As part of my training as a counselling psychologist I was working in a team offering psychological therapy in Primary Care settings. People were referred to our team by their GP and might be experiencing chronic depression or anxiety, the reaction to a trauma, either recent or in childhood or feel trapped in obsessive behaviour. Almost all would fall into what is misleadingly referred to as the "mild to moderate" category of mental distress. Almost all had lives seriously restricted by this distress.

I was struck by the derogatory terms many would use to describe themselves. Words such as "psycho", "nutter" and, very often, "mental" were used to indicate how they had labelled themselves. I undertook a small research study based within the community in which I was working, a large council estate in the north-west, to explore how people within the estate perceived the concept of mental health.

The study used different methodological approaches but the two key sources of my understanding came from a brief questionnaire and semi-structured interviews. The questionnaires demonstrated that for many the concept of mental health remains dominated by an assumption of illness; mental health was seen as an absence of pathology. Forty-nine per cent of the respondents gave an illness-related response to the question: "What comes into your mind when you see or hear the term 'mental health'?" Some even suggested particular illnesses such as schizophrenia; many used dismissive terms similar to those that had prompted the study. In these responses lay great fear of such diagnoses and of being labelled. This theme was further developed in the interviews.

The questionnaire also enquired how people maintained their psychological wellbeing. Their responses supported previous findings indicating the importance of social networks. They also referred to the value of making a contribution to the community, whether through paid employment or in some other way. Again this was expanded by those who were interviewed.

The concept of mental health pivoted around control. Both the lay participants and the GPs whom I interviewed saw being able to manage one's life and its difficulties as indicative of good mental health. Coping was an indication of being in control and therefore mentally healthy; not coping indicated failure and seemed to be equated with losing control and with losing one's mind. Being in control incorporates the concept of choice. Those whom I interviewed had their choices limited by economic difficulties; many were on benefits or in low-paid employment. One of the GPs commented on the negative impact of "being pushed into a position where you feel you haven't got routes out”. He noted how many of his patients felt in that position where their employment options were few, where caring for sick family members further reduced their energy and how, for some, even access to the countryside was limited because of cost. For these patients there is greater risk that their sense of control will ebb and their sense of no longer coping, with its concomitant fear of madness, will increase.

Coping was further seen as indicating a successful gender identity. Whereas all the participants interviewed linked coping with good mental health, a failure to cope was seen differently by men and women. One man talked of his being "less of a man" because he had sought help. One woman referred to her husband as not being a "proper Dad" because of his need for medication; for her own part, she saw her struggle to cope with the pressures of her husband's needs and those of her children as reflecting badly on her as a mother.

Throughout the interviews shame and isolation were linked themes of mental illness. There was great fear of being categorised as "screwy". One woman treated for depression felt she had been "classed as abnormal". Several spoke thoughtfully about their own understanding of distress, but equally feared that others, including mental health professionals, might attach labels to them rather than recognising them as individuals. With these labels came the sense of alienation, a feeling prevalent amongst those with a mental illness. This can be seen as associated with the need to do something of value. If someone is engaged in an activity that contributes in some way, they are more likely to retain their sense of agency and worth.

There is much professionals can do, and are doing, to help lessen the fear of being labelled and judged. Increasingly diagnostic terms are being replaced by a more particular understanding of each person's distress. There is also a role for others to acknowledge that most of us at some time in our lives encounter difficulties that push us beyond our usual coping mechanisms and that the world is not divided into two classes of people, those who are mentally ill and those who are mentally well.