Jelena Krgović SARTREAN ACCOUNT OF MENTAL HEALTH ABSTRACT: The anti-psychiatrists in the 1960's, specifically Thomas Szasz, have claimed that mental illness does not exist. This argument was based on a specific definition of physical disease that, Szasz argued, could not be applied to mental illness. Thus, by problematizing mental illness, the spotlight had turned to physical disease. Since then, philosophers of medicine have proposed definitions applying both to pathophysiological and psychopathological conditions. This paper analyzes prominent naturalist definitions which aim to provide value free accounts of pathological conditions, as well as normative accounts which propose value-laden accounts. The approaches surveyed differ not only in terms of value, but also in terms of their perspective. This perspective concerns whether the concept of health, illness or disease/disorder is emphasized. The emphasis on health or illness is holistic as it looks at the human being as a whole, while focus on disease or disorder is analytic as it considers part functions. I will here argue in favor of holism and will propose a definition of mental health based on Sartre's existential psychoanalysis of Gustave Flaubert. KEYWORDS: Mental disorder, mental health, pathological condition, dysfunction, holism, Sartre. Introduction Contemporary concerns in psychiatry involve, among other issues, medicalization of the human condition. Wakefield and Horwitz (2007, 2012) have argued that the Diagnostic and Statistical Manual of Mental Disorder1 (DSM) IV and 5 have pathologized normal human suffering by not allowing that external stressors such as a loss of a job can be the reason for depression-like symptoms (DSM IV), and by removing the bereavement exclusion (DSM 5). In order to distinguish between normal suffering and depression, we need to first investigate what constitutes mental disorder. The first part of this paper will analyze prominent naturalist and normativist accounts of malady concepts. I here borrow Culver and Gert's term "malady" (1982) as an umbrella term for concepts of illness, disease, 1 DSM is published by the American Psychiatric Associations (APA) and lists the classification of mental disorders used in the US. World Health Organization (WHO) publishes International Classification of Disease (ICD). ICD 11 is to be published in 2018. THEORIA 3 BIBLID 0369–2485 : (2017) : 60: str. 17–31 https://doi.org/10.2298/THEO1703017K Originalni naučni rad Original Scientific Paper 18 Sartrean account of mental health disorder and pathological condition, since philosophers disagree on the matter of which concept should be emphasized. Naturalist accounts of mental disorder aim to provide value-free definitions and rely on biological function. These accounts are also analytic since they are focused on part-functions of human organism. On the other hand, normativist accounts claim that definitions of mental disorder at least in part involve values. Normative accounts are also often holistic as they are focused on the human being as a whole. The second part of the paper will argue in favor of a definition of mental health based on Sartre's existential psychoanalysis of Gustave Flaubert. In particular, this definition of mental health is based on the abilities required to have a meaningful life and, as such, it is part of the "embedded instrumentalism" (Richman, 2004) accounts of health, where health is defined in terms of how well an individual can fulfill her goals. Part I Naturalist and normative accounts of malady Psychiatry had faced significant challenges in the 1960's. Psychiatrists, as well as prominent intellectuals, argued that mental illness is nothing more than a learned abnormality of behavior (Hans Eysenck), a sane response to an insane environment (Ronald Laing), a response to being labeled as deviant (Thomas Scheff), or a means of social control (Foucault, Szasz). Thomas Szasz's critique (1974) is interesting for our purposes as he argued that mental health was a myth. He claimed that mental illness can only be an illness if there are physical lesions in the brain. Since there are no lesions, there is no mental illness. Rather, those labeled as mentally ill are suffering from problems in living. Szasz's view rests on the understanding of illness and its correlate disease as involving anatomical and physiological changes. However, disease can be defined by referring to biological function rather than anatomy and physiology. This is exactly the approach that Christopher Boorse took, explicitly referring to Szasz's view when he wrote: "... with Szasz and Flew, I shall assume that the idea of health ought to be analyzed by reference to physiological medicine alone" (Boorse, 1975). Boorse then agrees with Szasz that definition of malady should be value-free and seeks to provide a value-free definition of a pathological condition which corresponds to the medical use of the term. Initially, Boorse distinguished between illness and disease in order to differentiate between medical theory, which he claims to be value-free, from medical practice, which he recognizes as value-laden. He has since modified his view by substituting the term "disease" with "pathological condition" since the latter is a broader concept as it includes, in addition to disease, injuries, poisonings, and birth defects. In addition, Boorse has withdrawn his analysis of illness, but has introduced disease-plus concepts such as diagnostic abnormality and therapeutic abnormality, which I will explain shortly. Most recently, Boorse defines pathological condition as a "state of statistically species-subnormal biological part-dysfunction, relative to sex and age". (2014, 3) 19Jelena Krgović 1. The reference class is a natural class of organisms of uniform functional design; specifically, an age group of a sex of a species. 