long-lasting effects (ages 39-41)
• school success - literacy, grades and completion
  rates
• socioeconomic success - employment, earnings,
  home ownership
• social responsibility - reduced crime levels
• marriage and parenthood
• Cost effectiveness - solid investment

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Multi-component comprehensive programmes

• The Midwestern Prevention Project (Pentz et al.,
  1997) - comprehensive community-based programme
• School component - student skills and school
  policies
• Parental programme - skills training,
  communication
• Community component- community leaders engaged in
  service planning
• Health policy change - local government leaders
• Mass media - supportive messages

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Adopt a comprehensive approach

• Effective school programmes - whole school
  approach - the school curriculum and pupils
  knowledge and skills, the school ethos and
  environment, involving the parents and the local
  community (Lister-Sharp et al., 1999 Well et
  al., 2003)
• Australian MindMatters programme (Wynn et al.,
  1999)
• Olweus et al. (1998) Bullying Prevention
  programme - school, classroom and individual
  level
• Workplace stress - organizational wide approaches
• - legislation on bullying and harassment
• - sense of control, social support and
  involvement in decision-making

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Quality implementation support system

• Adopting a best practice programme does not in
  itself guarantee success
• Provide adequate resources for good quality
  planning and implementation - staff skills,
  training, supervision, organisational support
• Mobilise support of key stakeholders

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Quality implementation support system

• Identify core components of the programme
• Quantity and quality of programme delivery
• Invest in process as well as outcome evaluation
• Sustainability - organizational and system-level
  practices and policies that will ensure the
  long-term impact of high quality programmes
• (Barry et al., 2005 IUHPE Special Issue)

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Research Challenges for the Future

• Development and refinement of measures of
  positive mental health
• - mental health status and well-being
  determinants
• Evaluating upstream interventions addressing
  the broader determinants of mental health
• Documenting wider health and social gain
• - integration of mental health in health
  promotion and public health initiatives
  cost-effectiveness studies
• Developing methodologies that seek to capture
  dynamic interactions in context - process and
  outcomes
• - evaluation of programme implementation

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Research into Practice and Policy

• Building and disseminating the knowledge and
  evidence base - identifying and filling the gaps
• Translating the evidence into policy and practice
  - databases, evidence briefings, best practice
  guidelines
• Translational process - more active dissemination
• - evidence needs to be contextualised and usable
• IUHPE Getting Evidence into Practice project
• Methodologies for integrating the evidence into
  the realities of current practice - technical
  assistance and capacity building

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Practice Challenges for the Future

• Capacity building in programme adoption and
  implementation
• training in evidence-based programme planning and
  evaluation
• Collaboration and shared learning
• Two way process - capturing knowledge and
  learning from best practice and the policy making
  process
• Models of best practice - effective, feasible and
  sustainable in the local context
• Making knowledge work for improved mental health
• Wider community participation
• removing the shadows - stigma reduction and
  community awareness, media

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Policy - creating a mentally healthy society

• The science of mental health promotion
• - the knowledge and research base for mental
  health promotion
• The art of enabling and creating positive mental
  health
• empowering, participative and collaborative
  process
• addressing the broader determinants of mental
  health
• The politics of effective action
• policy, research and practice are mediated
  through political processes
• Engaging the political will to promote mental
  health at a government policy level
• Mobilising a public demand for a mentally healthy
  society

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Art, science and politics of creating a mentally
healthy society
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