Occupational Perspectives on Mental Health and Well-Being Sheena E

17 Chapter 2 Occupational perspectives on mental health and well-being Sheena E. E. Blair , Clephane A. Hume , Jennifer Creek

INTRODUCTION CHAPTER CONTENTS FINAL Introduction 17 The beginning of the 21st century is characterised by an increased interest in the prevention of men- Understanding the terminology 17 tal ill health and the promotion of well-being. All Health 18 professionsNOT involved in health and social care have Mental health 19 explored- ways of broadening their remit, perhaps Well-being 19 ELSEVIERencouraged by the shift of working contexts in Health promotion 19 the United Kingdom, which are now largely com- Disease prevention 20 OF munity based. The World Health Organization Health education 20 (WHO) (2001) has more formally linked ideas of Mental health promotion 20 activity and participation within the International Wellness 21 Classification of Functioning, Disability and Health . Lifestyle 21 CONTENTIn Scotland, a link between policy and services is Quality of life 21 apparent, for example in the National Programme Factors contributing to mental health and Action Plan 2003 – 2006 to improve mental health and ill health 21 wellbeing in Scotland (2001). In turn, this is part of Protective factors 23 a broader Scottish Executive policy initiative that Risk factors 24PROPERTY includes attention to health improvement, social justice, education and lifelong learning. Promoting positive mental health 24 SAMPLE Until recently, the responsibility for health pro- Occupational therapy and health motion lay within the field of public health. Now, promotion 26 more attention is being given to health promo- Occupational therapy and well-being 26 tion within health-care policies; for example, The The contribution of occupational science 27 Health of the Nation (DoH 1992), Saving Lives (DoH Summary 27 1999) and the National Programme for Improving Mental Health and Well-Being (Scottish Executive 2003). These policies give priorities for action, such as dementia awareness; suicide reduction; eliminating stigma and discrimination in minority ethnic groups, and the mental health of children and young people. Policies designed to integrate spirituality into health care, together with other 18 PHILOSOPHY AND THEORY BASE

publications such as Caring for the Spirit (South past decade from a preponderance of medical Yorkshire Workforce Development Confederation terminology to a more client-centred and occupa- 2003), have led to changes in education for staff tion-focused style. The concepts defined here are that broaden the focus of health promotion and health, mental health, well-being, health promo- health education. tion, disease prevention, health education, mental These policy initiatives have implications for health promotion, wellness, lifestyle and quality occupational therapists throughout the UK and of life. Creek (2004) predicted that the profession will continue to have a much higher profile within HEALTH health promotion. Those occupational therapists who have accepted the challenge of explor- Defining health is a complex matter and the con- ing the relationship between occupation and cept defies neat description. The occupational health, and of working towards occupation- scientist, Wilcock (1998), offered an occupational centred practice, are finding this an exciting perspective on health in which she explored time. The discipline of occupational science has the relationship between occupation and health boosted knowledge generation in this area and and the importance of this relationship for pub- the ideas of people as occupational beings, whose lic health. Wilcock acknowledged the enduring complex actions and interactions significantly nature of the WHO (1946) definition of health: impact on health, have stimulated the enthu- ‘Health is a state of completeFINAL physical, mental and siasm of students, educators, practitioners and social well-being, and not merely the absence of researchers (Wilcock 1998). Occupational sci- disease or infirmity’. ence has also encouraged a broader vision of the However, NOT there have been many criticisms of contribution of occupation to social justice, with this definition;- for example, Webb (1994) noted the notion of occupational justice (Wilcock & ELSEVIERthat it implies a static rather than a dynamic Townsend 2000). phenomenon. In contrast, the moral philosopher This chapter begins with an exploration OFof the David Seedhouse (1986, p61) offered a definition terminology used to refer to mental health, men- that acknowledges the dynamic nature of health tal disorder and the promotion of positive mental and recognises individual differences: health. There is then a discussion of the personal characteristics, events and experiences thatCONTENT have A person's optimum state of health is equivalent been found to promote or inhibit positive mental to the state of the set of conditions which fulfi l health: protective factors and risk factors. The or enable a person to work to fulfi l his or her third section describes strategies and interven- realistic chosen and biological potentials. Some tions used to promote positive mental health in of these conditions are of the highest importance individuals and communities.PROPERTY It concludes with for all people. Others are variable dependent upon some thoughts on the role of occupational therapy individual abilities and circumstances. in promoting mental healthSAMPLE and well-being. The WHO has been moving towards an under- standing of the dynamic relationship between UNDERSTANDING THE TERMINOLOGY what people do and their health. The Ottawa Charter for Health Promotion (WHO 1986, p1) stated There are many terms used in the field of health that health is ‘a resource for everyday life, not promotion and disease prevention, each one the objective of living … it is a positive con- given a variety of different meanings. These key cept emphasizing social and personal resources, terms can be found in published papers and glos- as well as physical capacities’. The International saries, and are frequently heard in occupational Classification of Functioning, Disability and Health therapy seminars and conferences. It is particu- (WHO 2001) has a focus on activity and participa- larly interesting to note that language usage by tion that locates occupation as a major domain occupational therapists has changed over the within health. OCCUPATIONAL PERSPECTIVES ON MENTAL HEALTH AND WELL-BEING 19

