The roots of the concept of mental health

Abstract

This paper reviews the origins of the current concept of mental health, starting from the mental hygiene movement, initiated in 1908 by consumers of psychiatric services and professionals interested in improving the conditions and the quality of treatment of people with mental disorders. The paper argues that, more than a scientific discipline, mental health is a political and ideological movement involving diverse segments of society, interested in the promotion of the human rights of people with mental disorders and the quality of their treatment.

The concept of mental health, given its polysemic nature and its imprecise borders, benefits from a historical perspective to be better understood. What today is broadly understood by “mental health” can have its origins tracked back to developments in public health, in clinical psychiatry and in other branches of knowledge.

Although references to mental health as a state can be found in the English language well before the 20th century, technical references to mental health as a field or discipline are not found before 1946. During that year, the International Health Conference, held in New York, decided to establish the World Health Organization (WHO) and a Mental Health Association was founded in London. Before that date, found are references to the corresponding concept of “mental hygiene”, which first appeared in the English literature in 1843, in a book entitled Mental hygiene or an examination of the intellect and passions designed to illustrate their influence on health and duration of life 1. Moreover, in 1849, “healthy mental and physical development of the citizen” had already been included as the first objective of public health in a draft law submitted to the Berlin Society of Physicians and Surgeons 2.

In 1948, the WHO was created and in the same year the first International Congress on Mental Health took place in London. At the second session of the WHO’s Expert Committee on Mental Health (September 11-16, 1950), “mental health” and “mental hygiene” were defined as follows 3: “Mental hygiene refers to all the activities and techniques which encourage and maintain mental health. Mental health is 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.”

However, a clear and widely accepted definition of mental health as a discipline was (and is) still missing. Significantly, the Dorland’s Medical Dictionary does not carry an entry on mental health, whereas the Campbell’s Dictionary of Psychiatry gives it two meanings: first, as a synonym of mental hygiene and second, as a state of psychological wellbeing. The Oxford English Dictionary defines mental hygiene as a set of measures to preserve mental health, and later refers to mental health as a state. These lexicographic concepts nonetheless, more and more mental health is employed in the sense of a discipline (e.g., sections/divisions in health ministries or secretaries, or departments in universities), with an almost perfect replacement of mental hygiene.

In addition, given this polysemic nature of mental health, its delimitation in relation to psychiatry (understood as the medical specialty concerned with the study, prevention, diagnosis and treatment of mental disorders or diseases) is not always clear. There is a more or less widespread effort to set mental health at least aside from psychiatry and at most as an overarching concept with encompasses psychiatry.

THE ORIGINS OF MENTAL HEALTH

The mental hygiene movement

The origin of the mental hygiene movement can be attributed to the work of Clifford Beers in the USA. In 1908 he published A mind that found itself 4, a book based on his personal experience of admissions to three mental hospitals. The book had a great repercussion and in the same year a Mental Hygiene Society was established in Connecticut. The term “mental hygiene” had been suggested to Beers by Adolf Meyer 5 and enjoyed a quick popularity thanks to the creation in 1909 of the National Commission of Mental Hygiene. From 1919 onwards, the internationalization of activities of this Commission led to the establishment of some national associations concerned with mental hygiene: in France 6 and South Africa 7 in 1920, in Italy 8 and Hungary 9 in 1924. From these national associations the International Committee on Mental Hygiene was created and later superseded by the World Federation of Mental Health.

The mental hygiene movement, in its origins and reflecting Beers’ experience in mental hospitals, was primarily and basically concerned with the improvement of the care of people with mental disorders. In Beers’ own words: “When the National Committee was organized, in 1909, its chief concern was to humanize the care of the insane: to eradicate the abuses, brutalities and neglect from which the mentally sick have traditionally suffered.” 4.

It was at a later stage that the Committee enlarged its program to include the “milder forms of mental disability” and a greater concern with preventive work. The rationale behind this shift was the belief that “mental disorders frequently have their beginnings in childhood and youth and that preventive measures are most effective in early life”, and that environmental conditions and modes of living produce mental ill health.

