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BOOK REVIEWS |
Intimate Attachments: Toward a New Self Psychology
edited by Morton Shane, Estelle Shane, and Mary Gales
reviewed by Paul M. Cameron
Individual Differences in Posttraumatic Response: Problems With the Adversity-Distress Connection
edited by Marilyn Bowman
reviewed by Diana Koszycki
A History of Psychiatry: From the Era of the Asylum to the Age of Prozac
edited by Edward Shorter
reviewed by Ellen Margolese
Professor of Psychiatry, Director of Psychotherapy Program, University of Ottawa, Ottawa Hospital, General Campus, Room 4422, 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada
Morton Shane, Estelle Shane, and Mary Gales
The Guilford Press, New York, 1997, 242 pages, $35
Strengths: current interest, clearly written, creative new concepts
Weaknesses: requires some knowledge of self psychology
Target reader: psychotherapist of any discipline
This very readable book is written by distinguished psychoanalysts who are very creative and free-thinking writers within the self-psychology stream of psychoanalysis. The book has 9 chapters, is just over 200 pages, and gives understandable clinical vignettes to illustrate the approach to psychoanalysis and self psychology that is being described.
Key concepts are the importance of a positive new experience within the psychoanalytic situation and some very simple, yet new, notions of three different relational configurations between the analyst and patient. Also, the Shanes discuss two dimensions of intimacy that they view as important: the self of the patient with the other as a self-transforming person and the self of the patient with the other involved in interpersonal sharing.
The model that the Shanes advocate is what they describe as "nonlinear dynamic systems model." This means that psychoanalysis can unfold in different ways with different patients. It does not go through stages in a linear manner. For instance, they describe an anecdote of a patient who spends 18 months with the analyst and has no negative experience or no demonstrations of transference as transference used to be understood. The doctor may often experience this with patients and wonder if this was psychoanalysis. The Shanes address the question, "Yes, this is analysis because the process is unfolding in a different sequence." They suggest that that type of analysis may be the patient experiencing a new self with a new other.
They highlight the importance of the developing self, the role of trauma and the change promoting value of new experience with the analyst. The authors point out that to use what is good in different models requires integration. They state that their model allows them to integrate the point of view that the self is the prime organizer of development together with Bowlby’s notion that the secure base of attachment is the prime organizer of development. Their model, which encourages nonlinear understanding and systems, makes it possible to integrate different concepts from different models to understand the patient’s development.
The authors emphasize the importance of mutual influence of both members of the analytic diad on each other’s understanding and subjective state. They give an example of a new type of interpersonal sharing occurring with the analyst and the patient where the patient arrives late a number of times to see the analyst. One day after arriving late, the patient asserts, "You are really angry with me, aren’t you? The analyst did not feel very angry and said so, but did acknowledge mild frustration about the patient being late so often." As sometimes happens, the patient kept insisting that the analyst was really quite angry. This persistent insistence by the patient that the analyst was feeling something that the analyst was not feeling lead to the analyst becoming increasingly frustrated and angry. Eventually the analyst stated that this patient’s insistence that she was enraged was creating more anger in her that the patient had originally stated was there. This honest admission by the analyst broke the tension and was eventually worked through so that the patient felt safer to speak about anger with this new type of response by the analyst.
One particularly important chapter is entitled "Reconceptualizing Transference," and here, once again, we see the authors’ original notions of transference. They also discuss how some of the advances of self psychology have added to our understanding of transference. The authors distinguish transference as a fantasy distortion of the past compared with transference as an accurate reflection of the past. They examine positive experience as transference experience as compared with positive experience as a new experience with the analyst, and they discuss all of these transferences as an opportunity for interpretation and insight.
The notions of three different relational configurations of old-old, old-new, and new-new is extremely freeing in understanding of the interactions possible within the analytic situation. The book ends with chapters about the clinical situation during different life cycle periods. This book is recommended because it is extremely lucid, and it contains a number of new concepts that allow more freedom of both conceptualization and intervention for the therapist.
