Kecmanovi D.

EDITORIAL UDC 616.89:613.86

WHY PSYCHIATRISTS ARE NOT INTERESTED AND WHY THEY SHOULD BE INTERESTED IN MENTAL HEALTH ZATO PSIHIJATRE NE INTERESUJE I ZATO BI TREBALO DA IH INTERESUJE MENTALNO ZDRAVLJE Duan Kecmanovi1 Abstract: Mental pathology is the primary focus of psychiatrists attention. Yet it is difficult to get a better understanding of mental disorders without knowing what mental health is, what its manifestation are, how it can be defined and recognized. Hence, psychiatrists should be more interested in mental health. So long as they ignore the relevance of mental health to psychiatry, they cannot acquire knowledge about it, and consequently they cannot be competent to provide proper assistance to those in need. Key words: mental disorders, mental health Saetak: U centru panje psihijatara je mentalna patalogija. Ipak, teko je razumeti mentalne poremeaje ukoliko ne znamo ta je mentalno zdravlje, kako se ispoljava, kako se moe definisati i prepoznati. Stoga bi psihijatri trebalo da se vie interesuju za mentalno zdravlje. Sve dok ignoriu znaaj mentalnog zdravlja za psihijatriju psihijatri ne mogu stei znanje o njemu, a stoga ni biti kompetentni za pruanje adekvatne pomoi onima kojima je ta pomo potrebna. Kljune rei: mentalni poremeaj, mentalno zdravlje

1 Correspondence to: Duan Kecmanovi, MD, PhD. E-mail: dkecmanovic@gmail.com * Received March 1, 2011; accepted March 14, 2011.
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A review of the titles of papers published in most prestigious psychiatric journals over the last twenty or thirty years sufficies to demonstrate how scanty interest psychiatrists have in mental health as compared to their interest in mental pathology. One comes to the same conclusion, if they inspect the most frequent topics of psychiatric conferences, seminars, and congresses held in this period. Furthermore, psychiatry textbooks devote very limited space to mental health, its dimension and its definition. With the exception of very few textbooks for example, Signs and Symptoms in Psychiatry1 and Comprehensive Textbook of Psychiatry2 there is no psychiatric textbook in which a chapter deals with mental health and the numerous questions that arise when trying to define it. In this text I will indicate why psychiatrists should be more interested in mental health. Prior to doing this I will point at the possible reasons why psychiatrists do not pay due attention to mental health or even pay lip service to it. Why Are Psychiatrists Not Interested in Mental Health? First, the majority of psychiatrists are more interested in practical aspects of their job than they are keen on pondering issues related to the basic notions of psychiatry, such as mental disorder and mental health. Psychiatrists leave the deliberation about these topics to those among them whom they consider as theoretically-minded. And they are certain these people deal with less important issues than they do. They themselves care for those in need, as they put it, all day long, without asking themselves and others how to tell the difference between mentally sound and mentally deranged people, what kind of general concepts underpin this or that definition of mental disorder and/or mental health, and what are conceptual grounds of psychiatry. Question as what is mental disorder are considered purely theoretical and as such have nothing to do with their day-to-day clinical practice. Second, any deliberation about the cited questions cannot help but to imply a critical view of psychiatry because psychiatrists have not provided satisfactory answers to those questions. 2

The key psychiatric concepts are in question. The paired concept normal and abnormal are the key concepts of psychiatry, and the determination of the exact locus of the boundary between them is the crucial problem of psychiatry, as Devereux 3 put it. (Devereux means pathological by abnormal.) Since these questions are related to the basics of psychiatry, the majority of psychiatrists believe that considering such questions is, in fact, criticism of psychiatry. And no one likes to have the fundamentals of the job they do disputed. Therefore, psychiatrists prefer to keep away from discussing the key concepts of psychiatry including mental health. Third, psychiatrists often mention that mental health is the topic of psychology rather than that of psychiatry. The wide-spread belief is that psychologists, with the exception of clinical psychologists, deal with undisturbed, and psychiatrists with disturbed psyche. Though there is a ring of truth in such a belief, the question might be raised why clinical psychologists treat issues related to mental health more frequently and more studiously than psychiatrists do. If one surveys the titles of papers published in clinical psychology journals, it is not difficult to infer that this is the case. The possible answer is that psychology students are thought more subjects related to the mental sides of human beings than psychiatrists are, and thereby psychologists are more familiar with mental health issues, more qualified to discuss them, and more interested in them. When these circumstances are taken into consideration, it becomes clear why psychologists more than psychiatrists deal with mental health, and why psychiatrists are not intent on changing anything in such a division of labour regarding deliberations about mental health. Fourth, mental health has more numerous and more various meanings than mental disorder. And what is particularly important, the category of mental health is used in more areas of social life than the category of mental disorder. Here are some meanings of mental health. Mental health is a norm; a form of behaving, feeling, relating to oneself and others that is most widespread in a given society; mental health is an ideal belief and behaviour pattern; it is one of the key dimensions or manifestations of a human being; it is built

