Model D: Mental Health
as Social-Emotional Intelligence
In the Nicomachean Ethics, Aristotle defined social-emotional intelligence as follows: “Anyone can becomeangry—that is easy. But to be angry with the right person,
to the right degree, at the right time, for the right purpose,
and in the right way—that is not easy.”Nevertheless, as re-cently as 40 years ago a textbook on intelligence dismissed
the concept of social intelligence as “useless.”Indeed, only
since the 1970s has modulation of “object relations”
seemed more important to psychoanalysis than modula-tion of “instinct.”
The benefits of being able to read feelings from nonver-bal cues have been demonstrated in almost a score of
countries (56). These benefits include being better emo-tionally adjusted, more popular, and more responsive to
others. Empathic children, without being more intelli-gent, do better in school and are more popular than their
peers. Head Start found that early school success was
achieved not by intelligence but by being able to wait and
knowing what kind of behavior is expected, how to rein in
the impulse to misbehave, and how to get on with other
children (57).
Social-emotional intelligence can be defined by the fol-lowing criteria (56):
1. Accurate conscious perception and monitoring of
one’s own emotions.
2. Modification of one’s emotions so that their expres-sion is appropriate. This involves the capacity to self-soothe anxiety and to shake off hopelessness and
gloom.
3. Accurate recognition of and response to emotions in
others.
4. Skill in negotiating close relationships with others.
5. Capacity for focusing emotions (motivation) on a de-sired goal. This involves delayed gratification and
adaptively displacing and channeling impulse.
Over the last 15 years, two important empirical steps
have been taken in our understanding of the importance
of social-emotional intelligence to positive mental health.
The first step is that both functional magnetic resonance
imaging (fMRI) and ingenious neurophysiological experi-mentation (58, 59) have led to advances in our under-standing of the integration of the prefrontal cortex with
the limbic system, especially with the amygdala and its
connections. This in turn has brought us closer to under-standing emotions as neurophysiological phenomena
rather than as platonic abstractions.
The second step has been our slow but steady progress
in conceptualizing and even measuring “emotional intelli-gence”(60). High emotional intelligence reflects above av-erage mental health in the same way that a high IQ reflects
above average intellectual aptitude. Gardner described
emotional intelligence as the capacity to “discern and re-spond appropriately to the moods, temperaments, moti-vations and desires of other people”(61, p. 8).
Where the study of positive mental health ends and pri-mary prevention begins is unclear, but like the model of
positive psychology, the model of social-emotional intelli-
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gence is potentially interventionist. Just as we can have
above average musical skill or physical coordination and
yet can train these strengths to be even greater; so we are
learning to enhance emotional intelligence. There are al-ready exercises in teaching emotion recognition and dif-ferentiation to patients with eating disorders and teaching
anger modulation and how to find creative solutions to so-cial predicaments for individuals with behavior disorders.
Once we have a firmer grasp of its measurement, the rela-tive importance of emotional intelligence to other compo-nents of mental health can be assessed. I wager that it will
emerge as the most important single dimension of mental
health.
Model E: Mental Health
as Subjective Well-Being
Is it better to meet some expert’s definition of mental
health, or is it better to feel subjectively fulfilled? The an-swer is “both.”For positive mental health does not involve
just being a joy to others; one must also experience subjec-tive well-being. Indeed, long before humankind consid-ered definitions of mental health, they pondered criteria
for subjective happiness. “No man is happy who does not
think himself so.”
Nevertheless, the mental health issues involved in sub-jective well-being are complicated and clouded by histori-cal relativism, value judgment, and illusion. As already
noted, Europeans have been skeptical of American con-cern with happiness. On the one hand, happiness that
comes from joy or unselfish love (agape), that comes from
self-control and self-efficacy, or that comes from play or
deep but effortless involvement (62) reflects health. On
the other hand, happiness can be based on illusion or on
dissociative states, and the search for happiness can ap-pear selfish, narcissistic, superficial, and banal. Examples
of maladaptive “happiness”include the excitement of risk
taking, being “high”on drugs, and short-lived satisfaction
from binge eating, tantrums, promiscuity, and revenge. It
is because of such ambiguity of meaning that throughout
this section the term “subjective well-being”is substituted
for “happiness.”
