“Mental health is the capacity of each and all of us to feel, think, and act in ways that enhance our ability to enjoy life and deal with the challenges we face. It is a positive sense of emotional and spiritual well-being that respects the importance of culture, equity, social justice, interconnections and personal dignity”
Thematic analysis 19 was used to evaluate the core concepts of mental health, followed by triangulation (ie, multiple methods, analysts or theory/perspectives) to verify and validate the qualitative data analysis. 20
First, multiple analysts with knowledge from different disciplines reviewed the data. 20 Our collective areas of expertise encompass the following: animal models of human behaviour; arts; clinical, cognitive, political and social psychology; ecology; education; epidemiology; evolutionary theory; humanities; knowledge translation; measurement; molecular biology; neuroscience; occupational therapy; psychiatry; qualitative and quantitative research; social aetiology of mental illness; toxicology and transcultural health. All transcripts were reviewed by each coder first independently, then collectively, to become familiar with the data and create a mutually agreed on code book using NVivo 10. Codes were organised into themes, and compared and contrasted manually and through NVivo10 coding queries within each major theme and across response items. Initial models derived from the data were created and validated by the multidisciplinary research team.
Second, method triangulation was used to assess the consistency of our findings. 20 Preliminary results from the survey were presented and discussed at the 4th Annual Social Aetiology of Mental Illness Conference (20 May 2014) at the Centre for Addiction and Mental Health, University of Toronto (Toronto, Ontario, Canada). Attendees were divided into five focus groups of 10–12 people facilitated by a project leader and 2 trained note takers. The two consecutive 1 h focused discussions used the ORID method (Objective, Reflective, Interpretive and Decisional) 21 in order to elicit feedback on the methods and results of the survey. All responses from each of the five groups were transcribed by two recorders and disseminated to the research team for individual and collaborative review.
A second round of data analysis was conducted to validate the results according to key areas of interest and critique reported by the conference participants.
Fifty-six surveys were distributed in the first round, 28 in the second and 38 in the third. Fifty people completed the survey (rounds 1, 2 and 3 had 32, 12 and 6 respondents, respectively) with a total response rate of 41%. Two-thirds of respondents (66%) were male and one-third were female (34%). Respondents’ current country of residence/employment included Canada (52%), UK (20%), USA (14%), Australia (6%), New Zealand (2%), Brazil (2%), South Africa (2%) and Togo (2%). The majority of respondents (72%) held academic positions at postsecondary institutions and were conducting research in the broad field of mental health. Sixty per cent were also involved in giving advice to mental health services or managing them. Thirty-four per cent of respondents were clinicians.
Respondents had diverse expertise (see table 2 ). Forty-six per cent of respondents rated the Public Health Agency of Canada (PHAC) 18 definition as their most preferred. However, 30% stated that none were satisfactory. The WHO definition 12 was preferred by 20%. The least preferred definition of mental health was the general definition of health adapted from Huber et al 15 (see table 1 ).
Self-reported areas of expertise
Categories | Examples |
---|---|
Social and community health | Health (global, public, promotion, policy); community development; community empowerment; community research; healthcare access; homelessness; immigration; international development; mental health; social inclusion; social support; sociology, research and programme development |
Human rights: law/ethics/philosophy | Bioethics; child protection; constitutional law; discrimination/stigma; emancipatory approaches; health equity; human rights; philosophy (science, psychiatry); politics; rights activist, systematic advocacy for service users |
Positive health: flourishing/positive psychology/recovery/resilience | Flourishing; happiness; peer support; measurement; mental health recovery (advocacy, research, education, family); social inclusion; injury prevention |
Clinical and biomedical | Biomedical sciences, community based psychosocial rehabilitation; epidemiology; clinical psychiatry/psychology (mood disorders, psychosis), social work, occupational therapy, social psychology; social scientist; chronic health, complex trauma and healing, medicine (end-of-life care/palliative; internal medicine, haematology); HIV; pain, physical disabilities; genetics, outreach, research, youth health, forensics |
Human positioning: anthropology/culture/evolution/geography/history | Medical anthropology; population health (Asia, Latin America, Inuit/First Nations, low/middle income countries); evolutionary biology; history (health, social movements); transcultural mental health, urban geography |
Other | Lived experience; Ehealth; music/dance/performance; event production; innovation; instruction; information and communication technologies |
Analysis of the three open-ended items established four major themes— Positionality, Social/Environmental Factors, Paradigms/Theories/Models and the Core Concepts of Mental Health —and five-directional relationships between them ( figure 1 ). Positionality represented the overarching perspective or point-of-reference from which the Core Concepts were derived; whereas Paradigms/Theories/Models represented the theoretical framework within which the Core Concepts were described. Core Concepts represented factors related to the individual; these were distinguishable from the Social/Environmental Factors related to society. Five significant relationships between these themes were established ( figure 1 ). First, respondents’ theoretical framework (Direction A) influenced the overarching point-of-reference they used to describe the core concepts and vice versa (Direction B). Positionality and Paradigms/Theories/Models significantly influenced the core concepts respondents provided and the corresponding descriptions (Direction C). Respondents described how social and environmental factors impacted the core concepts (Direction D) and reciprocally, how the core concepts could influence society (Direction E) ( tables 3 and and4). 4 ). Feedback from the conference focus groups showed support for these five-directional relationships but questioned whether there was evidence for other direct relationships, specifically the impact of Social/Environmental Factors on both Paradigms/Theories/Models and Positionality . A second round of data analysis confirmed these relationships were not explicitly reported by respondents in the survey. Respondents did not discuss how social factors (ie, education or employment) would impact the adoption of a particular paradigm, theory or model (ie, quality of life, evolutionary theory or biomedical model).
