what is mental health?

Notions like 'mental illness' and 'mental disorder' are sometimes defined negatively. That is to say that the presence of 'illness' or 'disorder' is often defined as the absence of 'health' or 'flourishing'. But what is this elusive notion of 'health' or 'flourishing'?

Axis V of the Diagnostic System is concerned with just this notion. According to the 'Global Assessment of Functioning' scale (GAF) mental illness is defined as being on a continuum with mental health as follows:

91-100 Superior functioning in a wide range of activities, life's problems never seem to get out of hand, is sought out by others because of his or her many positive qualities. No symptoms

81-90 Absent or minimal symptoms ( e.g., mild anxiety before an exam ), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns ( e.g., an occasional argument with family members )

71-80 If symptoms are present, they are transient and expectable reactions to psychosocial. stressors ( e.g., difficulty concentrating after family argument ); no more than slight impairment in social occupational, or school functioning ( e.g., temporarily falling behind in schoolwork ).

61-70 Some mild symptoms ( e.g., depressed mood and mild insomnia ) OR some difficulty in social occupational, or school functioning ( e.g., occasional truancy or theft within the household ), but generally functioning pretty well, has some meaningful interpersonal relationships.

51-60 Moderate symptoms ( e.g., flat affect and circumstantial speech, occasional panic attacks ) OR moderate difficulty in social, occupational, or school functioning ( e.g., few friends, conflicts with peers or co-workers ).

41-50 Severe symptoms ( e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting ) OR any serious impairment in social, occupational or school functioning ( e,g., no friends, unable to keep a job ).

31-40 Some impairment in reality testing or communication ( e.g., speech is at times illogical, obscure, or irrelevant ) OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood ( e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school ).

21-30 Behavior is considerably influenced by delusions or hallucinations OR serious impairment in communication or judgment ( e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation ) OR inability to function in almost all areas ( e.g., stays in bed all day, no job, home, or friends ).

11-20 Some danger of hurting self or others ( e .g., suicidal attempts without clear expectation of death; frequently violent; manic excitement ) OR occasionally fails to maintain minimal personal hygiene ( e.g., smears feces ) OR gross impairment in communication ( e.g., largely incoherent or mute ).

1-10 Persistent danger of severely hurting self or others ( e.g., recurrent violence ) OR persistent inability to maintain minimal personal hygiene OR serious suicidal act with clear expectation of death.

0 Inadequate information.

So, people: mild anxiety and an occasional argument with family members means that you are not functioning optimally. Says the American Psychiatric Association. Do people find the values implicit in this definition of human 'flourishing', 'health', or 'functioning' to be problematic?

I do.

I think that the description in the 91-100 category is something that I do not wish to aspire to (sounds mechanical and not emotionally responsive to me).

'The GAF Report decision tree is designed to guide clinicians through a methodical and comprehensive consideration of all aspects of a patients symptoms and functioning to determine a patients GAF rating in less than 3 minutes'.

'Less than 3 minutes'...

How much is the spread of western psychiatry and western psychiatric treatment to the third world a matter of colonalisation of values...

And how much is the spread of western psychiatry and western psychiatric treatment to the third world a matter of providing much needed treatment according to their values...

Difficult questions...

Are psychotic symptoms MALFUNCTIONAL becuase they are so in western culture (typically)?

Are psychotic symptoms DIF-FUNCTIONAL (JUST DIFFERENT) because they are so in some third world places?

Are psychotic symptoms SUPER-FUNCTIONAL (BETTER) because they are positively valued in some third world places?

Colonalisation of values...
Or value-neutral treatment for objectively debilitating conditions (that are debilitating whether they are recognised as such or not)...

Any thoughts?

> Do not include impairment in functioning due to physical or environmental limitations.

Hmm.. So if my parents pick arguments with me and I argue with them then does my having occasional arguments with them not show that I'm malfunctioning after all? It is just that my environment is limited?

If I get depressed in response to having lost my family in terrorist attacks then does my response count as being due to 'environmental limitations' again?

What if I meet criteria for borderline personality because of my invalidating childhood environment? Is that an environmental limitation? If I have a genetic predisposition that acts as part of that then does that count as a physical limitation?

How can this be used to make treatment decisions (in all seriousness)?

It was introduced in an attempt to justify removing homosexuality from the DSM (no harm is present). But is is of course absurd to say that the homosexual who lives in an intolerant society isn't harmed by their condition.