2. A normal function of a part or process within members of the reference class is a statistically typical contribution by it to their individual survival [or] reproduction. 3. Health in a member of a reference class is normal functional ability: the readiness of each internal part to perform all its normal functions on typical occasions with at least typical efficiency. 4. A disease [later, pathological condition] is a type of internal state which impairs health, i.e. reduces one or more functional abilities below typical efficiency. (Boorse, 2014, see also, 1977, and 1997) This means that health is a normal function, i.e. statistically typical contribution to survival or reproduction relative to age and sex. Boorse had initially claimed that the goals are survival and reproduction, but has since modified his position (2014) because reproductive functions such as pregnancy can jeopardize survival, and people can have diseases past their reproductive age. Pathological condition is part-dysfunction and so value-free because none of its components requires values. As Boorse writes: "...if diseases are deviations from species biological design, their recognition is a matter of natural science, not evaluative decision" (1977, 543). Presence of pathology on its own implies nothing about necessity of treatment since the Bio-Statistical Theory (BST), as Nordenfelt (1987) named it, is meant to provide a theoretical definition of pathological condition, rather than a practical one or, in other words, to distinguish between absence of disease and absence of treatable disease (Boorse, 2014). What is needed in order to decide whether to treat a pathology are Boorse's disease-plus concepts I have mentioned previously. The first of his two concepts is diagnostic normality, which signifies an absence of clinically detectable pathological condition. The second concept is therapeutic normality, which signifies an absence of diagnostic abnormality worthy of treatment. These two disease-plus concepts do not enter the analysis of theoretical health.2 To illustrate how Boorse's definition works, I will use Elselijn Kingma's (2013) example of vision. Suppose that visual perception can be interpreted as the mind's understanding of visual information which facilitates tracking of the environment. This is a statistically typical contribution the mind makes to survival or reproduction. If I am as accurate in interpreting visual information as others in my age and sex group, my vision functions normally and so I am healthy. If, on the other hand, my visual information involves hallucinations, then this is a case of atypical failure in tracking the environment (in 2 In addition, Boorse also recognizes societal value-laden disease-plus concepts such as criminal insanity, civil incompetence and disability. (Boorse, 2014) 20 Sartrean account of mental health contrast to optical illusions which are typical) and, thus, in Boorse's account, I would have a disorder as my visual perception is functioning below typical efficiency. The virtues of BST are that it applies to all organisms as well as that it is clearly based on science. On the other hand, BST has been criticized on account of biological function used, the goals of survival and reproduction (Nordenfelt, 1987), inability to account for universal disease (Guerrero, 2010), inability to account for environmental variation as well as the choice of reference classes (Kingma, 2013). The main objection has been that Boorse does not succeed in providing a value-free definition of pathological condition. The critics claim that both the choice of goals (Engelhardt,1976) and the choice of reference classes (Kingma, 2013) are value-laden. BST needs reference classes in order to determine normal functioning given the differences between normal functioning of a toddler and an adult human being as well as differences between sexes. However, Kingma claims that BST cannot explain why sexual orientation, for example, is not a reference class. If it were, homosexuality would not classify as a pathological condition. However, on the BST account, homosexuality3 would be a pathological condition because it is worse than typical in terms of contribution to reproduction. Kingma's claim is that Boorse cannot give a non-circular and value-free justification for the BST's choice of reference classes. Boorse has since replied to this objection (2014) which I will not examine here. Instead, I want to draw attention to another issue with reference