A few months ago I received a referral for a new patient with a history of depression who’d made a serious suicide attempt. Perhaps unsure how to describe these episodes, the referring clinician wrote vaguely that the person had a “history of mental health.”
Ordinarily, the word “health” implies an absence of illness. That is no longer how the term “mental health” gets used. The idea of mental illness, or mental disorder — both terms that have been subjected to their own intractable debates — has come to be supplanted by a broader umbrella notion, “mental health,” which somehow, confusingly, gets used to refer to states of both wellness and distress. Some awareness campaigners have even adopted the slogan “We all have mental health,” which seems on the face of it to be a stigma-busting, solidarity-building mantra. On closer examination, however, it manages a double exclusion. It fails to actually name any mental health problems — those about which we ought to be raising awareness — and it also makes a claim that is sadly untrue; there are many people who, at least some of the time, do not have mental health.
We are talking more and more about our mental health, and this has been enormously positive. It is no longer unusual to see celebrities or politicians referencing the concept. The rise of social media has introduced a generation of clinicians who have been adept at using it to communicate. In the United States, Dr Emily Anhalt produces elegant aphorisms and promotes the virtues of psychodynamic psychotherapy on Twitter. In Britain, Dr Julie Smith has turned her well-crafted TikTok advice videos into a best-selling book of practical psychology.
The focus of most of these discussions is improved mental health for all, rather than focusing on a particular group or condition. But language can be slippery.
The term “mental health” is a euphemism, and euphemisms are what we use when we want to obscure something. This language — in contrast to “mental illness” — encourages us to focus on the regulation of more or less transient states, and on the maintenance of something we supposedly all have. “Mental health” conjures phenomena that are, more or less, relatable: anxiety and depression. But who is being excluded as a result? The change in language was supposed to address stigma. But it has simply moved our attention away from the very people who face the most stigma — those with diagnoses of schizophrenia, for example, or symptoms that do not allow ready participation in the mental health curriculum.
This shift also cuts in another direction. An emphasis on health and equilibrium, with accompanying “advice” and “techniques” for self-regulation, has resulted in the term “mental health” undergoing a kind of mission creep: from providing increased awareness of specific difficulties to offering a broad set of prescriptions about how we should live.
The way we talk about mental health as a motivator for so many of our activities risks becoming a substitute for more broadly grounded discussions of how we should act. Consider the relatively recent notion of a mental health day. We absolutely need to take days off work for our mental health sometimes, and it is important that employers recognise our needs. But people also need — deserve — days away from their work without justification. They should then be free to spend those days doing whatever they like. Is a day off less valid if it isn’t spent engaged in something that has been approved by one of the many websites that now offer mental health day advice?
When mental health is given as a principal motivator for our choices, we are prioritising our own experiences. As a result, there is less room for moral or ethical considerations for our behaviour, and also less room for motivations that have to do with social, community or familial commitments, or doing something for its own sake. There are probably lots of things we should do in spite of our mental health: helping others, forming deep emotional ties that may then need to be painfully broken, becoming immersed in sometimes maddening, at times obsessive political or creative projects. These are choices that need deep rational, ethical and personal engagement.
I work in a hospital with people who have experienced acquired brain injuries; it’s a setting that inescapably involves loss and despair. Although my professional life is organised around reducing suffering, and although I think some emotional experiences represent clear illnesses, I also understand that many forms of misery are bound up with the experience of being a person. Distressing or extreme states can at times be part of what makes for a life worth living. There are feelings that are unavoidable, purposeful or morally significant.
The shift toward prioritising mental health might be benign if it were only one way of reframing the question of what our priorities should be. But it comes with the imprimatur of clinical authority. As a result, therapists increasingly stray into a broader ethical arena while appearing to remain within their own zones of expertise.
During an inpatient hospitalisation, the writer James Mumford took part in a form of therapy called acceptance and commitment therapy, which emphasises the subjectivity and personal significance of our values — the idea being that we can better create a more meaningful life if we focus on what is important to us. Perhaps. But Mr Mumford, an ethicist, observed that his therapist seemed to slide too readily into implying that values are entirely subjective, that there are no moral facts. This is a theoretically substantive claim, one that is controversial among philosophers; Mr Mumford tried to engage the therapist in discussion but was brushed off. Here was a situation in which mental health expertise came into conflict with philosophical reflection.
The contemporary cultural landscape’s recent zeal for mental health as an important good has been accompanied by a faith in therapy as the best way to obtain it. Some, including Dr Anhalt in a TED Talk, go so far as to propose that everyone should try therapy. Dr Anhalt even suggested on Twitter recently that therapy become a prerequisite for becoming a parent. The tweet was enthusiastically embraced by some, though she received pushback from those who noted its cultural insensitivity and its resemblance to the eugenic idea of government-issued licenses for parenthood. In the end, Dr Anhalt deleted the tweet.
I have had therapy at various points in my life, including right now. Many more people would likely benefit from therapy than currently engage in it. Nonetheless, I feel more circumspect about the generality of the prescription. Therapy is important as a valuable health intervention for many, rather than a universal prerequisite to a good life. Most people simply cannot afford to have lengthy therapy, or it doesn’t fit with their cultural or religious worldview. Do we really want to suggest that this compromises their mental health or their ability to do things like parent well?
The vagueness of the term “mental health” also means that it is ripe for cynical co-option. When, during the early stages of the pandemic, many Republicans opposed mask mandates in schools, the issue of masks’ effect on children’s mental health was a key talking point. Tucker Carlson specifically raised the issue in a lengthy anti-mask screed, the phrase lending a cheap veneer of clinical authority to his histrionics.
It is insulting to hear platitudes about children’s mental health from a part of the political spectrum that routinely blocks serious action to stop school shootings. Conservatives do draw on mental health as a talking point in this context too, but here it used to draw attention away from the political and societal causes of gun violence. Instead of seeing internationally unparalleled access to guns as a relevant public health issue, we are encouraged to consider the mental health of the shooter. A clear causal link between psychiatric illness and gun violence has not been established, but the imprecision of the term “mental health” allows the argument to prosper. When, in the wake of the Uvalde shooting, Greg Abbott, the governor of Texas, said, “Anybody who shoots somebody else has a mental health challenge, period,” he was saying something that was arguably true, but so trivial and imprecise as to be useless.
As a psychologist, I am heartened by the increase in our attention on mental health. But I see it as one way of looking at our lives among others. Mental health professionals are understandably interested in mental health — but we need to remain interested in how people lead lives that are good, happy or meaningful without ever spending much time with clinicians. When we move away from a focus on psychological problems and toward “mental health” more broadly, clinicians stumble into terrain that extends beyond our expertise. We ought to be appropriately humble. We need to be mindful of the perennial difficulty of defining the boundary between sanity and madness, or of deciding what constitutes a good and valuable life.
This article originally appeared in The New York Times.
Huw Green is a clinical psychologist specialising in neuropsychology.