CONCLUSION
After seventy-five years of collecting, analyzing, and reanalyzing our data on aging, what have we learned from all this? First, we’ve been reminded again and again that a strong association does not necessarily imply cause. Snow is associated with winter, but snow does not cause winter. Heavy smoking is strongly associated with fatal automobile accidents, but not because drivers take their eyes off the road to search for the cigarette lighter. The association is the result of a third factor—alcoholism, which very significantly increases the likelihood both of heavy smoking and of fatal accidents.39 The seventy-year duration of the Grant Study have been invaluable in allowing us to draw lines between causes and associations.
For example, there is a strong association between exercise and physical health, which most of us understand to mean that exercise causes good health.40 But might it not be the other way around? Healthy people enjoy exercise. Among the College sample, exercise at age sixty correlated more highly with health at age fifty-five than with health at eighty. Health at fifty very significantly predicted exercise at eighty, and health at sixty significantly predicted exercise at eighty. In other words, health predicted exercise at all ages, but exercise did not predict health in later years.
Admittedly, exercise at age thirty did significantly predict health at fifty-five and sixty, and exercise at sixty predicted health at age seventy through eighty-five, although not significantly. Presumably the exercise mavens must not be written off entirely. But it’s important to keep in mind—as the Museum of Science computer didn’t—that everything affects everything else, and that some things are horses and others are carts. When it comes to physical aging, alcohol abuse and education are looking more and more like horses. And, as Table 7.3 documents to my sorrow, after thirty years of betting the farm that maturity of defenses (the involuntary coping mechanisms that I’ll discuss in the next chapter), would be the horses that pull us to late-life physical health, longitudinal study has proved me wrong. He who lives by the sword dies by the sword.
Social supports are often assigned a causal role in successful aging. In his classic review of the evidence, however, sociologist James House acknowledged that almost no attention has been paid to social supports as a dependent variable.41 That is, social supports may be the result of the very variables that they are supposed to be causing. In the prolonged prospective view of the Grant Study, social supports at age seventy were strongly associated with the pre-age-fifty protective health factors identified in Table 7.2, yet only weakly associated with longevity (Table 7.3). In other words, good health predicts good social support better than good social support predicts future health. Indeed, good social supports in old age may be in large part a result of earlier habits that preserve physical health.42
There was a powerful association between the absence of cigarette and alcohol abuse before fifty and good social supports at seventy. Specifically, there were some with good supports among the Grant Study men who abused alcohol or cigarettes. There were also men with poor social supports but no tobacco or alcohol abuse. In these asymmetric pairs, the risky habits of alcohol and cigarette use were the horse, and social supports the cart. Study men with good social supports but risky habits suffered health just as poor as men with poor social supports and risky habits. Men with poor social supports but good habits enjoyed good health almost as often as men with good social supports and good habits.
My point here is not that love and exercise aren’t good for you. For most of us, the more social supports we have in our old age the happier we’ll be, and the more exercise we get the better we’ll feel and look. I only wish to underscore that the etiology of successful aging is multifactorial in ways that self-help books and cross-sectional studies do not necessarily take into account. Furthermore, the Grant Study demonstrates, if you follow lives long enough, the risk factors for healthy life adjustment change. There is an age to study the relation between mental and physical illness and an age to ignore it. There is an age to curse your arthritis and an age to appreciate it as the price of having survived to attend your granddaughter’s wedding.
Please note too that I report these contrary findings as an investigator who claimed in Chapter 1 that love is the root of all blessings, and who believed, and for many years tried to prove, that mental health caused physical health. I’ve had to give up on that second claim, alas; my own worldview is as vulnerable to the upheavals of longitudinal follow-up as anyone else’s. But I will retreat no farther than that. I am wiser than the Museum of Science computer, and I have grasped clearly that when it comes to healthy aging, everything really is connected to everything else. A happy old age requires both physical health and mental health. For mental health, love is a necessity. So is being alive. So is being able to think straight. We need physical and cognitive competence to build the social surrounds that give us love and support later on, and it is love and support that encourage us to care for ourselves well and keep ourselves healthy, even when the going gets rough. “Button Up Your Overcoat” isn’t so far off the mark after all. The ninety-year-olds of the Grant Study took good care of themselves and of their important relationships. And for the most part, they’ve been very happy to be alive.
