Reprinted from the "Wellness" issue of Visions Journal, 2013, 7 (1), pp. 7-9
What do you see when you think of “a person who is experiencing problematic substance use?”
For many of us, the image that comes to mind is a person overwhelmed by their substance use, unemployed and disconnected from family and friends. Likewise, when we think of a person who is mentally healthy and thriving, we tend to imagine someone who is cheerful, holds a satisfying job, has close relationships and sees the future as promising.
But if problematic substance use sits at one end of the spectrum and wellness at the other, how can we explain people who use alcohol in ways that might damage their physical health but also use it to build social and business relationships? And what are we to make of people who inject drugs but also hold jobs and volunteer in their community?
These real-life situations, among many others, do not fit neatly into a linear notion of substance use and mental health. To understand real life, we need to rethink our ideas about what wellness looks and feels like, particularly if our aim in society is to promote and support health and well-being for everyone.
If we support people who use drugs to manage their substance use more safely and help them to achieve their personal goals, we centre attention on their health and well-being rather than on the substances they use. In the process, though, a new set of questions emerges as important. What exactly do we mean by the term “mental health”? How does our behaviour impact health and wellness? What factors influence a person’s behaviours and choices related to their substance use? And how do things look from a well-being perspective?
What is Mental Health?
A model developed by Keyes provides a framework to help us think about a broader view of mental health (also see Guest Editorial on page 5). This framework looks at thriving (or flourishing), and surviving (or languishing). It views the range of surviving to thriving as a spectrum of mental health that is related to well-being rather than to the presence of a mental illness. This goes beyond the question of whether or not a mental illness is a factor in a person’s life situation.1
This more complex model of mental health implies that experiencing less mental illness does not necessarily equate with experiencing better mental health. A person, for instance, may have learned to manage symptoms of anxiety, but may not feel happy or hopeful about the future.
It also highlights the possibility of achieving high levels of positive mental health despite the presence of mental illness.2 For example, a person may be living with a bipolar disorder, yet may feel optimistic and be actively engaged in their community.
This perspective on health and wellness helps us consider multiple sides of substance use and can help guide the responses of family, friends and other helpers involved in the lives of people who use substances in harmful ways. It encourages us to reflect on what matters to a person who is using drugs—rather than what matters to us—and to consider ways to help this person achieve their goals. It helps us understand and engage with a person who, say, injects drugs but doesn’t view it as a core aspect of their identity, and who is cultivating strengths and making plans for their future—who may, indeed, be thriving.
According to the World Health Organization, mental health involves a state in which one “realizes his or her abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.”3 A more expanded statement by Joubert and Raeburn describes mental health as “the capacity of each and all of us to feel, think and act in ways that enhance our ability to enjoy life and deal with the challenges we face. It is a positive sense of emotional and spiritual well-being that respects the importance of culture, equity, social justice, interconnections and personal dignity.”4
Behaviour − What role does it play?
A variety of influences may contribute to our behaviours, and our behaviours may influence our health, in complex ways. Our capacity to navigate the world can be negatively affected by unhealthy behaviours such as risky substance use, which may result in a variety of chronic diseases and a decline in our mental health. In this case, our substance use behaviour impacts our health, which then restricts our ability to “enjoy life and deal with the challenges we face.”4
On the other hand, earlier trauma may weaken our ability to build social relationships and lead us to turn to a readily available substance like alcohol as a means to “cope with the normal stresses of life.”3 If the alcohol use is too much, too often, it may lead to harms such as unemployment and a state of surviving rather than thriving.
A theory of behaviour developed by Glass and McAtee5 proposes that behaviours are shaped by many different factors and situations. They suggest that each person is influenced by a unique set of opportunities and constraints within a complex interaction of biological, environmental and social factors that play out over a life course.
This theory encourages a shift, from thinking of health behaviour as a response to internal and external stimuli, toward viewing it as self-directed action within the limits set by circumstances. The individual, who is knowledgeable about their own unique situation, is placed at the centre, pursuing goals within a particular context. This shift allows us to consider that real people with varying social, psychological, physical and material circumstances use substances in different ways to meet different needs.
