key: cord-1055491-73sc35h6
authors: Willen, Sarah S.; Williamson, Abigail Fisher; Walsh, Colleen C.; Hyman, Mikayla; Tootle, William
title: “Rethinking flourishing: Critical insights and qualitative perspectives from the U.S. Midwest”
date: 2021-12-22
journal: SSM Ment Health
DOI: 10.1016/j.ssmmh.2021.100057
sha: a2dded70a64336f5c43453cafa4b0bff0053ff73
doc_id: 1055491
cord_uid: 73sc35h6

In recent years, human flourishing and its relationship to mental health have attracted significant attention in a wide range of fields. As an interdisciplinary, mixed-methods team with strong roots in critical medical anthropology and critical public health, we are intrigued by the possibility that a focus on flourishing may reinvigorate health research, policy, and clinical care in transformative ways. Yet current proposals to this effect, we contend, must be met with caution. In particular, we call attention to the troubling disconnect between current research on flourishing, on one hand, and the voluminous body of scholarship demonstrating the detrimental impact of structural inequities on health, on the other. We illuminate this blind spot in two ways. We begin with a critical assessment of leading conceptions to flourishing in positive psychology, which are compared to current approaches in the critical social sciences of health. In the second half of the paper, we support our argument by presenting original findings from a mixed-methods study with a diverse sample of interviewees in the Midwestern U.S. city of Cleveland, Ohio (n=167). Our interviewees' rich narrative accounts, which we analyze both quantitatively and qualitatively, highlight important ways in which everyday understandings of flourishing diverge from prevailing scholarly accounts. Given these gaps and blind spots, now is an opportune time for robust interdisciplinary discussion about the implicit values and presumptions underpinning leading approaches to flourishing and their wide-ranging implications for research, policy, and clinical care in mental health fields and beyond.

1 "Rethinking Flourishing: Critical Insights and Qualitative Perspectives from the U.S.

One year into the COVID-19 pandemic, the New York Times published a series of articles on "flourishing" and its presumed inverse, "languishing," that tapped a nerve among readers. One article-which garnered well over 1,200 reader comments-defined flourishing as "the peak of well-being," contrasting it with depression ("the valley of ill-being") and languishing ("the neglected middle child of mental health") (1, citing 2). Related articles followed, including a "flourishing quiz" (3, citing,4) and an article outlining "simple activities" that "can lead to marked improvement in overall well-being" (5) . This New York Times series and lively response speak not only to a strong popular sense that the COVID-19 pandemic has impeded people's ability to flourish, but also to a burgeoning interest in flourishing in both the scholarly and policy realms (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) .

So strong is this interest that a vast amount of research investment is now being channeled toward the topic, in mental health fields and beyond (16) (17) (18) . It has even been suggested that a strategic focus on flourishing might "open a national conversation that reframes and reimagines traditional concepts of health," including "a more useful way to address policy and societal goals than current options" (13) .

As an interdisciplinary research team with strong roots in critical medical anthropology and critical public health, we argue that the idea of reorienting health research, care, and policy around the goal of promoting human flourishing is intriguing-but that current proposals to this effect must be met with caution. Before bold efforts to promote flourishing can be justified, we first must ask: Whose definition/s of flourishing provide the roadmap? What assumptions undergird these leading definitions? Whose flourishing are they designed to support? Additionally, do scholarly definitions of flourishing resonate with J o u r n a l P r e -p r o o f 2 everyday, real world usages of the term, or are any essential dimensions overlooked?

Above all, we must ask: Are prevailing conceptions of flourishing well-suited to the task of confronting the most urgent problems in current health research, care, and policy-or, alternatively, might they risk leading us astray?

These questions are both timely and urgent for one principal reason. As we elaborate below, leading approaches define flourishing largely in terms of individual psychological characteristics, with the implication that efforts to promote flourishing should concentrate on individual-level, psychological interventions. Absent from most approaches is any substantive attention to the broader structures and dynamics-historical, political, sociocultural, environmental, and ideological-that shape and constrain individual and collective chances of flourishing in the first place.

