What is the concept of mental health?

This is a simple question but the answer is far from clear. If the question refers to mental ill-health (rather than health), most people would probably take it to mean being stressed, anxious, depressed, or to be suffering from a ‘psychiatric disorder’. Logically, to be mentally healthy should mean the opposite of being mentally unhealthy, which would signify the absence of any psychological problem. However, if we look to the World Health Organization as our authority, their definition of ‘health’ is wider than this: health is ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’. Many researchers have bought into this dual meaning and have investigated the relationship between the two aspects of health, firstly, the degree to which a person is disordered (from having no disorder to being diagnosable with a physical or mental disorder), and secondly, the degree to which a person enjoys a state of well-being (from ‘languishing’ at the bottom end of the scale to a feeling that life is going swimmingly at the top). According to the WHO definition, you would have to score highly on both dimensions to be positively mentally healthy. The definition doesn’t seem to allow for being happily mad or sanely unhappy.

Another feature of the WHO definition is that it could be taken to imply that ‘languishing’ is a state of poor mental health. If well-being is integral to health, it follows that a lack of it is unhealthy. In reality, there must be hundreds of ways in which a person can languish in a sub-optimal state of well-being: being chronically unemployable, losing religious faith, having few friends, getting old, etc. These are not connected with a state of health in a strictly medical sense. In fact, when responding to these circumstances, it is probably not a good policy to think of them as examples of mental ill-health. If mental means ‘to do with the mind’, there is no reason to believe that a person who is languishing has lost the capacity to use their mind or that their brain is diseased. That would be to go down the path of responding to languishing by allowing oneself to fall into the sick-role. The person would not be demonstrably ‘sick’ but might be encouraged to take a brain tonic. The pharmaceutical industry has, of course, devised many kinds of brain tonic. Although these medicinal products might take the edge off languishing, it seems far preferable to tackle low well-being in other ways.

How then should we promote ‘positive mental health’? In the 1950s, the US Joint Commission on Mental Illness and Health employed a social scientist, Marie Jahoda, to investigate the matter. When answering this question, she did not consider a concept of mental disorder to be relevant. She came up with a number of alternative suggestions that did not equate positive mental health with freedom from disorder. Her own definition was multi-layered and did justice to the complexity of the topic. Subsequent research on well-being has, instead, contented itself with self-report scales that measure ‘happiness’, ‘life satisfaction’ or ‘quality of life’. Some measures are as simple as asking a person to rate their life on a scale from 1 to 10. Well-being scores have been of considerable interest to economists, who have sought alternatives to assessing the progress of a country in terms of its Gross Domestic Product, a purely monetary indicator. They have been struck by the fact that people’s rated satisfaction with life hasn’t changed much (if at all) over the last fifty years despite considerable improvements in average income, possession of luxury goods, and the provision of greater social welfare. If being mentally healthy means the same as being satisfied with life, it seems we are not making much progress in advancing it.

The best judge of whether someone is ‘mentally healthy’ is probably a person him or herself. It is difficult to get away from a subjective judgment. However, a problem with a subjective scale is that it seems to depend on unknown and shifting reference points that could be quite different for each person. It is likely that how satisfied you are depends on how well you consider yourself to be doing (or expect to be doing) with respect to your peers or other people in general. For instance, most people in the West have access to running water, and so access to it no longer enters into a judgment of life satisfaction. This might not have been the case when some people had to travel a long distance to use a well while others had piped water. Similarly, to take a more contemporary example, if a woman earns less than a man for doing the same job, she might, understandably, feel dissatisfied, and this might possibly influence her rating of satisfaction, well-being, or even mental health. The relative basis for subjective judgments also has other implications. It means that if one section of the population gets very much richer relative to the rest (as has happened in the USA), the majority will become more dissatisfied even though their general wealth has stayed the same or improved. This would be so if they use the richest as their reference point to make comparisons. The upshot of all that I have been saying is that subjective ratings of positive mental health have extremely complex causes. I think it is safe to assume that these causes have little to do with health or medicine (except, of course, in particular cases, when life satisfaction could be affected by physical ill-health.)

So in answer to the question of ‘what is mental health’, I would advocate being much clearer and more single-minded about a definition of health. By and large, we have a pretty clear idea of what a physical health problem is. In most countries, physical and mental health services employ different professionals who occupy different premises. Textbooks of medicine rarely mention ‘psychiatric disorder’ apart from discussing the effects of head injury or the known diseases of the central nervous system. A person does not normally go to a physician to check up on their ‘mental health’. Let’s adopt a far stricter definition of a disorder of the body and stop talking about ‘mental health’ altogether. As Thomas Szasz pointed out many years ago, the mind is not the kind of thing that can be disordered in a physical sense. To live unwisely to one’s own detriment is not a mental disorder. If we followed his advice, we might cease to confuse remediable social and personal circumstances with remediable bodily disorders.

Marie Jahoda. Current concepts of positive mental health. New York, Basic Books, 1958

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