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In Australia, as elsewhere, the promotion of mental health has lagged far behind the promotion of physical health.1 For instance, despite the publication of a comprehensive review of the evidence for prevention and early intervention in mental illness in 1993,2 the Australian goals for better health published in 1994 saw improved mental health simply as a possible spin off of strategies to reduce the suicide rate and the effects of mental disorders.3 Also, a review of mental health activities across Australia in 1994 concluded that there was, ‘no identifiable “critical mass” of promotion and prevention work in mental health.’4 Despite this, some mental health promotion programmes have been undertaken by enthusiasts, for example promoting the physical health and enhancing the life skills and social participation of people with severe mental illness. The emphasis, however, has been on health promotion in the context of mental illness rather than mental health.
More recently a broader, better conceptualised notion of mental health promotion has begun to emerge in Australia; one that adopts the principles of public health and, while continuing to recognise the importance of preventing and mitigating the effects of mental illness, also emphasises promoting mental health (what is sometimes referred to as promoting positive mental health).
In 1997 in the state of New South Wales (NSW), the Health Department published a framework for identifying and developing mental health promotion initiatives.5 The framework cross tabulated four aspects of mental health promotion ((a) promoting positive mental health and the (b) primary prevention, (c) early recognition and intervention, and (d) treatment and rehabilitation of mental health problems and mental disorders) with the five actions for health promotion articulated in the Ottawa Charter.6 This was a significant advance as it provides a simple, comprehensive model to assist practitioners not only to identify opportunities for action but also to see where their contribution fits into the larger picture. Usefully the document also proposed 11 principles of mental health promotion.
The framework was followed in NSW by a revised mental health care policy, which includes “mental health promotion, prevention and early intervention” as one of six strategic directions. The strategies for achieving this include (mostly unspecified) interventions to (a) enable people to increase control over and improve their mental health, well being, resilience and social functioning, (b) prevent depression, and (c) prevent conduct disorder and aggressive and antisocial behaviours and the consequences of violence. The policy also includes a Charter for Mental Health Care asserting that every person has the right to mental health services that promote positive mental health.7
At the national level a Mental Health Promotion and Prevention Action Plan has been developed as part of the Second National Mental Health Plan: 1998–2003.8 The Action Plan provides a “framework for a co-ordinated national approach to the promotion of mental health and the prevention of mental illness.” Building on “convincing evidence” that preventive interventions can be effective', particularly in the area of child and adolescent mental health, but “a lack of evidence” concerning the effectiveness of mental health promotion interventions, the Action Plan identifies 11 priority groups, seven related to life stages and four to high risk populations. In addition, four groups are identified whose participation is considered crucial to the success of the Action Plan: consumers, carers and community organisations; the whole community; the media; and health professionals. Significantly, the Action Plan explicitly identifies the importance of tackling issues such as poverty, racism, violence, unemployment, workplace practices, parenting skills, self worth, and social relationships.
These developments, in addition to a marked increase in the academic interest being shown in mental health promotion, are very encouraging but two essential elements are still missing from a concerted effort to improve the mental health of the whole community. Firstly, for conceptual and practical reasons we need to develop a more sophisticated understanding of what is meant by mental health and positive mental health.1 Australian government documents have tended to draw on a Canadian definition of mental health: “the capacity of the individual, the group and the environment to interact with one another in ways to promote subjective well-being, the optimal development and use of mental abilities (cognitive, affective and relational), the achievement of individual and collective goals consistent with justice and the attainment and preservation of conditions of fundamental equality.”9 However, different documents have amended it in slightly different ways to define mental health,3 5 8 10 and it has also been amended as a definition of positive mental health.5 Additionally, all the definitions bear similarities to the Australian Aboriginal definition of health: “not just the physical well being of an individual, but . . . the social, emotional and cultural well being of the whole community in which each individual is able to achieve their full potential as a human being thereby bringing about the total well being of their community. It is a whole of life view and includes the cyclical concept of life-death-life.”11
Progress towards a clearer understanding of positive health has been assisted by Ryff and Singer. Their careful analysis of the philosophical issues underlying “the good life” concludes that “a comprehensive assessment of positive health must include both mental and physical components” and “positive human health is best construed as a multidimensional dynamic process rather than a discrete end state.”12 We must, however, exhibit considerable caution about trying to be too definitive. Ryff and Singer themselves draw attention to cultural variations in formulations of “the good life” by illustrating the strongly collectivist thinking of may African peoples, echoing the Aboriginal definition of health above. Also, after attempting with great difficulty to discover what the concept of positive mental health means to ordinary people, Pavis, Masters and Cunningham-Burley conclude that: the concept, not just the actual words, has little salience in everyday life; people firmly expect negative emotions to be part of everyday life; and separating the negative and positive aspects of mental health for the purposes of health promotion does not relate to everyday experience.13
Secondly, there needs to be a greater appreciation that the promotion of mental health, and health generally of course, is an intensely political issue. Mental health is heavily dependent on the values, structures and processes operating at all levels of society. Also, its promotion is, more than any other aspect of health, outside the traditional arenas of influence of the health care services. Thus, the central question for a public health approach to promoting mental health is, “What sort of society, locally, nationally and internationally, do we want to live in?” For instance, are we really promoting mental health when we:
enact policies that polarise resources internationally and intranationally and make it difficult for many to feel part of, and participate fully in, society?
place all the blame on individuals when a child is battered to death rather than examine the social conditions that create child abuse?
ignore for pragmatic reasons the systematic abuse of human rights?
The policies of the health departments of Australia, and elsewhere in the developed world, are beginning to recognise the importance of mental health promotion. The challenge now is to move beyond the policy rhetoric and create not only health care services that promote mental health but also, more importantly, societies that promote health as broadly as conceived by Australian Aborigines and Ryff and Singer.
Addendum Since writing this editorial there have been two further significant developments. Firstly, the Health Promotion Journal of Australia produced a special issue (September 1999) on mental health in Australia, which included articles describing and evaluating interventions designed to improve mental health. In addition, the editorial proposed a model that identified three major dimensions of mental health promotion (the influence of settings, the wider social determinants and personal coping skills), which recognises the importance of the interaction of the person and the environment and takes the debate about mental health beyond the traditional two dimensional clinical/promotive scale.14
Secondly, in the state of Victoria the Health Promotion Foundation has produced a well researched, comprehensive mental health promotion plan.15 The plan's proposed areas of activity are based on a clear framework that incorporates the determinants of mental health, themes and settings for action, outcomes and benefits. The three priority themes for action, based on the perceived determinants of mental health, are social connectedness, freedom from discrimination and violence, and economic participation.