From a critical public health standpoint, this inattention to structure, power, and history constitutes a serious blind spot, and it signals a troubling disconnect between the growing field of flourishing research, on one hand, and the voluminous body of work on the impact of context and environment on health, on the other. In recent decades, a powerful evidence base has illuminated the many pathways through which historical and present-day forms of inequity and injustice harm individual and population health (19) (20) (21) (22) (23) . We now know in great detail how mental and physical health are harmed by inequities in access to the social and structural determinants of good health (e.g., food, housing, education, jobs), and how racism and other forms of institutional, interpersonal, and internalized discrimination can compound the detrimental impact of structural injustices, often in intersectional ways (21, (24) (25) (26) (27) . Given the overwhelming evidence that inequity and injustice harm health, why aren't we paying equally careful attention to the ways in which upstream structural factors can thwart individual and collective opportunities to flourish? J o u r n a l P r e -p r o o f 3 With this overarching question in mind, this paper aims to lay the groundwork for broader interdisciplinary dialogue around what flourishing means, how we should study it, and how it can best be promoted, especially in relation to mental health. We begin by reviewing the current landscape of research on flourishing and mental health, where approaches from positive psychology predominate, then compare leading approaches to an alternative set of perspectives from the critical social sciences of health.

In the second half, we present findings from a mixed-methods study that reveals important divergences between prevailing analytic (or what anthropologists call "etic") perspectives on flourishing and everyday vernacular ("emic") understandings. Our empirical findings, drawn from a series of interviews conducted with a diverse sample of people (n=167) in the Midwestern U.S. city of Cleveland, Ohio, highlight the importance of considering how flourishing is both understood and pursued in real-life contexts.

Interviewees' first-person perspectives shed both quantitative and qualitative light on the powerful role of structural, material, and political circumstances in shaping people's opportunities to flourish, especially among those whose lives are constrained by disadvantage (see also 28) . In addition, our interviewees' narrative accounts reveal, in rich and vivid detail, how everyday understandings of flourishing are complex, dynamic, and relational-and, as such, are poorly captured by prevailing indexes (4, (29) (30) (31) (32) (33) (34) (35) .

Overall, these research findings bolster our argument that now is an opportune time for robust interdisciplinary discussion about the implicit values and presumptions underpinning leading approaches to flourishing; the gaps that separate "emic" and "etic" understandings; and the implications of these insights for researchers, clinicians, and policymakers in mental health and beyond. The New York Times series mentioned earlier offers a convenient opportunity to pose these vital questions: Whose vision of flourishing undergirds these popular articles? Who is most likely to benefit from the "simple activities" J o u r n a l P r e -p r o o f 4 (5) to promote flourishing they propose? Whose flourishing, in contrast, can only be advanced through very different kinds of action, including actions to confront and combat the root causes of today's vast health inequities?

By asking questions like these, and by subjecting leading definitions of flourishing to critical scrutiny, our aim is not to advance a singular, alternative set of "right answers," but rather to sharpen our collective understanding by seeking "better questions to ask" (36: 7).

Before tackling these questions, it is first worth asking: Why does the concept of flourishing hold appeal across disciplines and domains?

For researchers, clinicians, and policymakers, the appeal of this concept is clear.

Flourishing bears strong positive associations. It has a familiar ring in everyday parlance, at least in English, and it evokes a holistic sense of things going well-of moving steadily forward on a stable path. From a health sciences standpoint, flourishing resonates with assets-based alternatives to deficit models that have drawn criticism, whether for failing to acknowledge (and leverage) individual or community strengths, or for the graver misstep of blaming sufferers for their own misfortune (31, (37) (38) (39) .

Above all, flourishing holds considerable appeal as an alternative to biomedicalized conceptions of health, whose limitations are especially evident in the present moment of global pandemic (25, (40) (41) (42) . Although current efforts to promote flourishing appear to hew toward psychological interventions, the concept could, at least in principle, help reinvigorate the holistic WHO definition of health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity" (43) -a definition that has played a pivotal role in the emergence of critical public health and related fields (44) (45) (46) (47) , but proven extraordinarily difficult to translate into policy and practice.

J o u r n a l P r e -p r o o f 5 In short, flourishing has garnered interest in a range of mental health and related fields as a nimble and useful "boundary object"-a concept that is "plastic enough to adapt to local needs and constraints … yet robust enough to maintain a common identity across sites" (48: 393); [see also XXX, this volume]. Yet this very plasticity, and the presumption of agreement it engenders, conceal significant differences-differences, we argue, that matter a great deal and thus merit careful scrutiny.