Stress and Anxiety Research Unit, Assistant Professor of Psychiatry, University of Ottawa, Royal Ottawa Hospital, 1145 Carling Avenue, Ottawa, ON K1Z 7K4 Canada, Email: dkoszyck@rohcg.on.ca
Marilyn Bowman
Lawrence Erlbaum Associates, Publishers, 1997, 189 pages, $39.95
Strengths: interesting and readable
Weaknesses: no major weaknesses
Target reader: an academic readership interested in posttraumatic psychological response
In recent years there has been a burgeoning interest in the psychological effects of traumatic life experiences. One of the most fascinating topics in the area of trauma is why some people develop clinically significant psychopathology after exposure to a traumatic life event, whereas others are relatively unscathed by such an event. Unlike many books on trauma, Individual Differences in Posttraumatic Response: Problems with Adversity-Distress Connection by Marilyn Bowman seeks to shed light on the factors that contribute to the divergent emotional response to traumatic stressors. Drawing on the availability research, Dr. Bowman exposes the shortcomings of the prevailing view that catastrophic life experiences are powerful determinants of serious mental health problems and proceeds to present a persuasive argument that emotional reactions to traumatic events are largely shaped by individual differences in pre-event characteristics. The book argues that if advances in our understanding of the etiology and treatment of trauma-related disorders are to continue, it is imperative that we go beyond a focus on the event to explore relevant vulnerability factors.
This slim book is divided into 14 brief chapters. Each chapter highlights key issues and summarizes the most relevant research in the area. The book starts out by discussing some popular and professional assumptions about the primacy of catastrophic events in the etiology of clinical disorders such as posttraumatic stress disorder (PTSD). In the next four chapters, the author critically evaluates the validity of these taken-for-granted assumptions and concludes that there is little empirical support for a simple cause-effect relationship between trauma and stress-related disorders. For example in Chapter 2, she points out that although extreme traumatic events occur at a high frequency in the general population, the prevalence of PTSD is vastly lower than what might be expected. Thus, exposure to catastrophic events does not significantly increase risk for serious mental health problems. The focus of Chapters 3, 4, and 5 is the dose-response relationship between adversity and distress and the assumption that more severe traumatic experiences elicit more severe and enduring distress. Here, the author reveals that studies involving representative samples (as opposed to clinical or litigation populations) have generally failed to detect a simple linear relationship between dose and response. The psychological impact of direct or indirect exposure to extremely traumatic events is highly variable and the vast majority of people do not develop PTSD or other clinically significant distress syndromes.
Having made the case that traumatic events are not sufficient for the development of stress-related disorders, the next four chapters explore a broad range of individual difference variables, which the author maintains increase risk for psychopathology because of exposure to trauma. Among the variables discussed are: preexisting mental disorders, personality traits, past actions, preevent life history and mental competency (Chapter 6); individual differences in the personality dimensions of emotionality and sensation seeking (Chapter 7); beliefs and attributional style (Chapter 8); and gender, culture, and ethnic status (Chapter 9). Generally, the author does a reasonably good job to synthesize concepts and research findings in these chapters. Chapter 10 addresses the question of what is the relative power of preevent characteristics when both individual differences variables and event characteristics are considered. Not surprising, the author concludes that there is clear and compelling evidence that preevent factors contribute more to serious distress disorders than the traumatic event itself.
Chapter 11 raises a question that is well worth pondering; why are mental health professionals reluctant to look for causes of distress beyond the event? In this chapter, the author theorizes that proponents of the adversity-distress model make fundamental errors in explaining human emotion; this includes making erroneous causal inferences about adversity and emotional dysfunction, failing to consider alternative explanations for distress, misinterpreting or ignoring relevant research findings, errors of logic, and making incorrect predictions about the deleterious effects of events on mental health. These processes and attributional biases may obscure important antecedent variables that shape response to traumatic events. An interesting thesis of the subsequent chapter is whether a person’s affective experience is a valid indicator of well-being. Bowman suggests that subjective reports of emotional distress may not always be an accurate marker of the objective severity of an event, as powerful contextual variables such as culture, emotionality, and personal agendas can color the expression of emotion. Because a diagnosis of PTSD depends, for the most part, on subjective reports of distress, the confounding inherent in such reports has important implications for the assessment and treatment of trauma-related disorders. In Chapter 13, the author draws our attention to the limitation of psychotherapy for trauma-related disorders, and questions the necessity of professional interventions aimed at mitigating the psychological sequelae of traumatic events and the effectiveness of stress inoculation training in preventing trauma-induced distress. In the final chapter, Bowman summarizes the material presented in the preceding chapters and discusses the implications of the way she conceptualizes posttraumatic response for the diagnosis and treatment of trauma-induced stress disorders.
