Originally peer-reviewed and published in 2012 in The British Journal of Visual Impairment 30(1) 50–55.
What is meant by the term ‘wellbeing’? Much has been written on the relationship between chronic illness and mental health outcomes, particularly in terms of ‘happiness’, and the reciprocal relationship between physical and emotional health. Visual impairment research into wellbeing hastended to focus specifically on the concept of emotional wellbeing, and how functional disabilitymay impact negatively on mental health. As a consequence of such research, there is an increasing awareness of the importance of ‘preventing’ negative mental health outcomes in the visuallyimpaired population and ‘promoting’ emotional wellbeing. However, despite the many wellbeing interventions and initiatives, the actual meaning of the term remains rather nebulous. Dependingon one’s standpoint, ‘wellbeing’ may translate as a physical, social, emotional or even spiritual construct and follow different models which all have their own agendas, aims, methodologies and discourse. Furthermore, a shift is evident towards a two-dimensional framework of wellbeing which considers not just what makes chronically ill individuals happy in terms of goals and aspirations, but what makes them ‘flourish’ and find meaning in life. It is specifically this second dimension of wellbeing which remains to be investigated in visual impairment research. The purpose of this article is therefore to present the theoretical underpinnings of the wellbeing agenda, the methodological implications, and the impact on future research into wellbeing and visual impairment.
emotional wellbeing, eudemonic, flourishing, hedonic, measurement, spiritual wellbeing,
Shifting public health discourse
A sea change is evident in public health discourse, which has specific consequences for the arena of vision impairment. This paradigm shift is evident in the growing interest in the concept of ‘wellbeing’. Perpetuated by a change in impetus from gross domestic product (GDP) to more subjective experiences of life satisfaction, we as a population are increasingly demanding that the health and social realm of care, policy and academia should concern itself with wellbeing as well as disease (Thompson & Marks, 2008; Michaelson et al., 2009).
This discursive shift is also evident in the domain of visual impairment. At the UK Vision 2020 Conference in June 2011, there was talk of ‘a vision of the Big Society’, underlining a holistic, joined-up approach to visual impairment services. The term ‘wellbeing’ surfaced frequently in debates about ‘individual needs’, ‘empowerment’, ‘health outcomes’ and ‘quality-of-life’. ‘Wellbeing’, and the many ideas and concepts that fall within its broad reach, has thus begun to establish itself within the main discursive practices in public health care and in the realm of vision impairment.
Wellbeing and visual impairment – why the link?
Why then the current interest in wellbeing? Although the term appears to be all-encompassing, visual impairment research has tended to look specifically at the concept of emotional wellbeing. Much has been written on the relationship between chronic illness and mental health outcomes, particularly in terms of ‘happiness’ (Easterlin, 2003; Layard, 2006; Diener and Chan, 2011). Indeed, one of the key findings from publications such as The Happy Planet Index (Abdallah et al., 2009), is that people who report frequent happy feelings are less likely to suffer the effects of particular chronic diseases, and live up to seven years longer than those who are less happy. In terms of the visually impaired population, there is a growing awareness of the importance of both physical and emotional health, and the reciprocal relationship between the two. Further, in addition to the functional disability associated with vision loss, it is becoming increasingly apparent that the emotional impact of visual impairment is also substantial. A wealth of evidence exists to support the relationship between vision loss and functional disability, and subsequent negative effect on quality of life and emotional wellbeing (e.g., Rovner & Casten, 2001; Horowitz, 2004; Reinhardt, Boerner & Horowitz, 2009). As a consequence of such research, there is an increasing awareness of the importance of ‘preventing’ negative mental health outcomes in the visually impaired population and ‘promoting’ emotional wellbeing, especially in children and young people.
The wellbeing agenda has infiltrated many disciplines, and brought with it a new discourse. It has made us think about the importance of emotions and subjective experiences in terms of health care and vision impairment. However, in taking a reflective step backwards, we are faced with the unanswered question of what is ‘wellbeing’?
What is meant by the term wellbeing?
