Complete mental health recovery: bridging mental illness with positive mental health

Evaluation

Complete mental health recovery: bridgingmental illness with positive mental health

Helene L. Provencher and Corey L.M. Keyes

Abstract

Purpose – The purpose of this paper is to propose that the study, and the promotion, of recovery can be

augmented by adopting the model of mental health as a complete state.

Design/methodology/approach – A literature review of the last two decades was undertaken and

pathways to complete mental health in recovery are proposed.

Findings – More work is needed to further develop interventions oriented towards the promotion of

positive mental health in recovery, targeting the enhancement of positive emotions towards life and a

sense of fulfillment in private and social life. Positive mental health also deserves more research attention

to assess the full range of recovery outcomes related to the restoration and optimization processes.

A better understanding of individual and environmental factors facilitating or hindering the achievement

of complete mental health in recovery is warranted as well.

Originality/value – Unlike previous conceptions, the model presented in the paper proposes to

redefine recovery from the complete view of mental health and introduces positive mental health as an

additional outcome of recovery.

Keywords Mental illness, Quality of life

Paper type General review

Mental health, as more than the absence of mental illness and involving the presence of

subjective well-being as well, is a view that has been represented in the scientific literature for

more than half a century (Jahoda, 1958; TheWorld Health Organization, 1948). However, this

complete vision of mental health remained undefined, unmeasured and therefore largely

ignored for several decades. Recently, a new approach has been developed for evaluating

states of complete mental health, including criteria for combining indicators of mental illness

and positivemental health (i.e. subjective well-being). This has been used to study themodel

of complete mental health, also called the two continua model (Keyes, 2005a, 2007). Overall,

this line of research has demonstrated the independence of mental illness and positive

mental health, representing two separate continua rather than the opposite ends of a single

continuum. This implies that experiencing less mental illness does not necessarily equate

with experiencing better positivemental health and also highlights the possibility of achieving

a high level of positive mental health despite the presence of enduring psychiatric symptoms

and deficits.

Over the last twodecades, recovery has become the overarchingaimofmental health services

systems inmany countries, Australia, New Zealand, England, Scotland and the USA to name a

few (Slade et al., 2008). An extensive body of literature on recovery has emerged fromnarrative

studies (Silverstein and Bellack, 2008) and numerous published personal accounts (Ridgway,

2001; Spaniol and Koehler, 1994). This has provided a better understanding of personal and

DOI 10.1108/17465721111134556 VOL. 10 NO. 1 2011, pp. 57-69, Q Emerald Group Publishing Limited, ISSN 1746-5729 j JOURNAL OF PUBLIC MENTAL HEALTH j PAGE 57

Helene L. Provencher is

based in the Faculty of

Nursing, Laval University,

Quebec, Canada.

Corey L.M. Keyes is based

in the Department of

Sociology, Emory

University, Atlanta,

Georgia, USA.

environmental factors hindering or facilitating this journey as well as valuable insight about its

key dimensions (e.g. hope, empowerment, positive identity) and phases (Onken et al., 2007).

Consumers’ views of recovery stress the importance of having a pleasant and fulfilling life

despite the presence of mental illness, drawing attention to aspirations that are similar to any

other citizen. As Deegan (1988, p. 15) put it, recovery implies ‘‘to live, work, and love in a

community in which one makes a significant contribution.’’ Consistent with this view, The

World Health Organization (2005, p. 2) has recently defined mental health as:

[. . .] a state of well-being in which the individual realizes his or her own abilities, can cope with the

normal stresses of life, canwork productively and fruitfully, and is able tomake a contribution to his

or her community.

This definition reflects a salutogenic approach of mental health focusing on the presence of

positive human capacities and functioning (Antonovsky, 1979), which has also been retained

to measure positive mental health within the model of complete mental health.

The consumer-oriented vision of recovery has been taken up by a large number of

researchers and clinicians and has challenged the traditional and clinical way of defining this

phenomenon. This second vision defines recovery through the lens of the disease and

improvements in psychiatric symptoms and impairments represent signs of recovery, which

may indicate partial or full remission from mental illness (Silverstein and Bellack, 2008).

Based on this vision, several long-term follow-up studies (Calabrese and Corrigan, 2005)

have reported that more than half of personswith schizophrenia had completely recovered or

had shown significant improvements in psychiatric symptoms and functional deficits over a

period of about 20 years.