Theme—Positionality
Categories | Participant responses |
---|---|
Binary/conflicting dynamic | “There are two options represented in the philosophy of mental health. EITHER the absence of mental illness/disease/disorder where that is defined in some either value-laden or value-free way. It may be a simple definition (such as endogenous failure of ordinary doing or harmful dysfunction) or a cluster concept. Health is then its absence. Typically such definitions unify mental and physical health. OR the positive presence of something like flourishing. This underpins approaches to recovery in mental healthcare. It risks equating health and wellbeing” (ie, Directions A and B) |
“The core concepts of mental health can be organized as a binary and conflicting dynamic that is seeking integration and resolution. On the one hand we have inequity, adversity, trauma, alienation, exclusion, discrimination, stigma, loneliness, stress and mental overwhelm. On the other we have empathy, compassion, dignity, honesty, innovation, peer support, economic equity, social justice, community involvement, mindfulness and recovery” (ie, Directions B–C) | |
Complexity | “The term means little to me. It is too general and is used, either in the negative or the positive, to indicate such a range of states of being that the term is almost without meaning” |
“Not located only in the person, but in the interaction between the person and her/his environment” | |
“Mental health does not exist within the individual, within the brain, within the neurons or within brain chemicals, or within genes. Mental health is both affected by them all but also has effect upon them all. That relation extends also to everything outside the individual: eg, my relations with myself, other individuals, the human world, my immediate environment, my neighbourhood, culture, society, socio-political-economic systems, my environment and the planet we live on” (ie, Direction A; Directions B–C–E) | |
Dichotomy vs continuum | “The mental wellbeing of the individual as well the ‘health’ of the community in which they exist—social determinants that lead to good or poor mental health—mental health = continuum between mental wellbeing and mental illness—prevention as well as treatment” (ie, Directions B–C–E) |
“Health and illness belong to distinct continuous dimensions” | |
Descriptive vs prescriptive (Hume's law*) | “The key is to shoot for a definition which is in the middle: not to high, so that perfect is required, nor too low…it must have something to do with reasonably good functioning, where reasonably is conceived in terms of the legal standard as average quality. Clearly, you're not mentally well, if you have below-average mental functioning, such that your ability to perform average tasks is impaired” |
“Moreover, what includes too much. The references to spiritual well-being have got to go, as if non-believers have defective mental health by definition—The third [definition] is good, except for the excessively demanding realization of potential. There's a difference between perfect mental health, and just simply mental health, and too many definitions conflate the two…the offered definition is too much and too contested qua definition (as opposed to theory)” | |
“I think all of these definitions are too broad. The first, third, and fourth [definitions] look closer to definitions of the good life, or good community, than of health. Lots of things can cause people problems—poverty, vices, social injustice, stupidity—a definition of health should not end up defining these as medical problems” | |
“There is no definition of positive mental health nor will there be in my view because too many issues are at stake and the most important is the absence of a serious mental illness or other emotional, psycho-physical, and moral problems” | |
“Most of these [definitions] have too much stuff, creating unattainable goals and sounding like they were crafted by a committee wanting to cover all the bases and to be politically correct” |
*Hume's law, that is, an “ought” cannot be derived from an “is” (Segal and Tauber). 22
Theme—Core Concepts
Categories | Core Concepts of mental health |
---|---|
Agency/autonomy/control | “The core concepts of mental health that I find useful are very similar to Amartya Sen's conception of “capabilities”—the things a person is able and substantively free to do in pursuit of a life that the person has reason to value” (ie, Direction C) |
“I would say that the positive subjective evaluation of one's own mental health focuses on the feeling or belief that one can cope with one's life circumstances…I hesitate to include a broader range of negative outcomes since they would be determined by one's circumstances (e.g., the amount of control one has in one's life)…sphere or community (with the distinction between the two being important primarily to allow for the option of an isolated existence by choice versus social exclusion)” (ie, Direction D) | |
Coping with stressors/adapting to change | “The ability to navigate and adapt to one's environment seems key…” |
“Ability to adapt psychologically to adverse circumstances…a sense of social/emotional wellness or maturity in the face of life's vicissitudes (not necessarily happiness, but dealing with life's ups and downs in a relatively effective and steady way)” | |
Balance/stability | “Well-being, with a particular emphasis on resources for living with lucid thinking and emotional depth and stability” (ie, Direction D) |
Meaningful relationships and participation | “Sense of being part of a vibrant society, with agency to make change for your and others, and supportive relationships and governance” (ie, Direction E) |
“The objective evaluation focuses on one's ability to participate meaningfully in one's life sphere or community (with the distinction between the two being important primarily to allow for the option of an isolated existence by choice versus social exclusion). However, meaningful participation is typically defined by local social norms” (ie, Directions D and E) | |
“Being able to offer some sort of product to the society (where you can get your essentials to live), to have empathy for another human being and capable of having an intimate and sustainable affectionate relationship” (ie, Direction E) | |
Dignity | “A state of mind that allows one to lead one's life knowing that one's dignity and integrity as a human being is respected by others, that in the journey of life one's diversity of experiences thereof will be embraced” (ie, Direction D) |
Enjoying life/satisfaction/pleasure | “Mental health is expressed by the ability to enjoy life and love…” |
Hope/optimism for Future | “Mental Health is living a hopeful, fulfilling, self-determining life…” (ie, Direction C) |
Insight/mindfulness/rational thought | “Logic and analyzing of scenarios, reflective & reflexive thinking” |
Themes of Positionality, Core Concepts, Social/Environmental Factors, and Paradigms/Theories/Models. *Indicates answers specifically from the third open-ended question asking respondents to state “what is missing” from the definitions provided for ranking.