By 1937, the US National Committee for Mental Hygiene stated that it sought to achieve its purposes by: a) promoting early diagnosis and treatment; b) developing adequate hospitalization; c) stimulating research; d) securing public understanding and support of psychiatric and mental hygiene activities; e) instructing individuals and groups in the personal application of mental hygiene principles; and f) cooperating with governmental and private agencies whose work touches at any point the field of mental hygiene.

Thus, the mental hygiene movement had initially a para-psychiatric nature, directing its efforts towards the improvement of psychiatric care. The inclusion of preventive activities among its interests did not distinguish it from psychiatry: the movement aimed at maximizing what was accepted and proposed by the most advanced psychiatrists of the epoch in the USA, most of whom followed a psychoanalytical orientation.

According to the group which launched it, the mental hygiene movement “visualized, not a single patient, but a whole community; and it considered each member of that community as an individual whose mental and emotional status was determined by definite causative factors and whose compelling need was for prevention rather than cure. The Mental Hygiene Movement, then, bears the same relation to psychiatry that the public-health movement, of which it forms a part, bears to medicine in general. It is an organized community response to a recognized community need.” 4. On the other hand, it was also stated that: “At the present time both psychiatrists and mental hygienists are more than ever conscious that their objectives are in fact identical and that each group needs the other for the fulfilment of their common task.” 4.

The World Health Organization

From its very beginning, the WHO has always had an administrative section specially dedicated to mental health, as an answer to requests from its Member States. The first Report of the WHO’s Director General 10, in its English version, refers to an administrative section called “Mental Health”. However, the French version of the same report calls it “Hygiène Mentale”. Well until the 1960s we find hygiène as the French translation of health in some WHO publications and in some instances we find also mental hygiene used interchangeably with mental health in the English version of some documents. The volume no. 9 of the WHO’s series Public Health Papers was published in 1961 in English with the title Teaching of Psychiatry and Mental Health 11, in 1962 in French with the title L’enseignement de la Psychiatrie et de l’Hygiène Mentale 12 and in 1963 in Spanish with the title Enseñanza de la Psiquiatria y de la Salud Mental 13.

In the preamble to the WHO Constitutions, it was stated that “health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity” 14, a now widely quoted definition. This definition is clearly a holistic one, intended to overcome the old dichotomies of body vs. mind and physical vs. psychic. It is also a pragmatic one, insofar as it incorporates into medicine a social dimension, gradually developed in Europe during the 19th century.

It should be noted that mental, in WHO’s definition of health (as well as physical and social) refers to dimensions of a state and not to a specific domain or discipline. Therefore, according to this concept, it is incongruous to refer to physical health, mental health or social health. Should one wish to specify a particular dimension, the most appropriate noun to designate it should be wellbeing and not health (e.g., mental wellbeing or social wellbeing). This negligent use of the word health seems to have been also in operation when mental hygiene (a social movement, or a domain of activity) was replaced by mental health (originally intended to designate a state and later transformed in a particular domain or field of activity).

The International Congress of Mental Health

The First International Congress of Mental Health was organized in London by the British National Association for Mental Hygiene from 16 to 21 August, 1948. Starting as an International Conference on Mental Hygiene, it ended with a series of recommendations on mental health. Throughout the proceedings of the conference, hygiene and health, qualifying mental, are used interchangeably, sometimes in the same paragraph, without any clear conceptual distinction. However, in the 17 pages of the recommendations of the conference, hygiene is very sparingly used. At the end of the congress, the International Committee on Mental Hygiene was superseded by the World Federation for Mental Health.

In addition to the wording employed in the proceedings of that congress, gradually replacing hygiene by health, some of its recommendations were also influential at other levels. An example is recommendation 6 to the WHO that “as soon as practicable, an advisory expert committee be established, composed of professional personnel in the field of mental health and human relations”.

