Rethinking the concept of mental health

Rethinking the concept of mental health

Modesto Solís Espinoza modesto333@comunidad.unam.mx

Comisión Nacional de Salud Mental y Adicciones, México

Esta obra está bajo una Licencia Creative Commons Atribución 4.0 Internacional.

1950 saw the emergence of one of the most essential definitions of mental health by the World Health Organization (WHO), by what was then known as the Committee of Experts on Mental Hygiene:

It implies an individual’s ability to establish harmonious relationships with others and to participate in or contribute constructively to changes in his physical and social environment. It also implies his ability to achieve a harmonious and balanced satisfaction of his own potentially conflicting instinctive drives harmoniousness in that it reaches an integrated synthesis rather than the denial of satisfaction to specific instinctive drives to avoid the thwarting of others. It implies, in addition, an individual whose personality has developed in a way which enables his potentially conflicting instinctive drives to find harmonious expression in the full realisation of his potential. (WHO Expert Committee on Mental Health, World Health Organization & Pan American Health Organization, ‎1952, p. 4).

Echavarría (2012) notes that although this definition has been reformulated, it arose as a response to the political and social interests of the United Nations Organization (UN). It emphasised the person's harmony with himself and others, a concept that responded more to the time's socio-historical needs than scientific advances. This concept has been abbreviated, and the way it has been most widely disseminated and remains in force on the websites of both the World Health Organization (WHO, 1992) and other health institutions is as follows:

Mental health is a state of mental well-being that enables people to cope with the stresses of life, realise their abilities, learn and work well, and contribute to their community. It is more than the absence of mental disorders. (WHO, 2001, p. 1).

It was only a short time before this concept drew criticism. Specialists reached a similar conclusion: there needed to be a consensus on a satisfactory definition. Although it is assumed that mental health does not imply a mental illness or disorder, it is difficult to determine what is expected, given the risk of value judgments and the impossibility of establishing a standard across all cultures (Jahoda, 1958). In reviewing the origin of mental health and mental hygiene movements, Bertolote (2008) explores the changes in the last century, concluding that previous concepts no longer suffice.

It has been argued that the definition of health appears to be about happiness, which has harmful consequences. One of them explicitly concerns the concept of mental health. An alteration of happiness, however minimal, could strictly be considered a health problem (Saracci, 1997), according to an unrealistic perspective of always being and feeling well. As Galderisi et al. (2017) point out, the definition provided emphasises well-being, which, according to Keyes et al. (2014), implies, among other things, positive emotions such as happiness and satisfaction, a construct that creates unrealistic, highly demanding and even oppressive expectations (Wren-Lewis & Alexandrova, 2021) if it fails to consider its alternation with many other moods. This perspective, which focuses on well-being, is in line with the attitude pointed out by Barraca (2007), in which it appears that pain should not even be experienced, according to the belief that a person must be happy all the time.

Reviews of the approaches used in mental health promotion programs have found that most of them focus on young people who have age-specific needs that do not necessarily correspond to those of other ages. It is, therefore, essential to detect and develop the needs of each stage of the life cycle (Fusar-Poli et al., 2020). At the same time, it is worth mentioning that mental health, in the sense of "contributing to society and work," is not only the responsibility of health professionals. It is also essential to emphasise the importance of the context in which each community is embedded. Health conditions vary, while job insecurity influences people negatively and in various ways (Valero et al., 2022). Why treat what may be primarily associated with unfair working conditions as a "mental problem"?

The fact that specific mental health problems are life problems is usually overlooked and, in some cases, not even considered. Labelling certain situations as mental problems appears to delegate responsibility exclusively to each person, emphasising the individual nature of psychological work (Pavón-Cuéllar, 2012) and minimising the importance of the community and social structures.

The limitations of the classic concept of mental health are borne out by the fact that it has drawn criticism from quite different currents of psychology. For example, well-being (a central tenet of the concept of mental health) has been questioned by the Lacanian school (Lacan, 1992), in which the conception of the human being is conflict and its condition erratic, according to which well-being would not necessarily be viable or at least not as posited in the classic concept of mental health. In his criticism of the concept of mental health, Boorse (1976) proposed psychoanalysis as a better explanation than the WHO proposal since it refers to the structures of consciousness.

