The skill of mental health. The skill of mental health Towards a new theory of mental health and disorder Garson Ledera (leder.garson@gmail.com) Tadeusz Zawidzkib (zawidzki@email.gwu.edu) Abstract This paper presents a naturalist skill-based alternative to traditional function-based naturalist theories of mental health and disorder. According to the novel skill view outlined here, mental health is a skilled action of individuals, rather than a question of the functioning of mental mechanisms. Mental disorder is the failure or breakdown of this skill. This skill view of mental health is motivated by focusing on the process of mental healing. This paper argues that, when we start with a focus on how and why individuals heal from mental disorders, we gain a better understanding of what mental health is: the exercise of self-regulatory metacognitive skill. Keywords Mental disorder ∙ Mental dysfunction ∙ Mental health ∙ Skill ∙ Stigma This article is part of a special issue on “Models and mechanisms in philosophy of psychiatry,” edited by Lena Kästner and Henrik Walter. 1 Introduction While it is generally agreed that mental disorders are a serious problem, there is far less agreement about what the problem actually is. What exactly is disordered about mental disorders? The answer is normally situated somewhere between the naturalist/normative divide. Naturalism, roughly, is the position that mental disorders are value-independent, scientifically identifiable and explainable mental phenomena. Normative theories of health conceive of mental disorder as primar- ily a problem of the meanings attached to behavior and bodies; whether some way of being is a mental disorder is primarily a question of value judgments about aCenter for Bioethics and Medical Humanities, Medical College of Wisconsin. bDepartment of Philosophy, The George Washington University. Leder, G., & Zawidzki, T. (2023). The skill of mental health. Philosophy and the Mind Sciences, 4, 3. https://doi.org/10.33735/phimisci.2023.9684 ©The author(s). https://philosophymindscience.org ISSN: 2699-0369 https://philosophymindscience.org https://orcid.org/0000-0003-1350-1579 https://doi.org/10.33735/phimisci.2023.9684 https://creativecommons.org/licenses/by/4.0/ https://philosophymindscience.org Garson Leder and Tadeusz Zawidzki 2 norm-transgressing behavior. Hybrid theories land somewhere between these poles. Naturalism, or hybrid theories with a necessarily naturalistic component, are the received views in academic psychology and psychiatry. 1 Despite their wide acceptance, there have been significant problems in formulating naturalist views. Notably, it has proven difficult to identify what, exactly, the value-independent basis of mental illnesses is supposed to be. According to the most influential naturalist approaches, mental disorders are constituted, at least in part, by mental dysfunctions. 2 The assumed relationship between function and naturalism is so strong that ‘naturalism’ is often just (mis- takenly) defined as a function-based view. 3 Function-based naturalist views posit that mental disorders necessarily involve the failure of some mental mechanism, or mechanisms, to function ‘normally’. The most serious difficulty facing these views has been providing an account of normal psychological functioning. The perceived failure of function-based naturalist views to offer a plausible theory of normal mental function has been taken by many to be evidence for the failure of naturalism, full stop, and motivation for the acceptance of normative views. 4 In contrast, this paper argues that mental functions are the wrong point of empha- sis in explaining the value-independent nature of mental disorder and that a more plausible naturalist theory can be constructed by grounding the value-independent basis of mental disorder in the concept of skilled action, rather than proper mental function. 5 According to this view, mental health is a type of skilled activity per- formed by individual persons, not the normal functioning of mental mechanisms. Mental disorder is the failure or breakdown of this skill. There are at least two desiderata that a theory of mental health should address: (1) it should offer a plausible theory of the boundary between health and disorder, and (2) it should explain how we might know whether any particular mental state falls on one side or the other of this boundary. The motive for the first desideratum is clear: a naturalist theory of mental disorder needs to explain what differentiates disorder from health. The second desideratum is also crucial: a good theory of mental health and disorder should be useful and provide us with the means to differentiate between the two. The skill view of mental health provides a natural- ist answer to both (1) and (2), while avoiding the more serious metaphysical and epistemic problems of traditional function-based views. 1For example, the two primary diagnostic manuals in the West (the DSM-5 and ICD-10) both adopt function-based definitions of ‘disorder’ with naturalistic components. 2For example, see: Wakefield (1992); Boorse (1977); Boorse (2014); American Psychiatric Associa- tion (2013); World Health Organization (1992). We use the term ‘naturalist’ to refer to both ‘pure’ naturalist views (e.g., Boorse, 1977) and hybrid views with a necessary naturalist component (e.g., Wakefield, 1992). 3For example, see: Murphy (2020); Kingma (2013). 4E.g.: Cooper (2007); Fulford (1989). 5This paper does not directly address the tenability of normative views. The focus here is on whether a strong naturalist view can be developed. Leder, G., & Zawidzki, T. (2023). The skill of mental health. Philosophy and the Mind Sciences, 4, 3. https://doi.org/10.33735/phimisci.2023.9684 ©The author(s). https://philosophymindscience.org ISSN: 2699-0369 https://doi.org/10.33735/phimisci.2023.9684 https://creativecommons.org/licenses/by/4.0/ https://philosophymindscience.org The skill of mental health 3 The structure of the paper is as follows. Section 2 addresses the flaws of tradi- tional function-based views. Section 3 introduces the alternative skill-based natu- ralist theory of mental health and argues for the conceptual and explanatory supe- riority of the skill view over function-based naturalist theories. Section 4 addresses potential concerns with grounding the concepts of mental health and disorder in skill rather than function. Section 5 discusses broader theoretical and practical benefits of adopting the skill view of mental health. 2 Mental disorders and mental functions Mental disorders are traditionally conceptualized in functional terms. For exam- ple, both the Diagnostic and Statistical Manual of Mental Disorders [5th ed.; DSM-5, American Psychiatric Association (2013)], the primary diagnostic manual in North America, and the DSM’s international counterpart, the World Health Organiza- tion’s International Classification of Diseases (ICD-10, World Health Organization, 1992), adopt function-based conceptions of disorder. The DSM-5 defines mental disorders as follows: A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behav- ior that reflects a dysfunction in the psychological, biological, or de- velopmental processes underlying mental functioning. (italics added) (American Psychiatric Association, 2013) Both the DSM-5 and ICD-10 are intended to serve as theory-neutral diagnostic tools for the identification of symptoms that are jointly sufficient for the diagnosis of a disorder, not to be theories of what disorders are. Theories of mental disor- der, on the other hand, are attempts to explain what it is about certain ways of being that makes them healthy, disordered, or benign. And, according to the most influential naturalist views, what differentiates ‘genuine’ disorders from normal human variation is that the former, but not the latter, are marked by dysfunctions of some kind. The primary challenge facing function-based naturalist views has been to pro- vide a value-independent account of ‘normal’ mental functioning. Naturalist so- lutions to this problem differ in their specifics, but share the common strategy of defining normal mental function as the contribution of a mental part or process to an ultimate biological norm. The most influential candidates for this ‘ultimate’ norm have been evolutionary design or individual survival and reproduction. 6 Ac- cording to these ‘biological norms’ views, the normal function of, e.g., the heart is to pump blood, and not make pounding sounds, because the pumping of blood, but not the production of sound, conforms to some ultimate biological norm (e.g., it is what the heart was designed by natural selection to do, it contributes to the 6The touchstones for the evolutionary and longevity/reproduction views are Wakefield (1992) and Boorse (1977), respectively. Leder, G., & Zawidzki, T. (2023). The skill of mental health. Philosophy and the Mind Sciences, 4, 3. https://doi.org/10.33735/phimisci.2023.9684 ©The author(s). https://philosophymindscience.org ISSN: 2699-0369 https://www.psychologytoday.com/basics/cognition https://www.psychologytoday.com/basics/emotion-regulation https://doi.org/10.33735/phimisci.2023.9684 https://creativecommons.org/licenses/by/4.0/ https://philosophymindscience.org Garson Leder and Tadeusz Zawidzki 4 ultimate end-goals of individual survival and reproduction, or it conforms to some other biological norm). The problems with function-based views are well known. 7 Most notably, dysfunction appears to be neither necessary nor sufficient for the presence of a mental disorder. Dysfunction is likely not sufficient for disorder. For example, depending upon what theory of ‘normal’ function one adopts, exclusive homosexuality, asexuality, and a lack of desire to reproduce may all be considered ‘dysfunctions’ (because of their effects on reproduction), but they should not be considered disorders (e.g., Cooper, 2007). Defenders of the sufficiency view have responded to this concern by arguing that we should divorce our theory of disorder from any normative judg- ments we have about experiencing a disorder or being labeled as having a disorder (e.g., Boorse, 2014). However, even if we accept that the concept of disorder should be value-neutral, we should still be judging a theory of disorder based on the plau- sibility of its extensional assignments. The sufficiency view is not incoherent, but it is highly implausible. Dysfunction is also likely not necessary for disorder. For example, it is an open empirical question whether behaviors and mental phenomena normally con- sidered to be ‘disordered’, such as the phenomena associated with depression, anxi- ety, and schizophrenia, are in fact the result of dysfunctioning mental mechanisms rather than being the consequences of mechanisms functioning as they normally should. 