International Journal of Mental Health Promotion Mental

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International Journal of Mental Health
Promotion
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Mental health as perceived by
persons with mental disorders – an
interpretative phenomenological
analysis study
a
b
a
Nina Helen Mjøsund , Monica Eriksson , Irene Norheim , Corey L.
c
d
M. Keyes , Geir Arild Espnes & Hege Forbech Vinje
e
a
Division of Mental Health and Addiction, Department of Research
and Development, Vestre Viken Hospital Trust, Drammen, Norway
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b
Department of Nursing, Health and Culture, University West,
Trollhättan, Sweden
c
Department of Sociology, Emory University, 1555 Dickey Drive,
Tarbutton Hall, Atlanta, GA, USA
d
Center for Health Promotion Research, Norwegian University of
Science and Technology, Trondheim, Norway
e
Department of Health Promotion, Faculty of Health Sciences,
Buskerud and Vestfold University College, Kongsberg, Norway
Published online: 12 May 2015.
To cite this article: Nina Helen Mjøsund, Monica Eriksson, Irene Norheim, Corey L. M. Keyes, Geir
Arild Espnes & Hege Forbech Vinje (2015): Mental health as perceived by persons with mental
disorders – an interpretative phenomenological analysis study, International Journal of Mental
Health Promotion, DOI: 10.1080/14623730.2015.1039329
To link to this article: http://dx.doi.org/10.1080/14623730.2015.1039329
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International Journal of Mental Health Promotion, 2015
http://dx.doi.org/10.1080/14623730.2015.1039329
Mental health as perceived by persons with mental disorders – an
interpretative phenomenological analysis study
Nina Helen Mjøsunda*, Monica Erikssonb,1, Irene Norheima,2, Corey L. M. Keyesc,3,
Geir Arild Espnesd,4 and Hege Forbech Vinjee,5
a
Division of Mental Health and Addiction, Department of Research and Development, Vestre Viken
Hospital Trust, Drammen, Norway; bDepartment of Nursing, Health and Culture, University West,
Trollhättan, Sweden; cDepartment of Sociology, Emory University, 1555 Dickey Drive, Tarbutton
Hall, Atlanta, GA, USA; dCenter for Health Promotion Research, Norwegian University of Science
and Technology, Trondheim, Norway; eDepartment of Health Promotion, Faculty of Health
Sciences, Buskerud and Vestfold University College, Kongsberg, Norway
(Received 19 March 2015; final version received 19 March 2015)
In this interpretative phenomenological analysis study, we explored how persons with
mental disorders perceive mental health. Adapting a salutogenic theoretical
framework, 12 former inpatients were interviewed. The analysis revealed experiences
of mental health as a movement, like walking up and down a staircase. Perceived
mental health is expressed both verbally in an everyday language and through body
language. Mental health is an aspect of being that is always present and which is
nourished by four domains of life: the emotional; physical; social and spiritual
domains. Mental health is experienced in everyday life as a sense of energy, and as
more or less wellbeing. Exploring persons’ meanings of mental health from a
subjective perspective can extend the knowledge base that can be used in mental health
promotion strategies.
Keywords: Salutogenesis, flourishing, positive mental health, well being, IPA.
Introduction
Positive mental health is recognized as a key resource for wellbeing and is currently
receiving increased attention in research, policy making, and clinical practice (World
Health Organization [WHO], 2014). Research shows that the concept of mental health
means different things to people, which can create confusion and misunderstandings
(Green & Tones, 2010; Lehtinen, 2008; Mittelmark & Bull, 2013). An understanding of
mental health as something more than the absence of mental illness has promoted the use
of concepts such as positive mental health and wellbeing. Research on wellbeing is
extensive, see Diener (2009). Our study emanates from a hospital in Norway which several
years ago changed from a psychiatric hospital to a mental health hospital, according to The
Mental Health Care Act, 1999. Positive mental health is explored from the perspectives of
persons with inpatient experiences. European studies show that one-third of the population
suffers from mental disorders (Wittchen et al., 2011). The terms illness, disease and
disorder can be used interchangeably in the literature. In our study, all participants were
diagnosed according to standard procedures for inpatients in hospital; hence, we use the
term disorder. Mental health needs to be explored both epidemiologically (Keyes, 2009;
Lehtinen, Sohlman, & Kovess-Masfety, 2005); from different conceptual and theoretical
*Corresponding author. Email: nina.helen.mjosund@vestreviken.no
q 2015 The Clifford Beers Foundation
2
N.H. Mjøsund et al.
frameworks (Barry, 2001, 2009; Jane-Llopis, 2007) and from the individual’s point of
view (Kiefer, 2008).
Background
Antonovsky (1979) coined the word salutogenesis (salus: health, genesis: origins) and
formulated the salutogenic question ‘What are the origins of health?’. His answer was the
Salutogenic Model of Health, with the sense of coherence (SOC) and generalized
resistance resources as key elements. Antonovsky claimed that there was a need to
complement the traditional pathogenic dichotomous (sick/healthy) understanding of
health with the salutogenic understanding of health as a continuum. Choosing a holistic
paradigm can enclose positive aspects of suffering as a source of learning (Oliveira, 2014).
