Mental Health Promotion in Public Health: Perspectives and Strategies From Positive Psychology

Abstract

Positive psychology is the study of what is “right” about people—their positive attributes, psychological assets, and strengths. Its aim is to understand and foster the factors that allow individuals, communities, and societies to thrive.

Cross-sectional, experimental, and longitudinal research demonstrates that positive emotions are associated with numerous benefits related to health, work, family, and economic status. Growing biomedical research supports the view that positive emotions are not merely the opposite of negative emotions but may be independent dimensions of mental affect.

The asset-based paradigms of positive psychology offer new approaches for bolstering psychological resilience and promoting mental health. Ultimately, greater synergy between positive psychology and public health might help promote mental health in innovative ways.

Mental health promotion seeks to foster individual competencies, resources, and psychological strengths, and to strengthen community assets to prevent mental disorder and enhance well-being and quality of life for people and communities.^1–4 Positive psychology is the study of such competencies and resources, or what is “right” about people—their positive attributes, psychological assets, and strengths.⁵ Its mission is to understand and foster the factors that allow individuals, communities, and societies to thrive.^5,6 It complements theories and models of individual, community, and organizational deficits with theories and models of assets.⁷ Positive psychology offers new approaches for bolstering psychological resilience and for promoting mental health, and thus may enhance efforts of health promotion generally and of mental health promotion specifically.^1–4,7–10

Health promotion strategies, in general, include implementing health-enhancing public policy (employment opportunities, antidiscriminatory laws), creating supportive environments (parenting interventions), strengthening community action (participatory research, media campaigns), developing personal skills (resilience), and reorienting health services (postpartum depression screening) to enhance health.^1,2,11–13 Public health has focused its efforts on these health determinants primarily as they relate to preventing physical illness, injury, and disability, resulting in increased longevity.^14,15 Similarly, clinical psychiatry and psychology have been successful in identifying, classifying, and treating mental illness and disorder, resulting in better quality of life for many. However, just as the 1986 Ottawa Charter for Health Promotion¹³ shifted greater attention in public health from disease prevention to health promotion, positive psychology shifts attention from pathology and dysfunction to positive emotions and optimal functioning. Underlying both of these shifts are the fundamental views that health is more than the absence of illness and that fostering individual and social resources can lead people, organizations, and communities to thrive.

In public health, this shift has also become evident in the field of mental health promotion, seen as an integral part of health promotion practice.^1–3,12,16 Common to both mental health promotion and positive psychology is a focus on “positive mental health,” an empowering resource, broadly inclusive of psychological assets and skills essential to human fulfillment and well-being.^1,3,4 Activities and programs that foster positive mental health also help to prevent mental illness, highlighting the benefits of mental health promotion to overall population health.² Assessment of positive mental health and related outcomes such as well-being can help in supporting and evaluating health promotion and public health wellness initiatives.¹⁷ Thus, positive psychology deserves a place in health promotion, and health promotion theory and methods can enhance positive psychology research and practice to improve population mental health.^7,8,17–19

Whereas discourse on human fulfillment is rooted in ancient Western and Eastern philosophy, as well as in more recent disciplines of human development and humanistic and educational psychology, positive psychology applies a common language and an empirical approach to the study of 4 areas: (1) positive emotions (happiness, gratitude, fulfillment), (2) positive individual traits (optimism, resiliency, character strengths), (3) positive relationships among groups, and (4) enabling institutions (schools, worksites) that foster positive outcomes.^5,18,20–24 This contrasts with post–World War II psychology, which concentrated on repairing damage using the prevailing disease model of human functioning (i.e., mental ill health), while largely ignoring psychological assets (e.g., courage, kindness) and positive aspects of behavior (e.g., responsibility, compassion) that could also assist in therapy.²⁵ The focus on mental ill health—its causes, symptoms, and consequences—resulted in stigma associated with these factors, euphemistic use of the term “mental health” to describe treatment and support services for people with mental illness, and vague language, especially among the public, about what mental health means.¹

