HEALTH EDUCATION RESEARCH Theory & Practice

Vol.13 no.l 1998 Pages 57-66

Current conceptualizations of mental health and mental health promotion

J. Seeker Abstract Health promotion is generally agreed to be underpinned by a set of principles which distinguish it from other disciplines and professions. This paper takes these principles as the starting point for a review of the literature of mental health promotion. The aim is to clarify the ways in which mental health and mental health promotion are currently conceptualized, in order to identify areas where health promotion can make a unique contribution to complement that of other interest groups. In the first section, it is suggested that current definitions of mental health are inadequate for health promotion practice in that they either equate health with the absence of illness or present a culturally skewed, individualized and 'expert'-led version of what it means to be mentally healthy. The second section then traces the implications of these definitions as they emerge from the literature relating to mental health promotion practice. The paper concludes with a discussion of some ways in which health promotion specialists might begin to develop a mental health promotion agenda which is more consistent with health promotion principles.

Introduction Although regarded as a relatively new area of work by health promotion specialists (Shipman, 1995), Centre for Mental Health Services Development, King's College London, Campden Hill Road, London W8 7AH, UK

© Oxford University Press

within other disciplines mental health promotion has a long history. Amongst psychologists, in particular, the concept of positive mental health is well established and references to the importance of promoting health rather than simply preventing ill-health date back to the 1950s (Jahoda, 1958). More recently, the mental health targets set out in The Health of the Nation strategy for England (DoH, 1993) have provided a focus for activity amongst other interest groups, including mental health service users, psychiatrists and service providers. While there seems to be little consensus amongst these different groups about the aims of mental health promotion, the perspectives of some groups appear to be increasingly influential in driving the health promotion agenda. Although this may not be wholly inappropriate, health promotion is generally agreed to be underpinned by principles which differ in some respects from those of other interest groups (WHO, 1986; Green and Kreuter, 1991). These include an emphasis on: • Holistic approaches to health. • Respect for diverse cultures and beliefs. • Promoting positive health as well as preventing ill-health. • Working at structural not just individual levels. • Using participatory methods. Arguably, if these principles are not reflected in practice, health promotion will not fulfil its potential for developing new approaches to complement those of other interest groups. Instead, we will simply have invented 'a new title for an old story' (WHO, 1986), within which the dominant themes are imported uncritically from other disciplines

57

J. Seeker and professions. To avoid this, what is required is a critical analysis of current thinking about mental health and mental health promotion in order (1) to clarify where it is appropriate to draw on concepts derived from other disciplines and (2) to identify areas where health promotion can make its own unique contribution. This paper, therefore, takes health promotion principles as the starting point for a review of the literature of the field. In the first section, approaches to the definition of mental health are considered. The second section then examines published discussions and accounts of mental health promotion practice in order to assess the extent to which these are consistent with health promotion principles. Finally, some ways are discussed in which health promotion specialists might begin to develop a mental health promotion agenda which is more clearly their own. Before moving on to examine current definitions of mental health, it should be noted here that although a considerable body of literature exists on the prevention of mental illness, the literature of mental health promotion itself is at an early developmental stage, as indicated by the fact that very few peer-reviewed papers were found in a search of the relevant data bases using mental health and health promotion as key words. In general, publications addressing the prevention of illness are not included in this review, except where these make some claim to deal with the promotion of mental health. This means that the bulk of the literature reviewed consists of conference proceedings which are available in the public domain. Where appropriate, reference is also made to more general texts and to the small number of journal articles available.