‘Emotional wellbeing’ has been documented as being of paramount importance to the future of visually impaired children, for example (Jemtå et al., 2009), however what do we actually mean when we use this term? It seems that wellbeing is a ubiquitous word, occurring frequently and widely in scientific, political, academic and social realms. As noted in the literature (Ereat and Whiting, 2008), it has a ‘holographic’ quality in the sense that different meanings are being projected by different agents, and the meaning of the term depends on the individual’s standpoint. In this sense, although it seems like a solid construct, it can easily be deconstructed when we look beyond its surface. Depending on one’s standpoint, ‘wellbeing’ may translate as a physical, social, emotional or even spiritual construct and follow different ‘models’ of wellbeing which all have their own agendas, aims, methodologies and discourse. Such a multitude of meanings and models runs the risk of leading us down a slippery slope of never-ending deconstruction of terms. The term ‘wellbeing’ may at once mean everything and nothing. In order for us to bring it back to a tangible, practical level on which we may act, perhaps a balance is needed between appreciating wellbeing’s multiple discursive framework and understanding how this impacts upon the subject of interest.
One way in which the multiple ‘voices’ of the term may be understood is by framing the concept within a clear two-dimensional framework. The majority of research into wellbeing has concentrated on the ‘life satisfaction’ or ‘hedonic’ dimension – hence claims about people who report frequent happy feelings being less likely to suffer the effects of particular chronic diseases. Life satisfaction and subjective experience is indeed important for understanding the psychological impact of vision loss (e.g. the risk of depression). However, there is a growing number of academics who suggest that looking at this dimension of wellbeing in isolation may not tell the whole story. As noted at a King’s College seminar in early 2011 (Measuring Well-being: A Need or Political Agenda?) and in the wellbeing literature (Ryan & Deci, 2001; Seligman, 2002; Vittersø, 2004), academics are now focusing on a two-dimensional framework of wellbeing which includes both life satisfaction and experiences (‘hedonic’) and a personal development (‘eudemonic’) dimension. A two-dimensional framework not only considers how vision loss affects subjective experiences, but also what conditions are required to develop in a fulfilling way as a functioning individual.
‘Interventions’ and ‘promotion’ of wellbeing would therefore take into account both of these dimensions rather than just focusing on the former. Signs of this shift from a one- to a two-dimensional framework of wellbeing are evident in the discourse on distinguishing ‘flourishing’ from ‘happiness’, and the need to consider wellbeing from a holistic standpoint, thus taking into account the needs and personal development of visually impaired individuals physically, socially, emotionally and spiritually. A rise in concepts such as ‘mindfulness’ (van Son et al., 2011) and ‘human givens’ (Bueno, 2009) echoes this underlying need to account for not just these two overarching dimensions of wellbeing, but also specific areas of emotional and indeed spiritual wellbeing that have to date remained under-researched, especially in the area of visual impairment.
A link has been established between positive mental health and physical wellbeing, however this raises the question of whether wellbeing can be ‘measured’? (Stewart-Brown, 2002). The waters are muddied even further when we bear in mind that the underlying standpoint of those who seek to measure or give wellbeing ‘training’ will influence where the parameters of such indicators or guidance are set. Why measure wellbeing? For those who seek to improve or promote emotional wellbeing in the visually impaired in order to improve functionality, measuring the success of such programmes is vital. Without the necessary measurement tools however, any wellbeing interventions would be rendered impotent because there would be no officially recognised way of measuring the success of such rehabilitative regimes. Measuring wellbeing therefore is high on the agenda in research environments that are underlined by outcomes, accountability and evidence-based practice. However, does this approach to research lie comfortably within the over-arching holistic ethos currently popular in healthcare discourse?
The majority of wellbeing measures, whether generic or specifically for vision loss, tend to follow the dominant ‘disease-as-deficit’ model. This point has been underlined by positive psychology and followers of assets-based models who argue that wellbeing measures tend to focus on illness rather than wellbeing (Foot & Hopkins, 2009). Furthermore, such measures appear to have conceived wellbeing as a hedonic entity, looking at wellbeing in terms of people’s satisfaction with their lives. Authors such as Waterman et al. (2010) therefore look towards constructing measures of the eudemonic dimension of wellbeing. Although within the realm of visual impairment we have seen an increased interest in the link between emotional and physical wellbeing, the majority of wellbeing measures have tended to focus on the physical and social elements of general quality of life. However, as underlined in the King’s College seminar and elsewhere in the literature (e.g., Tennant et al., 2007), wellbeing covers not only the physical and social, but also the emotional and spiritual needs and capabilities of the individual. The majority of indicators, however, tend to over-emphasise the first two elements at the expense of the latter two. It is suggested, therefore, that the eudemonic dimension of wellbeing warrants further attention, especially within visual impairment research. As noted by Vázquez et al. (2010), this second dimension of wellbeing is particularly related to long-term health outcomes and to the ability to cope flexibly and creatively with life’s challenges. Such findings therefore raise important questions about defining, promoting and measuring wellbeing in visual impairment research.
