1 In October 2021, during the COVID-19 pandemic, the French Ministry of Health issued a warning about a “third wave” of a different kind: a psychiatric wave. This was primarily due to the impact of lockdown, which has been responsible for a slow decline in the “mental health” of the French population.  Since then, the term “mental health” has entered French public discourse as a key health priority. From the “Assises de la santé mentale et de la psychiatrie” conference in September 2021, to the introduction of the “MonPsy” reimbursement scheme for consultations with a psychologist or psychiatrist from February 2022, mental health has become the name of a leading public policy justifying government intervention in the organization of psychiatric care and the promotion of citizens’ well-being.
2 In the 1978 Alma-Ata Declaration, the World Health Organization (WHO) defines health on the basis of two criteria: one positive, as “a state of complete physical, mental and social well-being,” and the other negative, as “the absence of disease or infirmity.” But extending this definition to the field of “mental health” is problematic in a number of ways. First, how would this state of mental well-being manifest itself? It is difficult to see what criteria could be agreed upon to evaluate mental health, since this represents an internal, subjective state at the intersection between the personal and the societal, which eludes a blanket, totalizing definition—perhaps because “well-being” can mean different things to different people.
3 The term “mental health” also presupposes a divide between the normal and the pathological. But unlike in physical illness, mental phenomena do not, strictly speaking, have biological markers by which a pathological threshold might be quantified and defined. They can, however, be observed in what individuals say, and how they behave: and what we observe is a continuum from the normal to the pathological.
4 This dossier looks back at the origins of the concept of “mental health” based on two questions: the concept to which it is opposed, and how it is embodied in patient care. The first article reviews its emergence in the mid-twentieth century, while the second looks at the work of a team of psychiatrists who, for the last thirty years, have been trying to implement and embody the precepts promoted by the concept of mental health, working as closely as possible with the “service users” of a community psychiatry service in Lille. Finally, the third article demonstrates the difficulties still faced by psychiatrists and philosophers in defining mental disorders.
From mental hygiene to mental health
5 The “alienists” of the nineteenth century had little interest in “mental health.” When the subject was addressed, it was at best in the context of issuing a “series of formulas for individuals and families to follow” combining various lifestyle tips, typically relating to child and adolescent development.  It was not until the period between the 1940s and 1960s that mental health became a frame of reference for practice and discourse , with the creation of the National Institute for Mental Health in the United States. In the aftermath of the Second World War, in a world divided into two blocs, the function of mental health was to “turn potential social conflicts, whether in industry or in developing countries, into individual ‘intrapsychic’ conflicts or interpersonal conflicts between individuals that needed to be ‘harmoniously resolved’.”
6 The shift from “mental hygiene” to “mental health” was not therefore simply a semantic one. Due to its very broad scope, mental health acts as a vague unifying term. For the health authorities, this was a strength, as they were easily able to rely on this new term to orient their research and care policies—but for service users it was also a weakness, because these actions indirectly established a norm for their psychological state. In the decades since, mental health has become part of a “biopolitics of emotions and affects”—a way of managing the mental phenomena of individuals using the devices of power.
7 Far from trying to reform the environment responsible for the mental suffering, or tackling “social issues,” health policies aimed instead to intervene at the level of individual psychological factors: “A whole psychosocial clinical practice is thus developed, the main effect of which is to pose the question of socioeconomic development not in terms of social relations, class inequality, or political discrimination, but in terms of ‘feelings of insecurity,’ psychic instability, and nervous tension.” Mental health was part of this strategy.
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Mental health: a humanist example
François Tosquelles (1912–94) and Jean Oury (1924–2014) were psychiatrists and psychoanalysts, and leading figures in institutional psychotherapy.
Lucien Bonnafé (1912–2003) was a French anti-alienation psychiatrist who developed and established community psychiatry in France from the 1960s onward.
9 Based on the WHO’s tripartite foundation of empowerment, recovery, and citizenship, Dr. Jean-Luc Roelandt and his colleagues illustrate the application of these concepts in community mental health care through the experiment in citizen psychiatry they have been running in the suburbs of Lille over the last thirty years. This citizen psychiatry aims to keep patients in the heart of the community and is based on four principles:
- “being” a partner in the patient’s care (rather than “having” partners in care)—a key principle of empowerment and citizenship;
- focusing on prevention by strengthening the presence of health care personnel in the community;
- developing mobile teams providing at-home care;
- promoting service user independence in line with the slogan of American service user associations: “nothing about us without us.”
