BOOK REVIEWS

Jeffrey L. Geller, M.D., M.P.H., Editor

The Talking Cure: The Science Behind Psychotherapy

by Susan C. Vaughan, M.D.; New York City, G. P. Putnams Sons, 1997, 208
pages, $24.95

Psychotherapy With Impossible Cases: The Efficient

Treatment of Therapy Veterans
by Barry L. Duncan, Psy.D., Mark A. Hubble, Ph.D., and Scott D. Miller, Ph.D.;
New York City, W. W. Norton & Company, 1997, 222 pages, $35

Psychological Mindedness: A Contemporary Understanding

edited by Mary McCallum, Ph.D., and William E. Piper, Ph.D.; Mahwah, New
Jersey, Lawrence Erlbaum Associates, 1997, 276 pages, $39.95
Nancy Glimm, M.S.W., C.S.W.

hree recent books have different

contributions to make to mental
health professionals who practice psychotherapy. In the first, psychiatrist
and psychoanalyst Susan Vaughan
very readably draws on neuroscience
and other disciplines to address the
question of how psychotherapy affects the brain. Next, three experienced therapists and supervisors offer
a specific approach to dealing with
impossible casespatients who
have not responded to therapy. The
third book, edited by two research
psychologists, examines psychological
mindedness from a research perspective.
Dr. Susan Vaughans engaging new
book, The Talking Cure: The Science
Behind Psychotherapy, demonstrates
her knowledge and mastery of varied
subjects including neuroscience, psychotherapy research, developmental
psychology, and psychoanalysis. She
provides the reader with an overview
of the state-of-the-art research integrating the neuroscientific basis of
dream theory, intelligence, memory,
cognition, and infant development.
Dr. Vaughan is a National Institute
of Mental Health fellow at the New
York State Psychiatric Institute and a
senior candidate at the Columbia
Center for Psychoanalytic Training
and Research in New York City. She
has applied current quantitative science to the theory of psychotherapeutic practice. She is a gifted writer,
Ms. Glimm is a psychiatric social worker
with the child and adolescent team at the
Bronx Mental Health Center of the Health
Insurance Plan of New York.
1624

which makes this intriguing book accessible and the concepts easy to
grasp.
The author states that she wrote
the book for her patients because
they deserve to know as much as she
does about how psychotherapy works.
Dr. Vaughan believes the modality
works because it produces enduring
change on a neuronal level, a view she
proceeds to illustrate chapter by
chapter. This process coincidentally
reinforces the enduring nature of the
patient-therapist relationship. The
book takes us on a scientific journey
that reconfirms the ultimate humanness of psychotherapy and psychoanalysis.
In her first chapter, Putting the
Neuron Back in Neurosis, the author
applies current dream theory, neurology, and psychotherapy research to
elucidate her ideas. Freuds genius is
acknowledged, as is his training as a
neurologist and biologist of the soul
and his prescient view of psychotherapy. What would he make of the science now available to Dr. Vaughan?
She refers to her work with patients
as carefully and systematically examining, challenging, and rewiring the
story synthesizer [the patients] cortex
contains.
The author next moves to artificial
intelligence and memory research,
with a dash of Heinz Kohut. She uses
the sea slug to teach about the psychotherapy of the single synapse,
and she draws on learning theory, habituation, and neurochemistry. An examination of long-term memory,
Pavlov, and the associations of a patient named Ted is next. Dr. Vaughan

reviews and applies the work of infant

observer Daniel Stern, using examples from his work as prototypes for
the development of self and other.
She addresses the affective component in development and its neural
basis.
Dr. Vaughan also takes care to address the issue of medication and the
impact the psychotherapeutic relationship has on brain chemistry. She
examines the complicated interplay
between early life relationships, positive and negative affects, and the regulation of emotions and self-esteem
and then explains how she thinks
medications fit into that picture.
The final chapter presents a psychoanalytic case in which much synthesis, integration, and progress takes
place, both for the patient and for the
authors theory. Dr. Vaughan playfully
ends the book with an analysis of one
of her own dreams. The reader is left
with the feeling that psychotherapy
can change brain chemistry in ways
that are positive and with lasting results.
The Talking Cure makes an important contribution to the psychotherapy community as well as to patients
who wish to explore intellectually why
they are feeling better. Dr. Vaughan
puts hard science into the psychotherapy treatment process. Her
book certainly challenges blanket applications of models of brief treatment. She also directly addresses the
use of medication without conjoint
psychotherapy and the potential for
relapse it carries.
This book provides a rich overview
of current brain research, and it is
written in a popular manner for both
the lay and the professional community. The authors approach to the
complex material is sometimes glib,
which can be forgiven if the reader
remains focused on the content and
scope of what is covered. Psychotherapy patients will find the authors integration of this remarkable subject
matter to be accessible. Therapists in
all mental health disciplines will benefit from Dr. Vaughans integration
and application as well. The Talking
Cure: How Psychotherapy Works dem-

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December 1998 Vol. 49 No. 12

BOOK REVIEWS
onstrates mastery of complex, fascinating material.
Psychotherapy With Impossible
Cases: The Efficient Treatment of
Therapy Veterans accomplishes several important services. Authors Barry Duncan, Psy.D., Mark Hubble,
Ph.D., and Scott Miller, Ph.D., are
experienced therapists, teachers, and
supervisors who became curious
about how a client becomes impossible, and how such a situation can be
overcome.
They were no longer satisfied, they
say, with answers that blamed the
client or criticized the therapist and
embarked on a five-year course of
working with or consulting on impossible cases. From it and from previous
work with treatment failures, they
concluded that success can occur
with impossible patients when therapy is accommodated to the clients
frame of reference and the clients
theory of change is honored. They
humbly and elegantly report their
findings, including explicit accounts
of how to approach clients who have
not responded to or have had negative experiences in therapy. They consider this book a companion to their
Escape From Babel, in which they
conceptualize a psychotherapy that
maximizes known curative factors (1).
In the current book the authors describe how psychotherapy cases become clinically impossible. The
client who has received multiple
treatments often is labeled problematic, or a therapy veteran. The authors
reflect on the training of therapists as
fundamentally a theory-driven educational process, which they believe can
lead to theory countertransference
when the therapist confronts a challenging case. The therapist pursues
agendas that fit the therapists own
theoretical premises but that can violate the clients sensibilities and beliefs. This process can lead to doing
more of the same and to a treatment
that does not work. The authors present a method for redirecting therapy from confirming theory-driven objective truths to discovering subjective truths that promote the possibility for change by the client.
They make other important points
PSYCHIATRIC SERVICES