Definitions of mental health Two main issues emerge from the literature in relation to the definition of mental health. Firstly, in contrast with the emphasis of health promotion on health as a positive quality, it remains common in the field of mental health to define health as no more than the absence of illness. Secondly, where more positive definitions are employed these never-

58

theless pose problems in relation to other health promotion principles. Before examining these issues in more detail, it should be made clear that the intention in doing so is not to attempt to develop a new, more appropriate definition. As will be argued in the concluding section of the paper, to do so would require an extensive programme of research which is at present at an early stage of development Here, the intention is simply to examine the implications of those definitions which are currently in common use. Turning to the definition of mental health in terms of the absence of illness, one explanation for the continuing prevalence of such definitions is that little reference is made to health promotion theory in conceptualizing the relationship between mental health and illness. It is striking, for example, that no reference is made in the literature of mental health promotion to the conceptualization put forward by Downie et al. (1990) within which health and illness occupy two separate but intersecting continua. Although Trent (1992) has attempted a not dissimilar re-conceptualization of mental health and illness, he does not draw on the literature of health promotion in doing so and his attempt remains at the level of an analogy within which the two concepts are portrayed as separate but intertwined strands of cable. Rather than developing this analogy by examining the implications for mental health promotion theory and practice, in a later paper Trent (1994) presents a different analogy, this time involving the Four Horsemen of the Apocalypse. Here, he appears to abandon his earlier development of two separate continua, since shame, guilt, fear and isolation (the 'Four Horsemen') are put forward as an appropriate focus for mental health promotion on the grounds that they are precursors of mental illness. As the only attempt within the literature of mental health promotion to re-conceptualize the relationship between health and illness, Trent's work is therefore disappointing. In fairness, however, few other writers have made any attempt to address the relationship between the two. Instead, some define mental health as no more than the absence of illness (Cox, 1992; Kendell, 1995),

Conceptualizations of mental health and mental health promotion while others dismiss the concept of positive health as too nebulous or woolly to merit serious attention (Newton, 1988; Royal College of Psychiatrists, 1993). As noted above, when more positive definitions of mental health are put forward, these nevertheless pose problems for health promotion. Although there is little consensus about the conceptual and ideological framework within which such definitions should be located (Tudor, 1992), in effect most appear to be derived from cognitive, behavioural and developmental psychology. The result is that mental health tends to be conceptualized in terms of 'component parts' such as problemsolving skills (Parkins, 1994), social competence (Bosma and Hosman, 1991) and autonomy/mastery (Evans, 1992). Clearly, such a reductionist approach sits uneasily with the emphasis of health promotion on holistic understandings of health. In addition, however, it generates the potential for conflict with other health promotion principles. Firstly, the skills and attributes put forward as essential components of mental health are derived not simply from particular psychological perspectives, but also, more fundamentally, from the predominant ideology of the western societies within which psychology itself is located. Thus the image of the 'mentally healthy person' which emerges is of an autonomous, self-actualizing individual in Line with the increasing emphasis on these qualities in the US and Britain since World War II (Rose, 1989). In contrast with the emphasis placed by health promotion on respect for diverse cultures and beliefs, other perspectives are rarely recognized (Sartorius, 1992). For example, neither the intergenerational dependence not the attribution of control to a deity which are central to many cultures are reflected in the western ideals of autonomy and mastery. Secondly, psychological definitions of mental health pose problems in relation to the concern of health promotion to work at structural as well as at individual levels and to involve people as full participants, not simply as recipients or targets. From this perspective, the definitions discussed in this section present a challenge to those involved in

developing mental health promotion as a specialism within the broader context of health promotion, in that they revolve around individual skills and attributes which are identified as essential for mental health not by lay people but by professional 'experts'. As noted earlier, some ways forward in developing more appropriate definitions will be discussed in the concluding section.

Mental health promotion practice The tensions outlined above between current definitions of mental health and health promotion principles are reflected in turn in discussions and accounts of mental health promotion practice. These are examined here in relation to health promotion's emphasis on promoting positive health, working at structural levels and using participatory methods. In each case, it will be seen that these principles are rarely embodied in mental health promotion practice.

Promoting positive health As was seen in the previous section, psychologists have been influential in the development of the concept of positive mental health. Unsurprisingly, this influence is also discernible in discussions of mental health promotion practice. In particular, the organizers of a conference on the prevention of psychopathology held annually in Vermont since 1975 have consistently sought to stress the importance of promoting positive health alongside more established preventive measures (Bond and Joffe, 1982). A forthcoming bibliography of publications in this area cited by Mrazek and Haggerty (1994) suggests, however, that the emphasis of the Vermont conferences on positive health is not typical of North American practice. Of 1326 references contained in the bibliography, only 22 focus primarily on the promotion of health as opposed to the prevention of illness. Although this may be partially balanced out by the fact that many preventive programmes do address elements of positive health, the main emphasis is clearly on prevention.

