Positive mental health: a note of caution

The concept of positive mental health is doubtless “too important to ignore”. At the same time, as Vaillant states in his thought-provoking paper, “the study of positive mental health requires safeguards”. Here I wish to emphasize two points: that positive mental health remains a fuzzy and contested construct, and that there are currently few data on clinician driven positive mental health interventions.

While Vaillant performs a service by outlining different models for conceptualizing positive mental health, the multiplicity of models underscores that this is a contested construct. While there is some agreement about the boundaries of typical physical disorders, there is likely less agreement about the concept of physical fitness. After all, definitions of physical fitness depend greatly on the particular individual at hand, and on the particular activity for which fitness is being determined 1. Similarly, while there is some agreement about the boundaries of typical mental disorders 2, there is likely less agreement about those for positive mental health.

Given the potential importance of positive mental health, how do we develop consensus? Vaillant argues for terms that are culturally sensitive and inclusive. While such a goal seems laudable, cultures can be entirely wrong about scientific constructs. Another approach might be to rely on evolutionary theory, as have some approaches to disorder 3. But, given the apparent plasticity of human nature, evolutionary theory may emphasize precisely such plasticity, rather than specific fixed universal features of mental health. Relatedly, contra Vaillant, evolutionary theory emphasizes that negative emotions may be useful, while positive emotions may be maladaptive 4.

In the case of disorder, for typical conditions (e.g., acute infection), there may be substantial universal agreement that the condition is harmful, that individuals are not responsible for the condition, and that medical intervention is deserved. However, for atypical conditions (e.g., excessive alcohol use), there may be substantial disagreement from time to time and place to place about whether the condition is harmful, whether individuals bear responsibility, and whether medical intervention is deserved 5. A reasonable decision can, however, be made on the basis of arguments for and against categorizing a particular atypical condition as a medical disorder.

Similarly, for positive mental health, there is likely to be substantial agreement about some typical components (e.g., resilience to stress) 6, and controversy about more atypical components (e.g., career consolidation). In many regions, high levels of unemployment and other social factors may prevent transformation of “jobs” into “careers”. As in the case of categorizing particular conditions as mental disorders, however, a reasonable decision can be made on the basis of a rigorous assessment of the relevant facts and values 5.

Concerning positive mental health interventions, we can easily agree that cosmetic surgeons who help treat disfigured children are doctors. We can easily agree that a surgeon who is willing to transform a particular individual to look more like his favourite movie star is not a doctor, but a schmoctor 7. And we can reasonably debate whether cosmetic surgery to enhance appearance in particular ways for particular individuals is doctoring or schmoctoring.

Similarly, in the case of positive mental health, mental health clinicians may reasonably be interested in key aspects (e.g., resilience after trauma). It may be harder to obtain consensus that mental health clinicians who help individuals, say, “tune into the energies of the universe” are not doctors, but schmoctors. Again, however, we can reasonably debate about whether particular mental health interventions aimed at enhancing the mind are doctoring or schmoctoring.

Such debate is in part about the validity of the relevant goals (e.g., surgery to look like a favourite movie star does not seem to be a health issue), and it is in part about the cost-effectiveness (e.g., society may be able to bear the costs of cosmetic surgery for major disfigurement, but not for enhancement procedures). Similarly, society may decide to focus on treating patients with severe mental disorders, rather than to fund clinical interventions to enhance resilience.

It is noteworthy that many interventions can potentially help humans to flourish mentally, including education, participation in the arts, etc. Indeed, there are growing literatures in the areas of conceptual work on the meaning of life 8, and empirical research on well-being and happiness 9,10,11. That said, it is a moot point as to whether interventions to improve positive mental health should necessarily fall within the purview of mental health clinicians.

Furthermore, empirical studies of costs and benefits of interventions are needed to inform decision-making. Vaillant argues that, in healthy individuals, psychopharmacological interventions are negative. Remarkably, large numbers of the population are using psychotropic agents for enhancement purposes 12. There is, however, no a priori reason to conclude that such agents are always harmful; indeed, given genetic variability, individual responses may be quite variable 13.

Vaillant’s view is that we can enhance mental health through cognitive, behavioural and psychodynamic means. However, there is a dearth of empirical data on the efficacy and cost-effectiveness of positive mental health interventions. Arguably, appropriate nutrition and exercise are likely amongst the most efficacious and cost-effective positive mental health interventions 14. More certain is the need for additional research in this area.

In conclusion, debate in the arena of public health often refers not to psychiatric disorders, but rather to mental health. This is exemplified perhaps by the World Health Organization’s slogan “no health without mental health”. Such rhetoric may offer a number of advantages. Furthermore, the science of positive mental health is an important area of investigation.

At the same time, caution is warranted. While there is universal agreement about the need to treat some typical and burdensome physical and mental disorders, there is less agreement about what constitutes positive mental health, and about which clinical interventions may be efficacious and cost-effective. Empirical data may help shed more light on these key questions.