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The Science of Well-being

The science of well-being is a multifaceted concept that encompasses both physical and mental health. It involves a sense of happiness, meaning, and joy in life’s experiences and is supported by resilience, which is the ability to withstand and recover from adversity.

One way to enhance both physical and mental health and performance is to intentionally regulate the nervous system when in stressful situations. Understanding the nervous system’s typical stress response and engaging in behaviors that return the mind and body to a state of calm — including NSDR, physiological sighs, and cold exposure — can help us manage stressors more effectively.

But stress in and of itself isn’t inherently bad. The upside of stress is that it can be a powerful tool to build physical and mental resilience. More than just a personality trait, building resilience is a skill that can be nurtured and honed. Embracing a growth mindset towards life’s challenges encourages creative problem-solving, reduces burnout, and improves overall mental health.

Remember, the pursuit of well-being is a lifelong journey, one that involves continually learning, growing, and improving. Many of the tools discussed around happiness, personal development, and growth are zero-cost: a gratitude practice or an evening journaling ritual can provide self-awareness and mental clarity, and a greater sense of connection to ourselves and others.

The science content below further explores these fascinating concepts, allowing you to better understand and leverage the potential of mindset, stress resilience, and well-being.

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The Self-Care Wheel: Wellness Worksheets, Activities & PDF

Thankfully, the cause was not an underlying physical condition; instead, it was behavioral. Tess was approaching burn out.

Managing her two children, setting up a new business, learning additional skills, and keeping up with her mortgage repayments were proving to be too much.

We have all experienced similar times in our lives, and burnout is real.

Irritability, drinking to feel better, trouble sleeping, headaches, and a lack of energy are all early signs that you are heading toward a meltdown (Salvagioni et al., 2017).

The Mayo Clinic describes burnout as physical and mental exhaustion, often associated with a loss of identity and the sense that we are not accomplishing anything.

So, how do you stop? How do you take care of yourself?

In this article, we explore a wellness tool that helps you regain control and focus on your busy life. The Self-Care Wheel is a positive psychology tool for supporting a balanced life while maximizing potential.

Before you read on, we thought you might like to download our three Self-Compassion Exercises for free . These detailed, science-based exercises will not only help you increase the compassion and kindness you show yourself, but also give you the tools to help your clients, students, or employees show more compassion to themselves.

This Article Contains:

What is the self-care wheel, templates, worksheets, and useful pdfs, self-care activities by the domains of the wheel, a look at popular self-care apps, a take-home message.

Work, parenting, education, and relationships are all sources of stress.

Research over the last two decades has confirmed the severe impact of our failure to handle situations in which we find ourselves.

Indeed, chronic stress at work is recognized by:

• Overwhelming exhaustion
• Lack of commitment
• Negative attitudes
• Dissatisfaction with performance

Self-care can help, but it needs to be planned, acted upon, and practiced (Myers, Sweeney, & Witmer, 2000; Windey, Craft, & Mitchell, 2019).

What is wellness?

Healthy people strive towards growth, self-actualization , and excellence; it’s a natural, universal tendency (Maslow, 1970).

But all of us, at times, need help to get and stay there.

Wellness is about maintaining mental and physical fitness and having enough energy to meet occupational and personal commitments. The Global Wellness Institute (n.d.) describes it as “ the active pursuit of activities, choices, and lifestyles that lead to a state of holistic health. ”

Wheel of Wellness

In 2000, psychologists Jane Myers, Thomas Sweeney, and Melvin Witmer were concerned about deaths occurring in the U.S. as a result of poor lifestyle choices. They suggested an important shift in emphasis, from a disease and illness model to one of wellness and health.

In response, they created a tool called The Wheel of Wellness to help achieve a life defined by optimal health and wellbeing, “ in which body, mind, and spirit are integrated by the individual to live more fully within the human and natural community ” (Myers et al., 2000).

The wheel is a pictorial representation of wellness. Each spoke depicts an interrelated set of tasks that interact with the life forces affecting your life, including:

• Business and industry

Wellness wheels remain accessible and helpful in the promotion of wellbeing.

Clarion University , for example, encourages students to use a copy of their wheel as part of their wellness program. Students are asked to consider how they manage their health in each of the following areas of their lives:

• Emotional health – managing stress , sufficient sleep, staying on top of work, seeking therapy
• Intellectual health – staying curious, learning new things, reading, joining clubs, enhancing intellectual interests
• Physical health – sufficient exercise, balanced nutrition, preventative medical care
• Social health – robust social network offering guidance and reducing stress
• Environmental health – caring for surroundings, avoiding clutter, recycling and volunteering for environmental initiatives
• Financial health – living within financial means, creating a budget
• Spiritual health – understanding the beliefs and values that shape who you are and guide your life

Recent research into healthcare has confirmed the value of the wellness wheel in promoting wellness and good health in nurses and, subsequently, better treatment of patients (Windey et al., 2019).

The Self-Care Wheel

The Self-Care Wheel is similar to the Wellness Wheel and provides a structure for identifying and nourishing areas where you are either failing, surviving, or thriving.

The most widely used assessment wheel, created by the Olga Phoenix Project , is based on the work of Karen Saakvitne and Laurie Pearlman (described in Transforming the Pain: A Workbook on Vicarious Traumatization; 1996).

The Olga Phoenix Self-Care Wheel consists of two sheets, each containing a set of six dimensions placed on the outside rim of the wheel, including:

• Psychological
• Professional

Each dimension represents an area of your life that, ideally, deserves daily attention.

The first sheet contains a suggested list of topics, placed between the spokes of the wheel below the relevant dimension. Each item is an inspiration or a prompt to take an action that promotes nurture in that area.

The second wheel is left blank for personalization.

A therapist or coach typically supplies both sheets to a client, but there may be times (to avoid bias) where only the blank sheet is given.

However, it is essential to make the wheel personal and to document follow-up actions that address dimensions negatively impacting your wellbeing.

Self-Care Wheel

Download Olga Phoenix’s free starter kit for a copy of the Self-Care Wheel.

Creating a Self-Care Vision Board

PositivePsychology.com’s Self-Care Vision Board is particularly well suited to practicing self-care and completing a blank copy of the wheel.

Download the tool for free as part of our Self-Compassion Exercises Pack.

The Self-Care Vision Board exercise is a positive and practical way for you to personalize the list of items under each dimension (physical, psychological, emotional, spiritual, personal, and professional).

It consists of four steps:

• Brainstorm self-care activities.
• Collect positive images for the vision board.
• Collect positive words and phrases for the vision board.
• Build the vision board.

Additional self-care resources from PositivePsychology.com

Committing to taking care of yourself is one of the most effective ways to make self-care a lifelong priority. Use the My Self-Care Promise template to help clients formalize their commitment in the form of a contract.

The following exercises and downloads offer useful guidance for specific activities listed under each dimension:

• Nature Play
• My Personal Beliefs
• Self-Love Journal
• The Five Senses Worksheet
• Stacking the Deck
• Exploring Character Strengths
• 3-Step Mindfulness Worksheet

Implementing the wheel as part of overall self-care

The Self-Care Wheel is one part of a more extensive process on your journey to wellbeing and can be embedded in the following three steps:

Step 1 – Assess

Identify areas that require additional attention for your self-care and are necessary for the completion of the Self-Care Wheel.

• Understand your current wellness position using the Self-Care Wheel.
• Download and personalize a blank copy.

Step 2 – Plan

Plan to transform those areas of your life that are currently failing, or surviving, into ones that are thriving.

• Identify how you can progress each aspect of your self-care and complete the activities defined in step 1.
• Write it down in a plan.

ReachOut provides a practical guide for developing a self-care plan along with a free downloadable template.

Step 3 – Implement

A plan has no value unless acted upon.

• Schedule the actions that implement your self-care.
• Commit to yourself that you will perform the steps and that you are worthy of self-care.
• Share the plan with someone close, who will provide support and encouragement.

Self-care wheel: the ultimate 3-step self-care formula – Olga Phoenix

For example, your spiritual dimension can be nurtured through yoga, self-forgiveness, and nature, while your psychological state will benefit from self-awareness , relaxation, and a focus on positive qualities.

Review each of the following sections for a list of activities that nurture or nourish the six dimensions of your Self-Care Wheel.

Note that these are suggestions. Some actions may be more or less appropriate and can be added to or removed from your list.

The list is modified from the Self-Care Wheel created by Olga Phoenix but also contains links to articles within PositivePsychology.com to further your understanding and provide additional guidance.

Other useful advice and practical tips are available from the University of California and Princeton University .

Self-care activities for your physical domain

Your physical health is vital to your overall wellbeing, And, according to the American Nurses Association , it is not only the absence of disease, but also lifestyle choices that avoid preventable illnesses, maintaining a balanced mind, body, and spirit.

Things you can do to nurture yourself:

• Eat healthily
• Exercise regularly
• Be sexual (safely)
• Put good sleeping habits in place
• Take vacations
• Take time off and ensure downtime
• Schedule regular massages
• Seek out a qualified acupuncturist
• Take relaxing baths
• Kiss (your partner, family, your dog)
• Ask for nurture
• Take daily walks (if possible in nature )
• Turn off or put your phone on silent

Consider putting in place:

• Safe housing
• Regular medical care and check-ups

Self-care activities for your psychological domain

Psychological wellbeing is crucial to not only your state of mind, but also your physical health. According to the American Psychological Association , psychological wellbeing involves being both happy and content, with low levels of distress, good mental health, and quality of life.

• Perform self-reflection and self-awareness
• Sensory engagement
• Schedule aromatherapy
• Do something creative, draw, paint, quilt, cook, etc.
• Go to the ballet, a symphony, or a concert
• Relax in your garden, park, or at the beach
• Read a self-help book
• Think about your positive qualities and your strengths
• Practice (and visualize) asking for and receiving help
• Practice mindfulness
• Join a support group

Self-care activities for your emotional domain

Emotional wellness can be described as understanding and being aware and comfortable with your feelings, and being able to express emotions constructively.

• Perform affirmations
• Social justice engagement
• Say “ I love you ” (show positive emotions more often, and mean them)
• Watch a funny or heartening movie
• Find a hobby
• Flirt (if appropriate)
• Buy yourself a present
• Spend time with your pet
• Practice forgiveness
• Self-compassion

Download 3 Free Self-Compassion Exercises (PDF)

These detailed, science-based exercises will equip you to help others create a kinder and more nurturing relationship with themselves.

Download 3 Free Self-Compassion Tools Pack (PDF)

By filling out your name and email address below.

Self-care activities for your spiritual domain

Spiritual wellness has a different meaning for each of us. Typically, it is about having values and beliefs that provide meaning to your life and having the opportunity and motivation to align your behavior to them.

• Perform self-reflection
• Spend time in nature
• Self-cherish
• Meditate or practice mindfulness
• Sing and dance
• Play with your children
• Be inspired
• Practice yoga
• Bathe in the sea, a river, a lake
• Watch the sunset or sunrise
• Find a spiritual mentor
• Volunteer for a cause close to your heart
• Foster self-forgiveness
• Join a spiritual community that aligns with your values and beliefs

Self-care activities for your personal domain

Being engaged intellectually and at a profoundly personal level in your actions, environment, and social group is likely to promote growth and wellbeing in your personal domain.

• Learn who you are
• Explore what you want out of life
• Plan short- and long-term goals
• Make a vision board
• Foster friendships
• Go on dates
• Get a coffee or drink with a friend
• Learn to relax
• Write poetry, short stories, or a book
• Spend time with loved ones
• Learn to play an instrument
• Get out of debt (this may be aspirational)

Self-care activities for your professional domain

Wellbeing in the professional domain is most likely when your work and studies leave you feeling fulfilled, while you continue to grow, learn, and make meaningful contributions.

• Make time for lunch, and take regular breaks
• Do not repeatedly work late
• Do not work during time off
• Find a good mentor
• Get support from colleagues
• Take mental health days
• Learn to say no
• Plan your current or next career
• Learn, take a class
• Take vacation and sick days
• Set boundaries. Where does work start and end?

17 Exercises To Foster Self-Acceptance and Compassion

Help your clients develop a kinder, more accepting relationship with themselves using these 17 Self-Compassion Exercises [PDF] that promote self-care and self-compassion.

Created by Experts. 100% Science-based.

Find it in the App Store or Google Play .

Anxiety Solution: Calmer You

Find it in the App Store .

Balance in life is crucial.

When you have it, you can divide your time and energy across all areas of your being, ensuring an appropriate focus on family, learning, spirituality, career, etc. while nurturing overall wellness.

However, when balance falters, parts of your life remain unnourished. They begin to fail, impacting other areas and your overall wellbeing. You begin to burn out.

If you step back and look at your life, you can see the warning signals – overeating, over-drinking, lethargy, stress, irritability – all are signals that change is needed.

And yet, if you recognize the signals, then you can do something about them.

Firstly, download the Self-Care Wheel, and along with some of the other tools introduced, identify and document the actions and steps that will help you find balance and ultimately lead you to flourish in life.

You may not have time or resources to play out all the actions or put in place every condition, but be realistic. Plan how you are going to perform the activities that are going to give you the big wins. Once they are in place, you can begin to find other ways to include the smaller, complementary, positive changes in your life.

You have what it takes to make your life more complete, but it takes self-care.

Perhaps most surprisingly, the crucial takeaway is not that you have the potential to put in place a routine of self-care, but that you deserve it.

You, like the rest of us, are worth investing in.

So, what’s stopping you? Use the Self-Care Wheel to take stock, regain focus, and take control of your busy, precious life.

We hope you enjoyed reading this article. Don’t forget to download our Self-Compassion Exercises for free .

• Global Wellness Institute. (n.d.). What is wellness? Retrieved from https://globalwellnessinstitute.org/what-is-wellness/
• Maslow, A. (1970). Motivation and personality (2nd ed.). Harper & Row.
• Myers, J. E., Sweeney, T. J., & Witmer, J. M. (2000). The wheel of wellness counseling for wellness: A holistic model for treatment planning. Journal of Counseling & Development, 78 (3), 251-266.
• Salvagioni, D. A. J., Melanda, F. N., Mesas, A. E., González, A. D., Gabani, F. L., & de Andrade, S. M. (2017). Physical, psychological, and occupational consequences of job burnout: A systematic review of prospective studies. PLOS One, 12 (10).
• Saakvitne, K. W., & Pearlman, L. A. (1996). Transforming the pain: A workbook on vicarious traumatization. Norton & Company.
• Windey, M., Craft, J., & Mitchell, S. L. (2019). Incorporating a wellness program for transitioning nurses. Journal for Nurses in Professional Development, 35 (1), 41-43.

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This article gave me the knowledge and insight on how to begin myself care. I have downloaded all activities sheet, and I can’t wait to get started.

very useful information .Thanks for sharing

Hi there, I see a wrong link in this article. In your “Additional self-care resources”, the 6th link “Eight Steps to Forgiveness” send us to a different exercise (Exploring Character Strengths).

Thanks so much for pointing this out. We will fix this shortly 🙂

Kind regards, -Caroline | Community Manager

Very helpful article. Thanks for sharing this information for free.

