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Concepts of mental health–a survey of attendees at a mental health promotion conference
Patient Education and Counseling 40 (2000) 83–91 www.elsevier.com / locate / pateducou
Concepts of mental health–a survey of attendees at a mental health promotion conference Eve Braidwood Arcadia House, The Drive, Great Warley, Brentwood, Essex CM13 3 BE, UK Received 12 June 1998; received in revised form 9 March 1999; accepted 5 April 1999
Abstract This survey of attendees at a Mental Health Promotion Conference in Hull, Yorkshire, England in the summer of 1996 was undertaken in part fulfilment of an MSc in Health Promotion. Of the 120 delegates, 99 attended the conference. There were 77 completed questionnaires. The most outstanding result of the survey was the very strong agreement among respondents that sense of self-worth is the most important attribute of being mentally healthy. The respondents were also strongly in favour of enablement strategies but on the whole envisioned these as having primarily an educational rather than a societal focus. About a third of the respondents tended to conceptualise mental health promotion within a clinical framework. The survey demonstrates the need to strengthen concepts of positive mental health and for mental health professionals to identify and work more closely with non-health workers in the promotion of positive mental health. 2000 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Mentally healthy; Sense of self-worth; Positive mental health
1. Introduction The Ottawa Charter [1] to which Britain is a signatory emphasised that promotion of health requires not only the dissemination and development of health related knowledge and skills (health education) but also the implementation of public policies which provide people with the opportunity to live healthy and fulfilling lives. This requires intersectorial collaboration and the recognition of the key roles played by nonhealth professionals in promoting health. Health promotion literature contains many examples of the general application of this principle but there are few published examples of its application to the promotion of mental health. This is also a dearth of papers on mental health promotion in 0738-3991 / 00 / $ – see front matter PII: S0738-3991( 99 )00036-1
comparison to those focusing on the treatment of mental illness; and, the term mental health is used predominately to mean mental ill health. For mental health promotion to be effectively developed and implemented, it requires shared understanding between professional groups and a common language. Different agencies and professional groups may conceptualise mental health differently or may give profoundly different emphasis to the various attributes of mental health. As part of a larger study aimed at identifying the extent to those engaged in promoting mental health, share common concepts and values, attendees at a mental health promotion conference were surveyed for their beliefs about mental health and mental health promotion.
2000 Elsevier Science Ireland Ltd. All rights reserved.
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E. Braidwood / Patient Education and Counseling 40 (2000) 83 – 91
2. Process Information was gathered through a self-administered written questionnaire as this format facilitates the collection and collation of significant amounts of data. The questionnaire was administered to delegates attending a mental health promotion conference run under the auspices of Hull and Holderness Community Health in the summer of 1996 at the Post Graduate Centre. Hull, UK. Invitations to the conference were circulated to a wide range of professional and lay groups with a health promotion role. The largest number of invitations were forwarded to the education services, that is, schools and the youth service, because of the potential for mental health promotion work with young people (Table 1).
3. Design and content of questionnaire In order to provide both quantitative and qualitative data, the questionnaire included closed and open-ended questions. The questionnaire included ten questions covering four themes: what it means to be mentally healthy; influences on mental health; strategies to promote mental health; and, individual professional roles in promoting mental health. The questionnaire was piloted twice to ensure clarity, lack of ambiguity and ease of completion.
3.1. Being mentally healthy Given the frequent conflation in the literature of being mentally healthy with influences on mental health, the first two questions were phrased in terms of the attributes possessed by a person if s / he is mentally healthy rather than what is mental health. In the first question respondents were asked to select from 16 attributes of being mentally health, Table 1 Dissemination of invitations Education (schools and youth services) Health (mental health and primary care teams) Social services teams Work places Voluntary agencies Faith groups / Churches Private counselling agencies
186 121 20 39 30 24 6
those which they regarded as being important, and from their selection to rank these with regard to their relative importance. The 16 listed attributes were used in the questionnaire on the basis of having been commonly cited in the literature and having congruence with the Four Paradigm Framework which, prior to the publications of Raeburn and Rootman [2] and Macdonald and O’Hara [3] was the only published conceptual framework for mental health promotion. The four paradigms are Radical Humanist, Interpretative Humanist, Functionalist and Radical Structuralist. The framework, based on the work of Burnell and Morgan [4] was first adapted for use in health promotion by Caplan [5]. Tudor [6,7] and Macdonald [8] have further refined it to describe mental health and mental health promotion. The Radical Humanist paradigm is underpinned by concepts of self-actualisation, that is, an inner sense of mental wellness is regarded as paramount. The Interpretative Humanist paradigm is characterised by being able to form constructive relationships with other people. The Functionalist paradigm focuses on normal behaviour, good mental health being typified by being able to conform to societal norms. The Radical Structuralist is concerned with having compassion and the desire for a just and equitable society. Macdonald [8] argues that there will be both personal and professional preferences for working in and adhering to different paradigms. Question 2, asked respondents to list any important aspects of being mentally healthy which they felt have been missed from the list offered in question 1.
