Why Mental Health Is Not the Same for Everyone

We are often told that mental health matters. A person ought to go to a psychotherapist, or to a psychiatrist, in order to improve her mental health. If a career or family choice is bad for someone’s mental health, then she ought not to make it. These are modern platitudes, and they guide our thinking about psychotherapy and psychiatry—the ‘mental health professions’—and about life more generally. Yet we are not always given an answer to a natural question: what exactly is mental health?

I became interested in this question in my first full-time job as a psychotherapist, in a Boston clinic working with adults with what is sometimes called ‘serious mental illness.’ A variety of people came into the clinic. We were affiliated with a prestigious Boston hospital, and were also located directly below a city shelter for the unhoused, so people came to us from the hospital, or from the shelter, or from some other route. Our clients were mostly men, of a fairly diverse range of ages and racial and ethnic identities. It was, in short, a somewhat typical city clinic for the treatment of serious mental illness. ‘Serious mental illness’ is something of a euphemism, or a catch-all term for individuals whose psychiatric conditions have an especially profound effect on their day-to-day lives. In the case of the clinic where I worked, this primarily meant that the clients I worked with had a diagnosis of schizophrenia.

That somewhat generic description of the people I worked with fails to capture the endless variety that I witnessed in the psychological lives of my clients. Some were remarkably content and involved in meaningful work and friendships—though few had paid employment and even fewer had long-term romantic relationships. Others were in one way or another discontent. This was sometimes due to symptoms of psychotic disorders such as persistent hallucinations or delusions, but just as often due to life problems such as difficulties with housing or insurance. Some were religiously observant and others were atheists. Some seemed to look forward to psychotherapy and engaged in it wholeheartedly, while others showed up begrudgingly if at all. In short, they were a varied group of people, just as any random assemblage of people would tend to be.

Consider one of the people I worked with, Greg. (To preserve privacy, Greg is a kind of fictional construction, with a made-up name and a mix of different properties of clients.) Greg lived, like many of the people I saw, in the shelter immediately above the clinic. He had significant delusions of being observed and monitored, which led to persistent conflicts with shelter staff and roommates. At the same time, his mood was generally upbeat, he read widely, and he was a pillar of his local church. Our sessions largely consisted of him reflecting on the various things in his life he was grateful for, as well as the things he mourned (he had a daughter whom he had not seen for years). He reported little stress or anxiety. Greg had many challenges in his daily life, but his attitude towards them was generally one of forbearance.

Return now to the question of mental health. Did Greg have good mental health? I think he did. He was at home in his own mind, and seemed to find a measure of solace and indeed pleasure in his mental life. The same is true of many, though hardly all, of the people I saw. It is hard to be certain of anyone else’s mental health, but my best guess was that there was a spectrum here. Some of the people I saw, like Greg, seemed to have excellent mental health—indeed some seemed to have better mental health than I did. For others, their mental health seemed to be uneven, or a work in progress. And still others seemed to have poor mental health: they were out of tune with their own minds, and found that their psychologies were very different from what they wanted them to be. Again, none of this is remarkable: a group of people diagnosed with a psychotic disorder can be expected to vary along many dimensions, and mental health is one of these.

But I want to suggest that these simple observations pose a challenge to standard ways of thinking of mental health. And that, I think, gives us a good reason to reject these ways of thinking, and to consider what an alternative might look like.

Consider one standard theory of mental health, which holds that mental health is simply the absence of mental disorder. We can call this the negative theory of mental health, since it defines mental health in terms of what it is not. On this theory, the people I was working with, almost by definition, did not have mental health. All of these people had a diagnosis of some mental disorder, and often a diagnosis of schizophrenia. Therefore, almost by definition, these individuals cannot have mental health. Since the negative view yields the implausible consequence that none of these individuals had mental health—despite the intuitive evidence that some of them clearly did—we should reject the negative view.

There are other reasons to reject the negative view as well. Many of us know in our own lives people who do not have a mental health disorder but nonetheless do not have mental health either. Consider someone who is constantly frustrated by work, resentful of her friends, and generally discontent. Such a person, I think, may not have mental health, and certainly not to the degree that someone like Greg had mental health. So just as the presence of a psychiatric diagnosis is no obstacle to mental health, so is the absence of such a diagnosis no guarantee of it. So we should reject the negative view and its identification of mental health with the absence of mental disorder.

In recent decades, many researchers have also found this negative view of mental health inadequate. They have therefore proposed a positive view of mental health, on which mental health is defined not in terms of what it is not but rather in terms of certain achievements and capabilities of the mentally healthy person. Thus the World Health Organization defines mental health as follows: mental health is a state of mental well‐being that enables people to cope with the stresses of life, realize their abilities, learn well and work well, and contribute to their community. On this definition, it is possible for someone to have a diagnosed mental health disorder and to have mental health, so long as she realizes certain positive goods in her life.

But here too, I think, the proposed definition of mental health is incompatible with some basic observations about people such as Greg. While there are many positive aspects to Greg’s life, he is not always able to realize his abilities, or for that matter to learn well or to work well. He is strongly involved in his religious community, but he is not able to ‘contribute to his community’ as that term is normally understood: he does not work or pay taxes, for example. This is not, I think because he does not have a state of mental well-being—he does—but rather because he does not fulfill those functions that the World Health Organization takes to be constitutive of mental health. This is not because of any lack of mental well-being, but rather because his mind is mismatched in a certain way with the kind of mind that society tends to expect or demand.