And it is absurd to attempt to distinguish facts that are internal to the person from facts that are external to the person (e.g., 'internal nature' from 'environmental limitations' and of course 'physical limitations' would count as both). We are inexorably tied together with our environment. %#@&#!, it would have been adaptive to have had a trigger startle response to loud noises when loud noises reliably signalled threat...

I don't understand how this is supposed to ground psychiatry as a science

:-(

you got me there. i don't have a clue, either. lol.

I think it's about "Now" rather than yesterday or tomorrow and is kind of comparable to those pain questions, 0-9 that they ask you for physical pain in the ER or for chronic pain, etc.?

http://www.nccn.org/patients/patient...assessment.asp

Too, other people aren't being evaluated, just you, so you would have to be picking fights with your parents not the other way around :-) If your parents are picking fights with you, then they're not-so-good parents :-) How you respond would be the criteria. It's about your symptoms, not "you".

Everything looks like it is worded to "help" the person being evaluated to me? Kind of asking about "emotional pain" as evidenced in one's symptoms. I would imagine the speed thing is so they can start helping as soon as possible, not "categorize" the person in any way as to what is wrong with them, just how much psychic pain are they in:

http://dpa.state.ky.us/library/manuals/mental/Ch22.html

Pain is an interesting case. Pain (in medicine) is described as a SUBJECTIVE state rather than an OBJECTIVE STATE. Basically the notion is: If someone says they are in pain then (so long as they aren't lying in order to avoid work or obtain narcotics) they are in pain.

E.g.,

> Pain: An unpleasant sensation that can range from mild, localized discomfort to agony. Pain has both physical and emotional components. The physical part of pain results from nerve stimulation. Pain may be contained to a discrete area, as in an injury, or it can be more diffuse, as in disorders like fibromyalgia. Pain is mediated by specific nerve fibers that carry the pain impulses to the brain where their conscious appreciation may be modified by many factors.

Now sometimes people report that they have the experience of pain even in the absense of nerve stimulation. SOmetimes people report that they have the experience of pain even in the absense of brain activation in the areas that have been associated with painful nerve stimulation. So the subjective experience of pain can come apart from the objective notion of pain and the medical definition tracks the subjective experience. In the case of mental illness, however, subjective distress can come apart from objective dysfunction and mental illness is meant to track the objective dysfunction (in the sense that we classify and treat people against their will if necessary).

Pain is a 'thick concept' (which is to say that it has an evaluative component). Pain is disvalued (bad) by definition. (Massochism creates a problem and there is a bit of a literature on how pleasurable experiences can come to be associated with painful experiences). Mental disorder is similarly a 'thick concept' (which is to say that it has an evaluative component). Mental illness is disvalued (bad) by definition. The idea is that people would be (objectively) BETTER OFF if they weren't in pain and they would be (objectively) BETTER OFF if they werne't mentally ill.

The internal / external problem

Would it be adaptive to not have a negative emotional response to rape? Would the DSM consider rape to be a negative ENVIRONMENTAL event such that my negative emotional response would be excusable (so not a mark of mental non optimality)? How about childhood sexual abuse? Childhood neglect? Those have been found to have a significant impact on later mental illness. But is it really the case that people aren't mentally ill when their symptoms are due to what are fairly obviously environmental events?

One idea is that the response to the environmental event must be 'unexpected'. The idea here is that some people aren't negatively affected by rape or by childhood neglect to the point of displaying symptoms of mental illness. Other people are, however. Since there is variation maybe the people who do respond with symptoms count as being mentally ill because it must be that something is wrong with them that it affects them so. What if 99% of people respond to rape or childhood neglect with symptoms of mental illness and 1% don't... Does that make the symtpoms of mental illness due to EXTERNAL or ENVIRONMENTAL factors rather than malfunction of the person? How do we decide?

> Everything looks like it is worded to "help" the person being evaluated to me?

Sure. What is controversial, however, is how much we should lament the fact that more people don't ask for help (take drugs seek therapy) when we have decided that they have a mental illness. What is controversial, however, is how much we should go on in to india and diagnose and attempt to treat people where indian society (for example) regards the person as being merely different, or in some cases positively revered. We might think we are 'helping' but outcomes of therapy and medication intervention are problematic... It is controversial whether the benefits from medication outweigh the harms from side-effects in quite a number of cases. It is controversial whether the benefits from being categorised as 'mentally ill' outweigh harms of being categorised as 'mentally ill'.

