Reviews and Overviews

Mental Health

George E. Vaillant, M.D. Objective: Only in the last 30 years has chology, is intervention to maximize posi-
psychiatry begun to develop empirical tive qualities, such as self-efficacy. Maturity
approaches to conceptualizing and as- and Erikson’s four developmental tasks
sessing positive mental health. Six models (identity, intimacy, generativity, integrity)
of mental health are reviewed here. are the basis of the third model. The au-
Method: The author points out pitfalls in thor adds two other tasks: career consoli-
research on mental health, e.g., equating dation and “keeper of the meaning.” The
average with healthy, failing to distinguish fourth model is emotional or social intelli-
trait from state, overlooking cultural gence, the ability to read other people’s
norms, and conversely, blindly accepting emotions. Surprisingly, subjective well-be-
the culture’s values. He describes the six ing, the fifth model, is as much a charac-
models and provides history and research teristic of temperament as of a benign en-
needs for each.
vironment. The last model, resilience, is
Results: The first model, being “above epitomized by DSM-IV’s Defense Function
normal,” is epitomized by DSM-IV’s axis V, Scale, which categorizes coping mecha-
the Global Assessment of Functioning nisms in terms of adaptational value.
Scale. High scores represent “superior
functioning in a wide range of activities, Conclusions: As with the blind men and
life’s problems never seem to get out of the elephant, each model describes only
hand, is sought out by others because of some aspects of mental health. Further
his or her many positive qualities.” The research may reveal the contribution of
goal of the second model, positive psy- each.

(Am J Psychiatry 2003; 160:1373–1384)

We cannot even really know what causes neurotic of clearly defining what is meant by mental health, and
suffering until we have an idea of what causes real over the last 30 years research has slowly moved the study
health. This we have only begun to investigate. of mental health from pious platitude toward science.
—Erik Erikson (1, p. 93) Finally, 10 years ago, when evidence (5) emerged to sup-

T oo often, psychiatry has been preoccupied only with

mental illness. To paraphrase Mark Twain’s quip about the
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.
weather, psychiatry is always talking about mental health, Previously, there had been an implicit assumption that
but nobody ever does anything about it. Mental illness, af- mental health could be best defined as the antonym of
ter all, is a condition that can be reliably defined, and its mental illness, but accepting that assumption is to under-
limits are relatively clear. In contrast, mental health seems estimate human potential. Starting early in the last cen-
to lie more in the domain of value judgment than of sci- tury, internists, as they recognized that health was more
ence. For example, mental illness can be defined as the than an absence of symptoms, began studying high-alti-
presence of selected symptoms, but mental health is tude physiology and developed measures of positive phys-
something more than the absence of symptoms. With the ical health for athletes, pilots, and finally astronauts. Thus,
notable exception of the chapter by Offer and Sabshin in the antonym of physical illness is physical fitness. In the
the third and fourth editions of Comprehensive Textbook of late 1930s, Arlie Bock, an internist trained in high-altitude
Psychiatry (2), recent major psychiatric textbooks reveal physiology and interested in positive physical health, be-
virtually no serious discussion of positive mental health. gan at Harvard the Study of Adult Development, an inter-
An electronic search of Psychological Abstracts since 1987 disciplinary study of both positive mental and physical
turned up 57,800 articles on anxiety and 70,856 on depres- health (6, 7). The results of that study, lasting for 60 years
sion, but only 5,701 mentioned life satisfaction and only (8), inform many facets of this paper.
851 mentioned joy (3). It must be admitted that above average mental health is
But mental health is too important to be ignored. In 1978 more difficult to define than physical fitness. Nevertheless,
the report to the President by the President’s Commission it is important for psychiatry to emulate sports medicine
on Mental Health (4) forcefully reiterated the importance and to provide precise definitions and measures of positive