The theme of Positionality demonstrated how respondents positioned their conceptualisations of mental health within an explicit or implicit framework of understanding ( table 3 , figures 2 and and3). 3 ). Several respondents described the core concepts in terms of binary or conflicting dynamics or as categorical or continuous . Some respondents pointed to the mutual exclusivity of ‘mental health’ and ‘mental illness’ while others described these concepts as distinct points separated on a continuum or as overlapping. Respondents specified the complexity of mental health, for example, positioning mental health explicitly outside of, and specifically in between, the individual and society. Several respondents framed the core concepts of mental health as descriptive versus prescriptive , arguing that these must be empirically determined and defined (ie, describing what is ) rather than prescribed according to values and morals (ie, describing what should be ). In accordance with Hume's Law (ie, an ‘ought’ cannot be derived from an ‘is’), 22 several respondents cautioned that problems of living, such as ‘poverty, vices, social injustices and stupidity’, should not be defined ‘as medical problems’. Many respondents described mental health in relation to hierarchical levels , and/or temporal trajectories , and/or context ( table 3 , figure 3 ). Respondents articulated the multiple levels at which mental health can be understood (ie, from the basic unit of the gene, through the individual and up to the globe) and how meaning changes across time (ie, mental health described as functioning in line with our evolutionary ancestors, to current developmental mechanisms and including expectations of a peaceful death and spiritual existence) and across context (ie, from region, to race, to culture, to epistemology). In the second round of data analysis, we searched for bias in participants’ reporting of evidence-based models and bias against other sources of information; there was support for objective and subjective sources in conceptualising mental health.
Positionality. The overarching perspective or point-of-reference used to describe the constructs of mental health and illness.
Complexity. Descriptions of mental health in relation to hierarchical levels, and/or spatial directions, and/or temporal trajectories.
A second theme of Paradigms/Theories/Models developed as respondents discussed the need to perceive health through various frameworks (eg, recovery, resilience, human flourishing, quality of life, developmental and evolutionary theories, cultural psychiatry and ecology). Some respondents noted that current definitions of mental health treat problems of living as medical problems, rather than adaptive responses to the conditions that people experience, and that alternative explanations should be considered: “An evolutionary approach to these conditions suggests that anxiety and depression (as responses to social stressors) evolved to help the individual take corrective action that could ameliorate the negative effects of these stressors”. Some respondents emphasised that ‘low’ mental health did not equate to mental illness, but rather a state of hopelessness and lack of personal autonomy, whereas ‘high’ mental health was demonstrated by ‘meaningful participation, community citizenship, and life satisfaction’. Others referenced Westerhof and Keyes's 23 two-continuum model describing mental illness and mental health as related by two distinct dimensions.
The Core Concepts of mental health ( figure 1 , table 4 ) largely described factors relating to the individual—as opposed to society—that are observed in correlation with mental health and which are necessary, to some degree or another, but not normally sufficient on their own to achieve mental health. Concepts related to agency, autonomy and control appeared frequently in relation to an individual's ability or capacity to effectively deal with and/or create change in his or her environment (Directions D–E). Agency/autonomy/control reappeared as an essential component of other core concepts: agency may be required in order to engage in meaningful participation (eg, ‘sense of being part of a vibrant society, with agency to make change for you and others, and supportive relationships and governance’) and in dignity (eg, ‘a state of mind that allows one to lead one's life knowing that one’s dignity and integrity as a human being is respected by others’). A cluster of concepts describing the self signified (1) the subjective experience of the individual as fundamental to well-being and (2) the importance of one's ability, confidence and desire to live in accordance with one's own values and beliefs in moving towards the fulfilment of one's goals and ambitions ( figure 1 ).
Social and Environmental Factors reflected the societal factors external to the individual that affect mental health. Although many respondents listed the basic necessities for general health/mental health (eg, housing, food security, access to health services, equitable access to public resources, childcare, education, transportation, support for families, respect for diversity, opportunities for building resilience, self-esteem, personal and social efficacy, growth, meaning and purpose, and sense of safety and belonging, and employment), some also recommended approaches to achieving social equity (eg, “mental health needs to be protected by applying antiracism, antioppression, antidiscrimination lens to prevention and treatment”) ( figure 1 , Direction D). A distinct category of human rights developed from responses to the third open-ended question (eg, “What is missing?”) ( figure 1 ). Several respondents suggested that a basic standard, analogous to a legal definition, is required ( table 3 ) and/or that “a human rights, political, economic and ecosystem perspective” should be included.