Only in the last decade have investigators such as Bar-bara Fredrickson (63), Martin Seligman (36), and David
Snowdon (64) pointed out that a primary function of posi-tive emotional states and optimism is facilitation of self-care. Subjective well-being makes available personal re-sources that can be directed toward innovation and cre-ativity in thought and action. Thus, subjective well-being,
like optimism, becomes an antidote to learned helpless-ness. Again, after control for income, education, weight,
smoking, drinking, and disease, happy people are perhaps
only half as likely to die at an early age or become disabled
as unhappy people (65).
Until recently the scientific parameters of subjective well-being were as vague as those for objective mental health. A
1967 definition suggested that a happy person is “young,
healthy, well-educated, well paid, extroverted, optimistic,
worry free, religious and married with high self esteem, a
good job, morals, and modest aspirations”(italics added)
(66). In the last 30 years, however, empirical research has
shown such a vacuous generalization only partly correct.
The italicized adjectives are all untrue or true only with
qualifications (37).
The Nuns Study provides perhaps the most convincing
link between subjective happiness and health (64, 67).
When they were in their 20s, 180 nuns were asked to write
a 2–3-page autobiography. Of those who expressed the
most positive emotion, only 24% had died by age 80. In
contrast, by the same age 54% of those who expressed the
least positive emotion had died.
Only in the last three decades have investigators, espe-cially Edward Diener (3, 68), made a serious effort to re-search the definitional and causal parameters of subjec-tive well-being and thereby address important questions.
One such question is, Is subjective well-being more a
function of environmental good fortune, or is it more a
function of an inborn, genetically based temperament?
Put differently, Does subjective well-being reflect trait or
state? If subjective well-being reflects a safe environment
and the absence of stress, it should fluctuate over time,
and individuals happy in one domain in their lives might
not be happy in another.
The answer is that subjective well-being has more effect
on the environment than the environment exerts on it. For
example, investigators have been startled that a signifi-cant number of AIDS victims perceive that their illness has
enhanced the quality of their subjective lives. Similarly, af-ter a few weeks of temporary elation, the subjective well-being of lottery winners returns to baseline.
In other words, subjective well-being is due more to
“top-down”processes—temperamental factors governing
subjective well-being—than to “bottom-up factors”—for
example, the fulfillment of universal human needs. In-deed, subjective well-being is highly heritable and rela-tively independent of demographic variables. The subjec-tive well-being of monozygous twins raised apart is more
similar than that of heterozygous twins raised together
(69). Among the partially heritable factors making signifi-cant contributions to a high level of subjective well-being
are a low level of trait neuroticism, high level of trait extra-version, absence of alcoholism, and absence of major de-pression (3). For example, when heritable variables are
controlled, subjective well-being—unlike tested intelli-gence—is not affected by environmental factors such as
income, parental social class, age, and education.
Consistently, relationships are more important to sub-jective well-being than is money. In a representative study
of 800 college alumni, respondents who preferred high in-come, occupational success, and prestige over having very
close friends and a close marriage were twice as likely to
describe themselves as “fairly”or “very”unhappy (70).
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Over the last two decades the doubling of net disposable
income in the western world did not affect subjective well-being (3). Mean life satisfaction in socioeconomically
challenged Brazil and China is higher than in socioeco-nomically blessed Japan and Germany.
In some instances environment can be important to
subjective well-being. Young widows remain subjectively
depressed for years. Even though their poverty has been
endured for centuries, respondents in very poor nations,
such as India and Nigeria, report lower subjective well-be-ing than those in more prosperous nations. Pain from the
loss of a child never stops.
Maintaining self-efficacy, agency, and autonomy make
additional environmental contributions to subjective
well-being. Subjective well-being is usually higher in de-mocracies than in dictatorships. Assuming responsibility
for favorable or unfavorable outcomes (internalization) is
another major factor leading to subjective well-being.
Placing the blame elsewhere (externalization) signifi-cantly reduces subjective well-being. In other words, para-noia and projection make people feel worse rather than
better. Religiosity is consistently and positively correlated
with well-being, but there may be a chicken-egg relation-ship between social support and religious observance. For
example, among church-goers it is difficult to disentangle
where spiritual faith ends and community support begins.
