I. DEFINITION, USE AND MEANING

The concept of mental illness, including its lay counterparts such as madness and insanity, has been subject to widely different interpretations since classical times and between different cultures (Robinson). Models of mental disorder, as they are now called, continue to be hotly contested between different stakeholder groups in mental health right up to the present day (Fulford et al., 2003). Running through these differences and disputes, as outlined later in this entry, is a tension between what may be called moral and scientific models. Mental illness, understood in terms of this tension, is poised between the everyday moral world of free agency, subjectivity and reasons, and a scientific world of determinism, objectivity and causal laws.

How the tension between moral and medical models of mental illness is resolved in a period of unprecedented advances in the neurosciences—in behavioral genetics, in functional brain imaging, and in psychopharmacology—is critical to a range of ethical issues in psychiatry: the insanity defense (Robinson), ethical aspects of diagnosis (Dickenson and Fulford, ch. 4), the nature of autonomy in psychiatry and psychotherapy (Hinshelwood, 1995, 1997), the boundary between medical psychiatric treatment and social control (Bloch and Reddaway; Fulford, Smirnoff and Snow), the growing role of users (or consumers) in the design and delivery of services (Department of Health), and not least, the fight against prejudice and discrimination, that brand of internal racism (Fulford and Radden) to which all those concerned with mental health, whether as users or as providers of services, remain subject.

This entry explores the meaning of the concept of mental illness, not directly, by way of a critique of the very large number of competing definitions available in the literature, but indirectly, by way of the use made of the concept in practice. This approach—examining the use of concepts as a guide to their meanings—is exemplified by the work of the English philosopher J. L. Austin (1911–1960) and others working mainly in Oxford in the middle years of the twentieth century (Warnock, 1923–1995). The approach, called linguistic analysis or ordinary language philosophy, although relatively neglected by subsequent generations of philosophers (Williams, 1929–2003), and certainly very far from being a philosophical panacea (Fann), provides a conduit or bridge between philosophical theory and medical practice (Fulford 1989, 1990, 2001). In psychiatry, linguistic analysis offers a number of helpful insights into:(1) the nature of the problem presented by the concept of mental illness; (2) the methods available for tackling the problem; and (3) the outcomes that can be expected in tackling problems of this kind.

The Problem: Many Definitions

Difficulties in the use of the concept of mental illness have traditionally been assumed to reflect difficulties of definition. This assumption, of a genetic link between difficulties of use and difficulties of definition, was not unreasonable given the successes of psychiatry in the second half of the twentieth century in improving the reliability of its diagnostic categories by clarifying the definitions of many of its key diagnostic terms: The US-UK Diagnostic Project (Cooper et al.), for example, and the International Pilot Study of Schizophrenia (World Health Organization, 1973), showed that difficulties in the use of the concept of schizophrenia were indeed due to difficulties of definition (discrepant rates of diagnosis turned out to reflect discrepant definitions). There are, furthermore, as this entry shall explore, many examples of continuing difficulties both in the use of the concept of mental illness and in its definition. These examples, however, understood linguistic analytically, point, not to the traditional assumption of a genetic link between use and definition, but rather to the need for a reformulation of the problem as one of difficulty in the use of the concept of mental illness rather than a difficulty of definition.

CASE EXAMPLE: SIMON. Simon, a forty-year-old African-American lawyer, was threatened with a malpractice action, which he believed to be racially motivated, by a group of colleagues. Although he had never been a particularly religious man, he responded to this situation by setting up a makeshift altar in his front room and praying all night. In the morning he found that wax had run down from a candle on to his bible, marking out certain words and phrases. This is how he described his experience: "I got up and I saw the seal (wax mark) that was in my father's bible and I called (my friend) and I said, you know, something remarkable is going on over here. I think the beauty of it was the specificity by which the sun burned through. It was … in my mind, a clever play on words." Simon continued to have similar experiences for eighteen months. His seals meant nothing to anyone else. But for Simon they were direct communications from God, showing that he was "…the living son of David…and captain of the guard of Israel."

TWO CLASSIFICATIONS, TWO DEFINITIONS, TWO DIAGNOSES. Simon's story, which is based on a real person's experiences, comes from a study of the differences between delusion and spiritual experience carried out by a British psychologist Mike Jackson, at the time working as a doctoral student with Gordon Claridge at Magdalen College, Oxford (Jackson, 1997; Jackson and Fulford). The study included blind ratings using one of the first carefully standardized instruments for assessing a person's mental state, the Present State Examination (PSE). Developed by John Wing, John Cooper and Norman Sartorius at the Institute of Psychiatry in London, the PSE includes a glossary of carefully crafted definitions that, together with a standardized interview schedule, allow the identification of over one hundred symptoms and signs of mental disorder with high degrees of reliability (Wing, Cooper, and Sartorius). PSE ratings of Simon's story identified his experience as a delusional perception, a form of primary delusion. The PSE defines this as a delusion which is "based upon sensory experiences (delusional perceptions) in which a patient suddenly becomes convinced that a particular set of events has a special meaning" (Wing, Cooper and Sartorius, p. 172–173).

