Freud once wrote, “But you will be able to convince yourself that much will be gained if we succeed in transforming your hysterical misery into common unhappiness. With a mental life that has been restored to health you will be better armed against that happiness” (Breuer & Freud, Studies on Hysteria, p. 306). Freud was clearly no optimist when it came to mental health. For Freud, society generally serves to discourage our natural libidinal and aggressive wishes through the creation of various social prohibitions that demand our drives be sublimated into healthy, socially acceptable channels. Freud never believed that psychoanalysis promised happiness. Instead, psychoanalysis is a quest for truth through the analysis of the patient’s unconscious wishes and beliefs.
Ego psychologists (such as Hartmann) believed that the reduction of drive tension (in accordance with the pleasure principle) was a sign of mental health. Ideally, the subject can develop conflict-free autonomous ego functions that can function relatively unimpeded by intrapsychic conflicts. Ego psychologists believed that the strengthening of the ego’s capacities and defenses enabled the ego to mediate between various forces (id-superego-external reality). Ultimately, Hartmann argued that healthy adaptation to reality was the gold standard of mental health.
Kleinians conceive of the child, at birth, as having to cope with annihilation anxiety in response to the child’s death drive during the paranoid-schizoid position (0-6 months). In this position, the Kleinian infant experiences others as part-objects (non-integrated, i.e. either as bad breast or good breast) and resorts to using primitive defenses (splitting, projection, projective identification) in response to overwhelming anxiety. Later, the Kleinian infant moves into the depressive position, and the infant experiences others as integrated whole objects (both good and bad); hence the child can experience both hating and loving feelings towards the mother at the same time. Klein once said that a split in the object is a split in the ego. In other words, as the individual develops a more integrated, realistic view of others, she will develop a more integrated view of self. Hence, the capacity for conflict resolution (integration), the management of anxiety and the capacity to view others as integrated wholes are signs of mental health for Kleinians.
Winnicott argued that the development of a true self allows one to discard the false self, a self that is created in response by inhospitable caretakers that do not foster the child’s sense of creativity, spontaneity, and authenticity. This false self is a necessary armor the pre-Oedipal child develops if it is not provided an adequate holding environment by the inadequate mother. I can’t find the reference but Winnicott once said that when the individual develops a true self she is able to enjoy being purposeless (capacity to play). I like that idea.
Kohut, the founder of self psychology, believed that mental health was based on the individual’s capacity to develop an integrated, creative and vital self. The goal of self psychological treatment is to facilitate this development of a healthy self, which can be facilitated by improving the patient’s selfobject functioning (an intrapsychic capacity to regulate self-esteem based on one’s experience with early caregivers). The self psychological analyst provides empathy, strengthening the patient’s selfobjects and healthy sense of narcissism. Basically, Kohut thought that mental health was equivalent to healthy, realistic self-esteem.
Brenner, the founder of modern conflict theory (an American revision of classical psychoanalysis), argued that the individual’s capacity to develop healthy compromise formations (resolutions between intrapsychic conflicts due to competing wishes from the libidinal and aggressive drives) was the gold standard for mental health. For Brenner, conflicts are never resolved but constantly mediated through various compromise formations (solutions). Pathological compromise formations are symptoms, and the distinction between healthy compromise formations and symptoms is difficult to define.
Lacan rejected social adaptation (a la ego psychology) as the goal of psychoanalytic treatment. Instead, Lacan suggested that individual’s fidelity to her desire (Sem VII) was the way to get beyond the false identifications of the ego. For Lacan, the ego is a symptom (a defense), an attempt to bring together fragmentary, unintegrated subjective experiences. The unconscious (the discourse of the Other) irrupts the false sense of wholeness and coherence of the patient’s ego (ego ideal). The patient’s capacity to take responsibility for her unconscious (where the id was there the ego shall be) is a sign of psychological health and authenticity (although Lacan would undoubtedly reject the way these terms are normally used by analysts).
Finally, object relations and relational analysts (from Fairbairn to Mitchell) stress the individual’s capacity to develop holistic, fulfilling relationships with others. Too often, patients suffer from painful repetitive relational experiences with others, due to neglectful and abusive caregivers. The goal of treatment is for the analyst to offer a corrective emotional experience to the patient. This enables the patient to set aside ingrained, pathological patterns of relating and to develop the ability to view others in new, satisfactory ways. In the final analysis, the ability to have new relational experiences and the creation of a new healthy object relationship fosters change.
Mental health is based on the analyst’s view of human nature (Fromm). I would argue (following Freud and Lacan) that neutrality has to be the guiding analytic posture for treatment. Clinicians should not tell patients what to do (lest we slip into suggestion, a technique Freud rejected based on his experience with Charcot), as we do not want to tell the patient how to resolve their conflicts. Otherwise we might end up implicitly siding with the status quo and endorsing society’s current arrangements.
In the end, a discussion of pathology, diagnosis, and symptoms must be re-thought. The majority of psychiatric diagnoses are based on the individual’s inability to conform to normative societal expectations. For instance, many patients are diagnosed with a personality disorder. What is a personality disorder? Basically, it’s a fancy term clinicians use to label patients who are difficult to get along with. However, what is the proper standard for such diagnoses? Don’t these type of diagnoses betray a belief in the ‘health’ of society and the goodness of adaptation? I’m not trying to romanticize ‘mental illness’ (a term fraught with controversy) because many people genuinely suffer. Instead, I’m trying to raise the important question of how we distinguish between ‘health’ and ‘sickness’. Some would be quick to say that whatever causes an individual undue, unmerited suffering is ‘sick’. However, this assumes that a symptom is causing the individual distress, which is not always the case. Symptoms can be ego-syntonic (i.e. they are normative and not rejected by the patient).
Recently Nancy McWilliams, a prominent American analyst, presented at my graduate program. Here’s her list of mental health. Let me know what you think.
Signs of Mental Health based on McWilliams’ Presentation at GWU (March 2012):
1) Capacity to Love (Freud)
2) Capacity to Work (Freud)
3) Capacity to Play (Winnicott)
4) Secure Attachment (Bowlby)
5) Sense of Agency/Autonomy (Erikson)
6) Self Constancy/Identity Integration (Stern)
7) Object Constancy (Stern)
8) Ego Strengths (Westen/Shedler)
9) Realistic/Reliable Self-esteem (Kohut)
10) Sense of Values (Superego) (Cleckley)
11) Affect/Thought Tolerance/Frustration (Tomkins)
12) Insight (Reality Testing) (Fenichel)
13) Mentalization (Reflective Functioning) (Fonagy)
14) Good Coping Strategies/Defensive Flexibility (A Freud)
15) Balance between Self-Definition & Self-in-Relationships (Balint)
16) Passion/Vitality/Purpose (Winnicott)
17) Acceptance & Capacity to Mourn/Suffer (Klein)
Notice, the absence of sex and aggression!