The positive definition of mental health, then, is too demanding, or demanding in the wrong sort of way. It counts as mentally healthy only those people who have mental well-being and whose mental well-being enables certain sorts of goods or functions. But it may be that, due to external circumstances, a person’s mental well-being does not enable him to make certain kinds of social contributions. Indeed, this is the default situation for many people with a diagnosis of schizophrenia.

These observations should lead us to reject both the negative definition of mental health, on which mental health is the absence of disorder, on the one hand, and the positive definition of mental health, on which mental health involves a certain kind of positive functioning, on the other. But if mental health is neither the absence of something nor its presence, then what is it?

At this point it is natural to be a skeptic about mental health. Maybe there is really no such thing as mental health. Maybe the phrase ‘mental health’ is designed to place certain kinds of normative expectations or demands on people whose minds do not fit certain expectations about what a person’s mind is supposed to be like. If this is right, then the answer to our puzzle is not to better understand our talk of ‘mental health,’ but to do away with it altogether.

I have some sympathy with this skeptical attitude, and it is true that the language of ‘mental health,’ especially when coupled with the positive or negative definitions sketched above, has been used to impose unreasonable demands on the forms that human psychology may take. Nonetheless, I think there is also something right in the thought that mental health is something valuable to pursue, and that some people have it to a greater degree than others. I therefore think we should seek out a better account of mental health, if one is possible, one that genuinely captures the variety of the human mind, and which is fitting for people whatever their psychiatric diagnosis.

The starting place for an account of mental health is a passing remark I made above.  I said that people I worked with who seemed to have poor mental health had psychologies very unlike what they wanted them to be. In contrast, someone such as Greg seemed to be in some sense at peace with his mind, to accept its idiosyncratic challenges as well as its distinctive strengths. I want to suggest that this difference is a key to the idea of mental health, and that mental health is in a certain sense a matter of having the mind one wants, while having poor mental health is a matter of not liking or valuing the mind one has.

To approach this idea, consider the idea of having a good life. What is it to have a good life? I think there is no single answer to this question. There are many different kinds of professional, personal, and spiritual trajectories that can make for a good life. For some people, a good life is one devoted to work. For others, a good life consists largely of travel and excitement. Neither one of these views, I think, is right or wrong in itself. Rather, the good life is a matter of perspective. If you have all the goods and accomplish all the goals that you yourself take to constitute the good life, then you have a good life. If your life falls short of your own standards for a good life, then perhaps your life is not a good one. Having a good life is, at first pass, a matter of having the kind of life one wants.

We should see having a good mind is a lot like this. One person might want a mind that is a place of tranquility and ease. Another might want a mind that is full of tumult and excitement. Neither one is right or wrong. They just want different things for their minds. And what we want from our mind might change over time. A person with a highly variable mood might value and indeed embrace that aspect of her mind. Another person might initially dislike this aspect of her mood, but come to accept it over time. Still another one persistently dislikes her mood instability, and takes whatever measures she can to change it. Again, I think none of these people is right or wrong. Each of them wants to have a mind that is ‘good,’ but their perspectives on what is good vary, and they accordingly take different measures in changing, or coming to terms with, their own minds.

This is the right model, I think, for thinking about mental health. There is such a thing as mental health, but it is not an objective good, one that is the same for everyone. Rather, it is a subjective good, one that depends on a person’s own standards. It is like having a good life, or for that matter a good relationship or a good job. What counts as ‘good’ will depend on what the person herself wants, and different people want different things. In the same way, mental health depends on what a person wants for herself, and different people want different things for their minds.

This is a conception of health that leaves space for medical and other clinical interventions, but a very different kind of space from what is suggested by more objective conceptions of mental health. If we thought of mental health as something relatively objective, and we thought we had good evidence on what did or did not promote that supposedly objective good, then we might promote certain medical interventions as ones that promoted mental health. Indeed, this is how many pharmaceutical interventions are currently marketed. Once we think of mental health as something more subjective, medical interventions still can be of value, but their relationship to mental health is considerably more complex.

Consider, for example, a mood stabilizing medication such as lithium. Does this promote mental health? It depends. There is first of all the empirical question of whether a mood stabilizing medication in fact promotes stability of mood in a given population. But even if this empirical question were settled, it is a further question whether mood stability is an element of mental health. And, as suggested above, this will depend ultimately on the attitudes of the person in question. For a person with a certain set of desires for his own mind, a mood stabilizer may indeed promote mental health. But for another person—whose symptomology is the same but whose preferences or values are different—it may not. Even if we know all the data about the effects of a given medication (which often we do not), we still cannot say with any certainty whether that medication is good for mental health, because mental health is so variable, and so personal, a good.

The same applies to all the other interventions that make for mental health. Is psychotherapy good for mental health? Is exercise? What about meditation? The answer to each of these questions will depend irreducibly on the desires of the person in question. The subjective nature of mental health is I think especially important to emphasize in the context of psychiatry, where objective conceptions have tended to predominate. But it applies, on the present picture, across the board.

If this is right, then mental health does matter, but the implications of this fact for policy and clinical practice are complex. In particular, the promotion of mental health should not lead us to insist on generic interventions of any kind, even when these are underwritten by medical research or claimed to be ‘evidence-based.’ On the contrary, a focus on mental health should lead us precisely to insist on the irreducible subjectivity of the psychological, and to recognize that what is good for a person’s mind will depend ultimately on what kind of mind that person takes to be good.