MENTAL HEALTH and welfare: ‘healthy, contented or prosperous condition; moral or physical welfare’. An The concept of mental health can be problematic, Australian occupational therapist, Therese Schmid not least because it may be understood very dif- (2005, p7), emphasised that the state of well-being ferently in different cultural contexts (Fernando is a subjective experience consisting of: ‘feelings of 1993). Indeed, it has been said that ‘every defini- pleasure, or various feelings of happiness, health tion of mental health has inherent cultural assump- and comfort, which can differ from person to per- tions’ (Chwedorowicz 1992, cited by Tudor 1996, son’. Wilcock (2006, p36) agreed that ‘Health, hap- p22), which means that no one definition will be piness and prosperity have more than an intuitive appropriate for all purposes. fit with well-being’. Mental health can be defined as the absence of The American occupational therapist Betty objectively diagnosable disease – a deficit model – Hasselkus (2002, p60) wrote that ‘Research on or as a state of physical, social and mental well- the human state of well-being is permeated by being – a positive model (mentality 2004). Current the belief that a person's ability to engage in life's definitions of mental health usually incorporate daily activities is a key ingredient’. She referred both personal characteristics and the influence to the work of two psychologists, Ryff & Singer of environmental and social conditions. In other (1998, cited by Hasselkuss 2002, p61), who sug- words, mental health is an interaction between the gested that well-being can be defined by two individual and her or his circumstances. core features: ‘1) leadingFINAL a life of purpose, and 2) The Health Education Authority (1997) defined quality connections to others’. This description is mental health as: ‘the emotional and spiritual resil- reminiscent of Winnicott's idea of reciprocity as a ience which enables us to survive pain, disappoint- necessary precursorNOT to well-being. ment and sadness. It is a fundamental belief in our The psychotherapist- Donald Winnicott is re- own and others' dignity and worth’. The ScottishELSEVIER puted to have pronounced that ‘health was more Public Mental Health Alliance (2002, p4) sug- difficult to deal with than disease’ (Phillips1989, gested that positive mental health is a resourceOF that p612). Certainly, changes have to be made in strengthens the ability to cope with life situations. It attitude, ideology and delivery of practice to went on to say that the ‘core individual attributes of accommodate the values of client education and positive mental health include the ability to: enablement, which are central to the promotion of health. For over 40 years, Winnicott's work charted develop self-esteem/sense of personal worthCONTENT • influences on personal growth and development, learn to communicate • and one of his key themes was the metaphor of express emotions and beliefs • a containing space or holding environment as form and maintain healthy relationships • a necessary precursor to health and well-being. and develop empathy for others’. • PROPERTY For him, health was concerned with nurturing Being mentally healthy implies having the ability relationships and reciprocity. Occupation tends to to cope with changes andSAMPLE life transitions, adapt to engage people in mutual endeavour where such circumstances, set realistic aims, reach personal reciprocal relationships can develop and, there- goals and achieve life satisfaction. In contrast, fore, offers real possibilities for the promotion of mental health problems disrupt people's capacity healthy individuals and of healthy communities to think and feel in a way that is normal for them, where people can live and learn together. interfere with the ability to make decisions and shatter people's sense of well-being. HEALTH PROMOTION