What then does this delusional perception mean diagnostically? There are currently two major classifications of psychiatric disorders, chapter V of the tenth edition of the International Classification of Diseases (ICD-10), produced by the World Health Organization under the direction of Norman Sartorius (World Health Organization (WHO), 1992), and the fourth edition of the Diagnostic and Statistical Manual (DSM-IV),, produced by a taskforce of the American Psychiatric Association (APA) chaired by Allen Frances (APA, 1994).

The ICD-10 and the DSM-IV classifications are in many respects similar. In particular both are descriptive in orientation. That is to say, both seek to define mental disorders as far as possible descriptively, by reference to the presence of specific symptoms, like delusional perception, of known reliability. Yet ICD-10 and DSM-IV suggest radically different diagnoses in Simon's case. In ICD-10 delusional perception (as defined in the PSE) is one of a number of symptoms that, if present, are sufficient for a diagnosis of schizophrenia (or of some other psychotic illness—affective, organic, or other—depending on associated features). According to ICD-10, then, Simon had schizophrenia (or some related psychotic disorder). DSM-IV, by contrast, requires for a diagnosis of schizophrenia, not only one or more of the relevant symptoms (summed up in its Criterion A), but also deterioration in social and/or occupational functioning (Criterion B of "social/occupational dysfunction," p. 285). And inquiry about Simon's social and/or occupational functioning, reveals that, far from deteriorating, as required by Criterion B, it actually improved! He was empowered and guided by his experiences, idiosyncratic as they were; he won his court case; and his career consequently went from strength to strength. By the lights of ICD-10, then, Simon had a psychotic illness (albeit one with, in this instance, a benign course); but by the lights of DSM-IV, he had a positive (albeit idiosyncratic) spiritual experience.

MANY DEFINITIONS OF MENTAL ILLNESS. On first inspection, it is somewhat disconcerting, at least from psychiatry's point of view, to find that its two major classifications, although closely similar in their scientific orientations, should yield radically different ways of understanding Simon's story. This is the more surprising given that those responsible for the two classifications worked hard to make them compatible. Simon's case, furthermore, is not marginal in these classifications: Karl Jaspers, the founder of modern descriptive psychopathology, placed delusion among the central symptoms of mental disorder (Jaspers, 1913a); and the case for a medical model of mental disorder is regarded by many as being strongest for the psychoses. It was for this reason that Thomas Szasz, notorious for the slogan mental illness is a myth (Szasz, 1960), called schizophrenia, in the title of a later paper, the "sacred symbol of psychiatry" (Szasz, 1976).

Disconcerting, though, as this incompatibility between ICD and DSM may be, viewed in its historical context it is but a manifestation of the long-running tension between medical and moral understandings of madness. As noted at the start of this entry, this tension runs across many cultures and back at least as far as classical Greece (Robinson). In the early-twentieth century, the tension surfaced in Jaspers's insistence on the need for both causal (medical) and meaningful (moral) accounts of psychopathology (Jaspers, 1913b). Psychiatry, for much of the twentieth century, ran mainly with the causal side of Jaspers's psychopathology. But the tension continued to be evident in the conflicting scientific and hermeneutic interpretations of psychoanalysis (Ricoeur), in the rediscovery of meanings by psychology, and of causes by phenomenology, in the second half of the twentieth century (Fulford et al., 2003), and, perhaps most transparently of all, in the so-called debate about mental illness in the 1960s and 1970s (Siegler and Osmond; Caplan et al). In this debate the medical (causal-disease) model of mental disorder was directly opposed by a variety of non-medical models—for example, psychological (Eysenck), social role theory (Scheff), labeling theory (Rosenhan), political (Foucault), existential (Laing) and moral (Szasz 1960, 1987). Each of these alternatives to the medical model sought to shift our understanding of mental disorder away from the causaldisease framework of medicine towards frameworks in which, to varying degrees and in different ways, agency and subjectivity are retained. Szasz's model is among the most overtly moral in the sense that he takes mental disorders to be problems of living, defined by psychosocial, ethical, and legal norms, to which we should respond, not passively, by seeking treatment, but actively, by taking responsibility for them.

It has been rightly pointed out, in respect of this debate, that the term medical model in fact covers a number of rather different models (Macklin); and that psychiatry, in particular among medical disciplines, aspires to a balanced biopsychosocial approach in which different models represent no more than perspectives on (McHugh and Slaveney) or levels of (Tyrer and Steinberg) the subject. Modern psychiatric textbooks all emphasize the importance of considering social and psychological aspects of mental disorder alongside the biological. Anecdotal reports, nonetheless, from people who actually use services (Campbell), taken together with both surveys (Rogers, Pilgrim and Lacey), and empirical social science research (Colombo et al.), all suggest that, in practice, mental health professionals, whatever their theoretical commitment to a broad biopsychosocial model, tend in practice still to be guided by very different implicit models in their approach to their work.