On the whole, this is a rather interesting, thought-provoking, and readable book that is intended primarily for academic and professional readership. Dr. Bowman urges us to go beyond a simple cause-effect relationship between adversity and distress and to consider that posttraumatic response is the result of a complex interaction between the event and predisposing variables.
Resident, Department of Psychiatry, University of Toronto, Toronto Hospital General Division, Department of Psychiatry, 200 Elizabeth Street, Rm 231, Toronto, Ontario M5G 2C4, Canada, Email: emargole@magma.ca
Edward Shorter
John Wiley and Sons, Inc, New York, 1997, 436 pages, $19.95
Strengths: lucid, readable prose; sets the topic in the broader social and cultural contexts; extremely thoroughly researched (90+ pages of footnotes)
Weaknesses: a clear bias against psychoanalysis and relatively short shrift given to psychotherapy as a whole
Target reader: general public; psychiatrists
As a first-year resident in psychiatry, as well as having a background in social policy law, I am very interested in the development of psychiatry as a medical specialty, and also its role within society and the doctor/patient relationship. Shorter is Hannah Professor in the History of Medicine at the University of Toronto and has written on the doctor/patient relationship as well as psychiatry in the past and, thus, brings an interesting perspective to the story of psychiatry.
Psychiatry has had a complicated relationship with both medicine and society over the years. What Shorter does in this narrative is to provide a dynamic and eminently readable view of the major forces and personalities that have shaped psychiatry over the last 200 years and thus driven its role in medicine and society. The evolution of psychiatric practice and treatment is divided into eight chapters, the titles of which set out the structure of the history: "The Birth of Psychiatry," "The Asylum Era," "The First Biological Psychiatry," "Nerves," "The Psychoanalytic Hiatus," "Alternatives," "The Second Biological Psychiatry," and "From Freud to Prozac." Each of these eras is documented in a social, historical, and economic context, noting how different political and cultural milieus impacted on psychiatric care and treatment. Thus, the narrative is both a history and a book about psychiatry.
In describing the earlier years where personalities and political affairs impacted most strongly on psychiatry, the author is at his best. One of the more fascinating aspects to this narrative is that, although many readers will be familiar with parts of the story, there are surprises even in the familiar. For example, many readers may be surprised to learn that the early asylums were not all the horror houses many later developed into, but many were actually run humanely on the principle of a therapeutic milieu. We also get to know more about some of the "names" with which we may be familiar (such as Pinel and Kraeplin), and perhaps more importantly, we learn about people who have had a significant impact on the development of psychiatry, but whose contributions may be less well known. Of course, any good history of psychiatry will remind the reader that in many respects things have not changed enough. I was struck by the applicability of some of the conditions in the earliest pages to the present day. Although there has been substantial evolution, mental illness still is stigmatized, and many of the chronically mentally ill are still faced with substandard and difficult living conditions.
Throughout the narrative, psychiatry is described as historically split between two competing views of mental illness; the biological, encompassing neuroscience, medication etc., and the psychosocial, which sees mental illness as caused by environmental stressors. Shorter’s position is made clear early on when he describes a statement by German psychiatrist Wilhelm Griesinger to the effect that "mental illness... . are really... illnesses of the nerves and brain" and "Psychiatry must therefore ’emerge from its closed-off status as a guild and become an integral part of general medicine accessible to all medical circles’" as "among the most portentous words ever uttered in the history of psychiatry." (pg. 86).
