Home

 

Read this month’s featured article from our monthly newsletter, Health Promotion Connection/ Conexiones para la Promoción de la Salud/Connexion pour la Promotion de la Santé- Enjoy!

The battle of Mental Health Theories and Implications for Research and Practice

Written by Angelina Wilson

Introduction

Mental health theorists have not been able to come to a consensus as to what the definition of mental health or positive mental health should entail. Different authors with different paradigms and ideologies have suggested varying definitions for mental health. Major contentions exist between the view of mental health as the absence of disease and the consideration of mental health in its positive sense. Other authors fall along this continuum of mental health as the absence of disease and, mental health as a state well-being whereby the individual is able to adequately contribute to his or her community. The definition of mental health is important to consider as what definition is adopted has implications for research and practice. Current trends in research lean towards a disease orientation of mental health. Most studies focus on disease and its prevention; few studies discuss or highlight mental health promotion. Mental health promotion is only possible if mental health is conceived in its positive sense. The proceeding paragraphs will be focused on highlighting some of the competing mental health paradigms and the implications for research and practice. Although there are several definitions, theories and paradigms, the author in this article will highlight four of the multiple prominent viewpoints followed by a discussion of their implication for practice.

WHO definition of mental health

The World Health Organization (WHO) defines mental health “as a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively, and is able to make a contribution to his or her community” (1). This definition has two major components. The first is concerned with individual well-being, whilst the second component is concerned with the individual’s well-being in relation to his or her community. This conceptualisation of mental health is focused on the positive aspects of health with important pointers such as realising an individual’s own abilities, productivity and community contribution. One important question one would want to ask is why realising one’s potential is important for mental health. A slight derivation from the positive component of mental health is the ability to cope with normal stresses of life. “Stress” in itself has a negative connotation but the ability to cope provides a positive ring to it. This definition does not necessarily include the absence of mental illness but covers this notion. This is because an individual may not be capable of positively contributing to their community and working productively given the presence of mental illness.

It is important to realise that given the relationship between physical health and mental health, such a positive conception of mental health is necessary (2, 3). This definition of mental health has important implications for research and practice which will be discussed shortly.

Mental health as flourishing

Another author that advocates for the conceptualisation of mental health in a positive sense is Corey Keyes (2003, 2005, 2012). He defines mental health as a state of flourishing or optimal functioning. This aspect of functioning resonates with the WHO definition of mental health. Functioning on both the individual and communal level has therefore been identified as central for mental health. Keyes has done extensive research on the relationship between mental health and physical health, and also provided detailed discussion on why mental health cannot be conceived of as the absence of disease through his use of cross-sectional and longitudinal research (see Keyes 2003, 2005, 2012 for detailed analysis and discussion). Keyes in his analysis suggested that mental health has a continuum consisting of mental health as flourishing, moderate mental health, and mental health as languishing.

According to Keyes, mental health as languishing was defined as the worst state of mental health and was associated with the greater likelihood of mental illness, as compared to moderate mental health and mental health as flourishing. Studies have shown that an individual’s state of mental health is a good predictor of the occurrence of mental illness in the future (4). For this reason, Keyes advocates that resources be invested in mental health promotion and not just the cure and prevention of mental illness. See Keyes’ analysis (5) for more details on the measurement and dimensions of mental health

Salutogenic and fortigenic orientation of mental health

The salutogenic and fortigenic orientations are not frameworks peculiar to mental health. As a matter of fact, salutogenesis has been proposed as a viable theory for health promotion (6). Antonovsky suggested that salutogenesis and fortigenesis can be regarded as plausible mental health frameworks (6). The main thrust of salutogenesis is a focus on health and resources for well-being rather than diseases (6, 7). Fortigenesis, a closely related term is focused on the study of strengths or human capabilities (8). These orientations seemed to follow in the footsteps of the earlier frameworks (WHO’s definition and mental health as flourishing) but fall short in some areas. For example, Antonovsky did not intend to explain well-being in his theory of salutogenesis (9). His intention was to explain how people move from the disease-end of his health/disease continuum to the health-end. He was interested in the maintenance of health and order in the midst of disease and chaos. This view shares some similarity with pathogenic ideas and it does not adequately explain health, and in this case, mental health in its entirety.

Disease or pathological orientation of mental health

The last orientation to mental health that will be discussed in this article is the disease orientation. The pathogenic orientation is mainly concerned with defining mental health as the absence of disease. This is the predominant view and it is reflected in policy, research and practice within the mental health field. There is a need for a reconceptualization given that it has been shown that optimal mental health does not stem from the absence of disease. In  addition, the associated human suffering has created the need to change focus from not just cure and prevention but to promotion.

Implications for research and practice

The definition of mental health that is adopted has implications for practice and research. One implication for research is that it will determine what is placed on the policy, funding, and research agenda. The definition adopted will determine what will be regarded as true mental health research.

Secondly, the current trend in existing mental health programs reveal a preoccupation with curative services. Few programs are planned with the focus on improving the mental health in a positive sense (10). An example of such trend is the implementation of the Mental Health Act in Ghana, which is focused primarily on the inclusion of mental health professionals (clinical psychologists) in primary health care services (11). In this act, no mention was made of public mental health professionals whose dealings would have included incorporating mental health promotion (positive mental health) into mental health reform programs.

Acknowledgement

Some of the ideas presented here were adapted from the unpublished PhD thesis of Angelina Wilson, under the auspices of Stellenbosch University.

References
1. WHO | What is mental health? [Internet]. [cited 2012 Feb 15]. Available from: http://www.who.int/features/qa/62/en/index.html
2. Prince M, Patel V, Saxena S, Maj M, Maselko J, Phillips MR, et al. No health without mental health. The Lancet. 2007;370(9590):859–77.
3. Keyes CLMS. To Flourish or Not: Positive Mental Health and All-Cause Mortality. Am J Public Health. 2012 Nov;102(11):2164.
4. Keyes CLM. Mental illness and/or mental health? Investigating axioms of the complete state model of health. J Consult Clin Psychol. 2005 Jun;73(3):539–48.
5. Keyes CLM. Complete mental health. An agenda for the 21st century. In: Keyes CLM, Haidt J, editors. Flourishing Posit Psychol Life Well Lived Lived. Washington DC: American Psychological Association; 2003. p. 290–312.
6. Antonovsky A. The salutogenic model as a theory to guide health promotion. Health Promot Int. 1996 Mar 1;11(1):11–8.
7. Antonovsky A. Unravelling the mystery of health. How people manage stress and stay well. San Francisco: Jossey-Bass; 1987.
8. Strumpfer DJW. The Strengths Perspective: Fortigenesis in Adult Life. Soc Indic Res. 2006 May;77(1):11–36.
9. Mittelmark MB, Bull T. The salutogenic model of health in health promotion research. Glob Health Promot. 2013 Jun;20(2):30–8.
10. Patel V. Mental health in low- and middle-income countries. Br Med Bull. 2007;81-82:81–96.
11. Doku V, Ofori-Atta A, Akpalu B, Read U, Osei A, Ae-Ngibise K. A situational analysis of the mental health system in Ghana. Phase 1: Country Report. Cape Town, South Africa; 2008.

Published: November-December, 2013, HPC

This site is protected by Comment SPAM Wiper.