MANY DEFINITIONS OF BODILY ILLNESS. The range and diversity of competing models of mental illness has been subject to different interpretations, none particularly flattering to psychiatry (Phillips). At best, psychiatry is taken to be scientifically primitive (Boorse, 1976), our use of models being assumed to be a temporary expedient reflecting the "limited information" about mental illness currently available (Tyrer and Steinberg, p. 2). Linguistic analysis, by contrast, offers a positive rather than negative interpretation, an interpretation in which the different models represent different aspects of the meaning of mental illness with complementary, rather than competing, roles in clinical work and research. This positive interpretation will be discussed further in the section on Outcomes. But a first linguistic analytic step towards it is to see that, so far as definition is concerned, one is no more able to define bodily illness than mental illness.

From the perspective of those wedded to a genetic link between transparency of definition and ease of use, this may seem to be a somewhat surprising claim. For the concept of bodily illness, after all, if not wholly unproblematic in use, is at least considerably less so than that of mental illness: In contrast with even the central cases of mental illness, such as schizophrenia, there is no dispute about whether heart attacks or appendicitis, for example, as central cases of bodily illness, are diseases.

That bodily illness, nonetheless, is no easier to define than mental illness, is shown by three considerations:

1. There is an on-going debate about the meaning of bodily illness, less high profile, certainly, than the debate about the meaning of mental illness, but, if anything, growing in volume and intensity rather than moving towards resolution. As recently as 2002, Richard Smith, the editor of a leading medical journal in the United Kingdom, the British Medical Journal, reignited the debate about the meaning of bodily illness by asking where we should draw the boundary of disease (Smith).
2. The derivations of some of the most contested positions on the meaning of mental illness stand in direct line of descent from equivalent positions on the meaning of bodily illness. Thus current attempts to define mental illness employing criteria derived from evolutionary biology (e.g., Neander, Wakefield) are derivative, through the work of the American philosopher Christopher Boorse (1975, 1976, 1997), on an earlier debate, which started in respiratory medicine, about the definition of bodily illness (e.g., Scadding).
3. Much of the debate about mental illness, although indeed ostensibly a debate about the meaning of mental illness, actually turns on differences of view about the meaning of bodily illness. The critical difference between Thomas Szasz (1960), for example, and his British opponent, the psychiatrist R. E. Kendell, the difference that led to their respective moral and medical interpretations of mental illness, was a difference in their understandings of the meaning not of mental illness but of bodily illness: Szasz took genuine illnesses as instantiated by a series of examples of bodily illness to be defined by anatomical and physical norms, which, being absent in putative mental illnesses, made mental illness a myth; Kendell took genuine illnesses as instantiated by (many of the same) examples of bodily illness to be defined by evolutionary norms of reduced life/reproductive expectations, which, being satisfied by (many) putative mental illnesses made mental illness no different in principle from bodily illness (see Fulford, 1989, ch. 1). Similar differences about the meaning of bodily disorder continue to drive current debates about the meaning of mental disorder (Fulford, 2000).

These three points about the concept of bodily illness have been spelled out at some length because they are the lynch pin of the linguistic analytic reformulation of the problem of mental illness. It is a matter of observation that the concept of mental illness is more problematic in use than that of bodily illness. But since bodily illness turns out to be no more transparent to definition than mental illness, the difficulties associated with the use of mental illness are unlikely to be derived (directly at least) from difficulties of definition. This is the sense in which, as indicated at the start of this section, the problem of mental illness is one of use rather than definition. The problem itself, indeed, reformulated linguistic analytically, turns out to be as much a problem of bodily illness as of mental illness. Before spelling out this reformulation of the problem more precisely, though, a brief look at two definitional blind alleys, the causal blind alley, and the dualism blind alley, is necessary.

THE CAUSAL BLIND ALLEY. One of the most widespread misperceptions in so-called biological psychiatry is that our current difficulties in defining mental illness will be resolved by future scientific advances. The origin of this misperception is the success of physical medicine in developing diagnostic tests to detect the causes of bodily illness, the employment of these tests diagnostically, and their incorporation into classifications of disease. A disease, so defined, is a change in the structure/function of the body that has a tendency to cause illness. But causation as such does not define pathology (health no less than illness is caused). The chain of causation does indeed, on this model, flow from disease (the change in bodily structure/function) to illness (the changes in the patient's experience and/or behavior). But the flow of meaning runs the other way, from illness to disease. It is the status of an experience and/or behavior as pathology which determines the status of the underlying bodily causes of that experience and/or behavior as pathology, not vice versa.