This view is reinforced further by an analogy much later where the introduction of chlorpromazine in psychiatry is compared with the introduction of penicillin in general medicine. Although there is no doubt that the first drugs with a truly ameliorating effect on psychosis were of great importance in the history of psychiatry, the comparison overlooks the fact that for its indications, penicillin was a complete cure whereas chlorpromazine, and indeed, any of the antipsychotic medications developed thus far, only control symptoms to a greater or lesser degree. There is still no curative medication.
The evolution of psychiatry is also discussed in terms of its relationship with the field of medicine as a whole. There is a recurrent theme viewing changes in psychiatry as resulting from different factions struggling for power. This is manifest in varying ways. One example is the debate as to whether the development of psychiatry is driven by the need to care for people suffering new illnesses or whether psychiatry manufactures illness for its own professional gain. Another illustration used is the argument over whether schizophrenia was a new disease that increased rapidly in the nineteenth century; whether it had always existed and simply was not well described in the literature; or, whether the asylums of the time "medicalized" people and turned the mildly ill into "chronic" cases. Psychiatry’s interaction (and competition) with other disciplines, especially neurology, is of particular interest. The role of neurologists in dealing with psychiatric illnesses has waxed and waned over the decades according to both the labeling of illness in society, the acceptability of seeking treatment for mental illnesses, the conceptualization of mental illnesses, and the evolution of psychiatric practice. Psychiatry is still viewed by Shorter as different from most other areas of medicine. He thinks this is most evident inasmuch as most realms of medicine classify disease according to causation, psychiatry still classifies disease by symptoms. Even so, the DSM-III is seen by Shorter as a pivotal point in returning psychiatry "to the world of medicine," because it was the first attempt to standardize diagnostic criteria. (p. 302).
The one strong exception I have to this book as a history of psychiatry is its clear bias against psychoanalysis. Although some of the criticisms are valid, (for example, the cult of personality around Freud) the concepts and practice of psychoanalysis have had a more profound impact on the development of present psychotherapeutic practice than Shorter seems willing to acknowledge. In other developments, Shorter allows for the natural evolution of ideas and movements, keeping the strengths and letting other aspects go, but he seems unwilling to acknowledge the positive contributions psychoanalysis has made to psychotherapy. On the last page of the book is the statement, "This combination of psychotherapy plus medication represents the most effective of all approaches in dealing with disorders of the brain and mind." Although I am not sure Shorter’s belief in the powers of psychotherapy come through as strongly in the rest of the book as they do in the conclusion, this book nonetheless represents a very engaging and well-written history of psychiatry. It provides a perspective on the area that is refreshing.
Director of Research, Mental Health Patient Service Unit, Children’s Hospital of Eastern Ontario, 401 Smyth Rd., Ottawa, Ontario K1H 8L1, Canada
Charles V. Ford Editor
Robert T. Ammerman and John V. Campo
Allyn & Bacon, Boston, 1998; Vol 1: 352 pages; Vol 2: 398 pages
Strengths: fairly comprehensive, good references to key literature, some unique chapters add scope to the issues at hand
Weaknesses: some redundancy across chapters, inconsistent quality across chapters
Target reader: pediatricians, psychologists, and psychiatrists who care for children and adolescents
As a scientist practitioner who works in the area of mental health within a regional pediatric hospital, I found this multi-authored handbook to be a fairly comprehensive reference to the many issues faced by psychologists and psychiatrists working in pediatric health care. The two-volume handbook is organized into 31 chapters and covers a variety of both general and specific issues. From the onset, the editors have strived to create a text that bridges the boundaries, often artificial and obstructive, among pediatrics, psychiatry, and psychology. Each volume is organized accordingly, with cross-disciplinary input and significant attention to the biopsychosocial aspects of each issue raised.