59

J. Seeker A similar picture emerges from the European literature. Amongst the papers presented at the annual European mental health promotion conference in London, for example, the majority of accounts of practice have so far described initiatives which are arguably closer to primary, secondary or tertiary prevention than to health promotion. Illustrations include initiatives aimed at people identified as at risk of mental health problems (Goodbody, 1993), the early detection and treatment of mental illness (Armstrong, 1993), the provision of therapy or counselling (Moore and McAdoo, 1992) and wide range of services for people diagnosed mentally ill (e.g. Roulston and Kappler, 1994). The picture which emerges from the literature, then, is of a field of practice where the boundary between promotion and prevention is far from clear. As a result, almost any activity can be and is described as mental health promotion, and prevention in its various forms dominates the agenda.

Working at structural levels Turning to health promotion's emphasis on working at structural levels, arguments for approaches which move beyond the development of individual skills and attributes have been put forward in the literature of mental health promotion in relation to three areas of work: addressing social and economic inequalities, promoting mental health in schools, and tackling stress at work. For the purpose of this review, only the first of these areas will be considered, on the grounds that finding ways of addressing inequalities is one of the greatest challenges facing health promotion. Here, arguments based on the now vast body of evidence that poor mental health is associated with oppressive social and economic conditions are not uncommon (Albee, 1983; Heginbotham, 1988). In practice, however, these arguments have rarely been translated into action. The most striking illustration is probably provided by the fifth Vermont conference, which focused on political action and social change. Although a conference addressing this theme might have been expected

60

to attract papers describing relevant initiatives, the organizers themselves acknowledge that more questions were raised than answered (Goldston, 1981). Reviewing progress 5 years later, Cowen (1986) observes that the need for action at a structural level had remained a consistent theme of the conference series, but that little had been achieved in practice. Rather than addressing social and economic inequalities, many of the initiatives discussed at Vermont aim to assist oppressed groups to cope with the destructive effects of poverty and discrimination. For example, although Hilliard (1981) argued forcefully at the fifth conference that any mental health strategy for Black Americans must be aligned with the total liberation struggle of Black people, only one initiative embodying civil rights principles was described at the conference (Clark, 1981). Again, a similar picture emerges from the European literature. In several cases, for example, arguments for addressing inequalities are followed by descriptions of initiatives concerned exclusively with individual skills (e.g. Wylie, 1993). Not dissimilarly, a collection of papers from the conference on promoting mental health through purchasing organized by the South Thames Regional Health Authority includes two papers addressing the need for structural change (Barker, 1994; Edeh, 1994). In the checklist provided to guide purchasing policy, however, no mention is made of activity at this level. In both cases, attention to inequalities seems to be little more than lip service paid in introducing the topic of mental health promotion. As in North America, those initiatives which have aimed to address inequalities have focused on helping individuals cope with oppressive conditions such as unemployment (Daniels and Coyle, 1993), racism (Guernica, 1994) and inadequate housing (Saetre, 1994). Despite this tendency for rhetoric to collapse back into an emphasis on individual skills and coping strategies, the North American literature does provide a small number of illustrations of action at a more structural level. In some cases, though, the validity and effectiveness of the action

Conceptualizations of mental health and mental health promotion described is a matter of dispute. In particular, although developments such as the women's movement and the growth of pressure group politics have been claimed to contribute to the promotion of mental health (Brodsky and Miller, 1981), other writers argue that such actions are ultimately ineffective because they divide oppressed groups from one another (Goldenberg, 1981). From this perspective, the solution lies in a coalition across single issue boundaries to act as a foundation for the vigorous political action required (Binstock, 1981). Unsurprisingly, perhaps, no attempt to forge such a coalition is described in the literature of mental health promotion. An alternative to 'big ideas' like these is suggested by Trotter (1981), who argues in favour of small-scale action at a local level on everyday problems defined by local people themselves. Almost uniquely, as far as the literature of mental health promotion is concerned, Trotter also provides examples of initiatives at the local level which can claim with some justification to have addressed inequalities. These include a community poverty agency which set up an economically viable sawmill providing secure jobs within the community and a neighbourhood scheme which succeeded in providing decent, affordable housing. Such initiatives are, however, very rare and the emphasis remains on interventions at the individual level. Although some writers argue that enhancing individual skills and attitudes can lead to structural change in the longer term (Guttentag, 1977), others point out that to date this remains an unrealised goal (Levin, 1981).