If, therefore, as in the case of many bodily illnesses, an experience and/or behavior is unequivocally pathological, the underlying causes of that experience and/or behavior will be unequivocally pathological as well. Conversely, though, if, as in the case of many mental illnesses, an experience and/or behavior is only equivocally pathological, then the underlying causes of that experience and/or behavior will be only equivocally pathological as well. Causation, then, or more precisely knowledge of causation, is, for the purposes of conceptual clarification, a blind alley. (See Fulford, 1989, chapter 4, for a more detailed treatment, including the place of "stipulative definition," in Urmson's sense of the term.).

THE DUALISM BLIND ALLEY. A second widespread misperception is that our difficulties with mental illness are derived in some (generally undefined) way from the (supposed) ills of Cartesian dualism, the separation of mind and brain as distinct substances. This misperception is evident in the positions of those both for and against the concept of mental illness (see, e.g., respectively, Roth and Kroll; Szasz, 1998). It can be taken as two rather different claims. As a claim that solving the mind body problem will solve the problem of mental illness, it substitutes for our local difficulties with mental illness, some of the deepest and most intransigent problems of general metaphysics—not much of a bargain, conceptually speaking! As a claim, alternatively, that there is no real difference between mind and body, and hence no real difference between mental illness and bodily illness, it simply begs the (operative) practical question, namely, just why mental illness (conventionally denotated) is so problematic in use compared with bodily illness. Either way, then, dualism, or more precisely the denial of dualism, is, like causation, a conceptual blind alley.

The distinction between bodily illness and mental illness it is worth adding, is, anyway, readily drawn at the relevant level, i.e. of experience and/or behavior (Fulford, 1989, chapters 5, 7 and 8). Thus, bodily illness is concerned (mainly) with movements (e.g. paralysis), perceptions (e.g. blindness) and bodily sensations (e.g. nausea, dizziness, and pain), while mental illness is concerned (mainly) with the higher mental functions, such as emotion, desire, volition, belief and motivation. The distinction between mental illness and bodily illness, drawn in this (ordinary language) way, is entirely neutral, equally to the provenance of different causal theories (biological, social, psychological, etc), and to the many different philosophical propositions on the mind-body problem. It is also, as will be shown below (section on Outcomes), the basis for a positive way of understanding the more problematic use of mental illness compared with bodily illness, derived from philosophical value theory.

A LINGUISTIC-ANALYTIC REFORMULATION OF THE PROBLEM OF MENTAL ILLNESS. The problem of mental illness, then, to return to the starting point of this section, really is a problem in use rather than a problem of definition. There is a problem of definition, certainly, but it is a problem of definition of the generic concept of illness (including related concepts of pathology, such as disease, dysfunction and disorder) whether bodily or mental.

This reformulation of the problem can be further clarified in terms of the linguistic-analytic distinction between lower-level and higher-level concepts. Thus the traditional assumption, that difficulties in the use of the concept of mental illness have their origin in difficulties of definition, was based, as noted above, on twentieth-century successes, as in the US-UK Diagnostic Project, in solving difficulties in the use of psychopathological concepts by clarifying their definitions. The psychopathological concepts in question, however, were all, linguistic-analytically speaking, lower-level concepts—the lower-level delusion of guilt, for example, proved easier to define than the higher-level concepts of delusion and psychosis. From the perspective of the traditional assumption, this was an (unexplained) failure of the definitional program. From the perspective of linguistic analysis, by contrast, it is a reflection of a property common to all concepts, namely, that higher-level concepts in general, although used with often effortless facility, are peculiarly difficult to define.

A standard non-medical example is the concept of time. Most of the time, the concept is used (as in this sentence) seamlessly. Yet, if pressed, one would not be able to define it. Saint Augustine (354–430), the early Christian philosopher and Archbishop of Hippo, in his Confessions, said, "So what is (a) time? If no one asks me, I know; if they ask and I try to explain, I do not know" (Bk. II, ch. 14, No. 17). We can define lower-level concepts, of course: a watch face is, simply, the display side of a watch; a watch is, almost equally simply, an instrument for measuring time; but time is … here, as with the concept of illness, we get stuck.

We can extend the parallel with the concept of time. For with time, as with the concept of illness, there are contexts in which the concept does run into difficulties in use. In the case of illness, difficulties in use arise in psychological medicine. In the case of time, difficulties in use arise in theoretical physics, for example. In theoretical physics, the difficulties in use arise because the concept of time has to be used in contexts and at scales very different from those in which it developed. Some might argue for a broadly parallel explanation in the case of illness: the French philosopher and historian, Michel Foucault (1926–1984), for example, argued that the concept of mental illness arose by extension from that of bodily illness as a response to the work ethic of the industrial revolution (Foucault); and, as will be discussed in the Conclusions, there is indeed a sense in which the concept of illness is increasingly under pressure through scientific advances in medicine, much as that of time has been in physics. But Foucault's explanation, and others like it, all fail to explain the long history of difficulties about the concept of mental illness, stretching back, as indicated at the start of this entry, at least 2,500 years.

