Mental health articles

OF mental health care and mentally ill

Mental health, mental well-being and mental illness

Many people are used to hearing ‘mental health’ as a euphemism for ‘mental illness’. A real problem in talking about mental health is that very often we are led into a way of thinking based on ideas and assumptions about mental illness – issues like depression, suicide, paranoia, schizophrenia come to the fore. On the other hand, it can be argued that mental health has very little if anything to do with mental illness. But the problem is that for so long the ‘mental health as mental illness’ euphemism has been a stable part of our ordinary language and the illusion sticks. So it becomes very hard to think of mental health as anything other than something affected by the values, myths and fears that often surrounds mental illness. In this chapter it will be argued that it is possible and desirable to agree to a characterization of mental health without resorting to ‘mental illness’ discourses. But it may not be helpful to fudge the issue by introducing new terms like ‘mental well-being’ or ‘emotional intelligence’, as these may only tell part of the story.

And in any case, many people feel quite angry about the hijacking of the term ‘mental health’ by what they see as the power of the mental illness field. I want to reclaim a more positive, humanistic and celebratory meaning of the term ‘mental health’. However, this cannot be achieved unless our thinking about mental illness is very clear, and how thinking about mental health can be different.

Both these represent what is known as the pathogenic view of mental health. For many health professionals and people with mental health problems, this is the reality of mental health – the idea that we are healthy until something happens or something goes wrong and we become ‘mentally ill’. Some people see mental illness as something to be frightened of, to be embarrassed about, and to fear. Some who have mental health problems will go to some length to deny or avoid being labelled as ‘mentally ill’ because of this fear, because of the stigma and victim blaming,3 because of what it might lead to in terms of their job, their relationships and their own sense of worth. Others are accepting of the label and are even glad to have it – they feel they are being taken seriously, they feel their problems have been identified and acknowledged. Both of these are understandable and valid views and it is not appropriate to be judgemental about people who embrace the term or those who deny it applies to them. However, it is important to consider some of the problems that arise with the concept of mental illness, especially in relation to an understanding of mental health.

One problem with the pathogenic view is that the starting point for recognition and intervention is the opinion of those who have the knowledge and influence to decide what is mental health and who is mentally ill. The argument against this view can be summarized by a long-standing health promotion principle of needing to ‘start where people are at’ – people who may not share this ‘medicalization’ of their problems. As Ingleby (1981) observes, the norms of mental ‘health’ and ‘illness’ are essentially matters of cultural judgement, although positivism misrepresents them as matters of empirical fact. Another point is that life can be profoundly shaken by traumatic events and unresolved chronic problems, and these can assault our very foundation and raise broad questions about one’s life such as: ‘Does my suffering have a purpose and meaning?’ or ‘Am I responsible for my suffering?’ (Van Egeren 2000). So maybe we need to do more for people than fix their mental illness. Other arguments are that the pathogenic model frequently leads to the disempowering of the ‘patient’, and that it creates a dependency for those who are categorized as ill for treatment provided by those doing the categorizing. Also, the main focus of any prevention work is the identification or elimination of a specific pathogen and so resources are concentrated or diverted onto technologies to deal with the pathogen rather than the host or the context in which the host lives her or his life. Another important problem with the pathogenic view is that the focus is on ‘what makes people ill’, not ‘what makes people healthy’, and involves a very narrow and mechanistic model of being human. Antonovsky argues strongly against this: ‘It is impermissible to identify or equate a rich, complex human being with a particular pathology, disability or characteristic, or a particular set of risk factors’.

Perhaps the strongest argument against the pathogenic model is its assumption that a focus on curing or preventing disease in individuals is the most effective way of improving the health of populations. This has been challenged because it avoids or even diverts attention from systemic determinants of health (environmental, social, economic). It does nothing for people ‘waiting to be ill’ – the idea (returned to later) that given the environmental, economic and social conditions some people live their lives within, it is not a question of, ‘Will they get ill?’ but, ‘When?’ It can also be argued that the pathogenic model assumes there will always be an adequate supply of carers to meet the demands of those who need the care. Albee argues: ‘one to one intervention is hopeless … it’s humane, it’s kind but it’s hopeless … because of the unbridgeable gap between the large numbers in need and the small numbers of helpers’. So these problems with the pathogenic view make it untenable to define ‘mental health’ as the absence of ‘mental illness’. Maybe the field of ‘mental illness’ has enough unresolved problems to make it an unacceptable starting point for a useful account of mental health.

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