Promoting wellbeing: Emotional literacy, emotional intelligence and an unsteady discursive ground
A second area of interest, specifically for those working with the young visually impaired population is that of ‘training’ or ‘promoting’ wellbeing. This shift of emphasis towards ‘prevention’ of negative mental health and ‘promotion’ of emotional wellbeing has had an effect on vision loss rehabilitation and ‘interventions’. Fuelled by the current interest in wellbeing, significant links have been made between emotional wellbeing and constructs such as optimism, resilience and self-esteem. In the field of child psychology and Special Educational Needs (SEN) for example, it may be suggested that emotional wellbeing has been re-labelled and defined as ‘emotional literacy’ or ‘emotional intelligence’ (EI). The School of Emotional Literacy in the UK, and the government programme SEAL (Social and Emotional Aspects of Learning) both examine children’s social, emotional and moral development in order to identify the processes and mechanisms that foster traits such as empathy, compassion, and optimism and which may propel children towards positive mental health.
As noted by Schonert-Reichl (2009), implicit in this trend is the assumption that interventions can be designed to foster children’s strengths and resiliency. In relation to visual impairment, this suggests that it is possible to ‘prevent’ negative mental health and the risk of depression by ‘training’ visually impaired children to develop concepts such as self-esteem, self-control and how to ‘cope’ with their impairment. However, commentators from within positive psychology have asked if such ‘skills’ can indeed be ‘taught’, and even more so to populations who may have alternative ways of ‘making sense’ of the world, their experiences and personal development (Seligman, 2004).
Craig (2007a, 2007b) and Ecclestone and Hayes (2004, 2008), question the overall negative nature of emotional literacy and specifically, SEAL’s model of EI which follows the mainstream approach made popular by Goleman (1995). Craig (2007b: 12) notes that although EI as a concept has a ‘positive ring about it’, a great deal of which is very negative about emotions, viewing them as something to be feared, controlled and regulated. Do emotional literacy programmes for visually impaired children therefore run the risk of contributing to a deficit model that focuses on human failings that need to be ‘fixed’? If so, what are the alternatives?
Craig suggests that although the underlying values and motivations of the emotional literacy framework are about enhancing emotional wellbeing, it may be pertinent to be cautious about how much reliance is placed upon concepts such as EI and its inherent negative psychology. In turn, Craig suggests that emotional wellbeing initiatives for children should look towards positive psychology, and the work of authors such as Seligman and Csikmentmihalyi (2000). This approach to wellbeing is therefore concerned about finding the conditions which create good, flourishing lives (eudemonic wellbeing) whilst removing the focus on negativity and ‘emotional problems’ (Kobau et al., in press).
The discourse on wellbeing continues to gather speed and infiltrate areas that have an impact upon those working in visual impairment services and research. The debates presented in this commentary will continue to take shape, be contested, rejected, twisted and turned and taken up again. The purpose of this commentary has not been to present one definite position on the wellbeing agenda, but to open up the debate to those involved in visual impairment research, in the hope that it will ultimately lead to happy, flourishing lives of those with vision loss.
Abdallah, S., Thompson, S., Michaelson, J., Marks, N., & Steuer, N. (2009). The Happy Planet Index 2.0. London: New Economics Foundation.
Bueno, J. (2009). Human Givens. Therapy Today: The Journal for the British Society of Counselling and Psychotherapy Professionals, 20(10).
Craig, C. (2007a). The Potential Dangers of a Systematic, Explicit Approach to Teaching Social and Emotional Skills (SEAL): An Overview and Summary of the Arguments. Report for the Centre for Confidence and Well-being: Glasgow.
Craig, C. (2007b). The Potential Dangers of a Systematic, Explicit Approach to Teaching Social and Emotional Skills (SEAL). Report for the Centre for Confidence and Well-being: Glasgow.
Diener, E., & Chan, M. Y. (2011). Happy People Live Longer: Subjective Well-Being Contributes to Health and Longevity. Applied Psychology: Health and Well-Being, 3(1): 1–43.
Easterlin, R. A. (2003). Explaining Happiness. Proceedings of National Academy of Science, 100(19): 11,176–83.
Ecclestone, K. (2004). Learning or Therapy? The Demoralisation of Education. British Journal of Educational Studies, 52(2): 112–37.
Ecclestone, K., & Hayes, D. (2008). The Dangerous Rise of Therapeutic Education. London: Routledge.
Ereat, G., & Whiting, R. (2008). What Do We Mean by ‘Wellbeing’? And Why Might It Matter? Linguistic Landscapes/DCSF.