The international exploratory ‘What is Mental Health?’ survey sought the opinions of individuals, across multiple modes of inquiry, on what they perceived to be the core concepts of mental health. The survey found dissatisfaction with current definitions of mental health. There was no consensus among this group on a common definition. However, there was significant agreement among subcomponents of the definitions, specifically factors beyond the ‘ability to adapt and self-manage’, such as ‘diversity and community identity’ and creating distinct definitions, “one for individual and a parallel for community and society.” The Core Concepts of mental health that participants identified were predominantly centred on factors relating to the individual, and one's capacity and ability for choice in interacting with society. The concepts of agency, autonomy and control were commonly mentioned throughout the responses, specifically in regard to the individual's ability or capacity to effectively deal with and/or create change in his or her environment. Similarly, respondents pointed to the self as an essential component of mental health, signifying the subjective experience of the individual as fundamental to well-being, particularly in relationship to achieving one's valued goals. Respondents suggested that mentally healthy individuals are socially connected through meaningful participation in valued roles (ie, in family, work, worship, etc), but that mental health may involve being able to disconnect by choice, as opposed to being excluded (eg, having the capacity and ability to reject social, legal and theological practices). In contrast, Social and Environmental Factors reflected respondents’ emphasis on factors that are external to the individual and which can influence the core concepts of mental health. Many respondents reiterated the basic necessities for general health/mental health, similar to the foundations of Maslow's hierarchy of needs, 24 and their recommendations for achieving social equity.
Descriptions of the core concepts of mental health were highly influenced by respondents’ Positionality and Paradigms/Theories/Models of reference, which often propelled the discourse of “What is mental health?” in opposing directions. The debate as to whether mental health and illness are distinct constructs, or points of reference on a continuum of being, was a common theme. Respondents were either, adamant in asserting the distinction between the descriptive or prescriptive nature of the core concepts, or, ardent in integrating them, producing ideas such as describing mental health as a life free of poverty, discrimination, oppression, human rights violations and war. Respondents’ made repeated references to human rights, suggesting that a basic standard, analogous to a legal definition, is required, and that ‘a human rights, political, economic and ecosystem perspective’ should be included. Again, in the tradition of Hume's ‘ought–is’ distinction, several respondents cautioned that problems of living, such as ‘poverty, vices and social injustices…’ should not be defined ‘as medical problems’. The significance of this issue cannot be understated: while we asked respondents what the core concepts of mental health are , overwhelmingly they answered in terms of what they should be. This finding is similar to other issues in public health policy that address instances of ‘conflating scientific evidence with moral argument’. 15 22 Indeed, a primary criticism of the WHO definition of health is that its declaration of “complete physical, mental, and social wellbeing” 6 is prescriptive rather than descriptive. 15 Such a definition “contributes to the medicalization of society” and excludes most people, most of the time, and has little practical value “because ‘complete’ is neither operational nor measurable.” 15
Accordingly, we propose a transdomain model of health ( figure 4 ) to inform the development of a comprehensive definition for all aspects of health. This model builds on the three domains of health as described by WHO 6 12 and Huber et al, 15 and expands these definitions to include four specific overlapping areas and the empirical, moral and legal considerations discussed in the current study. First, all three domains of health should have a basic legal standard of functioning and adaptation. Our findings suggest that for physical health, a standard level of biological functioning and adaptation would include allostasis (ie, homeostatic maintenance in response to stress), whereas for mental health, a standard level of cognitive–emotional functioning and adaptation would include sense of coherence (ie, subjective experience of understanding and managing stressors), similar to Huber et al 's 15 proposal. However, for social health, a standard level of interpersonal functioning and adaptation would include interdependence (ie, mutual reliance on, and responsibility to, others within society), rather than Huber et al 's 15 focus on social participation (ie, balancing social and environmental challenges). Our results provide further insight into how these domains interact to affect overall quality of life. Integration of mental and physical health can be defined by level of autonomy (ie, the capacity for control over one's self), whereas integration of mental and social health can be defined by a sense of ‘us’ (ie, capacity for relating to others); the integration of mental and physical health can be defined by control (ie, capacity for navigating social spaces). The highest degree of integration would be defined by agency , the ability to choose one's level of social participation (eg, to accept, reject or change social, legal or theological practices). Such a transdomain model of health could be useful in developing cross-cultural definitions of physical, social and mental health that are both inclusive and empirically valid. For example, Valliant's 25 seven models for conceptualizing mental health across cultures are all represented, to varying degrees, within the proposed transdomain model of health . The basic standard of functioning across domains which is proposed here is congruent with Valliant's 25 criteria for mental health to be ‘conceptualised as above normal’ and defined in terms of ‘multiple human strengths rather than the absence of weaknesses’, including maturity, resilience, positive emotionality and subjective well-being. In addition, Valliant's 25 conceptualisation of mental health as ‘high socio-emotional intelligence’ is also represented in the transdomain model's highest level of integration of the three areas for full individual autonomy. Finally, Valliant's 25 cautions for defining positive mental health—being culturally sensitive, recognising that population averages do not equate to individual normalcy and that state and trait functioning may overlap, and contextualising mental health in terms of overall health—are all addressed within the transdomain model .
Transdomain Model of Health. This model builds on the three domains of health as described by WHO 6 12 and Huber et al 15 and expands these definitions to include four specific overlapping areas and the empirical, moral, and legal considerations discussed in the current study. There are three domains of health (ie, physical, mental, and social), each of which would be defined in terms of a basic (human rights) standard of functioning and adaptation . There are four dynamic areas of integration or synergy between domains and examples of how the core concepts of mental health could be used to define them.
