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Carol D. Ryp Burton Singerb

a Department of Psycholow. university of ~isconsin:~adison,Wisc., Oflice of Population Research, Princeton University,Princeton, N.J., USA

Special Article

Psychother Psychosom 1996;65: 14-23

PsychologicalWell-Being:

Meaning, Measurement, and implicationsfor Psychotherapy Research

Key Words

Self-acceptance Purpose in life Positive relationships Personal growth Autonomy Environmental mastery . Sociodemographicdifferences Vulnerability Resilience Quality of life

Abstract

A model of positive psychological functioning that emerges from diverse domains of theory and philosophy is presented. Six key dimensionsof wellness are defined, and empirical research summarizing their empirical translation and sociodemographic correlates is presented. Variations in well-being are explored via studies of discrete life events and enduring human experiences. Life histories of the psychologically vulnerable and resilient, defined via the cross-classification of depression and well-being, are summarized. Implica- tions of the focus on positive functioning for research on psychotherapy, quali- ty of life, and mindlbody linkages are reviewed.

Introduction

Historically, mental health research is dramatically weighted on the side of psychological dysfunction.That is, studies of positive psychological functioning are minus- cule compared to investigations of mental problems. In fact, the meaning of basic terms, such as mental health, are negatively biased - typical usage equates health with

the absence of illness rather than the presence of wellness.

Such formulationsignore human capacities and needs for flourishing as well as the protective features associated with being well. This article summarizes the development of a multidi- mensional model of positive psychological functioning and reviewsempiricalresearch folllowingfroni it. The key components of well-being are first presented, with empha- sis given to their theoretical and philosophical underpin- nings. Operational definitions of the six dimensions are provided, and empirical research regarding their mea-

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surement properties and sociodemographic correlates is briefly described. Life event and life history studies attempting to explain variations in well-being are also reviewed. Pertinent to psychotherapy research, final sec- tions examine the implications of a focus on well-being for studies of vulnerability to psychological dysfunction, re- covery from psychological disorders (resilience),and the need to expand quality of life indicators to include assess- ment of the positive in people's lives.

The Meaning and Measurement of Well-Being

An extensive theoretical literature has addressed the meaning of positive psychological functioning. This work includes Maslow's [I] conception of self-actualization Roger's [2] view of the fully functioning person, Jung's [3, 41 formulation of individuation, and Allport's [5]concep tion of maturity. A further domain of theory for defining

Carol D. Ryff, PhD

Instituteor Aging 2245 Medical SciencesCenter 1300 Un~versityAvenue Mad~son,WI 53706 (USA)

psychological well-being comes from life-span develop mental perspectives, which emphasize the differing chal- lenges confronted at various phases of the life cycle. Included here are Erikson's [6] psychosocial stage model, Buhler's [7, 81 basic life tendencies that work toward the fulfillment of life and Neugarten's [9,101 descriptions of personality change in adulthood and old age. Jahoda's [I I] positive criteria of mental health, generated to re- place definitions of well-being as the absence of illness, also offer extensive descriptions of what it means to be in good psychological health. When one reviews the characteristics of well-being described in these formulations [12], it becomes apparent that many theorists were writing about similar features of positive psychological functioning. These points of con- vergence in the prior theories constitute the core dimen- sions of the model of well-being pursued in the following program of research. Each dimension is briefly described below. SelfAcceptance. The most recurrent criterion of well- being evident in the previous perspectives is the individu- al's sense of self-acceptance. This is defined as a central feature of mental health as well as characteristic of self- actualization, optimal functioning, and maturity. Life span theories also emphasize acceptance of one's self and one's past life. Thus, holding positive attitudes toward oneself emerges as a central characteristic of positive psy- chological functioning. Positive Relations with Others. Many of the preceding theories emphasize the importance of warm, trusting interpersonal relations. The ability to love is viewed as a central component of mental health. Self-actualizers are described as having strong feelings of empathy and affec- ton for all human beings and as being capable of greater love, deeper friendship, and more complete identification with others. Warm relating to others is posed as a criterion of maturity. Adult developmental stage theories also em- phasize the achievement of close unions with others (inti- macy) and the guidance and direction of others (genera- tivity). Thus, the importance of positive relations with others is repeatedly stressed in conceptions of psychologi- I cal well-being. I Autonomy. There is considerable emphasis in the prior literature on such qualities as self-determination, inde-

I pendence, and the regulation of behavior from within. Self-actualizers are described as showing autonomous functioning and resistance to enculturation. The fully functioning person is described as having an internal locus of evaluation, whereby one does not look to others for approval, but evaluates oneself by personal standards.