classes and statistical dysfunction. Schwartz (2007) argues convincingly that Boorse's references classes coupled with statistically measured normal biological functioning entail that any pathology, such as prostate cancer, that may be typical in older men will not count as pathological, which goes against the medical view. Furthermore, substituting the age reference class with young adults doesn't solve the problem as menopause would then be a pathological condition. The reader will have noticed that we have introduced BST as an account that would explain mental disorder. However, as the discussion illustrates, Boorse's elaboration of BST has turned to physical disease. He does, though, provide some guidelines as to how to apply BST to mental health and disorder provided that physiology has a parallel in psychology; in other words, that there are psychological part-functions with species typical contributions to reproduction or survival. (2011, 29). He thinks that good examples of an account of psychological part-functions are given by Freud's psychoanalysis and evolutionary theory. On the other hand, Boorse does not explain why, if a theory should provide a system of psychological part-functions, these functions need to make species typical contribution to survival or reproduction, i.e. biological goals, rather than psychological goals whatever those may be. Moreover, as Kingma argues, one would have to justify a choice of a particular account of part-functions in value-free terms if there were a choice between accounts. On the other hand, Radden (2009) worries about the choice 3 Boorse, as Kingma also acknowledges, claims that homosexuality, even though a pathology, is not a bad thing and so should not be treated. Boorse claims that he has never called homosexuality pathological, but rather that he suggested that it might be. (Boorse, 2014, see also 1975, 63). Homosexuality was removed from the DSM in 1980. 21Jelena Krgović of reference class with respect to mental disorder. She thinks that reference classes would track beliefs. If this were the case, differences in spiritual beliefs would lead to problems. Radden gives an example of a group of people X who believe in an afterlife, a group Y who don't believe in an afterlife and have a tragic view of life, a group Z who are agnostic and believe in having a dignified attitude in any circumstance. I don't think it is necessary that mental disorder reference classes track beliefs and worldviews unless we specifically sought to investigate which beliefs are worse than typical in contributing to survival or reproduction. This, however, would face too many problems, especially given the variety and potential cultural differences that might result in some cultures imposing views on other cultures. If we are following BST to the letter, reference classes for physical disease are necessary because babies can't walk, as are the differences in reproductive functions between sexes. If any reference classes were chosen on the basis of beliefs for example, BST would no longer be a value-free account. On the other hand, reference classes for mental disorder cannot be based on sex as this would presume that men and women differ psychologically, rather than those differences, assuming there are any, being a product of society. Thus, the only reference class left would be age, given differences between infants and adults. Yet, we still need an account of mental functions. To examine a definition of mental disorder very much in alignment with BST, we will turn to Jerome Wakefield's view, which provides an evolutionary account of functions. Wakefield gives a definition of physical and mental disorder in terms of harmful dysfunction (HD). A disorder is a term that is meant to cover all medical conditions, including diseases and traumatic injuries. Wakefield wishes to analyze the concept of disorder as used in physical medicine. (1992b, 233) While Boorse and Reznek aim to define pathological condition, Wakefield, as Boorse notes, may have in mind a partially clinical concept of disorder given that he views disorder as a practical concept meant to "pick out conditions that are undesirable and grounds for social concern". (1992b, 237, see also Boorse, 2011, 32) For Wakefield, a mental or physical state is a disorder if: a) it is "harmful, that is negative as judged by social values, and b) caused by a dysfunction, that is a failure of psychological mechanism to perform its function, in the sense of biological function" (Wakefield, 2005, 891). While BST was only concerned with theoretic account of pathological condition, HD, by including a harm clause, addresses the concern of many a normativist – that diseases/disorders are bad things to have. It is important to point out that this account is also a naturalist one like BST, since both conditions for disorders involve facts – the first condition involves social facts, and the second biological ones. But, the harm clause seems redundant. This is because Wakefield agrees with Boorse that the issue of whether a condition is pathological or not has no therapeutic or social implication. Wakefield writes: "the status of a condition as