Not long ago, mental health recovery used to mean the amelioration of symptoms. With their focus on symptomatology, psychiatrists and clinical psychologists developed elaborate assessment tools to measure symptom severity levels as well as functioning. The late 1980s saw the recovery movement, an initiative by mental health service users to incorporate a broader concept of recovery. William Anthony [1] then laid out the vision of personal recovery in mental health services. Today, personal recovery is defined by the Substance Abuse and Mental Health Services Administration (SAMHSA) [2] of the United States Department of Health and Human Services as a process of change, through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential. It is not synonymous with cure [3]. Mental health recovery is holistic, which involves not only the recovery of one’s mental state, but also an individual’s full life spectrum of mind, body, spirit, and community [2]. Along with the development, Keyes [4] proposed a complete state model of mental health, by which mental health and mental illness represent two distinct domains, i.e., the absence of mental illness does not imply the presence of mental health, and the absence of mental health does not imply the presence of mental illness. This suggests that regardless of the presence of mental illness, individuals can flourish and enjoy well-being at multiple domains. For example, personal recovery of people with schizophrenia was found to positively predict well-being above and beyond clinical and functional recovery [5]. Adopting this model, Provencher and Keyes [6] augmented the promotion of personal recovery to include positive mental health as an additional outcome. As seen from the latest development in mental health recovery, well-being is an important element that has to be incorporated in assessment, service planning and evaluation in mental health organization. The following sections will outline current definitions of well-being, highlight the importance of the impact of spiritual well-being to mental health and our proposal to develop a comprehensive well-being measure for people in recovery of mental illness.
Definitions of well-being
Well-being has long been defined by the World Health Organization (WHO) [7] as being multi-faceted, composing of physical, mental, and social dimensions beyond the absence of disease. In particular, mental well-being is further defined as the abilities of individuals to cope with daily stressors, contribute productively in the community, and actualize their potentials [8]. These components of mental well-being have been categorized as hedonic well-being, eudaimonic well-being, and social well-being [9,10,11,12]. Hedonic well-being, also known as emotional well-being or subjective well-being, involves life satisfaction, presence of positive affect, and absence of negative affect [10, 13]. This narrow rendition of happiness was deemed inadequate [14], which gave rise to the other concept of eudaimonic well-being. Deci and Ryan [15] highlighted three basic psychological needs, namely autonomy, competence and relatedness, as a core of eudaimonic well-being. Seligman’s PERMA model [16] focuses on five elements of eudaimonic well-being: positive emotions, engagement, meaning, positive relationships, and accomplishment. Ryff [14, 17] derived six elements of eudaimonic well-being, namely self-acceptance, purpose in life, autonomy, positive relations with others, environmental mastery, and personal growth. Furthermore, Keyes [9] extended eudaimonic well-being from Ryff’s [14] intrapersonal model to an interpersonal focus, and came up with five elements of social well-being, namely social coherence, social acceptance, social actualization, social contribution, and social integration. Put together, intrapersonal and interpersonal well-being are believed to be in congruence with the WHO’s definition of mental health, as well as a comprehensive working definition of well-being.
Despite its multidimensionality, the WHO’s definition of mental health has been criticized for missing a fourth dimension—spiritual well-being [18,19,20,21]. The body-mind-spirit model has had a long history in Western religions like Christianity [22] as well as Eastern religions and philosophies including Confucianism, Taoism, Buddhism, and Hinduism [23]. Nevertheless, spirituality, religion, and personal beliefs are not synonymous [24]. One of the earliest definitions of spiritual well-being by the National Interfaith Coalition on Aging (NICA) [25] is the affirmation of life in the relationship with oneself, others, nature, and God. Following the NICA definition, Fisher [26] proposed the spiritual well-being model, pertaining to domains of personal, communal, environmental, and transcendental well-being. According to Fisher [26], personal domain deals with how one intrarelates with oneself with regard to meaning, purpose, and values in life; communal domain is expressed in the quality and depth of interpersonal relationships, between the self and others, relating to morality, social justice, culture, and religion; environmental domain includes the care and nurture for the physical environment and other organisms, as well as a sense of awe and wonder; transcendental domain is the relationship of the self with something or someone beyond humanity (i.e., ultimate concern, cosmic force, transcendent reality, or God).