PsychologicalWell-Being:Meaning, Measurement,and Implicationsfor Psychotherapy Research

Individuation is seen to involve a deliverance from con- vention, in which the person no longer clings to the collec- tive fears, beliefs, and laws of the masses. The process of turning inward in the later years is also seen by life-span developmentalists to give the person a sense of freedom from the norms governing everyday life. Environmental Mastery. The individual's ability to choose or create environments suitable to his or her psy- chic conditions is defined as a characteristic of mental health. Maturity is seen to require participation in a sig- nificant sphere of activity outside of oneself. Life-span development is described as requiring the ability to ma- nipulate and control complex environments. These theo- ries emphasize one's ability to advance in the world and change it creatively through physical or mental activities. Successful aging also emphasizes the extent to which the individual takes advantage of environmental opportuni- ties. These combined perspectives suggest that active par- ticipation in and mastery of the environment are key ingredients in an integrated framework of positive psy- chologicalfunctioning. Purpose in Life. Mental health is defined to include beliefs that give one the feeling that there is purpose and meaning to life. The definition of maturity also empha- sizes clear comprehension of life's purpose, a sense of directedness, and intentionality. The life-span develop ment theories refer to a variety of changing purposes or goals in life, such as being productive and creative or achieving emotional integration in later life. Thus, one who functions positively has goals, intentions, and a sense of direction, all of which contribute to the feeling that life is meaningful. Personal Growth. Optimal psychological functioning requires not only that one achieve the prior characteris- tics, but also that one continue to develop one's potential, to grow and expand as a person. The need to actualize oneself and realize one's potential is central to clinical perspectives on personal growth. Opennessto experience, for example, is a key characteristic of the fully functioning person. Such an individual is continually developing, rather than achieving a fixed state wherein all problems are solved. Life-span theories also give explicit emphasis to continued growth and to facing new challengesto tasks at different periods of life. Thus, continued growth and self-realization are prominent themes in the aforemen- tioned theories. In sum, the integration of mental health, clinical, and life-span developmental theories points to multiple con- verging aspects of positive psychological functioning. Conceptually, these criteria are distinct from prominent

Psychother Psychosom 1996;65:14-23

15

empirical indicators of well-being such as happiness and life satisfaction (13, 141, most of which lack theoretical foundation.There are, however,notable parallels between the formulation of wellness emerging from the literature and philosophical perspectives on the meaning of 'the good life' [IS]. Diverse philosophical frameworks give emphasisto the individual's potential to choose and then carry out projects that are valuable; that is, to have active pursuits that give life dignity [16-181, akin to the above formulation of a purpose in life. Mastery is also evident in philosophical descriptions of self-command, which in- volve decision-making and taking action. Ideas of self- love, self-esteem, and self-respect are also evident in lists of criteria1 goods [16], showing parallels to self-accep tance. Philosophicalwriting about benevolence, involving the concern and affection one feels for others [I61, com- panionship [18], love [17], and deep personal relations [19] underscore the importance of positive relations with others. The dimension of personal growth parallels Aristo- telian conceptions of human excellence, human flourish- ing, and the realization of one's true potential [20]. Eudai- monistic accounts of ethics and the good life [2 11point, in fact, to the imperativeto know onself (one's daimon) and to choose to turn it, as completely as possible, from an ideal to an actuality. Finally, philosophers emphasize a focus on whole lives, that is, the importance of looking at all aspects of an individual's life through time - an argu- ment elaborated in a long succession of texts on the histo- ry of ethics [16]. Definitions of the good life that emphasize happiness, pleasure, and satisfaction (more hedonistic and epicurean views) have been criticized by philosophers, using well- known historical figures who experienced pleasure in their lives, but were so unjust, evil, or pointless in the pur- suit of their lives as to preclude a description of being good. Alternatively, other historical figures led desolate lives in terms of personal well-being, but were nonetheless profoundly noble, creative, courageous, self-sacrificial 1161. John Stuart Mill [22] extends the critique of happi- ness, arguing that it is not to be attained if made an end in itself. It is rather a byproduct of other pursuits - 'Those only are happy who have their minds fixed on someobject other than their own happiness, on the happiness of oth- ers, on the improvement of mankind, even on some art or pursuit, followed not as a means, but as itself in ideal end. Aiming thus at something else, they find happiness by the way [p. 1151. Taken together, these many lines of philosophical and scientific inquiry converge in their depiction of the good and healthy life as one that involves processes of setting

