Instead of focusing all the time on mental illness, sometimes it pays in psychiatry to study the lives of people who are well. Long ago, the Harvard Study of Adult development set out to do just that. And now, having followed the physical and mental health of its subjects prospectively for 7 decades, it’s beginning to offer some new insights into health and development in aging. This study is the life work of psychiatrist George Vaillant (see his book on the study, Aging Well, Little Brown, 2003). The study sample is made up of 3 cohorts — 268 Harvard graduates born around 1920; 456 socially disadvantaged Inner City men born around 1930; 90 middle class, intellectually gifted women born about 1910. The data included regular questionnaires, repeated in-depth interviews with psychiatric clinicians, and physical examinations.

One important finding is that bad events seemed to be less determinative of outcome in life than the presence of good people who can offer love and support. In many instances such connections appeared to be crucial. Related to this was the capacity to love and to feel gratitude or forgiveness. A good marriage at 50 predicted positive aging at 80. Conversely, alcohol abuse predicted unsuccessful aging in all cohorts. Objective physical health was less important than subjective good health — you might be ill but if you don’t feel sick, good adaptation is possible.

Improving with age

Research into adult development has consistently found that many people show increases in 3 broad components of their personality related to social functioning as they age — self-confidence, interpersonal warmth and the ability to be outgoing. Many people continue their emotional growth into old age. Erik Erikson identified the adolescent’s task as developing Identity; the young adult’s task as growing toward Intimacy and Career Consolidation. In later life, the mastery of Generativity (concern for younger people and nurturing of their development) and the capacity of being The Keeper of the Meaning (preserving and teaching about past and tradition) become important. Maintaining a sense of Integrity throughout the years of aging was Erikson’s final developmental challenge.

The quality of childhood was an important factor in predicting college age adjustment and adjustment in mid-life. Those who were loved as children were able to develop trust, a sense of self and hope along with the capacity to forge new relationships. A good childhood predicted high income later; but a bad one did not predict the outcome of the person’s future life. By old age, the effects of childhood in this study faded — a bleak childhood did not predict a miserable old age.

Looking at 2 extreme outcomes in old age — the Happy-Well and the Sad-Sick — Vaillant found 7 key independent predictors of healthy mental and physical aging.

Never smoking or stopping smoking before age 45 was very important.

Adaptive coping style — the capacity to “make lemonade out of life’s lemons” and to not make mountains out of molehills was also prominent.

The following also play a significant role:

• Absence of alcohol abuse
• A healthy weight
• A stable marriage
• Having some exercise throughout life
• Years of education

Coping mechanisms

The predictors of success in long-term psychotherapy often have more to do with patients’ strengths than with their particular pathology. This study shows that such strengths can often overcome early adversity. Coping mechanisms, also known as defenses, can be changed through psychotherapy. Less adaptive defenses interfere with perception of reality. For example, projection attributes disowned feelings (often aggressive or sexual); acting out leads to destructive behaviours; absorption in fantasy leads to avoidance and nonengagement with life. The more adaptive defenses include altruism, humour (affiliative, not hostile) and suppression (setting a need aside to achieve an end — like studying for an exam).

Vaillant’s work showed that the defensive style of many subjects became more adaptive as they grew older. Those who continued to use immature defenses usually had more social difficulties and ultimately had more trouble adapting to life. There’s good evidence that psychotherapy can help people change their defensive style, improving their relationships. It’s tempting to think that psychotherapy earlier in life can help adaptation in middle life and old age.