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Theory in mental health promotion practice

Caplan and Holland have stated that ‘effective practice in mental health promotion depends on good theory’. Awareness of the wide range of theories is needed, they said, together with a critical attitude to them since theories contain contradictions and may lead users into unforeseen and unwanted implications. What is theory and why is its use important? The role of theory is to untangle and simplify the complexities of nature. Theories present in an abstract way the key features of some aspect of the world. They can address either universal, or more localized phenomena, and can relate to micro-, meso- or macro-levels of analysis. The same aspect of the world can be understood differently according to the theory used. O’Brien has used a nice analogy:

A simple way of understanding theory is to compare it with a kaleidoscope. As the tube is turned different lenses come into play and the combination of colours and shapes shift from one pattern to another. In a similar way we can see social theory as a sort of kaleidoscope – by shifting theoretical perspective the world under investigation changes shape.

Different theories bring different aspects of the world into view. The nature and purpose of theory differs according to epistemological (theories of knowledge) position with a simple distinction drawn between positivist and interpretivist positions. According to positivist thinking there is an objective world that can be measured, causal relationships identified, and general theories developed which can be tested against reality. No distinctions are drawn between the natural and social sciences. A definition of theory from this perspective is ‘a set of interrelated concepts, definitions and propositions that present a systematic view of events and situations by specifying relations among variables in order to explain, and to predict events or situations’ (Glanz and Rimer 1995). Theories can be arrived at through deduction from other existing principles as, for example, in mathematics, or built up by induction from empirical investigations.

Good theories are testable, generalizable and have power. Within the alternative intellectual positions that can be taken together and labelled as interpretivism social reality is understood as a meaningful construction based on subjective understandings rather than objective measurements. Through gaining access to these understandings theory can be drawn out from research findings. This can consist of theoretical concepts, presented singly or combined into theoretical models. The resulting theories are seen to relate to the situations from which they were derived and while they may be transferable to similar ones are not claimed to be generalizable. The disciplines which underpin health promotion have drawn on theory within both traditions. Theories can be presented in the form of models which offer meaningful ways of presenting the relationships between events and which can be informed by more than one theory.

At the same time it should be emphasized that not all models are theory based with some simply providing visual descriptions of particular situations or processes. Deciding definitively whether a model should, or should not be described as theoretical does, to a considerable extent, depend on the conception of theory being held – positivists being more stringent than interpretivists. What is theory used for in mental health promotion? First, theory can be used in the analysis of situations or problems of interest in order to understand and explain and, where appropriate, to define areas for action. Second, theory is used to guide the nature and process of interventions and their evaluation. Prior to commenting on mental promotion theory some comment can be made the theory of health promotion in general. This theory base has broadened over time. As health promotion began to evolve from health education theory was drawn from several contributory disciplines – predominantly psychology, epidemiology, education and sociology. As health promotion developed it extended its theory base in accordance with its broad range of activities drawing on social policy, political theory, organizational theory, community studies, marketing, economics, etc. Theory was also, to a certain extent, developed within the discipline itself. It is necessary to ask whether mental health promotion uses the same theory as general health promotion or whether it has a distinctive theoretical basis. To some extent both questions can be answered in the affirmative.

Where a conception of mental health promotion is held which fits with the values and principles of health promotion discussed earlier the same broad theory base is clearly relevant. Secker (1998) has observed, however, that general health promotion theory while clearly applicable to developing mental health had not made considerable impact. As noted earlier the fact that mental health promotion developed to some extent independently from general health promotion has led to some differences between its theory base and that of general health promotion. For example, the development of community mental health centres in the USA in the 1960s associated with the field of community psychology stimulated theory development in mental health promotion before the active development of general health promotion. The values of community psychology and its theory and values are similar to the values of health promotion (Orford 1993) and some of the key people involved in the community mental health movement were influential in the development of health promotion.

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