The Mental Health Continuum

October 27, 2019 by John Andrew Williams

A 2002 study by psychologist Corey Keyes clarifies the scope of coaching, the need for coaching, and its possible usefulness. The study quantifies a correlation between flourishing well-being and lowered likelihood of mental illness, and between incomplete well-being and higher likelihood of mental illness. The key here is that it’s a correlation, but the two aren’t mutually exclusive. Mental illness was not totally absent in the study’s adults who were also flourishing, and it was not all-pervasive in the study’s adults who showed low well-being. This finding provides a theoretical basis for where coaching fills a need for people helping people outside of therapy and medical psychology. There are people out there who are not flourishing, but who are not mentally ill, for whom coaching practices could make a really big difference. What’s even more fascinating is the finding that with mental illness and well-being, it’s not either/or**. It’s maybe/and. The study suggests that it’s possible (not likely, but possible) for a flourishing adult to also experience mental illness. This is mind-blowing to me – that 4.9% of the people who participated in this study were doing extremely well according to the well-being scales, but had also experienced symptoms of a major depressive episode in the last 12 months. I want to talk to those people. I want to know how they manage mental illness and still achieve high levels of well-being.

This study uses the pathological methodology that is so well-developed in mental illness fields to describe positive psychology.** “Symptoms” is a term traditionally used to describe maladies, the presence of something bad. This study uses the “symptoms” to describe both mental illness and positive well-being parameters. There is a model here that looks at symptoms as the presence of something good.


  • In the introduction to the study, Cory Keyes frames his guiding question: “Are adults who remain free of mental illness annually and over a lifetime mentally healthy and productive?” (p. 208). Building on Jahoda (1958) and Ryff (1989), he suggests that the definition of mental health and well-being isn’t simply the absence of mental illness. In other words, he hypothesizes that mental health isn’t binary – if a person lacks mental illness, that doesn’t necessarily mean they are flourishing, and vice versa. Instead, there may actually be a continuum of well-being with flourishing defined as complete mental health and languishing as incomplete mental health. 
  • Keyes designed the study to assess how American adults are distributed on the continuum of flourishing to languishing in terms of subjective, emotional, and social well-being. Subjective well being is a person’s evaluations of their own life in relation to their psychological functioning. Emotional well being is reflected in whether someone has positive, negative, or apathetic feelings about life. Social well being integrates how well someone is functioning in society – how much they contribute to it and also feel supported by it. 
  • Keyes quantified the continuum with survey data that allowed him to look for correlations between states of well-being and mental illness. Indeed, he found that adults who had incomplete mental health (AKA “languishing”) were not all mentally ill, but were far more likely to be mentally ill than flourishing people. 


  1. Keyes conceptualizes mental health as a symptom of positive feelings and positive functioning in life, rather than merely the absence of mental illness. This marks the cornerstone of the positive psychology field as an alternative to the traditional psychology standpoint of measuring pathological illness. Keyes looks at positive parameters of well-being as symptoms, in addition to mental illness symptoms. It’s no longer looking at the absence of something bad, but the presence of something good. 
  2. This study suggests that a large proportion of American adults may be operating below their fullest potential for well-being, but without hindrance from mental illness. This presents an enormous need that life coaches are trained to address. 72% of people who scored as languishing had not experienced major depressive symptoms in the last 12 months. These people are struggling in various ways but without mental illness – they may not seek traditional psychological treatment because they lack severe symptoms. They still need help. They’d have so much to gain through working towards achievable goals with a life coach. Coaching may be able to help these people move forward along the continuum towards flourishing. 
  3. People who are languishing are more vulnerable to mental illness. 28% of people who were languishing had recently experienced symptoms of a major depression, markedly more than the moderately mentally healthy group and the flourishing group. This marks a great need to help people avoid languishing, help them move towards flourishing and away from the threat of mental illness. 
  4. There is a correlation between flourishing and mental health, but it is not a definitive correlation. Mental health and flourishing aren’t mutually exclusive – they can exist with or without one another. 


  1. Keyes used data generated from the MacArthur Foundation’s 1995 Midlife in the United States Survey, which included 3,032 non-institutionalized adults ages 25 to 74 across the lower 48 states. The survey was an intensive process that took a little over a year to complete and consisted of two parts: a phone interview followed by a lengthy questionnaire that took over an hour to complete. To make this worth peoples’ whiles, the MacArthur Foundation offered a nice incentive package of a commemorative pen, twenty dollars, reports of study findings, and a copy of the final results. Both the interview and the questionnaire used proven psychological measurement tools to measure mental illness parameters, as well as psychological, social, and emotional well-being. 
      The mental illness tools were based on Kessler et al. (1998)’s Composite International Diagnostic Interview Short Form scales. The questions targeted whether the participant had recently experienced the symptoms of a major depressive episode. They also rated their mental health on a scale from “poor” to “excellent”, and reported how much their mental health limited them in their personal or working lives. The psychological tools were based on Ryff’s (1989) six dimensions of psychological well being. These measured someone’s perception of their personal growth, self-acceptance, environmental mastery, positive social relationships, autonomy, and sense of purpose. The social tools were based on Keyes’ (1998) five scales of social well being. These measured someone’s perception of their social acceptance (caring for other peoples’ problems), coherence (understanding what’s going on in the world), actualization (the sense that society is improving for someone like you), integration (feeling close to other people in the community), and contribution (feeling like what you do every day contributes to your community’s well-being). The emotional tools integrated questions targeting positive attitude and satisfaction with life. Participants rated their satisfaction with life on a scale of 0 to 10, in ascending order of value. They were also asked to what extent they experienced feelings of being calm and peaceful, satisfied, full of life, in good spirits, extremely happy, and cheerful during the past 30 days.
  2. Keyes then took the results of the above scales of well-being and statistically analyzed them to categorize respondents as flourishing, moderately mentally healthy, or languishing. In total, there were 13 scales of well-being (six for psychological, five for social, and two for emotional). The analysis scored respondents within each of these 13 scales. Each scale was divided into thirds to represent the three tiers of the flourishing continuum. People were classified as flourishing if they scored in the upper third of 6 out of the 11 scales for psychological and social well being, and in the upper third of 1 of the 2 scales for emotional well being. People were classified as languishing if they scored in the lower third of the same. If they were somewhere between these two extremes, they were classified as moderately mentally healthy.
  3. Keyes then cross referenced the flourishing to languishing results with the mental illness parameters. The results suggested that mental illness is positively correlated as languishing symptoms increase along the continuum. Only 4.9% of the flourishing adults reported symptoms of a major depression in the last 12 months, while 28% of those who scored as languishing reported depression. As could be expected, the moderately mentally healthy people were somewhere in the middle, with 13.9 % reporting depressive symptoms.

References: Kessler, et al. 1998, republished 2006. The World Health Organization Composite International Diagnostic Interview short‐form (CIDI‐SF). International Journal of Methods in Psychiatric Research, 7 (4)., C. L. M. 1998. Social well-being. Social Psychology Quarterly, 61 (2): pp. 121 -140., C. L. 2002. The Mental Health Continuum: From Languishing to Flourishing in Life. Journal of Health and Social Behavior, 43 (2): pp. 207 – 222. Ryff, C. D. 1989. Happiness is everything, or is it? Explorations on the meaning of psychological well-being. Journal of Personality and Social Psychology, 57 (6): pp. 1069-1081.

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