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Spring 2001
Volume 00, Number 2

Newsletter on Philosophy and Medicine

Papers, Poems and Narratives

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The Concept of Mental Health

George Englebretsen
Bishop's Universit

genglebr@ubishops.ca

What indeed is "mental health"? Who indeed is "normal"?

Robert Coles

Over this past century psychologists and psychiatric therapists have happily supplied us with an ever-expanding vocabulary of pejorative labels for an ever-widening range of personal traits, tendencies, and behaviors. The only thing that distinguishes this vocabulary from more traditional kinds of vituperative, execratory censure is that it has been coined in seminar rooms and lecture halls rather than in the streets. It carries, since this kind of stuff is taken by the general public to be a science, the stamp of "science," providing it with a kind of self-licencing authority. In earlier times the church had supplied the more exalted vocabulary of personal critique; now a social science does the job. At any rate, an entire new industry and bureaucracy has been built-up around the new branch of medicine-psychiatry. Health care is big business; mental health care is a big part of it. No longer do we hide away the unfortunate who suffer from mental "diseases." Nor do we still display them for our own entertainment. Now we treat them. Since there are mental diseases there must be mental doctors and mental hospitals for their humane treatment. And since our natural inclination is to devote resources to those most obviously in need, we tend to provide what we can (or are at least willing to) bear for the treatment of bodily diseases like cancer and heart disease. Consequently, in order to guarantee its share of the pie, the mental health community provides us every few years with a new (dare I say 'designer') disease of its own-multiple-personality-disorder, repressed memory, and so on. In spite of the fact that for nearly forty years a number of people, most prominent among them being the well-known psychiatrist Thomas Szasz, have shown clearly that mental hospitals have become little more than warehouses for the elderly, the uneducated, the criminal, and the unwanted; that mental illness is, to put it simply, something 'manufactured' by the mental health professional; that, indeed, mental illness is a myth, the industry thrives and grows.

As a philosopher I am happily free from any responsibility for this (as I am also immune to any honors that may come from engaging in any kind of science). What I am responsible for is the clarification and ordering of concepts. Coles put quotes around "mental health" not because he was interested in the words per se, but because he was interested in the concept they express. Just what is that concept? Well, as a starter, we might say that just as the Scholastic theologians thought of good as the absence of evil we can take the concept of mental health as the concept of a general mental condition in which disease is absent. So, obviously, the salient issue is how to account for the concept of mental illness/disease. In getting clear about concepts it is usually a good idea to get clear first about just what sorts of things those concepts can be sensibly applied to. We apply a concept to a thing by predicating a term of it. Consider the concept of rationality. We apply it to persons by saying certain things (e.g., 'John is rational,' 'Sarah is acting more rationally than Tom,'). But we also predicate terms such as 'rational' to numbers ('2 is both prime and rational,'). Does this mean that there are two concepts of rationality, one applied to persons and another applied to numbers? In other words, is the predicate term 'rational' ambiguous (able to be used to express more than one concept)? Or, if there is but a single concept of rationality, does this mean that persons and numbers are more alike than we thought?

Now consider the concept of disease. Bodies can be diseased, so we clearly apply the concept of disease to them. If minds are also diseased, is it the same concept of disease that is being applied in both cases? Is 'disease' ambiguous over minds and bodies? If not, then does this mean that minds are more like bodies than we thought? What is needed in such cases is a bit of conceptual cartography. We need some principles for mapping out the ways in which concepts are used and how they relate to one another. Armed with a principle for conceptual mapping we can apply it to the concept or concepts that interest us. As I see it, the key concepts here are those of person, mind, body, and disease. So where do we find our conceptual cartographer?

Half a century ago Gilbert Ryle saw the need to do conceptual cartography. He even forged, in a fairly informal way, a principle for doing so. Ryle's principle was simple: Any term that is predicable of two things, which themselves belong to different categories, must be ambiguous. If it is not, then the two things must actually belong to the same category. Ryle believed that one would commit a 'category mistake' by applying a concept to pairs of hetero-typical things (things belonging to separate categories). Moreover, he took bodies and Cartesian egos/minds to belong to separate categories so that to say of both that they exist is to commit a "big category mistake." (We need not pause now over just what Ryle meant by "predicate," "category," or "category mistake.") But does Ryle's Rule work? It certainly seems to in a case such as the one involving 'rational.' The term is predicated of both a person and a number; persons and numbers surely belong to distinct categories; therefore 'rational' is ambiguous. And it seems to work in the case of "weighs more than 100 kilos" as applied to both Sarah and her luggage. Persons and luggage must belong to a common category since "weighs more than 100 kilos" applies to both and is not ambiguous (otherwise we couldn't weigh people and suitcases on the same scale). But does the rule always work? If not, then it's not a rule after all. And the fact is there are counter-examples to Ryle's Rule. Agreeing that persons and numbers belong to different categories, we nonetheless predicate of each such terms as "was mentioned by Wittgenstein" and "puzzled Sartre." Yet surely it would be counter-intuitive to insist that such terms are ambiguous. Compare: "Tom is more rational than 2" and "Sartre was more puzzled by people than by numbers," the first of which is pure nonsense while the latter makes quite good sense.