At the same time, according to the behaviourist tradition, it could be considered mentalism, the attempt to explain behaviour through internal dimensions other than the behavioural, based on spiritual or neural characteristics (Hayes & Brownstein, 1986; Skinner, 1987). From a behaviourist perspective, it is essential to establish clear behavioural referents of what mental health should imply. Other criticisms stem from considering mental health from a primarily biomedical approach. This model is based on Cartesian rationalist thought, with the division between body and mind, which is the basis of modern scientific medicine, in which illness is due to the improper functioning of biochemical mechanisms (Baeta, 2015). Although the main developments in medicine and health care are based on this model, this perspective cannot be applied in the same way to what we feel, think and act, placing significant constraints on the understanding of pathological processes (Johnstone & Boyle, 2019; Olabarría, 2023; Ríos Osorio, 2011).

According to Restrepo and Jaramillo (2012), in diagnostic manuals, the biomedical model in the mental health sphere is based on the absence of mental disorders. In doing so, they appear to adopt the biostatistical theory, according to which what interferes with the natural functions of a species in terms of reproduction and survival, or what is atypical in the species, is regarded as disease. These aspects have been used as an argument to make value judgments and to regard what deviates from the norm as pathological, as in the case of homosexuality, removed from the latest versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) (Boorse, 1976).

In contrast to the above statements, one of the arguments in defence of the biomedical model in mental health is that since some psychiatric issues are based on a medical condition, as in the case of hypothyroidism and cerebrovascular events (Huda, 2021; Lishman, 1997), a radical position of excluding the biomedical model in mental health has not been considered feasible. The traditional biomedical model implies a power relationship in which patients assume a passive role and are classified and limited to mindlessly following medical instructions. This is why it has been criticised in medicine for years (Greenhalgh et al., 2014). A patient-centred approach has been recommended, in which the patient should be empowered and responsible for their care (Langberg et al., 2019). A passive role in treatments is of little or no use; it is essential to listen to the voices of consultees.

Alternatively, greater visibility could be given to other conceptualisations of mental health, epistemological alternatives encompassing other elements of human existence that prevent people from adopting the passive role of containers of conditions (Ríos Osorio, 2011). These include the behavioural perspective that refers to behavioural health, regarding adaptation as an adjustment to the context and the productive system; the cognitive perspective, involving the rational adaptation to internal and external demands; and the socioeconomic perspective focused on rights and human development (Restrepo & Jaramillo, 2012). Although an exhaustive analysis of each model is beyond the scope of this document, it would be helpful to review them and their advantages and disadvantages.

Since the origins of the concept of mental health, it has often been defined in terms of what it is not (Jahoda, 1958), to the extent that various mental health organisations have much more research on the prevention of mental disorders than on how to improve mental health (Fusar-Poli et al., 2020). This is possibly due to the difficulty of proposing a "standard" of what it means to be mentally healthy (Wren-Lewis & Alexandrova, 2021), or as Echavarría (2012) notes, discomfort or disorders may be more evident than what is healthy. Perhaps for this reason, ironically, mental health reports focus on the distribution of disorders as if they were a benchmark for determining mental health.

Figure 1
The Continuum Between Mental Disorder and Good Mental Health

When delving into the relationship with what is "unhealthy," some research has focused on its relationship with mental disorders, producing diagrams of the continuum between mental health and mental disorders (Manwell et al., 2015), such as the one in Figure 1 (Keyes et al., 2010), showing that mental health does not move along the axis of whether one has a mental disorder. There are specific characteristics of what is mentally healthy that are not reduced to the absence of symptoms of mental disorders.

Diagnostic manuals such as the DSM have been continuously updated to clarify mental disorders. The DSM and its categorical system contribute to research and communication between health personnel. However, historically, it has been based more on subjective clinical criteria than scientific evidence and more on subjective clinical judgments and consensus, which is why the validity of its categories has been called into question since it sometimes creates more problems than it solves (Hernández-Guzmán et al., 2021; Kotov et al., 2017, 2022).

Although classifying clinical pictures facilitates professional communication and provides a basis for research, the DSM is "closer to a descriptive dictionary than a psychopathology manual" (Echeburúa et al., 2014, p. 70). It tends to have homogeneous categories that describe without identifying causes or previous mechanisms, making them only partially useful for clinicians (Huda, 2021). It must go beyond labelling problems to topographic analysis and the functional analysis of behaviour.

