Health Promotion International, Vol. 25 No. 4
doi:10.1093/heapro/daq037
Advance Access published 12 June, 2010
# The Author (2010). Published by Oxford University Press. All rights reserved.
For Permissions, please email: [email protected]
Leisure as a context for active living, recovery, health
and life quality for persons with mental illness
in a global context
YOSHITAKA IWASAKI 1*, CATHERINE P. COYLE 2 and JOHN W. SHANK 2
1
Department of Therapeutic Recreation and 2Department of Therapeutic Recreation, College of Health
Professions, Temple UniversitySuite 313, 1700 North Broad Street, Philadelphia, PA 19121, USA
*Corresponding author. E-mail: [email protected]
SUMMARY
Globally, the mental health system is being transformed
into a strengths-based, recovery-oriented system of care, to
which the concept of active living is central. Based on an
integrative review of the literature, this paper presents a
heuristic conceptual framework of the potential contribution that enjoyable and meaningful leisure experiences
can have in active living, recovery, health and life quality
among persons with mental illness. This framework is
holistic and reflects the humanistic approach to mental
illness endorsed by the United Nations and the World
Health Organization. It also includes ecological factors
such as health care systems and environmental factors as
well as cultural influences that can facilitate and/or
hamper recovery, active living and health/life quality.
Unique to this framework is our conceptualization of
active living from a broad-based and meaning-oriented
perspective rather than the traditional, narrower conceptualization which focuses on physical activity and exercise.
Conceptualizing active living in this manner suggests a
unique and culturally sensitive potential for leisure experiences to contribute to recovery, health and life quality. In
particular, this paper highlights the potential of leisure
engagements as a positive, strengths-based and potentially
cost-effective means for helping people better deal with
the challenges of living with mental illness.
Key words: culture; recreation; mental health; quality of life
LEISURE AS A CONTEXT FOR ACTIVE
LIVING, RECOVERY, HEALTH AND LIFE
QUALITY FOR PERSONS WITH MENTAL
ILLNESS IN A GLOBAL CONTEXT
Globally, mental disorders are prevalent across
all cultures—more than 450 million people
suffer from mental disorders worldwide
(Hyman et al., 2006). The World Health
Organization (WHO, 2001a) estimated that
mental disorders would account for 15% of the
total burden of disease in the year 2020, and
showed that mental disorders would be the
principal cause of Years Lived with Disability
internationally. Despite advances in pharmacological and psychosocial treatments, the quality
and adequacy of health care for persons with
mental illness ‘remain fragmented, disconnected, and often inadequate, frustrating the
opportunity for recovery’ (New Freedom
Commission on Mental Health, 2003, p. 1).
Within Transforming Mental Health Care in
America, Federal Action Agenda, recovery is
emphasized as the single most important goal
for the mental health system (USDHHS, 2006).
Also, as a follow-up to the 2001 World Health
Report, the mental health Global Action
Programme (mhGAP) was developed and
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Y. Iwasaki et al.
provides a strategy for closing the gap between
what is urgently needed and what is currently
available to help individuals and families
affected by mental illness (WHO, 2001a).
Achieving the highest level of recovery was
identified as a major goal of the mhGAP
(WHO).
concluded, ‘Recovery is not about going back to
a pre-illness state, and means something very
different from the ‘old’ emphasis on controlling
symptoms or cure. Rather, it is a complex and
multifaceted concept, both a process and an
outcome, the features of which include strength,
self-agency and hope, interdependency and
giving, and systematic effort, which entails
risk-taking’ ( p. 119).
RECOVERY DEFINED
According to the National Consensus Statement
on Mental Health Recovery, derived from over
110 expert panelist deliberations, recovery is
defined as ‘a journey of healing and transformation enabling a person with a mental health
problem to live a meaningful life in a community of his or her choice while striving to
achieve his or her full potential’ (USDHHS,
2006). Recovery involves a holistic, personcentered, strengths-based approach that focuses
on: self-direction, respect, hope, connectedness,
peer support, empowerment, spiritual fulfillment and meaningful life (including education,
employment and leisure) (Sells et al., 2006;
USDHHS, 2006). The practical use of these key
elements of recovery (e.g. hope as the very idea
that recovery is possible) was emphasized in
Sartorius and Schulze’s (Sartorius and Schulze,
2005) document based on reports from the
World Psychiatric Association’s effort to fight
against stigma of mental illness.