about clients motivation. Clearly,

treatment can become impossible
when the clients motivation is misunderstood or neglected. Even the most
experienced therapist can easily overlook what the client wants to accomplish while focused on what the therapist believes might be best. We are
reminded of the work of Carl Rogers
and his empathic and client-centered
approach. The authors also stress the
critical importance of therapist-client
collaboration.
Drs. Duncan, Hubble, and Miller
summarize their approach by stressing that the therapy veterans frame of
reference should guide the therapists
actions. They trust that within each
client is a theory of change waiting for
discovery, a framework for intervention to be unfolded and intentionality
accommodated for a successful outcome. Each client holds the potential for his or her own creative cure,
and the potential for new theory and
interventions for the therapist.
The authors illustrate their beliefs
with chapters on clinical methods, including exploring the clients own theory of change and accommodating
therapy to the clients frame of reference. They provide rich clinical examples of their work with individuals
carrying some of the most difficult di-

In this section . . .
Therapy and therapists are what
many of the books in this
months section coverincluding the science behind psychotherapy, treatment of impossible cases, and supervision.
At least two of the books challenge professional codes of
ethics, but the authors views
are ultimately rejected by the
reviewers. Also in the ethics area
is a review of a decision-making
guide for health professionals
on assisted suicide. Books on
transcultural psychiatry, mental
health library services, traumatic events, and other topics
round out the section.

December 1998 Vol. 49 No. 12

agnosesdissociative identity disorder, delusional disorder, borderline

personality disorder, alcoholism, and
manic-depressive illness. These examples are down to earth and highly
respectful of the clients, exploring,
discovering, and validating their
world.
Some therapists will have difficulty
with the treatment outcomes in
which insight or appropriate states of
conventional mental health are not
achieved. Yet in each clinical example, the client reports a satisfactory
outcome.
Psychotherapy With Impossible
Cases is a reminder of the basic wisdoms of treatment: empathic listening, collaborating, empowering, and
allowing the client to discover the
cure. The authors use a team approach in working with these cases,
and they remind fellow clinicians that
collaboration with colleagues about
therapeutic impasses can be liberating.
This book would benefit the experienced psychotherapist, whether a
psychiatrist, social worker, or psychologist. It could be used as a teaching
tool for students because of its practical and time-honored messages. The
authors have made a valuable contribution to the therapy community, to
help us remember to see and hear the
real communication within the most
dire clinical situation or diagnosis.
Psychological Mindedness, by Mary
McCallum, Ph.D., and William E.
Piper, Ph.D., is a book of inquiry. A
creatively developed volume of essays, it explores the concept of psychological mindedness from the research psychologists perspective. The
reader is offered a masterful composite of information that illustrates the
range of thinking in the literature today.
The editors, who are affiliated with
the University of Alberta department
of psychiatry, are senior research psychologists who have published widely.
In 1977 Dr. Piper began to investigate psychological mindedness as a
variable therapists use to rate psychotherapy patients, and in 1981 Dr.
McCallum began looking for a more
refined measure for psychological
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BOOK REVIEWS
mindedness. Research collaborations
between the two eventually led to this
current volume of essays. Leading
North American researchers on psychological mindedness were invited
to contribute, with the editors suggesting a common outline for the
chapters.
The editors stated purpose in compiling this volume is to increase mental health practitioners understanding of the concept of psychological
mindedness in assessment and treatment. Their secondary purpose is to
address psychological mindedness in
interpersonal contexts outside of
mental health, including motivational, developmental, creative, and cognitive research.
Part 1 reviews questionnaire measures of psychological mindedness;
alternative methods of assessing this
variable, including Piper and McCallums own measure; and assessment
of psychological mindedness in children. Part 2 describes related concepts the editors discovered during
their literature searches. The concept
of alexithymia, considered the opposite of psychological mindedness, is
reviewed, as are personal and private
self-consciousness, personal intelligence, reading between the lines,
and social perspective taking among
children. Part 3 contains two chap-

ters, one of which describes the psychological mindedness of psychotherapists. In the final chapter the editors
review and integrate the material presented.
Psychological Mindedness makes a
clarifying contribution to the literature. The book is carefully conceived
and organized; intellectual freedom is
evident, and ideas unfold without
bias. Positive and negative findings
are reported with clarity and fairness.
The chapters highlight the problems
in psychological and psychotherapy
research, the limitations of language
in describing mental states, and the
difficulty in pinpointing the variables
in treatment that contribute to positive or negative outcome.
As appropriate, Psychological Mindedness raises more questions than it
answers, and does so in a straightforward manner. It may be of most interest, as the editors note, to therapists with a psychodynamic orientation. However, psychotherapists interested in expanding their understanding of the construct of psychological mindedness should be able to
draw useful ideas from it.
Reference
1. Miller SD, Duncan BL, Hubble MA: Escape From Babel: Toward a Unifying Language for Psychotherapy Practice. New
York, Norton, 1996

The Vulnerable Therapist: Practicing Psychotherapy

in an Age of Anxiety
by Helen W. Coale, M.S.W.; Binghamton, New York, Haworth Press, 1998, 272
pages, $49.95 hardcover, $24.95 softcover
Nancy A. Bridges, L.I.C.S.W., B.C.D.