3.2. Influences on mental health In question 3, from 16 listed influences, respondents were asked to select those with which they agreed. From this selection, they were asked to identify those which they believed would have the most widespread / and or lasting impact on mental health in our society. They were then asked to rank their selection with respect to their relative potential to impact on mental health. The selected influences on mental health are drawn primarily from the work of George Albee [9], Professor Emeritus, University of Maryland who has written extensively on public health approaches to the prevention of mental ill health. He cites six
E. Braidwood / Patient Education and Counseling 40 (2000) 83 – 91
themes which must be addressed at a societal level if the incidence of mental ill health is to be significantly lowered: Stress arising from experiences, such as, isolation, excessive caring burdens, financial insecurity; Exploitation, e.g., child labour, child pornography, low wages, long working hours; opportunities to acquire Lifeskills and Self-esteem; Support, e.g., respite care, aids to independent living, during periods of crisis or adjustment; and, Brain damage arising from preventable causes, such as, poor maternal health in pregnancy, environmental pollutants, accidents. Professor Albee places his own work within the radical structuralist paradigm which he believes to be the most consistent with a public health response to mental ill health, that is, one which is proactive and operates at a social policy level [10–12]. Therefore, although self-esteem can be placed within the radical humanist paradigm, lifeskills within the interpretative humanist paradigm, and the prevention of brain damage the functionalist paradigm, Albee argues that the only effective means of bring about change is at a societal level, that is, by applying the radical structuralist paradigm. Counselling and other person centred therapies were offered to test how the respondents rated this as an influence on mental health since therapy is a response to an existing problem and has no impact on incidence. Albee has demonstrated by the use of simple arithmetic that there will never be enough therapists to respond to mental ill health and, therefore, the only sensible solution is to tackle mental ill health at its root causes [13]. In Question 4, respondents were asked to list any other interventions which they believed would significantly contribute to the promotion of mental health in our society.
3.3. Strategic approaches The British Government launched a national strategy for health in 1992, Health of the Nation [14]. With respect to mental health, it set out four strategic areas for intervention: reduction in suicides, destigmatisation of mental illness, improvements in the care and treatment of mental illness and in living and working conditions for mentally ill people. These governmental strategic priorities were offered
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for the respondents consideration alongside broadbased strategic approaches which exemplify each of the four paradigms. In Question 5, respondents were asked to select the strategic interventions which they believed would be effective. From those selected, they were asked to decide which they believed would be the most effective and then to rank these in terms of relative effectiveness in promoting mental health. In Question 6, respondents were asked if there were any other interventions, which should be included in a mental health promotion strategy. In Question 7, respondents were asked, if they had the resources to implement one mental health promotion intervention what would this be and what would be their reasons for choosing this intervention.
3.4. Individual role and responsibility for promotion mental health In Question 8, respondents were asked how they believed they contributed in their own work, (including voluntary work), to the promotion of mental health? In question 9, respondents were asked to indicate the client group(s) with whom they work and in question 10, respondents were asked to indicate their professional group.
4. Results Of 99 attendees at the conference, 77 returned completed questionnaires. Table 2 shows the returns by professional group. Table 2 Questionnaires returned by profession (from question 10) School Teacher Psychologist Youth Worker Psychiatrist Education Manager Psychiatric Nurse School Nurse Counsellor Local Authority Managers Community Health Worker Office Manager Nursery Nurse
7 2 2 2 1 8 1 2 2 3 1 1
Health visitor Minister Religion Social Services Manager Voluntary Agency Worker Social Services Worker Occupational Health Health Promotion Specialist Human Resources Health Services Manager Housing Officer Public Health Consultant Shelter Housing Warden
3 1 4 5 6 1 7 3 7 1 1
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Despite a focused effort to attract education professionals, the majority of the respondents were health professionals. Analysis of questions 8, 9 and 10 showed that nearly 50% of the respondents were either directly or indirectly involved with mental health care.
4.1. Characteristics of a mentally healthy person Radical Humanist has a sense of self-worth feels at peace feels glad to be alive has a purpose in life Interpretative Humanist develops personal skills a develops interpersonal skills b is able to take on responsibility is able to assess situations realistically
Radical Structuralist aims to contribute to the common good resists oppression acts against injustice is considerate of the rights of others Functionalist is able to cope with every day life has self-control can experience the full range of human emotions is able to act rationally and purposefully
a
Personal skills: — problem solving: decision making; goal setting; expressing thoughts and feelings; thinking rationally; relaxing; recognising and managing emotions: self-awareness. b Interpersonal skills: — assertiveness; empathy; communication and negotiation skills.
The frequency with which respondents place each of the attributes in the first, second and third position is
shown in Fig. 1. Having a sense of self-worth, which falls within the radical humanist paradigm, was selected by the majority of the respondents as being the most important attribute of being mentally healthy. Being able to cope, which falls within the functionalist paradigm, was the next most strongly supported attribute of mental wellness. After selfworth and being able to cope respondents ranked skills; namely, interpersonal and personal skills. Attributes relating to the radical structuralist paradigm, such as resists oppression, acts against injustice attracted very little support. In other words, the attributes which focus on the individual are more strongly supported than those which require collaborative action or concern for others. The radical structuralist statement attracting the most support was ‘‘is considerate of the rights of others’’ which is closer to relationship skills than either of the other three, again reflecting a concern for skills development. Twenty three people answered the open-ended question. Of these, 11 responses described influences on mental health, e.g., employment opportunities, good physical health, good relationships, good parenting. The other 12 responses embellished attributes already listed, e.g., sense of fulfilment / accomplishment which is inherent in sense of self-worth, and content and peace of mind which are contained with glad to be alive, or gave examples of complex skills, composed of several of the given attributes, e.g,
Fig. 1. Characteristics of a mentally healthy person—frequency of responses.