The research agenda for subjective well-being includes
establishing with greater definition the relative contribu-tions of heredity and of environment and culture. In ad-dition, we need to establish the magnitude of the contri-bution of subjective well-being to the other models. We
need to disentangle interpersonal happiness (model D)
from intrapersonal happiness (model E).
Model F: Mental Health as Resilience
In 1865, Claude Bernard, the founder of experimental
medicine, declared, “We shall never have a science of
medicine as long as we separate the explanation of the
pathological from the explanation of normal, vital phe-nomena”(71). Later, Meyer (72) perhaps overstated the
case when he asserted that there are no mental diseases,
there are only characteristic patterns of reaction to stress.
But Meyer drew attention to the fact that mentally healthy
responses to stress, analogous to pus and cough, are often
misinterpreted as pathological.
There are three broad classes of coping mechanisms
that humans use to overcome stressful situations. First,
there are the ways in which an individual elicits help from
appropriate others: namely, consciously seeking social
support. Second, there are conscious cognitive strategies
that we intentionally use to master stress (73). Third, there
are involuntary mental coping mechanisms (often called
“defense mechanisms”or “denial”) (74). This third, invol-untary class of coping mechanisms reduces conflict and
cognitive dissonance during sudden changes in internal
and external reality. If such sudden changes are not “dis-torted”and “denied,”they can result in disabling anxiety
and/or depression. Such homeostatic mental defenses
shield us from sudden changes in the four lodestars of
conflict. These four lodestars are affect/impulse, reality,
relationships, and social learning. Involuntary coping
mechanisms can abolish impulse (e.g., by reaction forma-tion), relationships (e.g., by schizoid fantasy), reality (e.g.,
by psychotic denial), or social learning (e.g., by acting out).
They can alter our conscious recognition of the subject
(e.g., by projection) or the object (e.g., by turning against
the self ) of a conflict, our awareness of the conflictual idea
(e.g., by repression), or the conflictual affect associated
with the idea (e.g., by isolation of affect).
By 1970, defense mechanisms, like many psychoana-lytic metaphors, had been largely discarded by most em-pirical social scientists. Consistency of definition and rater
reliability were lacking. But over the last 30 years, the idea
of healthy involuntary coping has entered the literature of
empirical cognitive psychology under such rubrics as
“hardiness”(75), “self-deception”and “emotional coping”
(73), and “illusion”(76). In the last decade experimental
strategies for assessing defense mechanisms have also im-proved (77–80). Several reviews have also clarified our un-derstanding of healthy and unhealthy defenses (81, 82). By
offering both a tentative hierarchy and a glossary of con-sensually validated definitions, an optional axis of invol-untary coping mechanisms was added to DSM-IV. The De-fensive Function Scale (DSM-IV, p. 752) has set the stage
for further progress in our understanding of positive men-tal health. In addition, in terms of predictive validity (i.e.,
predicting future mental health), the Defensive Function
Scale is as powerful a tool as we have (83–85). Neverthe-less, no one has yet developed a method for assessing de-fenses that meets conventional standards for psychomet-ric reliability. The Q-sort technique is perhaps the most
promising (80).
All classes of defenses in the Defensive Function Scale
are effective in “denying”or defusing conflict and in “re-pressing”or minimizing stress, but they differ greatly in
the psychiatric diagnoses assigned to their users and in
their consequences for long-term biopsychosocial adap-tation. In level 1, the most pathological category, are found
denial and distortion of external reality. These mecha-nisms are common in young children, in our dreams, and
in psychosis. To breach them requires altering the brain by
neuroleptics or waking the dreamer.
More common to everyday life are the relatively mal-adaptive defenses found in levels 2–5. Defenses in these
categories are common in adolescents, in immature
adults, and in individuals with personality disorders. They
often make others more uncomfortable than the user.
Such defenses are consistently and negatively correlated
with global assessment of mental health, and they pro-foundly distort the affective component of interpersonal
relationships. The third class of defenses, those in level 6,
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are often associated with what DSM-IV calls axis I anxiety
disorders and with the psychopathology of everyday life.