Emotional pain isn't sufficient for mental disorder. It isn't the case that whenever there is emotional pain there is mental disorder. Who has not experienced emotional pain at some point in their life? People in the grip of a manic episode often report feeling WONDERFUL and people in the grip of a psychotic episode often similarly deny that they are experiencing emotional pain. And yet... We slap a treatment order on them and medicate them against their will if necessary.

What justifies that kind of 'helping'?????

There must be an OBJECTIVE (and not merely SUBJECTIVE) definition of 'health' or 'functioning' that justifies psychiatrists (and others) regarding people to be mentally disordered even when subjectively the person denies that they are distressed or dysfunctional.

Part of the colonialism involves trying to persuade people that they have a MEDICAL problem rather than a SPIRITUAL or ENVIRONMENTAL problem. If we can persuade them that this is the case then they are less likely to resist (or refrain from seeking) medical intervention (which begins with a diagnosis of mental illness). In our society people are quick to regard themselves to be mentally disordered and people are quick to run off to medical doctors in the face of emotional pain. In other soceities people are more likely to seek social supports in the form of family or friends or priests or religious leaders. The problem is that we look at people in india and we say 'they are delusional! they are psychotic! they are mentally ill! they need medical treatment!' and we don't have very many qualms with going on in and medicating people to a state that we think is better (e.g., so they don't report hearing voices anymore). Are they better off for our having done so? WE think they are but THEY often don't think they are.

Trouble is that we think that OBJECTIVELY they are malfunctioning / mentally ill. We think we are OBJECTIVELY right and they are OBJECTIVELY wrong. We pity people for not seeing that they have a MEDICAL CONDITION

Here is a thought (a thought that I've never seen expressed before):

Biology (or perhaps evolutionary biology) is to conservation ecology as comparative physiology / comparative anatomy is to medicine.

People have tried to ground medicine (and psychiatry as a branch of medicine) in the biological sciences. A way of saying 'psychiatry deals in facts too so it clearly isn't SOLELY a matter of value colonialisation' (as some anti-psychiatrists / social constructionists have thought). But the jump from the biological sciences to medicine is problematic in a number of respects...

One feature is that psychiatry (and medicine) is applied. To say that someone is mentally and / or physically ill / disordered is to say that that person would be better off if that person were not mentally and / or physically disordered. The application seems to make it evaluative.

Similarly, conservation ecology is all about maximising 'diversity' (similarly to how medicine / psychiatry is about maximising 'health'). There are different measures of 'diversity' (e.g., morphological / phenotypic difference, difference (with respect to evolutionary history) from other surviving species, the role the organism plays in an ecological niche (e.g., as a prey for a different species or whatever). It has been thought... That while there are many measures of 'diversity' none is equivalent to the concept itself (and of course the concept of diversity is normative in the sense that diversity is something that it is good to maximise).

One could argue that medicine in analogous. It involves (as does psychiatry) this notion of 'health'. While there are many different measures of health none is equivalent to the concept itself (which is partly normative in the sense that organisms would be better off if they were healthy).

Interesting.

Or interesting-ish.

Not sure...

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alexandra_k said:
What is controversial, however, is how much we should lament the fact that more people don't ask for help (take drugs seek therapy) when we have decided that they have a mental illness.

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Okay, Alex, you're losing me. WHO is "we" and how have we decided they have a mental illness if they haven't come to us to ask for help or have hurt themselves or others without "realizing" it. And you have to define "ask for" in a better way too; people sky diving are not deemed (by society) to be seeking help but people trying to kill themselves by jumping from high places without "nets"/parachutes or talking about doing same are "seeking attention" and crying for help.

We don't pass laws that people have to get better in any particular way (therapy or meds) either, anymore than we pass laws insisting that people have to buy health insurance. They have to buy car insurance because their uninsurance could impact me in a car but if they don't "like" doctors or don't want to spend their little bit of money on doctors (preferring to eat, perhaps, instead) then that is their perrogative.

Your rape problem,

"Would it be adaptive to not have a negative emotional response to rape? Would the DSM consider rape to be a negative ENVIRONMENTAL event such that my negative emotional response would be excusable (so not a mark of mental non optimality)?"