disordered or nondisordered from the HD or any other perspective has no necessary implication for the priority the condition deserves with respect to treatment, prevention, or policy". (1999a, 374) Wakefield does not spend much time discussing the harm condition, but instead concentrates on dysfunction. Drawing on biology and evolutionary psychology, dysfunction 22 Sartrean account of mental health is defined as "failures of mechanisms to be capable of performing their functions under environmental circumstances for which the mechanisms were designed to perform such functions" (2005, 893) Wakefield illustrates the application of HD by giving examples that show how it can account for disorders given in DSM IV (1994). For instance, Wakefield explains psychotic disorders as failures of thought processes to work as they were designed, anxiety disorders as failures of anxiety and fear-generating mechanisms, etc. The worry here is with the HD basis on evolutionary function. Surely a person suffering from a psychotic disorder is not thinking clearly and is not rational, but that is insufficient for us to stipulate from the arm chair alone as to what mechanism may have become dysfunctional. There is a danger of positing mechanisms which just aren't there. When it comes to fear, for instance, it is plausible to claim that there is an evolutionary mechanism that developed in order to signal and warn of danger. However, when we think of anxiety, this is not at all so obvious. I understand anxiety here in Sartrean terms, according to which fear involves an acknowledgement of an imminent threat and danger, whereas anxiety is a fear of one's own possibilities. For Sartre (1943), anxiety is awareness of our freedom awareness that we have to choose what to make of our lives and accept responsibility for our choices. This anxiety especially appears when a project pursued breaks down, and then the individual must choose who to be yet again. It is unclear in what sense evolutionary perspective can explain such anxiety. Rather, it seems like it is more that we are seeing people having anxiety disorders and then we come to the conclusion that there is in fact a mechanism that controls anxiety, but this is obviously not warranted. Wakefield, importantly, does not claim to explain what mechanisms underlie each disorder. Instead, he uses black box essentialism to stipulate the existence of a hidden mechanism that is yet to be discovered and which would explain why these mechanisms he claims we have stop functioning. This is problematic. What needs to be shown in order for Wakefield to use black box essentialism is that there are in fact mechanisms that explain all mental disorders, and how we have developed these mechanisms. As Houts (2001, 1114) points out: "From the standpoint of evolutionary biology, the claim that thought or that any other psychological construct has a distinctive function, which explains why it exists, is simply vacuous speculation. We have absolutely no idea what brought thought into existence, and even if we did, we have no warrant for saying that those original conditions can provide a standard for judging whether or not thought has dysfunctioned in the present." Houts finds that Wakefield's definition of dysfunction leads to invention of mechanisms that supposedly failed to function properly and believes rightly that this is pseudoscience as it cannot be falsified. Houts further points out that Wakefield keeps comparing designs of artifacts with design by evolution. Wakefield is here clearly mixing what is selected and the function or purpose for which it is selected. I also want to mention another issue brought up by Bolton (2013), which concerns the separation between social and natural. Wakefield's analysis rests on the assumption that natural functions can be separated from social functions. However, Bolton claims that 23Jelena Krgović is not possible for the following reasons. First, evolution occurs within societies, which makes it the case that some evolved functions will be social such as social collaboration, mating etc. The second reason is that physiological and behavior phenotypes are not produced only by environmental and social condition nor are they only natural functions, but an interaction of the two. The dichotomy of nature versus nurture, according to new developments in genetics, has given way to the view that the two influences interact. Moreover, Bolton claims that the current genetics also recognizes a third kind of influence on one's makeup and that influence is individual choice. Bolton also stresses the fact that mental disorders are identified on the basis of the activities in which they operate, which means that the "breakdown really is in the personal and social activities which then brings us back to the fundamental importance of personal and social phenomenology in the attribution of illness and disorder". (p. 444) Now, here are the two main problems I see with Wakefield's HD, following this discussion: the epistemological problem and the problem of separating the social from the natural – i.e. that we do not know which evolutionary developed functions humans have, and that