What about addiction?
A common perception in our culture is that some drugs are intrinsically dangerous and possess the power to control human behaviour. According to this notion, a person takes a drug until, one day, the drug takes the person.6 Once this occurs, the person is characterized as addicted and powerless to exercise personal control related to their drug use. Though a common belief, this view actually has very little evidence and no solid theoretical basis.7
When we recognize that various factors contribute to the constraints and opportunities an individual experiences at any given point in time, we can understand why some people may feel a sense of dependence on a drug. A drug may be their only known means to cope with a mental health problem or deal with a chronic physical health issue.
When we recognize this range of contributing factors, a range of interventions also opens up.
So how do we help people from a wellness perspective?
If we think of substance use from a wellness perspective, it takes the focus away from the substances—it’s not all about drugs. In this context, helping and supporting a person is guided by a desire to maximize “the capacity of each and all of us to feel, think and act in ways that enhance our ability to enjoy life and deal with the challenges we face.”4 It includes attention to the health behaviours and skills of individuals seeking to manage their lives. But it also includes attention to the environments in which those behaviours and skills play out.
The factors that influence health and wellness for an individual go far beyond individual choices, or even individual abilities such as social and emotional skills. They include a whole range of factors related to the physical, social and political environments. So, for example, opportunities to participate in the life of the community, no matter what level of ability the person has, is critical to well-being and may impact decisions related to substance use.
A wellness approach puts the individual at the centre in terms of making sense of life and directing personal behaviour. It may mean encouraging reflection on goals, desires, needs and resources. It may take the form of reaching out to a person who injects drugs to share ideas with them on safer injection practices. Or it could be as simple as engaging a person who drinks in risky ways in a conversation about their future aspirations. But it may also involve changing social attitudes or policies that cause harm. For instance, it could mean giving all community members—including people who use drugs in harmful ways, or other marginalized people—a voice in advocating for change to policies that impact their well-being.
With this more balanced approach, the view of the individual changes from an “alcoholic” or “addict” who is controlled by a drug to a “thinking and feeling human being” who uses substances within certain contexts and for various reasons. We place the person before the drug and work with the individual to help them make sense of the factors that influence their health and well-being. We support them to increase their capacity to manage those factors in order to achieve their personal aspirations, and ultimately, to engage in creating healthier environments.
Working from a wellness perspective also offers a baseline for us to begin to explore our own beliefs about addiction and the complex relationship our culture has with substance use.
About the author
Dan is Assistant Director (Knowledge Exchange) with the Centre for Addictions Research of BC
Bette is a Research Associate with the Centre for Addictions Research of BC
Dan leads a team that communicates current evidence with respect to substance use in a way that supports the evolution of effective policy and practice. This involves advising government departments and regional authorities, as well as creating materials that are responsive to real-world contexts. Bette is a member of this team
Keyes, C.L.M. (2007). Promoting and protecting mental health as flourishing: A complementary strategy for improving national mental health. American Psychologist, 62(2), 95–108.
Provencher, H.L. & Keyes, C.L.M. (2011). Complete mental health recovery: Bridging mental illness with positive mental health. Journal of Public Mental Health, 10(1), 57–69.
World Health Organization (2004). Promoting Mental Health: Concepts, Emerging Evidence, Practice: Summary Report. Geneva.
Joubert, N. & Raeburn, J. (1998). Mental health promotion: People, power and passion. International Journal of Mental Health Promotion, 1(1), 15-22.
Glass, T.A. & McAtee, M.J. (2006). Behavioral science at the crossroads in public health: Extending horizons, envisioning the future. Social Science & Medicine, 62(7), 1650–1671.
Small, D. (2012). Canada’s highest court unchains injection drug users: Implications for harm reduction as standard of healthcare. Harm Reduction Journal, 9, 34.
Alexander, B.K. (2010). The globalization of addiction. New York: Oxford University Press.