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Human mental health is deeply complex and cannot merely be reduced to a checklist of symptoms


Professor Mark Tomlinson is co-director of the Institute for Life Course Health Research in the Department of Global Health at the Faculty of Medicine and Health Sciences at Stellenbosch University. These are his personal views.

We are increasingly seeing a conflation of mental health with mental disorder. And where quite normal responses to adversity become medicalised, and where we squeeze the deep complexity of people’s lives into a checklist of symptoms. 

World Mental Health Day is marked each year on 10 October. The day is intended to bring global attention to issues around mental health and mental disorders. The theme for 2023 is “Mental health is a universal human right and this year the goal is to raise awareness and initiate action to promote and protect the mental health of everybody as a universal human right.

Recent years have brought renewed focus on mental health. There are many reasons for this. Perhaps the most proximal one is the fallout from the Covid-19 pandemic. Lockdowns, school closures, quarantine, and the deaths of millions of people have resulted in a surge of distress, anxiety, depression and suicidality.

The renewed focus on mental health is to be welcomed. There is not a single country in the world where everyone suffering from a mental disorder receives the care they need.

And the poorer the country the bigger the gap between need and treatment. To date, much of the focus has been on identifying symptoms, diagnosis and referral for care. And of course, this is essential. 

But I have increasingly begun to worry about the technical nature of much of this. We are increasingly seeing a conflation of mental health with mental disorder. Where scoring above 11 on a 27-point rating scale has become a sign of depression. It is not. And where quite normal responses to adversity (such as loss) become medicalised, and where we squeeze the deep complexity of people’s lives into a checklist of symptoms.  

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Recently, I had the good fortune to be an adviser on a learning platform that supports youth mental health innovators globally (funded by Grand Challenges Canada). One of these innovators is Organización de los Pueblos Indígenas de la Amazonía Colombiana (Opiac). Opiac works in Colombia in Latin America in partnership with indigenous young people.

The region is characterised by historical trauma, loss of territory, violence, discrimination, economic precariousness, and the breakdown of many social institutions. Deforestation, logging, and forced removal have resulted in many young people losing their ancestral homes and their connection to the jungle and the river.

In recent years there has been a significant increase in the number of young people in this region attempting and committing suicide. In my first engagement with the young people, they were quick to tell me (politely, forcefully and with utter conviction) that “we do not want your checklists of depression or anxiety”. They described these as irrelevant to the situation they found themselves in — no matter what the diagnostic manuals said.

“What we are experiencing is spiritual loss, the loss of our connection to the river, the jungle and our ancestral homes”. “Please don’t talk to us about depression.”

New approaches in understanding mental health

In recent years, through the work of funders such as the Templeton World Charity Foundation (TWCF), there has been a global effort to broaden our understanding of what constitutes well-being and mental health. A key tenet of this is the concept of human flourishing.

For TWCF, flourishing is understood as something holistic encompassing physical as well as mental well-being. At its core is the idea of social connectedness, and that agency and the capacity to act in a focussed way in the world is scaffolded by strong social relationships.

Flourishing is acting in the world with purpose, humility, empathy and with a deep sense of curiosity about the world. For some, it encompasses the spiritual — in its broadest definition — a sense of something larger than ourselves. For some, this might be God. For others it is the sense of awe felt when gazing at the Milky Way, or the wonder at the birth of a child.

I want to touch briefly on three strengths — and to locate them temporally — that I believe are integral to flourishing. These include gratitude (for the things we are grateful for in our past), kindness (being kind in the current moment), and hope (how do we face an uncertain future). We need a mindset shift that targets past, present and future challenges, using gratitude, kindness and hope. 

Gratitude: It is rare that a person has nothing to be grateful for. For many whose lives have been characterised by hurt and disappointment, it may not immediately be obvious. But it may be a teacher who took interest. A neighbour. It might even be a stranger who sacrificed for something that you have now. In South Africa, it might be the thousands of activists who gave their lives in the Struggle against apartheid. Gratitude, almost by definition, makes us focus on the positive. On what we have, rather than what we don’t. Being grateful also makes us less anxious.

Kindness: Kindness is the act of helping another without any promise of reward or punishment. Functionally, it is gratitude in the present moment. Kindness is a key contributor to social cohesion and social connectedness. It is also really good for both the giver and the receiver. And finally, it is closely tied to empathy.

Hope: Hope is the idea that goals can be met through action and agency even though it may not always be clear whether the goals may actually be met. Hope is not optimism. There is some uncertainty in hope, and as Rebecca Solnit has pointed out, unlike optimists and pessimists who already know the outcome, people with hope choose instead to act to make things happen. Hope is about activism. For Solnit, “hope is not a door, but a sense that there might be a door at some point, some way out of the problems of the present moment even before that way is found or followed”.

I am not arguing that the identification and treatment of mental disorders is not essential. It is. As I said earlier, there is not a country in the world where the provision of mental health care meets the actual need.

But what I am suggesting is there is more to it than that.  We are always more than our current symptoms. We have lost touch with the role that the deeply human needs of belonging, social connectedness, gratitude, kindness and hope play in our wellbeing, and how in fact they are likely to be the only way out of our current moment of psychic discontent. DM


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