elen Coales book, The Vulnerable Therapist, is, as the author informs us, a passionate book with an
attitude. Coale, a licensed marriage
and family therapist, explores therapist and client vulnerability in a professional context that is increasingly
(and unethically) rule-based. With
Ms. Bridges is a clinical supervisor in the
department of psychiatry at Cambridge
(Mass.) Hospital and a lecturer in psychiatry at Harvard Medical School.
1626

this opening statement, the author offers her observations on the construction and deconstruction of common
ethical dilemmas facing clinicians. The
aim of her book is to challenge professional ethics as they exist today. Coale
believes that ethics rules are increasingly limiting therapeutic possibilities
for clinicians and clients.
In the first ten chapters, Coale describes the crisis of meaning in the
mental health professions and the
fundamental limitations of rule-based

ethics. Through detailed accounts of

inhibitory regulations and economic
and legal constraints, she outlines
ethical challenges for practicing therapists. In the remaining chapters, she
offers alternative perspectives to address these ethical dilemmas. Coale
does a fine job of clearly articulating
the use of more than one theoretical
approach. Her discussion of multiple
theoretical approaches to ethical
problems is a strength of the book
and may be of particular benefit to
beginning practitioners as they struggle to identify a theory that suits their
practice and person.
Although Coale advocates for a
more complex and therapeutically
sensitive understanding of ethical
dilemmas, her view of ethics codes
as concrete structures rather than as
guiding parameters that orient a
therapeutic conversation is not useful. She objects to ethics codes that
hold the therapist totally responsible for maintenance of professional
boundaries, and she freely abandons the concept of the fiduciary relationship. The tone of the text is
polemical. Often the authors opinions are overdrawn to the point of
caricature and ultimately decrease
her credibility.
There are other problems with the
book. While it is easy to agree with
the authors social-constructivist perspective, her application of theory
and examples of contextually based
ethics often miss the mark. For example, she describes a champagne celebration some years earlier for a termination of a patients therapy. Coale often fails to comprehend the impact of
her person and her needs on the clinical encounter, and her interventions
often seem self-serving.
The Vulnerable Therapist, a provocative but uneven book, offers a detailed account of ethical dilemmas
and challenges and urges the reader
to get involved in changing clinical
practice for the better. This book is
intended for all practicing psychotherapists. Although the book has
strengths, the problems outweigh the
strengths, largely because of the
treatment of clinical material and the
hyperbole of the authors language.

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December 1998 Vol. 49 No. 12

BOOK REVIEWS

The Intimate Hour: Love and Sex in Psychotherapy

by Susan Baur; New York City, Houghton Mifflin, 1997, 309 pages, $23.95
Joan Berzoff, M.S.W., Ed.D.

he last decade has seen public

fascination with erotic relationships between powerful adults and
their less powerful counterparts. The
public debate on childhood sexual
abuse, Anita Hills sexual harassment
charges against Clarence Thomas, the
allegations of sexual impropriety
made about psychiatrist Margaret
Bean Bayog, and now the allegations
of sexual misconduct made about the
President of the United States have
forced our society to struggle with the
moral limits of sexual conduct between those who hold power and
those who dont. As a society, we have
been trying to define what constitutes
coercion and whether sexual behavior
between unequals can ever be considered mutual. In the Oval Office,
the classroom, the boardroom, or the
therapy room, true intimacy and love
seem to be imperiled.
Some of the questions dividing our
nation are taken up in psychologist
Susan Baurs new book, The Intimate
Hour: Love and Sex in Psychotherapy. The author asks whether it is ever
possible to enter into an intimate and
erotic therapeutic relationship that is
not exploitative. She also poses the
question of whether there can ever be
a successful psychotherapy without
love between therapist and client.
The first question Dr. Baur explores is whether the love between a
doctor and patient, regardless of betrayal or abuse, can ever be curative.
Citing the marriages between priests
and parishioners, and therapists and
patients, she begins by exploring the
love affairs of two famous analysts,
Carl Jung and Sandor Ferenczi.
While married, Jung entered into a
passionate 12-year relationship with
Sabina Spielrein, who was then 19
years old. She was institutionalized
and had been diagnosed as having a
Dr. Berzoff is associate professor and
codirector of the doctoral program of the
Smith College School for Social Work in
Northampton, Massachusetts.

PSYCHIATRIC SERVICES

psychotic hysteria when her treatment began with Jung. In the course
of their tumultuous love affair, Spielrein became well enough to attend
and graduate from medical school
and analytic training. A prolific writer,
she later analyzed Jean Piaget.
For Jung, the relationship provided
a sympathetic muse and a soulmate
on his creative journey. While Spielreins letters and journals suggest that
the relationship was tortuous and the
cause of great bouts of depression,
she also saw Jung as a source of inspiration for her own creative work. Was
this simply an exploitative relationship? Or was it, Baur asks, a relationship that offered healing to both the
patient and the doctor?
Baur goes on to describe Sandor
Ferenczis relationship with his thenmarried patient, Gizella Palos. When
Ferenczi wrote Freud about this love
affair, Freud was, as he had been with
Jung, initially indulgent. But when
Ferenczi fell in love with Gizella Palos daughter as well, Freud angrily
intervened, charging that Ferenczis
behavior threatened the entire field
of psychoanalysis.
Ultimately Palos daughter was sent
to Freud for an analysis. She eventually lived out a loveless marriage and a
bleak adult life. On the other hand,
Ferenczi married her mother and succeeded in achieving lifelong marital
contentment. Could Ferenczi, asks
Baur, have developed his theory of
mutual analysis without these intense
interpersonal experiences? Should his
ultimately stable marriage to Palos be
judged simply as exploitative?
It is rare to ask these questions, because to the well-trained clinician the
answers seem self-evident. What is
very clearand Baur attends to this
point wellis that the answers to
such questions are always socially and
culturally constructed and that the
moral discourse is always shaped by
the historical time in which they are
asked. Both Jung and Ferenczi lived
in a time in which patriarchal rela-

December 1998 Vol. 49 No. 12

tionships were normative, and women were largely objects of desire.

