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by Peter Zachar
John Benjamins Publishing, 2000
Review by Christian Perring, Ph.D. on Jan 4th 2003

Psychological Concepts and Biological Psychiatry

Psychological Concepts and Biological Psychiatry argues against the reductionist program of contemporary biomedical psychiatry.  Peter Zachar argues that the psychological has an essential role in the scientific understanding and clinical treatment of mental illness, and he provides a framework to explain and justify this role.  His broad-ranging approach includes discussion of biomedical materialism, eliminative materialism, behaviorism, physicalism, classification, evolutionary psychology, and the relation between psychiatry and scientific realism.  The book ends with a brief consideration of stigma and mental illness and the temptations to believe in biomedical and eliminative materialism. 

This is one of the most important books to be published in the philosophy of psychiatry.  Zachar’s approach is scholarly and thoughtful, and he does a wonderful job of bringing together scholarship from neuroscience and other branches of academic psychology, clinical psychology, philosophy of mind, and philosophy of science.  Given the breadth of the book, it will be a challenge for any single reader to master all aspects of the argument.  But Zachar’s writing style is engaging and straightforward, and he provides examples of his points from clinical practice as well as frequent summaries of the trust of his argument and overviews of his general plan.  The book is well organized, with three sections:

·        3 chapters on “The Attack on Psychology” explaining the concerns over the scientific credibility of psychology, proposals for the replacement of psychology with brain science, and the philosophical school of eliminative materialism.

·        4 chapters on “The Robustness of Psychology,” in which Zachar argues a simplistic understanding of “folk psychology,” criticizes behaviorism and eliminativism, and sets out what he takes to be the foundation or “anchors” of psychology, as well as how to accept the importance of neurophysiology without resorting to a strong reductionist program.

·        5 chapters on “The Psychology in Psychiatry,” providing an explanation of the importance of the role of first-person information in understanding people, a proposal for “biosocial pluralism,” a pragmatist account of classification, a defense of the idea that understanding reality as material does not exclude psychology, and an argument against the claim that biomedical materialism in psychiatry is a solution to the problem of stigma and discrimination against the mentally ill.

Given the importance that Zachar places on the concept of psychology, it is a little odd that we have to wait until the sixth chapter for a definitional explanation of what he means by the term.  He argues that psychology is best understood as a specialty in its own right.  He refers to the idea that there are many possible levels of analysis in understanding human life, ranging from the lowest level of subatomic particles to the highest level of the biosphere.  He locates psychology at a mid-level, at the level of a person, sandwiched between the smaller level of the nervous system and the higher level of the two-person dyad.  He endorses the suggestion of McCauley that “different levels of analysis make separate explanatory contributions, with each level having its own internally consistent legitimacy” (p. 130).  But psychology is special because it provides an integrative framework for lower and higher levels of explanation.  Zachar writes, “our behavior is going to be the result of complex interactions between brain and society, and in order to understand that interaction, we need a common standard.  Psychology is that common standard” (p. 135, italics in the original).

Arguing that psychology provides an explanation of human behavior through a person’s “inner world,” Zachar says that the concepts of representation, imagination, fantasy, imagery, scheme, and perspective are essential to this mode of explanation.  Here, as throughout the book, Zachar compares debate in contemporary philosophy of psychology with debates within psychoanalysis.  He discusses Freud’s 1895 work Project for a Scientific Psychology, as well as object relations theory and the interpersonal/relational school, commenting “These debates in psychoanalysis are debates about where on the continuum from brain to world psychology should be placed” (p. 140).  He relates this to criticisms by William Bechtel of Paul Churchland’s embracing of connectionism.  Zachar says “any in-the-head focus has to consider internal-external relations, and hence become psychology” (p. 143). 

Finally in this central chapter, Zachar argues that psychology is anchored in the understanding of the self and the distinction between self and other.  He surveys some of the empirical literature on the development of the concept of self, and criticizes suggestions that “psychological concepts are ad hoc constructions use to make sense of behavior” (p. 153), a view he attributes to behaviorists and some social psychologists such as Nisbett and Ross.  Instead, Zachar favors the view that “the psychological framework is a propter hoc consequence of a biologically enabled, referential, metarepresentational capacity” (Ibid.)

