Peer Review Paper
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Citation: Schrank B, Riches S, Coggins T, Tylee A, Slade M (2013) From objectivity to
subjectivity: conceptualisation and measurement of well-being in mental health,
Neuropsychiatry, 3, 525-534.
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Revision submitted to Neuropsychiatry on 18th July 2013.
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From objectivity to subjectivity: conceptualisation and measurement of well-being in
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mental health
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Beate Schrank, Simon Riches, Tony Coggins, Andre Tylee, Mike Slade
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Practice points
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Incorporating research on well-being into clinical practice has the potential to improve
mental health care
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Using a combination of approaches to measure components of well-being and mental
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health together with or in addition to scales capturing multidimensional concepts of well-
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being, is recommended for clinical practise
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The Complete State Model of Mental Health, which captures both mental health and
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mental ill-health and allows the consideration of well-being despite the presence of
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mental illness, is recommended as a framework for clinical practice
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Elements of the ‘Good Life’ approach to well-being have the potential to be included in
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clinical practice as they conform with the transcendent principle of personhood and allow
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for varied and everyday approaches to increase well-being
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A range of promising interventions exist that target components of well-being, such as
self-worth, meaning or hope
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Positive psychology interventions combining a range of resource oriented exercises
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appear to be promising to improve well-being. Their application to people with mental
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illness, particularly severe, will need to be established in further research.
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Abstract/Summary
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The concept of well-being has not been well defined or reliably measured in academic
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research. This article identifies four academic strands of well-being conceptualisation and
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measurement (economic, medical, psychological, and integrative) and shows how well-being
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has shifted from being conceived as a collectivist concept with objective measures, to being
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conceived in individualistic terms, with subjective measures. Given its clinical relevance the
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main emphasis is on subjective well-being. While well-being has become a key concept in
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mental health, the article also discusses some limitations to its use in practice and proposes
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considerations for future research. Key issues are a consensus definition of well-being in
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people with mental illness, and empirical studies on the measurement of well-being and its
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determinants. Future research might be based on the ‘Good Life’ approach, the Complete
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State Model of Mental Health, or the academic field of Positive Psychology.
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Introduction
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Well-being has been a topical policy focus in recent years and has attracted research interest
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across health conditions. An explicit description of the concept of well-being is often absent
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in research [1]. This article provides an overview on the various concepts of well-being in the
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literature and their related measurement tools, with a specific reference to mental health. In
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examining the definitions of well-being, we identify four academic strands of well-being
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research:
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Economic Strand: grounded in economic research, well-being is framed in terms of
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national wealth, social determinants, development and general quality of life.
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Medical Strand: grounded in medical research, well-being is framed in relation to
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disorder and illness.
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Psychological Strand: Grounded in psychological research, well-being is framed in
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terms of subjective and mental concepts.
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Integrative Strand: informed by economic, medical, and psychological phases, with a
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distinct focus on positive psychology and recovery research.
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The paper discusses each phase, with particular focus on the birth of the psychological
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conception and its evolution into the contemporary, integrative phase. The primary focus is to
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show how well-being has shifted from being conceived as a collectivist concept with objective
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measures, to being conceived as an individualistic concept with subjective measures. This
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transition was instrumental in well-being becoming a key concept in mental health.
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From the economic phase to the medical phase
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In the economic strand, well-being was initially conceived of primarily in collectivist terms.
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Measuring and comparing the well-being of populations (rather than individuals) was first
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undertaken by economists in the early 20th century. Initially, financial indicators of well-being
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such as Gross National Product (GNP) were used to measure and compare. As these failed
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to discriminate between countries of similar developmental status, alternative economic
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indices were proposed to estimate societal functioning [2]. These composite measures
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further increased the validity of well-being estimates. Today, they are known as “Quality of
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Life” measures. First, they included purely objective measures, such as mortality, nutrition,
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literacy, clean water supply, or education [3]. Later ‘subjective’ indicators, such as affect,
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well-being, or life satisfaction were added to capture how people actually feel about their
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lives [4]. Composite measures of population well-being are still developed today. For
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example, the UK Office for National Statistics has developed a new assessment of
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population well-being, including subjective domains such as spirituality, personal and cultural
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activities, political participation, or life satisfaction in addition to environmental and
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sustainability issues and UK economic performance [5].
