Introduction
Positive Psychology has traditionally been aimed at moving those without mental illness from a state of languishing towards flourishing. In this blog I argue that it also has an important role in helping those struggling with mental ill health on their road to recovery, in finding sustainable wellbeing and in preventing relapse.
The cost of mental illness
The Centre for Mental Health (Cardoso & McHale 2024) report on the economic and social costs of mental ill health in the UK suggests that in 2022 mental illness cost £300 billion. This covers three elements; economic costs such as sickness absence, staff turnover and people with mental ill health being unable to work, health care costs of providing formal and informal treatment and support for those needing mental health care and human costs which comprise an estimate of the monetary cost of the reduced quality of life of those living with mental illness. The authors suggest that this is effectively equivalent to the economic impact of having a pandemic every year. Mental ill health is a huge challenge for our society and we need to move towards prevention and sustainable approaches to maintaining treatment effects if we are to address this. Can PP have a role in this?
Mental health is not the absence of mental illness
PP was founded on the premise that it is not enough just to reduce distress, we need to understand the factors which promote wellbeing and thriving. PP research has supported the idea that separate dimensions exist for mental illness and mental wellbeing in large surveys, clinical populations and longitudinal studies (Bohlmeijer & Westerhof 2021, Keyes 2005, Kraiss et al. 2023). Therefore it is possible to be free of diagnosable mental illness but not thriving or functioning well, this is what is known as languishing. It is also possible to live a pretty meaningful and fulfilled life even in the presence of a mental illness although more commonly mental illness is also associated with poor mental wellbeing. Ideally of course we want people to be free of mental illness and high in mental wellbeing, this is what we mean by flourishing.
Many approaches to therapy still focus primarily on reducing negative symptoms. This makes sense at first glance because most clients come wanting to get rid of their difficulties. Mental health provision (in the UK at least) also sits within the wider health service. The “medical model” still pervades health care. If there is a problem we assess it, diagnose it, apply the designated treatment and fix it. This doesn’t work as well with mental illness as a broken leg. Although mental illness and mental wellbeing are separate dimensions they interact in complex ways. Surely if we want to promote sustainable mental wellbeing and reduce the economic impact of mental illness, it makes sense to equip those who come for treatment with PP skills aimed at enhancing flourishing in addition to the ability to manage their difficulties? Yet PP is rarely taught as part of clinical training and despite the popularity of “solution focused” approaches much therapy work remains problem focused. We know that our negativity bias and threat responses make it so easy, even as therapists, to fall into this approach. For me, PP provides a counterbalance and reorientation in therapy which helps me work more holistically with clients. I think this was always what it was intended to be given that many of the early pioneers of PP were clinical psychologists. PP is not just for the mentally well, one could argue those who are struggling with their mental health need it even more.
In addition, current approaches to mental health treatment have limitations in terms of availability, acceptability, cost and effectiveness (Layous et al. 2011). Cuijpers et al. (2014) found that only fifty percent of people treated for mental health issues showed successful outcomes and of those, around fifty percent relapsed within two years. Residual wellbeing issues were also found in many people who had been “successfully” treated.
What’s the evidence?
The impact of Positive Psychology Interventions (PPIs) and targeting improved mental wellbeing on the symptoms of mental illness has been studied in clinical and wider populations. Research supports the premise that improving mental wellbeing can impact mental illness in the following ways:
- Prevention: By reducing the risk of developing mental illness in those not mentally ill (Keyes et al. 2010, Wood & Joseph 2010)
- Intervention: PPIs have been shown to be effective in reducing symptoms of mental illness in a range of clinical populations (Chakhssi et al. 2018, van Agteren et al. 2021). Research is less clear for severe mental health conditions (Geerling et al. 2020)
- Recovery: Incorporating a PP approach into treatment improves the chance of full recovery in those with mental illness (Isalleo et al. 2019, Schotanus-Dijkstra et al. 2019, Slade 2010)
- Relapse prevention: Targeting wellbeing protects against relapse in those recovered from mental illness (Layous et al. 2011, Ostergaard et al. 2020).
This suggests to me that it is time for PP to integrate into wider clinical approaches to supporting mental health. Many therapies such as Acceptance and Commitment Therapy (ACT), Mindfulness Based Cognitive Therapy (MBCT) and Compassion Focused Therapy (CFT) already do this to a certain extent. However, I feel there is a need for a more strategic approach. There are empirical questions to answer regarding who might benefit from which PP approaches/ models in what contexts, combined with which more traditional therapeutic approaches in which way at what stage of treatment etc.
Conclusion: Positive Therapy?
An integrated positive therapy might be defined as one which aims to help people become more fully functioning rather than a focus on the reduction of mental ill health (Joseph 2015). A number of approaches to this have already been developed and trialled with some success (see Dunn et al. 2023, Fava 1999, Frisch 2016, Seligman et al. 2006, Wong 2020). There are key issues in terms of integrating approaches from different theoretical backgrounds in coherent ways. Some models to help guide such synthesis have begun to be developed (see Ciarrochi et al. 2022). However, this approach to alleviating the impact of mental illness in a sustainable way by including a specific wellbeing focus does not seem to have gained the traction it needs to be effectively developed amongst clinical psychologists in terms of education, practice or research.
PP broke off from traditional psychology research to redress the balance around looking at what is right with humanity rather than what goes wrong. I believe that clinical approaches need to embrace what has been learned from nearly a quarter of a century of PP development if we are to address the current mental health crisis in the most effective way.
References
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