The question, then, that should be asked regarding the concept of illness, is not why it is difficult to define: this is an interesting question, philosophically, that we can indeed ask of higher-level concepts in general. But the question that should be asked is just why the concept of illness is relatively difficult to use in psychological medicine compared with bodily medicine. Reformulated in this way, furthermore, in linguistic-analytic terms, the problem is no longer a problem merely of mental illness at all. The challenge, for analysis, is, indeed, to explain why mental illness is relatively problematic in use. But there is an equal and opposite challenge to explain why bodily illness, although no less easy to define, is relatively un-problematic in use. So how should we go about this?

The Method: Philosophical Field Work

The method of linguistic analysis, noted above, of focusing on the use of concepts as a guide to their meanings, directly exploits the fact that, with higher-level concepts, people are better at using than defining them. Austin, whose now classic paper, "A Plea for Excuses," illustrates the linguisticanalytic approach, called this philosophical "field work" (Austin, p. 25). As already noted, linguistic analysis is neither unproblematic nor a panacea. There is, furthermore, no a priori reason why someone may not still come up with a definition, a neat formula or code, which encapsulates the full meaning of illness, higher-level concept as it is, and explains, even-handedly, its relatively problematic use in psychiatry and its relatively unproblematic use in bodily medicine. There is no a priori reason, similarly, why someone may not come up with a simple formulaic definition of some other related higher-level concept, such as health (Nordenfelt) or disorder (Wakefield). Nonetheless, linguistic analysis, as a method, can be used to good effect both negatively, to critique proposed definitions of mental illness and related concepts, and positively, to raise awareness of aspects of the meanings of these concepts which would otherwise tend to remain hidden.

NEGATIVE USE OF LINGUISTIC ANALYSIS: AS A CRITIQUE OF DEFINITIONS. Linguistic analysis, then, involves attending to language use. Normally we attend to the message. Linguistic analysis involves taking a step back, as it were, and attending to the language—to the actual words and phrases—in which the message is delivered.

As applied to proposed definitions, this stepping back and attending to language use can be helpful in its own right. Jerome Wakefield, for example, has argued in a series of impressively detailed articles (e.g., Wakefield, 1999, 2000), that dysfunction, as a component of his proposed definition of disorder (the other component is harm), can be defined value-free by reference to evolutionary norms. In this Wakefield stands in direct line of descent not only from Boorse, Kendell, Scadding and others in the debate about disorder (noted above), but also from a long line of philosophers working on the concept of function in biology (e.g., Neander; Thornton). Wakefield's enthusiasm and his rhetorical style make him a particularly effective current advocate of this approach. If one steps back, though, from his message and considers the words in which his proposed definition of dysfunction is actually expressed, it is possible to see that many of these are, in part, ambiguous as to factual and evaluative meaning. The terms in which Wakefield's definition of dysfunction are expressed, that is to say, can be used (as is required to support his claim to a value-free definition) descriptively; but they can also be used evaluatively. His definition includes the word "failure," for example (Fulford, 1999, p. 412). From a linguistic analytic perspective, then, there has to be a suspicion that while the rhetorical effectiveness of Wakefield's claim to a value-free definition of dysfunction is carried by presenting us with the value-free side of the meanings of these terms, the actual work (the linguistic work) of the concept of dysfunction as it is actually used (even by Wakefield) nonetheless depends (in part but essentially) on the evaluative side of their meanings (Fulford, 2000).

Others have succeeded in producing unambiguously value-free definitions of relevant terms. Boorse, for example, whose work was also noted above, defined disease stipulatively as a "… deviation from the natural (= statistically typical) functional organization of the species … " (1975, p. 59), adding, to cover endemic diseases, that disease should be "… mainly due to environmental causes" (1975, p. 59). Boorse's definition of disease, then, unlike Wakefield's definition of dysfunction, is indeed unambiguously value-free. But its persuasiveness, even as a stipulative definition, is undermined by the fact that Boorse himself continues to use the term disease with clear evaluative connotations. Thus his value-free criterion of statistical deviation becomes, only four lines later, the value-laden "deficiencies in functional efficiency" (1975, p. 59 [emphasis added]) and the value-free "environmental causes" becomes, again only a few lines later, the value-laden "hostile environment" (1975, p. 59 [emphasis added]). Boorse has rightly pointed out that this is very far from being a knockdown argument against his definition of disease (Boorse, 1997). But from a linguisticanalytic perspective it is at least suggestive that the meaning of disease, and hence the use that people (including Boorse himself) make of the term, does include an essential element of evaluation.