16 Psychother Psychosom

1996;65:14-23

and pursuing goals, attempting to realize one's potential, experiencing deep connections to others, managing sur- rounding demands and opportunities, exercising self- direction, and possessing positive self-regard. We posit that such features of human wellness are not culture- bound, although their phenotypic forms (i.e., how pur- pose is expressed),and the relative emphasis given to dif- ferent components, may be quite varied. Life purpose in Africa, as we have described elsewhere [15], may be expressed with a focus on maintaining the social order, in contrast to more individualized pursuits in our own con- text. Similarly, people everywhere have abiding needs for deep, meaningful connectionsto others, although external manifestations of these social ties may vary from expres- sions of obligation and responsibility to experiences of companionship, intimacy, and love.

EmpiricalTranslation

Scale Construction and Evaluation. Self-descriptive

items were generated to operationalize both high and low scorers for each of the six dimensions of psychological well-being (table I). Extensive item analyses were con- ducted to refine the final measurement scales [23]. The 20-item parent scales demonstrate high internal consis- tency reliability (alpha range = 0.86-0.93) and temporal reliability (test-retest coefficients range from 0.81 to 0.88). The scales also correlated modestly and positively with existing measures of positive functioning (e.g. life satisfaction, affect balance, self-esteem, internal control) and negatively with extant measures of negative function- ing (e.g. depression, powerful others, control, chance con- trol), thereby demonstrating convergent and discriminant validity. Recent data from a national probability sample [24], using a dramatically reduced version of the well- being scales, supported, via confirmatory factor analyses, the hypothesized six-factor structure. Among the many descriptive questions that can be asked about well-being, we have addressed whether pro- files of positive functioning vary across the life course, whether men and women differ in basic dimensions of wellness, and whether well-being varies by social class sta- tus and acrosscultures. Age Differences. To explore differences, we have asked young, middle-aged and old adults to rate themselves on each of the dimensions of well-being [23,25,26]. Ratings from the original validation study revealed a diverse pat-

tern of cross-sectional differences (see top half of fig. 1).

Certain aspects of well-being, such

as environmental mas-

Table 1. Definitions of theory-guided dimensions of well-being

SelJ-acceptance

High scorer Possesses a positive attitude toward the self, acknowl-

edges and accepts multiple aspects of self including good and bad qualities; feels positive about past life Low scorer Feels dissatisfied with self; is disappointed with what has occurred in past life; is troubled about certain per- sonal qualities; wishes to be different than what he or she is

Positive relations with others

High scorer Has warm, satisfying, trusting relationships with oth- ers; is concerned about the welfare of others: capable of strong empathy, affection, and intimacy; understands give and take of human relationships Low scorer Has few close, trusting relationships with others; finds it difficult to be warm, open, and concerned about oth- ers; is isolated and frustrated in interpersonal relation- ships; not willing to make compromises to sustain

80

 

Young

Midlife

Older

l8117

9-

 

Young

Midlife

Older

Fig. 1. Significant age differences in the validation (a) and national (b) samples. Dimensions of well-being: = Positive rela- tions; A = personal growth; A = purpose in life; = environmental mastery; 0 = autonomy.

important ties with others

Autonomy

High scorer Is self-determining and independent; able to resist social pressures to think and act in certain ways: regu- lates behavior from within; evaluates self by personal standards Low scorer Is concerned about the expectations and evaluations of others; relies on judgments of others to make impor- tant decisions; conforms to social pressures to think and act in certain ways

Environmental mastery

High scorer Has a sense of mastery and competence in managing the environment; controls complex array of external activities; makes effective use of surrounding opportu- nities; able to choose or create contexts suitable to per- sonal needs and values Low scorer Has difficulty managing everyday affairs; feels unable to change or improve surrounding context; is unaware of surrounding opportunities; lacks sense of control over external world