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into the foundations of the social life insofar as a mentally healthy individual is the individual who is able to love and work (S. Freud), and there is no community where people are not able to love and work. Also, mental health is a state of mental homeostasis, as well as resistance to stress, and the capability of living with ones own contradictions and frailties. Those who are in power in a given society rely on mentally healthy, as in the sense of mentally normal individuals. They cannot stay in power without mentally normal people who are crucial to keeping the social status quo alive and well. Psychologists, philosophers, sociologists, and anthropologists are much more interested than psychiatrists in these trans-psychiatric dimensions of mental health. On the other hand, psychiatrists are mostly happy with a disease or medical definition of mental health according to which mental health is absence of disease. This kind of definition is also called a negative definition of mental health. Fifth, psychiatrists cannot charge the services they provide to mentally healthy people. Insurance companies are reluctant to cover the bill for services provided to mentally healthy people. Insurance companies merely disregard the fact that a good number of the mentally healthy people have mental problems, and that they need assistance of general practitioner, clinical psychologist, or psychiatrist. Since they cannot have the bill covered for the services provided to mentally healthy people who are in need of psychological-psychiatric help, psychiatrists pathologize the mental difficulties of healthy people, their problems in living. They diagnose their problems as mental disorders. Over time, they forget that they have pathologized problems in living of healthy people. Thus, even when they treat mentally healthy people it is far from them that they deal with people who are not mentally disturbed, and that consequently they should show interest in mental health, study it, analyze its various manifestations or states. Sixth, psychiatrists tend to misidentify mental health states as pathological states. A good example is conflating sadness with cause, or normal sadness, and depressive disorder which develops for no apparent reason. Allan V. Horwitz

and Jerome C. Wakefi eld 4 have shown that the recent epidemic of depressive disorder results from covering quite normal states of sadness which develop secondary to some loss with the notion of depressive disorder. The guess is that if psychiatrists were more cognizant of mental health and its various manifestations, they would not confuse sadness (mental health) with depression (mental disorder). Seventh, questioning the very existence of mental disorder has a long history, as long as the history of psychiatry is. It goes without saying that those who question mental disorder are actually questioning psychiatry. A number of psychiatrists reacted angrily to this questioning and published papers and books, showing that claims about the dubious existence of mental disorder are unsubstantiated. Thus psychiatrists, or at least a number of them, were forced into thinking and re-thinking about mental disorder, analyzing its definition, trying to figure out what mental disorder is all about. Antipsychiatrists were the leading figures of such attacks on psychiatry in the 1960s and 1970s. Yet the existence of mental health has rarely been questioned; in any case much less frequently than the existence of mental disorder. So the psychiatrists did not feel prompted to explain mental health, what it consists of, how it is defined. When someone challenges mental disorder, psychiatrists as professionals feel threatened. Questioning the existence of mental health does not cause the same feeling among psychiatrists. 5 Eighth, the costs of mental health services are mounting. So are the costs incurred by work absenteeism, diminished productivity, and invalidity of mentally ill people.6 As a result, the significance of mental illnesses for the society is enormous. Since thus mental disorders are in the focus of public attention, mental health is given second-rate importance. Psychiatrists mainly espouse such way of looking at mental health. They tend to overlook or completely disregard the mental health concept and accordingly controversies and dilemmas associated with it. Why Psychiatrists Should Be Interested in Mental Health Is there any need for a definition of mental health, be it scientific or non-scientific? Furthermore, 3

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is it better to have one universally agreed-upon definition of mental health, or is it more appropriate to have many different definitions? John K. Wing wrote that he is not sure that a scientific definition of mental health should be sought. Virtually all that is scientifically useful seems to be better dealt with by discussing the prevention of disease, and here various concepts of fitness may be useful. The remaining component is the definition of mental health can then be seen for what it ispertaining to art, myth, and social tradition, rather than to science.7 Indeed, opinions are split as to whether there should by a definition of mental health. Some authors (for example, David Freides 8) are of the view that the notion of mental health should be eliminated. They cite the multitude of the definitions of mental health as corroborating their position. Others (for example, Maurice Korman 9) are of the opinion that the notion of mental health should be kept, and that an operational definition should be formulated. My view is that mental health workers need to know what mental health is all about. They should deliberate about the nature of mental health, about its dimensions and manifestations as well as about its definition. Mental health should be high on the agenda of those who provide care to the mentally healthy and mentally ill people alike. I will substantiate my claim as follows. First, there is belief that no one is totally mentally healthy or mentally disturbed, but rather both at the same time, only to various extents. Thus the relationship between mental disorder and mental health should be inspected. Can they be presented dimensionally, or are mental health and mental illness qualitatively different, and cannot be presented on one dimension? When they treat people with mental illness psychiatrists try to boost health potential in patients, to make it stronger. The idea is that it will develop and eventually prevail. In order to know what the health potential is like psychiatrists should get acquainted with the concept of mental health, with mental health dimensions; briefly, they should know what mental health is all about. Jahoda maintained that it will take special efforts to introduce concern with health into clinical work 4