Ryle saw the need for conceptual cartography, but his rule didn't work. Still, it worked sometimes. It seems right to hold, as he did, that there is an intimate connection between category difference or sameness and predication. In the 60s and 70s the American philosopher Fred Sommers replaced Ryle's Rule with his own, and in so doing gave us the tools required to analyze our cluster of concepts (person, mind, body, disease).1 Sommers's rule is formulated in terms of the "spanning" relation between a term and an object, where spanning is meant to be more precise than Ryle's notion of predication. A term, P, is said to span an object, a, if and only if affirming or denying either P or its logical contrary (negation), non-P of A would not be prima facie nonsense. Thus, "The moon is purple," "The moon is non-purple (i.e., red, green, pink,...), "The moon isn't purple," "The moon isn't non-purple," and the like, are all sensible (though not all are true). On the other hand, "The moon is envious," or "The moon isn't married" are nonsense-category mistakes. A category of objects is a set, all of whose members are spanned by a given term. So a category is always determined relative to a given term. To apply a term to an object not in the category determined by that term is to commit a category mistake. Sommers calls his rule the Rule for Enforcing Ambiguity. What the rule says is: Given any two terms, P and Q, and three objects, a, b,and c, such that P spans a and b but not c and Q spans b and c but not a, either P is ambiguous over a and b, or Q is ambiguous over b and c, or there is no a, or there is no b, or there is no c, or c is spanned by P or a is spanned by Q.2 The best way to understand this rule, and to see how is relates to Ryle's Rule, is to diagram it. Using lines to indicate the spanning relations, we can depict the rule as follows:

P Q
/ \ / \
a b c

In effect, the rule is a negation; it rules out any theory that would allow the above situation. Sommers calls such a theory ontologically incoherent (i.e., it commits a category mistake). To render it coherent one must either (i) make P ambiguous over a and b, (ii) make Q ambiguous over b and c, (iii) deny a, (iv) deny b, (v) deny c, (vi) put c in the category determined by P, or (vii) put a in the category determined by Q. Ryle's Rule could be diagrammed simply as:

P
/ \
a b

It says, in effect, that any theory that allows such a situation commits a category mistake and can be saved only by either (i) making P ambiguous, (ii) denying a, (iii) denying b, or (iv) putting a and b in the same category. Sommers's rule is more complex, but it can account for much more. How can it be used to shed light on our cluster of concepts (person, mind, body, disease)?

Consider the following set of two terms and three objects: "understands Hegel" "weighs more that 100 kilos" Tom's mind, Tom, Tom's body. Let us say that the first term spans the first two objects but not the third and that the second term spans the last two objects but not the first. In other words, the following incoherent theory:

'understanding...'    'weighs...'
/                \     /    \
mind               Tom    body

As we have seen, there are several routes to coherence. Some are unreasonable. For example, one would be reluctant to claim that 'weighs 100 kilos' is ambiguous. Aquinas thought we could make terms such as 'understands Hegel' ambiguous over us and God. We could follow his lead and take such terms to be ambiguous over persons and minds. But Aquinas had theological reasons for enforcing his ambiguity, we seem to have none. We could be Cartesian dualists and deny Tom (he is just a composite of his mind and his body. We could be idealists and deny bodies. Or, like Ryle, we could deny minds (they are mythical ghosts). Let's reserve judgment for now.

Next, consider the following set: 'diseased', 'purple', Tom's mind, Tom's body, Tom's house. Let us, again, say that the first term spans the first two objects but not the third and that the second term spans the last two objects but not the first. Thus:

'diseased'    'purple'
/     \    /   \
    mind    body    house

Again, some options for achieving coherence are not viable. We do not want to make 'purple' ambiguous over bodies and buildings. Nor would we be willing, unless we are radical idealists, to deny either such kind of objects. We certainly would not want to put minds in the same category with bodies (doing so would mean taking sentences like 'Tom's mind is purple' to make sense). The only really viable choices are (a) deny minds or (b) accept that terms like 'diseased' (e.g, 'ill', 'healthy', 'well', 'sick') are ambiguous. Choosing (b) means giving up the disease model of psycho-pathology, the foundational theory for most of the mental health care industry. Notice that choosing (a) renders our first case (the one involving terms like 'understands' and 'weighs') coherent and does the same for the present case. Let us call this the strong choice. Choice (b) would be, then, a weak choice. In either case the disease model for psycho-pathology fails. If there are no minds, then there are no diseased (or healthy) minds. And even if there are minds, the concept of disease, as it applies to bodies, cannot be unambiguously applied to them. All other options seem less reasonable. Of course there is a meta-option: one might reject Sommers's rule by finding a counter-example to it (as in the case of Ryle's Rule). Thus far, no such examples have been found.3

