Mental health pluralism

Indeed, the question of how to define mental health has received relatively little attention in philosophy especially when compared with related concepts such as mental illness or disorder. Notable exceptions include Macklin (1972), Boorse (1976), Brown (1977), Engelhardt and Spicker (1978), Tengland (2001), Keller (2020), and Wren-Lewis and Alexandrova (2021).

See also Manwell et al. (2015).

Some of these comparisons reflect the structurally different health concepts we operate with. These include but aren’t limited to health as freedom from illness, health as the ability to function, health as fitness, and health as a reserve (Blaxter 1990, p. 16). See also Sholl and Rattan (2020) for a discussion of various concepts of health.

This is not to say that there are no existing anti-pluralist views. The point is that because of the neglect of the question of pluralism in the literature, it is often unclear whether or not existing views on the nature of mental health should be understood in pluralist or anti-pluralist terms. Some do proceed as if there is a single phenomenon or concept of mental health in play (e.g., Tengland 2001, and Wren-Lewis and Alexandrova 2021). But this doesn’t mean that they reject pluralism. The question of pluralism is not on the table in such discussions, and so it is difficult to say whether they take their analyses to be of the phenomenon of mental health, or just one of potentially many mental health phenomena.

Such plurality comes across well in collections on mental health such as Reynolds et al. (2009) and Bhugra et al. (2018), and in textbook treatments such as Pilgrim (2023). See also Mirowsky and Ross (2017) on mental health and development, and Richter and Dixon (2023) on mental health models and measures.

For similar reasons, ‘medical pluralism’ (Khalikova 2021) is not sufficient for mental health pluralism.

On the difference between ‘constitutive’ and ‘threshold’ dependence, see Alexandrova (2017, p. 8).

Though I am yet to find explicit proponents of this specific view in philosophical literature, I interpret Jahoda (1958, pp. 66–73) as accepting a similar view, as she emphasises the diversity of both concepts and types of mental health. See also Hartmann (1981, p. 365) who reminds us that ‘theoretical standards of health are usually too narrow in so far as they underestimate the great diversity of types which in practice pass as healthy.’ For pluralist conceptions of health more generally see Nordby (2006, 2019), Haverkamp et al. (2018), Valles (2018), van der Linden and Schermer (2021), Binney et al. (2024), Kukla (2024), and De Vreese (2024).

C.f., Nordenfelt (1995, p. 6) and Mitchell and Alexandrova (2021, p. 2416).

See also Nordenfelt (1995, pp. 6–7) who offers a substantive philosophical analysis of health, yet aims merely to capture our conventional understanding, which he distinguishes from essentialist approaches. Tengland (2001) applies this to mental health.

See: WHO (2022).

See: WHO (n.d.).

Similarly, see Tengland (2001, p. 16).

Jahoda (1958, p. 8) draws a similar distinction between mental health as ‘an enduring attribute of a person’ and mental health as a ‘momentary [i.e. relatively temporary] attribute of functioning’.

See, e.g., Stuifbergen et al. (1990) and Lindsey (1996).

Positive psychology conceptions of mental health explicitly make room for the co-instantiation of mental health and (so-called) mental illness, see Delle Fave and Negri (2021).

For another example, consider the debate between naturalists (e.g., Boorse 1976, 1977) and normativists (e.g., Reznek 1987, Nordenfelt 1995, and Cooper 2002). Crudely, naturalists hold that health and disease can be analysed in objective, value-free, biological terms (e.g., in terms of biological function/dysfunction). Whereas normativists reject this, and hold that health and disease are thoroughly value-laden (for helpful critical overviews of this dispute, see Nordenfelt 2006 and Kingma 2019). To apply what I’ve argued, we can observe that any naturalist or normativist account of mental health is inherently unclear or ambiguous unless it is related to the question of pluralism. For unless it is so related, we won’t know whether it is to be understood in anti-pluralist terms or pluralist friendly terms—and if pluralist friendly, whether it applies to all or just some forms of mental health (assuming there are multiple forms). Indeed, embracing pluralism opens up the potential for embracing both views (and not in the hybrid way that Wakefield (1992) embraces both views): if, that is, it turns out that some forms of mental health are best understood in naturalist terms, yet other forms of mental health are best understood in normativist terms. Unfortunately, the question of pluralism is largely neglected in the debate between normativists and naturalists.

