This interdisciplinary work addresses the question, What role should psychological conceptualization play for thinkers who believe that the brain is the organ of the mind? It offers readers something unique by systematically comparing the writings of eliminativist philosophers of mind with the writings of the most committed proponents of biological psychiatry, and by critically scrutinizing their shared 'anti-anthropomorphism' from the standpoint of a diagnostician and therapist. Contradicting the contemporary assumption that common sense psychology has already been proven futile, and we are just waiting for an adequate scientifically-based replacement, this book provides explicit philosophical and psychological arguments showing why, if they did not already have both cognitive and psychodynamic psychologies, philosophers and scientists would have to invent them to better understand brains.
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AUTHORS' RATIONALE FOR SOLICITING MULTIPLE REVIEW: "Psychological Concepts and Biological Psychiatry" is unique in addressing psychiatric issues within a cognitive-science framework. This book should interest not only clinical psychologists and psychiatrists, but also cognitive neuroscientists, evolutionary psychologists, researchers studying social cognition, and anyone with training in the philosophy of science. It would be a mistake for cognitive and social psychologists to think that the topic of the book is mainly clinical. The examples are clinical, but the issues are fundamental to the legitimacy of psychological explanation and understanding in a discipline that is, justifiably, increasingly dominated by the neurosciences. The reason for requesting a multiple book review is that, because the whole argument is integrative and multidisciplinary, in the same way that Cognitive Science is multidisciplinary, a multiple book review would bring different kinds of scholars together to discuss a single work. More importantly, reading multiple book reviews will help the audience further understand how those in different research traditions evaluate fundamental issues that concern all thinkers in psychology, professionally and personally.
PART I: THE ATTACK ON PSYCHOLOGY
CHAPTER 1: PSYCHOLOGY IN TROUBLE
1. A common refrain in contemporary philosophical discourse is that much of what passes for psychological explanation and understanding is illegitimate, or at least seriously flawed. These criticisms are dramatic ones, especially when applied to psychotherapy. Although psychotherapists are supposed to be trained in psychological explanation, critics such as Dawes (1994) have argued that, to maintain a belief that their training provides them with legitimate skills, psychotherapists have to misinterpret the results of psychotherapy outcome research. They reinterpret the findings that training as a therapist makes no difference in outcome into the finding that therapeutic orientation makes no difference in outcome.
2. The most persuasive critiques of psychological explanation are drawn from research in social and cognitive psychology, and they cannot be written off as the criticisms of scholars committed to the behavioral perspective. In social psychology Nisbett and Wilson (1977) show that we hold common sense ideas about topics such as why people enjoy parties. When a particular person is asked why she enjoyed the party last night, she does not introspect the contents of her consciousness; rather she consults the common sense model and picks a reasonable answer. In attribution experiments people can be shown to choose such common sense explanations for their behavior; and even when they are given evidence that their behavior had another cause, they continue to prefer the common sense explanation. Just picking an explanation has been called 'confabulation.' Social psychologists show that confabulation is a normal process.
3. Research in cognitive psychology by Loftus and her colleagues indicates that our memory of the past is often a reconstruction, and the reconstructive process is vulnerable to interference. Cognitive psychologists believe that one's confidence in the accuracy of a memory is not related to its actual accuracy. Furthermore, we are demonstrably willing to believe quite improbable things about our personal past. This research is important because therapists often ask people about their past in order to provide psychological explanations of current behavior. A therapist's explanation of why a client's depression is related to how his mother treated him may be based on reconstructed 'evidence,' and follow from a common sense model of depression rather than the elusive 'contents of consciousness.' This would explain psychotherapy outcome research.
4. The 'confabulation' analysis is primarily favoured by philosophers such as Daniel Dennett (1987) and Paul Churchland (1984). Social and cognitive psychologists have been unwilling to use such a pejorative term. However, given the fact that they are psychologists, and they have dedicated much of their lives to the discipline of psychology, they might be reluctant to undermine the very notion of psychological explanation and understanding. Philosophers who have studied the relevant research and are not committed to the discipline of psychology have no guild interests to protect. Taking seriously the psychology-in-trouble claim requires carefully considering the arguments of the thinkers who are most skeptical about psychological explanation and understanding, especially those who think that psychological explanation needs to be replaced and have firm ideas about what to replace it with.
5. Those who take the psychology in trouble claim most seriously are the biomedical materialists in psychiatry and the eliminative materialists in philosophy. The biomedical materialists believe that psychiatrists should think of themselves as medical doctors whose goal is to treat broken brains. The eliminative materialists believe that the psychology of beliefs, desires, intentions, and emotions is a false and defective way of understanding human behavior, and should be eliminated from our scholarly discourse and replaced by explanations using concepts drawn from neuroscientific research. Both groups share a common attraction to 'anti-anthropomorphism.' Taking them seriously is what this book is about.
CHAPTER 2: TROUBLE FROM PSYCHIATRY: BIOMEDICAL MATERIALISM.
6. Biomedical materialism is an integrated view of psychiatry which includes assumptions about what counts as a good problem, what counts as good evidence, and what counts as a good solution. It is also a view about the nature of science and science's relation to psychiatry. In addition, biomedical materialism contains an ethics and provides a moral justification for professional practice based on biomedical principles.
7. Biomedical materialism is rooted in the evidence that the brain is the substrate of psychological states. Most people understand that if we took away a person's brain, there would be no psychological states remaining even if we could keep the rest of the body alive. The biomedical materialists extend the substrate analysis into the Brain as the Organ of the Mind doctrine. Believing that the brain is the organ of the mind is a form of scientific realism which holds that psychological states are really brain states. This doctrine operates in any claim of the form - 'depression is really a chemical imbalance.' Biomedical materialists believe that responsible psychiatrists should focus their attention on the real causes of psychiatric illness, i.e., broken brains.
8. Biomedical materialism began with the development of psychiatry as a distinct discipline in the late 19th century. Even Freud believed in the importance of the brain's role in the generation of psychiatric disorders, and held out the hope that his field could someday treat psychiatric disorders through direct chemical manipulation of the brain. During Freud's lifetime, this was only a hopeful project. The introduction of psychotropic medications such as Thorazine and Imipramine in the 1950s transformed biomedical materialism into a practical treatment model.