8
RESILIENCE AND UNCONSCIOUS COPING
The mechanisms of defense serve the purpose of keeping off dangers. It cannot be disputed that they are successful in this; and it is doubtful whether the ego could do without them altogether during its development.
—SIGMUND FREUD
ONCE UPON A TIME at an amusement park in Florida, I watched some passengers (including my grandson) on a loop-the-loop roller-coaster. They gathered speed, swept up the curve, and hung suspended upside down at the top, waving their arms with excitement. I could see that for them the experience was one of ecstasy, exhilaration, and release. But it seemed to me that their elation, like the Ode to Joy of the angry and depressed Beethoven, reflected serious denial. For me, there would be nothing even remotely pleasurable in an experience like that. Just thinking about it I could feel the stress ulcering the lining of my stomach, upholstering the walls of my coronary arteries, and overwhelming my immune system with an avalanche of corticosteroids. A ride like that would take years off my life. But my grandson was over the moon.
By what alchemy had the brains of the laughing riders transformed into exaltation an experience that in me would evoke only misery and fear? It’s not that we understood the risks any differently, at least not cognitively. I know, after all, that most of the time nothing really bad happens in amusement parks. It’s not that the external physical stressors were any less for them than they’d be for me, dangling head down ten stories above the ground. Styles of conscious stress management don’t account for it either; there isn’t time for those. The difference is in the ways our individual minds work to convert a concrete situation into an experience of either excitement or terror. Who is sane and who is crazy—the excited teen or the cautious grandfather?
The Grant Study’s second lesson, and perhaps the one dearest to my heart, is that any exploration of the links between positive mental health and psychopathology requires an understanding of adaptive coping. As cough, pus, and pain remind us with disconcerting regularity, the processes of illness and the processes of healing look startlingly alike.
In this chapter, I will use the terms adaptation, resilience, coping, and defense interchangeably; likewise unconscious and involuntary. The study of psychological adaptive mechanisms began for me years before I became involved with the Grant Study. I had learned in an earlier longitudinal study to admire the means by which some people manage to achieve lasting remission from schizophrenia and heroin addiction. But I was not interested only in the resilience that comes with seeking social supports and devising ingenious conscious coping strategies. We’ve all got a few of those, and we know about them. I was interested in involuntary coping, analogous to the ways we clot our blood and send white cells out to fight infection. Or
transform terror, like my grandson did on that roller coaster.
What makes the study of defenses so fascinating is the ambiguity of the boundary between psychopathology and adaptation. Early nineteenth-century medical phenomenologists viewed pus, fever, pain, and cough as evidence of disease, but less than a century later their colleagues had learned to recognize these “symptoms” as involuntary efforts of the body to cope with mechanical or infectious insult. Similarly, psychological defense mechanisms produce behaviors that may appear pathological to others (or even at times to us), but in fact reflect efforts of the brain to cope with sudden changes in its internal or external environment without too much anxiety and depression.
We depend physiologically on multiple elaborate systems of homeostasis, the task of which is to buffer sudden change; we don’t faint when we stand up quickly, for example, because our bodies adjust our blood pressure to the demands of the new position. The task of the psychological homeostatic system that I am calling involuntary coping is to buffer sudden change in the four sources of mental conflict: relationships, emotions, conscience, and external reality. Defenses are extremely important to comfortable and effective functioning, like our other homeostatic systems. But they are difficult to study. They resemble hypnotic trance in that their use alters the perception of both internal and external reality, and may compromise other aspects of cognition as well.
