Mental Health, Meaning of Mental Health

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MENTAL HEALTH, MEANING OF MENTAL HEALTH

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Notions of health and mental health neither arose nor developed in a cultural and conceptual vacuum; their ancestral and contemporary kindred and relationships are multiple and far-reaching. Traces of their past live on in present quandaries and controversies. The interpretation and analysis that follow are historical and sociocultural, as well as philosophical and clinical.

Historical and Philosophical Background

NEAR EASTERN AND CLASSICAL CONCEPTS. Our story begins with the high civilizations of the ancient Near East. Initially, disturbances in customary and acceptable human functioning were experienced and interpreted in magico-religious and moral modes. Ancient Near Eastern personhood blended into a cosmos permeated by the divine and comprising countless interactions among fluid and loosely bounded beings and forces. Demarcations such as those between religion and medicine, psychic and somatic, material and immaterial, or spiritistic, natural, and supernatural would have been incomprehensible to early Egyptians and Mesopotamians. Even surgical and pharmaceutical interventions were accompanied by prayer, rituals, and magical formulas and paraphernalia.

Much the same can be said for the people of Mycenaean and Homeric Greece, whose worldviews and concepts of human beings were inseparable and thoroughly magical, animistic, and religio-moral. Cognition, affect, and motivation were experienced as divinely or demonically implanted, or else literally inspired from the ambient air. The earliest Homeric internalizations of motivation were localized to a semiautonomous region of the midriff or diaphragm called phthumos. As in Near Eastern antiquity, all sickness or disease, including madness, was magical (caused by spells or curses), demonic, or religious and moral (caused by divine possession, or divine punishment for ritualistic infractions, taboo-breaking, and sins of all sorts).

Health or wellness referred equally to states of the cosmos, society, or person. For example, the Egyptian goddess Maat personified a diffuse constellation of truth, balance, and right ordering or right acting, understood as antithetical to the primal chaos of the universe. Likewise, preclassical Greek ideas of health or wholeness were religio-moral, the corrections of imbalances. These metaphors and concepts of equilibrium, refined and codified by the classical Greeks, have remained central to modern Western medical and psychiatric norms or ideals of healthy functioning.

Classical Greece is commonly deemed the birthplace of both the psychological individual and secular medicine. Actually, however, medicine's vocational identity, cosmology, and philosophical anthropology were still imbued with religious aspects. The Greeks invoked deities such as Asklepios/Apollo; and nature itself (Physis), and humanity as part of it, remained divinized. Maladies, healing, and health were at once medical and sacred. The more medical facet of Hippocratic doctors' health and disease concepts concerned the bodily humors and their ratios to one another (balance versus excess or deficiency). Madness was explicated humorally as well, in a sort of proto-"physiological psychology" and psychopathology (Jackson); and the brain was considered the organ of mental activity.

By contrast, Plato and his philosophical successors disseminated a psyche-body dualism that influenced Western medicine for centuries. Plato characterized as "divine" physicians who were also philosophers, who thus knew soul as well as body. Nevertheless, he apparently thought such practitioners so rare that he roundly criticized doctors' practices of "dietetics"—which included what we would call counseling, lifestyle management, and prevention. In line with his dualism, Plato argued that philosophers were the rightful "physicians of the soul," thereby inaugurating a lengthy tradition of philosophical therapy. Such philosophers progressively adopted medical models and metaphors for the psyche in states of wellness and disease (pathé). In the first and second centuries c.e., Epictetus termed the philosopher's lecture room a "hospital"; he likened the pain necessary in spiritual and moral healing to that in medical measures such as the lancing of an abscess (see Edelstein). Centuries later, Sigmund Freud characterized analysis with surgical metaphors, and Henri Ellenberger thought psychoanalysis itself a latter-day version of philosophical healing.

The Hellenistic and Roman Stoics and Epicureans were other famous proponents of psychotherapeutic philosophy. Like all philosophical physicians, they were infatuated with metaphors of balance. The soul's health was equated with states such as ataraxia or apatheia (equilibrium, tranquility, serenity). The Stoic idealization of reason, and concomitant depreciation of passion, probably influenced subsequent rationalistic criteria for mind in health and illness. In any event, Plato and company, with their dualism and healing ambitions, paved the way for current concepts of mental health and psychotherapy. Nonetheless, their images of such health were spiritual/ethical, and their healing was dialectical and pedagogical—and, hence, a far cry from our ostensibly metaphysically and morally neutral mental health and psychotherapy; though Freud himself emphasized the educational and ethical aspects of analysis far more than any presumable medical ones (Wallace, 1986).

