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.

Categories: Philosophical, MentalHealth