To this end, we follow anthropologists Das and Fassin, who argue that, "Scrutinizing the terms" we use and "exploring their meanings and histories" can be a powerful way to "refresh our perspective on the most serious issues of our time" (36: 6) . As the next section shows, such an exercise can help clarify where our concepts "may not express what we try to think"-or, as importantly, where they may be failing us.

In the increasingly lively and interdisciplinary landscape of research on flourishing and health, approaches from positive psychology predominate. As noted earlier, flourishing is framed in positive psychology as an individual, psychological matter and conceptualized, in top-down fashion, as an abstract and presumably universal research construct that can best be assessed in quantitative terms. Although positive psychologists have invested a tremendous amount of effort in operationalizing the concept, "no internationally recognised gold-standard measurement tool for flourishing exists" (49) . For this reason, among others, Agenor and colleagues emphasize argue that the concept is still "immature" (6) .

Efforts to define flourishing in positive psychology, and to distinguish it from similar and related terms, have posed ongoing conceptual challenges. In a frequently cited 2014 J o u r n a l P r e -p r o o f 6 article, Hone and colleagues (49) compare four leading approaches to flourishing, 1 each involving a quantitative index comprising five or more factors. In Table 1 , we update their original chart to include two additional indexes. In the original comparison, only three factors-"positive relationships," "meaning and purpose," and "engagement" or "positive affect"-were common across the set. In our updated comparison, a mere two factors-"positive relationships" and "meaning and purpose"-figure in all six. Three additional factors-"self-acceptance/"self-esteem," "engagement" (or "flow"), and "positive emotion"appear in four of the six.

Given these wide variations, it is perhaps unsurprising that leading models also yield different results. In fact, a nationally representative study designed by Hone and colleagues revealed strikingly low levels of correspondence among them (49) . The authors surveyed 10,000 adults in New Zealand with the goal of replicating the four models in their comparison. Depending which model was used, rates of flourishing spanned a stunning range-from about one-quarter (24%, using Huppert and So's model) to nearly twice that number (47% using Seligman's).

A WELTER OF DEFINITIONS 1 At the time of submission, Hone and colleagues' 2014 paper had been cited 365 times according to Google Scholar. Of the four models they compare, the paper by Keyes had accumulated 4,304 cites; Huppert and So 1,427 cites; Diener et al 3,105 cites; and Seligman 8, 468 cites. Of the two models we add to theirs in Table 1 , Ryff and Singer's paper has 3,220 cites, and the more recent VanderWeele piece from 2017 just 249although it bears mention that he is a PI of the Global Flourishing Study, a US$43 million, 22-country initiative that aspires to include 240,000 participants. 7 Yet inconsistencies among leading conceptions of flourishing are not the only source of conceptual confusion. Another involves slippage between flourishing and other terms such as "resilience," "functioning," and especially "well-being" (33, 32, 34, 39, (50) (51) (52) (53) (54) . This overall terminological slipperiness is evident in Table 2 , where we consolidate a range of definitions from multiple health fields. Our aim here is not to present a systematic review, but rather to highlight the terminological slippage both among positive psychology approaches and between those approaches and another family of approaches: those in the critical social sciences of health.

In the first group, Seligman (who recently declared his shift in interest from "happiness" to "flourishing") contends that "the topic of positive psychology is well-being,"

and "the gold-standard for measuring well-being is flourishing" (51: 13). Keyes also suggests an equivalence among flourishing, "complete mental health," and "high levels of well-being. To be flourishing," he continues, "is to be filled with positive emotion and to be functioning well psychologically and socially" (31: 210). VanderWeele takes an even more expansive view of both flourishing and well-being-and often uses them interchangeably.

In his view, flourishing is "a state in which all aspects of a person's life are good" (4: 8149,39 cf. ).

A divergent approach in positive psychology is rooted in the influential work of Ryff, who conceptualizes flourishing explicitly in relation to Aristotle's notion of eudaimonia, a term that is variably translated as "flourishing," "the good life," or-however misleadinglyhappiness (10, 33, 34) [cf. XXX this issue]. Ryff's conception of "eudaimonic well-being," which she uses interchangeably with flourishing, involves "striving toward excellence based on one's unique potential" (34: 14) . This formulation resonates in important ways with approaches introduced in the second half of Table 2 . (It also resonates with the contemporary rereading of Aristotle proposed in the introduction to this series [XXX]), which J o u r n a l P r e -p r o o f 8 argues that the ability to reach one's potential depends not only on internal factors, but also on the environments in which we live.) As a result, Ryff's approach is somewhat less susceptible to some of the blind spots to which we now turn.