But by the late 20th century, within
the context of feminism, our society
has declared any sexual intimacy between therapist and patient to be
both unethical and unacceptable. The
codes of ethics of the American Psychological Association, the American
Psychiatric Association, and the National Association of Social Workers,
developed between 1977 and the present, are very clear in prohibiting sexual intimacies between therapists and
the people they treat and train. These
codes have been developed in a social
era of increased attention to womens
rights and sensitivity to violence
against women.
However, in The Intimate Hour Dr.
Baur maintains that she is apprehensive about legislating moral behavior.
In fact, she makes the case that the
overregulation of intimacy between
patient and client is unfortunate and
robs the therapeutic encounter of
some of its creative potential. She
fears a backlash from therapists, who,
too greatly constrained, may act out
toward their clients. She worries that
clients who feel increasingly isolated
and estranged by overregulation of
their intimate encounters with their
therapists may take their troubles to
increasingly angry men. She writes,
How disturbing for a technologically
sophisticated society to discover that
a form of intimacy akin to love and
closely allied to desire may lie at the
heart of one persons ability to help
another.
Herein lies the problem. Dr. Baur
is unable to clearly distinguish between love in psychotherapy and
erotic love that is acted on. It is a little like taking Winnicotts concept of
holding and suggesting that it is really acceptable for a therapist to hold
a client.
That is, the author turns to several
important current relational sources,
Christopher Bollas, Leston Havens,
and Michael Tansey, all of whom have
written about love and eroticism in
the countertransference. But none of
these analysts have ever suggested
that falling in love with ones patient
means sexually acting on these feel1627

BOOK REVIEWS
ings. Neither would they suggest that
a mother who falls in love with her
child should be permitted to sexually
act on those feelings. Loving therapists, like loving parents, do not freely
act on their own loving impulses. And
because they must maintain their authority and their power, they maintain
their boundaries and limits. Although
Baur laments limits, it seems to me
that only when the therapist establishes and maintains the frame can
both patient and therapist be free to
fully love.
Instead Baur turns to Annie Rogers A Shining Affliction and Carter
Heywards When Boundaries Betray
Us as reliable first-person accounts of
how maintaining the frame was detrimental to the client. Having read
both womens books about their own
failed treatments, I am not convinced
that the dissolution of boundaries, including physical boundaries, that
both women advocate was therapeutic. Yet Dr. Baur increasingly asserts
that the therapeutic profession is
overly conventional, regulated by rule
makers who rob therapists and patients of their creativity.
According to Baur, psychiatrist
Bean Bayogs unconventional treatment of Paul Lozano (in which she is
alleged to have written extensive
notes of her sexual fantasies about the
client, to have physically masturbated
with him, and to have had him call
her Mommy) was a step backward for
psychiatry in that it forced those engaged with very sick patients to practice defensively. Frankly, after that
case, psychiatry should be practiced
defensively. It is my own conviction
that clear and explicit limits on sexual
behavior in therapeutic practice must
be maintained. As a result, I had increasing difficulty with Baurs attempt to maintain the complexity of
the love in the therapeutic encounter,
on the one hand, and her moral relativism, on the other.
Finally, because the author does
not distinguish clearly between love
and sexuality, she locates herself in an
ethical morass in which therapists are
largely portrayed as overregulated
male victims whose power attracts
and excites women. She writes: Fe1628

male patients, like females for half a

million years, are likely to be attracted to the most powerful and established males in the communityolder men who can protect them and
their offspring and who presumably
have genes that will ensure success
for their children. Women are attracted to men who are competitive, assertiveif not downright aggressiveand physically robust. In other
words, they are attracted to potent
males or healers with relatively high
levels of testosterone. They are
primed to say yes to such a man. Psychotherapy is rapidly turning into a
field that is much less welcoming to
the potent, macho healer. Perversely,
I am saddened by this.
Ultimately, I also was saddened,
but by a book that laments the loss of

the macho healer and takes the position that the rules and standards of
sexual conduct make the therapeutic
encounter too arid. Although in The
Intimate Hour Baur tries to maintain
that love and pleasure are the very
stuff of therapy, a point with which I
would not disagree, her argument
fails by confusing love with sexual acting out, and countertransference love
with erotic love. Just as good parenting requires rules, boundaries, and
limits, I would be a lot more comfortable with a conclusion that recognizes
the value of maintaining the therapeutic frame at all cost.
Nonetheless, this is a very provocative book, which made me in fact define some of my own limits, and for
that I found it a valuable and worthwhile encounter.

Supervision of Psychotherapy and Counselling: Making

a Place to Think
edited by Geraldine Shipton; Buckingham, England, and Bristol, Pennsylvania, Open University Press, 1997, 159 pages, $29.95

More Than a Mirror: How Clients Influence Therapists Live s

edited by Marcia Hill, Ed.D.; New York City, Harrington Park Press, 1997, 145
pages, $24.95
John P. Bair, Ph.D.

ublications on theory, practice,

and research in psychotherapy
have proliferated in recent years. In
contrast, only modest new work in
the closely related fields of psychotherapy supervision and the interaction between clients and psychotherapists has appeared. The two
books reviewed here are bold and
creative pioneering efforts that contribute to the expansion and deepening of the understanding of psychotherapy supervision and the therapist-client interactional field.
Supervision of Psychotherapy and
Counselling: Making a Place to Think
grew out of two British conferences
Dr. Bair is assistant clinical professor of
psychiatry at the Chicago Medical School
and director of the dual diagnosis program at the Veterans Affairs Medical Center in North Chicago.

