Ethical and Moral Values in Conceptions of Positive Mental Health
I will concentrate the final part of my triadic analysis on how conceptions of positive mental health are laden with generic ethical values. Other values will be noted where appropriate. Some values might be clinically significant to mental health but lack generic ethical relevance. It is no doubt a good thing for a patient diagnosed with schizophrenia to ignore the internal voices urging him to prepare for the apocalypse. It would be clinically desirable for a patient diagnosed with major depression to be symptom free for a year. But it is not obvious in either case that these patients have thereby restored their ethical identity. As we saw with the Demoralized Woman and Linda Logan, effective drug treatments will reduce symptoms but will not retrieve a lost self.
Drug treatments may, however, enable a patient to begin the work of self-restoration. These cases indicate that mental health is not the absence of symptoms that comprise a disorder. If mental health consists in part of an affirmative sense of self, and if Taylor is right that one cannot find one’s self without finding one’s ethical identity, then there are close connections between mental health and considerations of a good and satisfactory life that is right for me. This indicates a desirable and valued set of psychological traits that both reflect and contribute to ethical identity. These traits can overlap conceptually with virtues of character. I would argue that if they can be developed to the point at which they enable a person to meet the demands of the world in an excellent or good enough way, then they can become virtues.
Virtues are revealed in therapeutic goals that stress the desirable and stable traits of character that mentally healthy persons have and that patients who want to restore lost selves ought to strive for. Hence the idea that mental health amounts to a virtuous state. Again, a plurality of multi-track dispositional states is endorsed in the literature. They range from “a sound personality structure characterized by growth, development, self-actualization, integration, autonomy, environmental mastery, ability to cope with stress, reality orientation [and] adaptation” to authenticity, altruism, honesty, and responsibility.82 I will focus on what I regard as the ethical values that are implicit in the cultivation of a good life. In sum, my argument is that the realization of certain virtues, e.g., self-love, self-respect, and empathic concern and respect for others, are plausible psychotherapeutic goals for some patients given the problems they present. Their cultivation and attainment as sufficiently stable states amounts to positive mental health. The cultivation of other virtues enables the patient to realize these goals as fine inner states from which he will act. These virtues are instrumental to the healing project and include hopefulness, perseverance, courage, healing curiosity, respect for the healing project, and virtues of focus, dialogue, and constraint integration. The challenge is to formulate a psychotherapeutic approach that is suitably tailored to these patients and to a constructive exploration of their problems.
Martin proposes an “integrated moral-therapeutic perspective” that, while not equating mental health and moral virtue, affirms that they are “significantly interwoven in their meaning and reference.”83 Martin’s integrated approach develops three themes that bridge morality and mental health. First, sound morality tends to overlap with mental health; it is realistic in its demands and aspirations, and tends to promote some degree of well-being and self-fulfillment. Second, while persons do not have complete control over their health, they do bear significant responsibility for taking prudent measures to care for their health within limits set by their resources, opportunities, and other obligations. It follows for Martin that sickness does not automatically excuse wrongdoing. We need to take seriously our “responsibilities to prevent disorders, to cope with them once they arise, and to avoid using them as excuses for wrongdoing. Those responsibilities must be understood contextually in assessing when and how far sickness excuses or mitigates responsibility.”84 Third, conceptions of positive mental health and modes of psychotherapy are laden with moral values. Defining mental health in negative terms as the absence of mental disorders presupposes moral values because the disorders invariably refer to standards of normal functioning that overlap with morally acceptable behavior. Think again about the Cluster B personality disorders. Positive definitions of mental health “as well-being, effective functioning, adaptive behavior, normalcy, growth, and maturity” can reveal moral values. Self-esteem, for example, can be seen to largely overlap with the virtue of self-respect “and self-control is both a moral and a therapeutic value.”85
My approach is to acknowledge the conceptual distinction between mental health and moral virtue in narrow terms and pursue cases of their overlap largely in terms of Martin’s integrated moral-therapeutic perspective. There is a plausible but narrow sense in which one can have, say, an obsessive compulsive disorder and yet be diligent in meeting one’s other-regarding moral responsibilities. One may also have enough ethical self-regard to seek treatment. We see this in the case of the Demoralized Woman. Even though she continues to suffer from the attitudinal residue of her depression, she still sees herself as worth the effort of asking for help.