We are unaware of any study to date that has asked this research question to a group of international experts in the broad field of mental health. Although our survey sample was small (N=50), it was diverse with regard to place of origin and expertise; it was also further validated by participants (N=58) at a day-long conference on mental health through discussion, debate and written responses. The current study included global experts who dedicate their research and professional lives to advancing the standards of mental health. Of particular note was that little to no consensus among the selected group of experts on any particular definition was found. In fact, this was simultaneously a limitation and strength of the study: the small sample size limited the scope of the core concepts of mental health, but indicated that it was sufficient to demonstrate that there are highly divergent definitions that are largely dependent on the respondents’ frame of reference. It is possible that saturation was not achieved in regards to the diversity of responses. Further, more than half of the survey respondents were from Canada, which may have influenced the preference towards the PHAC definition of mental health. Although there were advantages to using a snowball sampling method, another type of sampling method (eg, cluster sampling, stratified sampling) may have resulted in more varied responses to the survey items. The next logical step would be to survey experts in countries currently not represented and then ultimately survey members of the general public with regard to their conceptual and pragmatic understanding of mental health. One of the a priori objectives for the survey was to eventually create a consensus definition of mental health that could be used in public policy; this objective was not communicated in the survey, nor did we actually ask this question. Our results indicate that finding consensus on a definition of mental health will require much more convergence in the frame of reference and common language describing components of mental health. Even we, as authors, have been challenged by consensus. For example, some of us wish to emphasise that future work should focus on developing an operational definition that can be applied across disciplines and cultures. Others among us suggest further exploring what purpose a definition of mental health would or should serve, and why. In contrast, others among us wish to emphasise the process of conceptualising mental health versus the outcome or application of such a definition. What we hoped would be a straightforward, simple question, designed to create consensus for a definition of mental health, ultimately demonstrated the nuanced but crucial epistemological and empirical influences on the understanding of mental health. Based on the results of the survey and conference, we present a preliminary model for conceptualising mental health. Our study provides evidence that if we are to try to come to a common consensus on a definition of mental health, we will need to understand the frame of reference of those involved and try to parse out the paradigms, positionality and the social/environmental factors that are offered from the core concepts we make seek to describe. Future work may also need to distinguish between the scientific evidence of mental health and the arguments for mental health . Similar debates in bioethics 22 26–28 demonstrate the theoretical and practical limitations of science for proscribing human behaviour, especially with regard to individual freedom and social justice.
Our results suggest that any practical use of a definition of health will depend on the epistemological and moral framework through which it was developed, and that the mental and social domains may be differentially influenced than the physical domain. A definition of health, grounded solely in biology, may be more applicable across diverse populations. A definition of health encompassing the mental and social domains may vary more in application, particularly across systems, cultures or clinical practices that differ in values (eg, spiritual, religious) and ways of understanding and being (eg, epistemology). A universal (global) definition based on the physical domain could be parsed out separately from several unique (local) definitions based on the mental and social domains. Understanding the history and evolution of the concept of mental health is essential to understanding the problems it was intended to solve, and what it may be used for in the future.
The authors wish to extend their gratitude to their colleagues for their generous feedback, constructive critiques and recommendations for the project, and to the many volunteers who organised the conference. Special thanks to Nina Flora, Helen Thang, Andrew Tuck, Athena Madan, David Wiljer, Alex Jadad, Sean Kidd, Andrea Cortinois, Heather Bullock, Mehek Chaudhry and Anika Maraj.
Contributors: All the authors contributed to the conceptualisation of the project. LAM wrote the manuscript. SB, KR, ZD, CL and KM contributed to the content and editing of the manuscript. LAM, SB, KR, ZD, CL and EW created the survey and conducted data analyses. SB, KR and LAM presented findings at the conference. LAM, SB, KR, ZD and EW led the focused discussion groups. KM supervised the project. LM is the guarantor.
Funding: This work was performed with grants from the Canadian Institutes of Health Research (CIHR) for the Social Aetiology of Mental Illness Training Program at the Centre for Addiction and Mental Health.
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed.
Data sharing statement: No additional are data available.
Professor of Psychology and Director of Clinical Training, University of Montana
Bryan Cochran does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.
University of Montana provides funding as a member of The Conversation US.
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The percentage of Americans seeking mental health treatment nearly doubled between 2004 and 2022 , with almost a quarter of the population reporting that they saw a mental health care professional in 2022.
This surge in help-seeking has many potential explanations. The pandemic , along with other external stressors , led to unprecedented high rates of anxiety and depression across all age groups .
Yet the majority of Americans with a mental health condition are not receiving adequate treatment or any treatment at all .
People who are pondering getting help face a lot of decisions with little information about how to navigate the system available to them.
As a licensed clinical psychologist and director of clinical training for a clinical psychology program at the University of Montana in Missoula, I spend a lot of time thinking about how to increase folks’ access to treatment. I also field a lot of practical questions that people have about the process.
It’s a difficult landscape to navigate, particularly when there is a nationwide shortage of mental health care providers .
Mental health conditions – technically diagnoses or disorders – are defined by either feeling distress or experiencing impairment in one or more areas of your life.
If you seek out mental health treatment, a diagnosis is often required for you to receive services. You should seek out professional advice as a first step. Clinicians make diagnostic determinations based on the Diagnostic and Statistical Manual of Mental Disorders , currently in a revised, fifth edition.
Mental health practitioners include, but are not limited to, psychologists, social workers, counselors, psychiatric nurse practitioners and psychiatrists. Many people start with a referral to one of these providers through their primary care provider.