8 Depression, for example, is variously hypothesized to be the result of dys- functioning mental mechanisms that lead to ‘interlocked’ cognitive-affective cy- cles of mental processing (Teasdale & Barnard, 1993), the product of normally func- tioning mental mechanisms that lead to an increase in critical ruminative thought (Andrews & Thomson, 2009), the result of dys-functioning mental mechanisms that produce negatively valenced loss-based cognitions (Beck & Alford, 2009), or the result of normally functioning mental processes that socially signal the need for assistance (Watson & Andrews, 2002). And we see similar variations in the hypothesized role of ‘dysfunction’ for other paradigmatic disorders such as gener- alized anxiety disorder, schizophrenia, and bipolar disorder. The take-away point here is not that each of these theories is equally as plausible, nor is it that we are never able to make plausible inferences about the existence or functions of mental mechanisms. Rather, the point is that if we accept dysfunction as the grounding of our concept of disorder, then we must accept that it is an open question whether some paradigmatic disorders are in fact disorders. Function-based theories commit us to the view that mental health necessarily involves the adherence of mental mechanisms to certain ultimate biological norms. This focus on biological norms (e.g., evolutionary design or individual survival and reproduction), while potentially establishing a value-free foundation for the concept of disorder, also leads to a potentially massively revisionary conception 7The literature here is extensive. E.g.: Cooper (2007); Kingma (2014). 8This concern has been raised by a number of authors (e.g., Lilienfeld & Marino, 1995; Woolfolk, 1999). Leder, G., & Zawidzki, T. (2023). The skill of mental health. Philosophy and the Mind Sciences, 4, 3. https://doi.org/10.33735/phimisci.2023.9684 ©The author(s). https://philosophymindscience.org ISSN: 2699-0369 https://doi.org/10.33735/phimisci.2023.9684 https://creativecommons.org/licenses/by/4.0/ https://philosophymindscience.org The skill of mental health 5 of mental health. 9 Dysfunction views are committed to the claim that it is an open (though possibly unanswerable) empirical question whether any postulated ‘mental disorder’ is in fact the result of a dysfunctioning mental mechanism, and thus a genuine mental disorder. It is possible that paradigmatic disorders such as depression, anxiety, and phobias may turn out not to be mental disorders, but rather products of healthy minds dealing with mere problems of living. While, on the other hand, behavior not commonly considered to be a product of unhealthy minds, such as homosexuality, a lack of desire to reproduce, and the engagement in dangerous ‘thrill-seeking’ activities, may in fact be mental disorders if it turns out that they are the result of dysfunctioning mental mechanisms.10 This is not incoherent, but it is highly counterintuitive. The use of dysfunction, then, to ground the value-neutral basis of mental dis- orders appears unsuccessful. If function-based theories of health make it possi- ble that depression and anxiety are not mental disorders, but homosexuality is, then this gives us good reason to think that the presence or absence of mental dysfunctions is not necessarily related to the concept of mental health. That the entailments of function-based views may be so revisionary and contrary to com- mon folk conceptions of disorder is prima facie evidence that something has gone wrong with the focus on dysfunctions to explain the distinction between mental health and disorder, and gives us reason to search for a more plausible naturalist conception of mental health. The problem is this: despite their prominence, there have been serious prob- lems in formulating a naturalist conception of mental disorder. Dysfunction-based naturalist views are not incoherent but they are seriously flawed. These flaws can either be accepted as part of the cost of formulating a naturalist theory, or taken as evidence for the failure of naturalism. In contrast, this paper argues that a more plausible naturalist view of health can be constructed if we reorient the dialectic away from the concept of normal function and focus instead on the skills consti- tutive of mental health. Skill, rather than function, can provide the objective basis for a naturalist theory of mental disorder. The new naturalist theory of mental health outlined here argues that mental health is best conceived of as a skill. More specifically, this paper argues that mental health is skilled metacognitive self-regulation; mental disorder is a failure or breakdown of this skill. The skill view of mental health provides a naturalist framework for the scientific study and treatment of mental disorders that avoids 9Murphy (2006) makes a similar point. 10Note that while function-based views agree that mental dysfunctions are necessary for disorders, they differ over whether they are also sufficient. ‘Pure’ function-based views posit that the pres- ence of a mental dysfunction is both necessary and sufficient for disorder. ‘Hybrid’ views posit that dysfunction is necessary, but not sufficient for disorder; disorders must also be judged to be ‘harmful’ (with the ‘harm’ criterion being a value-based claim that varies between cultures and value systems). So, for example, the ‘pathological’ status of homosexuality depends upon its status as a dysfunction (for both pure and hybrid views) and whether it is judged to be harmful in a given value-system (for hybrid views only). Leder, G., & Zawidzki, T. (2023). The skill of mental health. Philosophy and the Mind Sciences, 4, 3. https://doi.org/10.33735/phimisci.2023.9684 ©The author(s). https://philosophymindscience.org ISSN: 2699-0369 https://doi.org/10.33735/phimisci.2023.9684 https://creativecommons.org/licenses/by/4.0/ https://philosophymindscience.org Garson Leder and Tadeusz Zawidzki 6 the epistemological and conceptual failings of traditional function-based views. The focus on skilled action, rather than adherence to biological norms, allows for a flexible theory of health that avoids pathologizing normal human difference while also providing a non-revisionary accounting of paradigmatic mental disorders. 3 The skill of mental health The skill view of mental health makes the following two claims: 1: Mental health is skilled metacognitive self-regulation. 2: Mental disorder is a failure or breakdown of this skill. Sections 3.1-3.2 outline theory-neutral naturalist accounts of skilled action and self-regulation. Sections 3.3-3.4 will address the skill view’s claims in order. 3.1 The value-neutrality of skill The term ‘skill’ has a number of common uses. ‘Skill’ can refer to a particular type of possible action (e.g., the skill of playing tennis), to a way of acting (e.g., being a skilled, as opposed to unskilled, tennis server), and to expertise in action (e.g., being a skilled, as opposed to novice, tennis player). This paper is concerned only with the first two conceptions of skill. The focus here is on what differentiates skilled from unskilled action, not what differentiates low skill from high skill, or skill from expertise. This paper adopts a theory-neutral conception of skill: minimally, to be skilled at ɸ-ing requires that one possesses the ability to ɸ intelligently.11 Both ‘ability’ and ‘intelligence’ can be disambiguated. Following Mele (2003), we can distinguish between two senses of ‘ability’:12 Ability1: An agent is able to ɸ, given appropriate background conditions. Ability2: An agent is able to ɸ and has the appropriate background conditions satisfied to successfully ɸ. The distinction is straightforward. There are many things an agent may be gener- ally able1 to do (such as play tennis), but that she is at some point in time unable2 to do because of something that masks this ability1 (such as a sprained ankle). Skill at ɸ-ing necessarily requires the ability1 to ɸ. There is no scenario in which an agent is skilled at performing some action, yet there is no possible circumstance in which she is able1 to do so. For example, whatever the specifics are of a theory of skill, a person cannot be a skilled tennis player if she is not now, nor ever was, able1 to play tennis. However, possessing the ability1 to ɸ does not entail that one is always able2 to ɸ. A skilled tennis server is able1 to strike tennis balls into the 11This definition is consistent with both Intellectualist (e.g., Stanley & Williamson, 2017) and Non- Intellectualist (e.g., Ryle, 1949) theories of skill. 12Mele (2003) does not use this exact formulation. Leder, G., & Zawidzki, T. (2023). The skill of mental health. Philosophy and the Mind Sciences, 4, 3. https://doi.org/10.33735/phimisci.2023.9684 ©The author(s). https://philosophymindscience.org ISSN: 2699-0369 https://doi.org/10.33735/phimisci.2023.9684 https://creativecommons.org/licenses/by/4.0/ https://philosophymindscience.org The skill of mental health 7 service area, only given that certain background conditions are met (e.g., that she has access to a racket, ball, is free from injury, and so on). The lack of a racket or a sprained ankle might render her unable2 to play tennis on any given day, without necessarily affecting her ability1, or skill, to play. Skills may diminish after long periods of being unable2 to perform, but one’s ability1 to ɸ is not necessarily de- pendent upon whether one is able2 to ɸ at any given time. A skilled action, on the other hand, does require that one is able2 to ɸ. For example, skilled tennis service requires that one is both able1 to strike balls into the opposing service box, and that the enabling conditions are met for her to do so successfully. Skill may require ability1, but ability1 is not sufficient for the presence of skill. A person learning to strike tennis balls may be able1 to regularly propel balls into the opposing playing area if the balls are carefully teed up, but this activity is not necessarily a skilled act. The ‘intelligence’ constraint is meant to distinguish skill from reflexive, lucky, or merely successful action. Theories of skill differ greatly over how to specify the intelligence clause, but there is broad agreement that, min- imally, ‘intelligence’ requires the ability1 to adapt, learn, and intentionally modify one’s behavior in response to novel stimuli.13 The new tennis player learning to strike a ball off a tee lacks the ability1 (at least at that moment) to intentionally modify their behaviors to adapt to new problems such as a change in ball trajec- tory, speed, or spin. A skilled tennis player, on the other hand, would be able1 to learn from, and adapt to, different shots, opponents, and physical constraints. The- ories of skill differ over what else, if anything, is needed in addition to intelligence and ability1 to explain skill. As with our analysis of function-based views, we need not take a position here. The aim of this paper is not to argue for a particular the- ory of skill, but rather to examine whether the concept of skill (given the above constraints) can ground a naturalist theory of mental health. Importantly, the concept of skilled action can be formulated in value- independent terms. Judgments of how well one performs some task and how well one modifies one’s behavior clearly are value-judgements. The judgment of skill as expertise also appears to be value-laden (insofar as whether or not some action is done expertly varies depending upon the standards set). In contrast, whether an agent is able2 to intelligently ɸ is not, or at least need not be, a value judgment. For example, metaphysical theories of ability commonly take the conditional form: an agent is able2 to ɸ if she would ɸ if she tried (Maier, 2021). Theories differ over how to best specify these enabling conditions, but these theoretical differences needn’t be differences in value (just as metaphysical disputes over the existence of midsize objects are not necessarily disputes over values). Similarly, theories of the metaphysics of intelligence generally are attempts to precisify some cognitive faculty that things like humans have, and things like modern computers currently lack. There is certainly room for values to enter into the answer to this question, but there is no necessary reason that this need be the case. More generally, insofar as a value-independent metaphysics is possible, the 13For example, both Stanley & Williamson (2017) and Ryle (1949) adopt this view. Leder, G., & Zawidzki, T. (2023). The skill of mental health. Philosophy and the Mind Sciences, 4, 3. https://doi.org/10.33735/phimisci.2023.9684 ©The author(s). https://philosophymindscience.org ISSN: 2699-0369 https://doi.org/10.33735/phimisci.2023.9684 https://creativecommons.org/licenses/by/4.0/ https://philosophymindscience.org Garson Leder and Tadeusz Zawidzki 8 metaphysics of skill, like the metaphysics of function, poses no unique problem that necessitates a value-based theory. There are, of course, epistemic challenges in identifying when any particular action is skilled. Section 3.4 will address these epistemic constraints, and show that they compare favorably to those facing function-based views. Sections 3.2 and 3.3 will outline theoretical commitments of the skill-based view of mental health. 