In short, consumers’ viewpoints reflect a salutogenic approach of recovery which

emphasizes the achievement of positive mental health, indexed by a sense of pleasure

and accomplishment in life. On the other hand, scientifically oriented definitions reflect a

disease-oriented or pathogenic approach of recovery, focusing on psychiatric symptoms

and deficits. So far, theoretical guidelines for bridging together the pathogenic and

salutogenic views of recovery have been overlooked, and from these may emerge a more

integrated view of this phenomenon. We argue, in this paper, that the study and the

promotion of recovery, as a process and as an outcome, can be augmented by the model of

complete mental health (Keyes, 2005a, 2007).

Following a brief overview of Keyes’ model, current definitions of recovery are further

discussed based on their underlying conceptions ofmental health, including the relevance of

positive mental health to tackle this phenomenon. Third, recovery is redefined as a complete

mental health view, relying on two complementary experiences – restoration from mental

illness and optimization of positivemental health. An emphasis is placed on outcomes, which

are viewed as pathways in complete mental health over the recovery process. How the

proposed complete view of recovery coincides with and departs from previous conceptions

is discussed along with some suggestions for future interventions and research.

Mental health is a complete state

Positive mental health

Positive mental health corresponds to feelings, thoughts and behaviors that are required for

having a good life and those have been studied in the domain of subjective well-being for

more than four decades. Critical reviews of this literature (Keyes, 2006b; Ryan and Deci,

2001) has proposed that positive mental health relies on two distinct but complementary

perspectives: hedonic well-being (also called emotional well-being) refers to positive

emotions toward one’s life such as happiness and life satisfaction, whereas positive

functioning (also called eudaimonic well-being) consists of a sense of engagement and

fulfillment in one’s private and social life, which reflects psychological and social well-being

(Keyes, 1998; Ryff and Singer, 1996).

PAGE 58 j JOURNAL OF PUBLIC MENTAL HEALTHj VOL. 10 NO. 1 2011

The study of mental health as a complete state has contributed to the building of new

instruments for assessing positive mental health. More specifically, research on Keyes’s

model has validated the theoretical assumption stating that positive mental health is more

than emotional well-being and also includes positive functioning. Indeed, 13 dimensions,

when factor analyzed, represented the two visions of well-being, and such structure was

found in adults (Keyes et al., 2002) and adolescents (Keyes, 2005b, 2006a). As shown in

Table I, two dimensions are related to emotional well-being and the remaining dimensions to

positive functioning – six dimensions for psychological well-being and five dimensions for

social well-being. Interestingly, there is a growing consensus on the value of hedonic and

eudaimonic well-being as a framework to further advance knowledge on positive mental

health in the field of mental health promotion, which has traditionally used a piecemeal

approach for evaluating specific and often only emotional aspects of well-being rather than

including positive functioning (Barry, 2009). Of particular relevance are the long (Keyes,

2002) and short (Keyes, 2006a) versions of the ‘‘Mental Health Continuum Form’’ and their

expanding use to measure positive mental health and to guide the construction of new

instruments (Tennant et al., 2007).

Research on mental health as a complete state has also required the development of criteria

for diagnosing states of positive mental health. Like mental illness, positive mental health is

viewed as a syndrome of symptoms that consist of emotional well-being and positive

functioning (Keyes, 2005b, 2006b; Ryan and Deci, 2001), which mirror the diagnostic

criteria for major depressive episode in the DSM-IV-TR (American Psychiatric Association,

2000). Depression requires symptoms of anhedonia, and positive mental health consists of

symptoms of hedonia or emotional well-being; depression requires symptoms

of malfunctioning, and positive mental health consists of symptoms of eudaimonia or positive

functioning.

Criteria for diagnosing states of positive mental health are based on the 13 dimensions or

symptoms that are represented in Table I. To be diagnosed as flourishing in life, individuals

must exhibit high levels (‘‘every day’’ or ‘‘almost every day’’ during the past two weeks) on at

least onemeasure of hedonic well-being (see dimensions 1 and 2) and high levels on at least

six measures of positive functioning (see dimensions 3 to 13). Individuals who exhibit low

levels (‘‘never’’ or ‘‘once or twice’’ during the past two weeks) on at least one measure of

hedonic well-being and low levels on at least six measures of positive functioning are

diagnosed as languishing in life. Adults who are moderately mentally healthy do not fit the

criteria for either flourishing or languishing.