Need to balance my wheeel so that I can domuch better to excell in what I am doing. Thanks for the positive advise.

‘So what’s stopping you?’ Precisely. That is worth unpacking. If it is so easy to prioritise self-care, why is it so hard for people to do? It is getting beyond the pre-contemplative stage that is the issue.

Great observation. My own reflection of this question is that I haven’t felt ‘worthy’. Everything and everyone else seems more important There has to be a mind shift.

Great read. I like that there were actual resources given for each domain. This makes the information easier to understand and a lot more practical than most articles about concepts and theories. Thank you

love this article! thank you!

Very useful Blog. Thank you for sharing

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The Importance of Mental Health

Elizabeth is a freelance health and wellness writer. She helps brands craft factual, yet relatable content that resonates with diverse audiences.

Akeem Marsh, MD, is a board-certified child, adolescent, and adult psychiatrist who has dedicated his career to working with medically underserved communities.

Westend61 / Getty Images

Risk Factors for Poor Mental Health

Signs of mental health problems, benefits of good mental health, how to maintain mental health and well-being.

Your mental health is an important part of your well-being. This aspect of your welfare determines how you’re able to operate psychologically, emotionally, and socially among others.

Considering how much of a role your mental health plays in each aspect of your life, it's important to guard and improve psychological wellness using appropriate measures.

Because different circumstances can affect your mental health, we’ll be highlighting risk factors and signs that may indicate mental distress. But most importantly, we’ll dive into all of the benefits of having your mental health in its best shape.

Mental health is described as a state of well-being where a person is able to cope with the normal stresses of life. This state permits productive work output and allows for meaningful contributions to society.

However, different circumstances exist that may affect the ability to handle life’s curveballs. These factors may also disrupt daily activities, and the capacity to manage these changes. 

The following factors, listed below, may affect mental well-being and could increase the risk of developing psychological disorders .

Childhood Abuse

When a child is subjected to physical assault, sexual violence, emotional abuse, or neglect while growing up, it can lead to severe mental and emotional distress.

Abuse increases the risk of developing mental disorders like depression, anxiety, post-traumatic stress disorder, or personality disorders.

Children who have been abused may eventually deal with alcohol and substance use issues. But beyond mental health challenges, child abuse may also lead to medical complications such as diabetes, stroke, and other forms of heart disease.

The Environment

A strong contributor to mental well-being is the state of a person’s usual environment . Adverse environmental circumstances can cause negative effects on psychological wellness.

For instance, weather conditions may influence an increase in suicide cases. Likewise, experiencing natural disasters firsthand can increase the chances of developing PTSD. In certain cases, air pollution may produce negative effects on depression symptoms.  

In contrast, living in a positive social environment can provide protection against mental challenges.

Your biological makeup could determine the state of your well-being. A number of mental health disorders have been found to run in families and may be passed down to members.

These include conditions such as autism , attention deficit hyperactivity disorder , bipolar disorder , depression , and schizophrenia .

Your lifestyle can also impact your mental health. Smoking, a poor diet , alcohol consumption , substance use , and risky sexual behavior may cause psychological harm. These behaviors have been linked to depression.

When mental health is compromised, it isn’t always apparent to the individual or those around them. However, there are certain warning signs to look out for, that may signify negative changes for the well-being. These include:

• A switch in eating habits, whether over or undereating
• A noticeable reduction in energy levels
• Being more reclusive and shying away from others
• Feeling persistent despair
• Indulging in alcohol, tobacco, or other substances more than usual
• Experiencing unexplained confusion, anger, guilt, or worry
• Severe mood swings
• Picking fights with family and friends
• Hearing voices with no identifiable source
• Thinking of self-harm or causing harm to others
• Being unable to perform daily tasks with ease

Whether young or old, the importance of mental health for total well-being cannot be overstated. When psychological wellness is affected, it can cause negative behaviors that may not only affect personal health but can also compromise relationships with others. 

Below are some of the benefits of good mental health.

A Stronger Ability to Cope With Life’s Stressors

When mental and emotional states are at peak levels, the challenges of life can be easier to overcome.

Where alcohol/drugs, isolation, tantrums, or fighting may have been adopted to manage relationship disputes, financial woes, work challenges, and other life issues—a stable mental state can encourage healthier coping mechanisms.

A Positive Self-Image

Mental health greatly correlates with personal feelings about oneself. Overall mental wellness plays a part in your self-esteem . Confidence can often be a good indicator of a healthy mental state.

A person whose mental health is flourishing is more likely to focus on the good in themselves. They will hone in on these qualities, and will generally have ambitions that strive for a healthy, happy life.

Healthier Relationships

If your mental health is in good standing, you might be more capable of providing your friends and family with quality time , affection , and support. When you're not in emotional distress, it can be easier to show up and support the people you care about.

Better Productivity

Dealing with depression or other mental health disorders can impact your productivity levels. If you feel mentally strong , it's more likely that you will be able to work more efficiently and provide higher quality work.

Higher Quality of Life

When mental well-being thrives, your quality of life may improve. This can give room for greater participation in community building. For example, you may begin volunteering in soup kitchens, at food drives, shelters, etc.

You might also pick up new hobbies , and make new acquaintances , and travel to new cities.

Because mental health is so important to general wellness, it’s important that you take care of your mental health.

To keep mental health in shape, a few introductions to and changes to lifestyle practices may be required. These include:

• Taking up regular exercise
• Prioritizing rest and sleep on a daily basis
• Trying meditation
• Learning coping skills for life challenges
• Keeping in touch with loved ones
• Maintaining a positive outlook on life

Another proven way to improve and maintain mental well-being is through the guidance of a professional. Talk therapy can teach you healthier ways to interact with others and coping mechanisms to try during difficult times.

Therapy can also help you address some of your own negative behaviors and provide you with the tools to make some changes in your own life.

A Word From Verywell

Your mental health state can have a profound impact on all areas of your life. If you're finding it difficult to address mental health concerns on your own, don't hesitate to seek help from a licensed therapist .

World Health Organization. Mental Health: Strengthening our Response .

Lippard ETC, Nemeroff CB. The Devastating Clinical Consequences of Child Abuse and Neglect: Increased Disease Vulnerability and Poor Treatment Response in Mood Disorders . Am J Psychiatry . 2020;177(1):20-36. doi:10.1176/appi.ajp.2019.19010020

 Helbich M. Mental Health and Environmental Exposures: An Editorial. Int J Environ Res Public Health . 2018;15(10):2207. Published 2018 Oct 10. doi:10.3390/ijerph15102207

Helbich M. Mental Health and Environmental Exposures: An Editorial. Int J Environ Res Public Health . 2018;15(10):2207. Published 2018 Oct 10. doi:10.3390/ijerph15102207

National Institutes of Health. Common Genetic Factors Found in 5 Mental Disorders .

Zaman R, Hankir A, Jemni M. Lifestyle Factors and Mental Health . Psychiatr Danub . 2019;31(Suppl 3):217-220.

Medline Plus. What Is mental health? .

National Alliance on Mental Health. Why Self-Esteem Is Important for Mental Health .

By Elizabeth Plumptre Elizabeth is a freelance health and wellness writer. She helps brands craft factual, yet relatable content that resonates with diverse audiences.

The Palgrave Handbook of Sociocultural Perspectives on Global Mental Health pp 129–150 Cite as

Positive Mental Health and Wellbeing

• Sarah C. White 5 &
• Carola Eyber 6  
• First Online: 04 February 2017

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The past 20 years have seen an explosion of interest in positive approaches to mental health, happiness, and wellbeing. While these concepts vary considerably from one another, they act as bridges between Global Mental Health and the broader arena of national and international policymaking. This chapter begins by sketching out some of the trajectories across different academic and policy fields that have contributed to this field and provides a critical discussion of the key concepts of ‘subjective wellbeing’ and ‘psychological wellbeing’. It then considers two very different ways that positive approaches are being pursued in policy and practice in the Global South: psychosocial wellbeing in the context of disasters and humanitarian crises, and political mobilisation around notions of ‘living well’ in Latin America.

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Whether it is useful to characterise emotions as ‘positive’ or ‘negative’ is itself open to debate, of course.

Seligman ( 2011 , p. 12) characterises well-being as a construct made up of: positive emotion, engagement, positive relationships, meaning, and accomplishment.

See Miller ( 2002 ) for a helpful discussion of the individualism/collectivism binary that has dominated cross-cultural psychology.

The inner well-being domains are economic confidence, agency and participation, social connections, close relationships, physical and mental health, competence and self-worth, values and meaning.

Buen vivir is the Spanish term for ‘living well’. Alternative terms are also used, which express allied concepts in indigenous languages.

Fernando Huanacuni Mamani ( 2010 ). ‘Buen Vivir/Vivir Bien Filosofía, políticas, estrategias y experiencias regionales andinas’.

Buen vivir is the Spanish term. Other terms in indigenous languages include suma qamaña (Aymara) and sumac kawsay (Quechua).

Ahmed, S. (2010). The promise of happiness . Durham, NC: Duke University Press.

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Atkinson, S. (2013). Beyond components of wellbeing: The effects of relational and situated assemblage. Topoi, 32 (2), 137–144.

Benjamin, J. (1988). The bonds of love. Psychoanalysis, feminism, and the problem of domination . New York: Random House.

Berridge, K., & Kringelbach, M. (2011). Building a neuroscience of pleasure and well-being. Psychology of Wellbeing: Theory, Research and Practice, 1 (3), 1–26.

Camfield, L., Crivello, G., & Woodhead, M. (2009). Wellbeing research in developing countries: Reviewing the role of qualitative methods. Social Indicators Research, 90 , 5–31.

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White, S.C., Eyber, C. (2017). Positive Mental Health and Wellbeing. In: White, R., Jain, S., Orr, D., Read, U. (eds) The Palgrave Handbook of Sociocultural Perspectives on Global Mental Health. Palgrave Macmillan, London. https://doi.org/10.1057/978-1-137-39510-8_7

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9 Successful students practice mental wellness

Wellness is more than just avoiding disease. Wellness involves feeling good in every respect, in mind and spirit as well as in body. Your emotional health is just as important as your physical health—and maybe more so. If you’re unhappy much of the time, you will not do as well as in college—or life—as you can if you’re happy. You will feel more stress, and your health will suffer. Still, most of us are neither happy nor unhappy all the time. Life is constantly changing, and our emotions change with it. But sometimes we experience more negative emotions than normally, and our emotional health may suffer. Emotional balance is an essential element of wellness—and for succeeding in college. Emotional balance doesn’t mean that you never experience a negative emotion, because these emotions are usually natural and normal. Emotional balance means we balance the negative with the positive, that we can be generally happy even if we’re saddened by some things. Emotional balance starts with being aware of our emotions and understanding them.

Everyone knows about stress, but not everyone knows how to control it. Stress is the great enemy of college success. But once you’ve learned how to reduce it where you can and cope with unavoidable stress, you’ll be well on the road to becoming the best student you can be. We all live with occasional stress. Since college students often feel even more stress than most people, it’s important to understand it and learn ways to deal with it so that it doesn’t disrupt your life.

Emotional Health

Emotions can be problematic.

When is an emotion problematic? Is it bad to feel anxious about a big test coming up or to feel sad after breaking up a romantic relationship?

It is normal to experience negative emotions. College students face so many demands and stressful situations that many naturally report often feeling anxious, depressed, or lonely. These emotions become problematic only when they persist and begin to affect your life in negative ways. That’s when it’s time to work on your emotional health, just as you’d work on your physical health when illness strikes.

Anxiety is one of the most common emotions college students experience, often as a result of the demands of college, work, and family and friends. It’s difficult to juggle everything, and you may end up feeling not in control, stressed, and anxious. Anxiety typically results from stress. Some anxiety is often a good thing if it leads to studying for a test, focusing on a problem that needs to be resolved, better management your time and money, and so on. But if anxiety disrupts your focus and makes you freeze up rather than take action, then it may become problematic. Using stress-reduction techniques often helps reduce anxiety to a manageable level.

Anxiety is easier to deal with when you know its cause. Then you can take steps to gain control over the part of your life causing the anxiety. But anxiety can become excessive and lead to a dread of everyday situations.

There are five types of more serious anxiety:

• Generalized anxiety disorder is characterized by chronic anxiety, exaggerated worry and tension, even when there is little or nothing to provoke it.
• Obsessive-compulsive disorder (OCD) is characterized by recurrent, unwanted thoughts (obsessions), repetitive behaviors (compulsions), or both.
• Panic disorder is characterized by unexpected and repeated episodes of intense fear accompanied by physical symptoms.
• Post traumatic stress disorder (PTSD) can develop after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened.
• Social phobia (or social anxiety disorder) is a persistent, intense, and chronic fear of being watched and judged by others and being embarrassed or humiliated by one’s own actions.

These five types of anxiety go beyond the normal anxiety everyone feels at some times. If you feel your anxiety is like any of these, see your health-care provider. Effective treatments are available to help you regain control.

Loneliness is a normal feeling that most people experience at some time. College students away from home for the first time are likely to feel lonely at first. Older students may also feel lonely if they no longer see their old friends. International students may also feel lonely. Loneliness involves not feeling connected with others. One person may need only one friend to not feel lonely; others need to feel more connected with a group. There’s no set pattern for feeling lonely.

If you are feeling lonely, there are many things you can do to meet others and feel connected. Don’t sit alone in your room bemoaning the absence of friends. That will only cause more stress and emotional distress. You will likely start making new friends through going to classes, working, studying, and living in the community. But you can jump-start that process by taking active steps such as these:

• Realize you don’t have to be physically with friends in order to stay connected. Many students use social Web sites to stay connected with friends at other colleges or in other locations. Telephone calls, instant messaging, and e-mail work for many.

• Understand that you’re not alone in feeling lonely. Many others like you are just waiting for the opportunity to connect, and you will meet them and form new friendships fast once you start reaching out.

• Become involved in campus opportunities to meet others. Every college has a wide range of clubs for students with different interests. If you’re not the “joiner” type, look for individuals in your classes with whom you think you may have something in common and ask them if they’d like to study for a test together or work together on a class project.

• Remember that loneliness is a temporary thing—it’s only a matter of time until you make new friends. If your loneliness persists and you seem unable to make friends, then it’s a good idea to talk with one of the college counsellors. They can help.

Depression, like anxiety and loneliness, is commonly experienced by college students. It may be a mild sadness resulting from specific circumstances or be intense feelings of hopelessness and helplessness.

Many people feel depressed from time to time because of common situations:

• Feeling overwhelmed by pressures to study, work, and meet other obligations
• Not having enough time (or money) to do the things you want to do
• Experiencing problems in a relationship, friendship, or work situation
• Feeling overweight, unhealthy, or not in control of oneself
• Feeling that your new life as a student lacks some of the positive dimensions of your former life
• Not having enough excitement in your life

Depression, like stress, can lead to unhealthy consequences such as poor sleep, overeating or loss of appetite, substance abuse, relationship problems, or withdrawal from activities that formerly brought joy. For most people, depression is a temporary state. But severe depression can have crippling effects.