on the Sheffield model of supervision, with its focus on the exploration

of the psychotherapists own reaction
to patient and client material. Geraldine Shipton is a lecturer in psychotherapeutic and psychoanalytic
studies in the Centre for Psychotherapeutic Studies at the University of
Sheffield, England. Ms. Shipton
brings together articulate contributors who share in the freedom of expression of psychoanalytic work. Indeed, Shipton achieves her goals of
inviting the reader to step outside of
his or her usual way of thinking about
supervision of clinical work and to
entertain a few novel ideas and to
stimulate fresh ideas or enthusiasms in this area.
As the book progresses, new ideas
are fashioned and used to integrate
historical perspectives. Curiosity
management is considered a primary

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December 1998 Vol. 49 No. 12

BOOK REVIEWS
theme for supervisors. This concept is
detailed and advanced with new object relations formulations and lexicon to describe the positioning of the
supervisors self in the relationship
between patient and therapist. The
scrutiny and description of the space
for thinking that is essential for supervision is this books contribution.
Woven into the descriptive fabric
of supervisory space are conceptualization and linkage of Bions reflective thinking, social constructivist
views of inhabiting a neutral reflexive
text, Freuds evenly-suspended attention and love of truth, Kleins
fantasy-dreaming-aesthetic reaction
and unconscious wish fulfillment,
Hillmans fantasy images as a privileged mode of access to knowledge
of soul, Jungs active imagination,
Coleridges primary imagination,
Wittgensteins image as a form of
life, and Baars global workspace.
A metaphor with fresh imagery used
to describe the overall space of supervision is Foucaults garden and
heterotopia. The term heterotopia
refers to the garden as a microcosm,
at the same time the smallest parcel
of the world and the totality of the
world.
Shipton states that defining the
boundary area of supervision as a
public or private space beats a
rhythm throughout this book and
that the tension between predatory
gaze and respectful regard enter into
the supervisory relationship and create an optimal climate for thinking
about and learning from experience.
Several chapters are more traditionally concrete in discussing in detail
the history of psychodynamic supervision, the use of audiotaping in supervision, Kagans technique of interpersonal recall, and the need for sensitivity to issues of race and culture in
supervision.
Marcia Hill is a feminist therapist
in private practice in Montpelier,
Vermont. She is past chair of the
Feminist Therapy Institute and editor of More Than a Mirror: How
Clients Influence Therapists Lives.
In this unusual book, the goals for the
volume are not clearly stated. The
implication is that personal accounts
PSYCHIATRIC SERVICES

of the all-female contributors model

the examination of how deeply and
personally the practice of psychotherapy and the interaction with
clients can affect one as a therapist
and as a person.
Twenty-one brief personal and
moving disclosures by female therapists follow. These personal narratives include situations of treating a
patient who has a history of physical
and sexual torture, stresses of a therapist in training, treatment of the dying, the impact of a therapists pregnancy on the treatment of an inmate
charged with infanticide, a therapists
wish to have children while treating
patients who are mothers, a therapists response to a man who appears
to be psychologically tormenting his
wife, mandatory reporting of suspicions of abuse in minors, merger and
unconditional love between therapist
and client, and other difficult therapist dilemmas.
Clearly, this volume of therapists
revelations is courageous in entering
the difficult terrain of how clients influence therapists lives. But however
moving these stories may be, there is
a danger of stark reporting without
depth analysis. Accounts that may
stimulate learning for some readers
may be underformulated and underdiagnosed for others. Vignettes that
inadequately model the use of supervision, consultation, or knowledge of
professional traditions and literature
have been included. This volume
would benefit from a title more descriptive of the contents and a foreword that better explains the very serious goals of the book and the complexity of the clinical situations described.
Certainly both Supervision of Psychotherapy and Counselling and
More Than a Mirror make a contribution to the in-depth exploration of
supervision and the influence of
clients on therapists. The experienced psychodynamic clinician and
supervisor will be delighted by Supervision of Psychotherapy and
Counselling, while More Than a Mirror raises issues that may be valuable
for the less experienced therapist to
consider.

December 1998 Vol. 49 No. 12

Assisted Suicide: A
Decision-Making Guide
for Health Professionals
by Stephen Jamison; San Francisco,
Jossey-Bass Publishers, 1997, 248
pages, $34.95
Andrew Edmund Slaby, M.D., Ph.D.

aregivers have always been confronted with a need to ease the

pain and assuage the anxiety of those
with terminal illness. For centuries
nuns attending the dying in ancient
European hospitals, and more recently staff of hospices created for those
dying in this century, have provided
what is needed to comfort the terminally ill, even if at times what ameliorates pain hastens death. Regrettably,
in the past decade, what was considered humane and caring has been increasingly labeled as one extreme of
assisted suicide.
This unfortunate appellation has
led some caregivers sensitive to the
issue of the medical mission to preserve life, and the ethical dilemma associated with the provision of anything that may shorten it, to ignore
the growing body of literature discussing what may be provided in the
context of ones own religious, ethical,
and legal beliefs. Psychologist Stephen Jamison, a past-president of the
Mental Health Association of Marin
County, California, offers such material in this interesting and easily readable book.
Although the author is not without
his biaseshe was a regional director
of the Hemlock Society, a national
right-to-die organizationhe does
discuss the contributions of many
others who do not necessarily share
his viewpoint. They include prominent suicidologists Edwin Shneidman
and Herbert Hendin, ethicists Kathleen Foley and Daniel Callahan, and
hospice pioneer Cicely Saunders.
Assisted Suicide is well written, is
easy to understand, and covers topics
ranging from the ethical debate about
Dr. Slaby is clinical professor of psychiatry at New York University and New York
Medical College and past-president of the
American Association of Suicidology.
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BOOK REVIEWS
assisted suicide to explicit application
of options available and questions we
should ask ourselves before we make
a decision either way. The book is intended to help caregivers work effectively with incurable or terminally ill
individuals expressing a desire to die.
It fulfills this mission by helping us to
become aware of ethical concerns
surrounding assisted dying and to understand more clearly our own
thoughts and feelings about dying
ourselves and about working with
people who are dying. It provides
ways to better grasp the meaning of
patients expressed desire to die and
the full range of concerns they and we
must deal with. Finally, it provides direction for listening to our patients
and for increasing the quality of our
interaction with terminally ill patients, regardless of whether they are

considering a decision to die; it also

provides a framework to help us feel
comfortable about our own considered opinion regarding assisted dying
and the confidence to maintain it consistently.
I enjoyed reading this book, including the open discussion of the controversy impacting patients and caregivers decisions at this sacred moment in life. My only criticism is that
there is not greater discussion of how
affective illness may confound an individuals thinking about the desire to
die and how, after depression is treated psychopharmacologically and psychotherapeutically, many may wish to
continue to live as long as they comfortably can, to be with those they
love and put in order their life before
they must complete the final transition.