Table I Factors and 13 dimensions reflecting mental health as flourishing

Hedonia (i.e. emotional well-being) 1 Positive affect: cheerful, interested in life, in good spirits, happy, calm and peaceful,full of life

2 Avowed quality of life: mostly or highly satisfied with life overall or in domains of lifePositive psychological functioning(i.e. psychological well-being)

3 Self-acceptance: holds positive attitudes toward self, acknowledges, likes most parts ofpersonality

4 Personal growth: seeks challenge, has insight into own potential, feels a sense of continueddevelopment

5 Purpose in life: finds own life has a direction and meaning6 Environmental mastery: exercises ability to select, manage, and mold personal environs tosuit needs

7 Autonomy: is guided by own, socially accepted, internal standards and values8 Positive relations with others: has, or can form, warm, trusting personal relationships

Positive social functioning (i.e. socialwell-being)

9 Social acceptance: holds positive attitudes toward, acknowledges, and is accepting ofhuman differences

10 Social actualization: believes people, groups, and society have potential and can evolve orgrow positively

11 Social contribution: sees own daily activities as useful to and valued by society and others12 Social coherence: interest in society and social life, and finds them meaningful and

somewhat intelligible13 Social integration: a sense of belonging to, and comfort and support from, a community

VOL. 10 NO. 1 2011 j JOURNAL OF PUBLIC MENTAL HEALTHj PAGE 59

Empirical support for mental health as a complete state

Findings summarized next come from papers using 1995 Midlife in the United States survey

(MIDUS), a random sample of 3,032 adults between the ages of 25-74 (Keyes, 2005a, 2007).

With regards to mental illness, the DSM-III-R (American Psychiatric Association, 1987)

criteria were used to diagnose four mental disorders – major depressive episode, panic,

generalized anxiety, and alcohol dependence – and the Composite International Diagnostic

Interview Short Form scales (Kessler et al., 1998) served to assess the number of symptoms

in those four psychiatric disorders over the past year. States of positive mental health were

evaluated through the above procedure.

The model of complete mental health is based on the assumption that mental illness and

positive mental health represent two distinct dimensions or continua. This suggests that the

absence of mental illness does not imply the presence of mental health (and, the absence of

mental health does not imply the presence of mental illness). Empirical findings have

supported this hypothesis, as confirmatory factor analysis revealed that the latent factor of

mental illness correlated 20.53 with the latent factor of mental health, providing support for

their relative independence. The two continua model has been validated in adults (Keyes,

2005a) and adolescents (Keyes, 2009b).

Languishing adults (e.g. low levels of positivemental health) reported the highest prevalence

of any of the four mental disorders as well as the highest prevalence of reporting two or more

mental disorders during the past year. In contrast, flourishing individuals reported the lowest

prevalence of any of the four 12-month mental disorders or their comorbidity. Compared with

languishing or flourishing, moderately mentally healthy adults were at intermediate risk of any

of the mental disorders or two or more mental disorders during the past year. Those findings

suggest that languishing may act as a risk factor of mental illness, and flourishing as a buffer

protective factor against mental illness.

Six states of complete mental health emerged from the combination of mental illness and

positive mental health and their prevalence rates were determined:

1. Mental illness and languishing (7%).

2. Mental illness and moderate mental health (15%).

3. Mental illness and flourishing (1%).

4. absence of mental illness and languishing (10%).

5. Absence of mental illness and moderate mental health (51%).

6. Absence of mental illness and flourishing (17%).

Of note, less of one-fifth of adults achieved a state of complete mental health, being free of

mental illness and flourishing.

Additional data revealed that any less than complete mental health resulted in increased

impairment and disability. Among adults who were free of mental illness, those who were

flourishing functioned better than those who were moderately mentally healthy, who in turn

functioned better than those who were languishing. Individuals free of mental illness and

flourishing reported the fewest workdays missed, fewest workdays cutback by one-half, the

lowest rate of cardiovascular disease, the lowest level of health limitations of activities of daily

living, the fewest chronic physical conditions at all ages, and the lowest healthcare use (e.g.

medical visits, hospitalizations, medications). Those individuals also reached the highest

levels of psychosocial functioning, showing the lowest level of perceived helplessness, the

highest level of knowing what they want from life, the highest level of self-reported resilience

(e.g. learning from adversities), and the highest level of close relationships and intimacy.

Finally, of adults who had at least one of the four mental disorders, those who were flourishing

functioned better than those with moderate mental health, who in turn functioned better than

those were languishing.