Aristotle, Plato's greatest pupil, avoided a frankly dualistic mind-body position and touted the philosopher's role as ethical teacher. The doctrine of the golden mean and prudential and moral virtues, or character ethics, held the place in Aristotle's philosophy that had been occupied by psychical or spiritual health in Plato's. This "golden mean," yet another manifestation of balance, was the cardinal feature of the virtues—for example, courage as the midpoint between temerity and timidity. In light of the individualistic thrust of ancient philosophical therapies such as Stoicism and Epicureanism, and of many present-day psychotherapies and notions of mental health, it is noteworthy that Aristotle considered his Ethics and Politics integral to each other. Citizenship, reflecting the individual's self-acknowledged embeddedness in a community, was central to Aristotle's idea of proper human functioning. Whereas we might accuse Aristotle of collapsing mental health into social ethics, he might have charged us with the reverse.

MEDIEVAL AND RENAISSANCE CONCEPTS. In the Christian West, institutionalized medicine was in priestly hands. The closest thing to medical schools were monastic, and most medieval infirmaries were operated by the Church. Medical theory and therapy followed the Hellenistic Galen's final codification of humoralism and anatomy. Madness was explained and treated somatically, as well as with the prayers and healing rites offered for any severe medical condition.

Somatic perspectives on madness meshed nicely with the Church's Platonic dualism, since the immortal and immaterial soul, unlike the body and brain, was not corruptible by disease. Meanwhile, the Church continued to use medical metaphors for many spiritual and moral problems. It is hard to know whether some of these approximated our nonpsychotic and less severe categories of mental illness—such as dysthymia or the personality disorders; aspects of the latter clearly falling under the traditionally moral purview. Medieval clerics themselves meditated over gray zones, such as whether acedia, a common monk's affliction, was sin (slothfulness) or disease (a mild form of melancholia) (Jackson). There was nothing corresponding to contemporary concepts of mental health. Norms and ideals were spiritual and moral, biblically and theologically derived.

Thomas Aquinas added loss of free will to irrational thinking and behavior as another cardinal sign of madness. This has influenced juridical processes up to the present, posing problems to psychiatrists espousing determinism(i.e., that all human mentation and behavior are causally necessitated). It has also borne on contemporary conceptions of mental health, some presupposing a capacity for nonnecessitated choosing (e.g., humanistic and existentialist) and others (e.g., classical psychoanalytic and neuromolecular) usually not. The ramifications for morality and ethics are obvious (Wallace, 1986).

As the great universities arose between the twelfth and the fourteenth centuries, they incorporated monastic medicine. Nonpriestly physicians returned to the scene, but medical theory and the treatment of madness remained much the same. There was no real secularization in Europe until the Renaissance, with its novel and heightened forms of individualism among certain educationally and financially favored segments of Europe's populations and its protopsychological concept imaginatio, a catchall for feeling, imagination, and fantasy (the very items ignored by hitherto hyperrationalistic norms of personhood).

This same period, however, witnessed the Inquisition, and its mass persecution of heretics and alleged witches. Medical men such as Johannes Weyer, with special interests in madness, argued that accused and "confessed" witches were actually insane, one of the few conditions that legally exonerated them. Still, Weyer's diagnoses were not purely medical, for he thought the witches' delusions had been implanted by Satan. Many modern historians of psychiatry have lauded Weyer for his insight and courage (e.g., Zilboorg). Some psychiatrists and psychoanalysts, including Freud, followed Weyer's example and facilely diagnosed whole institutions and cultures as psychopathological. Several decades of careful scholarship suggest that most "witches" were not in fact psychotic (e.g., Spanos). Furthermore, concepts of normality and pathology are complex, and they vary greatly from one culture or historical period to another. Moreover, transferring concepts of mental health and illness from the individual domain to the arenas of groups, cultures, and even families is questionable at best (Ackerknecht, 1971; Wallace, 1983).