From a critical social science perspective, positive psychology approaches to flourishing display a number of troubling blind spots, some epistemological and others methodological, as the second half of Table 2 suggests.

First, it is self-evident to critical social scientists of health that people's capacity to flourish depends heavily on the circumstances in which they live (10, 11, (55) (56) (57) . But who has the good fortune of living in environments that promote flourishing, and who ends up inhabiting hostile ones? This question points to a second and related blind spot involving the role of power and (in)justice in shaping not just who has a chance to flourish but also, for that matter, how flourishing itself is defined in policy conversations. As J o u r n a l P r e -p r o o f 9 Roberts points out, "It is not an accident that the assumed understanding of human flourishing has been determined by what improves the well-being of those who are the most privileged in society and in a way that legitimizes their privileged position … [which] has elided structural inequalities that advantage them and disadvantage others" (55: 203).

Third, indexes that conceptualize flourishing in static terms as a condition or state fail to capture the dynamic and contextually-specific ways it is imagined, pursued, and experienced in everyday settings-including possibilities of flourishing in one domain, but not others. As Garland-Thomson puts it, "Flourish is a verb, and as such expresses action.

To flourish is to do something" (56: 21) . Understood in this way, flourishing is an active pursuit that involves choice-making and action, under conditions of constraint, over time.

Moreover, this "active pursuit" is no solo endeavor; rather, it is "informed by cultural expectations and social relationships" [XXX 2021] (28) .

Finally, the pursuit of flourishing may be informed by shared values and expectations, but it is also a deeply personal matter shaped by individual efforts to live in keeping with those values and life commitments that are "so deep" to who people are that they "would not know themselves" without them ( We designed the study in partnership with a local health and equity initiative that has been recognized nationally as a well-coordinated, thoughtful strategy for tackling health inequities and promoting health equity (62) . The existence of this local initiative was a key factor in selecting Greater Cleveland as fieldsite for this research, as was two of the three lead researchers' deep familiarity with the city and its broader metropolitan area. As an urban center, Cleveland is similar in key respects to many other American cities. Yet it also exhibits some of the country's greatest disparities in health outcomes by race-ethnicity and class, including bellwether indicators like life expectancy, infant mortality, and childhood lead exposure (63) . These inequities reflect a deep and troubling legacy of laws, policies, and informal practices that explicitly have treated certain groups in the city as more deserving than others of society's attention, investment, and concern (64)-and, as we heard from our interviewees, that continue to have palpable effects today. Interview locations spanned both the city proper and the broader metropolitan area. Our team consisted of five anthropologists (including one graduate student), a political scientist, an urban sociologist, a public health and law scholar, and a public health professional.

Interviews lasted approximately 1½ hours, and participants completed a demographic survey on an iPad after completion of their interview. Interviewees received a US$25 gift card as a token of appreciation. The study was approved by the IRB at XXX.

As Table 3 illustrates, these recruitment strategies yielded a diverse sample of local residents that included public health professionals (n=21), clinicians (n=21), metro-wide decisionmakers (n=21), and community leaders (n=24), as well as community members 

We developed the interview guide (Appendix A) in consultation with our racially and economically diverse Advisory Board. Given our interest in interviewing a wide range of interviewees from a divergent set of backgrounds and social positions, the task of developing a viable interview guide posed unique challenges. Initially we were unsure about whether the term "flourishing" would resonate meaningfully for interviews with different levels of education, socioeconomic statuses, and racial/ethnic backgrounds, or whether they would comfortably use the term in responding to our questions. A preliminary set of pilot interviews (n=11) allowed us to test an early version of the interview guide, identify challenges, and adapt as necessary. A key finding from this early work was the insight that "flourishing" did, indeed, resonate with interviewees of different backgrounds, even as specific interpretations of the term varied.

