Long

On Wellbeing

At the moment, a number of public bodies are actively pursuing wellbeing, both for individuals and populations[1]. These bodies use ideas of ‘wellbeing’ to inform their attitudes, ways of working, processes and measures.  We might assume that wellbeing is subjective — a feeling of general contentment, happiness, of being loved, feeling good about one’s lot in life, not being fearful or anxious. Most of us experience contentment from time to time, and the idea of more permanent ‘wellbeing’ is a seductive aspiration; indeed, who has not yearned for something like this as we struggle, daily, to live our lives?  It resonates with a much older idea of fulfillment, something once offered, perhaps, by religious observance. Contentment, security, happiness, being loved or free from anxiety are undoubtedly individual and subjective states of feeling, but they all emerge in relationships with other people. In other words, wellbeing is relational. It arises in interactions between people. It is dynamic and changes over the course of life. Groups of people can find wellbeing, not just individuals.

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Illustration: Roxana Etzkorn

 

Wellbeing and Resilience

Generalised wellbeing – as the ancients knew, leading them to seek it in the next life rather than the present – is rare. The human condition has seldom been one in which generalised wellbeing and happiness flourished. Our ancestors lived in anarchy for much of recorded and unrecorded history, and fear of violence was endemic to the human species. The notion that somewhere or somehow there is a blissful state of wellbeing is not borne out by empirical data. Thomas Hobbes’ description of life as nasty, brutish and short seems to be much closer to the mark[2].

At present, it isn’t philosophers who cultivate a view of blissful wellbeing. It is advertisers that sell us a mythic future of good will, wellbeing and self-fulfilment, to be delivered when we purchase their products. We are promised this — through new cars, holidays, sofas or kitchens — but the result tends to disappoint us, falling short of our expectations. We can see, reading reviews on Trip Advisor, that many consumers seem to exist in a permanent state of disappointment.

Aaron Antonovsky’s work has been very important in helping us to understand the nature of wellbeing[3]. Antonovsky focused on a tradition called pathogenesis, which he saw as dominating a range of disciplines, including medicine and sociology. These disciplines tend, he argued, to think about what goes wrong or what is wrong in systems, whether biological or social. The raison d’être of medicine is putting things right when they go wrong in the human body. Sociology has its origins in the writings of theorists who observed a modern world, changing rapidly and replete with problems which deserved attention. This sociological tradition continued in the twentieth century with the ‘social problems’ approach adopted by writers like George Herbert Mead and Charles Cooley in the USA. In medicine, the pathogenic approach really picked up steam with the discovery of microbes, in the late nineteenth century, which caused very specific pathologies in quite predictable ways. Later, with the discovery of antibiotics which could counteract the actions of these microbes, the dominance of the pathogenic approach was assured[4]. These elements in the social and medical sciences, Antonovsky argued, have not only become dominant paradigms but have prevented us from seeing the bigger picture.

Antonovsky’s insight was his realisation that understanding people’s health cannot come from understanding what causes disease but rather through understanding what made people resilient to external stressors and insults, keeping them healthy. External stressors are everywhere in the human biological, social and physical environment, but people seem remarkably resilient and show extraordinary fortitude even in dire circumstances. This led Antonovsky to develop his alternative paradigm, called salutogenesis. If pathogenesis focuses on the origin of disease, salutogenesis looks at the origins of health. For Antonovsky an underlying state of mind — what he called a sense of coherence — was at the heart of resilience and salutogenesis. Antonovsky believed that if we believe that life makes sense, that life is reasonably predictable, that all things considered we have done reasonably well to hold things together, then our sense of psychological equanimity will be such that we will be able to cope with most of the travails that life throws at us. This is certainly not blissful contentment. This state is grounded in a real world which does throw up awful things; it is being able to manage or cope with those things which provides for a sense of wellbeing.