Even after I got to the Study and the investigation of unconscious coping became a central focus of its research activities, we never applied for an NIMH grant to inquire into this phenomenon. In fact, from 1970 to 2000 defenses took a backseat when we asked for money. Times had changed since the days when psychoanalysts were influencing the research agenda of the NIMH, and by 1970, defenses were too unfashionable for NIMH support. Yet at the Study, we were finding that defensive style predicted the future as well as, if not better than, any other variable we possessed.
The scientific community was trying to do its job when it dismissed defense mechanisms as a holdover from the (now outmoded) metaphysics of psychoanalysis. Yet defenses are real enough. They’re elusive, yes, but not like fairies, yetis, and UFOs are elusive, and the other such will-o’-the-wisps that somehow always manage to elude our cameras. Defenses are more like rainbows and lightning and mirages—they’re fleeting, but they can be photographed, replicated, and, above all, explained.
It was the many decades of detailed Grant Study recording, like sequential photographs or the transcripts of a neutral observer, that allowed us to identify in real behavior coping measures that are usually invisible to their users. This was necessary, because defenses are unconscious and involuntary. If I say, “You’re projecting!” you will reply (probably angrily), “No, you’re projecting!” and an argument is on that even an outsider wouldn’t be able to resolve. A major contribution of the Grant Study, and one of its most appreciated results, has been to make the scientific study of defenses respectable.
WHAT ARE DEFENSES (INVOLUNTARY MENTAL COPING MECHANISMS)?
In 1856, Claude Bernard, a French physiologist and a founder of experimental medicine, started us on our way to understanding adaptation to stress when he wrote, “We shall never have a science of medicine as long as we separate the explanation of the pathological from the explanation of normal, vital phenomena.”1 Pus, cough, and fever are certainly unpleasant, and sometimes dangerous. But they can also be lifesaving; it is these superficially pathological homeostatic responses to physiological stress that in many cases permit us to survive it. In 1925, Adolph Meyer, a founder of modern American psychiatry and an early consultant to the Grant Study, believed that there were no mental diseases, only characteristic reactions to stress.2 He thought that while patterns of mental reaction like denial, phobias, and even the projections of the paranoid character may look like illness, they may in fact be examples of Bernard’s “normal, vital phenomena,” promoting adaptation, healing, or at least psychological time-out. Just as fever, clotting, and inflammation use mechanisms that disrupt ordinary bodily equilibriums to do their healing work, so defense mechanisms heal through characteristic disruption of ordinary mental processes.
Figure 8.1 The four sources of intrapsychic conflict.
As outlined in Figure 8.1, defenses deflect or deny sudden increases in emotional or biological intensity, such as the heightened aggression and sexual awareness of adolescence. Psychoanalysts call this source of conflict id, fundamentalists call it sin, and cognitive psychologists call it hot cognition. Neuroanatomists locate it in the hypothalamic and limbic regions of the brain.
Defenses also enable individuals to mitigate sudden upsurges in guilt, such as might occur when a child puts a parent into a nursing home. Psychoanalysts call this source of conflict superego, anthropologists call it taboo, behaviorists call it conditioning, and the rest of us call it conscience. Neuroanatomists point to the frontal lobe and the amygdala. Conscience is not only the result of admonitions from our parents absorbed before age five, or even of cultural identifications; it is also formed by evolution, and sometimes by the irreversible learning that results from overwhelming trauma.
Defenses can moderate sudden conflicts with important people, living or dead, and protect us from the vulnerability and intensity aroused by sudden changes in intimacy. When a business partner walks out; when a marriage proposal is accepted; when a beloved child receives a fatal diagnosis—situations like these make for anxiety, excitement, or depression that can feel unbearable. In an adolescent striving for identity, even parental love that was once accepted without ambivalence may be unconsciously distorted for a while to make room for psychological separation to take place.