Not everyone experiences the same symptoms, but the following are most common:

• Persistent sad, anxious, or “empty” feelings
• Feelings of hopelessness or pessimism
• Feelings of guilt, worthlessness, or helplessness
• Irritability or restlessness
• Loss of interest in activities or hobbies once pleasurable, including sex
• Fatigue and decreased energy
• Difficulty concentrating, remembering details, and making decisions
• Insomnia, early morning wakefulness, or excessive sleeping
• Overeating or appetite loss
• Thoughts of suicide or suicide attempts
• Persistent aches or pains, headaches, cramps, or digestive problems

If you have feelings like this that last for weeks at a time and affect your daily life, your depression is more severe than “normal,” temporary depression. It’s time to see your health-care provider and get treatment as you would for any other illness.

We all live with occasional stress. Since college students often feel even more stress than most people, it’s important to understand it and learn ways to deal with it so that it doesn’t disrupt your life. Stress is a natural response of the body and mind to a demand or challenge. The thing that causes stress, called a stressor, captures our attention and causes a physical and emotional reaction. Stressors include physical threats, such as a car we suddenly see coming at us too fast, and the stress reaction likely includes jumping out of the way—with our heart beating fast and other physical changes. Most of our stressors are not physical threats but situations or events like an upcoming test or an emotional break-up. Stressors also include long-lasting emotional and mental concerns such as worries about money or finding a job.

What Causes Stress?

Not all stressors are bad things. Exciting, positive things also cause a type of stress, called eustress. Falling in love, getting an unexpected sum of money, acing an exam you’d worried about—all of these are positive things that affect the body and mind in ways similar to negative stress: you can’t help thinking about it, you may lose your appetite and lie awake at night, and your routine life may be momentarily disrupted. But the kind of stress that causes most trouble results from negative stressors.

Life events that usually cause significant stress include the following:

• Serious illness or injury
• Serious illness, injury, or death of a family member or loved one
• Losing a job or sudden financial catastrophe
• Unwanted pregnancy
• Divorce or ending a long-term relationship (including parents’ divorce)
• Being arrested or convicted of a crime
• Being put on academic probation or suspended

Life events like these usually cause a lot of stress that may begin suddenly and disrupt one’s life in many ways. Fortunately, these stressors do not occur every day and eventually end—though they can be very severe and disruptive when experienced. Some major life stresses, such as having a parent or family member with a serious illness, can last a long time and may require professional help to cope with them.

Everyday kinds of stressors are far more common but can add up and produce as much stress as a major life event:

• Anxiety about not having enough time for classes, job, studies, and social life
• Worries about grades, an upcoming test, or an assignment
• Money concerns
• Conflict with a roommate, someone at work, or family member
• Anxiety or doubts about one’s future or difficulty choosing a major or career
• Frequent colds, allergy attacks, other continuing health issues
• Concerns about one’s appearance, weight, eating habits, and so on.
• Relationship tensions, poor social life, loneliness
• Time-consuming hassles such as a broken-down car or the need to find a new apartment

Thought Exercise

Take a moment and reflect on the list above. How many of these stressors have you experienced in the last month? The last year? What additional things cause stress?

How many stressors have you thought of? There is no magic number of stressors that an “average” or “normal” college student experiences—because everyone is unique. In addition, stressors come and go: the stress caused by a midterm exam tomorrow morning may be gone by noon, replaced by feeling good about how you did. Still, most college students are likely to experience about half the items on this list. But it’s not the number of stressors that counts. You might have only one item on that list—but it could produce so much stress for you that you’re just as stressed out as someone else who has all of them. The point of this thought exercise is to start by understanding what causes your own stress as a base for learning what to do about it.

What’s Wrong with Stress?

Physically, stress prepares us for action: the classic “fight-or-flight” reaction when confronted with a danger. Our heart is pumping fast, and we’re breathing faster to supply the muscles with energy to fight or flee. Many physical effects in the body prepare us for whatever actions we may need to take to survive a threat. But what about nonphysical stressors, like worrying about grades? Are there any positive effects there? Imagine what life would feel like if you never had worries, never felt any stress at all. If you never worried about grades or doing well on a test, how much studying would you do for it? If you never thought at all about money, would you make any effort to save it or make it? Obviously, stress can be a good thing when it motivates us to do something, whether it’s study, work, resolving a conflict with another, and so on. So it’s not stress itself that’s negative—it’s unresolved or persistent stress that starts to have unhealthy effects.

Chronic (long-term) stress is associated with many physical changes and illnesses, including the following:

• Weakened immune system, making you more likely to catch a cold and to suffer from any illness longer
• More frequent digestive system problems, including constipation or diarrhea, ulcers, and indigestion
• Elevated blood pressure
• Increased risk of diabetes
• Muscle and back pain
• More frequent headaches, fatigue, and insomnia
• Greater risk of heart attack and other cardiovascular problems over the long term

Chronic or acute (intense short-term) stress also affects our minds and emotions in many ways:

• Difficulty thinking clearly or concentrating
• Poor memory
• More frequent negative emotions such as anxiety, depression, frustration, powerlessness, resentment, or nervousness—and a general negative outlook on life
• Greater difficulty dealing with others because of irritability, anger, or avoidance

No wonder we view stress as such a negative thing! As much as we’d like to eliminate all stressors, however, it just can’t happen. Too many things in the real world cause stress and always will.

Unhealthy Responses to Stress

Since many stressors are unavoidable, the question is what to do about the resulting stress. A person can try to ignore or deny stress for a while, but then it keeps building and starts causing all those problems. So we have to do something. Consider first what you have typically done in the past when you felt most stressed. Here are a few examples of how college students have responded to stress.

• Drinking alcohol
• Drinking lots of coffee
• Sleeping a lot
• Eating too much
• Eating too little
• Smoking or drugs
• Having arguments
• Sitting around depressed
• Watching television or surfing the Web
• Complaining to friends
• Exercising, jogging, biking
• Practicing yoga or tai chi
• Using relaxation techniques
• Talking with an professor or counsellor

What’s wrong with the first ten stress-reduction behaviors listed first? Why not watch television or get a lot of sleep when you’re feeling stressed, if that makes you feel better?

While it may feel better temporarily to escape feelings of stress in those ways, ultimately they may cause more stress themselves. If you’re worried about grades and being too busy to study as much as you need to, then letting an hour or two slip by watching television will make you even more worried later because then you have even less time. Eating too much may make you sluggish and less able to focus, and if you’re trying to lose weight, you’ll now feel just that much more stressed by what you’ve done. Alcohol, caffeine, smoking, and drugs all generally increase one’s stress over time. Complaining to friends? Over time, your friends will tire of hearing it or tire of arguing with you because a complaining person isn’t much fun to be around. So eventually you may find yourself even more alone and stressed.

Yet there is a bright side: there are lots of very positive ways to cope with stress that will also improve your health, make it easier to concentrate on your studies, and make you a happier person overall. The last five items on our list are more positive ways to cope.

Coping with Stress

Think about your list of stressors. For each, consider whether it is external (like bad job hours or not having enough money) or internal, originating in your attitudes and thoughts.

You may be able to eliminate many external stressors. Talk to your boss about changing your work hours. If you have money problems, work on a budget you can live with, look for a new job, or reduce your expenses by finding a cheaper apartment, selling your car, and using public transportation.

What about other external stressors? Taking so many classes that you don’t have the time to study for all of them? Keep working on your time management skills. Schedule your days carefully and stick to the schedule. Take fewer classes next term if necessary. What else can you do to eliminate external stressors? Change apartments, get a new roommate, find better child care — consider all your options. And don’t hesitate to talk things over with one of our counsellors, who may offer other solutions.

Internal stressors, however, are often not easily resolved. We can’t make all stressors go away, but we can learn how to cope so that we don’t feel so stressed out most of the time. We can take control of our lives. We can find healthy coping strategies.

All the topics in this section involve stress one way or another. Many of the healthy habits that contribute to our wellness and happiness also reduce stress and minimize its effects.

Get Some Exercise

Exercise, especially aerobic exercise, is a great way to help reduce stress. Exercise increases the production of certain hormones, which leads to a better mood and helps counter depression and anxiety. Exercise helps you feel more energetic and focused so that you are more productive in your work and studies and thus less likely to feel stressed. Regular exercise also helps you sleep better, which further reduces stress.

Get More Sleep

When sleep deprived, you feel more stress and are less able to concentrate on your work or studies. Many people drink more coffee or other caffeinated beverages when feeling sleepy, and caffeine contributes further to stress-related emotions such as anxiety and nervousness.

Manage Your Money

Worrying about money is one of the leading causes of stress.

Adjust Your Attitude

You know the saying about the optimist who sees the glass as half full and the pessimist who sees the same glass as half empty. Guess which one feels more stress? Much of the stress you feel may be rooted in your attitudes toward school, your work—your whole life. If you don’t feel good about these things, how do you change?

To begin with, you really need to think about yourself. What makes you happy? Are you expecting your college career to be perfect and always exciting, with never a dull class or reading assignment? Or can you be happy that you are in fact succeeding in college and foresee a great life and career ahead? Maybe you just need to take a fun elective course to balance that “serious” course that you’re not enjoying so much. Maybe you just need to play an intramural sport to feel as good as you did playing in high school. Maybe you just need to take a brisk walk every morning to feel more alert and stimulated. Maybe listening to some great music on the way to work will brighten your day. Maybe calling up a friend to study together for that big test will make studying more fun. No one answer works for everyone—you have to look at your life, be honest with yourself about what affects your daily attitude, and then look for ways to make changes. The good news is that although old negative habits can be hard to break, once you’ve turned positive changes into new habits, they will last into a brighter future.

Learn a Relaxation Technique

Different relaxation techniques can be used to help minimize stress. Following are a few tried-and-tested ways to relax when stress seems overwhelming. You can learn most of these through books, online exercises, CDs or MP3s, and DVDs available at your library or student services offices. Practicing one of them can have dramatic effects.

• Deep breathing. Sit in a comfortable position with your back straight. Breathe in slowly and deeply through your nose, filling your lungs completely. Exhale slowly and smoothly through your mouth. Concentrate on your breathing and feel your chest expanding and relaxing. After five to ten minutes, you will feel more relaxed and focused.
• Progressive muscle relaxation. With this technique, you slowly tense and then relax the body’s major muscle groups. The sensations and mental concentration produce a calming state.
• Meditation. Taking many forms, meditation may involve focusing on your breathing, a specific visual image, or a certain thought, while clearing the mind of negative energy. Many podcasts are available to help you find a form of meditation that works best for you.
• Yoga or tai chi. Yoga, tai chi, and other exercises that focus on body position and slow, gradual movements are popular techniques for relaxation and stress reduction. You can learn these techniques through a class, online or from a DVD.
• Music and relaxation CDs and MP3s. Many different relaxation techniques have been developed for audio training. Simply play the recording and relax as you are guided through the techniques.
• Massage. Regular massages are a way to relax both body and mind. If you can’t afford a weekly massage but enjoy its effects, a local massage therapy school may offer more affordable massage from students and beginning practitioners.

Get Counselling

If stress is seriously disrupting your studies or your life regardless of what you do to try to reduce it, you may need help. There’s no shame in admitting that you need help, and college counsellors and health professionals are there to help.

Tips for Success: Stress

• Pay attention to, rather than ignore, things that cause you stress and change what you can.
• Accept what you can’t change and resolve to make new habits that will help you cope.
• Get regular exercise and enough sleep.
• Evaluate your priorities, work on managing your time, and schedule restful activities in your daily life. Students who feel in control of their lives report feeling much less stress than those who feel that circumstances control them.
• Slow down and focus on one thing at a time—don’t check for e-mail or text messages every few minutes! Know when to say no to distractions.
• Break old habits involving caffeine, alcohol, and other substances.
• Remember your long-range goals and don’t obsess over short-term difficulties.
• Make time to enjoy being with friends.
• Explore new activities and hobbies that you enjoy.
• Find a relaxation technique that works for you and practice regularly.
• Get help if you’re having a hard time coping with emotional stress.

What is Good2Talk?

Good2Talk is a free, confidential helpline providing professional counselling and information and referrals for mental health, addictions and well-being to post-secondary students in Ontario, 24/7/365.

If you are dealing with anxiety, depression, loneliness or stress, talking with a professional about it can help. The Good2Talk professionals are available day and night to talk to you whenever you need to. They can also help you with referrals to local resources and professionals for further support which can be helpful if you are studying away from home.

Good2Talk Helpline for postsecondary students 1-866-925-5454

Key Takeaways

• Emotional balance starts with being aware of your emotions and understanding them, balancing the negative with the positive.
• Anxiety and Depression are common emotions we all feel at one time or another, if you are experiencing serious anxiety or depression, seek help from your healthcare professional or a college counsellor just like you would for any other illness.
• Loneliness is a normal feeling college students can experience in a new education setting. Getting involved in the college community, staying in touch with friends and family, and study with classmates are excellent coping strategies. If you are having difficulty making new friends or dealing with loneliness, see a college counsellor for assistance.
• Stress is a natural response to a demand or challenge. Stress can be good if it motivates you to action. Chronic or acute stress can cause unhealthy responses. Learning to cope with stress in a positive way can maintain and improve your health emotionally and physically.

A Guide for Successful Students Copyright © 2019 by St. Clair College is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

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Existential Well-being, Mental Health, and COVID-19: Reconsidering the Impact of Lockdown Stressors in Moscow.

Author information, affiliations.

• Klimochkina AY 1
• Nekhorosheva EV 2
• Kasatkina DA 2

ORCIDs linked to this article

• Nekhorosheva EV | 0000-0002-1243-4223
• Kasatkina DA | 0000-0002-5248-5367

Psychology in Russia : State of the art , 15 Jun 2022 , 15(2): 14-31 https://doi.org/10.11621/pir.2022.0202   PMID: 36699708  PMCID: PMC9833610

Abstract 

Free full text .

Existential Well-being, Mental Health, and COVID-19: Reconsidering the Impact of Lockdown Stressors in Moscow

Anastasia y. klimochkina.

a HSE University, Moscow, Russia

Elena V. Nekhorosheva

b Moscow City University, Moscow, Russia

Daria A. Kasatkina

Initial psychological papers on COVID-19, mental health and wellbeing mostly focus on the aftermath lockdown-related stress and stress related to the disease itself. Still, we presume that personal well-being can be resistant to stressors depending on the way the person is settled in their life.

We seek to reconsider the contribution of lockdown-related stressors to existential well-being, to assess existential well-being during the outbreak and to compare the contribution of living conditions and COVID-19-related factors on well-being.

An online survey was conducted during the peak of the outbreak in Moscow (April-May 2020) (N=880). The data was obtained using the “Test of Existential Motivations” questionnaire and a series of questions addressing (1) living conditions — mental and physical health, employment, and social distancing; (2) COVID-19-related stressors — non-chronic illness, financial losses, and unavailability of goods or services; (3) sociodemographic indicators — age, gender, and income. Data analysis included hierarchical multiple regression, one-sample t-test, and analysis of variance.

Surprisingly, the existential well-being of Moscow citizens during the research period was moderate. Each of the three groups of factors predicted a similar proportion of the variance of well-being (3-3,9%). The strongest predictors of well-being were long-term mental health status and financial stability. The effect of COVID-19-related stressors was most pronounced when they co-occur.