Using participatory methods In relation to this third health promotion principle, it was seen earlier that current definitions of positive mental health revolve largely around skills and attributes identified by professional 'experts', particularly psychologists. Equally, initiatives intended to promote mental health have tended to be designed and implemented by professionals on the assumption that they have the expertise necessary both to identify those who need their help and to decide how best their needs can be met (Compas et al., 1989).

Although some writers appear to take the validity of this assumption for granted, others question the value of expert-led approaches and advocate the use of participatory methods on a number of grounds. In some cases, the arguments put forward stem from a particular theoretical framework, such as the evolutionary perspective advocated by Trickett and Birman (1989) or the community development perspective adopted by Steuart (1993). Here, emphasis is placed on recognizing lay knowledge and skills as valuable sources of expertise from which professionals can learn. In addition, these writers share with others the belief that participatory methods are empowering and that such methods therefore contribute to the promotion of mental health, whether this is an explicit aim or not. However, other arguments in favour of participatory methods appear to stem as much from the agenda of professionals themselves as from a concern to value lay perspectives and promote empowerment For example, some writers argue that the use of participatory methods will result in more effective initiatives, since these will have the support of the people concerned (Bond, 1982; Schweinhart and Weikart, 1989). Although this emphasis on effectiveness is by no means incompatible with a concern to value lay perspectives, there is clearly a possibility that participatory methods might be used in order to ensure people's compliance and not because their perspectives are valued for their own sake. Certainly, some accounts of the use of participatory methods suggest that this is the case. Examples include a parenting skills programme cited by Bond (1982) and a peer group training programme for young people described by Cauce and Srebnik (1989). In each case, although parents and young people themselves were trained to implement the programmes, they had no part in shaping the content. In contrast with this apparent ambivalence on the part of some writers about the value of lay perspectives, a few do provide examples of approaches where unequivocal attempts appear to have been made to involve the people concerned and to value their perspectives. For example, a

61

J. Seeker peer training programme described by Wheatley and Linney (1994) involved young people not simply in delivering the programme, but also in deciding which issues they would address.

Discussion: developing a health promotion agenda Overall, the literature reviewed here suggests that health promotion specialists have so far had little influence in shaping the mental health promotion agenda. Instead, the perspectives of other interest groups have tended to dominate, with the result that few initiatives currently described as mental health promotion embody health promotion principles. This is not to suggest that either the prevention and treatment of illness, or the individualized, often expert-led work described in the literature is in itself misguided or unhelpful. However, what distinguishes health promotion from other disciplines and professions is a commitment to the principles outlined earlier. The challenge, then, is to develop an agenda which will enable us to complement the work of other interest groups in a way which is consistent with health promotion principles. Given the continuing prevalence of illnesscentred definitions, a first step must be to develop a more rigorous conceptualization of the relationship between mental health and illness. Here, health promotion specialists could make a valuable contribution by drawing more explicitly on health promotion theory in relation to mental health. At present, when health promotion specialists do contribute to the literature of mental health promotion, it appears that they have either forgotten their theoretical base or take it for granted to the extent that it remains entirely implicit For example, Wylie (1992) emphasizes the importance of positive health, but fails to ground the concept in health promotion theory. This is a pity, partly because it has left others, notably Trent (1992, 1994), struggling to 'reinvent the wheel', but also because health promotion theory has considerable relevance for mental health promotion. In terms of the reconceptualization of health and illness put for-