SEVENTEENTH- AND EIGHTEENTH-CENTURY CONCEPTS. The seventeenth century was characterized by the continuing expansion of individualism and by a rationalism that paid less attention to aspects of personality, such as imaginatio, explored by the Renaissance. Irrationality became the key criterion for madness, giving the social philosopher Michel Foucault (1965) the ostensible grounds for his thesis that seventeenth-century asylums were filled with persons who had violated their era's canons of reason and socially acceptable behavior. Foucault alerted us to possible linkages between sociocultural and political-economic special interests, and psychiatric institutions, concepts, and practices—including formulations of mental health and illness.

The epoch from 1600 to 1750, then, was a watershed in many ways. Its scientific paradigms, ultrarationalism, and sociocultural-economic developments paved the way for the West's ensuing secularism and capitalism. The coming age would require and give rise to different forms of humanity, with novel notions and modes of well-being, dysfunction, and distress. Not coincidentally, it would also spawn a new medical specialty: psychiatry.

Contemporary Concepts and Issues

The mid-eighteenth century constitutes the headwaters of the stream that culminates in the modern or postmodern mental-health complex. The rise of economic capitalism, with its emphasis on free-market competition and individual acquisitiveness, went hand in hand with the progressive breakdown of traditional social-political structures and cultural institutions, along with the Christian worldview that had hitherto sustained them. New modes of personhood appeared, modes that were exquisitely self-aware and self-oriented, shunning binding institutional and interpersonal commitments, and shrewdly combining hedonism with "social adjustment."

The Enlightenment witnessed novel varieties of what we would designate as functional (versus organic) psychiatric disorders: the vapors, nerves, and so forth, resembling conversion, dissociative, anxiety, dysthymic, personality-disordered, and neurotic categories (American Psychiatric Association, 1987). Initially comprehended and treated somatically with magnetism, or hypnosis, they were gradually conceptualized psychologically. Feminist historians (e.g., Decker) interpret these experiential and behavioral configurations as disguised forms of women's rebellion against male-dominated society.

Meanwhile, in early and mid-eighteenth-century Great Britain, a new breed of physicians began devoting their practices to madness. The most brilliant of these "maddoctors," Alexander Crichton, influenced Philippe Pinel, generally called psychiatry's father. Previously an internist, Pinel flourished in post-Revolutionary and early nineteenth-century France. Until then, madness had not been institutionally medicalized. Asylums typically fell under lay management, with doctors no more than general medical consultants. Pinel's orientation was psychological as well as medical, and he came to favor abbreviated systems of diagnostic classification. However, his successors in the powerful French clinical school, presuming the inevitable degeneration of many conditions, became progressively and pessimistically organic. Notions approximating mental health were far from their minds.

Contemporary German psychiatry was pursuing a semimystical and Romantic psychological path (Ellenberger). Abstruse and difficult to summarize, it conceptualized nature and humankind as manifestations of a World Spirit or Soul. Although often obscure and moralistic, it contributed some genuine psychological insights, including many on unconscious mentation and motivation. In England and the United States, despite some admixture of somatic theory and practice, early nineteenth-century psychiatry—or alienism, as it was called (thus underscoring its subjects' social estrangement)—was predominantly psychologically and sociotherapeutically oriented. The Anglo-American moral treatment movement envisioned the then relatively small country asylum as a healing family, with the medical superintendent its father. For much of the nineteenth century, the word moral still denoted an amalgam of what was later divided into mental or psychological, and moral or ethical.

As the twentieth century approached, the number and size of asylums grew geometrically; treatment became custodial, and Anglo-American and European psychiatry grew increasingly neuropathologically inclined. Its interest in diagnostic classification and the results of autopsies contributed to what Foucault (1973) called the "objectification" of the patient. The rise of organic and custodial psychiatry reflected many social and demographic changes in the United States: rapidly increasing population; greater social and geographic mobility; replacement of small and culturally homogeneous communities by urban centers swelled by immigration; the continuing disempowerment of institutional religion; movement toward monopolistic capitalism, an orientation toward productivity and consumerism; individualism and waning local charity; and generally changing social mores. Together, such factors made moral therapy unworkable and led to further transformations in popular conceptions of personhood in wellness and illness. Communities and even families transferred responsibilities for their psychiatrically disturbed members to the large central facilities.

