What is an example of a health continuum?

If you think of mental illness and conditions such as anxiety, depression, bipolar and OCD, you wouldn’t be alone. All too often we frame mental health as a negative and forget that health is more than just the absence of illness.

We all have days when we feel better than others. And, just like with our physical health, we can all do things that make us mentally healthier. No one should leave it until they are ill to start thinking about their mental health.

In this article, I want to introduce you to the mental health continuum. It helps us view mental health as a positive and highlights signs and symptoms that we can all recognise and proactively improve.

Read on to see how the continuum works in practice.

Contents hide

1 Mental health is a continuum

1.1 Mental health from illness to wellness

2 The five zones of the mental health continuum

2.1 Excelling

2.2 Thriving

2.3 Surviving

2.4 Struggling

2.5 In crisis

3 Consequences of a continuum of mental health

3.1 Mental health varies continuously

3.2 Pay attention to people in all zones

3.3 Mental health depends on the person

3.4 A continuum illuminates symptoms

3.5 Emotional states change quickly

3.6 Good working conditions improve everyone’s mental health

4 The continuum and mental health conditions

4.1 Someone with a mental illness can be mentally healthy

5 Stress and mental health

6 What does all this mean for managers?

7 Learn more

Mental health is a continuum

We think it’s important to understand mental health as not just the absence of illness, but as a broad concept that applies to us all. The World Health Organisation agrees.

It defines mental health as:

a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.

Mental health from illness to wellness

So mental health is not a binary state – you are not either mentally healthy or ill. Our mental health falls on a continuum, ranging from excellent mental health to severe symptoms such as panic attacks or major depressive episodes.

Our continuum of mental health model, inspired by Canada’s The Working Mind, illustrates this idea. We have created five zones, although there are many shades within each zone.

The five zones of the mental health continuum

Excelling

The highest level of mental wellbeing in our continuum is ‘Excelling’. Given the right conditions, and a positive mindset, this is us functioning at our peak level. This can be at a time of great joy or fulfilment, such as the birth of a child, or a major personal success.

Another form of ‘Excelling’ is when we are performing at our fullest potential. This could apply to an interest such as art or music, but it also applies to work. The more often someone is in this state, the better their job outcomes. So it is worth thinking about how people can be encouraged to get into the Excelling zone. And how they can stay there.

This state of high performance has been described as ‘flow’. Flow has been studied extensively, beginning with the renowned psychologist Mihaly Csikszentmihalyi (pronounced ‘Me high Chick sent me high’). Here is a quote from him:

“The best moments in our lives are not the passive, receptive, relaxing times . . . The best moments usually occur if a person’s body or mind is stretched to its limits in a voluntary effort to accomplish something difficult and worthwhile” (Csikszentmihalyi, 1990).

So the good news is that encouraging flow in your staff is not only good for the organisation, it’s good for them too. For more on this subject, see our blog here.

Thriving

A normal, healthy state of mental health is indicated by the light green zone, which we call ‘Thriving’. In this zone you would feel fine – not necessarily completely free from troubles, but basically calm and content. Whatever worries or annoyances you face are coped with fairly well; they don’t make you feel unsettled in the long term. You are functioning normally with regard to basic behaviours like eating and sleeping. Your work patterns and social life are what is normal for you.

Of course how you socialise and work depend on lots of factors other than mental health. Personality is important. If you are introverted you will socialise less than an extravert. If you are conscientious you will work harder and have a more organised workspace than someone who is not conscientious. And of course if you don’t enjoy your job, or if you love it, this will affect your job performance too.

So when it comes to spotting an employee who is having mental health issues, managers need to bear in mind what the employee’s baseline behaviour is. Are they acting differently from usual? Do they appear to be under more stress than usual, whether at work or at home? Spikes in stress often lead to episodes of poor mental health.

Surviving

The yellow zone stands for an unsettled state of mind. A person can slip into ‘Surviving’ fairly easily, and it is important to watch out for the signs and symptoms. The yellow zone is not a severe state of distress, but it can indicate problems that could get worse, so it requires action. So how does someone experience this zone? Worries prey on the mind more than usual. Thoughts may be more negative than usual. Appetite and sleep may be affected. It will be harder to concentrate on work or other tasks.

