The broad reach of the wellbeing debate: Emotional wellbeing and vision loss

Shifting public health discourse

A sea change is evident in public health discourse, which has specific consequences for the arena of vision impairment. This paradigm shift is evident in the growing interest in the concept of ‘wellbeing’. Perpetuated by a change in impetus from gross domestic product (GDP) to more subjective experiences of life satisfaction, we as a population are increasingly demanding that the health and social realm of care, policy and academia should concern itself with wellbeing as well as disease (Thompson & Marks, 2008; Michaelson et al., 2009).

This discursive shift is also evident in the domain of visual impairment. At the UK Vision 2020 Conference in June 2011, there was talk of ‘a vision of the Big Society’, underlining a holistic, joined-up approach to visual impairment services. The term ‘wellbeing’ surfaced frequently in debates about ‘individual needs’, ‘empowerment’, ‘health outcomes’ and ‘quality-of-life’. ‘Wellbeing’, and the many ideas and concepts that fall within its broad reach, has thus begun to establish itself within the main discursive practices in public health care and in the realm of vision impairment.

Wellbeing and visual impairment – why the link?

Why then the current interest in wellbeing? Although the term appears to be all-encompassing, visual impairment research has tended to look specifically at the concept of emotional wellbeing. Much has been written on the relationship between chronic illness and mental health outcomes, particularly in terms of ‘happiness’ (Easterlin, 2003; Layard, 2006; Diener and Chan, 2011). Indeed, one of the key findings from publications such as The Happy Planet Index (Abdallah et al., 2009), is that people who report frequent happy feelings are less likely to suffer the effects of particular chronic diseases, and live up to seven years longer than those who are less happy. In terms of the visually impaired population, there is a growing awareness of the importance of both physical and emotional health, and the reciprocal relationship between the two. Further, in addition to the functional disability associated with vision loss, it is becoming increasingly apparent that the emotional impact of visual impairment is also substantial. A wealth of evidence exists to support the relationship between vision loss and functional disability, and subsequent negative effect on quality of life and emotional wellbeing (e.g., Rovner & Casten, 2001; Horowitz, 2004; Reinhardt, Boerner & Horowitz, 2009). As a consequence of such research, there is an increasing awareness of the importance of ‘preventing’ negative mental health outcomes in the visually impaired population and ‘promoting’ emotional wellbeing, especially in children and young people.

The wellbeing agenda has infiltrated many disciplines, and brought with it a new discourse. It has made us think about the importance of emotions and subjective experiences in terms of health care and vision impairment. However, in taking a reflective step backwards, we are faced with the unanswered question of what is ‘wellbeing’?

What is meant by the term wellbeing?

‘Emotional wellbeing’ has been documented as being of paramount importance to the future of visually impaired children, for example (Jemtå et al., 2009), however what do we actually mean when we use this term? It seems that wellbeing is a ubiquitous word, occurring frequently and widely in scientific, political, academic and social realms. As noted in the literature (Ereat and Whiting, 2008), it has a ‘holographic’ quality in the sense that different meanings are being projected by different agents, and the meaning of the term depends on the individual’s standpoint. In this sense, although it seems like a solid construct, it can easily be deconstructed when we look beyond its surface. Depending on one’s standpoint, ‘wellbeing’ may translate as a physical, social, emotional or even spiritual construct and follow different ‘models’ of wellbeing which all have their own agendas, aims, methodologies and discourse. Such a multitude of meanings and models runs the risk of leading us down a slippery slope of never-ending deconstruction of terms. The term ‘wellbeing’ may at once mean everything and nothing. In order for us to bring it back to a tangible, practical level on which we may act, perhaps a balance is needed between appreciating wellbeing’s multiple discursive framework and understanding how this impacts upon the subject of interest.

One way in which the multiple ‘voices’ of the term may be understood is by framing the concept within a clear two-dimensional framework. The majority of research into wellbeing has concentrated on the ‘life satisfaction’ or ‘hedonic’ dimension – hence claims about people who report frequent happy feelings being less likely to suffer the effects of particular chronic diseases. Life satisfaction and subjective experience is indeed important for understanding the psychological impact of vision loss (e.g. the risk of depression). However, there is a growing number of academics who suggest that looking at this dimension of wellbeing in isolation may not tell the whole story. As noted at a King’s College seminar in early 2011 (Measuring Well-being: A Need or Political Agenda?) and in the wellbeing literature (Ryan & Deci, 2001; Seligman, 2002; Vittersø, 2004), academics are now focusing on a two-dimensional framework of wellbeing which includes both life satisfaction and experiences (‘hedonic’) and a personal development (‘eudemonic’) dimension. A two-dimensional framework not only considers how vision loss affects subjective experiences, but also what conditions are required to develop in a fulfilling way as a functioning individual.

‘Interventions’ and ‘promotion’ of wellbeing would therefore take into account both of these dimensions rather than just focusing on the former. Signs of this shift from a one- to a two-dimensional framework of wellbeing are evident in the discourse on distinguishing ‘flourishing’ from ‘happiness’, and the need to consider wellbeing from a holistic standpoint, thus taking into account the needs and personal development of visually impaired individuals physically, socially, emotionally and spiritually. A rise in concepts such as ‘mindfulness’ (van Son et al., 2011) and ‘human givens’ (Bueno, 2009) echoes this underlying need to account for not just these two overarching dimensions of wellbeing, but also specific areas of emotional and indeed spiritual wellbeing that have to date remained under-researched, especially in the area of visual impairment.