The slips that Boorse, and others (Fulford, 2000), make from value-free definition to value-laden use, can be understood in terms of the idea that words are, as Austin put it, "our tools" (p. 24). Based on this then, we can say that Boorse defines say, a hammer, stipulatively in terms only of its handle (equivalent to the fact part of the meaning of disease/dysfunction). But as soon as he has to use a hammer for real, the head (equivalent to the value part) becomes essential. Without the handle, to extend the analogy, the hammer cannot do the job we require of it; but the use that we actually make of a hammer for real, shows that the head (the value part) is essential as well.

Further examples of use providing a critique of definition are to be found in psychopathology. As already noted, the reliability of psychiatric diagnosis has been much improved by careful definition at least of lower-level psychopathological terms. The validity of psychiatric diagnosis, on the other hand, far from being improved, has in some cases actually been prejudiced by attempts to extend the approach of simple formulaic definition from lower-level to higher-level concepts. Delusion, for example, a term, as noted above, of central importance in descriptive psychopathology, is regularly defined in textbooks by criteria that transparently fail to encompass the full uses of the term in practice (Fulford, 1989, ch. 10).

The concept of psychosis, a step higher up the hierarchy than delusion, provides an even more dramatic example. In ICD-9 (World Health Organization, 1978), mental disorders were divided up (consistently with traditional descriptive psychopathology) primarily into psychotic and non-psychotic varieties. In ICD-10 and DSM-III (American Psychiatric Association, 1980), this primary division was abandoned on the grounds essentially that the concept of psychosis is resistant to operational definition, both classifications adopting instead a larger number of primary divisions (10 for ICD-10; 15 plus Personality Disorders and V codes for DSM-III). Closer inspection, however, shows that these new primary divisions contain, implicitly or explicitly, the traditional subdivisions into psychotic and non-psychotic categories (Fulford, 2003a). In other words ICD-10 and DSM-III are, so far as the psychotic/non-psychotic division is concerned, just ICD-9 and traditional descriptive psychopathology, turned upside down! The implication, linguistic analytically, is that the psychotic/non-psychotic distinction, difficult as the concept of psychosis is to define, continues, like the head of the hammer in the example above, to be essential to the set of conceptual tools that we need in speaking of psychopathology.

POSITIVE USE OF LINGUISTIC ANALYSIS: TO RAISE AWARENESS. The above examples should all be understood, on the linguistic analytic model, as showing, not that this or that proposed definition is wrong, but that it is incomplete. The continued use of a concept with a meaning that is denied or excluded in a proposed definition, shows that the meaning in question is, again like the head of a hammer in our example above, essential to the work that that concept does for us, linguistically speaking. Linguistic analysis, then, as a former Professor of Psychiatry at the Institute of Psychiatry in London, Sir Denis Hill, put it, is in this respect like psychoanalysis, a consciousness-raising exercise (personal communication). Examining the actual use of concepts for real thus helps to raise awareness of aspects of their meanings which, otherwise, would be neglected or ignored.

It is important to be clear that very little is claimed for this positive use of linguistic analysis. In the first place, examining the use of concepts, is, as Austin put it, in the title to an informal talk on the subject, no more than "… one way of possibly doing one part of philosophy" (Warnock, p. 6): or, again, ordinary language, although always the first word, "… is not the last word" (Austin, p. 27). Then second, linguistic analysis is no Royal Road to a grand unified theory. Like empirical scientific work, linguistic analysis is piecemeal, tackling doable projects, and satisfied with small increments in understanding. As Austin, again, pointed out, this means that the work of linguistic analysis, like the work of a scientific research program, can be broken down across a team or community of researchers, in contrast to the lone scholar model traditional in philosophy (Warnock, ch. 1). And all this in turn means, finally, that linguistic analysis can be connected with other methods, philosophical and empirical, with, as will be explored in the next section, outcomes that are well-grounded and directly relevant to policy, practice, training, and research in mental health.

Outcomes: From Meaning to Usefulness

Recent linguistic-analytically oriented work on the concept of mental illness has been focused on raising awareness of the role particularly of evaluation (of judgments of good and bad) alongside description in our psychopathological concepts. The American psychiatrist, John Sadler, for example, has carried out a detailed study of the epistemic values shaping the construction of the diagnostic categories of personality disorder in DSM-IV (Sadler, 1996). Such epistemic values include coherence, comprehensiveness, simplicity, instrumental efficiency, and relevance. Sadler explored the roles of such values in shaping DSM-IV, however, not by general speculation, but by careful analysis of the language of a foundational paper on the classification of these disorders by the man who, as noted above, was later to become chair of the DSM-IV taskforce, Allen Frances published in 1982. Frances, like the DSM taskforce itself (APA, 1994, p. xv), was concerned (rightly) with the evidence base of the classification of personality disorders. Work in the philosophy of science, though, suggests that proposals for classifying these disorders would be likely to be driven, also, by epistemic and other kinds of evaluation (Luntley). Sadler's analysis showed that this was in fact so, and it defined precisely the kind and impact of some of the values actually involved.

