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BOOK REVIEWS |
Cognitive Psychodynamics: From Conflict to Character
Edited by Mardi J. Horowitz
reviewed by Paul Ian Steinberg
Socioeconomic Status and Health in Industrial Nations:
Social, Psychological and Biological Pathways
Edited by Nancy E. Adler, Michael Marmot, Bruce S. McEwen, and Judith Stewart
reviewd by Mark Dignan
Medicolegal Issues in Clinical Practice: A Primer for the Legally Challenged
Edited by Deborah J. Wear-Finkle
reviewed by James F. Hooper
Essential Spirituality: The 7 Central Practices to Awaken Heart and Mind
Edited by Roger Walsh
reviewed by Robert D. Phillips
Department of Psychiatry, University of Alberta Hospital, 1E1.01 Walter C. Mackenzie Centre, 8440 112th Street, Edmonton, Alberta T6G 2B7, Canada, Email: lnelson@cha.ab.ca
Mardi J. Horowitz
John Wiley and Sons, Inc, New York, 1998, 224 pages, $85.00.
This text attempts to integrate cognitive and psychodynamic psychology to illustrate processes that bring about psychotherapeutic change. Horowitz considers both conscious and unconscious mental processes in the development of identity and relationships. The book is organized around three theoretical constructs: states of mind; defensive control processes used to regulate emotion; and person schemas, cognitive maps that organize patterns of relationship and identity. Chapter 1, "Conflict," describes how awareness, insight, and new decisions occur at three major levels: states of mind, altering defensive controls of ideas and emotions, and person schemas. Horowitz presents useful figures and tables that summarize his concepts. Chapter 2, "States of Mind," distinguishes three main categories of states of mind: the emotional coloration of a mood; state regulation; and types of motivation, such as wished-for and dreaded states. Horowitz describes under-, over-, and well-modulated as well as shimmering states of mind. To this he adds quasiadaptive and problematic states that people defensively use to avoid entering into states they dread. He describes phases of response after stressful life events and states precipitated by stress or events. Horowitz uses clear, instructive case examples that illustrate his theory about configuration of states. Chapter 3, "Awareness," emphasizes different levels of awareness and introduces Horowitz’s notion of schema or the cognitive map. Horowitz avers that identity and relationship goals are important motivators and are formed by person schemas, scripts, and unconscious intentions as well as conscious decisions. He adds that people are inclined to activate schemas that support a positive and coherent sense of self. Horowitz suggests that conscious thought requires different modes of representation for expressing the full picture of a person’s thoughts and feelings and that these representations are organized by schemas. Three major categories of representation include body enactions, mental images, and mental words. Chapter 4, "Control of Emotion," describes how some defensive control processes shift thought contents, alter the form of thought, or shift the person schemas that knit information together to reduce emotional arousal. Horowitz classifies control processes and describes dreaded, desired, problematic, and quasiadaptive outcomes. Four control processes for affecting the consequences of conscious experience include altering topics, altering concepts, altering the importance of a chain of concepts to the self, and altering the threshold for disengaging awareness from a topic. Horowitz also describes processes used in controlling the form of conscious experience and controlling the person schemas that organize a state of mind.
In Chapter 5, "Identity," Horowitz describes self-schemas, organized compendia of meanings that a person attributes to himself or herself, including body image, roles of self, associated memories of self, emotional response style, scripts of action sequences, values and rules, self-regulatory style, and future intentions and plans. He describes conflictual configurations, in which a supraordinate schema contains enduring but poorly integrated connections between elements. Maladaptive state cycles are described as being associated with conflicted and nonintegrated supraordinate configurations. Horowitz summarizes developmental influences on self-concepts, relying on eriksonian concepts. Chapter 6, "Relationships," deals with the role relationship model (RRM), a format used to define a recurrent pattern in a narrative or observed transaction. Horowitz’s working model of a social transaction with enduring person schemas seems to be related to object relational concepts involving the interaction of self-images and internalized objects. Horowitz illustrates configurations of RRMs with detailed diagrams and uses desired, dreaded, and defensive RRMs in making formulations. He describes developmental contributions to relationship schemas and describes unconscious and person schematic fantasies. In Chapter 7, "Character," Horowitz discusses configurations of form and content, and describes the well-developed character and levels of psychopathology of character, in terms of neurotic, narcissistically vulnerable, borderline, and fragmented levels. He again takes a developmental approach, comparing personal tasks and social expectations, identity, relationships, and character in each of eight developmental periods. Horowitz describes balance and imbalance in character, indicating that imbalance often tilts character toward either an excessive focus on the self or an excessive focus only on the interests of others. Chapter 8, "Character Integration During Psychotherapy," applies what has come before in the previous chapters. Horowitz illustrates an RRM of a therapeutic alliance and the controls and schemas that may occur in psychotherapy. He also illustrates conflictual and more harmonious RRM configurations in the case examples.