PAGE 60 j JOURNAL OF PUBLIC MENTAL HEALTHj VOL. 10 NO. 1 2011

Recovery

Current definitions of recovery

Two distinct but complementary definitions of recovery prevail in the literature. Reflecting the

disease-oriented or pathogenic approach, the first and traditional definition focuses on

psychiatric symptoms and impairments, which are used to evaluate the extent of remission

from mental illness (Silverstein and Bellack, 2008).

The second definition views recovery as a personal and social process (Noordsy et al., 2002;

Onken et al., 2007). The emphasis here is placed on personal transformations that emerge

throughout this journey, such as positive changes in views about oneself, purpose in life,

relationships with others, and ways of perceiving and managing the mental illness. These

personal changes interact with actions that are undertaken to make transformations at

the community level, involving the reduction of barriers to social exclusion (e.g. stigma,

discrimination) as well as the provision of opportunities and the creation of niches for

increasing social participation and civic engagement. Through their personal stories and

scientific work, consumers have particularly endorsed the view of recovery as a process,

insisting on the unique, non-linear, and subjective aspects of this experience. Such

conceptualization is represented in personal recovery (Slade, 2010) and the experience of

recovering ‘‘in’’ mental illness (Davidson and Roe, 2007).

Both the pathogenic and salutogenic views are represented in defining recovery as a

process. In line with the stress-vulnerability model of psychiatric disorders (Corrigan et al.,

2008), this vision of recovery highlights the importance of personal and environmental

changes that act as protective factors and contribute to the alleviation ofmental illness and its

negative social consequences, such as illness management strategies, restored functional

skills, or environmental support against social discrimination. Interestingly, other aspects of

recovery as a process concern the experience of moving beyond the mental illness and

growing from it (Onken et al., 2007). Rather overlooked, this underlies a salutogenic view in

which recovery is seen as the passage from a languishing to a flourishing life, which is

oriented towards the search for positive emotions (e.g. happiness, pleasure) and fulfilling

activities and roles (Table I). Therefore, recovery as a process is not only concerned with the

reduction of mental illness but the maximization of positive mental health as well.

Relevance of positive mental health to recovery

Although never recognized as such, the recovery literature has tapped on several

dimensions of subjective well-being that makeup the assessment and diagnosis of positive

mental health (Table I). First, qualitative research and personal accounts draw attention to

consumers’ experiences and aspiration that are aligned with positive mental health. Brown

and Kandirikirira (2007), for instance, found that persons in recovery require and strive for a

positive identity, which reflects ‘‘self acceptance.’’ Individuals also said they require and

seek to engage in meaningful activities and to develop positive relationships with other

people and with their environments, which reflect ‘‘purpose in life,’’ ‘‘positive relations with

others,’’ and ‘‘social acceptance.’’ Narratives of persons in recovery also reveal their need

and aspiration for living in communities where they are seen as more than their illness and

where their contributions are valued, which are signs of ‘‘social integration’’ and ‘‘social

contribution.’’ Persons in recovery also need and strive to manage their lives to stay healthy

and to be resilient to setback, which reflect ‘‘environmental mastery’’ and, to some extent,

‘‘autonomy’’ (i.e. confidence in own opinions and ideas).

Second, several aspects of positive mental health are promoted in recovery interventions.

As an example, supported socialization (Davidson et al., 2004) is an intervention program in

which positive emotions, such as pleasure, fun, and a sense of happiness, are enhanced

through involvement in leisure and social activities. The optimization of psychological

well-being (Table I) is also the target of a recent self-development program (Oades, 2008)

and other treatment programs, e.g. well-being therapy (WBT; Fava and Ruini, 2003) for

persons with depression, and functional cognitive behavioural therapy (Cather et al., 2005)

for those with schizophrenia.

