George Graham is a prominent philosopher of mind and philosopher of psychiatry. In The Disordered Mind he applies current theories in the philosophy of mind to dispute the view that psychiatry should be merged with neurology and that mental disorders are ‘really’ and ‘always’ broken brains. He does so by arguing that mentality is an essential, constitutive feature of mental disorders. For instance, both Parkinson's disease (a neurological disorder) and major depression (a psychiatric disorder) have mental symptoms. What makes a case of depression psychiatric rather than neurological, he argues, is that mentality is important in the generation, progression, and maintenance of the depression.
According to Graham, exemplary mental disorders involve non-voluntary failures of psychological capacities. They are also failures that are considered harmful in every culture at all times because they interfere with a satisfying and worthwhile life. His list of capacities encompasses those assessed in the mini-mental status exam, basic interpersonal capacities, capacities for self-control, and capacities for practical reasoning. Later in the book, Graham illustrates his capacity failure model by exploring addiction and psychotic disorders with delusional symptoms.
Graham states that uncovering neurological mechanisms is important for understanding mental disorders because mental disorders are implemented in brains. However, claims Graham, if a case of depression can be fully accounted for by something like a stroke, then it should not be considered a mental disorder.
Graham's concept of mental disorder has both psychological and ethical features that come together in his assertion that mental disorders are involuntary impairments in one's ability to direct and control behaviour. For example, an alcoholic may have many reasons for refusing to drink until he blacks out. The pathology of alcoholism is constituted by his repeated failure to respond to these reasons. Mental disorders interfere with what philosophers call autonomy, or to use Graham's catchy phrase, they gum up the works.
In the context of Graham's model, involuntary connotes that the person both wanted to and could have potentially behaved differently, but was unable to do so. Although a subtle distinction, Graham's model suggests that there is an important difference between involuntary (‘not being able’ to stop oneself from taking the additional drink despite sincerely wanting to stay sober) and autonomic (literally ‘being unable’ to see due to blindness).
Among the features that make mental disorders mental rather than neurological, the one most emphasized by Graham is an impaired capacity for reason responsiveness. Reasons involve meanings, or what philosophers call intentional content. For instance, when a depressed woman's guilt about her failure to care for her three-year-old child feeds back onto and worsens her depression, seeking to understand that process by referring to brain events alone would be like trying to explain the spelling errors in a book by referring only to activity of the printing press.
Spelling errors are violations of norms for spelling such as i before e except after c. Likewise the psychology in psychopathology involves beliefs, emotions, desires, and purposes which are only meaningful with respect to the background conditions called norms of rationality.
According to Graham, in mental disorders the capacity to respond to reasons is impaired or truncated, but not obliterated. Just as a book must contain interpretable spellings in order to have spelling errors (rather than being random strings of letters), so impaired reason responsiveness must occur in the context of interpretable reasoning.
One disanalogy between spelling errors and mental disorders is that spelling errors might occasionally be the result of a faulty printing press, but usually are not. In contrast, Graham traces some of the involuntariness of all mental disorders to ‘irruptive’ neural mechanisms, but not necessarily to broken mechanisms. The brains of addicts may be responding to drug exposure in a way that is consistent with neural design, but for some people the brute neural response to the drug interferes with adaptive self-control.
Reasons and meanings play multiple roles for Graham's understanding of mental disorder. First, reasons form the background condition for understanding our own and others' behaviour in general (e.g. the reasons why I wrote and the reasons why you are reading this book review). Second, reasons and meanings play a role in the generation and progression of proper mental disorders (e.g. an amphetamine triggered panic attack is not a proper mental disorder, a panic attack initiated by fear of speaking in public is). Third, the abstract notion of reason responsiveness is important for understanding the nature of mental disorder itself.
The capacity to respond to reasons, says Graham, should not be interpreted as being only a matter of logic and cognition. The capacity (and freedom) to act in accord with reason is strongest, claims Graham, when cognition, desire, and emotion are coordinated.
Many of the concepts used by philosophers to understand reason responsiveness intersect with those concepts used to understand personhood, dignity, and morality. One of the complicating yet elegant features of Graham's notion of mental disorder is that in addition to being important for developing an adequate philosophy of mind, the study of mental disorders can also deepen and enrich our philosophical notions of personhood. This also is explored later in the book.
Graham's particular capacity failure model could be viewed as a less obscure version of the biopsychosocial model, with the primary emphasis being placed on the roles of the biological and the psychological. How much of a disorder is best considered biological and how much psychological is not specified by the model, but anything that is not constituted psychologically is not considered by Graham to be a real mental disorder.
Adhering to the conventions of analytical philosophy, Graham is using conceptual analysis to demarcate mental disorder from both general medical conditions and normal problems in living. As illustrated by Graham's own claim that this model leaves him unable to decide if multiple personality disorder is a real mental disorder, we see that analysing exemplary cases of mental disorder to formulate a general concept does not ensure that the resulting concept will readily apply to problematic cases. Rather than strictly regimenting the concept of mental disorder, this analysis serves as a general guide. Overall it is a helpful guide, and in many respects, a wise one.