3.2 Skill and self-regulation Claim (1), defended in the next section, states that mental health is skilled metacog- nitive self-regulation. ‘Self-regulation’, here, refers to the process of altering or controlling one’s responses to align with one’s goals or standards (Baumeister et al., 1993; Fujita, 2011). The absence of self-regulation is met by purely automatic cognition, emotion, and behavior based on ‘learning, habit, inclination, or even innate tendencies (Baumeister et al., 1994).14 Everyday examples of self-regulation include regulating emotional responses to perceived losses or gains (e.g., inhibiting the experience of intense emotions), regulating cognitions (e.g., avoiding rumina- tive patterns of thought, or conversely, focusing one’s attention despite distrac- tors), and regulating impulses (e.g., in regard to food, drink, or self-expression). Psychological accounts of self-regulation are traditionally focused on the ability2 to regulate one’s responses towards some ultimate distal goal or idealized concep- tion of self (Carver & Scheier, 1982). This paper adopts a more restricted concep- tion of self-regulation; we are interested in the ability2 to regulate one’s responses to one’s immediate willings. We are not concerned here with the notion of the idealized self or in identifying individuals’ ultimate goals. Rather, the focus is on whether one is able2, at any given time, to skillfully regulate one’s responses to whatever standard one wills. There is also an important difference between regulating one’s responses and completely controlling one’s mental life. Self-regulating involves the ‘overriding, stopping, modifying, or otherwise changing’ of one’s responses to exogenously and endogenously generated stimuli (Rawn & Vohs, 2011). This skill can, but need not, involve controlling the generation of mental content. Completely controlling the generation of mental content would require the ability2 to only think, feel, and desire what one wills (e.g., only thinking pleasant thoughts and experiencing posi- tive emotions). Self-regulation does not require the (possibly superhuman) ability2 to completely control the generation of one’s cognitions and emotions. Regulatory strategies may include the attempt to control the generation of mental content (e.g., by avoiding situational triggers), but attempts to control content can also be part of the problem that requires regulation (as can be the case with obsessive disor- 14The skill view does not claim that all instances of self-regulation must be conscious and effortful. It is generally accepted that self-regulation may involve automatic processes (though there is debate about how much) (e.g., Vohs & Baumeister, 2004). This paper uses ‘self-regulation’ to refer to self-regulatory processes (both ‘automatic’ and ‘conscious’) that are directed at regulating one’s responses towards some self-initiated goal (Duckworth et al., 2016). Leder, G., & Zawidzki, T. (2023). The skill of mental health. Philosophy and the Mind Sciences, 4, 3. https://doi.org/10.33735/phimisci.2023.9684 ©The author(s). https://philosophymindscience.org ISSN: 2699-0369 https://doi.org/10.33735/phimisci.2023.9684 https://creativecommons.org/licenses/by/4.0/ https://philosophymindscience.org The skill of mental health 9 ders). Automatic and unwanted thoughts, emotions, and urges are a normal part of mental functioning, and the failure to completely control the content of one’s mental life is not necessarily a failure of self-regulation. Failures of self-regulation involve inability2 to regulate how one responds to these thoughts, emotions, and life-events. 3.3 Skill and mental health Claim (1) states that mental health is skilled metacognitive self-regulation. The term ‘skilled’ in both claims (1) and (2) refers to the exercise of the skill of self-regulation. Mental health requires not just the possession of the skill to self-regulate, but also that the appropriate enabling conditions are met in order to be able2 to exercise this skill. According to this conception of health, mental health is a skilled way of acting, rather than the proper functioning of mental parts. The term ‘metacognitive’ in claim (1) refers to the fact that the skillful self- regulation exercised in mental health is directed at cognitive states, broadly con- strued, including beliefs, desires, and emotions. As explained in Section 3.2, self- regulation involves the ability2 to regulate one’s responses to thoughts, emotions, and life-events, and these responses are, in the first instance, other cognitive states. Even if behavioral responses are also in the scope of such self-regulation, such be- havioral responses are products of prior cognitive responses, and cannot be skill- fully regulated without the skillful regulation of the latter. Hence, the kind of skillful self-regulation relevant to mental health is inevitably metacognitive. Un- like embodied skills, like athletics or musicianship, or intellectual skills, like chess or advanced mathematics, both of which make use of cognitive states and capaci- ties, metacognitive skills, in addition to making use of cognitive states and capaci- ties, are also directed at cognitive states and capacities. Their domain is cognition, unlike embodied skills, the domains of which typically involve some socially con- stituted, bodily activity, or intellectual skills, the domains of which are more ab- stract, like chess or mathematics. Hence, the skills of self-regulation relevant here are aptly called ‘metacognitive’. The skill view of mental health is motivated by focusing on the process of men- tal healing. Theories of mental health are typically developed without an explicit focus on the process of mental healing. On the one hand, this is understandable. Theories of health are normally considered to be the basis from which we can de- termine what healing is. Health is logically prior to healing; if we don’t know what health is, then we don’t know what healing is (i.e., ‘healing’ is healing from what and to what?). On the other hand, the traditional disregard of mental healing in the construction of theories of mental health has missed a significant source of data from which to build a theory. Theories of mental health and disorder are not (or at least should not be) developed a priori; they begin with observations about mental phenomena and human behavior (e.g., the ‘symptoms’ of mental disorders) and Leder, G., & Zawidzki, T. (2023). The skill of mental health. Philosophy and the Mind Sciences, 4, 3. https://doi.org/10.33735/phimisci.2023.9684 ©The author(s). https://philosophymindscience.org ISSN: 2699-0369 https://doi.org/10.33735/phimisci.2023.9684 https://creativecommons.org/licenses/by/4.0/ https://philosophymindscience.org Garson Leder and Tadeusz Zawidzki 10 attempt to explain what, if anything, differentiates health from disorder. These observations should include, as important components, what happens when indi- viduals mentally heal.15 In order to figure out what has ‘gone wrong’, theories of health and disorder should look to what happens when things go back to ‘being right’. In support of (1), we should first notice that mental healing and health nec- essarily involves self-regulation. This is made clear if we consider the process of mental healing. Regardless of whether disorders are conceived of as problems of natural function or of value, one of the primary end-goals of psychotherapy is improved self-regulation. In the case of normative theories of mental health, suc- cessful psychological treatment just is whatever causes the patient to regulate her responses to fit within the established norms of ‘healthy’ functioning. In the case of naturalist function-based theories of mental health, whatever the mental dys- function is that is hypothesized to be responsible for a particular mental disorder, the proper function of this hypothesized mechanism involves the ability2 to self- regulate. This is not to say that function-based theories are committed to the claim that self-regulation is the only function of the mind or that self-regulation is the ultimate function of all mental mechanisms. However, if, after successful therapy, the proper functioning of some hypothesized mental mechanism involves persons being unable2 to self-regulate, then we should take this as evidence that we are mistaken about our standard of mental health. There is nothing that should be recognizable as a mental disorder (as opposed to a neurological disorder) that does not involve a problem of self-regulation.16 For example, if a naturalist-inclined therapist claims that a patient seeking treat- ment for major depression is ’healed’ (i.e., her hypothesized dysfunctional mech- anism(s) have returned to normal functioning), yet reports that the patient is still unable2 to regulate her negative emotions and cognitions, we should conclude that the therapist is confused about what depression is. Similarly, obsessive compul- sive disorder (OCD) involves the experience of recurring intrusive and unwanted thoughts, urges, or impulses, as well as compulsive repetitive behaviors or mental acts to suppress or ignore these obsessions; any psychological intervention that successfully treats OCD necessarily requires that patients become able2 to regu- late their responses to their obsessions and compulsions. And we see the same patterns with other paradigmatic disorders. Different mental disorders involve different regulatory problems: anxiety disorders are marked by excessive anxiety and worry, and difficulty in controlling these worries; schizophrenia is marked 15Of course, a theory of mental health and disorder may end up revising our pretheoretical assump- tions about the observed ‘symptoms’ used to construct the theory. 