It is likely that such facilities came to house many who were merely elderly, socially deviant but not criminal, and economically unproductive. Certain contemporaneous diagnoses—such as volitional old maid, vagabond, and eccentric character—would be laughable if they had not also been socially coercive. State hospitals usually fell under the autonomy of those social agencies that dealt with the socially and economically marginal and dependent (see Grob, 1973, 1983). Drawing on such historical sources, as well as on present-day events, a school of social scientists and political philosophers underlines the status quo-supporting and professionally self-serving features of psychiatry and its related disciplines, including their diagnostic schemata and notions of health and illness (e.g., Foucault, 1965, 1973; Ingleby; Horwitz). These include gender, socioeconomic class, and ethnic biases (e.g., Chesler; Russell).

The organic orientation of the second half of the nineteenth century promoted a seemingly paradoxical soul-body or mind-body dualism among Anglo-American psychiatrists. In their view, psychiatric disturbance or disease was wholly a function of body and brain; the soul or mind, being immaterial and immortal, was not susceptible to disease. Such a schema, which obviously protected their theological tenets, virtually ruled out ideas of mental health and illness, and practices such as secular psychotherapy. Nevertheless, psychotherapeutic perspectives began forming in the late nineteenth century. They emerged among outpatient neurologists who were encountering increasing percentages of functionally disordered patients, and among psychologically minded psychiatrists, who were treating ambulatory patients with milder problems. The distress and dysfunction these professionals were treating became less commonly experienced and interpreted in religious and moral terms. Such problems were therefore less amenable to healing through confession, penance, and recommitment to the Catholic ideology, institutions, and community, or to their Protestant counterparts, often including more counseling ("the cure of souls").

Twentieth Century

To serve these new varieties of troubled persons, innovative therapies arose in the latter nineteenth century and the first decade of the twentieth. These mind-cure or healthy-mindedness approaches, as William James (1902) named them, comprised purely secular healings; heterodox religious approaches such as Seventh-Day Adventism and Christian Science; Americanized variations of Eastern religions and philosophies; and various integrations of religious, medical, and psychiatric proposals. In Europe, psychoanalysis emerged, the prototype of twentieth-century secular therapies and the ultimate progenitor of most current psychological theories and treatments. Psychoanalysis and its offshoot dynamic schools would contribute significantly to the clinical and popular dissemination of concepts of mental health and mental illness.

By 1910, events were gathering momentum. The important Mental Hygiene Movement, a joint lay-psychiatric venture, had been formed in Boston in 1909 (by former mental patient Clifford Beers and Harvard psychiatrist E. E. Southard). Though it had been started to improve the plight of the severely mentally ill (formerly the mad), its concerns shifted swiftly toward mild-to-moderate psychiatric problems and to community mental hygiene, which led eventually to the burgeoning community mental-health movement of the 1950s, 1960s, and 1970s. This movement, like the dynamic therapies, fueled public preoccupation with mental health (Grob, 1983).

During these same decades, psychiatrists in the United States had begun moving toward acute-treatment psychiatric facilities and wards in general hospitals, the psychopathic units that treated less chronically severe patients—those with acute crises, neurotic symptoms, and personality problems of all sorts. Outpatient work continued to grow as well. Clinical psychology and social work started evolving as professions. General medicine's public-health and preventive wings, joined by lay wellness proponents, enlarged their territory, too. These developments have led many critics, such as Ivan Illich (1976), to speak of medical and psychiatric imperialism, the medicalization of society, and so forth. Indeed, as early as 1856, physicians such as Oliver Wendell Holmes contended that doctors and deterministic medicine should replace priests and religion as society's moral arbiters. The eminent medical historian Owsei Temkin (1977) charges that health has become a "summum bonum," whose values encroach on morality and ethics (e.g., the virtual criminalization of smokers). Don Browning (1987) points out the various ethical, social-valuational, and cosmological dimensions of the major psychotherapeutic approaches. Many have commented on the normative-prescriptive aspects of the mental-health and mental-illness concepts of the multifarious psychiatric and clinical psychological vantages.

Definitions of health as broad as the World Health Organization's (1991) "state of complete physical, mental, and social well-being," certain epidemiologic projects (Srole et al.), and categorizations of mental disorder as extensive as those of the American Psychiatric Association (1987, 1994), seem to ground the accusations of Illich and others. Aspects of hitherto normal aging are deemed disease and treated as such, and similar attitudes toward features of other developmental periods could be cited. Indeed, pathology has narrowed the domain of human physiology to the point that doctors and the public alike view death itself as all but a potentially preventable disease.