62

ward by Downie et al. (1990), for example, it becomes possible to recognize that people diagnosed mentally ill nevertheless have the potential to enjoy positive health. Equally, it becomes possible to acknowledge that while many of us may not have a diagnosable illness, we are not necessarily in the best of mental health. Thus two potential areas for mental health promotion activity are brought into sharper focus, and, as will be argued shortly, the relationship between promotion and prevention becomes clearer. Staying with definitions for the present, reconceptualizing the relationship between mental health and illness is only a starting point. In addition, there is an urgent need to develop definitions of positive mental health which are more consistent with health promotion principles. Here, the ecological and community development perspectives brought to mental health promotion by Trickett and Birman (1989) and Steuart (1993) provide a useful starting point, in that they attempt to move away from individualized approaches by recognizing the importance for mental health of the social contexts in which we live our everyday lives. However, like the individualized, psychological definitions documented earlier, the definitions derived from these perspectives remain 'expert' definitions and their salience from the lay perspective has only just begun to be explored. In this respect, the recent publication of two studies of lay understandings of mental health (Pavis et al., 1996; Rogers et al., 1996) represents an important development in an under-researched area. While both studies confirm the significance of social contexts, as ground breaking studies they are inevitably limited in scope. What is required is an extensive programme of research capable of exploring the meaning of mental health in a wide range of different contexts and cultures. In addition to developing concepts of mental health grounded in lay rather than professional understandings, developing a health promotion agenda will entail reaching a clearer position about the relationship between prevention and promotion, and in particular about the relevance for mental health promotion of services for people diagnosed

Conceptualizations of mental health and mental health promotion mentally ill. In this respect, much of the discussion contained in the literature appears to reflect the concern of those involved in preventive work to achieve a shift of resources from treatment to prevention. Thus both Mrazek and Haggerty (1994) and Newton (1988) put forward alternatives to the classic public health categories of primary, secondary and tertiary prevention which are designed to prevent the inclusion of treatment in the guise of tertiary prevention. However, the literature of mental health promotion provides support for an argument put forward by Olsen (1992), to the effect that some services and other initiatives for people diagnosed mentally ill can be regarded not as tertiary prevention, but as mental health promotion in its most positive sense. The rationale for this argument lies in the fact that many such initiatives focus on people's quality of life and potential for health rather than on symptoms and deficits. As was seen above, recognizing the potential for health of people diagnosed mentally ill is an important consequence of reconceptualizing the relationship between health and illness in terms of health promotion theory. In addition, the quality of life of people diagnosed mentally ill is identified as an important issue in key policy documents, including the NHS and Community Care Act and The Health of the Nation strategy for England. Arguably, then, this is an area where principles, policy and practice coincide, and one which health promotion specialists might therefore legitimately prioritize. It is not enough, however, simply to reframe any and every service provided for people diagnosed mentally ill as mental health promotion. To be consistent with health promotion principles, these must be demonstrably grounded in the concerns of service users themselves and evaluated accordingly. At present, needs assessment studies which reflect service users' concerns are rarely reported in the literature and evaluative research is scarcer still. Health promotion specialists could, therefore, make a significant contribution in this area by working with other interest groups to develop

and implement appropriate needs assessment and evaluation research strategies. The issues addressed here so far pose a considerable challenge. It was suggested earlier, however, that one of the greatest challenges in developing a mental health promotion agenda is to find ways of addressing the social and economic inequalities which are almost universally accepted to be associated with poor mental health. Here, the literature of mental health promotion suggests that one way forward might be to support the development and evaluation of the kind of local community-based initiatives described by Trotter (1981). This approach would accord with an argument recently put forward by Whitehead (1995), who observes that while many anti-poverty organizations do not see themselves as having a contribution to make to health, conversely few community health organizations make links with the anti-poverty movement. Given this lack of communication, Whitehead concludes that forging links between the two is imperative if a more systematic and comprehensive response is to be made to the challenge of addressing inequalities. Turning finally to the use of participatory methods, the claims made by several writers for the benefits of these methods have an intuitive appeal. Unfortunately, however, little research appears to have been carried out to support them. Here again, health promotion specialists could therefore make a valuable contribution by working with other interest groups to develop and implement appropriate research strategies. Moreover, we might gain valuable information if we were to include a mental health dimension in the evaluation of a wide range of initiatives where participatory methods are used, whether or not these initiatives are directly concerned with mental health. For example, the two studies of lay understandings of mental health mentioned earlier (Pavis et al, 1996; Rogers et al., 1996) suggest that people value sport and other physical activity as a way of feeling good mentally as well as physically. Evaluating initiatives in these and other potentially relevant areas from a mental health perspective might therefore make an important contribution to our