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MENTAL HEALTH

mental health. Psychologists, like physiologists, have This article will contrast six different empirical ap-
learned to quantify not only normal but better than aver- proaches to mental health. It is significant that the empir-
age intelligence. Thus, we regard the antonym of mental ical underpinnings for each of the six models have
retardation not as an IQ of 100 but as an IQ over 130. Psy- emerged only recently. First, mental health can be concep-
chiatry must follow suit. For rather than merely deciding tualized as above normal, a mental state that is objectively
who is too sick for a job, psychiatrists are called on to make desirable—as in the capacity to work and to love. Second,
decisions about who is mentally healthy enough for certain mental health can be conceptualized as positive psychol-
positions—such as air traffic controllers and submariners. ogy, an early example of which was Maslow’s “self-actual-
Before positive mental health can be defined, several izing” individual (9). Third, from the viewpoint of healthy
cautionary steps are necessary. The first step in discussing adult development, mental health can be conceptualized
mental health is to note that average is not the same as as maturity. Fourth, mental health can be conceptualized
healthy, for average always includes mixing in with the as emotional or social intelligence. Fifth, mental health can
healthy the prevalent amount of psychopathology. For ex- be conceptualized as subjective well-being—a mental
ample, in the general population the mean weight or eye- state that is subjectively experienced as happy, contented,
sight is actually unhealthy, and if all sources of biopsycho- and desired. Finally, mental health can be conceptualized
social pathology were excluded from the population, the as resilience, as in successful adaptation and homeostasis.
average IQ would be significantly above 100. Put differ- A moment’s reflection reveals that each of these models
ently, being at the center of a normal bell curve of distribu- describes only part of the “elephant” of mental health.
tion may or may not be healthy. In the case of red blood One research agenda must be empirically to decide, by
cell count, body temperature, or mood, the middle of the means of multivariate modeling, which facets of each
bell curve is healthy. In the case of eyesight, exercise toler- model are additive.
ance, or empathy, only the upper end of the bell curve is
healthy; in the case of serum cholesterol, bilirubin, and Model A: Mental Health
narcissism, only the low end of the curve is healthy. as Above Normal
A second cautionary step in discussing mental health is
to appreciate the caveat that what is healthy sometimes In 1835 Adolphe Quetelet published what appears to be
depends on geography, culture, and the historical mo- the first important book on normality (10). Rather than fo-
ment. Punctuality is a virtue in some countries and a fail- cus on pathology, he tried “to approach more closely to
ing in others. General George Patton’s competitive tem- what is good and beautiful” (p. x), and his goal was the sta-
perament was a psychological liability in time of peace but tistical analysis of healthy humans. He challenged genera-
a virtue in two world wars. tions of future investigators with his introductory sen-
A third cautionary step is to make clear whether one is tence, “Man is born, grows up, and dies, according to
discussing trait or state. Who is physically healthier: an certain laws which have never been properly investigated”
Olympic miler disabled by a simple but temporary (state) (p. 5).
ankle fracture or a type 1 diabetic (trait) with a temporarily Until World War II, however, Quetelet’s challenge to
normal blood sugar level? mental health professionals went largely unheeded. When
In defining mental health, the fourth and most impor- in 1941 the U.S. draft board asked health professionals to
tant cautionary step is to appreciate the two-fold danger define 1-A mental health, they were assigning a novel task.
of “contamination by values.” On the one hand, cultural Indeed, it was not until after World War II that tentative
anthropology teaches us how parochial a given culture’s works on normal adaptive behavior began to be pub-
definition of mental health can be. And, even if mental lished—White’s Lives in Progress (11), Srole and associates’
health is “good,” what is it good for? The self or the society? Mental Health in the Metropolis (12), Erikson’s “Growth
For fitting in or for creativity? For happiness or survival? and Crises of the ‘Healthy Personality’” (1), the Stirling
And who should be the judge? As Erikson warned, “The County studies by the Leightons and colleagues (13, 14),
healthy personality is a topic approaching which the ex- and Grinker and Spiegel’s Men Under Stress (15). Such
pert becomes a fearful angel” (1, p. 92). studies concentrated on the adaptation of nonpatient or
On the other hand, common sense must prevail. Biology normal populations but from different vantage points.
trumps anthropology. Every culture differs in its diet, but Nevertheless, many distinguished postwar psychiatrists
the World Health Organization would be in error to ignore continued to agree with Freud, who had dismissed mental
the universal importance to diet of vitamins and of the health as “an ideal fiction.” In the late 1950s Lewis wrote,
four basic food groups. Although almost no form of behav- “Mental health is an invincibly obscure concept” (16, p.
ior is considered abnormal in all cultures, that does not 227), and Redlich asserted, “We do not possess any general
mean that the tolerated behavior is mentally healthy. Just definition of normality and mental health from either a
because colonial America did not recognize alcoholism as statistical or a clinical viewpoint” (17).
an illness does not mean that alcoholism contributed less Shortly thereafter, Jahoda’s report to the Joint Commis-
to 18th-century morbidity. sion on Mental Illness and Health led to a psychiatric sea

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 GEORGE E. VAILLANT

FIGURE 1. Three Definitions of Mental Health in the Last Half Century

MODEL A MODEL B MODEL C

Mental Health/Normalitya Positive Psychologyb Maturityc

Ability to Love, Work, and Play Love Capacity for Love

● Empathy ● Intimacy/reciprocal attachment ● Capacity for a variety of mutually
● Adequacy in interpersonal relations ● Kindness/generosity/nurturance fulfilling and lasting relationships
● Social intelligence/emotional ● Need to seek a major source of
intelligence fulfillment in productive work

Efficient Problem Solving Temperance Absence of Stereotyped and Unpro-

● Accurate perception of reality ● Forgiveness/mercy ductive Patterns of Problem Solving
● Resistance to stress ● Modesty/humility ● Ability to discharge hostility without
● Environmental mastery ● Prudence/caution harming others or oneself
● Self-control/self-regulation ● Capacity to adapt to change and
endure frustration and loss

Investment in Life Wisdom and Knowledge Realistic Acceptance of the

● Self-actualization ● Curiosity/interest Destiny Imposed by One's Time
● Orientation toward future ● Love of learning and Place in the World
● Judgment/open-mindedness
● Perspective
● Creativity/originality/ingenuity

Autonomy Courage Appropriate Expectations and

● Recognition of one's own needs ● Valor Goals for Oneself
● Being in touch with one's own identity ● Honesty/authenticity ● Ability to respond to the uncertainties
and feelings ● Industry/perseverance of reality in a manner consistently free
● Zest/enthusiasm of domination by one's wishes or
peers

Justice
● Citizenship/loyalty/teamwork
● Equity/fairness
● Leadership

Transcendence Capacity for Hope

● Awe/wonder ● Altruistic concern for other human
● Gratitude beings outside one's own group and
● Hope/future-mindedness beyond one's own time and place
● Spirituality/faith ● Capacity to suspend one's adult
● Playfulness/humor identity and engage in childish play at
appropriate times

a Based on description by Jahoda (18) as summarized by Offer and Sabshin (19).

b Based on description by Peterson and Seligman (20).
c Based on description by Menninger (21).

