The 3 Kinds of Mental Health
Conformity, psychological integration, and freedom from disease.
Posted Apr 30, 2019
There are three kinds of mental health—growth (or psychological integration), adjustment (or conformity), and freedom from disease. Growth involves one’s biopsychosocial definition of what it is to be human; adjustment involves one’s cultural definition. People can be healthy in both senses (growth and adjustment), unhealthy in both senses, or healthy in one sense and not in the other. The more your culture embraces a definition of humanity that comports with the biopsychosocial one, the more likely you are to find an adjustment that is also healthy (in the growth sense). The opposite of mental health in the growth model is neurosis or lack of integration, which usually takes the form of fragility, rigidity, or lack of coherence (a fragmented self). The opposite of mental health in the adjustment model is nonconformity.
The third kind of mental health is analogous to physical health—an absence of physiological disease or impairment.
If you think humans are by nature sexual, aggressive, collaborative, and generative, as I do, then mental health (growth) would mean a person who has found a reasonable degree of satisfaction and self-expression in these areas. The growth model begins with a secure attachment and proceeds through the Eriksonian stages, autonomy, initiative, and so on. Its hallmarks are the accurate perception of reality, satisfaction of impulses and needs, and the capacity to develop collaborative bonds. Advantageous behavior requires the psychological flexibility to alter or even discard old patterns that have outlived their usefulness; a fragile self makes people cling to old patterns, which leads to misperceiving reality. Healthy people (growth) are resilient and adaptable, with well-integrated self-definitions that do not run afoul of predictable emotions and impulses. Mental health (growth) means treating yourself with the humor, circumspection, tolerance, acceptance, guidance, and affection that good parents treat their kids with.
Adjustment (adaptation to cultural expectations) is the kind of mental health that keeps you out of trouble and out of treatment. It’s fitting in with societal expectations, playing a role that you can carry off. Jonathan Shedler called it the illusion of mental health, meaning it can look like mental health (growth), but it isn’t. Mental health (adjustment) means you’re symptom-free. But you can be symptom-free because your cultural role genuinely suits your nature or because you have suppressed and betrayed your nature so thoroughly that you fit your cultural role. An example of someone who is healthy growth-wise but not well-adjusted would be Winston Smith in Orwell’s 1984. In the novel, he is treated “successfully” (via torture) to the point where he is healthy adjustment-wise but at the sacrifice of his soul. The society of Oceania was so out of line with humanity that one could not be healthy in both senses; some families are like this. Richard Cory, from the E.A. Robinson poem, is an example of the well-adjusted but not healthy (growth) type, envied by all and unquestionably successful, but empty to the point of committing suicide. All thinking therapists worry that this is the type of treatment they are actually providing, helping people fit in rather than blossom. It’s what Otto Rank meant when he said that the secret goal of psychoanalysis was to turn people into “patient, docile Philistines.”
Mental illness (physiological) can interfere with both growth and adjustment. An obvious example is the way brain dysfunctions can interfere with a secure attachment, often because emotions are either too muted to bond with parents or too explosive for the individual to knit them into a cohesive sense of self. Although physiologically-based depressions are relatively rare, they can undermine sexuality, constructive aggression, and generativity. They can also inhibit participation in social and vocational activities.
Stigma operates on mental health (growth), on mental illness (adjustment), and on disease. Stigma is the social force that punishes people for attempting cultural roles they cannot pull off, and healthy people (growth) are often punished for trying to express their joy, for example, in situations defined as joyless. Stigma also imposes conformity, and it is the way diseases are responded to (and, typically, over-responded to). Otto Rank, again, noted that the neurotic and the artist (his term for extreme health in the growth model, a person who changes the culture to include one’s nature) have more in common with each other than either does with the well-adjusted person because both are in conflict with the prevailing ideology. Neither fit in. Groups will stigmatize the excellent, not just those who lag behind if excellence is inconsistent with the group’s definition of the role as no-better-than-anyone-else. This is at the heart of Nietzsche’s revaluation, where he said that Christianity as often practiced says that being good at something is evil and being bad at something (or no better than others) is good. Seek sexual, collaborative, and aggressive fulfillment and see what happens to you.
Stigma, in Goffman’s analysis, is society’s way of promoting predictable cultural practices by making people fit in, by highlighting and besmirching aspects of their identities that don’t fit the roles that people are attempting to perform. Stigmatizing either forces people to hide their natures or to relinquish their roles. Its deployment is obvious when people are not well-adjusted or are diseased, and in my view, instead of calling for an end to stigma, which is human nature, we ought to be calling for a more conscientious application of it. An anxious or diseased person is not well-suited to certain roles and should be discouraged from performing them; the real problem is that we overgeneralize to other roles the person can still play. Instead, we ought to distinguish the stigmatization of problems from the stigmatization of solutions (getting therapy ought to be applauded, not derided). And we ought to distinguish calling something a weakness from stigmatizing it. These seem to have become conflated so that you are seen as a monster if you say that fragile people and people who don’t know themselves well don’t make good therapists. But everybody has weaknesses and silencing people who notice weaknesses doesn’t turn weaknesses into strengths.
The fact that we use the same language (“mental health” and “mental illness”) for three different phenomena makes it easier to mix them up. There was a time when someone could have a disease like schizophrenia or autism and doctors would say, in essence, that since they treat “mental illness” (meaning, impairments in growth) with psychotherapy, they could use talk therapy for these conditions as well. Now the pendulum has swung the other way: We apply the label “mental illness” to all three sorts of health problems, creating the sense that they are all to be accepted or lived with rather than changed (as if depression were like diabetes), leaving people with little more to do than take an ineffective drug, since drugs work with mental illness (disease). Patients and practitioners alike would benefit from specifying which sort of mental illness we’re talking about in any given situation—neurosis, nonconformity, or disease.