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autonomy, able to manage change, both of which are embedded in personal skills.
4.2. Influences on mental health • access to personal skills education for all age groups • access to interpersonal skills education for all age groups • access to counselling • support for people experiencing difficulties with parenting • education for parenting • self-esteem building opportunities for young people • support for people going through crises • anti-isolation programmes • green spaces in towns and cities • housing policies which prevent ghettos • opportunities for meaningful paid and unpaid employment • respite opportunities • enforced safety legislation to prevent brain damage • increased screening for congenital abnormalities • minimum and maximum pay legislation • improved child protection.
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Fig. 2 shows how the respondents ranked the given list of influences. Repondents were more divided in their beliefs about what influences mental health than what it is to be mentally healthy (Fig. 1). Only ‘‘more personal skills education for all age groups’’ stands out; the majority of respondents regarding this as having the greatest potential influence on mental health. ‘‘More interpersonal skills education for all age groups’’ was most frequently selected as the next greatest influence. ‘‘Planning policies which ensure more trees, grass, and flowers in all parts of towns / cities’’, ‘‘housing policies which reduce ghettos’’ and ‘‘high density schemes and more meaningful paid and unpaid employment’’ were selected by 10% or more of the respondents as having the greatest potential to influence mental health. ‘‘Housing policies’’ were a favoured third choice. ‘‘Education for parenting and parenting support’’ received similar support as the third most important influence on mental health. The low level of support for improved child protection is perhaps consistent with a belief that improved support for parenting and improved parenting education would ultimately reduce the number of child protection cases. ‘‘Improved access to counselling’’, although a first choice with some of the respondents, did not rank particularly highly and received less overall
Fig. 2. Influences on mental health—frequency of responses.
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support than improved safety legislation. Pay legislation was the least well supported. Although there was an evident recognition of the importance of environmental factors, the respondents appear to favour educational interventions which is consistent with the responses to Question 1. Nineteen people responded to this open-ended question: eight people embellished the suggested influences; six people focused on the treatment and care of the mentally ill; four people emphasised collective responsibility; one person mentioned alcohol education.
4.3. Strategic interventions Relating to the four paradigms • Enable people to achieve their full potential (Radical Humanist) • Improve living and working conditions (Radical Structuralist) • Improve life skills (Interpretative Humanist) • Prevent brain damage before birth and in later life (Functionalist) From Health of the Nation • Improving the diagnosis and treatment of mental illness • Destigmatise mental illness • Improve the living and working conditions of people with mental illness • Prevent suicide.
Fig. 3 shows how respondents ranked strategic interventions. Enabling people to achieve their full potential scores highest as a first choice and receives the overall highest ranking as most effective strategic intervention. This is also consistent with the beliefs expressed in the earlier questions with respect to the importance of self-worth and opportunities for personal development. The strong support for ‘‘destigmatise mental illness’’ and the comparatively good support for ‘‘improve the diagnosis and treatment of mental illness’’ is also consistent with responses to the previous questions which indicate that some of the respondents are using the term mental health to refer predominantly to mental illness. Thirty-five people responded to the open-ended question. Of these, 13 focused on mental illness, e.g., more user friendly information, especially after diagnosis, involvement of users with diagnosis and treatment, early treatment and advocacy. Ten responses focused on educational interventions with four identifying contraceptive and sexual health education, three personal development education and three education about child development, listening to children and meeting their needs. Six responses emphasised social issues, such as relative poverty and collective responsibility and a more cooperative way of living, which celebrates differences and provides a strong sense of equality between people. The remaining comments related to contribution of nonmental health services to mental health; work place as a key setting; involvement of General
Fig. 3. Strategic interventions—frequency of responses.
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Practitioners; the Health Trust to clean up its own act; and, support for post-traumatic stress.
4.4. Individually selected interventions Fifty people responded to the question: If you had the resources to implement one mental health promotion intervention what would this be and what are your reasons for choosing this intervention. Twenty-one of these focused on mental illness, of which, ten mentioned treatment and care, e.g., lifestyle and coping education for clients, 24 h crisis service, a user led service, resourcing care; eight dealt with destigmatisation; and, three mentioned increased awareness and understanding of mental health problems. Eighteen focused on educational responses, 13 of which gave examples of personal development / lifeskills and five of which cited parenting education and understanding child development. Seven responses emphasised the need for measures which improve self-worth and which enable people to reach their full potential: three of which stressed the importance of this taking place in schools; and the remaining four stressed increasing awareness of interventions; recognising that all can play a role; the provision of counselling services for young people; the need for joint working and alliances; and, that improving living and working conditions is the key. This question probably gives the real insight into how individual respondents conceptualise mental health promotion: for 21 of the repondents, the care and treatment of people with mental health problems exemplifies mental health promotion.
