What is 'Mental Health', Really?

Redefining 'Mental Health' Beyond Productive Output and Toward 'The Good Life'

There is a difference between the asymptomatic life and the good life. I believe that, were the mental health industrial complex to define ‘mental health’ as the latter rather than the former, we would all be better for it. Under current healthcare guidelines, ‘mental health’ instead represents a simple lack of suffering or, perhaps more accurately, enough management of suffering to keep you functional within a society that measures your worth by your productive output. This is actually, in no small part, a philosophical problem. Ideology and philosophy inform theoretical orientation and, therefore, diagnosis, research and intervention. A society’s assessment of ‘health’ cannot be disentangled from its ethics. And so, psychopathology is somewhat subjective. I address this in much more depth in ‘They Convinced you to Love Yourself So you’d Forget to Respect Yourself’:

“The philosophical soil from which modern secular psychology grew was not neutral. As modernity unfolded, materialism replaced metaphysics, and the philosophy of the West became individualistic in essence and capitalistic in manifestation. The physical world became the only world that mattered, and all higher realities were reduced to chemical, biological, or neurological processes. This is demonstrated in its obsession with mental health & wellness. Much of Western psychological research is conducted with the overarching objective of curing mental & emotional suffering (e.g. depression & anxiety) and producing happiness, pleasure and productivity.

In this materialist framework, value no longer derived from moral hierarchy but from the individual’s experience of pleasure and pain. Morality dissolved into preference. The good life was redefined as the comfortable life: the maximisation of happiness and the minimisation of suffering. The individual, detached from community, became the final arbiter of meaning and purpose. However, without a common conception of the good, moral discourse loses coherence; it becomes negotiation rather than truth-seeking. In such a world, the moral language survives, but its substance is gone. We speak of ‘rights,’ ‘authenticity,’ and ‘values,’ yet these words float free from any metaphysical anchor. They are fragments of an older moral architecture whose foundations have long since eroded. It falls on the self to now continually redefine itself, its commitments, and its virtues in response to an ever-shifting social terrain. A fixated commitment to our individualistic pursuit of happiness now lies at the heart of what we perceive as mental and emotional ‘health’.”

Psychology can be, should be, another wisdom tradition. One that takes seriously the question of what it means not just to function, but to live well. What follows is an attempt to name the ten dimensions of psychological progress. Not just the absence of suffering, but the presence of something worth calling ‘health’.

Attachment Security

The first and perhaps most foundational dimension is the one that makes all the others possible: the capacity to feel safe in relationship with another human being. Attachment security, or the lack of it, shapes everything downstream. If you grew up learning that other people were primarily sources of torment rather than comfort, that lesson doesn’t stay in childhood. It follows you into every room you enter, every relationship you attempt, every moment you might otherwise turn toward someone for help (read Attachment—δεσμός—التعلق for a comprehensive introduction to attachment theory).

Peter Fonagy calls this epistemic trust: the ability to receive knowledge and care from another person without the transmission being distorted by fear. For someone with a deeply insecure attachment style, even the most well-intentioned gesture from another person gets filtered through a nervous system that has learned to treat proximity as danger. A therapist or clinician’s job, in part, is simply to be a sustained, reliable presence, someone who keeps showing up, who doesn’t retaliate, who doesn’t disappear, until that nervous system begins, slowly, to revise its assumptions. It is not a quick fix. It is, in many ways, a re-education of the self at its most fundamental level.

Self-Continuity

Self-continuity is, at its most basic, the sense of being essentially the same person moving through time and space. A stable subjectivity. It sounds obvious, of course you’re you, but for many people, this continuity is truly fractured. In my time working in a mental health treatment and assessment unit, there were patients in the depths of depression or psychosis and if I asked what kind of child they were, they would stare back at me as if I had three sets of eyes. Ask them where they see themselves in five years, and you’re met with a blankness much deeper than uncertainty. It’s not that they don’t know the answer, it’s that the question itself doesn’t quite compute.

All human beings slip between different self-states. We’re not the same person at a job interview as we are at two in the morning after a long day. But in healthier functioning, there’s a thread connecting these states, some core sense of me that persists. I can do a bad thing on Monday but still conclude on a Tuesday that I’m a generally good person. When that thread is absent or very thin, you lose what might be called self-continuity or constancy: the capacity to hold good and bad in the self simultaneously, without tipping into the extremes of “I am perfect” or “I am worthless.”