I will be presenting cases in which moral virtue and mental disorder co-exist. The former need not negate all vestiges of the latter. Thus mental disorder need not entail a lack of stable virtues, let alone pronounced vice. Conversely, a lack of stable virtues need not entail mental disorder. One might not meet the diagnostic criteria for a DSM mental disorder and yet be less than consistent in meeting one’s other-regarding moral responsibilities. One’s character can be weak and undependable without the presence of depression or schizophrenia. One might be wanting in moral strength, courage, and will without attaining the pervasive extremes of the Cluster B personality disorders. These are questions of judgment and perceptions of clinical degree.
The fact that some mental disorders do not entail conceptions of moral vice should not obscure the fact that some do. For instance, given its diagnostic criteria, some notion of vice is a logical consequence of antisocial personality disorder. Yet obsessive compulsive or anxiety disorders present no such logical entailment. Hence the conceptual overlap between mental disorder and vice in the Cluster B personality disorders. If a desirable treatment outcome in such cases is enhanced mental health, then that notion of mental health entails that the patient will evince appropriate ethical and moral response. Further, we need not, indeed should not, speak exclusively of vice when considering the conceptual and material overlap of generic ethical and clinical values.
In simple terms, we want successful treatment to replace deficits with gains in psychological assets, but these assets may not just spring back to life once symptoms are relieved. If we look at what the disorders take away from the patient, we might see that there is not always a simple precedent state to which the patient should be restored. In fact, they may have never been adequately developed in the first place. A patient on antidepressants might experience considerable relief from the symptoms of depression but have little psychological resilience to face situational adversity and handle stress. She may lack the ability to build and strengthen a durable sense of self-worth. She may need to work on her character by developing a capacity for self-love.
Martin’s analysis of the relationship between virtues and the psychological components of positive mental health is most instructive, especially given his incorporation of Marie Jahoda’s 1958 work Current Concepts of Positive Mental Health.86 Jahoda was a seminal forerunner of the shift toward positive psychology. She proposed six major categories of positive mental health concepts: (1) attitudes toward the self; (2) growth, development, and self-actualization; (3) integration; (4) perception of reality; (5) autonomy; and (6) environmental mastery. She then elaborated on the psychological meanings of each category.87
As per (1), one’s self must be accessible to the kind of “realistic” and “objective” reflection that enables one to distinguish pretensions and wishes from actual abilities. One should have an attitude of general acceptance toward one’s self and recognize shortcomings in relation to strengths. These need to be realistically evaluated in considering the possibilities and costs of changing one’s self. Citing Erikson, she states that balanced self-acceptance in adults assumes a sense of identity and a positive self-regard by which one maintains “inner sameness and continuity (one’s ego in the psychological sense).”88
As per (2) one should be motivated to utilize one’s developmental abilities with an orientation toward the future. Self-actualization requires “investment in living,” or “the range and quality of a person’s concern with other people and the things of this world, the objects and activities that he considers significant.”89 It is an attitude of affirmative dedication to living a meaningful life. It is also, I suggest, an affirmative dedication to creating an authentic one and living by one’s deep evaluations and critical interests.
As per (3), integration requires a balance of psychic forces, a unifying outlook on life, and the ability to handle stress.90 As per (4), perception of reality means empathy for others and the ability to perceive one’s situation absent the distortions of wishful thinking. One should be able to see things as they are, and not as one needs them to be. As per (5), autonomy means inner regulation and self-determination in decision-making. Jahoda also related autonomy to self-reliance and the ability to take care of oneself: “an individual must be able to stand on his own feet without making undue demands or impositions on others.” She noted that this ability is valued highly and is compatible with almost all of the positive mental health concepts she discusses.91 Interestingly enough, the notion that well-being involves care of the self has been revived by current proponents of positive psychology. “Self-care entails the recognition that a meaningful life is one that uses signature strengths in the fulfillment of important goals ... [and one’s] highest aspirations.”92 Finally, as per (6), environmental mastery means the ability to love; adequacy in love, work, play, and interpersonal relationships; behavior appropriate to situations; adaptation and adjustment to one’s environment; and the ability to solve problems.93