change regarding the existence of mental health (18). As il- normality (19), investigators began to study mental health
lustrated in Figure 1, Jahoda suggested that a mentally empirically. Although data from the Terman Study at Stan-
healthy individual should 1) be in touch with his or her ford (23), the Institute of Human Development at Berkeley
own identity and feelings, 2) be oriented toward the future (24, 25), and the Study of Adult Development at Harvard
and remain fruitfully invested in life, 3) have a psyche that (7, 8) were later to be highly informative, the first longitu-
provides resistance to stress, 4) possess autonomy, per- dinal study of positive mental health to be harvested was
ceive reality without distortion, and yet possess empathy, arguably the elimination process by which out of 130
and 5) be able to work, to love, to play, and to be efficient healthy jet pilots, already winnowed for over a decade for
in problem solving. Although the purpose of Jahoda’s re- psychological resilience, the seven original astronauts
port was to rid the term “mental health” of “vague, elusive were selected (26). This study underscored both the
and ambiguous connotation,” Jahoda could not marshal importance and the commonsensical nature of mental
empirical evidence to prove that her plausible definition health. The final seven astronauts not only enjoyed exem-
was more than platitude. plary work records but were also competent at loving. All
In the 1960s, beginning with Grinker and associates’ had come from intact, happy, small-town families. In their
studies of “homoclites” (22) (physical education majors 30s, they all were married with children. Although ven-
selected for normality) and Offer and Sabshin’s text on turesome test pilots, they had suffered unusually few acci-

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MENTAL HEALTH

dents during their years as pilots or even earlier. They clozapine or with cognitive behavior therapy we can raise
could tolerate both close interdependent association and a GAF Scale score from 40 to 70, but how would we raise a
extreme isolation. They trusted others and were uncom- score from 70 to 90? This is an important research ques-
plaining under discomfort. Emotions, both negative and tion that psychiatry has not yet begun to address.
positive, were strongly experienced. Not introspective, the
astronauts seldom dwelled on their inner emotions; but Model B: Mental Health
they could describe them when asked. They were aware of
as Positive Psychology
the feelings of others, and they avoided interpersonal dif-
ficulties. Their group score on the neuroticism scale of the The second model, as old as Aristotle, conceives of men-
Maudsley Personality Inventory has been described as the tal health as a utopian ideal and has provided the impetus
lowest of any group reported in the literature (27). for the recent positive psychology movement (33). In the
A more influential early study of mental health was the 19th century mental health was viewed as related to mo-
Menninger Psychotherapy Project (28). To assess the psy- rality. Psychiatrists wrote of both “moral insanity” and
chological functioning of study subjects, Menninger psy- “good character.” But in the 20th century, as psychiatry be-
chologist Lester Luborsky devised an empirical measure came more concerned with pathology, only educational
of mental health (Health-Sickness Rating Scale), a scale of psychology remained interested in character and “virtue.”
0–100 (29, 30). In 1976, because Luborsky’s scale had been In psychology, interventions to improve already ade-
designed to evaluate candidates for psychotherapy rather quate intelligence and social skills are common, while in
than for general epidemiological studies, two of the archi- medicine and psychiatry to meddle with adequate thyroid
tects of DSM-III modified the Health-Sickness Rating function, a healthy hematocrit, or a normal mood is only
Scale and rechristened it the Global Assessment Scale to invite trouble. It can be argued that in the healthy rested
(GAS) (31). The reliability values for between-rater agree- individual virtually all psychopharmacological interven-
ment on each instrument and agreement between the two tions will, over time, make the brain function worse; it can
instruments were 0.85 to 0.95 (5). In a cross-cultural com- also be argued that many nonpharmacological interven-
parison Armelius and co-workers (32) noted that “the use- tions (e.g., literacy training, stress management, and ten-
fulness of the Health-Sickness Rating Scale as an interna- nis lessons) will make the brain function better. Thus,
tion al ther mometer of mental health is strongly those with the medical goal of using medication to remove
supported.” A modified version of the GAS was introduced pathology sometimes forget educational interventions to
in DSM-III-R as the GAF Scale, or axis V. enhance above average functioning.
As with excellence in the decathlon, no single measure Over the last 40 years, Maslow’s concept of self-actual-
defines mental health, but all measures are highly inter- ization and his emphasis on humanistic psychology (9, 34)
correlated. On the Health-Sickness Rating Scale a score of have drawn attention to full use and exploitation of tal-
95–100 reflects “an ideal state of complete functioning in- ents, capacities, potentialities. But until very recently,
tegration, of resiliency in the face of stress, of happiness such humanistic psychology did not provide empirical re-
and social effectiveness.” On the DSM-IV GAF Scale, a search and ignored both predictive validity and follow-up.
score of 91–100 equals “superior functioning in a wide As early as 1925, psychiatrist Adolf Meyer was already
range of activities, life’s problems never seem to get out of warning psychologists of the difference between “moraliz-
hand, is sought out by others because of his or her many ing” about mental health and studying it by “conscien-
positive qualities; no symptoms.” The words differ, but the tious and impartial study” and “constructive experimen-
melody is the same. Figure 1 illustrates how multifaceted tation” (35, p. 118).
and unique models of positive mental health can be and Recently, Seligman (36, 37) has served notice that posi-
yet how strong their “family” resemblance. tive psychology will follow Meyer’s rules of conscientious
Some items on a future research agenda seem clear. and impartial study and constructive experimentation.
First, it behooves psychiatry to pursue cross-cultural vali- Seligman’s concept of learned optimism incorporates the
dation and refinement of the GAF Scale. Second, since pri- empirical advances in cognitive psychology that have
mary prevention is clearly superior to treating disease taken place over the past three decades. Creating a posi-
once it has occurred, we need to study individuals with tive attributional style not only serves as a cognitive be-
positive mental health the way that agronomists study havior treatment for depression (36, 37) but can lead to
wheat that is resistant to drought and blight. Third, the positive mental states.
concept of mental health raises the issue of therapeutic in- Advocates of positive psychology wish to learn how to
terventions to achieve it. Which facets of mental health are build the qualities that help individuals and communities
fixed and which are susceptible to change? By analogy, in not just to endure and survive but also to flourish. For-
most individuals the most intensive educational interven- mally introduced in the January 2000 issue of American
tion will raise IQ only about 7 points, but sustained thera- Psychologist, positive psychology entails rendering “hu-
peutic intervention can change individuals utterly illiter- manistic” psychology amenable to scientific study and
ate in Italian into fluent Italian conversationalists. With intervention.