Antonovsky (1996) further suggested salutogenesis as a theoretical framework for health
promotion research and practice. In salutogenesis, health is a dynamic, holistic concept,
developing along a continuum with the imaginary poles ease and disease (Antonovsky,
1979, 1987).
Even if Antonovsky’s primary focus was on the salutogenic model of ‘health’, he also
described ‘mental health’ as a continuum with a sense of psychological wellbeing at the
positive pole.
Mental health, as I conceive it, refers to the location, at any point in the life cycle, of a person
on a continuum which ranges from excruciating emotional pain and total psychological
malfunctioning at one extreme to a full, vibrant sense of psychological wellbeing at the other.
(Antonovsky, 1985, p. 274)
According to Keyes (2002), mental health is not the absence of mental disorder, but
the presence of sufficiently high levels of wellbeing. Mental health and mental
disorders belong to distinct, albeit correlated, dimensions, indicating that the presence
of mental disorders does not necessarily mean the absence of good mental health
(Keyes, 2007, 2014; Keyes, Dhingra, & Simoes, 2010; Westerhof & Keyes, 2010). The
mental health continuum consists of three levels of positive mental health: flourishing,
moderate and languishing (Keyes, 2002). Persons can be categorized according to their
recent mental disorder status and according to their level of mental health (Keyes,
2010). Hence, the prevention and treatment of mental disorders will not necessarily
result in a more mentally healthy population (Cloninger, 2006; Keyes, 2002). Neither
Antonovsky’s nor Keyes’ model has been studied from the perspective of persons with
mental disorders, thus the extent to which they fully capture these perspectives is
unclear.
Our literature review shows that individuals define and conceptualize mental health
and wellbeing in various ways. Some studies have focused on the understanding of
wellbeing; adults in Singapore (Vaingankar et al., 2012); young adults with Down
syndrome (Scott, Foley, Bourke, Leonard, & Girdler, 2014); service users in mental health
services (Owens, Crone, Kilgour, & El Ansari, 2010) and youth recently diagnosed with
psychosis (Lal, Ungar, Malla, Frankish, & Suto, 2014). These four studies illustrated that
individuals viewed wellbeing as both multidimensional and holistic. The multidimensionality included psychological, physical, emotional, spiritual and social
functioning. Moreover, wellbeing is perceived to include community participation,
financial and material aspects, and coping skills.
Ypinazar conducted a qualitative meta-synthesis of five articles investigating
Indigenous Australians’ understanding of mental health and mental disorders (Ypinazar,
Margolis, Haswell-Elkins, & Tsey, 2007). From their synthesis, an overarching theme
International Journal of Mental Health Promotion
3
emerged: the dynamic interconnectedness between multi-factorial components of life
circumstances. The understandings of mental health and mental illness were synthesized
into five themes: culture and spirituality; family and community kinship; historical, social
and economic factors; fear and education; and loss.
A review of the literature on children’s perception of their mental health problems and
mental wellbeing, unveils the latter as fluid and related to internal feelings about self and
others, as well as to external experiences and life events. Young people’s understanding of
mental wellbeing focused on themes of being happy, and feeling good about themselves
(Shucksmith, Spratt, Philip, & McNaughton, 2009). Another study (Svirydzenka, Bone, &
Dogra, 2014) explored schoolchildren’s perspectives on how to stay mentally healthy.
Mental health was viewed in terms of personal attributes such as a good brain, emotional
and physical functioning and development. A high self-esteem and a clear idea of who
they are also qualified them as mentally healthy (Svirydzenka et al., 2014).
Two qualitative studies revealed an understanding of women’s perceptions of mental
health. Elderly women recognize the essence of mental health as confirmation, trust and
confidence in the future, as well as a zest for life and involvement in relationships (Hedelin
& Strandmark, 2001). Women from India understood mental health as a product of
cultural and socio-economic factors, and it was commonly described as the absence of
stress or conflict with husband and mothers-in-law, and freedom from domestic violence
and poverty (Kermode et al., 2007). Persons affected by severe mental disorders seem to
be overlooked as sources of credible and useful knowledge on mental health and wellbeing
(Lal et al., 2014). Although one study of patients in a psychiatric clinic about the sources
of health revealed the need for autonomy, meaningfulness and a satisfactory social life
(Svedberg, Jormfeldt, Fridlund, & Arvidsson, 2004). To our knowledge, the research on
the meaning of positive mental health among adult patients affected by mental disorders
remains limited.
Aim
The aim of this study was to explore, from a health promotion perspective, how mental
health is perceived by adults affected by severe mental disorders and with inpatient
experiences.
Methodology and design
The methodological framework for this study is based on the interpretative
phenomenological analysis (IPA) (Smith, Flowers, & Larkin, 2009). This approach
involves a combination of phenomenological and hermeneutic insights, guided by an
idiographic sensibility towards particular instances of lived experiences. Research data
were gathered through individual in-depth face-to-face interviews. By using an IPA
approach, we aimed to reveal and to capture the participants’ experiences as fully and
thoroughly as possible. However, this endeavour inevitably becomes interpretative.
