The concept of mental health lives a double life. On the one hand it denotes a state today universally valued. Not simply valued but newly prioritised by governments, hospitals, schools, employers, charities and so on. Expressions such as “mental capital” or “mental wealth of nations” appear in official reports and high profile articles emphasising the importance of public policy aimed directly at enhancing mental health. You’d think that when something is so valuable and so uncontroversially prized, there’d be an accepted definition of it. I am not asking for knowledge of the nature mental health and its causes, just a statement of what counts and doesn’t count as mental health. After all it’s hard to value something when you don’t know what to point at when you name it. And yet when you look closely at the existing efforts to define mental health, all you see is a multitude of definitions being bandied around with little consensus. Mental health appears to be prized more as a label than as a concept.
On the face of it the World Health Organisation appears to provide such a definition:
Mental health is defined as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.
This statement harks back to WHO’s definition of health which appeared in its 1948 constitution: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Mental health according to WHO is also a positive state: it is not enough to be free of depression, anxiety or schizophrenia, or any other diagnosable psychiatric condition, you also need to be well enough to thrive and flourish in your community.
Moved by similar considerations a growing number of public health scholars also identify mental health with “wellness” or “mental well-being.” This development probably stems from the rise of positive psychology – a field of social science that in the last decades has positioned itself as a science of well-being. Proponents of positive psychology like to say that the methods of measurement and data analysis have progressed so much that now it becomes feasible to have a science of happiness, flourishing, satisfaction, and fulfilment. One popular scale for measuring “mental well-being” is the Warwick and Edinburgh Mental Well-being Scale which asks people to judge the extent to which they feel optimistic, effective, useful, relaxed, able to get along with other people and to make up their mind about things.
But notice how different all these ideas are. WHO’s expansive definition describes a life that’s functioning in harmony with the norms of a given community – these norms set what counts as normal stress, productive work, and contribution to society (I hope the WHO realises the relativity of this definition to social norms, and some very modern ones at that). It is an explicitly objective definition in that it demands that the person actually meets these standards not just thinks they do. The Warwick and Edinburgh scale on the other hand is entirely subjective – it measures people’s own sense of their personal effectiveness for going through with basics of life. But if you look closer you’ll notice the difference between this sense of personal effectiveness on the one hand, and subjective well-being on the other. Intuitively the latter refers to our emotional well-being, our happiness, our fullness of heart, joy and contentment. Feeling happy takes more than just patting yourself on the back for being effective. And yet it is also common to come across this happiness-based definition, such as when mental health charities advertise “pathways to well-being” through engaging in those activities that maximise happiness.
Mental health appears to be prized more as a label than as a concept.
To take stock, there are at least three definitions here: functioning according to norms of society, feeling personally effective, and being happy. And that’s not counting the definition all of these three oppose – mental health as mere absence of psychiatric disease. Ironically it’s the latter much maligned minimalist definition that does much of the work when it comes to policy and advocacy. On the WHO website, just under their ambitious definition, we are invited to check out the top ten facts about mental health. With a few exceptions all these facts are actually about mental illnesses – how costly they are economically, how they exacerbate existing inequalities, and how much needs to be done to address them. Those few facts that are phrased in terms of mental health – for example, “Fact 8: Globally, there is huge inequity in the distribution of skilled human resources for mental health” – do not in fact need a definition of mental health in any other terms than absence of illness. It’s as if the positive definition is largely superfluous to the good efforts the WHO is advocating.
In my estimation this is a common pattern. The long search for a positive definition of mental health (the debate started after World War II and is ongoing) is a struggle to balance cross-cultural applicability, measurability, and conceptual validity. There are many valiant attempts, each of which faces basically the same objection: depending on context, being unhappy, idle, indecisive, or anti-social can be perfectly mentally healthy. Few people deny that defining mental health takes a value judgment, but which value judgments are robust enough to do this job is still a mystery.
Meanwhile the worthy work helping people with mental illness proceeds relatively untouched. This summer I attended an event in London at which academics, doctors, service providers, patients and their families were tasked with finding a standard by which a mental health intervention should be judged, i.e. what outcomes matter for evaluation of the state of a young person with mental illness. Karolin Krause of University College London listed twenty four different outcomes on a big poster – two of them were negative (having fewer symptoms and engaging less in harmful behaviour) and the rest were various shades of positive outcomes, from ability to focus, to getting on with others, feeling understood, etc. Krause asked participants to put stickers next to the outcomes they consider most important. At the end of the day the two negative outcomes, though they had many positive competitors, won the plurality of votes.
Arguments about the proper positive definition of mental health will rage on. But in the meantime just freedom from illness can be quite enough.