The following is an excerpt of the keynote address delivered by Dr. L. Read Sulik at MACMH’s 2006 Child and Adolescent Mental Health Conference. Dr. Sulik is an M.D., FAAP, Medical Director, Child and Adolescent Psychiatry, St. Cloud Hospital, St. Cloud, Minnesota.

What Is Mental Health?
For the past couple of years, I have explored this question with hundreds of participants at various lectures that I have given across the United States. Any time I have been asked to speak on depression or anxiety or trauma or ADHD or any other common mental health problem or illness in children, I have challenged my audiences to answer the question “What is mental health?” It has often been an exercise in improving my tolerance for uncomfortable silence!

The Questions
Questions that I have found myself asking people to stimulate some thinking include the following (note that I do not pretend to know the answers to these questions):

Question 1: Is “mental health” just the absence of mental illness or mental problems? If you are not depressed, anxious, or don’t have ADHD, are you mentally healthy? If you don’t have chemical dependency, a learning disability, a pervasive developmental disorder, or a personality disorder, are you mentally healthy? If you don’t have suicidal thoughts or hear voices are you mentally healthy? CONSENSUS: Certainly mental health refers to much more than just the absence of illness.

Question 2: Is there a difference between mental health problems and mental illness? Can you struggle with depression but not have the illness of depression? CONSENSUS: Certainly, someone can experience mental health problems without being mentally ill or having a mental illness.

Is there a difference between physical health and mental health? This question tends to lead to silence for a while also. Is there a mind/body connection? If there is a mind/body connection, does that imply that there is a separation between the mind and the body? Does it make sense that the mind and body are separated? If it doesn’t make sense, then is mental health separate from physical health? Can someone have optimal physical health without optimal mental health? Or can someone have optimal mental health without optimal physical health? CONSENSUS: There is a lot of uncertainty about this. Many people agree that in order to achieve optimal physical and mental health one should be both mentally and physically healthy. Yet, everyone seems to agree that some people who have a physical illness or disease do have optimal mental health. But also a person’s physical health can be impacted by less-than-optimal mental health.

Question 3: Can someone with a chronic illness be well or healthy? Can someone with bipolar affective disorder be mentally well or healthy or even mentally fit? For that matter, can someone with diabetes be physically well or healthy or even physically fit? If so, how does this happen? What does someone need to do to overcome an illness so that he or she can be well and healthy? CONSENSUS: Most agree that with appropriate treatment and care, someone can (but not always) overcome or recover from an illness or live with a chronic illness and achieve wellness and health.

Question 4: Can we promote mental wellness and fitness like we do physical fitness? CONSENSUS: I consistently hear “well of course we can—why not?” The next question though is “how”? Although the responses to this question have been quite varied, the answers may lead us to a better description of what we mean by mental health. For example, most of the time people suggest things such as teaching relaxation and coping skills; improving communications skills; improving the connection with family, friends, and other support people in an individual’s life; improving exercise, nutrition, and sleep; and reducing the noxious or toxic stressors in the environment as well as noxious or toxic behaviors such as substance abuse.

Question 5: Can we prevent mental illness? Can someone have a mental health problem in response to a genetic vulnerability or environmental stressor but not develop a mental illness? To be more specific, can we prevent depression or anxiety disorders or personality disorders? CONSENSUS: There is a mixed response here. Most people immediately respond “yes, of course,” but then quickly retreat with “but, wait . . . what if . . . .” Very often we can prevent the development of mental illness by identifying the mental health problem at the earliest possible stage and intervening with guidance and teaching or some type of treatment.

Question 6: Has anyone ever achieved optimal mental health and mental fitness? Who are they? What is it about them that makes us feel like they have achieved optimal mental health? In response to this last question, I have found myself thinking about great individuals who have accomplished much while maintaining peacefulness. Individuals like the Dali Lama, Tenzin Gyatso, Thich Nhat Hahn, Pope John Paul II, and Mother Teresa of Calcutta. What is it about great worldwide religious or spiritual leaders that brought me to immediately think of them as having achieved optimal mental health, wellness, and even mental fitness? I think it is because I see these individuals as being able to self-reflect and able to think and communicate clearly. They all also seem to have had an incredible ability to connect with others with peacefulness, tolerance, and acceptance. And, at least to me as a distant observer, they seem to have had balance between their thinking, their feelings, and their physical condition. Finally, I consider them to be spiritually sound and balanced with a sense of who they are and their place in their own world. Thich Nhat Hahn teaches of the beauty one can see and experience in washing dishes. He must be mentally fit!

So does one need to be a world wide spiritual leader to have achieved optimal mental health? Of course not. Who else comes to mind? I have also thought of Oprah. She has overcome a great deal, spent much of her life striving to achieve, and she embodies a sense of meaning of who she is and what her world is all about. She certainly seems to have great self-awareness, and she has had to struggle like all of us with problems throughout different phases of her life.

When I discussed this topic with my wife, she was quick to point out that everyone I identified isn’t married and doesn’t have children! She said that she immediately thought of Jimmy Carter. He, like the spiritual leaders I mentioned earlier, seems to have balance between his thinking, his feelings, and his behaviors. He also has an ability to interrelate and connect with others and to function and perform optimally in tasks and endeavors. He seems to be spiritually sound and balanced with a sense of who he is and his place in the world. And he’s married and he’s a parent.