In each interview, we sought to develop rapport and gain insight into interviewees' In addition to asking interviewees to explain whether or not they viewed themselves as flourishing, we also asked them to reflect in broader terms on the top three things people need, in general, to flourish. In analyzing their responses, we were especially interested in exploring comparisons to the flourishing indexes described above and in Table 1 .

On this count, two of the three factors most commonly mentioned by our interviewees-a stable income and the social determinants of health (SDoH)-focused explicitly on structural and material considerations. We defined SDoH (generally understood to encompass the political and social circumstances in which people live, work, play, and pray (21, 44) ) to include access to food, housing, transportation, and education; 

How do these findings correspond to prevailing flourishing indexes? Since we used an inductive coding strategy, some factors identified in Figure 3 resonate with, but do not correspond directly to, elements of the six indexes outlined in Table 1 . Those six indexes involve considerable variation, but two factors remain constant: "close" or "positive relationships," and "meaning and purpose." In addition, "self-acceptance"/"self-esteem," "engagement" (absorption or "flow"), and "positive emotion" appear in four of the six. Among our community member sample, factors related to "close relationships" were mentioned by a substantial majority, and factors related to "self-acceptance" were mentioned by just over half. Other factors common to the indexes, however, were less evident in interviewees' understandings of flourishing.

"Close" or "positive relationships" are variably defined in different indexes but tend to involve experiences of warmth, trust, satisfaction, or contentment, or a sense of feeling respected, cared for, or loved. This cluster of sentiments is captured in our analysis using two different codes. "Social support" captured interviewees' sense of feeling valued, appreciated, needed, or loved by non-family members (i.e., friends, mentors, colleagues, neighbors, or community members), and the "family" code was applied when similar sentiments were mentioned in relation to family members, including intimate partners. More than two-thirds of community members (71%) identified social support from people outside of one's family as a key factor affecting flourishing, while 53% mentioned family, and many mentioned both.

Likewise, more than half of community members (56%) pointed to a strong sense of identity or self-worth as central to flourishing. In our coding scheme, this code corresponded roughly to "self-acceptance" and "self-esteem" (typically defined as generally feeling "very positive" about oneself) in four of the indexes described above.

Our sample was less likely to see "meaning and purpose" as central to flourishing. In sum, of the top six factors identified by our diverse sample of Midwestern Americans, four correspond in some respects to existing indexes of flourishing. The other two-a stable income and SDoH, each mentioned by well over two-thirds of community members (71% and 69% respectively)-are almost completely absent from existing indexes. Notably, these factors are entirely absent from the indexes in Table 1 , save for one that mentions a correlate of "stable income" ("financial security"), but only as an optional, add-on component (4).

18 Not only does this mixed-methods strategy help identify notable differences between "etic" and "emic" conceptions of flourishing, but it also provides a portal into the texture and nuance of individual people's everyday understandings and self-assessments.

In the open-ended narratives presented below, we hear how people think both with and about flourishing. We hear our interlocutors refine their definitions in the flow of thought and speech, and how they parse the applicability of the term-for instance by noting its presence in some areas of life and absence from others. In addition, we hear how flourishing can be reckoned relationally, for instance as people compare themselves to other people or to themselves at another point in time.

Importantly, our interviewees' reflections also support our overall claim about the central importance of structural and material factors in everyday perspectives on what flourishing means and on who does, or does not, have a fair shot at a flourishing life. We hear this in particular among people whose lives are constrained by social disadvantage.

These narrative perspectives further bolster the claim that the blind spots identified here are not just epistemologically important, but also deeply relevant to real people in everyday settings-and, by implication, for both clinical and policy-oriented efforts to promote flourishing.

For most of our interviewees, flourishing is a verb-it refers to something dynamic, aspirational, and frequently elusive. Many described the pursuit of flourishing as a process of searching and striving, either in general or in relation to specific goals that must be articulated before they can be pursued. For some of our interviewees, the pursuit of flourishing has an aspirational quality-a recognition of what's been accomplished, paired with a hopeful sense that more effort, and likely more satisfaction, lie ahead. For others, the dynamic nature of flourishing has a darker cast, evoking reflection on unmet goals, past experiences that prove difficult to overcome, or a sense that one's dreams lie out of reach, often for reasons beyond one's control.

