11 ESSAY Why Flourishing? Corey Keyes SCIENTISTS AND INVESTIGATORS of mental illness believe and convey to the public that the treatment, cure, and prevention of mental illness are the only and the best ways to promote the overall mental health of the population. Our nation continues to advocate for doing more of the same thing for mental illness again and again but now expects a different outcome, a cure. Our approach to mental illness is insane. Recent talk of find- ing a cure for mental illness is promising too much at best or providing false promises at worst. The Diagnostic and Stasistical Manual of Mental Disorders contains hundreds of purportedly distinctive disorders, each characterized by a collection of signs and symptoms. ‘Will there be a single cure for all? Unlikely. Will we have to wait years for many cures for all mental illnesses? Most likely. What is the cost to all who may become mentally ill while we wait? More suffering and lost life, Such calls for finding a cure may be effective for persuading the U.S. Congress to devote more financial support to the National Institute of Mental Health. But I believe that promising a cure for mental illness diverts atention and sesources away from a second, viable, and complementary approach to mental illness—one that increases happiness. Happiness is no laughing maccer, and promoting it might be just what we need to promote good mental health and prevent some cases of common mental disorders. Happiness, which is also called well-being, represents individuals’ evaluations of the quality of theit lives. There are two approaches to and types of happiness: hedonic happiness and eudaimonic happiness. The first approach frames happiness as positive emotions and represents the opinion that a good life is measured by feeling good or experiencing more moments of good feelings. The second approach frames happiness as away of doing by how well individuals cultivate their abilities to function well or to do good in the world. gs in the world and represents the opinion that a good life is measured Simply pus, happiness is feeling good or happiness is Functioning wel. ‘My own and others’ research revealed as many as fourteen facets of hedonic and ceudaimonic happiness. Those facets are shown in Table 1 on the next page, and represent the items or questions that form my measure of good mental health (ie., the Short Form Questionnaire of the Mental Health Continuum). The first three items (happy, interested in life, and satisfied) represent emotional well-being, che formal term I use to represent the feeling good approach to happiness. The remaining eleven items represent the functioning well approach to happiness. Of those eleven items, five represent social well-being, which is the formal term for the different ways that we can assess how well an individual functions as a citizen and member of a collective o community. The remaining Why Flourishing? 9Emotional Well-Being louishing requtes almost cory day o every day on 1 oF more ofthe follwing | How often during the past month did you feel | |. Happy oo | |. Safed | Positive Functioning most evry day ot every day on 6 or more of the following: | ‘id you feel | 4 thaeyou had something importans conta sce (oil conti | Flourishing requires How often during the past mon 5, That you belonged to a community (ikea social group, your school, or your neighborhood) (social incegration) & Thar erin bmi ever leo pope ik yo Gch gow | | 7. Tha people are basically good (social zeceprance) | “That che way our society works made sense you (socal coherence) 9, That oud mou parts of your penal alFacepancs) | | 10. Good at managing the responsibilities of your daily life (environmental mastery) | | 1 Thatyou tad van and unigiclombis wih or basin whos) 1. That you had experiences thac challenge you ro grow and become a beste person (personal growth) | | 13. Confident co chin or express your own ideas and opinions (autonomy) | | 14. Thar your life has a of direction oF meaning to it (purpose in life) _ | six items represent psychological well-being, which is the formal term for the ways we he difference between social measure how well an individual functions in personal life. and psychological well-being hinges on the pronoun and frame of mind: Social well- being reflects our functioning as “we and us” (when I am a member of a larger group) while psychological well-being reflects our functioning as “me and I” (when I am in my private, personal, and incimace sphere of life). You may have noticed earlier that I used the words mental health when referting to happiness. In my own research, I argued that both kinds of happiness together help us to measure and therefore study good, of positive, mental health. I call che pinnacle of good ‘mental health flourishing and chose that term to be clear that I am talking about true ‘mental health, not merely the absence of mental illness. | measure mental health in the same way that psychiatrists measure common mental illnesses’To be diagnosed with depression, for instance, one has to have a last one symptom of anhedonia (loss of pleasure of loss of interest in life) combined with four of the seven symptoms of malfunctioning, “To be diagnosed with flourishing mental health, individuals must experience in the past month every day or almost every day at least one of the