Mental health articles

OF mental health care and mentally ill

Mental health – concepts, paradigms, elements

There are, no doubt, as many definitions of mental health as there are readers of this book. Although some authors offer definitions of mental health, they are inevitably subjective, partial and, at worst, simplistic – Making It Happen defines mental health as ‘thinking, feeling and physical health and well-being’ and the relationship between the three described and defined by three double-headed arrows! More useful than any one definition is to consider the elements of mental health common to such definitions – hence the importance of concepts of mental health. This approach to the subject was first adopted by Marie Jahoda in 1958 who, in a report to a United States Joint Commission on Mental Illness and Mental Health (readers will note the distinction explicit in its title) identified six major categories of concepts:

mental health as indicated by the attitudes of an individual towards themselves;

mental health as expressed in the individual’s style and degree of growth, development or self-actualisation;

mental health as integration of the above (that is, the individual’s ability to integrate developing and different aspects of themselves over time).

mental health based on the individual’s relation to reality in terms of:

autonomy;

perception of reality;

environmental mastery.

While these are categories of concepts, each one of which represents a literature in itself (which, in the last four decades has obviously expanded with the growth of interest in self-development and popular psychology), nevertheless Jahoda’s categories may be adopted by professionals and clients as the basis of a genuine mental health assessment. Drawing on an appreciation of the interpersonal field and the significance of the environment or context, mental health may be viewed as relevant at four levels – the personal, the interpersonal, the institutional and the cultural – first identif ied by Jones (1972) as ones in which racism is expressed; and, in relation to mental health, as with racism, all four levels interact. Applying Jahoda’s categories to these levels offers practitioners, workshop participants (and, of course, the reader) a comprehensive and practical frame with which to assess mental health – for themselves, for and with others, and as regards the institution or workplace as well as the broader culture or sub-culture.

Drawing on the work of Kuhn (1970) and Burrell and Morgan (1979), I followed in this tradition of conceptualizing mental health, developing a conceptual framework of mental health through the application of paradigm analysis to the different and differing definitions of mental health and its promotion. Putting together two dimensions as axes – one, concerning assumptions about the nature of science (a subjective–objective dimension), the other concerning assumptions about the nature of society (a regulation–radical change dimension), Burrell and Morgan defined four distinct sociological paradigms.

Burrell and Morgan make a number of points about the nature and use of paradigm analysis:

1 That although each paradigm contains a variety of viewpoints, there is essential unity within the paradigm, defined by its external boundaries. Thus, the ‘essential unity’ of notions of mental health within the interpretive paradigm is defined by the boundaries of and adherence to subjective knowledge and social regulation. In this paradigm mental health is viewed in interpretive and relational terms with a focus on the regulation of the individual to conform to a harmonious and integrated sense of self and society.

2 That ‘all social theorists can be located within the context of these four paradigms according to the meta-theoretical assumptions reflected in their work’. Thus when Preston (1943) talks about mental health as consisting of ‘the ability to live … happily … productively … without being a nuisance’, he is clearly reflecting a view of society that is concerned with social regulation, and representing a view of mental health which claims a certain certainty and ‘objectivity’ – and thus, in terms of our analysis, is located within the functionalist paradigm. This is confirmed by an appreciation of the wider historical context of the mental hygiene movement that predominantly portrayed a conformist and functional view of health and productivity: ‘a healthy worker is a productive worker’.

3 That, by definition, the four paradigms are mutually exclusive: ‘a synthesis is not possible’ (ibid. p. 25). Paradigm analysis thus describes the conceptual and theoretical assumptions underpinning differences which lead to – and are often demonstrated through – differences in practice and action such as that of the consultant psychiatrist who refused to sit on the same conference platform as representatives of the psychiatric user movement. Paradigm analysis has thus proved useful in understanding and exploring differences in definition, policy and practice. Caplan (1986) applied this analysis to health education theory – and in doing so, offers a paradigmatic way out of the often futile ‘health promotion versus health education’ debate: theory and practice in both is based on underlying assumptions which may be analysed and located within the four paradigms. Developing Caplan’s ideas, the present author subsequently applied it to the field of mental heath and community mental health promotion, and in doing so identified mental-illness prevention with its focus on identifying vulnerability and causative factors and ‘targeting’ as little to do with mental health promotion. In elaborating this analysis, as a result of an extensive literature review and in the spirit of Jahoda’s work, I identified eight elements (two representing each paradigm: the functionalist, interpretive, radical humanist and radical structuralist, respectively), each of which may be viewed as on a continuum of health–ill-health.

These elements do not stand alone as defining mental health; they are representative of the literature and of the four paradigms. McDonald and O’Hara (1998) also identify elements of mental health, mapping ten, comprising five elements each of mental health promotion and demotion. McDonald and O’Hara map these elements on three levels, a mapping that acknowledges (at least conceptually) the relevance of the individual (micro level), groupings (meso level) and wider, social systems (macro) in terms of taking action on promoting mental health. However, it is not exactly clear in McDonald and O’Hara’s model what the relationship between promotion and demotion is.

Thus, for instance, emotional abuse is not the opposite of self-esteem or the only element that demotes self-esteem; also, identifying stress as demoting mental health does not account for positive stress (or ‘eustress’). Finally, the interpersonal aspect of mental health is almost completely missing from this model. Undoubtedly the most impressive piece of empirical research on mental health is Stephens’s (1998) work on population health in Canada. Prepared for the Mental Health Promotion Unit, Health Canada which, under the directorship of Natacha Joubert, led the field in its advocacy and resourcing of positive mental health promotion, the report is clear in the distinction between mental health and mental illness.

From his survey of data and previous research Stephens presents evidence that considers mental health status on the ‘positive dimension’ in terms of happiness, self-esteem, mastery, sense of coherence and work satisfaction, as well as the negative (in relation to depression, distress, child emotional disorders, cognitive problems, hospitalized disorders and suicide). The whole report is set in the context of socioeconomic restructuring and health care reform in Canada. Stephens distinguishes between indicators of mental health status (as above) and its determinants (demographic characteristics, social conditions, social status, working conditions, personal health practices and physical health).

While the conclusion is that superficially the mental health status of Canadians appears to be reasonably good – three quarters of the population describe themselves as usually happy and interested in life and 91 per cent report some degree of job satisfaction – Stephens cautions that: ‘comparisons among population groups reveal that both positive and negative mental health are far from evenly distributed in the population: there are sharp differences according to an individual’s household type and age, and, to a lesser extent, province of residence and gender’.

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