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The connection between the brain and behavior is both fascinating and frustrating, and something about which mental health clinicians should care deeply. Indeed, the distinction between brain and mind is at the heart of many of the debates about what constitutes good, or even adequate, mental health treatment. Despite the truism that biology constitutes the substrate of human life, the link between the biology of the brain and the genesis of mental disorders is poorly understood and inadequately described. Even non-medical mental health clinicians, however, seem to have adopted a medical model of mental illness, where specific pathologies can be treated with specific medications (which have specific effects) and lead to specific changes in behavior and improvements in mood. There is a compelling profit motive to the search for such discreet causal chains for mental disorders. Despite this, there have not been notable successes in determining the medical causes for mental disorders.
F. Scott Kraly has written a useful, if flawed, introduction to the current state of neurological science about the brain and psychological disorders. "Brain Science and Psychological Disorders" is clearly written, well-organized, and does an excellent job of juggling both the complexities of neurology and the needs of lay readers. Sections of the book should be required reading for any mental health practitioner who cares about what has emerged as the central debate in mental health treatment. In particular, Kraly's introductions to the fundamental principles of brain neurology are excellent. There are other sections of the book, however, particularly those that attempt to outline the state of knowledge about the brain abnormalities that Kraly would like to claim as responsible for mental illnesses, that are poorly presented and overreach in their conclusions.
The first section of Kraly's book, "Treatment of Behavioral and Brain Disorders" is a good introduction to the series of problems that he hopes to examine. Kraly does an admirable job of discussing the various treatment modalities currently available, and of demonstrating his very evident desire to focus on the treatment of patients' mental suffering. The title of the section, however, indicates his implicit bias, which is to view human psychology first through a biological lens. While he is careful to use modulated language in order not to suggest that we know more than we do about the (supposedly) biological causes of mental illnesses, his honestly contingent language begs the question. If no definitive statements can be made about even the existence of such things as "inherited vulnerabilities", much less the amount of environmental stress a person with such a supposed vulnerability can suffer prior to the vulnerability contributing to clinical depression, it's not at all clear that we gain anything useful to treatment by supposing the existence of such brain weaknesses. Kraly never adequately explains why biological treatments (medications) should be favored simply because there is a biological component to a mental disorder.
Kraly is most strong in the second section of his book, which serves as a cogent introduction to the "Fundamental Principles of Brain and Behavior." It's clear that Kraly is a gifted teacher who manages to integrate and present an immense amount of complex material for the lay reader. His précis is simple enough to understand without being simplistic, and he takes care to explain the simplifications that he is making for the sake of ease in presentation. Kraly's constant reminders that our current understanding of neurology is more complex than he can do justice to in the format of this particular book are helpful, as are the two extended case studies of the history of research into hunger and sexual behavior. The former case study, which demonstrates that simplistic explanatory models for the relationship between brain and behavior are likely to be considerably complicated as more research is done, suggests that many of the more simplistic suggestions about the relationship between particular medications and the etiology of specific mental disorders will probably be found to be without basis.
Kraly uses the third section of his book to detail the current state of neurological research and thinking on a host of different behavioral disorders. Unfortunately the book contains no footnotes of any sort, and while each section has a few selected books recommended at the end for further reading, and there is a large bibliography appended to the text, the lack of references makes this section essentially useless. Kraly's focus is on biological processes and research, which is understandable given the scope of his book, but the determination of causes for mental illness, and the subsequent exploration of what constitutes appropriate treatment, is inevitably controversial. By failing to include references to his claims Kraly presents the science as more settled than it is while preventing interested and concerned readers from following-up on any questions they might have. He helpfully discusses gender differences in presentation of behavioral disorders and even in treatment, but again, the lack of references makes it hard to gauge how reliable these differences are, a weakness further exacerbated by a failure to discuss his criteria for this category of information. (For instance, he discusses the higher level of depressive disorders in women without discussing the possible diagnostic causes of this. (Möller-Leimkühler, et al. 2003; Winkler, 2005)) The third section of Kraly's book feels disappointing precisely because it seems to hold so much un-realized promise.
Kraly is too convinced that biological processes contain the most important answers about human psychology. He makes an illustrative and typical decision early in Chapter Three while discussing the role of placebos in mental health treatment. Although he later discusses placebos as a potential treatment in their own right, he does not extrapolate their effects into the effects of pharmaceutical medications. In other words, he fails to account for the placebo effect present in the action of pharmaceuticals. This leads to an overestimation of the efficacy of psychotropic medications. Meta-analyses have found that only 18-25% of improvement from an SSRI is separate from the placebo effect. (Kirsh & Sapirstein 1998; Kirsh et al. 2002)
Fostering expectation for improvement is central to the role of all mental healthcare providers, but when the effects of medications are overstated the centrality of that role may be ignored. Of more importance for Kraly's book, where he repeatedly suggests that if medications have an effect it is reasonable to assume that the etiology of the mental problem alleviated is related to that effect, is that when the role of the chemical constituents of psychotropic medications in patient improvement is overstated, it's more likely that researchers and clinicians will form faulty assumptions about the causes of mental disorders. When it seems that the chemical constituents of a medication are helping 50% of the people who take it one set of conclusions may be warranted, but those same conclusions may be overstated once it is recognized that, due to the effects of placebo, the role of the chemical constituents is significantly less.
More troubling is that despite Kraly's evident interest in helping distressed patients he makes several comments about the lack of knowledge we have about the effects of psychotherapy. While it's true that we do not know as much about the specific effects of psychotherapy in the brain as we do about the effects of specific medications, we do know that psychotherapy is very effective in treating patients with all sorts of psychiatric diagnoses. Bruce Wampold (2001) has reviewed many meta-analyses of psychotherapy which prove that it has an effect size of 0.80, which constitutes a large effect in the social sciences. In addition, we know that it does not have adverse side effects and that it works in ways (through its general constituents) that challenge the very premise that mental illnesses are best understood by the medical model with which Kraly views them.
Kirsh, I. et al. (2002). The emperor's new drugs: An analysis of antidepressant medication data submitted to the U.S. Food and Drug Administration. Prevention & Treatment, 5, art 23.
Kirsh, I. & Sapirstein, G. (1998). Listening to Prozac but hearing placebo: A meta-analysis of antidepressant medication. Prevention & Treatment, 1, art 0002a.
Möller-Leimkühler, A. M., Bottlender, R., Strauss, A.& Rutz, W. Is there evidence for a male depressive syndrome in inpatients with major
depression?. Journal of Affective Disorders, 2003, 80:1, 87-93.
Wampold, B. (2001). The great psychotherapy debate. NY: Lawrence Erlbaum.
Winkler, D., Pjrek, E. & Kasper, S. Anger Attacks in Depression: Evidence for a Male Depressive Syndrome. Psychotherapy and Psychosomatics 2005, 74, 303-307.
© 2007 Andrew Pollock
Andrew Pollock is a psychotherapist working in Baltimore, MD, where he is a Director of the Baltimore Psychotherapy Institute.