Understanding the true meaning and essence
of recovery as an expectation for and by people
with mental illness is a global concern.
Davidson and Roe conducted an extensive
review of the empirical literature on recovery
from an international perspective (Davidson
and Roe, 2007). They identified two complementary meanings of recovery—‘The first
meaning of recovery from mental illness derives
from over 30 years of longitudinal clinical
research, which has shown that improvement is
just as common, if not more so, than progressive
deterioration. The second meaning of recovery
in derives from the Mental Health Consumer/
Survivor Movement, and refers instead to a
person’s rights to self-determination and
inclusion in community life, despite continuing
to suffer from mental illness’ ( p. 459).
Ramon et al. also surveyed the meanings of
the term recovery from a global perspective,
with particular attention given to service
users’ definitions (Ramon et al., 2007). They
RE-DEFINING ACTIVE LIVING
The concept of recovery is based on a vision
that a majority of people with mental illness can
lead meaningful lives in their community (Clay
et al., 2005). Within the USA, active living is a
public health issue and its health benefits have
been well documented. Beneficial outcomes
include improved health (Tudor and Bassett,
2004), physical functioning (Brach et al., 2004),
health-related quality of life (Brown et al., 2004)
and lower mortality (Gregg et al., 2003).
However, active living is typically understood
from a physical activity/exercise perspective.
This is increasingly the case in an international
context, as well (e.g. Murray, 2006; Carless,
2007). While physical activity and exercise is
undeniably a core component in active living,
there is a risk of over-emphasizing physical
activity as the defining element of active living.
This creates a biased view of active living by
overlooking the potential value of other types
of activities that promote active engagement in
one’s life, such as non-physical or less physically
demanding forms of leisure (e.g. expressive/
creative, social, spiritual or cultural forms of
leisure).
We propose a broader and more strengthbased, humanistic approach to the conceptualization of active living. This conceptualization
views active living as being actively engaged in
living all aspects of one’s life both personally
and in families and communities in a meaningful and enriching way rather than the narrower
conceptualization of active living, which is predominately biased toward physical activity and
exercise only (Iwasaki et al., 2006; Kaczynski
and Henderson, 2007). Both the United Nations
(UN; Quinn et al., 2002) and World Health
Organization (WHO, 2005) support such a conceptualization, given their endorsement of a
broad and strengths-based, human rights
approach to health promotion among global
Leisure, active living and mental health
populations (including individuals with disabilities such as mental illness) in both developing
and developed countries.
A broader conceptualization of active living
may be particularly salient to persons with
mental illness not only because sedentary and
inactive lifestyles are prevalent among this
population group (McElroy et al., 2006), but
also because their lives are often characterized
by loneliness and isolation and a disconnection
from their community (Lemaire and Mallik,
2005). A conceptualization of active living that
is attentive to the humanistic as well as physical
outcomes derived from activity may be more
effective in this population, especially since it
can embrace the individual’s need for meaningseeking or -making. Examples of activities that
illustrate this conceptualization of active living
would include: (a) Tai Chi, a physical activity
that promotes physical health but which also
focuses on body-mind-spirit harmony; (b) social
leisure activities with peers/friends that promote
emotional health and which do not emphasize
living with mental illness as an issue (i.e.
stigma); and (c) culturally meaningful, spiritually refreshing and/or creative/expressive
leisure activity such as art/crafts, music and
dance that promote self-expression and identity.
ENJOYABLE AND MEANINGFUL
LEISURE AS A CONTEXT FOR ACTIVE
LIVING
In this paper, leisure is defined as a relatively
freely chosen humanistic activity and its accompanying experiences and emotions (e.g. enjoyment and happiness) that can potentially make
one’s life more enriched and meaningful. The
meaning-seeking or meaning-making functions
of leisure have a long tradition in the leisure
research field (e.g. Shaw, 1985; Samdahl, 1988;
Henderson et al., 1996; Kelly and Freysinger,
2000). Recently, Iwasaki (Iwasaki, 2008) identified key pathways to meaning-making through
leisure-like pursuits in global contexts. He
showed that in people’s quest for a meaningful
life, these leisure-generated pathways seem to
simultaneously involve both ‘remedying the bad’
(e.g. coping with/healing from stressful or traumatic experiences, reducing suffering) and
‘enhancing the good’ (e.g. promoting life
satisfaction and life quality) through facilitating,
for example, positive emotions, identities,
485
spirituality, connections and a harmony, human
strengths and resilience, and learning and
human development across the lifespan.
