Introduction
The definitions of health and disease have important social and financial implications, as people affected by disease have special rights (paid medical consults, paid medical leaves etc.) and as society shares responsibility with individuals in preventing disease and promoting health. The limits of these rights and responsibilities are first and foremost set by their respective definitions. In the field of mental health, such definitions are even more difficult to elaborate due to the multiple pathogenic models and significant cultural influence. Furthermore, the research in this field has made important progress in the last few years. It is therefore necessary to regularly review the literature on the subject and, if necessary, to revise these definitions.
Thus, the aim of this paper was to review the current knowledge on the currently used models for mental health.
The concept of mental health
Any discussion about mental health must start from the more general concept of health. It is defined by the World Health Organization (WHO) as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”(1). There are three aspects of this definition that need further attention: (1) the absence of clinical signs and symptoms does not warrant health, (2) the concept of “well-being”, and (3) the domains of application (physical, mental and social). All these aspects need to be properly conceptualized for this definition to be operational in the field of mental health. Therefore, current mental health models put them in the context of the theories they have been derived from. Thus, six mental health models are generally described in the literature: (1) mental health as above normal, (2) mental health as maturity, (3) mental health as positive or “spiritual” emotions, (4) mental health as socioemotional intelligence, (5) mental health as subjective well-being, and (6) mental health as resilience (2).
Mental health as above normal
When considering this model, the first concept that needs to be addressed is “normality”. It is usually defined using four criteria or norms: the statistical norm, the ideal norm, the functional norm and the cultural norm(3). The statistical norm posits that what falls between average and, usually, ± 2 standard deviations is normal (e.g., intelligence quotient – IQ). However, some deviations from this norm are not considered abnormal – e.g., IQs>130. The ideal norm posits that the ideal is normal, but “ideal” is greatly influenced by values. Therefore, one could encounter a different “normality” for different individuals. The functional norm posits that being functional is normal. Functionality is greatly influenced, however, by several factors. It is first and foremost influenced by age (see cognitive and psychosocial stages of development). Furthermore, a frontal lobe pathological process might reduce the IQ of an individual from more than 130 to 105. Such an individual would still be considered statistically normal. Thus, several authors consider normality as being able to function according to age and abilities(4). Finally, normality cannot be judged outside of the individual’s culture. However, cultural norms have varied greatly over time and there are numerous examples throughout history of cultural norms that came into conflict with the most basic human values that are generally accepted today. It is therefore necessary to keep track of content, context and consequences of a certain behavior, also, when judging whether it is normal or not.
At the other end of the spectrum lies mental disorder. It is defined by the Diagnostic and Statistical Manual of Mental Disorders, the fifth edition (DSM-5), as “a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning, usually associated with significant distress or disability in social, occupational, or other important activities”(5). DSM-5 also states that “an expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder” and that “socially deviant behavior (e.g., political, religious or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above”(5).
It is clear then that there is a significant gap between mental disorders and mental health (and health in general) – e.g., delinquent behavior that is not caused by a disfunction of the individual’s psychological, biological or developmental processes, or a situation that significantly influences the individual’s well-being, but does not result in mental disorder. Thus, reaching mental health needs more than proper management of mental disorders and, since mental health specialists’ aim is to promote mental health, they are supposed to cover these topics also.
In this context, the formulation “mental health as above normal” is precise, as populational statistics include persons with mental disorders and eliminating these persons from the samples would lead to a significant increase in the reference intervals for most mental health or psychiatric assessment instruments.
Mental health as maturity
The central nervous system is a dynamic and plastic system that continuously adapts to changes throughout the lifespan. Consequently, its functionality changes throughout the life. Nonetheless, maturity is a state in which the individual can manifest identity, intimacy, career consolidation, generativity and integrity. Identity basically means that the individual is ideologically, socially and economically independent. It depends on biological maturity, internalization and identification with models outside the individual’s original family and the proper resolution of childhood tasks and crises(2). Intimacy is reciprocal and selfless involvement in significant relationships(2) or, better yet, the ability of the individual to engage in close connections and concrete partnerships, and to develop the ethical competence to remain loyal to such engagements, even though this needs sacrifices and significant compromises(6). Intimacy, thus, needs self-disclosure, self-acceptance and acceptance of a significant other, and an ability to negotiate even central elements of identity. Of course, secure attachment is central to the individual’s ability to develop intimacy. Career consolidation is evaluated by using contentment, compensation, competence and engagement as criteria. Generativity is the preoccupation for the creation and guidance of new generations(6). Finally, integrity means accepting one’s only (unique) cycle of life, and accepting and defending one’s lifestyle, while being perfectly aware of the relativity of all lifestyles and one’s successes and failures (which are inherent in any human life)(6).
Mental health as positive or “spiritual” emotions
This model defines mental health as the experience of “positive” emotions that connect us to other people. Examples of such emotions are love, hope, joy, forgiveness, compassion, faith, awe, gratitude etc.(2) Other emotions that are positive in valence, like excitement, interest, contentment (happiness), humor and a sense of mastery, are omitted because they are taught not to play a significant role in interpersonal connections(2). This model also posits that, while negative emotions like fear, anger or sadness are essential for survival, they are linked to the self. In contrast, positive emotions can free the ego from the self(2). All things considered, spirituality and sociality allowed us to grow as a species.