VOL. 10 NO. 1 2011 j JOURNAL OF PUBLIC MENTAL HEALTHj PAGE 61

Measures of positive mental health – emotional, psychological, and social well-being – have

been underutilized in recovery. However, recovery instruments do include some dimensions

aligned with positive mental health. For instance, subjective quality of life, as indexed by life

satisfaction, reflects emotional well-being and has been widely used in clinical practice and

evaluation research. Another example is the Well-Being Scale (WBS; Campbell et al., 2004),

a self-report measure evaluating major subjective recovery outcomes, such as self-esteem,

self-worth, empowerment, self-efficacy, which reflect self-acceptance, environmental

mastery, and autonomy. The Recovery Assessment Scale (RAS; Corrigan et al., 2004) is

another questionnaire that is widely used and relies on five dimensions – personal

confidence and hope, willingness to ask for help, goal and success orientation, reliance on

others, and no domination by symptoms – and those somewhat overlap with purpose in life,

environmental mastery, autonomy, and positive relations with others. The WBS and RAS thus

reflect psychological well-being and, to a greater extent, post-traumatic growth, which

captures the process of thriving in recovery, or becoming better off than beforemental illness

(Onken et al., 2007). More specifically, post-traumatic growth refers to positive shifts in

personality schema and assumptive worlds (Tedeschi et al., 1998) and relies on three

dimensions that overlap with those of psychological well-being. Changes in philosophy

reflect the dimensions of purpose in life and autonomy; changes in perceptions of self are

aligned with environmental mastery, personal growth, and self-acceptance; and changes in

relationships mirror positive relationships with others (Table I). The assessment of

psychological well-being (Ryff and Singer, 1996) has been thus recommended for tracking

changes in growth in longitudinal studies (Joseph and Linley, 2008). However, flourishing

implies thriving but also directs attention to other meaningful experiences, such as positive

emotions and a sense of fulfillment in social life.

In short, recovery has been traditionally defined pathogenically, focusing on psychiatric

symptoms and impairments as outcomes. However, a salutogenic view of recovery has

emerged over the last two decades, as particularly expressed in narratives, focusing on

pleasant and fulfilling experiences despite the presence of mental illness.

Complete mental health recovery

The two continuamodel (Keyes, 2007) incorporates the pathogenic and salutogenic views into

a unitary, complete approach of recovery. From the perspective of complete mental health,

recovery is seen as restoration from mental illness and optimization of positive mental health,

which are viewed as two complementary processes and outcomes. Through restoration,

individuals seek to manage the limitations imposed by mental illness while working toward

symptom alleviation and reduction of impairments as well as healing from the negative social

consequences of the illness (e.g. stigma). Such personal efforts are supported by community

interventions aiming at the reduction of barriers to social exclusion (e.g. stigma, discrimination)

and the provision of accommodations and opportunities for restoring roles and regaining

human and civil rights (Noordsy et al., 2002; Onken et al., 2007). Through optimization,

individuals strive to reach a sense of accomplishment and to experience pleasure and

happiness in life while developing personal and social strengths (Davidson and Strauss, 1992;

Resnick and Rosenheck, 2006). This is supported by community interventions for reducing

poverty, increasing access to services (e.g. education, employment, affordable housing), and

promoting civic engagement andsocial participation (Ware et al., 2007), in linewith capabilities

approaches (Nussbaum, 2000; Sen, 1999). As an example, the Strengths Model (Rapp and

Goscha, 2006) targets the optimization process through the provision of support aimed at the

enhancement of personal and environmental strengths.

Restoration and optimization overlap with key features that underlie consumers-oriented

definitions of recovery (Silverstein and Bellack, 2008), personal recovery (Slade, 2009), and

the experience of recovering ‘‘in’’ mental illness (Davidson and Roe, 2007). What is here new

is that those processes are clearly distinguished, relying on the pathogenic and the

salutogenic views, respectively. The complete view of mental health also draws attention to

the combined use of restoration and optimization strategies, neither one being sufficient to

promote recovery. Although their detailed discussion is beyond the scope of this paper,

PAGE 62 j JOURNAL OF PUBLIC MENTAL HEALTHj VOL. 10 NO. 1 2011

several recovery-oriented programs provide restoration as well as optimization strategies,

such as supported approaches in the areas of employment, housing, and education

(Corrigan et al., 2008), peer support interventions and other specific interventions aligned

with the process of psychiatric rehabilitation (Farkas and Anthony, 2010). All these

interventions assist the person in the pursuit of meaningful goals in life, taking into account

individual preferences and aspirations and tailoring support for the restoration of skills

altered by the illness, the enhancement of personal strengths, and the provision of

opportunities for reducing social exclusion and promoting social inclusion.

Pathways to complete mental health in recovery

Recovery is a non-linear and highly individualized process that is punctuated by progress

and setbacks (Spaniol et al., 2002). Changes in mental health status occur throughout this

journey. As guided by Keyes’s model, a categorical approach here is used to illustrate

pathways in complete mental health over the recovery process. This implies the use of cut-off

points and other specific criteria to classify individuals into distinct and mutually exclusive

groups, as based on their ratings on outcomes of mental illness and positive mental health.