As Smith et al. (2009) say: ‘Without the phenomenology, there would be nothing to
interpret; without the hermeneutics, the phenomenon would not be seen’ (p. 37).
Participants
Twelve participants were purposively selected for the study by staff working at inpatient
sections in the Norway. In Division of Mental Health and Addiction at Vestre Viken
4
Hospital Trust, this is quite a large hospital trust, with a total catchment area of 465,000
inhabitants. These health professionals were informed by the first author about the aim
of the study and the following inclusion criteria: former, not current experience of
hospitalization (minimum 2 weeks in the past 2 years); ability to narrate their
experiences; considering themselves to be in recovery from mental disorder and viewing
their lives as having improved with the help of mental health services. Seven women
and five men (ranging in age from 23 to 80), with both short and long histories of being
diagnosed with a mental disorder (1 –24 years) were recruited. Their number of
inpatient stays varied from one to over fifty times. Five were diagnosed with bipolar
disorder, three with substance abuse, two with schizophrenia and two with severe
depression. They lived alone or together with a partner, with or without children, in the
countryside or in town. One of the participants had a full-time job; the rest had income
from the Labour and Welfare Service.
Data collection
Twelve interviews were conducted by the first author between June 2012 and November
2013; each interview lasting between 50 and 120 min. The participants decided where the
interview was held. Four chose their own home; four opted for a hospital office; two came
to the researcher’s office and two chose to sit/walk outdoors. All interviews began with an
open question: Can you please tell me about a nice day? In order to ensure that important
issues were covered, a guiding interview schedule with open and expansive questions was
developed. Some prompts were prepared in case a participant found it difficult to respond.
Minor changes were made to the schedule from one interview to the next. The interviews
were audio taped and transcribed verbatim.
Ethics
The study was conducted in accordance with the Norwegian Health Research Act, 2008
and approved by the Regional Committees for Medical and Health Research Ethics
(2012/566/REK). Health professionals contacted the potential participants, and provided
both oral and written information about study aims, method of data collection, estimated
use of time, anonymity and the right to withdraw from the study at any point until the
findings were submitted for publishing. All contacted participants agreed to participate in
the study, and signed informed consent forms. The participants’ names are replaced with
pseudonyms.
Analysis
The analytical approach consisted of two different levels. At the first level, based on IPA,
an ideographic inspired case-focused analysis was carried out (Smith et al., 2009). The
second level was a cross-case –focused analysis inspired by Weiss (1995). The casefocused analysis of each of the 12 interviews comprised 5 steps conducted by the first
author: (a) the analysis started already in the first interview; (b) continued while listening
several times to the audio tape and (c) while reading and re-reading the transcript. With the
voice of the interview present in mind: (d) descriptive, conceptual and linguistic
comments and (e) emergent themes were added to the transcript at an exploratory level
(Figure 1).
5
Figure 1. Illustration from step (d) and (e) in the case-focused analysis.
Through this case-focused analysis emerged a preliminary understanding, which was
elaborated on in the following interviews. Consequently, one interview informed the next.
This iterative stepwise procedure was used on all 12 interviews before moving on to the
next level. Subsequently, in the cross-case-focused analysis, five analytical steps were
conducted. (a) Excerpts from all transcripts were aggregated under emergent themes
aiming to (b) synthesize themes and sub-themes. Then, (c) emergent themes and/or subthemes were compared aiming to contrast or merge them together. Finally, we looked for
(d) links and connections, before (e) formulating our insights in the written words and in
the figures presented in this paper. The process of analysis was aided by drawing mindmaps and illustrations. In addition, the computer software NVivo 10 (QSR International,
2012) was used (Figure 2).
Figure 2. Illustration of the cross-case focused analysis.
6
Quality and validity
To enhance the quality and the validity of the study, an advisory team consisting of five
members was established. Three of them were diagnosed with a severe mental disorder
and had their own inpatient experiences, and the remaining two had relatives with such
experiences. The advisory team members were different from the 12 participants in the
study. The team was involved in all stages of the research process. They collaborated
actively with the first author and gave advice regarding the letter of participation, the
interview guide, ethical issues, the analysis and interpretations (including the emergence
of illustrations). The team was invited to reflect on and share their own experiences, which
resonated with the preliminary findings. The team members’ experiences gave valuable
insight into the research process and findings that also increased the study’s clinical
relevance.
Last author listened to three of the audio-taped interviews. The research team (in
particular, first and last author, and to some extent second and third author) were engaged
in systematic discussions and reflections with each other concerning ethical and
methodological issues, as well as emergent themes, sub-themes and figures. Similarly, the
first author discussed methodology and emergent findings on several occasions with
colleagues from other professions (at workshops, seminars, lectures and conferences).
This contributed to the reflexive process that is the hallmark of qualitative research
(Alvesson & Sköldberg, 2009; Malterud, 2001).
Findings
The participants have had a wide range of experiences in illness, health and wellbeingrelated issues. They expressed an immediate and intuitive understanding and spoke about
mental health in a straightforward manner. The interviews, for the most part, were
meaning making research dialogues where we were invited into the participants’ wealth of
experiences, and insights. The participants’ ability to reflect upon their experiences was
strikingly apparent in the material, as was their ability to seemingly grasp, articulate and
make sense of the tiniest bits of significant information coming from their internal and or
external environment.