16Possible exceptions to this claim are some of the Cluster B personality disorders. The skill view entails that at least some personality disorders are not mental disorders if it is the case that they do not involve inabilities2 to skillfully self-regulate. And this is just what we should expect. If a putative nosological entity such as narcissistic personality disorder does not involve any inability2, it seems clear that the behavior being pathologized better reflects disvalued behavior and character, not poor health. Leder, G., & Zawidzki, T. (2023). The skill of mental health. Philosophy and the Mind Sciences, 4, 3. https://doi.org/10.33735/phimisci.2023.9684 ©The author(s). https://philosophymindscience.org ISSN: 2699-0369 https://doi.org/10.33735/phimisci.2023.9684 https://creativecommons.org/licenses/by/4.0/ https://philosophymindscience.org The skill of mental health 11 by delusional beliefs or hallucinations as well as disorganized speech and behav- ior; bi-polar disorders may involve both serious depressive symptoms and manic behaviors and patterns of thought (American Psychiatric Association, 2013). It is an open empirical question how best to treat these disorders, but the end-goal of psychotherapeutic treatment is the same: no successful treatment leaves patients unable2 to regulate their responses to these symptoms. Theories of psychotherapy differ over the causes of the symptoms that are be- ing regulated, and over how to best ameliorate these problems. But, regardless of whether the therapy focuses on identifying and challenging core beliefs, pro- viding insight into subconscious processes, extinguishing learned behavioral re- sponses, or ameliorating any other hypothesized cause of psychopathology, suc- cessful psychotherapeutic interventions involve the patient (re)gaining the skill to self-regulate. If successful treatment does not involve the patient (re)gaining some ability2 to intelligently control how she responds to thoughts, emotions, and events, then it is unclear what is supposed to be ‘successful’ about the therapy. For example, no effective psychotherapy for anxiety (measured by the patient no longer fitting the diagnostic criteria for a disorder) leaves the patient unable2 to regulate how she responds to anxious feelings, thoughts, or (formerly) anxiety- producing life events. And no effective therapy for schizophrenia leaves a patient without the ability2 to regulate her mental phenomena. This is not to say that effec- tive therapy needs to completely excise all symptoms from patients’ mental lives; individuals can experience anxious thoughts, intrusive thoughts, compulsions, and hallucinations without fitting the diagnostic criteria of any mental disorder. This is also not to say that improved self-regulation is the only goal of all psychotherapies, or that it is even necessarily an explicit goal. The point here is that if psychother- apy is effective, it is effective insofar as it enables improved self-regulation. If there is no problem of self-regulation, then there should be no problem of mental health. However, some state’s not being a mental disorder does not mean that it is not a disorder. The focus on skilled self-regulation helps explain the com- mon distinction between mental disorders and neurological disorders. Neurolog- ical disorders, such as amnesia disorders, epilepsy, learning disorders, dementia, and Alzheimer’s disease, may result in failures of self-regulation, but they are not best treated as regulatory problems. Treatment for neurological disorders such as Alzheimer’s disease may include skill training (e.g., learning to cope with the fear and frustration sometimes associated with memory loss), but even if a patient were to (somehow) be able2 to skillfully self-regulate, this would not make it the case that she no longer has a disorder (though it may be less subjectively distress- ing). In contrast, if an individual seeking treatment for a mental disorder such as depression or anxiety no longer has a problem skillfully self-regulating, then there should no longer be any disorder. What makes a mental disorder mental, rather than somatic, is that mental disorders are best explained and treated as problems of skilled self-regulation while somatic disorders are not.17 17Graham (2013) makes a similar point. Leder, G., & Zawidzki, T. (2023). The skill of mental health. Philosophy and the Mind Sciences, 4, 3. https://doi.org/10.33735/phimisci.2023.9684 ©The author(s). https://philosophymindscience.org ISSN: 2699-0369 https://doi.org/10.33735/phimisci.2023.9684 https://creativecommons.org/licenses/by/4.0/ https://philosophymindscience.org Garson Leder and Tadeusz Zawidzki 12 Both normative and function-based naturalist theories should agree with this; they just disagree about whether individuals with mental disorders are regulat- ing their mental lives to an objective standard of health, and what, if anything we need to posit in addition to self-regulation to explain mental health. For normative views, the additional explanatory piece is a value-judgment. According to these views, while self-regulation plays a role in mental healing, whether the healing is successful, and, more generally, whether an individual is judged to be mentally healthy, depends on a value judgment of some kind. In contrast, function-based naturalist theories posit that we need the extra concepts of normal function and dysfunction in order to establish a value-independent basis for the distinction be- tween health and disorder (and between healthy and disordered self-regulation). The problem, as we’ve seen, is that the use of function to draw this boundary leads to serious epistemic and conceptual problems. The concept of skill can do better. 3.4 Skill, mental disorder, and the boundary problem There are two related, but distinct, concerns about boundaries that theories of men- tal disorder must address: the first is a metaphysical issue (‘what is the difference between mental disorder and health’), the second epistemic (‘how might we know the difference’). The epistemic boundary problem will be addressed in section 3.5. This section is focused on the metaphysical question. Claim (2) states that mental disorder is unskilled self-regulation. According to the skill view, the boundary between mental health and mental disorder is a question of ability2 to intelligently self-regulate. This does not entail that any reg- ulatory failure is necessarily a sign of mental disorder. Healthy individuals can and do lose control of their thoughts and emotions, and act in ways contrary to their explicit intentions. This is normal and often benign. The difference between normal regulatory lapses and breakdowns of skilled self-regulation (and, thus, the difference between mental health and disorder), is that disorders involve an inabil- ity2 to self-regulate, not just the poor exercise of regulatory skill. Just as a skilled athlete does not become unskilled when she misstrikes a ball or makes a tactical mistake, mentally healthy individuals do not become disordered merely by engag- ing in dysregulated behavior. The boundary between mental health and disorder is a question of what individuals are able2 to do, not just what they do. This solution to the boundary problem provides a principled, value- independent distinction between mental disorders and merely socially disvalued behaviors. Mental health requires being able2 to regulate one’s responses to emotions and cognitions, but not necessarily that one regulates the content of these mental states to any particular end. The difference between paradigmatic mental disorders (such as GAD or OCD) and instances of normal human variation (such as fringe religious or political beliefs) is that the latter involve the ability2 to skillfully self-regulate, while the former do not. This is not to say that individuals with a mental disorder do not have the capacity to self-regulate (presumably they do), but only that at the time in question they do not have the ability2 to Leder, G., & Zawidzki, T. (2023). The skill of mental health. Philosophy and the Mind Sciences, 4, 3. https://doi.org/10.33735/phimisci.2023.9684 ©The author(s). https://philosophymindscience.org ISSN: 2699-0369 https://doi.org/10.33735/phimisci.2023.9684 https://creativecommons.org/licenses/by/4.0/ https://philosophymindscience.org The skill of mental health 13 intelligently do so.18 A mentally healthy political radical who suffers as a result of her beliefs could (in the sense of having the ability2) choose not to focus her mental life exclusively on her political views, while an individual suffering from GAD is not, at that time, able2 to skillfully regulate her anxious emotions and cognitions. Similarly, the skill view entails that while some sexual thoughts or behaviors may be symptoms of a mental disorder (e.g., unwanted and intrusive obsessive sexual thoughts and images), there is nothing necessarily disordered about any particular norm-transgressing sexual behavior or thought. Mental disorders (such as OCD) can be differentiated from non-disordered states (such as homosexuality) because the former, but not the latter, necessarily involve the inability2 to successfully regulate cognitive and emotional patterns. The content or object of one’s sexual desires, as opposed to the ability2 to intelligently regulate one’s responses to these sexual thoughts or desires, have no necessary relation to mental health. Being attracted to some object O, is not necessarily a problem; being unable2 to regulate one’s responses to one’s O-directed obsessions and compulsions is.19 It is possible that individuals with norm-transgressing sexual orientations or preferences may experience distress at their sexual thoughts and desires (e.g., be- cause they run counter to social norms) based on their inability2 to alter or control the content of these thoughts and desires. This felt need to control the object of one’s sexual desires and thoughts may lead to mental health problems, but this does not entail that there is anything pathological about the content of these thoughts or the objects of these desires. These problems, if disordered, would be mood dis- orders (likely influenced by cultural norms). The focus on skill, rather than function, also explains the difference between disorder and normal human difference. People differ greatly in the content of their mental states. There is nothing necessarily disordered about atypical or norm- transgressing beliefs or emotional reactions, and a theory of mental health should reflect this. This normal human variation reflects a disorder only when persons are no longer able2 to regulate these mental states. For instance, both a philosopher and an individual suffering from psychotic episodes may claim that the moon does not exist.20 Both persons may present arguments in defense of this claim, and both may also become emotionally agitated when others disagree with them. The dif- ference between a philosopher denying the reality of the moon (and, say, all other non-living composite objects) and a person suffering from delusional beliefs is that, presumably, the philosopher has the ability2 to challenge and regulate her thoughts and beliefs about the moon while the person suffering from delusions cannot. Sim- ilarly, most people report experiencing intrusive thoughts (e.g., about unwanted sex acts, violence, contamination, etc.), while only a small minority meet the diag- 18‘Capacity’, here, refers to the neurocognitive resources necessary to acquire the relevant ability1. 19This argument extends to desires and behaviors currently falling under the category of ‘Paraphilic Disorders’ in the DSM-5. 