Overall, these notions of leisure emphasize: (a)
meaning-oriented emotional, spiritual, social and
cultural properties of leisure that reflect a
broader and humanistic perspective than physical
activity alone, and (b) the role of meaningmaking through leisure in promoting active
living, health and life quality for people including
individuals with mental illness. Leisure is a key
context for active living and an important
pathway toward recovery, health promotion and
life-quality enhancement. Leisure represents
broad aspects of human functioning including
emotional, spiritual, social, cultural and physical
elements. The forms that leisure expressions take
(e.g. sport, exercise, art, crafts, visits with friends)
are secondary to the meanings derived from and
associated with the leisure experiences, and it is
the outcomes/meanings derived that present the
potential contributions to these pathways.
Recent research has shown that leisure
opportunities (e.g. through a peer-run program
at recreation centers) can play a key role in the
recovery of persons with mental illness
(Swarbrick and Brice, 2006). Davidson et al.’s
multinational study on recovery from serious
mental illness highlighted the importance of
going out and engaging in ‘normal’ activities,
and having meaningful social roles and positive
relationships outside of the formal mental
health system (Davidson et al., 2005) . Not only
can leisure and recreation provide an opportunity for going out and socially valued normal
activities, but these activities can also provide a
context for having a positive relationship and
pursuing a meaningful social role among
people including individuals with disabilities
(Henderson and Bialeschki, 2005; Iwasaki et al.,
2006; Hutchinson et al., 2008). Fullagar’s qualitative study with 48 women with depression in
Australia found that creative (e.g. art/craft, gardening, writing, music), actively embodied (e.g.
walking, yoga, Tai Chi, swimming) and social
(e.g. cafes, friend/support groups) leisure activities acted as a counter-depressant by eliciting
positive emotions (e.g. joy, pleasure, courage)
that facilitated recovery and transformation in
ways that biomedical treatments could not
(Fullagar, 2008). These findings show important
practical implications that advocate a more
humanistic, strengths-based and potentially
cost-effective health-care approach.
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Y. Iwasaki et al.
PURPOSE STATEMENT
Unfortunately, active living and health promotion research for individuals with mental
illness has never directly integrated the concept
of recovery. Conceptualizing active living from
a broader, humanistic and meaning-oriented
perspective is proposed as being preferable over
a narrow single-dimensional (e.g. physical
activity) perspective. Also, leisure pursuits seem
to provide an important context for active living
and recovery-oriented health and life-quality
promotion (Godbey et al., 2005; Henderson and
Bialeschki, 2005; Sallis et al., 2005). This potential, however, has been neglected (and perhaps
undervalued) and seldom studied directly.
Therefore, based on an integrative review of the
literature, this paper presents a heuristic conceptual framework of the potential role of
enjoyable and meaningful leisure in facilitating
active living, recovery and health/life-quality
promotion among persons with mental illness
from a more holistic/ecological and humanistic
perspective in a global cross-cultural context.
Holistic and ecological concepts supported by
Ng et al. (Ng et al., 2009), DeLeon (DeLeon,
2000) and Bambery and Abell (Bambery and
Abell, 2006) are a basis of our framework.
First, inspired by Chinese medicine’s holistic
model, Ng et al. (Ng et al., 2009) conceptualized
an Eastern body-mind-spirit approach to achieving a primary therapy goal of facilitating a harmonious equilibrium within oneself as well as
between oneself and the natural and social
environment. Advocating the notion of ‘beyond
survivorship,’ this approach focuses on human
strengths and thriving. For example, in this
approach, striving for a vibrant mind/spirit is
pursued through Tai Chi and Qigong exercises,
which enable one to appreciate and affirm one’s
life through meaning-making, which can be a
catalyst to transform clients for positive change.
The aim of this holistic approach is to activate
an interconnected body-mind-spirit system in
order to reestablish a balance and harmony
among clients contextualized within their
broader community, society and environment.