Actually Rosalyn Carter is one of the world’s greatest spokespersons on the importance of mental health. She is a good reminder to all of us that everyone has a story and that each of us, with care and support, can achieve and overcome. Perhaps optimal mental health is achieved not alone but in partnership with others. Then again, of course it is.

I certainly do not believe that one must be a spiritual or political leader, a world celebrity, or a Nobel Peace Prize winner to achieve optimal mental health, but perhaps it is optimal mental health, wellness, and fitness that allows these people to achieve and impact their world at such a level.

What I Needed Then to Move on to Now
I have had the opportunity and the honor to work with many children and adolescents and their families through the years. When people ask me “Why do you do what you do?” I say it is because I get to see young people who are suffering and even tortured by their inner and outer worlds get better! I get to see them heal and recover from an illness and begin to thrive as they become well and healthy. I have seen moms, dads, foster parents, and grandparents create a healing, nurturing, and loving environment for their child who is suffering with mental illness or a severe mental health problem. What I have seen has validated my belief that for children, adults are not only important but critical to the process of healing and recovery and to the process of growth and development.

A little over a year and a half ago we opened Clara’s House, a free-standing mental health and chemical dependency partial hospital facility for children and adolescents. One of our donors, Mae Ellingson Skalicky, gave us a large gift and requested that we name the facility after her mother, Clara. When I first met Mae, she shared with me her mother’s story. Mae was one of Clara’s eleven children. Because Clara’s husband died when the children were quite young, Mae had to run the small family farm while single handedly raising the couple’s eleven children. Mae told us that the community came to know Clara’s house as a place where children were always welcome. The name Clara’s House could not have been more perfect.

For the grand opening celebration, I asked several young adults who had suffered from mental health problems in their adolescent years to speak about how important it was to create a space for this kind of program. I asked each of them to prepare a brief talk that would be titled “What I needed then to move on to now.” To prepare their talk, I asked each of them to reflect on what helped them through their crisis and allowed them to not only recover but to have the strength and courage to stand up and tell their stories.

I also asked Minnesota singer-songwriter Michael Monroe if he would prepare a song at the grand opening. I gave Michael the same words that I had given each of the former patients, and relayed to him what we had learned of Clara’s story. He took the words, “what I needed then to move on to now” and captured the essence of the support, understanding, guidance, and acceptance that one needs to heal during a time of emotional struggle or crisis. I listened again to this song recently and cannot help but notice the parallel in themes that so many have indicated over the past years when I have asked what does a child need in order to recover from a mental illness . . . respect, acceptance, support, nurturance, understanding.

Then I found a house I could call a home,
For a while or a place I could learn and be and grow
A place full of love and open arms
I found some people I could call my own
Understanding and a feeling that I’m not alone
It’s what I needed most to move on to now

Just as the song captures well the experience of a young person in need, the five former patients (who are all young adults now) revealed that they could “move on to now” so long as their needs were met.

The Definition
So the interplay of our physical condition, our emotions, and our thinking is at the core of our capacity for mental health. It is our physical condition, our emotional state, and our ability to think clearly that impacts our ability to relate positively in a connected way with others in our lives, to perform to our fullest potential, and to regulate our behaviors. Finally, all of this impacts our sense of who we are and our place in the world . . . our sense of meaning and being.

Many people realize that children need safety, warmth, unconditional love, health, acceptance, and support to achieve optimal mental health. Common themes that have come up in discussions about what is optimal mental health have included the ability to be self aware, to communicate clearly, to tolerate environmental and social stress and “bounce back,” to be aware of and empathetic of others, and to be able to positively relate and connect with others. The most common word that I have heard come up in each discussion is “balance.”

Mental health then is a balance of the physical, emotional, cognitive, social, behavioral, and spiritual aspects of an individual as they interact with the broader physical and social environment. And optimal mental health involves the capacity to tolerate an array of environments, thoughts, emotions, physical states, and social situations while functioning or performing well at tasks, regulating behaviors, and remaining mindful of how the present moment fits into the overall scheme of life.

Promoting Mental Health, Wellness, and Fitness
By no means can this be a complete discussion about what is needed to promote and protect our children’s mental health. However, in using the model of understanding and the definition that I have proposed, I can suggest the following key themes to consider. First, “How do we get good at anything?” . . . Practice!

We have to identify what our children can practice to improve their mental health. We need to help children practice self-awareness, self-soothing, and tolerance. We need to give them opportunities to practice communication skills and to become comfortable expressing their thoughts and feelings, and make sure they have plenty of practice interrelating and connecting with others. We need to give our children opportunities to reflect on their performance, their functioning, and their behaviors. Finally, we need to help our children find ways to reflect on and improve their purpose and meaning.

Children need the adults in their lives to be healthy. They need to see us striving for our own optimal mental health. They need to see adults put words to feelings and thoughts. They need to see us communicate effectively, self-soothe, sleep enough, eat well, exercise, and have fun. They need to see us recognize when the environment is becoming more noxious or harmful and make changes. Our children need us to TEACH them how to practice!