“Review of Disordered Minds”

Book Review Pp. xiv + 288. P/b £18.99. Karl Jaspers famously maintained that no adequate understanding of psychopathological phenomena could be achieved without genuinely philosophical reflection (the result would be ‘disastrous’ he noted). Equally, we might say, no philosophical understanding of the mind is comprehensive if it fails to take into consideration those aspects of the mind that reveal themselves in mental disorder. In his illuminating book, George Graham takes this view seriously, investigating the intimate relation between psychiatry and philosophy while offering an original introduction to the philosophy of mind in which central topics like mental causation, mind–body problem, consciousness, and rationality are introduced and discussed through the lens of mental disorder. Besides this innovative angle, the book is clearly and engagingly written, complex discussions are elucidated by hypothetical examples and case-studies, and the reader is provided with helpful chapter summaries and suggestions for further reading. In addition to presenting an innovative introduction, Graham also develops and defends a non-reductive theory of mental disorder. In fact, the majority of the book (six out of the full roll of nine chapters and an epilogue) is devoted to laying out and defending his account. It is this well-articulated aspect of the book that I shall focus on. The last three chapters discuss topics like addiction, delusion, and thought insertion, culminating in considerations about the metaphysics of the self and the nature of mental health. Graham closes the book by reflecting on whether the elimination of a distress through medication may diminish the sense of personal achievement. Graham puts forward an account of prototypical mental disorders, according to which a mental disorder involves a partial impairment (not complete destruction) in the reason-responsive operation of one or more of the basic psychological capacities of a person. Moreover, the impairment afflicting a basic psychological capacity is brought about by a mix of mental activity and a-rational neural mechanisms, and has harmful consequences for the person (p. 156). While Graham’s careful development of this idea over the course of six chapters involves drawing on a broad range of philosophical sources, his commitment to what he calls realism about mental disorder functions like a Mind, Vol. 0 . 0 . 2013 ß Mind Association 2013 Downloaded from http://mind.oxfordjournals.org/ at University of Memphis - Library on April 19, 2013 The Disordered Mind: An Introduction to Philosophy of Mind and Mental Illness, by George Graham. London and New York: Routledge, 2010. 2 Book Review Mind, Vol. 0 . 0 . 2013 ß Mind Association 2013 Downloaded from http://mind.oxfordjournals.org/ at University of Memphis - Library on April 19, 2013 thread that runs through the book. This general realist view is rich on details, but has two central components that I shall be concerned with in the following. It entails (a) that mental disorder cannot be fully comprehended in ‘mechanistic’ terms and (b) that while mental disorders may have fuzzy boundaries, they have discoverable and objective standards and norms. Let us consider (a) first. Graham’s realism involves a rejection of approaches that aim to reduce mental disorder to neurological or chemical problems. The language of somatic disease provided by brain science is inadequate to account for mental disorders, since they are characterized by the interactions between brute, a-rational forces and mind-centered-rational factors: ‘the mind qua mind puts its inscription on the sources of a disorder. We cannot recognize a mental disorder without uncovering that mark’ (p. 11). Graham acknowledges that Alzheimer’s disease or Down’s syndrome possess psychological symptoms, but claims that these are non-mental, neurological disorders. This is because a reference to intentionality and rationality is not part of ‘the best explanation’ of their ‘origin, source or developmental propensity ’ (p. 128). Consequently, Graham argues that an adequate explanation of mental disorder must include reference to both brute, a-rational neural mechanisms and to impaired or truncated rationality and reason-responsiveness (pp. 7, 129). This position is defended against those sceptics who believe, on ‘empirical’ or ‘metaphysical’ grounds, that the use of mental terms to explain mental disorder should be and/or will be replaced by neural, chemical, or otherwise non-mentalistic descriptions (p. 71). However, at times this defence lends itself to misunderstanding — something that could have been avoided by stressing the difference between metaphysical and (what we might call) ‘empirical’ scepticism. The latter has a long history, starting with founding figures of psychiatry such as Emil Kraepelin, Eugen Bleuler, and Wilhelm Griesinger, who all maintained that eventually