with the sick. And she added: But such efforts may well be worthwhile.10 Second, in psychiatric research the notion of mental health cannot be avoided, at least not in any research in which control group is used as a methodological device. A control group consists of mentally healthy subjects. Since in terms of methodology the control group is as important as the experimental group, one could expect researchers to pay as much attention to mental health as they do to mental disorder. Members of experimental groups are required to be the same in regard to as many variables as possible, first of all in regard to diagnosis. They have to suffer from the same mental disorder. It is extremely rare for the question to be raised whether the members of the control group are the same as far as their mental health is concerned. It is taken for granted that they are the same due to the mere fact that they are mentally healthy, that is, that they do not display the symptoms of any mental disorder. However, that is not the case. The manifestations of mental health are numerous and various. If mentally healthy people are the same, they are not the same in the same way. To date, psychiatric researchers have been focused on mental disorder, on diagnostics and the classification of mental disorders. It is high time they paid more attention to mental health, if for no other reason than to make the members of the control group as similar to one another as possible. And this cannot be done without knowing what mental health is, and who healthy subjects are. Third, as demonstrated by Corey L.M. Keyes 11, a great many individuals who are not mentally disordered do not feel healthy and do not function well. Nearly half of adults receive mental health services annually because a mental health problem is inferred, meaning that there was no diagnosable disorder. Since they so often treat mental health problems in people who have no diagnosable disorder psychiatrists should learn more about mental health, its manifestations, its deficiencies and imperfections. Fourth, mental health is the key category of any kind of psychiatric treatment. The same question re-emerges all the time: what is the goal of the treatment? To reduce the number and intensity

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of symptoms, or to make the patient as healthy as they were before they fell ill, or to make them healthier than they were before they fell ill, or to make them as healthy as the normal mean (This last goal is quite often mentioned in the context of psychodynamic psychotherapy). Ernest Jones, the most renowned biographer of Sigmund Freud, also thinks that the definition of mental health will be helpful in the assessment of the result of the therapeutic intervention. What constitutes a normal mind, and whether such a thing can actually exist, are questions of considerable technical, and sometimes of practical, interest. Even if we conclude that in an absolute sense no mind can be entirely and completely normal, it is nevertheless worth asking what the attributes of such a mind would be. For, with such a standard before us, it would be easier to determine how far a given mind under treatment had progressed in the direction of normality.12 Obviously the notion of mental health is unavoidable whenever the goal of the treatment is discussed, whenever the question is raised: what do we want to achieve by the use of a particular treatment. In this sense Aubrey Lewis13 appropriately remarked that if psychiatrists could agree on the concept of mental health, there would be more accordance in regard to therapeutic efficacy and treatment goals. Fifth, an agreed-upon definition of mental health is a prerequisite for designing programs aimed at improving the mental health of the population. And how can mental health of the population get improved if there is no knowledge of what mental health is, if we do not know what we would like to improve and consequently what the expected result of epidemiological endeavours should be. Sixth, a better knowledge of numberless variants of mental health is essential in early intervention in psychosis. If psychiatrists are not well-informed about numerous manifestations of mental health, if they are not skilful enough at recognizing them, and are not keen on studying them in depth, they run the risk of confusing oddity, eccentricity, developmental variations, prodromal symptoms, and risk syndromes. There is no need to stress how serious consequences might have psychiatric and particularly medical intervention in states that fall (more) at the site of normality than pathology or risk of pathology. 14

Seventh, a classification of mentally normal states is long overdue. The statement that there is one mental health and many mental disorders is faulty. The same as there are many forms of mental disorder, there are many kinds of mental health. Normatology, the science of mental normality, deals with the latter. 15, 16 Many misunderstandings and misnomers would be eschewed if psychiatrists made efforts to identify various forms of mental health, if they gave them the particular names, and if they classified them. And they cannot achieve this, if they deem that research on mental health and dealing with mental health is not their cup of tea. Conclusion In spite of its relevance to their profession, psychiatrists do not reflect on mental health as much as they should do. There are numerous reasons for their comparatively scanty interest in mental health. The fact that psychiatrists are primarily trained to deal with mental disorder rather than mental health seems to underpin psychiatrists disregard of mental health. Given the importance of the notion of mental health not only for the consideration of conceptual issues but also for day-to-day clinical practice psychiatrists are due to pay more attention to mental health. The first step they should take in the right direction is to stop considering themselves as experts at pathology and nothing but pathology. Corresponding changes in psychiatric curricula would be instrumental in making psychiatrists familiar with mental health issues. Those who approach psychiatrists seeking help will be the major beneficiaries of such change of perspective. Disclosure The author reports no conflicts of interest. The author alone is responsible for the content and writing of this paper. REFERENCES
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