Mental Health

I. THE CONCEPTMorris S. Schwartz and Charlotte Green Schwartz

BIBLIOGRAPHY

II. SOCIAL CLASS AND PERSONAL ADJUSTMENTWilliam H. Sewell

BIBLIOGRAPHY

I. THE CONCEPT

The meaning of the term –mental health—is ambiguous; not only is it difficult to agree on its general application, but even in a single context it may be used in many different ways. This lack of agreement will probably continue because the term has been adopted for a variety of purposes. One conclusion, however, can be reached: –mental health—is not a precise term but an intuitively apprehended idea that is striving for scientific status while also serving as an ideological label.

Problems of definition

The word ‘mental’ usually implies something more than the purely cerebral functioning of a person; it also stands for his emotional-affective states, the relationships he establishes with others, and a quite general quality that might be called his equilibrium in his sociocultural context. Similarly, ‘health’ refers to more than physical health: it also connotes the individual’s intrapsychic balance, the fit of his psychic structure with the external environment, and his social functioning. It is not surprising that the combination of two such terms produces an elastic and ambiguous concept. Another ambiguity attends this phrase. In common usage ‘mental health’ often means both psycho-logical well-being and mental illness.

Definitions obviously vary with the perspective of the definers, the point of reference used, and the values considered important. Thus, the psychoanalytic perspective focuses on the intra-psychic life of the individual. Freud defined mental health in his programmatic statement: ‘Where id was, there shall ego be’ (1932, p. 112). Here the value is awareness of unconscious motivations and self-control based upon these insights. The interpersonal frame of reference, on the other hand, is more concerned with the functioning of individuals in interpersonal situations. Sullivan identifies a person’s drive toward mental health as those ‘processes which tend to improve his efficiency as a human being, his satisfactions, and his success in living‘ (1954, p. 106) and places major value on effective and efficient social functioning. The social relatedness perspective is exemplified by Fromm, who focuses on the individual’s relationship with the larger social environment.

The mentally healthy person is the productive and unalienated person; the person who relates himself to the world lovingly, and who uses his reason to grasp reality objectively; who experiences himself as a unique individual entity, and at the same time feels one with his fellow man; who is not subject to irrational authority, and accepts willingly the rational authority of conscience and reason; who is in the process of being born as long as he is alive, and considers the gift of life the most precious chance he has. ([1955] 1959, p. 275)

Here the values are humanism, individualism, freedom, and rationality.

The most comprehensive and definitive summary of the multiplicity of criteria used in defining mental health is that of Jahoda (1958). She rules out certain criteria as unsuitable because they are unsatisfactory for research purposes. ‘Absence of disease,’ for instance, is rejected as a criterion, not only because of the difficulty in circumscribing disease but also because common usage of the term ‘mental health’ now includes something more than the mere absence of a negative value. ‘Statistical normality’ is also considered unsuitable on the grounds that the term is unspecific, bare of content, and fails to come to grips with the question. Finally, ‘happiness’ and ‘well-being’ are ruled out because they involve external circumstances as well as individual functioning.

Jahoda then summarizes what are to her the acceptable sets of criteria in current use. These are attitudes toward the self, which include accessibility of the self to consciousness, correctness of the self concept, feelings about the self concept (self-acceptance), and a sense of identity; growth, development, and self-actualization, which include conceptions of self, motivational processes, and investment in living; integration, which refers to the balance of psychic forces in the individual, a unifying outlook on life, and resistance to stress; autonomy, which refers to the decision-making process, regulation from within, and independent action; undistorted perception of reality, including empathy or social sensitivity; environmental mastery, including the ability to love, adequacy in interpersonal relations, efficiency in meeting situation requirements, capacity for adaptation and adjustment, efficiency in problem solving, and adequacy in love, work, and play.

Since Jahoda’s statement is a summary and not an attempt to integrate the criteria currently used in defining or identifying mental health, various difficulties (many recognized and discussed by her) attend her presentation. The criteria are over-lapping, and the relationship between criteria is not spelled out (for example, the degree to which they are independent). Moreover, no method is indicated for identifying satisfactory indexes for the criteria, thus making it impossible to measure the degree of a particular criterion or even to discover its presence or absence. Ambiguities and different levels of specificity characterize the different criteria, and the impact of the social situation and the relevance of the society as context criterion are largely ignored.

Jahoda does not attempt a solution for these difficulties. She simply recognizes the impossibility of arriving at a ‘correct’ definition and of attaining a consensus, because values underlie the defi- nitions proposed and because the concept is used for different purposes. Jahoda’s analysis of mental health as a concept deals mainly with the problems it poses for the empirical researcher: whether—and if so, how far—the various criteria can be integrated into one criterion or a set of criteria; the kinds of criteria that are required by different definitions; whether and how one might distinguish between “optimal” and “maximal” mental health; and operationalizing the definitions used. She deals minimally with the approach that the student of society would take: the meaning of this concept in society, its various functions, the ways in which it constitutes and expresses societal values, and the nature of the kinds of social environments that influence a person’s psychological well-being. Nevertheless, her work represents the best summary of the current major definitions and the controversy connected with them.

Aspects of the mental health controversy

Discussions of the concept of mental health naturally reflect the interests of the principal groups involved in the mental health movement. One of the leading issues is whether “mental health” and “mental illness” should be conceptualized on the same continuum or on different continua that cut across each other. The conventional medical view holds that mental health is the absence of mental illness, that both terms represent the extreme ends of the same continuum, and that the difference between the two states is one of degree. A contrary view is that mental health is qualitatively different from mental illness and that a person can be both mentally healthy and mentally ill at the same time. Jahoda, as an advocate of the concept of “positive mental health,” maintains that the absence of certain qualities does not imply the presence of others. For example, the absence of hallucinations does not imply the presence of accurate self-appraisal; conversely, the presence of creativity does not exclude the presence of severe anxiety. But if mental health and mental illness are placed on different continua, then it becomes necessary to specify their relationship. For this reason, Conrad (1952) has suggested that “negative health,” or the absence of pathology, be used as an interstitial term.

A related issue is whether mental health is to be seen as a relatively constant and enduring function of personality or as a momentary function of person and situation. For instance, Klein (1960) distinguishes “soundness” from “well-being”: the former refers to the level of integration of the general, more enduring personality structure, and the latter to the individual’s current state of equilibrium. This distinction may be a useful way of identifying two different kinds of mental health.

There also are differences of opinion on whether the concept of mental health is ever value-free. Some authors—medically oriented professionals—view psychological health as analogous to physical health, which, they maintain, can be evaluated by objective medical standards, without regard to the patient’s sociocultural context. Another view maintaining that mental health is a value-free concept equates it with the statistically normal: mentally healthy behavior is that which is considered average or conventional behavior for a particular population. Here, good mental health is evaluated in terms of adjustment to and acceptance of current societal norms. Clearly, these criteria are not value-free. Indeed, many students of the field maintain that criteria of mental health cannot be established in complete independence from the particular values and ideology of the society or group in which they are formulated and applied. According to this view, the study of definitions of mental health becomes a branch of the sociology of knowledge. But such an approach, although sociologically meaningful, cannot settle the question of which criteria are the most useful for therapy and mental health research.

Some of those who maintain that all definitions of mental health are culture-bound hold that multiple criteria should be used, depending upon the values cherished by each society or subculture. Thus, criteria for mental health in the lower classes may have to be different from those for the middle classes, and those for citizens of Japan would have to differ from those for India or the United States. The issue here is that of the relation of the mental health of a person to the nature of the society in which he lives. Although this issue is rarely discussed, its clarification and resolution are critical in identifying the field of interrelated variables that are relevant to the study of mental health. What is needed is nothing less than a complete theory of the relation between the individual and society.

Other students of the field hold that the criteria for mental health, though value-laden, can transcend situational or cultural boundaries and that an area of general value consensus can be arrived at. For example, M. B. Smith has suggested that universal criteria for mental health might be “identified with the stability, resilience, and viability—in a word the system properties—of these external and internal subsystems of personality” (1959, pp. 680-681). Similarly, Fromm (1955) insists that criteria for mental health must be based on some concept of a universal human nature rather than on the values of particular cultures or societies.

In summary, mental health can be viewed either as an ideal-type concept or as an empirical construct referring to a state that actually occurs. In the former view, mental health is an ideal to be striven for but never fully attained; it serves, however, as a standard against which to measure any particular individual. In the latter view, mental health is realistically attainable, though there is much dispute about the frequency with which it is encountered.

Mental health as a movement and a profession

The emergence of the concept of mental health is closely related to the growth of the mental hygiene movement in the United States and to the development of psychotherapeutic practice and personality research. As an explanatory construct, “mental health” emerged out of the concern with “mental hygiene” that gained its first adherents at the beginning of the twentieth century. Originally, this social movement focused on improving the wretched conditions in mental hospitals and providing better care and treatment for the mentally ill wherever they might be. In the 1920s interest shifted to promoting “mental hygiene” and establishing child-guidance clinics. The term “mental health” began to replace “mental hygiene” in the 1930s, and by the late 1940s it assumed an independent status with a growing and enthusiastic social movement operating in its name. This shift in terms signified the beginning of the era of concern with the prevention of mental disorders rather than merely care and treatment and the broadening of focus to include all forms of social and psychological maladjustment rather than just the severely emotionally disturbed or psychotic. The movement began to promote “positive” mental health as a goal distinct from the elimination of mental illness.

The popularity of mental health as a desired value in the United States is in part related to its advocacy by those in the mental health movement and in part to the growth of psychoanalytic theory and acceptance of psychotherapeutic practice in the past several decades. The orthodox psychoanalytic viewpoint that mental health is a property of individuals and a function of intrapsychic development and dynamics is still dominant. It maintains that an individual acquires good mental health as a consequence of fortunate early socialization; psychoanalysis or some other form of psychotherapy is a corrective for unfortunate early development. Thus, the individual remains the unit of analysis, and psychological health is seen as a function of the individual’s unique, private intrapsychic development and life history. Subsequently, the unit of analysis was extended to include the patterning of an individual’s interpersonal relations. Recently, another view of mental health was put forward by the proponents of social psychiatry [see PSYCHIATRY, article on Social Psychiatry]. Only a few authors, such as Fromm (1955) and Frank (1948), take a comprehensive view of mental health as a function of the total society—its dominant ideologies, assumptions, norms, values, institutions, and general style of life. Such a perspective is largely ignored or considered irrelevant by the great majority of ideologists, practitioners, and researchers in the field of mental health.

Ideologists, practitioners, researchers

Action in the name of mental health has occasioned the development of three distinct groups whose membership may overlap but whose interests and functions are separable: they can be called the ideologists, the practitioners, and the researchers. The ideologists are primarily interested in promoting psychological well-being as a value and in encour-aging action to prevent and eliminate mental illness. Well-developed mental health organizations, both private and public, now exist in the United States at the national, state, and local levels. In 1960 the National Association for Mental Health reported that, in addition to the state mental health associations, there were some eight hundred affiliated local mental health associations in 42 states, with a total registered membership and volunteer participation exceeding one million persons (Ride-nour 1963). In addition, a network of federal governmental agencies, led by the National Institute of Mental Health (NIMH), spent a ast sum for research, training, education, demonstration, and the building and development of treatment facilities (during the fiscal year 1964/1965 the NIMH alone spent over $200 million). The NIMH also maintains links with the privately sponsored branches of the mental health movement. In addition to the federal government, each state and many cities and counties have a department of mental health or a mental health officer. Private and governmental agencies often join with practitioners to educate the public about mental illness and health, to urge persons to become concerned about their own and others’ psychological health, and to collect funds for research.

The importance of the mental health movement has enhanced the prestige and power of its practitioners, who range from psychoanalysts to marriage counselors. They have gradually widened their sphere of operation and now function in institutions such as schools, courts, and industry. Although many of their activities are undertaken in the name of mental health, little work is directed toward mental health as distinct from mental illness. Primarily, their concern is treatment; secondarily, it is research; it is only minimally prevention.

The interests of researchers in mental health span the entire range of human behavior from circumscribed biochemical problems to existential problems of living. Despite the increasing number of research projects over the past decade, etiological problems remain unsolved and the field awaits conceptual clarification.

Mental health and American values

The mental health concept is related to current and traditional American values in three ways. First, it reflects and embodies many of these values; second, it functions to preserve certain of them; finally, it is a highly valued end in itself. In fact, mental health has become so esteemed that in some circles it has taken on the characteristics of a secular religion. In the twentieth century, human health is prized as it has been in no other. In the United States, in particular, we have moved from valuing sheer physical health to cherishing the psychological well-being of the total person. In pursuing these goals, we have relied on medicine, psychology, and social science to produce more valid knowledge and techniques with which to serve this value. Science and medicine, in turn, are values that are used to promote psychological health as a social and ethical goal. Thus, the importance of health, the faith in science and medicine, the reliance on technology to produce means for the ends declared desirable by experts, and the development of professional skill and specialization as attributes of the technology all combine to maintain and reinforce mental health as a value.

The high degree of acceptance of this value also seems related to its congruence with the Protestant ethic. Kingsley Davis (1938) has suggested that the mental health movement took over the Protestant ethic as a system of conscious preachment and unconscious premises and that it bases itself upon much the same values. But we suggest that the movement has done more than take over the Protestant ethic—it has dressed it up in a modern scientific cloak. Thus it serves as a new ideology that recommends, in nonreligious, quasi-scientific terms, a way of dealing with personal troubles and anxieties without the necessity for becoming involved in broader social issues or societal reconstruction. In any case, its popularity among middle-class, college-educated Americans cannot be denied.

For some ideologists of the movement, “mental health” has become a mystique and a secular religion. Dicks, for example, proposes that it be conceived of as a new value in our world that is “comparable to the notions of ’finding God, ’salvation/ ’perfection’ or ’progress’ which have inspired various eras of our history, as master-values which at the same time implied a way of life. . . . Some of the attributes of a secular priesthood or therapeutae are attached to us, and it is questionable whether we ought to divest ourselves of them even if the community would let us” (1950, pp. 3-4). Thus, for the mental health enthusiast, “mental health” becomes the standard for evaluating human behavior. Further, the mental health idea implies a new conception of moral and social progress in the form of self-correctability, self-perfectibility, inner growth, personal fulfillment, and inward and outward harmony, or the like. We are told that in the same way that we have achieved physical comfort—through the instrumental application of knowledge and understanding—we can achieve psychological mastery over the self. This idea of progress embodies a new conception of success. No longer is it sufficient to measure achievement in tangible coin; we are persuaded to evaluate our-selves in terms of self-development and maturity. But there are no clear guidelines as to the means of reaching this goal or even to knowing that one has reached it.

Orientations toward mental health

Orientations toward mental health as a desirable objective, as a subject matter, and as a field of work, knowledge, and inquiry oscillate between two poles. On the one hand, mental health is seen as a restricted and circumscribed “state of being” and as the subject matter of a field of work that is a specialty among other specialties. The individual or his immediate social environment is the unit for analysis, attempted control, and change. On the other hand, mental health is seen as the sum total of the individual personality, and the field of work associated with it is a superordinate, all-inclusive science of man.

In the more restricted orientation, the acquisition of mental health is viewed as a technical problem that is to be solved under the direction and leadership of experts. Mental health technology is seen as being contained in and developed and transmitted by practitioners who claim special skills and expertise and who are legitimated by the society as the vehicle for the ethical application of knowledge about mental health. Operational techniques and procedures are established, and frames of reference and explanatory theories are developed and fiercely adhered to. In general this orientation stresses the separateness of persons and encourages them to seek inner tranquility and self-actualization on a private basis; psychological well-being is seen as a function of personality dynamics, which, in turn, are supposed to be primarily a function of early experience and only secondarily of later interpersonal relations. [For an approach that stresses primarily social factors, see PSYCHIATRY, article onSocial Psychiatry.]