Positive psychology does not claim that mainstream psychology is negative or less important because it focuses on pathology and mental illness. Its aim is not to deny the distressing or unpleasant aspects of life; the value of negative experiences on human development, coping, and creativity; or the critical need to ameliorate distress.^23,26 Despite what its critics say, positive psychology seeks to provide a more complete scientific understanding of the human experience—including positive and negative experiences—to better integrate and complement existing knowledge about mental illness with knowledge about positive mental health.^23,24,27,28 Researchers have addressed these critics' objections, which are primarily concerned with adaptation, goals, temperament, heritability, forecasting, recall biases, and accurately measuring or intervening on well-being.^29–36 Research from multiple disciplines suggests that positive mental health and well-being can be measured relatively accurately and that appropriately targeted interventions can affect well-being.^{4,24,30,35,36} However, more research in positive psychology that generalizes to the broad population is warranted. Given the benefits of positive emotions, positive psychology parallels efforts in mental health promotion to advance the value of positive mental health in individuals and society.^1–4 We present a brief overview on the benefits of positive emotions, the recognition and impact of positive individual traits for mental health promotion, and the influence of enabling social-environmental factors on positive mental health.

POSITIVE EMOTIONS

Many people know about the benefits of negative emotions such as fear, disgust, and anger in securing our personal safety and survival (e.g., fight or flight), and the harms of increased stress levels, narrowed responses for action, and withdrawal associated with negative emotions. Fewer know that positive emotions (e.g., joy, interest, contentment) quell autonomic arousal, signal approach and safety, and prompt individuals to engage with their physical and social environments by exploring new objects, people, or situations (for reviews, see Fredrickson^6,37,38 and Tugade et al.³⁹). Although sometimes confused with related affective states such as short-term sensory pleasure (e.g., satiety, warmth) and longer-lasting positive moods, positive emotions are typically brief and result from personally meaningful circumstances (e.g., joy from a social encounter).

Broaden and Build

The Broaden and Build theory of positive emotions proposes that positive emotions broaden people's attention, expand cognition (e.g., curiosity, creativity) and behaviors (e.g., exploration, play), and consequently foster physical, intellectual, and social resources (e.g., intelligence, mastery, social competence) for optimal functioning.^6,37,38 So, whereas negative emotions are adaptive in the short term, positive emotions may be adaptive in the longer term by building personal resources that function as psychological reserves for continued growth.^6,38,39

Regulating Negative Emotions

Moreover, positive emotions can more quickly quell or undo the adverse effects of negative experiences by reducing stressful reactions (e.g., increased blood pressure) and returning the body to a balanced state.^6,40,41 For example, in previous studies, individuals in whom positive emotions such as contentment and mild joy were prompted immediately after a stressful situation had faster cardiovascular recovery (e.g., reduced heart rate, peripheral vasoconstriction, and blood pressure) than did those in a control group.^6,40 According to the Broaden and Build theory, resilient people experience positive emotions more frequently and recover more quickly from specific life stressors.^6,38,39

Biological Markers of Positive Emotions

Positive emotions have numerous health, job, family, and economic benefits.^31,42–44 In numerous cross-sectional studies, positive emotions and positive evaluations of life are associated with decreased risk of disease, illness, and injury; healthier behaviors; better immune functioning; speedier recovery; and increased longevity.^{31,40,43–46} Longitudinal and experimental studies show that positive emotions precede many successful outcomes related to work, social relationships, and physical health.⁴⁴ Growing biomedical and related research supports the view that positive emotions are not merely the opposite of negative emotions but independent dimensions of mental affect.^47,48 Positive emotions and negative emotions appear to have different determinants, consequences, and correlates, but differentiating these requires more study.^44,49,50

Positive emotions are partially heritable (estimates of heritability range from 0.36 to 0.81), suggesting a genetically determined set point for emotions such as happiness and sadness.^51–55 The expression of genetic effects, however, often results from environmental stimuli; social context matters because it can affect the opportunity for, and the frequency of, expressing positive emotions.^30,53 (The frequency of positive emotions predicts well-being better than does their intensity.⁴⁴) Furthermore, individuals' circumstances and social contexts are amenable to intervention by public health, mental health, and positive psychology practitioners. Several interventions described in this essay and elsewhere have succeeded in boosting positive emotions and minimizing negative affect and depression over time.^36,53,56