Mental health as socioemotional intelligence
Socioemotional intelligence involves: correct and precise perception and monitorization of one’s emotions, the ability to modify or modulate one’s emotions so that they become adequate, the ability to reduce anxiety, hopelessness and sadness, recognizing and responding adequately to the emotions of others, the ability to negotiate close relationships with others, the ability to modulate and channel one’s emotions in such a way that they become sources of motivation for reaching one’s goals, the ability to delay gratification and to adequately direct impulses(2). It has been well proven that socioemotional intelligence correlates with school performance, empathy and the ability to adapt emotionally(2), which, in turn, have been proven to be protective factors against the development of mental and behavioral disorders.
Mental health as well-being
The concept of well-being has at least two accepted definitions, that are significantly different and lead to very different approaches to mental health promotion.
The dictionary of the American Psychological Association defines well-being as “a state of happiness and contentment, with low levels of distress, overall good physical and mental health and outlook, or good quality of life”(7). This definition has been rightfully dismissed by others as the experience of emotions with negative valence, resulting for example from the death of a loved one (e.g., a parent), cannot be avoided during one’s life and cannot be considered a priori a marker of mental illness(8). Furthermore, under the biopsychosocial model of disease, such a definition would make mental health professionals and society in a larger sense responsible for promoting happiness and contentment, although the experience of negative emotions cannot be avoided, and is considered essential for survival (as mentioned before, in the section on mental health as “positive” or “spiritual” emotions). Furthermore, under such a paradigm, individuals would eventually become less able to deal with stressors – i.e., more vulnerable, more at risk for developing mental and behavioral disorders. Thus, such a conceptualization of well-being cannot be accepted in the definition of mental health.
A more adequate approach would therefore be the one postulated by Diener, that considers well-being as “global judgments of life satisfaction” or “overall satisfaction with life”(9). Such a definition allows for the experience of negative emotions or events that are inherent to any human existence.
Mental health as resilience
The American Psychological Association defines resilience as “the process of adapting well in the face of adversity, trauma, tragedy, threats, or significant sources of stress – such as family and relationship problems, serious health problems, or workplace and financial stressors”(10).
The dictionary of the American Psychological Association states that resilience is “the process and outcome of successfully adapting to difficult or challenging life experiences, especially through mental, emotional and behavioral flexibility and adjustment to external and internal demands”(7). It also states that there are several factors that significantly influence resilience, namely “(a) the ways in which individuals view and engage with the world, (b) the availability and quality of social resources, and (c) specific coping strategies”(7).
The ways in which individuals view and engage with the world is mostly influenced by their beliefs. These beliefs play a fundamental role in the pathogenesis of mental and behavioral disorders, as they mitigate the effect of adversity on the individual(11). Mental health promotion therefore should aim to diminish irrational beliefs in all people, even though they do not suffer from mental and behavioral disorders. Such beliefs can be absolute requirements and needs, dramatizations, “I cannot stand this” type of attitudes, and disdain of self and others(11). Deriving on the aforementioned basic irrational beliefs, people can also show derived irrational beliefs, dysfunctional schemas or attitudes like overgeneralization, rushed conclusions, overemphasizing negative aspects, disdain of positive aspects, taking things personally, overemphasizing falsity, and perfectionism(11).
Social resources and social support can be both instrumental and emotional. Therefore, factors like physical distance should not pose a significant threat if people are encouraged to use both. However, functional interpersonal relationships need to be developed by individuals in order to have proper social support, and this requires socioemotional intelligence.
Several coping strategies that promote resilience have been demonstrated: optimism (i.e., a realistic belief in a favorable future); confronting fear (i.e., a confrontative coping style); social support (i.e., sought and accepted); choosing robust role models; orienting behavior on ethical principles and altruism; spirituality (including religiosity); cognitive and emotional flexibility (i.e., using coping mechanisms flexibly and accepting what cannot be changed); looking for sense and opportunity in the midst of adversity to be able to build a platform for growth; and, finally, accepting responsibility for one’s own well-being and active involvement in being physically and psychologically fit(12). Furthermore, several defense mechanisms have also been proven to promote resilience: humor, altruism, sublimation, suppression and anticipation(2).
The available data demonstrate that all these factors – and, therefore, resilience as a whole – can be trained(7,12).
Discussion
WHO defines mental health as “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”(13). This definition is not satisfactory in the opinion of many, not only because of the debate around the concept of well-being, but also because it lacks many of the elements described in the above-mentioned models.
An alternate definition has been proposed by Galderisi and collaborators, and it defines mental health as “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, the 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”(8). This alternate definition includes many more of the concepts included in the theoretical models of mental health, but still lacks a few.
A more systematic and operational approach to mental health would have to state that mental health is a state of well-being, defined as an overall satisfaction with life, in which the individuals can develop and function to their full potential. Under such a model, people would have to acquire several skills on three major levels: personal, interpersonal and general functioning. At a personal/individual level, individuals need to acquire basic cognitive skills: the ability to recognize, modulate and express their own emotions, a feeling of self-worth, self-value and competence, and the ability to forgive themselves. At an interpersonal level, individuals need to acquire the ability to be empathic: the ability to trust others and the ability to forgive others. On a general functioning level, individuals would have to acquire the ability to grow and mature: the ability to face stress and flexibly adapt to change and the ability to function in the major domains (i.e., familial, professional and social).
Conclusions
Current mental health definitions fail to cover all the theoretical knowledge on the factors that promote mental health and/or diminish the risk for mental and behavioral disorders. A revised definition of mental health would therefore be necessary, especially since the definition of mental health has a profound impact on mental health promotion policies.