George E. Vaillant, M.D
Objective: Only in the last 30 years has
psychiatry begun to develop empirical
approaches to conceptualizing and as-
sessing positive mental health. Six models
of mental health are reviewed here.
Method: The author points out pitfalls in
research on mental health, e.g., equating
average with healthy, failing to distinguish
trait from state, overlooking cultural
norms, and conversely, blindly accepting
the culture’s values. He describes the six
models and provides history and research
needs for each.
Results: The first model, being “above
normal,” is epitomized by DSM-IV’s axis V,
the Global Assessment of Functioning
Scale. High scores represent “superior
functioning in a wide range of activities,
life’s problems never seem to get out of
hand, is sought out by others because of
his or her many positive qualities.” The
goal of the second model, positive psy-chology,
is intervention to maximize posi-tive qualities,
such as self-efficacy. Maturity
and Erikson’s four developmental tasks
(identity, intimacy, generativity, integrity)
are the basis of the third model.
The au-thor adds two other tasks:
career consoli-dation and
“keeper of the meaning.” The
fourth model is emotional or social intelli-gence,
the ability to read other people’s
emotions. Surprisingly, subjective well-be-ing,
the fifth model, is as much a charac-teristic of
temperament as of a benign en-vironment.
The last model, resilience, is epitomized by
DSM-IV’s Defense Function
Scale, which categorizes coping
mecha-nisms in terms of adaptational value.
Conclusions: As with the blind men and
the elephant, each model describes only
some aspects of mental health. Further
research may reveal the contribution of
each.
We cannot even really know what causes neurotic
suffering until we have an idea of what causes real
health. This we have only begun to investigate.
—Erik Erikson (1, p. 93)
Too often, psychiatry has been preoccupied only with
mental illness. To paraphrase Mark Twain’s quip about the
weather, psychiatry is always talking about mental health,
but nobody ever does anything about it. Mental illness,
af-ter all, is a condition that can be reliably defined, and its
limits are relatively clear. In contrast, mental health seems
to lie more in the domain of value judgment than of sci-ence.
For example, mental illness can be defined as the
presence of selected symptoms, but mental health is
something more than the absence of symptoms. With the
notable exception of the chapter by Offer and Sabshin in
the third and fourth editions of Comprehensive Textbook of
Psychiatry(2), recent major psychiatric textbooks reveal
virtually no serious discussion of positive mental health.
An electronic search of Psychological Abstractssince 1987
turned up 57,800 articles on anxiety and 70,856 on depres-sion,
but only 5,701 mentioned life satisfaction and only
851 mentioned joy (3).
But mental health is too important to be ignored. In 1978
the report to the President by the President’s Commission
on Mental Health (4) forcefully reiterated the importance
of clearly defining what is meant by mental health, and
over the last 30 years research has slowly moved the study
of mental health from pious platitude toward science.
Finally, 10 years ago, when evidence (5) emerged
to sup-port the validity of axis V (the Global
Assessment of Func-tioning [GAF] Scale) in DSM-IV (p. 32),
psychiatry actually
possessed a metric for the measurement of mental health.
Previously, there had been an implicit assumption that
mental health could be best defined as the antonym of
mental illness, but accepting that assumption is to
under-estimate human potential. Starting early in the last cen-tury,
internists, as they recognized that health was more
than an absence of symptoms, began studying high-alti-tude
physiology and developed measures of
positive phys-ical health for athletes, pilots, and finally astronauts. Thus,
the antonym of physical illness is physical fitness. In the
late 1930s, Arlie Bock, an internist trained in high-altitude
physiology and interested in positive physical health,
be-gan at Harvard the Study of Adult Development,
an inter-disciplinary study of both positive mental and physical
health (6, 7). The results of that study, lasting for 60 years
(8), inform many facets of this paper.
It must be admitted that above average mental health is
more difficult to define than physical fitness. Nevertheless,
it is important for psychiatry to emulate sports medicine
and to provide precise definitions and measures of positive
mental health. Psychologists, like physiologists, have
learned to quantify not only normal but better than aver-age intelligence.
Thus, we regard the antonym of mental
retardation not as an IQ of 100 but as an IQ over 130.
Psy-chiatry must follow suit. For rather than merely deciding
who is too sick for a job, psychiatrists are called on to make
decisions about who is mentally healthy enough for certain
positions—such as air traffic controllers and submariners.
Before positive mental health can be defined, several
cautionary steps are necessary. The first step in discussing
mental health is to note that average is not the same as
healthy, for average always includes mixing in with the
healthy the prevalent amount of psychopathology.