9. The dominance of the biomedical model in psychiatry was initiated in the 1960s by a group of researchers called the neo-Kraepelinains. These psychiatrists claimed that psychiatry would be better if it were more integrated with the rest of medical science, primarily because psychiatry had not participated in the great medical advances of the first half of the 20th century. They believed that it could begin to participate in these advances. To do so it would have to adopt the scientific approach to medicine, including: (a) the systematic identification and classification of syndromes, including a detailed description of what happens to people who are 'infected' and (b) the experimental investigation of the biological basis of syndromes, beginning with anatomy and physiology, and progressing to biochemistry and genetics.
10. The desired outcomes of this process are verified etiological hypotheses and the development of effective treatments. The biomedical materialists believe they have an ethical responsibility to apply the scientific model to their own professional problems, and they are very hopeful about the future of their discipline. As an initial step, they helped revolutionise psychiatric diagnosis by being the driving force behind the establishment of modern psychiatric nosology that began with the publication of the DSM-III in 1980.
11. The alleviation of suffering via treatment is central to the humanitarian claims of the biomedical materialists. Their most prominent example of a successful solution to a psychiatric problem is general paresis of the insane. At the turn of the century general paresis accounted for 25% of the admissions to psychiatric hospitals. Once it was shown to be the effect of untreated syphilis, and treatment for syphilis became available, general paresis was eliminated. From a humanitarian standpoint, the goal of the biomedical materialist is to eliminate other psychiatric disorders just as general paresis was eliminated.
12. Unlike psychotherapists, who claim that lack of progress may be related to the patient's not being ready to get well, biomedical materialists believe that once a treatment is prescribed, if the patient follows the treatment regimen, success or failure is attributable only to the treatment. In some ways, focusing on impersonal brain mechanisms is more respectful to persons who are psychiatric patients. Psychological analyses by their very nature can potentially lead to blaming the person, whereas in the biomedical model only the body can be blamed.
13. Proponents of biomedical materialism believe that psychological thinkers who ignore biomedical approaches are too often unfamiliar with the relevant details of biological psychology. They think their field needs people who are smart enough and disciplined enough to understand physiology and genetics, and they question the scientific values of those who reject biomedical approaches without understanding the evidence on which they are based.
CHAPTER 3: TROUBLE FROM PHILOSOPHY: ELIMINATIVE MATERIALISM
14. Contemporary eliminativism began with Feyerabend's (1963) notion that our common sense way of talking about ourselves is biased in favour of mentalistic concepts. He acknowledges that the existence of mental states is self-evident, but thinks that this self-evident intuition is a cultural convention. Feyerabend suggests that there is nothing inherently sacred about this convention, and believes that we could gain explanatory power if we were willing to be less conservative and describe ourselves in different ways. We could eliminate mentalism in favour of materialism. Congruent with the model of scientific change that he developed in cooperation with his colleague Thomas Kuhn, Feyerabend would say that, as in any scientific revolution, a radically better theory of human behavior would seem ludicrous to us. He believes that too many philosophers adopt the conventional argument that materialistic theories are false because they seem ludicrous.
15. Based on Wilfrid Sellars' (1956) argument that sensations such as seeing green and feeling pain are not-self-evident, Richard Rorty (1965) extends eliminativism by arguing that it is logically possible that we could use neuroscience-based frameworks to (non-inferentially) understand our immediate sensory experiences. We are all experts on reporting our own mental states, but we learn to be experts. We could learn to report things differently, especially if we had accurate information about the biological basis of sensory states. Once we learn to automatically experience a state of pain as referring to a particular kind of body state, we could come to believe that the 'mental state' of pain never existed. It will have been eliminated as both a referent and as a conceptual framework for understanding conscious content.
16. Paul and Patricia Churchland expand eliminativism into a more forceful program, trading claims about what we could do for prescriptions about what we should do. Paul Churchland is the more committed eliminativist of the pair. He adopts a post-positivistic philosophy of science that downplays the distinction between theory and observation. Scientific research is about building models and seeing how different theoretical models fit together. As a scientific realist, he suggests that the key to unifying our various scientific models is to place things in causal chains. Something is real if it can be understood to play a role in the causal networks defined by the natural sciences. Although many kinds of concepts can play causal roles, we should invest in those conceptual models that are the most consistent, comprehensive, parsimonious, and fruitful.
17. From this perspective the Churchlands adopt a behavioristic anti-anthropomorphism and claim that beliefs and desires are conceptual artifacts left over from humanity's pre-scientific history. They think that beliefs and desires constitute 'folk psychology,' which is a common sense theory and not a scientific theory. They argue that just as concepts of chemistry such as phlogisten were eliminated from scientific discourse, the concepts of folk psychology such as beliefs and desires, plus sensory states such as pain, could also be eliminated. In their view, 'psychology' would be better if it were more integrated with the natural sciences, primarily because psychology has not participated in the great scientific advances of the past 300 years. They believe that it could begin to participate in these advances.
18. Paul Churchland lists a set of fundamental problems that folk psychology has failed to explain, and suggests that it cannot explain them. An example of what it has failed to explain is the nature of conscious intelligence. Proposition-based concepts such as belief and desire can never explain the nature of conscious intelligence, if for no other reason than the fact that many different kinds of organisms can be said to have some form of conscious intelligence or rationality, but only human beings have propositions. We should not look to proposition-based theories (such as Aristotelian or symbolic logics) to explain what rationality really is. What it really is will better be explained in terms of the neurosciences. Looked at as a whole, folk psychology is a degenerating and dying research paradigm.