4.5. Professional contribution to mental health promotion Seventy-four of the 77 respondents answered this question. Thirty-nine defined their role in the context of service provision either within the National Health Service or the voluntary sector. Of these, fifteen described one to one support, such as counselling; six included an educational brief, in addition to a treatment / care role, e.g., supporting and educating
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clients and their carers; five felt that they promoted mental health through their professional practice, e.g., respect for clients; five stated their professional role, e.g., ‘‘through my role as a psychologist’’; five were managers and cited strategic planning, prioritising and targeting resources towards those with greatest need. Advocacy, creating opportunities and providing accommodation were individually mentioned. Twelve people mentioned an educational role; three of these were specifically with school pupils; six gave specific examples, such as, stress management training and parenting; and, three emphasised coping strategies. Six described health promotion approaches; e.g., health promoting schools; community peer education. Six described a community development role; e.g., ‘‘involving local people and building self-confidence’’, ‘‘helping young people to live independently’’. Five respondents reported promoting mental health with staff / employees; e.g., supporting staff in distress. Two of the respondents felt they promoted mental health through their personal behaviour, e.g., in my personal life through expression of values. Two said they ‘‘did not know, yet’’, one said,‘‘ not a significant aspect of my job’’; and, one identified prevention and therapy of physical illness. This part of the questionnaire helps identify the proportion of respondents whose role focused directly or indirectly on the delivery of services for people with mental health problems Table 3 was constructed by reconciling profession group with the principal target group only, some professionals having indicated more than one target group. It is not immediately apparent from this table what proportion of respondents are working with people with mental health problems or working on issues which relate to mental health problems.
5. Practice implications Although the survey clearly demonstrated certain features of agreement, e.g., the very strong support
E. Braidwood / Patient Education and Counseling 40 (2000) 83 – 91
90 Table 3 Target / client group Target group
No. of respondents working with this group
Target group
No. of respondents working with this group
General public Women’s groups Employees People over 65 G.P. population Mentally ill people People in crisis Mentally distressed people
16 1 8 2 1 18 3 11
People with drug problems People recovering from mental illness Families with young children Young people School pupils, 11–18 School pupils, 5–11 Adolescents with problems People with alcohol problems
1 1 4 1 6 2 1 1
for sense of self-worth as the most important attribute of being mentally health and strong support for enablement as a key strategic approach, it would appear that a significant proportion, about a third of the respondents perceived mental health promotion to be primarily about treatment and care of people with mental health problems. This suggests that there is a need to develop shared concepts of mental health across professional groups. Although respondents favour enablement, the majority were in favour of educational (interpretative humanist) as opposed to societal (radical structuralist) approaches to achieving this. Given that the Ottawa Charter stresses the need for opportunity alongside education, the survey suggests that there is a need to expand participants’ appreciation of necessary synergy between education and opportunity. The conference primarily attracted those working directly or indirectly with people with mental health problems. Perhaps the survey results would have been different had the title of the conference been mental wellness promotion rather than mental health promotion given that the literature demonstrates the overwhelming use of the term mental health to mean mental illness. The term mental health is potentially a barrier to mental health promotion. The survey demonstrated the need for more collaborative action on the promotion of good mental health, the need to share competencies and understanding and to pull resources to bring about significant developments in the field.
6. Postscript Subsequent to the conference a multiagency plan-
ning team was formed which has recently published a combined mental health promotion strategy and a parenting education strategy. Also, since the election of a Labour government in 1997, a number of strategic interventions have been introduced which echo the views of the respondents, e.g., the SureStart Scheme which aims to provide a positive start in live for children in deprived areas. Central to this scheme is parenting education and support programmes. Also, the Health Action Zone and the Education Action Zone programmes which aim to revitalise areas of the country with low levels of health and educational achievement. All of these scheme require active intersectorial partnerships.
References [1] WHO. Ottawa Charter for Health Promotion. Health Promot 1986;1(iii–v):649–55. [2] Raeburn J, Rootman I. Person-centred health promotion, Chichester: Wiley, 1998. [3] Macdonald G, O’Hara K. Ten elements of mental health, its promotion and demotion: implications for practice, promoting good health, Society of Health Education and Health Promotion Specialists, May 1998. [4] Burrell G, Morgan G. Sociological paradigms and organisational analysis, London:: Heinemann, 1979. [5] Caplan R. Implications of the socio–theoretical constructs for the evaluation of health education theory. M.Sc. Dissertation, Kings College London, 1986. [6] Tudor K. Community mental health promotion: a paradigm approach, Promotion of mental health, Vol. 1, Aldershot: Avebury, 1991. [7] Tudor K. Mental health promotion, London: Routledge, 1996. [8] Macdonald G. Defining the goals and raising the issues, Promotion of mental health, Vol. 2, Aldershot: Avebury, 1992.
E. Braidwood / Patient Education and Counseling 40 (2000) 83 – 91 [9] Albee GW. Towards a just society: lessons from observations on the primary prevention of psychopathology. Am Psychologist 1986;37(9):1043–50. [10] Albee GW, Joffe JM, Dusenbury L. Prevention, powerlessness and politics, Newbury Park, CA: Sage, 1988. [11] Albee GW. Prevention is the answer. Open Mind 1988;35:14–6.
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[12] Albee GW. Keynote address to the mental health promotion conference. In: Promotion of mental health, Vol. 1, Aldershot: Avebury, 1992. [13] Albee GW. The fourth revolution, Promotion of mental health, Vol. 3, Aldershot: Avebury, 1993. [14] Department of Health. Health of the nation, Her Majesty’s Stationery Office, 1992.