In the yellow zone, you may just feel on edge without knowing why. Sometimes in this state we try to identify a reason. This may be obvious – an argument with a loved one, or conflict with a colleague. But the cause is often difficult to understand. It is important not to blame the wrong cause, as we may start to think negatively about the wrong thing. And that can lead to further problems.

For example, we may feel anxious because of drinking too much caffeine. But we may then decide our anxiety is caused by something else that just happened, such as being in a group of friends. This sort of experience can lead to social phobia.

Here’s another example. A poor night’s sleep makes us feel tired and grumpy. But we then falsely blame our irritation on another person. We get annoyed with a colleague over some minor comment, and this leads to conflict or poor work relationships.

The good news is that with the right steps it can be – relatively – easy to pull yourself out of the yellow zone. Relaxation techniques, positive and rational thinking (as used in CBT), exercise, or just getting out and having fun can all help. If it’s a conflict at work, a friendly and constructive conversation can fix the problem. Managers can play a helpful role in having a conversation (link to blog) with employees in this zone.

On the downside, if steps aren’t taken, there is a danger of slipping into the orange zone.

Struggling

In the orange zone we are significantly troubled. We may feel so much anxiety that life becomes a misery. Mood may be so low we feel it is hard to do anything well. Concentration is poor, energy is low, and work suffers. In this state we may feel pain both emotionally and physically, or we may feel numbed and empty. Thoughts will be negative – for example ideas of worthlessness or that others dislike us. Basic habits are affected – we may have little appetite or sex drive and sleep poorly.

Hope is not lost though. We remember how we have felt better in the past and wish we could feel better now. In the orange zone it is important to take steps to pull yourself out of it. Employees should talk to managers about their difficulties with working. Managers should spot the signs of this state and talk to employees quickly. Employees may need time off or support from an EAP or a professional such as a GP or psychologist. See our blog on how to have a conversation like this.

In crisis

Unfortunately there is a state of mental health beyond Struggling. People with diagnosed mental health conditions may have found themselves in this zone in the past, which led to their diagnosis and treatment. But anyone can fall into this state given the right circumstances.

‘In crisis’ means a person is in a state of great suffering and needs immediate help. Their emotional pain may be so unbearable that they want to take their own life. Symptoms include severe anxiety or depression, or even both at the same time. There will be great difficulty in performing work and other ordinary daily acts such as personal hygiene, eating and sleeping. They may just stay in bed all day and avoid all social contact. It is likely they will stay off work sick. If they are ashamed of their condition, which is sadly often the case, they may give some other reason for their absence.

It is possible nonetheless that a person may enter this state while at work, or come in through habit or a sense of duty. They will not get much done however. A manager will need to approach them and have that all important chat about their wellbeing. But the manager should bear in mind that having a normal conversation may be impossible for an employee in the red zone. They will certainly need professional help and time off work.

If they seem to have suicidal ideas, more serious steps should be taken. Visit the Rethink website for some expert advice on how to talk to them. Suggest they speak to the Samaritans. If they seem at immediate risk of suicide, stay with them and call mental health services or the police. Make sure there are no dangerous items around which they could use to harm themselves. Two important things to remember are:

• talking to someone about their suicidal thoughts does not make them more likely to end their life
• you can help someone who is feeling suicidal by listening, without judging them.

Consequences of a continuum of mental health

One US study of 3,000 people published in the Journal of Health and Social Behavior in 2002 found that 17% of those sampled were flourishing (‘Excelling’ or ‘Thriving’ in the continuum model, 57% were moderately mentally healthy (‘Thriving’ with some symptoms of ‘Unsettled’), and 12% were languishing (‘Unsettled’, ‘Struggling’ or ‘In Crisis’).

The remaining 14% had a condition fitting a psychiatric diagnosis, but 2/3 of these were coping well. This illustrates an important point: people with a long-term mental disorder can be mentally healthy. If they receive treatment, in the form of psychotherapy such as CBT or medication, and have good support at work and at home, they may find themselves mostly in the yellow, green and even dark green zones of the mental health continuum model.

So if mental heath is a continuum, how does this help us deal with mental health issues, whether our own or those of our employees? Our model tells us a few vital things about mental wellbeing.

Mental health varies continuously

Mental health varies continuously all the way from severely ill (‘In crisis’) to high functioning (‘Excelling’). But we can find ourselves at any point along that spectrum. The point is that the needle can move up and down the dial.