WELL-BEING Since the mid-1980s, a confusing array of terms has been used in this area, including health The state of well-being, like health, is a multifac- promotion, health education, disease prevention eted phenomenon. The Oxford English Dictionary and health protection. For example, Downie and (Brown 1993) definition links it with both health colleagues (1993, p59) defined health promotion 20 PHILOSOPHY AND THEORY BASE

as ‘effort to enhance positive health and prevent Secondary prevention refers to all treatment-related ill-health, through the overlapping spheres of strategies designed to reduce the prevalence of health education, prevention and health protec- mental disorder, and tertiary prevention refers to tion’. They emphasised that the health promotion interventions that reduce disability, mitigate the approach involves a sense of individual control. severity of disease, prevent relapse or contribute Seedhouse (1997, p61) also defined health promo- to rehabilitation and recovery. tion in terms of effort, and helpfully attempted to unpick some of the terms used within his definition: HEALTH EDUCATION Health promotion comprises efforts to enhance All health-care professionals have a responsibil- ways of acting and believing based on conservative ity in terms of health education, which has been political values and to prevent disease and illness, described by Downie and colleagues (1993, p28) through a co-ordinated plan to infl uence individual as ‘communication activity aimed at enhancing behaviour in specifi c ways (health education), positive health and preventing or diminishing providing and strongly promoting the uptake of ill-health in individuals and groups, through medical surveillance (disease prevention), and by influencing beliefs, attitudes and behaviour of legislating to guarantee or fi rmly enforce some those with power and of the community at large’. behaviours in order to reduce some morbidities Health education canFINAL also be targeted at different (health protection). levels (Draper et al 1980).

The WHO (1986, p1) definition is useful for occu- 1. Health education about the body and its main- pational therapists because it views health promo- tenance, NOTfor example at school. tion as a process of enablement: ‘Health promotion 2. Health- education involving information about is the process of enabling people to increase control ELSEVIERaccess to and appropriate use of health serv- over, and to improve, their health’. ices, such as radio advertisements about sexual OF health advice lines. DISEASE PREVENTION 3. Health education within a wider context that includes education about national, regional The prevention of mental disorders, or the preven- and local politics that have ramifi cations for tion of relapse, is often seen as one of the aimsCONTENT of health. mental health promotion strategies (WHO 2002). The WHO (2002) pointed out that the idea of pri- MENTAL HEALTH PROMOTION mary disease prevention as a way of preventing disease from developing does not work well in the Interest in the promotion of mental health has a field of mental health,PROPERTY where it can be difficult to history of more than 100 years, dating back to the determine the exact time of onset or even to agree formation of the Finnish Association for Mental on a definite diagnosis. Rather,SAMPLE the primary preven- Health in 1897. The World Federation of Mental tion of mental disorders involves interventions at Health was founded in 1948 to promote better three levels. understanding of mental illness and to serve as a means of drawing attention to mental health. • Universal prevention targeting a whole popula- More recently, an initiative between the European tion group; for example, advertising on televi- Commission and the WHO (WHO 1999) acknowl- sion the safe limits of alcohol consumption. edged that issues surrounding mental health • Selective prevention targeting subgroups at high problems contribute to five of the 10 leading risk; for example, providing free nursery places causes of disability worldwide and that, while for the children of single parents. ongoing improvements in physical health can be • Indicated prevention targeting individuals at detected, this is not the case for mental health. high risk; for example, offering counselling to Mental health promotion is about ‘improving the children of mothers with depression. quality of life and potential for health rather than OCCUPATIONAL PERSPECTIVES ON MENTAL HEALTH AND WELL-BEING 21 the amelioration of symptoms and deficits’ (WHO would also suggest that a balance of occupations 2002, p8). It consists of actions taken to enhance contributes to a state of wellness. the mental well-being of individuals, families, organisations and communities (mentality 2004). LIFESTYLE There are several complementary models of mental health promotion which acknowledge both Lifestyle has been defined as ‘the particular way individual and broader socio-economic deter- of life of a person or group’ but the term is often minants of mental health. A common feature of used to refer to ‘health-related behaviour such as these models is recognition of the need to broaden smoking, drinking, diet and exercise’ (Ewles & mental health promotion programmes and inter- Simnett 2003, p337). Occupational therapists think ventions beyond those targeting the individual. more broadly about lifestyle as being the con- For example, community interventions that focus figuration of an individual's activities that links on building social capital or policy-level interven- with both personal needs and the expectations of tions which widen participation in education have society. For example, Mayers (2003) designed a also been identified as mental health promotion. lifestyle questionnaire that covers self-care, living A public mental health approach, that supports situation, looking after others, being with others, the enhancement of well-being or the promotion work or education, beliefs and values, choices, of positive mental health, reflects a public health finances and desired activities. ethos which looks beyond individuals to the phys- FINAL ical, social and environmental context for health QUALITY OF LIFE (DoH 2001). The logical endpoint of this approach is the design and delivery of interventions and It is difficultNOT to agree on what constitutes qual- programmes to promote the mental health of ity of life,- since it can mean different things to organisations and communities with a view toELSEVIER different people. Mayers (1995) searched the fostering a mentally healthy society. literature and found that, while the concept of OF quality of life was widely used, there were few WELLNESS attempts to define it. Common features of exist- ing definitions included subjective satisfaction, In 1986, an American occupational therapist, Jerry choice, sense of well-being, fulfilment of hopes Johnson, wrote a book about wellness, whichCONTENT she and spiritual satisfaction. Mayers (2000) sug- described as ‘a context for living’ (Johnson 1986, gested that quality of life is concerned with both p13). By this, she meant that wellness is a process of the satisfaction of needs and the ability to meet caring for oneself, including care for the body, the personal priorities. emotions, personal identity and the spiritual self. Since quality of life is a subjective experience, The WHO definitionPROPERTY of wellness includes both it should be measured using self-completed ques- individual characteristicsSAMPLE and social integration: tionnaires or rating scales (Mayers 1995). Wellness is the optimal state of health of individuals and groups. There are two focal concerns: the realization of the fullest potential of FACTORS CONTRIBUTING TO MENTAL an individual physically, psychologically, socially, HEALTH AND ILL HEALTH spiritually and economically, and the fulfi lment of one's role expectations in the family, community, Many factors have been found to influence the place of worship, workplace and other settings. mental health of individuals and communities, (Smith et al 2006, p344) including both individual coping mechanisms and social support. These factors can be divided Wellness requires that a harmony is sought into three categories: biological, psychological and between mind, body and spirit and also between sociological/environmental. Some examples of the individual and society. Occupational therapists each are given in Box 2.1 . 22 PHILOSOPHY AND THEORY BASE