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Inclusion of population level health indicators, e.g. mortality, into composite measures
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evolving from economic research signifies the emergence of the medical strand to well-being
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research. The addition of subjective measures, e.g. life satisfaction, signifies the emergence
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of the psychological strand to well-being research. Medical research also marks a shift in that
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it emphasises individual health status in understanding well-being. Health research is
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another major application of the concept of quality of life, in this context called “Health
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Related Quality of Life” (HRQoL).
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HRQoL has attracted substantial research since its introduction, as well as criticism for its
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lack of uniformity and clarity. The terms ‘health related quality of life’, ‘quality of life’ and ‘well-
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being’ are often used interchangeably, and few articles claiming to measure HRQoL provide
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a definition or identify constituent domains [6]. Conceptualisations and measures of HRQoL
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can be described according to a number of defining features, e.g. generic versus disease
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specific, or objective versus subjective. Individual measurement tools often cover widely
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different dimensions, including access to resources and opportunities, environmental factors,
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social relationships, employment, leisure activities, sex life, mobility, or satisfaction with
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social domains. The unifying feature of HRQoL concepts is their focus on illness symptoms
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and functioning based on the assumption that illness and disability inhibits full well-being [7].
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While physical health symptoms and functioning are major domains within HRQoL,
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measurement tools also often use the terms well-being and mental health (i.e. the absence
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of mental illness symptoms) interchangeably [8]. Examples of generic HRQoL measures with
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a mental health or well-being sub-scale include the World Health Organization Quality of Life
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(WHOQOL) questionnaires with their domain on ‘psychological health’ [9], the European
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Quality of Life-5 Dimensions questionnaire (EQ-5D) with its ‘anxiety and depression’ domain
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[10], or the Short Form (SF) measures, with their ‘emotional well-being’ domain assessing
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feeling happy, sad, depressed, or anxious [11]. Other scales use a more elaborate
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conceptual foundation grounded in and overlapping with psychological conceptions of well-
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being. For example, the Lancashire Quality of Life Profile [12] and the Manchester Short
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Assessment of Quality of Life [13] base their well-being domain on concepts of affect
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balance, life satisfaction and happiness.
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One issue in measuring HRQoL in people with mental disorders is the potential distortion of
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subjective assessments due to ’psychopathological fallacies‘, most prominently the ‘affective
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fallacy’ which indicates that the momentary affective state can influence people’s judgement
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about their overall life [14]. This is most problematic in case HRQoL measures which contain
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‘emotional’ items relating to feelings of depression and anxiety, as is the case e.g. in the
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Quality of Life in Depression Scale [15]. Quantitative results support the ‘affective fallacy’ as
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depressive symptoms have been shown to have an independent and significantly negative
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effect on subjective ratings of HRQoL [16].
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A second issue is concerns about the reliability of subjective assessment in people with
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psychiatric disorders. This concern led to the inclusion of supposedly objective assessment
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methods, derived from clinicians or family members [14]. However, subjective assessment
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has become more accepted as people with severe mental illness were shown to reliably and
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consistently complete self-rating questionnaires [17]. Moreover, the views of clinicians and
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family members may be biased, and service users’ subjective position is argued to be no
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less true in case it diverges from an outsider. In fact, ‘insider’ and ‘outsider’ perspectives
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have been shown to differ due to differing values placed on contextual factors and a
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tendency towards a negative bias from the outsider perspective [18]. This supports the
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meaningfulness of the subjective assessment of well-being. While in HRQoL subjective and
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objective measures still coexist, the psychological approach has completely shifted to
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subjective assessment [19,20,21].
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The emergence of the psychological phase
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Psychological research has created specific conceptualisations and measures to capture
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well-being in its own right without embedding it within other constructs such as national
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development or HRQoL.
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As with HRQoL, a review on psychological concepts of well-being criticised frequently
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missing or ambiguous definitions and the interchangeable use of similar terms [22].
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Distinctive features of the psychological approach include its focus on subjective experience
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and personal feelings, and on positive mental health and functioning, e.g. positive affect, life
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satisfaction, autonomy, competence or personal growth [19,20,21]. Moreover, specific well-
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being concepts allow for peak experiences (e.g. peak positive affect) or for the temporary
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cessation of affective experience during flow [23]. Such specific states of well-being may
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bring symptomatic relief which will not be captured in measures of HRQoL.