DeLeon’s Therapeutic Community (TC)
model is also relevant to this holistic and ecological concept (DeLeon, 2000). The TC model
is more comprehensive and integrative than
those based on symptom reduction alone. It
emphasizes the transformative influences of
one’s identity and culture through collective
intervention formats using the power of social
groups in augmenting active learning, personal
and social responsibility, and collective growth.
DeLeon’s TC model aims to achieve an existentially derived and authentic purpose in life as
the primary value of living, which he theorizes
to include personal and social accountability,
collective learning, community involvement and
good citizenry within a broad societal system.
These concepts are also in line with Bambery
and Abell’s (Bambery and Abell, 2006) urge for
shifting the mental health field’s current paradigm of psychopathology to a more holistic and
ecological perspective by supporting Fromm’s
(Fromm, 1941, 1955, 1976) advocacy for a more
comprehensive treatment of individuals including its sensitivity to a macro-context in which
society (e.g. culture, historical forces, social
class) influences one’s behavior. These notions
are further supported by Bambery and Abell’s
case study that addressed both individual psychopathology and larger societal ills influencing
their study participants’ lives including family,
social and environmental factors from an ecological perspective.
TOWARD A HOLISTIC/ECOLOGICAL
FRAMEWORK OF THE ROLES OF
LEISURE IN ACTIVE LIVING,
RECOVERY AND HEALTH/
LIFE-QUALITY PROMOTION AMONG
PERSONS WITH MENTAL ILLNESS
Using a holistic and ecological perspective, our
proposed conceptual framework (Figure 1)
depicts the potential interrelationships among
active living, recovery and health/life quality
among people with mental illness. These potential pathways were derived from an extensive
and comprehensive review of the literature
including both qualitative and quantitative data
from studies conducted in a cross-cultural, international context.
In this framework, enjoyable and meaningful
leisure expressions are emphasized as a key
context for active living, and as a major
pathway to recovery, health and life quality. We
recognize that other activities (e.g. employment) also contribute to active living and the
reader should not think that we are placing
leisure as the sole construct contributing to
active living. Rather, this conceptual framework
is developed to highlight how enjoyable and
Leisure, active living and mental health
Fig. 1: A heuristic holistic/ecological framework of the roles of leisure in active living, recovery and health/life-quality promotion among persons with
mental illness. Broken lines (---) represent transactional reciprocal relationships and connectedness between the various factors depicted in the
framework.
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Y. Iwasaki et al.
meaningful leisure, an often neglected life
activity in the rehabilitation process, can and
should be considered when designing interventions to promote active living, recovery and
health/life quality for individuals with mental
illness.
As depicted with bi-directional arrows, enjoyable and meaningful leisure is assumed to function as a critical proactive agent via its potential
to promote personal identity and spirituality,
positive emotions, harmony and social connections, effective coping and healing, human
development, and physical and mental health.
The bi-directional arrows also indicate the converse that personal identity and spirituality,
harmony and social connections, coping and
healing, etc., in turn, influence leisure
expressions.
The circular structure in our framework illustrates a system of micro and macro factors from
a holistic/ecological perspective. The factors
within the outer circle (i.e. cultural, environmental and health-care system factors) are considered more macro than the factors within the
inner circle. Also, both the distinction and interconnectedness between micro and macro factors
are implied. For example, personal identity and
spirituality as a micro element are located
within the inner circle along with other potential leisure outcomes such as positive emotions,
harmony and social connections, coping/healing
and health, which are distinguished from (yet
are connected to) cultural factors as a macro
element. On the other hand, active living,
recovery and life quality are highlighted as
key leisure-generated outcomes, contextualized
within the outer layer of macro factors (i.e. cultural, environmental and health-care system
factors). These transactional reciprocal relationships and connectedness between the various
factors within multiple layers of circles are
depicted with broken lines (---) of circles in the
conceptual framework. It must, however, be
cautioned that our intention here is not to
suggest causation. Rather, our conceptual framework is presented as a ‘heuristic’ map to
stimulate a more balanced, holistic/ecological
and humanistic orientation of practice toward
active living, recovery and the promotion of
health and life quality among culturally diverse
groups of people with mental illness in a global
context. It is also recognized that this reciprocal
transaction can be both positive and negative.