There are clear differences between these professions in terms of training and scope of practice, but all require licensure. The best way to check if a practitioner’s license is valid or if they have had misconduct actions is to do a search for your jurisdiction, the profession (such as psychiatrist), plus “license lookup” or “license verification” to be directed to your state’s official licensure site.
The training of mental health professionals is vastly different within this broad category . Psychiatrists, psychiatric social workers and some psychologists (in states that allow it) are trained in prescribing medications for mental health conditions. Counselors and social workers typically hold a master’s degree that is focused on understanding humans’ well-being, methods of psychotherapy and providing treatment. Psychologists typically hold a doctorate degree and have additional, specialized training in psychological assessment, research and supervision.
The right specialist for you might be determined by your specific needs, such as an assessment or medication, but pragmatic issues are often key factors.
If you are one of the 92.1% of Americans who are fortunate to have health insurance , by law you should receive coverage for therapy that is comparable to what you would receive for medical or surgical procedures. However, mental health care is still difficult to access in many parts of the U.S.
Exact coverage may depend on your deductible, whether the therapist is in- or out-of-network, and the therapist’s rates. Ethical guidelines for all of these professions dictate that a therapist should let you know about their rates, expected course of treatment and your rights as a client as soon as possible in the therapy process. Not all therapists accept Medicare or Medicaid, unfortunately; these plans often reimburse providers at lower rates than private insurance companies .
Often the number of sessions that are covered by insurance is determined by your diagnosis. Your therapist should always be able to tell you the diagnosis that you have and what they have submitted to your insurance company. It’s important to know that many mental health care providers are limited in the types of insurance that they take, if they do so at all. Check with your health care plan to see your exact coverage for mental health services, including more complex situations such as inpatient hospitalization or long-term treatment.
Many communities have excellent school-based health centers for youth and certified community behavioral health centers for all ages. These useful resources often provide “one-stop shopping” for health care and can sometimes provide therapy services on a sliding fee scale.
The exact type of therapy you receive depends on several factors: your diagnosis, your therapist’s specialized training, your goals for treatment and your preferences.
Research indicates that certain treatments are particularly effective for some specific diagnoses . Pay attention to what treatment specialty your therapist provides: Some offer specific approaches such as cognitive behavioral therapy, psychodynamic psychotherapy or dialectical behavior therapy .
Regardless of the specific type of therapy you receive, you can expect to be asked a lot of questions about your thoughts, behaviors and feelings. Information about your past challenges and successes can help to clarify the goals for treatment. Knowing when you started feeling distressed, how it’s affecting your life and what you would like to be different are all important in helping your therapist to formulate a treatment plan.
Some of the things that you talk about in therapy are likely to be painful or difficult, and it’s not uncommon for you to sometimes feel worse in therapy than you felt before. This is because a lot of people have pushed away emotionally challenging aspects of their lives before coming to therapy. Coming to terms with these experiences by sharing them with your therapist is most often beneficial.
Medication and psychotherapy are often used in combination with one another. If the person prescribing your medication and your therapist are two different people, you’ll be asked to sign a release of information for each of them so that they can coordinate your treatment.
For example, you may meet with a psychiatrist just a few times each year, but a weekly therapy session may give your therapist insight into how you are responding to medication on a more timely basis.
Certain conditions may particularly benefit from the combination of therapy and medications. For instance, major depression, obsessive-compulsive disorder (OCD) and panic disorder often have better outcomes with combined treatment . Sometimes the steps that people need to take in order for therapy to be effective, such as gradually confronting feared situations for those with OCD, are more approachable for people who are also taking effective medication.
Research has long established that having one mental health diagnosis increases the risk of having another one ; for example, people who have attention-deficit/hyperactivity disorder, or ADHD, are frequently also diagnosed with other conditions such as anxiety, depression and substance use disorder . Situations where people have more than one diagnosis may also be best treated through a combination of psychotherapy and pharmacotherapy .
Several research studies have indicated that the quality of the therapy relationship based on the client’s feeling of connectedness is an important factor in treatment outcome.
If you don’t feel that there’s a great match between what you need and what your therapist is offering, you should keep looking for a better fit.
Kelly is a high-performance expert and author of Intentionality : A Groundbreaking Guide to Breath, Consciousness, and Radical Self-Transformation . His mission is to help world-changing leaders implement his Intentionality methodology to find new levels of fulfillment and growth in their creative endeavors, relationships, and overall well-being
W hen we talk about effective business strategies, breathing is probably not a concept that crosses our minds. These conversations more often than not gravitate toward the conventional markers of success—market share, competitive advantage, profit margins, and growth trajectories. We picture meticulously crafted plans that map out the path to achieving corporate goals, driven by data analytics, market research, and financial projections.
But what if we took a radically different approach, one where we measured our success on prioritizing our employees well-being, rather than solely focusing on the company’s output? What if we prioritized one simple thing that we all have access to and can deploy at any time: the power of our breath.
It may seem “airy-fairy” or far leaning into the new age movement, but incorporating well-being and mental health into business strategies is starting to gain ground as a transformative trend. It turns out that a happy and healthy workforce is not just a moral imperative—it is a competitive advantage.
In an age where the business landscape is quickly evolving, the modern market demands more than just traditional tactics; it calls for a holistic approach that integrates the human element at its core, especially with the rise of AI. We’ve seen that the next generation of talent is demanding more from their employee experience, one where how they feel at work matters just as much as how they are compensated. And the truth is that companies that actively support their employees' mental and emotional health are also seeing improvements in productivity, morale, and retention.
