There is perhaps no profession held more strictly to their own standards than healthcare workers. From shrewd passer-by gazes on scrub-wearing smokers, to light-hearted jibes at the dentist deliberating over the sugar-laden dessert menu, the expectation to walk the walk is evident. It’s no surprise that patients are more receptive to health advice prescribed by providers who adopt healthy personal practices themselves. It’s one thing to accommodate public perceptions of how health professionals are supposed to be, but quite another when we place similarly unrealistic expectations on ourselves. When it comes to mental health, hyperawareness and excessive pressure to recover can paradoxically backfire.

Just as health does not merely mean the absence of disease, mental health is similarly complex and multidimensional. Given that our curriculums centre around improving the health of patients, communities and society at large, healthcare students are well aware of this. But even as an archetypal student over reliant on learning aims and objectives, the WHO-approved definition of mental health – ‘a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community’ – does nothing for me except highlight the chasm that exists between what I know I should be doing to improve and safeguard my mental health, and what I actually end up doing. But it’s not an empty chasm that I find myself staring at. There are evidence-based interventions and treatments that I know will help in the never-ending quest for better mental health. The nagging discomfort that accompanies this self-awareness has been termed ‘cognitive dissonance’, the uneasiness experienced when a person holds contradictory ideas or beliefs.

It turns out that the lexicon we use to speak to ourselves can play a role in bridging this gap. Words matter. Rather than morning power poses and self-affirmation chants, the self-talk that I’m referring to takes a slighter form. Discussions with a therapist elucidated that I was imposing an overwhelmingly strict ‘should’ mindset to all my actions. I should get more sleep to stabilise my mood the next day. I should see the GP about restarting medication. I should be feeling better by now. Following her suggestion to exchange these instances of ‘should’ for ‘could’ has been unexpectedly transformational. Curious as to how this subtle change made such a discernible difference, I turned to the internet for some answers. Prefacing with a disclaimer that I am by no means anywhere near an expert on the complex field of linguistics, I nonetheless found these short one-syllable words to be loaded with meaning. From my cursory browse online, should and could both belong to the category of modal verbs. But in serving to give more information about the function of the main verb they govern, modal verbs are used in various senses. Lying in the realm of interpersonal meanings, modal verbs are used to indicate various shades of necessity and possibility:

• Epistemic modality relates to likelihood and certainty based on knowledge. This modality is to do with the speaker’s perception of whether or not a proposition is true, in relation to their existing knowledge.

• Deontic modality concerns necessity in relation to a sense of obligation and duty (or its lack).

• Dynamic modality refers also to possibility and necessity, but where the modality is centred on the subject’s own ability and not to externally imposed obligations or duties. It expresses the subject’s internal willingness to act.

Examining a table that listed examples of the various senses in which modal verbs were used, I found it interesting that should lacked a dynamic modality:

Although this is only scratching the surface from a linguistics perspective, it shed some light on why simple word substitutions were so effective. As always, context is king and the distinction between necessity and possibility conferred by these different modalities is no exception. But by intentionally ensuring that could featured more frequently than should in my everyday vernacular, I began to take autonomous steps towards better mental health. I allowed myself permission to just be (it’s well-being, not well-doing after all). This replaced the stress and anxiety caused inadvertently by an overly prescriptive, external sense of obligation. The space and permission to feel howsoever I felt was freeing.

Breaking old habits isn’t an overnight task. If only there existed a search and replace keyboard shortcut for internal dialogue. Rewriting the loop involves behaviour change, and this remains a work in progress. What has helped me to stay on track is drawing parallels between how we are advised to be good listeners for our friends and loved ones: allowing others a safe space to disentangle their thoughts, vocalise how they feel, and explore what the course of action is that they themselves want to take. These all pave the way for a route of possibility that focuses on the subject’s own ability and willingness to act, an altogether more effective approach than immediately bulldozing in with unsolicited advice on what they ‘should’ be doing. The need for an individual to be intrinsically motivated to successfully sustain long-term behaviour change is even recognised in our teaching on patient communication.

Take someone who has been smoking ten cigarettes per day for the past thirty years. They are likely to already be well aware of the health risks associated with smoking. Being admonished repeatedly (however good-intentioned) may prove mildly annoying at first, but risks generating defensive reactions or even desensitisation to health advice over time. Motivational interviewing is a counselling approach that we are encouraged to utilise with our patients in health promotion to avoid these issues. Characteristic elements of motivational interviewing include expressing empathy through reflective listening, being curious to know more, asking permission to offer views, following-up on responses and supporting self-efficacy. Rather than solely telling the patient what they should do, it focuses on what they could do and supports them in realising their goals. This has been invaluable in the practice of self-compassion and genuinely embracing mindfulness.

However, although the idea of vocabulary choice always being a straightforward distinction is appealing because of its transferability, individual differences preclude a one-size-fits-all approach. Sometimes an obligation-inducing should is more appropriate. In moments where I’ve been unable to rationally and objectively determine the best course of action for my mental health, I resorted to relinquishing autonomy – something to me that embodied possibility and permission – and relying on the decision-making of professionals. While only temporary, it provided a much-needed buoy until I was ready to take the wheel. The pressure to practice what you preach is inevitable. But each person’s road to reaching and maintaining mental health is unique.

Health, including mental health by default, means different things to different people, and different things to the same person at different times. The question posed poignantly asks what mental health means to you. Choosing to engage in healthy self-talk is an ongoing challenge. Truthfully, fluctuating between could and should is always going to be a dynamic process, because mental health operates on a continuum. Instead of rigidly adhering to what I expect I should be doing, saying or thinking, electing for a kinder, flexible, more permissive approach has invited me onto a more pleasant journey towards the upward end of the continuum. Should serves as the compass needle, pointing north towards the omnipresent need to prioritise and care for one’s mental health. Could provides the space and freedom to track one’s own path towards the destination.