Purpose in life

High scorer Has goals in life and a sense of directedness; feels there

-

is meaning to present and past life; holds beliefs that give life purpose; has aims and objectives for living Low scorer Lacks a sense of meaning in life; has few goals or aims, lacks sense of direction; does not see purpose in past life; has no outlooks or beliefs that give life meaning

Personal growth

High scorer Has a feeling of continued development; sees self as

growing and expanding; is open to new experiences; has sense of realizing his or her potential; sees im- provement in self and behavior over time; is changing

in ways that reflect more self-knowledge and effective- ness

Low scorer Has a sense

of personal stagnation;

improvement or expansion over time;

lack sense of feels bored and

tery and autonomy, showed incremental patterns with age, particularly from young adulthood to midlife. Other aspects, such as personal growth and purpose in life, showed decremental patterns, especially from midlife to old age. Still other aspects, notably positive relations with others and self-acceptance, showed no significant age dif- ferences across the three age periods and thus are not shown in the figure. Initial samples were based on com- munity volunteers, and as such, lacked generalizability. Data from a probability sample [24] further underscore the consistency of the cross-sectional age patterns (see lower portion of fig. 1).Environmental masterycontinued to show incremental patterns with age, purpose in life and

tudes or behaviors personal growth showed declines with aging, and self- acceptance revealed no age differences. For self-ratingsof

uninterested with life; feels unable to develop new atti-

Psychological Well-Being: Meaning, Measurement, and Implications for Psychotherapy Research

PsychotherPsychosom 1996;65:1423

17

autonomy and positive relations with others, the results across studies varied between no differences and incre- mental age patterns. Longitudinal studies are needed to clarify whether these age patterns reflect developmental changes or co- hort differences. Whatever the explanation, the recurring reports of lower self-ratings among older adults on pur- pose in life and personal growth warrants attention. These patterns point to possibly important psychological chal- lenges of later life, and related arguments that contempo- rary social structures lag behind the added years of life many people now enjoy. That is, opportunities for contin- ued growth and development and for meaningful experi- ence may be limited for current cohorts of older persons. An alternative hypothesis is that older persons place less value on personal growth and purpose in life than younger age groups. We have also had respondents rate their ideals of well-being, and these data challenge the notion that the aged no longer idealize continued self-development or purposeful living. Sex Differences. Across multiple datasets, we have found that women of all ages consistently rate themselves higher on positive relations with others than do men, and that women tend to score higher than men on personal growth. The remaining four aspects of psychological well- being have consistently shown no significant differences between men and women [25].These findingsare particu- larly relevant in light of prior mental health research, which repeatedly documents a higher incidence of certain psychological problems such as depressionamong women [27]. When the positive end of the mental health spectrum is considered,however, women are shown to have greater psychologicalstrength compared to men in certain aspects of well-being, and comparable profiles with regard to oth- er dimensions. To miss these findings is to tell an incom- plete story about the mental health of women. Class Differences.Whether socioeconomic status, typi- cally defined in terms of education, income, and occupa- tional standing, is linked with profiles of psychological well-being has been examined in the Wisconsin Longitu- dinal Study of educational and occupational attainment. Based on a sample of midlife adults who have been fol- lowed since their senior year in high school, the research shows higher profiles of well-being for those with higher educational attainment [28], with differences particularly evident for the dimensions of purpose in life and personal growth (for both men and women). Education remains strongly linked with well-being, even after controlling for prior life history variables (e.g., high school IQ; parental education, income, and occupational status). Higher well-