For ex-ample, in the general population the mean
weight or eye-sight is actually unhealthy, and if all sources
of biopsycho-social pathology were excluded from the population, the
average IQ would be significantly above 100. Put differ-ently,
being at the center of a normal bell curve of distribu-tion
may or may not be healthy. In the case of red blood
cell count, body temperature, or mood, the middle of the
bell curve ishealthy. In the case of eyesight,
exercise toler-ance, or empathy, only the upper end of the bell curve is
healthy; in the case of serum cholesterol, bilirubin, and
narcissism, only the low end of the curve is healthy.
A second cautionary step in discussing mental health is
to appreciate the caveat that what is healthy sometimes
depends on geography, culture, and the historical mo-ment.
Punctuality is a virtue in some countries and a fail-ing in others.
General George Patton’s competitive tem-perament
was a psychological liability in time of peace but
a virtue in two world wars.
A third cautionary step is to make clear whether one is
discussing trait or state. Who is physically healthier: an
Olympic miler disabled by a simple but temporary (state)
ankle fracture or a type 1 diabetic (trait) with a temporarily
normal blood sugar level?
In defining mental health, the fourth and most impor-tant cautionary
step is to appreciate the two-fold danger
of “contamination by values.”On the one hand, cultural
anthropology teaches us how parochial a given culture’s
definition of mental health can be. And, even if mental
health is “good,”what is it good for? The self or the society?
For fitting in or for creativity? For happiness or survival?
And who should be the judge? As Erikson warned, “The
healthy personality is a topic approaching which the
ex-pert becomes a fearful angel”(1, p. 92).
On the other hand, common sense must prevail. Biology
trumps anthropology. Every culture differs in its diet, but
the World Health Organization would be in error to ignore
the universal importance to diet of vitamins and of the
four basic food groups. Although almost no form of behav-ior is
considered abnormal in all cultures, that does not
mean that the tolerated behavior is mentally healthy. Just
because colonial America did not recognize alcoholism as
an illness does not mean that alcoholism contributed less
to 18th-century morbidity.
This article will contrast six different empirical ap-proaches
to mental health. It is significant that the empir-ical
underpinnings for each of the six models have
emerged only recently. First, mental health can be
concep-tualized as above normal,a mental state that is objectively
desirable—as in the capacity to work and to love. Second,
mental health can be conceptualized as positive psychol-ogy,an
early example of which was Maslow’s “self-actual-izing”individual (9).
Third, from the viewpoint of healthy
adult development, mental health can be conceptualized
as maturity.Fourth, mental health can be conceptualized
as emotional or social intelligence. Fifth, mental health can
be conceptualized as subjective well-being—a mental
state that is subjectively experienced as happy, contented,
and desired. Finally, mental health can be conceptualized
as resilience,as in successful adaptation and homeostasis.
A moment’s reflection reveals that each of these models
describes only part of the “elephant”of mental health.
One research agenda must be empirically to decide, by
means of multivariate modeling, which facets of each
model are additive.
Model A: Mental Health
as Above Normal
In 1835 Adolphe Quetelet published what appears to be
the first important book on normality (10). Rather than fo-cus on pathology,
he tried “to approach more closely to
what is good and beautiful”(p. x), and his goal was the
sta-tistical analysis of healthy humans. He challenged genera-tions
of future investigators with his introductory sen-tence,
“Man is born, grows up, and dies, according to
certain laws which have never been properly investigated”
(p. 5).
Until World War II, however, Quetelet’s challenge to
mental health professionals went largely unheeded. When
in 1941 the U.S. draft board asked health professionals to
define 1-A mental health, they were assigning a novel task.
Indeed, it was not until after World War II that tentative
works on normal adaptive behavior began
to be pub-lished—White’s Lives in Progress(11), Srole and associates’
Mental Health in the Metropolis(12), Erikson’s “Growth
and Crises of the ‘Healthy Personality’”(1), the Stirling
County studies by the Leightons and colleagues (13, 14),
and Grinker and Spiegel’s Men Under Stress(15). Such
studies concentrated on the adaptation of nonpatient or
normal populations but from different vantage points.
Nevertheless, many distinguished postwar psychiatrists
continued to agree with Freud, who had dismissed mental
health as “an ideal fiction.”In the late 1950s Lewis wrote,
“Mental health is an invincibly obscure concept”(16, p.
227), and Redlich asserted, “We do not possess any general
definition of normality and mental health from either a
statistical or a clinical viewpoint”(17).
Shortly thereafter, Jahoda’s report to the Joint
Commis-sion on Mental Illness and Health led to a psychiatric sea
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