20The example is adapted from Van Inwagen (1990). Leder, G., & Zawidzki, T. (2023). The skill of mental health. Philosophy and the Mind Sciences, 4, 3. https://doi.org/10.33735/phimisci.2023.9684 ©The author(s). https://philosophymindscience.org ISSN: 2699-0369 https://doi.org/10.33735/phimisci.2023.9684 https://creativecommons.org/licenses/by/4.0/ https://philosophymindscience.org Garson Leder and Tadeusz Zawidzki 14 nostic criteria for obsession-related disorders (Rachman & Silva, 1978; Radomsky, 2014). The difference between normal (if still distressing) intrusive thoughts, and disorders (such as OCD), is demarcated by individuals’ ability2 to intelligently reg- ulate their cognitive and emotional responses to them.21 The difference between mental health and disorder, in general, is drawn by individuals’ ability2 to regulate their mental lives, not by the content or objects of their cognitions and emotions. It is important to note what the skill view is not claiming. The skill view is not claiming that mental content plays no role in the etiology or experience of mental disorders- this is clearly not the case. For example, negatively valenced thoughts and emotions are constitutive of depression; a necessary condition of what it is to be depressed is the presence of depressed mood or diminished pleasure. But the presence and prevalence of negatively valenced mental content is not sufficient for mental disorder. Nihilists and existential philosophers may regularly think about the meaninglessness of life, and may even feel intense and persistent angst or sad- ness in response to these thoughts, but they needn’t be suffering from clinical de- pression (or any other mental disorder). A predominance of negatively valenced thoughts and emotions may play a causal role in the development of depression, but this need not be the case. One needn’t be disordered to believe that life is meaningless and painful, to devote much of one’s mental life to these beliefs, and to even be profoundly saddened by this. What makes a state marked by negatively valenced mental content a disorder is the failure of skilled self-regulation of this content, not merely the presence of any specific thoughts or emotions. The differ- ence between normal (even if intense) sadness, dysphoria, or hopelessness, on the one hand, and depression on the other, is that depression (and mental disorders in general) involve an inability2 to skillfully regulate how one responds to mental content. Mental content, then, plays a role in mental health insofar as responses to content are often what is being regulated, but the presence or absence of any particular mental content does not explain why certain states are disordered and others not. If there is a mental health problem, it is because of a failure of skilled self-regulation, not because of content being regulated. The skill view is also not claiming that any problem of self-regulation is a prob- lem of mental health. There are numerous instances of poor self-regulation that are clearly not disorders. These problems can range from the seemingly trivial (e.g., one can have difficulty resisting a bowl of sweets), to the potentially more serious (e.g., sticking to a diet, or keeping one’s temper while watching a sport- ing event). The skill view predicts that these cases are, or at least can be, normal problems of living. Normal problems of living may be harmful and distressing, but they become mental disorders only if they involve unskilled self-regulation (which requires a genuine inability2 to intelligently modify, override, or change one’s re- sponses). Having difficulty regulating one’s diet is not a mental disorder, being 21The skill view provides a similar explanation for the symptoms of schizophrenia. Both the positive and negative symptoms associated with schizophrenia can be found in the absence of any mental disorder (Van Os & Reininghaus, 2016). These ‘symptoms’ reflect a disorder only insofar as they involve an inability2 to skillfully regulate how a person responds to them. Leder, G., & Zawidzki, T. (2023). The skill of mental health. Philosophy and the Mind Sciences, 4, 3. https://doi.org/10.33735/phimisci.2023.9684 ©The author(s). https://philosophymindscience.org ISSN: 2699-0369 https://doi.org/10.33735/phimisci.2023.9684 https://creativecommons.org/licenses/by/4.0/ https://philosophymindscience.org The skill of mental health 15 unable2 to skillfully regulate one’s food intake is. And this is just what we should expect: mental disorders (such as eating disorders) involve genuine inabilites2 to skillfully self-regulate; normal problems of living (such as having a problem limit- ing carbohydrates in one’s diet) do not. The skill view does not claim that a lack of the capacity (as opposed to ability2) to skillfully self-regulate entails that an individual has a mental disorder. Infants and small children may be unable2 to skillfully self-regulate, yet they are clearly not mentally disordered. The skill view argues that mental disorders are failures to skillfully self-regulate; this assumes that one has the capacity to accomplish this act. In the case of adult mental disorders, the disorders usually involve an inability2, rather than an inability1, to self-regulate (e.g., an adult experiencing clinical depression is likely to be able1 to self-regulate, but may be temporarily unable2 to exercise this skill). In contrast, infants and small children are poor self- regulators not because of a breakdown or failure of ability (1 and 2), but because of the lack of the development of the psychological tools necessary to skillfully self- regulate. Small children do not have a problem of ability, but a (normal) lack of capacity. The skill view is also not claiming that the act of self-regulation, by itself, ex- plains mental health. The act of self-regulation may be necessary for mental health, but it is clearly not sufficient; mental health, according to the view defended here, is skilled self-regulation. For example, an individual under the influence of in- toxicants or psychotropic drugs may be willing to engage in harmful activities and regulate their responses towards this end. Similarly, a person experiencing a manic episode (which is often marked by grandiosity, flight of ideas, and in- creased goal-directed behavior) may successfully regulate her responses towards some mania-inspired standard. Neither case of successful self-regulation is nor- mally considered to be part of healthy mental states. The difference between mere successful self-regulation to a potentially harmful standard, on one hand, and men- tal health, on the other, is that mental health requires the ability2 to intelligently and flexibly modify one’s responses. This skill is often masked or absent while individuals are experiencing delusions, manic states, or are under the influence of psychotropic drugs. The skill view also does not entail the (false) claim that mental disorders re- quire a global inability2 to self-regulate. Individuals suffering from addictions, for example, may be able2 to regulate their responses to their addiction-specific urges and desires in some circumstances (e.g., while in the presence of a police officer). The skill view claims that mental disorders require an inability2 to skillfully self- regulate (which is consistent with individuals being able2 to merely successfully regulate their responses in some situations). The skill view is also not claiming that mental health requires the ability2 to skillfully regulate one’s responses to all possible stimuli. For example, consider someone who lives an utterly untroubled mental life, but who might contingently be unable to skillfully self-regulate their responses to some psychiatric symptoms (say, auditory hallucinations) in other circumstances which, fortunately, do not ob- Leder, G., & Zawidzki, T. (2023). The skill of mental health. Philosophy and the Mind Sciences, 4, 3. https://doi.org/10.33735/phimisci.2023.9684 ©The author(s). https://philosophymindscience.org ISSN: 2699-0369 https://doi.org/10.33735/phimisci.2023.9684 https://creativecommons.org/licenses/by/4.0/ https://philosophymindscience.org Garson Leder and Tadeusz Zawidzki 16 tain. Intuitively, although this person may lack the skill to regulate her responses to certain psychiatric symptoms (if they were to manifest), this is a person in good mental health. And this is what the skill view predicts. The skill view argues that mental health is the skilled action of regulating one’s responses to one’s mental phenomena (not to all possible mental phenomena that a person may experience). In the hypothetical case noted above, the individual is mentally healthy as long as she is able to regulate her responses to her mental phenomena (which, in this case, does not involve any psychiatric symptoms). This person may certainly develop a mental disorder if she were to develop psychiatric symptoms that she was unable to intelligently self-regulate, but she is not mentally ill just because she lacks the skill to regulate her response to symptoms that she does not have. The skill view also does not entail the (false) claim that all instances of mental healing necessitate the development of new skills. Mental healing may involve the development of new self-regulatory metacognitive skills, but it may also involve the unmasking of previously developed skills. Mental health requires the exercise of self-regulatory metacognitive skill, and this can be accomplished in many ways (e.g., by acquiring new skills, strengthening old skills to adapt to new conditions, or by removing environmental factors that mask or overwhelm one’s current ability1 to intelligently self-regulate). Finally, as noted in Section 2, the skill view adopts a restricted definition of self-regulation that focuses on whether individuals are able2 to intelligently al- ter, modify, or control their responses to their mental phenomena, regardless of the standard that they are attempting to regulate to. This is not to claim that the standard is irrelevant to health; individuals’ goals or standards are often part of the problem that therapy is attempting to ameliorate (e.g., overly high or ‘perfec- tionist’ standards). In the case of perfectionist or unrealistic goals, therapy may attempt to modify a patient’s high standards, but the high standards are maladap- tive only if the patient is genuinely unable2 to intelligently alter or control how she responds to them. Impossibly high standards needn’t be maladaptive, and may often serve as useful motivators. The skill view argues that mental health is determined by one’s ability2 to intelligently modify, alter, control their responses towards the achievement of some end; it does not matter (at least in the context of mental health) how well one does this or how achievable the goal is. 3.4.1 Skill and function The skill view offers a naturalist definition of mental disorders that is conceptu- ally superior to traditional function-based views. The skill view, in contrast to function-based views, captures what is disordered about mental disorders (i.e., a failure of skilled self-regulation) without revising our conception of paradigmatic disorders and without pathologizing normal human difference. Unlike dysfunc- tion views, the skill view predicts that paradigmatic mental disorders such as de- pression, anxiety, and schizophrenia are clear instances of disorder insofar as they