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being is also evident for those with higher occupational status [29]. Findings from The National Survey of Fami- lies and Households, a nationally representative US sam- ple, also show large education differences on all six mea- sures of well-being [30]. Viewed from the perspective of the growing scientific literature that links social class standing to health, these findingsindicate that lower posi- tions in the social order not only increase the likelihood of negative health outcomes, they also decrease the likeli- hood of positive well-being [311. We submit that the pres- ence of these goods in life affords important protective factors in the face of stress, challenge, and adversity, and for those lacking such goods, creates vulnerabilities. Cultural Differences. How culture bears on fundamen- tal conceptions of self, self-in-relation-to-others, and health is an increasingly prevalent theme in social scien- tific inquiry [28]. Much discussion involvescontrasts between individu- alisticlindependent cultures with those that are more col- lectivisticlinterdependent. These ideas suggest that more self-orientedaspects of well-being, such as self-acceptance or autonomy, may have greater salience in Western cul- tural contexts, while others-oriented dimensions of well- being, such as positive relations with others, might be of greater significance in Eastern, interdependent cultures. To examine these issues, self-reported psychological well- being was investigated in a midlife sample of US adults and a sociodemographically comparable sample of adults from South Korea [33]. It was found that, on the whole, Americans were much more likely to see positive qualities in themselves than Koreans, a finding consistent with formulations of un- derlying cultural variation in self-presentation (i.e., ten- dencies toward modesty in the East, proclivities for hono- rific self-evaluation in the West). Despite these main effects of culture, analyses within cultures revealed that Koreans, as predicted, showed highest self-ratings on the measure of positive relations with others, and lowest rat- ings for self-acceptance and personal growth. Among US respondents, personal growth was rated highest, especially for women, while autonomy, contrary to the purported emphasis on self-determination in our own culture, was rated lowest. Sex differences were the same in both cul- tures - women rated themselves significantly higher than men on positive relations with others and personal growth. Supportive of cultural similarities in basic fea- tures of wellness, qualitative data revealed themes of self- hood (e.g., self-realization, self-knowledge, self-reliance) as well as connection to others (e.g., faithfulness, responsi- bility, kindness, trust) in both Korean and US responses.

UnderstandingVariations in Well-Being

The above sociodemographic profiles point to social structural variations in psychological well-being. Prior research on subjective well-being [14] suggests that these broad factors, even in combination, rarely account for more than 10% of the variance in reports of happiness

and life satisfaction. We propose

does and does not possess high well-being requires closer examination of the actual substance of people's lives, that is, their life experiences.The findings from two avenues of empirical inquiry are briefly summarized. The first per- tains to studies of particular life events or experiences and their effects on well-being. The second addresses more complex life history analyses, and how they have been linked with psychological vulnerability and resilience.

Life Event/Experience Studies. In a series of studies,

that understanding who

we have investigated life experiences, and individuals' interpretations of these experiences, as key influences on psychological well-being [34-401. The experiences range from the having and raising of children, to growing up with an alcoholic parent, to health problems and reloca- tion experiences in later life. These experiences vary by their location in the life course, by the nature of the chal- lenge or task posed, and by their typicality (whether the experience is shared by many or few). Our formulation of how experiences are interpreted draws extensively on social psychological theory. For example, we are inter- ested in how people make sense of their life experiences by comparing themselves with others (social comparison processes), by evaluating the feedback they perceive from significant others (reflected appraisals), by their under- standing of the causes of their experiences (attributional processes), and by the importance they attach to such experiences (psychological centrality). Specific hypothe- ses regarding the influence of these interpretive processes on well-being outcomes are detailed in each study. Collectively,these investigations demonstrate that life experiences and how they are interpreted provide useful avenues for understanding human variations in well- being. The research on midlife parenting shows, for exam- ple, that considerable variance in adults' environmental mastery, purpose in life, self-acceptance,and depression is accounted for by parents' perceptions of how their grown children have 'turned out' and how these children compare with themselves. In later life, we have found that the physical health problems of aging women, combined with their assessments of how they compare with other older women, explain substantial variation in reports of personal growth, positive relations with others, autono-

Psychological Well-Being: Meaning, Measurement,and Implications for PsychotherapyResearch

my, depression, and anxiety. Importantly, this work shows that older women in poor physical health who engage in positive socialcomparison processes, have com- parable psychological well-being to that of women in good physical health. Our longitudinal research on community relocation among aging women shows how changes in central features of the self-concept can enhance well-being during a life transition. Thus, multiple experiences and diverse avenues for interpreting them point to gains or losses in psychological well-being through time.