Concepts of mental health–a survey of attendees at a mental health promotion conference Eve Braidwood Arcadia House, The Drive, Great Warley, Brentwood, Essex CM13 3 BE, UK Received 12 June 1998; received in revised form 9 March 1999; accepted 5 April 1999
Abstract This survey of attendees at a Mental Health Promotion Conference in Hull, Yorkshire, England in the summer of 1996 was undertaken in part fulfilment of an MSc in Health Promotion. Of the 120 delegates, 99 attended the conference. There were 77 completed questionnaires. The most outstanding result of the survey was the very strong agreement among respondents that sense of self-worth is the most important attribute of being mentally healthy. The respondents were also strongly in favour of enablement strategies but on the whole envisioned these as having primarily an educational rather than a societal focus. About a third of the respondents tended to conceptualise mental health promotion within a clinical framework. The survey demonstrates the need to strengthen concepts of positive mental health and for mental health professionals to identify and work more closely with non-health workers in the promotion of positive mental health. 2000 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Mentally healthy; Sense of self-worth; Positive mental health
1. Introduction The Ottawa Charter [1] to which Britain is a signatory emphasised that promotion of health requires not only the dissemination and development of health related knowledge and skills (health education) but also the implementation of public policies which provide people with the opportunity to live healthy and fulfilling lives. This requires intersectorial collaboration and the recognition of the key roles played by nonhealth professionals in promoting health. Health promotion literature contains many examples of the general application of this principle but there are few published examples of its application to the promotion of mental health. This is also a dearth of papers on mental health promotion in 0738-3991 / 00 / $ – see front matter PII: S0738-3991( 99 )00036-1
comparison to those focusing on the treatment of mental illness; and, the term mental health is used predominately to mean mental ill health. For mental health promotion to be effectively developed and implemented, it requires shared understanding between professional groups and a common language. Different agencies and professional groups may conceptualise mental health differently or may give profoundly different emphasis to the various attributes of mental health. As part of a larger study aimed at identifying the extent to those engaged in promoting mental health, share common concepts and values, attendees at a mental health promotion conference were surveyed for their beliefs about mental health and mental health promotion.
2000 Elsevier Science Ireland Ltd. All rights reserved.
84
E. Braidwood / Patient Education and Counseling 40 (2000) 83 – 91
2. Process Information was gathered through a self-administered written questionnaire as this format facilitates the collection and collation of significant amounts of data. The questionnaire was administered to delegates attending a mental health promotion conference run under the auspices of Hull and Holderness Community Health in the summer of 1996 at the Post Graduate Centre. Hull, UK. Invitations to the conference were circulated to a wide range of professional and lay groups with a health promotion role. The largest number of invitations were forwarded to the education services, that is, schools and the youth service, because of the potential for mental health promotion work with young people (Table 1).
3. Design and content of questionnaire In order to provide both quantitative and qualitative data, the questionnaire included closed and open-ended questions. The questionnaire included ten questions covering four themes: what it means to be mentally healthy; influences on mental health; strategies to promote mental health; and, individual professional roles in promoting mental health. The questionnaire was piloted twice to ensure clarity, lack of ambiguity and ease of completion.
3.1. Being mentally healthy Given the frequent conflation in the literature of being mentally healthy with influences on mental health, the first two questions were phrased in terms of the attributes possessed by a person if s / he is mentally healthy rather than what is mental health. In the first question respondents were asked to select from 16 attributes of being mentally health, Table 1 Dissemination of invitations Education (schools and youth services) Health (mental health and primary care teams) Social services teams Work places Voluntary agencies Faith groups / Churches Private counselling agencies
186 121 20 39 30 24 6
those which they regarded as being important, and from their selection to rank these with regard to their relative importance. The 16 listed attributes were used in the questionnaire on the basis of having been commonly cited in the literature and having congruence with the Four Paradigm Framework which, prior to the publications of Raeburn and Rootman [2] and Macdonald and O’Hara [3] was the only published conceptual framework for mental health promotion. The four paradigms are Radical Humanist, Interpretative Humanist, Functionalist and Radical Structuralist. The framework, based on the work of Burnell and Morgan [4] was first adapted for use in health promotion by Caplan [5]. Tudor [6,7] and Macdonald [8] have further refined it to describe mental health and mental health promotion. The Radical Humanist paradigm is underpinned by concepts of self-actualisation, that is, an inner sense of mental wellness is regarded as paramount. The Interpretative Humanist paradigm is characterised by being able to form constructive relationships with other people. The Functionalist paradigm focuses on normal behaviour, good mental health being typified by being able to conform to societal norms. The Radical Structuralist is concerned with having compassion and the desire for a just and equitable society. Macdonald [8] argues that there will be both personal and professional preferences for working in and adhering to different paradigms. Question 2, asked respondents to list any important aspects of being mentally healthy which they felt have been missed from the list offered in question 1.
