Title of the module: What is poor mental health?

Organisation: Institute for Roma and Minorities Inclusion

Providing the facilitators with the up-to-date knowledge on the mental health theories (e.g. analytical/developmental, behavioural, cognitive, social, humanistic) in the context of poor mental health, mental disorders, and mental illnesses.

Learning goals of the module:

After completing this module, the learner will be able to:

• Define Poor Mental Health
• Differentiate between psychological approaches to mental health and non-pathologizing approaches to philosophical counseling.
• Understand how philosophical counseling helps empower migrants and refugees to gain a sense of agency and navigate challenges within their cultural and social contexts.
• Develop the ability to assess when to apply philosophical counseling and when to refer individuals to clinical mental health care.
• Understand the importance of professional ethics in making decisions about intervention methods for migrants and refugees.

Theoretical Foundations of Mental Health

Mental health is a complex and multifaceted aspect of human well-being, influencing how we think, feel, and act. Understanding the theoretical foundations of mental health helps to explain how mental health problems arise and how they can be treated or managed. Various psychological theories provide insights into the factors that contribute to mental health, offering different perspectives on why individuals might experience poor mental health and mental disorders. These theories also guide interventions and support strategies in clinical and non-clinical settings. This description explores several key psychological theories—analytical/developmental, behavioral, cognitive, social, and humanistic—that form the foundation for understanding mental health.

1. Analytical/Developmental Theory (Freud and Erikson)

The analytical or psychoanalytic theory, developed by Sigmund Freud, emphasizes the role of unconscious processes, childhood experiences, and internal conflicts in shaping an individual's mental health. Freud proposed that unresolved unconscious conflicts from early childhood could manifest as emotional difficulties or mental health disorders in adulthood. Central to Freud’s theory is the concept of the id, ego, and superego—the three components of the psyche that interact to balance desires, moral standards, and reality.

According to Freud, if these unconscious conflicts are not addressed or resolved, they can lead to symptoms of poor mental health, such as anxiety, depression, or neuroses. For example, repressed memories or unresolved trauma from childhood may later influence adult behavior and emotional health.

Erik Erikson, a key figure in developmental psychology, extended Freud’s work by emphasizing the role of social and cultural factors in human development. Erikson’s psychosocial stages of development outline how individuals face specific challenges or conflicts at each stage of life. The successful resolution of these challenges is essential for the development of a healthy identity and good mental health. For example, in adolescence, the challenge of forming an identity (vs. role confusion) is central to mental health development, and failure to resolve this stage can contribute to struggles with self-esteem and identity in adulthood.

2. Behavioral Theory (Pavlov, Watson, Skinner)

The behavioral theory focuses on observable behaviors and the idea that mental health issues can be understood as learned responses to environmental stimuli. This perspective argues that behaviors, including those associated with poor mental health, are learned and reinforced through experience.

Ivan Pavlov’s classical conditioning theory demonstrated how a neutral stimulus could become associated with a particular response. For instance, a person may develop a phobia (an irrational fear) through a traumatic experience, such as being bitten by a dog. The fear of the dog becomes linked to the presence of any dog, leading to an anxiety response even in neutral situations.

John B. Watson, a behaviorist, extended Pavlov’s ideas, suggesting that all behaviors, including those associated with mental health, are learned through conditioning. According to Watson, fears and phobias could be conditioned through repeated experiences. This understanding led to the development of behavioral therapies, such as exposure therapy, which aims to unlearn maladaptive behaviors by confronting them in a controlled and gradual manner.

B.F. Skinner, another key figure in behavioral theory, focused on operant conditioning, where behaviors are influenced by their consequences (reinforcements and punishments). According to Skinner, behaviors that are reinforced are more likely to be repeated, while behaviors that are punished tend to be extinguished. This concept is widely applied in behavior modification techniques used to treat mental health disorders, such as anxiety disorders or addictions, by reinforcing positive behaviors and discouraging harmful ones.

3. Cognitive Theory (Beck, Ellis)

Cognitive theory focuses on the role of thoughts and beliefs in shaping an individual's mental health. This perspective suggests that our mental health is heavily influenced by how we perceive and interpret events, rather than the events themselves. Aaron Beck, one of the pioneers of cognitive therapy, developed the Cognitive Triad, which posits that individuals with poor mental health often hold negative thoughts about themselves, the world, and the future. These distorted thoughts can contribute to mental health problems, such as depression, anxiety, or post-traumatic stress disorder (PTSD).

For instance, someone with depression may have negative self-beliefs like "I am worthless" or "Nothing ever goes right for me," leading to a cycle of negative thinking that exacerbates the symptoms of depression. Cognitive therapy seeks to challenge these distorted thoughts and replace them with more balanced and realistic ones, thus improving mental health.

Albert Ellis developed Rational Emotive Behavior Therapy (REBT), which emphasizes the role of irrational beliefs in creating emotional distress. According to Ellis, mental health issues arise when individuals hold unrealistic or unreasonable beliefs about themselves and the world. For example, the belief that "I must be perfect at everything I do" can lead to anxiety and frustration when perfection is unattainable. REBT helps individuals identify and dispute these irrational beliefs to reduce emotional suffering.