63

J. Seeker understanding of mental health promotion. In addition, this would have the advantage of integrating mental health with other aspects of health in a way which might sit more easily with the emphasis of health promotion on holistic approaches than the rather compartmentalized approach reflected in the literature to date. However, evaluation strategies developed in this field must themselves exemplify the use of participatory methods. An illustration of the importance of this is provided by the research review recently undertaken by Hodgson and Abbasi (1995). Here, the randomized controlled trial (RCT) was used as the 'gold standard' for assessing the effectiveness of mental health promotion interventions, with the result that qualitative evaluations, including studies based on participants' views, were excluded. This is clearly of concern because it means that information which might help us understand why some interventions seem to work and others do not is not available. In addition, the kind of interventions which are assessed as effective are experimental projects using experimental research designs. Typically, these are individualized, psychological interventions initiated and carried out by professional 'experts', with little or no attempt to use participatory methods. The danger, then, is of generating a self-fulfilling prophecy. Because psychological interventions are evaluated using RCTs, these interventions will be singled out as effective with the result that more interventions of this type are undertaken and evaluated, and so on. This is not to suggest that the RCT is of no value at all in assessing the effectiveness of mental health promotion. Rather, if health promotion is to develop a mental health promotion agenda consistent with its principles, it is essential to recognize the value of qualitative research alongside that of experimental methods and to reflect that recognition in the research strategies we develop. To summarize then, the development of a mental health promotion agenda consistent with health promotion principles might involve: • Drawing on health promotion theory to reconceptualize mental health and illness.

64

• A commitment to exploring and valuing lay understandings of mental health. • A proactive approach to defining the boundary between prevention and promotion based on needs assessment and evaluation research. • Alliances with anti-poverty and other organizations aiming to address social and economic inequalities. • The validation of participatory methods through evaluation research. • The development of research strategies which are themselves consistent with health promotion principles.

References Albee, G. (1983) Introduction. In Albee, G., Gordon, S. and Leitenberg, H. (eds), Promoting Sexual Responsibility and Preventing Sexual Problems. University Press of New England, Hanover, NH. Armstrong, E. (1993) Mental health: a primary care perspective. In Trent, D. and Reed, C. (eds), Promoting Mental Health. Avebury, Aldershot, vol. 2. Barker, I. (1994) Introduction to the conference. In South Thames Regional Health Authority, Promoting Mental Health through Purchasing: Conference Report and Checklist for Developing a Mental Health Promotion Specification. South Thames Regional Health Authority, London. Binstock, R. (1981) The politics of aging: dilemmas and opportunities. In Joffe, J. and Albee, G. (eds), Prevention through Political Action and Social Change. University Press of New England, Hanover, NH. Bond, L. (1982) From prevention to promotion: optimising infant development In Bond, L. and Joffe, J. (eds), Prevention through Political Action and Social Change. University Press of New England, Hanover, NH. Bond, L. and Joffe, J. (1982) Preface. In Bond, L. and Joffe, J. (eds). Prevention through Political Action and Social Change. University Press of New England, Hanover, NH. Bosma, M. and Hosman, C (1991) Programmes for competence enhancement In Bosnia M. (ed.), Mental Health Promotion and Prevention in Schools. Dutch Centre for Health Education and Health Promotion, Utrecht. Brodsky, S. and Miller, K. (1981) Coercing changes in prisons and mental hospitals—the social scientist and the class action suit In Joffe, J. and Albee, G. (eds), Prevention through Political Action and Social Change. University Press of New England, Hanover, NH. Cauce, A. and Srebnik, D. (1989) Peer networks and social support: a focus for preventive efforts with youths. In Bond, L. and Compas, B. (eds), Primary Prevention and Promotion in Schools. Sage, Newbury Park, CA. Clark, K. (1981) Community action programmes—an appraisal. In Joffe, J. and Albee, G. (eds), Prevention through Political Action and Social Change. University Press of New England, Hanover, NH.

Conceptualizations of mental health and mental health promotion Compas, B., Phares, V. and Ledoux, N. (1989) Stress and coping preventive interventions for children and adolescents. In Bond, L. and Compas, B. (eds), Primary Prevention and Promotion in Schools. Sage, Newbury Park, CA. Cowen, E. (1986) Primary prevention in mental health—ten years of retrospect and ten years of prospect In Kessler, M. and Goldston, S. (eds), A Decade of Progress in Primary Prevention. University Press of New England, Hanover, NH. Cox, J. (1992) Guest speaker presentation. In Trent, D. and Reed, C. (eds), Promoting Mental Health. Avebury, Aldershot, vol. 2. Daniels, M. and Coyle, A. (1993) Health dividends: the use of co-operative inquiry as health promotion intervention with a group of unemployed women. In Trent, D. and Reed, C. (eds), Promoting Mental Health. Avebury, Aldershot, vol. 2. Department of Health (1993) The Health of The Nation: A Strategy for Health in England. Department of Health, London. Downie, R. S., Fyfe, C. and Tannahill, A. (1990) Health Promotion: Models and Values. Oxford University Press, Oxford. Edeh, J. (1994) Definition of mental health promotion. In South Thames Regional Health Authority, Promoting Mental Health through Purchasing: Conference Report and Checklist for Developing a Mental Health Promotion Specification. South Thames Regional Health Authority, London. Evans, J. (1992) Healthy minds. Nursing Times, 88(16), 54-56. Goldenberg, I. (1981) Dilemmas of social intervention: a retrospective analysis. In Joffe, J. and Albee, G. (eds), Prevention through Political Action and Social Change. University Press of New England, Hanover, NH. Goldston, S. (1981) Messages for preventionists. In Joffe, J. and Albee, G. (eds), Prevention through Political Action and Social Change. University Press of New England, Hanover, NH. Goodbody, L. (1993) Developing community resources for carers: a prevention model in practice. In Trent, D. and Reed, C. (eds), Promoting Mental Health. Avebury, Aldershot, vol. 2. Green, L. and Kreuter, M. (1991) Health Promotion Planning: An Educational and Environmental Approach. Mayfield, Mountain View, CA. Guernica, Z. (1994) Reforming mental health care and promoting mental health among minority ethnic families. In Trent, D. and Reed, C. (eds), Promoting Mental Health. Avebury, Aldershot, vol. 2. Guttentag, M. (1977) The prevention of sexism. In Albee G. and Joffe J. (eds), The Issues: An Overview of Primary Prevention. University Press of New England, Hanover, NH. Heginbotham, C. (1988) Is there a right to mental health? In Farrell, E. (ed.), Life Matters. A conference report on a 1day conference held to strengthen the understanding and development of positive mental health. South East Thames Regional Health Authority, London. Hilliard, T. (1981) Political and social action in the prevention of psychopathology of blacks. In Joffe, J. and Albee, G. (eds), Prevention through Political Action and Social Change. University Press of New England, Hanover, NH. Hodgson, R. and Abbasi, T. (1995) Effective Mental Health Promotion: Literature Review. Health Promotion Wales, Cardiff.