Box 2.1 Factors that may affect mental health

BIOLOGICAL PSYCHOLOGICAL SOCIOLOGICAL/ ENVIRONMENTAL Biochemical Stressful life events Deprivation and poverty, including Cerebrovascular accident Learned behaviour homelessness Trauma, e.g. head injury Relationships Social status Genetic - expressed emotion Unemployment Toxins, e.g. alcohol - double bind Gender/sexual orientation Deafness Loss Racism Physical ill health Loneliness Vandalism Pollution Abuse Migration Nuclear contamination Experience of being a Climate refugee Noise Natural disasters Terrorism

The rapid pace of change in modern society, along a complex mix of personal, social and economic with increased geographical and social mobility, is factors. The robustnessFINAL of personality plus sound putting stress on people while weakening support- support systems usually enable people to negoti- ive social structures, such as the extended family. ate transitions, but anxiety and depression can When the normal balance of life is disturbed by result from NOTmajor life cycle changes such as mar- external or internal factors, the relationship between riage, parenthood,- unemployment, retirement or stress and the ability to cope with the demands ELSEVIERloss. of everyday life can be depicted in the form of a Occupational therapists are interested in the curve, in which performance increases whileOF the ways in which occupations change over the course individual is in a state of ever-heightening arousal. of the lifespan and correspond to life events. This arousal prevents attention to the warning signs A sense of continuity is an important element of fatigue, culminating in physical or psychological in understanding an individual's strengths and ill health. A model of how interacting demandsCONTENT can coping capacity when faced with transitions in contribute to illness is shown in Figure 2.1 . life. Kaplan & Sadock (1991), in a general text on Across the lifespan, everyone experiences a range psychiatry, included a section on ‘phase of life of transitions such as leaving home, starting work, problem’. It is recognised that stresses in the life marrying or retiring. These transitions will be chal- cycle, due to life changes and transitions, can be lenging but are regardedPROPERTY as normal stages within key aspects of a presenting problem. development (see Box 2.2 ). People in general have The context in which life events occur is obvi- considerable capacity to withstandSAMPLE the stresses of ously of importance – the widower with young transitions and other traumatic events. Many years children who is made redundant will not experi- ago, Holmes & Rahe (1975) identified life events ence the same reactions as the older man with which were significant and rated these according a grown-up family. Perceived support is one of to the stress which they provoke. Events relating to the key factors in ability to cope when life events loss, such as bereavements, unemployment and ill threaten a person's sense of well-being. One per- health, are examples of significant crisis situations. son's stress is another person's motivation to However, more positive events such as the forma- continue and many people operate at high stress tion of partnerships are not without stress! levels, producing excellent work. Unexpected life events and normal transitions, Stress is a process in which perceived demands such as those shown in Box 2.2, have impor- (internal or external) severely tax or exceed avail- tant implications for health and well-being. How able coping resources. This leads to a vicious cycle individuals manage such events depends upon in which mood (depression) influences feelings OCCUPATIONAL PERSPECTIVES ON MENTAL HEALTH AND WELL-BEING 23