These include mechanisms such as repression, intellectu-alization, and reaction formation. They are common to
everyone from 5 years old until death. They are neither
healthy nor unhealthy.
The mechanisms at level 7 still distort and alter feelings,
conscience, relationships, and reality, but they achieve
these alterations gracefully and flexibly. These mecha-nisms allow the individual consciously to experience the
affective component of interpersonal relationships but in
a tempered fashion. Thus, the beholder may regard level 7
adaptive defenses as virtues, just as the same beholder
might regard the prejudice of projection and the tantrums
of acting out as sins. Doing as one would be done by (altru-ism), keeping a stiff upper lip (suppression), keeping fu-ture pain in awareness (anticipation), being able not to
take one’s self too seriously (humor), and turning lemons
into lemonade (sublimation) are the very stuff from which
positive mental health is made. In addition, the thoughtful
reader may wish to add involuntary but adaptive offences:
for example, creativity, charisma, leadership, courage, and
vision. Unfortunately, like tightrope walking, without
months of practice mature mechanisms cannot easily be
deployed voluntarily and only then by those with innate
balance.
Identification of defenses is difficult and has impeded
research. Rarely can we identify our own defenses, and we
often fail to recognize them in others or even project our
own. Like other facets of mental health, the reliable identi-fication of healthy but unconscious defenses requires lon-gitudinal study. Whether we ultimately view another’s
coping response as healthy or psychopathic depends on
the results of their involuntary efforts.
Besides establishment of rater reliability and obtaining
further evidence that the Defensive Function Scale de-serves to be retained, twin and fMRI studies are needed to
test whether these metaphorical mechanisms are, as hy-pothesized, biologically based homeostatic processes. The
research agenda must include examination of how best to
facilitate in the clinic the transformation of less adaptive
defenses into more adaptive defenses. One suggestion has
been, first, to increase social supports and interpersonal
safety and, second, to facilitate the intactness of the CNS
(e.g., through rest, nutrition, and sobriety) (53).
Future Directions
In conclusion, it seems important to review some of the
safeguards for a study of positive mental health. Mental
health must always be broadly defined in terms that are
culturally sensitive and inclusive. The criteria for mental
health must be empirically and longitudinally validated.
Third, validation means special attention to cross-cultural
studies (86). Fourth, in trying to improve mental health we
must respect individual autonomy. Finally, any student of
health must remember that there are differences between
real mental health and value-ridden morality, and be-tween real success at living and mere questing after the
bitch goddess success.
Nevertheless, we need to be able to measure and
record mental health. The mental status and formulation
should both reflect not only the absence of symptoms
but also an assessment of social competence and coping
style. Although room exists for improvement, axis V, the
GAF Scale, provides the same reliability as and greater pre-dictive validity than the presence or absence of most axis I
and II designations. No psychiatric chart should be with-out it. The capacities to work and to love over time are ex-tremely important indices of mental health. They are far
more important than the cross-sectional presence or ab-sence of anxiety, depression, or illegal drug use. But such
capacities must be assessed longitudinally. “How many
years since age 21 have you spent employed?”is a more
useful question than “What is your present job?”Again,
“Tell me about your longest intimate relationship”is much
more useful than “Are you married?”
As with the blind men and the elephant, this article has
suggested six conceptually distinct ways to assess a single
construct—mental health. It would be a terrible mistake to
believe any one of these six models superior to all the oth-ers. Rather, all are important and all are highly correlated
with each other (83). In conducting future research on
positive mental health, multivariate comparison will be
needed to reveal the relative contribution of each model.
Equally important, in the area of national health policy, if
and when interventions to improve positive mental health
are identified, who should pay: the consumer, the educa-tional system, the medical care system, or some as-yet-to-be-identified payer?
Received Aug. 21, 2002; revision received Dec. 27, 2002; accepted
Jan. 10, 2003. From the Department of Psychiatry, Brigham and
Women’s Hospital. Address reprint requests to Dr. Vaillant, Depart-ment of Psychiatry, Brigham and Women’s Hospital, 75 Francis St.,
Boston, MA 02115; gvaillant@partners.org (e-mail).
Supported by NIMH grant MH-42248
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