Finally, defenses allow us a period of respite, when necessary, to master inescapable realities that cannot be integrated immediately. They provide a mental time-out without which the individual would become acutely anxious and depressed. That is what would have happened to me had I been so imprudent as to join my grandson on the roller coaster. The events of 9/11 demonstrated this dynamic on a very large scale; the change in self-image resulting from an amputation is a smaller-scale example.
Over a period of forty years, Freud discovered most of the involuntary coping mechanisms that we recognize today, and identified five of their important properties.3
• Defenses are a major means of mitigating the distressing effects of both intense emotion and cognitive dissonance.
• They are unconscious.
• They are discrete from one another.
• Although they may look like mental illness—sometimes like severe mental illness—defenses are dynamic and reversible.
• They are potentially as adaptive, even creative, as they are pathological.
I will add one last property to Freud’s list:
• To the user, defenses are invisible; to the observer, defenses usually appear as odd behavior.
In 1971 the Grant Study offered a hierarchy of defenses from the psychotic to the sublime.4 In 1977 and 1993, we were able to show, not just tell, how defenses worked.5 Over the last twenty years, Cramer, and Skodol and Perry, have reviewed several empirical studies investigating the clinical value of retrieving defenses from Freudian oblivion.6 As a result, the fourth diagnostic manual for the American Psychiatric Association (DSM-IV) finally organized defenses into a hierarchy of relative psychopathology similar to ours, and formally included it as an optional diagnostic axis.7
A HIERARCHY OF DEFENSES
All defenses can effectively minimize the experience of conflict, stress, and change, but they differ greatly in their consequences for long-term psychosocial adaptation. Here they are organized into four levels, from least to most mature.
The psychotic defenses include delusional projection, psychotic denial, and psychotic distortion. They involve significant denial and distortion of external reality. They are common in young children and in dreamers, as well as in psychosis. To alter them requires altering the brain—either by maturation, by waking, or by the use of n
euroleptic drugs.
The immature defenses include acting out, autistic fantasy, dissociation, hypochondriasis, passive aggression, and projection. Immature defenses externalize responsibility and are the building blocks of character disorders. They are familiar to most of us by observation. Immature defenses are like cigars in crowded elevators—they may feel innocent to the user, but observers often experience them as deliberately irritating and provocative. Defenses in this category rarely respond to verbal interpretation alone.
The intermediate defenses include displacement (kicking the dog instead of the boss), isolation of affect or intellectualization (separation of an idea from the emotions that go with it), reaction formation (turning the other cheek), and repression (keeping the affect visible but forgetting the idea that gave rise to it). Intermediate defenses keep potentially threatening ideas, feelings, memories, wishes, or fears out of awareness. They are frequently associated with anxiety disorders, but they are also part of the familiar psychopathology of everyday life, and they may be seen clinically in amnesias and in displacement phenomena like phobias, compulsions, obsessions, and somatizations. Intermediate defenses tend to be uncomfortable for their users, who may seek psychological help for that reason, and they respond more consistently than the lower-level defenses to psychotherapeutic interpretation. Intermediate defenses are common in everyone from the age of five until death.
The mature defenses include altruism, anticipation, humor, sublimation, and suppression. By allowing even anxiety-laden feelings and ideas to remain in awareness, they promote an optimum balance among conflicting motives and maximize the possibility of gratification in complicated situations. Altruism (doing as one would be done by), anticipation (keeping future pain in awareness), humor (managing not to take oneself too seriously), sublimation (finding gratifying alternatives), suppression (keeping a stiff upper lip) are the very stuff of which positive mental health is made. Although they may appear to be under conscious control, unfortunately they cannot be achieved by willpower alone; just try to be really funny on demand. Furthermore, their deployment must be facilitated by others who provide empathy, safety, and example. If Gandhi had lived under Hitler instead of Churchill, he would have been a victim, not a hero.
Triumphs of Experience: The Men of the Harvard Grant Study Page 26