it may very well be impossible to separate those functions from the social functions. This points to the need to acknowledge that our "nature" does not only include our biological and evolutionary functions, but involves culture as well. As Sartre (1971a) shows in relation to his concept of the singular universal, it is through socio-historical culture that we become human. Any definition of mental disorder will have to incorporate the social and cultural dimension but will also have to provide an account as to what constitutes mental health. Even though we do not know what evolutionary functions people have developed, we can know what kind of psychological capacities are needed for us to be mentally healthy and able to have meaningful lives. Before explaining this in detail, I turn to two normative accounts of mental disorder. Lawrie Reznek (1987), a philosopher and a psychiatrist, argues that definitions of malady involve values because diseases as well as pathological conditions are not natural kinds. Reznek claims that there are no qualities that separate pathological conditions from non-pathological ones. This is because dysfunction is not a necessary condition for disease nor a sufficient one for pathological condition. It is not necessary for being a disease because organisms have traits which are not functions. Human appendices no longer have a function and traits could be acquired as a by-product of natural selection. Reznek also gives an example where a menopausal woman can no longer contribute to biological fitness and, therefore, her organs would have no functions. However, we would still think that the woman could have a disease, even if there was no dysfunction. In order to show that dysfunction is not a sufficient condition, Reznek imagines a case in which a self-destructive function has been naturally selected. Suppose that a group of people were to become infected with a virus, for example, and as result lived to be 200 years old – we wouldn't consider this a disease. Also, supposing we didn't know what interfered with the self-destructive function, there would be no pathology. If it is the case that necessary 24 Sartrean account of mental health and sufficient conditions cannot be given for a pathological condition, what then? Reznek claims that we should use Wittgenstein's family resemblance as we can certainly analyze the meaning of the pathological condition. He provides the following definition: "A has a pathological condition C if and only if C is an abnormal bodily/mental condition which requires medical intervention and for which medical intervention is appropriate, and which harms standard members of A's species in standard circumstances." (Reznek, 1987, 167) Reznek argues that what makes a condition pathological is the harm it produces rather than the dysfunction. In his view, functions can be detrimental and even kill an organism. An example (Reznek, 1987, 159) is a species of octopus wherein a reproductive function kills the mother octopus. This particular species of octopus has an endocrine organ that shuts off the octopus mother's appetite once she has laid eggs, so that she can focus all her attention on the eggs until they hatch, after which she dies. Removal of the organ allows the octopus to live an octopus-long life, even though she is not as perfect mother. So, the function of the endocrine organ is harmful to the octopus. Reznek defines harm involved in a pathological condition as follows: "X does A some harm if and only if X makes A less able to lead a good or worthwhile life." (1987, 153) Reznek wishes to apply his analysis of pathological condition to all organisms which he believes to have some welfare defined by their flourishing. When it comes to humans, their welfare "consists in satisfaction of worthwhile desires and the enjoyment of worthwhile pleasures". (ibid., 151) The following qualifications are added to the account: a) species reference class as what is harmful to one species is adaptive to another; b) standard circumstances as special circumstance may make diseases harmless as someone with hemophilia may never be in circumstances in which she is exposed to the harm of it; c) pathological conditions harm only standard members of the species, and not all of them a woman who does not wish to have children may welcome infertility; d) medical treatment for pathological conditions is both necessary and appropriate. This is because there are harmful conditions which are not pathological, like starvation. If Reznek did not add the clause that a medical treatment is necessary, starvation would qualify as pathological. In addition, medical treatment must be appropriate, because there are conditions which may be medically treatable but which should not be. For example, suppose we discover that all criminal behavior can be prevented by performing frontal lobotomy. Reznek claims that, given that we view criminal behavior as freely chosen, medical treatment would not be appropriate in this case. There are several criticisms of Reznek's analysis. The first of the ones I will list concerns environmental relativity. As I have previously mentioned, what is pathological in one