In reports from Gallup's December 2023 poll , nearly half of U.S. adults, upwards of 45%, reported frequently feeling stress, and this is undoubtedly magnified in the workplace. Many organizations think they have a people problem when, in fact, they have a leadership opportunity. A critical component of effective leadership is identifying whether you are operating from a state of fear, or a state of love. When we are stressed our decisions and behaviors are driven from an unconscious emotional operating system and we contribute to a culture of fear-based incentivizing.
Read More: 6 Expert-Backed Ways To Manage Your Stress
The science of stress can be broken down like this: when someone faces a stressful situation, the amygdala—a part of the brain involved in processing emotions—sends a distress signal to the hypothalamus. Upon receiving the distress signal, the hypothalamus activates the sympathetic nervous system by sending signals through autonomic nerves to the adrenal glands. These glands then release the hormone epinephrine (adrenaline) into the bloodstream. As epinephrine spreads throughout the body, several physiological changes occur. The heart starts beating faster, increasing blood flow to the muscles, heart, and other vital organs, while restricting the blood cells in our forebrain. Pulse rate and blood pressure rise, and breathing becomes quicker.
With our blood now flowing to our limbs in order to help us, quite literally, flee the situation, our cognitive processing, things like rational and logical decision-making, is impaired. We are now operating from a conditioned state of survival, but the challenge is that in the modern-day world, we’re not very good at distinguishing threats from non-threats. And if our limbic system (whose function is to process and regulate our emotions, memories, instincts, and moods) isn’t attuned to know the difference in what we perceive as threats, our decision-making abilities can quickly become compromised. For example, when receiving a distressing e-mail, your body will activate the same stress response that it would if you were evading a saber-toothed tiger back in primitive times. So the experience of dealing with the e-mail includes restricted blood flow to the conscious mind and a reduced conscious awareness of the correlating physiological responses. In essence: you forget to breathe. And this greatly reduces anyone’s capacity to make an intelligent decision or regulate their behavioral or emotional responses in a productive way.
Studies have demonstrated that various emotions correlate with distinct breathing patterns, and by altering our breath, we can influence our emotional state. For instance, when experiencing joy, our breathing tends to be steady, deep, and slow. Conversely, feelings of anxiety or anger often lead to irregular, rapid, and shallow breaths. By consciously adopting the breathing rhythms linked to specific emotions, we can effectively induce and experience those emotions ourselves.
In other words, if the order is reversed and the physiological state is consciously changed, it can have an immediate effect on the psychological state. The quickest way to do this is by employing conscious breathing. One can use the breath to reset their own system, and it can also be employed with a team to release stress and get everyone energetically connected. This can be especially helpful before a team strategy meeting, creative planning, or even at the start of each day since everyone comes in with their own stressors from their individual lives.
One such breath is an “Emotional Clearing Breath,” which can be used to change your energy and calm the nervous system down. First, a negative feeling that needs clearing should be identified. Focus on a recent event or encounter that resulted in a negative reaction. Try to get to the root of what triggered the reaction—not the act itself but what the event activated within. This will be a core emotion like feeling unworthy, unseen, unlovable, unvalued, inadequate, insignificant, helpless, or rejected.
Next, engage in diaphragmatic breathing. Use the inhale breath to fill the belly like a balloon, deepening the breath into the lungs, then empty the lungs and slightly contract the belly to release the air on the exhale. Continue to take big, deep breaths in through the nose while restricting the throat, resulting in an oceanic-sounding breath. Then exhale the air out of the mouth, keeping the restriction of the throat and maintaining the oceanic sound—as if fogging up a mirror with the breath. Once in a rhythm, repeat this inhale-exhale cycle of breath for four rounds and then take a few moments to come back to a natural pattern of breathing. Anchor into the present moment and notice the peacefulness that occurs.
What often stands in the way of our growth is our attachment to outcomes, rather than our attention to our feelings. Breath is the simplest and most effective tool that allows us to respond rather than react and override negative feelings and beliefs. Strategies that emphasize human connection, a collective purpose, and emotional intelligence are proving to be just as crucial as those centered on fiscal prudence. When we include these softer dimensions, we are not abandoning rigor or profitability. Instead, we are enhancing our capacity to connect with customers, inspire employees, and build resilient organizations that thrive in the long term.
Let's get back to the basics and reconnect with our breath as we recognize that the most successful strategies are those that balance the head with the heart, numbers with narratives, and profits with principles. These multidimensional strategies are not just a response to a changing world—they are the blueprint for building businesses that are resilient, sustainable, and truly impactful. In doing so, we will pave the way for a more inclusive, innovative, and humane approach to business that meets the needs of our time.
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"i try not to think too much about my looks in general but of course, being a woman in the country music industry, that’s impossible.".
Reporter's Note: This story explores suicidal thoughts. If you are at risk, please stop here and contact the National Suicide Prevention Lifeline for support at 988.
On Wednesday, Margo Price published a personal essay on writing platform Substack that details the health issues and decisions that went into her receiving a nose operation.
The country and Americana singer — known for songs "Hurtin' (On the Bottle)," "Change Of Heart" and her collaborations with Willie Nelson — has opened up about her choice to undergo septoplasty and rhinoplasty.
In a vulnerable essay titled "As Plain as the Nose on My Face: Why I Got Septoplasty & Rhinoplasty, And Why I Want To Be Completely Transparent About It," Price explains that she's always felt insecure about her nose, and she's been dealing with painful injuries to it since her birth.