Dag: “Mental health? It is the appetite for life; it has to do with that”.
Anna: “What mental health is? It is when I cope with daily life. I can feel good and deal with
everything”.
The analysis revealed five essential characteristics of subjective mental health, as
illustrated in Figure 3: ‘Perceived mental health – a holistic experience’.
Mental health is (a) experienced as process, a constantly ongoing movement up and
down a staircase; (b) expressed both verbally and through body language. (c) The
movements up and down are affected by experiences in life and in turn, the place in the
staircase at a given moment influences functioning in daily life. (d) Emotional, physical,
social and spiritual domains of life nourished perceived mental health. (e) Underpinning
these domains is a sense of energy, experienced both mentally and physically as vitality
versus fatigue.
Movement up and down
Mental health is described in the participants’ narratives as a process, like movements both
up and down in a staircase as illustrated in Figure 4.
7
Figure 3. Perceived mental health – a holistic experience.
It is seen as a phenomenon in motion, something dynamic. The direction of the movement
is expressed as vertical rather than horizontal:
Irene: “It is like I’m moving slowly up or down a spiral staircase”.
The participants perceived it as positive to be up in the staircase, something they
wanted to promote. However, the experience of being down also belonged to life and their
experience of mental health as the dynamic movement represented hope for a positive
change in future.
Ruth: “I know I will get back up again after being down”.
I’m good
I’m fine
I’m down
Figure 4. Mental health – a movement up and down a staircase with corresponding bodily and
verbal expressions.
8
Expressed verbally and with body language
The participants described mental health through an everyday language different from a
more theoretical or professional language, as illustrated in Figure 4.
To articulate the experience of positive mental health, the most frequently used term
was: ‘I’m good.’ To describe being at the bottom of the stairs they said: ‘I’m down.’ To be
somewhere in between was spoken as: ‘I’m fine’. To further elaborate on the conditions
close to the extremities of the staircase, the participants used metaphors. The experiences
of being down were expressed through stories about being close to the bottom, on the floor,
in a ditch or down in the cellar.
Paul: “I’m heavy at heart. It feels like I’m wading in deep water all the time. An uphill battle”.
The experience of good mental health was illustrated by expressions such as being at
the top, flying like a bird or jumping from cloud to cloud.
Marit: “Sometimes I feel like I need to hold on so I don’t fly away. There are, like, bubbles
inside me, like I’m overflowing with joy”.
The participants’ inner sense of mental health was expressed through body language.
These gestures make perceived mental health available for observation by important
people in their lives without the use of words. Facial expressions and eyes were
particularly pointed to be expressive sources for observation of mental health. Sometimes
a spouse, parents, friends, primary nurse or other important persons discovered changes in
mental health before the participants themselves even realized.
Irene: “I get a completely different face. They notice my activity and the sound of my voice.
All those who know me well, they can tell straight away by looking at me. They see it
sometimes even when I don’t see it myself, like family and close friends. They can tell
immediately”.
Participants’ descriptions of what it looks like when they are far down include their
face looking drawn out, an unfocused gaze, looking away into space, little gestures and
smiles. The eyes are described as empty and without light and life. When they feel good on
the other hand, the eyes have charisma and the mimics of the face are livelier.
Kari: “Then my nurse says to me: Kari, look at your eyes, they are sparkling”.
Mental health intertwined with daily life
The interpretation of lived experiences revealed that mental health is omnipresent in life.
The staircase of mental health occupies a central position in the participants’ lives. Mental
health is entrenched in all the small activities of daily life – from dealing with basic needs,
to having plans and expectations for any given day.
Roar: “You don’t have to do a lot, just a little each day. I don’t think it’s a good feeling for
example if you tie up the trash bag, put it on the floor and then leave it there. Instead of just
taking it out, because that is what everyone else does. So it’s just about doing the small things.
I don’t, need to climb a mountain to be happy”.
Influenced by domains of daily life
In the analysis, four domains of life evolved, each influencing the participants’ perceived
mental health. These dimensions, illustrated in Figure 5 were; the emotional, spiritual,
physical and social domains of life.
9
Figure 5. Mental health is intertwined with four domains of life.
The four domains flow into one another; they influence each other and are
interconnected, sharp boundaries cannot be delineated and they are not clearly distinctive.
Emotional domain of life. The perceived position in the staircase is characterized by
presence, absence, intensity and nuances of different emotions. The position in the
staircase expressed like ‘I’m good’, close to the top of the staircase is constituted by
emotions as the presence of happiness and good mood, as well as a feeling to be alive and a
bodily lightness and ease, the presence of contentment and gratitude.
Ruth: “Then I’m the very happy – I think it’s such a great feeling. I get so relieved when I
recognize a very good feeling in here. I have great joy within myself”.
The absence of unsatisfactory feelings is important for their perception of mental health.
Guro: “If I don’t have bad feelings, then I think . . . then it’s good”.
