GIPPS / ILLNESSES AND LIKENESSES ■ 255
Illnesses and
Likenesses
I
N THIS RESPONSE to Neil Pickering’s paper I
shall focus only on what he describes as the
“strong objection” to the typical use of the
likeness argument. The likeness argument, to re-
cap, has it that we can decide whether conditions
such as schizophrenia, depression, or alcoholism
do or do not deserve the designation of illness
depending on whether they possess features
which, if they occurred in physical conditions,
would enable one to decide for or against the
designation. To take an implausible example, if it
were decided that it would be enough to describe
a physical condition as an illness if it involves
pain not caused through injury, then a psycho-
logical condition would be appropriately de-
scribed as an illness just to the extent that it too
involved such pain.
In arguing against typical deployments of the
likeness argument, Pickering finds that it is only
on questionable initial descriptions of psycho-
logical conditions that such conditions appear to
share the features that, in physical conditions,
would be taken to be indicative of illness. That is
to say, theorists who deploy the likeness argu-
ment to urge either the reality or unreality of
mental illnesses typically presuppose what both
we and they had all along hoped would be dem-
onstrated in their argument. In terms of the above
example, we might say that a certain psycholog-
ical condition can count as an illness if it involves
psychic pain. The concept of psychic pain is
however (so the argument would have it) con-
© 2004 by The Johns Hopkins University Press
10.3gipps. 255
Richard G. T. Gipps
testable; there exist other descriptions that make
no reference to pain and in so doing fail to
provide what a user of the likeness argument
would need to substantiate the claim that a con-
ception of the condition as an illness is more
than a façon de parler.
By way of arriving at this conclusion the fol-
lowing precondition for the applicability of the
likeness argument (Pickering’s “assumption” (2))
is insisted on: “That, with respect to the presence
or absence of [those features of conditions which
features decide whether or not the conditions are
illnesses], a condition such as schizophrenia [must
be] describable independently of the category it
is assigned to.” This can seem a quite reasonable
restriction, for—it could be said—one can only
win an argument if it is first allowed that there is
actually something to argue about. That is, it is
only if both partisans and detractors of the ill-
ness conception first accept a certain description
of schizophrenia as spelling out what schizo-
phrenia essentially involves that they can then
progress to determining whether or not such a
condition so described is or is not an illness.
Yet, whereas this seems like a perfectly rea-
sonable requirement, it is I believe uncertain
whether it will always capture the form of the
intuitions of adherents and detractors of the ill-
ness conception—or of the form of philosophical
arguments more generally. To be sure, some philo-
sophical discussions can perhaps be reconstruct-
ed as debates about the validity of certain infer-
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 256 ■ PPP / VOL. 10, NO. 3 / SEPTEMBER 2003
ences from mutually understood premises (i.e.,
given X, does Y follow or not?). Yet if this were
the case, then genuinely interesting philosophical
arguments would probably be few and far be-
tween. If we are agreed as to the precise signifi-
cance of our premises, and are not furthermore
just making straightforward mistakes in reason-
ing, it is hard to see how or why we could all fail
to arrive at the same conclusions.
In the Philosophical Investigations paragraph
128 Wittgenstein wrote that “If one tried to
advance theses in philosophy, it would never be
possible to question them, because everyone
would agree to them” (Wittgenstein 1953). Now
that proposition might seem on rather weak
grounds, because all one has to do to actually
disprove it is merely disagree with it. But pre-
sumably Wittgenstein is rather articulating his
intuition that although philosophical arguments
often take the form of clashes concerning what
conclusions can be drawn from what premises,
most of their substance comes from a prior fail-
ure to unpack the intrinsic significance of their
premises. Hence an alternative form of philo-
sophical procedure which consists rather in re-
minding us of what we already know (paragraph
127: “The work of the philosopher consists in
assembling reminders for a particular purpose”).
What I am suggesting is that proponents of
the illness conception who deploy the likeness
argument are, far from needing to accept ab
initio that an articulation of the essential charac-
ter of schizophrenia is possible which is itself
neutral as to the question of its status as a genu-
ine illness, perhaps better understood as attempt-
ing to remind us of what they believe we tacitly
already know. And revealing likenesses between
mental illnesses and physical illnesses may be
one way of getting us to accept that which is all
along implicit in our talk about the condition in
question—that here of course we are dealing
with something validly thought of as an illness
and not a condition fully and adequately de-
scribed as a “crisis,” “problem in living,” “some
ways of being human,” or what have you. In this
vein it could even be argued that Pickering’s use
of the phrase psychological conditions, although
it might sound helpfully neutral between illness
10.3gipps. 256
and nonillness models, is really little more than a
euphemism, a euphemism that has to already be
implicitly understood in context to either mean a
mental illness or something quite different.