mental disorders would be explained as distinct brain diseases. Their view became increasingly popular on the threshold of the twentieth century, as technological advances made it possible to prove that some mental disorders were caused by physical factors. For instance, laboratory studies clarified the etiology of the mental disorder of general paresis (usually involving delusions of grandeur, dementia, paralysis, and defective speech), and revealed that it could be traced back to brain tissue damaged by syphilitic infection. After this discovery, biological treatment was developed which ultimately resulted in the elimination of the disorder. Now, the relevant point is that such empirical scepticism does not have to entail any metaphysical commitment; just as Graham (p. 86), the empirical sceptic, may very well subscribe to a metaphysically agnostic strategy, and to the idea of the causal efficacy of states with intentional content (p. 86), only adding that it is very likely that at some point the relevant bio-chemical agents will be discovered. It seems as if Graham wants to counter empirical scepticism by rejecting metaphysical scepticism — a view that the empirical sceptic does not necessarily hold. Book Review 3 Whoever intends to refute the position of the empirical sceptic needs to prove that mental terms are necessarily part of an adequate explanation of mental disorders. Indeed, some passages in The Disordered Mind do sound as if this were the objective, for example: Passages like this could easily be understood as conveying that mental disorders are entities of a certain kind that are necessarily best understood in terms of reference to rationality and intentionality (pp. 79–80). However, Graham only provides evidence for the view that given our present knowledge about mental disorders, mental terms are part of an adequate description. Suppose that, one day, strong evidence is discovered in favour of the view (as proposed recently) that inflammation plays the major causal role in the pathophysiology of depression. In that case, following Graham’s account, we would have to redefine depression as a biological-neurological disorder that can be fully specified and comprehended in mechanistic terms. So lastly, while Graham rejects the position of the metaphysical sceptic, there is no significant disagreement between Graham and the empirical sceptic. Now I will turn to (b). Another issue connected to Graham’s realism concerns the claim that, while mental disorders may have fuzzy boundaries, they have discoverable and objective standards and norms: ‘[t]o qualify as a disorder a condition or disturbance must meet certain standards or norms. Success or failure in meeting such standards or norms also is discoverable’ (p. 10). Graham rejects positions in which mental disorders figure as socially constructed or merely reflect cultural conventions (p. 108), and he affirms ‘the existence of objective truths about mental disorder attributions and diagnoses’ (pp. 154, 9). In other words, ‘there are facts of the matter as to whether someone is depressed’ (p. 59). This realism, if true, ensures that a mental disorder is something that detects a clinically significant disability or impairment in rationality, not mere distress (as the philosophical despair of Augustine) or a mere performance lapse, error or anything that is undesirable only within a certain cultural horizon. Rather, mental disorders are ‘undesirable period — unwanted in any or virtually any context or cultural environment’ (p. 113), ‘no matter when or where we are’ (p. 113). At this point it is apparent that Graham’s realism entails a universalist position: a condition is significant or serious enough to qualify as a mental disorder if there is an impairment occurring in a fundamental psychological competence, which is basic because leading any kind of a ‘decent or personally satisfying life’ requires it (pp. 131–2). Using Rawls’s thought experiment, Graham argues that basic mental capacities are like ‘primary goods’ that each person would choose independently of any access to knowledge concerning their social Mind, Vol. 0 . 0 . 2013 ß Mind Association 2013 Downloaded from http://mind.oxfordjournals.org/ at University of Memphis - Library on April 19, 2013 On the approach I am recommending, there is something different about disorders associated with brain damage (neurological disorders) and disorders not associated with brain damage, the difference being that in the former case the (proximate) sources of a disorder can be fully comprehended in mechanistic (brute a-rational neural) terms, whereas in the latter case they cannot. (p. 127) 4 Book Review Mind, Vol. 0 . 0 . 