I have assumed throughout this brief essay that a central task of philosophy is to seek a rational account of certain concepts and concept-clusters. Philosophers, especially analytic philosophers, have proffered a number of methods for arriving at such an account (e.g., logical analysis, attention to ordinary uses of terms). But the important point is that, at least until fairly recently, philosophers took it for granted that any account must be rational-to forgo reason is to turn away from philosophy (not to mention science) altogether. In recent years, however, the stench of French perfume has wafted through the halls of the academy and nonsense has become fashionable. The fad has spread from philosophy and literature through the humanities in general and into the social sciences and even the natural sciences. It may yet not have taken hold of medicine, but it has certainly warped the thinking of many who make decisions about how medical research money is spent.4 In the field of mental health care, on the other hand, the anti-realism, anti-rationalism, radical relativism that advertises itself as postmodern has been more successful. The new psychotherapy, eschewing the disease model, aims at treating the mental health patient not by helping the patient bring his or her distorted world-views into closer conformity with reality (there just is no such thing anyway) but by helping to validate (whatever that means, given that objective truth has gone the way of reality) the patient's own, unique world-view (=the patient's world/reality). The theory is "constructivist" in that it takes what is known to be an individual or social construct, in no way determined by an objective reality (if, indeed, there could even be a reason to posit such a thing). Here is a succinct statement of the new program for psychotherapy: "Like the broader postmodern zeitgeist from which it derives, constructivist psychotherapy is founded on a conceptual critique of objectivist epistemology. In particular, it offers an alternative conception of psychotherapy as the quest for a more viable personal knowledge, in a world that lacks the fixed referents provided by a directly knowable external reality."5

In the face of this new psychotherapy one finds oneself hungering for the old-fashioned, robust realism that was once a common property of all those who sought to get clear about the central concepts involved in the concept of mental illness-no matter which particular theory they happened to advance.

Notes

1. See especially: 'The Ordinary Language Tree,' Mind, 68 (1959) 160-185; 'Types and Ontology,' Philosophical Review, 72 (1963) 327-363 (reprinted in P.F. Strawson (ed), Philosophical Logic, 1967, Oxford: Oxford University Press); 'Predicability,' in M. Black (ed), Philosophy in America, Ithaca: Cornell University Press; 'Structural Ontology,' Philosophia, 1 (1971) 21-42; and chapter 13 of his The Logic of Natural Language, 1982, Oxford: Clarendon Press. A number of developmental psychologists have made use of Sommers's theory. See in particular: F.C. Keil, Semantic and Conceptual Development, 1979, Cambridge: Harvard University Press; F.C. Keil and M.H. Kelly, 'Theories of Constraints and Constraints on Theories,' in W. Demopoulos and A.Marras (eds), Language Learning and Concept Acquisition: Foundational Issues, 1986, Norwood, N.J.: Ablex Publishing; D.N. Osherson, 'Three Conditions on Conceptual Naturalness,' Cognition, 6 (1978), 263-289; I. Hacking, 'Working in a New World: The Taxonomic Solution,' in World Changes: Thomas Kuhn and the Nature of Science, P. Horwich (ed), 1993, Cambridge: The M.I.T. Press.

2. For a thorough discussion of the rule and its role in Sommers's general theory of conceptual cartography (which he calls the 'tree theory' because the structure of categories is tree-like) see the following by G. Englebretsen: 'La theorie des categories de Sommers: une nouvelle introduction,' Dialogue, 27 (1988) 451-473; and chapter 1 of his Essays on the Philosophy of Fred Sommers: In Logical Terms, 1990, Lewiston, N.Y.: Mellen.

3. Not that no one has tried. For rebuttals of such attempts see the following by G. Englebretsen: 'Elgood on Sommers' Rules of Sense,' Philosophical Quarterly, 21 (1971), 71-73; 'On the Nature of Sommers' Rule,' Mind, 80 (1972), 608-611; 'On van Straaten's Modification of Sommers' Rule,' Philosophical Studies, 23 (1972), 216-219;

4. See, for example, two critiques of this development: G. Weissmann, 'Sucking with Vampires: The Medicine of Unreason,' and W. Sampson, 'Antiscience Trends in the Rise of the "Alternative Medicine" Movement,' both in P.R. Gross, N. Levitt, and M.W. Lewis (eds), The Flight from Science and Reason, 1996, New York: New York Academy of Sciences.

5. R.A.. Neimeyer, 'An Appraisal of Constructivist Psychotherapies,' Journal of Consulting and Clinical Psychology, 61 (1993), 230. This passage is quoted in B.S. Held, 'Constructivism in Psychotherapy: Truth and Consequence,' in The Flight from Science and Reason. Held offers an especially clear critique of the new psychotherapy both here and in her book Back to Reality: A Cr Citique of Postmodern Theory in Psychotherapy, 1995, New York: W.W. Norton.

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APA Newsletters

Spring 2001 Volume 00, Number 2

Spring 2001
Volume 00, Number 2