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Differences between measures of HRQoL and psychological well-being are empirically
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confirmed by their only moderate statistical correlations. Factor analysis including twelve
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scales assessing HRQoL and seven psychological well-being scales showed the two
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concepts to generally load on separate factors. Correlations between these scales ranged
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between 0.05 and 0.63, but mostly around 0.2 to 0.4 [24].
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Despite broad agreement that well-being is a subjective condition in which positive feelings
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dominate, there is disagreement over more detailed ingredients of well-being in the
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psychological approach. Diverging views are often grouped under two broad perspectives:
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hedonic and eudaimonic. In this context hedonism usually refers to maximising pleasure and
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happiness while reducing pain. The eudaimonic perspective maintains that not all desires
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yield well-being when achieved, even though they might produce pleasure. Instead well-
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being means to live in accordance with one’s true self and derives from personal growth and
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self-actualisation, from actively contributing, holding virtue and doing what is right. Happiness
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may be a pleasant result of this way of living but not its core [19,25].
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Another organising principle for psychological well-being concepts is the distinction between
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the absence of mental illness symptoms and the presence of positive mental health, e.g.
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framed as positive emotion. This is reflected in an increasing focus on positively framed
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items in well-being questionnaires.
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One rationale for including positively framed variables (e.g. “I have felt cheerful and in good
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spirits”, “I woke up feeling fresh and rested”) into measurement tools was the observation
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that a substantial proportion of people in the general population rarely or never report
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occurrences of psychological distress symptoms [26]. For example, the USA national
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comorbidity survey found a proportion of 14.9% of people from 26 samples worldwide to
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qualify for the diagnosis of a mental disorder [27]. This introduces a ceiling effect [8], i.e. a
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zero score on a depression scale indicates the absence of depression but not the presence
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of happiness [28]. Including characteristics of psychological well-being (e.g. zest, interest in
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and enjoyment of life) increases measurement precision and distinguishes among persons
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who receive perfect scores on measures of psychological distress [26]. An example of a
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scale covering both ends of a continuum is the Depression-Happiness-Scale [28,29]. The
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WHO-5 goes one step further. It contains only positive items and assesses emotional well-
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being. However, although framed positively the WHO-5 still covers core dimensions of
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depression and proved to be a sensitive tool for screening for depression and suicide risk
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[30,31]. This may indicate that simply rewording negative to positive items may not be
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sufficient to meaningfully capture well-being.
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The complex interrelations between the mental health domain in HRQoL and assessment
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tools designated to specifically measure mental health or well-being are exemplified by the
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RAND health survey. The original survey included the 38-item Mental Health Inventory (MHI-
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38) to assess mental health [26]. The MHI-38 had assimilated 15 questions from Dupuy’s
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General Well-being Index [19,32]. Later, the MHI-38 was condensed into the 5-item MHI-5,
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which was in turn used as the mental health sub-scale in the ‘Short Form’ HRQoL measures
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(e.g. SF-36 and SF-20) [33, 34]. In addition, from the same item pool items were adapted
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into the WHO-5, which aims to assess positive mental well-being [8,19]. These measurement
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overlaps show the gradual development from purely deficit-focused HRQoL measures to
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measures of positive well-being.
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Measuring subjectivity in the psychological strand
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Despite their contrasts, the hedonic and eudaimonic views are not independent but overlap
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conceptually and correlate with each other with varying magnitude [19,25]. The same issue
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of contrasting but overlapping dimensions also applies to a view of well-being as lack of
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mental illness versus positive mental well-being, or positive versus negative affect [35].
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Hence, measurement tools for well-being may be better described according to their focus on
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affective, cognitive and multidimensional components.
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Affective measures
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Assessment tools that conceptualise well-being in terms of affect usually use the term affect
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to refer to mood states or feelings, without acknowledging the psychological distinctions
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between affect, emotion and feelings. These scales assume that well-being is the degree to
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which positive feelings outweigh negative feelings. They measure positive and negative
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feelings either as two distinct dimensions resulting in separate scores or in one overall
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‘balance score’. Prominent examples are the Positive and Negative Affect Scale (PANAS)
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[36], Bradburn’s Affect Balance Scale (ABS) [25], the Affectometer [37] or the Everyday
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Feeling Questionnaire [38]. The evident overlap between affective well-being measures and
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measures of psychiatric symptoms is empirically supported by high correlations especially
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with depression [29].