three signs of emotional well-bein, ry day y iB 100 Wall-Being and Higher Educationcombined with six or more of the signs of positive functioning. At the opposite end of Aourishing on what I call the mental health continuum is languishing, which is diagnosed by never ot once or swice during the past month having at least one sign of emotional well-being combined with six or more signs of positive functioning. Individuals who are neither flourishing nor languishing are diagnosed with moderate mental health. Floutishing represents the achievement of a balanced life in which individuals feel good ss is consistent about lives in which they are functioning well. My approach to happi with those views of happiness as more than secking and feeling pleasure. Buddhism, for example, posits happiness as a wholesome and balanced state that includes a meaningful and constructive approach to life. Such a view of happiness is consistent with Aristotle's view of eudaimonia (translated as ew = good and daimon = soul or spitit) asa deliberate way of being and acting in the world that is vireuous not only for oneself, but also for others and the world. ‘Tue Two Continua Monet. AND THE Nos1e TRUTHS While the more complete approach to measuring happiness allows us to approach mental health positively, it has also allowed me to investigate what I consider the most fundamental premise of pursuing happiness: the two continua model. In 1946, the World Health Organization (WHO) defined health not merely as the absence of disease, but also as a BAL OP at SAR eli Sn seate of complete physical, social, and mental wel-being.? In doing so, the WHO declared 4 hypothesis that remained untested until very recently—that mental health is more than the absence of mental illness; it is the presence of happiness or well-being. If this hypothesis is supported, it has extremely important implications. First, even if we could find a cure for mental illness tomorrow, ie docs not mean that most people would necessarily be flourishing in life, In other words, we cannot treat our way out of the problem of mental SES illness; we must also promote a life of balance in which people can achieve happiness and realize lives in which they can flourish. T have found strong evidence in support of the two continua model in studies of adults in the United States and the Netherlands, in black Setswana-speaking South AMticans, and in youth ages 12 and older in the United States and Australia, We have also shown that positive mental health, as I measure it, is just as heritable as common mental illnesses (depression, panic attacks, and generalized anxiety). We then discovered that the two continua model is encoded in our DNA because barely half of the genes for good mental health are shared with the genes for mental illness. This means we inherit a genetic level of tisk for depression while we also inherit a genetic potential for flourishing. However, the absence of or very low genetic tisk for depression does not mean a high genetic potential for flourishing. And the presence of high genetic tisk for depression does not % mean a life doomed for depression because one might also plausibly inherit a high y genetic potential for flourishing. What wins, depression or flourishing? It may very well . depend on the kinds of experiences that unlock the genes for flourishing and what experi- i ences silence the genes for depression. This focus may come in the future, but right now, t the National Institute of Health supports research on genetic risk of mental illness, not t genetic potential fot good mental health. In other words, we may be locking for the % answer to the problem of mental illness in the wrong place by only Jooking at genetic g risk rather than at genetic potential for flourishing, a ‘Why Flourishing? 101Ina recent study, we found that approximately 75 percent of American college students were free of common mental illness as measured in the past two weeks. Yet only 46 percent of college students were fice of mental illness and were also flourishing, In short, the absence of mental illness does not imply the presence of mental health among college students,’ and we found the same ching in adolescents? and adules.6 Another important implication of the qwo continua model is that the level of good mental health should differentiate how well people with and without mental illness can inua model, For instance, almost 6 percent of college students are flourishing and also have function in theie lives. All of my research has supported this aspect of the two cot ‘mental illness. These students have a lower risk of suicidal tendencies than the 17 percent of college students who have moderate mental health with a mental illness. Roughly 3 percent of college students who are languishing and have ‘mental illness are at the highest risk for suicidal tendencies Adults with less shan flourishing To be more specific, among students who would screen mental health report more for a current mental illness, 7 percent who were flourishing physical ailments and chronic showed suicidal tendencies, compared to 18 percent with disease, miss more days moderate mental health and 28 percent with languishing of work, use more health care mental health. When compared to students with mental (more prescriptions, more illness, those currently free of mental