The negative association between lockdown-related stressors and poor well-being is not universal. It is necessary to study the effect of COVID-19-related stressors in combination with individual living conditions and region-specific factors and to focus on the prevention of the occurrence of stressors.

• Introduction

The COVID-19 pandemic generated social and psychological changes globally. Mental health specialists have been registering various behavioral and psychological challenges, such as hoarding behavior, emotional eating, dependencies, anxiety, and depression ( Banerjee, 2020 ; Barcın-Güzeldere, 2022 ; Rajkumar, 2020 ; Talevi et al., 2020 ; Zandifar & Badrfam, 2020 ). The negative impact of the pandemic on mental health was observed during various “waves” of the pandemic and was considered more harmful than other stressful events ( Olff et al., 2021 ). Some researchers noticed a delayed or cumulative effect of the pandemic on people’s well-being (Zacher and Rudolph, 2020).

Many scientists have stated that the COVID-19 pandemic, lockdown, and situational factors such as harsh security measures, self-isolation, fear of being infected, a lack of relevant information, loneliness, boredom, and financial troubles, negatively affected people’s mental health ( Capuzzi et al., 2020 ; Newby et al., 2020 ; Rajkumar, 2020 ; Satici et al., 2020 ; Tian et al., 2020 ; Yıldırım et al., 2020 ). Though many scholars observed similar mental health issues across different countries, the effects of lockdown on well-being differed. Ausín et al. (2021), comparing Spanish and Russian general populations, stated that loneliness and alienation, as a tendency to gain social support from family only, were more pronounced among the Russian population.

Some researchers have highlighted that a person’s lifestyle and level of life satisfaction before the onset of COVID-19 could predict how they would feel during the pandemic ( Hoffman, 2020 ; Trzebiński et al., 2020 ; Yang, 2020 ). Sutin et al. (2020) noted that people remain resilient in the face of catastrophic events despite the stress they cause, at least in the short term.

We aim to reconsider the contribution of lockdown-related stressors to the level of existential well-being. Our goal was to compare the contributions of long-term and short-term (lockdown-related) factors affecting self-reported existential well-being, and to assess the level of Muscovites’ well-being during the most stressful period of the pandemic. We hypothesized that, despite initial studies of the psychological effects of the pandemic, long-term factors were more significant for existential wellbeing than short-term stressors and that the well-being of the participants would not be poor.

COVID-19 in Russia: Background

COVID-19 began to spread in Russia at the end of January 2020 (Mankoff, 2020). Lockdown restrictions varied from region to region and according to morbidity levels. In Moscow, which has a registered population of around 12.5 million, a high-alert regime was imposed on March 5 th , while the morbidity was still low (Moscow Government, 2020a). Moscow residents were obliged to inform the authorities of their condition and self-isolate for 14 days after returning from abroad. The authorities canceled all public events with over 5,000 participants. By March 12 th , there were 25 new cases in Moscow and the Moscow Region, compared with 45,000 cases with 4,917 deaths worldwide.

A strict lockdown was introduced in Moscow on April 15 th ( Moscow Government, 2020b ). Following this, residents were required to stay at home or use a digital pass for any travel. A shortage problem and a temporary price increase occurred for certain goods, including medicines, medical masks, and antiseptics. Temporary hospitals were opened. Students began to study online.

Morbidity reached its height by May 7 th , with 6,703 new cases and 39 deaths in Moscow and 842 new cases and 15 deaths in the Moscow Region. Moscow authorities introduced one-time payments to support families with children, pensioners, and the unemployed and provided a COVID-19 hotline on the Moscow Mayor’s official webpage. Most employees started to work remotely ( Nekhorosheva et al., 2020 ), and business tax holidays were introduced.

By June 9 th , the morbidity level in Moscow decreased to 1,500 new cases and 12 deaths, compared with 7.3 million global cases, with a daily increase of 124,700 cases and 32,474 deaths. Moscow authorities gradually put an end to lockdown restrictions and canceled digital passes, many small businesses and services reopened.

Understanding Mental Health and Well-being: An Existential Approach

Well-being is a core concept in mental health science. According to the World Health Organization (WHO, 2001, 2018), mental health is both absence of mental disorders and a state of emotional, mental, and behavioral well-being that allows for adaptation to everyday life. Mental health implies the ability to deal with the stressors of daily life, fulfill one’s potential, and work fruitfully (WHO, 2013). The pandemic has drastically altered several societal fundamentals, such as security of life, reliability of public institutions, and freedom of movement and communication. We take an existential approach to assessing these fundamental changes. Existential models allow us to consider the psychological characteristics of a person’s quality of life by assessing their interaction with external life circumstances ( Längle, 1993 ; Längle & Klaassen, 2019 ).

Anxiety about one’s mortality (death anxiety) is a fundamental concept in existential psychology ( Frankl, 1992 ; Yalom, 1980 , 2008), which is thrust to the forefront of our minds due to awareness of the threat posed by the virus. For example, Tomaszek and Muchacka-Cymerman (2020) studied the mediating effect of existential anxiety and life satisfaction on the relationship between PTSD symptoms and post-traumatic growth during the pandemic. Existential psychology understands wellbeing as fulfillment, perceiving life as good, having inner consent to life’s conditions and limitations, and choosing an authentic way of life ( Längle, 2003 ). An existentially prosperous person can cope with everyday tasks, build warm relations with themselves and others, have healthy emotions, be authentic and productive, and make meaningful contributions to the future ( Längle, 2011 , 2014).

Theoretical Model: Three Groups of Factors Impacting Existential Well-being During COVID-19

Applying an existential approach, we identified three groups of factors that could predict the psychological fallout of lockdown.

The first group includes the sociodemographic features that influence social status and living conditions — age, gender, monthly household income. According to researchers, females, children, adolescents, and the elderly are prone to anxious or depressive reactions during the pandemic ( Brooks et al., 2020 ; Fernández-Castillo et al., 2021 ; Inchausti et al., 2020 ; Rajkumar, 2020 ; Yenan Wang et al., 2020 ). Women who have experienced traumatic events are more likely to develop anxiety symptoms ( Cai et al., 2021 ; Remes et al., 2016 ). Women and the elderly were more open to help-seeking behavior ( MacKenzie et al., 2008 ; Mojtabai et al., 2002 ). Researchers stress the differences in “socially acceptable methods of coping with stress and care-seeking rates for mental disorders between men and women” ( Cabrera-Mendoza et al., 2020 , p. 68). People with lower incomes could suffer from fear and stigmatization ( Tian et al., 2020 ). All this justifies the inclusion of this group of factors into the model as control variables.

The second group refers to ongoing living conditions and individual way of life. It includes (1) mental health status (diagnosed psychiatric conditions such as depression and anxiety), (2) physical health status (chronic physical conditions such as hypertension, lung disease, and heart disease), (3) working status (employment of any type, or non-working status including being a housewife, student, or pensioner), and (4) self-isolation or social distancing (the degree of changes in personal daily life and behavior caused by the lockdown restrictions).

Tian et al. (2020) demonstrated that employment, financial problems, lower levels of education, and migrant status had affected the mental health of Chinese citizens, while mental health literacy among Chinese college students was associated with lower stress and anxiety levels ( Hu et al., 2021 ). The impact of poor health conditions, specifically diagnosed mental disorders, has been noted in COVID-19 studies in different countries ( Newby et al., 2020 ). The relevance of self-isolation behavior has also been widely discussed (Rubin & Wessely, 2020; Taylor, 2019 ). For example, Talevi et al. (2020) found that increased length and severity of quarantine was associated with increased anxiety, depression, coping strategies, and stigmatization.

Situational stressors constitute the third group of factors in our model. A psychological stressor is a “life situation that creates an unusual or intense level of stress that may contribute to the development or aggravation of mental disorders, illness, or maladaptive behavior” ( VandenBos, 2015 , p. 1204). We study the following situational COVID-19-related stressors: health, financial complications, and lockdown.

The first stressor is becoming infected with COVID-19 or having a family member infected. Fear of death, loss of loved ones, damage to health, and lack of information (the so-called “headline stress disorders’’) can provoke a stress reaction. People diagnosed with COVID-19 experienced different mental outcomes depending on the severity of the disease and quarantine conditions — from anxiety, shame, and stigmatization ( Tian et al., 2020 ), to post-traumatic stress symptoms ( Bo et al., 2020 ). People who did not suffer COVID-19 experienced the emergence of defensive mechanisms, panic, and various anxiety-related reactions due to abundant or controversial reports about regarding virus and the epidemiological situation ( Cuiyan Wang et al., 2020 ; Dong & Zheng, 2020 ; Zandifar & Badrfam, 2020 ).

The second stressor is the economic crisis which creates financial losses, unemployment, and unpredictability. This stressor leads to social fears, xenophobia, detachment, anxiety, and depressive disorders ( Banerjee, 2020 ; Talevi et al., 2020 ).

The third stressor is the lockdown itself, manifested in restrictions, loss of freedom, social distancing, lack of social contacts, routine changes, and inaccessibility of some basic supplies. It triggers various feelings (anger, irritation, confusion, anxiety, loneliness), post-traumatic stress symptoms, and other severe psychological and behavioral deviations, such as suicidality, dependencies, and somatization ( Banerjee, 2020 ; Bo et al., 2020 ; Brooks et al., 2020 ; Inchausti et al., 2020 ; Roy et al., 2020 ; Talevi et al., 2020 ; Yenan Wang et al., 2020 ).

This study aims to assess the existential well-being of Muscovites during the lockdown period and compare the contribution of the participants’ living conditions and COVID-19-related factors on well-being. We hypothesized that factors relating to long-term and ongoing life events would have a more significant impact on existential well-being than short-term stressors and that the participants’ well-being would not be poor.

In order to test this hypothesis, we compared the unique contributions of two groups of factors (ongoing living conditions and situational COVID-19-related stressors) towards levels of existential well-being, while controlling sociodemographic variables. The factors were structured so as to compare the relevance of long-term dispositions and short-term stressors in the same areas of life: (1) health, (2) work, and (3) state of social distancing during the pandemic. Each factor is treated as an independent variable, while the dependent variable is existential fulfillment as a measure of well-being ( Shumskiy et al., 2017 ; Shumskiy & Klimochkina, 2018 ).

We used a cross-sectional research design. The quantitative data was collected using verbal questionnaires based on self-reports. The survey was conducted online due to lockdown restrictions.

Participants

The raw sample consisted of 1839 unique answers, before the following exclusion criteria were applied:

Agreement for the processing of personal data.

No missing data (all fields were filled).

Using the answer “prefer not to say” in the question about monthly family income.

The final sample consisted of 880 participants (9.2% male, 90.8% female; M age = 39.55 years, SD = 10.33, range = 17–75 years) (see Table 1 ).

Sample characteristics (N=880)

The average monthly family income (50 000–100 000 RUB 1 ) was reported by 47.5% of respondents, 29.5% reported a subsistence level of income for a two-person family living in Moscow (< 50 000 RUB), 23% had a high level of income (> 100 000 RUB). The respondents exhibited good health: only 4% had been diagnosed with neuropsychological conditions (depression, anxiety, or other) at the time of the survey; 33% had chronic physical conditions (heart disease, lung disease, or other). Concerning working status, most were employed (70%), while 30% were non-working, including housewives, students, pensioners, and persons with disabilities. As for self-isolation status, 68% maintained a reasonable degree of self-isolation, 8% supported all restrictive prescriptions, and 24% reported they had not changed their routine during the pandemic. Respondents faced the following COVID-19-related stressors: 3% fell ill themselves (any infection) or had a family member fal ill; 30% faced a decrease in earnings or job loss; 41% faced the unavailability of goods, medicines, or services during the lockdown.

The study was approved by the Psychological and Pedagogical Research Ethics Committee (PPREC) of the Institute of Pedagogy and Psychology of Education (Moscow City University) on 01/04/2020. The online questionnaire was made on the Survey-Monkey platform. The participants were provided with the web-link sent through urban parental and professional communities (such as academic, pedagogical, medical, and law enforcement communities) using social networks and messengers. Participation in this study was voluntary and anonymous. Participants were also asked to provide electronic consent for the processing of personal data.

The target sample was used, in accordance with the target audience — Muscovites (“living in Moscow”). According to the Federal State Statistics Service, 12.6 million people were living in Moscow by 2020. With the sample reliability of 99%, our sample size ( N= 880) was sufficient. Also, it was important to represent people of different gender, age, occupation, and social status, as well as to comprehensively cover the working part of the city’s population, since changes in the working status and income were expected to be one of the consequences of the pandemic.

The survey was conducted from April 19 th to May 18 th , during the time when citizens were obliged to use digital passes, avoid public places (including schools and kindergartens), wear medical masks, and maintain self-isolation. Most of the data was collected during the first COVID-19 wave in Moscow (from April 27 th to May 3 rd ), when restrictions were tightest.

Statistical analysis

We used R-studio and SPSS software to perform the statistical analysis:

One-sample t-test to examine the difference between the sample mean and the standard TEM values for the Russian population.

Hierarchical multiple regression to explore the relationship between existential well-being as a dependent variable and the three groups of independent variables: (1) sociodemographic indicators (as controlled variables), (2) ongoing life conditions, and (3) COVID-19-related stressors. Variables were included in each of the groups of factors in accordance with the theoretical model. This analysis allowed us to measure the contribution of COVID-19-related stressors against the long-term living conditions of the respondents. Thus, we could test the claim of whether COVID-19-related stressors had a universally harmful effect, and identify the stressors to which respondents were most sensitive.

ANOVA was used to further refine the relationship between categorical variables (and their interactions) and existential well-being.

Questionnaires

Existential well-being was measured using the Test of Existential Motivations questionnaire (TEM) ( Shumskiy et al., 2017 ) based on Längle’s theory of four fundamental existential motivations ( Längle, 2016 ). The questionnaire consisted of 36 items (24 were reverse-scored and 12 straight), 4 subscales (with 9 items in each scale), and one summarizing indicator. Each item was assessed using a Likert scale over a range of 1 to 4, where 1 = “ strongly disagree ”, 2 = “ disagree ”, 3 = “ agree ”, and 4 = “ strongly agree ”. Each subscale represented the prerequisites for existential fulfillment — fundamental motivations (FM): 1 FM referred to fundamental trust; 2 FM referred to the fundamental value of life; 3 FM referred to the authenticity and fundamental self-value, and 4 FM referred to the meaning of life. Due to the need for further confirmation of the factor structure of the questionnaire subscales, this study used only an aggregated indicator of existential well-being.

Other variables were evaluated by direct questions:

Sociodemographic characteristics were assessed using questions on matters of gender, age, and family monthly income. The option “prefer not to say” was available for the question regarding income.

Ongoing life conditions were measured using questions concerning:

Mental health status: “Do you have any clinically diagnosed mental disorders, such as depression, anxiety disorder, or other clinically diagnosed mental disorder?” (1 = yes , 0 = no ).