Clinical Methods in Transcultural Psychiatry

edited by Samuel O. Okpaku, M.D., Ph.D.; Washington, D.C., American
Psychiatric Press, 1998, 458 pages, $65
Carl C. Bell, M.D.

his book has a global perspective

on transcultural psychiatry. It
does not focus just on major U.S. minority populations. Accordingly, I recommend it. As human migration increases and international business
continues to grow, American psychiatrists will need to become more
versed in transcultural psychiatry.
The text is chock-full of useful
pearls and illuminating examples of
how culture affects behavior and the
treatment of mental illness. It includes meaningful paradigms that are
easy-to-remember guideposts for
transcultural psychiatric efforts. The
book embodies the goals of transcultural psychiatry by seeking to explore
the epidemiology of mental illness in
different cultures, identifying cultural
factors facilitating the development
of mental illness, describing forms of
Dr. Bell is clinical professor of psychiatry
at the University of Illinois and president
and chief executive officer of the Community Mental Health Council in Chicago.
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treatment practiced in different cultures, and comparing different attitudes toward mentally ill persons in
different cultures.
The books first section provides an
overview of transcultural psychiatry,
explores the relationships between
personality and culture, and addresses mental health aspects of voluntary
and forced immigration. Given the
large numbers of refugees who are at
risk because of traumatic experiences, clinicians need to know how to
assess, formulate, and treat patients
who are culturally different from
themselves.
Section 2 recommends, among other considerations, that practitioners attend to the cultural aspects of the spiritual realm. An outstanding chapter
addresses mental health professionals
attitudes toward traditional healing.
Curanderismo, espiritismo, santeria,
umbanda, vodou, obeah, and Southern
black rootwork are thoroughly explained. Further, the conceptual bases
of alternative healing systems, cover-

ing natural, mystical, animistic, and

magical causation, are discussed.
Also in this section is a unique, exemplary chapter on how New Zealand Maori adapt to mainstream
Western medicine. Another commendable original chapter, focusing
on psychiatry in an English inner-city
community, gives some poignant examples of how the culture of poverty
and religion influences behavior. A
third novel chapter focuses on psychiatry in Arabian Gulf communities.
These contributions illuminate the
stark contrasts between American
culture and other cultural contexts.
They heighten our awareness of our
own culture and how culture influences behavior and the practice of
psychiatry in various contexts. Another outstanding chapter points out how
different ethnic groups respond to
various medications. The section concludes with a chapter by authors who
are appropriately critical of Western
psychiatrys disdain for religion as a
negative influence on mental health.
Section 3 highlights the role of culture in psychiatric assessments and
advises that the patients explanatory
model of the psychiatric problem be
explored. Useful treatment approaches range from interpreting somatic
symptoms using several different levels of meaning to establishing a therapeutic alliance across cultures. Section 4 has distinctive chapters on
somatization patterns among Mediterranean migrants and on religion
and magic in Italy.
The following section, on education
and training, presents curricula for
transcultural training of mental
health professionals. DSM-IV cultural formulations are highlighted in
hopes they will provide leadership for
psychiatric residency education in
transcultural psychiatry. Section 6 explains how children and families in
cultural transition are influenced by
differential rates of acculturation, culture clashes, culture-bound developmental myths, cultural adaptation,
and a cultures impact on identity. A
model of transcultural family therapy
is provided.
The bottom line is that there is a lot
to learn from this book.

PSYCHIATRIC SERVICES

December 1998 Vol. 49 No. 12

BOOK REVIEWS

Library Services in Mental Health Settings

edited by Mary E. Johnson, M.A.L.S., A.H.I.P.; Lanham, Maryland, Scarecrow
Press, 1997, 236 pages, $42
Lyn M. Dietrich, M.S.L.S., A.H.I.P.

his significant volume is the first

to examine the specialized health
care information provided by mental
health libraries that are undergoing
major organizational and technological change. Issues and models of service are clearly organized and presented by experts from mental health
libraries in hospitals, mental health
centers, academic centers, state institutions, schools of psychology, and
professional associations.
Mary Johnson, the books editor,
has provided services to public mental health institutions throughout
Missouri for 13 years. She is the library director of the Missouri Institute of Mental Health in St. Louis.
She is also the author of the first
chapter, which presents an insightful
brief overview of mental health care
and treatment and the librarians role
in providing essential information
that has an impact on treatment outcomes.
Two descriptive chapters offer an
overview of library resources that aid
mental health clinicians, educators,
researchers, and policy makers. Susan
Heffner of the American Psychiatric
Association presents a well-organized, concise history of health policy
in the United States. Bruce Gardham
of the Canadian Mental Health Association clearly describes the Canadian
community health system and how it
has affected demands and roles for
Canadian library collections.
A highlight of the book is the presence of extensive bibliographies and
directories. Early on Heffner provides directories for researching policy questions on the World Wide Web.
Barbara Epstein of the University of
Pittsburgh with Ester Saghafi of the
Ms. Dietrich is librarian at the Mental
Health Sciences Library of McLean Hospital in Belmont, Massachusetts, and is
past chair of the mental health librarians
section of the Medical Library Association.

PSYCHIATRIC SERVICES

Western Psychiatric Institute and

Clinic and members of their staffs
have compiled a selective guide to
print literature that could be recommended as a core collection in clinical
psychiatry, a list of core periodicals
for a psychiatric library, and a list of
psychiatric Internet resources, including Web sites, electronic mailing
lists, and news groups. This comprehensive material will be helpful for
collection development for any organization.
Dorothy Spencer of Samuel Merritt College in California and Louise
Colbert of the California School of
Professional Psychology propose new
standards to evaluate whether libraries are meeting the needs of
clients and fulfilling their service mission in this era of change. The authors
outline the agencies and organizations that currently provide standards
and regulations for mental health information services in a variety of settings and present methods to assure
compliance. The authors practical
list of quality indicators is recommended for use by librarians in collaboration with their administrations
for self-evaluation of mental health
information services.
Of particular note is the history of
consumerism discussed in a chapter
on library services for persons with
psychiatric disabilities by Anita Lyon
of the Southeast Missouri Mental
Health Center. Historically, patient libraries contained popular books,
magazines, and multimedia to engage
the mind during recovery. In mental
health settings today, library services
to consumers include access to authoritative materials for medical information. Lyon presents models for
meeting consumers information
needs. Along the same lines, reflecting the importance of patient-focused
care and an informed, satisfied customer, the consumer and patient
health information section of the
Medical Library Association has de-

December 1998 Vol. 49 No. 12

veloped a statement on roles for the

librarian in consumer health information and patient education, which is
included in an appendix.
Presenting an overview of the specialized collections and roles of mental health librarians, Library Services
in Mental Health Settings should appeal to a wide audience of clinicians,
educators, researchers, and policy
makers who require mental health information for decision making, patient care, and research.

Malpractice Risk
Management in Psychiatry:
A Comprehensive Guide
edited by Frederic Flach, M.D.; New
York City, Hatherleigh Press, 1998,
304 pages, $39.95 softcover
Jeffrey S. Janofsky, M.D.

his multiauthored book attempts

to explain both the legal and the
clinical aspects of psychiatric malpractice. Physicians who call an 800
number can also obtain continuing
medical education credits by correctly answering 74 questions at the back
of the book. Although this information is not disclosed in the text, on
calling the 800 number I was informed that the credits cost an additional $110.
As with most multiauthored texts,
the writing and editing are uneven.
The basic chapters on malpractice by
Michael Perlin are well written but essentially a summary of one of his prior
publications. The Tarasoff decision on
mental health professionals duty to
protect third parties from their patients dangerous behavior is discussed in seven different chapters in
an extremely repetitive and annoying
fashion. Other introductory chapters
concentrating on clinical issues summarize and repeat information better
covered in subsequent chapters.
Dr. Janofsky is associate professor and director of the law and psychiatry program
in the department of psychiatry and behavioral sciences at Johns Hopkins University School of Medicine in Baltimore.
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BOOK REVIEWS
I found most interesting the
chapters called Are You Liable for
Your Patients Sexual Behavior? by
Douglas Mossman and Guidelines
to Avoid Liability in Managed Care
by Lawrence Kerns and Carol Gerner. These two chapters give fresh
insight into areas that are not often
covered by similar texts. The chap-

ter by Otto Kausch and Philip Resnick entitled The Assessment of

Violence in the Workplace and Its
Legal Ramifications is also a good
read. However, I am not sure what
it is doing in a text on psychiatric
malpractice.
Overall, I would not recommend
this book.

Traumatic Events and Mental Health

by L. Stephen OBrien; New York City, Cambridge University Press, 1998, 302
pages, $100 hardcover, $42.95 softcover
Stuart L. Lustig, M.D., M.P.H.

his book is a generously referenced, well-written account of research on posttraumatic stress disorder (PTSD) by a British psychiatrist
with military and civilian clinical experience.
An introductory chapter chronicles
the historical development of PTSD,
indicating that Vietnam veterans were
the focus of most early research.
OBrien distinguishes between PTSD
and posttraumatic illness, a recurrent
consideration throughout the book.
Next, he debates whether PTSD is a
normal or abnormal response to a
trauma, a question that has enormous
legal ramifications addressed later in a
fascinating chapter that considers
PTSD and the insanity defense, as well
as the very weak link between PTSD
and criminal behavior.
Coverage of PTSD and posttraumatic illness epidemiology wisely begins with general caveats, such as the
impact of priming questionnaire respondents on subsequent symptom
endorsement. Major epidemiologic
endeavors, such as the National Vietnam Veterans Readjustment Study,
are described, and studies of other
traumatic events, such as terrorist activities or natural disasters, are also reviewed. A table would help summarize
the huge blur of incidence and prevalence rates.
Dr. Lustig is a resident in the Harvard
Longwood psychiatric residency training
program at the Massachusetts Mental
Health Center in Boston.
1632

OBrien next addresses etiology and

predisposing factors by considering
the importance of trauma severity versus the role of various pretrauma vulnerability factors. Biological etiology,
such as the hypothesized role of the
hypothalamic-pituitary axis, is nicely
summarized. Next, an entire chapter
examines the nature of a stressor,
which has evolved from DSM-III to
DSM-IV. These classification systems
are then contrasted with ICD-10.
OBrien explains why the requisite occurrence of a traumatic event may not,
in fact, be diagnostically useful as currently dictated.
A chapter on posttraumatic illness
other than posttraumatic stress disorder follows. The useful, though short,
section on PTSD comorbidity with
other diagnoses could serve as a helpful road map of the chapter if placed
before the sections on individual, nonPTSD disorders. In addition, explanations of the temporal relationship of
the trauma to the disease course seem
a bit basic for the modal reader, who is
probably a mental health professional.
The chapter on diagnosis and assessment briefly mentions physiological
parameters in diagnosis, but it mostly
reviews the many survey instruments
and interviews in use. Again, a summary table would help convey their
psychometric properties and the populations on which they were normed.
OBrien points out the lack of a gold
standard, and he also notes later that
none of these instruments have been
normed in the legal arenafor exam-

ple, on patients seeking compensation

through the judicial system.
A summary of treatment approaches
covers the standard, symptom-driven
pharmacological remedies as well as
various psychotherapies. A description
of the principles of combat psychiatry
provides an interesting diversion. The
section on eye movement desensitization and reprocessing is skimpy and
leaves the reader eager for more commentary on this controversial subject.
The medicolegal chapter is followed
by one on posttraumatic illness prevention, with a convincing debunking
of posttrauma debriefing. A final summary touches on highlights in the
book. Summary bullets at the end of
each chapter help recapitulate the
highlights in this very useful, comprehensive description of the state of
PTSD research.

Neurodevelopment and
Adult Psychopathology
edited by Matcheri S. Keshavan,
M.D., M.R.C.Psych., and Robin M.
Murray, F.R.C.Psych., D.Sc.; New
York City, Cambridge University
Press, 1997, 282 pages, $120
hardcover, $44.95 softcover
Sandra DeJong, M.D.

t is a contemporary clich to talk

about the overwhelming flood of
neuroscientific data on possible etiologies of mental illness. Here is a
book that attempts to help the overwhelmed in the way a good teacher
does, by starting with basic principles.
This carefully-thought-out text,
edited by Dr. Keshavan from Pittsburghs Western Psychiatric Institute
and Clinic and Dr. Murray of Londons Institute of Psychiatry and
Kings College, is divided in three sections. The first focuses on normal
brain development; the second looks
at research findings that influence
current theories of adult psychiatric
illness, particularly schizophrenia;
Dr. DeJong is a psychiatric resident at the
University of Massachusetts Medical Center in Worcester.

PSYCHIATRIC SERVICES

December 1998 Vol. 49 No. 12

BOOK REVIEWS
and the third provides a range of developmental models to explain this
disorder based on current data, plus
suggested directions for future research. Given its neurobiological focus, the book will be most accessible
to professionals with some basic science background.
The first section usefully updates
readers on key findings of basic neuroscience research. It outlines primate neurodevelopment and its genetic underpinnings, emphasizing the
principles of how adult neurons are
organized and connected in the brain
and where potential genetic defects
may occur. Additional chapters provide a helpful explanation of studies
of the developing brain using magnetic resonance imaging, (including
functional MRI), magnetic resonance
spectroscopy, and positron emission
tomography. Although the details
may lose some readers, the concepts
are quite clearly explained. Finally,
this section includes a fascinating
chapter by Stephen J. Suomi looking
at the possible impact of experience
and environment on biological systems and behavior by examining work
on rhesus monkeys.
The middle section, with its emphasis on schizophrenia, covers a
spectrum of research approaches to
neurodevelopment and psychopathology, including longitudinal birth cohort studies, developmental theory
and analysis of epidemiologic data,
gender differences in schizophrenia,
comparisons with other neurodevelopmental disorders such as obsessive-compulsive disorder, and structural imaging studies. Each chapter
explicitly states the uses, limitations,
and future potential of each method.
This panoply of concepts and thoroughly documented data culminates
in the final sectionthree chapters
outlining possible models of the development of schizophrenia. Irwin
Feinberg presents a late developmental model that focuses on neurologic
changes during adolescence such as
synaptic pruning and the possible role
for sex hormones, including adrenal
androgens. Dr. Murray and three
coauthors outline their dysplastic
net hypothesis, an early developPSYCHIATRIC SERVICES

mental model that proposes a dysplastic process in the second half of

gestation resulting in disrupted connections between different parts of
the cerebral cortex.
The final chapter, by Dr. Keshavan,
ties together these two theories by
pointing out that early brain injury
could have an impact on the later
pruning and final organizational pro-

cess that seems to close the doors on

brain plasticity. His summary of future directions in research is succinct
and sensible.
The net effect is that the reader
comes away still overwhelmed by the
complexity of the schizophrenic spectrum of illness, but considerably more
informed about current thinking on
its etiology.

Understanding Violence
by Elizabeth Kandel Englander; Mahwah, New Jersey, Lawrence Erlbaum
Associates, 1997, 187 pages, $45 hardcover, $19.95 softcover
Harold Carmel, M.D.

his is a well-intended, albeit imperfectly edited, attempt to produce a college-level textbook on violent crime. The books title does not
quite convey this aim. While emphasizing the need to see the forest for
the trees, much of the book consists
of individual descriptions of studiesthe bibliography is 20 pages
long, but not all cited studies can be
found in itwith rare summaries of
take-home conclusions. In some cases, well-accepted concepts are not

Dr. Carmel is director of medical affairs

for the Virginia Department of Mental
Health, Mental Retardation, and Substance Abuse Services in Richmond. He is
also associate clinical professor of psychiatry at the Medical College of VirginiaVirginia Commonwealth University.

December 1998 Vol. 49 No. 12

presentedfor example, on child

abuse, that younger children are at
higher risk for death than older ones;
that adult males are more likely to
kill; and that the most common cause
of death is head injury.
Too much emphasis is given the authors idiosyncratic concept of pan violence to describe men violent both
at home and in the street when the information presented suggests that the
pan violent are a subset of street offenders who are also abusive at home.
The diagnosis of antisocial personality disorder is trivialized, and the relation between serious mental illness
and violence is dismissed in three
paragraphs.
There may well be a need for a
good text on violent crime. This is not
quite it.

Change of Address
Authors of papers under peer review or being prepared
for publication in Psychiatric Services are reminded to
notify the editorial office of any changes in address.
Please call the editorial office at 202-682-6070, or send
updated information by fax to 202-682-6189 or by email to psjournal@psych.org.

1633