19. The Churchlands' belief that folk psychology is a false theory naturally leads to the conclusion that it would be better to understand the real causes of human cognitive activity and behavior. In this respect, they mirror the biomedical materialists. They describe the potential explosion of information we would gain if we accurately perceived our internal states. We would become experts at reporting on our internal states for the first time. They also share the same humanitarian goals as the biomedical materialists. Although the biomedical materialists do not refer to eliminativist philosophy, the eliminative materialists have long talked about the psychiatric implications of their model. They claim that psychiatric disorders are really disorders of the brain, that psychoanalytic and other therapeutic approaches are based on radically false models of human behavior and are harmful, and that we could make the world a better place if we understood what psychiatric disorders really are.
PART II: THE ROBUSTNESS OF PSYCHOLOGY
CHAPTER 4: WHY THERE IS NO SUCH THING AS 'FOLK PSYCHOLOGY'
20. This chapter provides an anti-essentialistic analysis of folk psychology. Eliminativist arguments target a coherent bounded entity called folk psychology. It becomes clear that the meaning of 'folk psychology' is less static and more fluid than they acknowledge.
21. Although eliminativists such as the Churchlands claim to be arguing against only folk psychology, their definition of folk psychology (FP) covers all specializations in psychology except radical behaviorism - making folk psychology another name for psychology-in-general. When social psychologists talk about folk psychology they refer to person-in-the-street notions such as 'there must be complete trust between people for a marriage to succeed.' This narrower kind of folk psychology is rarely referred to by philosophers.
22. In philosophy, the adjective 'folk' is also used as a pejorative term - suggesting something opposed to science. Eliminativists continually argue that folk psychology belongs to common sense, and not to science. Being a part of common sense is what it means to be folk psychology. This strict dichotomy between science and common sense, however, cannot be maintained. Importantly, the most robust and irrefutable aspects of eliminative materialism itself are derived from common sense understanding. The common sense basis of eliminativism is called folk materialism. For example, even four-year-old children believe that we think with our brains.
23. The exclusively common sense status of folk psychology is also questionable. For example, Tellegen (1985) distinguishes between folk concepts and systematic psychological concepts. According to Tellegen, if psychological concepts can be integrated into scientific theories and shown to be internally coherent, externally testable, and consistent with the known facts, they can become systematic psychological concepts. Most of the concepts used by psychologists in empirical research have this kind of systematic quality, a fact that is often ignored by the eliminativists
24. The eliminativists suggest that scientific advances are often counter-intuitive. They claim that defending psychological explanations with respect to their intuitive plausibility and universal use is primarily a conservative attempt to hold on to a familiar but depleted model. They effectively label common sense psychological concepts 'lay models.' This argument, however, contradicts another argument the eliminativists use against psychological explanation - specifically the argument that psychoanalytic thinking is an empty and confabulatory art. This is inconsistent of them because therapists often learn to notice things and to talk about clients in ways that are counter-intuitive - and it takes some years of in vivo experience to learn this. The eliminativists then label what is counter-intuitive to them as 'confabulatory.' There is no way for a psychologist to win this argument as it has been structured by the eliminativists. Scientific understanding is counter-intuitive and common sense understanding is not, except any counter-intuitive psychological models are confabulations.
25. Eliminativists also define folk psychology as a degenerating research program, essentially unchanged since the time of the Ancient Greeks. Contrary to their claims, even so-called soft psychology has advanced in the past 50 years, let alone the past 2000. For example, the description of defence mechanisms such as conversion of passive to active is usually news to college students. The problems psychologists struggle with involving the measurement or interpretation of defence mechanisms would not have even occurred to the Ancient Greeks. Models that were once 'professional common sense' have also been improved. Clinical psychologists currently believe that simple fixation-regression models, which characterize child psychology in terms of adult psychopathology and characterize adult psychopathology in terms of child psychology, are mistaken. The child is not an arrested adult, and adults, however disturbed, have experiences, cognitive skills, and emotional pressures that are not a part of normal childhood.
26. When examining the explanatory failures offered by the Churchlands (e.g., the nature of mental illness, memory, and sleep), it is obvious that the only kind of psychology which could meet their criteria for a non-degenerating research program would be a near utopian psychology that can successfully explain everything. Their criteria are far too stringent.
CHAPTER 5: A CRITIQUE OF ANTI-ANTHROPOMORPHISM
27. Contemporary eliminativism is a restatement of the anti-anthropomorphism favoured by the radical behaviorists Skinner and Watson. Many of the eliminativist arguments, especially those comparing folk psychological concepts to eliminated scientific concepts such as phlogisten, were also used by Skinner. The major difference is that Skinner is an eliminativist externalist who would prefer to replace 'in the head' variables with external variables. His primary variables belong to the environment as the agent of selection in Darwin's sense. Paul Churchland is an eliminativist internalist who would prefer to replace conventional 'in the head' variables with a different framework for understanding our cognitive-emotional architecture. His primary variables belong to connectionist networks and computational neuroscience.
28. The academic justification for eliminativism is based on a distorted, even demonstrably false interpretation of the history of scientific psychology. What is false is the notion that, by accepting evolution and the continuity of species, psychology naturally evolved into an objective, behaviorally-based discipline. Properly understood, and as it is understood by most of its proponents, evolutionary biology does not lead to the kind of anti-anthropomorphism favoured by eliminativists. Evolution favours a limited anthropomorphism of animals at least as much as it favours an anti-anthropomorphic understanding of human behavior. This was the whole point of Morgan's and Romanes' evolution of mind research program.
29. Anti-anthropomorphic thinkers trace their model back to Morgan's view that it is improper to interpret an act in terms of a higher mental process if that act can be interpreted as the outcome of a process which is lower on the psychological scale. Behaviorists understand Morgan to mean that we should keep explanations of behavior as non-cognitive as possible. Morgan and his Darwinian colleagues actually held a 'triangulation' view of explanation. They believed that animals had cognitive states of some sort, but they wanted to triangulate objective and subjective evidence so as not to make animal cognition more complex than it really is. The anti-anthropomorphic interpretation of Morgan's project follows from an exaggerated critique of Romanes by E. L. Thorndike. Thorndike needed an enemy from whom he could appear to be saving science.
