Toward a new definition of mental health

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. Aware of the fact that differences across countries in values, cultures and social background may hinder the achievement of a general consensus on the concept of mental health, we aimed at elaborating an inclusive definition, avoiding as much as possible restrictive and culture-bound statements. The concept that mental health is not merely the absence of mental illness 1, 8 was unanimously endorsed, while the equivalence between mental health and well-being/functioning was not, and a definition leaving room for a variety of emotional states and for “imperfect functioning” was drafted. The proposed definition is reported herewith: Mental health is a dynamic state of internal equilibrium which enables individuals to use their abilities in harmony with universal values of society. Basic cognitive and social skills; ability to recognize, express and modulate one's own emotions, as well as empathize with others; flexibility and ability to cope with adverse life events and function in social roles; and harmonious relationship between body and mind represent important components of mental health which contribute, to varying degrees, to the state of internal equilibrium. The addition of a note explaining what is meant in the definition by the expression “universal values” is deemed necessary, in the light of the misleading use of this expression in certain political and social circumstances. The values we are referring to are: respect and care for oneself and other living beings; recognition of connectedness between people; respect for the environment; respect for one's own and others' freedom. The concept of “dynamic state of internal equilibrium” is meant to reflect the fact that different life epochs require changes in the achieved equilibrium: adolescent crises, marriage, becoming a parent or retirement are good examples of life epochs requiring an active search for a new mental equilibrium. This concept also incorporates and acknowledges the reality that mentally healthy people may experience appropriate human emotions – including for example fear, anger, sadness and grief – whilst at the same time possessing sufficient resilience to timeously restore the dynamic state of internal equilibrium. All components proposed in the definition represent important but not mandatory aspects of mental health; as a matter of fact, they may contribute to a varying degree to the state of equilibrium, so that fully developed functions may offset an impairment in another aspect of mental functioning. For instance, a very empathetic person, highly interested in mutual sharing, may compensate for a moderate degree of cognitive impairment, and still find a satisfactory equilibrium and pursue her/his life goals. The main reasons underlying the choice of the components included in the definition are provided hereafter. Basic cognitive and social skills are regarded as an important component of mental health in the light of their impact on all aspects of everyday life 12-15. Cognitive skills include the ability to pay attention, remember and organize information, solve problems, and make decisions; social skills involve the ability to use one's own repertoire of verbal/non-verbal abilities to communicate and interact with others. All these abilities are interdependent and allow people to function in their environment. Reference to the “basic” level of these abilities is meant to clarify that mild degrees of impairment are compatible with mental health, while moderate to severe degrees of impairment, especially if not balanced by other aspects, may require support by other members of the society and a number of social incentives, such as facilitated job opportunities, financial benefits or ad hoc training programs. Emotional regulation, i.e. the ability to recognize, express and modulate one's own emotions, is also regarded as an important component of mental health 16. It has been proposed as a mediator of stress adjustment 17, 18, and a link between inappropriate or ineffective emotional regulation and depression has been found in clinical and neuroimaging studies 19-22. A variety of modulated emotional response options, that can be flexibly employed, contribute to an individual's mental health, and alexithymia (i.e., an inability to identify and express one's own emotions) is a risk factor for mental and physical disorders 23, 24. Empathy, i.e., the ability to experience and understand what others feel without confusion between oneself and others, enables individuals to communicate and interact in effective ways and to predict actions, intentions, and feelings of others 25. The absence of empathy is not only a risk factor for violence and a feature of antisocial personality disorder, but also impairs social interactions at all levels. Flexibility and ability to cope with adverse events are also deemed important to mental health maintenance. Flexibility refers to the ability to revise a course of action in the face of unpredicted difficulties or obstacles, change one's own ideas in the light of new evidence, and adapt to changes that different life epochs or contingent situations may require. Lack of flexibility may result in great distress for a person undergoing sudden and/or important life changes, and is an important aspect of several psychiatric disorders, such as obsessive personality or delusional disorder 26. The basic ability to function in social roles and to participate in meaningful social interactions is an important aspect of mental health and particularly contributes to resilience against distress; however, social exclusion and stigmatization often impair social participation, so any definition of mental health alluding to this aspect has to avoid “blaming the victim” and to carefully analyze social patterns of stigmatization, discrimination and exclusion that impair participation 27. The inclusion of a harmonious relationship between body and mind is based on the concept that mind, brain, organism and environment are heavily interconnected, and the overall experience of being in the world cannot be separated from the way in which one's body feels in its environment 28. Disturbances of this interaction may result in psychotic experiences, eating disorders, self-harm, body dysmorphic disorder or poor physical health. The definition of mental health drafted in this paper is aimed to overcome perspectives based on ideal norms or hedonic and eudaimonic theoretical traditions, in favor of an inclusive approach, as free as possible of restrictive and culture-bound statements, and as close as possible to human life experience, which is sometimes joyful, and at other times sad or disgusting or frightening; sometimes satisfactory, and at other times challenging or unsatisfactory. The proposed definition is also compatible with the recovery movement perspective, in which recovery after an illness is seen as a process aimed to attain a fulfilled and valued life by building on the functions spared by the illness, in spite of the fact that other functions have been impaired 29. This paper was drafted as part of the activities of the Committee on Ethical Issues of the European Psychiatric Association.