"I have broken my nose on multiple occasions and as a child, I felt broken from the start," she writes.
Her nose was fractured when she came out of the birth canal, again on the playground, and injured throughout her adolescence and college years.
"During my twenties and throughout the rest of my adult life, I took several inebriated falls that cemented its crooked and distinct appearance," Price writes.
View this post on Instagram A post shared by Margo Price (@missmargoprice)
In the midst of her injuries, Price began dealing with serious sinus issues around 2017. At first she blamed the "high pollen count in Nashville," but soon found her health issues more severe than ever before.
She had a deviated septum and nasal blockage; Price would face pain, sinus infections, migraines and breathing problems.
On top of that, she was still the target of online appearance-based hate.
"I was bullied online constantly and every time I did any kind of TV appearance, or said something politically that might not align with my fan base, the trolls would come for me," Price writes. "It was deeply painful. Since my career has taken off, I have often wanted to just disappear from existence."
On March 6, 2024, after struggling with her health and insecurity, Price underwent both cosmetic and reparative surgery.
After the surgery, Price writes, "I gazed into the mirror at my reflection, I didn’t recognize the person staring back at me."
She continues, "What had I done? Who was I without my giant, crooked Barbara Streisand-esque nose? Even though it made me insecure and I hated it, my nose had completely defined who I was for decades, it gave me character and empathy I might not have otherwise had."
The cosmetic elements of her surgery were subtle; Price kept a slight hint of her nose bump.
But in the months following her surgery and during her recovery, Price said she struggled with depression, anxiety, and was even borderline suicidal. She felt shame, cognitive dissonance and even nostalgia for her old nose.
Price writes, "I try not to think too much about my looks in general but of course, being a woman in the country music industry, that’s impossible."
"I’ve heard from some friends that people around town are talking about how I look different. I guess that’s one of the reasons why I’m writing this because I just want to take control of the narrative and also be totally transparent about what I did," Price writes.
"I’m tired of feeling the shame of it all. Women are designed to fail. You’ll be shamed for being ugly, then you’ll be called fake and shamed for having work done. We can’t win. It’s so tiring."
And now, Price says she is singing better than ever before, and breathing better than ever before.
Toward the end of the essay, Price writes that American teen girls are in the midst of a mounting mental health crisis and that the CDC reports an unprecedented rise in suicidal behavior.
Nearly one third of U.S. teen girls seriously considered attempting suicide in 2021, Price writes.
Price notes that body image issues and self-hatred can create a big toll on one's mental health.
"I want to tell little girls growing up today that it’s okay to be yourself," she writes. "It’s okay to have a unique look. It’s normal to have stretch marks and cellulite and acne and hairy skin and scars! Beauty fades and it’s what’s inside that really matters."
Price concludes her essay by saying she has once again returned to her music and poetry to help her "climb out of the dark."
"Right now, I’m busy pouring my heart and soul into my music and focusing on my art," she writes.
"Music has always been the thing that has saved me and helped me process my feelings and I don’t know where I’d be today without it."
To learn more about Price's essay, visit margoprice.substack.com .
Audrey Gibbs is a music reporter at The Tennessean. You can reach her at agibbs@tennessean.com.
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Guest Essay
By Hillary Rodham Clinton
Mrs. Clinton was the Democratic nominee for president in 2016.
Last week I had the time of my life at the Tony Awards introducing a song from “Suffs,” the Broadway musical I co-produced about the suffragists who won women the right to vote. I was thrilled when the show took home the awards for best original score and best book.
From “Suffs” to “Hamilton,” I love theater about politics. But not the other way around. Too often we approach pivotal moments like this week’s debate between President Biden and Donald Trump like drama critics. We’re picking a president, not the best actor.
I am the only person to have debated both men (Mr. Trump in 2016 and, in the 2008 Democratic presidential primary race, Mr. Biden). I know the excruciating pressure of walking onto that stage and that it is nearly impossible to focus on substance when Mr. Trump is involved. In our three debates in 2016, he unleashed a blizzard of interruptions, insults and lies that overwhelmed the moderators and did a disservice to the voters who tuned in to learn about our visions for the country — including a record 84 million viewers for our first debate.
It is a waste of time to try to refute Mr. Trump’s arguments like in a normal debate. It’s nearly impossible to identify what his arguments even are. He starts with nonsense and then digresses into blather. This has gotten only worse in the years since we debated. I was not surprised that after a recent meeting, several chief executives said that Mr. Trump, as one journalist described it, “could not keep a straight thought” and was “all over the map.” Yet expectations for him are so low that if he doesn’t literally light himself on fire on Thursday evening, some will say he was downright presidential.
Mr. Trump may rant and rave in part because he wants to avoid giving straight answers about his unpopular positions, like restrictions on abortion, giving tax breaks to billionaires and selling out our planet to big oil companies in return for campaign donations. He interrupts and bullies — he even stalked me around the stage at one point — because he wants to appear dominant and throw his opponent off balance.
These ploys will fall flat if Mr. Biden is as direct and forceful as he was when engaging Republican hecklers at the State of the Union address in March. The president also has facts and truth on his side. He led America’s comeback from a historic health and economic crisis, with more than 15 million jobs created so far, incomes for working families rising, inflation slowing and investments in clean energy and advanced manufacturing soaring. He’ll win if that story comes through.
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It may seem "airy-fairy," but incorporating well-being and mental health into business strategies is transformative, writes Finnian Kelly.
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