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by Per-Anders Tengland
Kluwer Academic, 2001
Review by Aleksandar Dimitrijevic on Sep 8th 2003

Mental Health

The book published by Kluwer Academic Publishers is Per-Anders Tengland's PhD dissertation.  Therefore, a part of it is highly predictable.  Organized in nine chapters, it contains everything a work of this kind should: Introduction to the problem, Forschung Geschichte, analysis of the main problem, and conclusions.  Still, the book is not that predictable in the contents of each of these parts.  Though they seem not to be of equal quality, some parts are very provocative for a practitioner in the field of mental health.  But the book's subtitle is very important, or a future reader could be misled. This is a book of philosophical analysis, and a contribution to a growing field of philosophical psychopathology.  Moreover, it is one of a small number of books dedicated to analysis of the very concept of mental health.

Although the title does not indicate so, "the main purpose of the book is to find defining characteristics of positive mental health" (p. 4).  Since this concept was first introduced by Marie Jahoda in the late 1950s (the author gives an excellent review of her book, with some criticism that may improve her position (see esp. pp. 59-60), it attracted considerable attention.  The attention it gained, though, was from strictly defined groups.  Since it does not define mental health as absence of some phenomena (like symptoms, disorders, failures, impairments, etc.), psychologists of humanistic orientation refer to it very frequently, but psychiatrists who apply medical model do not want to deal with it very much. However, Tengland's problem is of a different kind.  Without giving any arguments for doing so, he uses terms mental health and positive mental health interchangeably, as if they were synonyms, despite there are many theories of mental health that would not agree with that.

Another problem in Tengland's approach concerns his definition of positive mental health.  His definition definitely is not negative in its form, but the part I find problematic is how reached it.  Namely, he uses Nordenfelt's definition of general health as his starting point (Lennart Nordenfelt being mentor of his dissertation), and he simply applied it to mental health.  The question is whether mental health is just a specific modality of general health, or the two are quite distinct phenomena.  I do not think that consensus could be reached easily.

This definition of positive mental health claims "P is mentally healthy if and only if P has the mental ability necessary for realizing P's vital goals, given acceptable circumstances" (p. 5).  To my mind, there are several problems with this definition.  The first one is who defines vital goals and who gives one the right to define them (for oneself and/or for the group).  Further, if every individual can create his/her own vital goals, how could anyone write a psychiatry textbook or organize a psychiatric hospital?  Second, patients suffering from personality disorders or what used to be called "dementia paranoides" often managed to achieve their "vital goals," but we still cannot treat them as mentally healthy. And if someone deliberately tries to be evil and destructive, and succeeds at least sometime, do we have the right to think of his mental health status? The third problem, to my mind, is in treating non-cognitive features (such as feelings, autonomy) as abilities in the usual sense of the word. The author says that personality traits are important only insofar as they "play an important part in the general ability, or disability, to reach vital goals" (p. 171). Still, it remains unclear how we are to decide on their importance; (love is, for example, rendered not to be a requirement for acceptable mental health, after only several sentences of examination (pp. 126-7)).

One very useful concept that I have never met before is that of "acceptable mental health."  We all know that one of the models of normality Offer and Sabshin identified was idealistic - normality refers to ideal potentials of an individual, or even of a human being (though normality and mental health are not identical, I have no place here to discuss that in detail). Since this model was find problematic and of scarce use practically, it could nicely be replaced by Tengland's suggestion: "Acceptable mental health is the level where the individual can attain a minimally decent life. The technical term 'survival' is introduced to describe this level ... Acceptable health is the lowest (acceptable) point on the positive health scale" (pp. 5, 97).  And an excellent criterion in work with psychotic patients, one might add.

In his effort to determine the defining characteristic of positive mental health, the author reviews several suggested definitions, extracts abilities mentioned in them and applies a "quasi-empirical" analysis of these abilities. The review is partial and based largely on secondary sources (in the case of psychoanalytic approaches to mental health, it is almost always one book).  The quasi-empirical analysis is defined as follows: "The method has to do with asking if something is empirically necessary for something else to be the case.  That it is 'quasi' means that this is not done by going out into the world observing or experimenting; instead one reflects upon one's experience of how things in the world work" (p. 7).  Many abilities are examined in this way, but the final definition includes only two that are considered irreducible: "P has acceptable mental health iff P has a high degree of practical rationality and some degree of the ability to co-operate" (p. 150).  Both the method and the definition will surely look problematic to many readers.  Since I am not a philosopher, I cannot tell whether everything is all right with this analysis.  The definition is, I dare say, not easy to use in clinical practice.  It seems applicable to anyone but psychotic patients, and it cannot be that only the psychotics are not mentally healthy.

I think that it is obvious that the book's problems stem from the same source as its strengths.  It is not written by a clinically trained professional, and therefore lacks clinically usable recommendations. Though the conceptual analysis is often very stimulating, there is still a long way before it can be applied to a clinical setting. Of course, the author was not expected to go all the way in this work, and we can expect that he will achieve more in the years to come. Books that discuss the concept of mental health are rare, and we should hope for more such contributions to the field and from the author himself.

 

© 2003 Aleksandar Dimitrijevic

 

Aleksandar Dimitrijevic, Faculty of Philosophy, Department of Psychology, Belgrade, Yugoslavia.