3.2. Influences on mental health In question 3, from 16 listed influences, respondents were asked to select those with which they agreed. From this selection, they were asked to identify those which they believed would have the most widespread / and or lasting impact on mental health in our society. They were then asked to rank their selection with respect to their relative potential to impact on mental health. The selected influences on mental health are drawn primarily from the work of George Albee [9], Professor Emeritus, University of Maryland who has written extensively on public health approaches to the prevention of mental ill health. He cites six
E. Braidwood / Patient Education and Counseling 40 (2000) 83 – 91
themes which must be addressed at a societal level if the incidence of mental ill health is to be significantly lowered: Stress arising from experiences, such as, isolation, excessive caring burdens, financial insecurity; Exploitation, e.g., child labour, child pornography, low wages, long working hours; opportunities to acquire Lifeskills and Self-esteem; Support, e.g., respite care, aids to independent living, during periods of crisis or adjustment; and, Brain damage arising from preventable causes, such as, poor maternal health in pregnancy, environmental pollutants, accidents. Professor Albee places his own work within the radical structuralist paradigm which he believes to be the most consistent with a public health response to mental ill health, that is, one which is proactive and operates at a social policy level [10–12]. Therefore, although self-esteem can be placed within the radical humanist paradigm, lifeskills within the interpretative humanist paradigm, and the prevention of brain damage the functionalist paradigm, Albee argues that the only effective means of bring about change is at a societal level, that is, by applying the radical structuralist paradigm. Counselling and other person centred therapies were offered to test how the respondents rated this as an influence on mental health since therapy is a response to an existing problem and has no impact on incidence. Albee has demonstrated by the use of simple arithmetic that there will never be enough therapists to respond to mental ill health and, therefore, the only sensible solution is to tackle mental ill health at its root causes [13]. In Question 4, respondents were asked to list any other interventions which they believed would significantly contribute to the promotion of mental health in our society.
3.3. Strategic approaches The British Government launched a national strategy for health in 1992, Health of the Nation [14]. With respect to mental health, it set out four strategic areas for intervention: reduction in suicides, destigmatisation of mental illness, improvements in the care and treatment of mental illness and in living and working conditions for mentally ill people. These governmental strategic priorities were offered
85
for the respondents consideration alongside broadbased strategic approaches which exemplify each of the four paradigms. In Question 5, respondents were asked to select the strategic interventions which they believed would be effective. From those selected, they were asked to decide which they believed would be the most effective and then to rank these in terms of relative effectiveness in promoting mental health. In Question 6, respondents were asked if there were any other interventions, which should be included in a mental health promotion strategy. In Question 7, respondents were asked, if they had the resources to implement one mental health promotion intervention what would this be and what would be their reasons for choosing this intervention.
3.4. Individual role and responsibility for promotion mental health In Question 8, respondents were asked how they believed they contributed in their own work, (including voluntary work), to the promotion of mental health? In question 9, respondents were asked to indicate the client group(s) with whom they work and in question 10, respondents were asked to indicate their professional group.
4. Results Of 99 attendees at the conference, 77 returned completed questionnaires. Table 2 shows the returns by professional group. Table 2 Questionnaires returned by profession (from question 10) School Teacher Psychologist Youth Worker Psychiatrist Education Manager Psychiatric Nurse School Nurse Counsellor Local Authority Managers Community Health Worker Office Manager Nursery Nurse
7 2 2 2 1 8 1 2 2 3 1 1
Health visitor Minister Religion Social Services Manager Voluntary Agency Worker Social Services Worker Occupational Health Health Promotion Specialist Human Resources Health Services Manager Housing Officer Public Health Consultant Shelter Housing Warden
3 1 4 5 6 1 7 3 7 1 1
E. Braidwood / Patient Education and Counseling 40 (2000) 83 – 91
86
Despite a focused effort to attract education professionals, the majority of the respondents were health professionals. Analysis of questions 8, 9 and 10 showed that nearly 50% of the respondents were either directly or indirectly involved with mental health care.
4.1. Characteristics of a mentally healthy person Radical Humanist has a sense of self-worth feels at peace feels glad to be alive has a purpose in life Interpretative Humanist develops personal skills a develops interpersonal skills b is able to take on responsibility is able to assess situations realistically
Radical Structuralist aims to contribute to the common good resists oppression acts against injustice is considerate of the rights of others Functionalist is able to cope with every day life has self-control can experience the full range of human emotions is able to act rationally and purposefully
a
Personal skills: — problem solving: decision making; goal setting; expressing thoughts and feelings; thinking rationally; relaxing; recognising and managing emotions: self-awareness. b Interpersonal skills: — assertiveness; empathy; communication and negotiation skills.
The frequency with which respondents place each of the attributes in the first, second and third position is
shown in Fig. 1. Having a sense of self-worth, which falls within the radical humanist paradigm, was selected by the majority of the respondents as being the most important attribute of being mentally healthy. Being able to cope, which falls within the functionalist paradigm, was the next most strongly supported attribute of mental wellness. After selfworth and being able to cope respondents ranked skills; namely, interpersonal and personal skills. Attributes relating to the radical structuralist paradigm, such as resists oppression, acts against injustice attracted very little support. In other words, the attributes which focus on the individual are more strongly supported than those which require collaborative action or concern for others. The radical structuralist statement attracting the most support was ‘‘is considerate of the rights of others’’ which is closer to relationship skills than either of the other three, again reflecting a concern for skills development. Twenty three people answered the open-ended question. Of these, 11 responses described influences on mental health, e.g., employment opportunities, good physical health, good relationships, good parenting. The other 12 responses embellished attributes already listed, e.g., sense of fulfilment / accomplishment which is inherent in sense of self-worth, and content and peace of mind which are contained with glad to be alive, or gave examples of complex skills, composed of several of the given attributes, e.g,
Fig. 1. Characteristics of a mentally healthy person—frequency of responses.