 

Wellbeing and Coping Strategies

The literature on the sociology of chronic disease has a large amount to say about wellbeing, coping and quality of life. The central observation is that people who have illnesses which have extraordinarily debilitating symptoms and which severely restrict their functional capacity do not necessarily feel they have a poor quality of life and are certainly not devoid of a sense of wellbeing. So studies of emphysema, rheumatoid arthritis, epilepsy, diabetes, Parkinson’s disease and colitis all revealed that the meanings that patients attribute to what is happening to them and their bodies are critical for the ways in which these patients cope with their disease[5].

Several key strategies for coping with illness have been described in this literature.  The first is denial. The person with the illness tries to convince her or himself and others that there is nothing wrong — or at least nothing seriously wrong! This is not uncommon at all in the early phases of illness and indeed can be very positive. It allows for a period of adjustment to the changed bodily functions and new limitations that the symptoms present. Denial is about the deliberate non-acknowledgement that there is anything wrong. As a holding strategy, when the patient is in the early stages of her or his illness, this does have the positive benefit of buying time while the patient gets used to the situation, but it is inherently unstable, particularly if the symptoms become more and more intrusive. Denial has tended to get bad press over the years, depicted as a kind of psychological regression or a failure to face reality. This way of describing denial is not helpful, however, because gaining control of symptoms and changes to bodily functions often creates time and space in which coping can begin.

Another common way of dealing with the symptoms and consequences of chronic illness is called passing. In essence, the sick person seeks to pass her or himself off as healthy or well to the outside world. This person does not deny that she or he has a problem because she or he knows and recognises that this is the case. This person, however, does all that’s possible to keep up the appearance of normality, discharging their usual role responsibilities and fulfilling obligations, while working very hard to deal with an illness and symptoms in a private world. Self-medicating, changing dressings, or simply resting away from the public eye, while attempting to appear as normal as possible in the public world, are examples of this approach. What comes across in the literature describing this response to illness is the sheer labour involved, both in the act of trying to appear normal in the public world and in the work that must go on in private to sustain this appearance. The degree to which symptoms do interfere with and are intrusive and the extent to which things are well controlled determines how easy passing will be. This response to chronic illness is particularly important in discussions about wellbeing. Private difficulty is contrasted with public appearance. This is an effort to present to the external world a picture of wellbeing. “All is well,” the sufferer tries to say. If we only focus on the public manifestations of this behaviour, we miss the difference between the public and the private domains. This underlines the fact that wellbeing is something that changes shape through interaction, in human relationships, rather than something constant which rests in the individual.

Closely related to passing is a strategy called normalisation. Here, the person with the illness seeks to fulfill role responsibilities when possible, but recognises her or his limitations as real but as normal for them, if not for the world at large. There is a recognition that capabilities are limited, but an attempt is made to live as normal a life as possible within those limitations. The sufferer is not saying that to have these symptoms is normal, but is convincing her or himself and others that these symptoms are normal for them. So the person’s goals and aspirations are changed or scaled back to meet the realities of the way a body functions. Somebody with rheumatoid arthritis does not seek to run marathons; a diabetic does not try to be a gourmand. Actually, it has been observed that sufferers may seek to push or extend her or his limits, whilst acknowledging them. This may be viewed as heroic or self-destructive, and it could be both simultaneously. The process is dynamic and changing. This strategy puts much less pressures on a person to keep up appearances and end up in a private struggle, and so the sense of wellbeing extends to both the private and public worlds.

Then, there is a strategy called accommodation. Here, the person with the disease does not pretend to be healthy, but seeks instead to live as normal or ordinary a life as possible, acknowledging the limitations imposed by the illness. This person minimises these limitations, however, by emphasising aspects of personhood other than illness. She or he may have diabetes, rheumatoid arthritis or colitis, and must deal with this, but tells the self and others that the disease is not the most significant part of life. Such people might define themselves as parents, citizens, Catholics, scientists or football fans. They seek to engage with the world on those terms, rather than in terms of disease. There are other aspects of their persons that are much more important than their illnesses. This is a very stable strategy, so long as the symptoms do not become over intrusive.