That is, discretionary time behaviors (leisure)
can be detrimental to health just as environmental factors can support or impede meaningful leisure experiences. Nevertheless, this article
focuses on ideal transaction.
POTENTIAL CONTRIBUTIONS OF
LEISURE TO ACTIVE LIVING,
RECOVERY AND HEALTH/LIFE
QUALITY AMONG PEOPLE WITH
MENTAL ILLNESS
Leisure’s potential has increasingly been shown
in a series of empirical research. For example,
Lloyd et al.’s (Lloyd et al., 2007) study with 44
Australian clubhouse members with mental
illness found a significant association between
leisure motivation (measured with leisure
motivation scale, Beard and Ragheb, 1983) and
recovery (measured with recovery assessment
scale, Corrigan et al., 2004). Specifically, individuals who were motivated to engage in leisure
were functioning well at a higher level of recovery, while goal- and success-oriented leisure
motivation (r ¼ 0.84) and leisure motivation
toward personal confidence and hope (r ¼ 0.83)
had strongest correlations with recovery. These
findings are consistent with Hodgson and
Lloyd’s (Hodgson and Lloyd, 2002) qualitative
study showing that the involvement in leisure
activities plays a vital role in relapse prevention
for individuals with dual diagnosis of mental
illness and substance misuse, and with Moloney
(Moloney, 2002) and Ryan (Ryan, 2002) who
emphasized that the engagement in leisure is
instrumental in a journey for recovery from a
consumer perspective. Trauer et al.’s study with
55 clients with serious mental illness reported
that one’s satisfaction with leisure had the strongest association with global well-being (GWB)
(r ¼ 0.76) (Trauer et al., 1998). This association
between leisure satisfaction and GWB was
greater than any other life-domain measures
such as health, family and social relations. Also,
Lloyd et al.’s (Lloyd et al., 2001) study found
that individuals with mental illness who participated in a community-based rehabilitation
program reported positive effects of leisure on
intellectual stimulation, relaxation and enjoyable relationships with others. By integrating
the findings of these studies, Lloyd et al. (Lloyd
et al., 2007) emphasized that leisure-based programs should be considered for community
reintegration and social inclusion of people with
Leisure, active living and mental health
mental illness. This recommendation is in line
with Heasman and Atwal’s (Heasman and
Atwal, 2004) finding that leisure participation
can contribute to greater social inclusion among
British adults with mental illness.
Frances’ (Frances, 2006) evidence-based
review highlighted the role of outdoor recreation (e.g. walking, cycling, hiking, kayaking,
canoeing) as a viable therapeutic means for
people with mental illness, particularly its role
in facilitating positive identity and life quality
(Frances, 2006). Also, Babiss’ (Babiss, 2002)
ethnographic study of women with mental
illness provided evidence that expressive activities such as art, music, writing and dance
promote the process toward recovery, specifically as a vehicle for learning about self and for
identifying feelings one cannot express verbally.
Babiss indicated that ‘expression just for the
sake of expression has value’ ( p. 118), while
emphasizing ‘the stunning importance of the
human interaction and the human touch’
( p. 106). In fact, self-expressions and meaningful interpersonal interactions are two key
benefits of leisure and recreation (Driver and
Bruns, 1999).
Yanos and Moos’ integrated model of the
determinants of functioning and well-being
among individuals with schizophrenia identified
leisure activities as a key dimension of social
functioning (Yanos and Moos, 2007). Minato
and Zemke’s study with 89 community residents
(aged 19 –64 years) with schizophrenia in
Sapporo, Japan showed that leisure can act as a
stress-reliever (Minato and Zemke, 2004). As
shown earlier, Davidson et al.’s (Davidson et al.,
2005) international study (conducted in Italy,
Norway, Sweden and the USA) found that
going out and engaging in normal activities,
having meaningful social roles and maintaining
positive interpersonal relationships outside of
the formal mental health system were found as
salient themes of recovery processes.
From a positive strengths-based perspective,
Carruthers and Hood (Carruthers and Hood,
2004) stressed the role of therapeutic recreation
services for individuals with mental illness in
facilitating resilience, thriving and life satisfaction. Pedlar et al.’s study pointed to the importance of informal recreation opportunities (e.g.
informal get-together during which women
inmates with mental health challenges living in
a prison system spent a leisurely evening
together with people from the community)
489
rather than a conventional formalized intervention to facilitate friendship and community
reintegration (Pedlar et al., 2008).