By contrast, those who take an all-encompassing view of mental health phenomena claim as their province the entire range of human thought and behavior; they believe that the human panorama is to be interpreted within the mental health frame-work rather than vice versa.

These contrasting orientations have different advantages and disadvantages in achieving mental health objectives. The psychotherapeutic orientation is far more specific about the nature of the phenomena to be affected, be they biochemical, individual, or social; it therefore affords greater opportunity for intervention and control. However, by restricting the variables to be dealt with, it may neglect significant and, perhaps, crucial phenomena. By contrast, the broader orientation opens up greater possibilities of discovering the various inter-connections between the variables involved. however, its very diffuseness and scope make it a poor guide for scientific research or social action.

The functions of mental health ideology

The mental health ideology and movement function, in general, whether deliberately or inadvertently, to preserve and enhance certain values in American society. Outstanding among these is the human-istic value that emphasizes the importance of the individual as well as his development and fulfillment. Thus, the mental health movement contributes to and reinforces certain aspects of American democratic ideals and also promotes a form of “inwardness” by emphasizing introspection and self-awareness. By focusing on changing the individual rather than the society, the mental health movement directs effort away from social reconstruction and thereby functions to preserve the status quo and those middle-class values that are an intrinsic part of it. This is not to deny that some practitioners use the mental health idea as a vehicle for achieving social reform; but they are interested only in specific social changes which they hope to effect in the name of mental health, such as changes in child-rearing practices in the family or in the ways in which students are handled in public school.

For the ideologists, the conception provides a Weltanschauung of self-betterment to which they can devote themselves at a time when sociopolitical ideologies are unfashionable in the United States. Thus mental health is put forward as the panacea for all social problems and for the wholesale improvement of mankind. For the practitioner, on the other hand, the concept of mental health usually serves as a goal—albeit an ambiguous one—against which he can measure the current functioning of his patients and toward which he can direct his and their efforts; it is an implicit or explicit standard against which he measures the success and failure of his efforts and those of his colleagues.

Problems for the future

Despite the expansion of the mental health movement and the prestige of the professionals involved with it, little is known about how to achieve mental health. Moreover, the mechanisms for applying this meager knowledge and effecting the ends sought are extremely inadequate. Of the many issues that need resolution, three are central. The first is the necessity for conceptual extension beyond the individual intrapsychic life, interpersonal relations, and limited social contexts. For no matter how sophisticated, discerning, or scientific is our understanding of human beings as individuals, this framework is insufficient for understanding mental health, which also needs to be seen as a function of social roles, institutions, and communi-ties. The second problem concerns this very scope of the mental health conception, which, because it involves a number of aspects of human living, demands an integration of the biochemical, psychological, social, and philosophical disciplines that is not yet in sight. The third problem involves the difficulties in intervention, implementation, and control that would remain even if conceptual expansion and the integration of relevant disciplines were achieved. Even if mental health can be achieved by rational planning, how much planning of this kind is desirable? Would it not threaten other cherished values, or have consequences that we cannot now foresee? From one perspective, the problem of mental health is identical with the eternal question of how to lead the good life. Perhaps this is not subject matter for academic disciplines, whether they be expanded or integrated, but rather an emergent from the human condition, in its infinite complexity, only a part of which can be planned for. Perhaps we need to raise the issue of how much mental health can be achieved by science and planning. It may be that the ultimate goal of positive mental health for all will continue to elude us as one of our persistent human limitations.

Morris S. Schwartz and Charlotte Green Schwartz

[Directly related are the entries on Health; Illness; Life Cycle; Mental Disorders, Treatment of, article on THE Therapeutic Community; Psychiatry, article on Social Psychiatry; Psychoanalysis.Other material relevant to the concept of mental health may be found in Mental Disorders; and in the biographies of Freud; Rank; Reich; Sullivan.]

BIBLIOGRAPHY

Caplan, Gerald 1964 Principles of Preventive Psychiatry. New York: Basic Books.

Clausen, John A. 1956 Sociology and the Field of Mental Health. New York: Russell Sage Foundation. Conrad, Dorothy C. 1952 Toward a More Productive Concept of Mental Health. Mental Hygiene 36:456-473.

Davis, Kingsley 1938 Mental Hygiene and the Class Structure. Psychiatry 1: 55-65.

Dicks, Henry V. 1950 In Search of Our Proper Ethic. British Journal of Medical Psychology 23:1-14. Eaton, Joseph W. 1951 The Assessment of Mental Health. American Journal of Psychiatry 108:81-90.

Educational Practices. 1960 Pages 111-170 in Pennsylvania Mental Health, Incorporated, Mental Health Education: A Critique. Philadelphia: The Corporation. Felix, Robert H. 1957 Evolution of Community Mental Health Concepts. American Journal of Psychiatry 113:673-679.

Frank, Lawrence K. 1948 Society as the Patient: Essays on Culture and Personality. New Brunswick, N.J.: Rutgers Univ. Press.

Frank, Lawrence K. 1953 The Promotion of Mental Health. American Academy of Political and Social Science, Annals 286:167-174.

Freud, Sigmund (1932) 1965 New Introductory Lectures on Psycho-analysis. New York: Norton. -> First published as Neue Folge der Vorlesungen zur Einfiihrung in die Psychoanalyse.

Fromm, Erich 1947 Man for Himself: An Inquiry Into the Psychology of Ethics. New York: Holt.

Fromm, Erich (1955) 1959 The Sane Society. New York: Holt.

Ginsburg, SOL W. 1955 The Mental Health Movement: Its Theoretical Assumptions. Pages 1-29 in Ruth Kotinsky and Helen Witmer (editors), Community Programs for Mental Health: Theory-Practice Evaluation. Cambridge, Mass.: Harvard Univ. Press. GURSSLIN, O. R.; HUNT, R. G.; and ROACH, J. L. 1959-1960 Social Class and the Mental Health Movement. Social Problems 7:210-218.

Hartmann, Heinz 1939 Psychoanalysis and the Concept of Health. International Journal of Psycho-analysis 20:308-321.

Jahoda, Marie 1955 Toward a Social Psychology of Mental Health. Pages 296-322 in Ruth Kotinsky and Helen Witmer (editors), Community Programs for Mental Health: Theory-Practice Evaluation. Cambridge, Mass.: Harvard Univ. Press.

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II. SOCIAL CLASS AND PERSONAL ADJUSTMENT

If personality is seen as referring to the relatively enduring needs, motives, attitudes, values, belief systems, and self-conceptions that characterize the behavior of the individual, there is good reason to expect a substantial relationship between social class (one’s position in the stratification structure) and personality.

The basis for expecting such a relationship rests on widely accepted assumptions regarding man and society. Human personality is to a large extent a product of the social learning experiences that the individual undergoes in the sociocultural environment in which he lives. Moreover, there seems to be almost complete agreement among social scientists that the early experiences of the individual are of critical importance in personality development and in later adjustment, although there is considerable disagreement as to the dynamics of the relationship between early experience and later personality. It is also generally accepted that personality continues to develop throughout the life cycle (although probably at a less rapid rate than in childhood) in response to learning experiences and environmental pressures which the person encounters in the performance of his social roles. Finally, it is readily apparent that one of the most pervasive aspects of the social structures impinging on the individual throughout his life cycle is the stratification system of his society.

This last observation is true not only because all societies have a system of stratification in which the members are differentiated into strata of unequal status but also because of the unique function of the family as a status ascription and socialization agency. Because in all societies the child is accorded the same status as his parents, the family of origin serves as the main link between the child and society. Since the family is the major agency charged with the early socialization of the child, its position in the stratification structure will to a large extent determine the social learning influences to which the child will be subjected during the most formative periods of his life. Moreover, the family’s position in the stratification structure will greatly affect the child’s choice of associates outside of the family, which in turn will go far in determining the social opportunities he will encounter throughout his life. Thus the stratification system may be seen as one of the most important and continuous social contexts in which the individual’s developmental history takes place; certainly, one’s position in it should have a substantial bearing on his personality. This is not to say, however, that personality is wholly determined by social class. The possible influences on personality development to which the individual is subjected are many and varied and are by no means all class-linked.

The two principal sources of research evidence on the relationship between social class and personality are studies of social class and the socialization of the child and studies of social class and mental illness. In the past 25 years many studies in both of these areas have appeared. Fortunately, reviews of much of this literature are available (Bronfenbrenner 1958; Dunham 1961; Sewell 1962; Mishler & Scotch 1963) so that only major trends and more recent developments are covered here.

Social class and socialization

In one of the early studies of social class and personality, Davis and Dollard (1940) attempted to show how the social structure influences the nature of the learning process by which Negro children are trained to take on the behavior appropriate to their position in the social stratification system of the southern United States. The authors trace the process by which the child learns and acquires from his parents, his family’s social clique, his peers, and his interactions with white adults the needs, motives, cognitions, attitudes, values, and behavior patterns of the class subculture of which he is a member. These results were based mainly on informal observational procedures and, consequently, are suggestive rather than definitive; but they stimulated many subsequent studies of social class and child rearing. Perhaps best known is the study by Davis and Havighurst (1946) of middle-class and lower-class Negro and white children in Chicago. Using interviewing procedures, they found that the social class differences were much greater than the race differences and clearly indicated that middle-class mothers were more restrictive than lower-class mothers in the critical early training of the child. For instance, middle-class mothers were more likely to bottle-feed, follow a strict nursing schedule, restrict the sucking period, wean earlier and more abruptly, and begin and complete toilet training earlier than lower-class mothers. They also followed stricter regimens in other areas and expected their children to assume responsibilities earlier.

These differences in early feeding and toilet training were widely interpreted by psychoanalytically oriented writers as evidence that middle-class child-training practices were baneful to middle-class children and were likely to produce mal-adjusted adults. Subsequent and more carefully designed studies of social class differences in child-rearing practices have failed to confirm the findings of the Chicago study. In fact, on many points, the results of later studies (see, for instance, Sears, Maccoby & Levin 1957) have contradicted those of the Chicago study—particularly on toilet-training and infant-feeding practices—and have shown that lower-class mothers are more restrictive and punitive in relation to basic needs than middle-class mothers. Urie Bronfenbrenner (1958), on the basis of a detailed examination of data from a number of studies covering a 25-year period, concluded that lower-class mothers have probably become more restrictive in infant feeding and toilet training since World War II, while middle-class mothers have become more permissive, with the result that the gap between them has tended to close. However, throughout this period, middle-class mothers have been consistently more permissive toward the child’s expressed needs and wishes, less likely to use physical punishment, and more accepting and equalitarian in dealing with the child than have lower-class mothers. Thus, it would appear that there is little evidence from these studies to support the view that the lower-class child undergoes socialization experiences that are more favorable to his later personality than does the middle-class child; if anything, the evidence points in the opposite direction.

Possibly as a result of these findings, and because empirical research has cast doubt on the importance of toilet training and infant-feeding practices for later personality (Sewell 1952), recent studies of social class and personality development have tended to place less emphasis on infant training and more stress on parent–child relationships extending into childhood and adolescence. Several studies illustrating this trend may be briefly mentioned. Kohn (1959 a; 1959 b) finds that middle-class parents emphasize internalized standards of conduct, including honesty and self-control, while working-class parents stress respectability, obedience, neatness, and cleanliness. Middle-class parents tend to respond to misbehavior in terms of the child’s intent and to take into account his motives and feelings, while lower-class parents focus on the child’s actions and respond in accordance with the seriousness of the act. Moreover, there is evidence that middle-class parents are less authoritarian in their relations with their adolescent children than lower-class parents but have higher expectations of them (Elder 1962). Rosen (1961) finds that not only do middle-class junior-high-school boys have higher achievement motives and values than lower-class boys, but that middle-class parents put more pressure on them to succeed, teach them to believe in success, and create conditions in which success is possible. Studies of lower-class adolescent boys, on the other hand, testify to the influence of peer groups and of the lower-class culture of the community, especially in socialization to delinquent roles (Miller 1958). Still other studies have shown that middle-class adolescents are trained to defer their gratifications and lower-class youths to satisfy their current needs (Schneider & Lysgaard 1953). Finally, many other studies show that middle-class parents, in comparison with lower-class parents, place more stress on values which result in high levels of aspiration and achievement in the educational and occupational spheres (Kahl 1953).

Another quite different recent emphasis in socialization research has been renewed interest in cognitive development. Studies thus far reported indicate that lower-class children suffer from cognitive deficits that may seriously impede their later adjustments to school and adult roles (Deutsch 1963; Hess & Shipman 1965).

Much more needs to be done to discover the full range of class differences in socialization practices and especially to determine their effects on personality development and adjustment in the various classes. Studies, not reviewed here, relating socioeconomic status to scores on personality tests indicate a low but positive correlation between social class and the personality adjustment of the child (Sewell 1962, pp. 348–349). Some good work on socialization and social class is being done, but much more is needed using better samples, a wider range of socialization practices, and better data-gathering and data-analysis techniques.

Social class and mental illness

The largest body of evidence on the relation of social class to personality comes from the findings of a number of studies of social aspects of mental illness. One of the most important of these is the study by Faris and Dunham (1939), who found, among other things, an inverse association between socioeconomic characteristics of Chicago census tracts and first admission rates for schizophrenia. Since the publication of this research, similar studies of American, European, and Asian cities have essentially replicated these results (Dunham 1961, pp. 274–290). Ecological studies of this kind have been criticized because of bias arising from socioeconomic selection in first admissions to mental hospitals; the possibility that mentally ill persons have drifted from the better into the poorer areas of the city after the onset of their illness; and reliance on purely ecological correlations. Studies (Clark 1948; Ødegaard 1956) based on the association between occupation or income and admission rates for psychoses, especially schizophrenia, generally confirm the results of the ecological studies, but are also subject to the criticism that admission rates to mental hospitals tend to be selective of lower-class persons.

Hollingshead and Redlich (1958), in their study of social class and mental illness in New Haven, improved on the earlier studies by obtaining detailed classifications of all cases in treatment with a psychiatrist or under the care of a psychiatric clinic or mental hospital, by carefully assessing individual socioeconomic status, by taking a city-wide control sample of normal persons for comparative purposes, and by computing rates for treated cases of various types of mental illness by class status. Most of their findings are for treated prevalence and therefore understate the total prevalence of mental illness in the community, but they clearly indicate that the lower classes have much higher rates for psychiatric illness, especially for psychoses.

Other evidence collected by Hollingshead and Redlich indicates that diagnosis and treatment favor the higher social classes, with the consequence that members of the lower social classes tend to be diagnosed more readily as psychotics, to receive less individually oriented treatment, and to remain in custodial care for much longer periods of time. Because this piling-up of cases might explain the higher treated prevalence rates of the lower classes, incidence rates (based on the number of patients who entered treatment during the interval of observation) were computed. Again the lowest social class had the highest rates, although the differences between the other classes were no longer as marked. Moreover, while there was no relationship between social class and the incidence of neuroses, the inverse relationship of class membership and psychoses remained, with the rate for the lowest class being twice that for the next highest class and almost three times as high as for the two highest classes. This finding is particularly impressive because it confirms the results of the earlier ecological and correlational studies.