environment need not be so in a different one. The critics charge that this confuses disease with what causes it. For instance, Boorse asks whether a Pygmy's size would become pathological if he began living with the Maasai people? (Boorse, 2011, 51). Another issue concerns values. For example, Reznek claims that patterned scars in African culture are not pathological because they are deemed attractive. However, if this is so, Boorse points out that effects of clitoridectomy in African girls would not be pathological insofar as 25Jelena Krgović they make the girls better off in their societies. (ibid.) This is certainly an issue, as Reznek wants to be able to say that drapetomania (the diagnosis given to slaves if they tried to run away in the US South) is not a mental disorder. Despite the obvious problems, I do agree with Reznek that whether a condition is pathological or not will be related to welfare. Several philosophers have argued that health should be defined as roughly the ability to achieve vital goals (Nordenfelt, Pörn, Richman). I will propose a similar definition. First, I wish to examine Fulford's definition because it emphasizes illness, and its problems show that subjective experience of malady is insufficient as a basis for an account of malady. Bill Fulford, also a psychiatrist, aims to analyze "everyday use" of medical concepts common to physicians and laypeople. He argues that someone is ill if she experiences a failure of action. Rachel Cooper summarizes Fulford's position as follows: "Illnesses are states that directly interfere with ordinary action, or states characterized by unpleasant sensations that cannot be stopped by normal action." (Cooper, 2007, 53) By ordinary actions, Fulford means the action "we just get on and do" (Fulford, 1989, 116), drawing on J. J. Austin's philosophy. Fulford believes his analysis can apply to illnesses which involve unpleasant sensations as well as those which do not. He claims that there is a difference between pain-as-illness and normal pain, where the former is such that "one is unable to withdraw in the (perceived) absence of obstruction and/or opposition." (ibid, 138) Fulford's analysis is meant to apply both to physical and mental illness, so that physical illness involves failure of physical actions, whereas mental illness involves failure of ordinary mental actions. The concept of disease is derived from illness, and is such that disease is involved in producing illness in various ways. He calls this the "reverse view" as it is contrary to the medical approach. While Fulford is right in that what matters about maladies is how they affect us, his view has several issues. Rachel Cooper shows that disfigurement cannot qualify as an illness because it does not directly interfere with someone's ability to act. This is because disfigurement may be a result of a wound or a birth defect and so is properly classified as a condition rather than a disease. Diseases are processes, disfigurement is not. Thus, not all diseases, which all are linked to illnesses, lead to action failure. Another problem is that many pathologies are not experienced so the person with a pathology does not experience the inability to act. In addition, it is questionable that Fulford's analysis can apply to mental illness. As Boorse (2014) mentions, most insane killers fully intend to kill their victims, and fully act in doing so. Psychopaths are a case in point. This leaves Fulford unable to explain how psychosis can involve a failure of ordinary doing if it does not prevent acting. Fulford is also unable to account for lack of insight which is a symptom in some mental disorders. Moreover, as Nordenfelt points out, experience of action failure is not necessary for illness, given that one cannot experience anything while one is in a coma. Boorse (2014) claims that illness is too narrow a concept to define disease. Cataract and macular degeneration are diseases that cause blindness, but blindness is not an illness. 26 Sartrean account of mental health This leads Boorse to claim that any analysis of disorder-related concepts needs to involve both a holistic and analytic component. In other words, the holistic element needs to be related to the biological part-dysfunction. I do think that Boorse is right in this. However, since I am concerned only with defining mental health, my claim is that we need an account of mental health that combines psychological capacities necessary for a meaningful life. As Eric Matthews (2013, 537) states, most psychiatric disorders are diagnosed on the basis of their effects on the individual's life, whether these effects are seen in terms of the individual's experiences of the world or in terms of individual's social functioning (e.g. one's ability to maintain relationships, function in society etc.) rather than in terms of biological dysfunctioning of the brain. Part II Sartrean Account I am basing my account of mental health on Sartre's existential psychoanalysis of Gustave Flaubert "The Family Idiot". This work, while too long with its roughly 3000 pages, is Sartre's most extensive psychoanalysis, and my application of it will concern not whether