A majority of community members we interviewed made it clear that they either were flourishing (51%) or were not (16%), but a full third (33%) offered a mixed assessment. Our qualitative methodology enabled us to interpret these mixed assessments and recognize that most were flourishing in some respects, but not others. For some, a mixed assessment reflected a sense of being midway on their life journey, still working toward key goals. When we asked a Latino student in his 20s whether he is flourishing, for instance, he said, "yes, and no. I think yes, in the sense that I've accomplished many things and I've gotten to where I am now .... But also, no" because "there's still a lot more things that I want to achieve." 

Once again, our findings also highlight the vital importance of structural and material factors for individual and collective capacities to flourish. Below, we concentrate on two such factors: (1) income and other SDoH, and 2) the toxic role of racism in impeding opportunities to flourish, even for people of color who experience social advantage in other domains. In addition to a steady (and livable) income, interviewees also were quick to point to other SDoH as bearing heavily on whether or not one can flourish. A few interviewees mentioned just a single factor (for instance, education), but 44% of community members mentioned more than one, and a quarter mentioned three or more.

We can hear how tightly structural and material considerations are entwined in the narrative of a Latina woman in her 50s. For her, flourishing starts with having "a healthy home,"

Because your home is your sanctuary. ... But if you have a home that's falling apart, ... that's infested in roaches, and mold, and, and lead, and… water coming in, and then after you've worked so hard, and then you come home and you just wanna rest, and then you're like oh I don't have food, and, ... it's raining; oh now we gotta put you know, buckets here. ... there we go, mice again. … you cannot rest ... So now your health is going out of whack. You get depressed, mental issues. Violence, 'cause you're angry. ... because Ah! Why do I have to live life like this? And Ah! Why can't I pay for this? Why can't I get-why can't the landlord fix this? … So you're not being a good mom because you're angry. So you didn't even want to talk to your kids ... you didn't wanna cook ... So then you're eating unhealthy. So you're creating all these negative environments. So it's mental health, stress, … so you cannot give 100% at home. So if you cannot give 100% at home, you cannot give 100% to work, and you cannot give 100% to social life, and you have no friends, 'cause you're so angry nobody wants to talk to you. So for me, it's very important that you have a healthy home.

J o u r n a l P r e -p r o o f 24 Three-quarters (75%) of low income and over two-thirds (69%) of high income interviewees mentioned one or more SDoH as having a significant impact on the ability to flourish. Again, the overwhelming importance of these factors in interviewees' narratives stands in stark contrast to their almost total absence from the leading indexes.

Lack of access to the SDoH can impede flourishing in a wide range of ways. Many interviewees described how their own capacity to flourish was harmed by exposure to serious mental or physical illness, substance dependence, incarceration, debt, prolonged unemployment, homelessness, or the death of a close relative. Often forms of adversity cooccurred, especially among people already experiencing one or more forms of social disadvantage. For instance, a Black man in his thirties who had experienced mental illness, incarceration, homelessness, and substance dependence described himself in vivid terms as "a dying rose bush, in the middle of the summer, in the middle of the desert, in Pasadena, California." He pointed to his "rough background" as impeding his ability to flourish: "either jail, the grave, or just… lost. A lost cause. ... that's honestly the path I was on growing up." Now, he explained, he is "nowhere near … where I need to be, in life."

Another key theme was the negative impact of racism in all its forms (structural, institutional, interpersonal, internalized (66) The accounts of these successful Black professionals provide especially clear evidence of the degree to which structure, power, and historical injustice affect the capacity to flourish. While all suggest that their achievements mean that they should be flourishing, racism and discrimination nonetheless impede both their own capacity to flourish and that of people who share their racial background and life circumstances. For them, flourishing is clearly an active pursuit-and despite clear advantages, they too struggle, with many cards stacked against them. The strong relational stakes and implications of these struggles further remind us that flourishing is far more than just a solo psychological concern. The parallel rise in focus on "well-being" (50, 67, 53, 54, 68, 39) -and, importantly, the persistent slippage between these two terms [XXX this volume]-only heightens the importance of "Scrutinizing the terms we use" (36: 6) and carving out space for robust interdisciplinary dialogue (69) (70) (71) .