Life History Agenda: Pathways to Vulnerability and

Resilience. The above works focus on particular life events or experiences and how they influence well-being. Individual's lives are, however, a composite of many events and experiences.To capture this richer, more com- plex set of antecedents, we are currently conducting life history research with the members of the Wisconsin Lon- gitudinal Study (WLS). We approach the life histories from the perspective of the limited differences theory [41], which emphasizes the events to which individuals are exposed over their lives and their reactions to these events. Over short time intervals, events and reactions to them produce small, or limited, differences in outcome measures. Such small differences tend to accumulate, however, and over the life course,these cumulative effects can substantiallyinfluence mental health. We elaborate and extend these conceptual principles in the WLS [42]. Key hypotheses are that: (a) adversity and its cumulation over time have negative metal health con- sequences; (b) advantage and its cumulation over time have positive mental health consequences; (c) reactions to adversity and advantage can heighten or reduce the im- pact of life experiences; (d) position in social hierarchies through time has consequences for mental health, and (e) social relationships can heighten or reduce the impact of life experiencesand enduring conditions. The life histo- ry data to which we apply these principles consist of 36 years of information regarding the respondents' family background, intelligence, adolescent aspirations and re- sources, education and training, job characteristics, mar- riage and parenting, social support and social participa- tion, health and health-related behaviors, social compari- sons, and acute events. Using the above conceptual guides, we examine the life histories of four specific mental health groups that emerge from the cross classification of positive and negative men- tal health indicators. The depressed/unwell are those with prior episode@)of major depression who also lack high psychological well-being (across the six dimensions).The healthy are those with high levels of well-being and who

Psychother Psychosom 1996;65:14-23

19

have no history of depression. The resilient are individu- als with a prior history of depression, but who report high current well-being. The vulnerableare those with no histo- ry of depression and who have low levels of well-being. Our methodology begins with detailed biographies of individuals and progressestoward a formulation of gener- ic life histories within each of these four groups (as well as separately for men and women) [43]. The central objec- tive of the life history analyses is to understand how a giv- en outcome (e.g., depression, resilience) came about; that is, what particular experiences of adversity, advantage, social position, and so on, are associated with each of the four mental health groups. Analyses to date have characterizedthe life histories of vulnerable men and resilient women [44]. Vulnerable men are distinguished from other men in the mental health typology by their low starting resources (family background) and persistently high work stress. These cumulative adversity factors are not offset by the presence of significant advantage experiences. With regard to so- cial orderings, these men tend to lack post high school education, are in consistently low-status jobs, and have low perceived success about their own lives. Finally, they tend to have little closeness with a spouse or confidante and have experienced conflictual relationships (some times because of drinking). Such profiles of negative cumulative experience provide a partial explanation for the men's lack of positive well-being in midlife. We pro- pose that the absence of positive 'goods' in these men's lives creates in them a vulnerability to possible future adversities, particularly those associated with aging pro- cesses. We will test such ideas as their mental and physical health is tracked through the transition to old age. Resilient women have lives that also include adversity, typically growing up with an alcoholic parent or exper- iencing early family deaths, but these women possess important factors of advantage (high IQ, high grades in high school, good physical health). With regard to social orderings, many have experienced upward mobility in the workplace and tend to have supervisory work status. Their social relationships are also frequently character- ized by closeness with a spouse or confidante as well as high participation in social organizations. We propose that the presence of these positive work and relational experiences have contributed to their high profiles of life purpose, mastery, growth, and quality connectionsto oth- ers. Further, we predict that such features of well-being will offer important protective resources as these women confront the vicissitudes of growing old.

20 Psychother Psychosom 1996;65:14-23

While not described here, we emphasize that our life history analyses elaborate within-group variability (e.g., different routes to resilience) as well as between-group dif-

ferences(e.g., how life histories of the healthy and vulner- able differ from those of the resilient). The larger aim is to utilize the tensions created by working simultaneously with thickly described, finely nuanced details of individu-

al lives and thinner, less textured summaries of groups of

lives. Other dialectics are embodied in the general ap proach as well, such as our efforts to work inductively up from the life history data and deductively down from the guiding principles, and back and forth between qualita- tive and quantitative data sources. These combined strat- egies, we believe, advance understanding of the diverse human pathways to psychological well-being, depression, resilience, and vulnerability.