THEORY: A MORE COMPLETE VIEW. The significance of Sadler's work, consistently with the consciousness-raising outcomes of linguistic analysis, is not to undermine the scientific basis of psychiatric classification. It is rather to show how the science of diagnostic classification (to the extent that this is confined to the evidence-base of our classifications) is combined with (generally unrecognized but nonetheless logically operative) evaluations. The importance of this more complete view of what another Oxford philosopher Gilbert Ryle (1900–1976) would have called the logical geography of our classifications, is evident in the case history of Simon at the start of this article. DSM, despite its claims to being a descriptively-based classification, is shot through with evaluations (Fulford, 1994). The DSM (like ICD) is descriptive, of course; but it is also evaluative. And Criterion B, the criterion of social/occupational dysfunction at the heart of the DSM classification, which, as discussed above, turned out to be crucial to the differential diagnosis in Simon's story, is a case in point. An exclusively factual account of dysfunction requires that Criterion B be understood, like the symptoms in Criterion A, as a matter exclusively of evidence. But when it comes to social and occupational functioning, it is hard to avoid the conclusion that what counts as good or bad functioning is, in part, a matter also of value judgments. In Simon's case, then, the operative diagnostic criterion, as to the differential diagnosis between delusion and spiritual experience, was not a descriptive but an evaluative criterion.

This of course raises the question of why evaluation is so much more prominent in psychiatric classification and diagnosis compared with their counterparts in bodily medicine. The answer one gives to this question depends on which model of disorder one accepts. Szasz, at one extreme, argued, as noted above, that psychiatry is value-laden in this way because mental disorders are really moral not medical problems. Kendell, Boorse (1976), and others have argued that psychiatry is value-laden because it is at a primitive stage of its development as a science. Linguistic analysis suggests a third kind of answer, namely that it is because psychiatry is concerned with areas of human experience and behavior, such as emotion, desire, volition, belief, and sexuality, in which human values differ widely and legitimately.

Thus, values, according to this linguistic-analytic answer, stand alongside facts in the definition of diagnostic concepts in all areas of medicine, bodily as well as mental. But the conditions with which bodily medicine is typically concerned, like heart attacks for example, tend to be painful and life threatening, and, hence, bad conditions by anyone's standards. There is no Criterion B for a heart attack, therefore, not because there is no evaluative element in the diagnostic concepts used in cardiology, but because what counts as bad functioning in hearts is widely agreed upon, hence is not problematic diagnostically, and hence can (generally) be safely ignored in practice. Where, however, cardiology, and disciplines like it, are, in this sense, evaluatively simple, psychiatry is evaluatively complex. Psychiatry needs a Criterion B in cases like Simon's, therefore, or some equivalent evaluative criterion, because what counts as bad functioning in areas such as emotion, desire, volition, belief, and sexuality, is not widely agreed upon, hence is problematic diagnostically, and hence cannot be safely ignored in practice.

This linguistic-analytic interpretation of the more valueladen nature of mental illness, which we owe to yet another Oxford philosopher, R. M. Hare, provides at least one reason why, in terms of the linguistic-analytical reformulation of the problem of mental illness developed in the first part of this article, the use of illness is relatively problematic in psychiatry while being relatively unproblematic in physical medicine. It is now clear that this is not because bodily illness is easier to define than mental illness, still less because psychiatry is less scientific than bodily medicine, but because psychiatric diagnostic concepts are evaluatively more complex than diagnostic concepts employed in (most) areas of bodily medicine.

PHILOSOPHY INTO PRACTICE. The recognition that the concept of mental illness is, in the sense just outlined, evaluatively complex, has been the basis for a number of recent developments taking philosophical theory into the heartland of mental health practice.

In the United Kingdom, for example, new training programs, aimed at giving mental health practitioners the skills for effective decision making where legitimately different values are in play (Fulford, Williamson, and Woodbridge), have been developed within the National Service Framework, a policy document defining the U.K. government's core strategies on mental health (Department of Health). These training initiatives draw in particular on the principles and skills-base of Values-Based Practice (Fulford, 2003b), and on research combining linguistic analysis with empirical social science methods to explore the different models of disorder implicit in multi-disciplinary teams (Colombo et al.). They are also closely linked with recovery-oriented and other innovative user-centered approaches to the development and delivery of services (Allott et al.). On a wider international canvas, these initiatives connect with practicallyoriented research employing a growing number of other philosophical methods, including the German philosopher and mathematician Gottlob Frege's (1848–1925) logic of relations (Van Staden and Kruger), the use of discursive methods to reveal the meaning and intentionality implicit in the speech and behavior of Alzheimer's disease sufferers (Sabat), and a whole series of studies in phenomenological psychopathology (e.g., Musalek, Stanghellini).