Jahoda made no attempt to systematically integrate her criteria and was aware of the difficulties her summary raised. The criteria often overlap and we have no clear idea of the relationship between them. We don’t, for instance, know anything about the degree to which they might be independent. Nor does Jahoda indicate a method for identifying satisfactory indexes of the criteria, which would enable us to confirm the presence or absence of a given criterion and measure its degree of manifestation. Jahoda saw these as problems for the empirical researcher. Overall, her summary has been assessed as rife with ambiguities and different levels of specificity. It has also been criticized for ignoring the idea that societal values might be relevant contextual criteria as well as for disregarding the psychological impact of one’s social situation. Jahoda conceded the difficulties of reaching a correct or even a consensual definition of positive mental health given the value-laden nature of the criteria.94
Although I propose positive mental health as a threshold state of well-being, I also take Martin’s point that it has to be more than the ability to function without being disabled by mental disorders—otherwise, positive and negative definitions of mental health will be fused. I thus understand positive mental health as falling somewhere between complete and barely adequate well-being, i.e., sufficient in degree to make a positive difference in one’s life. It can be nascent and subject to incremental development. I diverge from Martin in seeing a plurality of different virtues that can overlap with Jahoda’s criteria.95
As I explicate these virtues in the next two chapters, I will only note them provisionally here. I see (1) attitudes toward the self as overlapping with virtues of self-love and self-respect, which I articulate as recovery virtues in a psychiatric healing project; (2) growth, development, and self-actualization as overlapping with any virtues cultivated in the work of self-improvement, e.g., the healing virtues of honesty, courage, creative flexibility, and perseverance; (3) integration as overlapping with the virtue of self-love; (4) perception of reality as overlapping with the epistemic virtues noted in chapter three; (5) autonomy as overlapping with any virtues involved in self-regulation and the use of signature strengths to fulfill important goals; and (6) environmental mastery as overlapping with a multitude of other-regarding moral virtues, as well as Swanton’s problem-solving virtues of focus, dialogue, and constraint integration which I discuss in chapter five.
This conception of positive mental health illuminates the existential malaise of demoralization. I will note the traits most relevant to my case examples. The Demoralized Woman was lacking in five of the six categories of positive mental health. Her attitude toward herself lacked positive self-regard and an accessible identity. Her potential for growth, development, and self-actualization was in a state of entropy that inhibited investment in living. She exhibits negative mental health, by which I do not mean pathology “but some form of vegetating without either positive health or disease"96 She lacks integration through a unifying outlook on life. Her self-determination to care for herself is stalled. While perception of reality enables her to acknowledge her situation, she lacks much in the way of environmental mastery.
The challenge for the empirical researcher is to work out indexes to discover the presence of mental health and measure its degrees of manifestation. It is interesting to consider the application of current methods of measuring positive mental health that were not available in 1958. These assessments indicate that the problems acknowledged by Jahoda are still with us. On the basis of his thirteen-factor scale, Keyes distinguishes between “flourishing," or optimal mental health, “moderate mental health" and a state of negative mental health absent mental disorder that he terms “languishing" Flourishing persons score high on one of two measures of hedonic well-being and at least six of eleven measures of positive functioning. Languishing persons score low on at least one measure of hedonic well-being and low on at least six measures of positive functioning. They are in a state of being stuck, empty, stagnant, and seriously deficient in positive functioning. Persons in moderate mental health do not fit either of these criteria.97
Where might the Demoralized Woman fall on this scale? We might agree that the Demoralized Woman is languishing given her pervasive sense of emptiness. She could thus be assessed on Keyes’ scale as exhibiting minimal mental health, e.g., she could score very low on the second hedonic criterion of feeling happy and satisfied with life overall and very low on the flowing four positive functioning criteria: (3) self-acceptance and a positive attitude to her past; (5) insight into her own potential and development; (7) goals and beliefs that affirm a sense of purposeful direction in a meaningful life; and (11) self-direction guided by socially acceptable standards. Jahoda’s notion of “vegetating” might in the Demoralized Woman’s case merely approximate the more serious state of languishing. There is much room for divergent opinion here.
Either way, I take two implications from the Demoralized Woman’s case and the analysis preceding it. First, if concepts of mental disorder are ethically value-laden, then concepts of positive mental health are no less so. Assessments of positive mental health will likely pose challenges to the validity and inter-rater reliability of the concepts that purport to define it. It will be challenging to mark clear boundaries between criteria for, and constituent features of, positive mental health. Second, there is a plausible overlap between the concepts of positive mental health, notions of ethical identity, and meeting the demands of the world by living in accordance with the virtues that inform it. Empirical indexes aside, assessments of positive mental health are holistic in considering the whole person and generically ethical in evaluating his way of life.