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 GEORGE E. VAILLANT

At the individual level, it is about positive individual social scientists, especially those in Europe, have mis-
traits; the capacity for love and vocation, courage, in- trusted optimistic cognition, especially religious opti-
terpersonal skill, aesthetic sensibility, perseverance, mism, as a maladaptive “American” illusion interfering
forgiveness, originality, future mindedness, spiritual-
ity, high talent, and wisdom.… And in this quest for with accurate perception of reality. Nietzsche, Freud,
what is best, positive psychology does not rely on Marx, and Darwin all perceived optimism as evidence of
wishful thinking, faith, self-deception, fads, or hand an ingenuous cultural adolescence, not of mature mental
waving; it tries to adapt what is best in the scientific health. It is healthier to face the hard facts of life. Besides,
method to the unique problems that human behavior
there is a significant body of work suggesting that the de-
presents to those who wish to understand it in all its
complexity. (33, p. 5) pressed perceive the world more accurately (38).
Nevertheless, over the past 30 years cognitive therapists
Recently, advocates of positive psychology have divided have demonstrated that altered cognition can not only
positive mental health into four components: talents, en- change behavior, it can also alter brain function (39). If pes-
ablers, strengths, and outcomes (20). Talents are inborn, simism is the dominant cognition of the depressed, opti-
are genetic, and are not much affected by intervention mism appears the dominant cognition of the mentally
(e.g., high IQ, being an easy baby). Enablers reflect social healthy. If learned helplessness leads to depression, learned
interventions and environmental good luck (e.g., strong optimism and self-efficacy lead to mental health (37).
family, good school system); these can be experimentally
In part, the importance of optimism to positive mental
modified to enhance strengths. Strengths (Figure 1) are
health depends on an explanatory style that asserts, “The
character traits such as curiosity and openness that reflect
good things that happen to me will last forever. They are
facets of mental health that are amenable to change. Out-
pervasive, and they are my own doing. The bad things that
comes reflect dependent variables (e.g., improved score on
happen to me occur by chance, are limited, and are un-
the GAF Scale, positive social relationships, subjective
likely to happen again.” The explanatory style of many
well-being) that can be used to provide evidence that clini-
chronically depressed individuals is just the opposite (40,
cians’ efforts to alter strengths are not just wishful thinking.
41). In addition, optimism includes hope, a facet of mental
As components of mental health, the specific ideal
health as old as the Greek myth of Pandora. Yet hope is a
strengths (or virtues) are subject to debate. Wisdom, kind-
topic to which psychiatry up to now has given little formal
ness, and the capacity to love and be loved are strengths
consideration. In addition, the illusion of optimism per-
over which few would argue. But should courage be in-
mits one to contemplate and plan for, rather than to deny,
cluded as a strength, and why were intelligence, perfect
the future. Longitudinal studies have repeatedly shown fu-
musical pitch, and punctuality excluded? The answer is
ture-mindedness to be a critical ingredient of mental
that the 24 strengths listed in Figure 1 may be subjected to
a variety of tests. First, they have been recurrent positive health (7, 24). Finally, positive psychology is the only
values across cultures and across centuries. Second, they model of mental health that suggests, even tentatively,
may be valued in their own right and not just as a means to how a GAF Scale score of 75 might be raised to 90. The re-
ends. search agenda for positive psychology includes continu-
There are pitfalls with positive psychology. First, the ing to build bridges to medicine and to build on work (42)
perspective of mental health as Utopia is one of the bogey- that undergirds such humanistic ideas with Meyer’s “con-
men of national health policy makers. They are afraid, structive experimentation.”
without directly expressing it, that this perspective, com-
monly adhered to by some mental health specialists, will Model C: Mental Health as Maturity
put a backbreaking burden on health insurance. Is helping
people to become happier with themselves a process that Unlike organs of the body that are designed to stay the
any health insurance program should be expected to same, the brain is designed to be plastic. A 10-year-old’s
cover? Over time society will have to decide who should lungs and kidneys are more likely to reflect health than
pay for positive mental health: the individual, the educa- those of a 50-year-old, but that is not true of the central
tional system, third-party payers, religious organizations, nervous system (CNS). To some extent, then, adult men-
or a combination of all four. tal health reflects a continuing process of maturational
A second caution about positive psychology relates to unfolding.
the danger of the culturally insensitive prescription of pa- It may be argued that the “brain” gets worse with age, so
rochial virtues. The dangers of value judgments are enor- why should the “mind” get better? But research reveals
mous. We need to distinguish virtues, even Aristotelian that in the absence of disease the brain works surprisingly
virtues, from health. Keeping wounds clean is healthy but well until age 80 (43) and that neurologically optimal brain
not a virtue. Body hygiene in public places is a virtue but development requires almost a lifetime (44, 45). Prospec-
not necessarily healthy. tive studies reveal that individuals are less depressed and
A third controversial facet of positive psychology is its show greater emotional modulation at 70 than they did at
emphasis on optimism. Since the late 19th century, many 30 (8, 25).

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MENTAL HEALTH

FIGURE 2. Model of Adult Development Combining Erik- Pennsylvania Dutch cartoons of life span development.
son’s Four Tasks With Two Others (Career Consolidation Rather, Eriksonian development can be conceptualized as
and Keeper of the Meaning)
expanding ripples in a pond. Over time the adult social ra-
dius expands through the mastery of four tasks: identity
Integrity
versus identity diffusion, intimacy versus isolation, gener-
the Me
er of an ativity versus stagnation, and integrity versus despair. On
eep in the basis of empirical data from Harvard’s Study of Adult
K e rativity g
Gen Development, I have added two more tasks—career con-
Consolida solidation and “keeper of the meaning”—to Erikson’s four
e er ti
r macy (52) (Figure 2) and demonstrated their sequential nature.
ti

on
Ca

In Mastery of such tasks appears relatively independent of

education, gender, social class, and arguably, culture (53).
Identity In such a model the social radius of each adult develop-
mental task fits inside the next. First, the adolescent must
evolve an identity that allows him or her to become sepa-
rate from the parents, for mental health and adult devel-
opment cannot evolve through a false self. The task of
identity requires mastering the last task of childhood: sus-
tained separation from social, residential, economic, and
ideological dependence on one’s family of origin. Such
separation derives as much from the identification and in-
ternalization of important adolescent friends and mentors
as it does from simple biologic maturation (54). For exam-
ple, our accents become relatively fixed by age 16 and re-
Erikson, influenced by his work at the Institute of Hu- flect those of our adolescent peer group rather than the
man Development, provided the first model of adult social accents of our parents.
development (1, 46). Although he devoted only four out of Then adults develop intimacy, which permits them to
55 pages to his three stages of adult development, he saw become reciprocally, and not narcissistically, involved
each of his eight developmental stages as a “criterion of with a partner. To many young adults, to live with one
mental health” (1, p. 142). Later, Jane Loevinger provided a other person in an interdependent, reciprocal, commit-
model of adult ego development (47), Lawrence Kohlberg ted, and contented fashion for years and years may seem
proposed a model of adult moral development (48), and neither desirable nor possible. Once achieved, however,
James Fowler described a model of spiritual development the capacity for intimacy may seem as effortless and desir-
(49). Implicit in all these models is the assumption that able as riding a bicycle. Sometimes the relationship is with
greater maturity reflects greater mental health. Perhaps a person of the same gender; sometimes it is completely
the best definition of mental health that we have is Will- asexual; and sometimes, as in religious orders, the inter-
iam Menninger’s definition of maturity (21) (Figure 1). In dependence is with a community. In different cultures and
this model maturity is not only the antonym of narcissism epochs, mastery of intimacy has taken very different
but is quite congruent with other models of mental health. guises but “mating for life” and “marriage-type love” are
To confirm the hypothesis that maturity and positive tasks built into the developmental repertoires of many
mental health are almost synonymous, the study of the warm-blooded species, including our own.
behavior and feeling states of persons over a lifetime be- Career consolidation is a task that is usually mastered
comes necessary. Although most such longitudinal studies together with or that follows the mastery of intimacy. Mas-
have come to fruition relatively recently (7, 23, 25, 50, 51), tery of this task permits adults to find a career as valuable
all illustrate the association of increasing mental health as they once found play. On a desert island one can have a
with maturity. (After age 50, of course, the association hobby but not a career, for careers involve being of value
between mental health and maturity is contingent on a to other people. There are four crucial developmental cri-
healthy CNS. The ravages of brain trauma, major depres- teria that transform a job or hobby into a career: content-
sion, arteriosclerosis, Alzheimer’s disease, alcoholism, and ment, compensation, competence, and commitment. Not
schizophrenia can all reverse the process.) only people with schizophrenia but also individuals with
The association of mental health with maturity is prob- severe personality disorder often manifest a lifelong in-
ably mediated not only by progressive brain myelinization ability to achieve either intimacy or sustained, gratifying
(44, 45) but also by the evolution of emotional and social employment. Such individuals rarely enjoy a GAF Scale
intelligence over time. Erikson conceptualized such devel- score over 65.
opment as a “widening social radius.” In his view, life after Mastery of the fourth task, generativity, involves the
age 50 is no longer a staircase leading downward, as in the demonstration of a clear capacity to unselfishly care for

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 GEORGE E. VAILLANT

and guide the next generation. Existing research reveals angry—that is easy. But to be angry with the right person,
that sometime between ages 35 and 55 our need for to the right degree, at the right time, for the right purpose,
achievement declines and our need for community and and in the right way—that is not easy.” Nevertheless, as re-
affiliation increases (55). Depending on the opportunities cently as 40 years ago a textbook on intelligence dismissed
that the society makes available, generativity can mean the concept of social intelligence as “useless.” Indeed, only
serving as a consultant, guide, mentor, or coach to young since the 1970s has modulation of “object relations”
adults in the larger society. Generativity reflects the capac- seemed more important to psychoanalysis than modula-
ity to give the self—finally completed through mastery of tion of “instinct.”
the first three tasks of adult development—away. Its mas- The benefits of being able to read feelings from nonver-
tery is strongly correlated with subsequent mental health bal cues have been demonstrated in almost a score of
in old age (8). For in old age there are inevitable losses, and countries (56). These benefits include being better emo-
these may overwhelm us if we have not continued to grow tionally adjusted, more popular, and more responsive to
beyond our immediate family. others. Empathic children, without being more intelli-
The penultimate life task is to become a keeper of the gent, do better in school and are more popular than their
meaning. Like grandparenthood, this task involves passing peers. Head Start found that early school success was
on the traditions of the past to the future. Generativity and achieved not by intelligence but by being able to wait and
its virtue, care, require taking care of one person rather knowing what kind of behavior is expected, how to rein in
than another. Keeper of the meaning and its virtues of wis- the impulse to misbehave, and how to get on with other
dom and justice are less selective; for justice, unlike care, children (57).
means not taking sides. The focus of a keeper of the mean- Social-emotional intelligence can be defined by the fol-
ing is with conservation and preservation of the collective lowing criteria (56):
products of mankind—the culture in which one lives and
1. Accurate conscious perception and monitoring of
its institutions—rather than with just the development of
one’s own emotions.
its children. Clearly, caretakers and grandparents are not
2. Modification of one’s emotions so that their expres-
mentally healthier than caregivers and parents. The dis-
sion is appropriate. This involves the capacity to self-
tinction is only that grandparents are usually better at the
soothe anxiety and to shake off hopelessness and
tasks of keeper of the meaning than are 30-year-olds.
gloom.
Finally, in old age it is common to feel that some life ex-
3. Accurate recognition of and response to emotions in
ists after death and that one is part of something greater
others.
than one’s community. Thus, the last life task is integrity,
4. Skill in negotiating close relationships with others.
the task of achieving some sense of peace and unity with
5. Capacity for focusing emotions (motivation) on a de-
respect to one’s own life. One’s social radius may expand to
sired goal. This involves delayed gratification and
embrace the whole world. Erikson described integrity as
adaptively displacing and channeling impulse.
an experience that conveys some world order and spiritual
sense. “It is the acceptance of one’s one and only life cycle Over the last 15 years, two important empirical steps
and of the people who have become significant to it as have been taken in our understanding of the importance
something that had to be and that, by necessity, permitted of social-emotional intelligence to positive mental health.
of no substitutions” (1, p. 143). The first step is that both functional magnetic resonance
Of course, healthy adult development does not follow imaging (fMRI) and ingenious neurophysiological experi-
rigid rules, nor are butterflies healthier than caterpillars. mentation (58, 59) have led to advances in our under-
Some individuals, often because of great stress, tackle de- standing of the integration of the prefrontal cortex with
velopmental tasks out of order or all at once. Beethoven the limbic system, especially with the amygdala and its
enjoyed a brilliant committed career but never enjoyed connections. This in turn has brought us closer to under-
intimacy. standing emotions as neurophysiological phenomena
The research agenda for the maturational model is the rather than as platonic abstractions.
same as for positive psychology—to provide such human- The second step has been our slow but steady progress
istic concepts of adult development with more opera- in conceptualizing and even measuring “emotional intelli-
tional, empirically grounded, prospectively derived, and gence” (60). High emotional intelligence reflects above av-
cross-culturally validated definitions of maturational erage mental health in the same way that a high IQ reflects
tasks and then to demonstrate their predictive validity. above average intellectual aptitude. Gardner described
emotional intelligence as the capacity to “discern and re-
Model D: Mental Health spond appropriately to the moods, temperaments, moti-
vations and desires of other people” (61, p. 8).
as Social-Emotional Intelligence
Where the study of positive mental health ends and pri-
In the Nicomachean Ethics, Aristotle defined social- mary prevention begins is unclear, but like the model of
emotional intelligence as follows: “Anyone can become positive psychology, the model of social-emotional intelli-

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MENTAL HEALTH

gence is potentially interventionist. Just as we can have 1967 definition suggested that a happy person is “young,
above average musical skill or physical coordination and healthy, well-educated, well paid, extroverted, optimistic,
yet can train these strengths to be even greater; so we are worry free, religious and married with high self esteem, a
learning to enhance emotional intelligence. There are al- good job, morals, and modest aspirations” (italics added)
ready exercises in teaching emotion recognition and dif- (66). In the last 30 years, however, empirical research has
ferentiation to patients with eating disorders and teaching shown such a vacuous generalization only partly correct.
anger modulation and how to find creative solutions to so- The italicized adjectives are all untrue or true only with
cial predicaments for individuals with behavior disorders. qualifications (37).
Once we have a firmer grasp of its measurement, the rela- The Nuns Study provides perhaps the most convincing
tive importance of emotional intelligence to other compo- link between subjective happiness and health (64, 67).
nents of mental health can be assessed. I wager that it will When they were in their 20s, 180 nuns were asked to write
emerge as the most important single dimension of mental a 2–3-page autobiography. Of those who expressed the
health. most positive emotion, only 24% had died by age 80. In
contrast, by the same age 54% of those who expressed the
Model E: Mental Health least positive emotion had died.
as Subjective Well-Being Only in the last three decades have investigators, espe-
cially Edward Diener (3, 68), made a serious effort to re-
Is it better to meet some expert’s definition of mental search the definitional and causal parameters of subjec-
health, or is it better to feel subjectively fulfilled? The an- tive well-being and thereby address important questions.
swer is “both.” For positive mental health does not involve One such question is, Is subjective well-being more a
just being a joy to others; one must also experience subjec- function of environmental good fortune, or is it more a
tive well-being. Indeed, long before humankind consid- function of an inborn, genetically based temperament?
ered definitions of mental health, they pondered criteria Put differently, Does subjective well-being reflect trait or
for subjective happiness. “No man is happy who does not state? If subjective well-being reflects a safe environment
think himself so.” and the absence of stress, it should fluctuate over time,
Nevertheless, the mental health issues involved in sub- and individuals happy in one domain in their lives might
jective well-being are complicated and clouded by histori- not be happy in another.
cal relativism, value judgment, and illusion. As already The answer is that subjective well-being has more effect
noted, Europeans have been skeptical of American con- on the environment than the environment exerts on it. For
cern with happiness. On the one hand, happiness that example, investigators have been startled that a signifi-
comes from joy or unselfish love (agape), that comes from cant number of AIDS victims perceive that their illness has
self-control and self-efficacy, or that comes from play or enhanced the quality of their subjective lives. Similarly, af-
deep but effortless involvement (62) reflects health. On ter a few weeks of temporary elation, the subjective well-
the other hand, happiness can be based on illusion or on being of lottery winners returns to baseline.
dissociative states, and the search for happiness can ap- In other words, subjective well-being is due more to
pear selfish, narcissistic, superficial, and banal. Examples “top-down” processes—temperamental factors governing
of maladaptive “happiness” include the excitement of risk subjective well-being—than to “bottom-up factors”—for
taking, being “high” on drugs, and short-lived satisfaction example, the fulfillment of universal human needs. In-
from binge eating, tantrums, promiscuity, and revenge. It deed, subjective well-being is highly heritable and rela-
is because of such ambiguity of meaning that throughout tively independent of demographic variables. The subjec-
this section the term “subjective well-being” is substituted tive well-being of monozygous twins raised apart is more
for “happiness.” similar than that of heterozygous twins raised together
Only in the last decade have investigators such as Bar- (69). Among the partially heritable factors making signifi-
bara Fredrickson (63), Martin Seligman (36), and David cant contributions to a high level of subjective well-being
Snowdon (64) pointed out that a primary function of posi- are a low level of trait neuroticism, high level of trait extra-
tive emotional states and optimism is facilitation of self- version, absence of alcoholism, and absence of major de-
care. Subjective well-being makes available personal re- pression (3). For example, when heritable variables are
sources that can be directed toward innovation and cre- controlled, subjective well-being—unlike tested intelli-
ativity in thought and action. Thus, subjective well-being, gence—is not affected by environmental factors such as
like optimism, becomes an antidote to learned helpless- income, parental social class, age, and education.
ness. Again, after control for income, education, weight, Consistently, relationships are more important to sub-
smoking, drinking, and disease, happy people are perhaps jective well-being than is money. In a representative study
only half as likely to die at an early age or become disabled of 800 college alumni, respondents who preferred high in-
as unhappy people (65). come, occupational success, and prestige over having very
Until recently the scientific parameters of subjective well- close friends and a close marriage were twice as likely to
being were as vague as those for objective mental health. A describe themselves as “fairly” or “very” unhappy (70).

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 GEORGE E. VAILLANT

Over the last two decades the doubling of net disposable and external reality. If such sudden changes are not “dis-
income in the western world did not affect subjective well- torted” and “denied,” they can result in disabling anxiety
being (3). Mean life satisfaction in socioeconomically and/or depression. Such homeostatic mental defenses
challenged Brazil and China is higher than in socioeco- shield us from sudden changes in the four lodestars of
nomically blessed Japan and Germany. conflict. These four lodestars are affect/impulse, reality,
In some instances environment can be important to relationships, and social learning. Involuntary coping
subjective well-being. Young widows remain subjectively mechanisms can abolish impulse (e.g., by reaction forma-
depressed for years. Even though their poverty has been tion), relationships (e.g., by schizoid fantasy), reality (e.g.,
endured for centuries, respondents in very poor nations, by psychotic denial), or social learning (e.g., by acting out).
such as India and Nigeria, report lower subjective well-be- They can alter our conscious recognition of the subject
ing than those in more prosperous nations. Pain from the (e.g., by projection) or the object (e.g., by turning against
loss of a child never stops. the self) of a conflict, our awareness of the conflictual idea
Maintaining self-efficacy, agency, and autonomy make (e.g., by repression), or the conflictual affect associated
additional environmental contributions to subjective with the idea (e.g., by isolation of affect).
well-being. Subjective well-being is usually higher in de- By 1970, defense mechanisms, like many psychoana-
mocracies than in dictatorships. Assuming responsibility lytic metaphors, had been largely discarded by most em-
for favorable or unfavorable outcomes (internalization) is pirical social scientists. Consistency of definition and rater
another major factor leading to subjective well-being. reliability were lacking. But over the last 30 years, the idea
Placing the blame elsewhere (externalization) signifi- of healthy involuntary coping has entered the literature of
cantly reduces subjective well-being. In other words, para- empirical cognitive psychology under such rubrics as
noia and projection make people feel worse rather than “hardiness” (75), “self-deception” and “emotional coping”
better. Religiosity is consistently and positively correlated (73), and “illusion” (76). In the last decade experimental
with well-being, but there may be a chicken-egg relation- strategies for assessing defense mechanisms have also im-
ship between social support and religious observance. For proved (77–80). Several reviews have also clarified our un-
example, among church-goers it is difficult to disentangle derstanding of healthy and unhealthy defenses (81, 82). By
where spiritual faith ends and community support begins. offering both a tentative hierarchy and a glossary of con-
The research agenda for subjective well-being includes sensually validated definitions, an optional axis of invol-
establishing with greater definition the relative contribu- untary coping mechanisms was added to DSM-IV. The De-
tions of heredity and of environment and culture. In ad- fensive Function Scale (DSM-IV, p. 752) has set the stage
dition, we need to establish the magnitude of the contri- for further progress in our understanding of positive men-
bution of subjective well-being to the other models. We tal health. In addition, in terms of predictive validity (i.e.,
need to disentangle interpersonal happiness (model D) predicting future mental health), the Defensive Function
from intrapersonal happiness (model E). 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-
Model F: Mental Health as Resilience
ric reliability. The Q-sort technique is perhaps the most
In 1865, Claude Bernard, the founder of experimental promising (80).
medicine, declared, “We shall never have a science of All classes of defenses in the Defensive Function Scale
medicine as long as we separate the explanation of the are effective in “denying” or defusing conflict and in “re-
pathological from the explanation of normal, vital phe- pressing” or minimizing stress, but they differ greatly in
nomena” (71). Later, Meyer (72) perhaps overstated the the psychiatric diagnoses assigned to their users and in
case when he asserted that there are no mental diseases, their consequences for long-term biopsychosocial adap-
there are only characteristic patterns of reaction to stress. tation. In level 1, the most pathological category, are found
But Meyer drew attention to the fact that mentally healthy denial and distortion of external reality. These mecha-
responses to stress, analogous to pus and cough, are often nisms are common in young children, in our dreams, and
misinterpreted as pathological. in psychosis. To breach them requires altering the brain by
There are three broad classes of coping mechanisms neuroleptics or waking the dreamer.
that humans use to overcome stressful situations. First, More common to everyday life are the relatively mal-
there are the ways in which an individual elicits help from adaptive defenses found in levels 2–5. Defenses in these
appropriate others: namely, consciously seeking social categories are common in adolescents, in immature
support. Second, there are conscious cognitive strategies adults, and in individuals with personality disorders. They
that we intentionally use to master stress (73). Third, there often make others more uncomfortable than the user.
are involuntary mental coping mechanisms (often called Such defenses are consistently and negatively correlated
“defense mechanisms” or “denial”) (74). This third, invol- with global assessment of mental health, and they pro-
untary class of coping mechanisms reduces conflict and foundly distort the affective component of interpersonal
cognitive dissonance during sudden changes in internal relationships. The third class of defenses, those in level 6,