Importance of spiritual well-being to mental health
Spiritual well-being is important to mental health from the perspective of people in recovery [27]. In particular, research suggested that spiritual well-being is related to reduced anxiety [28, 29], depressive symptoms [28, 29], suicidal ideation [28] and improved post-traumatic recovery [29]. Despite the importance of spiritual and transcendental well-being in the mental health recovery, this aspect of well-being was not emphasized in models of mental health recovery. For instance, in the 10 guiding principles of recovery proposed by SAMHSA [2], spirituality was only very briefly mentioned under the guiding principle that recovery is holistic: ‘recovery encompasses an individual’s whole life, including mind, body, spirit, and community’. It was also not clear whether the spirit and community component encompasses aspects of communal and transcendental well-being, which highlights how an individual relates with people and things beyond themselves, including people in the community as well as the environment and the Divine [26]. Furthermore, the well-being model proposed by Keyes [9] extended the definition of well-being to a social one, but dimensions of spiritual well-being are not covered. Thus, we proposed that a comprehensive well-being model for individuals in recovery of mental illness should include physical, psychological, social and spiritual well-being.
Intrapersonal and transpersonal well-being
In this research, we proposed domains of Intrapersonal and Transpersonal Well-being to reconcile the overlaps between different conceptual definitions of well-being, as well as to fill in the existing research gap and extend the concept of well-being in people in recovery to a more comprehensive definition. As reviewed in previous sections, the personal domain of spiritual well-being proposed by Fisher [26] and the psychological well-being proposed by Ryff [14] both concern how an individual intrarelates with themselves. Also, the communal domain of spiritual well-being proposed by Fisher [26] and the social well-being proposed by Keyes [9] both regard how an individual interrelates with other people. Furthermore, Fisher’s [26] other domains of spiritual well-being, i.e., environmental and transcendental well-being, extend beyond how an individual interrelates with other people to how an individual interrelates with the environment and something or someone beyond humanity. To cover the above aspects of well-being, we proposed the following operational definitions of well-being: intrapersonal well-being as involving how an individual intrarelates with themselves, including positive physical health and a positive sense of the self [13, 14]; transpersonal well-being as encompassing how an individual relates with people and things beyond themselves, including people in the community [9] as well as the environment and the Divine [26].
Purpose of scale development
To the best of our knowledge, no scale has been developed to encompass all the domains of well-being that have been discussed in literature. A recent systematic review of 99 well-being scales identified as many as 196 dimensions that clustered around six key themes, while pinpointing the ambiguity around the conceptual similarities and differences among different dimensions [30]. Existing scales measuring well-being mainly encompass physical, psychological and social well-being, for instance, Ryff Scales of Psychological Well-being [14, 50], and Mental Health Continuum Short Form [4], but do not extend to domains of spiritual and transcendental well-being. Existing scales for measuring recovery, for instance, Recovery Assessment Scale [31], Mental Health Recovery Measure [32], and Recovery Self-Assessment [33], are limited to the mind, body, and community, but do not extend to environmental and transcendental well-being.Some scales attempt to encompass more dimensions of well-being, for instance, Body-Mind-Spirit Well-Being Inventory [34] and Holistic Well-Being Scale [35], but do not cover well-being in terms of one’s relationship with the environment and something or someone beyond humanity.
The aims of the present study were to reconcile and extend different conceptual definitions of well-being among people in recovery of mental illness to cover transcendental aspect of well-being, and to develop a comprehensive well-being scale that grasps every intra- and trans-personal domain. The current paper also aimed to provide a practical and efficient tool for mental health organization to routinely measure comprehensive well-being, and to develop and evaluate services that aim to improve the well-being of people in recovery of mental illness. In addition, the scale would also provide mental health service users a brief scale for easier assessment of well-being for increasing awareness and for monitoring of one’s mental health.
In this research, Study 1 aimed at establishing a preliminary well-being scale. This preliminary scale would then be used to form our Comprehensive Well-being Scale using principal component analysis. Study 2 aimed at confirming the factor structure established in Study 1 using confirmatory factor analysis and examining the scale’s concurrent, convergent and discriminant validity.
Study 1
The aims of Study 1 were to explore the factor structure of the scale and to select items from a preliminary well-being scale through principal component analysis to form a comprehensive well-being scale.