30. Thorndike's approach is characteristic of scientism. Scientism is the view that, in addition to the superiority of scientific methodology, the more rigorously and exclusively we use the scientific approach in any endeavour, the more superior the product. Those who subscribe to scientism also hold utopian views about the possible progressive benefits of scientific research.
31. This way of thinking about science comes from identifying with the story of Galileo and his battle with the Catholic Church. We all want to see ourselves as being on the side of Galileo who is the hero of the story, whereas Cardinal Bellarmine and what he represents is the villain. Within the context of this story, labelling any systematic theory as spiritualistic or theological is an insult. Eliminativists particularly favour the strategy of comparing folk psychology to theology.
32. Scientistic thinkers are, however, mistaken in believing that their position is the radical and progressive one. Ever since the victory of science over religion during the Enlightenment, taking the side of science constitutes a defence of the current social order, not a criticism of it. Of course there are still theological fundamentalists who view science as the enemy, but that does not describe those thinkers committed to psychological explanations who are fully naturalistic, and in Freud's case, fully atheistic. Rejecting scientism does not require rejecting naturalism, and clearly does not require that we start talking about Angels again. Contrary to eliminativist assumptions, psychological thinking is not closet theology, and there is a pluralistic naturalism that is both psychology-friendly and to the left of eliminativism's rather conventional deference to the absolute authority of the natural sciences as they are currently understood.
CHAPTER 6: THE ANCHORS OF PSYCHOLOGY
33. In this chapter I outline a framework for thinking about psychological explanation and understanding called the anchors of psychology framework. Anchors are fundamental without being foundational. They reoccur again and again in the writings of any 'big idea thinker' who attempts to develop a comprehensive model of human behavior, no matter what his or her philosophical orientation with respect to 'psychology.'
34. The first anchor is psychology as a level of analysis between internal and external worlds. This anchor is exemplified by work on levels of analysis by Wimsatt (1976) and McCauley (1996) in philosophy, and Engel (1977) in psychiatry. Also important is the concept of an interlevel theory in the work of Darden and Maul (1977). Interlevel contexts include disciplines such as microbiology and social psychology. They were initially attempts to integrate two different levels of analysis, but became distinct levels of analysis (or specialization areas) themselves (Darden and Maul actually used the term "interfield theory").
35. A levels of analysis perspective is integrative rather than dualistic. A lower level of analysis can be considered to be a substrate of the higher level, but the principles of the higher levels are not to be eliminated in favour of lower level principles. This non-reductive attitude leads to explanatory pluralism, the view that scientists should attempt to build models that consult explanatory rules on many levels of analysis, primarily because reducing explanations to a single level of analysis would be costly in terms of lost information. This way of thinking helps us see that depression can be a biochemical state, a personal reaction to a mother's death, and a cultural prescription.
36. The pluralistic attitude has been called a molar analysis - especially by thinkers such as Skinner. A molar analysis of an organism is an evolutionary analysis, which views an organism as having an ecology. Any internal or biological causes of an organism's behavior (such as an adrenaline rush) is itself the result of natural selection, i.e., selection by the environment. The levels of analysis approach has the problem of finding a space to talk about how internal biological and external social influences interact, and psychology is that space. It allows us to talk about what goes on in the head as both a reaction to our own internal processes and the external world. Even if we did not have psychology in our disciplinary framework, we would have to develop it in the name of model building, just as we had to develop microbiology and molecular genetics.
37. The second anchor is psychology as explanation with reference to what is in the head. Even though part of an interlevel theory, psychological explanations of behavior highlight the extent to which behavior is the result of personal factors, or how events 'in the head' influence behavior. The fundamental concepts of psychological explanation include representation, concept, image, perception, and schema.
38. The development of psychoanalysis in the 20th century constitutes a debate about the importance of head versus world in psychological explanation. Like the eliminative materialists, Freud-as-neurologist wanted to emphasize the importance of the brain as a cause of behavior, and his life-long commitment to infantile sexuality was an attempt to keep his model biologically-based. Unlike the eliminative materialists, he had to deal with practical problems involving people interacting with the world. As he began treating disorders such as depression and psychosis, he had to concern himself with adaptation, and external objects came to play a greater role in his theories.
39. This problem is faced by any thinker who is attempting to explain behavior with respect to the body, but is also aware of the evolutionary concept of organisms. Focusing on adaptation always takes us out of the head and into the world. Debates in psychology between ego psychologists and object relations theorists and in philosophy between representation versus participation or internal versus external representation are about claiming a position on the head-to-world continuum. Eliminative and biomedical materialists choose to make the biological aspects of the organism primary and foundational, while more Darwin-based thinkers view the interaction between organism and environment as the primary level of analysis.
40. The third anchor of psychology is understanding with reference to the self. The concept of self is fundamental, and even eliminativists justify their project with respect to the benefits it has for our self-understanding. Both animals and humans gain survival advantages by being able to make self-other distinctions. One of the first signs of the self-other distinction is the internal-external distinction. Research on the child's 'theory of mind,' which is another term for the development of psychological mindedness, shows that the internal-external distinction is a maturationally-programmed cognitive capacity that develops into psychological mindedness, i.e., viewing others as having internal states of their own, knowing the difference between beliefs and desires, distinguishing between different emotional states, and understanding misrepresentation.
41. In cognitively complex creatures such as human beings, this capacity becomes folk psychology. Children generate folk psychology themselves, i.e., like language it is learned actively not passively. Although an evolutionary-maturational account of the development of psychological mindedness does not prove that thinking about ourselves in terms of beliefs and desires and intentions is an accurate way of thinking, it does show, contra eliminativist assumptions, that it is not just made up, and we can't just teach our children something else.
CHAPTER 7: MATERIALISM WITHOUT PHYSICALISM
42. According to Carnap's initial definition, physicalism is the epistemological view that, in theory, we can know anything we want by means of intersubjectively confirmable observation, i.e, third-person descriptions. Materialism without physicalism is introduced by examining Jackson's (1982) thought experiment about Mary the blind neuroscientist. Most of the arguments against Jackson are defences of materialism - specifically claiming that if identity materialism is true, then seeing red is a brain state. The blind neuroscientist Mary, who knows all there is to know about the physiology of visual perception would not learn any new third-person information about perceiving red if she was to actually see red for herself.