When coping with the challenges of daily life and managing meaningful activities, the
interconnectedness between the domains becomes evident. Self-care, ordinary household
tasks, as well as social interactions constitute the participants feeling of mastery (emotion),
which seems to be closely connected to the performance of practical tasks (physical
activity). Activities that gave a visual result, something specific they had done or made,
were described as significant and tangible activities that promote a sense of satisfaction.
Roar: “I’m going out in the garden to mow the lawn; that gives a visible result. One can tell
that you have done something, right”?
Physical domain of life. Whether or not one participates in activities has a significant
impact on perceived mental health. Activity is understood as a positional change and use
of the body to fulfil an aim. Performing daily activities required that they could rely on and
trust their body. As Dag said; ‘A good day for me is knowing that I operate properly’.
Some of the participants themselves had experienced the fact that physical exercise
promoted physical fitness, which in turn influenced the experience of mental health. To be
active is rewarded with a good feeling afterwards. They talk about the feeling of wellbeing
10
spreading throughout the body after some physical activity, working outside, a work out or
just walking.
Roar: “Yes, if you are physically fit, then you probably have a little more energy to do things;
to get things done. I make the conscious decision to exercise because I know it is good for
mental health. Then there’s the added bonus of becoming a little stronger”.
Before introducing the social domain, a quote from Roar can illustrate the
interconnectedness between domains. From the analysis evolved an understanding of the
importance of participating in activities (physical) together with others (social) and this
infiltrated into their feelings (emotions) thereby influencing their mental health.
Roar: “You go outside to have good experiences, the way summer is right now. You don’t sit
inside when it’s like this. You go out, right, bring a disposable grill, with someone,
somewhere – just sit and relax outside in the sun, by the water or something. You never know
if something fun will happen . . . Yes, maybe I meet someone also”.
Social domain of life. The participants enlightened several aspects of belonging to and
being included in a social context. Mental health was nurtured in the mutuality in
relationships where the participants were of importance to others and the other was
someone they could trust and rely on. A good relationship manifests through staying
together, supporting, reflecting, correcting and helping each other both with practical
issues and with a good chat.
Roar: “Getting out, being amongst people and socialising, that is important. If you’re on your
own a lot, then you create your own reality in your head, like ‘I’m fat’, and then you don’t
have anyone to contradict you or give you other input. Then it becomes true for me. So, if I
don’t have a sparring partner, then things quickly get a little tangled”.
The interpretation disclosed how their perception of the fulfilment of their own
expectations linked to different roles they play in life affected their level of mental health.
To be a friend, a colleague, a sparring partner, an employee, a fellow patient or a neighbour
influenced their mental health.
Anna: “When I got a reference letter, it said that I was a considerable contribution to the social
environment. I thought that was very ok”.
To fulfil their own expectations of different family roles as a spouse, mother, son, sister
or grandmother nourished mental health, and gave opportunities to give and receive.
Marit: “If I’m doing really well, then I call my mom and say ‘you know what . . . I’m doing so
well right now’. I know that makes her happy, because my mom has listened to all the negative
stuff and she has followed me. So it feels good to be able to give something positive”.
Spiritual domain of life. The domain of spirituality emerged through the participants’
narratives about their passions in life. In cultivating these special interests, they found
comfort and salvation; this constituted a condition for feeling good. If they could not carry
out this activity, however, this passion evoked a longing or suffering.
Kari: “I have such fascinating books. I’m looking so forward to read them. I can’t explain it.
Ooh, the reading is great. It is so good and it’s my books that help me”.
Opportunities to contemplate and to find peace of mind were appreciated. Their stories
about their passions can be interpreted as an utterance of more existential areas of life.
Roar: “I am often in the forest; I go fishing and spend the night. It’s the only place you will find
100% peace with yourself, that’s my feeling – away from the city hustle and bustle, the city
11
rumble. It’s not like that in the forest. I was born in nature, so it’s natural for us to be there,
I feel. It’s really nice to be there. It’s health promoting, definitely”.
Sense of energy
The sense of energy was underpinning experiences of mental health in all the four domains
as shown in Figure 6, and could range anywhere from total absence of energy to
overwhelming vitality.
The energy experienced included both a purely mental experience of energy as well as
a more physical energy, such as power and strength. This feeling of energy was associated
with the initiation and completion of actions and activities, as well as the experience of
mental health. The sense of energy experienced when feeling good; close to the top of the
staircase, seems to be vitality and aliveness with increased activity, an energy that
reinforces itself. The participants described how they moved easily were in a good mood
and the laughter was getting looser. They described themselves as more accessible and
open to other people and that everyday life was no problem.
Marit: “If you’re happy, it’s all blob, bloob, oooh, and everything goes upward. When I have
energy; I get energy. Yes, I feel like somebody needs to hold on to me so I do not take off and
fly to the sky. Everything just becomes easy”.
Towards the opposite end of the spectrum, close to the bottom of the staircase, the
experience of energy was completely different. When their mental health was poor, the
participants became less social and quieter. No energy; like an apathetic state, a fatigue
that made it difficult to start any activities. Dag illustrated this feeling with an engine that
is difficult to start.