Leder, G., & Zawidzki, T. (2023). The skill of mental health. Philosophy and the Mind Sciences, 4, 3. https://doi.org/10.33735/phimisci.2023.9684 ©The author(s). https://philosophymindscience.org ISSN: 2699-0369 https://doi.org/10.33735/phimisci.2023.9684 https://creativecommons.org/licenses/by/4.0/ https://philosophymindscience.org The skill of mental health 17 involve failures of skilled self-regulation. And, unlike dysfunction views, the skill view predicts that mental states that merely involve norm-transgressing mental content and behavior (or even dysfunctional mental mechanisms), but do not in- volve problems of skilled self-regulation (such as homosexuality, asexuality, and norm-transgressing gender-identification), are clearly not mental disorders. Men- tal disorders are best conceived of as problems of skilled mental regulation, not mental content or the proper functioning of mental mechanisms. The skill view of health, in contrast to function-based views, is also consistent with divergent theories of psychopathology and psychological healing. The causes of breakdowns in skilled self-regulation are likely various, and may include phys- iochemical, genetic, cognitive, or environmental factors (and likely some combina- tion of multiple variables). A significant advantage of the skill view over function- based views is that the identification of mental disorders does not depend upon the truth of any particular theory of psychopathology and psychological functioning. According to function-based views, accuracy about the etiology of hypothesized disorders is crucial, given that whether or not some way of being (such as anxi- ety or homosexuality) counts as a disorder necessarily depends on whether it is the result of a mental dysfunction. The skill view of health, on the other hand, is compatible with the etiology of mental disorders being an open empirical and conceptual question. Mental disorders are failures or breakdowns of skillful self- regulation, whatever the cause. Regardless of whether the etiology of a disorder is best described by a cognitive-behavioral theory, psychodynamic theory, or any other theory of psychopathology, if some state is a disorder, it is marked by an inability2 to skillfully self-regulate. 3.5 The epistemic boundary problem The skill view draws the metaphysical boundary between health and disorder at in- dividuals’ ability2 to intelligently self-regulate. There remains the question of how we might know when this is the case. There are two types of epistemic challenges in identifying mental disorders: one is nosological, the other diagnostic. The noso- logical question is concerned with identifying what types of mental phenomena are and are not mental disorders (i.e., is the mental state normally associated with depression a disorder or a mere problem of living?). The diagnostic question is concerned with how clinicians might identify disorders, given the answers to the nosological question (i.e., how might we know if an individual meets the crite- ria for any given mental state that we postulate to be disordered?). This section argues that there is a degree of vagueness in the answer to both questions, but, importantly, the epistemic uncertainty facing the skill view is more benign than the vagueness facing function-based views. The skill view identifies mental disorders by identifying inabilities2 to intel- ligently self-regulate. This requires identifying when individuals cannot flexibly alter or control how they respond to their thoughts, emotions, and behaviors. So, Leder, G., & Zawidzki, T. (2023). The skill of mental health. Philosophy and the Mind Sciences, 4, 3. https://doi.org/10.33735/phimisci.2023.9684 ©The author(s). https://philosophymindscience.org ISSN: 2699-0369 https://doi.org/10.33735/phimisci.2023.9684 https://creativecommons.org/licenses/by/4.0/ https://philosophymindscience.org Garson Leder and Tadeusz Zawidzki 18 identifying specific disorders (such as depression, anxiety, and OCD) is a matter of identifying inabilities to skillfully self-regulate (e.g., to regulate responses to depressive thoughts and emotions, anxious feelings and worry, or obsessions and compulsions). Psychometric and diagnostic tools like the DSM-5 and ICD-10 are heuristics that should be seen as doing just this. While no one should think that these diagnostic tools are carving nature at its joints, they do a good, but imperfect job of identifying when individuals are unable2 to intelligently self-regulate and are in need of help. Diagnostic tools are, of course, imprecise (e.g., there is no meta- physical significance to the DSM-5’s requirement of a minimum of two-weeks of symptom expression for the diagnosis of major depressive disorder, as opposed to three weeks or ten days). And diagnostic tools may be based on mistaken noso- logical assumptions (e.g., homosexuality was considered a mental disorder in the DSM-II and was not fully removed until 1973). However, while the diagnostic tools’ lack of precision clearly has practical implications (insofar as diagnoses often en- tail improved access to resources and aid), this epistemic problem does not reflect a metaphysical shortcoming of the skill view (i.e., the skill view provides us with a framework to differentiate between accurate and mistaken nosological claims: we know that if someone is genuinely unable2 to skillfully self-regulate, then they are experiencing a mental disorder).22 The issue here is one of psychometrics, not metaphysics. The skill view also faces no unique diagnostic challenges. While the skill view and function-based views may differ over their nosological commitments, both views have to rely on the same diagnostic and psychometric tools (such as the DSM-5 and ICD-10, and the Beck Depression Inventory and the Hospital Anxiety and Depression Scale, respectively) in order to differentiate between health and disorder for any hypothesized nosological entity. For instance, even if one were to adopt a function-based conception of mental health, identifying the precise bor- der between any particular individual’s poor functioning (say, normal, but intense, anxiety) and dys-functioning (say, GAD) still comes down to the arbitrary drawing of lines. Similarly, whether an individual is unable2 to intelligently self-regulate (as opposed to just being a poorly skilled self-regulator) is not always clear. But in both cases, this is an issue of psychometrics, not metaphysics. Providing a specific answer to the diagnostic question is going to be a problem for any naturalist view, and the existence of fuzzy boundaries between health and disorder for any particu- lar nosological entity is problematic only if we take diagnosis to accurately reflect metaphysical distinctions rather than serving as imperfect heuristics to identify breakdowns of skilled action. Both dysfunction views and the skill view accept that diagnostic boundaries are fuzzy. This is a serious practical problem, but not a metaphysical one. What is crucial for a naturalist theory of mental disorder is that it provides a plausible value-neutral metaphysical grounding from which we can base the epistemic dif- 22In contrast, the imprecision of diagnostic tools is a serious problem for function-based views given the etiological commitments noted in section 3.4.1. Leder, G., & Zawidzki, T. (2023). The skill of mental health. Philosophy and the Mind Sciences, 4, 3. https://doi.org/10.33735/phimisci.2023.9684 ©The author(s). https://philosophymindscience.org ISSN: 2699-0369 https://doi.org/10.33735/phimisci.2023.9684 https://creativecommons.org/licenses/by/4.0/ https://philosophymindscience.org The skill of mental health 19 ferentiation of genuine disorders from mere problems of living and value-based ‘disorders’. The skill view does this. 4 The skill view and dysfunction The previous section has shown that the skill view offers us a more plausible an- swer to the boundary problems than dysfunction-based theories. This section ad- dresses some further points of difference. A significant difference between the skill view and function-based theories is that the skill view is a theory of mental health, not health, full stop. Traditional function-based views adopt the same conception of health for both somatic and mental health. This uniformity may be considered an advantage in their favor. However, the cost of this uniformity in our conception of somatic and mental dis- orders is a theory of disorder that is both potentially massively revisionary and epistemically weak. This is a high price. While a thorough defense of this dis- tinction is beyond the scope of this paper, it is important to note that the focus on skill, rather than function, closely aligns with how we normally conceive of mental health and healing.23 Mental health is best conceived of as a quality of persons, not of impersonal mechanisms. Dysfunction views assume that the same standard of health can be used for any living thing (be it a plant, a bacterium, or a mind). In contrast, the skill view posits different standards of health for minds and bodies. It is far from clear why we would think otherwise. Why think that the questions concerning the health of a mind and the health of a plant or a bone are af- ter the same information? Two concerns may be that adopting different standards of health assumes some sort of substance dualism about minds and bodies and an anti-scientific conception of mental disorders. But neither worry is legitimate. We needn’t claim that minds are non-material to also posit that their health is best explained by skill rather than function. Minds are more complex than bones and plants, and it is not surprising that their health is best judged by different stan- dards. A second significant difference is that many advocates of function-based theo- ries take the concept of normal function to be necessarily connected to our under- standing of health. The two most influential naturalist theories of health, Boorse’s (1976) ‘pure’ naturalist theory, and Wakefield’s (1992) ‘hybrid’ view, both appear to share this view. For example, Boorse states that: There is clearly some plausibility in the claim that the history of med- ical theory is nothing but a record of progressive investigation of nor- mal functioning (1977, p. 560). 23See: Leder (2019); Zawidzki (2019). Leder, G., & Zawidzki, T. (2023). The skill of mental health. Philosophy and the Mind Sciences, 4, 3. https://doi.org/10.33735/phimisci.2023.9684 ©The author(s). https://philosophymindscience.org ISSN: 2699-0369 https://doi.org/10.33735/phimisci.2023.9684 https://creativecommons.org/licenses/by/4.0/ https://philosophymindscience.org Garson Leder and Tadeusz Zawidzki 20 And Wakefield: [It is a] virtual universal tendency to fall back on dysfunction to ex- plain disorder (1992, p. 381). Boorse and Wakefield may both be correct in claiming that health and disorder (or at least naturalist views of health and disorder) are normally conceptualized in functional terms. But, given the conceptual and epistemic problems facing function-based views, we have little reason to continue to do so. The intuitive strength of the presumed connection between normal function and health, if felt at all, should be dependent upon whether or not function-based conceptions of mental disorder can offer us explanatorily successful theories of health and disor- der. The concept of natural function hasn’t been able to do this. Skill can. 5 Broader advantages of the skill view The previous sections have articulated a precise conception of mental health in terms of metacognitive self-regulatory skill and have shown its superiority to function-based conceptions, relative to a number of core theoretical and practical issues. In this section, we turn to some broader considerations in support of conceptualizing mental health as a skill. In particular, we argue that if mental health consists of metacognitive skills, this (1) shows a way past the historically recurring trilemma of psychiatric reductionism, eliminativism, and dualism; (2) defuses motivations for anti-psychiatry by accommodating cultural variance in mental illness within a value-neutral framework and providing an objective foundation for the scientific study of mental health and healing, and (3) suggests a novel and promising way of striking the delicate balance between stigma reduction and promoting individual agency in mental health. 