The notion of leisure as an antidote to
depressive symptomotology was shown in
Fullagar’s (Fullagar, 2008) study with 48
Australian women with depression. This study
drew on post-structural feminist theories of
emotion to explore the significance of leisure
within women’s narratives of recovery from
depression. Specifically, Fullagar found evidence that leisure: (a) helped open up positive
experiences of self beyond the experiences with
the medical/clinical treatment, (b) had transformative effects on gender identity (learning
really ‘who I am’), (c) generated ‘hope’ that
there is life beyond depression and (d) enabled
the women to exercise a sense of entitlement
to play and enjoy life. Importantly, recoveryoriented leisure practices involved setting new
boundaries for self (e.g. personal space) and
others, and elicited emotions (e.g. joy, pleasure,
courage) that facilitated transformation in ways
that biomedical treatments could not. Fullagar
stated, ‘The recovery practices adopted by
women were significant not because of the
“activities” themselves but in terms of the
meanings they attributed to their emerging
identities. Women talked about how they
engaged in leisure “for” themselves (e.g. alone
or with others)’ through creative (e.g. art/craft,
gardening, writing, reading, music, community
theatre, self-education), actively embodied (e.g.
martial arts, walking, bowls, dance, yoga, Tai
Chi, swimming, meditation) and social activities
(e.g. cafes, dance courses, support groups, pets,
church, helping others) ( p. 42).
Thus, active engagements in leisure give
attention to the experiences and meanings
derived from these engagements. For example,
individuals with mental illness can engage in a
nature walk with peers and/or friends that can
provide an opportunity to gain social (e.g. companionship), emotional (e.g. positive moods)
and spiritual (e.g. spiritual renewal) benefits
within a natural environment beyond physical
and physiological benefits of a nature walk.
Empirical evidence is emerging to demonstrate
that enjoyable and meaningful leisure can facilitate coping with stress and healing from trauma,
and promote hope, identity (e.g. deeper understanding of self ), connectedness, appreciation
for life, human growth/transformation and life
quality among people including persons with
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Y. Iwasaki et al.
mental illness (e.g. Kleiber et al., 2002;
Hutchinson et al., 2006, 2008; Iwasaki et al.,
2006). Consistent with this evidence, Ritsner
et al.’s (Ritsner et al., 2005) study with Jewish or
Arab Israelis with mental illness found that
leisure activities facilitated finding meaning in
life, which counteracted negative states of
depression and emotional distress. In addition,
a recent National Alliance on Mental Illness
(NAMI, 2004) document included an illustration about the power of enjoyable and meaningful forms of actively engaged leisure for
individuals with serious mental illness.
Furthermore, from a health-promoting perspective, leisure seems to have the potential to
reduce secondary health conditions (e.g.
obesity) of individuals with mental illness.
Healthy People 2010 (USDHHS, 2000) defines
secondary conditions as ‘medical, social,
emotional, family, or community problems that
a person with a primary disabling condition
likely experiences.’ It has been shown that
the reduction and prevention of secondary
conditions are very important for persons
with mental illness because of their adverse
effects on health and life quality (Johnson,
1997; Perese and Perese, 2003; Merikangas and
Kalaydjian,
2007).
The
International
Classification of Functioning, Disability and
Health (ICF) also recognizes the importance of
managing secondary conditions of people with
disabilities (WHO, 2001b). Beyond the primary
disabling conditions, physical, social and
environmental factors amendable through
public health intervention are widely acknowledged to mediate the development of secondary
conditions (Wilber et al., 2002), yet targeted
lifestyle interventions for persons with mental
illness are lacking (Bradshaw et al., 2005).
Within our model, and supported by recent
research findings, the potential exists in utilizing
leisure activities within a health promotion framework, especially physically and socially active
leisure. For example, Richardson et al.
(Richardson et al., 2005) implemented an
18-week lifestyle intervention program to
promote physical activity and healthy eating
among 39 individuals with serious mental illness
and found observable weight loss (to reverse
weight gain as a secondary condition) over the
course of the intervention. Also, Cournos and
Goldfinger (Cournos and Goldfinger, 2005)
reported some success with a cognitivebehavioral therapy (CBT) intervention to
promote walking among individuals with
comorbid depression and diabetes (i.e. another
secondary condition). The role of social leisure
in dealing with social isolation (still as another
secondary condition) has been found (e.g.