11 These four principles, put into action in this experiment, have made it possible to establish public psychiatric facilities and provide over 170 housing units for patients, enabling anyone who remained in hospital due to lack of accommodation to be discharged. At the same time, a genuine policy of integrating patients into the community has been implemented: mobile teams have helped to reduce the stigma attached to patients in the community, the municipal authority has freed up hospital beds by rehousing many of the patients, and the number of outpatient consultations has been increased in partnership with primary care physicians. The emphasis has therefore been placed on “ working with the environment ” (rather than changing it), i.e., “preserving social and family ties” and also “supporting caregivers.”
12 Through this focus on “people, not walls,” Roelandt situates the community mental health care approach in the wake of the work of Lucien Bonnafé, who developed community psychiatry in France in the 1960s (developed after the pilot experience of the ASM 13 in 1958), in an era marked by the innovative institutional psychotherapy of François Tosquelles and Jean Oury. This community approach first made it possible to provide care for patients in their own local area, and then evolved later to ensure continuity of care for people “beyond the asylum walls.” It represents an example of humanist psychiatric care.
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The flipside of “mental health”: defining “mental disorder”
14 In the second half of the twentieth century, the concept of mental health emerged in response to the criticism of psychiatry by the “antipsychiatry” movement, which attacked the asylum system as coercive and challenged the idea of psychiatry as a science.  In this article, Maël Lemoine tackles the original question posed by Thomas Szasz, psychiatrist and advocate of antipsychiatry, who, in his 1960 article “The Myth of Mental Illness,” stated that all illness presupposes an organic lesion. Consequently, he claimed that since mental disease has no biological basis, it is in fact merely a myth, and psychiatry cannot claim to be a medical science. 
15 In this article, Lemoine looks back on the 1973 Rosenhan experiment, in which psychiatrists were unable to detect pseudopatients among new admissions to a psychiatric institution. This experiment had a major impact and helped to redefine the category of “mental disorder.” Christopher Boorse, for example, later proposed a definition of mental disorder as attached to a dysfunction, namely “ the inability of part of an organism to achieve the goal that is typical of the way similar organisms survive and reproduce .” This solution was unsatisfactory and widely criticized (think of the example of homosexuality), but then built on in 1992 by Jerome Wakefield with the notion of "harmful dysfunction." According to Wakefield, for a condition to be a disease it is necessary and sufficient for there to be “harm” and a “dysfunction.” He adds that dysfunction is defined as a “ failure to adapt to an environment that has shaped the species through selective pressure at some point in its evolution .” Although it has been attacked many times, this definition is still the reference point for all analyses of the concept of mental disorder.
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17 The more inclusive, flexible, and vague concept of “mental health” can thus be seen as the “positive” side of the restrictive, hard-to-define, and pejorative concept of “mental disorder.” Fundamentally, talking in terms of mental health means trying to describe what contributes to the proper function—rather than dysfunction—of human psychic life, in more consensual terms.
18 This new, “politically correct” term does, however, hide a grim reality for health-care professionals: despite the stated ambitions of mental health policy, there is a conspicuous lack of resources, and some have gone as far as describing mental health as “the poor relation of the French health care system.”  Without proper resources, it is difficult to envisage the large-scale development of the kind of health-care system advocated by Jean-Luc Roelandt: one in which service users are able to work with the environment in order to take back their place in the community.
Translator: Hayley Wood, Editor: Suzy Bott, Senior editor: Mark Mellor
Yannick Kusy, “Covid19: Le confinement dégrade lentement la santé mentale des français, selon le psychiatre lyonnais Nicolas Franck,” France Info, November 17, 2020, available online at: https://france3-regions.francetvinfo.fr/auvergne-rhone-alpes/rhone/lyon/covid19-confinement-degrade-lentement-sante-mentale-francais-psychiatre-lyonnais-nicolas-franck-1895830.html.
2 Thomas Clouston’s The Hygiene of Mind, published in 1906, is a classic example.
3 Erving Goffman, Asylums: Essays on the Social Situation of Mental Patients and Other Inmates (New York: Anchor Books, 1961).
Thomas Szasz, “The Myth of Mental Illness,” American Psychologist 15, no. 2 (1960): 113.
Marie-Cécile Renault, “La santé mentale, parent pauvre du système de soins française,” Le Figaro Économie, December 8, 2020, online at: https://www.lefigaro.fr/conjoncture/la-sante-mentale-parent-pauvre-du-systeme-de-soins-francais-20201208. Translator’s note: Our translation.