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Cognitive measures
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Affective and cognitive measurement strategies overlap. An example for the intersection
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between emotional and cognitive understandings of well-being is Diener’s concept of
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‘subjective wellbeing’ and the corresponding Satisfaction With Life Scale [39] which assesses
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positive affect and subjective life satisfaction. Similarly, the Oxford Happiness Inventory
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defines happiness as a combination of positive affect or joy, satisfaction, and the absence of
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distress and negative feeling [40].
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Purely cognitive measures of well-being include single item questionnaires asking one
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question such as “How satisfied are you with your life overall?” or “Taking everything into
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consideration, how would you say you are today?”[19]. This requires respondents to reflect
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on their overall state of life including all individually relevant domains [41]. As with HRQoL,
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the ‘affective fallacy’ caveat applies to global cognitive ratings, as they may be influenced by
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momentary affective states [42]. At the same time global ratings are thought to better reflect
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subjective valuation since different areas of life may be valued differently by individuals
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[43,44].
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Global cognitive measures of well-being have been widely applied and inspired the theory of
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‘subjective well-being homeostasis’. This theory is based on the finding that mean population
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values of overall life satisfaction typically vary only within a narrow range. On a scale from 0
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to 100, people in Western countries answer the question for overall life satisfaction roughly
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around 75, in non-Western countries the average lies around 70 [35]. The theory of
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subjective wellbeing homeostasis is comparable to the homeostatic regulation of body
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functions. It proposes that subjective well-being is maintained within narrow margins (a ‘set
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point’) by a set of psychological devices, e.g. cognitive bias, personality factors, and
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adaptation [46,47,48]. Hence, people maintaining a normally functioning homeostatic system
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show little fluctuations in well-being as a consequence of normal variations in their living
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conditions. Only highly unusual events cause the level of global subjective well-being to
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change temporarily, but it will return to its previous level over time, e.g. the subjective
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happiness of both lottery winners and paralyzed accident victims soon returns to previous
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levels [47]. The conclusions that may be drawn for the measurement of well-being in general
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are that the classic “life as a whole” question is useful as an estimate of the personal set-
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point of well-being, and is unlikely to change as a result of a therapeutic intervention [49].
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Multidimensional measures
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Multidimensional well-being concepts and their corresponding measures include widely
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varying psychological dimensions apart from affective and cognitive aspects. Even though
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multidimensional well-being concepts are most comprehensive, none of them covers all
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potential well-being dimensions. No single concept can be regarded generally superior to
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others as their utility strongly depends on the target group to which they are applied.
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Ryff’s (1989) multidimensional concept of ‘psychological well-being’ and corresponding Scale
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of Psychological Well-being (SPWB) captures positive functioning with a focus on life span
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development, individuation, maturity and self-actualisation [44,50]. The scale’s unstable
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factor structure has attracted criticism but the particularly comprehensive concept is still used
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today and informs other conceptualisations of well-being. Likewise, the Warwick-Edinburgh
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Mental Well-being Scale (WEMWBS) covers a comprehensive understanding of well-being
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including affective-emotional aspects, cognitive-evaluative dimensions and psychological
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functioning [51]. It builds on previous measures including the Affectometer, Psychological
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Well-being Scale, PANAS, Depression-Happiness Scale, and WHO-5 [52]. Other
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multidimensional well-being scales include the “l’Echelle de Bien-Etre” (EBE), which aims to
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capture
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circumstances [53]; the Mental, Physical and Spiritual Well-being Scale (MPSWB) which
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defines well-being as the balanced nourishment of the mind, body, and spirit [54]; the Life
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Satisfaction Index (LSI) which focuses on morale and adjustment in the elderly [19]; or the
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Philadelphia Geriatric Center Morale Scale (PGCM) which equals morale with ‘generalized
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well-being’ [55]. Table 1 organises these measure of multidimensional well-being into
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categories, to illustrate the variable coverage of diverse dimensions with relatively little
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overlap between the individual measures.
variations
in
well-being
following
changing
environmental
and
personal
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Insert Table 1 here
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Integrative phase
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The World Health Organisation (WHO) defines health as “a state of complete physical,
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mental and social well-being and not merely the absence of disease or infirmity” and mental
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health as “a state of well-being in which the individual realises his or her own abilities, can
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cope with the normal stresses of life, can work productively and fruitfully, and is able to make
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a contribution to his or her community" [56]. These highly inclusive definitions of well-being
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and mental health span both poles of the spectrum, i.e. illness or the absence thereof as well
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as optimum or peak states.