Sartre's understanding of Flaubert's life and his illness was correct, but rather, what criteria Sartre used to make this judgment. While Sartre's early works have been criticized on account of radical freedom he ascribed to people, even though one could plausibly argue that his early position is compatibilist (Sutton Morris, 1976), his later work does not have this problem, and is the basis of my account. I have so far suggested that an account of mental health should involve psychological goals, rather than biological ones. The first question is Sartre's position on this matter4. Even though Sartre denies that humans have a fixed nature, he has from his earlier works onward claimed that there is a "universal human condition" (1946), which entails that all of us have to live, work, die etc. His later position, and the basis of his second ethics (Anderson, 1993), is based on needs. He thinks of needs not simply as a lack of a certain object, but as a "felt exigency". As Anderson explains, the needs are such that an organism, by surpassing and negating them, affirms its own integrity and its "duty-to-be". Thus, from needs the "first normative structure" appears and "by need, which demands to be satisfied, human life is given to be reproduced by man." (Sartre, 1961, 98, as quoted in Anderson, 1993, 120) It may seem that Sartre identifies human needs with animal needs when he claims that animal needs become human needs within a society and through culture, which is not quite so. It is through culture that we become human. The difference between human and animal needs is that any animal needs of humans can only be fulfilled in human culture and society. So, some of our needs are biological, others are not, but the two are inextricably intertwined. However, Sartre does make a distinction between a "nude" human being understood as a member of human species and a human being who is part of a certain society. Thus, when he speaks of basic human needs, he is speaking of basic 4 My exposition of Sartre's views is based on Anderson's (1993) discussion. 27Jelena Krgović human needs of the nude human being, stripped of the characteristics she has by virtue of belonging to a specific culture. In The Family idiot, he claims that a man is never simply an individual, but is a singular universal, or a universal singular. He writes: "For a man is never an individual; it would be more fitting to call him a universal singular. Summed up and for this reason universalized by his epoch, he in turn resumes it by reproducing himself in its singularity. Universal by the singular universality of human history, singular by the universalizing singularity of his projects, he requires simultaneous examination from both ends." (1971a, ix) This means that a person is always conditioned by the specific social and historical conditions of her time as well as, and importantly so, being a particular and individual response to that conditioning. On the basis of this, he then proceeds to claim that the goal of all human actions and history is human fulfillment, i.e. integral humanity, which is reminiscent of Aristotle's claim that the goal of all people is happiness, understood as the fulfillment of their natural and human natures. (Anderson, 1993, 123) How does this apply to mental health? First, Sartre claims that the goal of our endeavors is fulfillment, and that we all share certain needs. The question now is which needs are the basis of mental health. Here we turn to The Family idiot. Sartre understood Flaubert as someone who failed to perceive himself as an agent in the world. He thought that this was a result of the passivity he developed as a result of his mother's loveless care for him and his father's judgment that he is an idiot because he didn't learn to write at the expected age. As Anderson writes, "he does not recognize himself as a free praxis capable of changing reality, and that is why he seeks to flee to the imaginary". (1993, 140) I will not here analyze Sartre's diagnosis of Flaubert, but, as I previously stated, wish to determine which needs Sartre thinks we need in order to be fulfilled. Sartre claims that infants must be able to experience their needs as "sovereign demands" on the world and so as rudimentary projects and actions. (ibid.) In order to be able to recognize themselves as such, they need to be recognized by others as potential agents who can act on the world so as to achieve their goals and fulfill their needs. Additionally, the love of others is necessary for them so that they are assured that they have something worth doing, i.e. a worthwhile purpose in life. Sartre sees the need for love as fundamental to one's development as an agent. As he writes: "Briefly, the love of the Other is the foundation and guarantee of the objectivity of the individual's value and his mission; this mission becomes a sovereign choice, permitted and evoked in the subjective person by the presence of self-worth." (1971a, 135) This means that the individual who is so loved will be grounded in reality and will develop as someone who sees objective worth and value in herself as an agent. This is what enables one to experience one's