Physical health status: “Do you have any clinically diagnosed chronic physical disorders, such as hypertonic disease, diabetes, heart diseases, lung disease (including asthma, COPD, etc.), oncological diseases, disability, or mobility limitation, or other clinically diagnosed chronic diseases or vulnerable states?” (1 = yes , 0 = no ).

Working status: “Are you currently employed?” (1 = yes , 0 = no ).

Social distancing status: “How would you describe your current routine during lockdown?” Respondents were asked to choose from three options: (1) “I am on strict self-isolation or quarantine, I don’t leave home and follow all the authorities’ guidance”; (2) “I can leave home if necessary, following authorities’ guidance on self-isolation and social distancing”; (3) “I am moving freely around the city, and nothing has changed in my daily routine”.

Situational COVID-19-related stressors were measured with the question: “For the last seven days, have you experienced any of the following?”: (1) “I or my family members have become ill (any illness) and/or had to see a doctor” (1 = yes , 0 = no ); (2) “financial loss, a reduction in earnings or job loss” (1 = yes , 0 = no ); (3) “the unavailability of goods, medicines or services” (1 = yes , 0 = no ).

We used a one-sample t-test to examine the difference between the sample mean and the value established by the norms of the TEM test for the total Russian population, including Moscow (see Table 2 ).

Summary of One Sample T-Test for the Level of Existential Well-being (fulfillment)

Note. *** p < 0.00

The mean in the Moscow sample during the lockdown period turned out to be significantly higher than TEM norms. Although the difference was significant, its effect size was relatively small (Cohen’s d = 0.249).

We used hierarchical multiple regression to explore the relationship between existential well-being as a dependent variable and the three groups of independent variables (see Table 3 ).

Summary of Hierarchical Regression Analysis Estimating the Level of Existential Well-being (N = 880)

Note. a 0 = male, 1 = female. b 0 = subsistence level, 1 = middle level, 2 = high level. c 0 = no diagnosed conditions, 1 = have diagnosed conditions. d 0 = non-working, 1 = working/employed. e 0 = no self-isolation/distancing, 1 = strict self-isolation, 2 = reasonable distancing. f 0 = no stressful situations 1 = faced illness. g 0 = no stressful situations 1 = faced financial loss or job loss. h 0 = no stressful situations 1 = faced unavailability of goods or services. *p < .05. **p < .01. ***p < .001

Categorical variables with multiple categories were transformed into dummy variables. Three models were created with factors added sequentially to each model, while controlling the previous ones. The fourth model was the most complete due to the inclusion of the interaction of the variables; it was created to achieve maximum model fit.

The coefficients of determination show that all three groups of factors predict a similar proportion of the variance in the measured well-being (ΔR-squared model 1 = .039, ΔR-squared model 2 = .035, ΔR-squared model 3 = .033). However, the most complete model explains 11.4% of the variance in existential well-being. Adjusted coefficients of determination make it possible to compare models, since they consider the number of explanatory variables and the number of observations. We see that the fourth model, which considers the interaction of stressors, is the most accurate of the four presented models (Adjusted R-squared = .101).

The models allow us to estimate the significance of each factor. In the first group of factors, age and household monthly income were statistically significant. In the second group, working status was significantly positively related to well-being, while health conditions were negatively related. The negative effects of mental diseases were greater than those of physical diseases. Social distancing caused by the lockdown was not significant as a separate variable nor in its interaction with others. Problems caused by a job loss or a reduction in earnings and lockdown-related stressors were statistically significant.

Standardized regression coefficients allow us to compare the strength of the effect of each independent variable to the dependent variable. Based on the most complete model, the negative factors had the greatest effect: mental health status ( β = –.16), financial stressors ( β = –.15), and interaction of health stressors and lockdown stressors ( β = –.14).

The interaction of variables was discovered by a combination of two stressors. The unavailability of goods or services moderated the connection between illness in the family and existential well-being. Increasing the moderator increased the effect of the predictor: having an ill family member did not produce a significant effect if the respondent could receive all the necessary assistance and medicines; but when these two stressors co-occurred, a significant decrease in well-being level was revealed.

ANOVA was used to determine whether the explanatory variables and their interactions were related to the dependent variable. The relevance of income appeared to be most prominent when comparing the difference between respondents who had a high household income and those whose income was close to the subsistence level ( F = 11.186, p Tukey = < .001, Cohen’s d = 0.449). Respondents with higher income levels report a higher level of well-being, even during the pandemic. Upon comparison of groups by physical health status, no significant differences in well-being were observed ( F = 0.354, p = .552, Cohen’s d = 0.043), while mental health had a greater effect ( F = 28.465, p = < .001, Cohen’s d = 0.976). Working status was also a significant factor ( F = 13.226, p = < .001, Cohen’s d = 0.267). The analysis of variance showed that being employed was associated with existential well-being, regardless of the respondent’s social status and income. Respondents who faced financial difficulties during the final week of lockdown more clearly demonstrated lower well-being ( F = 24.183, p = < .001, Cohen’s d = –0.365).

Assessing the existential well-being

The average of the Muscovites’ well-being during the lockdown was higher than the average TEM test scores as calculated for the general Russian population during an ordinary period. We assume either that initially high existential well-being in Moscow decreased during the pandemic but remained higher than in the whole of Russia, or that the existential well-being had not decreased at all. It is possible that the wellbeing of citizens has not declined due to changes brought about by the pandemic. Several other studies conducted in Russia at the beginning of the pandemic give further grounds for such an assumption.

Rasskazova et al. (2020) compared the well-being level between a group of 409 healthy adults in the period from April 17 th to April 26 th 2020, and three samples of 98, 66, and 293 people who completed the same tests (Satisfaction with Life Scale and Scale of Positive and Negative Experiences) in 2017 and 2019. Their results showed no differences between groups in the level of life satisfaction, although the intensity of positive emotions decreased. Some studies in other countries show similar data. The longitudinal study by Fernández-Abascal and Martín-Díaz (2021) comparing the level of well-being of Spanish adults throughout different weeks (a typical week, the week before the lockdown, and a week during the lockdown). They reviewed no progressive decrease of psychological well-being in either gender group over time. At the same time, the authors note that positive affects progressively decrease, while negative affects remain stable without increasing over time.

However, the results of global studies on well-being at the start of the pandemic remain conflicting. For example, Zhang et al. (2020) collected data on the well-being of 2231 adults living in 454 counties across 48 states in the US where the severity of the pandemic varied. The research was based on an analysis of Twitter profiles and tweets posted between April 1 st and April 24 th . They found that pandemic severity gave rise to negative affects in adults (such as feeling scared, hostile, and nervous) rather than positive affects (such as excitement and enthusiasm), and the relationship between pandemic severity and the negative affects was moderated by personality and family connectedness. An Australian study by van Agteren et al. (2020) , comparing the level of well-being (Satisfaction with Life Scale and MHC-SF), stress, and anxiety during the lockdown period, between March-April 2020, with the same indicators used from February 2019 to February 2020, showed that well-being and resilience were significantly lower during the period of the pandemic. In a study of Italian population stress and well-being during the pandemic, Rania & Coppola (2021) observed a decrease in well-being and mental health, regardless of gender differences and of whether or not participants had had direct contact with the virus.

We can see that the research results are not consistent due to the complexity of the phenomenon of well-being, a variety of measuring instruments, and the differences in lockdown conditions in different countries (and even within regions of one country). Thus, the conclusions about the greater or lesser significance of lockdown stressors cannot be universal.

If the level of well-being of Moscow citizens did not decrease, what could have determined its sustainability at the beginning of the pandemic? Under the existential approach, the absence of a decline may indicate the resistance of this form of well-being to situational changes. According to Längle (1993) , existential fulfillment is the result of living with “inner consent”. During the measurement period, many residents had hope that the pandemic would recede in the summer and the stressors could seem like a challenge requiring a personal response. Lockdown created a new personal experience in many ways. Many residents began to pay more attention to their interests and communication with loved ones. These factors could support the inner consent and may have contributed to sustainability of existential well-being.

This result may also have occurred due to sample specifics. Moscow is a prosperous and wealthy city with an advanced social support system that had introduced additional support measures during the pandemic. It is possible that the citizen’s wellbeing in Moscow was higher before the pandemic and decreased under its influence but remained higher than in Russia as a whole. Clarification of this result provides an opportunity for future research.

Also, Pervichko et al. (2020) indicate that many Russians perceived COVID-19 as a “disease of the elite” at the beginning of pandemic. They believed that those affected were people who have opportunity to travel abroad (the entry route of the virus to Russia) and spend more time in informal communication, not limited by social distancing. The authors report that 38% of participants think the danger of COVID-19 is exaggerated.

Finally, the participants of the online studies can be assigned specific characteristics: they are socially active, well adapted to the online space and stay more connected to others. These factors are common for all online research ( Payne & Barnfather, 2011 ), but during self-isolation, the opportunity to communicate online could significantly support the well-being of participants. However, clarifying the actual impact of these limitations requires testing additional hypotheses in future research.

The effects of COVID-19-related stressors

We aimed to assess the impact of specific pandemic-related difficulties on Moscow citizens’ existential well-being. Ongoing living conditions and COVID-19-related stressors did not affect well-being as we expected. All groups of factors showed approximately equal statistical significance but had relatively weak explanatory power regarding existential well-being. Thus, both COVID-19-related stressors and ongoing living conditions predict well-being to a certain extent, but other factors were not measured in this study. This result emphasizes the importance of not neglecting both factors for predicting well-being: understanding the way a person is settled in life at a basic level is just as important as information about the difficulties that a person faced during the specific crisis.

Among the variables included in the group of long-term ongoing factors, the most significant was mental health. This result shows the crucial importance of taking a person’s mental state into account in well-being research. This finding is consistent with other studies, revealing that participants with self-reported mental health diagnoses had significantly higher distress, health anxiety, and fears of COVID-19 than those without a mental health diagnosis ( Newby et al., 2020 ). However, given the small number (N = 31) of respondents diagnosed with mental conditions in our sample, this contrast should be treated with caution.

The most significant of the studied stressors were financial losses (a reduction in earnings or job loss) in the final week of lockdown and the co- occurrence of two stressors — illness and the unavailability of necessary services and medicines.

The importance of stable employment in times of change is shown. Similar results are discussed by Blustein and Guarino (2020) : job loss provokes existential anxiety that has psychological consequences. Prime et al. (2020) emphasize that financial stability is one of the conditions for maintaining a safe living environment and therefore crucial for subjective well-being. From an existential-psychological perspective, support, a protected private space, reliability, and confidence in the future are prerequisites for well-being.

The discovered interaction of two stressors is interesting for the field of social welfare planning. Any physical illness that the respondent or someone in their family suffered from during the pandemic caused a decrease in well-being when social insecurity co-occurred with the instance of poor health. In such circumstances, growing stress can occur due to the unavailability of social services or the lack of access to necessary goods. Namely, Muscovites experienced temporal unavailability of free medical care for non-COVID-19 patients due to extreme congestion in hospitals. This combination of stressors is negatively related to existential well-being. This result can be used by social services to provide citizens with the necessary support.

The study allows us to reconsider the impact of COVID-19-related stressors. In the context of the pandemic in Moscow during the first wave, we see a moderately high level of existential well-being and a moderate connection between existential well-being and COVID-related stressors when other factors are controlled. We may conclude that the impact of lockdown stressors is not universal. It varies according to region, living conditions, the severity of the lockdown, the dynamics of the pandemic, and cultural specifics.

The results may also vary depending on the measurement specifics of well-being. We assume that existential well-being can be resilient to rapid social changes, as it is more determined by internal factors like the ability to find meaning.

The existential well-being of the Moscow citizens during the first wave of the pandemic was affected by both the ongoing living conditions and COVID-19-related stressors (while sociodemographic variables were controlled). Thus, it is fruitful to use a comprehensive approach to measure the COVID-19-related stressors’ effect on well-being and is insufficient to consider only the frequency of exposure to stressful situations.

We discovered that a combination of COVID-19-related stressors (facing unavailability of goods, medicine, or services while falling ill or having a sick family member) was associated with poor well-being, while facing these situations separately did not produce a significant decline in well-being.

These results can find practical application in planning programs to support socially unprotected categories of citizens and in the work of social welfare services.

• Limitations

This research has been restricted by the unbalanced sample due to the research procedure (voluntary online survey), where female participants of the active middle age with access to the internet prevailed. It should also be noted that the research was carried out among Moscow citizens, thus the conclusions about the greater or lesser significance of lockdown stressors cannot be universal.

1 100 000 RUB ≈ 1300 USD (for 2020–2021)

• Ethics Statement

All subjects gave informed consent for the sharing of their data before taking part in the study. This research obtained ethical approval by Dr. Alexey M. Dvoinin, Chair of the Psychological and Pedagogical Research Ethics Committee (PPREC) of the Institute of Pedagogy and Psychology of Education (Moscow City University) 01/04/2020.

• Author Contributions

Elena Nekhorosheva conceived the idea, developed the design and questionnaire, selected the research methods, and provided data collection. Anastasia Klimochkina contributed to the theoretical review, development of the theoretical model, performed data analysis and description of results. Daria Kasatkina contributed to the questionnaire development, theoretical review, and editorial work. All authors discussed the results and contributed to the final manuscript.

• Conflict of Interest

The authors declare no conflict of interest.

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Pryjmachuk S, Elvey R, Kirk S, et al. Developing a model of mental health self-care support for children and young people through an integrated evaluation of available types of provision involving systematic review, meta-analysis and case study. Southampton (UK): NIHR Journals Library; 2014 Jun. (Health Services and Delivery Research, No. 2.18.)

Developing a model of mental health self-care support for children and young people through an integrated evaluation of available types of provision involving systematic review, meta-analysis and case study.

Chapter 6 discussion and conclusion.

In the previous three chapters, we presented our findings from the three interconnected stages of the study: the literature reviews, the mapping exercise and the case study. In this chapter, we synthesise the three sets of findings, using an approach similar to that which we used to integrate the effectiveness and perception reviews in Chapter 3 , additionally discussing our findings with reference to current research, policy and practice and with due regard to the aims of the study and our research objectives. Figure 13 outlines this process schematically.

Schematic diagram of the overall study synthesis.

The strengths and limitations of the study and the degree of patient and public involvement (PPI) are then considered. We conclude this chapter, and the report, by discussing the implications for policy and practice that have emerged from our study and by offering some recommendations for further research.

We begin the discussion by making some general observations about the evidence that we have obtained. An observation across of all of our data sources is that the interventions and services we examined are largely targeted at CYP with mood disorders or behaviour problems. This is relatively unsurprising given that emotional and behavioural problems are by far the most common problems in CYP’s mental health. 3 However, it is worth noting that there is relatively little about the more serious mental health problems like self-harm, psychosis and eating disorders, given that these are the problems which tend to worry education and health professionals the most. 40 , 197

Most of the literature we examined originated in the USA and Australia. Again, this is a relatively unsurprising finding given that the most of the manualised treatments seem to emanate from these two countries: The Incredible Years 183 parenting and Coping Cat 198 CBT programmes in the USA, and the Triple-P 164 parenting and FRIENDS 199 CBT programmes in Australia, for example. Moreover, the architects of these programmes and their associated research teams are highly active in conducting research and publishing about their respective interventions; indeed, the studies we examined in the systematic reviews were conducted by relatively few research teams. This, of course, does not explain why these approaches originated in the USA and Australia in the first place, but it is notable that they have different health-care systems to that of the UK and no ‘national’ health service. It does, however, raise some questions about their transferability to a UK context, a point made by some of our case study participants when they talked about some of the manualised programmes’ materials.

