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Time to stop being one-dimensional

May 1, 2009
by Ronald W. Manderscheid, PHD
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We're focused on disease while neglecting health

For the past threescore years, we in the mental health and substance use care fields have been “one-dimensional” people: We have focused only on disease and its remediation. Our efforts have produced exquisite classification systems for disease and its treatment, and our language has evolved apace: first “schizophrenic,” then “patient,” and now “consumer.”

This one-dimensional focus has blinded us to a much broader universe of possibilities, including the world of health. We really have no corresponding classification system, interventions, or language to reflect mental and addictive health. In the late 1940s, the World Health Organization (WHO) defined health as “a complete state of mental, physical, and emotional well-being.” We need to revisit this concept so that we can begin to apply it in our day-to-day work.

In fact, consumers have been trying to alert us to this second dimension for decades. By endorsing and promoting the concept of recovery, consumers indirectly introduced the health dimension to us. Recovery encompasses new hope, positive affect, and future possibilities. Hence, I think recovery can be thought of as a bridging concept between the dimensions of disease and health (figure).

Figure. The relationships among disease, health, and recovery
This second dimension (health) clearly can foster a world of new possibilities for consumers with mental and substance use conditions. They can become integrated into their support networks and communities; they can begin to live. It also can open up a whole new world for all of us who work in these fields. This dimension accentuates the positive, and it can change the practices employed throughout our fields.

National health reform (repeat, health reform) will focus not only on healthcare but also on health promotion and the determinants of positive health. Because our current, exclusive focus on disease does not work well, yet is very costly, we can expect that reform legislation will target resources on personal and population health promotion, as well as related interventions and measurement systems. We need to be ready for these important changes.

We should pause and ask ourselves several important questions: What research do we have on the shelf regarding interventions that promote mental and addictive health? Which of these interventions have been implemented in our fields? What outcomes have been achieved? A moment's reflection will tell us that the answer to these questions is generally none! None!

Tools are available to help us in this quest. For more than 20 years, work has been under way to define and measure the concept of well-being (Recall the WHO definition). If we can understand well-being's key components, we then can begin to understand the interventions needed to enhance well-being. Kudos to the Centers for Disease Control and Prevention for supporting this work during the past two decades! Not only do we need such work to enhance consumers' recovery potential, we also need it to bring the mental health and substance use care fields to the health reform table.

What are some of the next steps? Clearly, it will be important to consult consumers who have been trying to traverse the recovery bridge. They understand in intimate detail the quest for well-being and health. Their lived experiences can be an important teacher for us. We also should review the key dimensions and measures of well-being, as well as the related research findings, so that we can learn which interventions can promote positive health. Some of these interventions can be naturally occurring in the community, such as community-organized health collaboratives, while others, such as consumer wellness initiatives, may require enhancement at the personal or community level. Finally, we urgently need to undertake community demonstrations to promote positive health among persons with mental and substance use conditions.

A part of our national advocacy needs to be a call for inclusion of the mental health and substance use fields in work that will be undertaken through the Prevention and Wellness Fund recently approved as part of the federal stimulus package. Currently, our fields are not specifically a part of this initiative. Funding through the stimulus initiative could help us to become two dimensional. Otherwise, as you can see, being one dimensional will continue to be very costly in a two-dimensional world.

Ronald W. Manderscheid, PhD, currently Director of Mental Health and Substance Use Programs at the consulting firm SRA International, Inc., worked for more than 30 years in the federal government on behavioral health research and policy. He is a member of

Behavioral Healthcare's Editorial Board.

To contact Dr. Manderscheid, e-mail ronald_manderscheid@sra.com.

Behavioral Healthcare 2009 May;29(5):37-38