5.1 Avoiding the reductionism-eliminativism-dualism trilemma Much of the history of psychiatry can be characterized, with little exaggeration, in terms of a periodic vacillation between three unstable ontological frame- works: reductionism, eliminativism, and dualism. According to reductionists, psychiatric disorders are nothing over and above (neuro-)physiological dys- functions. According to eliminativists, psychiatric disorders do not really exist; only (neuro-)physiological dysfunctions exist. According to dualists, psychiatric disorders are afflictions of a domain which is, in some sense, autonomous from (neuro-)physiology. Each of these frameworks has ultimately proven unstable, for different reasons. Reductionism assumes that psychiatric disorders can be mapped directly onto (neuro-)physiological dysfunctions, but, as noted above, this has repeatedly been shown to be untenable. Eliminativism makes psychiatry (as commonly practiced) impossible, and jeopardizes the very notion of mental Leder, G., & Zawidzki, T. (2023). The skill of mental health. Philosophy and the Mind Sciences, 4, 3. https://doi.org/10.33735/phimisci.2023.9684 ©The author(s). https://philosophymindscience.org ISSN: 2699-0369 https://doi.org/10.33735/phimisci.2023.9684 https://creativecommons.org/licenses/by/4.0/ https://philosophymindscience.org The skill of mental health 21 health. And dualism makes mysterious the patent dependence of mental health and disorder on physiological and other physical factors. It is plausible that one reason these three unstable, alternative frameworks have proven perennially seductive consists in the underlying assumption that mental disorder must consist in some kind of dysfunction. If it is not a (neuro-)physiological dysfunction, then it must either not exist, or consist in the dysfunction of some non-physical capacity. However, if mental health is conceptualized as a skill, then this seductive trilemma can be avoided. This is best appreciated in terms of an analogy to a typical embodied skill. Consider tennis again. Nobody is at all tempted by either reductionism, elimi- nativism, or dualism about skill at tennis. Although (neuro-)physiological func- tionality, and other physical factors are required to successfully acquire and exe- cute skill at tennis, there is no sense in which skill at tennis is the same thing as (neuro-)physiological functionality; this is why lack of skill at tennis is clearly not any kind of (neuro-)physiological dysfunction. However, this in no way supports eliminativism about skill at tennis; it is clearly a real phenomenon. Nor does the fact that skill at tennis cannot be identified with (neuro-)physiological functional- ity in any way make dualism about skill at tennis at all tempting. Skill at tennis just seems to belong to the wrong logical category to even raise the question of whether or not it consists in (neuro-)physiological functionality. The question of whether or not, or to what degree, someone is skilled at tennis just seems entirely orthogonal to questions of (neuro-)physiological functionality. The criteria by which and reasons why we make judgments about the former have noth- ing to do with the criteria by which and reasons why we make judgments about the latter. If we conceive of mental health in terms of self-regulatory metacognitive skills, rather than in terms of biologically normal functionality, then the fruitless vacillation among the horns of psychiatry’s historical, ontological trilemma can be avoided. In many respects, the idea here resembles Ryle’s more general perspective on ‘the concept of mind’ (1949). Ryle sought to avoid the traditional dilemma between dualism and reductionism (while resisting eliminativism), by arguing that folk psychological concepts are used to track abilities, skills, and disposi- tions of persons, rather than mechanical facts about our (neuro-)physiology, or “para-mechanical” facts about a “spectral” machine somehow lodged within it. Similarly, we claim that the language of mental health and disorder is better understood as tracking metacognitive abilities, skills, and dispositions, rather than facts about (dys-)functioning (neuro-)physiological mechanisms, and that this reconceptualization can help us avoid the persistent ontological trilemma. On our view, like any other skill, self-regulatory, metacognitive skills are valued in specific cultural contexts, can be acquired to greater or lesser degrees by persons inhabiting those contexts, and depend on (neuro-)physiological functionality and other physical facts for their successful acquisition and exercise. None of this requires either reductionism, eliminativism, or dualism about them, any more than about skill at tennis. Leder, G., & Zawidzki, T. (2023). The skill of mental health. Philosophy and the Mind Sciences, 4, 3. https://doi.org/10.33735/phimisci.2023.9684 ©The author(s). https://philosophymindscience.org ISSN: 2699-0369 https://doi.org/10.33735/phimisci.2023.9684 https://creativecommons.org/licenses/by/4.0/ https://philosophymindscience.org Garson Leder and Tadeusz Zawidzki 22 5.2 Respecting cultural variance while avoiding anti- psychiatry Mental illnesses may manifest different symptomologies in different cultures and across time (Radden, 2003). If we think of mental illnesses as dysfunctions of bi- ological mechanisms, then this kind of cultural variance is hard to explain. The functionalist view is largely motivated by the desire to assimilate psychiatry to the rest of medicine (Wakefield, 1992). But this kind of cultural variance in symp- tomology seems far less pronounced in the case of somatic illness: COVID-19, can- cer, heart disease, etc., all display remarkably homogeneous manifestations across cultures. If the functionalist view is the only possible foundation for scientific psy- chiatry, cultural variance in mental illness can naturally motivate skeptical and anti-psychiatry views. In contrast, if we think of mental illness as a deficit in self-regulatory metacog- nitive skill, then cultural variance can be accommodated without embracing anti- psychiatry or sacrificing the objectivity of mental illness. Although cultures can differ in the sorts of goals relative to which their members want to self-regulate, it remains an objective fact whether or not they are able2, skillfully, to do this. Perhaps the task of managing grief differs across cultures. In one culture, it may require a Stoic return to normal life within a few weeks, while in another, more expressive culture, it might require public expressions of grief over the course of months. Such differences might yield different judgments of mental illness with re- spect to individuals incapable of meeting such goals. An individual may be judged mentally ill relative to a Stoic culture, even if they are fully within the norm rel- ative to a more expressive culture, and vice versa. However, on the skill view of mental health, there remains an objective fact of the matter as to whether or not they are mentally ill: if they cannot skillfully self-regulate relative to one of their (sometimes culturally determined) goals, e.g., appropriate grieving, then they count as objectively mentally ill. Thus, the skill view predicts that cultural norms may influence the standard one attempts to regulate their responses to, but they do not influence whether any way of being should be considered disordered. Once again, a comparison to embodied skills is pertinent here. Consider speech therapy. This clearly involves a degree of cultural relativity, since different lan- guages place different phonetic demands on their speakers. Hence, someone may count as speech disabled relative to one language and not relative to another. Nev- ertheless, there are objective facts about whether or not someone is speech disabled relative to some language, about the relevant (neuro-)physiological capacities, and about the sorts of behavioral interventions that enable them to overcome their dis- ability. Speech therapy is an entirely objective enterprise, based on investigation of such facts and the implementation of relevant interventions. Just as such facts and interventions may partially but not wholly overlap across languages, our sugges- tion here is that facts and interventions relevant to psychiatric care may partially but not wholly overlap across cultures. Leder, G., & Zawidzki, T. (2023). The skill of mental health. Philosophy and the Mind Sciences, 4, 3. https://doi.org/10.33735/phimisci.2023.9684 ©The author(s). https://philosophymindscience.org ISSN: 2699-0369 https://doi.org/10.33735/phimisci.2023.9684 https://creativecommons.org/licenses/by/4.0/ https://philosophymindscience.org The skill of mental health 23 The skill view offers a robust antidote to anti-psychiatry; self-regulatory metacognitive skills, like embodied skills, involve objective, (neuro-)physiological capacities that psychiatrists can study. This perspective suggests the following taxonomy of objective, psychiatric sciences. Neuropsychiatry can be seen as the study of the neural mechanisms underlying self-regulatory, metacognitive skills. Clinical psychiatry can be seen as the study of the sorts of interventions required to develop or unmask such skills (including therapies involving mindfulness and other forms of metacognitive practice). And applied clinical psychiatry can involve the implementation of such therapies and regimes of practice. The latter might be analogized to such well-established health professions as occupational therapy, which focus on (re-)training of patients wanting to re-enter the workforce after debilitating traumas. 