It is worth noting that some of the disorders in the latest version, the DSM-5, lack solid empirical support for their origins, creating the risk of unnecessary medication and treatment for behaviours that are relatively normal or can be explained by their context, such as disruptive mood disorder, grief over the loss of a loved one, or menstrual dysphoric disorder (Echeburúa et al., 2014; Frances, 2013). They may also have risky implications for sexual diversity and individual differences by regarding the lack of or low sexual desire as pathological unless the person identifies as asexual (Margolin, 2023). In addition, its criteria are not helpful for all populations, as in the case of adolescents with substance use disorder, since its criteria fail to match their neurodevelopment (De Micheli et al., 2021).

According to Gamba et al. (2020), the categorical system of personality, with its overlapping criteria, has been more of a hindrance than a help in psychotherapeutic clinical practice. The same problem occurs with mental disorders, as no test can be used to determine whether something classifies as a mental disorder (Frances & Widiger, 2012). Creating diagnoses and further classifications stimulates the general population, family members, and clinicians (Read et al., 2006).

DSM diagnoses and classifications lack discriminant validity, as confirmed by the high comorbidities, overlapping diagnoses and frequency of subcategories of unspecified disorders (Hernández-Guzmán et al., 2011; Pérez Álvarez, 2014; Widiger & Samuel, 2005). Their shortcomings are borne out by the increase in categories from approximately 106 diagnoses (American Psychiatric Association, 1952) to approximately 300 (American Psychiatric Association, 2013). There is also the Charcot effect: doctors find what they expect to find (Pérez-Álvarez & García, 2007). The declaration of the existence of specific diagnoses can cause clinicians to begin to identify these disorders more frequently, which is one of the reasons why there has been talk for decades about the overdiagnosis of certain conditions (Sánchez Trujillo & Torres López, 2018; Santana-Vidal et al., 2020).

Furthermore, the emphasis on diagnostic categories can overlook critical aspects of the person being cared for and their distinctive, idiosyncratic qualities (Gamba et al., 2020). In some primary care services, the most frequent care category is "life problems." This contrasts with the biomedical vision of ailments as diseases to be cured. Instead, it involves seeing life as something to be implemented, a component of contextual philosophy, through a phenomenological-behavioural model focusing primarily on the experience and behaviour of people in keeping with their circumstances (Kanter et al., 2009; Pérez-Álvarez & Fernández-Hermida, 2008). Moreover, addressing psychological problems as problems or difficulties rather than as mental illness is less stigmatising (Pérez Álvarez, 2014).

Among the alternatives, the dimensional perspective has been cited as an appropriate option, with evidence showing great explanatory potential, specifically in eating psychopathology (Hernández-Guzmán et al., 2021). This has even been proven with the transdiagnostic perspective for emotional regulation when addressing problems associated with binge eating (Reyes, 2013). In addition to the effectiveness of its treatments and the theoretical approach, the transdiagnostic approach brings clinical practice closer to more integrated and less stigmatising interventions (González Pando et al., 2018).

In addition to considering alternative or complementary systems to the categorical system, analysing what is labelled as healthy or pathological enriches work in mental health. Studying what is understood as pathological provides a starting point for adequately defining what is considered healthy and, in turn, for determining more apparent objectives in prevention and health promotion.

What Alternatives Are Available for Defining What is Healthy?

Given some of the limitations of classical concepts, Galderisi et al. (2015) proposed the following definition:

Mental health is a dynamic state of internal balance, enabling people to use their abilities in harmony with the universal values of society. Basic cognitive and social skills, the ability to recognise, express and modulate one´s own emotions, as well as empathise with others; flexibility and ability to cope with stressful life events and functions in social roles; and a harmonious relationship between body and mind are crucial elements that can contribute, in varying degrees, to a state of internal balance (p. 231).

This definition highlights the changing nature of life, fluctuations that do not respond to a loss of health but rather to changes in the dynamics of life. It also mentions specific skills, which, although not compulsory, are regarded as relevant insofar as they contribute to everyday life (Galderisi et al., 2015). Identifying specific skills contributes to a more accurate delimitation of tasks to promote mental health. Other definitions of mental health have emerged in recent decades, such as that of the Public Health Agency of Canada (PHAC, 2006):

Mental health is the ability of each of us to feel, think and act in ways that enhance our ability to enjoy life and cope with the challenges we encounter. It is a positive sense of emotional and spiritual well-being that respects the importance of culture, equity, social justice, interconnection and personal dignity (p. 2).