Think about how you feel at this moment and which zone you are in. Now think about how you felt when you woke up this morning. Or last night. Or a week ago. In all likelihood, you will tend to be in a certain zone, but at different times will find yourself in other zones. And even within one zone your feelings and symptoms will vary. In the morning you might be at the low end of Surviving, and in the afternoon at the high end.

Pay attention to people in all zones

This means that most people we encounter will be in a fair to good mental state most of the time. But that doesn’t mean we shouldn’t be concerned with their mental health. The NHS states that 1/4 of people have a mental heath condition at some point in their lives.

An employee may be ‘Thriving’ but vulnerable to falling into ‘Surviving’. It’s important for a managers or HR to keep an eye on those vulnerable, especially if some situation might trigger a turn for the worse. An obvious example of that is the current COVID-19 crisis. This in itself is causing an increase in poor mental health. That is, many of those with underlying conditions are finding their symptoms being triggered. But many who do not have a recognised condition will still be experiencing difficulties. The stresses of working at home can cause someone in the green to slip into the yellow.

Mental health depends on the person

We may tend to fall in one zone most of the time, but can drop into lower zones or go up to healthier zones. What’s really important to understand is that how variable someone’s emotional state is varies itself among people. We can measure a person’s emotional instability using a personality scale called Neuroticism. So managers should learn which of their staff are more emotionally unstable and keep a closer eye on them.

A continuum illuminates symptoms

The idea of a continuum can be applied to specific types of symptoms. For example, anxiety is one of the most common experiences of poor mental health. Anxiety can be manifested as a slight worry that passes quickly. Or it can be a major concern that keeps you up at night. Or it can be a severe condition triggered by specific situations. Panic, heart palpitations, shortness of breath, sweating, nausea, and fearful thoughts are just a few of the symptoms which can be felt to different degrees.

What matters is that individuals learn to recognise their own symptoms at the earliest stages. Managers and HR can also learn to spot these early signs. By catching problems early you can take action to prevent the symptoms getting worse. This can help people stay out of the orange or red zones, and move up to the green zones.

Emotional states change quickly

Managers should be wary that emotional states can change very quickly. The anxiety response, for example, evolved to help us deal with dangerous situations. If a lion appeared we needed a quick burst of adrenalin to help us escape. In modern times anxiety can be triggered by all sorts of situations, often in ways that don’t seem very helpful. We often want to calm down to deal better with a challenge.

This is another reason why it is important to keep a watchful eye on emotional states and signs of poor mental health. If not caught quickly, moods can change quickly and drastically for the worse. And some people’s mental states are more fragile than others. These are the employees it is especially important to keep an eye on.

Good working conditions improve everyone’s mental health

One of the main points about the continuum of mental heath is that everyone has mental health. We all fall at a certain point on the continuum. So whether an employee is in the orange, yellow or green, with the right support and the right work conditions, they can rise up the continuum. If they are in the red they should not be at work of course. And some people in the orange may need time off too, although some may be able to continue to work.

So making adjustments to work conditions to make them less stressful is beneficial for everyone. It may help someone in the yellow rise to the light green. And it may help someone who is Thriving rise to Excelling.

The continuum and mental health conditions

In the Journal of Health and Social Behavior in 2002 study mentioned above, 14% of the sample had a condition fitting a psychiatric diagnosis. But what do we mean by that? Is that the same as being ‘In Crisis’? Not necessarily. In the medical model used by psychiatrists, a person’s mental health symptoms are assessed. This can be by face to face interview, questionnaires, or observation. If the symptoms are severe enough and last long enough, a diagnosis will be made.

The psychiatric handbook, the DSM-V, states that for a diagnosis of depression a person must have had 5 symptoms during a two week period. Two of these symptoms must be either low mood or loss of interest or pleasure. Some of the other symptoms include tiredness, weight loss and feelings of worthlessness, or excessive guilt.

To receive a diagnosis of depression, these symptoms must cause the individual clinically significant distress or impairment in social, occupational, or other important areas of functioning. The symptoms must also not be a result of substance abuse or another medical condition.

