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.

Categories: Philosophical, Psychology, Ethics