Having clarified what conception of psychology Zachar is defending, we can turn to the general argument of the book.  Part I of the book sets out familiar material in summarizing criticisms of psychology and the program of biomedical materialism.  It will be a valuable resource for those wanting clear statements of various ideas, since Zachar has a commanding knowledge of the literature. It is particularly interesting to see the comments of Paul Churchland concerning mental disorders and the extent to which it is possible to show the connection between his views and the radical reductionist program in psychiatry.  Zachar’s defense of psychology in Part II is more original, although much of this is also well-trodden ground.  The book is most interesting when it brings together issues from philosophy of mind with clinical psychology.  For example, in chapter seven, Zachar defends materialism (the ontological thesis that the world is made of matter) but rejects physicalism (the reductionist thesis of epistemology that we can understand the world purely in physical terms).  He argues that subjectivity gives us important knowledge, and he provides some fascinating examples, such as alexithymia, the inability to recognize the affective state one is in.  Examples of this disorder suggest “first-person awareness is our most natural and consistent indicator of emotional states” (p. 167).  He also discusses the idea of Marsha Linehan that borderline personality disorder involves a failure to learn consistent labels for private experiences, and the theory that psychopaths do not fully feel worry or guilt.

Part III is the most innovative part of the book.  Zachar builds on the discussion of reductionism in the first two parts to give his view of the role of first-person information in diagnosis, the relevance of evolutionary psychology to our understanding of dysfunction, and a pragmatic account of the classification of psychopathology.  Some of the section titles in Chapter 8 give a clear idea of Zachar’s main theses:

·        Adjoining Levels of Analysis Cross-Fertilize Each Other

·        Systematic Diagnosis is not Co-extensive with Biomedical Materialism

·        Psychological Approaches are not Anti-diagnostic or Anti-operational

·        DSM-III and DSM-IV Utilize First Person Information

Near the end of the chapter, Zachar sets out three core ways that psychology is manifest in psychiatry.  These are management issues involving treatment (e.g., ways to get patients to take their medication), and secondary and pathogenic reactions involving diagnosis.  Secondary reactions involve a person’s reaction to a more primary disorder, while pathogenic reactions are part of the development of the disorder.  Oddly, Zachar gives Adjustment Disorder as an example of a secondary reaction, but this does not seem to fit his description of a secondary reaction, since it normally a reaction to an event or change in one’s life, not necessary to an illness.  Maybe Zachar simply meant an Adjustment Disorder in reaction to an illness, but it is not clear from the text.  He gives a longer discussion of pathogenic reactions, showing that what counts as such a reaction is a matter of debate.

Chapter 10 argues that the classification of mental illness is not based on natural kinds, and furthermore, the same holds for all diseases and even species.  His central proposal is that mental illnesses do not have essences.  Surprisingly, there’s little discussion of the central figures in the classification of mental illness, such as Boorse or Fulford, and given that he is proposing a pragmatic model, it is surprising that Zachar does not refer to the work of Agich.  Chapter 11 extends his approach to the nature of psychiatric truth and reality, although it seems to basically recap what has gone before about the relation between biomedical materialism and psychology, and most philosophers are unlikely to be satisfied by the quick survey of different theories of truth and scientific realism and their application to psychiatry.  Chapter 12 is narrower in scope, making a clear argument that the stigma attached to mental illness does not derive from psychological theories and is not reduced by biomedical materialism.  The final chapter briefly explores why biomedical materialism is so appealing to some researchers. 

