The need for a consensual definition of mental health
Authors: Silvana Galderisi
Journal: World Psychiatry (2024)

The first conceptualization of mental health can be traced back to 1948, when J.C. Flugel, Chairman of the First International Congress of Mental Health, proposed to define it as "a condition which permits the optimal development, physical, intellectual and emotional, of the individual, so far as this is compatible with that of other individuals". In 1950, at the second session of the Expert Committee on Mental Health of the World Health Organization (WHO), mental health was defined as "a condition subject to fluctuations due to biological and social factors, which enables the individual to achieve a satisfactory synthesis of his own potentially conflicting, instinctive drives; to form and maintain harmonious relations with others; and to participate in constructive changes in his social and physical environment". Neither definition included the concept of well-being (and neither was very influential). In 2004, the WHO provided a definition of 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"1. This definition has been highly influential, and several subsequent definitions of mental health have been organized within the same framework, in which a key role is assigned to the person's well-being (the "hedonic" perspective) and his/her self-actualization (the "eudaimonic" perspective). According to the American Psychological Association, for instance, mental health is "a state of mind characterized by emotional well-being, good behavioral adjustment, relative freedom from anxiety and disabling symptoms, and a capacity to establish constructive relationships and cope with the ordinary demands and stresses of life"2. For the Public Health Agency of Canada, mental health is "the capacity of each and all of us to feel, think, and act in ways that enhance our ability to enjoy life and deal with the challenges we face. It is a positive sense of emotional and spiritual well-being that respects the importance of culture, equity, social justice, interconnections and personal dignity"3. This emphasis on positive feelings and self-actualization in the definition of mental health has been a matter of debate. First, this view is difficult to reconcile with the many challenging life situations in which well-being may even be regarded as unhealthy (indeed, people in good mental health are often sad, angry or unhappy; and it would be problematic to regard as unhealthy a person feeling desperate after being fired from his/her job in a situation in which occupational opportunities are scarce). Second, this view would exclude from the definition of mental health the many adolescents who struggle to find their place in the community, the many elderly people who are not able anymore to work productively and fruitfully, and the many migrants and other members of minority groups who are marginalized and therefore unable to make a contribution to their community. To overcome the above emphasis on the hedonic and eudaimonic perspectives, a group of experts proposed in 2015 a new definition of mental health as "a dynamic state of internal equilibrium", to which several components contribute in varying degrees, including "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"4. This definition allows for the possibility of experiencing crises (e.g., adolescence, retirement) which certainly do not generate a state of well-being, but may lead to a new equilibrium, with a higher level of complexity. Moreover, the definition acknowledges the fact that mentally healthy people may experience negative emotions such as fear, anger, sadness or grief, while at the same time possessing sufficient resilience to timeously restore their state of internal equilibrium. In 2022, the WHO's World Mental Health Report redefined mental health as "a state of mental well-being that enables people to cope with the stresses of life, to realize their abilities, to learn well and work well, and to contribute to their communities"5. This definition confirms the emphasis on well-being (apart from adding the specifier "mental") and seems to soften the emphasis on productivity of the previous definition by replacing the expression "work productively and fruitfully" with "learn well and work well". Furthermore, when describing "the intrinsic and instrumental value" of mental health, the report mentions several aspects of the alternative definition proposed in 20154, including cognitive skills, understanding and managing emotions, and empathizing with others. However, the statement that mental health is "a state of mental well-being" remains a matter of concern. In fact, although a comprehensive review has reported as many as 191 components of the well-being construct6, the concept is still conceived by many within a hedonic perspective. For instance, 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"2. Thus, there is not a consensus at the moment about the definition of mental health, in spite of the increasing popularity of this concept and the high frequency with which it is used in the literature, in public health and clinical contexts, and in policy documents. Sometimes the fuzziness of a concept may favor its success, but this is certainly not what all the stakeholders involved in the field wish to pursue. It seems to be agreed that mental health is not just the mere absence of mental illness, but the relationship of the concept with that of mental well-being remains unclear or equivocal; the requirement for productivity and/or contribution to the community may lead to regard entire sections of the population as mentally unhealthy, thus "blaming the victims" of stigmatization, discrimination and exclusion; and the acknowledgement that healthy human life experience may be sometimes joyful and satisfactory, but at other times sad, disgusting or frightening seems to be lacking in several definitions. On the other hand, the importance of components such as basic cognitive skills (i.e., paying attention to a task, remembering past and recent information, being able to solve simple problems and make decisions); the basic ability to function in social roles and to entertain social relationships; emotional regulation (i.e., being able to recognize, express and modulate one's own emotions); flexibility (i.e., being able to modify one's own goals and plans in the light of new events or unpredicted difficulties, and adapt to changes required by different life periods or contingent situations); and a harmonious relationship between body and mind (since the quality of this interaction is instrumental to the overall experience of being in the world7) does not seem to be sufficiently recognized. Future developments in the definition of mental health would benefit from a more systematic and substantial contribution of experts by experience, as well as from a greater conceptual sophistication.