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autonomy, able to manage change, both of which are embedded in personal skills.
4.2. Influences on mental health • access to personal skills education for all age groups • access to interpersonal skills education for all age groups • access to counselling • support for people experiencing difficulties with parenting • education for parenting • self-esteem building opportunities for young people • support for people going through crises • anti-isolation programmes • green spaces in towns and cities • housing policies which prevent ghettos • opportunities for meaningful paid and unpaid employment • respite opportunities • enforced safety legislation to prevent brain damage • increased screening for congenital abnormalities • minimum and maximum pay legislation • improved child protection.
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Fig. 2 shows how the respondents ranked the given list of influences. Repondents were more divided in their beliefs about what influences mental health than what it is to be mentally healthy (Fig. 1). Only ‘‘more personal skills education for all age groups’’ stands out; the majority of respondents regarding this as having the greatest potential influence on mental health. ‘‘More interpersonal skills education for all age groups’’ was most frequently selected as the next greatest influence. ‘‘Planning policies which ensure more trees, grass, and flowers in all parts of towns / cities’’, ‘‘housing policies which reduce ghettos’’ and ‘‘high density schemes and more meaningful paid and unpaid employment’’ were selected by 10% or more of the respondents as having the greatest potential to influence mental health. ‘‘Housing policies’’ were a favoured third choice. ‘‘Education for parenting and parenting support’’ received similar support as the third most important influence on mental health. The low level of support for improved child protection is perhaps consistent with a belief that improved support for parenting and improved parenting education would ultimately reduce the number of child protection cases. ‘‘Improved access to counselling’’, although a first choice with some of the respondents, did not rank particularly highly and received less overall
Fig. 2. Influences on mental health—frequency of responses.
E. Braidwood / Patient Education and Counseling 40 (2000) 83 – 91
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support than improved safety legislation. Pay legislation was the least well supported. Although there was an evident recognition of the importance of environmental factors, the respondents appear to favour educational interventions which is consistent with the responses to Question 1. Nineteen people responded to this open-ended question: eight people embellished the suggested influences; six people focused on the treatment and care of the mentally ill; four people emphasised collective responsibility; one person mentioned alcohol education.
4.3. Strategic interventions Relating to the four paradigms • Enable people to achieve their full potential (Radical Humanist) • Improve living and working conditions (Radical Structuralist) • Improve life skills (Interpretative Humanist) • Prevent brain damage before birth and in later life (Functionalist) From Health of the Nation • Improving the diagnosis and treatment of mental illness • Destigmatise mental illness • Improve the living and working conditions of people with mental illness • Prevent suicide.
Fig. 3 shows how respondents ranked strategic interventions. Enabling people to achieve their full potential scores highest as a first choice and receives the overall highest ranking as most effective strategic intervention. This is also consistent with the beliefs expressed in the earlier questions with respect to the importance of self-worth and opportunities for personal development. The strong support for ‘‘destigmatise mental illness’’ and the comparatively good support for ‘‘improve the diagnosis and treatment of mental illness’’ is also consistent with responses to the previous questions which indicate that some of the respondents are using the term mental health to refer predominantly to mental illness. Thirty-five people responded to the open-ended question. Of these, 13 focused on mental illness, e.g., more user friendly information, especially after diagnosis, involvement of users with diagnosis and treatment, early treatment and advocacy. Ten responses focused on educational interventions with four identifying contraceptive and sexual health education, three personal development education and three education about child development, listening to children and meeting their needs. Six responses emphasised social issues, such as relative poverty and collective responsibility and a more cooperative way of living, which celebrates differences and provides a strong sense of equality between people. The remaining comments related to contribution of nonmental health services to mental health; work place as a key setting; involvement of General
Fig. 3. Strategic interventions—frequency of responses.
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Practitioners; the Health Trust to clean up its own act; and, support for post-traumatic stress.
4.4. Individually selected interventions Fifty people responded to the question: If you had the resources to implement one mental health promotion intervention what would this be and what are your reasons for choosing this intervention. Twenty-one of these focused on mental illness, of which, ten mentioned treatment and care, e.g., lifestyle and coping education for clients, 24 h crisis service, a user led service, resourcing care; eight dealt with destigmatisation; and, three mentioned increased awareness and understanding of mental health problems. Eighteen focused on educational responses, 13 of which gave examples of personal development / lifeskills and five of which cited parenting education and understanding child development. Seven responses emphasised the need for measures which improve self-worth and which enable people to reach their full potential: three of which stressed the importance of this taking place in schools; and the remaining four stressed increasing awareness of interventions; recognising that all can play a role; the provision of counselling services for young people; the need for joint working and alliances; and, that improving living and working conditions is the key. This question probably gives the real insight into how individual respondents conceptualise mental health promotion: for 21 of the repondents, the care and treatment of people with mental health problems exemplifies mental health promotion.