events, are called emotionally resilient. Emotional Physical Social Cultural resilience is the name given to the range of protec- tive mechanisms and processes that enable people to withstand the potentially damaging effects of Variables stress and to maintain high self-esteem and self- efficacy in the face of adversity (Rutter 1987).

Nervous system PROTECTIVE FACTORS Factors that have been found to protect against the damaging effects of stress and adversity fall into Variables four main groups: individual factors, family fac- tors, life experiences and community factors.

Psychiatric Physical • Individual factors (including personal char- illness illness acteristics). The individual with an easy temperament is more likely to have har- Figure 2.1 Factors Contributing to illness. monious interactions with others, and this has been shown FINALto contribute to resilience. An easy temperament is characterised by eq- (‘I am useless’) and tends to alter behaviour (not uable mood, mild-to-moderate intensity of participating in activities) which, in turn, increases emotionalNOT reactions, malleability, predictable the level of depression. External events are more behaviour,- openness to new situations and a likely to conquer someone's adaptive ability if: ELSEVIERsense of humour (Rutter 1987). Other personal characteristics that protect against the damag- they are unexpected • ing effects of stress include above-average in- the events are numerous OF • telligence or an aptitude for a particular skill, the resulting stress is chronic and unremitting • good problem-solving skills, an internal locus one loss triggers many other necessary adjust- • of control, effective social skills, optimism, ments. CONTENTmoral beliefs and high self-esteem. People who Those people who are able to engage success- are more active, physically and/or mentally, fully with the conditions that life presents to them, are also more likely to be emotionally resil- including adverse circumstances and stressful ient. Other factors include personal awareness of strengths and limitations, a belief that one's Box 2.2 TransitionsPROPERTY and life events own efforts can make a difference and an ability to empathise with others (Newman 2002). Ad- POSSIBLE CRITICAL SAMPLEUNANTICIPATED ditional individual factors in childhood include TRANSITION POINTS LIFE EVENTS attachment to the family, adequate nutrition Birth Accidents and school achievement (DoH 2001). Adolescence Life-threatening • Family factors. Families that promote positive Marriage/partnership disorders mental health are secure, stable and harmoni- Pregnancy Natural disasters ous. They also tend to be small, with more than Separation/divorce Wars 2 years' age difference between siblings. Other Unemployment/ retirement Physical/mental protective factors within the family include Dying illness strong family norms and morality and at least Loss of status/ one supportive, caring parent or a supportive re- prestigious role lationship with another adult during childhood Bereavement (DoH 2001). Where there is parental disharmony, a close relationship with one or other parent is a 24 PHILOSOPHY AND THEORY BASE