In any event, though most philosophers of general medicine (e.g., Pellegrino and Thomasma; Kass) declare promoting health to be the physician's primary objective, few medical authors conceptualize and elaborate it very explicitly. More often it is a negative notion—the absence of significant disease or illness. Although conceptions of mental health in psychiatric and related practitioners' textbooks and treatises are frequently negative as well, the writers of such books are more likely to attempt positive conceptions than are their general medical counterparts. Daniel Offer and Melvin Sabshin (1966, 1984, 1991) list dozens of notions or definitions of mental health by theorists and therapists of many persuasions. These range from simplistic extremes such as "social adjustment" or "self-actualization," to more complex and reflective notions. Some assess mental health, like mental illness, by dimensions and degrees; others proffer categorical constructs of both. There are naturalistic-universal, psychological, sociocultural-contextual, and biopsychosocial ones. In short, the ways of classifying conceptions and criteria of mental health are potentially exhausting. Through surveying an immense range of pertinent sources, Marie Jahoda (1959, 1977) identified the six indexes of mental health that appear most frequently: (1) the individual's attitudes toward himself or herself; (2) the person's "style and degree of growth, development, or self-actualization"; (3) a central synthesizing psychological function, or "integration"; (4) "autonomy," or "independence from social influences" (the single most cited index); (5) adequacy of reality perception; and (6) mastery of the environment.

However useful they may be, these criteria can hardly claim to be purely natural or scientifically derived; they are clearly a function of time- and place-bound cultural contexts, as well as of presupposition-laden psychological orientations. It is not so much a question of whether they imply values, for no theories and concepts escape their authors' values altogether. Rather, the questions concern the kinds of values, and their relationships to one another and to those in other endeavors and institutions.

Of Jahoda's indexes, most are self-oriented, depicting the natural and social environment as something virtually inimical to personal well-being. The "healthy" are independent of its influences, mastering it to their self-actualizing ends—which, ironically, may be quite serviceable to those of the prevailing political economy. Of course, there are also formulations of "mental health" at the opposite, or socially conformist, pole; their professional exponents probably have frequently fallen into the service of dominant socioeconomic agendas. In any case, Jahoda's analysis suggests that there are other sorts of dangers associated with ideas of mental health. Such common extremes in positive conceptions of mental health make one wonder whether they should be attempted at all. The American Psychiatric Association (1987) avoids defining mental health.

Many of the profoundest students of human experience and behavior, such as Freud, have not issued definitive pronouncements on mental health. Freud's theories and observations contain many items relevant to assessing dimensions and degrees of psychic well-being and its reverse (Wallace, 1986; Vergote; Wallwork). Nevertheless, apart from hearsay attributions to him of the spare desideratum Lieben und Arbeiten (loving and working), Freud bequeathed us no extensive positive constructions of mental health. In fact, he stressed the continuum from neurosis to "normality." Nor did he harbor utopian ambitions for psychoanalytic therapy, firmly denying that it promised happiness or contentment. It was quite enough if treatment alleviated the analysand's more troublesome, historically determined psychic and interpersonal conflicts, misapprehensions of self and others, and modes of gratifying and inhibiting hitherto repressed or symptomatically expressed desires and strivings. Such imperfect but significant transformations enhance the patient's grasp of his or her particular life's realistic problems and possibilities. Freud had no notions akin to Abraham Maslow's and Carl Rogers's of the easy and automatic harmonization between "self-actualization" and the requirements for a humane and civilized society. His concept of adaptation, hardly collapsible into Darwin's, implied neither mastery of nor submission to the sociocultural and political-economic surround, but rather a prudent and moral interweaving of "autoplastic" (self-transformative) and "alloplastic" (environmentally altering) activities (see Hartmann; Wallace, 1986; Vergote; Wallwork).

Although Freud was capable of psychoanalytically masked moral and metaphysical judgments, such as those about religion, he was usually quite sensitive to the interface between moral/ethical perspectives and theoretical/clinical ones. Psychoanalytic insights and findings might inform the ethical enterprise, but Freud did not think moral values themselves could be deduced from analytic premises. Regarding moral values in the psychoanalytic endeavor itself, he emphasized honest self-awareness and its potentially beneficent personal and interpersonal effects (Wallace, 1986; Rieff). Freud intended the clinician's analytic neutrality, with its customary suspension of explicit moral evaluation, purely as a means to enhance the patient's disclosure and self-discovery; it was confined to the consulting room and not suggested as a recipe for living.