Most of the interventions and services considered in our study were designed to manage and treat symptoms rather than prevent them. This may reflect the medical dominance in CAMHS provision in most countries – one that tends to have an overemphasis on outcomes relating to symptoms and a focus on deficits rather than strengths. Consequently, the ethical, political and clinical advantages of preventative interventions (normalisation and de-stigmatisation, for instance) may be overshadowed in systems that are concerned with ‘illness’ rather than ‘health’. It may also be that those interested in preventative approaches are those who often sit outside of, or challenge, the traditional medico-scientific culture. A disadvantage of this, however, is that they might not necessarily embrace the ‘hard’ outcomes that are required to further promote an intervention or service as effective in a literature where medico-scientific approaches (such as rigorous RCTs) have the most authority. 200

The remainder of our discussion focuses on four overarching themes that provide a framework for the application of our findings to policy and practice, and in the context of the existing literature. These themes are: what works in supporting self-care in CYP’s mental health?; choice and flexibility; the interface between the NHS and other providers of self-care support; and how self-care support in CYP’s mental health might be conceptualised.

What works in supporting self-care in children and young people’s mental health?

One of the aims of our study was an evaluation of mental health self-care support for CYP. Clearly, in carrying out such an evaluation, we were interested in finding out ‘what works?’ in terms of self-care support, but in asking this question some significant tensions have emerged. These tensions arise because the answer to the question depends on two inter-related factors: how the question is interpreted (whether ‘works’ means effective, enjoyable or satisfying, for example) and who is being asked the question (the researcher, parent, clinician or child/young person).

From the meta-analysis, we found that self-care support interventions appear to be modestly effective in improving CYP’s mental health symptoms, a finding not dissimilar from other reviews and meta-analyses examining psychosocial interventions in CYP’s mental health. For example, meta-analyses on technology-based self-help in CYP, 25 parenting for early-onset conduct problems 201 and psychological and educational interventions for preventing depression in CYP 202 have all identified small to medium intervention effects on relevant mental health symptomatology.

However, two further questions arise here: one concerns the sustainability of these effects, and the other relates to our earlier point about whose perspective – researcher’s, parent’s, clinician’s, or child or young person’s – is the more important when the value of (small to medium) intervention effects on mental health symptomatology is being considered.

Sustainability

An evaluation of CAMHS innovation projects over a decade ago 203 identified a number of key elements in services that work, including having a capacity to keep in touch with CYP over the long term and offer additional, short-term intervention or support if needed. This message of sustainability in self-care support interventions has been repeated more recently in both adult mental health 12 and CYP’s mental health, 204 in mental health promotion in schools 200 as well as in a general review of the evidence on self-management. 205 From a service user perspective, it has also been neatly summarised by a SAG member who argued that the principle should be one of ‘give us the skills, remind us of the skills and help us when we get stuck’. Given that our effectiveness review focused on short- to medium-term follow-up (6- and 12-month time points), it can, to some extent, also be seen as a ‘sustainability’ review. Our findings thus suggest that few of the self-care support interventions examined were sustainable, as effectiveness was only moderate at 6-month follow-up and it subsequently declined at 12-month follow-up. Moreover, our effectiveness review found that interventions that were longer also tended to be more effective, an observation that further suggests that a longer-term commitment may be beneficial.

Different perspectives

One clear finding from our data is that, in evaluating mental health self-care support for CYP, a range of different perspectives surface. Not only is the perceived value of an intervention or service dependent on who is asked, but some biases in the overall literature imply that certain information about interventions and services is valued more than others. Regarding the former, our satisfaction data, for example, noted that adults (parents and teachers) often rated interventions better than CYP, a finding that has been observed elsewhere, 206 and in both our satisfaction and qualitative data, there was evidence that CYP did not agree among themselves about the value of a particular intervention or which specific components were the most valuable to them.

Regarding the latter, the dominance of trial studies compared with perceptions studies suggests that an effectiveness perspective is generally more valued. In addition, the observation that most outcome measures in the effectiveness studies were concerned with mental health symptomatology (see Chapter 2 , Table 4 ) also demonstrates a particular (i.e. clinical) perspective regarding the importance of particular outcomes. This contrasts with our previous NIHR study exploring children’s long-term physical health conditions, 15 where a much wider range of outcome measures were considered, including health service use, which was notably absent from all of the studies we included. Moreover, the effectiveness of an intervention or service can be measured across many domains, such as a child or young person’s ability to cope or move on from a difficult situation, and not just in improvements in symptoms, and there is evidence that CYP’s problems can be addressed more effectively if their strengths, self-efficacy and resilience are promoted. 204 This is a point that the recent CYP’s IAPT programme seems to have conceded, given that the programme considers a range of outcomes including strengths, general well-being, employment, and education uptake and attendance, as well as mental health symptoms. 31

Choice and flexibility

The most salient finding of our study is, perhaps, the contrast between the effectiveness data and the perceptions data. In comparing the effectiveness and perceptions data, two related tensions arise: the tension between flexibility and fidelity, and the tension between choice and constraint.

Flexibility versus fidelity

Flexibility appears to be a key element of self-care support. Inflexibility of services was a common criticism made about standard CAMHS services by CYP and parents in the case study sites, and flexibility was identified as a valued feature of self-care support in both our previous NIHR report 15 and the recent NIHR project on self-care support in adult mental health. 12 However, almost all of the interventions considered in our effectiveness review were manualised, a status that implies that there are ‘rules’ as to how an intervention should be delivered. This raises the issue of fidelity , a concept that it is somewhat at odds with flexibility. Compare, for example, the case study sites that used The Incredible Years, where fidelity to the manual appeared to be paramount (to the service lead, at least), to the perceived inflexibility of some of the manualised interventions that was evident in the perceptions review.

The issue of fidelity in manualised interventions is interesting as there is no consensus on its importance in achieving the best outcomes in psychosocial interventions. The evidence for fidelity in parenting interventions, in particular, is equivocal, with some arguing that it is a necessary component for effectiveness, 207 while others argue that there is scant evidence that manuals improve treatment effects. 208 A recent discussion paper from the British Psychological Society 209 attempted to reconcile these two positions in the context of the real-life service delivery of parenting programmes, arguing that fidelity is important but not at the expense of acceptability, and that fidelity should be redefined as those principles critical to effectiveness, rather than being seen as the duplication of an original in vitro model.

Choice versus constraint

In attempting to integrate the effectiveness and perceptions reviews at the end of Chapter 3 , we concluded that a key message might be one of service providers constrained by homogeneity, in terms of largely providing manualised, group-based, face-to-face (cognitive–)behavioural interventions. Homogeneity of intervention erroneously assumes homogeneity of recipient, an assumption that has been challenged in many aspects of CYP’s health-care delivery. For example, this has been pointed out in relation to human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) prevention programmes for CYP 210 and the mental health needs of homeless CYP, 211 and in a review of CYP’s general perspectives on health and health services. 212 Treating patient groups as homogenous purely on the basis of qualifying for a specific diagnosis has also been critised, 208 a fair point given that CYP diagnosed with a specific mental health condition such as anxiety will vary immensely in their needs, their experiences and the resources they have, as will their families. In terms of effectiveness, it might therefore be more appropriate to ask ‘what works for whom and in what circumstances?’ rather than merely asking ‘what works?’.

However, assuming that different things work for different people brings about the question of choice . Choice does not necessarily mean choice only in terms of specific interventions or services. It might also mean choice in terms of specific elements of the service: face to face or telephone, or group or individual. It might mean choice in terms of location: home or school. It might mean choice in the referral process including the opportunity for self-referral, a feature of two of our case study sites and a salient observation in the recent NIHR study on self-care support in adult mental health. 12 Finally, it might mean choice in terms of who makes that choice: the child or young person, a parent or, as is too often the case, the staff providing the service. In other words, choice should mean taking into account the CYP’s and their families’ individual needs. 203

In raising the issue of choice, it is not to say that effectiveness is unimportant, just that some generally effective interventions might not work for some CYP. Standard effectiveness tools such as meta-analysis are not able to assess the issues of accessibility and engagement very well, where choice might be a more significant issue and driver of outcomes. A pragmatic compromise, therefore, is that services should still consider effectiveness when providing interventions but that there should also be a reasonable choice in evidence-based approaches. To some extent, this has been recognised by the CYP’s IAPT programme, 31 in that initially only cognitive–behavioural and parent training (the dominant models in terms of effectiveness data) were available but the programme has recently been extended to include other interventions with evidence of effectiveness, such as systemic family therapy and interpersonal therapy. However, even if a range of evidence-based interventions are available, the issue of who makes the choice remains. Moreover, if it is to be CYP and their parents who make that choice, there is a need to ensure that sufficient information about interventions and services, including information about their effectiveness with different CYP, different problems and different circumstances, is available so that CYP and their parents can make informed choices.

A further issue in discussing choice, and a key element of the overall acceptability of a service or intervention, is an appreciation of the CYP’s or their parents’ readiness to self-care. 12 , 24 Although there was little explicit reference to readiness in our findings, there were definite hints from the case study data that readiness could be an issue in terms of accessing self-care support, and it was a noticeably absent concept in most of the interventions examined in our literature reviews. Our previous NIHR study 15 also picked up some hints about readiness in relation to decisions about whether to access services or not. A related concept to readiness is health activation , 213 a concept we will discuss further in the Conceptualising self-care support in CYP’s mental health section later in this chapter.

Choice and groups

While discussing choice, it is worth talking about one particular feature of our overall findings. Group interventions and services dominated all of our data sets, although the groups varied from relatively small groups to groups as large as whole primary or secondary school classes. It is not difficult to understand the popularity of groups, given the peer support and shared experience advantages of group approaches in health care identified in this study, our previous study 15 and elsewhere, 214 – 216 their relatively low costs compared with individual attention, and the evidence that social support networks are associated with better mental health outcomes, fewer problem behaviours and more health-promoting behaviours in CYP. 217

However, there was some evidence from our meta-analysis that individual interventions may be more effective than group interventions for CYP, though the difference in effect size between the two (a difference in SMD of –0.11 in favour of individual interventions at 6 months) may be insufficient to counter the additional benefits that groups provide and the additional costs involved.

Furthermore, there is evidence that there are some risks to CYP in group interventions. A recent review on the role and impact of social capital on the health and well-being of CYP 217 reported that, in certain circumstances, social support networks could increase participation in health-risk behaviours such as alcohol and tobacco misuse, an observation backed up by our case study reports concerning the risk of ‘contagion’ in eating disorders and self-harm groups.

Interface between the NHS and other providers of self-care support

The second aim of our study concerned the interface between the NHS and other providers of self-care support. Compared with our previous study, 15 the role of the NHS was less defined in self-care support in CYP’s mental health than it was in CYP’s physical health. In particular, the voluntary sector dominated the services identified in the service mapping. This could, of course, be down to the NHS not publicising any self-care support services it operates in its CAMHS provision; however, it is more likely to be an accurate reflection of current service configuration, given that commissioners of CYP’s mental health services are looking increasingly at alternative providers to NHS organisations to deliver NHS-commissioned and funded services, a situation we found previously in relation to CYP’s physical health. 15 Indeed, the voluntary sector currently has significant involvement – even to the point of subcontracting from the NHS – in two flagship CAMH service innovations in England: the CYP’s IAPT 31 and the Better Outcomes New Delivery (BOND) early intervention programmes. 218

The general policy consensus is that the interface between statutory services such as the NHS and the voluntary sector should be one of partnership . 9 In the recent NIHR study on self-care support in adult mental health, 12 projects not under the control of the NHS (i.e. voluntary sector projects) were seen as risky by the NHS, which implies a lack of either understanding or communication between one or both parties. This might be down, in part, to tensions between two sets of ‘experts’, each feeling their expertise to be more important than the other’s, and to some extent this parallels the tensions already seen between provider and recipient when we considered the ‘effectiveness’ and ‘acceptability’ of self-care support interventions.

It terms of service provision, it is worth looking at a couple of other salient findings from our study: the location in which the service is provided, and the underuse of technology.

Location of service

The evidence on where services should be located is somewhat equivocal. Our effectiveness review findings suggest that the setting (clinic, home, school, etc.) is a largely irrelevant factor in the effectiveness of an intervention and no argument in favour of any particular location emerged from the perceptions review. This suggests that other factors need to be taken into account when considering the location at which self-care support should be delivered. The case for hospital-based services is generally weak. A recent King’s Fund paper 219 argues that health service delivery in general needs fundamental change and that hospital-based care should be reserved for those who cannot be treated more appropriately elsewhere. Our case study data also suggested that inpatient hospital care was not particularly well liked by participants. In terms of mental health provision, current government policy 9 is that people with mental health problems – including CYP – should be treated in the least restrictive environment. For CYP, the least restrictive environment usually means school, home or some other community-based location such as a clinic or community centre. All of these locations have advantages and disadvantages. Clinics, community centres and schools often have town centre locations close to transport hubs, a factor seen as important in terms of access 214 though our case study data implied that physical access was not necessarily a critical factor for participants. Formal clinics, however, may, at best, reinforce the medicalisation of the CYP’s problems and, at worse, stigmatise the CYP. The family’s own home offers convenience and few access problems but not everyone is comfortable with professionals intervening at home. Perhaps the best candidate for location is schools: schools are part of the CYP’s normal experience, and the fact that most of the studies in the effectiveness review were school based demonstrates that schools are feasible places for delivering such interventions. Moreover, there is evidence that schools are substantially more cost-effective at delivering mental health interventions for CYP than routine CAMHS. 220 On the other hand, there was some evidence in our case study data that schools are not necessarily prepared for the task (as they came in for criticism, along with inpatient hospital care, from some of our participants), and there is some evidence, at least in terms of preventative approaches, 200 that schools may need to have the right ethos in place to be centres for mental health support.