This growing literature demonstrates that positive emotions are important psychological resources to be nurtured, rather than only enjoyed as brief, elusive outcomes.^{4,6,31,37,38,44} Positive psychology interventions (e.g., those that promote resiliency, optimism, or gratitude) may enhance the value of public health interventions based on effective behavioral science theories (e.g., Stages of Change)⁵⁷ and methodologies (e.g., motivational interviewing) in improving health outcomes. Framing individual and population health communication messages around positive experiences and emotions may foster behavior change better than using messages based on fear.⁸ For example, Kaiser Permanente's “Thrive” campaign links its brand and its health services with the theme of living life fully and happily, and may be morale boosting for some.^58,59

POSITIVE INDIVIDUAL TRAITS

Positive individual traits include a number of positive dispositions present in individuals to different degrees, such as creativity, bravery, kindness, perseverance, and optimism, which, when cultivated, can increase resiliency, buffer against psychological disorder and other adversities, and promote mental health.¹⁸ Several methods exist to help individuals improve their resiliency and identify their positive dispositions.

Resiliency and Optimism

Resiliency is the process of positive adaptation in the context of adversity or risk.^1,4,60 Resiliency helps people to cope with life's challenges and confers a sense of mastery over one's life.^1,4 Promotion of resiliency can occur within persons (e.g., coping, optimism), among persons (social support), and across social levels (public health or educational systems).⁶⁰ Studies of resiliency focus on positive adaptation and achievement and stress the importance of promoting competence (e.g., autonomy, goal-directed behavior) through interventions.^4,61 Substantial public health efforts are designed to promote resiliency among persons and across social levels. For example, prevention programs that safeguard against illness and injury might promote resiliency directly (e.g., vaccinations, nutritional fortification of foods) or indirectly (e.g., after-school programs).¹ The US Administration on Aging supports congregate meal programs through its network of Area Agencies on Aging, not only to provide meals to older adults but also to promote social interaction and social support that may confer greater psychological resiliency.⁶² Parenting interventions and preschool interventions are effective in boosting resiliency in mothers and children.^1,2,4

Positive psychology offers several approaches for improving individual resiliency that may be relevant for public health interventions aimed at schools, worksites, health care settings, and Area Agencies on Aging. For example, individuals can change their “explanatory style”—that is, how they interpret day-to-day events and their interactions with others.^4,63–65 Specifically, they can learn skills for more optimistic ways of thinking and reacting to improve their resiliency.^4,63 Besides certain personality characteristics (e.g., dispositional optimism) and the physical and social environment, explanatory style can predict depression and other negative physical health outcomes.^66,67 Skills based on learned optimism—such as challenging beliefs, avoiding thinking traps, calming and focusing, and putting things in perspective—can improve psychological resiliency in individuals. These skills closely resemble “cognitive symptom management,” effectively used in interventions such as the Chronic Disease Self-Management Program.⁶⁸ However, expanding the use of skills like learned optimism to the broad population holds promise for promoting mental health.^63,64,69,70

The Penn Resiliency Program (PRP) is a group intervention delivered to children aged 8 to 15 years after school that teaches resiliency skills based on learned optimism. The PRP has been effectively implemented in the United States, United Kingdom, Australia, China, and Portugal, providing evidence of its effectiveness in diverse cultural settings.^2,70,71 Students learn to adopt more optimistic explanatory styles by detecting inaccurate thoughts, evaluating the accuracy of those thoughts, and challenging negative beliefs by considering alternative interpretations.^70,71 Students also learn how to negotiate, make decisions, and relax. In 21 studies (most of which used randomized controlled designs) that comprised about 3000 children, the PRP prevented disruptive behaviors for up to 36 months and depression and anxiety symptoms for up to 2 years, especially in students with more severe symptoms.^70–73 Thus, a mental health promotion intervention like the PRP may reduce the likelihood of onset of mental illness in children, but it requires more study.⁷⁴ The PRP works equally well among boys and girls and for children of various racial/ethnic backgrounds.^70,74 Similar school-based interventions have demonstrated improvements in empathy, cooperation, assertiveness, self-control, coping skills, resilience, and other social competencies aligned with positive mental health outcomes.^2,70