Heasman and Atwal, 2004; Davidson et al.,
2005; Pedlar et al., 2008), as well as the role of
leisure in relapse prevention for individuals
with dual diagnosis of mental illness and substance misuse (Hodgson and Lloyd, 2002).
IMPORTANCE OF CULTURAL AND
ENVIRONMENTAL FACTORS AND
HEALTH CARE SYSTEMS
The framework includes cultural factors, health
care systems and other environmental factors
(e.g. family and peer support, socio-economic
living conditions, neighborhood and community
including parks and recreation centers, educational and employment opportunities). The
interactive effects of these macro factors are
assumed to influence the other components
included in the framework, which is consistent
with an ecological perspective of health and disability (WHO, 2001b).
Giving attention to cultural factors (e.g. race/
ethnicity) is a must in the conceptualizations of
leisure, active living, recovery, health promotion,
life quality and health care, and its interrelationships. For example, Davidson et al.’s (Davidson
et al., 2005) multinational study showed that cultural differences among individuals with mental
illness from each country were noted primarily
in the nature of the opportunities and supports
offered rather than in the nature of the recovery
processes described. Mendenhall (Mendenhall,
2008) discussed factoring culture into outcome
measurement in mental health, while Warren
(Warren, 2007) described cultural aspects of
bipolar disorder and interpersonal meaning for
clients and psychiatric nurses. Also, Ida (Ida,
2007) suggested that the critical role of culture
should be acknowledged in the recovery and
healing process within the context of ‘racism,
sexism, colonization, homophobia, and poverty,
as well as the stigma and shame associated with
having a mental illness’ (p. 49). Hopper et al.,
2007) conducted a cross-cultural inquiry into
marital prospects after psychosis, and Rosen
(Rosen, 2003) discussed how developed
countries can learn from developing countries
in challenging psychiatric stigma from a
Leisure, active living and mental health
cross-cultural perspective. This may ‘include
wider communal involvement in addressing
external ( psycho-sociocultural) causal or precipitating factors (e.g., losses, lack of meaningful
role, spiritual crises) rather than relying on
internal biological explanations and treatments’
(Rosen, 2003, p. S95). Fallot showed that
spirituality is central to self-understanding and
recovery experiences of many individuals with
mental illness, and that recognizing the role of
spirituality and religion in a particular culture is
often essential to offering culturally competent
services (Fallot, 2001). Also, Hwang et al.
(Hwang et al., 2008) provided a conceptual paradigm for understanding how cultural factors
(e.g. cultural meanings, norms, expressions)
influence several core domains of mental health,
including (a) the prevalence of mental illness,
(b) etiology of disease, (c) phenomenology of
distress, (d) diagnostic and assessment issues, (e)
coping styles and help-seeking pathways and (f )
treatment and intervention issues. In addition,
cultural meanings of leisure engagements for
racial/ethnic minorities should be acknowledged
rather than imposing a dominant western idea of
leisure, as emphasized in Iwasaki et al.’s
(Iwasaki et al., 2007) call for a power-balance
between East and West in leisure research.
Besides cultural factors, the other macro
factors included in the framework represent
health care systems and other environmental
factors. Certainly, access to and the approaches
used in mental health care systems will affect
active living and recovery, including the propensity to consider leisure-based active living in
overall health and life quality. Consider, for
example, the personal recovery experiences
described by Schiff (Schiff, 2004). As a consumer –survivor, Schiff described a recovery
process that involved connections with others,
the environment and the world as a key contributor to life quality. Specifically, besides her
inner desire for ‘wanting to get better’ ( p. 215),
she talked about her own recovering experiences facilitated by her relationships with
patients, medical staff and some others at university, and through reclaiming social roles with
peers including helping others who have mental
illness. Similarly, from a consumer perspective,
Happell’s (Happell, 2008) study found a supportive environment, especially connectedness with
and encouragement/support from staff and
peers, as a key aspect of mental health services
to enhance recovery, while emphasizing that
491
increased attention should be given to the views
and opinions of consumers to develop more
responsive mental health services. Also, Yanos
and Moos (Yanos and Moos, 2007) identified
various environmental conditions—including
social climate (e.g. community stigma, economic
conditions, local mental health policies),
resources (e.g. social support, family resources)
and stressors (e.g. family relationships, neighborhood disadvantage)—as key determinants of
functioning and well-being among individuals
with schizophrenia.