But even the study just described is seriously defective because it is based only on treated cases. Evidence has been mounting for some time that the prevalence and incidence of mental illness in the community are much greater than the treated rates because many cases are either not treated or are handled by others than psychiatrists, mental health clinics, and mental hospitals. This is apparently true even for quite serious forms of mental illness. Recently, attempts have been made to obtain more satisfactory evidence concerning total prevalence of mental illness by means of sample surveys in which clinical examinations or symptoms inventories are used to determine mental health status. Obviously, the magnitude of the rate will depend on the inventories and the cutting points used in determining who is and who is not mentally ill. The results of the Midtown Manhattan Study (1962; 1963), based on a large probability sample of adults, are especially informative in that a consistent inverse relationship is found between socioeconomic status and poor mental health and a direct relationship between status and absence of significant symptoms of mental pathology. Of all of the many variables tested, socioeconomic status was the one most clearly associated with mental health. Moreover, this relationship held whether parental socioeconomic status or the person’s own socioeconomic status was taken as the status measure, and it persisted when age and sex were controlled.

The finding of an inverse relation between socioeconomic status of parents and impaired mental health is particularly significant because it indicates that successively lower parental status carries for the child progressively greater likelihood of inadequate personality adjustment in adulthood. The finding that one’s current socioeconomic status is even more closely related to one’s mental health suggests that the effects of low socioeconomic status are probably cumulative in that the vulnerable personalities developed by some low-status children prevent their upward mobility and destine them to the further burdens and stresses that low socioeconomic status adults typically encounter in the United States. Moreover, lower-class persons tend toward socially disturbing psychotic adaptations that further complicate their adjustment to an already stressful environment, while higher-status persons tend to respond to stress with mild neurotic responses that are socially more adaptive. Thus, the cumulative effects of unfavorable childhood and adult experiences on the lower-class person may result in a higher degree of vulnerability not only to mental illness but also to the development of more serious psychiatric symptoms.

Another important finding of the Midtown Manhattan Study is that those who are downwardly mobile present more symptoms of mental disturbance than those who are nonmobile, with those who are upwardly mobile having the fewest symptoms of all. Evidence indicates that downward mobility is associated with the character disorders, or personality-trait disturbances, while upward mobility tends to be associated with neurotic behavior. These findings confirm the conclusions of earlier studies based on clinical observations (Hollings-head & Redlich 1958). The task of unraveling cause and effect in this area is indeed challenging and demands further research; whereas mobility may result in some types of psychiatric illnesses, it is also likely that certain personality characteristics—including psychiatric symptoms—may help determine who rises or falls in the stratification system (Dunham et al. 1966).

The one finding from the studies of social class and mental illness which comes through most clearly is that the lowest social class has the highest incidence and prevalence of major psychiatric illness. The explanations offered for this finding vary considerably, but they may be conveniently subsumed under three general notions. First is the claim that class variations in rates of mental illness are due to the way in which a social system functions over time to sort and sift persons with certain personality characteristics or vulnerabilities into social class positions. Second, it is argued that differences in the extent and nature of environmental stress in the various classes account for differences in rates. Finally, some authors argue that class differences in socialization, especially early socialization, are responsible for differing rates of mental illness among the various social classes. As we have seen in our examination of the research evidence so far available, it is clear that no one of these explanations has ever been subjected to anything approaching a scientifically adequate test.

It may be concluded that there are good theoretical reasons for expecting an association between social class and personality development and adjustment. However, studies to date do not indicate a sizable relationship but suggest that lower-class status is associated with socialization experiences that foster the development of needs, motives, attitudes, belief systems, self-conceptions, cognitive modes, and styles of coping with stress which result in personality maladjustment. Much more needs to be known about the socialization experiences that members of the various classes undergo, particularly how these affect personality systems. Finally, more systematic and theoretically informed studies of the role of social class in the etiology of mental illness are greatly needed.

William H. Sewell

[See alsoAchievementmotivation; Life Cycle; Mental Disorders, article on Epidemiology; Personality; Personality Measurement; Psychiatry, article on Social Psychiatry; Social Mobility; Socialization; Stratification, Social.]

BIBLIOGRAPHY

Bronfenbrenner, Urie 1958 Socialization and Social Class Through Time and Space. Pages 400–425 in Society for the Psychological Study of Social Issues, Readings in Social Psychology. 3d ed. New York: Holt.

Clark, Robert E. 1948 The Relationship of Schizophrenia to Occupational Income and Occupational Prestige. American Sociological Review 13:325–330.

Davis, Allison; and Bollard, John (1940) 1953 Children of Bondage: The Personality Development of Negro Youth in the Urban South. Prepared for the American Youth Commission. Washington: American Council on Education.

Davis, Allison; and Havighurst, Robert J. 1946 Social Class and Color Differences in Child Rearing. American Sociological Review 11:698–710.

Deutsch, Martin 1963 The Disadvantaged Child and the Learning Process. Pages 163–179 in Work Conference on Curriculum and Teaching in Depressed Urban Areas, Columbia University, 1962, Education in Depressed Areas. Edited by Harry A. Passow. New York: Columbia Univ., Teachers College.

Dunham, H. Warren 1961 Social Structures and Mental Disorders: Competing Hypotheses of Explanation. Milbank Memorial Fund Quarterly 39:259–311.

Dunham, H. Warren et al. 1966 A Research Note on Diagnosed Mental Illness and Social Class. American Sociological Review 31:223–227.

Elder, Glen H. 1962 Adolescent Achievement and Mobility Aspirations. Chapel Hill: Univ. of North Carolina, Institute for Research in Social Sciences.

Paris, Robert E. L.; and Dunham, H. Warren (1939) 1960 Mental Disorders in Urban Areas: An Ecological Study of Schizophrenia and Other Psychoses. New York: Hafner.

Hess, Robert D.; and Shipman, Virginia C. 1965 Early Experience and the Socialization of Cognitive Modes in Children. Child Development 36:869–886.

Hollingshead, August B.; and Redlich, Fredrick C. 1958 Social Class and Mental Illness: A Community Study. New York: Wiley.

Kahl, Joseph A. 1953 Educational and Occupational Aspirations of “Common Man” Boys. Harvard Educational Review 23, no. 3:186–203.

Kohn, Melvin L. 1959 a Social Class and the Exercise of Parental Authority. American Sociological Review 24:352–366.

Kohn, Melvin L. 1959 b Social Class and Parental Values. American Journal of Sociology 64:337–351.

The Midtown Manhattan Study 1962 Mental Health in the Metropolis: The Midtown Manhattan Study, by Leo Srole et al. Vol. 1. New York: McGraw-Hill.

The Midtown Manhattan Study 1963 Life Stress and Mental Health: The Midtown Manhattan Study, by Thomas S. Langner and Stanley T. Michael. Vol. 2. New York: Free Press.

Miller, Walter B. 1958 Lower Class Culture as a Generating Milieu of Gang Delinquency. Journal of Social Issues 14, no. 3: 5–19.

Mishler, Elliot G.; and Scotch, Norman A. 1963 Sociocultural Factors in the Epidemiology of Schizophrenia. Psychiatry 26:315–351.

Ødegaard, Ø. 1956 The Incidence of Psychoses in Various Occupations. International Journal of Social Psychiatry 2:85–104.

Rosen, Bernard C. 1961 Family Structure and Achievement′ Motivation. American Sociological Review 26: 574–585.

Schneider, Louis; and Lysgaard, Sverre 1953 The Deferred Gratification Pattern: A Preliminary Study. American Sociological Review 18:142–149.

Sears, Robert R.; Maccoby, E. E.; and Levin, H. 1957 Patterns of Child Rearing. Evanston, III.: Row, Peterson.

Sewell, William H. 1952 Infant Training and the Personality of the Child. American Journal of Sociology 58:150–159.

Sewell, William H. 1962 Social Class and Childhood Personality. Sociometry 24:340–356.

Mental Health

One of the most studied and, at times, most misunderstood phenomena of biology (study of living organisms) and psychology (study of the mind) is how people develop mentally: how do people become who they are? How do individuals develop the capacity for learning, memory, intelligence, and personality? Why do two or more individuals, born to and reared by the same parents (and therefore possessing similar genetic makeup to their siblings), often turn out to be individuals with such different likes and dislikes, different strengths and weaknesses? Why do some people develop mental illness while their brothers or sisters do not?

As with most studies pertaining to the mind, there are not many hard and fast answers. Scientists, doctors, and mental health professionals have different theories as to how people develop and grow mentally. Some theorists believe that the environment in which a person is raised contributes not only to one's personality but also to overall intelligence, and can even foster or prevent the development of certain mental illness. Still other scientists propose that biology plays a bigger role than environment and people develop as they are genetically programmed to do. For the most part, those in the field of mental health and development research take into account both biological and environmental factors as equally important in the development and growth of the mind.

This chapter will discuss the different areas of development that contribute to the whole of mental health, including identity and personality, memory, learning, intelligence, creativity, and self-esteem. Together, these areas are the things that make people who they are.

NATURE VS. NURTURE: DOES BIOLOGY OR ENVIRONMENT INFLUENCE DEVELOPMENT?

The nature vs. nurture debate revolves around the following question: what factors contribute to the mental development of an individual: nature (that is, the biological or genetic makeup of a person) or nurture (that is, how a person is raised, by whom, and in what environment)? Just as human beings inherit certain physical traits from their biological parents (such as height, eye color, and even predisposition to physical ailments), human beings can also inherit certain mental characteristics and traits from their parents, such as a propensity for certain mental disorders. What else is inherited and what traits and characteristics develop as a result of the environment in which an individual is raised? Some researchers believe that things such

Mental Health: Words to Know

Alzheimer's disease:

A degenerative disease of the brain that causes people to forget things, including the people in their lives, and which eventually leads to death.

Autonomy:

Being in charge of oneself; independent.

Classical conditioning:

Learning involving an automatic response to a certain stimulus that is acquired and reinforced through association.

Convergent thinking:

Thinking that is driven by knowledge and logic (opposite of divergent thinking).

Creativity:

One's capacity to think and solve problems in a unique way.

Divergent thinking:

Thinking driven by creativity (opposite of convergent thinking).

Eidetic memory:

Also known as photographic memory; the ability to take a mental picture of information and use that picture later to retrieve the information.

Extrovert:

Being outgoing and social.

Identical twins:

Also called monozygotic twins; twins born from the same egg and sperm.

Innate:

Inborn; something (a characteristic) a person is born with.

Intelligence:

The ability and capacity to understand.

Intelligence Quotient (IQ):

The measure of intelligence as based on intelligence tests and the intelligence of the general population.

Introvert:

Being quiet and soft-spoken.

Learning:

Modifying behavior and acquiring new information or skills.

Memory:

The ability to acquire, store, and retrieve information.

Modeling:

Learning based on modeling one's behavior on that of another person with whom an individual strongly identifies.

Nature:

The biological or genetic makeup of a person.

Neurons:

Nerve cells that receive chemicalelectrical impulses from the brain.

Nurture:

How a person is raised, by whom, and in what environment.

Observational learning:

Learning from the examples of others.

Operant conditioning:

Learning involving voluntary response to a certain stimuli based on positive or negative consequences resulting from the response.

Personality:

All the traits and characteristics that make people unique.

Reinforcement:

Making something stronger by adding extra support.

Self-esteem:

How an individual feels about her or himself.

Stimulus:

Something that causes action or activity.

Synapse:

Gaps between nerves; the connections between neurons that allow people to make mental connections.

Temperament:

How people behave.

as alcoholism or even intelligence are biologically inherited while other people support the theory that many of these things are a product of the environment in which an individual is raised.

Many studies in the nature versus nurture conflict center on identical twins. Researchers look not only at twins raised together but those raised apart to determine whether or not a certain trait is biologically programmed or if it evolves as a result of the environment in which one twin was raised. However, a flaw in research of this type is that, often times, the twins who had been separated by adoption were raised in very similar environments.

Intelligence

The most controversial area in the nature vs. nurture debate is intelligence. The reason for this may be that intelligence (which is a person's capacity to think rationally and deal with challenges effectively) is closely related to achievement, both scholastic and in other situations. While most researchers agree that intelligence is influenced by genetics to a great degree, studies show that twins of all kinds and biological siblings are more likely to possess similar intelligence. In fact, the closer the biological link, the stronger the similarity in intelligence. However, there are also similarities in intelligence between unrelated children raised together in the same household, though these similarities are not as great as those between biological siblings and, especially, twins.

What this and other similar research says is that no one definitive factor solely affects intelligence. The manner in which an individual is raised greatly influences one's intelligence. While one researcher, psychologist Arthur Jensen, put forth that intelligence is 80 percent determined by biological factors, other researchers have settled upon figures

ranging between 50 and 70 percent. This means that whatever an individual's natural intelligence, it can always be improved or obstructed by his or her environment.

Personality

In addition to physical characteristics and intelligence, researchers have also tried to determine whether genetics or the environment influences an individual's personality. If a really outgoing, social individual has a child, will that child also be outgoing? Some researchers say yes. In fact, scientists have been able to prove that there is a biological relationship in terms of personality where extroversion (being outgoing and social) and neuroticism (being touchy, moody, or overly sensitive) are concerned.

How can this be proven? Through studies involving twins living apart. In fact, similar studies have found that many things seem to be inherited—from values and political attitudes to the amount of time people spend watching television! This may sound silly and, of course, no one is suggesting that a specific gene has evolved that directly influences a person's preference for watching television. Rather, what researchers are focusing on is that the act of watching television is usually a solitary, passive one. This could be something that is tied to whether or not a person is extroverted. Findings of this type are also confirmed by the fact that scientists have identified a gene that affects brain chemistry and may be the reason that certain individuals engage in risk-taking behaviors, such as bungee jumping or extreme sports, while others do not.

Mental Disorders

As discussed in Chapter 12 on Mental Illness, schizophrenia (a serious psychological disorder marked by scattered thoughts, confusion, and delusions) has been found to have a high genetic correlation, meaning that if one family member has schizophrenia, there is an increased likelihood that another family member (or future offspring) may also develop it. Of course, while an individual may be predisposed to schizophrenia because of genetics, that is not to say that he will ever develop the disorder. Other psychological disorders that may be hereditary include alcoholism and major depression. [See Chapter 12: Mental Illness.]

Most researchers now agree to some extent that both biology and environment play important roles in shaping people. Just as children may share traits with biological parents, adopted children may also share many traits and habits with their adoptive parents. What this information serves to do is help mental health professionals, teachers, and researchers help all people realize their potential for growth and accomplishment in their lives.

BECOMING AN INDIVIDUAL: PERSONALITY, INDIVIDUALITY, AND TEMPERAMENT

All people have completely unique behavioral traits, likes and dislikes, and habits that make them who they are. This uniqueness comes not only from biological factors, such as temperament, but is also developed from experiences, such as a person's sense of individuality, or a combination of both environmental and biological factors, such as personality.

Personality

Personality refers to all of the traits and characteristics individuals show the world, and which make them different from others. In fact, the word personality comes from a Latin term meaning "mask." As stated in Chapter 12 on Mental Illness, people who have extreme personalities often have personality disorders. However, most people have a personality type that does not prevent them from functioning effectively within society. For example,

some people may be naturally more self-involved than others. These people may have a narcissistic personality type, meaning they are driven more by their own needs and desires than others are; however, this does not mean that they are dysfunctional in any way. Some people may desire close relationships with others and base much of what they do on the opinions of those other people. These individuals may have a dependent personality type; again, though, this is not necessarily an indication of dysfunction.