States of complete mental health recovery

Those can be depicted through the use of a figure in which the horizontal x-axis, representing

the mental illness continuum, is crossed with a vertical y-axis, representing the positive

mental health continuum (Figure 1). Liberman and Kopelowicz’s (2005) criteria are here used

as an example to illustrate how recovery can be assessed on the mental illness continuum,

distinguishing persons who are recovered from schizophrenia from those who are not.

Figure 1 Pathways to complete mental health in recovery

3. Non recovered from mental illnessa

and flourishingb

5. Recovered from mental illnessa

4. Recovered from mental illnessa

and languishingb

6. Recovered from mental illnessa

and flourishingb

Complete recovery

and moderately mentally healthyb

2. Non recovered from mental illnessa

and moderately mentally healthyb

1. Non recovered from mental illnessa

and languishingb

Mos

t sev

ere

leve

l of

men

tal i

llnes

s

Abs

ence

of

men

tal i

llnes

s

Absence of positive mental health

Notes: aUse of Liberman and Kopelowicz's (2005) criteria to illustrate how recovery can be assessedon the mental illness continuum; buse of Keyes's (2007) criteria to illustrate how recovery can beassessed on the positive mental health continuum

Highest level of positive mental health

VOL. 10 NO. 1 2011 j JOURNAL OF PUBLIC MENTAL HEALTHj PAGE 63

With regards to the positive mental health continuum, Keyes’s (2005a, 2007) criteria are used

to differentiate individuals who are flourishing, moderately mentally healthy, or languishing.

As shown in Figure 1, the midpoint of the horizontal axis corresponds to moderate levels of

symptoms (i.e. score of four or less on each of the positive and negative symptom items of the

brief psychiatry rating scale) and the restoration of roles in normative settings. Concerning

functional recovery, individuals who are located at the right side of the midpoint hold part- or

full-time competitive jobs whereas those who have other work status are located at the left

(e.g. unemployment, transitional jobs, prevocational training). In addition to work on the

regular market, recovered individuals have to live on their own (without supervision) and to be

involved weekly in social or recreational activities with persons without mental illness, and

those who do not meet these criteria are located at the left. The vertical axis is divided into

three parts corresponding to the states of languishing, moderate, and flourishing mental

health. Six states of complete mental health recovery emerge from the combination of mental

illness and positive mental health outcomes. What follows are plausible thumbnail sketches

of individuals from each of the six categories.

At the bottom left of Figure 1, the shaded area correspond to the initial phase of recovery, being

overwhelmed by the disability (Spaniol et al., 2002). These individuals use ineffective skills to

managemental illness and tend to feel disconnected from the self, others, and the community,

resulting in high levels of psychiatric symptoms and functional deficits. In addition, they are

languishing in life, as they sufferwith the lackof purposeandmeaning in lifeandhavedifficulties

to articulate clear and challenging goals that are anchored in reality. This state is thus

characterized by severe impairments in positive mental health and mental illness.

Among individuals who are not recovered from mental illness, perhaps the transition out of

languishing and movement toward flourishing (see states nos 1, 2, and 3 in Figure 1) comes

with the process of building on some talent or strength, and enabling them to transition from

placing importance on ‘‘who they want to be’’ rather than ‘‘who they are.’’ Activities such as

volunteering or prevocational training may start to bring joy and some realization they have

the potential for contributing to society. The learning of empowerment strategies over the

illness (e.g. coping skills for preventing relapses) also may help individuals to work towards

partial remission of mental illness – moving from the left side to the middle point of the

horizontal axis.

The complete recovery model highlights the need for continued work even after individuals

have recovered in the pathogenic sense, which here ranges from partial to full remission of

mental illness. Among individuals who have recovered from mental illness (see states nos 4,

5, and 6 in Figure 1), level of positive mental health may be implicated in the stability and the

quality of recovery from mental illness. Flourishing in life may reduce the vulnerability to

mental illness, acting as a buffer or a protective factor, whereas languishing may be a risk

factor for relapse and further deterioration in functioning.