According to a panel of experts, the definition above is one of the best, and they analysed and rated a series of mental health definitions (Manwell et al., 2015). It served as the starting point for proposing an alternative concept: the capacities of each of us to feel, think and act that enable us to value and commit to life (Wren-Lewis & Alexandrova, 2021). Well-being is considered a basis (although not a synonym of). It includes a commitment to live, giving rise to psychological flexibility (the ability to implement conscious, committed behaviours to achieve valuable goals (Hayes et al., 2011), which is in line with the management of chronic pain and other conditions (McCracken, 2024; Rolffs et al., 2018).

On the other hand, there is some agreement on most of the components identified as part of mental health. Based on this analysis and the incorporation of the elements indicated by WHO (2001) and Huber et al. (2011), a model was proposed with different health domains, to which relevant aspects and their interrelations in different areas of health were added (Manwell et al., 2015):

Figure 2

This model proposes standard levels of functioning, one of its main contributions being the proposal of overlapping components, which, when applied to the model, would involve recognising and addressing healthcare tasks differently, encouraging multidisciplinary approaches. This model outlines the relationships between different areas of health and capabilities with multiple influences, such as agency, autonomy, control and sense of self (see the full article by Manwell et al. (2015) for a detailed explanation of its construction).

An added value of the transdomain model is its contribution to delimitating physical and mental health. WHO has emphasised its relevance: "There is no health without mental health" (WHO, 2005), albeit without precise limits. This raises the question of what health can there be without mental health and where mental health begins and ends. Despite its limitations and conceptual shortcomings, the transdomain model allows for a more comprehensive health analysis.

The proposals mentioned are some examples of how to delve deeper into the conceptualisation of health. They highlight the possibility of seeing health as beyond a synonym for well-being, provide more concrete guidelines by pointing out specific skills, and propose a means of understanding the relationship between different areas of health. Becoming aware of new and different ways of understanding mental health is essential.

Together with the discourse from different models on mental health, new technologies have romanticised the issue, thereby misinterpreting psychological problems. Some mental disorders are “glamorised,” indirectly promoting eating disorders (Peter & Brosius, 2021) and even suicidal risk behaviours (Jadayel et al., 2017), which is why research is already being conducted on this subject, analysing discussions about mental health on Twitter, for example, and identifying both content that promotes and content that raises awareness about the need to address psychological problems (Issaka et al., 2024). The mass media are crucial to promoting or avoiding prejudices towards psychological problems (Edney, 2004; Khorgade, 2020).

Another problem arising from new technologies, which is becoming increasingly frequent, is “self-diagnoses,” where criteria and sometimes even clinical recommendations are disseminated on social networks without professional accompaniment or specialist support. This issue requires further research (Ahuja & Fichadia, 2024). What is not reported with scientific evidence promptly produces misinformation, which spreads rapidly.

As noted by Galderisi et al. (2015), it is challenging to create a concept of mental health, given the various cultural implications each word can have. In line with this research, Wang (2022) analyses the fact that the definition of mental health has a different perspective in Eastern and Western cultures and between cultures centred on the individual and those that are not. Wang (2022) identifies how Chinese cultural thinking is similar to certain philosophies, which directly impact how life and, therefore, health are perceived. Along these same lines, it is necessary to analyse what type of definition would be most suitable for the multiculturalism of Mexico, given its community roots (López, 2002).

Although this was one of the first criticisms of WHO's Definition of mental health, it is still helpful today for confirming one of the points analysed by Jahoda in 1958: the standards of mentally healthy or normal behaviour vary across time, place, culture, and social groups. Different populations have different standards. In this respect, the definition of mental health is not static; the parameters used to assess it are constantly changing.

While mental health is being researched, it is necessary to rethink what is known as psychopathology and the implications of the approach used. It is important to recognise from the health field that suffering is inherent to life and to promote tolerance of behaviours regarded as different: “No one behaviour, feeling or mental activity can be classified as pathological without examining its possible adaptive and strategic usefulness, and the contextual conditions in which it appears” (Echeburúa et al., 2014, p. 71).

The debate about what is healthy has intensified in recent decades. However, the most popular definition has hardly changed, as borne out by the General Health Act on Mental Health and Addictions (Cámara de Diputados del H. Congreso de la Unión, 2022): a state of physical, mental, emotional, and social well-being determined by the interaction of the individual with society and linked to the whole exercise of human rights.

The scope of this concept should be reviewed, considering the legislation that may be required to promote health in Mexico's current context. It is also necessary to consider whether the definition above is consistent with the practical work undertaken in the various mental health organisations. Public policy design and the dissemination of evidence are therefore required to facilitate health promotion strategies (Arango et al., 2018).

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