Keyes suggests that we should think about mental health in the way we
think of mental illness: as having particular symptoms which can be measured or
assessed. A key further idea is that mental health and its opposite (flourishing
versus languishing) may turn out not to have a simple relation to mental
illness and its opposite. In fact, he argues, those who are mentally ill may
not be languishing as much as some of those who are not mentally ill at all. The data he
presents suggest that this is the case.
This possibility in part rests on the fact that he takes only four
forms of mental illness into account (‘(a) MDE, (b) generalized
anxiety disorder, (c) panic disorder, and (d) alcohol dependence during the
past 12 months.’ [ibid: 542]’]. One way in
which this might not continue to be the case is if DSM V took the negations of
his account of flourishing to be a new form of mental illness. Since that seems
to be entirely plausible (given the history of the proliferation of mental
illness diagnosis), or, rather, given that it seems merely contingent that that is not the case now, I am not sure how important that result is.
Although most of the paper is concerned not with a dimensional approach (which also, eg., takes account of days worked versus days sick to measure flourishing versus languishing) there is also a sketch of a criteriological approach which, I think, makes the underlying issues of understanding mental health or well-being or flourishing (pictured, I think) a little clearer. It is this:
Categorical Diagnosis of Mental Health (i.e., Flourishing)
Diagnostic criteria
Hedonia: requires high level on at least one symptom
scale (Symptoms 1 or 2)
Positive functioning: requires high level
on six or more symptom scales (Symptoms 3–13)
Symptom description
2. Feels happy or
satisfied with life overall or domains of life (avowed happiness or avowed
life satisfaction)a Positive functioning: requires high level on six
or more symptom scales (Symptoms 3–13)
3. Holds positive
attitudes toward oneself and past life and concedes and accepts varied aspects
of self (self-acceptance)
4. Has positive
attitude toward others while acknowledging and accepting people’s differences and
complexity (social acceptance)
5. Shows insight
into own potential, sense of development, and open to new and challenging experiences
( personal growth)
6. Believes that
people, social groups, and society have potential and can evolve or grow
positively (social actualization)
7. Holds goals and
beliefs that affirm sense of direction in life and feels that life has a
purpose and meaning ( purpose in life)
8. Feels that one’s
life is useful to society and the output of his or her own activities are
valued by or valuable to others (social contribution)
9. Exhibits
capability to manage complex environment, and can choose or manage and mold environments
to suit needs (environmental mastery)
10. Interested in
society or social life; feels society and culture are intelligible, somewhat
logical, predictable, and meaningful (social coherence)
11. Exhibits
self-direction that is often guided by his or her own socially accepted and
conventional internal standards and resists unsavory social pressures (autonomy)
12. Has warm,
satisfying, trusting personal relationships and is capable of empathy and
intimacy ( positive relations with others)
13. Has a sense of
belonging to a community and derives comfort and support from community (social
integration)
One worry I have
concerns an ambiguity in the idea of flourishing. In the context of a
connection to mental health, it might mean having the capacity to flourish as we normally think of that. Or it might mean
enjoying that normal notion. Point 12 has both aspects of this. The second
aspect is reflected in the idea of that someone ‘has warm, satisfying, trusting personal relationships’ whilst the
first is reflected in ‘is capable of
empathy and intimacy’. Someone whose partner has left them is probably not
flourishing in one sense. But they may have the capacity for such relationships
and so have mental health and hence flourish in the more technical sense.
In discussion,
colleagues suggested contexts in which failing to meet a criterion was still
consistent with mental health where mental health=well-being=flourishing. So,
for example, Algerian revolutionaries may not have felt that ‘society and culture
are intelligible, somewhat logical, predictable, and meaningful’ but they still
had good mental health. There were other examples. This suggests two nested
dilemmas.
First: do such
examples (or counter-examples) work by presupposing 1--(n-1) and (n+1)—13 of
the criteria to put criterion n under pressure? Or do they rely on an
antecedent grasp of mental health or flourishing, which is not reflected in
these criteria, to put all under threat at the same time? Whilst the first seems readily
possible, the second may also be the case. The criteria do not seem necessarily
true and so in a particular extreme context there seems to be the standing
possibility of flourishing which fails to fit these culturally expected
norms.
Second: this
suggests a more general worry. Do we have a substantial grasp of mental health=well-being=flourishing
at all? We might trade across those equivalences but that seems merely
truistic. But if not, any substantial account seems likely to be false. The
worry is that any account of mental-health=well-being=flourishing is either
false or vacuous.
Keyes, C.L.M.
(2005) ‘Mental Illness and/or Mental Health? Investigating Axioms of the Complete
State Model of Health’ Journal of
Consulting and Clinical Psychology 73: 539–548