43. With respect to Mary, the important question to ask is the following: 'is there any information that we possess by virtue of being in a particular brain state that is different from the information we possess when we are knowing about that brain state?' If no, then materialism is physicalism. If yes, one can be a materialist but not be a physicalist. I claim that the answer is yes, and certain kinds of first-person information make a practical difference in how we explain and understand human behavior.
44. I illustrate the information-bearing role of subjective states using clinical examples, specially focusing on the role played by awareness of emotions. Emotions are clinically important subjective states, and they are often ignored by philosophers who prefer to think in terms of more trivial states, such as knowing what it is like to eat with chopsticks. The information gained from knowing what it is like to eat with chopsticks cannot be compared in terms of practical value to the information gained in knowing what it is like to feel emotions such as fear, anger, and sadness.
45. In the condition know as alexithymia, people lack first-person information about their own emotions. This makes it difficult for them to identify emotions using third-person information. Lacking affective information, they are not psychologically minded. Alexithymia is an important determinant of failure in psychotherapy because it prevents clients from receiving and using the maximum amount of information that subjective awareness of affect can bring. Attending to and conceptualizing our emotional reactions is central for adequate self-understanding on a daily basis.
50. Also import is understanding others as emotional beings or understanding that others have their own first-person experiences. It is almost a cliche in philosophy that understanding another as a subject is extraordinarily important to what might be called our 'humanity.' It would be impossible to understand the moral imperative 'do not inflict pain on others,' unless you had some knowledge of what pain is like. In Feigl's (1971) terminology, the surplus meaning that we get by knowing what pain feels like is indispensable.
51. Knowledge of our inner states aids us in making certain discoveries, e.g., that I am depressed or anxious. It also has heuristic value and helps us hypothesize about the nature of the world, e.g., that depression is worse in the morning but gets better as the day goes on. Having what Churchland calls an intimate causal connection to our inner states confers what Meehl (1967) called a 'cognitive edge.' This cognitive edge is clearly a difference that makes a difference. Subjectivity is not the foundation on which psychology is built, but it is part of the evidence.
PART III: THE PSYCHOLOGY IN PSYCHIATRY
CHAPTER 8: DIAGNOSIS, BEHAVIOR, AND FIRST-PERSON INFORMATION
52. In this chapter I show how attending to the biological fact of subjectivity in psychiatric patients, especially patient reactions, has always been and continues to be integral to psychiatry - including the most committed versions of biological psychiatry. In practice, biological psychiatrists are materialists, but not physicalists. I also defend a judicious use of operationalized diagnostic criteria, arguing that all psychologists need to attend to behavior. This is the behaviorism of Dewey rather than the behaviorism of Hull, Tolman, Skinner, and Watson.
53. The biomedical materialists identify systematic diagnosis with their model. This is because the operationalized diagnostic criteria, or Feighner criteria, developed in the 1960s by biomedical researchers became the framework for the DSM-III revolution in psychiatric diagnosis. This revolution was opposed by psychoanalytic psychiatrists. According to the biomedical materialists, scientific diagnosis is about objectivity, and more objective means more physiological and genetic.
54. Unfortunately, the biomedical materialists over-estimate the objectivity of scientific diagnosis. For example, in diagnosing panic attacks, criteria such as nausea, tingling sensations, and chest pains require a person to report subjective experiences. Such quasi-objective physical symptoms are not unknown in medical diagnosis. One could probably formulate behavioral indicators of nausea or chest pains, but no one has seen a need to do so in order to make them 'scientific'.
55. The psychodynamic and humanistic mistrust of behavioral criteria is also misplaced. We do not observe beliefs and desires like we observe tables and chairs. We have to infer them from behavior. The early behaviorists held that beliefs and desires are intervening variables - summaries of behavior. This aspect of logical positivism imploded on itself by the late 1940s. In the terminology of the network theory, the meaning of a belief is given not only in reference to behaviors, but also in reference to other beliefs. For example a belief in the first amendment is implicitly defined with respect to beliefs about the value of an open society. The network theory suggests that beliefs cannot be reduced to behaviors. Behaviors are, however, still part of the evidence for any psychological state. For example, in psychodynamic psychology, the person's most central beliefs and desires are inferred from those behaviors that are consistently and rigidly exhibited. This is called the repetition-compulsion.
56. Subjectivity is one of the elements distinguishing the biological sciences from the natural sciences. Because it deals with cognitively complex organisms, attending to subjective reactions is important in psychiatry. Those biomedical materialists who treat patients know this. Anticipating reactions helps psychiatrists manage patients. For example, it is important to anticipate the potential reactions of a person with paranoia during a diagnostic interview. It is unwise to tell a paranoid person that they can trust you. Not being able to think about and anticipate reactions would prevent psychiatrists from getting the information they need.
57. Psychiatrists also need to consider secondary reactions. They have to decide when something such as depression is a primary disorder and when it is a secondary reaction to another pre-existing disorder, such as panic disorder. Determining what is primary and what is secondary has implications for what biological interventions one makes. If the anxiety disorder is primary, we can treat the anxiety and predict that depression will then dissipate.
58. Finally, subjective reactions can play an important role in pathogenesis. An extrovert will react differently to a panic disorder than will an introvert - and these reactions to the disorder become intertwined with the disorder. Understanding pathogenic reactions is also important for conceptualizing genetically-influenced psychiatric disorders. For the most part, whatever the genetic basis of a disorder such as schizophrenia, it probably only initiates a process that ends up being a psychiatric disorder. The final disorder is the product of a cascade of reactions and counter-reactions, etc.
59. The difference between the eliminative materialist writing from the armchair and the biomedical materialist who has to deal with the complexities of interacting with persons is crucial. Persons are psychological creatures with subjective perspectives. Psychiatry should be less concerned with passively conforming to the rest of medicine and more assertive about what it has to teach other medical specialities. Psychiatry's sophisticated understanding of its patients is based on the active-mind model, rather than the classical empiricist's passive-mind model. In many ways, the profession of medicine would be better if it was more in conformity with psychiatry.