Some people are extroverted (outgoing) while others are introverted (shy, reserved). Some people are optimistic (positive) while others tend to be more negative, seeing the downside of situations rather than the upside. The type of personality a person has can, according to certain mental health professionals, cause him or her to seek out certain situations that agree with his view of the world and personality. This results in a certain consistency, in which the personality drives decisions that reinforce a person's personality.

Individuality

As personality begins to develop, it is reinforced and solidified during adolescence when young people begin to ask the question, "Who am I?". This quest for and achievement of individuality is perhaps best illustrated by looking at the work of renowned psychoanalytic theorist Erik Erikson (1902–1994), who mapped out an eight-stage process that covered all stages of development, with the stages in adolescence focusing on identity and individuality.

Erikson's stages include stage one, "basic trust versus mistrust," which takes place in infancy and usually centers on an infant learning trust through being cared for properly. In the toddler years, stage two, the "autonomy (independence) versus shame and doubt" stage, is resolved by allowing a child to assert independence and not feel bad for misbehaving or failing at his attempts at independence (toilet training, etc.). Stage three consists of a conflict related to "initiative versus guilt" in early childhood; at this time children begin to act on curiosities and explore new things, and the conflict is resolved if children are encouraged in their new interests and curiosities. In middle childhood stage four emerges, involving "industry versus inferiority"; and during this stage a child must achieve things (do homework, acquire skills) in order to avoid feeling inferior (less worthy than others).

BABIES AND TEMPERAMENT

People often make statements about others such as, "He was born happy," or "She's always been moody; she's been that way since birth." This may seem like an exaggeration, but, according to many theorists, this is explained by temperament. Alexander Thomas and Stella Chess, pioneers in the field of temperament, describe temperament as how people behave. How active is a child naturally? How does the child adapt to change? How energetic is a child? How responsive? All of these things, according to researchers, are genetically programmed for the most part.

Temperament could account for the dramatic differences in siblings' behaviors from infancy. Some infants are naturally "easy babies," with positive dispositions and who adapt and adjust easily, while other infants are categorized as "difficult babies" who are moody and easily irritated.

Researchers have put forth that, generally, temperament remains constant throughout the span of an individual's life.

Stage five, a pivotal stage in terms of this discussion, involves "identity versus role confusion" in the teen years. During this time, adolescents attempt to form their own personal identity based on who they were in childhood and where they wish to go personally and professionally in the future. What can happen at this stage, though, is that a teen who prematurely sets himself in a certain identity is at risk for having grasped onto a persona that is based on the approval of friends. Thus, this teen may be less autonomous (independent) and inquisitive (eager to learn) than others. All of this can lead to the formation of an individual who is not open to change and new experiences.

Another problem that can arise in Erikson's fifth stage of development is identity confusion. Erikson is referring to teens who simply are never certain of who they are. When this happens, a young person runs the risk of being unable to forge meaningful relationships and possibly alienating others with immature behavior and reasoning.

For all of these reasons, it is imperative that children and young adults be encouraged to figure out their likes and dislikes, talents and natural inclinations, and to try new things during the development process so that they will develop a sense of identity.

Stage six is concerned with the conflict of "intimacy versus isolation" stage during early adulthood. During this time, people seek out deep, meaningful intimate relationships or choose to isolate themselves, possibly with

very negative consequences later in life. Stage seven presents itself in a conflict of "generativity versus stagnation," meaning that people should feel that they have contributed to the development of other people, particularly young people, or they will be left feeling the effects of stagnation (not changing or growing), which is the opposite of generativity (growth or creativity).

The last stage, stage eight, plays out in late adulthood in the way of "ego integrity versus despair." At this stage, adults reflect on the lives they have led, evaluating whether they have accomplished something with their lives and choices and whether they have contributed to the betterment of society.

MEMORY

Memory is one of the most important functions of the brain. Whether people realize it or not, their memories define who they are. Without them,

SELF-ESTEEM

Self-esteem refers to how an individual feels about him- or herself. Does someone view himself as a good person, worthy of good things? If he does, he probably has healthy selfesteem. If an individual views himself as flawed and unworthy of praise or the respect of others, he probably has low self-esteem.

Self-esteem motivates people's actions as well as the decisions they make. Individuals with positive self-esteem are likely to believe that they measure up to others sufficiently. They are more likely to have the confidence to pursue different accomplishments, whether it is trying to do well on a test, trying out for a sports team, answering a question in class, or applying for a job. These individuals are not overly afraid of failure; they realize that failure is a natural part of life and whether they fail or succeed at something does not indicate their overall worth and ability as a person.

People with low self-esteem, however, are less likely to try their best at anything. They are so certain they will fail that they approach tasks and challenges with so much anxiety (worry or fear) that they are unable to concentrate. They are so afraid of failure (which, in their eyes, will only serve to confirm their lack of worth and ability) that they may not even try at all, finding it easier to believe that they may have succeeded had they really tried.

A strong sense of self and positive self-esteem can help prevent people from engaging in risky behavior or putting themselves in dangerous situations. These people know that, like all people, they deserve good things and that, regardless of one failure, success will come in the future in some way, shape, or form.

There are several factors that influence selfesteem. These include:

Age: Self-esteem tends to grow steadily up until middle school, which may be due to the transition of moving from the familiar environment of elementary school to a new setting with new demands. Self-esteem will either continue to grow after this period or begin to plummet.

Gender: Girls tend to be more susceptible to having low self-esteem than boys, perhaps because of increased social pressures that emphasize appearance rather than intelligence or athletic ability.

Socioeconomic status: Researchers have found that children from higher-income families usually have a better sense of self-esteem in the mid- to late-adolescence years.

people would not know where they came from, what they have experienced, or who their families and friends are. Memories are unique to each person. While many people may witness or experience the same event, each person will remember it differently. This is why memory is considered part of a person's complex personality.

Many scientists know what memory is, but they still don't know exactly how it works. Memory is defined as the ability to acquire information, store it, and then retrieve it later. It affects every aspect of people's daily lives. People have memories about facts, such as their names and phone numbers and birth dates. They also have memories about past events, such as graduation from high school, getting married, or the death of a loved one. In addition, memories of certain skills, such as how to talk, walk, cook, or play a sport exist in abundance. Still other memories seem to be instinctive. For example, people remember how to sleep, breathe, and digest food. These are just a few examples of what memory can do and how it helps people learn and live.

Different Kinds of Memory

Types of memory fall into two categories, or systems, in the brain. One system deals with fact knowledge, such as names and dates. The other system deals with skill. While scientists know these systems are separate, they think that the systems share with one another. What scientists do not know is how much they share and how closely they are connected.

Fact knowledge is usually referred to as short-term memory. Short-term memories can become long-term if the circumstances are right. Again, scientists are still unclear as to exactly how this works; however, they think that short-term memories do not last long because new information enters the part of the brain that stores short-term memories and then drives out older memories. If a short-term memory passes into the long-term memory, it has more staying power. It lasts longer and can eventually become permanent. The longer a memory lasts, the stronger it is and the less likely it will be forgotten. This happens because short-term memories are fragile, while long-term memories are sturdy. Some scientists believe that long-term memories are stored permanently because of chemical changes in the brain.

Other scientists do not categorize memories in terms of length. They believe that the length of a memory depends on certain circumstances; however, they do not know which circumstances produce long-term memories and which produce short-term memories. One thing scientists agree on, however, is the fact that the brain seems to have an unlimited capacity to store memories. Scientists continue to study how people store and retrieve memories and why, if they have an unlimited capacity to remember information, people forget.

How People Remember and Why People Forget

When memories are stored in the brain, they cannot serve people unless they are retrieved. How do people retrieve memories? This usually happens when memories are challenged. For example, if someone asks a question, a person must attempt to retrieve information in order to answer the question. Sometimes the answer is easy; other times, a person takes time to answer it. The amount of time it takes to answer the question is connected to a person's awareness of what memories are stored. Sometimes a person is not aware at the time that he or she knows the answer, but later realizes that the information is there, ready to be retrieved. Sometimes, a smell or a sound can trigger a memory that a person did not know was there.

THE POWER OF MEMORY

For unknown reasons, some people have a better ability to remember information than others. Ancient civilizations were able to maintain their history through an oral (spoken) tradition. Homer's epic poems Iliad and Odyssey were passed down through generations by word of mouth. It is believed that people's memories may have been stronger out of necessity. Because preliterate civilizations could not write, they were forced to remember things orally. When literacy (the ability to read or write) was developed, the need for oral stories diminished, which may explain why fewer people permanently store large amounts of information.

Some people have what is called eidetic imagery, or photographic memory, which enables them to take a picture of information and then use that picture to retrieve the information later. This picture is not just stored by sight. It can also be recorded through sound, taste, and smell. For example, a musician may be able to hear a song, and, without writing anything down, play back the song note for note. This type of memory is found more often in children than in adults. However, many people who have this ability as children often lose it as they grow older. Scientists do not know why some people have a photographic memory or why they eventually lose it.

There have been studies done, however, which reveal how too much memory can be harmful to a person. In the 1950s, a Russian man named Solomon V. Shereshevskii had the remarkable ability to remember an enormous amount of information. He was a reporter who was able to research and produce his stories without ever writing anything down. Shereshevskii eventually toured the world showing off his amazing ability to remember everything for an unlimited amount of time. Eventually, however, Shereshevskii's memory became an immense burden. Because he remembered so much information, he could not control his memories or when they surfaced. In the middle of conversations, he would be reminded of other events and facts until he could no longer concentrate on the conversation. He began to rant and rave like a madman. For the man who remembered everything, his greatest wish was to be able to forget.

Retrieving a memory involves finding the path that leads to the information and navigating that path. As more and more memories are stored from new experiences, those paths can become intertwined, making it more difficult to find the way back. It can become particularly difficult when stored information has similar meaning because a person will have trouble making distinctions between memories. For example, if a person has seen hundreds of movies, it may become difficult for the person to recall the details of each one. The person may mix together certain parts or lines from different movies or may even confuse the actors involved in the movies.

Some people have trouble retrieving a memory, but eventually manage to do it. However, sometimes a memory cannot be retrieved at all. Does this mean that the information has disappeared forever? Scientists believe that as people search for a particular memory, such as the name of a childhood friend for example, they are actively retracing the path to find the original information that was stored years ago. If they make it there, the memory is retrieved. However, if people cannot seem to make it back on that path, they will never be able to find the memory. Sometimes, though, people will find their way by taking an alternate route. For example, if a person asks a friend a question, and the friend thinks he knows the answer but cannot seem to retrieve the information, he might say something like, "It's on the tip of my tongue!" Then, as he is doing something completely unrelated later in the day, the information might pop into his head. Scientists believe this happens because the brain has found a related item, which then helps the person find the desired information.

Ways to Improve Memory

Some scientists believe the capacity to store information long-term is connected to concentration. Short-term memories can easily become long-term if a person is willing to concentrate on the facts. Lynn Stern, author of Improving Your Memory, says that to make a long-term memory a person must "focus on it exclusively for a minimum of eight seconds." With training, anyone can improve the capacity to remember.

Experts also recommend the following to improve and maintain a good memory:

• Exercise on a regular basis. Exercise helps keep the blood flowing, which increases the amount of oxygen that reaches the brain. With more oxygen, the brain, and therefore the memory, stays sharp and focused.
• Manage stress. Stress can affect the body and the mind in negative ways. Emotional disorders such as depression can harm a person's ability to retrieve information.
• Stay organized. Organization creates order in a person's life. If a person is always losing her keys, her brain is being used to try to find them everyday instead of thinking about more important matters.
• Use visualization. Visualization means creating an image that corresponds with a fact or an event. If a person is trying to remember a list of groceries, it is helpful to associate a word, such as bread, with its corresponding image.
• Write it down. Writing things down on paper or on the computer helps people to remember because the act forces them to concentrate on the things they are writing. Concentration, as stated above, is one of the keys to a good memory.

LEARNING

When most people think of learning, they think of acquiring knowledge or a specific skill, such as facts about history, new vocabulary words, or how to play an instrument. Learning also encompasses behavior in a much broader sense than the aforementioned specifics. To mental health professionals, learning, on a most basic level, involves behavior modification. For example, when students learn how to do long math problems, they are using a process that a teacher showed them, but they are actually learning a behavior (how to solve long math problems). As a result, when presented with a math problem in the future, people draw on that behavior (or learned method) to solve the problem.

Of course, not everything that people do is learned through teaching or firsthand experience. Rather, there do exist some behaviors that are purely instinctual, or behaviors that people (and animals, too) are genetically programmed to exhibit in certain situations. An example of this is the fight- or-flight impulse. In a scary situation, the human body produces the steroid adrenaline, which makes the heart pump faster and the lungs work harder. This is an unconscious response that readies a person to "fight" if the situation calls for it or to "flee"; again, this is not a learned response to fear or danger but an instinctual one. These behaviors are also referred to as being innate responses (or inborn).

ALZHEIMER'S DISEASE

Alzheimer's disease is an illness that causes people to forget things, even the people in their lives. They cannot remember recent experiences they have had or how to perform tasks that previously required little or no thought at all. Alzheimer's usually afflicts people in their late sixties, seventies, and beyond; however, the disease has been diagnosed in people as young as thirty. The disease often progresses until a person has difficulty speaking or functioning on his or her own. Eventually, the body's basic functions, such as breathing and digesting, break down until the person enters a coma and dies. Sometimes the disease progresses quickly, and death results in as little as five or six years. Other times, a person suffers with the disease for as long as twenty years.

Alzheimer's is a devastating disease not only to the person afflicted but also to the family and friends who must witness their loved one's suffering. There are many organizations devoted to supporting families and friends who are dealing with the disease. In addition, scientists are working hard to discover new ways of coping with the disease and to develop new treatment.

Alzheimer's disease is difficult to diagnose. There are, however, some warning signs that help physicians determine if a person has Alzheimer's disease. The Alzheimer's Association of America has developed these ten warning signs. They are:

1. Memory loss that affects job skills. It is normal to occasionally forget an assignment, deadline or colleague's name, but frequent forgetfulness or unexplainable confusion at home or in the workplace may signal that something is wrong.

2. Difficulty performing familiar tasks. Busy people get distracted from time to time. For example, you might leave something on the stove too long or not remember to serve part of a meal. People with Alzheimer's might prepare a meal and not only forget to serve it, but also forget they made it.

3. Problems with language. Everyone has trouble finding the right word sometimes, but a person with Alzheimer's disease may forget simple words or substitute inappropriate words, making his or her sentences difficult to understand.

4. Disorientation to time and place. It is normal to momentarily forget the day of the week or what you need from the store. But people with Alzheimer's disease can become lost on their own street, not knowing where they are, how they got there or how to get back home.

5. Poor or decreased judgment. Choosing not to bring a sweater or coat along on a chilly night is a common mistake. A person with Alzheimer's, however, may dress inappropriately in more noticeable ways, wearing a bathrobe to the store or several blouses on a hot day.

6. Problems with abstract thinking. Balancing a checkbook can be challenging for many people, but for someone with Alzheimer's, recognizing numbers or performing basic calculations may be impossible.

7. Misplacing things. Everyone temporarily misplaces a wallet or keys from time to time. A person with Alzheimer's disease may put these and other items in inappropriate places—such as an iron in the freezer, or a wristwatch in the sugar bowl—then not recall how they got there.

8. Changes in mood or behavior. Everyone experiences a broad range of emotions—it is part of being human. People with Alzheimer's tend to exhibit more rapid mood swings for no apparent reason.