There are a number of spelling errors, grammatical mistakes, and infelicities in wording, so the book could have done with more copy-editing.  Zachar is a little too fond of diversions and side-comments that distract the reader from the main argument.  Indeed, sometimes the interdisciplinary breadth of the discussion makes it hard to be clear about exactly what Zachar’s argument is.  For example, in the ninth chapter, he says at the start that he will argue that “biological psychiatry has to be concerned with the science of evolution as well as the science of physiology: (p. 211).  He discusses the relation between the concepts of adaptation and dysfunction, endorsing the view that psychopathology must be defined in terms of distress and disability, and this requires looking at “the molar level concept of adaption, which involves organism-world interactions” (p. 214).   He goes on to argue that a purely “bottom-up” model (such as defended by Guze in Why Psychiatry is a Branch of Medicine, 1992) that ignores higher levels of analysis in understanding psychopathology cannot work.  Within the space of a few pages, his argument covers Wexler’s view that when psychiatry uses syndromes, it is hard to isolate underlying causes of psychopathology, Damasio’s discussion of thinking about the brain in terms of integrated systems, Dennett’s criticisms of the Cartesian theatre model of consciousness and his own multiple drafts model, and Edelman’s “Neural Darwinism,” as well as referring to many other writers in passing.  His main aim here is to defend a “co-evolutionary biopsychosical perspective” and it is likely that those who are already familiar with the relevant material and who read this book very carefully, maybe twice, will achieve a clear idea of what he is proposing, but other readers are likely to be somewhat unsure about the details. 

This sort of problem comes with the territory of philosophy of psychiatry, and is shared by other important books in the field, such as Fulford’s Moral Theory and Medical Practice (1989) and Gillett’s The Mind and Its Discontents (1999).  Simpler works that are easier to understand, such as the books of Thomas Szasz, Nancy Andreasen’s The Broken Brain (1984), or the many popular science overviews of psychology and psychiatry, are unconvincing largely because they ignore so many of the complexities of the debate.  Authors in this area face a dilemma: either they oversimplify and thus risk dismissal by those who know all the complexities of the issues, or else they go into those complexities in detail, and in doing so, risk losing most of their readers.  Occasionally, books manage to narrow their scope enough to achieve both depth and clarity—a good example is Graham and Stephens’ When Self-Consciousness Breaks (2000).  But most often the subject of psychopathology very quickly raises such a host of issues that an author needs to take a stance on all of them in a wide-ranging discussion.  Zachar does well in balancing interdisciplinary complexity and comprehensibility, but nevertheless, the book will be a challenge to those who do not have a solid grasp of a wide range of the literature in philosophy and psychiatry.  Doubtless, some readers will still wish Zachar had addressed the arguments in more contemporary or classic works in philosophy of psychiatry.  For example, there’s no discussion of McHugh and Slavney’s The Perspectives of Psychiatry (1983, second edition 1998), Bolton and Hill’s Mind, Meaning, and Mental Disorder (1996), or any work by Gillett.  As for the older literature, there’s nothing on Karl Jaspers or Adolph Meyer, and no sustained discussion of Emil Kraepelin.  But if Zachar were going to make his book that comprehensive, it would have to have been twice the length, and it just too much to expect authors to discuss every possible relevant work.  Indeed, he may already have erred on the side of overinclusiveness, when he would have been better served by narrowing his focus and giving a more detailed discussion.  One is often left with the sense that he has run several related views together in his sweeping discussion, and that it might be helpful to separate them out more carefully.

Psychological Concepts and Biological Psychiatry should be accessible to mental health professionals and philosophers, and would be suitable for upper-level undergraduate and graduate courses, so long as the instructor was able to guide students in reading the text.  Zachar could have prevented possible misunderstandings if he had spent more time separating out the empirical questions from the conceptual and methodological ones, because it is likely that many readers, especially novices to the field, will be inclined to mix them together.  It is essential to Zachar’s argument that he is not denying the truth of most of the empirical claims from neuroscience or the great gains that have been made in biomedical psychiatry within the last century.  Furthermore, it might have been helpful if Zachar had been clearer about to what extent he is asserting the empirical truth of any particular psychological claims.  He is clearly sympathetic to psychodynamic and psychoanalytic approaches, but it does not seem that he requires the truth of Freudian theory, for instance, for his arguments to go through.   

In sum, Zachar’s excellent book is extremely impressive in its broad scope and sustained treatment of the inadequacies of biomedical materialism in psychiatry, and it deserves serious attention and discussion. 

 

© 2003 Christian Perring. All rights reserved.

Christian Perring, Ph.D., is Chair of the Philosophy Department at Dowling College, Long Island, and editor of Metapsychology Online Review. His main research is on philosophical issues in medicine, psychiatry and psychology.