The opposite of this strategy is resignation. For a resigned person, life is utterly absorbed by her or his illness and she or he completely adapts to the sick role. The person engaging in resignation tells the world at large that the most important part of her or his identity is disease, and wants to interact with the rest of the world on that basis. Sociologists talk not only about the sick role, but about its secondary gains —there are benefits that people can get as a consequence of this role. They can be absolved of social role responsibilities, don’t have to work, might get support with child care, failing examinations or keeping house. There are also secondary psychological gains, such as being the focus of attention, feeling cared for and looked after, and, of course, relatives and carers may also derive benefits from the role of carer. In some circumstances, feelings of wellbeing therefore derive from occupation of the sick role itself, which, on the face of it, seems like an inversion of the expectations we have of the idea of wellbeing, but which is nonetheless a real phenomenon[6].

 

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Illustration: Roxana Etzkorn

 

Wellbeing and Storytelling

These studies of chronic illness reveal the fundamentally interactive nature of wellbeing.  None of the above strategies can exist in isolation, but have to be enacted and then acknowledged by others in interaction. Germane to this idea is the concept of self — the idea that people carry about types of people they are, of who and what they are, their biographies, their consciousness of themselves as individuals separate from other individual selves. The person in denial is trying to think of and present her or himself to others as a healthy person. The person in passing knows that she or he is sick, but tries to conceal it from others. In normalisation the person has reorganised her or his sense of self to acknowledge the limitations imposed by illness. In accommodation the person subdivides the self into that which is sick and other more important parts of the self. In resignation’ the person’s whole sense of being is consumed by the illness. But none of this will work unless others legitimise the role which is being proffered in interaction and give the person with the illness the identity – the label imposed by others onto the self – which is congruent with the role she or he wishes to play[7]. Selves and identities emerge in interaction. They are not givens and they are not behaviours. They are relational and they are a point out of which states of wellbeing emerge. When the roles are played competently and satisfactorily from the perspective of self and others, patients gain a sense of wellbeing. The narrative which the sick person develops about her or himself is a very important part of this interaction.

Every illness narrative carries embedded ideas about wellbeing. In chronic illness, several types of narratives have been observed.  In tragic narratives, common in resignation, the person tells a story in which she or he is depicted as victim of the slings and arrows of outrageous misfortune, medical mismanagement, bad luck or some other set of external or internal circumstances over which they have had no control and which, from the outset, was set on a downward or tragic path. Epic narratives, in contrast, have the person depict her or himself as a hero who has had to struggle against adversity and who, in various ways, has succeeded. In comedy the person takes a somewhat detached sardonic approach to what has happened and are able to distance her or himself from the events going on in her or his own body. These narratives have to be acknowledged and agreed upon by others. And narratives change. Skilled social actors are highly adept at finding the right version of the narrative for the right social situation. So it is not that people always tell tragic, heroic or comic narratives so much as they will use narrative selectively to manage social situations to their advantage[8]. These narratives do contain elements of equanimity and, in Antonovsky terms, we are where the sense of coherence and the things that make it all meaningful are to be found.

 

Wellbeing and Threats

Narratives are central to the ways that people cope. Feeling that one is coping, that one is in control, contributes enormously to a sense of wellbeing and to the reduction of common anxieties and stress. The psychologist Richard Lazarus provides one of the best accounts of this process[9].  Over a career spanning many decades, Lazarus reached the conclusion that life is always potentially stressful, endemically and routinely. He did not mean that life was a series of disastrous major life events and crises, but rather that everyday life is routinely difficult in lots of ways, usually small. There will be major problems, too, periodically, with which we will have to deal. Lazarus’s key point is that it is not the nature of the stressor itself that is critical, but rather the transaction that takes place between the person and the environment in the face of the stressor in what Lazarus calls the “appraisal process”.