People DO have a negative emotional response to rape! It is the suppression of that negative emotion that is non-optimal; animals when they're dying don't have "emotions" like we have so don't get tangled in them. But rape is not environmental as much as it is idiosyncratic. The "environment" doesn't "choose"; if you have a wife and 4 kids and a "mean" drunk husband/father; everyone loses in that environment. If you have just a husband/wife and they argue and are going through an ugly divorce (or not - Richard Burton/Elizabeth Taylor) they both lose in that environment. But if you are out on a date and get date-raped, the "environment" doesn't have anything to do about it. It will probably be a bit more "private" than other environments but "private" can be selective too. I had a good friend in college, she had to work her way through, attending a semester then working a couple semesters to pay for the next semester. She was raped and murdered late one night waiting for transportion from her job at the train yard. The "environment" didn't cause or suffer; we, her friends, weren't anywhere near that kind of environment and it didn't happen to us. But I ended up at Georgetown University Hospital the next evening after work with stomach pains. They worked me up well (this was early 1970s when doctors/hospitals were still "good") and after 2-3 hours I suddenly remembered (and related) the news I'd gotten the night before and how "coincidental" it was that I now had these extreme pains in my "belly"?

I think it is not as cut and dried as any "tool" to help diagnose is going to appear. But the tool is not the diagnosis. Trying to quickly find a "level" of need like this tool appears to do does not mean anything is set is cement. No one is going to say, "Ah, level 4, she's Borderline for sure!" (or if they do, you go to a different facility where they have better doctors!).

> What is controversial, however, is how much we should lament the fact that more people don't ask for help (take drugs seek therapy) when we have decided that they have a mental illness.

The 'we' in this context is referring to professionals. The professionals who are willing to state such things as 'one in four people are suffering from mental illness' and 'mental illness is high in immigrant populations' and such things as 'they often seek help from spiritual leaders instead of realising that their problem is medical and seeking professional psychological / psychiatric interventions'. They are also willing to lament the current situation in third world countries where many people who they regard to be suffering from mental illness have no access (or desire to access) pscyhiatric help. Even when those people are regarded as 'different' or 'positively revered' in their home town. The idea is that mental illness is far more prevalent than people have supposed and that it is a tragic state of play indeed that more people aren't asking for psychiatric / psychological help for their condition - and where those people are instead turning to spiritual leaders and / or their family for supports.

Perhaps you aren't aware that people are doing this... They are, however. I have participated in a few threads over at the 'Student Doctor Network' where people training to be psychiatrists (and the psychiatrists over there) consider that a person who hears voices has a psychiatric condition (and should be medicated) and that it is a sad state when they aren't receiving psychiatric medication for (what they regard to be) a mental / medical disorder EVEN when the person, the persons family, and the persons society doesn't consider it problematic at all that that person reports hearing voices.

'We' decide that one in four people have experienced what we regard to be 'mental illness' because 'we' are determined that mental illness will be an 'epidemic' (a leading health issue) in the next few years. This is supposed to (somehow, in a way that is obscure to me) result in it being more likely that the american government will aprove parity between treatment for physical conditions (e.g., obesity - which of course looks rather ridiculous compared with cancer and AIDS) and mental health conditions (notably - at this point - depression (which again looks rather ridiculous compared with cancer and AIDS).

> We don't pass laws that people have to get better in any particular way (therapy or meds) either, anymore than we pass laws insisting that people have to buy health insurance.

We pass laws that say that people can be detained in an institution against their will under the 'mental health act'. Similarly, a person can be treated against their will (with medication most typically, though also with therapy, I guess) under the mental health act.

> People DO have a negative emotional response to rape! It is the suppression of that negative emotion that is non-optimal

Not according to the DSM definition of 'optimal' psychological, social, and occupational functioning (looking at the difference between the top and second top category here). Looks to me... That the 'optimal' category is based on a rather outdated theory that it is better to not have emotional responses at all. No appreciation of the importance of emotions and emotional expression seems to be noted...

> if you are out on a date and get date-raped, the "environment" doesn't have anything to do about it.

The issue is whether a negative response to rape constitutes a problem with the individual who has been raped (they have an internal malfunction that is responsible for their negative response therefore they have a mental disorder) or whether a negative response to rape constitutes an understandable response to an environmental event (so they aren't considered to have a mental disorder because their negative response doesn't imply that they have an inner dysfunction - it doesn't imply that something is wrong within them).

Because... That is meant to be the distinction between 'mental disorder' and 'problems in living'.