illness are less hospitalizations, more visits likely to have suicidal tendencies. Yet in this large group for physical, mental, emotional of students (.e., the 75 percent free of a current mental reasons), are more likely to die illness), those who are languishing have higher rates of premavurely and are more suicidal tendencies than those with moderate mental likely to develop mental illness health, who in turn have lower rates of suicidal tenden- cies than students who are flourishing. More specifically, among students who do not screen for a current mental illness, only 1 percent of flourishing students showed suicidal tendencies, compared to 4 percent with moderate mental health and 15 percent with languishing mental health? In short, anything less than flourishing is associated with worse outcomes for individuals with and those frce of meatal illness. Adults with less than flourishing mental health report more physical ailments and chronic disease, miss more days of work, use more health care (more prescriptions, more hospitalizations, more visits for physical, mental, emotional reasons), are more likely to die prematurely, and are more likely to develop mental illness.* Here again there are alignments with Buddhist views. T! two continua model and its implications share affinities with che Buddhist approach to enlightenment, namely the four noble truths. These truths are as follows: (1) One must first understand the nature of life as consisting of suffering because pleasure and satisfaction are fleeting and life involves sickness, sadness, pain, and death; (2) One must understand the origin of suffering; much of ic lows from our desires and expectations that encourage cravings and attachment to things we encounter in daily life; (3) Ifwe can understand our role in producing suffering, we can pursue the cessation of suffering (ie., nirvana) if we can rid our heart and minds of the hindrances of greed, anger, ignorance, and hatreds (4) The final eruth, which is the eightfold path, entails cultivating our ability to function well in ing wisdom: (right understanding and right aspiration), ethical conduct 102 Wall Being and Higher Education(right speech, right action and right livelihood) and mental development (right effore, right mindfulness and sight concentration) So after having grasped the nature and cause of suffering, and after avvempting to mitigate it, Buddhists shift greater attention to the task of living good and happy lives. This is done by pursuing wisdom through learning the truth about the imperfect nature of life and human nature and living in a way that mitigates suffering caused by those imperfections. We promote a beuter life by developing the ethical conduct of speaking ‘truthfully, compassionately, consistently with values and earning a living in a way that does not hurt others and possibly helps others. Last, we promote a good life if we develop our mental capacity by consistently trying to work on ie rather than making excuses or procrastinating and by strengthening our minds and attuning them to recognize and live in the present moment and situation, Using this engaging metaphor or analogy of living or being well together, the four noble truths and the eightfold | We must strive to act in ways path illustrate the principles and implications of the two | that develop our capacity continua model. That is, humans are prone to mental illness, | for doing and being good— a form of suffering. Mental illness represents a form ofimbal- | ‘to contribute to society ance of feeling and functioning, a state of mind and existence | to view ourselves and others consisting of a disinterest in life, sadness, and malfunctioning. | as fundamentally good, Buc mitigating mental illness through treatment or prevention | to develop warm and trusting does not result in a flourishing life. Indeed, one way to over- relations with others— come our vulnerability to mental illness is to achieve a bal- 50 that we come to feel pleasure anced, wholesome life in which feeling good is connected to | about living our lives well our ability to function well. ‘To flourish in life, we must understand that happiness as feeling good may be the aim of our lives, to paraphrase Thomas Jefferson, but virtue (and being in just relation with community) is the foundation for the fecling-good type of happiness. So the absence of suffering does not mean one has achieved nirvana and enlightenment, and the absence of mental illness does not mean one is flourishing. We must strive to act in ways that develop our capacity for doing and being good—to contrib- ute to society, to view ourselves and others as fundamentally good, to develop warm and trusting relations with others—so that we come to feel pleasure about living out lives well. In 1995, we surveyed a nationally representative sample of U.S. adults, ages wenty- five to seventy-five, and surveyed them again in 2005." Both times we measured good mental health as a continuum as described carlicr and for the presence of common mental disorders, including major depression episodes, panic attacks, and generalized anxiety disorder. We found that 18.5 percent of adults had one of three mental disorders in 1995, and 17.5 percent had one of the three in 2005. Although the rate of mental illness appears stable over time, just over half of the cases of mental illness in 2005 were new ones (participants did not have any of the three mental disorders in 1995 but had one of the three in 2005). So between 1995 and 2005, the United States made no. Progress in reducing the cases of mental illness. While half of the 1995 cases were resolved in one way or another, new cases emerged. These results suggest that the new cases emerged from the group of people who were initially feee of mental illness but lost their good mental health, which increased the risk of becoming mentally ill. ‘Why Hloueiching? 