5.3 Striking a delicate balance: Agency without stigma Perhaps the greatest advantage of the skill view is that it suggests a promising understanding of agency with regard to mental illness which avoids the kind of stigma that typically accompanies failures of rational agency, as traditionally con- ceived. One often touted, practical advantage of function-based views concerns stigma reduction. If mental illness is no different from somatic illness (i.e., result- ing from a biological dysfunction), then, so the argument goes, the mentally ill are no more to blame for their afflictions than those suffering from somatic illnesses. A person suffering from bipolar disorder, for example, should be subject to no more stigma than a person who has caught COVID-19: these are caused by bio- logical dysfunctions for which they are not responsible; they deserve medical care, not blame or stigmatization. Thus, on function-based views, stigma reduction is bought at the price of the near-elimination of agency: like patients with somatic illnesses, the most patients with mental illnesses can do is consult medical experts, and follow their orders and prescriptions. And for this reason, they should not be blamed or stigmatized. In contrast, the skill view offers a more promising means of stigma reduction, which does not depend on such an extreme diminution of agency in the mentally ill. One traditional reason individuals with mental illness have suffered from stigma has to do with a particular conception of rational agency. The idea is that when a rational agent knows the rational course of action, they are, in virtue of this knowledge alone, appropriately motivated to engage in it. According to the most stringent, traditional versions of this principle, any individual who fails to match this pattern fails to qualify as a rational agent, and hence, does not deserve the regard to which only rational agents are entitled.24 But such impairments are typical of those experiencing mental disorders: in most mental disorders, individuals know that avoiding the patterns of behavior to which they are prone 24This understanding of practical rationality, and its relationship to the central category of moral status, i.e., personhood, has dominated the western philosophical canon, at least since Kant. Leder, G., & Zawidzki, T. (2023). The skill of mental health. Philosophy and the Mind Sciences, 4, 3. https://doi.org/10.33735/phimisci.2023.9684 ©The author(s). https://philosophymindscience.org ISSN: 2699-0369 https://doi.org/10.33735/phimisci.2023.9684 https://creativecommons.org/licenses/by/4.0/ https://philosophymindscience.org Garson Leder and Tadeusz Zawidzki 24 is the rational course of action, yet they are unable2 or inappropriately motivated to avoid them. Viewing mental illness as a dysfunction, rather than such a lapse in rationality, can offer some respite from stigmas that attend the latter. However, these are not the only sorts of stigma that potentially accompany mental illness; biological dysfunctions, like somatic illnesses, carry their own forms of stigma. The evidence for the association between acceptance of dysfunction views and stigma reduction is mixed. While the acceptance of dysfunction views is associated with a reduction of perceived blame and responsibility of people with mental disor- ders (Phelan, 2002), it is also associated with an increase in essentialist conceptions of illness (i.e., beliefs that illness is caused by biological processes over which in- dividuals have little control), increased social rejection (e.g., beliefs about the dan- gerousness and ‘otherness’ of the mentally ill) (Schomerus, 2012), and prognostic pessimism about recovery (Deacon & Baird, 2009). So, while the ‘dysfunction’ nar- rative may reduce blame, it may also promote social rejection, hinder recovery, and diminish patients’ sense of agency. Hence, conceiving of mental illnesses as dysfunctions, while protecting against some forms of stigma, may foster others. In contrast, the skill view suggests a conception of agency different from the tradi- tional understanding of rational agency, which has the potential to reduce the kind of stigma that attends failures of the latter, to avoid the stigma that attends dys- function, and to promote a kind of agency among individuals with mental illness that is necessary for recovery. The skill view avoids two extreme conceptions of metacognitive agency: (1) taking metacognitive agency entirely for granted, as on some traditional views of rational agency, and (2) diminishing metacognitive agency, as on functionalist conceptions of mental health and illness. On the traditional view, to be practi- cally rational just is to exercise metacognitive agency: one is rational in virtue of willing appropriate means to one’s goals; if one cannot do that, one just is not ra- tional. On the functionalist view, there is limited metacognitive agency: choosing appropriate means to one’s goals is a matter of normal biological functioning, over which one has minimal control. The skill view provides a third alternative, inspired by notions of agency evident in embodied skill development, a notion of agency that neither ignores nor takes for granted metacognitive agency: on the skill view, metacognitive agency is something that persons can develop and maintain through practice, supported by appropriate social and physical scaffolds (e.g., supportive environments, protection against trauma, and undamaged (neuro-)physiological capacities). Athletes are rightfully praised for developing and exercising their skills; they have a kind of agency. However, this is not a kind of agency that they have automatically, in virtue of being athletes. It is an agency that they have to de- velop, through an arduous and gradual process. Similarly, we want to suggest, the metacognitive agency required for skilled self-regulation, in terms of which we understand mental health, is something that can be developed only gradually, through diligent practice (though much of this practice occurs during childhood Leder, G., & Zawidzki, T. (2023). The skill of mental health. Philosophy and the Mind Sciences, 4, 3. https://doi.org/10.33735/phimisci.2023.9684 ©The author(s). https://philosophymindscience.org ISSN: 2699-0369 https://doi.org/10.33735/phimisci.2023.9684 https://creativecommons.org/licenses/by/4.0/ https://philosophymindscience.org The skill of mental health 25 development). It is not a form of agency that we can just take for granted in virtue of being rational. Hence, there are steps that individuals experiencing mental dis- orders can take to improve their lot, just as there are steps that most persons can take to improve athletic skills. They retain agency. However, it is not the kind of agency presumed by traditional views of practical rationality: it is fragile, and con- tingent on adequate physical and social scaffolding. A failure to demonstrate this kind of agency does not motivate stigma, in the way that a failure to demonstrate the kind of agency traditionally deemed to be necessary for practical rationality can. With the exception of some outlier communities, nobody is stigmatized for not having had the opportunity to develop tennis skills, for example, or for los- ing the ability2 to play tennis as the result of some trauma. Similarly, we want to suggest, if we think of mental health as a skill that takes practice, together with contingent physical and social scaffolds, to develop and maintain it, there is no reason to stigmatize those who lack this ability or these opportunities. Thus, we have here a way of allowing for agency in individuals with mental disorder (the same kind of agency that persons in athletics have: the ability1 to acquire or regain skills), while avoiding the stigma that accompanies lapses in traditional rationality and avoiding the stigma that accompanies dysfunction. It might be objected that the adoption of the skill view may increase negative stigma sometimes associated with mental disorders. The concern may be that the conception of mental disorders as failures or breakdowns of skilled action could encourage the idea that mental disorders are the results of personal weakness. If you want to become more skilled at some mode of functioning, the thought might go, you just need to practice and put in the work to develop it. While it is certainly true that avoiding and recovering from mental illness is to some degree a matter of effort (this is something that most theories of psychological healing accept), conceiving of mental health as a skill does not entail that mental health is merely a question of willpower or effort. There are constraints to the development of any skill that have nothing to do with strength of character or volition. Individuals differ in their potential to de- velop specific skills due to biological, cognitive, and environmental differences. The skill of mental health, like skill in sports and intellectual activities, depends in large part on one’s physical and cognitive capacities. While it is likely that most individuals can improve their ability to perform skilled actions through practice and study, many factors constrain one’s development of skills; practice and dili- gence cannot overcome basic anatomical or cognitive constraints such as visual impairments or neurological deficits. The causes of variance in skill are likely very complex (including, but in no way limited to, a person’s prenatal environment, genetics, upbringing, and socio-economic standing), but clearly, they are not just a matter of will-power. The skill of mental health, like embodied or intellectual skills, is something that must be developed and maintained, and is significantly constrained or enabled by physiological and environmental factors. Leder, G., & Zawidzki, T. (2023). The skill of mental health. Philosophy and the Mind Sciences, 4, 3. https://doi.org/10.33735/phimisci.2023.9684 ©The author(s). https://philosophymindscience.org ISSN: 2699-0369 https://doi.org/10.33735/phimisci.2023.9684 https://creativecommons.org/licenses/by/4.0/ https://philosophymindscience.org Garson Leder and Tadeusz Zawidzki 26 6 Conclusion We have shown that a focus on skill, rather than function, provides us with a more explanatorily robust and pragmatically useful theory of mental health. On a theo- retical level, this conception of mental illness allows for more intuitive and tenable assignment of extensions to our mental illness categories. On the pragmatic level, the focus on metacognitive skill rather than function enables a conception of men- tal disorder that is consistent with the scientific study of psychopathology while also promoting human agency. Mental health, according to the skill view devel- oped here, is something that individuals do. References American Psychiatric Association. 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Philosophy and the Mind Sciences, 4, 3. https://doi.org/10.33735/phimisci.2023.9684 ©The author(s). https://philosophymindscience.org ISSN: 2699-0369 https://plato.stanford.edu/entries/health-disease/ https://doi.org/10.1016/s0166-2236(02)02209-9 https://doi.org/10.1016/0005-7967(78)90022-0 https://doi.org/10.1353/ppp.2003.0081 https://doi.org/10.1016/j.jocrd.2013.09.002 https://doi.org/10.1177/1088868310381084 https://doi.org/10.1111/j.1600-0447.2012.01826.x https://doi.org/10.1111/nous.12144 https://doi.org/10.1002/wps.20310 https://doi.org/10.1037//0003-066x.47.3.373 https://doi.org/10.1016/S0165-0327(01)00459-1 https://doi.org/10.5840/monist199982429 https://doi.org/10.5840/philtopics201947214 https://doi.org/10.33735/phimisci.2023.9684 https://creativecommons.org/licenses/by/4.0/ https://philosophymindscience.org Introduction Mental disorders and mental functions The skill of mental health The value-neutrality of skill Skill and self-regulation Skill and mental health Skill, mental disorder, and the boundary problem Skill and function The epistemic boundary problem The skill view and dysfunction Broader advantages of the skill view Avoiding the reductionism-eliminativism-dualism trilemma Respecting cultural variance while avoiding anti-psychiatry Striking a delicate balance: Agency without stigma Conclusion