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Promoting Positive Mental Health: Theoretical Frameworks for Practice

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Title: Promoting Positive Mental Health: Theoretical Frameworks for Practice


1
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
2
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

3
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

4
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

5
IUHPE Special Issue, 2005 there 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

6
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

7
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.
8
Positive concepts of mental health the 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)

9
Current definitions of mental health more 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)

10
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

11
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

12
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

13
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?

14
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?

15
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16
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17
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

18
  • Adopting a Mental Health Promotion Approach

19
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

20
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.

21
The importance of mental health there 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

22
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 environment organisation com
munity person 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)
23
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

24
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

25
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

26
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

27
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

28
  • Evidence of Effectiveness

29
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

30
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

31
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

32
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

33
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34
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

35
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

36
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

37
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

38
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)

39
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)

40
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

41
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)

42
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

43
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

44
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

45
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

46
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

47
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)

48
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

49
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

50
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

51
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

52
Art, science and politics of creating a mentally
healthy society
53
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