Toward a new definition of mental health.

Abstract

According to the World Health Organization (WHO), mental health is “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” (1). This definition, while representing a substantial progress with respect to moving away from the conceptualization of mental health as a state of absence of mental illness, raises several concerns and lends itself to potential misunderstandings when it identifies positive feelings and positive functioning as key factors for mental health. In fact, regarding well-being as a key aspect of mental health is difficult to reconcile with the many challenging life situations in which well-being may even be unhealthy: most people would consider as mentally unhealthy an individual experiencing a state of well-being while killing several persons during a war action, and would regard as healthy a person feeling desperate after being fired from his/her job in a situation in which occupational opportunities are scarce. People in good mental health are often sad, unwell, angry or unhappy, and this is part of a fully lived life for a human being. In spite of this, mental health has been often conceptualized as a purely positive affect, marked by feelings of happiness and sense of mastery over the environment (2–4). Concepts used in several papers on mental health include both key aspects of the WHO definition, i.e. positive emotions and positive functioning. Keyes (5,6) identifies three components of mental health: emotional well-being, psychological well-being and social well-being. Emotional well-being includes happiness, interest in life, and satisfaction; psychological well-being includes liking most parts of one's own personality, being good at managing the responsibilities of daily life, having good relationships with others, and being satisfied with one's own life; social well-being refers to positive functioning and involves having something to contribute to society (social contribution), feeling part of a community (social integration), believing that society is becoming a better place for all people (social actualization), and that the way society works makes sense to them (social coherence). However, such a perspective of mental health, influenced by hedonic and eudaimonic traditions, which champion positive emotions and excellence in functioning, respectively (7), risks excluding most adolescents, many of whom are somewhat shy, those who fight against perceived injustice and inequalities or are discouraged from doing so after years of useless efforts, as well as migrants and minorities experiencing rejection and discrimination. The concept of positive functioning is also translated by several definitions and theories about mental health into the ability to work productively (1,8), and may lead to the wrong conclusion that an individual at an age or in a physical condition preventing her/him from working productively is not by definition in good mental health. Working productively and fruitfully is often not possible for contextual reasons (e.g., for migrants or for discriminated people), which may prevent people from contributing to their community. Jahoda (9) subdivided mental health into three domains: self-realization, in that individuals are able to fully exploit their potential; sense of mastery over the environment; and sense of autonomy, i.e. ability to identify, confront, and solve problems. Murphy (10) argued that these ideas were laden with cultural values considered important by North Americans. However, even for a North American person, it is hard to imagine, for example, that a mentally healthy human being in the hands of terrorists, under the threat of beheading, can experience a sense of happiness and mastery over the environment. The definition of mental health is clearly influenced by the culture that defines it. However, as also advocated by Vaillant (11), common sense should prevail and certain elements that have a universal importance for mental health might be identified. For example, in spite of cultural differences in eating habits, the acknowledgement of the importance of vitamins and the four basic food groups is universal.