4.5. Professional contribution to mental health promotion Seventy-four of the 77 respondents answered this question. Thirty-nine defined their role in the context of service provision either within the National Health Service or the voluntary sector. Of these, fifteen described one to one support, such as counselling; six included an educational brief, in addition to a treatment / care role, e.g., supporting and educating
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clients and their carers; five felt that they promoted mental health through their professional practice, e.g., respect for clients; five stated their professional role, e.g., ‘‘through my role as a psychologist’’; five were managers and cited strategic planning, prioritising and targeting resources towards those with greatest need. Advocacy, creating opportunities and providing accommodation were individually mentioned. Twelve people mentioned an educational role; three of these were specifically with school pupils; six gave specific examples, such as, stress management training and parenting; and, three emphasised coping strategies. Six described health promotion approaches; e.g., health promoting schools; community peer education. Six described a community development role; e.g., ‘‘involving local people and building self-confidence’’, ‘‘helping young people to live independently’’. Five respondents reported promoting mental health with staff / employees; e.g., supporting staff in distress. Two of the respondents felt they promoted mental health through their personal behaviour, e.g., in my personal life through expression of values. Two said they ‘‘did not know, yet’’, one said,‘‘ not a significant aspect of my job’’; and, one identified prevention and therapy of physical illness. This part of the questionnaire helps identify the proportion of respondents whose role focused directly or indirectly on the delivery of services for people with mental health problems Table 3 was constructed by reconciling profession group with the principal target group only, some professionals having indicated more than one target group. It is not immediately apparent from this table what proportion of respondents are working with people with mental health problems or working on issues which relate to mental health problems.
5. Practice implications Although the survey clearly demonstrated certain features of agreement, e.g., the very strong support
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90 Table 3 Target / client group Target group
No. of respondents working with this group
Target group
No. of respondents working with this group
General public Women’s groups Employees People over 65 G.P. population Mentally ill people People in crisis Mentally distressed people
16 1 8 2 1 18 3 11
People with drug problems People recovering from mental illness Families with young children Young people School pupils, 11–18 School pupils, 5–11 Adolescents with problems People with alcohol problems
1 1 4 1 6 2 1 1
for sense of self-worth as the most important attribute of being mentally health and strong support for enablement as a key strategic approach, it would appear that a significant proportion, about a third of the respondents perceived mental health promotion to be primarily about treatment and care of people with mental health problems. This suggests that there is a need to develop shared concepts of mental health across professional groups. Although respondents favour enablement, the majority were in favour of educational (interpretative humanist) as opposed to societal (radical structuralist) approaches to achieving this. Given that the Ottawa Charter stresses the need for opportunity alongside education, the survey suggests that there is a need to expand participants’ appreciation of necessary synergy between education and opportunity. The conference primarily attracted those working directly or indirectly with people with mental health problems. Perhaps the survey results would have been different had the title of the conference been mental wellness promotion rather than mental health promotion given that the literature demonstrates the overwhelming use of the term mental health to mean mental illness. The term mental health is potentially a barrier to mental health promotion. The survey demonstrated the need for more collaborative action on the promotion of good mental health, the need to share competencies and understanding and to pull resources to bring about significant developments in the field.
6. Postscript Subsequent to the conference a multiagency plan-
ning team was formed which has recently published a combined mental health promotion strategy and a parenting education strategy. Also, since the election of a Labour government in 1997, a number of strategic interventions have been introduced which echo the views of the respondents, e.g., the SureStart Scheme which aims to provide a positive start in live for children in deprived areas. Central to this scheme is parenting education and support programmes. Also, the Health Action Zone and the Education Action Zone programmes which aim to revitalise areas of the country with low levels of health and educational achievement. All of these scheme require active intersectorial partnerships.
References [1] WHO. Ottawa Charter for Health Promotion. Health Promot 1986;1(iii–v):649–55. [2] Raeburn J, Rootman I. Person-centred health promotion, Chichester: Wiley, 1998. [3] Macdonald G, O’Hara K. Ten elements of mental health, its promotion and demotion: implications for practice, promoting good health, Society of Health Education and Health Promotion Specialists, May 1998. [4] Burrell G, Morgan G. Sociological paradigms and organisational analysis, London:: Heinemann, 1979. [5] Caplan R. Implications of the socio–theoretical constructs for the evaluation of health education theory. M.Sc. Dissertation, Kings College London, 1986. [6] Tudor K. Community mental health promotion: a paradigm approach, Promotion of mental health, Vol. 1, Aldershot: Avebury, 1991. [7] Tudor K. Mental health promotion, London: Routledge, 1996. [8] Macdonald G. Defining the goals and raising the issues, Promotion of mental health, Vol. 2, Aldershot: Avebury, 1992.
E. Braidwood / Patient Education and Counseling 40 (2000) 83 – 91 [9] Albee GW. Towards a just society: lessons from observations on the primary prevention of psychopathology. Am Psychologist 1986;37(9):1043–50. [10] Albee GW, Joffe JM, Dusenbury L. Prevention, powerlessness and politics, Newbury Park, CA: Sage, 1988. [11] Albee GW. Prevention is the answer. Open Mind 1988;35:14–6.
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[12] Albee GW. Keynote address to the mental health promotion conference. In: Promotion of mental health, Vol. 1, Aldershot: Avebury, 1992. [13] Albee GW. The fourth revolution, Promotion of mental health, Vol. 3, Aldershot: Avebury, 1993. [14] Department of Health. Health of the nation, Her Majesty’s Stationery Office, 1992.