Conclusion

Given the historical and cross-cultural variations in modes of conceptualizing personhood and ascribing abnormality, as well as the vicissitudes of sociocultural and natural environments, it makes little sense to seek timeless and placeless notions of health, illness, or even disease, psychiatric or otherwise. The extraordinarily complicated overlap and mutual determination among formulations and applications of mental health, and a host of external institutions, ensure that the former will reflect and affect myriad socio-cultural dimensions and processes. Insofar as ethical and metaphysical purviews are separable from scientific and medical/psychiatric theories and findings, one cannot facilely deduce moral values and ethical systems from the latter.

A biopsychosocially oriented functionalism proffers the least metaphysical and reductionistic, and the most comprehensive and open, model of the human organism in its ongoing cultural and natural milieu. This conceives of self-conscious and symbolizing personhood as the complexly integrated function of a plethora of subsidiary structures and functions, interacting both among themselves and with aspects of the physical and sociocultural ambience. It avoids either a dualistic or a mechanistic stance on humankind; it affirms the necessity of psychosocial, as well as biomedical and neurobiological, approaches to persons in health and illness (Wallace, 1990). Moreover, it permits medicine, psychiatry, and the mental-health disciplines a public philosophy open to dialogue with vantages from ethics, theology, jurisprudence, politics, and elsewhere (Wallace, 1992). In other words, a Homo sapiens does not comprise separate ontological compartments of spirit, morals, mind, and body. Rather, he or she is appreciated as a self-consciously reflective whole, with a history in a community, whose various experiences and activities require separate, but overlapping and interrelating, spiritual, moral, medical/psychiatric, and social perspectives. However one understands mental health and mental illness, they point toward forms of distress, disability, and well-being that are real and pervasively human concerns.

edwin r. wallace iv (1995)

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POSTSCRIPT

Western definitions and concepts of mental health have continued to multiply into the twenty-first century—usually permutations and combinations of desiderata already treated. However, there is a strengthening minority position taking sociocultural (including political-economic) and even spiritual parameters into account—both in definitions of mental health and in theories of causation of mental disorders (Kleinman and Good). This cadre is led by transcultural psychiatrists and psychological/psychiatric anthropologists (GAP). Western psychiatry is being cogently examined as one ethnopsychiatry among others (Kleinman). DSMIII and DSM-IV Axis I disorders such as Major Depression differ in core, and not merely peripheral, signs and symptoms—begging the question of whether psychiatry is dealing with different nosological entities (Kleinman and Good).

On the positive side, the psychiatrist and philosopher K. W. M. Fulford has proposed a notion of mental illness as "failure of action," rather than as the DSM-IV's "disturbed functioning." The latter implies component pathophysiological lesions about which the evidence is still very equivocal (Wallace, Radden, and Sadler; Ross and Pam; Bentall; Lewontin, Rose, and Kamin). "Failed action" refers to a variety of distressing or disabling experiences and behaviors that the person is unable to control (i.e., consciously will and enact otherwise). A definition of mental health is of course implied in this, and could be worked out conceptually. Fulford's notion does not rule out the potential explanatory and therapeutic applicability of both neurobiological/pharmacological and psychosocial/psychotherapeutic approaches.

A far more complex and controversial theorist of disease/illness and, by implication, of what he now prefers to call "normality" rather than "health" is Boorse (Boorse, 1977). Attacked by most bioethicists and medical philosophers (Humber and Almeder), Boorse has staunchly argued for human species-specific biostatistical, ostensibly objective and value-neutral, criteria for disease (Boorse, 1975). Initially limiting his argument to general medical disease, he later moved to biostatistically-based criteria for illness and for the mental disorders as well (Boorse, 1975, 1997). In a 1997 book chapter, he skillfully defended himself against a plethora of critics.

Since it is impossible to address his annexation of mental disorders (and, by implication, mental health) without appreciating Boorse's general medical concept of disease/illness, one must begin with the latter. His biostatistical criteria for disease/illness are extremely spare and Darwinian: the preservation of the individual (as opposed to the group or population) and his/her reproductive fitness. Disease is component pathophysiological dysfunction or subfunction within the organism. It is key to realize that Boorse is concerned with medical scientific (i.e., the pathologist's) or theoretical criteria for disease. He is not occupied with practical clinical diagnosis (which often deals with syndromes) or the clinical investigative and therapeutic manner of the physician. However, it is important to note that he appreciates the necessity for "disease-plus" concepts of humanitarian and ethical clinical behavior.