The US Army is applying resiliency training modeled after the PRP through its Comprehensive Soldier Fitness Program⁷⁵ to support the optimal mental and physical health of soldiers. As of October 1, 2009, the Army has supported resiliency training for its entire staff. The Comprehensive Soldier Fitness Program focuses on 5 dimensions of functioning: physical, emotional, spiritual, family, and social. It includes an anonymous, confidential, online self-assessment for all soldiers and will include a similar assessment for family members that will guide training needs. Resiliency skills to be taught include problem solving, energy management, explanatory style, and putting things in perspective. The Army is training master trainers to help other soldiers learn resiliency techniques. Additional pre- and postdeployment boosters will be implemented.⁷⁵

Learned optimism is not about looking at the world through rose-colored glasses or having unrealistic or self-deceptive expectations.⁷⁶ Instead, it is about teaching skills needed to promote mental health and to avoid excessive worry, rumination, or spirals of negative thinking.^63,64 Resiliency interventions such as the PRP might be disseminated more broadly in schools, worksites, and other community settings.^1,2,4

Character Strengths

With respect to mental illness, professionals have applied a common language and diagnostic criteria to identify and treat mental illness using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).⁷⁷ However, the DSM-IV is explicitly designed to diagnose and treat mental illness but provides no guidance to assess positive thoughts, emotions, or behaviors.^78,79 In 2000, with growing interest and support from the field of positive youth development, Peterson and Seligman organized a research team to develop a scientific classification scheme comparable to the DSM-IV as well as assessment strategies to identify psychological strengths.⁷⁹ After extensively reviewing literature from multiple disciplines, this team considered cross-cultural validity, possible unintended political consequences of their effort (e.g., value-laden applications, such as selecting people on the basis of strengths), and the implications of creating a classification system versus a taxonomy.⁷⁹ Team members assumed that character, like traits, was stable and general and that character strengths were not bound to culture. They then identified explicit criteria that guided their classification system to identify character strengths of human goodness and excellence of character (see box on this page).

Criteria Used by Positive Psychologists for Classifying Strengths of Human Goodness and Excellence of Character

A character strength—

1. Is ubiquitous: is widely recognized across cultures (e.g., bravery, kindness).

2. Is fulfilling: contributes to individual fulfillment, satisfaction, and happiness broadly construed.

3. Is morally valued: is valued in its own right and not for tangible outcomes it may produce.

4. Does not diminish others: elevates others who witness it.

5. Has a nonfelicitous opposite: has obvious antonyms that are negative.

6. Is traitlike: is an individual difference with demonstrable generality and stability.

7. Is measureable: has been successfully measured by researchers as an individual difference.

8. Is distinct: is not redundant (conceptually or empirically) with other character strengths.

9. Has paragons: is strikingly embodied in some individuals.

10. Has prodigies: is precociously shown by some children or youths.

11. Can be selectively absent: is missing altogether in some individuals.

12. Has enabling institutions: is the deliberate target of societal practices and rituals that try to cultivate it.

Finally, they developed and validated the Values in Action Inventory of Strengths (VIA-IS) to measure these character strengths. The VIA-IS includes 6 core or “signature” strengths, each with 3 to 4 component definitions (Table 1). Signature strengths are the mental and physical activities that we perceive as natural and desirable and that energize rather than exhaust us.⁷⁸ The VIA-IS, completed by a million individuals in more than 200 nations since 2002, has acceptable construct validity, discriminant validity, convergent validity, stability and internal consistency reliability, and test-retest reliability.^21,80–83 The VIA-IS has also been modified and validated for use in youths aged 10 to 17 years (VIA-Youth).⁸³

TABLE 1.

Core Strengths of Human Goodness and Character as Recognized by Positive Psychology

Core Strength	Components
1. Wisdom and knowledge—cognitive strengths that entail the acquisition of knowledge	Creativity; curiosity; judgment and open-mindedness; love of learning; perspective
2. Courage—emotional strengths that involve the exercise of will to accomplish goals in the face of opposition, external or internal	Bravery; perseverance; honesty; zest
3. Humanity—interpersonal strengths that involve tending and befriending	Capacity to love and be loved; kindness; social intelligence
4. Justice—civic strengths that underlie healthy community life	Teamwork; fairness; leadership
5. Temperance—strengths that protect against excess	Forgiveness and mercy; modesty; prudence; self-regulation
6. Transcendence—strengths that forge connections to the larger universe and provide meaning	Appreciation of beauty and excellence; gratitude; hope; humor; religiousness and spirituality

