The global shift in the framing of mental health

The importance of framing

The presentation of ideas can drastically alter the way that they are received and acted upon. This is one reason why, for all-encompassing public health matters like mental health, the framing of the problem can fundamentally define the approaches we consider for addressing it.

In the late 1970s/early 1980s, two researchers — Amos Tversky and Daniel Kahneman — laid the foundations of a psychological theory for understanding how the presentation of information affects peoples’ decisions. The key takeaway was the critical importance of message framing: even when the substance of two options are identical, our choices and decisions are highly swayed by the way in which they are presented. In doing so, Tversky and Kahneman transformed our understanding of human behavior by demonstrating that the way we interpret information is strongly biased by the framing of the message or concept.

Consider, for example, that the appeal of a hand sanitizer advertised as killing almost 90% of germs might vastly outweigh the appeal of one advertised as leaving more than 10% of germs behind. While the substance of the two options is effectively identical, the presentation can affect our preferences and influence how we evaluate the available options.

Since then, Tversky and Kahneman’s 1981 paper (The framing of decisions and the psychology of choice)^{Footnote 1} has been cited more than 24,000 times. While the nuance of how different conceptual frames affect our decisions remains a matter of ongoing debate and study, new work has shown that a wide variety of factors (like the emotional tone and context of a message) can influence how we interpret information^{Footnote 2}.

It is unsurprising, then, that this work has since been applied extensively in the context of political decision-making and policy^{Footnote 3} including in the context of public health. The importance of framing goes well beyond simple risk-choice experiments in a laboratory. The framing of a message or concept can affect public perception of major issues and support for policies, and some work has shown that changing the message framing can affect the way that people respond to policies^{Footnote 4}. In short, altering the framing of a concept or message can drastically change the way that people act or respond to it.

The disease-oriented framing of mental health

My name is Anthony Murkar, and I joined Impact Canada as a Behavioural Science Fellow in February 2022. I presently work jointly with the Public Health Agency of Canada’s (PHAC) Behavioural Science Office (BeSciO). When I joined the Impact Canada Behavioural Science Team, I started observing the discourse surrounding mental health in Canada. Prior to joining, I had been working in one of Canada’s largest mental health facilities on primarily pre-clinical models of mental illness. Naturally, the framing of mental health in the context of pre-clinical drug research was usually disease-oriented. When I transitioned into government work, I was met with a very different take on mental health: PHAC’s mandate towards health promotion and prevention of disease places a much greater emphasis on what can be done to improve the mental health of Canadians through preventative measures.

A colleague recently clarified the problem of our current framing of mental health in a striking way: “For many Canadians,” they said, “mental health means mental illness.” Indeed, it has long been the case that mental health has been defined solely as the absence of psychopathologies^{Footnote 5}.

The view of mental health as an ‘absence of mental illness’ certainly framed my own perspectives on mental health. As someone educated with a PhD in Psychology, I was alarmed by the realization that in nearly a decade of psychological education the concept of positive mental health had rarely come up.

Just as the framing of a concept affects choices, so too does the framing of a problem affect the approaches we consider for solving it. The conceptualization of mental health as an absence of mental illness has driven the way we talk about mental health problems as researchers and, subsequently, our approach to solving them.

While the medicalization of mental health has had some positive effects (e.g., reducing stigmatization and broadening the public understanding that mental disease has a biological origin), it has also presented a major roadblock to governments’ approaches to treatment. An illness-centric framing of mental health places the emphasis of intervention solely on those who have already reached a point of crisis. The treatment of disease only targets those with currently active illness, and is therefore unsuitable for making population-level shifts in health. Critically, the evidence indicates that this approach has not been successful at reducing the prevalence, age of onset, or disease burden of mental health problems ^{Footnote 6}. In other words, our efforts were too late: more upstream approaches are needed to promote positive mental health earlier, before problems arise.

Where we are now, how we got here, and the way forward

We are in the midst of a global shift in the way the concept of mental health is framed. For the past twenty-odd years, the characterization of mental health by public health officials has been re-orienting towards a definition that is more conducive to mental health promotion and the upstream prevention of mental health problems and their systemic causes and social determinants. While the idea of framing mental health as a positive factor that is common to everyone (instead of just an absence of mental illness) had been well established over 60 years ago ^{Footnote 7}, positive mental health promotion was still regarded as a new area of work in health promotion as little as two decades ago^{Footnote 8}.

In 1996, the World Health Organization (WHO)’s first Global Burden of Disease study brought mental illness into the spotlight of Public Health, with depression being revealed as the fourth leading cause of disease burden^{Footnote 9}. By 2004 the WHO had published its report on mental health promotion with the aim to shift the framing of mental health away from a sole focus on mental illness as a disease. The aim? Population-level changes that could reduce the disease burden of mental health. While the framing of mental health as the absence of mental illness only targets those with currently active disease, the promotion of positive mental health can instead target all members of society.

In short, by simply re-framing mental health as a positive concept that applies to all members of society, the approaches to targeting mental health were also shifted. By re-framing the concept, the trajectory of new approaches to reducing the global disease burden of mental health was fundamentally changed. The main problems were that an illness-centric model of mental health targets very few people, intervention occurs at too late a stage (only after illness has already begun), and the illness-centric framing largely leads to treating mental health with reactive measures alone.

In contrast, the framing of mental health as a positive trait that applies to everyone instead necessitates a proactive approach that occurs before the onset of mental health problems. Its target is also population-wide — and while the reactive approach was largely failing to move the needle on prevalence of mental health problems, the positive mental health approach demands preventative interventions that instead occur at a much earlier stage (before the onset of mental health issues). Thus, its reach is much broader and it has greater potential for making population-level changes in mental health status.

The WHO’s reports on mental health now explicitly emphasize that mental health is more than the absence of mental illness^{Footnote 10}, and this sentiment has been echoed by institutions around the world. In Canada, our institutions had already been leading the way by pivoting to make the shift to a more inclusive framing of mental health as a positive concept that applies to everyone. PHAC currently defines positive mental health as “the capacity of each and all of us to feel, think, 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.” PHAC has also developed frameworks for monitoring positive mental health and wellness (the positive mental health surveillance indicator framework). Some provincial jurisdictions now explicitly highlight that mental health is a positive concept^{Footnote 11}. Other institutions reinforce a two-continuum model of mental health^{Footnote 12} highlighting that it is possible to experience poor mental health without having a mental illness and vice versa^{Footnote 13} (i.e., that the predictors of positive mental health and the predictors of mental illness are distinct from one another). All in all the reframing of mental health in a positive light has been well underway in Canada for some time.

While this shift in the way we frame mental health is still ongoing, the way forward could not be clearer. Reinforcing these changes in the way we conceptualize mental health around the world continues to be critical towards fostering more upstream approaches that can improve mental health and reduce the global disease burden of mental health problems.