It is with these goals and challenges in mind that we have sought in this paper to interrogate the old-new concept of flourishing and foreground blind spots in the current research landscape-blind spots whose implications become evident through analysis of our mixed-methods findings. First, as a vast trove of critical health scholarship would anticipate, our findings provide clear evidence that people facing disadvantage-especially disadvantages associated with income, educational attainment, and race/ethnicity-report lower levels of flourishing than those who do not. Furthermore, our diverse sample of Midwestern U.S. interviewees helps us see, in vivid detail, how opportunities to flourish are advance-and whose might be less well captured, or not captured at all? By raising these questions, we are not proposing the wholesale replacement of quantitative measures with qualitative approaches. Neither do we mean to suggest that flourishing depends solely on the structural, material, or political circumstances of people's lives to the exclusion of psychological factors. Rather, we aim to carve out space for interdisciplinary dialogue that can span divergent epistemological assumptions, methodological approaches, and practical goals and, ultimately, that can bring us closer to an understanding of flourishing that can help "reframe and reimagine traditional concepts of health"-specifically, in a way that bends toward justice.

For various reasons, we must exercise caution in interpreting the findings reported here. Despite the internal diversity within our sample, all of our interviewees live within a single metro area in the Midwestern U.S. Given the design of our larger study, individuals with higher incomes and education are overrepresented in the qualitative findings. Still, the patterns described here provide valuable insight into everyday, vernacular understandings of flourishing. replacing deficit-oriented frameworks with assets-based or salutogenic [60] approaches; or conceiving of new strategies for global health promotion, the critiques presented here merit serious consideration from all researchers, clinicians, and policymakers who are interested in human flourishing.

While a focus on flourishing may indeed "open a national conversation" around "traditional concepts of health" (13), we caution against simply rallying behind current efforts to promote flourishing because of the term's strong positive, holistic associations and resulting widespread appeal. Before we can lift up flourishing as the answer, we first must subject the concept itself to deeper comparative scrutiny-and, moreover, we must have a robust interdisciplinary conversation to clarify whether we agree about what is wrong with "traditional concepts of health" in the first place.

This observation brings us back full circle to the New York Times series on flourishing that appeared near a peak in the COVID-19 pandemic in the U.S. Given the vast structural inequalities in health and, arguably, flourishing that have only deepened during the pandemic, it is now clearer than ever that the problems with "traditional concepts of health" are not primarily in our minds. While simple "do-it-yourself" flourishing exercises may help some people in a limited way, as a society-wide strategy for promoting human flourishing, they clearly will not do. If flourishing is fundamentally a matter of being able to realize one's potential, as Aristotle among others have argued (33, 32, 56) [XXX, this volume], then we cannot ignore the fact that people are and will be hard-pressed to reach their potential in environments of scarcity or risk, oppression, misrecognition, or violence.

Without confronting these vital insights head-on, efforts to promote flourishing will inevitably miss the mark. 

☒ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

☐The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:

There's a Name for the Blah You're Feeling: It's Called Languishing. The New York Times

Change in Level of Positive Mental Health as a Predictor of Future Risk of Mental Illness

Are You Flourishing? Take the Quiz

On the promotion of human flourishing

The Other Side of Languishing Is Flourishing

Flourishing: An Evolutionary Concept Analysis. Issues in Mental Health Nursing

Family Resilience And Connection Promote Flourishing Among US Children, Even Amid Adversity

Just healthcare and human flourishing: Why resource allocation is not just enough

Journal of Human Development and Capabilities

Moral Laboratories

Human flourishing in an age of gene editing

Positive Public Health Ethics: Toward Flourishing and Resilient Communities and Individuals

Reimagining Health-Flourishing

Current Recommendations on the Selection of Measures for Well-Being

Flourishing: migration and health in social context

Templeton World Charity Foundation. A new quest to uncover what helps humans flourish

Global Flourishing Study Launch

Social Conditions As Fundamental Causes of Disease

Is Racism a Fundamental Cause of Inequalities in Health?