Source. Peterson and Seligman.⁷⁹

The VIA-IS is available for public use⁸⁴ and, as part of the survey assessment, provides users with their strengths' rankings (so they can see where their strengths rank compared with other strengths), along with examples of methods to enhance strengths. Park and Peterson⁸³ have provided information on scoring, and Peterson²¹ has described methods to practice using signature strengths in new and different ways (i.e., reinforcing the strength) for mental health promotion. One Internet-based intervention encouraging people to use their strengths in new ways increased happiness and decreased depressive symptoms for 6 months.²⁴ Such strengths-based development has been linked to many positive outcomes in educational and workplace settings.⁸⁵ The public availability of the VIA-IS, its broad approach to characterizing individual strengths, and its psychometric properties make it potentially appealing for behavioral science intervention research as well as for health communication messaging.

Although more research is needed regarding its psychometric properties in diverse sociodemographic subgroups, the VIA-IS offers good face validity for use in communities. For example, among 383 African American adolescents surveyed with the VIA-Youth, love of learning was related to self-reported abstinence for boys and self-reported avoidance of drug use for boys and girls.⁸⁶ In a Department of Veterans Affairs psychiatric rehabilitation program to promote recovery from mental illness, simply taking the VIA-IS was described as an intervention itself, with most participants reporting positive outcomes associated with the experience.⁹ The study investigators encouraged veterans to use prompts such as a “strengths card,” which they carried with them as a reminder of their positive attributes and as help in their daily recovery.

Applying the VIA-IS could also be useful to those coping with other chronic diseases. For example, parents might devise ways to use their children's VIA strengths to help them better manage chronic illness. Additional studies of character strengths may show that these strengths buffer against risky health behaviors or adverse health outcomes. Such studies may help target health promotion messages and health marketing strategies to motivate groups in ways that complement their self-perceived strengths. However, because the VIA-IS is based solely on self-report, it is still unclear whether and how it relates to more objective measures of strengths, whether the strengths it identifies are enduring, and whether strength-based interventions are effective over the long term.

Although a comprehensive review of interventions that improve positive emotions is beyond the scope of this essay, practicing gratitude, performing acts of kindness, and mindfulness relaxation (nonjudgmentally focusing awareness on thoughts, sights, and sounds) can increase positive emotions and well-being.^36,56,87 Gratitude helps people to savor their life experiences and situations, maximize satisfaction and enjoyment from those experiences, and minimize adaptation.⁵⁴ Gratitude might also help people to cope with stress and trauma by positively reinterpreting negative life experiences.^33,88 Relative to control groups, participants who were asked to write down 5 things for which they were grateful (e.g., cherished interactions, overcoming obstacles) once a week for 10 weeks reported greater life satisfaction, more optimism, and fewer health complaints.⁵⁶ Other gratitude exercises improved positive affect and physical activity,^36,56,88 sleep quality,⁸⁹ and prosocial behavior.⁹⁰ Students who performed and tracked random acts of kindness increased their happiness relative to that of a control group.^36,91 Additional examples of interventions that have been shown to increase individual positive emotions and well-being are available,^22,36 as are examples of their use in schools.⁷⁰

SOCIAL-ENVIRONMENTAL FACTORS AND ENABLING INSTITUTIONS

Social and economic factors influence health and mental health, including access to employment; safe working conditions; education, income, and housing; stable and supportive family, social, and community environments characterized by opportunities for autonomy, social inclusion, and freedom from discrimination and violence; and taxation of addictive substances to prevent abuse.^1–4 Institutions such as schools, homes, worksites, places of worship, and health care settings that have been traditional targets for public health disease prevention and health promotion interventions also are settings for evidence-based mental health promotion interventions.² Policy initiatives that affect social and economic determinants of mental health (e.g., housing, employment) and that support the integration of evidence-based mental health promotion programs in community settings are warranted to improve population health.^1,4