But what if a person had only 4 symptoms? And what if the low mood was very severe? Or what if they had 7 symptoms but not low mood or loss of interest? By the discrete mode of thinking used in this medical model, they would not receive a diagnosis of depression. And yet it would be hard to argue that such a person was mentally well.

This is another benefit of the Continuum of Mental Health. It takes seriously all levels and symptoms of mental ill health.

Someone with a mental illness can be mentally healthy

In that same 2002 study in which 14% of the sample had a diagnosed condition, 2/3 of these were coping well. This illustrates an important point: people with a long-term mental disorder can be mentally healthy. Many may be receiving treatment, in the form of psychotherapy such as CBT, or medication. As a manager you can help a great deal by ensuring employees have good support at work and at home. In such cases, even those with diagnosed conditions may find themselves in the yellow, green and even dark green zones.

While work is often cited as a cause of stress, it is important to note that for most people work is good for their mental health. In most cases poor mental health is a result partly of genetics and partly life circumstances, especially childhood experiences such as abuse, as well as current problems. Recent or current stresses may include divorce, bereavement, loneliness, or physical illness.

For many people, even those with a mental health condition, work can be a refuge. It can be a source of meaning and purpose, as well as good social relationships. It can simply be a way to take the mind off problems outside work. Bosses and managers can give employees the right conditions to thrive at work, as well as the chance to develop and progress.

Stress and mental health

There is often confusion between stress and mental health. Stress is a very common reaction to extreme demands at work or to an otherwise toxic environment. It is not considered an illness in itself however. It is only when stress is prolonged and coping skills are poor that ill health can result – both physical and mental. Severe stress such as a trauma can also trigger a genetic predisposition to a mental health disorder. In our Building Resilience and Managing Stress Workshop we look at how to recognise and manage signs and symptoms of stress.

So if anyone can find themselves at any point on a continuum of mental health, what defines one person as having a mental disorder and another as being merely stressed?

It’s a question of how much time you spend in the various zones of the continuum. If you are mostly coping well, but experience stress for a while and recover, in other words you spend most of your time in the yellow to green zones, you are mentally healthy. If you suffer major symptoms a lot of the time, and spend most of your time in the red and orange zones, then you most likely have a diagnosable mental disorder.

It is also possible that you may be relatively well for your whole life, but then a trauma or prolonged period of stress can precipitate a full-blown mental disorder. This means a big shift from the green/yellow zones to the yellow/orange/red zones. And as we have seen, the reverse can happen, with the right treatment and support.

For more on work stress, see our blog here. To understand how stress varies and what effects different levels of stress can have, see our blog on the stress curve here.

What does all this mean for managers?

All of this means that managers can have significant effects on the mental wellbeing of their staff. This effect could be negative if they do not treat their employees well, or cannot solve issues which are causing them stress. However, managers can also have a very positive effect. They can promote staff wellbeing by:

• identifying and reducing sources of stress in the workplace
• encouraging a healthy approach to life, both physically and mentally, so as to build resilience
• being themselves a role model of mentally healthy behaviours and attitudes
• encouraging open and positive discussions of mental health among staff
• keeping a close eye on the wellbeing of their staff, checking in now and then with a friendly inquiry
• learning how to spot signs of poor mental health, both in themselves and in their staff, and
• learning how to approach and deal effectively with employees who are experiencing a mental health crisis

For more on how managers can help an employee with anxiety, visit our article here.

We hope you agree that the Continuum Model is a powerful tool for understanding mental health and nurturing employee wellbeing. Please share our ideas. All we ask is that you link back to this article: https://delphis.org.uk/mental-health/continuum-mental-health/

Learn more

If you’d like to learn more about mental health, you can get started with our bite-size Certificate in Mental Health Awareness. It’s a 30-minute certificated online course with an 85% discount if you use this link.

Delphis also offers on-site and online mental health workshops delivered and developed in partnership with organisations like yours. We work with you to create mentally healthy and productive working environments for your staff.

One major multi-national client says this about our workshops:

“Very relevant and informative with an engaging and inclusive style. Worth spending a whole day on. Loved the takeaway workbook, pretty much perfect, we need to roll out to whole company.”

Get in touch to discuss how we can provide customised mental health training for your organisation that fits your needs.

What is a health continuum?

What are the five spots of health continuum?

What are the three components of the health continuum?

What are the four levels of the health continuum?