This extends to the body, too. More and more, patients seemed to relate to their bodies as foreign objects, something to be cut, starved, burned, or simply neglected, as if the body were an it rather than a me. Full embodiment, the felt sense that this body is mine and it deserves care, is part of self-continuity. Various forms of dissociation, from mild detachment to more severe fragmentation, are the shadows it casts when it’s missing.

Agency

Agency, self-efficacy (as the CBT world tends to call it), or autonomy (in older psychoanalytic language) is the sense that you have some capacity to influence your own life. That you can make choices. That your life is, at least in part, something you are doing, not merely something that is happening to you.

You tend to notice agency most clearly in its absence. You could ask a patient why they married their wife, and the answer comes back: “I don’t know, it seemed like the thing to do at the time.” Or you gently ask a young woman whether, in a sexual encounter she’s describing, she had actually wanted what happened, whether desire for the other was present, and she looks at you with something close to bewilderment, as if it had genuinely never occurred to her that her own desire was supposed to be part of the equation. Even in extreme situations, complex trauma, even in Gaza at this moment, against all odds, people have found small ways to feel that they have some degree of freedom, choice, effect, some expression of their agency. Not only is this remarkably courageous, but it is crucial. I think of Omar and Ibrahim and their Pheonix Library rising from the ashes (donate or read more here: https://chuffed.org/project/firstgazalibrary). That is agency at its most essential.

Many people carry a profound shame around having needs at all. They accumulate resentment because other people should simply know what they need and provide it, and when you suggest they might try making their needs explicit, they look at you as if you’ve said something vaguely indecent. Helping someone discover that they are allowed to want things, to negotiate for those things, to exist in the world as an agent rather than a recipient, discovering that for yourself, this is central work.

Self-Esteem

The goal here is a self-esteem that is both realistic and reliable, and these two qualities are more distinct than they might seem.

Realistic self-esteem means evaluating yourself against standards that are reasonably high but genuinely meetable. Perfectionists tend to set the bar so impossibly high that anything short of flawlessness feels like failure, which, of course, means they feel like failures almost all the time. The inverse problem is equally real: the person who assumes that everything they say is essentially God’s truth revealed, that everyone around them should be quietly marvelling at their brilliance. Neither is accurate. Neither is ‘healthy’. The realistic part is simply: I’m good enough. Not perfect. Not worthless. Good enough.

Underneath self-esteem, holding it up, is something a little more demanding: self-respect. The two are often conflated, but they are not the same thing. Self-esteem is, in part, an evaluation (how good am I, how worthy, how capable). Self-respect is not an evaluation at all. It is a relationship with yourself built entirely through action, through the private, accumulating evidence of whether you do what you say you will do. You are, in every moment, simultaneously the actor and the observer of your own life. That inner observer does not grade on a curve. It registers constantly whether you are living in alignment with your values or falling short of them, and over time, those registrations become the foundation on which any genuine self-esteem must rest (read They Convinced you to Love Yourself So you’d Forget to Respect Yourself’ for more on this).

The reliable part is subtler. It refers to the stability of your self-regard under pressure. Whether you can receive criticism without being irredeemably flattened, or flattery without it becoming your heroin. Many people have what looks like self-esteem that is, in fact, a very fragile construction, endlessly requiring particular conditions to stay intact. A reliable sense of self can be temporarily dented by criticism or briefly puffed up by praise, but it survives those things. It returns to itself. The story you’ve made of who you are, your values, your sense of your own goodness, holds.

Psychological Resilience

Resilience is, at its core, about affect regulation. It is the capacity to keep yourself within a tolerable range of emotional experience. Not numb, not overwhelmed. Able to feel things without being devoured by them.

Part of this involves what the old psychoanalysts called mature defences: humour, sublimation, the ability to use self-talk to bring yourself back from the edge of a feeling that seems unmanageable. The CBT tradition has been genuinely useful here, the things you can say to yourself, the reframings, the recognition that a thought is not a fact. What used to be called ego strength lives in this territory: can you go through difficult things and still maintain a sense of your own ongoing existence? Can you trust that you will come out the other side?

