Thursday, 2 August 2012

Mental Illness and/or Mental Health? Investigating Axioms of the Complete State Model of Health

The School of Health mental health reading group met to look at Keyes, C.L.M. ‘Mental Illness and/or Mental Health? Investigating Axioms of the Complete State Model of Health’ helpfully introduced by Laura Buckley.

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
 1. Regularly cheerful, in good spirits, happy, calm and peaceful, satisfied, and full of life (positive affect past 30 days)
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