Moreover, in concerning himself with disease as intra-organismic component pathophysiological dysfunction or subfunction, he does not argue that the nexus of etiology is delimited to the subcomponent or even the organism itself. He includes physical environmental trauma and psychosocial causation (in the general medical, as well as psychiatric, realms). Illness is the systemic molar or total organismic (which may include the mind) subfunction or dysfunction accompanying the disease. Hence, illness represents the same sort of Darwinian impairment already addressed with reference to disease. By Boorse's criteria, it is possible to: (a) have a disease without an illness (e.g., molar dysfunction)—though eventually, of course, many or most diseases will also become illnesses; and (b) an illness (e.g., influenza) without a disease (e.g., delimited internal pathology).

One must also recognize that Boorse's biostatistical, Homo-sapiens-typical criteria are related to gender, age, and (to some extent) ethnic or racial reference-groups. This prevents a post-menopausal woman (who has lost reproductive fitness), a middle-aged man with some degree of "male pattern baldness," or a pygmy with group-wide growthhormone subfunction from being deemed diseased or ill. Nevertheless, things become more complicated for Boorse with African or African-American individuals heterozygous for sickle-cell disease. On the one hand, this state is survivalpromoting in malarial environments, but not at higher altitudes at which other "races" are not so vulnerable. Boorse attempts to sidestep this with his construct of "standard environment." This is problematic not only for general medical disease/illness, but especially for mental and behavioral functioning, since climatic, historical, and sociocultural relativity render the idea of a Homo-sapiens-specific standard physical and sociocultural environment suspect.

Finally, this author finds Boorse's insistence that component or circumscribed internal pathophysiology alone defines disease as bizarrely narrow; it excludes systemic dysfunction or subfunction, as well as the molecular level to which many pathological disease-formulations are now turning.

Turning especially to psychiatry, Boorse likewise stresses internal component pathology. To his credit, he considers psychological concepts a necessary subset of biological ones—to grasp human species-specific, symbolicallymediated mentation, communication, and behavior. This author has argued similarly in both monistic-dual-aspect and functionalist models of the mind-body relation (Wallace, 1988, 1990, 1997). In other words, Boorse contends that not only cerebral or extra-cerebral component pathophysiology (and here he chides biological psychiatry for its predominantly molecular approach) may be pathognomonic for mental disorders, but so might component psychological functions such as unconscious intrapsychic conflict among the psychoanalytically-conceived mental agencies and subsidiary functions. However, his delimitation of disease/illness criteria to individual self-preservation and reproductive fitness are problematic for notions of mental disorder and normality. For example, in non-Western cultures with intact, supportive kinship and community networks, psychiatrically-untreated schizophrenia does not pose the same personal survival or even reproductive fitness risks that occur in the urbanized West, with its relative dearth of community and kinship networks. And most DSM-IV Axis II sufferers (from perhaps Western culture-bound syndromes) often experience no increased physical survival or reproductivefitness risks. In short, Boorse's two Darwinian criteria are insufficiently robust for a concept of mental disorder/illness, much less for normality or mental health.

Pending further research, some varieties of the major mental disorders may turn out to be diseases in the Boorsian circumscribed pathophysiological (or even molecular) sense. However, this author suspects that most (Axis II) mental disorders (which keep multiplying over time in new editions of the DSM) will remain best understood in the psychosocial categories of human biological discourse.

In conclusion, there is nothing in Boorse's argument as applied to psychiatry that would countenance psychiatry's recent (patently, if partly, economically-motivated) turn to a radical neurobiological/pharmacological reductionism. Such an approach entails the concomitant jettisoning of psychosocial/psychotherapeutic approaches that demand a more laborious intimacy with the patient-as-person-in-anambience rather than as simply the epiphenomenon of a twisted molecule or component brain limbic pathophysiology. Again, Boorse asserts that disease- and illness-plus concepts and approaches are necessary to anyone who would be an ethical and competent clinician.

Space does not permit treatment of the recent evolutionary psychiatry of Randolph Nesse and George Williams, and others. They are obsessively committed to imagining historically remote conditions in which disorders is incapacitating as schizophrenia were once adaptive (i.e., atavism).

edwin r. wallace iv

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