Individuals who are recovered from mental illness and flourishing share characteristics with

those who are ‘‘living beyond the disability’’ (Spaniol et al., 2002). This profile corresponds to

the shaded area located at the top right of Figure 1. Individuals who belong to state no. 6 have

reached at least partial remission of mental illness as well as optimal levels of positive mental

health. They look for opportunities to challenge themselves and to reach a sense of serenity

and peace of mind. They hold competitive jobs, have intimate and reciprocal relationships

with others and may be involved in other roles, such as assuming parental responsibilities.

They see their futures as promising and perceive roles and activities as concrete means of

self-actualization as well as ways of contributing society. When deficits are still present,

individuals are well aware of them and know how to best use them while continuing to grow

and to optimize their own potential in the pursuit of challenging goals.

Finally, individuals who belong to state no. 3 are also flourishing even though they are not

engaged in normative activities and have not reached partial symptomatic remission. This

highlights the fact that consumers differ a great deal in their choice of meaningful and

challenging activities, some valuing normative activities while others do not. Several reasons

may account for preferences in non-normative activities (e.g. volunteering, transitional work)

PAGE 64 j JOURNAL OF PUBLIC MENTAL HEALTHj VOL. 10 NO. 1 2011

or occasional self-employment, such as having control over work hours, pacing the re-entry

to the regular market, or prioritizing creative or independent work over other types of jobs

(Brown and Kandirikirira, 2007). Individuals who are flourishing and performing

non-normative activities may see their impairments as parts of a positive identity, through

disability pride. In line with the social model of disability (Sayce, 2000), they may reject the

sick role, perceive social oppression as the main source of disability, advocate for their rights

and entitlements as disabled persons (e.g. housing and benefits services), and request

supportive and socially inclusive measures for living their lives as fully as possible (e.g.

vocational or educational opportunities, peer support, leisure activities). Some of them may

be involved in activism and join other disabled groups in the non-mental health sector for

struggling against social discrimination, which may enhance their sense of social

participation. On the other hand, other individuals belonging to state no. 3 may have built

a sense of positive identity apart from impairments, no longer viewing them as core aspects

of their selves. This may have emerged from the cultivation of personal strengths and positive

assets through volunteering or self-employment, providing a less structured working pattern

that allowed them to flourish alongside other preferential activities, such as leisure or artistic

work (e.g. painting, writing) (Brown and Kandirikirira, 2007).

Limitations

The proposed methodology for assessing pathways to complete mental health in recovery

should be seen as a first attempt to bridge mental illness and positive mental health, and in

need of refinement. Recovery from mental illness has been evaluated through the use of

Liberman and Kopelowicz’s (2005) criteria for three main reasons: both symptomatic and

functional recovery are assessed, clear guidelines are proposed for evaluating each

criterion, and previous research provides support for its discriminant and predictive validity.

However, consumers e.g., (Deegan, 1996) have disputed the re-entry into normal roles (even

on a partial basis) as a requirement for being considered as recovered from mental illness.

For them, roles and activities that bring a sense of satisfaction in life, pleasure and fulfillment

are the crucial issues, whatever the settings in which they are performed. There is also a lack

of consensus about criteria for evaluating partial or complete functional remission in the

scientific community. Beside the need to improve measures of functional recovery

(Mausbach et al., 2009), the debate needs to clarify issues that are related to both the level

(e.g. attempts, progress, and success in normative and non normative activities) and the

breadth of accomplishment in life domains (e.g. work, social activities) (Harvey and Bellack,

2009). For instance, there is considerable variation in the social life of healthy individuals,

which raises the question of the minimal requirement for recovery in this domain.

The three states of positive mental health have been mainly studied in persons with

depression and anxiety disorders. Additional research is required to further validate

the diagnostic criteria in persons with severe mental illness (e.g. schizophrenia, bipolar

disorders) and to specify how long a person has to meet the criteria for being considered as

flourishing, moderately mentally healthy, or languishing. Such refinement involves the

development of observer-rated measures for assessing positive mental health within this

population, making possible comparisons with self-report assessment and being more

suitable for persons with poor insight and severe cognitive deficits. Concerning the

subjective evaluation of positive mental health, new self-report measures are also needed

along with the further validation of available instruments, such as the mental health

continuum-short form (Keyes, 2009a) in which both emotional well-being and positive

functioning are assessed.

