To try to answer the perennial question I ask myself (“what am I doing?”), I recently read this 2015 article, What is mental health? Evidence towards a new definition from a mixed methods multidisciplinary international survey.
As a psychiatrist1, do I treat mental illness? What is mental illness? What is mental health?
The paper comments on the ambiguity in the definition of “mental health”:
Mental health can be defined as the absence of mental disease or it can be defined as a state of being that also includes the biological, psychological or social factors which contribute to an individual’s mental state and ability to function within the environment.
Upon reading this I recognized that I define “mental health” according to the second definition, “a state of being…”. This also explains why I internally bristle when people say “mental health” when they actually mean “mental illness”. (Example: The Lancet Commission on ending stigma and discrimination in mental health.)
Figure 2B, the Two Continua Model, resonates with me:
There are people with diagnoses of significant mental illnesses who have “high mental health”. (If we’re going to be picky about words, I’m not sure that I like grading mental health as “high” or “low”. Maybe “well” versus “unwell”? It is more common to hear “I’m physically doing well,” rather than “My physical health is high.”)
Consider the person with a diagnosis of schizophrenia who has been hospitalized multiple times in the past. However, now they go about their lives and only make contact with their healthcare team every few months for routine check-ins.2
Then there are people with no diagnosable mental illness who have “low mental health”. Consider the many people who felt psychologically unwell during the Covid pandemic.
I started doodling to try to determine where psychiatry should intervene along the axes of mental illness and mental wellness:
I have yet to come up with any convincing answers. This doodling did offer clarity, though:
My professional interest has been the diagnosing and treatment of (often severe) mental illness. There are many reasons for this. One compelling reason is that the severity of symptoms makes it unmistakable that professional intervention is warranted.3
Only after years had passed did I recognize that this worldview is why I chafed at some requests patients brought to me early in my career. I once went through an entire diagnostic interview with a guy who worked as a game designer. Nothing came up; according to the Two Continua Model, he had neither a mental illness nor low mental health. Only at the end did he reveal why he had sought care from a psychiatrist: “My girlfriend takes Prozac and it made her more creative. I thought that if I take Prozac, that might make me creative, too, which can help me with my work.”
My goal was to diagnose and treat a mental illness. His goal was mental enhancement.
Are these two goals mutually exclusive? I don’t think so, though I want to noodle on this more.
The history of psychiatry holds these two goals in tension, too: On one end are the state psychiatric hospitals (also called asylums) where some people with severe symptoms (or not) were held (warehoused?) prior to the elimination of these institutions. On the other end are the psychoanalysts, where the typical patient was “a college-educated, upper-middle class professional who paid for service out of pocket.”
More to follow as I continue to wonder what I am doing.
- It was never part of The Plan to become a psychiatrist. This is part of the reason why I ask myself the perennial question, “What am I doing?”
- When asked, “What is your best life?”, no one responds, “I want to spend as many precious moments of my existence in hospitals and clinics.”
- A choice quote from the paper that highlights why I personally like clarity about where professional intervention is warranted: “Lots of things can cause people problems—poverty, vices, social injustice, stupidity—a definition of health should not end up defining these as medical problems.”
Maria Yang, MD 