Measuring wellbeing

A link has been established between positive mental health and physical wellbeing, however this raises the question of whether wellbeing can be ‘measured’? (Stewart-Brown, 2002). The waters are muddied even further when we bear in mind that the underlying standpoint of those who seek to measure or give wellbeing ‘training’ will influence where the parameters of such indicators or guidance are set. Why measure wellbeing? For those who seek to improve or promote emotional wellbeing in the visually impaired in order to improve functionality, measuring the success of such programmes is vital. Without the necessary measurement tools however, any wellbeing interventions would be rendered impotent because there would be no officially recognised way of measuring the success of such rehabilitative regimes. Measuring wellbeing therefore is high on the agenda in research environments that are underlined by outcomes, accountability and evidence-based practice. However, does this approach to research lie comfortably within the over-arching holistic ethos currently popular in healthcare discourse?

The majority of wellbeing measures, whether generic or specifically for vision loss, tend to follow the dominant ‘disease-as-deficit’ model. This point has been underlined by positive psychology and followers of assets-based models who argue that wellbeing measures tend to focus on illness rather than wellbeing (Foot & Hopkins, 2009). Furthermore, such measures appear to have conceived wellbeing as a hedonic entity, looking at wellbeing in terms of people’s satisfaction with their lives. Authors such as Waterman et al. (2010) therefore look towards constructing measures of the eudemonic dimension of wellbeing. Although within the realm of visual impairment we have seen an increased interest in the link between emotional and physical wellbeing, the majority of wellbeing measures have tended to focus on the physical and social elements of general quality of life. However, as underlined in the King’s College seminar and elsewhere in the literature (e.g., Tennant et al., 2007), wellbeing covers not only the physical and social, but also the emotional and spiritual needs and capabilities of the individual. The majority of indicators, however, tend to over-emphasise the first two elements at the expense of the latter two. It is suggested, therefore, that the eudemonic dimension of wellbeing warrants further attention, especially within visual impairment research. As noted by Vázquez et al. (2010), this second dimension of wellbeing is particularly related to long-term health outcomes and to the ability to cope flexibly and creatively with life’s challenges. Such findings therefore raise important questions about defining, promoting and measuring wellbeing in visual impairment research.

Promoting wellbeing: Emotional literacy, emotional intelligence and an unsteady discursive ground

A second area of interest, specifically for those working with the young visually impaired population is that of ‘training’ or ‘promoting’ wellbeing. This shift of emphasis towards ‘prevention’ of negative mental health and ‘promotion’ of emotional wellbeing has had an effect on vision loss rehabilitation and ‘interventions’. Fuelled by the current interest in wellbeing, significant links have been made between emotional wellbeing and constructs such as optimism, resilience and self-esteem. In the field of child psychology and Special Educational Needs (SEN) for example, it may be suggested that emotional wellbeing has been re-labelled and defined as ‘emotional literacy’ or ‘emotional intelligence’ (EI). The School of Emotional Literacy in the UK, and the government programme SEAL (Social and Emotional Aspects of Learning) both examine children’s social, emotional and moral development in order to identify the processes and mechanisms that foster traits such as empathy, compassion, and optimism and which may propel children towards positive mental health.

As noted by Schonert-Reichl (2009), implicit in this trend is the assumption that interventions can be designed to foster children’s strengths and resiliency. In relation to visual impairment, this suggests that it is possible to ‘prevent’ negative mental health and the risk of depression by ‘training’ visually impaired children to develop concepts such as self-esteem, self-control and how to ‘cope’ with their impairment. However, commentators from within positive psychology have asked if such ‘skills’ can indeed be ‘taught’, and even more so to populations who may have alternative ways of ‘making sense’ of the world, their experiences and personal development (Seligman, 2004).

Craig (2007a, 2007b) and Ecclestone and Hayes (2004, 2008), question the overall negative nature of emotional literacy and specifically, SEAL’s model of EI which follows the mainstream approach made popular by Goleman (1995). Craig (2007b: 12) notes that although EI as a concept has a ‘positive ring about it’, a great deal of which is very negative about emotions, viewing them as something to be feared, controlled and regulated. Do emotional literacy programmes for visually impaired children therefore run the risk of contributing to a deficit model that focuses on human failings that need to be ‘fixed’? If so, what are the alternatives?

Craig suggests that although the underlying values and motivations of the emotional literacy framework are about enhancing emotional wellbeing, it may be pertinent to be cautious about how much reliance is placed upon concepts such as EI and its inherent negative psychology. In turn, Craig suggests that emotional wellbeing initiatives for children should look towards positive psychology, and the work of authors such as Seligman and Csikmentmihalyi (2000). This approach to wellbeing is therefore concerned about finding the conditions which create good, flourishing lives (eudemonic wellbeing) whilst removing the focus on negativity and ‘emotional problems’ (Kobau et al., in press).

Where next?

The discourse on wellbeing continues to gather speed and infiltrate areas that have an impact upon those working in visual impairment services and research. The debates presented in this commentary will continue to take shape, be contested, rejected, twisted and turned and taken up again. The purpose of this commentary has not been to present one definite position on the wellbeing agenda, but to open up the debate to those involved in visual impairment research, in the hope that it will ultimately lead to happy, flourishing lives of those with vision loss.