Use of technology

Given the commonly held view that CYP are inherently comfortable and confident with new technologies – that they are ‘digitally native’ – there was surprisingly little use of computers and internet technology in the interventions and services we examined. None of the interventions examined in the effectiveness review used computer or internet technology, there were only three such interventions in the perceptions review and only five were identified from the service mapping. This might be because the peer support and shared experience elements of face-to-face, group self-care support are harder to replicate online (though not impossible, as the eating disorders online support case study site has demonstrated); or it might be because NHS services in particular are inherently conservative and have not yet caught up with the technology. 221 On the other hand, it might be that the assumptions about CYP being digitally native are incorrect 180 , 222 – that CYP have no greater a preference for computers and internet technology than adults or that, again, homogeneity is being assumed in CYP when in fact some may embrace technology more than others. This is a salient point because it brings about once more the issues of choice and readiness, in that some CYP may not be ready to use technological interventions and some – as we found in our perceptions review – may not particularly like them. Nevertheless, there is evidence from elsewhere that technology can help in engaging CYP in mental health services: for example, the use of text messaging to reduce ‘did not attend’ rates. 214 , 223

Conceptualising self-care support in children and young people’s mental health

It is clear from this study that self-care support services in CYP’s mental health do exist, and are being researched, but what is interesting is that very few of these services make explicit reference to ‘self-care’ in their names or service specifications though, occasionally, a related term such as ‘self-help’ or ‘self-management’ may be used. This is in direct contrast to CYP’s physical health where self-care is an established part of the vocabulary. A similar conclusion was drawn in the recent NIHR-funded study on self-care support in adult mental health. 12 One reason for this might be the increasing adoption of ‘recovery’ as a general philosophy of mental health service provision over the last decade or so. In addition, the move towards strengths, rather than deficits, models in CYP’s mental health has brought into focus a related concept: resilience . The key elements of recovery are hope; the establishment of a positive identity; a meaningful life; and taking responsibility for, and control over, one’s own life. 18 All of these elements could describe self-care; indeed, they are implicit, if not explicit, in our definition of self-care (see Chapter 1 ). Moreover, in embracing a philosophy of recovery, the role of mental health practitioners becomes more about doing things with service users than doing things to them, and so, in a recovery framework, mental health practitioners are essentially guides, facilitators and coaches. It is thus not difficult to see how ‘recovery’ might simply be a synonym for self-care in a mental health context, or how it might be encapsulated as part of ‘resilience’ if the self-care support agent helps the CYP identify, and build upon, their strengths; at the very least the concepts are closely related. 12 , 224

Another interesting dimension in conceptualising self-care support in CYP’s mental health is the observation from the literature review and mapping exercise that most of the interventions and services are targeted at CYP rather than at families. This assumes that CYP are the ‘problem’, and there is perhaps a need within recovery- or resilience-focused approaches to ensure that (a) the emphasis is on strengths rather than problems, and (b) any problems are considered within the context of the family and the CYP’s social networks.

Conceptualising mental health

When considering how self-care support might be conceptualised in CYP’s mental health, it is not surprising to find that conceptualisations of ‘mental health’ can also be somewhat vague. For example, when reporting the case study findings, we noted that conceptualisations of mental health seemed to be connected to the CYP’s age, with mental health being conceptualised in younger children as a lack of confidence or difficulties with emotion and behaviour, and in older children as diagnosed conditions or severe mental health problems. The reasons for this are far from simple; being ‘diagnosed’, for example, may be down to capacity and configuration of local services, the expectations of the child and/or parent, and social constructions of mental illness. There is, nevertheless, a balance to be struck in conceptualising a child or young person’s difficulties as mental health problems or not. A diagnosis is often a criterion that triggers access to a potentially helpful service or it can act as a filter for different interventions and services, as there is evidence in self-care support that different conditions benefit from different approaches. 205 Yet a diagnosis can also have negative connotations (leading to stigmatisation and exclusion, for example), as one of our case study sites made clear when it asked for the removal of any reference to ‘mental health’ from our recruitment materials, even though it was delivering an ostensible mental health service. Maybe choice needs to be considered here too in that CYP should be allowed a choice as to whether they accept a diagnostic label or prefer to focus on, for example, identifying specific needs, feelings and opportunities to develop strengths. This is also reflected in the current debates expressing concerns about the increasing ‘medicalisation’ of emotions and behaviours in CYP. 225 , 226

It is also worth asking whether CYP’s mental health problems and needs should be considered as long-term conditions because the focus for many families is, as it is for the families of CYP with long-term physical health needs, often more about quality of life and living (well) with a condition than it is about ‘curing’ the condition. Mental health self-care support interventions for CYP need to be considered in a context where the majority of adult mental health problems have their origins in developmental problems in childhood; 227 yet, as our study illustrates, what tends to be on offer are relatively short interventions with erratic follow-up periods (often merely for research purposes) for CYP who have problems and mental health needs that are likely to extend into adulthood. Clearly, there is a relationship here with our earlier discussions on sustaining self-care, and a conceptualisation of CYP’s mental health in a longer-term context may help address some of the shortcomings in the sustainability of specific interventions and services.

A conceptual model of mental health self-care support in children and young people

In modifying the typology of self-care support (see Chapter 4 , Table 19 ), we argued that self-care support in CYP’s mental health can be seen as a process . There needs to be the acquisition of knowledge and skills, which require input and motivation on the child or young person’s (or parent’s) part; opportunities to practise and consolidate these requisite skills, with support and facilitation from a self-care support agent; and some positive outcomes for the child or young person and his or her family. Moreover, as we earlier argued, there is some evidence that this process should be long term rather than short term. On the basis of our findings and the discussion herein, a conceptual model of mental health self-care support is proposed in Figure 14 .

A conceptual model of mental health self-care support in CYP.

We have discussed a significant number of the elements of this model already, including effectiveness, acceptability, readiness and outcomes. Choice and flexibility, though not explicit in the model, permeate the whole model in that various elements of it, such as the types of skills on offer and the means of acquiring them, the outcomes used and even the self-care support agent, can all be tailored according to the individual needs of the child or young person and his or her family. Two critical elements of the model – skills and the self-care support agent – warrant further discussion, however.

Regarding skills, it seems that skills and the activities that support their development are a central feature of effective self-care support programmes 12 , 15 , 200 , 203 , 205 and of recovery in CYP’s mental health in general. 214 , 217 However, as mentioned above, choice and flexibility need to be considered when identifying these skills and providing the support CYP and their families need in acquiring them. This raises the issue of the personalisation of health-care services and the associated issue of personal health budgets, 219 , 228 although it seems these two issues raise tensions similar to the ones we identified when discussing effectiveness and acceptability, in that the patient preferences inherent in personalisation have to be reconciled with a co-existing framework of ‘payment by results’ where effectiveness is the key concern. 229

Regarding the self-care support agent, the principal issues that need discussing are the attitudes and attributes of the professional or lay person taking on this role. This involves some discussion of both the attitudes of the agent and their interpersonal skills, as well as some comments about education and training.

Qualities of the self-care support agent

Our case study data suggested that the personal qualities of the staff providing the self-care support were important, with staff generally seen to have positive attitudes such as being non-judgemental, welcoming and an active listener. There were also some hints in the perceptions review that the quality of the relationship with the agent and the expertise of the agent may be as important as, if not more important than, the intervention itself. This is a common theme in the literature: participants in our previous NIHR study 15 remarked on the approachability of the self-care support agents and their abilities to listen and be non-judgemental; a recent Health Foundation review on self-management 205 found that the attitudes and skills of staff can have a significant effect on perceived levels of engagement and support; and in CYP’s mental health, the ‘therapeutic alliance’ has been identified as a significant but neglected factor in treatment. 230

Leadership in self-care support services may also be an important personal and organisational attribute, and we saw evidence of strong leadership in our case study sites. Effective and consistent leadership was identified as a key element of ‘what works’ in CAMHS provision, 203 and the recent NIHR study on self-care support in adult mental health 12 noted that charismatic leadership was a feature of many of the projects examined.

Another key personal and organisational attribute is child-centredness. As in our previous NIHR study, 15 being child-centred was a feature of most of the case study sites. The general literature indicates that effective patient-centred care requires two specific elements: the straightforward eliciting and discussion of the patient’s perspective and ‘activation’, i.e. a deeper understanding of the individual’s motivation and readiness to become involved in a service, change their behaviour or self-care. 231 This suggests that for the self-care support agent to be truly child-centred, they need to understand not only the CYP’s problems and needs but also recognise the extent to which they are ready. This raises the question of whether or not a readiness measure of some sort, whether standardised and formal like the Patient Activation Measure 213 or something more informal like simply asking the question ‘do you feel you are ready?’, should be routinely used in health-care practice.

From an organisational perspective, child-centredness requires – as we saw in the case study sites in this study and in our previous study 15 – a friendly, fun, welcoming atmosphere where the CYP’s views are listened to and respected. Above all, child-centredness requires a partnership between the provider and family, one that demands that CYP and their families be seen as part of the care team or, to use a phrase currently gathering momentum in adult mental heath care, as ‘coproducers’ of their care. 232

A consideration of the attributes and skills of the self-care support agent inevitably raises the issue of education and training. None of the attributes and skills required of the support agent necessitate mental health training, and it was interesting to note that our effectiveness data suggested that there is no specific advantage in the agent being mental health trained, although there is some evidence 82 in the literature to counter this, and it was notable that around three-quarters of those delivering interventions in the effectiveness studies were specifically trained for the role. What seems to be essential is the ability to understand the CYP’s perspective, and to focus on their needs and the needs of their families, rather than on the needs of the service or the people leading the service. This may require attitude changes among CAMHS staff and those managing services and, certainly, if an eclectic range of interventions is to be made available within CAMHS, then it will require opportunities for staff to retrain and develop new skills. 204 In terms of attitude, in England and Wales at least, our findings suggest that the voluntary sector seems to be ahead of the NHS and other statutory services. However, as our case study data indicate, there is also excellent service provision in the NHS. Thus, it may not matter which sector delivers the service, so long as the staff are child-centred, have opportunities for training and development and are supported by strong leaders. Moreover, there could be considerable benefits for CYP with mental health needs and their families if opportunities are made available for the NHS and the voluntary sector to learn from each other.

• Limitations and strengths of the study

All research studies have limitations and in this section the limitations of the various aspects of the study are considered in turn, together with some overall limitations. Some comments are also made throughout about the study’s strengths.

Systematic reviews

As there was a common data pool for the effectiveness and perceptions reviews, the principal issue was the same for both: having to manage an unexpectedly large pool of literature. Although this was clearly related to the issue of how self-care is conceptualised in mental health, the sheer size of the returns we got from our searches and the time available for the systematic reviews meant that we had to make some post hoc, pragmatic decisions, and these decisions, while rational, may have introduced bias into the process. For example, searching electronically in Reference Manager and the Access databases to screen out irrelevant papers on the basis of title or abstract meant that we may have overlooked some relevant papers that manual inspection may have picked up. In hindsight, our search strategy may have been too inclusive although, given that self-care is an unexplored area in CYP’s mental health, we are confident that it needed to be broad.

The reason for the date from which we searched – 1 January 1995 – may have been tenuous, though again the decisions made were rational: it was the date used in our previous self-care support study 15 and the year in which major organisational change came about in UK CAMHS provision; 38 however, this latter point has less relevance to the international literature.

The effectiveness review and meta-analysis were limited in several ways. Firstly, the post hoc decision to exclude those RCTs with only short-term (postintervention) effectiveness data meant that we had a manageable number of RCTs to describe and meta-analyse, but it also meant that we may have missed some important findings in these studies. Nevertheless, there was an advantage in selecting only those RCTs with longer-term effectiveness data in that sustainable interventions are of more interest to policy-makers and practitioners. A second limitation was the generally poor quality of the included trials. Although we did not include a full Cochrane risk of bias analysis in the effectiveness review, we nonetheless explored the most significant risk – concealment of allocation – finding only seven and nine ‘high-quality’ RCTs at 6- and 12-month follow-ups, respectively. A further limitation is that we did not include cost-effectiveness as a factor in exploring mental health self-care support interventions for CYP.

The perceptions review was limited by the sizeable number of poor-quality studies. For the qualitative aspect, it was also confounded by a relatively small number of studies: just 33 in total, of which only 13 made it through qualitative appraisal. Moreover, of these, only two met all seven of the quality criteria on the quality appraisal tool used. For the quantitative aspect, there were no studies that collected numerical satisfaction data independently of a trial, i.e. all of the satisfaction data were nested within a trial of some sort, controlled or uncontrolled. Furthermore, almost all of these data – including those obtained from high-quality RCTs – were obtained from unvalidated, local satisfaction measures or tentative ‘proxy’ measures, such as attendance at sessions. Standardised statistics such as means and standard deviations were rarely reported; it was unfeasible, therefore, to conduct a second meta-analysis using ‘satisfaction’ as an outcome. It was also difficult to make any sort of quality judgement on the quantitative satisfaction data; indeed, it would have been rational to exclude all of the quantitative satisfaction data, but this would have left us without a ‘majority’ perspective to counterbalance the individual perceptions obtained from the qualitative studies. Again, therefore, a post hoc pragmatic decision was made and only studies initially qualifying for the effectiveness review were included.

Nevertheless, the size of the review is also one of its strengths in that we were able to give a broad overview of recent effectiveness evidence and explore some factors that may or may not be associated with outcome.

Service mapping

The service mapping stage was designed to enable us to provide a descriptive overview of mental health self-care support services for CYP in England and Wales, and was dependent on detective work on our behalf and the information that was volunteered by the networks we had contacted. To a large extent, service mapping is the process of trying to identify the ‘population’ of a particular service, and this brings about an inherent problem: in trying to identify, with little prior information, all members of a population, concepts like ‘sample’ or ‘response rate’ are meaningless. We thus have no way of knowing whether the services that we identified are the total population of mental health self-care support services for CYP in England and Wales, or a sample. If they are a sample, we likewise are unclear whether the sample is large or small, or whether or not it is representative of the total population. We are thus unable to say with any degree of confidence that we have produced a comprehensive overview of self-care support services in England and Wales, and although this is not a fatal aspect of our study, it does nevertheless have some bearing on the case study element in that the service map provided the sampling frame for our case study sites.

We could have been more assertive with the service mapping element by, for example, conducting a postal, telephone or online survey across the major statutory and non-statutory providers. However, we do not know whether or not the considerable additional resources required for this (especially in relation to postal and telephone surveys) would have elicited any more information than that which we gleaned using the methods we employed. Indeed, our experiences of an online survey in our previous study 15 suggested that it would not, and this, together with the generally low response rate in postal surveys of health-care professionals, 233 explains our approach here. There is nonetheless an argument for carrying out a more comprehensive service mapping exercise, and we make this one of our recommendations for further research.

A further limitation here involved the difficulties we had in tracking down sufficient information about potentially eligible services, when we only had very limited information about a service, such as its name or details of a website or a contact number. Following up these leads required considerable effort on our behalf, and numerous e-mails and telephone calls went unanswered, for a variety of reasons that we can only speculate on (the service having closed without our knowledge or the service having only a single member of staff, for example).

In selecting the case studies, we were careful to ensure that all of the typology and other relevant dimensions were considered, so that we obtained views on a range of different services. We also tried to ensure that we sought views from all stakeholders – CYP, parents and staff – at each of the sites. Although our case study sites are representative of the self-care support sites we identified in the service mapping, it is unknown how transferable they are to mental health self-care support services for CYP in general, given that we do not know what the true population of such services is. That our case study findings have resonance with other findings on CYP’s mental health services in the literature does, however, suggest some degree of transferability.

Regarding the source of our data for the case studies – CYP, parents and staff – there could be an inherent bias in that we were able only to speak to CYP and parents who had remained with a service. It was not possible for logistical and ethical reasons to recruit CYP or parents who had ‘dropped out’ of the services. In addition, although we managed to obtain ‘virtual’ non-participation observation at our online case study site, we could perhaps have enhanced our data pool by observing sessions at some of the other case study sites. Apart from the fact that it was not part of our original plan to obtain data by such means, there were several other reasons for not carrying out more general non-participation observation, including the ethical complexities of observing, rather than asking for views about, treatment and the practicalities of arranging it.