This text involves an interesting integration of many theories. The author has given considerable thought to cognitive aspects of understanding personality and has organized his ideas well. Experienced therapists likely consider many of these concepts and may develop them independently, but most do not usually formulate these concepts in such an organized and comprehensive way. The book is reasonably easy to read, although some of it (eg, the chapter on identity) is highly condensed and could benefit from some case examples. Horowitz demonstrates his approach toward formulation using the "configurational analysis method." He focuses on problematic phenomena, state analysis, habitual styles of defensiveness, and person schemas.
Horowitz’s RRMs seem to be another way to conceptualize self- and object-images, with the focus on expected relationships between the self and other. According to Horowitz, RRMs are important types of person schemata because they contain attributes of both self and others with scriptlike sequences for organizing intentions and expectations. New forms of experiences can lead to new RRMs. The many tables and figures help organize Horowitz’s concepts for the reader.
The author is obviously an expert practitioner who is able to organize his clinical experience of using various theories with an impressive degree of integration. His approach to cognitive psychodynamics should add a welcome new facet to most practitioners’ clinical work. This book is enjoyable and stimulating to read, and I recommend it for psychodynamic psychotherapists with some experience and knowledge of the relevant literature.
Professor, School of Public Health, University of Alabama at Birmingham, RPHB 227, M/C 0022, Birmingham, AL 35253, Email: mdignan@uab.edu
Nancy E. Adler, Michael Marmot, Bruce S. McEwen, and Judith Stewart, editors
New York Academy of Sciences, New York, 1999, 503 pages, $34.95
Strengths: presents a useful and up-to-date compendium of current research on many aspects of socioeconomic status; well referenced
Weaknesses: contents not indexed
Target reader: students, researchers, and policy makers
This book summarizes an interesting array of current research and writing about socioeconomic status (SES), a topic that is familiar to many in the health-related professions. The contents of the book are papers and posters presented at a conference entitled (same as the book) "Socioeconomic Status and Health in Industrial Nations: Social, Psychological and Biological Pathways," held at the National Institutes of Health in Bethesda, Maryland, May 11–12, 1999. The conference was jointly sponsored by the New York Academy of Sciences and the John D. and Catherine T. MacArthur Foundation Research Network on Socioeconomic Status and Health. The Robert Wood Johnson Foundation, the Office of Behavioral and Social Sciences Research, and the National Institute of Environmental Health Sciences also supported the conference.
The book is organized into six useful sections. The first five sections contain papers that focus on separate aspects of SES. Each section includes three to five papers and begins with an introduction that describes how the section relates to SES and the previous sections. Each paper is briefly described, and its contribution to the section is indicated. The sixth and final section of the book contains posters presented at the conference. Fifty-five posters are summarized in the 187 pages of the sixth section.
The first section of the book includes four papers and the overview. The papers describe and explore the curious finding that those of low SES not only suffer from diseases associated with poverty and other forms of deprivation but also have higher rates of diseases associated with high SES, such as coronary heart disease, stroke, and cancer. In addition to the focus on understanding disease patterns and SES, the hypothesis is proposed that psychosocial factors such as stress are important to what is observed.
The second section, "Developmental Influences Across the Lifespan," addresses the association between early childhood experiences and exposures and health later in life. The three papers present evidence from both animal and human studies demonstrating that early experiences can have significant and lasting impacts on subsequent health risks.
The five papers of the third section, "Effects of the Social Environment," focus on an interesting array of factors affecting health, including social capital, community effects, and chronic stress. The role of stress is also explored in a more focused way in papers that discuss atherosclerosis and stress and stress associated with low-status jobs and health status. The final paper in this section is quite broad, addressing the critical relationship among racism, SES, and health.
Section four, "Psychobiological and Psychosocial Pathways and Mechanisms to Disease," continues the theme of the previous section but focuses on the internalization of environmental factors. Internalization is described by Cullen as "how the external social and physical environments ... ‘get under our skin.’" Getting under the skin is a metaphor for the largely unknown processes by which deterioration results or resilience becomes apparent as a product of the interaction of the individual and the social and physical environments. One unique paper in this section focuses on sleep. Low SES is postulated to be associated with low levels of sleep, which facilitates translation of assaults by the social and physical environments into poor health.