Pickering tells us in his introduction that he
aims to throw doubt on the ability of the likeness
argument to work and to do so by questioning
not this or that application of it but rather by
calling into question its general form. Yet, to
evaluate whether the likeness argument has on
some or other occasion been put to good use, it is
necessary to see the details of the argument in
question. Pickering argues for example that a
cognitivistic account of mental illness in terms of
the dysfunction of mental mechanisms is not
invalid, but is only one among other possible
alternative descriptions of the scientific facts.
And “[i]n some of these alternatives, illness-like
features disappear.” But whether this is the case
for other accounts will depend on the particular
criteria for being an illness that are mooted. In
his introduction, for example, Pickering men-
tions K. W. M. Fulford’s suggestion that illnesses
can be understood as involving “action failure.”
The question of whether a conception of (for
example) schizophrenia can be articulated, such
that a description of its essential features in terms
of (for example) action failure can be revealed as
an optional interpretation as opposed to some-
thing entailed by the essential aspects of such
features, remains to be shown. Thus it seems to
this commentator that, whereas it may well turn
out that Pickering’s critique of typical deploy-
ments of the likeness argument will prove to be
quite general, this does not seem to be something
that can be decided in advance of the examina-
tion of particular cases.
This is worth spelling out in a little more
detail. It might be thought that any deployment
of the likeness argument is caught in a dilemma.
If on the one hand it deploys a description of the
condition in question which presupposes that we
are dealing here with an illness, then it will beg
the question. (Although, as I argued above, this
might not be such a bad thing, if instead the
argument were reconstructed as a reminder of
the actual character of our concepts.) Yet if on
the other hand it does not presuppose this—that
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is to say, if the concept of illness or some cognate
concept is not as it were simply built into the
concept of the condition in question—then it
must be purely extrinsic to the concept of the
condition. In which case it will not be possible to
validate talk of illness by means of a purely
logical argument. But this of course underesti-
mates the logical options. For it is possible that
the conditions in question simply happen to have
features which, without being among the criteria
for individuating the illness, are nevertheless in-
disputable symptoms of the condition—and
which entail the validity of an illness designa-
tion. For this reason, the applicability of any
alleged criterion of illness to psychological con-
ditions must be examined on a case-by-case basis
and surely cannot be decided on the basis of the
form of the likeness argument alone.
I do not suppose it likely that any version of
the likeness argument adhering to Pickering’s
strictures will survive some or other application
of Pickering’s general argumentative procedure.
On the other hand I am not convinced that Pick-
ering’s proposed alternative descriptions of schizo-
phrenia in terms that make no reference to dys-
function, deficit, or illness are plausible. Whether
we are concerned either with the symptom of
delusion in general or with the delusional experi-
ence of thought insertion in particular (Picker-
ing’s two examples), it seems to me impossible to
capture what is meant unless we think in terms
of some kind of basic failure in our comprehend-
ing contact with reality or with our own minds.1
If someone has the delusion (as opposed to a
mere false belief) that they are being controlled
by aliens, then no description in terms of “failing
to check reality,” “checking using the wrong
tools,” or “feeling unable or not wanting to
check the reality” of the belief, could possibly be
adequate (Pickering 2003, p. 251). And this is
because, as we know a priori, delusion involves
not the making of a mistake or a failure in the
checking of some opinion or in any other such
epistemic dilatoriness, but rather a fundamental
failure in that reality contact, which is presup-
posed by false or true belief formation. Cognitive
or psychoanalytic accounts of delusion might
presuppose that our contact with reality or our
10.3gipps. 257
GIPPS / ILLNESSES AND LIKENESSES ■ 257
fundamental self-understanding is explicable in
terms of reality checking or self-monitoring, but
such accounts are only as secure as the alienated
epistemology in terms of which they are cast.2
Showing that such descriptions of fundamental
schizophrenic symptoms are at best optional re-
veals the shortcomings of the metapsychological
foundations of such accounts. Yet this in itself
would seem to impact not at all on the pretheo-
retical idea that someone who is delusional has
something seriously wrong with their mind, which
failure, to be adequately theoretically understood,
requires theorization in noncognitivistic terms.
