The Many Faces of Mental Health: How Practitioners Enact Mental Health in Psychotherapy


Michael Slinger, University of Ottawa

In this paper, I explore how practitioners of psychotherapy enact or “do mental health”. I take a social constructionist approach to mental health and mental illness, seeking to understand how practitioners construct conceptualizations of “mental health” through the practice of psychotherapy. Despite psychotherapy’s growing popularity in recent decades, practitioners’ enactments of mental health remain poorly understood in both sociology and the clinical literature. While “mental illness” is defined through a combination of the Diagnostic and Statistical Manual (DSM-5-TR) and clinical training manuals, the concept of “mental health” is not articulated nor critically examined. Traditionally, the elimination of illness and disease was seen as the central goal of medicine, with many theorists—including Talcott Parsons, Erich Fromm, and Georges Canguilhem—arguing that “health” is primarily understood as an absence of symptoms. Several sociologists—notably Adele Clarke, Peter Conrad, and Nikolas Rose—have since challenged this view. These scholars argue that understandings of “health” have changed from the mid-1980s onwards, with patients, health care professionals, and governments increasingly orienting towards the optimization of well-being, evoked through concepts such as “flourishing” and being “better than well”. My paper builds on these theoretical frameworks, uncovering how practitioners enact “mental health” in their everyday work to examine whether psychotherapy conforms to the optimization trend observed in other areas of medicine. Using a grounded theory approach, I conducted 15 semi-structured interviews with two groups of practitioners in Ontario: clinical psychologists—who have completed a graduate program culminating in a PhD dissertation and year-long clinical internship—and MD psychotherapists—who have complete medical school, residency, and a year-long fellowship in medical psychotherapy. My investigation focused on how these practitioners attempt to produce changes in the patient’s condition—i.e., interventions—and evaluate when change has been successfully achieved—i.e., setting and monitoring goals. I argue that practitioners do not have a single, rigid enactment of mental health. Rather, practitioners flexibly enact four models of health—restoration, enhancement, management, and stabilization—with different patients at different points in therapy. Through restoration , practitioners aim to eliminate the patient’s symptoms and return them to “normal”. Practitioners alternatively define “normal” in reference to conformity to broader normative social roles or the patient’s personal values and sense of self, thus actively encouraging deviance or acting as agents of social control depending on the situation. Through enhancement , practitioners aim to improve patient well-being, often by attempting to enhance the patient’s social skills, mood, or sense of meaning. Through management , practitioners aim to maintain the gains made in therapy, teaching patients how to “become their own therapist” so they can stay healthy. Practitioners add a temporal dimension to health, encouraging extended self-surveillance to “treat” the patient’s susceptibility to imagined future symptoms and possible recurrences of mental illness. Finally, through stabilization , practitioners aim to prevent the patient from getting even worse, focusing on “stopping the bleeding”. Health is again seen as precarious, with practitioners seeking to reduce the patient’s potential for future dysfunction. However, the patient is still noticeably dysfunctional rather than “restored”, with practitioners considering that dysfunctional state a therapeutic success. In sum, enactments of mental health in psychotherapy are complex and context specific. Themes of enhancement and optimization do appear in psychotherapy, however, these practices are not recent additions but largely continuations of 1950s humanistic psychology. Furthermore, practitioners are often critical of optimization-oriented practices, preferentially enacting and endorsing other understandings of “mental health”. I propose that practitioners of psychotherapy are best thought of as possessing ambivalent attitudes towards the different enactments, alternatively endorsing and criticizing each approach depending on the patient and situation at hand.

The paper associated with this presentation has received the Sociology of Health Research Cluster's 2024 Best Student Paper Award.

This paper will be presented at the following session: