Positive mental health: is there a cross‐cultural definition?

The great epidemiological studies of the past half century have focused upon who was mentally ill and not who was well. Mental illness, after all, is a condition that can be defined reliably, and its limits are relatively clear. Until recently, only the Sterling County Studies by A. Leighton 1 came close to defining positive mental health operationally. In addition, it has been argued that achieving above average mental or physical health is not the province of medicine, but of education. Early in the past century, internists began studying physiology at high altitude and devise measures of positive physical health for athletes, pilots, and finally astronauts. In 1929–30, at the University of California at Berkeley, the Institute of Human Development was founded by H. Jones, N. Bayley and J. McFarlane 2,3. Originally created to study healthy child development, the Institute was to provide a seminal influence on E. Erikson's model of healthy adult development. In the late 1930s, A. Bock, an internist trained in high altitude physiology and interested in positive physical health, began the Study of Adult Development at the Harvard University 4,5. This was designed as an interdisciplinary study of both mental and physical health. Like physical fitness, positive mental health is too important to be ignored, but its definition is not easy. Several precautions are necessary. First, in defining mental health, cross-cultural differences must be kept in mind. My own efforts to define mental health may appear parochial to those from other countries. Thus, the commentaries on this paper will be particularly important. The second precaution is to keep in mind that “average” is not healthy. Community surveys always mix in the healthy with the prevalent amount of psychopathology. In the case of red blood count, or thyroid function, the middle of the bell curve is healthy. In the case of eyesight, only the upper end of the bell curve is healthy; and in the case of cholesterol and bilirubin only the low end of the curve is healthy. A third precaution is to make clear whether one is discussing trait or state. Longitudinal study is particularly important. A world-class soccer player temporarily sidelined with a sprained ankle (state) is probably healthier than a type 1 diabetic (trait) with a temporarily normal blood sugar. Finally, mental health needs to be seen in context. Sickle cell trait is unhealthy in Paris, but not in central Africa where malaria is endemic. In the 1940s, paranoid personalities made very poor submariners but excellent airplane spotters. Punctuality and competitiveness are seen as healthy in some communities, but not in others. Moreover, if mental health is “good”, what is it good for? The self or the society? For “fitting in” or for creativity? In defining mental health, biology usually trumps anthropology. Cultural anthropology teaches us that almost every form of behavior is considered healthy in some cultures, but that does not mean that the tolerated behavior is mentally healthy. Until recently, Portugal did not recognize alcoholism as an illness, but that did not reduce the contribution of alcoholism to mortality in Lisbon. The best way to enrich our understanding of what constitutes mental health is to study a variety of healthy populations from different perspectives, in different cultures and for a long period of time. This paper will contrast seven different empirical models of mental health. First, mental health can be conceptualized as above normal, as epitomized by a DSM-IV's Global Assessment of Functioning (GAF, 6) score of over 80. Second, it can be regarded as the presence of multiple human strengths rather than the absence of weaknesses. Third, it can be conceptualized as maturity. Fourth, it can be seen as the dominance of positive emotions. Fifth, it can be conceptualized as high socio-emotional intelligence. Sixth, it can be viewed as subjective well-being. Seventh, it can be conceptualized as resilience. To avoid quibbling over which traits characterize mental health, it is helpful to adopt the analogy of a decathlon champion. What constitutes a “track star”? A decathlon star must possess muscle strength, speed, endurance, grace and competitive grit, although the combinations may vary. Amongst decathlon champions, the general definition will not differ from nation to nation, or century to century. The salience of a given facet of a decathlon champion, or of mental health, may vary from culture to culture, but all facets are important. After World War II, influential works on mental health began to be published 7,8,9. Although all studies concentrated on normal populations, they still put their emphasis on not pathological rather than on above average mental health. Besides, many post-war psychiatrists continued to agree with S. Freud who had dismissed mental health as “an ideal fiction”. Then, in 1958, M. Jahoda's report to the American Joint Commission on Mental Illness and Health 10 led to a psychiatric sea change regarding the existence of mental health. She suggested that mental health includes autonomy (being in touch with one's own identity and feelings); investment in life (self-actualization and orientation toward the future); efficient problem solving (accurate perception of reality, resistance to stress, environmental mastery); and ability to love, work and play. However, at the time she published her criteria, there was still no evidence to prove that her plausible definitions were more than mere platitudes. Next, came R. Grinker's 1962 studies of “homoclites”, the first empirical study of positive mental health 11. Grinker's homoclites were physical education majors selected for normality but studied only briefly. A second more longitudinal study was the elimination process, by which out of 130 healthy jet pilots, already selected for mental health, the seven original American astronauts were selected 12. These astronauts not only enjoyed exemplary work records, but also were competent at loving. Although venturesome test pilots, they all had had very few accidents during their years of flying. They could tolerate both close interdependent association and extreme isolation. Although each of the astronauts was very different, they all would have starred in a mental health “decathlon”. An even more influential study of mental health was the Menninger Psychotherapy Project led by the psychologist L. Luborsky. He devised the Health-Sickness Rating Scale, with a scale from 0 to 100 13, based on behavior rather than pencil and paper tests. A score of 80 or above reflected positive mental health; a score of 95–100 reflected “an ideal state of complete integration, of resiliency in the face of stress, of happiness and social effectiveness”. Luborsky's scale was modified by two of the architects of DSM-III into what is now Axis V 14. In cross-cultural comparisons, investigators have confirmed the usefulness of Luborsky's measure as an international thermometer of mental health 15. The fact that psychologists have approached mental health somewhat differently from psychiatry has led to this second model, which has provided the basis for the positive psychology movement 16. Psychologists, like physiologists, look at continua (traits) rather than categories, while in medicine you either have an illness or you do not. In psychology, interventions to improve adequate intelligence or social skills are common, while in medicine to meddle with adequate thyroid function, or a healthy hematocrit or a normal mood, is only to cause trouble. In the healthy rested individual, virtually all psychopharmacological interventions will, over time, make the brain function worse. Thus, the medical goal of using medication to remove pathology is different from the psychologists’ goal of fostering positive mental health in an educative model. As early as in 1925, the psychiatrist A. Meyer was already warning of the need to stop “moralizing” about utopian mental health. Mental health, he suggested, should be studied through “conscientious and impartial study” and “constructive experimentation” 17. Subsequently, the psychologist M. Seligman stated that positive psychology will use evidence-based experimentation to study positive mental health and incorporate recent empirical advances in cognitive psychology 18. Since the late 19th century, many social scientists had mistrusted optimistic cognition, especially religious optimism, as a maladaptive “American” illusion interfering with accurate perception of reality. Nietzsche, Freud, Marx and Darwin all perceived optimism as evidence of an ingenuous cultural adolescence, not of mature mental health. However, cognitive therapists have then demonstrated that optimistic cognition can not only change behavior, but even alter brain function 19. If pessimism is the dominant cognition of the depressed, optimism appears the dominant cognition of the mentally healthy. In part, the importance of optimism to positive mental health depends upon an attributional cognitive style which asserts that the good things happening to me are my “fault”, will last forever and are pervasive, while the bad things are limited, not my fault, and unlikely to happen again 20. The psychologists C. Peterson and M. Seligman identified four components in positive mental health: talents, enablers, strengths, and outcomes. Talents are inborn, genetic and are not much affected by intervention (e.g., high IQ) 21. Enablers reflect benign social conditions, interventions, and environmental good luck (e.g., a strong family, a good school system, living in a democratic merito- cracy). Strengths are character traits (such as kindness, forgiveness, curiosity, honesty) which reflect facets of mental health that are amenable to change. Outcomes reflect dependent variables (e.g., improved social relationships and subjective well-being) which can be used to provide evidence that efforts by clinicians to enhance strengths are effective. Which strengths are most associated with mental health is open to debate. Wisdom, kindness and the capacity to love and be loved are strengths upon which few would argue. But should courage be included as a strength? And why were intelligence, perfect musical pitch and punctuality excluded? In addition, there is considerable debate within the mental health professions about whether positive mental health is a process that any insurance program should be expected to cover. Over time society will have to decide who should pay for positive mental health: the individual, the educational system, third party payers, religious organizations, or a combination of all four? Unlike other organs of the body that have evolved to stay the same or deteriorate after puberty, the human brain continues to evolve in adulthood. A ten-year-old's lungs and kidneys are more likely to reflect optimal function than are those of a sixty-year-old, but that is not true of their central nervous systems. To some extent, then, adult mental health reflects a continuing process of maturational unfolding and progressive brain myelinization into the sixth decade 22,23. Prospective studies reveal that individuals are less depressed and show greater emotional modulation at age 70 than they did at age 30 5,24. In some respects E. Erikson in 1950 anticipated Jahoda and Grinker when he provided the first model of adult lifespan development 25. All previous models had depicted deterioration after 45–50. In contrast, Erikson viewed each of his eight stages of human development as a fresh “criterion of mental health”. Subsequently, J. Loevinger provided a model of adult ego development 26 and L. Kohlberg built up a model of adult moral development 27. Implicit in all these models is the assumption that greater maturity reflects greater mental health. Arguably, the best definition of mental health that we have is W. Menninger's definition of maturity 28 as capacity for love, absence of stereotyped patterns of problem solving, realistic acceptance of the destiny imposed by one's time and place in the world, appropriate expectations and goals for oneself, and capacity for hope. In this model, maturity is not only the opposite of narcissism, but it is quite congruent with other models of mental health. To support the maturational model of mental health, the assessment of the behavior and feeling states of persons studied over a lifetime becomes necessary. Although such longitudinal studies have come to fruition only recently, all illustrate the positive association of maturity with increasing mental health 5,24,29,30,31. In order to illustrate the association between mental health and brain maturity, individuals with brain trauma, major depression, arteriosclerosis, Alzheimer's disease, alcoholism, and schizophrenia must all be excluded. Erikson conceptualized that maturity, through the evolution of adult development via life experience, produces a “widening social radius”. In Erikson's model, adult maturity is achieved over time through the mastery of the four sequential tasks of “identity”, “intimacy”, “generativity”, and “integrity”. On the basis of empirical data from Study of Adult has two more to and of the to the mastery of such tasks appears relatively of social and probably The age at which any is but the maturity of life is with mental health. is not a of of from or of to out of a is a of between the of from and the of where one's end and one's own as much from the and of important and as it does from For our relatively by age and reflect those of our rather than the of our Next, should which to and not with a with one other in an and may to a the capacity for may as and as a the is with a of the same it is and as in religious the is with a is a that is usually with or that the mastery of of this to a as as they play. are four that a into a to not a and to is almost of of the the of a clear capacity to for and the that between age and our need for and our need for and on the that the society can mean as a or to in the is achieved by a more than half the and is a of positive mental health in other The life is to a of the This of on the of the past to the The of a of the is on and of the of and its of one rather than In contrast, of the and its of and are less for not The last life is the of achieving some of and with to both one's own life and the world, and the acceptance of one's life as that had to be and by of no In our healthy adult development the same for and as for However, cross-cultural is In the 19th century, psychiatrists of like and and mental health was to and religious the century, the of cultural and in general led psychiatrists to there was any between as by and health. However, recent advances in the understanding of positive have psychiatry In the last positive to and have been years medical were about like and are also in and like and love were to be in the and in the of of education not of Then, in the H. and J. to love as rather than love as the basis for to provide to the of and even of with his of and The out that the our not only to but also to to out at and to of our own for of these a and she do but a competent her system, and she can still do but not her The of positive clear. the last have studies the of positive emotions. studies have human and in especially in the and These are and to us to and to recognize all that the of love and human In the last years like J. and have identified the and that human in the and and appear to the of the of The of in the and is most in individuals with the of social and confirmed by pencil and paper positive forgiveness, and the important positive and included in this model. great the eight selected positive all human is all about they are all and they all appear to be a of the major from the are other positive and a of for we can these while on a importance to are all about both the of and but the mental health of these two are very are for in time by like J. and psychologists like and S. while and the for the positive especially make patterns more and on time positive our for our moral and enhance our The of positive on the nervous has much in with the and via our nervous system, and via our nervous system, reduce blood and muscle studies of that of the and the which in to and the of socio-emotional intelligence reflects above average mental health in the same way that a high reflects above average emotional intelligence at the of positive mental health. In the defined socio-emotional intelligence as can that is easy. But to be with the to the at the time, for the and in the way that is not as as years a on intelligence dismissed the of such social intelligence as only in the did the modulation of more important to psychiatry than the modulation of and emotional intelligence can be defined by the accurate perception and of one's own of our that their is accurate of and to in in close relationships with capacity for toward a Over the last have been to our understanding of the of socio-emotional intelligence to positive mental health. The first is that both and experimentation have led to advances in our understanding of the of with the The second has been our but in the and even the of Over the last measures of emotional intelligence have been are now many in relationships that and more at and In the past there has also been an increasing to emotional and social for mental health, they considered for happiness and the However, if through the have regarded happiness as the psychologists and psychiatrists have to that from or love or from and or from and but reflects health. that from and or from mature or from of on and the is a to depends upon achieving positive and positive relationships 18. On the other subjective happiness can have maladaptive as as The for happiness can appear and can come and be happiness is seen in the character associated with and and with of by much American of maladaptive can to any but need like and is of such of in this the will be for The of the has always been of American with in the last have investigators like M. Seligman and E. out that a function of subjective is that it an to for and disease, high in subjective efforts to measure subjective have been quite and a investigators measure subjective as life other investigators more like work or However, the do you about life as a on a scale from to works well. environmental variables can have a is that are the most way to subjective well-being. such are by at during the for or and at each are to their subjective in order to from subjective experience, measures of measures of and by have also are of that use to The first two are social support and cognitive that we to The third of is by which our perception of and in order to reduce subjective and These mental are by the of as They can (e.g., by or (e.g., by or the need for other (e.g., by or (e.g., by They can our of the (e.g., by or the of a (e.g., by the or the (e.g., by or the associated with an (e.g., of The most pathological of includes and of reality. to life are the and maladaptive in and in with out and The third of associated with and with the of and at a more The of characterize mental health still and alter relationships and reality, but they these and as one would be by a upper in the ability not to one's self too and into are the very from which positive mental health is But these be achieved by a of Thus, the such as as the may the of and the of out as like other facets of mental health, the of healthy but longitudinal Studies from both Institute of Human Development and Study of Adult Development have the importance of the mature to mental health. as psychiatry needs to on Axis a score of psychiatry needs to best to the of less mature into more mature is in using studies to these are by the brain and to use empirical to change in the of during This paper has suggested seven models of positive mental health. As in the Study of Adult Development at Harvard an empirical of the of of these different models in a study of only was each of models by with the other but each model mental health years of the models was by social or even by a The of mental health the of interventions to What facets of mental health are and which are to As can mental illness, but do not improve healthy brain can enhance mental health only through and education. Finally, the study of positive mental health First, mental health must be defined in that are and Second, the for mental health must be and Finally, although mental health is one of important it should not be regarded as an good in must in our efforts to positive mental health while for This work was by from the Institute of Mental