Section five, "Aspects of Policy Implications for Health and Research," includes papers that focus on what society has done and should do to counteract the negative affects of low SES. The papers in this section review federal programs such as Social Security, Aid to Families with Dependent Children, and unemployment insurance, and examine how political systems in government can function to improve health among those with low SES.
Adler and Stewart, authors of the preface, provide a useful introduction to the book, articulating the view that the association between SES and health should be of interest from several points of view. From a scientific point of view, there is great interest in improving understanding of the association between SES and mental health, physical health, and longevity. From a practical point of view, improved understanding of SES may be useful in helping healthcare systems find ways to reduce the additional burden of disease associated with lower SES. Finally, from a political perspective, goals to improve health and reduce disease risks are unlikely to be successful without addressing the factors associated with low SES.
Taken as a whole, the book provides a useful summary of current thought about SES, including is measurement, current utility, and possibilities for the future. The organization of the book is clear and logical through the first five sections, and the papers are generally of high quality. The final section of the book, in which posters are presented, would be easier to use if the contents were organized by topic. However, readers who take the time to review the posters are likely to find timely, interesting, and useful information.
Clinical Associate Professor, University of Alabama, Director of Residency Education for Forensic Psychiatry, University of Alabama at Birmingham, Birmingham, AL 35253
Deborah J. Wear-Finkle, MD, MPA
Rapid Psychler Press, 2000, 274 pages
Strengths: concise, logical format; coverage of large field in small book
Weaknesses: a multitude of idiosyncratic abbreviations
Target reader: practicing clinicians and anyone working in forensic area
This book looks like an easy read, and indeed its layout and cartoons make it fun. This is a serious book, however, and although it may look like a diet snack, it has plenty of real meat.
The author, boarded in both general and forensic psychiatry, uses her expertise to shed light on many areas problematic to clinicians. Not only does she cover the perennial malpractice issues, she also provides good, straightforward advice on medical staff organization, health maintenance organizations, and risk management. There is a useful glossary and a "Ten Commandments" page that is copyright-free.
The only real problem with this book is the author’s use of abbreviations. I certainly love to write progress notes that say things like MSE WNL, no sxs of S/H ideation. My reason there is the effort of handwriting and the time involved. If you pick up this book and try to read a given chapter without reading from front to back, you may get lost on the SOC and RM involved in PAS. Printed type doesn’t take any more effort for a few extra words, and the abbreviations are not sufficient to reduce the physical size of the monograph.
I do like this book and think it is a worthy addition to most clinicians’ libraries. I should say, go buy it ASAP, PDQ, STAT.
2685 Jackson Road, Morris, AL 35116, Email: rphil205@aol.com
Charles V. Ford, Editor
Roger Walsh, MD, PhD, with forward by His Holiness The Dalai Lama
John Wiley & Sons, Inc, New York, 1999, 306 pages, $24.95
Strengths: draws from the combined wisdom of the great religions and develops thoughtful, systematic practices to explore and enhance one’s spirituality; powerful, practical, well-written
Weaknesses: none
Target reader: anyone interested in issues related to spirituality
This is a book of unpretentious erudition. The author, professor of psychiatry and religion at the University of California, Irvine, knows his subject. He integrates the combined wisdom of religious founders, sages, and scholars to provide the reader with a guide to finding and developing spirituality. He has "focused on seven major religions: The monotheisms of Judaism, Christianity, and Islam, and the Asian religions of Hinduism, Buddhism, Taoism, and Confucianism." The book is so easy to read that the reader may think it oversimplified. Don’t be misled. It takes a form of genius to make complex subjects seem simple, and such genius is a trait desired by all who would teach.
This is not a study of comparative religion. The author takes the positive and often common principles from each religion and describes pearls of wisdom that enable human beings to realize "the highest goal and greatest good of human existence." The author emphasizes that the book is intended to be practical. He takes the reader step by gentle step through the simple meditations that increase awareness of mundane but vital events that occur every day.
"The ultimate aim of spiritual practice is awakening; that is, to know our true Self and our relationship to the sacred." The book discusses the seven practices that the author considers necessary to essential spirituality. Of importance, these practices have some similarities to 12-step programs, especially steps 1 and 4. For each of the seven practices there are several exercises to assist in the development of that practice. They are:
This book is worthwhile to anyone seeking a broader understanding of spirituality and to anyone willing to look within one’s self to enhance awareness of the spiritual and sacred that the author believes is in all of us. Each revisit to this book will be rewarding, and even though the reader may be committed to one religion, the proposed seven practices will enhance rather than distract from that commitment.
In the words of Buddha, spoken 2500 years ago,
"However many holy words you read,
However many you speak,
What good will they do you
If you do not act on them?"
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