We outlined in Chapter 5 that the interview format was dictated largely by pragmatism, and that we allowed the sites and individual participants to determine the format most convenient for them. Given the views in the Choice and flexibility theme discussed earlier in this chapter, this was a somewhat fortuitous decision, though it is not without limitations. In the joint CYP–parent interviews, for example, we do not know the extent to which the presence of a parent influenced what the child or young person had to say, nor whether we would have obtained different data had the parent and the child or young person been interviewed separately. On the other hand, the variety of interview formats employed could be seen as a strength of the study in that we still managed to obtain some strong views from CYP regardless of whether parents were present in the interview or not, and the choice and flexibility offered may well have helped recruitment.

That we only managed to interview one young person at site 6 might be seen as inadequate if taken in isolation. However, as part of a collective case study designed to elicit a broad appreciation of a particular issue (see Chapter 5 , Design ), we are confident that the limited site 6 data have some value.

Across all stages of the study

Our experiences in conducting this study demonstrate that self-care support in CYP’s mental health is a complex area; there are multiple conditions, a variety of theoretical perspectives (though one or two dominate), widely different content in the services and interventions, and a range of agents and different intervention levels (most notably preventative vs. management interventions). Obviously, self-care support was a common feature of all the services and interventions. However, it may be that the multiple dimensions involved resulted in a somewhat unwieldy study that could have been better co-ordinated had we concentrated on a few specific aspects (e.g. interventions for CYP with mood disorders only) or, given our earlier discussion, avoided confounding management-level and preventative interventions and services by only studying one or the other. Nevertheless, there has been an advantage in exploring so many dimensions in that we are aware of where there are shortfalls in the knowledge, for example in relation to CYP with psychosis or an eating disorder or those who self-harm, and in relation to the use of technology.

Patient and public involvement in the study

One of the study’s strengths was its PPI. We had a significant advantage in this study in that it was planned and conducted with the support and involvement – as co-investigator – of YoungMinds, a specialist mental health charity for CYP and their carers. This was the first time that YoungMinds had been involved in NIHR-commissioned research, and the experience has led to further collaborations, including YoungMinds’ involvement in another NIHR-commissioned research study in which the principal investigator of the present study (Pryjmachuk) is a co-investigator. 7

As with most research projects, there were unexpected issues that prevented us from involving YoungMinds to the extent that we had anticipated. We originally intended to have a separate SAG made up of CYP only. However, when consulting with YoungMinds and other members of the stakeholder group, the consensus was that the CYP known to YoungMinds would be assertive enough to attend a single stakeholder group, and there was thus no need for a separate group. We planned to invite members of YoungMinds’ Very Important Kids (VIKs) – a group of CYP aged 11–24 years who advise YoungMinds on policy and campaign objectives – to this stakeholder group, but we were, unfortunately, unable to recruit any of the VIKs. We did, however, manage to recruit a project worker for the VIKs to the stakeholder group, who spoke on their behalf.

We did manage to involve the VIKs and some other CYP in some aspects of the study; they helped us out with the recruitment documentation for the case study element, giving us feedback about the age appropriateness and readability of the participant information sheets and consent/assent forms. We did plan to put the final results of the study to the VIKs for their views and for their assistance in ensuring that CYP could understand what we had found, but unfortunately, the VIK project ended during this study when its 3-year Big Lottery funding came to an end. Nonetheless, the final results have been put to a SAG that included advocates for CYP and parents, as well as representatives of health, education and social care.

• Conclusions

The aims of this study were to identify and evaluate the types of mental health self-care support used by, and available to, CYP and their parents, and to establish how such support interfaces with statutory and non-statutory service provision. Through two inter-related systematic reviews, a mapping exercise and a case study, we are confident that we have achieved these aims. Moreover, in doing so, we have developed a model of self-care support that can help policy-makers and practitioners make decisions about the organisation and delivery of mental health self-care support for CYP and their families, and help researchers identify gaps in the knowledge base that might be resolved with future research in this area.

Contribution of the study

This study makes a contribution to the knowledge base by being the first to formally explore self-care support in the context of CYP’s mental health, an area that is generally under-researched. It is also unique in that it has considered the evidence from a variety of perspectives – including both effectiveness and stakeholder views evidence – and has attempted to integrate those perspectives into a meaningful synthesis.

Implications for health care

In term of implications for policy and practice, we note the following:

• that self-care support in CYP’s mental health requires a partnership between service providers, the CYP and those who provide care for them
• that CYP and their families want ongoing support from, and contact with, services
• that the means by which professionals can support CYP and their families to self-care are not generally considered in the education and training of those working in all four tiers of CAMHS provision
• that effective services need not necessarily be delivered by mental health-trained staff or by NHS organisations – it is the child-centred skills and attributes of the individuals and organisations that are important
• that choice and flexibility seem to be important aspects of self-care support in CYP’s mental health, but true choice from a range of interventions is rarely available to CYP (although the continual rollout of the CYP’s IAPT project may resolve this)
• that practitioners working in CYP’s mental health rarely consider a child or young person’s readiness to engage with a service or commence an intervention
• that it is important that outcomes other than those relating to mental health symptoms are considered.

Recommendations for research

We make the following recommendations for research into mental health self-care support for CYP, in order of priority:

• that, because of under-representation in our data, research be undertaken on the potential for self-care support in the more serious mental health problems of psychosis, eating disorders and self-harm
• that, because of the surprisingly little work on the use and role of technology in self-care support for CYP’s mental health and a lack of consensus on its potential value, research be undertaken exploring the advantages and disadvantages of using computer and internet technology in self-care support
• that, because there were differences in perceptions of, and satisfaction with, services and interventions, both among CYP and between CYP and adults, more work is conducted on unpicking these differences
• that, because it is a relatively unexplored, yet important concept in self-care support, the concept of readiness to self-care be explored further
• that, because it is a relatively unexplored area and there were some potentially valuable findings from our study, research on leadership in CAMHS be commissioned
• that further research be undertaken on how self-care is conceptualised in CYP’s mental health and, in particular, its links to concepts such as recovery and resilience
• that, because of the limited service mapping data provided, a more systematic and comprehensive mapping exercise of self-care support services in CYP’s mental health be carried out
• that work be undertaken on the cost-effectiveness of providing self-care support in CYP’s mental health
• that there is more testing of interventions and services in real-life environments compared with laboratory or clinical environments (i.e. research on efficacy rather than effectiveness).

Included under terms of UK Non-commercial Government License .

• Cite this Page Pryjmachuk S, Elvey R, Kirk S, et al. Developing a model of mental health self-care support for children and young people through an integrated evaluation of available types of provision involving systematic review, meta-analysis and case study. Southampton (UK): NIHR Journals Library; 2014 Jun. (Health Services and Delivery Research, No. 2.18.) Chapter 6, Discussion and conclusion.
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How to Develop a Mental Health Wellness Plan

Developing a mental health wellness plan is an important part of building and maintaining mental health . If you find yourself working hard to take the steps you need to maintain your mental health wellness , but you find yourself struggling with where to begin or how to maintain consistency in your routine, it could be due to the fact that you have not yet developed a strong mental health wellness plan. Without a set plan of action that was created specifically for you, it can be hard to find the proper direction to ensure you build up the skills you need to maintain mental health wellness.

What is a Mental Health Wellness Plan?

A mental health wellness plan helps you keep track of what does and does not work for you in maintaining mental wellness. It helps you create a guide or regiment of what you need each day to maintain your mental health. It also helps you keep track of the coping skills you can utilize to ensure that you maintain the balance between your thoughts, emotions, and behaviors.

How to Start Your Mental Health Wellness Plan

Taking the first step to building your mental health wellness plan can be a challenge. It is sometimes helpful to consult with a mental health professional, who will know how to help you begin exploring your own mental health wellness needs and what needs to be included in your mental health wellness plan.

Everyone responds differently to different mental health methods, skills, techniques, and strategies. That is why it is important to do some self-exploration and develop an understanding of what you need to incorporate into your mental health wellness plan.

Common themes in mental health wellness plans include:

• Mindfulness and meditation
• A healthy lifestyle including exercise and foods for mental health wellness
• Emotional intelligence
• Self-reflection
• Cognitive restructuring

What is Needed in Your Mental Health Wellness Plan

Once you’ve developed an understanding of what you need to create your mental health wellness plan, you want to make sure you incorporate all of the elements needed in building a strong plan that will help you build your mental health. Your plan should include:

• An understanding of your own mental health status and your needs to maintain good mental health ( mental health wellness worksheets and apps can help with that).
• An understanding of your personal triggers and life stressors that may become a challenge in maintaining good mental health wellness.
• A daily regiment of mental health wellness activities to use for creating balance and structure in your mental health wellness.
• A list of coping strategies that help you cope with life stressors, emotions, unexpected circumstances and upsetting situations.
• A list of support that is available to you, including family, friends, mental health professionals, and possibly a mental health wellness center .
• A space for reflection on your progress for building mental health wellness.
• A space that provides flexibility to your mental health wellness plan, in the event that a step or element needs to be changed, modified, omitted or replaced.
• A means to maintain accountability for your mental health wellness plan, so you stick to the plan and do not stray from what you need to do to maintain your mental health wellness.
• Sitting down and putting an entire plan together all at once can seem overwhelming. Try starting with one section, then add to it as time goes along.

article references

APA Reference Guarino, G. (2018, June 12). How to Develop a Mental Health Wellness Plan , HealthyPlace. Retrieved on 2024, April 19 from https://www.healthyplace.com/self-help/self-help-information/how-to-develop-a-mental-health-wellness-plan

Medically reviewed by Harry Croft, MD

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5 Strategies for Improving Mental Health at Work

• Morra Aarons-Mele

Benefits and conversations around mental health evolved during the pandemic. Workplace cultures are starting to catch up.

Companies are investing in — and talking about — mental health more often these days. But employees aren’t reporting a corresponding rise in well-being. Why? The author, who wrote a book on mental health and work last year, explores several key ways organizations haven’t gone far enough in implementing a culture of well-being. She also makes five key suggestions on what they can do to improve the mental health of their employees.

“I have never felt so seen.”

• Morra Aarons-Mele is a workplace mental health consultant and author of  The Anxious Achiever: Turn Your Biggest Fears Into Your Leadership Superpower (Harvard Business Review Press, 2023). She has written for The New York Times, The Wall Street Journal, O the Oprah Magazine, TED, among others, and is the host of the Anxious Achiever podcast from LinkedIn Presents. morraam

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A holistic approach to wellbeing for international assignees

In an attempt to create better, more sustainable futures for mobile workforces, forward-thinking HR professionals are now considering the expat experience from a holistic standpoint, and employee wellbeing is one of the key components of this approach.

Taking comprehensive and inclusive care of an internationally mobile workforce has become a business imperative with regard to minimizing talent risk, optimizing productivity and improving the employee experience.

Research shows that as workers we typically fall into one of four categories at any given time: the ‘well’, the ‘at risk’, the ‘ill’, and the ‘long-term disabled’. In the expat context, employers traditionally insure the ‘well’ and hope for the best, are not aware of the ‘at risk’, and do not deploy the ‘ill’ or ‘long-term disabled’ in the first place. This approach is no longer enough when looking to ensure diverse and inclusive talent pools and support holistic wellbeing strategies for an internationally mobile workforce, and their dependent family members.

Wellbeing also means more than just physical health. Mercer identifies eight distinct wellbeing dimensions: physical, emotional, social, financial, environmental, intellectual, occupational, and spiritual. These dimensions can and will be impacted by international mobility, not only for the employee but their dependent family members as well, whether they accompany the employee on assignment or not.

What should you be doing to improve expat wellbeing?

Mercer advocates adopting a holistic wellbeing strategy which addresses physical, mental, social and financial health, and is underpinned by an organization’s culture, environment and diversity, equity and inclusion. The interventions that an organization can make also exist along a spectrum: as a baseline, they should mitigate and manage risk. Next level support is designed to increase productivity , while some organizations are leading the way with global and integrated support models driven by a strong wellbeing culture at a company level.  

Supporting physical health

Be sure to consider local environmental factors as well: e.g. in hardship locations, additional interventions may be required to support physical safety and wellbeing, such as air purification systems, electricity generators, security guards, drivers, or additional access to medications that are not available in the host location.

Supporting mental health

Mental health has had an increasing focus over the last few years and emerges as a pivotal issue post-pandemic. Ensuring the employee will have access to local or global EAP services, as well as private medical insurance, enables them to get reactive help and address crises in action.

However, many interventions in the mental health area are centered on identifying and preventing issues before they occur. Full use of holiday and leave entitlements can prevent burn out, and assignees can be encouraged to take advantage of new and emerging technologies such as mental health apps and other online tools and software. These tools help identify and prevent possible crises by flagging triggers or changes in mood that have the potential to lead to mental health ramifications. Some organizations are undertaking full mental health reviews prior to assignment and are creating comprehensive strategies to support employees and their families based on the information and insights they collect.

Supporting social health

The COVID-19 pandemic has led to greater acknowledgement of the impact of social health, and has driven an increase in technology to support social interaction and employee engagement for remote workers (e.g. using social apps to create a community of expatriate co-workers and quickly communicate key messages from the employer). When relocating, employees are leaving behind their established social networks, which can lead to increased feelings of solitude and loneliness that the pandemic has only exacerbated. New or unfamiliar aspects of the host country’s culture can lead to further disorientation. For this reason, immersive language and cultural training initiatives continue to be key international assignment components.

As dual-career issues can frequently present a barrier to mobility, many companies are also making an additional effort to secure the right-to-work for an employee’s partner . Not only does this increase the chance of an assignment being accepted, it also allows employees to bring one of their strongest support systems along with them.

Supporting financial health

Financial health means more than just fair and competitive compensation. Each individual has a unique personal financial situation, with different short, medium and long-term financial goals and priorities, which may be impacted by an international assignment. In addition to the provision of traditional retirement and insured benefits (e.g. life and disability cover), organizations are now looking to do more to provide employees with access to educational resources on how to properly manage their finances holistically as is appropriate for their life stage and personal circumstances (e.g. how to manage debt, insure for risk and invest for the future).

Optimizing your wellbeing action plan

Tackling wellbeing and finding an appropriate strategy that is unique to your organization involves understanding the needs of your employees and understanding how those needs align to your organizational goals. There is no point in investing time and money into a wellbeing strategy that your people will not value.

Be sure to:

• Take into account DEI factors such as modern family structures, life stages and the ethnic and cultural diversity of your internationally mobile workforce;
• Embrace a degree of flexibility when it comes to supporting individuals with their physical, mental, social and financial wellbeing needs and aspirations;
• Leverage broader global and local wellbeing initiatives for the benefit of the expatriate workforce: often there are already excellent initiatives in place which just need to be unlocked or optimized for those moving internationally, but if not, consider options for providing support via international schemes ;
• Finally, consider how you will monitor progress and measure success .

The benefits of mitigating risk, increasing productivity, and leading the way in the delivery of an exceptional employee experience, will be worth it!

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