Implications for Psychotherapy Research

What are the implications of the above program of research on largely healthy community and national Sam- ples for the study and treatment of mental disorders in clinical populations? Does the study of wellness offer any- thing of merit to those attempting to alleviate psychologi- cal distress and dysfunction? We propose four avenues of linkage. A first point pertains to the evaluation of treat-

ments, be they pharmacological or psychotherapeutic, for mental problems. To determine the effectiveness of such interventions, researchers often assess quality of life. Cur- rent and evolving indicators of quality of life [45,46] give emphasis to patients' self-reported problems or com- plaints across multiple domains (physical, cognitive, af- fective, social, economic). Much less attention is paid to their self-reported strengths or gains. Understanding the presence of the positive in patients' lives provides a more completepicture of their overall functioning,and thereby,

a more comprehensive analysis of treatment effective-

ness. Interventions that bring the person out of negative functioning into a neutral position are one form of suc- cess. Facilitating progressions toward restoration of the

positive (e.g., possessing mastery, self-regard, purpose, quality relations) is quite another. Second, knowledge of psychological well-being pro- vides insight and direction regarding the factors that

influence the occurrence of mental disorders. Etiologically

speaking, most formulations include both genetic and enviromental influences. The latter are frequently con- strued in terms of life stresses in the workplace, the home, the neighborhood,or community. An underlying assump

*

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tion is that the presence of such adversity is part of what contributes to the incidence of depression, anxiety, and other disorders. Recognition of the positive in human experience suggests another etiological route: that the absence ofgoods in people's lives may also affect why they become despondent about their lives. Viewed in this light, the explanatory task is broadened to encompass how the presence of the negative as well as the absence of the posi- tive work together to influence mental health. Such a dual emphasis has further implications for understanding recovery from psychological dysfunction [47]. Feelings of mastery and self-regard,the possession of quality relations with others, the capacity to set goals for living, and a sense of self-realization may play critical roles in the process of regaining mental health. Again, the message is that the route to recovery is not exclusively about alleviatingthe negative, but about engenderingthe positive. It may be the appearance (or reappearance) of such salubriousgoods in life that provides a critical impe- tus in the capacity to rebound from distress. Recognition of these pluses may also define important protective fac- tors in the face of future challengesand adversity. Our lifehistory studies giveemphasis to understanding

the cumulation of adversity and advantage experiences

from the distant past. Psychotherapy, particularly in the psychoanalytic tradition, emphasizesthe need to examine critical experiences from early childhood, although the focus is primarily on negative, traumatic events. We pro- pose that there is much to be gained in therapeutic con- texts from investigating lives of the mentally healthy and the resilient. Our data show that among the healthy are individuals who have experienced considerable adversity over the course of their lives. Understanding the factors that protect them from becoming physically or mentally ill provides critical preventive knowledge. Such factors, we note, are not restricted to early life events, nor are they limited to experiences in the family sphere (i.e., adult experiences, including those in work and community con- texts are also relevant). The lives of the resilient convey further important information about factors involved in the recovery from depression. In sum, life history data about the healthy, the distressed, and those who traverse both realms over the course of their lives enriches think- ing about relevant influences and targets in the treatment of mental illness.

Psychological Well-Being: Meaning, Measurement, and Implications for Psychotherapy Research

Future Studies of Well-Being:

The Connection of Mind and Body

A final implication of the study of well-being is that knowledge of positive mental health poses new directions for age-old quandaries about how the mind and body are connected. Existing knowledge of physical health, like mental health, is dramatically skewed toward the nega- tive, focusing almost entirely on indicators of disease, chronic conditions, functional impairment, and general dysfunction. Building on theoretical and empirical work summarized herein, we reconfigure the meaning of posi- tive human health and suggest new scientific agendas regarding the physiological substrates of human flourish- ing [15]. The challenge in such future inquiries is to map the biochemical and neurophysiological underpinnings of positive mental states; that is, what occurs in the body when the mind is actively engaged in meaningful pursuits, quality relationships, and salubrious self-regard. Animal and human literature on stress demonstrates extensive links of mental perceptions and behavioral responses to stress with physiological and biochemical processes, and ultimately neuroendocrine, immune and autonomic systems tied to disease outcomes [42]. McEw- en and Stellar [48] propose, for example, that a high 'allo- static load' (i.e., the strain on multiple organs and tissues resulting from repeated fluctuations in physiological re- sponse to perceived threat) leads to organ-system break- down, compromised immune response, elevated cortisol and insulin secretion, and thereby,todisease. The impact of stress on biological function is not, however, explained in strictly physical terms, but involves emotions, thoughts, and an array of psychological factors. Mood states associated with depression illustrate this linkage via dysregulation of the pituitary-adrenal system and chroni- cally elevated levels of glucocorticoids in the blood [49]. Generally missing in this prior literature is the positive counterpoint in mindlbody research, although there are glimmers in the direction of beneficial connections. For example, while overshadowed by the pervasive focus on negative emotions and immune responsiveness, there is a growing body of work on positive emotions and immune modulation [50]. Included are studies that demonstrate links between positive feelings and spontaneous remis- sions of cancers, intensive daily meditation and regres- sion of metastatic sarcomas, positive life outlooks and wound healing, quality social relationships and increased survival from cancer. Such investigations underscore the power of positive beliefs, emotions, and relationships in recovery from physical health challenges.