9. Changes in personality. People's personalities may change somewhat as they age. But a person with Alzheimer's can change dramatically, either suddenly or over a period of time. Someone who is generally easygoing may become angry, suspicious or fearful.

10. Loss of initiative. It is normal to tire of housework, business activities, or social obligations, but most people retain or eventually regain their interest. The person with Alzheimer's disease may remain disinterested and uninvolved in many or all of his usual pursuits.

Reprinted with permission of the Alzheimer's Association of America.

The Biology Behind Learning

When babies are born, their brains are made up of billions of neurons (nerve cells that carry messages to and from the brain to other parts of the body). Over time connections, called synapses, form among the neurons that are vital to proper brain functioning; these synapses help individuals make mental connections between different areas of the brain and between different information so that they may learn and develop to their fullest mental abilities. What drives the establishment of these synapses is stimulation, particularly during infancy and early childhood. Stimulation can be anything from color, to light, sound, or touch; anything that captures the child's attention and makes him or her think. When stimulation occurs, synapses are built and strengthened. Without stimulation or even reinforced stimulation, key synapses either will not form at all or will wither away. While things such as intelligence and creativity may be partially determined by heredity, these connections are what determine maximum development.

What Helps Learning and What Hinders It

Stimulation, then, appears to hold an important key to making certain that people are able to realize their cognitive potential. Because the most important connections are made before the age of ten, it is important for a child to receive proper stimulation. There are several things that hold the key to optimizing learning and mental development for a child. They include:

1. A nurturing, secure environment that provides emotional caring and safety.

2. A sense of predictability so that a child develops a sense of emotional stability.

3. Conversation and communication; the spoken word boosts brain-power.

4. Encouragement and praise with regard to a child's accomplishments, however minor, to provide a sense of empowerment.

5. Helping children make cognitive connections by pointing them out (point out the car in the picture and then take the child for a ride in the car).

6. Knowing when a child has had enough stimulation and needs some quiet time.

Mental disorders such as attention-deficit disorder and learning disabilities can hinder learning, as discussed in Chapter 12 on Mental Illness. However, certain environmental factors and conditions can also hurt a child's ability to learn. A neglectful home environment in which stimulation is absent can spell the beginning of future learning problems for any child. Particularly stressful events, such as the death of a parent, or a stressful situation, such as homelessness, can also have adverse affects on a child's ability to concentrate on and respond to mental stimulation.

Kinds Of Learning

Several kinds of learning that are present throughout the life span influence the acquisition of knowledge and the alteration of behavior. Proposed by prominent doctors, scientists, and therapists throughout the years, their principles remain unchanged and are the foundation for many forms of therapies (for more information see Chapter 15: Mental Health Therapies).

CLASSICAL CONDITIONING. Formulated by Russian physiologist Ivan Pavlov (1849–1936), classical conditioning involves an automatic response to a certain stimulus that is acquired and reinforced through association. Pavlov illustrated the principles of classical conditioning after training dogs to salivate (involuntarily) upon hearing the ringing of a bell. Pavlov accomplished this task by first ringing a bell just before he fed the dogs. After a while, the dogs began to associate the ringing of the bell with getting their dinner. However, the response was ingrained in the dogs on such a deep level that the food was no longer the stimulus for salivation; rather, the ringing of the bell alone made the dogs salivate.

This can be seen in people's everyday behavior in different situations. An infant will learn to respond to the sound and smell of its mother before being given a bottle; the child is responding not to the bottle, but to the voice or scent of the mother. Similarly, if every time a child's parent calls him by his full name ("Come here, John Michael Smith!"), he gets yelled at, his heart may beat fast just hearing his full name being called, before his parent has even scolded him.

LET THERE BE LIGHT

Light and different types of light can influence and affect how one learns. In the 1940s and 1950s, biologist John Ott discovered that cool fluorescent lights (which are used in many classrooms) can make some children overly excited, thus making it difficult for them to learn, especially those students with attention-deficit disorder (see Chapter 12: Mental Illness). Natural light, or light that closely mimics natural light, is best for studying and learning.

OPERANT CONDITIONING. Unlike classical conditioning (which involves involuntary response to a certain stimuli), operant conditioning involves voluntary response to a certain stimuli based on positive or negative consequences that result from the response. First put forth by psychologist B.F. Skinner (1904–1990), an example of operant conditioning is training a dog by using treats or verbal praise to reinforce the desired result. If an owner trains her dog Fido to give her a paw when the dog's shoulder is touched and the dog performs the task and is rewarded with a biscuit or kind words, the dog will associate successfully performing the task with the tasty treat or the praise. Similarly, if a dog is consistently scolded when it chews something it should not, the dog will make the association between chewing a forbidden item with harsh words and will learn not to engage in that behavior anymore. The same principles apply to human behavior. If a child learns that she is rewarded by successfully completing her homework each night, doing her homework will become important to her.

Positive reinforcement of a behavior will usually cause a certain behavior to continue, while punishment or the absence of reinforcement will result in a behavior being extinguished. Behavior modification, a way of promoting positive behavior and eliminating negative behavior, is built around principles of operant conditioning.

RIGHT-SIDE AND LEFT-SIDE DOMINANCE

There has been much attention given to the notion of brain dominance in recent years. A popular book on learning to draw is entitled Drawing on the Right Side of the Brain: A Course in Enhancing Creativity and Artistic Confidence. This refers to the split-brain theory put forth by scientists who believe that the left side and the right side of the brain represent different types of thinking and that each person leans toward one or the other.

The left side of the brain is geared toward verbal skills, analytical ability; the left side of the brain also emphasizes aggressiveness and rigidity, and organization. It has been found that left-brained individuals are typically drawn to pursuing careers as accountants, attorneys, or careers in the military. In contrast, the right side of the brain is more geared to artistry, playfulness, intuitiveness, and fluidity; passivity and emotional flexibility are signs of right-brain thinking. It has been found that right-brain people are more likely to become artists, entrepreneurs, and educators.

The theory of brain dominance, when applied to the arena of learning and education, means that instructors and parents, when possible, need to take into consideration whether a child is left-side or right-side oriented and tailor teaching methods to that dominance.

OBSERVATIONAL LEARNING. Another way that people learn is through watching others or observing. A teacher trying to teach students how to add several numbers together will often explain the principles behind the method and will then demonstrate the method by solving a sample problem. The students then learn by observing the teacher. This is true of sports as well (watching a team execute certain plays during a sporting event) or behavior (watching someone get a desired result by giving a certain response). For example, a person might learn how to disarm her parents when they are angry with her by observing and adopting her brother's response, which seems to effectively calm their parents.

Observational learning is important in social learning. Young adults are likely to observe the habits and behaviors of their peers and adopt them as their own if they see those individuals gaining social acceptance through those habits and behaviors. This can include innocent things, such as ways of dressing or studying, or more harmful things, such as choosing to smoke, because those who do have gained a result that is desirable to those observing them.

Modeling (basing one's behavior on that of another person with whom there is a strong identification or desire to be like) is a part of observational learning, and young adults can model their friends' behavior as outlined in the previous paragraph. Modeling can also take place between people and someone they admire but do not personally know, such as a celebrity. For instance, if a young adult is a big fan of Madonna and hears that she does yoga every day, that young adult might be likely to take up yoga. The same holds true even if the person upon whom the teens are modeling themselves engages in harmful behavior. A celebrity who is caught engaging in risky behavior may influence young adults (and older adults) to engage in similar behaviors. Celebrities and public figures are often called "role models," even when they do not wish to be. They are generally held to higher standards than other people because their behavior is more likely to influence a large number of people.

INTELLIGENCE

Intelligence is defined most broadly as the ability and capacity to understand. It has taken many years for researchers to understand how to determine the precise differences between very intellectual individuals and those

LEARNING CAN BE FUN (AND GAMES)!

According to psychiatrist Gene Cohen (a game inventor, founder of the game company Genco, and former director of the National Institute of Mental Health's Center on Aging) games are mental gymnastics that can help people stay mentally fit. Cohen and other mental health professionals believe that playing games allows for people to flex brain-power and connections that they don't typically get to use when working or doing everyday tasks. Exercising the brain in this manner promotes the growth of better neural connections and the growth of brain cells.

Cohen's theories are backed up by research performed by Marian Diamond, a mental health professional at the Brain Research Institute of the University of California at Berkeley, who found that laboratory rats given toys to play with were able to find their way through mazes more quickly than rats who were not provided with toys. Upon examination of the two sets of rats the researchers discovered that there were profound differences in the brains of the two groups; the brains of the rats that had been given toys had more well-developed cerebral cortexes (which is the part of the brain related to thought). These findings gave rise to fun educational programs such as Sesame Street.

What Cohen wants people to remember, though, is that mental exertion through games can boost the brainpower of people—and rats as evidenced by Diamond's study—of all ages. Also, Diamond's study found that rats that simply watched other rats playing did not increase their brainpower at all. So, instead of passive activity such as watching television every night, to be mentally nimble in the years to come Cohen advises playing board games or cards. And, according to Cohen, computerized games do not boost brainpower because they do not involve reading nonverbal cues like watching one's opponents' reactions, which are part of traditional games.

who are less so. Until Alfred Binet (1857–1911), a French psychologist, sought to identify why certain students in French schools in the early twentieth century were not learning at the same pace as other students, no one had come up with any sort of solution to the question of how to measure intelligence. Using a trial-and-error approach to compiling his test, Binet developed his questions based on a division of students into categories of "bright" or "dull." The questions that ended up on the test were the ones that reinforced the difference in knowledge between these two groups.

The intelligence quotient (IQ) is the measure of intelligence as based on intelligence tests and the intelligence of the general population. While Binet created and published the very first standardized test of human intelligence (which was revised several times), it was American psychology professor Lewis Terman, of Stanford University, who came up with the actual formula for determining IQ: divide the test taker's "mental age," which is revealed by his or her score on the intelligence test, by his or her chronological age. The resulting number is what Terman called the intelligence quotient or IQ. In 1916 Terman brought the existing Binet test from France to the United States, translated it into English, and developed a new set of standard questions for American children. He named the new test Stanford-Binet.

DIFFERENT SMARTS FOR DIFFERENT PEOPLE

Many times, there are people who are not necessarily "book" or "school" smart but who are whizzes when it comes to specific fields such as music, art, or the written word. In response to this phenomenon, psychologist Howard Gardner came up with seven different types of intelligence. They include: musical intelligence; intelligence involving envisioning and measuring space abstractly (in one's mind, as artists and architects often do); mathematical intelligence; and linguistic intelligence (superior writing skills). In addition, there is interpersonal intelligence (being able to relate to others in a productive manner); intrapersonal intelligence (having the ability to be deeply in touch with oneself on an emotional and mental level); and physical intelligence (skills possessed by superior athletes, dancers, or surgeons).

Other theorists have brought forth issues of practical intelligence, or the intelligence that correlates with a person's success in day-to-day life. According to these theorists, practical intelligence, which comes from observing others, has a great deal of validity in that traditional intelligence does not have any correlation to success in life; often times, people with high IQs never realize their potential or lack the common sense to make the best of their capacities.

In terms of how intelligent the general population is, the average IQ is 100, with 68.3 percent of people possessing IQs ranging between 85 and 115. People with IQs between 115 and 130 are classified as having superior IQs while those with IQs in excess of 130 are labeled as gifted. Those individuals whose IQ falls below 85 are labeled as borderline and any score under 70 often indicates that an individual is mentally impaired to some degree (see Chapter 12: Mental Illness for a discussion of mental retardation and its relationship to intelligence quotients).

IQ tests have come to be viewed as predictors of a person's performance in school and in given careers. Over the years, however, the idea of intelligence, which is strongly tied to Binet's initial test, has come under fire. The notion of intelligence and ways of measuring it do not take into account that individuals with learning disorders, while still being very intelligent, may have trouble with the standard test. In addition, many people feel that intelligence tests are culturally biased (preferential to certain groups of people).

For example, the Stanford-Binet Intelligence Scale, which is based on Binet's initial test, includes questions for young children about "typical" daily activities. However, depending upon where one lives (for example, in the city or in the country, or in California or New York) or what one's experiences are, it might be difficult for some children to come up with the "correct" answer, according to the intelligence test, of what a typical daily activity is. In the case of adult testing, participants are asked to interpret the meaning of "common" proverbs (short sayings such as "A stitch in time saves nine"). It may be difficult to answer the question if a person has never heard of a certain proverb, or perhaps the proverb has a slightly different meaning depending on where a person grew up. Is it fair to say that someone possesses less intelligence than someone else because his or her life experiences do not coincide with the intelligence test?

Objectors to this type of intelligence testing propose that basic intelligence is not necessarily tied to knowledge, the acquiring of which has cultural biases. These concerns have given rise to a variety of intelligence tests that will measure not only verbal skills but also nonverbal skills and which are free of any bias.

CREATIVITY

Just as intelligence is difficult to explain in a precise manner, so is creativity. While intelligence refers to one's capacity to understand, creativity can be referred to as one's capacity to think in unique ways and solve problems in an imaginative manner. However, intelligence and creativity are not necessarily linked. People who are highly intelligent may not be very creative at all while extremely creative individuals may not have a particularly high IQ. Creativity can be demonstrated in endless ways, from creative writing to painting to architecture to simply performing any task in a creative manner, whether it is parenting, teaching, or building and repairing things.

Creative Thinking

Whatever a person's creative talent may be, the key to creativity lies in divergent thinking. Many people will respond to questions using convergent thinking (thinking that is driven by knowledge and logic). Divergent thinkers, however, will respond to queries with unusual but still appropriate answers. For example, if a convergent thinker were asked how many ways he could think of to use a book, he might respond with a conventional answer such as, "You can read it and learn from it." A divergent thinker also gives conventional answers such as those given by a convergent thinker. But he may be more creative and say, "You could pile books on top of each other to create a step stool, or you could use the book as a doorstop, or you could use it as a serving tray."

Creative individuals tend to share certain characteristics, including a tendency to be more impulsive (spontaneous) than others. Nonconformity (not going along with the majority) can also be a sign of creativity. Many creative individuals are naturally unafraid of experimenting with new things; furthermore, creative people are often less susceptible to peer pressure, perhaps

because they also tend to be self-reliant and unafraid to voice their true feelings even if they go against conventional wisdom.

How to Promote Creativity

In addition to taking some of the suggestions in the "The Creative Household" sidebar (see page 320), child development specialists suggest that there are other specific ways to promote creativity in children. Parents, guardians, and teachers should urge children to think divergently and come up with many different answers to a question or problem, answers that may fall outside of a traditional response, and should be careful not to ridicule an offbeat solution; rather, this sort of response should be taken seriously. Children should also be encouraged to be free thinkers who do not always accept things as they are but, rather, question what is and why it is. In this vein, too, kids should feel they have a right to examine things independently and not always accept the answer, "Because that's just the way things are."

THE CREATIVE HOUSEHOLD

While no one is precisely sure why certain people are creative while others are not particularly so, researchers have been able to identify certain qualities that are often present in the upbringing and home environments of creative people. Parents and guardians of creative children have been found to have some things in common. Specifically, they are not very critical of their children and urge their children to pursue new activities and experiences. They also encourage openness and value creative thinking and curiosity; unusual questions and skills are also valued.