We understand relatively well why trauma breaks people. What we understand much less is why some people seem to go through the same ordeals as others and emerge not destroyed but stronger. The old phrase, whatever doesn’t kill you makes you stronger, is probably true, but we don’t know who it kills and who it strengthens, and we don’t know exactly why. What we do know is that good relationships (and good psychotherapy) should, over time, make you more robust, less reactive, less likely to regress under stress, better able to face difficulty without it feeling like an annihilation.

Reflective Functioning

Traditional psychoanalysts believed that insight was the engine of therapeutic change, that if you could understand yourself clearly enough, change would follow. Sometimes that’s true. But more often, in practice, it runs the other way: you begin to change, and then insight emerges. You start to experience things differently, and then you can look back and understand what you were doing before, and why.

Reflective function is the capacity to look at your own mind as if it were an object of curiosity rather than a source of verdict. Not I am this way but I notice that I tend to be this way, and I wonder why. It is the difference between being inside a feeling and being able to hold a feeling up to the light. Most of us can do this some of the time. Some people can barely do it at all, they are, in a sense, entirely inhabited by their own states, with no observing distance from which to examine them. If a person has this capacity, therapy moves relatively easily. If they don’t, developing it becomes the first order of business.

And the other face of reflective function is equally important: the capacity to imagine that other people have an inner life too. That the person in front of you is not simply a character in your story, helping you, threatening you, disappointing you, but a subject in their own right, with their own history, their own fears, their own reasons for doing what they do. This is what allows for a real relationship. Without it, you are always, in some sense, alone in a room full of projections.

Self-Advocacy

There is a tension that runs through all of clinical writing, and through all of human life: the pull between the self and the collective. Between advocating for your own needs and subordinating them to something larger, a family, a community, a tradition. Every culture that has ever existed has had to negotiate this tension. What varies is where they place the emphasis.

Western cultures, shaped by the philosophical inheritance described in the introduction, have come down hard on one side. The individual is sovereign. Your needs, your desires, your self-actualisation, these are the supreme goods. We tell children the intoxicating fiction that they can be anything they put their minds to, that the self is the final arbiter of its own destiny. This is not merely a cultural preference. It is a philosophical position, one that elevated the individual to a height that previous civilisations would have found not liberating but disorienting, even impious.

Indigenous, tribal, and many Eastern cultures have traditionally told a different story: that the self finds its meaning not in its own fulfilment but in its usefulness to the whole. That to know your place in a larger fabric is not diminishment but orientation. Western therapists have often pathologised this, reading collectivist cultures through an individualist lens and diagnosing their values as enmeshment, as failure to separate and individuate. But this is not pathology. It is a different account of what a human being is.

What the research actually shows is striking. People who score as psychologically healthy across multiple dimensions are not, as you might expect, those who have found a moderate position somewhere between the two poles. They are strong at both ends.¹ They can advocate fiercely and clearly for themselves when that is what the situation calls for. And they can subordinate their own needs, genuinely, without resentment, to those of another person, a child, or a community, when love or duty requires it. The goal is not the compromise of the middle. It is the flexibility to move between poles without losing yourself in either direction.

This is, in miniature, a rebuke to the individualist framework entirely. True psychological health is not the maximisation of the self. It is the capacity to hold the self lightly enough to give it away when necessary, and to reclaim it when that is what is needed.

Vitality

The people that clinicians often have the hardest time helping are not the most symptomatic. They are not the ones in the most visceral pain. The hardest patients to help are the ones who are, in some essential way, dead inside.

It’s not exactly depression, though it can look like it. It’s closer to a pervasive sort of anhedonia. A flatness, a vacancy where aliveness should be. And when you hear their histories, you often understand how it happened: some natural enthusiasm, some early curiosity or energy, was squelched so early and so thoroughly that it became almost impossible to recover. They arrive in therapy with a kind of defiant passivity.

When a person arrives furious at me, in a paranoid rage about something I’ve done, we’re at least engaged with each other. We’re working something out. But when the response to everything is flat, catatonic even, that deadness is harder to bear than almost anything else. There isn’t much theory about vitality. Maybe there doesn’t need to be. The question is simply: is this person alive to their life?