CHAPTER 9: EVOLUTION, PSYCHIATRY, AND ADAPTATION
60. Returning to evolution, I argue that in addition to the science of physiology, psychiatry must consider the science of evolution. The reason it must do so is that concepts of adaptive and maladaptive make sense primarily in an evolutionary framework. They involve interactions between the organism and the world, and necessarily contain value judgements. Although it is useful to think about the biological basis of depression, what depression 'is' and why it is a problem is not a purely physiological question. This way of thinking about the brain, and about the biological basis of psychiatric disorders is called the ecology of neuroscience.
61. Contrary to Paul Churchland's claim that the victims of mental illness are victims of sheer chemical circumstances whose origins are more metabolic than social or psychological, going outside the 'chemical' levels of analysis is a precondition for there even being any psychiatric disorders.
62. If I tell you that a particular person believes that the mafia is trying to kill him, that belief involves what philosophers call narrow content. We need to know more than the narrow content of the belief in order to evaluate its adaptiveness. If the mafia actually is trying to kill this person, we would judge the belief to be adaptive. If the mafia is not trying to kill this person, we would judge the belief to be maladaptive. Adaptive and maladaptive are evaluations. This is a fundamental principle of evolutionary theory. Rather than there being inherent monadic traits that define adaptiveness, adaptiveness is defined as whatever confers a competitive advantage.
63. No matter what biomedical materialists think about the nature of the underlying pathological process, they define treatment in terms of adaptive success, i.e., in terms of some evaluation of the interaction between the person and their environment. If they can evaluate an intervention as leading to adaptive success, they won't worry about whether they fully understand the underlying pathological process as it is biologically defined.
64. This ecological-evolutionary way of thinking goes all the way down and all the way through both psychology and cognitive neuroscience. It is contrary to the 'brain-first' bottom up model of the biomedical and eliminative materialists, and is more consistent with a focus on both development/ontogenesis and contextual analyses. Having a more molar approach is one of the advantages of the biopsychosocial model.
65. Biomedical materialists generally view the DSM-IV's rejection of the organic-functional distinction as supporting their position because it suggests that all disorders can be organic. As long as we accept a levels of analysis approach and believe that the brain is the substrate of psychological states, this has to be true. But the flip side, one that the biomedical materialists ignore, is that all disorders are also functional at some level of analysis. This has to be true as long as we understand organisms from the standpoint of evolutionary theory. From a levels of analysis perspective, we can design treatments that target events at many different levels of analysis - the physiological, the cognitive, the psychodynamic, etc. Effective treatment sometimes requires adopting different targets of intervention for clients who have the same disorder. The intervention we pick should be the one that will allow us to evaluate the person in question, in the long run, as better than before.
CHAPTER 10: PSYCHIATRY, SCIENCE, AND ANTI-ESSENTIALISM
66. The most complicated chapter in the book examines the notion that psychiatric disorders can be natural kinds. Biomedical model thinkers believe that psychiatric natural kinds can be isolated by studying underlying biopathological processes, while research-oriented clinical psychologists think they can be identified statistically. Both groups assume that if a category can't be conceptualized as a natural kind, it is an arbitrary category. I argue that conceptualizing psychiatric disorders as fixed bounded entities in nature is inconsistent both with medicine's understanding of disease and evolutionary biology's understanding of species. In contrast to natural kinds, I recommend the concept of practical kinds, which are stable patterns that can be identified with varying levels of reliability and validity. [I believe that the term 'practical kinds' comes from Paul Churchland (1993). Unfortunately, I failed to credit him in the book or in Zachar (2000a). My apologies to P.M.C.]
67. The advantage to a natural kind is that once we know its essential nature, it can be identified with perfect reliability. Psychiatrists and psychologists assume that if something is not a natural kind, it must be an artificial or arbitrary kind. Syndromes such as schizophrenia and the personality disorders have long been criticized because they cannot be diagnosed reliably. According to the critics, lack of reliability suggests that these syndromes do not carve nature at the joints. They are not natural kinds and what limited reliability they have capitalizes on chance.
68. The critics fail to consider the category of practical kinds. Practical kinds exist on a continuum running from high reliability to low reliability. The reliability of a practical kind does not capitalize on chance, but it is not perfect. Nor are practical kinds arbitrary. They are categories that are chosen for reasons. With practical kind categories, we can, in principle, develop alternative systems of categorization, each having its own uses. If a category is both useful and widely applicable we may say that it is a real category, but conferring reality status on a category is contingent on it usefulness.
69. The practical kinds model is more congruent with the prototype model of categories than it is with the classical model of categories. The classical model of categories is the Aristotelian model. Classical categories are essentialistic categories. They have necessary and sufficient properties for their identification, and an entity is or is not a member of the category. The prototype model is a non-essentialist model. According to the prototype model, some members of a category are better examples of the category; so a robin in a better example of a bird than is a penguin. There are no inherent necessary and sufficient criteria that must be fully present for category membership. Categories in the prototype model also have fuzzy boundaries. It is not always clear who is and who is not a member of the category.
70. As they are described in the DSM-IV, psychiatric categories conform to the prototype model. Each disorder is defined in terms of polythetic criteria. A disorder is identified by a list of criteria where a certain number of symptoms have to be present, but no criterion is itself necessary or sufficient. A syndrome such as borderline personality disorder is best considered to be a family of personality types. Psychiatric disorders also have fuzzy boundaries, as illustrated by the category of V-codes. A V-code is a condition such as marital discord that may be the focus of clinical treatment, but is not officially called a psychiatric disorder.
71. Darwin's view of species exemplifies the rejection of classical categories. The very notion of the evolution of species defies any fixed essentialistic understanding of a species. Darwin defined a species in terms of populations of unique individuals rather than individuals sharing a common essence. Rather than what an essentialist would call 'imperfections', 'errors', or 'accidents', individual variation is central for understanding the long-term fluid nature of species. Like psychiatric disorders, a species is a family of individuals.