Besides ensuring the quality and accessibility
of resources essential for daily community
living (e.g. safety/security, health care, educational and employment opportunities), creating a more active-living-friendly neighborhood
and community for people with mental illness is
very important. To achieve this aim, however,
the maintenance of accessible/inclusive, userfriendly and pleasant parks and recreation
centers that offer a diverse range of opportunities for all to enjoy quality leisure time is a
top priority. Recently, both American Journal
of Preventive Medicine (e.g. Godbey et al., 2005;
Sallis et al., 2005) and Leisure Sciences (e.g.
Henderson and Bialeschki, 2005) featured a
special issue on the role of recreation and
leisure in promoting active lifestyles in neighborhoods and communities (e.g. engineering a
safe/secure, visually attractive and user-friendly
urban-park landscape) from a transdisciplinary
perspective (e.g. urban planning, landscape
architecture, engineering, leisure sciences, medicine, public health).
HOLISTIC, PERSON-CENTERED,
RECOVERY-ORIENTED,
STRENGTHS-BASED, AND CULTURALLY
SENSITIVE HEALTH AND HUMAN CARE
Another proposition implied in this framework
is that persons with mental illness are in favor
of and demand more holistic, person-centered,
recovery-oriented, strengths-based and culturally sensitive health and human care beyond
illness-focused care. Integrating humanistic
leisure-based programs into health care systems
would give attention to the wholeness of the
individual and her/his life, in which personal
and social behavior (including leisure behavior)
and cultural and environmental factors influence each other. The quality and accessibility of
492
Y. Iwasaki et al.
community health care systems are an important factor for the lives of people with mental
illness because the ability of those systems to
adequately meet the unique needs of persons
with mental illness is a critical concern for their
health and life quality.
CONCLUSION
This paper has presented a heuristic conceptual
framework in which the centrality of leisure
engagements from a broader and more balanced
experience- and meaning-oriented perspective
(than simply behavioral) is viewed as a proactive, strengths-based agent and context for active
living to facilitate recovery and health/lifequality enhancement. Emphasized in the framework include the functions of enjoyable and
meaningful leisure not only to promote personal
identity and spirituality, positive emotions,
harmony and social connections, effective
coping and healing functions, human development, and physical and mental health, but also
the effects of these interrelated elements on promoting more enjoyable and meaningful leisure
in a reciprocal way for persons with mental
illness. This reciprocal transaction can, however,
be both positive and negative. That is, negative
discretionary time behaviors (e.g. deviant
leisure; Rojek, 1999) can be detrimental to individuals just as environmental factors can support
or impede meaningful leisure experiences.
Also, by adopting a holistic and ecological
perspective, this framework stresses the significance of social and environmental factors
including the need to transform neighborhoods
and communities to be more resourceful and
active-living friendly. From a global international perspective, however, the impact of
cultural/cross-cultural factors should not be
ignored as these are closely interconnected with
neighborhood and community factors, health
care systems and the other social and environmental factors (e.g. socio-economic).
Although potential contributions of leisure to
active living, recovery and the promotion of
health and life quality have been shown, empirical evidence is limited. Thus, we caution that:
(a) key ideas presented in our heuristic conceptual framework do not necessarily imply causation with strong magnitude and duration in
change through leisure, and (b) other factors
may be responsible for the promotion of active
living, recovery, health and life quality. Rather,
the framework presented, while based on preliminary, empirical evidence, should be considered ‘heuristic’ with the intention to
stimulate a more balanced, holistic/ecological
and humanistic orientation for research and
practice that focus on active living, recovery and
the enhancement of health and life quality
among culturally diverse groups of people with
mental illness from both clinical and research
perspectives. This paper offers some concepts
that can be a guide for further thinking and
inquiry about active-living and health promoting pathways through leisure from a holistic,
strengths-based and humanistic perspective for
culturally diverse populations with mental
illness in a global context.
FUNDING
This paper is based on our project supported
by the National Institutes of Health/National
Institute of Mental Health (Award Number
R21MH086136).
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