For those interested in fostering community or organizational change for mental health promotion, Appreciative Inquiry, a method closely aligned with positive psychology, holds promise.⁹² Appreciative Inquiry is a systematic development and improvement process for management and organizational change based on deliberately positive assumptions about people, organizations, and relationships.⁹² Its processes shift the focus and dialogue from problem solving to fostering assets by seeking to examine the strengths in a group, thus providing the starting point for positive change. In a typical Appreciative Inquiry session, participants are led through a series of systematic and provocative but affirming questions to identify what is positive in the group and to connect people in ways that heighten energy, vision, and action for change.^92,93

Appreciative Inquiry has been successfully and innovatively used by numerous private and governmental organizations, including the Cleveland Clinic, the National Aeronautics and Space Administration, the US Navy, Save the Children, the United Nations Global Compact, Imagine Chicago, Imagine Nagaland (India), and the United Kingdom's National Health Service.^92–94 Nursing has also frequently used Appreciative Inquiry to enhance education, management, and clinical care outcomes.^95–99 It may supplement current health behavior change models for health promotion.⁷ For example, health care providers, health educators, and other caregivers might incorporate Appreciative Inquiry in their interactions with patients, clients, families, or groups to help them focus on capabilities and competencies related to a healthy lifestyle. A provider might ask a patient a few questions from an Appreciative Inquiry perspective to help motivate behavior change or to help assist in sustaining behavior change (Table 2). Extensive resources exist to incorporate Appreciative Inquiry principles into daily settings or to more formally structure an Appreciative Inquiry summit for groups or organizations.^92,93 The implementation and effectiveness of Appreciative Inquiry in health promotion warrants more thought and study.

TABLE 2.

Use of Appreciative Inquiry as a Health Behavior Change Intervention Between a Clinician or Health Educator and a Client

Phase	Appreciative Inquiry Question
Discover—examining aspects of health people most value and want to promote	Describe a time when you had an exceptionally healthy lifestyle.
	What did you appreciate about the experience?
	What was it about you that made this happen?
	What was it about others that made this happen?
	What other situational factors supported this positive experience?
	Tell me a story of when you felt particularly healthy and alive. Why was it so powerful?
	What are the good things about you that helped make this a special time?
	Did you learn anything new about yourself?
	Who else was involved and how did they help?
Dream—challenging the status quo by envisioning a more valued and possible future	Imagine a world where everyone could be in charge of his or own health and care. What are the most important things you would need to take care of your own health and care?
	Your health and the health of your family are affected by what happens in your community. Imagine that you live in a truly healthy community. What would be different from the way things are now? What role do you see for yourself?
	What steps could your community take to ensure a healthy future?
	Imagine that you are so physically active that you feel very fit and healthy. What would you feel like on a daily basis?
	What would you be doing? What would you see yourself doing for exercise that would make you feel good while doing it? What could you do that would be different from the way things are now? What steps would those around you need to do to help you?
Design—a collaborative construction of bold statements of ideal possibilities	What could you do now to be more in charge of your own health and care?
	Who would you go to for help? Is there anything the people you go to now for help could do differently so you could take more charge of your own health and care?
Deliver—consensus is reached regarding principles and priorities; strategies are designed to accomplish short- and long-term goals	What are some short-term goals for you to try related to improving your health?
	What are your long-term goals?
	Who can help you achieve these goals and how can they help you?

Note. Discover, dream, design, and deliver are the 4 phases that guide Appreciative Inquiry.⁹²

Source. Modified from Moore and Charvat.⁷

CONCLUSIONS

Positive mental health is a resource for everyday living and results from individual and community assets. The health promotion theories, methodologies, and populations available through public health partners offer greater reach for positive psychology practitioners to implement and evaluate their interventions across diverse sociodemographic subgroups and community settings that currently receive little attention. Likewise, the asset-based and affirmation paradigms of positive psychology offer additional strategies for mental health promotion. Mental health promotion and positive psychology offer the public (1) an updated way of thinking about mental health that provides for the richness of human experience, (2) additional ways to describe and value the full spectrum of mental health to lessen the stigma associated with mental illness and to initiate conversations about mental health,¹⁰⁰ (3) enhancement of psychological screening,¹⁰¹ and (4) evidence-based individual, community, and social interventions that can enhance positive mental health.^1,2,4,31 Ultimately, greater synergy between positive psychology and public health might help promote positive mental health in innovative ways that can improve overall population health.