Lazarus divides appraisal into two parts, primary and secondary. Primary appraisal is about threat recognition – being able to tell which of the many things in the external environment that assail us every day are genuinely threatening or dangerous. Once that judgement has been made, secondary appraisal, the process of deciding what to do about it, can begin. In this latter regard, the common responses are to seek out information, worry, take direct action to mitigate the threat or to do nothing. Clearly, people differ in the resources that they can bring to bear during the secondary appraisal process, but their technical skills and know-how, interpersonal relationships, ability to manage emotions and find appropriate narratives are the basis of successful coping. The feeling that one has overcome some difficulty can produce a deep sense of wellbeing, but the inability to manage external stressors can produce very negative feelings about wellbeing.

Wellbeing is an interesting phenomenon. It seems to be best understood as something which emerges between people, and this is well illustrated by the studies of chronic illness referred to in this essay. These interactions produce subjective feelings, of course, but if we focus only on subjectivity we miss the importance of other ideas, like self, identity and narrative, and the appraisal processes.  When NICE developed guidelines for wellbeing it used a simple but clear way of describing the different elements:

– emotional wellbeing – this includes being happy and confident and not anxious or depressed

– psychological wellbeing – this includes the ability to be autonomous, problem-solve, manage emotions, experience empathy, be resilient and attentive

– social wellbeing – has good relationships with others and does not have behavioural problems, that is, they are not disruptive, violent or a bully.

The NICE position acknowledges the interactive and the contextual dimensions, as well as the fact that there are various strategies and interventions that may help in the encouragement of wellbeing, based on the principles of building resilience and developing skills. It is interesting to reflect on whether the broader social and economic conditions in an age of austerity are likely to help to build and encourage resilience and the mutual interdependence that goes with it. This is a good point on which to end this essay. Social and economic policies do make a difference to wellbeing, in tangible ways. And the degree to which policies foster resilience and interdependence, making these things more or less obtainable, ought perhaps to be a test of their value, if wellbeing is an overall policy goal.

 

 

 

 


[1] For example the British Office for National Statistics is involved in developing what it describes as new measures of national well-being. They are aiming to provide a full picture of how society is progressing by supplementing existing factual economic, social and environmental measures with assessments of how people think and feel:  http://www.ons.gov.uk/ons/guide-method/user-guidance/well-being/index.html On a broader canvas the OECD argues that being able to measure people’s quality of life is fundamental when assessing the state of societies. They suggest that measuring subjective wellbeing is an essential part of understanding quality of life alongside other social and economic dimensions. In their guidelines they identify eleven domains of well-being, ranging from jobs, health and housing, through to civic engagement and the environment: http://oecdregionalwellbeing.org/

[2] Pinker, S. (2011) The Better Angels of Our Nature, London: Allen Lane.

[3] Antonovsky, A. (1985) Health Stress and Coping, San Francisco: Jossey Bass; Antonovsky, A. (1987) Unraveling the Mystery of Health: How People Manage Stress and Stay Well, San Francisco: Jossey Bass

[4] Carter, K.C. (2003) The Rise of Causal Concepts of Disease: Case Histories, Aldershot: Ashgate

[5] Strauss, A., Corbin, J., Fagerhaugh, S., Glaser, B., Maines, D., Suczec, B., Wiener, C. (1984) Chronic Illness and the Quality of Life, 2nd ed, St Louis: Mosby.

[6] See Bury, M. (1991) The sociology of chronic illness: a review of research and prospects, Sociology of Health and Illness; 13: 451-68, for a helpful review.

[7] Kelly, M.P.(1992) Self, identity and radical surgery, Sociology of Health and Illness,14: 390 – 415.

[8] Kelly, M.P.& Dickinson H. (1997) The narrative self in autobiographical accounts of illness, Sociological Review, 45: 254-278.

[9] Lazarus, R. & Folkman, S. (1984) Stress, Appraisal and Coping, New York:Springer.


Professor Mike Kelly is a Fellow Commoner at St John’s College Cambridge and formerly Director of the Centre for Public Health at NICE.