being-for-self and being-for-others in an authentic way. On the basis of this brief exposition, we can say that the needs Sartre finds necessary for a fulfilling life are: self-love (I assume, following Sartre, that the ability for self-love is necessary and sufficient for being able to love others); the ability to recognize oneself as an agent with a purpose; and the epistemological ability to determine the truth about one's being-for-others. Sartre understands needs as being relational, i.e. as involving other 28 Sartrean account of mental health people. Defining health in terms of needs is not new. Maslow's account is based on needs. Freud has also based his psychoanalysis on needs of love and hunger. Freud took hunger to concern self-preservation, whereas love referred to the preservation of the species. (Freud, 1899, 1910, 1917) Both Maslow and Freud trace their respective accounts of needs to drives. Instead, I have argued that we should talk of psychological capacities. Thus, the needs we have described arise of psychological capacities to love, to act on the world and epistemological capacities that enable people to live fulfilling lives. The capacity to act on the world entails that one cannot be closed off in her own subjectivity but should act on the world5. As explained previously, Sartre understood people as universal individuals. This does not simply mean that one is affected by the world, but also, that the subjective goals have to be situated in the world and relate to it. Mental health will then involve both objective capacities, as well as fulfillment which relates to goals one choses for oneself. Mental disorder is inability to achieve fulfillment as a result of one's capacities, rather than socio-political factors. This account can accommodate the normative view that health is good for us, while maladies are bad, while also containing an objective component which concerns having certain capacities. In conclusion, I have shown that naturalist as well as normative accounts face problems. Naturalist accounts need to explain what psychological functions we have in order to provide an informative definition of mental disorder. On the other hand, normative definitions have a problem of illness being too narrow a concept (Fulford), and of harm being culturally relative (Reznek). Finally, by relying on Sartre's analysis of Flaubert, I have provided an account of mental health based on human capacities that enable us to pursue fulfilling lives. Rather than focusing on part-functions, this account is holistic, as it looks at the human being as a whole by focusing on the goals one chooses to pursue. Jelena Krgović References: American Psychiatric Association, 2000. Diagnostic Statistical Manual of Mental Disorders. Fourth edition, Text Revision. (DSM-IV-TR). 2013. Diagnostic Statistical Manual of Mental Disorders. Fifth edition. (DSM-5). Anderson, Thomas C. 1993. 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"The concept of mental disorder: on the boundary between biological facts and social values", American Psychologist 47:373-388. 1992b. "Disorder as harmful dysfunction: a conceptual critique of DSM-III-R's definition of mental disorder", Psychological Review 99:232-247. 1999. "Mental disorder as a black box essentialist concept." Journal of Abnormal Psychology, 108:465-472. 2005. "Biological function and dysfunction" in Foundations of Evolutionary Psychology, ed. Buss, D, 878-902. John Wiley and Sons. Zachar, Peter. 2000. "Psychiatric Disorders are not Natural Kinds," Philosophy, Psychiatry and Psychology 7 (3) (September): 167-182. 31Jelena Krgović Sartrovsko shvatanje mentalnog zdravlja (Apstrakt) Psihijatrija je šezdesetih godina prošlog veka bila osporavana kao grana medicine. Antipsihijatri, među njima Tomas Sas, tvrdili su da mentalna bolest ne postoji. Ovaj argument zasnivao se na određenoj definiciji fizičke bolesti koja se, Sas je tvrdio, ne može primeniti na mentalne bolesti. Tako je problematizovanjem mentalnih bolesti, središte pažnje okrenuto na fizičke bolesti. Filozofi medicine su otada predložili definicije kako za patofiziološka tako i za psihopatološka stanja. Ovaj rad analizira značajne naturalističke definicije koje su takve da isključuju vrednosti, kao i normativne koje vrednosti uključuju. Ovi pristupi se, pak, ne razlikuju samo po pitanju vrednosti, već i po pitanju perspektive. Perspektiva se odnosi na to da li je naglašen pojam zdravlja, subjektivni doživljaj bolesti ili naučno objasnjenje bolesti6. Naglasak na zdravlje ili subjektivni doživljaj bolesti predstavlja holistički pristup jer posmatra ljudsko biće kao celinu, dok je fokus na naučno objašnjenje bolesti analitičan jer razmatra parcijalne funkcije. Rad će izložiti argumente u prilog holizmu i predložiti definiciju mentalnog zdravlja baziranu na Sartrovoj egzistencijalnoj psihoanalizi Gistava Flobera. Ključne reči: Mentalna bolest, mentalno zdravlje, patološko stanje, disfunkcija, holizam, Sartr. 6 Kako u srpskom jeziku ne postoji ekvivalentan termin engleskom „illness", pojmovi „illness" i „disease" su prevedeni kao „subjektini doživljaj bolesti" i „naučno objašnjenje bolesti" u skladu sa značenjima ovih pojmova.