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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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.

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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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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.