Discussion

Unlike previous conceptions, our model proposes to redefine recovery from the complete

view of mental health and introduces positive mental health as an additional outcome of

recovery. Complete mental health recovery relies on two independent but complementary

experiences – restoration from mental illness and optimization of positive mental health –

and each experience is defined as a process and as an outcome. The view of recovery

VOL. 10 NO. 1 2011 j JOURNAL OF PUBLIC MENTAL HEALTHj PAGE 65

‘‘as a process’’ (Davidson and Roe, 2007) is here revisited, making a distinction between

factors and strategies involved in the restoration (e.g. contributing to the alleviation of mental

illness) and optimization (e.g. contributing to the enhancement of positive mental health)

processes. Recovery ‘‘as an outcome’’ (Silverstein and Bellack, 2008) is also revisited,

‘‘having a good or flourishing life’’ being proposed as a sign of recovery and complementing

mental illness outcomes. Therefore, our model does not reject a pathogenic conception of

recovery but views it as insufficient to capture this phenomenon. A salutogenic approach is

also necessary to promote recovery, focusing on the optimal development of strengths and

other characteristics of positive mental health.

How restoration and optimization can contribute to each other deserves more research

attention. One hypothesis concerns resources developed during restoration (e.g.

empowerment over the illness) and the role they may play in promoting positive mental

health, as personal growth is associated with coping successfully with the illness (Onken

et al., 2007). Another hypothesis involves the possibility that a flourishing mental state may

counteract the reappearance of the illness (Keyes, 2007). For instance, acquired skills during

optimization, such as strategies for getting involved in fulfilling activities (Fava and Ruini,

2003), may not only enhance positive mental health but also act as a buffer against mental

illness, potentially decreasing the detrimental effects of stress or illness-related factors (e.g.

substance abuse, poor premorbid history) on mental illness outcomes.

At the practical level, helping people with mental illness to flourish in life requires scholars

and practitioners to better integrate psychiatric treatment and rehabilitation practices

(Corrigan et al., 2008) with those used in mental health promotion (Barry, 2009) and positive

psychology (Seligman and Csikszentmihalyi, 2000). Of note, the enhancement of positive

mental health in persons with mental illness has become an important target of interventions

in mental health promotion (Barry, 2009) and is also addressed in therapeutic approaches

that are directly borrowed or derived from positive psychology (Resnick and Rosenheck,

2006; Slade, 2010). Novel interventions are particularly needed for enhancing not only

emotional well-being and psychological well-being but social well-being as well – a

dimension of positive functioning that has been overlook – and for this purpose, WBT (Fava

and Ruini, 2003) may be used as a guide.

It is plausible that the six proposed states of complete recovery may represent specific

stepping stones, and longitudinal data thus are required to study the evolution of individuals

within each state and among the six states of recovery over time, including the process of

moving from one state to another one. Such line of research also needs to focus on process

variables that are potentially related to the six states, including subjective factors (e.g.

self-redefinition, hope, empowerment, social connectedness) that are here redefined within

the specific contexts of restoration and optimization. For instance, the building of a sense of

empowerment involves the learning of management strategies for preventing mental illness

(e.g. restoration) as well as for experiencing positive emotions and fulfilling activities (e.g.

optimization). However, their detailed discussion is beyond the scope of this paper as well as

how they may interact with other environmental factors, such as social discrimination,

accommodations, or access to affordable housing and other basic resources.

Finally, our model draws attention to individuals who are involved in non-normative activities

and are flourishing. This implies that not only normative but also non-normative activities may

provide opportunities for optimal experiences, which are characterized by full absorption

(awareness of time disappears), high involvement in the task regardless of external rewards

(e.g. paid work), enjoyment, sense of accomplishment, and perceived control over the task

although still viewed as challenging and maximizing competencies (Della Fave and

Massimini, 2004). In particular, more research is needed to further determine the profile of

individuals who perceived optimal experiences in doing non-normative activities (Frese et al.,

2009). A variety of factors may be explored, such as illness-related factors (e.g. premorbid

functioning, cognitive and functional deficits), personal factors (e.g. values, life goals,

meaning of recovery) and how they interact with environmental factors (e.g. support for the

person’s own choice and pursuit of activities).

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Conclusions

The purpose of this paper has been to elevate the place of complete mental health in

redefining the experience of recovery. Restoration from mental illness and optimization of

positive mental health represent the two distinct but complementary processes and

outcomes of recovery. Both the alleviation of mental illness and the promotion of positive

mental health are viewed as necessary to move towards recovery.

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Corresponding author

Helene L. Provencher can be contacted at: [email protected]

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