Dag: “Yes, the start engine is shaky. I can’t seem to get started with anything. And the battery
is flat too . . . You sit down and resign to the way things are”.
In the last quote from Roar, he described energy as both mental and physical. He became
exhausted in different ways, but he was also in charge and influenced his own life.
Roar: “I spent the energy on something physical instead of just sitting at home all day and not
using the energy physically but rather running it up in your head instead. Sitting there and
thinking yourself to death, right. That’s tiring too . . . but in a completely different way.
It doesn’t make you tired in a good way, but when you have been physically active then you
feel good about yourself; or at least I do”.
Figure 6. A sense of energy underpinning the experiences of mental health.
12
Discussion
The purpose of this study was to explore how persons with mental disorders and with
inpatient experiences perceive mental health. The participants explained that the focus on
positive mental health for persons with mental disorders motivated their participation in
the study. From a pathogenic orientation, suffering from severe mental disorders is
understood as mostly challenging. Our participants however, told stories also conveying
life enriching experiences, which is in line with Oliveira’s (2014) argument that suffering
can be a source of significant learning. Adverse life events can have the potential of
becoming comprehensible and manageable experiences of importance and thereby even
be salutary (Antonovsky, 1979). Our participants did not experience mental health as the
absence of hardship caused by societal adversities or psychopathology. In comparison,
women in India conceptualized mental health as the absence of stress exemplified by
conflicts, violence and poverty (Kermode et al., 2007). By doing so, the Indian women
point to the same prerequisites for mental health as highlighted in the Ottawa Charter for
health promotion (WHO, 1986). The Indian context is different from ours; however, as the
Norwegian welfare state to a large extent provides these prerequisites for its citizens. Our
findings must be considered in light of these circumstances.
Our participants perceived mental health as the presence of several features as
displayed in the findings, some of which were expected, yet the comprehensiveness and
complexity of mental health was striking. Three of the findings are discussed below.
Perceived mental health is both dynamic and holistic by nature. Moreover, there is a sense
of energy underpinning the emotional, physical, social and spiritual domains of mental
health.
Dynamic nature of mental health
Mental health is expressed as a dynamic experience, such as moving up or down in a spiral
staircase (see Figure 4). Also young people perceive mental health as fluid (Shucksmith
et al., 2009). The everyday language used by the participants indicates that the
phenomenon mental health is always present in life; mental health is something you are
(i.e. I’m good or I’m fine). This concurs with schoolchildren who included a clear idea of
who they are into their definition of being mentally healthy (Svirydzenka et al., 2014). Our
findings suggest that mental health is constantly present in life; it forms part of being.
Mental health is described as being in a spiral like, smooth movement in a staircase
without definitive end-points, varying between good or bad, up or down. Mental health is
perceived qualitatively, not with quantitative entities such as in numbers, plus or minus,
more or less. The participants’ perception of mental health as a dynamic movement in a
staircase is to a large extent similar to mental health displayed on a vertical continuum in
the dual-continua model (Keyes, 2013).
Antonovsky (1979) was preoccupied with complementing the dominant pathogenic
understanding of health with a salutogenic perspective. Although different interpretations
exist, the most common understanding of Antonovsky’s health ease/disease continuum is
that it represents a horizontal line between total absence of health and total health
(Lindström & Eriksson, 2010). In order to understand mental health more fully, we will
argue that it is meaningful to turn the continuum 90 degrees to a vertical one. In doing so,
we are adding a more intuitive quality to the continuum, expressing that although one will
always be moving in the spiral staircase, it is a way of being, high is better than low, up is
better than down. Our findings can contribute to a further development of Antonovsky’s
health continuum as requested by Mittelmark and Bull (2013).
13
Nonetheless, theoretical models can never exactly mirror the reality. They are derived
with a purpose, from one reality, in a historical time and place and must be interpreted
accordingly. This also applied to the figures in this article. The purpose of making figures
was two-fold, first to illustrate the findings, and second to develop a pedagogic tool useful in
clinical practice with patients. In discussions and dialogs about promotion and protection of
mental health, the visualization seems relevant. Discussions with the advisory team, along
with our experiences from teaching students in health promotion and from clinical practice,
make us believe that the direction of the continuum, the small steps in the stairs and the four
dimensions of life nourishing mental health are all meaningful illustrations. The figures
(Figures 3 –6) are comprehensive, intuitive and promote dialogue about mental health.
Holistic nature of mental health
Our analysis revealed that mental health is perceived as a holistic phenomenon nourished
by several domains of life, and involving mind, body and soul. By compiling all the
findings (Figure 3), we wanted to emphasize our interpretation of holism in perceived
mental health. Holism is also supported by other studies (Kiefer, 2008; Lal et al., 2014;
Owens et al., 2010). Ypinazar et al. (2007), studying Indigenous people, support our
findings in describing a dynamic interconnectedness where no single aspect can be
considered in isolation from other areas of life and no theme appears to exist without the
other themes influencing and impacting on mental health. Inspired by the reductionism in
theories and guidelines, patients and health professionals in clinical hospital practice often
face organizational structures demanding that they focus on one element of human life at
the time. In order to ensure quality care and health promotion, there is a need to let
patients’ perception of health be the point of departure for all service. We acknowledge,
however, the difficulty in dealing with all aspects at once, and the need to pay attention to
each life domain one at the time. Further research is needed to clarify how the domains
influence each other. Our main argument remains that in quality mental health care, all
domains must receive focus.