Acceptance

Psychotherapy is not only about changing things. In fact, a great deal of it, perhaps the majority, is about learning to accept what cannot be changed. You cannot undo what happened to you at six years old. No insight, no effort, no reframe will make it not have happened. What therapy can do is help you stop fighting that fact. To grieve it, really, to let it be a loss rather than an open wound.

This is where positive psychology and I part ways. There’s a version of the pursuit of happiness that refuses to make room for grief, for loss, for the natural weight of a human life. But grief is not pathology. Going through a genuine mourning process in therapy will often temporarily worsen the numbers on a depression inventory scale, and that’s fine. That’s the treatment working. Because on the other side of grief, something opens up. Forgiveness becomes possible. Gratitude, real gratitude, not performed optimism, becomes possible.

Most people go through a phase of blaming their parents, their siblings, their early institutions, and that phase has its uses. But in good therapy, you eventually emerge with something deeper: a compassion for the fact that your parents were who they were because of everything that made them who they were. That was the hand you were dealt. You accept it, you grieve it, and then, perhaps, you can feel genuinely grateful for whatever good there was. I’ve known people who received a terminal diagnosis and found, in accepting it fully, that life suddenly became vivid and precious in a way it hadn’t been before. There’s something about really acknowledging mortality that makes even ordinary things luminous.

Love, Work & Play

When Freud was asked what defined psychological health, what a ‘non-neurotic’ person looked like, his answer was famously brief: “someone who can love and work”. In a later conversation, he seemingly added: “and play, of course”. Together, these three capacities form something like the fullest expression of everything else on this list.

Love, in this sense, has nothing necessarily to do with a particular kind of relationship. It is asking, can you love people as they actually are, rather than as idealised projections of your own needs? Can you be devoted to another person’s welfare? Can you make sacrifices on their behalf? Do they exist to you as a subject, with their own inner life, their own reality, or merely as an object that serves or threatens you? Some people never develop this capacity. It’s worth working toward.

Work doesn’t mean employment. It means doing something that has meaning for you. That meaning might be as simple and profound as: this puts food on the table for my family. Or it might be the deeper satisfaction of work that you love for its own sake. Much of what looks like psychopathology in young people today is, at its root, a crisis of meaningful work. They can get jobs. They can distract themselves endlessly. But they don’t feel like contributors, don’t feel like adults, don’t feel that what they do matters to the communities they belong to. The dignity of work, of any work, rests on the sense that I matter here. What I do counts.

And play, unscripted, adventurous, silly, naturalistic play, appears to do something specific to the developing brain. All known human cultures engage in play. They sing together, dance together, and compete together. Something within us requires it. There’s genuine concern that the decline of unsupervised outdoor play among children, replaced by screens and scheduled activities, may be connected to rising rates of attention difficulties. We seem to need to play in order to learn to focus. And adults need it too. Patients who cannot play are, in a particular way, diminished. Something in life has gone flat for them.

If you cannot love, cannot find meaning in work, and cannot play, you are in trouble. That’s true regardless of what your symptom scores look like.

These ten dimensions are not a checklist. They are not a diagnostic tool or a treatment protocol. They are an attempt to articulate what a human being looks like when they are, in the fullest sense, living. The mental health industrial complex will continue, for now, to measure progress in symptoms reduced and functioning restored. But beneath that narrow accounting, something else is always at stake: whether a person can feel safe with another human being, whether they know who they are across time, whether they have some sense that their life is theirs to live, whether they can love, work, and play. Not clinical variables but the substance of a life. I will confess that I considered adding an eleventh dimension: belief in something larger than oneself. The psychological case for it is not trivial, and I find it personally compelling. That no person can lead a truly adequate life relating only to the material world, and that what sustains people is not just work-related meaning, but a particular kind of meaning, and that kind of meaning arrives when we locate ourselves in a story greater than our own (read ‘Answer to Something Bigger Than Yourself‘ for more on that). But the ten dimensions here are grounded in the available clinical and empirical literature, and they are more honestly applicable across the full range of human lives and convictions. The eleventh remains, for now, a personal conviction rather than a clinical one.

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They Convinced you to Love Yourself So you’d Forget to Respect Yourself

Answer to Something Bigger Than Yourself

Real Psychotherapy is a Form of Worship

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1. Blatt, S. J. (2008). Polarities of Experience: Relatedness and Self-Definition in Personality Development, Psychopathology, and the Therapeutic Process. American Psychological Association.