One exception is Boorse. Though he doesn’t explicitly formulate the question of pluralism, he does seem to embrace a form of it, as he is clear that his value-free naturalist analysis is intended to apply only to a certain conception of health: theoretical health. He understands this in terms of the absence of disease, where this, in turn, is understood as a biological dysfunction. But in addition, he recognises practical health: a ‘value-laden practical counterpart’ (Boorse 1997, p, 97), which he initially understood in terms of the absence of illness (Boorse 1975), but later in terms of other concepts which reflect the values of medical practice, namely diagnostic normality (the absence of clinically detectable pathology), and therapeutic normality (the absence of clinically treatable pathology) (Boorse 1987, 2014).

I am indebted to Alexandrova (2017) who makes a similar argument with respect to well-being pluralism.

Elements of this example are drawn from Inada et al. (2020).

In Alexandrova (2017, p. 8)’s terminology, there seems to be a difference in what mental health constitutively depends on.

I’m assuming that in our specific contexts the psychiatrist isn’t concerned with whether Fabio has the kinds of states that the trainer focuses on (and so I’m assuming that their absence isn’t indicative of mental disorder), and that the trainer isn’t concerned with the disorder status that the psychiatrist focuses on. In other contexts, of course, such factors might be closely connected.

C.f., Circumscription views of well-being (Alexandrova 2017, p. 5).

C.f., Alexandrova (Alexandrova2017, pp. 8–10)’s worries about Circumscriptionist views.

This is akin to versions of monism about well-being that accept what Alexandrova (2017) calls ‘Differential Realisation’, or what Mitchell and Alexandrova (2021) call ‘constitutive pluralism’.

The contexts differ in what is relevant to mental health partly because of the differences in practical concerns/goals, and relationships: e.g., treatment vs moral support, doctor vs friend. (C.f., the differences in the context of palliative care and urban planning discussed earlier).

One might interpret Nordenfelt (1995, pp. 105–112) as endorsing this kind of view, since he claims that the reference class, but not the content, of a health ascription is sensitive to social context. Alexandrova (2017, p. 11) helpfully notes how in the case of well-being such a view is similar to subject-sensitive invariantist positions that we find in epistemology.

And here one might worry that what has been offered is an intuitive rather than a technical case. We haven’t considered whether contextualism about ‘mental health’ is technically possible or plausible by looking at the linguistic side of things. However, I am optimistic on the technical front, as mental health vocabulary seems to satisfy sensible linguistic criteria for context-sensitivity in just the way that well-being vocabulary does (see Alexandrova 2017, pp. 14–16, drawing on Stanley 2004, and Cappelen and Lepore 2005).

This point also applies to the account developed by Tengland (2001), given its similarity to that of Wren-Lewis and Alexandrova (2021). It also applies to a ‘disjunctive’ understanding of the essence of mental health on which it is either being free of mental disorder, or having certain positive psychological states.

C.f. Alexandrova (2017, p. 22).

This assumes that there would be more to being therapeutic than can be extracted from whatever structural core is common to multiple mental health phenomena.

Indeed, there is even an emphasis on plurality within certain psychotherapeutic approaches, most obviously in the approach known as ‘pluralistic psychotherapy’. This approach invovles ‘three pillars of pluralism’ such that a pluralistic practitioner (1) is open to a variety of psychotherapeutic orientations and methods, rather than those of just one particular school, (2) acknowledges and celebrates diversity across clients, and (3) emphasises the different perspectives of therapist and client in the therapeutic process (Cooper and Dryden 2016, p. 3). However, this approach doesn’t entail the further level of plurality that I am highlighting in outlining psychotherapeutic pluralism: wherein there are many forms of mental health which ground many ways of being therapeutic. For one could still endorse pluralistic psychotherapy, and emphasise the plurality of orientations, clients, and perspectives even if one holds that all psychotherapy (even pluralistic psychotherapy) ultimately aims at a single substantive thing, mental health.