protective factor. A supportive extended family and monitoring of the child, long-term paren- and a valued role for the child within the fam- tal unemployment, parental mental disorder ily, such as doing household chores, are further and/or criminality, a harsh or inconsistent protective factors (Newman 2002). disciplinary style, social isolation and lack of • Life experiences. Three types of experience warmth and affection. have been shown to increase the chances • Life events and situations. The factors that cre- that a person will grow up with feelings of ate risk include physical, sexual and emotional high self-esteem and self-effi cacy. The fi rst abuse, divorce and family break-up, death of a is secure early attachments to parents or family member, poverty or economic insecurity, parental fi gures. The second is successful school transitions and war or natural disaster. task accomplishment. This can include aca- • Community risk factors. These include socio- demic success, taking positions of responsibil- economic disadvantage, social or cultural dis- ity, social success, employment and success in crimination, social isolation, neighbourhood non-academic pursuits such as sports or music. crime and violence, poor housing and lack of There is evidence that feelings of self-esteem community facilities such as transport, shops and self-effi cacy, while initially formed in early and recreation centres. childhood, can be modifi ed by later life expe- riences (Rutter 1987). The third type of experi- Mental health promotionFINAL strategies may be tar- ence is opportunities at critical turning points geted at any or all of these areas. It has been in life, when doors to new, positive experiences shown that prevention and early intervention are are opened. far more effective for mental health than treating • Community factors. Positive mental health is illness once NOTit has become established. promoted by a sense of connectedness with - the community and attachment to community ELSEVIER networks. This may be through participation in PROMOTING POSITIVE MENTAL a particular community group, such as aOF faith HEALTH group. Healthy communities have a strong cul- tural identity and pride, and there are strong Over the last 50 years, traditional Western norms against violence (DoH 2001). health care has been challenged many times in CONTENTterms of its ideology, management and interven- RISK FACTORS tions. Dissatisfaction with the medicalisation of health has promoted new philosophies which, Factors that inhibit positive mental health are since the mid-1980s, have placed health care in called risk factors. These can be divided into the the context of the community. Consequently, the same four categoriesPROPERTY as protective factors: indi- challenge for all health-care professionals has vidual factors, family factors, life experiences and become a quest for more proactive approaches community factors (DoHSAMPLE 2001). to promote and maintain sound physical and mental health for people within their com- • Individual risk factors. These include prena- munities. Inherent in the new philosophies tal brain damage or birth injury, prematurity, of care are ideas of individual responsibility, low birth weight, poor health in infancy, physi- self-determination, empowerment and a more cal or intellectual disability, low intelligence, a equitable partnership between client and health diffi cult temperament, impulsivity, poor social professional. skills and low self-esteem. In 1986, the first International Conference on • Family and social risk factors. These include Health Promotion was held in Ottawa, prima- having a teenage mother and/or a single rily to acknowledge changing worldwide expec- parent, absence of father in childhood, large tations for a new emphasis in the public health family size, antisocial role models, family movement. The Ottawa Charter was the outcome disharmony and violence, poor supervision of this and it endorsed the need to work towards OCCUPATIONAL PERSPECTIVES ON MENTAL HEALTH AND WELL-BEING 25 healthy communities and a reorientation of health • Altering perceptions of or exposure to risk . services, including changes in health research For example, poor social skills are a risk factor and in professional education. In the same year, so social skills training programmes can pro- the Division of Health Psychology of the British mote positive mental health. Psychological Society was established, again with • Reducing the chain reaction that takes place a focus on health rather than on illness and a drive when risk factors compound each other and towards a psychology of prevention rather than multiply. For example, many young people treatment (Niven 1989). who drop out of school come from unstable Health education also shifted in emphasis families, have literacy and numeracy problems, away from the traditional imparting of sensi- are involved with the police, take drugs, engage ble information, which had been criticised for in risky sexual behaviour and so on. A 10-week its assumption that people are rational human programme for these young people was de- beings who are free to choose health-related signed to teach them basic social and person- lifestyles. Health education has become part of al skills in order to reduce or remove some of a broader approach to promoting health which these risk factors. incorporates efforts to change political, social • Improving self-esteem and self-effi cacy . For and economic conditions for individual groups example, a drop-in creative activity group was and communities. This implies co-operation provided in a communityFINAL centre on a large hous- between agencies in both the statutory and vol- ing estate. Participants gained in self-confi dence untary sectors. and self-esteem through making items that Mental health promotion functions at different they valued and that were admired by friends but interconnected levels (DoH 2001, Health and family.NOT Education Authority 1997). • Creating- opportunities for change . For exam- ple, a supported employment scheme can assist Level of the individual : increasing emotionalELSEVIER • someone with limited work experience to retain resilience through interventions designed to a job while learning the necessary skills. promote self-esteem, life skills and OFcoping skills, for example communicating, negotiating, Some mental health promotion strategies have relationship skills and parenting skills. This is been found to be more effective than others. A the level with which occupational therapists are review of the literature identified eight features most familiar. CONTENT that are characteristic of the most effective pro- Level of the community : increasing social • grammes (Sure Start 2004). support, social inclusion and participation, improving neighbourhood environments, anti- Comprehensiveness: no single type of bullying strategies at school, workplace health, • PROPERTY intervention has been found to prevent multiple community safety, childcare and self-help net- high-risk behaviour, so successful programmes works. Occupational therapists are increasingly SAMPLE involve a combination of intervention methods moving into this area of work. and aim to infl uence a combination of several Structural/policy level: developing initiatives • risk or protective factors. to reduce discrimination and inequalities and System orientation: successful interventions to promote access to education, meaningful • aim to change institutions as well as individuals, employment, affordable housing, health, social and involve the social network of the individual and other services which support those who or group. are vulnerable. Occupational therapists are Relatively high intensity and long duration : not yet working at this level, except in isolated • short-term programmes tend to have time- projects. limited benefi ts, especially with high-risk Strategies for promoting mental health oper- groups. Long programmes (years rather than ate through one or more of four processes months) have an impact on more risk fac- (Newman 2002). tors and have more lasting effects. The most 26 PHILOSOPHY AND THEORY BASE