4. Social Theory (Vygotsky, Bandura)

Social theories emphasize the role of social interactions, culture, and environment in shaping mental health. Lev Vygotsky, a Russian psychologist, argued that cognitive development and mental health are profoundly influenced by social interactions and cultural contexts. His concept of the Zone of Proximal Development (ZPD) suggests that individuals grow and develop mental health through interactions with more knowledgeable others (e.g., parents, teachers, peers). A lack of supportive social relationships or cultural stressors can contribute to poor mental health, especially in children and adolescents.

Albert Bandura, a leading figure in social learning theory, argued that individuals learn behaviors through observation, imitation, and modeling. This theory highlights how social environments, including family, peers, and media, influence mental health by shaping how individuals perceive and react to the world. Bandura's work also emphasizes the concept of self-efficacy, which is an individual’s belief in their ability to influence their own outcomes. Low self-efficacy, often resulting from negative social experiences, is associated with mental health challenges like depression and learned helplessness.

5. Humanistic Theory (Maslow, Rogers)

The humanistic theory offers a positive perspective on human nature, focusing on self-actualization, personal growth, and the inherent desire to achieve one’s full potential. Abraham Maslow's hierarchy of needs suggests that individuals must satisfy basic needs (such as food, safety, and belonging) before they can focus on higher-order needs like esteem and self-actualization. Poor mental health can arise when individuals' basic needs are not met, which can prevent them from achieving personal growth and fulfillment.

Carl Rogers, another key figure in humanistic psychology, emphasized the importance of a non-judgmental, empathetic environment for personal growth. According to Rogers, mental health challenges can result from a mismatch between an individual’s self-concept and their actual experiences. People may develop anxiety, depression, or low self-esteem if they feel that their true selves do not align with societal expectations or their own self-image. Humanistic approaches to therapy aim to create a supportive environment in which individuals can explore their feelings and achieve greater self-acceptance.

Sources:

Freud, S. (1923). The ego and the id. International Psychoanalytic Library.

Erikson, E. H. (1980). Identity and the life cycle. W. W. Norton & Company.

Pavlov, I. P. (1927). Conditioned reflexes: An investigation of the physiological activity of the cerebral cortex. Oxford University Press.

Beck, A. T. (1979). Cognitive therapy and the emotional disorders. Penguin.

Vygotsky, L. S. (1978). Mind in society: The development of higher psychological processes. Harvard University Press.

Maslow, A. H. (1943). A theory of human motivation. Psychological Review, 50(4), 370–396. https://doi.org/10.1037/h0054346

Understanding and addressing mental health in vulnerable populations, such as migrants and refugees, requires a nuanced approach. Traditional psychological methodologies often focus on identifying and treating clinical symptoms like anxiety, depression, and PTSD. These methods lean on diagnostic frameworks (e.g., DSM-5) to address mental health as a pathology. In contrast, philosophical counseling offers a non-pathologizing alternative. It views challenges not as mental illnesses but as existential dilemmas, emphasizing personal meaning-making and agency.

Psychological Approaches: The Clinical Lens

Psychological interventions are often structured around evidence-based frameworks like Cognitive Behavioral Therapy (CBT) or trauma-focused therapies. They address:

1. Trauma Symptoms: Techniques to mitigate flashbacks, hypervigilance, or emotional numbness.
2. Emotional Regulation: Teaching skills to manage overwhelming feelings.
3. Behavioral Patterns: Encouraging habits that foster psychological stability.

While effective, these approaches may inadvertently reinforce a medicalized view of distress, potentially stigmatizing individuals who experience suffering as a natural reaction to upheaval, displacement, or loss.

Philosophical Counseling: A Non-Pathologizing Perspective

Philosophical counseling takes a human-centered approach, asking not what’s wrong with you? but what matters to you? Rooted in philosophical traditions, it helps individuals explore life’s fundamental questions—identity, purpose, and belonging. Philosophical counseling rejects diagnostic labels, instead addressing:

1. Meaning-Making: Helping individuals articulate personal values and goals amid challenging circumstances.
2. Existential Resilience: Framing suffering as part of a broader human experience, enabling individuals to find strength in adversity.
3. Dialogical Methods: Using reflective conversation to unpack deeply held beliefs or cultural narratives.

For migrants and refugees, this approach can affirm their humanity beyond the confines of victimhood. It fosters empowerment by respecting their agency and cultural context.

Relevance to Migrants and Refugees

Migrants often grapple with identity fragmentation, loss of cultural anchors, and uncertainty. Philosophical counseling can uniquely support them by:

1. Cultural Sensitivity: Allowing space to reconcile their heritage with new societal norms.
2. Empowerment: Encouraging self-defined goals rather than externally imposed solutions.
3. Building Connections: Creating safe spaces for dialogue to bridge misunderstandings between migrants and host communities.

For example, a refugee questioning their place in a new country might benefit from exploring ideas of belonging and community within philosophical frameworks, such as Ubuntu’s emphasis on interconnectedness or Stoicism’s resilience principles.