Foot, J., & Hopkins, T. (2009). A Glass Half Full: how an asset approach can improve community health and wellbeing. London: I&DEA.
Goleman, D. (1995). Emotional Intelligence: Why it can Matter More than IQ. New York: Bantam Books.
Horowitz, A. (2004). The Prevalence and Consequence of Vision Impairment in Later Life. Topics in Geriatric Rehabiliation, 20(3): 185–95.
Jemtå, L., Fugl-Meyer, K. S., Öberg, K., & Dahl, M. (2009). Self-esteem in Children and Adolescents with Mobility Impairment: Impact on Well-being and Coping Strategies. Acta Paediatrica, 98(3): 567–72.
Kobau, R., Seligman, M. E. P., Peterson, C., Diener, E., Zack, M. M., Chapman, D., & Thompson, W. (in press). Mental Health Promotion in Public Health: Perspectives and Strategies from Positive Psychology. American Journal of Public Health.
Layard, R. (2006). Happiness: Lessons from a New Science. London: Penguin.
Michaelson, J., Abdallah, S., Steuer, N., Thompson, S., & Marks, N. (2009). National Accounts of Well-being: Bringing Real Wealth onto the Balance Sheet. London: nef.
Reinhardt, J. P., Boerner, K., & Horowitz, A. (2009). Personal and Social Resources and Adaptation to Chronic Visual Impairment Over Time. Aging and Mental Health, 13(3): 367–75.
Rovner, B. W., & Caston, R. J. (2001). Neuroticism Predicts Depression and Disability in Age-Related Macular Degeneration. Journal of the American Geriatrics Society, 49: 1097–1100.
Ryan, R. M., & Deci, E. I. (2001). On Happiness and Human Potential: A Review of Research on Hedonic and Eudaimonic Well-being. Annual Review of Psychology, 52: 141–66.
Schonert-Reichl, K. (2009). Accelerating the Development of Empathy, Optimism, and Altruism in Children and Adolescents. Paper presented at the International Emotional Intelligence Congress 2009, Santander, Spain.
Seligman, M. E. P. (2002). Authentic Happiness: Using the New Positive Psychology to Realize Your Potential for Lasting Fulfillment. New York: Free Press.
Seligman, M. E. P. (2004). Can Happiness be Taught? Daedalus, Spring 2004.
Seligman, M. E. P., & Csikszentmihalyi, M. (2000). Positive Psychology. American Psychologist, 55(1): 5–14.
Stewart-Brown, S. (2002). Measuring the Parts Most Measures do not Reach: A Necessity for Evaluation in Mental Health Promotion (Guest editorial). Journal of Mental Health Promotion, 1: 4–9.
Tennant, R., Hiller, L., Fishwick, R., Platt, P., Joseph, S., Weich, S., Parkinson, J., Secker, J., & Stewart-Brown, S. (2007). The Warwick-Edinburgh Mental Well-being Scale (WEMWBS): Development and UK Validation. Health and Quality of Life Outcome, 5(63) doi:101186/1477-7252-5-63(WRAP).
Thompson, S., & Marks, N. (2008). Measuring Wellbeing in Policy: Issues and Applications. London: New Economics Foundation.
Vázquez, C., Hervás, G., Rahona, J. J., & Gómez, D. (2010). Psychological Well-being and Health: Contributions from Positive Psychology. Annuary of Clinical and Health Psychology, 5: 15–27.
Vittersø, J. (2004). Subjective Well-being Versus Self-actualization: Using the Flow-simplex to Promote a Conceptual Clarification of Subjective Quality of Life. In A. Michalos (ed.) Social Indicators and Quality of Life Research Methods: Methodological Developments and Issues, Yearbook 1999. Dordrecht: Kluwer Academic Publishers.
van Son, J., Nyklíček. I., Pop, V. J., & Pouwer, F. (2011). Testing the Effectiveness of a Mindfulness-based Intervention to Reduce Emotional Distress in Outpatients with Diabetes (DiaMind): Design of a Randomized Controlled Trial. BMC Public Health, 11: 131.
Waterman, A. S., Schwartz, S. J., Zamboanga, B. L., Ravert, R. D., Williams, M. K., Agocha, V. B., Kim, S. Y., & Brent Donnellan, M. (2010). The Questionnaire for Eudaimonic Well-Being: Psychometric Properties, Demographic Comparisons, and Evidence of Validity. The Journal of Positive Psychology, 5(1): 41–61