Wakefield gives us the following example: Two people meet criteria for 'reading disorder' in precisely the same way. We then learn that the first individual wasn't ever taught how to read. We then consider his inability to read to be a limitation of his environment. Hence, his inability to read doesn't mean that there is a dysfunction within him. Hence, he doesn't have a mental disorder. The second individual was given as much instruction as most people get but he still never managed to learn. We then consider his inability to read to be due to a limitation / deficiency within him. Hence, his inability to read does mean that there is a dysfunction within him. Hence, he does have a mental disorder.

My thought was... Does rape or childhood neglect that results in someone meeting criteria for something or other... Constitute an environmental limitation (like never having been taught how to read) or does it constitute a malfunction within the individual (hence a mental disorder)

?

The problem is... That 'we' (drug companies, psychiatrists, psychologists) attempt to say that people 'should' seek psychiatric / psychological help WHETHER THEY THINK THEY NEED IT OR NOT. And my issue is: What gives them that authority?

The public are subjected to advertising which (conveniently enough) makes us DESIRE that kind of intervention. For the places where people haven't been affected by advertising people are reluctant to seek psychiatric / psychological help, however. We think that OBJECTIVELY they have a psychiatric / psychological condition and they SHOULD be receiving help (we will slap a treatment order on them if necessary and jolly well make them).

So...

What gives them that authority?

And... Should we rethink our views with respect to seeking that kind of help?????

Perhaps...

I think we should "run and hide" from that sort of "help"...its a fact that drugs are over prescribed in our society and that personal responsibility for ones own "thought life" is discouraged. where does that leave us? in a mess I would say,our whole medical establishment insures its survival by treating "symptoms" and when your condition becomes chronic they operate on you which has given rise to the saying "the procedure was a success,unfortunatly the patient did'nt make it" no one really wants to hear this but we as humans (mistake makers) are'nt open to the idea that the mind actually controls the body,if we were we'd find our own path to healing...

really great thread alex. thanks for this. i think its so important to put questions like this out there in the hopes more people read and then think than just those who respond!

i wish i had the time and energy and intelligence to devote to thinking these things through as you do. (im just that little bit more passionate about my actual job though!)

out of all you wrote there were several things that jumped out at me and made me go YES! this was only one of them:

"The professionals who are willing to state such things as 'one in four people are suffering from mental illness' and 'mental illness is high in immigrant populations' and such things as 'they often seek help from spiritual leaders instead of realising that their problem is medical and seeking professional psychological / psychiatric interventions'. They are also willing to lament the current situation in third world countries where many people who they regard to be suffering from mental illness have no access (or desire to access) pscyhiatric help. Even when those people are regarded as 'different' or 'positively revered' in their home town. The idea is that mental illness is far more prevalent than people have supposed and that it is a tragic state of play indeed that more people aren't asking for psychiatric / psychological help for their condition - and where those people are instead turning to spiritual leaders and / or their family for supports."

(just btw 'developing countries' is the politically correct term at the moment than 'third world countries' - though personally i have almost as many issues with the former term as the latter but anyways)

thanks for your thoughts. love reading your posts when i get the time! i think you have the potential to have a very big impact on the academic literature concerning mental health. keep at it!

Upcoming book:

Trauma and Serious Mental Illness
Edited by Steven N. Gold, PhD
Nova Southeastern University, Center for Psychological Studies, Fort Lauderdale, Florida
Jon D. Elhai, PhD
Disaster Mental Health Institute, Department of Psychology, University of South Dakota, Vermillion

For decades, the idea that serious mental illnesses (SMIs) are almost exclusively biologically-based and must be treated pharmacologically has been commonplace in psychology literature. As a result, many mental health professionals have stopped listening to their clients, categorizing their symptoms as manifestations of neurologically-based disturbed thinking. Trauma and Serious Mental Illness is the groundbreaking series of works that challenge this standard view and provides a comprehensive introduction to the emerging perspective of SMIs as trauma-based...

Publication Date: March 1, 2008.
Available: Available Winter 2007/2008.
$24.00 soft. ISBN-13: 978-0-7890-3651-3.
$40.00 hard. ISBN-13: 978-0-7890-3650-6.
Pages: Approx. 170 pp. with Index.
LC#: not set
Categories: Trauma; Psychotherapy, Mental Health, Psychology & Psychiatry
Web: http://www.HaworthPress.com/store/product.asp?sku=6151.