The conference had been convened under the theme “Mental Health and World Citizenship”. From a conceptual point of view, nevertheless, and perhaps reflecting an immediately post-war situation, discussions over world citizenship prevailed over those on mental health. Only one concept of mental health was put forward, by J.C. Flugel, Chairman of the Conference’s Programme Committee: “Mental health is regarded 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.” 15. Echoing concerns about the absence, or rather limited number of, participants from places such as Far East, South America and the Soviet Union, the hope was expressed that “mental health as understood in Western countries [is not] necessarily at variance with the sense in which it is understood in other countries” 15.

In a more detailed way, some delegates elaborated on what was summarized as the “four levels of mental health work: custodial, therapeutic, preventive and positive” 15. It is not difficult to see a considerable overlapping between this proposal and the one already implemented by the mental hygiene movement.

At the closing session, O.L. Forel, Lecturer in Psychiatry at the University of Geneva, answering to criticisms that mental hygiene, as understood in that conference, went beyond the medical and scientific framework, made a clearly political (in Plato’s sense) statement by saying that: “I dare hope to be your interpreter in expressing our pride that so many scientists came here not at all to develop their respective sciences, but to have them at men’s service” 15.

Reading through the proceedings of this congress gives one a feeling of the tensions between a pragmatic approach, developed by the mental hygiene movement (basically defended by delegates from the USA), and a more politically-oriented approach, proposed by other participants, perhaps translating the experiences of some delegates from European countries, which had severely suffered from the war. In the end this latter approach prevailed, with the transformation of the mental hygiene movement into the mental health movement. Perhaps as a reflection of this basically political movement, in 1949 the National Institute of Mental Health started its activities in the USA.

RECENT DEVELOPMENTS

After half a century of the mental health, and almost a century of the mental hygiene movements, some developments can be perceived. On a more general level, the WHO’s very concept of health has been recently questioned; formulated half a century ago, it is no longer felt by some as much appropriate to the current situation 16,17.

On the whole, mental health continues to be used both to designate a state, a dimension of health – an essential element in the definition of health – and to refer to the movement derived from the mental hygiene movement, corresponding to the application of psychiatry to groups, communities and societies, rather than on an individual basis, as is the case with clinical psychiatry. However, mental health is, quite unfortunately, still viewed by many as a discipline, either as a synonym of psychiatry, or as one of its complementary fields.

A recent trend has been the addition of the qualifier public to either mental health or to psychiatry, as it can be seen in a WHO document entitled Public mental health 18, or in a journal named Psiquiatría Pública, published in Spain since 1989. This is very much in line with the concept of mental health as a movement rather than a discipline.

In 2001, the WHO dedicated its annual report (The World Health Report - Mental health: new knowledge, new hope) to mental health 19. In that same year, the theme of the World Health Day was Stop Exclusion – Dare to Care, a quite clear political statement, that I am sure would have immensely pleased Clifford Beers.

In the message from the WHO Director-General that opens that report, Gro H. Brundtland summarizes the three main knowledge areas covered by the document: a) effectiveness of prevention and treatment, b) service planning and provision, and c) policies to break down stigma and discrimination and adequate funds for prevention and treatment. If one allows for the semantic variations between the beginnings of the 20th and the 21st centuries, the same concerns of the origins of the mental hygiene movement, discussed earlier on, can be found in the mental health content of the World Health Report. Perhaps the biggest difference between these two political platforms is the emphasis on the improvement of hospital care in the former (the only form of treatment available by then), and the contemporary emphasis on distancing mental health from psychiatric hospitals and placing it in the community.

However, one must admit that, unfortunately, what was high in Beers’ agenda in 1909, namely, an improvement in the standards of mental health care and an eradication of the abuses to which people with mental disorders are usually subject, is still a major concern of the most progressive and advanced agenda of people interested in the promotion of mental health around the world.