The participants emphasized their need to fulfil social roles, for example as a mother or
a friend. Mental health is nourished in relationships with others. This is iterated by elderly
women viewing mental health as an experience of confirmation – that one is noticed,
respected and regarded as a valuable person both by oneself and by others (Hedelin &
Strandmark, 2001). In mental health nursing, patients also confirm the significance of
being an important other and helping others (Svedberg et al., 2004). Schoolchildren
reported that having positive peer relationships and being able to fit in were significant for
the experience of good mental health (Svirydzenka et al., 2014). Social contacts and close
social relationships in particular have, however, been reported to be both supportive and
harmful to perceived mental health (Green, Hayes, Dickinson, Whittaker, & Gilheany,
2002; Kermode et al., 2007). Intrapersonal reflections and how one is functioning with
others constitute the psychological and social wellbeing in Keyes model of mental health
(Keyes et al., 2008).
Our findings confirm Keyes’ (2002) operationalization of mental health as feelings and
functioning in life. The participants talked about presence and absence of different
emotions which influenced and gave information about their perceived current position in
the mental health staircase. This metaphor underpins all emotions having their rightful
place in life and illustrates the participants’ stories about the need to react, accept, adjust
and adapt to life events.
14
Surprisingly, and unlike Antonovsky’s definition of mental health (Antonovsky, 1985)
and the complete model of mental health (Keyes, 2005), the participants emphasized the
significance of the physical domain of life for the experiences of mental health.
Participating in meaningful activities requires confidence in a fit body that has the strength
and power to fulfil desired activities. The participants yearned for more assistance to
increase their physical fitness. This gives the immediate benefit of feeling good, as well as
the more long-term result of being stronger. The importance of the physical dimension for
holistic wellbeing is also identified in other studies (Lal et al., 2014; Owens et al., 2010).
A first person account by Weiner (2013) identified the establishment of regular exercise as
one of six pillars of health in her journey of recovery.
The participants’ enthusiasm and passion for meaning making activities were
interpreted as an expression of spiritual wellbeing included into perceived mental health.
For Indigenous Australians, spirituality was linked to wellbeing and played a crucial role
in the understanding of mental health (Ypinazar et al., 2007). Meaning in life,
connectedness and transcendence are attributed to spirituality in a recent review of
conceptual and empirical literature (Weathers, McCarthy, & Coffey, 2015). These
attributes are recognized in our participants’ accounts of finding peace of mind and coming
to terms with their situation. To be engaged in their passions in life such as reading, sitting
by an outdoor fireplace, going fishing, playing theatre or baking gave opportunities to
contemplate and to have a break from upsetting thoughts and worries, as well as fuelling
their energy. These activities seem to promote a connectedness to nature and being a part
of a greater wholeness, supported by an integrative review of experiences of spirituality
(Rudolfsson, Berggren, & Barbosa da Silva, 2014). Spiritual wellbeing seems to give a
sense of peace, and enhances the ability to adapt and cope with adversity and alleviate
suffering (Weathers et al., 2015). It helps us enjoy life to the fullest; creates a zest in life
(Cloninger, 2006). None of our participants talked about spirituality in terms of religion, or
in ways that gave religious connotations, which is in line with understanding spirituality as
distanced from religiosity (Reinert & Koenig, 2013). Our study is conducted in [name
deleted to maintain the integrity of the review process ], in many ways a secular society,
where spirituality often brings forth thoughts of energy and meaning. Our analysis
confirms that engaging in important activities one is passionate about is significant to
mental health, which is highlighted by Keyes (2002) as one of the aspects of emotional
wellbeing. The relationship between spirituality in this secular form and the
meaningfulness component of the SOC construct in the salutogenic model of health
should be explored further. Research show that having a strong SOC is health promoting
(Antonovsky, 1996; Eriksson & Lindstrøm, 2006). Meaningfulness is of vital importance
for developing SOC. Antonovsky (1987) also introduced the concept of boundaries to
show that four spheres of life are considered paramount to the development of SOC: inner
feelings; major activity; relationships and existential issues. Although exploring SOC was
never part of this study, there are reasons to believe that our participants’ expressed need to
dedicate time and energy to their passion in life gave deep joy and meaning to their life.
In this way, they stimulate the imaginary movement upwards in the staircase of mental
health.
Further research is needed to more thoroughly discern similarities and differences
between mental health and wellbeing. Nevertheless, interpreting our material, we will
argue that mental health is an aspect of being that is always present. In the language of our
participants, mental health is described as ‘being’, and wellbeing as ‘having’. Perceived
mental health is being (always being somewhere in the staircase), and our participants
illustrate mental health by qualitative descriptions as good or poor (up or down in the
15
staircase). Physical, emotional, social and spiritual wellbeing, however, is something you
might have more or less of.