Another aspect these households share is that they are not overly strict in terms of having a lot of formal rules. There are a lot of family discussions and kids learn values and good behavior through these discussions and through modeling (see section on Learning). Adults in these households also try to give children access to lessons in different areas (dance, sports, music) and provide equipment to carry out these activities. Creative kids are also likely to collect certain things (dolls, trading cards), which is usually done with a parent's support. A strong sense of play and silliness was also present in the home.

Of course, creative individuals are raised in households of all kinds, and not just in environments such as described here.

Certainly, none of these things guarantees that a child or adult will necessarily be a creative person but it will help people to think creatively and to "color outside the lines."

FOR MORE INFORMATION

Books

Espeland, Pamela and Rosemary Wallner. Making the Most of Today: Daily Readings for Young People on Self-Awareness, Creativity, and Self-Esteem. Free Spirit Publishers, 1991.

Fogler, Janet and Lynn Stern. Improving Your Memory: How to Remember What You're Starting to Forget. Johns Hopkins University Press, 1994.

Gray, Heather M. and Samantha Phillips (illustrated by Ellen Forney). Real Girl/Real World: Tools for Finding Your True Self. Seal Press, 1998.

Palmer, Pat. Teen Esteem: A Self-Direction Manual for Young Adults. Impact Publishers, 1989.

Simmons, Cassandra Walker and Pamela Espeland. Becoming Myself: True Stories About Learning from Life. Free Spirit Publishers, 1994.

Web sites

The National Association for Self-Esteem. [Online] http://www.self-esteemnase.org/ (Accessed October 29, 1999).

Personality: What Makes Us Who We Are? [Online] http://www.learner.org/exhibits/personality (Accessed October 29, 1999).

MENTAL HEALTH

The field of mental health has made many advances, particularly since 1980. These developments include an increased understanding of the brain's function through the study of neuroscience, the development of effective new medications and therapies, and the standardization of diagnostic codes for mental illnesses. However, many questions about mental health remain unanswered, and many people around the world are unable to benefit from the knowledge and treatments that are available.

Seven in ten Americans with a mental illness do not receive treatment. Biases against mental illness and lack of public awareness are among the obstacles that limit access to treatment and affect willingness to seek care. Fewer individuals with major psychiatric illnesses were institutionalized in the United States in the year 2000 than in 1980, but limited community resources had not yet met existing treatment needs. Over one-third of the homeless in the United States have a severe mental illness. The prevalence of dementia is rising as people are living longer, adding to the need for more resources. One of the main challenges for the field of mental health is overcoming the gap between an increasingly sophisticated understanding and treatment of mental illness and the availability of these advances to individuals and populations in need.

Mental, or psychiatric, illnesses are a major public health concern. They adversely affect functioning, economic productivity, the capacity for healthy relationships and families, physical health, and the overall quality of life. They cut across racial, ethnic, and socioeconomic lines to affect a significant proportion of communities worldwide. They tend to develop and manifest in the early adult years, often preventing individuals from leading full and productive lives. The National Comorbidity Survey of 1994 found nearly half of the individuals in its random U.S. sample had a psychiatric disorder over their lifetime, and almost 30 percent had one in the past year. The World Health Organization's World Health Report 1998 lists mood and anxiety disorders among the leading causes of morbidity and mood disorders as the leading cause of severely limited activity. Mental disorders account for a quarter of the world's disability. Comorbidity (having more than one illness) is common and even further increases the risk of disability. Suicide is the eighth leading cause of death in the United States and the third leading cause in the fifteen- to twenty-four-year-old age group. More people die by suicide than homicide.

Dianne Hales and Robert Hales define mental health as

the capacity to think rationally and logically, and to cope with the transitions, stresses, traumas, and losses that occur in all lives, in ways that allow emotional stability and growth. In general, mentally healthy individuals value themselves, perceive reality as it is, accept its limitations and possibilities, respond to its challenges, carry out their responsibilities, establish and maintain close relationships, deal reasonably with others, pursue work that suits their talent and training, and feel a sense of fulfillment that makes the efforts of daily living worthwhile (p. 34).

A healthy pregnancy, adequate parenting, secure attachments to caretakers, regular involvement in groups, and stable intimate relationships all contribute to the development and maintenance of mental health. Mental health does not imply the absence of distress and suffering, or strict societal conformity. Mental health and illness, idiosyncratic beliefs and delusions, sadness and depression, and worry and severe anxiety lie on a continuum. An essential criterion for defining behavioral patterns or symptoms of psychological distress as a mental disorder is that they become significant enough to be functionally disabling and impose substantial increased risks ranging from an important loss of freedom to suffering pain, disability, or death.

Both genetic inheritance and environmental factors influence one's vulnerability to mental illness. Twin and family studies and genetic research have demonstrated the former, though specific genes have been difficult to identify, and there may be multiple genes involved in most psychiatric disorders. Traumatic events throughout one's lifetime, including childhood abuse or neglect, major losses, violence, military combat, and dislocation (as among the urban homeless or wartime refugees) are known to threaten mental stability. Nontraumatic stressors, including unemployment, bereavement, and relational or occupational problems, can impact mental health. Nutritional deficiencies (such as vitamin B12), infections (such as syphilis and HIV [human immunodeficiency virus]), and heavy metal poisoning (such as lead) can all cause psychiatric syndromes. Substance abuse contributes significantly to the exacerbation or even precipitation of other psychiatric illnesses and complicates their treatment. Poverty and home-lessness are risk factors for many of these problems, but may also be the outcome of psychiatric illness and the inability to function independently.

Many models of mental health and illness have been proposed. Emil Kraepelin (1856–1926) contributed to the development of the precise categorization of mental illnesses, particularly in distinguishing the long-term course of psychotic and mood disorders. Sigmund Freud (1856–1939) developed the theory of psychoanalysis, through which he claimed that symptoms of psychiatric disorders, as well as many phenomena of everyday life, have unconscious meanings and sources. Erik Erikson (1902–1994) formulated a theory of human development with specific tasks and crises at different stages of the life cycle. Failure to master these stages can lead to various forms of psychopathology. Neuroscientists have demonstrated molecular models of illness, which involve genetic, developmental, functional, anatomical, and molecular abnormalities of the brain. The biopsychosocial model, proposed by George Engel in the 1970s, integrates the biological, genetic, and molecular mechanisms of illness with a psychological understanding of personality development and response to stress as well as social, cultural, and environmental influences.

The Diagnostic and Statistical Manual of Mental Disorders (its 4th edition, DSM-IV, was published in 1994) is the product of research on standardized diagnostic criteria aimed at creating a common, validated descriptive system for all mental health care providers. It is nearly universally accepted, as it classifies and describes categories of illness and aims to be neutral about controversial theories of etiology (see Table 1). The following descriptions of various mental disorders are based on DSM-IV criteria.

Affective disorders involve a cyclical pattern of significant mood disturbance. A major depressive episode may be precipitated by a stressful life situation but also has genetic factors. Disturbances in appetite, sleep, energy, concentration, and sexual interest are common symptoms. The majority of patients respond to treatment with antidepressant medication and/or psychotherapy. An individual who has long-term (over two years) of minor to moderate depressive symptoms may have

Table 1

dysthymia. Substance abuse, medical disorders (such as hypothyroidism), and normal life cycle events in which hormonal changes are prominent (such as the postpartum period) can all cause symptoms of depression and should be considered carefully during an assessment. An adjustment disorder is a milder disturbance of mood that may occur in response to a stressful life situation, such as a personal loss or financial crisis, and that usually resolves when the stress is relieved. About 1 percent of the general population has bipolar disorder, also called manic-depressive disorder, in which manic episodes are present as well as depressive episodes. Mania is characterized by a persistently elevated or irritable mood for at least a week, often with decreased need for sleep, rapid speech, impulsivity in spending and other behaviors, and grandiosity. In more severe manic and depressive episodes, psychotic symptoms may emerge, which can complicate treatment. Bipolar disorder is treated with mood stabilizers, such as lithium or valproic acid, and supportive management. Antidepressant medications alone can precipitate mania in susceptible patients.

Psychotic disorders are characterized by "positive" symptoms such as hallucinations, delusions, and bizarre behaviors, as well as "negative" symptoms such as paucity of speech, poverty of ideas, blunting of affective expression, and functional deterioration. Cognitive problems such as disorganization of thought processes also occur. Schizophrenia is a chronic, disabling illness that affects almost 1 percent of the world population, independent of ethnic or cultural background. Risk factors include a family history and possibly psychosocial stressors. The precise cause is still unknown, but it is clear that certain areas of the brain and certain neurotransmitters are involved. Many of those affected are unable to maintain work or relationships and require supportive services to help them manage basic needs such as shelter and food. Treatment includes antipsychotic medication, comprehensive social services including social and occupational rehabilitation if possible, and substance abuse treatment if necessary. Newer antipsychotic medications such as clozapine, olanzapine, and risperidone have been able to treat more symptoms generally with fewer side effects, allowing many to lead more productive lives. Some patients with schizophrenic-type illness also experience prominent affective symptoms nonconcurrently and may have schizoaffective disorder. These patients often require a mood stabilizer as well as antipsychotic medication. Substance use, especially hallucinogens and stimulants (such as amphetamines and cocaine), can precipitate psychotic symptoms, and these may even endure beyond the period of substance use. Some medical conditions (such as epilepsy and delirium) and some medications (such as steroids) can also cause psychotic symptoms and should be considered in the assessment and treatment of psychosis.

Anxiety disorders are among the most prevalent psychiatric disorders in the general population, and these disorders lead to both psychological distress and increased health care utilization. Panic disorder often manifests with somatic symptoms, such as palpitations, chest pain, nausea, trembling, dizziness, and shortness of breath, and can be easily confused with a medical disorder by both patients and doctors. Patients develop persistent concerns about having further panic attacks. Some develop agoraphobia, or a fear of being in public places where their attacks may be triggered. Other phobias include simple phobia, such as fear of heights or specific animals, and social phobia, which is a marked and persistent fear of certain or all social situations, such as speaking in public or being around others in general. People with obsessive-compulsive disorder have obsessions, characterized by recurrent or persistent thoughts, impulses, or images that are experienced as intrusive and inappropriate, and/or compulsions, characterized by repetitive behaviors or mental acts often performed in response to an obsession. After one experiences a traumatic event, in which actual or threatened death or severe injury is witnessed or experienced, one may develop post-traumatic stress disorder. Intrusive recollections of the event (such as nightmares), avoidance of reminders of the event, and increased arousal (such as increased vigilance for potential threats) can all cause significant distress and impairment following a wide range of traumatic events, including an accident, military combat, torture, or rape. Generalized anxiety disorder is characterized by excessive and persistent anxiety or worry about a number of events or activities, such as work or school performance. For all anxiety disorders, specific psychopharmacologic and psychotherapeutic (such as cognitive-behavioral therapy) techniques of treatment can be effective and complementary.

Substance-use disorders are quite common and occur in all segments of society. They can lead to accidents, violent crime, and major problems in school and at work. They can cause or complicate various medical and psychiatric illnesses. Liver failure, ulcers, heart attacks, cognitive disorders, and depression are among the potential outcomes of various substances. These disorders pose major public health concerns for public safety, health costs, economic productivity, and pregnancy risks, among others. Substance abuse is defined as a maladaptive pattern of use indicated by continued use despite persistent or recurrent social, occupational, psychological, or physical problems caused or exacerbated by the use of the substance; or recurrent use in situations that could be physically hazardous (such as driving while intoxicated). With substance dependence, signs of physical dependence such as withdrawal symptoms are often present, and the person spends a great deal of time involved in substance-related activities, uses more of the substance than intended, is unable to cut down, and continues to use the substance despite social, occupational, or physical problems related to it. The first steps of treatment involve developing insight, acknowledging the problem, and wanting to change. There are various self-help groups (such as Alcoholics Anonymous), comprehensive treatment programs, psychosocial interventions, and medications that can help lead to successful recovery for the majority of those with substanceuse disorders.

Childhood disorders include pervasive developmental disorders, such as autism, which occurs in four out of ten thousand people; mental retardation, which can be caused by a variety of genetic abnormalities or prenatal insults; and attention deficit–hyperactivity disorder, which can lead to significant problems in school and in social relationships. Childhood abuse and neglect are tragically quite common, with one million children affected annually in the United States alone. These can have major adverse effects on development of personality, relationships, and the ability to function in the world.

Personality disorders are usually first evident in late adolescence and are characterized by pervasive, persistent maladaptive patterns of behavior that are deeply ingrained and are not attributable to other psychiatric disorders. Biological and genetic factors, as well as developmental difficulties, are significant contributors. Other disorders described in DSM-IV include eating disorders, with restriction (anorexia) and/or binging and purging (bulimia) and impulse control disorders (e.g., kleptomania). Somatoform disorders cause physical symptoms with no apparent medical cause (e.g., hysterical paralysis).

Gender, race, ethnicity, and culture are important factors in determining the expression and risk of mental disorders, and these factors also impact on treatment considerations. Certain disorders are more prevalent in women, such as depression and eating disorders, and some in men, such as substance abuse. Cultural background may influence the idioms of psychological distress. For example, nervios describes for many Latinos a constellation of somatic, anxiety, and depressive symptoms distinct from particular DSM-IV diagnoses. Psychiatric disorders are the main risk factor for suicide, but rates vary significantly depending on gender, age, race, religion, marital status, and culture.

Paul J. Rosenfield

stuart J. Eisendrath

(see also: Community Mental Health Centers; Dementia; Depression; Schizophrenia; Stress )

Bibliography

Bromet, E. J. (1998). "Psychiatric Disorders." In Maxcy-Rosenau-Last Public Health and Preventive Medicine, 14th edition, ed. Robert B. Wallace. Stamford, CT: Appleton and Lange.

Diagnostic and Statistical Manual of Mental Disorders (DSM IV) (1994), 4th edition. Washington, DC: American Psychiatric Association.

Eisendrath, S. J., and Lichtmacher, J. (1999). "Psychiatric Disorders." In Current Medical Diagnosis and Treatment 1999, eds. L. M. Tierney, Jr., S. J. McPhee, and M. A. Papadakis. Stamford, CT: Appleton and Lange.

Engel, G. (1980). "The Clinical Application of the Biopsychosocial Model." American Journal of Psychiatry 137(5):535–544.

Hales, D., and Hales, R. E. (1995). Caring for the Mind: The Comprehensive Guide to Mental Health. New York: Bantam Books.

Jamison, K. R. (1999). Night Falls Fast. New York: Alfred Knopf.

Kaplan, Harold I., and Sadock, Benjamin J., eds. (1995). Comprehensive Textbook of Psychiatry. 6th edition. Philadelphia: Williams and Wilkins.

Kessler, R. C.; McGonagle, K. A.; Zhao, S.; Nelson, C. B.; Hughes, M.; Eshleman, S.; Wittchen, H. U.; and Kendler, K. S. (1994). "Lifetime and Twelve Month Prevalence of DSM-III-R Psychiatric Disorders in the United States: Results from the National Comorbidity Study." Archives of General Psychiatry 51:8–19.

U.S. Public Health Service (1999). The Surgeon General's Call to Action to Prevent Suicide. Washington, DC: Author.

World Health Organization (1998). World Health Report 1998: Life in the Twenty-first Century, A Vision for All. Report of the Director-General. Geneva: Author.