What I am suggesting is that we need not be
thinking of the mind as some kind of mechanism
(and to think of mental illness as dysfunction in
such a mental mechanism) to accept that it might
not be optional to describe schizophrenia as a
mental illness (any more than we need to sup-
pose that the body is a mechanism before we talk
about physical illness). Concepts such as illness,
disorder, deficit, and health are, on this alterna-
tive view, not merely optional filters through
which perfectly otherwise describable facts of
our physical and mental lives can be viewed.
Abstract away the constituting concepts of health
and illness and, so my suggestion would have it,
one abstracts away the very phenomena of our
lives we were attempting to thematically com-
prehend. Such a conception is of course not at
odds with Pickering’s argument since he only
jibes against accounts which pretend not to pre-
suppose ab initio that it is illness that we have to
do with here (and which attempt to argue from
this starting point that—in his view unsuccess-
fully—we nevertheless find that we are commit-
ted to an illness designation). Yet in what re-
mains of this commentary I should like to consider
this alternative conception in a little more detail
because it might seem that if the use of illness
and cognate concepts really is something of an
inevitability then something like the likeness ar-
gument must after all be valid. Pickering is, of
course, careful to say that he is not arguing
against the viability of the concept of mental
illness itself, but only against the typical deploy-
ment of the likeness argument. Yet the failure of
the likeness argument might quite naturally be
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 258 ■ PPP / VOL. 10, NO. 3 / SEPTEMBER 2003
taken to show that the concept of mental illness
can hardly be an inevitability. If mental illness is
a valid concept, then surely it must share in the
features of uncontested cases of illness, for why
else should we be thinking of illness here at all?
And if mental illnesses do not share any features
of physical illnesses, this would seem to show
that we here have to do with a mere metaphor, in
which case, it might be thought, we should be
able to spell out what it means to have such a
psychological condition in terms that make no
reference to illness or cognate concepts.
To see that this these are not inevitable con-
clusions it is I believe helpful to consider a sec-
tion from Wittgenstein’s Philosophical Investiga-
tions that occurs somewhat later (on p. 216)
than the passages quoted above. Here Wittgen-
stein is considering the phenomenon of (what he
calls) secondary sense.3 A word has a secondary
sense if it is typically redeployed in a novel con-
text in a way which is governed not by a rule but
merely by an intuition. For example, if we were
asked to describe the five vowels as having either
a “darker” or a “lighter” tone, we should proba-
bly be able to do this, even though the sense in
which e is lighter than o is not the same in which
a mouse is lighter than an elephant or magnolia
lighter than midnight blue. Furthermore, the phe-
nomenon is thought by Wittgenstein to be of
significance not merely for trivial examples (such
as the sounds of vowels or, to pick another ex-
ample, the question of which of Wednesday and
Thursday is fat and which thin) but for large
swathes of our psychological vocabulary. We talk
of feeling high or low, we talk of a deep sorrow,
sharp words, grinding pain, a sweet smile, a
feeling of unreality, and so on.
For present purposes there are two significant
features of this phenomenon of secondary sense.
First, although it would not be inaccurate to
describe such cases as metaphors, what is not
necessarily true is that they can be translated out
into a straightforward, nonmetaphorical termi-
nology. Would any other phrase—other than per-
haps another which also deployed secondary
sense—enable us to translate talk of a “sweet
smile” or of the feeling of being “under pres-
sure”? Second, the two (primary and secondary)
10.3gipps. 258
uses need have nothing in common. There need
be no rational basis for the extension of the
vocabulary from that of taste to smile or from
altitude to feelings. A sweet smile has nothing in
common with a lump of sugar. Nevertheless our
genuine understanding of what people are telling
us about their feelings and states of mind charac-
teristically depends on a prior mastery of the
vocabulary in the primary domain.
What I want to suggest is that the concept of
mental illness can be seen as a kind of metaphor,
yet that this in no way impugns the status of the
concept, nor means that we can talk about men-
tal illnesses in any more literal terminology. The
point is not that we are somehow only able to get
an oblique take on the phenomena described by
psychopathology. They are as directly observ-
able and intelligible as anything else, and our
concern here is ontological and not epistemolog-
ical. The point is rather that we can allow both
that the likeness argument will fail and that the
concept of mental illness is perfectly acceptable.