103Compared to staying languishing, improving to moderate mental health cut the risk of future mental illness by nearly half. Individuals who improved to Hourishing—most of whom had moderate mental health in 1995—were no more likely than those who stayed flourishing to have mental illness in 2005. Adults who improved to or stayed flourishing had the lowest risk of developing mental illness. This suggests that we can prevent some mental illness if we help more people to flourish. ‘The numbers at the bottom of each bar in Figure 1 represent the proportion of the sample that belongs to each category of mental health or mental illness. Because the sample was designed to be representative of the U.S. adult population between the ages of ewenty-five and seventy-five in 1995, we can use the percent in each category to esti- mate how much of the U.S. adult population may be in each category of mental health. ‘The percentages of adults who stayed at moderate or improved or declined to moderate mental health, when combined, represent nearly half (48.1% exactly) of the U.S. adult population, and these adults are three to four times more likely to develop mei illness because they have moderate rather than Hourishing mental health. The percentages of the sample that stayed at languishing or declined to languishing, when combined, repre- sent one in ten (10.4% exactly) of the U.S. adults who are six to eight times more likely to develop mental illness because they are languishing rather than flourishing, In short, almost six in ten adults (10.4 languishing + 48.1% moderate = 58.5%) in the study sample were not flourishing as of 2005. This large group of adults was free of ‘mental illness in 1995. Yee those languishing had greater risk (odds ratios between 6.6 and 8.2) of mental illness in 2005 than those adults who Aad mental illness in 1995 (whose odds ratio was 5.0). Adults with moderate mental health had nearly as high of a risk (odds ratios between 3.4 and 4.4.) as adults wich a mental illness in 1995. So the amount of any mental illness was 18.5% in 1995 and 17.5% in 2005, which suggests that the United States did not make any significant progress in reducing mental illness. But 52% of adults with mental illness in 2005 did not have any in 1995. Many of 52% of new cases come from the large segment of people that does not have any mental illness buc is not flourishing. If we fail to focus on promoring and protecting positive mental health while we emphasize treating current cases of mental illness, we are unlikely to make any progress in reducing the amount of and suffering from mencal illness. How Can We Pursur FLourisHina? Ifour or any other nation wants a mentally healthy population, it must take both kinds of happiness seriously. We must promote what we want in our lives, and the concept of flourishing challenges us all to prioritize and balance both kinds of happiness—to feel ‘good about lives in which we can function well. But how do we get there? The two continua model requires us to think of new ways to achieve flourishing because treat- ments that aim co lower the bad do nor necessarily increase the good. Just as with the treatment for cholesterol, in which taking statins may lower bad cholesterol but will not increase good cholesterol, mental health therapies aimed at lowering mental illness may not increase mental health, To that end, colleagues in the Netherlands developed and tested a public health approach to promote mental health based on acceptance and commitment therapy (ACT)."* ‘The point of ACT is to increase mental flexibility. This flexibility is a competence that Why louishing? 105includes two interdependent processes: (1) acceptance of negative experiences and (2) choosing to change or persist in behavior based on values or principles. A person who is mentally flexible is willing.¢o remain in contact rather than avoid negative, undesirable, personal experiences. In other words, ACT promotes acceptance of the first noble cruth of Buddhism (that suffering exists) because most of us try control or avoid such unwanted private experiences. Rather than reacting emotionally co negative experiences, the ACT program also encourages us to become conscious about making choices toward unwanted experiences based on our values and goals for creating a good life Based on ACT, Fledderus et al. developed a course that could be administered to groups of people in a relatively brief period." Their program consists of a two-hour session once per week for eight weeks. Through structured activities, participants are encouraged to discover their values in multiple domains of life, and they are taught how to respond to negativity and adversity based on their own deeply held commitments and values. The course also teaches participants to be open and