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Researchers, mainly in psychology, have devised equally comprehensive and overarching
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definitions of well-being and health, i.e. of a good life, by including components of all
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previously outlined approaches. While the medical and psychological approaches are usually
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covered, the economic approach is represented to a lesser degree. This varying emphasis is
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partly supported by empirical research showing that the goodness of life is commonly judged
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by people according to happiness, meaning, and – to a lesser extent – wealth [57].
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Table 2 maps some examples of good life conceptualisations. While their constituent
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components widely overlap some differences also remain, e.g. physical health is only
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included in one definition [58,59]. Differences between good life concepts may arise from
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their target population, e.g. Lawton’s (1983) concept is specifically developed for older
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people [60], or from their cultural background, e.g. a concept developed in Asia includes
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conformity with conventions [61] while one developed in the United States includes ‘a life
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dedicated to achieving for the sake of achievement’ in its dimensions of the good life, or
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“authentic happiness” [62]. These overarching definitions of the good life have no
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corresponding measurement tools but come with recommendations for combinations of
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varying published or unpublished scales for their assessment.
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Insert Table 2 here
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In the integrative approach, positive mental health receives explicit attention. This added
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focus on the positive instead of just on deficits corresponds with the introduction of a
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recovery orientation in mental health research and practise as well as with the emergence of
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the academic discipline of positive psychology. Both developments provide an important
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context for the good life approach in a mental health context [63].
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However, the concept of positive mental health is also far from uniform. One proposed
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organisation identifies six models of positive mental health from the literature [64]: (i) ‘above
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normal’, i.e. supremely functioning, empathic, socially competent, resilient, self-actualised,
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future oriented, autonomous and self-aware; (ii) ‘positive psychology’, i.e. character strength,
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talents and enablers; (iii) ‘maturity’, i.e. reflecting theories of life time development with
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greater maturation reflecting better mental health, (iv) ‘social-emotional intelligence’, (v) ‘well-
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being’, i.e. happiness depending on genetic, environmental and personality factors; and (vi)
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‘resilience’. This suggested classification again stresses how diverse and entangled the
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concepts of well-being and mental health are and how subjective their classification.
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The Complete State Model of Mental Health is another classification proposed to provide
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clarity for research and practise. This conceptual framework includes both poles of mental
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health and well-being. Mental illness lies on a spectrum from absent to present. Well-being
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lies on a spectrum from low to high. This notion of a dual continuum may be particularly
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relevant in a mental health context, because it highlights that people can experience well-
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being at the same time as experiencing mental illness. Well-being in this model is
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conceptualised to include all aspects summarised in the psychological approach i.e. positive
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affect, satisfaction, psychological well-being according to Ryff’s (1995) comprehensive
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definition, and social well-being [44,65,66].
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Conclusion and Future Perspective
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There is substantial variation in the definition and measurement of well-being. Probably an
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integrative approach to the concept best reflects its complexity and may hence be most
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suitable for use in mental health research and practise.
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The emergent understanding of well-being as a multi-dimensional construct mirrors
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systematic review evidence on the recovery process [67]. Empirical research into these
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complex constructs is possible [68,69]. A recent clinically relevant advance in well-being
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research was the development of a dynamic framework of well-being applicable to people
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with severe mental illness. [70] This consensus definition of well-being was based on a
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systematic literature review and qualitative research, and found that improved well-being was
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equivalent to an enhanced sense of self. This definition links well-being to identity, and
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provides an empirically defensible basis for understanding well-being in terms of
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determinants, influences and indicators. The influences are targets for interventions to
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improve well-being, and the indicators are outcome domains to assess the effectiveness of
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interventions to support well-being. In practice, the convergence of well-being and recovery
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may suggest a re-orientation of mental health services towards mainstream sources of well-
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being. From a recovery perspective, it has been argued that mainstream solutions should be
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preferred over specialist solutions to mainstream problems [63]. The same may be true for
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well-being, in that factors such as employment, friendship, exercise, sex, or prayer, are as
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important for people with severe mental illness as for any other group in society. This is
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consistent with: the Transcendent Principle of Personhood which states that ‘people with
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severe mental illness are people’ [71]; the Good Life approach which allows a wide range of
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factors to be focussed on in potential interventions to improve well-being; and the Complete
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State Model of Mental Health which acknowledges the possibility of well-being co-existing
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with mental illness.