Mental Health

CHANGING UNDERSTANDINGS

PHYSICAL AND PSYCHOLOGICAL VIEWS

CARE AND TREATMENT

BIBLIOGRAPHY

Mental health has attracted considerable attention from social scientists. Poor mental health frequently creates personal distress for the individual and those around that individual; often has social causes; has significant social costs in the form of dependency, incapacity, and unemployment; and may also lead, on occasion, to social disturbance and disruption. Consequently social scientists have contributed to a series of related debates about the validity and boundaries of the concepts of mental health and illness, the social distribution and causes of mental illness, and the appropriate care and treatment of mental illness. To a more limited extent, social scientists have also added to discussions about the ways to facilitate and enhance mental health.

When defined positively, mental health tends to be described rather loosely as a state of psychological well-being or satisfactory psychological functioning. More frequently, however, much as with health generally, it is simply defined negatively as the absence of mental illness. Based on an analogy with physical illness, mental illness refers to mental functioning that is considered disordered and described in lay terms as mad, disturbed, or disruptive or as anxiety and unhappiness that is more extensive than usual. While the indicators of mental illness often take the form of behavior that seems inexplicable or unintelligible, the judgment made is of some pathology of mental functioning. In Madness and Civilization the social theorist Michel Foucault (1926–1984) argued that unreason is the defining characteristic of madness, although whether this applies to the full range of mental disorders that are now identified, which extends well beyond the narrower category of madness, is contested. In severe cases, mental illness impairs the individual’s capacity to carry out some ordinary tasks of living, although symptoms are often episodic. Mental illness can also generate behavior dangerous to self or others, which may be used to justify legal powers of detention on the grounds of the person’s lack of reason and the perceived threat to his or her own safety or that of the public. In less severe cases, it can lead to distress and suffering and difficulties with certain aspects of daily living. Consequently satisfactory performance of normal tasks of living often becomes a key indicator of mental health.

CHANGING UNDERSTANDINGS

The use of the language of health and illness reflects the role doctors have played in offering care and treatment for psychological problems. In European and North American societies medical understandings, which draw on a range of scientific ideas, tend to be dominant and inform much lay discourse, especially about mental illness. However, in many contexts the term mental disorder, which has fewer medical connotations, is used. The impact of scientific ideas, as well as the ideas themselves, has varied historically and cross-culturally, and there have been times and places when the understandings have been magical or religious rather than scientific. Magical or religious ideas relating to mental illness have not entirely disappeared from lay understandings, such as when people think a mental or physical illness is a judgment of God or that health is a matter of luck and good fortune.

Modern-day medical ideas about mental illness have largely been developed in psychiatry, a medical specialty that emerged as a profession in the mid-nineteenth century from the associations of doctors working in charitable and public asylums that catered for “lunatics” and had powers of detention. In Europe a few institutions for lunatics were set up in the medieval period; these were followed first by small private madhouses in the sixteenth and seventeenth centuries and then, from the beginning of the nineteenth century, by charitable and public asylums. As the century progressed asylums became increasingly large-scale. They were mainly staffed by untrained attendants, with doctors usually the key figure of authority.

In the twentieth century asylum attendants were transformed into mental health nurses, and a range of other professionals (e.g., mental health social workers, psychotherapists, and clinical and health psychologists) started to contribute to the care and treatment of those with mental health problems and to understandings about mental health and illness. Mental health practice outside the asylum also expanded in the twentieth century. In the mid-twentieth century there was a move toward “community care,” which is the provision of services within community settings, even for those with more severe disorders, with far fewer mentally ill admitted to a psychiatric bed (where compulsory powers of detention are frequently used). The extent and quality of community services have often been questioned.

The types of mental illness identified by psychiatrists are diverse, ranging from the relatively severe and less common, such as schizophrenia, to the less severe and far more common, such as mild forms of depression and anxiety. Classifications have varied enormously over time, and during the second half of the twentieth century there were major attempts to systematize and standardize mental illnesses in order to improve the reliability of psychiatric diagnosis. In the twenty-first century two major classifications were developed: the American Diagnostic and Statistical Manual of Mental Disorders (DSM) and the listing of mental disorders in The International Classification of Diseases. The two classifications do not group mental disorders in the same way.

An earlier distinction widely used in the early postwar decades was between psychoses and neuroses, a contrast between more and less severe disorders that linked to symptom differences and ideas about causation. Psychoses were held to be primarily disorders of thought (i.e., Foucault’s unreason) and caused by biological factors. Psychoses were typified by the delusions and hallucinations of schizophrenia, the archetypical madness, associated with disturbed and sometimes difficult behavior. Bipolar disorder (formerly referred to as manic depression) is also placed in this category, as are usually disorders where there is clear brain pathology, such as the senile dementias. Neuroses, such as anxiety states and phobias, were considered primarily disorders of emotion (usually called “affect” or “mood” by psychiatrists) rather than thought and were held to have psychological causes. However, in its third edition in 1980, the DSM decided (not entirely successfully) to eschew etiology as a basis for classification shifting to a symptomatological categorization and excluding the term neurosis. Official classifications also include a range of conduct or personality disorders in which the main symptoms relate to behavior, such as “antisocial personality disorder,” anorexia nervosa, and substance use disorders, including alcoholism and drug addiction. Comparison of the different editions of the DSM is salutary. According to Allan V. Horwitz, the number of mental disorders listed in the 1918 edition of the DSM was 22, whereas by the fourth edition in 1995 it was nearly 400. Such increases necessarily broaden the boundaries of mental disorder and narrow those of mental health.

PHYSICAL AND PSYCHOLOGICAL VIEWS

Consistent with medicine’s interest in the body, psychiatry has developed a “biomedical” model of mental illness. The biomedical model focuses on physical causes and the provision of physical treatments, although psychiatrists often deploy a wider range of understandings in their practice. The search for physical causes has concentrated on inheritance, brain pathology, and biochemistry. While there is strong evidence of a genetic tendency for more severe mental disorders, there can be no doubt that environmental factors play a part in causation, even with severe disorders, and are important to mental health. For instance, the evidence from a range of studies has shown that genetic factors play a role in the etiology of schizophrenia, but there is also evidence of environmental factors having a role. Biochemical processes in the brain have been shown to underpin some mental illnesses, most obviously conditions such as Alzheimer’s disease. However, significantly data also indicate that social and behavioral factors, such as exercise (physical and mental) as well as diet and obesity, play a part in the complex etiology of Alzheimer’s disease.

Biochemical changes in the brain are associated with other mental disorders. There is evidence, for instance, that serotonin levels play a role in depression. But in contrast to Alzheimer’s, it is not clear that brain pathology is the cause of depression. The build up of serotonin may be a consequence of social and psychological experiences that are themselves better viewed as the cause of the depression. Such examples indicate that the causes of any mental illness are multifactorial and are not the same for one disorder as for another. They also indicate that debates about causation that have so vexed discussions of mental illness depend in part on the choice of which causes to examine. Psychiatrists have tended to focus on physical causes and to give them primacy, downplaying social and psychological factors.

Evidence of the importance of social and psychological factors to mental health comes from a range of studies. Many studies show that early childhood experiences affect mental health and that external stresses (stressful life events or ongoing difficulties, whether in childhood or later) can lead to mental disorder, although some would argue that in some disorders stress is more a precipitating factor than a cause. Data on the distribution of mental disorders across populations also display a marked social patterning. International studies show that a condition similar to schizophrenia is common across a wide range of societies. However, within any given society data indicate that schizophrenia is more common among groups with lower socioeconomic status and that this difference cannot be adequately accounted for by individuals with schizophrenia drifting down the socioeconomic scale. The link between socioeconomic status and mental illness applies to other disorders, such as depression. It has been argued that depression is due not only to the frequency of adverse life events but also to difficult circumstances and low levels of social support, which affect coping and its adverse vulnerability. There is also a marked patterning by gender. Whereas levels of schizophrenia are roughly the same for men and women, depression and anxiety are far more common in women than men, and personality and conduct disorders are more common in men. Part of this difference appears to be due to gender socialization and differing expectations as to appropriate emotions and behavior. There are also ethnic differences in the patterning of mental disorder. In the United Kingdom, for instance, a 1997 study by James Nazroo showed that schizophrenia is more commonly diagnosed in Afro-Caribbean men than in other social groups, though the reasons for this are not entirely clear.

Equally controversial have been related issues around the validity and boundaries of mental illness. A number of authors from different theoretical perspectives have argued that it is only reasonable to talk of illness when there is a clear physical pathology. For the psychiatrist Thomas Szasz, who famously argued in 1961 that mental illness was a myth, this meant recognizing that disorders such as senile dementia are diseases of the brain. Where there is no biological pathology, Szasz stated, psychological problems should be termed “problems in living” and not regarded as illnesses at all. From a rather different perspective, a range of sociologists has argued that mental illness, with its overtly behavioral symptoms, is best understood as a form of deviance (i.e., a behavior that breaks social norms) and not as illness. This position was developed by the psychotherapist T. J. Scheff in his well-known 1966 study Being Mentally Ill. These two positions reflect a long-standing contest between those who espouse the biomedical model of mental disorder and wish to appropriate psychological problems to the domain of physical illness—a process sociologists term medicalization and which is reflected in the expansion of psychiatric categories—and those who wish to appropriate mental disorder to the social (or psychological) domain of behavior considered unacceptable or difficult. Horwitz, in Creating Mental Illness, accepts that the boundaries of mental health and illness are set by society and tries to resolve the conflict between the two positions by stating that a condition is a valid mental illness or disorder if (a) it involves a psychological dysfunction that is defined as socially inappropriate, and (b) it is socially useful to define the dysfunction as a disease.

CARE AND TREATMENT

Given such disputes, not surprisingly a further major area of controversy concerns care and treatment. When charitable and public asylums were first established, the most influential therapeutic model was that of “moral treatment.” This was a set of ideas about the importance for “lunatics” to live in a supportive, well-ordered, and wellstaffed environment that built on the individual’s capacity for self-control to facilitate his or her return to health. However, this social model, which was an important component of the pro-institutional discourse that underpinned the establishment of asylums, was resource intensive and difficult to implement in practice, especially when asylums became large-scale. The challenges of asylums were among the reasons they were increasingly replaced by biomedical approaches. Treatments in the early twentieth century included drugs, such as morphine and chloral hydrate, and various forms of hydro and electrical therapy. In the late 1930s electro-convulsive therapy (ECT) and psychosurgery (which involves the cutting of certain brain tissues) were introduced, and from the mid-1950s a range of synthesized drugs began to be used starting with chlorpromazine, an antipsychotic. In the beginning of the twenty-first century psychotropic medications provide the dominant form of treatment for mental health problems, from the most to the least severe, although many professionals accept that the drugs control symptoms rather than provide cures. Some medications, notably the antipsychotics, have unpleasant side effects, and patients may be reluctant to take them except by compulsion; they are also often prescribed on a long-term basis, which increases the risks to patients. Yet a number of factors encourage the medical reliance on drugs: efficacy in controlling symptoms; the scope of doctors’ expertise with its concentration on the physical at the expense of the psychological and social; pressures of time that make more intensive therapies seem harder to provide; and heavy marketing by the pharmaceutical industry.

Psychological theories and therapies have, however, played an important role in ideas about mental health and the treatment of the less severe forms of mental illness. In the first half of the twentieth century psychoanalysis had a major impact, and “talking cures” began to be used by trained psychoanalysts, especially for private patients (in the United States psychoanalysis had widespread acceptance within psychiatry). Psychological theories also informed child and educational psychology and the “mental hygiene” movement that flourished in the United States in the early decades of the twentieth century, in which the focus was on improving and sustaining mental health through education, early treatment, and public health.

However, some psychologists, highly critical of psychoanalysis, developed their own therapies based on the behaviorist ideas that swept academic psychology from the early decades of the twentieth century. Early behavior therapy excluded attention to thought and meaning but was gradually replaced by cognitive behavior therapy (CBT), which concentrates on the individual’s ways of thinking and is seen by some as offering a relatively speedy and effective route to mental health, especially for less severe disorders. CBT has been influenced by “positive psychology,” which is a set of ideas that seeks to encourage individuals to focus on what can give meaning in life, especially their strengths. Some also argue that CBT can be of value in treating psychosis. Yet psychological therapies such as physical remedies mainly concentrate on dealing with mental health problems that have already developed and not on mental health maintenance and prevention, the area to which social scientists have arguably more to contribute.

SEE ALSO Cognition; Disease; Emotion; Foucault, Michel; Intelligence; Madness; Medicine; Mental Illness; Personality; Personality, Type A/Type B; Psychoanalytic Theory; Psychotherapy; Stress; Trauma

BIBLIOGRAPHY

American Psychiatric Association. 1994. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV. Washington, DC: Author.

Brown, George, and Tirril Harris. 1978. Social Origins of Depression. London: Tavistock.

Foucault, Michel. 1967. Madness and Civilization. London: Tavistock.

Hollingshead, August, and Fredrick C. Redlich. 1958. Social Class and Mental Illness. New York: John Wiley.

Horwitz, Allan V. 2002. Creating Mental Illness. Chicago: University of Chicago Press.

Nazroo, James. 1997. Ethnicity and Mental Health. London: Policy Studies Institute.

Scheff, Thomas J. [1996] 1999. Being Mentally Ill: A Sociological Theory. 3rd ed. New York: Aldine de Gruyter.

Szasz, Thomas. 1961. The Myth of Mental Illness. American Psychologist 15: 113–118.

World Health Organization. 1992. The ICD-10 Classification of Mental and Behavioural Disorders: Cultural Descriptions and Diagnostic Guidelines. Geneva: Author.

Joan Busfield

MENTAL HEALTH

A popular contemporary joke says that anyone ahead of you driving slower than you want to go is an idiot and that anyone who passes you is a maniac. If someone disagrees with one's point of view, one might ask, "Are you crazy?" One might describe a chaotic classroom as like bedlam. People freely, even humorously, use the terms of mental health to define not only others but also themselves. The literary critic Shoshana Felman, in her study Writing and Madness, says, "To talk about madness is always, in fact, to deny it. However one represents madness to oneself or others [for example, a novelist to his or her readers], to represent madness is always, consciously or unconsciously, to play out the scene of the denial of one's own madness" (p. 252). Fictional representations of mentally disordered characters appear in the earliest works of American literature. The novel Wieland (1798), by the first professional belletristic writer in America, Charles Brockden Brown (1771–1810), is narrated by a confessed madwoman, Clara Wieland. Clara's brother, Theodore Wieland, thinks that God has spoken directly to him and commanded him to kill his family, but he has been tricked by a ventriloquist. His sister Clara analyzes her own feelings as she tells this tale of disturbing psychological imbalance.

A number of other classic American novels from the nineteenth century present characters with mental disorders. A mentally unhinged singing master, David Gamut, in James Fenimore Cooper's The Last of the Mohicans (1826), moves freely amid the murderous Magua and his band of Hurons because lunatics received reverential treatment. Nathaniel Hawthorne's (1804–1864) masterpiece The Scarlet Letter (1850) presents the demoniacally insane character of Roger Chillingworth, whose obsessive desire for revenge against his unfaithful wife, Hester Prynne, and her lover, the Reverend Arthur Dimmesdale, propels the novel's plot. Rather than acknowledge his situation in a stable fashion, Chillingworth—himself a physician with an understanding of medicinal herbs—displays neurotic behavior that seeks to rectify his feelings of betrayal by cunningly inflicting misery on others. The literary reputation of Hawthorne's friend and neighbor Herman Melville (1819–1991) rests with general readers largely on the basis of one novel: Moby-Dick (1851). Melville's character Captain Ahab is most often described by critics as being megalomaniacal (desiring omnipotence) or monomaniacal (pathologically obsessed with one idea) because of his single-minded purpose of using his ship and its crew to get revenge on the white whale that physically harmed him by biting off his leg; Ahab is unable to grasp the extent to which Moby-Dick caused him psychological harm.