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MENTAL HEALTH

are often associated with what DSM-IV calls axis I anxiety health must remember that there are differences between
disorders and with the psychopathology of everyday life. real mental health and value-ridden morality, and be-
These include mechanisms such as repression, intellectu- tween real success at living and mere questing after the
alization, and reaction formation. They are common to bitch goddess success.
everyone from 5 years old until death. They are neither Nevertheless, we need to be able to measure and
healthy nor unhealthy. record mental health. The mental status and formulation
The mechanisms at level 7 still distort and alter feelings, should both reflect not only the absence of symptoms
conscience, relationships, and reality, but they achieve but also an assessment of social competence and coping
these alterations gracefully and flexibly. These mecha- style. Although room exists for improvement, axis V, the
nisms allow the individual consciously to experience the GAF Scale, provides the same reliability as and greater pre-
affective component of interpersonal relationships but in dictive validity than the presence or absence of most axis I
a tempered fashion. Thus, the beholder may regard level 7 and II designations. No psychiatric chart should be with-
adaptive defenses as virtues, just as the same beholder out it. The capacities to work and to love over time are ex-
might regard the prejudice of projection and the tantrums tremely important indices of mental health. They are far
of acting out as sins. Doing as one would be done by (altru- more important than the cross-sectional presence or ab-
ism), keeping a stiff upper lip (suppression), keeping fu- sence of anxiety, depression, or illegal drug use. But such
ture pain in awareness (anticipation), being able not to capacities must be assessed longitudinally. “How many
take one’s self too seriously (humor), and turning lemons years since age 21 have you spent employed?” is a more
into lemonade (sublimation) are the very stuff from which useful question than “What is your present job?” Again,
positive mental health is made. In addition, the thoughtful “Tell me about your longest intimate relationship” is much
reader may wish to add involuntary but adaptive offences: more useful than “Are you married?”
for example, creativity, charisma, leadership, courage, and As with the blind men and the elephant, this article has
vision. Unfortunately, like tightrope walking, without suggested six conceptually distinct ways to assess a single
months of practice mature mechanisms cannot easily be construct—mental health. It would be a terrible mistake to
deployed voluntarily and only then by those with innate believe any one of these six models superior to all the oth-
balance. ers. Rather, all are important and all are highly correlated
Identification of defenses is difficult and has impeded with each other (83). In conducting future research on
research. Rarely can we identify our own defenses, and we positive mental health, multivariate comparison will be
often fail to recognize them in others or even project our needed to reveal the relative contribution of each model.
own. Like other facets of mental health, the reliable identi- Equally important, in the area of national health policy, if
fication of healthy but unconscious defenses requires lon- and when interventions to improve positive mental health
gitudinal study. Whether we ultimately view another’s are identified, who should pay: the consumer, the educa-
coping response as healthy or psychopathic depends on tional system, the medical care system, or some as-yet-to-
the results of their involuntary efforts. be-identified payer?
Besides establishment of rater reliability and obtaining
further evidence that the Defensive Function Scale de- Received Aug. 21, 2002; revision received Dec. 27, 2002; accepted
Jan. 10, 2003. From the Department of Psychiatry, Brigham and
serves to be retained, twin and fMRI studies are needed to Women’s Hospital. Address reprint requests to Dr. Vaillant, Depart-
test whether these metaphorical mechanisms are, as hy- ment of Psychiatry, Brigham and Women’s Hospital, 75 Francis St.,
pothesized, biologically based homeostatic processes. The Boston, MA 02115; [email protected] (e-mail).
Supported by NIMH grant MH-42248.
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
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