non-judgmental in per- sonal experiences. The goal is for participants to learn to consistently choose effective responses in any but especially in difficult situations to build behavior repertoires that are flexible and value driven. Continuing the analogy with the Buddhist strategy for living well, participants in the ACT intervention are learning aspects of the Buddhist eightfold path. They learn that adversity and negativity are natural and they can live in a way that mitigates the problems caused by avoidance or repression of negative experiences. Participants then learn to respond to adversity and negative emotions based on personal values. When compassion meditation is included in the intervention, participants acquire the mindser (and dispo- sition to behave or act) to live in a way that is more beneficial to others and, thereby, themselves, When mindfulness meditation is included, participants learn to strengthen their minds and to appreciate and live (act) in the present moment and situation."* In owo randomized controlled trials, one that included mindfulness training,” my colleagues found moderate to large effects for promoting flourishing. Because they also measured mental flexibility, chey were able to test whether the program enhances mental flexibility and if this enhancement of mental flexibility is the reason for increases in flourishing, In both studies, mental flexibility explained how the program enhanced flourishing. Impressively, che effects of the program were maintained three months lates. Unfortunately, the design of the study did not allow for learning how much the inclusion of mindfulness meditation added to the ACT program in promoting flourishing. Yee this is just the beginning of a very important line of research that connects mind and life in a way that promotes what we want more of in our lives: flourishing. In sum, we must train our minds to focus on what matters, to make conscious choices about how co best respond to the challenges and trials of life, to achieve a better balance of prioritizing feeling with functioning well, and to be compassionate to others and our- selves, No one can or should flourish all che time and everywhere, nor should anyone’ flourishing be at the expense of another’. I believe the ACT model can be used to encourage a more sustainable approach to flourishing in life because it is based on promotion of the happiness of others, not just one’s own. 106 Well-Being and Higher RducasionNotes ‘American Psychiatsic Association, The Diagnostic and Staitical Manual of Meneat Disorders, th ed (Arlington, VA: American Psychiatric Association, 2013) 2. World Healch Organization, "Health,” Geneva, Switzerland: World Health Organization, beep: hwo. ine/radelglossary/sory046ren! 3. Coney L. M. Keyes, “Mental Health as a Complete State: How the Salurogenic Perspective Completes the ictut,” in Bridging Occupational, Orgenizational and Public Health, ed. Georg F Bauer and Oliver Himmig, (Dordrech, Netherlands: Springer Netherlands, 2014), 179-92, 4. Corey LM. Keyes et al, "The Relationship of Level of Positive Mental Health with Comrent Mental Disorders in Predicting Suicidal Behavior and Academic Impairment in College Students,” Journal of American College Heales 60, no, 2.2012}: 126-33, 5. Corey L. M. Keyes, “Mental Health in Adolescence: Is Ameticas Youth Flourishing?” American Joxonal of Orthopsycbiaery 76, no, 3 (2006); 395-402. 6. Coney L. M. Keyes, “Mental Iiness and/or Mental Health? Investigating Axioms of the Complete Srate Model of Health,” Journal of Consulting and Clinical Pychology 73, no 3 (2005): 539-48, 7. Keyes eta. “Relationship of Level.” 8. Soe Keyes, “Mental Health as Complete Stare” and Corey L. M. Keyes and Eduardo J. Simoes, “To Flourish or Not: Positive Mental Health and All-Cause Morality," American Journal of Public Health 102, no. 11 (2012): 2166-72. ‘9, Bhildehu Bodhi, “The Noble Bightfold Path: The Way to End Suffering,” Buddhist Publication Society 1998, heeps/fwww.cecessoinsight.orplib/authors/bodhifwaytoend tcl 10. Corey L. M. Keyes, Satvinder 8. Dhingra, and Eduardo J. Simoes, “Change in Level of Positive Mi Healdh asa Predictor of Furore Risk of Mental Iles,” American Journal of Public Health 100, no, 12 (2010); 2366-71. doi: 10.2105/AJPH.2010.192245, Ibid ‘ce Martine Fledderus et al, “Accepeance and Commitment Therapy 2s Guided Sel-help for Psychological Distress and Positive Mental Health: A Randomized Controlled Tia.” Pyehological Medicine 42, no. 3 (2012): 485-95. doi: 10.1017/S0033291711001206 and Martine Fledderus et a, “Mental Health Promotion as 4 New Goal in Public Mental Health Care: A Randomized Controlled Trial ofan Intervention Enhancing Paychological Flexibility,” American Journal of Public Health, 100, no. 12 (2010): 2372-78, doi: 10.2105) AJPH.2010.196196, 13, Fledderus eta, “Acceptance and Commitment Therapy.” 14, Hledderus eal, “Acecprance and Committnent Therapy” and Fledderus e al, "Mental Health Promotion.” 15. Ibid ‘Why Flowing? 107+ LLL TT ee: cRNA NT a Well-Being and Higher Education A Strategy for Change and the Realization of Education's Greater Purposes Edited by Donald W. Harward. Bringing Theory to Practice Washington D.C.i Bringing red tO toflld Practice 1818 R Street NW, Washington, DC 20009 (©2016 by Bringing’Theory co Practice All rights reserved ISBN 978-0-9853088-6-5