Readers of literature typically want to see characters who resemble themselves but who also differ in some degree—better looking, wiser, more adventurous. Readers' interest also extends to characters who are psychotic, conflicted, emotionally disturbed, especially those who advance the story by means of deviously constructed schemes growing out of some form of mental derangement. In the early twenty-first century one refers to people with various mental disorders with compassion, but not so long ago in America individuals with mental illness were routinely called lunatic, maniac, mad, evil-possessed, deranged, and the like. Manifestations of odd behavior that both amuse and unsettle one have become a staple of American literature, whether in the form of minor characters such as Cooper's David Gamut or central characters in twentieth-century novels such as Frederick Exley's A Fan's Notes (1968) and Ken Kesey's One Flew over the Cuckoo's Nest (1962), both of which are principally set in psychiatric hospitals.

MENTAL HEALTH IN COLONIAL TIMES

The earliest settlers in America clustered for mutual protection and support in villages and towns along the eastern seaboard, so society was "urban" in the sense that people lived in close proximity. Aberrant behavior was readily apparent in these close-knit settlements that grew progressively into towns and cities. The citizen majority who consider themselves sane determine which individuals are not sane. Forms of insanity have always existed in American community life, and novelists and poets reflect these aberrancies in their writings. In literature, corruption, crime, or mental instability typically occur in cities, while the bucolic, scarcely populated countryside represents purity and normalcy. In colonial times, mentally handicapped people in American urban communities were kept by their families in private homes, but some towns housed the violently insane in jails with common criminals or in almshouses with the poor. As communities grew, they began developing institutions for the mentally ill as early as the middle of the eighteenth century.

The first mental hospitals arose in or near major cities—Philadelphia, Williamsburg, New York, Boston, Hartford, Lexington. The establishment of these specialized hospitals during colonial times was consistent with the egalitarian attitude that America could cure all its societal ills in its quest to improve upon the European culture from which it sought to dissociate itself. With characteristic optimism, Americans thought that if something was wrong, a solution lay in setting about to correct it. If some individuals were insane, then insane asylums would solve the problem. In 1751, when the first general hospital in the British North American colonies was founded in Philadelphia, Benjamin Franklin urged that it include facilities for the treatment of the mentally ill. In 1766 Governor Francis Fauquier of Williamsburg argued in the Virginia House of Burgesses for the establishment of a mental hospital. Norman Dain notes that Fauquier called attention to "a poor unhappy set of People who are deprived of their Senses and wander about the country, terrifying the Rest of their Fellow Creatures" (p. 7). He called the insane "miserable Objects who cannot help themselves" and called upon the colony to "endeavor to restore them to their lost Reason" (p. 7).

As state mental hospitals appeared, families often relinquished the care and treatment of the mentally ill from the home to the institution. Families were not only relieved of the burden of caring for a loved one in the home but also comforted by the developing medical specialty that treated the mentally afflicted. They did not send relatives away to be chained in a dungeon but to be cared for by trained professionals whose abilities surpassed that of family members. Communities actively sought to establish these facilities as a mark of their cultural progression and civic pride in caring for their citizenry. Nor were these hospitals simply madhouses where pandemonium reigned. Benjamin Reiss writes that the doctors at the New York State Lunatic Asylum at Utica, founded in January 1843, practiced medical intervention with their patients, but they became known for their innovative treatment of insanity as the result of a psychological or moral cause. In a nurturing environment, they closely monitored their patients and engaged them in useful and enriching activities such as reading, writing, performing plays, worshipping at chapel, and learning marketable skills.

MENTAL HEALTH AND SLAVERY

As the nation grew and as hospitals for the insane became widespread, a special problem arose. Before the Civil War, most asylums in the United States, both North and South, either refused admission to blacks or gave them inferior treatment and facilities. Indeed, common knowledge among both medical professionals and lay people held that blacks and whites were so different in every way that they could not even suffer the same forms of mental illness. Peter McCandless writes that South Carolinians admitted slaves to their state mental hospital in 1848 but not necessarily out of a sense of altruism. Politically, the admission of blacks blunted some abolitionists' criticism of the generally harsh treatment of slaves in the South.

The novelist and poet William Gilmore Simms (1806–1870), one of the most talented writers in the South and a native of Charleston, South Carolina, published his first novel, Martin Faber, a psychological study of a criminal, in 1833. He also spoke out on the issue of slavery and mental illness. Simms argued in an essay titled "The Morals of Slavery" (1838) that the slave system actually encouraged mental stability because the slaves had no concerns about the future, no worries about supporting themselves or their children, and no anxiety about being cared for in old age. Simms's views carried great weight in the South because of his influential position as editor of the prolavery Southern Quarterly Review (1849–1856), a widely circulated periodical with a strong regional slant that published stories, poems, book reviews, and essays. Others in the antebellum South dismissively thought that distinctive mental disorders occurred in blacks because of their belief in witchcraft, conjuring, spells, and potions—the deeply rooted cultural beliefs that originated in Africa and the Caribbean and were brought to America by the slaves. The African American writer Charles W. Chesnutt (1858–1932) uses conjuring as a psycho-physiological motif in his short story "The Goophered Grapevine," first published in 1887 but set in the antebellum South. The story depicts a slave whose physical appearance changes with the seasons of the year because of his belief in the power of a conjuring or spell cast on him.

A New Orleans physician, Samuel Cartwright (1793–1863), believed that slaves sometimes suffered from a peculiar form of mental illness that he termed drapetomania, the abnormality that caused slaves to run away, from drapeto, meaning "to flee," and "mania," "an obsession." Clearly, however, Cartwright had subjective motives for his peculiar example. Harriet Beecher Stowe (1811–1896), in a very different sense, employed the motif of the runaway slave in her widely influential novel Uncle Tom's Cabin, first published serially in the magazine the National Era in 1851 and 1852. Uncle Tom does not run away because his deep religious faith allows him to transcend his servitude; he will receive his freedom in heaven. But in one of the most memorable scenes in the novel, the slave Eliza Harris, holding her young son Harry, leaps from one ice floe to the other over the Ohio River in her successful escape from Kentucky to Ohio. Her husband, George, later runs away and is united with his wife and child. One of the ironies apparent to modern readers concerning an attempt to invent a medical term for the act of a slave's running away is that the institution of slavery itself represented a sort of regional insane asylum, a vast madhouse populated with slaves as unwilling inmates. To want to escape from a place of madness must surely be a form of sanity, not insanity.

QUACKERY

Because mental illness manifests itself in such a variety of individual ways, no single method of treatment or panacea drug is likely to be discovered. Certainly the modern day pharmacopoeia can bring about dramatic improvement in patients suffering from depression, schizophrenia, and other neuroses. In the early to mid-nineteenth century, psychiatry was an unknown term. Patients suffering from mental illness received treatment for their symptoms, not the underlying causes of the symptoms. If patients were violent, they were restrained. If they spouted nonsense and could not communicate, they were isolated from those who could talk sensibly. During this period in American history, some of the cures advocated by respectable physicians seem ridiculous in the early twenty-first century: shaving the patient's head and washing it with vinegar, making the patient stand under a waterfall, or pouring cold water on his or her head. The reasoning behind these practices held that if the patient is "out of his or her head," the problem must lie within the head itself; therefore, the application of physical therapies to the part of the body that is disordered must be the correct medical approach. Other cures called for a regimen of exercise, fresh air, games, special diets, bleedings, purges of the bowels, cold baths, the administration of various tonics, excursion trips to exotic locales, and the imbibing of alcohol.

One can see that the imprecise understanding of mental illness invited all sorts of quackery. Among them, as is now known, was the practice of phrenology (from the Greek phren, "the mind"; hence the word "frenzy"). Commonly misunderstood as simply feeling the bumps of one's skull, a phrenological reading was, in fact, analogous to the palpations of a modern clinician who feels and thumps not simply the exterior of a patient's body but also, and more importantly, the organs within; their sizes, shapes, and sounds can tell a skilled practitioner much about the patient's condition. Similarly, the skull and its bumps are not as crucial as the form of the enclosed brain. A trained phrenologist was believed to be able to read the bumps that reveal the shape of the brain beneath them. These shapes were said to indicate a person's behavioral qualities such as combativeness, wonder, cautiousness, ideality, and benevolence. Once diagnosed, the patients were encouraged to modify their behavior to suppress bad tendencies and endeavor to adhere to the good tendencies.

Enjoying its greatest respectability from the 1820s through the 1840s, phrenology, in its early stages, was a serious attempt at discovering the origins of human behavior. This quasi-scientific field of inquiry now belongs to the netherworld of palmistry, soothsaying, and snake-oil elixir treatments. In an era when devices such as sonograms, computed tomography imaging (CT scanning), magnetic resonance imaging, and X-rays were still yet to be imagined, a group of the most esteemed medical doctors in Philadelphia proposed testing the validity of phrenological theory by measuring and examining the brains of selected individuals who were known achievers, so the first phreno-logical society was established there in 1822. The German neurologist Johann Gaspar Spurzheim taught a course in phrenology at Harvard Medical School in 1832, increasing the discipline's following among physicians and the public in general. In 1839 George Combe, a Scottish phrenologist, delivered a series of lectures at the Philadelphia Museum. Edgar Allan Poe studied Combe's Lectures on Phrenology (1839) for assistance in writing his 1839 short story "The Fall of the House of Usher."

The second edition of Walt Whitman's Leaves of Grass was published in 1856 by Fowler and Wells, a company whose officers were, in fact, phrenologists. The brothers Orson Squire Fowler (a classmate of Henry Ward Beecher at Amherst College) and Lorenzo Niles Fowler along with Samuel R. Wells operated their phrenological cabinet in New York City following the success of their operation in Philadelphia. Lorenzo Fowler examined Whitman's cranium in July 1849, and it is possible to match, as scholars have done, all the qualities of Fowler's reading with selections from Leaves of Grass because Whitman consciously inserted phrases and imagery that would complement the reading. Although Whitman retained some references to phrenology until his masterwork's final edition in 1892, he gradually distanced himself from practitioners of the pseudoscience when they were supplanted by sincere, progressive alienists—the original term for psychiatrist.

Without completely embracing phrenology, most of the principals in the transcendentalist movement showed interest. Amos Bronson Alcott, the leader of the transcendentalists at his commune Fruitlands, gave little credence to phrenology, although he willingly sat for at least four readings in the 1830s, including one reading by Lorenzo Niles Fowler.

Initially fascinated with the promise of phrenology to decipher character, Ralph Waldo Emerson (1803–1882) later rejected phrenology. Perry Miller quotes Emerson as saying, "Phrenology laid a rough hand on the mysteries of animal and spiritual nature, dragging down every sacred secret to a street show" (p. 499). Even as he condemned its coarser aspects, Emerson credited phrenology with having "a certain truth to it; it felt connection where the professors denied it" (p. 499).

Margaret Fuller, who had a phrenological reading, was more enthusiastic than most of her transcendentalist friends, believing that any effort to understand the mind a worthwhile study; the parallels between idea and nature were central to transcendentalist thought. Theodore Parker, whose keen mind Emerson admired, credited the phrenologists with weakening old ways of thinking and inviting progress in understanding the nature of humankind. The transcendentalists' reaction to phrenology varied, and it never became integral to their movement; they viewed it as they would any scientific inquiry into the mind, and as phrenology's general appeal faded, so did their interest.

A REPRESENTATIVE WRITER

Of all American writers in the mid-nineteenth century, Edgar Allan Poe (1809–1849) is most often associated with madness or instability. A possible exception to this claim may be made for Jones Very (1813–1880), a minor poet and tutor in Greek at Harvard who insisted that his sonnets were communicated to him by the Holy Ghost. Very voluntarily committed himself to an insane asylum. Poe's legendary alcoholism and other unusual behavior such as his marriage to his thirteen-year-old cousin suggest an unstable individual. Lorenzo Niles Fowler conducted a phrenological reading of Poe (the date is not certain) and published his reading in the Illustrated Phrenological Almanac for 1851 (1851). The reading wove phrenological theory with the circumstances of Poe's life, such as his mother's career as an actress, his being orphaned at a young age, and his alienation from his foster father, to account for his personal behavior as well as his highly psychoanalytical writings.

Poe is foremost in American literature for using psychological abnormality in poetry and fiction. His poem "The Haunted Palace" (1839) symbolizes a deranged mind, and his most famous poem, "The Raven" (1845), presents a tormented narrator mourning the loss of his lover and imagining a dialogue with a fantasy bird. Among tales in which Poe uses insanity as a theme are "The Cask of Amontillado" (1846), "The Fall of the House of Usher" (1839), "The Black Cat" (1843), and "The Tell-Tale Heart" (1843). Without knowing the modern-day terminology for depression, Poe's unnamed narrator in "The Fall of the House of Usher" describes his friend Roderick Usher as "alternately vivacious and sullen" (p. 721), a clear example of bipolar disorder. As Roderick's mental state deteriorated, he "rocked from side to side with a gentle yet constant and uniform sway" (p. 729). Modern psychotherapists would view this action as part of the rapid cycling that signals the onset of a complete breakdown.

The narrator of "The Tell-Tale Heart" talks to investigating police after he has committed a senseless murder of an old man. He challenges the police: "How then am I mad? Hearken! and observe how healthily, how calmly, I can tell you the whole story" (p. 731). The narrator tells the police that "what you mistake for madness is but over-acuteness of the senses" (p. 731). The more he attempts to appear calm during the interrogation, the more excitable he becomes, especially as he thinks he hears the incessant beating of the heart of his victim lying beneath the boards of the floor. The only way the narrator can expiate himself of his intolerable guilt is to confess. The role of the police in this story is similar to that of a modern-day psychoanalyst. By allowing the narrator to tell his tale, to talk it out, the disturbed person arrives at his own cure: confession.

Because mental health—or mental illness, depending upon one's point of view—is part of the shared human experience, literature and madness have been intertwined since the earliest forms of storytelling, enriching generations of listeners and readers. In legends, folklore, mythology, and the Bible, evidence abounds that readers and writers have a continuing fascination with the abnormal and the inexplicable, a psychic belief in the supernatural, a fascination with the grotesque, and a respectful awe of the fearful aspects of the human psyche.

See also"The Fall of the House of Usher"; Leaves of Grass;Moby-Dick;Philosophy; Proslavery Writing; Psychology; "The Raven"; The Scarlet Letter;Science; Slavery

BIBLIOGRAPHY

Primary Works

Miller, Perry, ed. The Transcendentalists: An Anthology. Cambridge, Mass.: Harvard University Press, 1950.

Poe, Edgar Allan. "The Fall of the House of Usher." 1839. In The Norton Anthology of American Literature, edited by Nina Baym, shorter 5th ed. New York: Norton, 1999.

Poe, Edgar Allan. "The Tell-Tale Heart." 1843. In TheNorton Anthology of American Literature, edited by Nina Baym, shorter 5th ed. New York: Norton, 1999.

Secondary Works

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Hungerford, Edward. "Walt Whitman and His Chart of Bumps." American Literature 2 (1930–1931): 350–384.

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Shepard, Odell. Pedlar's Progress: The Life of Bronson Alcott. Boston: Little, Brown, 1937.

Trautmann, Joanne, ed. Healing Arts in Dialogue: Medicine and Literature. Carbondale: Southern Illinois University Press, 1981.

Philip W. Leon