Linguistic analysis, then, in itself and combined with other methods, empirical and philosophical, can help to clarify the place and roles of the evaluative elements of meaning in the concept of mental illness, adding finegrained, and hence potentially practically useful, detail to our understanding of the concept.

There is of course a good deal more to the meaning of mental illness (and of our concepts of disorder generally) than just this element of evaluation. Many of the most difficult problems in the use of the concept turn, indeed, not on whether someone is in a bad condition (as in Simon's case), but on whether they are in a bad condition of a kind that is properly thought of as an illness (the problems associated with the insanity defense, noted at the start of the entry, for example). The DSM, in an important caveat, rightly emphasizes that psychopathology is not defined by negative value judgments alone (DSM-IV refers specifically to social value judgments, APA, p. xxi–xxii). Values, then, as the DSM's caveat makes clear, although indeed necessary (along with facts) to the definitions of psychopathological concepts, are very far from being sufficient.

This brings the argument back to the wider debate about models into which, as noted above, the long-running historical tension between scientific and moral understandings of mental illness has resolved in recent decades. Coming back to this debate, though, within the now more complete view of the conceptual structure of medicine revealed by linguistic analysis, opens up to psychiatry an extensive resource of powerful philosophical methods for exploring the full richness and subtlety of its diagnostic concepts: besides analytic philosophy (e.g., Bolton and Hill), such methods include discursive analyses of the inter-personal creation of meaning (Gillett; Harré), hermeneutics (e.g., Widdershoven and Widdershoven-Heerding), existentialism (e.g., Morris), the phenomenologies of both Martin Heidegger (1889–1976) (e.g., Bracken) and Maurice Merleau-Ponty (1907–1961) (e.g., Matthews), and classical philosophy (Megone). Contrary to the causal blind alley, furthermore, noted above, research in these new areas of philosophical psychopathology (Graham and Stephens), as those most directly concerned have been among the first to recognize (Andreasen), is set to become more, not less, important with future advances in the neurosciences.

The practical impact of such research, it is important to add, understood within a (linguistic-analytically) more complete view of the conceptual structure of medicine, will not be to secure the dominance of any one model, medical, moral or otherwise; still less will it be to create a super model, an unstable oil-and-water amalgam of incompatible elements of meaning. The impact of such research will be, rather, to clarify, piecemeal but progressively, the elements of the different models and thus to endorse their roles as complementary ways of understanding what is, after all, at the center of mental healthcare, the distinct perspectives of individual people with particular experiences of mental distress and disorder. If mental illness is a complex and multifaceted concept, this is because, encompassing as it does such areas of human experience and behavior as emotion, desire, volition, belief and sexuality, it reflects the complex and multifaceted aspects of human nature itself. Psychiatry, above all among medical disciplines, is concerned, not just with bodies or with parts of bodies, nor even just with minds or with parts of minds, but with what the Oxford philosopher Kathleen Wilkes, in the title of her seminal 1998 book on the relationship between philosophy and psychopathology, reminded us are real people.

Conclusions: Psychiatry First

This article has explored the problems raised by the concept of mental illness through the lens of linguistic analysis as exemplified particularly by mid-twentieth-century philosophers of the Oxford school, such as J. L. Austin. Although not currently fashionable in philosophy in general, in relation to the concept of mental illness this approach has a number of clear implications, summarized here under problem, method and outcomes.

As to the problem of the concept of mental illness, linguistic analysis shows that this should be reformulated in terms of use rather than definition. The challenge is not, directly, to define the concept of mental illness, since the (relatively) unproblematic concept of bodily illness turns out to be no less difficult to define. The challenge, rather, is to explain, even handedly, why mental illness should be relatively problematic in use while bodily illness is relatively unproblematic in use, despite both concepts being equally difficult to define. The method suggested by linguistic analysis, correspondingly, is to focus on use rather than definition, to step back from the message (proposed definitions) and become more attentive to the language (the actual words and phrases) in which the message is expressed. This approach delivers no simple formulaic definition. Combined with other methods, though, philosophical and empirical, it has a number of outcomes relevant to policy, practice, training, and research in mental health. These outcomes, as illustrated in this entry, amount to one answer to why mental illness is relatively problematic in use compared with bodily illness, namely, because mental illness, in contrast to bodily illness, is concerned, characteristically, with areas of human experience and behavior, such as emotion, desire, volition, belief, and sexuality, in which human values differ widely and legitimately.

k. w. m. fulford

SEE ALSO: Medicine, Anthropology of; Mental Health, Meaning of Mental Health; Mental Health Services; Mental Institutions, Commitment to; Mentally Disabled and Mentally Ill Persons; Psychiatry, Abuses of; Psychopharmacology;Psychosurgery, Medical and Historical Aspects of; and other Mental Illness subentries

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