Structural Racism and Health Disparities: Reconfiguring the Social Determinants of Health Framework to Include the Root Cause

Weathering" and Age Patterns of Allostatic Load Scores Among Blacks and Whites in the United States

The impact of adverse childhood experiences on an urban pediatric population

Health Justice: A Framework (and Call to Action) for the Elimination of Health Inequity and Social Injustice

Health Justice Strategies to Combat the Pandemic: Eliminating Discrimination, Poverty, and Health Inequity During and After COVID-19

Building the case for housing policy: Understanding public beliefs about housing affordability as a key social determinant of health. SSM -Population Health

Cultural trauma as a fundamental cause of health disparities

Flourishing and the pursuit of a good life, and good health

New Well-being Measures: Short Scales to Assess Flourishing and Positive and Negative Feelings

Flourishing Across Europe: Application of a New Conceptual Framework for Defining Well-Being

The Mental Health Continuum: From Languishing to Flourishing in Life

On Happiness and Human Potentials: A Review of Research on Hedonic and Eudaimonic Well-Being

Happiness is everything, or is it? Explorations on the meaning of psychological well-being

Know Thyself and Become What You Are: A Eudaimonic Approach to Psychological Well-Being

Flourish: Positive Psychology and Positive Interventions. The Tanner lectures on human values

Introduction: From Words to Worlds

Making sense of assets: what can an assets based approach offer public health? Critical Public Health

Parental warmth and flourishing in mid-life

Measuring well-being: interdisciplinary perspectives from the social sciences and the humanities

We're Not All in This Together: On COVID-19, Intersectionality, and Structural Inequality

Responding to the COVID-19 Pandemic: The Need for a Structurally Competent Health Care System

How COVID-19 Reveals Structures of Vulnerability

World Health Organization

Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. Final Report of the Commission on Social Determinants of Health. Geneva: World Health Organization

Health Disparities and Health Equity: The Issue Is Justice

The political determinants of health--10 years on

Global mental health: anthropological perspectives

Translations" and Boundary Objects: Amateurs and Professionals in Berkeley's Museum of Vertebrate Zoology

Measuring flourishing: The impact of operational definitions on the prevalence of high levels of wellbeing

The Science of Well-Being

Flourish: a visionary new understanding of happiness and well-being

Building a Culture of Health: A Critical Role for Public Health Services and Systems Research

Well-Being: Expanding the Definition of Progress

Healthy People 2030 Framework -Healthy People 2030 | health

Human Flourishing in an Age of Gene Editing

Human Flourishing in an Age of Gene Editing

Bioethics Contra Biopower: Ecological Humanism and Flourishing Life

Sick and Vulnerable Migrants in French Public Hospitals. The Administrative and Budgetary Dimension of Un/Deservingness. Social Policy and Society

Deservingness: migration and health in social context

Performing deservingness. Humanitarian health care provision for migrants in Germany

We Cannot Let Them Die": Undocumented Immigrants and Media Framing of Health Deservingness in the United States

Session 1: Halko & Brown. Health and Medicine Division

History Matters: Understanding the Role of Policy, Race and Real Estate in Today's Geography of Health Equity and Opportunity in Cuyahoga County

Kirwan Institute for the Study of Race & Ethnicity and The City Regional Planning Program at the Knowlton School of Architecture, The Ohio State University

Racism is a Public Health Crisis

Data for Progress, the Justice Collaborative Institute

Advancing health and well-being: the power of evidence and collaboration

Cognitive and Physiological Measures in Well-Being Science: Limitations and Lessons

Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science

Mental Health and the Covid-19 Pandemic

COVID-19 mitigation policies and psychological distress in young adults. SSM -Mental Health

 Keyes 2002 Positive psychology "Adults with complete mental health are flourishing in life with high levels of wellbeing. To be flourishing, then, is to be filled with positive emotion and to be functioning well psychologically and socially."Seligman 2011 Positive psychology "I now think that the topic of positive psychology is well-being, that the goldstandard for measuring well-being is flourishing, and that the goal of positive psychology is to increase flourishing."

Positive psychology "Flourishing refers to the experience of life going well. It is a combination of feeling good and functioning effectively. Flourishing is synonymous with a high level of mental wellbeing, and it epitomises mental health (Huppert 2009a, b; Keyes 2002; Ryff and Singer 1998) ."

Positive psychology "Flourishing itself might be understood as a state in which all aspects of a person's life are good. We might also refer to such a state as complete human well-being, which is again arguably a broader concept than psychological wellbeing."

Positive psychology Flourishing, understood as "eudaimonic well-being," involves "striving toward excellence based on one's unique potential" or "striving to achieve the best that is within us."

Bioethics/Disability studies "Flourish is a verb ... To flourish is to do something. … to 'grow or develop ... in a vigorous way' within 'a particularly congenial environment.' [8]