This book is about a new intervention for people living with a diagnosis of psychosis. This group of disorders is high prevalence, high burden and often long-term.1 The most common psychosis diagnosis is schizophrenia, and it is estimated that 200,000 people live with schizophrenia in England alone.2 Despite continued progress in the development and evaluation of treatments for schizophrenia and other psychoses, a high proportion of people continue to suffer from symptoms and disability. Hence, innovations in treatments for psychosis have international relevance.
We believe,3 as do other commentators,4â6 that research on wellbeing can inform the development of new approaches to supporting the recovery of people living with psychosis. As a result, we undertook a research study, funded by Guyâs and St Thomasâ Charity between 2009 and 2015. The study developed and evaluated a new manualised intervention called Positive Psychotherapy for Psychosis, which aims to improve wellbeing in people with psychosis. We published some of the study findings in individual academic papers.7â15 This book brings together the complete body of work, including the revised manual for the new intervention.
In this chapter, we outline how the understanding of wellbeing has evolved over time. We tell this story in some detail, for three reasons. First, the concept of wellbeing is not yet well-defined in relation to people with severe mental illness such as psychosis.16 Therefore, marshalling and organising the complex history of wellbeing is a sensible starting point. Second, this story illustrates many of the challenges in improving wellbeing in people living with psychosis. This helps to make more explicit some of the choices made in developing Positive Psychotherapy for Psychosis. Third, describing the history of wellbeing introduces many of the constructs used in positive psychology â the study of wellbeing â which were used in developing Positive Psychotherapy for Psychosis.
The remainder of the chapter then makes the links between recovery and wellbeing explicit, and describes the structure of the rest of the book.
What is wellbeing?
Wellbeing has been a topical policy focus in recent years and has attracted research interest across health conditions. An explicit description of the concept of wellbeing is often absent in research.14 Four academic strands of wellbeing research can be differentiated:
1 Economic Strand: The earliest phase, grounded in economic research. Wellbeing is framed in terms of national wealth, social determinants, development and general quality of life.
2 Medical Strand: Grounded in medical research, wellbeing is framed in relation to disorder and illness.
3 Psychological Strand: Grounded in psychological research, wellbeing is framed in terms of subjective and mental concepts.
4 Integrative Strand: The latest phase, informed by economic, medical and psychological phases, with a distinct focus on positive psychology and recovery research.
We now discuss each phase, with a particular focus on the birth of the psychological conception and its evolution into the contemporary, integrative phase. The primary focus is to show how wellbeing has shifted from being conceived as a collectivist concept with objective measures, to being conceived as an individualistic concept with subjective measures. This transition was instrumental in wellbeing becoming a key concept in mental health.
From the economic phase to the medical phase
In the economic strand, wellbeing was initially conceived of primarily in collectivist terms. Measuring and comparing the wellbeing of populations (rather than individuals) was first undertaken by economists in the early twentieth century. Initially, financial indicators of wellbeing such as Gross National Product (GNP) were used to measure and compare. As these failed to discriminate between countries of similar developmental status, alternative economic indices were proposed to estimate societal functioning.17 These composite measures further increased the validity of wellbeing estimates. Today, they are known as âQuality of Lifeâ measures. First, they included purely objective measures, such as mortality, nutrition, literacy, clean water supply or education.18 Later, âsubjectiveâ indicators such as affect, wellbeing or life satisfaction were added to capture how people actually feel about their lives.19 Composite measures of population wellbeing are still developed today. For example, the UK Office for National Statistics (ONS) has developed a new assessment of population wellbeing, including subjective domains such as spirituality, personal and cultural activities, political participation or life satisfaction in addition to environmental and sustainability issues and UK economic performance.20
Inclusion of population level health indicators, for example, mortality, into composite measures evolving from economic research signifies the emergence of the medical strand to wellbeing research. The addition of subjective measures, for example, life satisfaction, signifies the emergence of the psychological strand to wellbeing research. Medical research also marks a shift in that it emphasises individual health status in understanding wellbeing. Health research is another major application of the concept of quality of life, in this context called Health-Related Quality of Life (HRQoL).
HRQoL has attracted substantial research since its introduction, as well as criticism for its lack of uniformity and clarity. The terms âhealth related quality of lifeâ, âquality of lifeâ and âwellbeingâ are often used interchangeably, and few articles claiming to measure HRQoL provide a definition or identify constituent domains.21 Conceptualisations and measures of HRQoL can be described according to a number of defining features, for example, generic versus disease specific, or objective versus subjective. Individual measurement tools often cover widely different dimensions, including access to resources and opportunities, environmental factors, social relationships, employment, leisure activities, sex life, mobility or satisfaction with social domains. The unifying feature of HRQoL concepts is their focus on illness symptoms and functioning based on the assumption that illness and disability inhibits full wellbeing.22
While physical health symptoms and functioning are major domains within HRQoL, measurement tools also often use the terms wellbeing and mental health (i.e. the absence of mental illness symptoms) interchangeably.23 Examples of generic HRQoL measures with a mental health or wellbeing sub-scale include the World Health Organisation Quality of Life (WHOQOL) questionnaires with their domain on âpsychological healthâ,24 the European Quality of Life-5 Dimensions (EQ-5D) questionnaire with its âanxiety and depressionâ domain,25 or the Short Form (SF) measures, with their âemotional wellbeingâ domain assessing feeling happy, sad, depressed or anxious.26 Other scales use a more elaborate conceptual foundation grounded in and overlapping with psychological conceptions of wellbeing. For example, the Lancashire Quality of Life Profile27 (LQoLP) and the Manchester Short Assessment of Quality of Life28 (MANSA) base their wellbeing domain on concepts of affect balance, life satisfaction and happiness.
One issue in measuring HRQoL in people with mental disorders is the potential distortion of subjective assessments due to âpsychopathological fallaciesâ, most prominently the âaffective fallacyâ, which indicates that the momentary affective state can influence peopleâs judgement about their overall life.29 This is most problematic in cases where HRQoL measures contain âemotionalâ items relating to feelings of depression and anxiety, as is the case, for example, in the Quality of Life in Depression Scale.30 Quantitative results support the âaffective fallacyâ as depressive symptoms have been shown to have an independent and significantly negative effect on subjective ratings of HRQoL.31
A second issue concerns the reliability of subjective assessment in people with psychiatric disorders. This concern led to the inclusion of supposedly objective assessment methods, derived from clinicians or family members.32 However, subjective assessment has become more accepted as people with severe mental illness were shown to reliably and consistently complete self-rating questionnaires.33 Moreover, the views of clinicians and family members may be biased, and service usersâ subjective position is argued to be no less true in case it diverges from an outsider. In fact, âinsiderâ and âoutsiderâ perspectives have been shown to differ due to differing values placed on contextual factors and a tendency towards a negative bias from the outsider perspective.34 This supports the meaningfulness of the subjective assessment of wellbeing. While in HRQoL, subjective and objective measures still coexist, the psychological approach has completely shifted to subjective assessment.
The emergence of the psychological phase
Psychological research has created specific conceptualisations and measures to capture wellbeing in its own right without embedding it within other constructs such as national development or HRQoL.
As with HRQoL, a review on psychological concepts of wellbeing criticised frequently missing or ambiguous definitions and the interchangeable use of similar terms.35 Distinctive features of the psychological approach include its focus on subjective experience and personal feelings, and on positive mental health and functioning, for example, positive affect, life satisfaction, autonomy, competence or personal growth.36â38 Moreover, specific wellbeing concepts allow for peak experien...