Practical Applications in Integration Programs

Incorporating philosophical counseling into integration services could complement psychological care:

• Workshops on Existential Resilience: Facilitators could lead group discussions about navigating change and finding meaning in shared experiences.
• Narrative Sessions: Migrants could engage in storytelling, exploring their journey’s philosophical themes, fostering reflection, and community connection.
• Ethics in Action: Facilitators might guide discussions about the ethical dimensions of adapting to new cultural norms without erasing one’s heritage.

Sources:

American Philosophical Practitioners Association. (n.d.). Philosophical counseling overview.

Nasr, L., & Fisk, R. (2019). Transformative services for migrant well-being: Service ecosystems for improving quality of life. Journal of Service Management, 30(4), 454–477. https://doi.org/10.1108/JOSM-11-2018-0377

World Health Organization. (2019). Mental health and psychosocial support for refugees and migrants: Global framework. World Health Organization. https://www.who.int

Facilitators working with migrants and refugees often navigate a complex terrain where poor mental health can manifest in various forms. Identifying when to employ philosophical counseling and when to recommend clinical intervention requires careful assessment, sensitivity, and a clear understanding of boundaries.

When to Use Philosophical Counseling

Philosophical counseling is appropriate for individuals experiencing existential crises rather than clinical pathologies. Facilitators can recognize suitable candidates by considering the following indicators:

1. Existential Questions:
   • Migrants may express concerns about identity, purpose, or belonging without exhibiting debilitating symptoms like severe anxiety or depression. For instance, a refugee may grapple with questions such as, Who am I in this new cultural context? or How do I honor my traditions while adapting to new norms?
2. Life Transitions:
   • Many migrants and refugees experience significant upheavals, such as loss of community, career, or cultural identity. Philosophical counseling can help them reflect on these changes and construct a narrative of resilience and adaptation.
3. Cultural and Ethical Dilemmas:
   • Individuals might struggle with reconciling their cultural values with those of the host country. Philosophical counseling provides a safe space to explore and mediate such conflicts.
4. Moderate Emotional Distress:
   • Emotional challenges like loneliness, confusion, or moderate sadness that do not impede daily functioning can be addressed through reflective, non-pathologizing dialogues.

For example, a facilitator might use philosophical counseling to guide a migrant who feels disconnected from their community to explore broader philosophical frameworks of belonging, such as Ubuntu (interconnectedness) or existential notions of self-redefinition.

When to Recommend Clinical Attention

Certain conditions require clinical intervention, and facilitators must recognize when philosophical counseling is inadequate or potentially harmful. The following criteria indicate the need for professional healthcare:

1. Severe Mental Health Symptoms:
   • Symptoms such as persistent sadness, extreme anxiety, intrusive thoughts, or inability to perform basic daily tasks signal clinical conditions like major depression or PTSD. These require evidence-based psychological or psychiatric treatment.
2. Risk of Self-Harm or Harm to Others:
   • If a migrant expresses suicidal ideation, self-harming behaviors, or aggression, immediate referral to mental health professionals is essential. Philosophical counseling is not equipped to manage crises.
3. Trauma Responses:
   • Refugees with symptoms like flashbacks, nightmares, or hypervigilance due to war or persecution need trauma-focused therapies rather than existential discussions.
4. Co-occurring Medical Conditions:
   • Migrants with health issues impacting their mental state, such as chronic pain or neurological disorders, may require an integrated clinical approach.

For instance, if a refugee describes severe insomnia and hyperarousal following traumatic events, a facilitator must prioritize connecting them with clinical care providers rather than philosophical counseling.

Demarcation Criteria for Facilitators

Facilitators can use structured approaches to define the boundary between philosophical and clinical needs:

1. Initial Assessment:
   • Begin every interaction with a comprehensive intake discussion. Tools such as the General Health Questionnaire (GHQ) or culturally sensitive checklists can help differentiate existential concerns from clinical conditions.
2. Ongoing Observation:
   • Watch for patterns in behavior and emotional expression. If distress escalates or interferes with daily functioning, clinical referral is warranted.
3. Consultation and Collaboration:
   • Collaborate with mental health professionals when in doubt. Creating a multidisciplinary support system ensures that migrants receive appropriate care.
4. Clear Communication:
   • When recommending clinical help, explain the reasoning sensitively. For example, frame it as part of a holistic care plan rather than a dismissal of their experiences.

Integration of Philosophical and Clinical Approaches

Facilitators can advocate for complementary use of philosophical counseling and clinical intervention. While clinical care addresses immediate mental health needs, philosophical counseling can support long-term integration by fostering meaning-making and resilience. For example, after receiving trauma therapy, a refugee may benefit from philosophical discussions about rebuilding life and identity, offering a framework for growth beyond recovery.

Sources:

World Health Organization. (2019). Mental health and psychosocial support for refugees and migrants: Global framework. World Health Organization. https://www.who.int/publications

Marinoff, L. (2002). Plato, not Prozac!: Applying eternal wisdom to everyday problems. Harper Perennial.

Patel, V., Minas, H., Cohen, A., & Prince, M. J. (2018). Global mental health: Principles and practice (2nd ed.). Oxford University Press. https://doi.org/10.1093/med/9780199920181.001.0001