72. Importantly, zoologists have developed alternative taxonomies of species. These include the cladistic model and the numerical phenetic model. Although these models overlap, there are cases where a family of organisms is classified as a member of one group in the cladistic model and not a member of that group in the numerical phenetic model. Taxonomists do not believe that species are inventions. The distinctions they accept are far from arbitrary, but they are not essentialist distinctions.
73. If philosophers of biology are correct, medical model theorists should be able to propose alternative taxonomic systems for defining syndromes, and each system may have different sets of syndromes. Classification schemes developed at different levels of analysis, e.g., (including but not limited to) the genetic level, the neurochemical level, the anatomical level, the affective level, the cognitive level, the phenomenological level, and the sociocultural level may not be perfectly isomorphic with each other. Each taxonomy would have validity for certain purposes, but no one could be called the real taxonomy.
74. Psychologists committed to the psychometric tradition believe that essentialistic categories can be discovered mathematically. In their opinion, multivariate methods such as factor analysis and cluster analysis, which can objectively determine the presence or absence of patterns in the data, may be more scientifically sound than the kind of clinical observation used in the medical model. Because the observer-independent patterns found by statistical analysis are also by definition non-random, they could even be called natural kinds.
75. Blashfield (1980) has criticized the naive empiricism adopted by some proponents of statistically-guided classification. Even with a random pattern of data, factor analytic procedures will extract factors. They capitalize on chance variance in the data to find a pattern. The same can be true for cluster analysis. There is a false positive problem with multivariate statistical methods. They may find patterns that are not really there. More seriously, if the appropriate variables are not entered into the analysis, multivariate methods can also fail to detect patterns, i.e., yield false negatives.
76. Meehl (1986) discussed the advantages of thinking of diagnostic taxa as open concepts, and considered any other strategy to be 'scientifically malignant.' No matter how specifically we define disorders such as schizophrenia, we will always have to admit exceptions - cases that do not fit the model. The more specific the criteria, the more exceptions we can expect. We can avoid the problem of exceptions by using broader definitions, but that would lower reliability. Thinking of our categories as natural kinds, as closed absolute concepts, is unwarranted. Scientific openness to evidence is supported better by considering psychiatric categories to be practical and not natural kinds.
CHAPTER 11: PSYCHIATRY AND REALITY
77. The levels of analysis perspective teaches us that the brain is the substrate of psychological states, but eliminative and biomedical materialists go beyond this, claiming that psychological states are really brain states. These ontological commitments appear in suggestions that psychological interventions gain more credence if they can be described in terms of what is happening in the brain.
78. One problem with this thinking is that psychology and physiology are not transitive. If we want to assert that psychotherapy is a biological treatment, then we should accept the corollary claim that pharmacological therapy is a psychological treatment. This ignores the whole point of the levels of analysis analysis. A college dean would not read an article about how successful behavior modification alters microbiology and then hire a behavioral analyst to teach in the microbiology department. For the same reason we should not blithely define psychotherapy as a biological treatment.
79. From the standpoint of explanatory pluralism, professionals benefit from having multiple exemplars of successful treatment. Exemplars are examples of successful problem solutions. They are taught to students with the hope that similar problems may be solved in the same way. The general paresis and traumatic brain injury exemplars favoured by biomedical and eliminative materialists are perfectly good exemplars. They suggest that directly modifying the brain is the most effective and ethical treatment. But there are additional exemplars that are also 'good,' and which need to be a part of our professional and personal repertoires when we are thinking about the psychology-neuroscience relationship.
80. One important exemplar is the temper-tantrum exemplar. Most people understand that a child's temper-tantrum is a brain state, and one which requires an intervention. But it would usually be foolish to treat temper-tantrums by giving children drugs that directly modify their brains. It is better to intervene psychologically and teach the children that they cannot always get what they want.
81. Another exemplar is the self-concept and brain injury exemplar. People with traumatic brain injuries have to deal with loss of self issues - the realization that some of the potentials their lives once held are now gone. They have to learn to value different possible selves. While mourning their loss of self, people can sometimes become suicidal. Although a self-esteem pill might be convenient, helping people develop new possible selves is a more elegant and effective treatment.
82. Another exemplar is the problems in living exemplar. A good deal of unhappiness in people's lives is a realistic reaction to bizarre, unnatural, or inadequate social-cultural contexts. It is never a waste of time for professionals to consider these external factors when evaluating individual reactions. We should not automatically medicalize psychiatric problems when alternative solutions may be available.
83. Another exemplar is the interpersonal intervention exemplar. Sometimes in therapy people learn how their behavior affects others - and therefore they get information about why others react to them the way they do. Consider a client who enters therapy depressed and feeling that people in his life are trying to control him. As long as the depression is not severe, it is sometimes better to not assuage the unpleasant feelings because they help motivate clients to change. In interpersonal therapy what the client might learn is that he tends to act so helpless that other people are motivated to take control - in order to take care of him. This kind of insight, coupled with the unpleasant consequences of the behavior, can lead him to change how he acts. Sometimes that can lead others to change how they act, which in turn eliminates the events that precipitate and feed the depression.
84. A final exemplar is the pharmacologically-initiated insight exemplar. The effects of medication can provide the opportunity for psychological changes. For example, experience with anti-depressant medication can teach some people that the immediate effect of the medication is to reduce their brooding, and it is the brooding that leads to depression. Learning more about what leads to brooding, and working on that problem therapeutically can initiate changes that are maintained independent of the medication.
85. Rather than proposing these exemplars as competitors to general paresis and traumatic brain injury (TBI), I am suggesting that biomedical and eliminative materialists are mistaken in trying to fit all psychiatric problems into the Procrustean beds of syphilis and TBI. This pluralistic model, similar to models offered by William James, Ian Hacking, and J. S. Mill, suggests that psychiatrists and psychologists should be developing multiple strategies (conceptual and applied) for solving professional problems. As Zachar (2000b) notes, this version of pragmatism is nominalistic without being anti-realistic.