2013 ß Mind Association 2013 Downloaded from http://mind.oxfordjournals.org/ at University of Memphis - Library on April 19, 2013 status, talents, abilities, or specific views concerning what constitutes the good life. Rawls assumes that regardless of ignorance about their personal characteristics and ideas of the good, individuals in the ‘original position’ would nonetheless strive to advance their interests and exhibit a preference for more rather than less primary goods. Graham’s list of what we could call ‘primary psychological goods’ (pp. 147–9) includes the ability to locate oneself bodily/spatially and historically/temporally, the ability to comprehend self and world, the ability to communicate, to engage emotionally, to assume self-responsibility and to make decisions. One problem with Graham’s approach is its susceptibility to arguments reminiscent of those launched against Rawls. In short, the problem is that this method of universalizability or objectivity yields a determinate set of human goods that either clash with standards embedded in the traditions of particular societies (Taylor; MacIntyre) or become far too vague and abstract to provide useful standards (Walzer). In a similar manner, the basic psychological capacities that Graham puts forward are both too vague and too narrow. On the one hand, talk of self/world comprehension, and of communication and decision-making capacities, is too vague if no specification is given of the capacities for comprehension, communication, and decision-making that individuals need in order to lead a good life. For instance, it is not clear whether and at what point intense feelings of care or love that alter self/world comprehension and decision-making should count as an impairment. On the other hand, less vague descriptions and further specifications of the relevant psychological capacities would most likely make these too narrow, thus excluding particular ideas of the good life. It is extremely difficult to eliminate the possibility that rational individuals may be hindered in pursuing their vision of a good life by possessing a particular primary good. Take for instance the ability to have emotional commitments to others that Graham includes in his list. A warrior or a devoted monk might both hold that in order to achieve a ‘personally satisfying life’ it would be better for them not to have emotional commitments to other people. In short, the ability for emotional engagement is not neutral: it is not only not necessary for particular understandings of being a devoted warrior or monk, but it may even be a hindrance in pursuing their idea of a good life. In sum, it seems near impossible to identify universal psychological capacities that are needed to realize any type of good life, without the choice of those capacities itself being led by a particular idea of the good life. Graham does not deal with such potential objections. Surely, he would grant that the notion of mental disorder is value-laden, but argue that so too is the notion of somatic illness (p. 12). As he says, we attribute somatic disease on the background of norms and standards of proper functioning parts of the body (p. 92), and hence ‘the notions of bodily health and physical well-being are evaluative or normative through and through’ (p. 93). However, it is important to differentiate between the normativity involved in the standards Book Review 5 Department of Philosophy University of Memphis 327 Clement Hall Memphis, TN 38152 USA [email protected] SOMOGY VARGA doi:10.1093/mind/fzt002 Mind, Vol. 0 . 0 . 2013 ß Mind Association 2013 Downloaded from http://mind.oxfordjournals.org/ at University of Memphis - Library on April 19, 2013 that govern the attribution of bodily disease, such as hypertension or infection, and the normativity involved in the standards that govern the attribution of mental disorder. The latter directly reflects fundamentally contestable value judgments that are often moral and political in character. These concerns notwithstanding, The Disordered Mind is an admirably wide-ranging book that provides a rich and stimulating introduction to central topics in the philosophy of mind, and shows the crucial role of philosophical reflection in providing an understanding of mental disorder, while identifying shortcomings in current psychiatric classification. One must applaud Graham for taking on the highly ambitious task of outlining those universal basic psychological capacities against which impairments of rationality can be identified. At the same time, one may wonder whether the context of an introductory book on the philosophy of mind is the right venue for such an ambitious task. But despite these concerns, The Disordered Mind should be essential reading both for those who are sympathetic and those who are antagonistic to the idea of a non-reductive notion of mental disorder. Graham’s book is highly recommendable to anyone working on (or merely interested in) these issues. Not only is it a welcome addition to the rapidly increasing literature on the philosophy of psychiatry, but it also contributes to establishing its legitimacy as a sub-discipline of philosophy.