The answers to several fundamental questions will influence perceptions about mental health and older people and the distributional issues that inevitably arise in their care. First, what goals should mental health care serve? Second, how do interventions relate to outcomes? Third, how much or what kind of care should society provide (Sabin & Daniels, 1994)? Each of these questions has contestable answers. For older people, mental health care can focus on any of three ends: helping to make well those already suffering from mental illnesses or impairments of various kinds; developing and implementing strategies that might help older people avoid mental illnesses; and striving for improved mental health and therefore enhanced potential for happiness. The first approach is circumscribed; the second and third approaches are more expansive, focusing not on the absence of mental disease but on the individual's ability to function in desirably positive ways, that is, to experience a subjective sense of well-being that is also socially validated. At their most expansive, these approaches can direct attention to identifiable prevention and enhancement strategies, especially for conditions that are provoked by the contingent features associated with old age. This view asks about the nature and extent of society's obligation to ameliorate conditions that contribute to disease. As such, it moves toward questions about culture, society, economics, and family, to name just a few variables, each beyond the biomedical system of care. Yet that system has tended to be the best-supported and the most available locus of care; thus older people are most apt to receive care in their role as patients or clients.
The prevailing, though not hegemonic, view is that mental health services for the old, as for other age groups, have as their primary obligation the treatment of mental illness and, to some extent, ''problems in living,'' however defined. Despite this bias, strong arguments for the more expansive view are readily available. For example, Browning (1991) observes:
Psychiatry cannot focus properly on mental illness unless it has positive images of mental health (which must in part be elaborated philosophically) as well as more general images of the good person and the good society. . . . [P]sychiatry can have no defensible grounds on which to address problems in living unless it attends to larger issues of social philosophy. Dealing with problems in living entails removing illness or developmental impediments; it also involves investigating with the client certain positive images of how to live—images that will inevitably entail ideas about the good person and the good society. (p. 7)
This view can consider psychiatry as a foundation for promoting social change and social reform (Drane, 1991). More modestly, it can ''survey and test images of the good person and good society'' as the substructure for working with individuals who are either mentally ill or experiencing ''problems in living''
(Browning, 1991, p. 7). These images, as the historical review has suggested, are necessarily value laden. It is possible, however, to face these value dimensions openly. If psychiatry does not do so, it has little recourse except retreat to the biomedical model and its reductionist views. A biological conceptualization of mental illness can, as observed earlier, result in the psychological abandonment of patients who face situational problems.
Medical understandings and medically managed treatment of mental illness constitute the biomedical model that has dominated care of the mentally ill for many years. The medicalization of old age, although a more recent development, is an undeniable if somewhat less pervasive reality. Because it typically ''treats'' problems that already exist, the medical approach favors what some have termed ''illness care'' as contrasted with health care. In the illness care approach, health has typically meant the absence of disease, and treatment of pathology has generally received more attention than prevention of illness or disease. The promotion of health or wellness, except on the explicitly individual level, has typically received even less attention.
In our view, the ethics of mental health and aging must place prevention and promotion on individual, social, and cultural levels at the center of its concern. To suggest a concept of mental health is to identify the goods at the intersection of aging and mental health that we as persons and as a society should enact and promote. Such a positive concept attempts to go beyond the biomedical model, which too often confines itself to identifying the evils (illness or pathology) to be avoided or mitigated. Thus in what follows we explore various ideas of mental health and suggest our own working concept, examine the prevention of mental illness and the promotion of mental health, and suggest approaches to prevention and promotion in light of our understandings of mental health and mental illness.
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