It is on this view no more in need of or requiring
of justification than the concept of physical ill-
ness, which itself can hardly be justified by ap-
pealing to anything external to it.
Here then is the suggestion. The use of illness
to describe regular physical illnesses describes
the primary sense of the term. This term is then
extrapolated in a metaphorical way to compre-
hendingly open up the domain of mental illness-
es. (Perhaps, as in T. S. Champlin’s helpful sug-
gestion, the concept of mental illness stands to
that of physical illness like the notion of “a
rhyme to the eye” [words ending with a similar
spelling] stands to that of a regular rhyme or a
“rhyme to the ear” [words sounding the same]
[Champlin 1996].) We will most likely only un-
derstand the secondary use of the term once we
understand its primary use. But in the secondary
context it has a life of its own. Its use is not
justifiable in any way by appealing to similarities
between mental and physical illnesses. Talk of
the mind is quite different from talk of the body,
just as talk of music or colors is logically quite
different from talk of altitudes. A quite different
set of facts of a quite different order have to be
true of someone if they feel happy than if they
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possess a belly button. And for this reason—that
what it is to have a healthy mind is something of
a quite different order than what it is to have a
healthy body—what it means to be mentally ill is
quite incommensurate with what it means to be
physically ill.
I have taken this little detour from the com-
mentary because it is I think often assumed that
the concept of mental illness is the particular
preserve of the medical model in psychiatry. That
is simply to say that it might be thought that talk
of mental illnesses would seem to one to be the
more valid the more one accepts the view that
mental illnesses are ultimately physical illnesses.
From the alternative perspective developed here
it is the opposite that appears to be the case. If
one is attached to the concept of mental illness,
the worst thing to do (from this perspective) is to
suppose that it requires some kind of justifica-
tion, a justification to be found by comparing it
to what is counted as illness in a quite different
order of reality. By accepting the sui generis char-
acter of the mental, one is able to accept the sui
generis character of mental illness, and thereby
obviate the requirement for justification of men-
tal illness in terms of something other than itself.
Pickering demonstrates for certain cases—and
plausibly urges the more general consideration—
that talk of mental illness cannot be justified by
appeal to likenesses with physical illness. I have
briefly argued that this need not be thought a
problem for the concept of mental illness. Yet
although the concept of mental illness may not
need the justification that Pickering shows it
cannot receive, this is not to show that we should
be using it. Even if we cannot make reference to
the phenomena in which psychiatrists are typi-
cally interested without the use of mental illness
and cognate concepts, this does not show that it
is helpful to use such concepts or take an interest
in such phenomena. Whether or not we should
be approaching other people in this way is in the
end an ethical and a political decision. Does talk
10.3gipps. 259
GIPPS / ILLNESSES AND LIKENESSES ■ 259
of mental illness lend itself to a more humane
treatment of certain people (who are now not
seen as culpable for certain crimes) or does it
tend toward a disempowering, disrespectful,
pathologizing and less humane treatment of cer-
tain members of society? Although Pickering’s
argument is in itself purely logical, it is I think a
helpful part of the argument that will move the
focus of attempts to justify talk of mental illness
from the purely logical into the pragmatic, polit-
ical, and ethical arenas.
Notes
1. For a discussion of what this might involve see
Gipps and Fulford (in press).
2. See Gipps and Fulford (in press) and Thornton
(2002) for a critique of the alienated epistemologies
presupposed by cognitivist theories of schizophrenia.
3. A helpful discussion of secondary sense can be
found in Hanfling (1991). The examples in the above
paragraph are taken from this work. A more general
treatment can be found in Lakoff and Johnson (1981).
References
Champlin, T. S. 1996. To mental illness via a rhyme
for the eye. Ed. A. O’Hear. Verstehen and humane
understanding (pp. 165–189). Cambridge: Cam-
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Gipps, R. G. T., and K. W. M. Fulford. In press.
Understanding the clinical concept of delusion: from
an estranged to an engaged epistemology. Interna-
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Hanfling, O. 1991. I heard a plaintive melody. Ed. A
Phillips Griffiths, Wittgenstein centenary essays (pp.
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Lakoff, G., and M. Johnson. 1981. Metaphors we live
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Thornton, T. 2002. Thought insertion, cognitivism,
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