Jahoda, M. (1958) Current Concepts of Mental Health. Basic Books, New York. Kendell, R. (1995) Mental health and mental illness. In Trent, D. and Reed, C. (eds), Promoting Mental Health. Avebury, Aldershot, vol. 4. Levin, H. (1981) Economic democracy, education and social change. In Joffe, J. and Albee, G. (eds), Prevention through Political Action and Social Change. University Press of New England, Hanover, NH. Moore, G. and McAdoo, P. (1992) Blythe Valley walk-in advice and information centre. In Trent, D. (ed.), Promoting Mental Health. Avebury, Aldershot, vol. 1. Mrazek, P. and Haggerty, R. (1994) Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. National Academy Press, Washington DC. Newton, J. (1988) Preventing Mental Illness. Routledge, London. Olsen, R. (1992) A critical review of psychiatric care in the 80s: the implications for the promotion of mental health. In Trent, D. (ed.), Promoting Mental Health. Avebury, Aldershot, vol. 1. Parkins, E. (1994) Equilibration and cognitive neuropsychology: is mental health just a question of balance? In Trent, D. and Reed, C. (eds), Promoting Mental Health. Avebury, Aldershot, vol. 3. Pavis, S., Masters, H. and Cunningham-Buriey, S. (19%) Lay Concepts of Mental Health and How it Can be Maintained. Department of Public Health Sciences, University of Edinburgh, Edinburgh. Rogers, A. and Pilgrim, D. with Latham, M. (1996) Understanding and Promoting Mental Health: A Study of Familial Views. Health Education Authority, London. Rose, N. (1989) Governing the Soul. Routledge, London. Roulston, R. and Kappler, G. (1992) Promoting a mixed economy of care through the use of specific grants for mental health projects. In Trent, D. (ed.), Promoting Mental Health. Avebury, Aldershot, vol. 1. Royal College of Psychiatrists (1993) Prevention in Psychiatry. Council Report CR21, Royal College of Psychiatrists, London. Saetre, R. (1994) Mental health promotion in a suburban neighbourhood. In Trent, D. and Reed, C. (eds), Promoting Mental Health. Avebury, Aldershot, vol. 3. Sartorius, N. (1992) The promotion of mental health: meaning and tasks. In Trent, D. (ed.), Promoting Mental Health. Avebury, Aldershot, vol. 1. Schweinhart, L. and Weikart, D. (1989) Early childhood experience and its effects. In Bond, L. and Compas, B. (eds), Primary Prevention and Promotion in Schools. Sage, Newbury Park, CA. Shipman, C. (1995) Mental Health Promotion: A Review of Evaluations and Activities. North Buckinghamshire Health Promotion Service, Aylesbury Vale. Steuart, G. (1993) Community intervention and mental health. Health Education Quarterly, Suppl. 1, 594-611. Trent, D. (1992) Breaking the single continuum. In Trent, D. (ed.), Promoting Mental Health. Avebury, Aldershot, vol. 1. Trent, D. (1994) Fighting the four horsemen. In Trent, D. and Reed, C. (eds), Promoting Mental Health. Avebury, Aldershot, vol. 3. Trickett, E. and Birman, D. (1989) Taking ecology seriously:

65

J. Seeker a community development approach to individually based preventive interventions in schools. In Bond L. and Compas B. (eds), Primary Prevention and Promotion in Schools. Sage, Newbury Park, CA. Trotter, S. (1981) Neighbourhoods, politics and mental health. In Joffe, J. and Albee, G. (eds). Prevention through Political Action and Social Change. University Press of New England, Hanover, NH. Tudor, K. (1992) Community mental health promotion: a paradigm approach. In Trent, D. (ed.), Promoting Mental Health. Avebury, Aldershot, vol. 1. Wheatley, M. and Linney, Z. (1994) Description of SPIT (Surrey Peer Issue Training): a peer-led group aiming to empower young people in health and education issues chosen

66

by young people for young people. In South Thames Regional Health Authority, Promoting Mental Health through Purchasing: Conference Report and Checklistfor Developing a Mental Health Promotion Specification. South Thames Regional Health Authority, London. Whitehead, M. (1995) Tackling inequalities in health. Health Education Journal, 54, 129-130. WHO (1986) Health Promotion: Concepts and Principles in Action—A Policy Framework. World Health Organization Regional Office for Europe, Copenhagen. Wylie, A. (1993) Promoting mental health. In Trent, D. and Reed, C. (eds). Promoting Mental Health. Avebury, Aldershot, vol. 2. Received June 26, 1996; accepted April 14, 1997