Sense of energy
A sense of energy is a salient marker of perceived mental health. The participants’
experiences of physical fitness, their described need to possess robust bodily functions and
strength (physically), as well as having a passion for something (spiritually), and the feeling
of happiness (emotionally), or being in love (socially) reciprocally influenced each other.
This concurs with Lerdal’s (1998) definition of energy as the individual’s potential to
perform physical and mental activity. The sense of energy seems to fluctuate between a
sense of vitality (feelings of high energy) and a sense of fatigue (feelings of low energy).
A sense of vitality can be seen as a significant indicator of personal wellbeing, defined as
one’s conscious experience of possessing energy and aliveness (Ryan & Frederick, 1997).
The experiences of low energy were given much attention by our participants. Energy
trouble influenced the starting-up-process of any mental or physical activity. Energy
management can influence the ability to initiate, perform and fulfil the wanted activities.
One of our participants, Roar, formulated it explicitly; ‘to use energy on appropriate
activities instead of running it up in your head’. The experiences of a ‘shaky start-up engine’
or totally loss of energy described by our participants are different from the experiences of
individuals with chronic somatic illness, for whom the sense of energy is distinctly located
in the head, arms, legs and feet (Lerdal, 1998). A sense of energy can be closely related to a
state of mental disorder, as psychopathology is associated with a lowered sense of personal
energy (Ryan & Frederick, 1997). Symptoms like hallucinations or thought chaos can drain
the energy level and make it unavailable. More research is needed about associations
between sense of energy and mental disorders and the influence on mental health. More
knowledge can clarify the need for care and how to perform it. The appropriate intervention
can be to ‘push’ or ‘pull’ into an activity or to advise rest (Lerdal, 1998).
The sense of energy is not directly apparent in Keyes’ model (2002). However, a
diagnosis of flourishing gives associations to enthusiasm, aliveness and vitality. Furthermore,
the interest in life, one of the aspects of subjective wellbeing can potentially be related to a
sense of energy. In Antonovsky’s definition of mental health, he uses the term ‘vibrant
psychological wellbeing’, which gives associations to a sense of energy (Antonovsky, 1985).
In the salutogenic model of health (Antonovsky, 1979), energy is not explicitly mentioned;
however, we believe a sense of energy can be seen as a generalized resistant resource and as a
characteristic of an individual that is effective in combating stressors.
Methodological considerations
This study was conducted in a relatively densely populated part of [name deleted to
maintain the integrity of the review process ], a western democracy, where basic needs
such as shelter, food and health services are mostly secured through social benefits. The
transferability of the findings to other contexts must be assessed carefully. Regarding
language, for the sake of presenting the findings internationally, everyday language used
by the participants to describe their perceptions has been translated from Norwegian to
English. Ascribed meanings from lived experiences are closely connected to the expressed
language. We acknowledge the possibility that the tone, nuances and meanings have been
altered in the translation process. To minimize this potential limitation we assigned a
translator who is fully bilingual.
16
We will argue that one of the strengths of this study is the methodological strategy of
service user involvement. The advisory team has given valuable input throughout the
research process, and their contributions to the analysis added new and nuanced meanings
and more depth into the interpretations. In order to establish the reliability of the study, we
have tried to provide detailed descriptions of the data collection and every step of the
analysis. This article reports from the accounts of purposively selected persons with
successful experiences from inpatient treatment. Persons with adverse experiences from
treatments in hospital and individuals that do not consider themselves to be in recovery, as
well as persons with somatic illness might give additional and extended understanding of
mental health. In order to develop mental health interventions and reorient the health
services in a health promotion direction, this knowledge is important.
Conclusion
Lived experiences of persons with severe mental disorders can contribute to health
promotion knowledge. Independent of the above-mentioned limitations, our findings
suggest implications and potential value for policy makers, researchers and practitioners.
Perceived mental health is accessible for significant others through a body language and
everyday spoken language. In agreement with the understanding of health as dynamic and
in constant movement, our participants perceive mental health as a movement up or down
a staircase. This movement is nourished by experiences in four key domains of life: the
emotional; the physical; the social and the spiritual. The place in the staircase, in turn,
influences feelings and functioning in daily life, expressed as more or less wellbeing, and
accompanied by a sense of energy. Mental health is an aspect of being that is always
present in life.
Acknowledgements
First and foremost, we are indebted to the 12 participants for sharing their experiences and
understandings. We are also very grateful for the valuable contributions and hard work put in by our
advisory team: Mette Haaland-Øverby, Sven Liang Jensen, Solveig Helene Høymork Kjus, Irene
Norheim and Inger-Lill Portaasen. Last but not least, we would like to thank Suzanne Moore for
scrutinizing the English language.
Disclosure statement
No potential conflict of interest was reported by the authors.
Funding
The first author has received financial support from the Norwegian ExtraFoundation for Health and
Rehabilitation through The Norwegian Council for Mental Health.
Notes
1.
2.
3.
4.
5.
Email: monica.eriksson@hv.se
Email: irene.norheim@vestreviken.no
Email: ckeyes@emory.edu
Email: geir.arild.espnes@svt.ntnu.no
Email: hege.f.vinje@hbv.no
17
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International Journal of Mental Health Promotion Mental

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