successful programmes intervene at a range of • Occupation is a tool for healthy participation in different times rather than once only. life. • Structured curriculum: successful interven- • Occupation can act as a barometer for gauging tions are targeted at risk and protective factors health. rather than at problem behaviours. • Early commencement : this is essential. Inter- An understanding of the value of activity is cen- vention during pregnancy brings additional tral to the profession's philosophy and its focus benefi ts. on occupational performance. The health-promot- • Specifi c to particular risk factors : prevention ing value of purposeful participation in activ- needs to be disorder, context and objective spe- ity is inherent in the concept of self-actualisation: cifi c. Generic prevention programmes have less through doing, people are confronted with the evi- impact. dence of their ability to function competently and • Specifi c training : there is no evidence about take control of their lives as far as they are able. what qualifi cations are needed for effective Personal dignity and beliefs are enhanced and a mental health promotion. All people who work sense of self-worth is developed. For example, with young children and their carers should Argyle (1987) suggested that Scottish country have skills in this area. dancing epitomises the totality of an enhancing • Attention to maintaining attendance : the peo- activity in which thereFINAL is social contact, skill, exer- ple who most need intervention are likely to be cise and involvement in culture. Gardening can be those who need most support if they are to stay understood in the same light; although different in a programme. in pace, it provides the participant with closeness to the seasonsNOT and the rhythm of life. It enhances - OCCUPATIONAL THERAPY AND HEALTH the quality of life by the provision of colour, smell, PROMOTION ELSEVIERexperiences and the produce which results from careful tending. Christiansen & Baum (1997, p600) definedOF occu- Giving people opportunities to take part in pational therapy as ‘a health discipline concerned demanding and challenging activities makes them with enabling function and well-being’ and Brown less sensitive to risk and more able to cope with (1987) considered that occupational therapy was physical and emotional demands (Newman 2002). an ‘unrecognised forerunner in the wellnessCONTENT A person needs to experience demands that are movement’. While few occupational therapists within his capabilities, or that stretch him slightly, in the UK work comprehensively with the well in order to develop a sense that he can manage. population. they have been involved in working If the demands are too great, leading to repeated with carers, offering support, advice and educa- failure, or too light, so that skills are not devel- tion, for many years.PROPERTY oped, then the individual will not be able to trust The values underpinning the promotion in his ability to cope (Antonovsky 1993). of sound mental healthSAMPLE have always been implicit within occupational therapy and they OCCUPATIONAL THERAPY AND have become more explicit since the renaissance WELL-BEING of occupation as a core construct within research, theory and practice. Some of the assumptions The occupational therapy process, as outlined made by occupational therapists about the rela- by Reed & Sanderson (1992), focuses on leisure, tionship between occupation and health are as personal care and occupation in relation to the follows. physical, psychological, social, economic and spir- itual aspects of a person's life. External factors, • People are occupational beings. both sociological and environmental, are taken • Engagement in occupation is healthy. into account and there is an emphasis on enhanc- • People need a healthy balance of occupation. ing the competence of the individual rather than • There are links with purpose and meaning. highlighting areas of disability or malfunction. The OCCUPATIONAL PERSPECTIVES ON MENTAL HEALTH AND WELL-BEING 27