Psychother Psychosom 1996;65:14-23

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Positive experience, we assert, plays further, perhaps more important roles in protecting and enhancing the integrity of the organism. Optimal human functioning, embodied by individuals who lead lives of purpose, pos- sess deeply felt and meaningful ties to others, exercise mastery over their environments, engage and realize their true capacities,has, in short, its own biological underpin- nings. These are the least understood of the mindhody connections, but again there are hopeful signson the hori- zon. Research on the transformation from rural to urban industrial society indicates that a purpose in life, stable social relations and social position, and individual moti- vation provide protection against excessive neuroendo- crine response [511. While such radical social changes dis- rupt familiar environments and pose new demands, those with positive social and psychological assets are buffered against emotional upheavals and ensuing neuroendocrine disturbances involving release of catecholamines, or corti- coids, or both, that may eventuate in cardiovascular and coronary heart disease. The benefits of social assets also appear in church societies such as monastic orders and other religious groups showing a lower incidence of coronary heart dis- ease. The stable, orderly life of these societies successfully blunts potentially harmful psychosocial stimuli, thereby maintaining the intensity of neuroendocrine responses below levels that would lead to pathophysiologic change [52]. Meditation and prayer activities play further physio- logically protective roles by leading to reduced oxygen consumption, heart rate, and blood pressure, all conse- quences of reduced activity of the sympathetic nervous systems. Interestingly, the incidence of coronary heart dis- ease is much lower in cloistered Benedictine Brothers than in Benedictine Priests who eat the same food at refectory tables (i.e., dietary control) [53]. The Priests' parochial and teaching duties in a competitive environ- ment were seen to produce Type A persons in Type A environments. Evolutionary perspectives emphasize the prepro- grammed 'biogrammar' that governs flexible behavior used to attain desired goals [54]. This biogrammar is seen as a vital but prerational element of behavior dependent on subcortical structures. The limbic and striatal regions of the brain are the locus for neuronal complexes mediat- ing the emotions and behavior critical for self- and species preservation [55]. These complexesare the result of genet- ically determined wiring and result in the organism engag- ing in territorial and attachment behavior appropriate for the occasion. Illustratingsuch substrates, neuroendocrine changes associated with the mother's care of her young

22 Psychother Psychosom 1996;65:14-23

shift abruptly when patterns of the attachment bond are disrupted. In man, attachment behavior persists for years after the young have become self-sufficientand with mod- ifications by symbolism motivates a lifetime of socialized behavior [56]. Positive psychological functioning, exemplified by the acquisition of mastery over the environment, possession of quality relations with others, utilization of innate capa- bilities, etc., represents elaborated versions of complex adaptive behaviors requisite to survival. These latter re- finements, like their evolutionary predecessors (e.g., terri- torial protection, caring for the young), have behavioral components, mental components, and underlying physio- logical profiles. Modem day science provides unprece- dented opportunities thus to map these multiple facets of healthy, adaptive functioning. Viewed from the vantage points of psychiatry and psychotherapy, well-established practice treats mental and behavioral problemswith phar- macological agents intended to alter the chemistry of the brain. Mindhody connections, in short, are far from nov- el in the clinical context. What is innovative is the call to shift the treatment focus to that of fostering positive human experience,which sets in motion its own biochem- istry. Quality ties to others, feelings of purpose and self- realization engender unique mindlbody spirals, but un- like those in the realm of stress, these move toward protec- tion and enhancement of the organism.

Acknowledgements

This research was supported by the John D. and Catherine T. MacArthur Foundation Research Network on Successful Midlife Development and a grant from the National Institute on Aging (lROlAG08979) (C.D.R.)and the MacArthur Foundation planning initiative and Socioeconomic Statusand Health (B.S.).

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