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One future research focus will need to be on developing reliable and valid measurement
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tools to capture outcomes consistent with these models. At present, using a combination of
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established measures is proposed to capture diagnoses of mental illness, functioning, social
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disability, as well as indicators of well-being such as hope, empowerment, self-esteem, social
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connection, self-worth or meaning, together with or in addition to broad multidimensional
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well-being scales.
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Specific interventions to target well-being and its associated dimensions, such as self-worth,
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meaning, or hope [72] will need to be further developed and evaluated. A promising resource
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to draw on is the academic discipline of Positive Psychology [73]. The promotion of well-
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being is a focus of this discipline, which has shifted away from ameliorating deficits (e.g.
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symptoms) towards building positive emotions, character strengths and meaning [74]. There
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is good evidence that interventions using positive psychology strategies increase well-being
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and decrease depression in its recipients [75]. One specific intervention based on this body
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of knowledge is Positive Psychotherapy (PPT). This intervention draws on a range of
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resource oriented exercises to improve well-being in its recipient [76]. Initial evidence
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suggests its usefulness for people with common mental disorders, such as depression
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[74,76,77], and it may also be promising for people with severe mental illness, such as
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psychosis [78]. Future research will have to establish the usefulness of positive psychology
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intervention approaches, including PPT, across a spectrum of mental illnesses.
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Disclosure
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The study is funded by Guy’s & St Thomas’ Charity (Ref G101016). Mike Slade and Andre
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Tylee are funded by the National Institute for Health Research (NIHR) Biomedical Research
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Centre for Mental Health at the South London and Maudsley NHS Foundation Trust and
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[Institute of Psychiatry] King's College London. The views expressed are those of the
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author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.
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Table 1: Dimensions of multidimensional well-being scales
captured
well-being
dimensions
Social
Scales
SPWB
WEMWBS
EBE
satisfying
social
interpersonal connectedness
relationships
competence
Psychological selfacceptance
personal
development
Physical
Spiritual
clear
thinking
energy
LSI
PGCM
positive
lonely
relations with
dissatisfaction
others
environmental
mastery
autonomy
resolution,
fortitude
selfpositive
acceptance
selfconcept
personal
growth
purpose in life
attitudes to
own aging
autonomy
Mental
MPSWB
mental
activities
zest
positive affect
mood
tone
Health
perception
physical
symptoms
spiritual
activities
positive and
negative
affect
agitation
595
596
597
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Table 2: Components of the ‘good life’
598
599
Components
General
Satisfaction
Happiness
Ventegodt 2003
[58,59]
well-being (i.e. overall
feeling about one’s
being)
satisfaction with life
happiness (i.e.
existential feeling of
cheerfulness and
harmony)
meaning in life
Meaning
biological balance of
the body, reflecting
overall physical health
realising life potential
Balance
Realise
potential
Authors [reference]
Cheung 1997
Lawton 1983
[61]
[60]
psychological
well-being
life satisfaction
positive and
negative affect
fulfilment of needs
objective factors (e.g.
income or marital
status)
Fitting in
engaged life (i.e.
optimal use of
character
strengths)
achieving life (i.e.
achieving for the
sake of
achievement)
Achievement
Connectednes
s
behavioural
competence
domain specific
perceived quality
of life
objective
environment
Meet needs
Observable
pleasant life (i.e.
hedonistic
orientation to
positive emotions
and pleasures)
meaningful life (i.e.
belonging to and
serving something
larger than oneself)
religious
commitment
autonomy, selfactualising
Seligman 2002
[62]
mutual
interpersonal
concerns (e.g.
marital
satisfaction,
understanding
others)
conformity with
conventions
600
601
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