philosophy underpinning this approach, which is THE CONTRIBUTION OF OCCUPATIONAL essentially holistic and focused towards empower- SCIENCE ment, is compatible with health promotion and the concepts of personal responsibility and control. The discipline of occupational science is con- The wellness and holistic health movement in cerned with the form, function and meaning of America, which emerged from the human poten- occupation. While its relationship with the prac- tial and counter-culture movements in the 1960s tice of occupational therapy is a robust one, it and 1970s (Johnson 1986), fitted well with philoso- draws its knowledge base from diverse interdisci- phies in occupational therapy that acknowledge plinary sources. This provides a rich contribution the dynamic interaction of mind, body, spirit and to our understanding of how occupation affects social context. The focus on spiritual well-being mental health and subsequent well-being. Yerxa encompasses the values of the individual and rec- (1993) was an early proponent of this new science, ognises the need for self-esteem and affirmation. believing that it offered a new way to comprehend Without some sense of spirituality, there is a lack the occupational nature of human beings and how of meaning in life, which can often be identified in this could enhance human potential and personal loneliness, depression and feelings of powerless- growth. ness (Neuhaus 1997). A number of theorists (for example, Clark 1993, A client-centred focus will in itself help to com- Townsend 1997, WatsonFINAL & Swartz 2004) have bat problems. Many people lack experience of extended these ideas and offered a type of qualita- warm and supportive relationships and the thera- tive research methodology in the form of narrative pist can facilitate the expansion of social networks analysis which has revealed how engagement to enhance feelings of well-being. in meaningfulNOT activities can be a transformative Some of the factors which promote a sense of experience.- Further, occupational patterns and well-being are reflected in the following six Cs. ELSEVIERroutines provide a sense of coherence and bal- ance (Ekelman et al 2003). Mental well-being can • Contribution . An old Indian proverbOF states be enhanced by the significant social, spiritual, that the smile you send out returns to you. psychological and biological features which a A sense of being able to give to others is an balanced occupational life offers (Wilcock 2006). essentially healthful phenomenon. Occupational balance is the result of healthy • Comfort with change in life . Self-regardCONTENT and resolution of occupational deprivation, alienation acceptance of one's lot lead to being at ease in and injustice, through the achievement of occu- one's surroundings. Parallel with this is the abil- pational justice (Townsend 2003, Whiteford 2000, ity to change and adapt so that the individual Wilcock 1998). does not sink into stagnation. • Contact/companionshipPROPERTY. Involvement and so- cial networks are essential for human survival SUMMARY and the degree of supportSAMPLE which a person per- ceives he is receiving from others is a crucial Prevention of ill health and the promotion of factor in the ability to cope. Empathy with oth- mental well-being are now regularly featured ers is an aspect of this. within the media. In one popular evening news- • Choice . Also signifi cant is the degree to which paper in the East of Scotland, on one night alone, the person feels in control, having a sense of there were features concerning volunteering to empowerment and choice. promote good mental health, an article advertis- • Competency. The ability to cope builds a posi- ing a module to assist police officers to recognise tive self-concept which reinforces a sense of the signs of dementia in the course of their work competency. Carrying out activities profi ciently and a feature on ways of combating depression promotes self-esteem. in young men. • Commitment. This brings a sense of purpose This chapter has explored some of the concepts and belonging and of direction in life. and ideas that underpin the promotion of mental 28 PHILOSOPHY AND THEORY BASE

health and well-being. It has identified the factors are now more confidently articulated, whether that have the potential to promote or inhibit in relation to micro, meso or macro aspects of positive mental health and looked at some of the society. The underlying philosophy of occupa- strategies and interventions used in mental health tional therapy is consistent with models of health promotion programmes. It finished by consider- which focus on the empowerment of individuals ing the role of occupational therapy in the promo- by acquiring life skills to achieve a greater sense tion of health and well-being, and the contribution of control. It is concerned with the constellation that occupational science is making to the field. of activities which give meaning to life by deter- The early years of the new millennium have mining roles, relationships and routines. These been exciting ones for the profession of occupational give shape and purpose to our lives and provide therapy in relation to ideas of health, wellness and the vital ingredients that contribute to a sense of well-being. Occupational perspectives of health well-being.

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