In the first volume, the emphasis is on general issues of relevance to those working in a pediatric setting as well as on a variety of specific psychiatric diagnoses. The more general chapters include discussions on developmental issues, consultation-liaison, cultural issues, legal issues, and the management of psychiatric emergencies. The developmental chapter, for example, provides some good basic information by developmental phase with specific "red flags" that the practitioner should watch out for. The authors in this chapter go back and forth from the theoretical to the pragmatic, perhaps in an attempt to meet everyone’s needs. The ability to maintain a balance between theoretical, empirical, and clinically pragmatic information is a challenge for most of the authors across the various chapters in the handbook. Although the inclusion of a specific chapter on developmental issues is an excellent frame for the rest of the text, an emphasis on developmental issues across all of the chapters would have been useful as well. The chapter on cultural and ethnic issues is a welcome and much needed addition. Although the emphasis is on the reality of these issues in the US, there is some reference to other nations as well. Some discussion of how different cultures view mental health and illness would have been useful. The chapters on factitious disorder by proxy, somatization, and sleep provide interesting and useful information, but fit less well into this section on general issues.
The balance of this first volume focuses on specific "psychiatric disorders." The perspective is a biobehavioral one as the editors attempt to bring together common interest from pediatrics, psychiatry, and psychology. Most chapters include one or more case examples that discuss both evaluation and management issues. A particular strength is that the various authors describe both treatment successes and relative failures in these case presentations, which is closer to the reality of actual practice. Given the scope of each chapter, however, it is difficult to include case examples of all of the main issues. Overall, the chapters provide an excellent methodological critique of the outcome research conducted across the various diagnoses. There are excellent references to key sources for more detailed discussions of approaches to assessment and intervention. The chapters do not, however, provide a step by step guide for the practitioner who is looking for specifics on the management of the various disorders presented. Some of the chapters are quite brief, which results in a somewhat limited overview of certain types of disorders. The section on anxiety disorders is a good example of this, with specific diagnoses such as obsessive compulsive disorder receiving very limited attention. Certain diagnoses, such as personality and conduct disorders, are not covered at all, although they do exist in the pediatric settings, primarily in adolescent populations. The inclusion of a chapter on developmental disabilities is noteworthy, although one can argue about its classification among the "psychiatric disorders."
The second volume is organized in much the same way as the first with both general and specific issues relating to pediatric disease, injury, and illness. The general chapters on pain management, preparation for medical procedures, child maltreatment, and treatment adherence are excellent, with the chapter on family adaptation to childhood disability and illness being of particular high quality. The balance of the chapters in this volume deal with specific topics in the area of disease, injury, and illness. These chapters are organized primarily by system or speciality area involved (eg, gastrointestinal, neurological, endocrine, pulmonary, hematologic, oncologic, and infectious diseases). Each one provides a description of key disorders/illnesses within each system and includes information on epidemiology, symptomatology, and evaluation from both a medical and a psychological perspective. Similarly, there is an overview of the medical management of the various disorders/conditions/illnesses as well as that of the psychological and behavioral interventions available. Unfortunately, there is a significant amount of overlap across the various chapters concerning both the tools used to evaluate psychosocial issues in the various populations as well as in the specific behavioral and psychotherapeutic strategies and techniques used in the management of these conditions. As well, some of the general-issues chapters at the beginning of this volume (ie, pain management, treatment adherence, and compliance) cover topics that are raised again across a variety of the more specific chapters. Although this is common across many edited texts, the combination of both general and specific chapters further contributes to the potential for overlap and redundancy.
It is difficult to include every topic that would be of relevance to pediatric psychology and psychiatry in any single source. The editors have done a commendable job in collecting papers by well-qualified experts in the field on a very informative mix of key issues. There are additional topics that are of significant relevance to those working in pediatric settings that would have made worthwhile additions to this text. The first relates to training issues in applied settings. Given the tone of this handbook, some discussion of cross-disciplinary training would have been interesting. A second topic relates to the increasing movement toward injury prevention and health promotion, including mental health promotion. Although historically primarily the domain of professionals in community health, injury prevention and health promotion are being viewed as key issues in pediatric health care settings. Increasingly, the role of pediatricians, psychiatrists, and psychologists is being extended beyond more traditional evaluation and intervention efforts to include prevention and health-promoting activities.
Overall, this is a worthwhile text that will provide practitioners across a variety of disciplines with insights into the comprehensive care of children and youth presenting with a variety of pediatric concerns. Although it is not organized as a complete step by step guide to clinical practice, it can serve as an excellent starting point with references to many key resources, both empirical and clinical.
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