Problems in the definitions of positive mental health
Authors: HASSE KARLSSON
Journal: World Psychiatry (2012)

I would like to congratulate George Vaillant for his balanced presentation and thoughtful discussion of seven main models of positive mental health. Although the paper has many merits, it also evokes several questions. Due to restricted space, I will just focus on a couple of them. First, I do not agree with Vaillant's statement that the limits of mental illness are relatively clear. I think that one of the main problems in modern psychiatry is the unclearness of diagnostic boundaries. As just one example, we recently showed that changing the threshold for only one question in a diagnostic interview resulted in major changes in the prevalence rates of major depressive episode 1. The use of the threshold “depressed mood all day” yielded a prevalence of 4.7%, while using the thresholds of “depressed mood most time of the day” or “at least half of the day” yielded prevalence rates of 9.2% and 11.9%, respectively. This same problem of unclear boundaries applies of course also to the question of positive mental health. The difficulty of defining positive mental health is exemplified by the obvious shortcomings of many of the definitions. In these definitions, functioning above normal, the presence of human strengths, positive emotions and subjective well-being are listed as criteria. However, if the basic idea is that positive mental health is more than just the absence of mental illness, it is problematic to say that these features are the core of positive mental health, because the lack of them has a high correlation with mental illness. From a Nordic perspective, especially the concept of “spirituality” as one component of positive mental health appears odd. The Nordic countries are probably more secular than most other countries in the world. For a Finnish scholar like me, using words such as “faith” and “spirituality” in the context of positive mental health sounds very strange. The definition of spirituality has changed over the years 2. If “spirituality” here means religiosity, I think it is wrong to link positive mental health to an ideology of any kind. This could imply that people without religious tendencies cannot be as mentally healthy as “spiritual” people. As far as I know, there are no studies showing that agnostic or atheist people have poorer mental health than “spiritual” people. On the other hand, if a broader definition of spirituality is taken, there are indeed some studies showing that spirituality is associated with mental health. But here the problem is that modern measures of “spirituality” actually measure such things as sense of purpose and meaning in life, social connectedness, optimism, harmony, peacefulness and general well-being 2,3. The tautology is obvious, because patients suffering from psychiatric illnesses usually do not at the time of illness exhibit these features. Thus, it is not surprising that these measures are positively related to mental health. The definitions of maturity and socio-emotional intelligence are to my mind less problematic, but their shortcoming is that they are restricted to the psychological sphere. If we assume that such characteristics as capacity for love, morality, generativity, conflict resolution and negotiation are some of the core features of positive mental health, we should perhaps include in the definition the evidence that these abilities are implemented in real life. Then we would have to define positive mental health in terms, for instance, of actions taken towards a society that is more equal and less competitive and exploitative than most of current societies are. My last point is that physical health is ultimately defined in biological terms. If the roots of human mind are in the brain, should not the ultimate definition of positive mental health rely on optimal brain functioning? There are some reflections on this in Vaillant's article when he describes the models of positive emotions and socio-emotional intelligence. Although I am sure that neurobiology will in the future contribute importantly to this discussion, I do not, however, believe that one day we will have an unambiguous neurobiological description of optimal brain function as a basis of positive mental health. In my mind, the first reason for this is that the “mental” exhibits emergent properties in relation to brain functions (see 4). The other reason is that the definitions are and should be to some degree context dependent. Positive mental health is not only a property of a certain individual, but is heavily influenced by social phenomena 5.