CHAPTER 12: PSYCHIATRY AND THE RHETORIC OF MORALITY
86. An important aspect of the biomedical and eliminativist materialists' critique of psychology is their view that psychological approaches to the treatment of psychiatric disorders are iatrogenic. Their appeals for a more exclusive reliance on neuroscience can be reduced to the claim that neuroscience is good and psychology is bad. Proponents of biomedical and eliminative materialism exaggerate the faults of psychological treatment and minimize the faults of biological treatment. They ignore the iatrogenic tragedy called the prefrontal lobotomy. They also forget that the racial purity ideology of the eugenics movement, and chronic hatred of the poor and the disadvantaged have long been defended as being justified by the facts of biological science. Biological solutions to deviance include sterilization and euthanasia. Harmful treatments and immoral social policies are not necessary consequences of biological psychiatry, but neither is blaming the victim a necessary consequence of psychological psychiatry.
87. Another argument used by biomedical materialists is that psychiatric patients would receive better treatment if the general public thought of psychiatric disorders as diseases similar to cancer or kidney failure. This is a demonstrably false assumption. One of the greatest problems faced by persons with traumatic brain injury is that the subtle personality changes occurring as a result of the injury lead to stigmatization, especially when there are no obvious physical disabilities. Both family members and the public know that traumatic brain injuries are biological or 'brain lesions,' but they still react to inappropriate behavior with rejection and avoidance.
88. Insurance companies are unlikely to increase funding for the treatment of psychiatric disorders if they are seen by the public as primarily a problem of 'broken brains,' especially disorders such as schizophrenia and bipolar disorder. The current lack of funding is not based on a common sense etiological theory that the problem is just in the person's head; rather, insurance companies are reluctant to fund services for chronic disabilities. Any condition labelled as genetically-based also runs the risk of being defined as a pre-existing condition - and insurance companies have strategies for limiting coverage for pre-existing conditions. This unfortunate fact of the actuarial viewpoint is not an argument against the biomedical model, but it is not true that psychiatric patients would be better off, tout court, if their problems were seen as diseases of the brain.
89. The psychology of moral reasoning has a narrative element. We each have favoured stories involving moral heroes and moral villains, and we make moral decisions by viewing our current situation as similar to the plots of our favourite moral stories. As stated in chapter 6, those of us raised in post-Enlightenment culture take Galileo's story to be a morality play, and we want to see ourselves as being on the side of Galileo whenever those plot elements arise in our own lives. Such moral stories could be called moral exemplars - and they function like scientific exemplars. They are examples of solutions to moral problems.
90. Some scientific exemplars are also moral exemplars - especially in psychiatry. The biomedical materialists use general paresis of the insane as both a scientific and moral exemplar. As with scientific exemplars, we need multiple moral exemplars to help us solve moral problems. The psychiatric exemplars discussed in chapter 11 are also moral exemplars. This includes the traumatic brain injury exemplar.
91. Paul Churchland (1995) states that one of the primary aims of medical science with respect to TBI is to promote whatever degree of cognitive recovery remains possible for the patient. He does not expand on this important point about rehabilitation. Although recovery includes struggling with loss-of-self issues and dealing with personal reactions to the new deficits, the guiding principle of rehabilitation psychology is that we have to focus people on their strengths, on what they can still do to compensate for some of their losses. Applying a deficit-oriented model of TBI to these problems would be inadequate. According to Prigatano (1991), research shows that failure to address broad psychological issues is correlated with long-term deterioration of functioning. For rehabilitation psychologists, deficit-oriented 'broken brain' approaches and pathologizing approaches are villainous.
CHAPTER 13: REFLECTIONS
92. I conclude with a series of reflections about how stubborn all of us, including biomedical and eliminative materialists, can be about philosophical and scientific opinions. Psychologically speaking, there is some validity to William James' belief that certain philosophical positions are related to intellectual temperament. Although it is a mistake to dichotomously categorize people as being tough-minded or tender-minded, or a scientist versus a practitioner, the Jamesian analysis reminds us that, when there are no clear solutions to fundamental philosophical problems, rational arguments themselves do not determine one's favoured position.
93. The conceptual issues endemic to psychology-and-the-brain are important because we learn how to think about ourselves. We learn that individualism is an achievement, or that individualism is being selfish at the expense of the group. We learn that having sex is sinful, or that not having sex means you are incomplete as a person. These beliefs contribute to our identities. We do not choose them like we choose an evening movie; we are influenced to believe these things about ourselves by numerous cultural prescriptions, many of them contributed by contemporary intellectuals.
94. What cognitive psychologists call the availability heuristic systematically biases the thinking of those biologically-oriented intellectuals who lack, dismiss, or reject an interdisciplinary framework. Many biologically-oriented thinkers immerse themselves in dramatic biological examples of successful problem solutions such as general paresis. When this kind of exemplar dominates their conceptual repertoires, they attempt to fit every problem into the Procrustean bed of the biomedical model. Research even indicates that the biomedical model is part of our folk understanding of what physicians do, and students come to medical school with certain biases already in place. Even when their curriculum encourages them to think about problems biopsychosocially, a majority of them still exclusively seek biomedical solutions to problems. The problem is compounded by the fact that many psychiatric disorders are treated by general practitioners, who have limited exposure to psychological conceptualizations.
95. Psychiatrists who try both to think about patients psychologically and to prescribe medication are undertaking an intellectually daunting task. Given the limits of human information processing, the convenience of thinking just psychologically or just biologically is understandable, even if it is often wrong. Non-professionals will be inclined to believe what psychiatrists and psychologists tell them. This also includes experimental psychologists, who therefore have some responsibility to familiarize themselves with these issues. With increased regularity, people are requesting answers to questions such as: How much of it is due to my brain?; How much of it is due to the way my mother treated me?; How much of it is due to the way my family was organized?' Providing nuanced rather the cliche answers to these kinds of question requires some familiarity with the philosophical issues discussed in this book. Although my outline for formulating an answer may not be the one people choose, any answer should consider physiology AND evolutionary biology; the scientific method AND the history of science; a theoretical model And one's own personal experience.
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