The Unknown Karen Horney: Essays on Gender, Cul- ture, and Psychoanalysis, by Karen Horney; edited by Ber- nard J. Paris. .... Horney K: Feminine Psychology. New York ...... Diagnosis and Management of Dementia: A Manual for Memory ...
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LIFE STORIES The Unknown Karen Horney: Essays on Gender, Culture, and Psychoanalysis, by Karen Horney; edited by Bernard J. Paris. New Haven, Conn., Yale University Press, 2000, 362 pp., $40.00. Beginning with his biography of Karen Horney in 1994 (1) Bernard Paris, a professor of English at the University of Florida, has taken Horney’s work as his special field of study, bridging literary theory and psychoanalysis. Paris has applied Horney’s unique psychoanalytic thinking about character to literary criticism; in Imagined Human Beings: A Psychological Approach to Character and Conflict in Literature (2), he presented analyses of several fictional characters from her perspective. Over the years, he has done the sort of archival and bibliographical work on Horney that a major literary figure deserves, and his last two collections of her papers are the result. In a volume published a year before this one (3), he presented lecture notes, unpublished or obscurely published articles, and reconstructed lectures by Horney on the subject of psychoanalytic therapeutic technique. In this book he has collected and annotated similar material that includes some of Horney’s early essays on the subject of femininity and women’s development and psychopathology as well as a number of essays and lectures that trace the development of her “mature work” (Paris’s term). Horney was among Freud’s early students and was one of the founders of the Berlin Psychoanalytic Institute. She was also an early critic of Freud’s theories of feminine development and the connection between castration anxiety and fantasies and passivity in women’s character structure. Her ideas were singled out by Freud, and she may be the only woman he names in one of his papers as a dissident who should be corrected. Many of her early essays on feminine development were translated into English and have been available for several years in a single volume (4). Several of the essays that Paris includes in this book are translated into English for the first time and show some of the development of Horney’s thinking on the subject from a time when she thought more along what came to be considered classical Freudian lines. The first section of the book is valuable from a historical point of view. Paris points out that Horney’s thinking about women culminated in her address to the National Federation of Professional and Business Women’s Clubs in 1935 titled “Woman’s Fear of Action,” which Paris had included as an appendix to his biography of Horney (1). Paris says that “this talk best explains why Horney stopped ‘bothering about what is feminine.’ She had reached the conclusion that all ‘we definitely know at present about sex differences is that we do not know what they are’ ” (p. 13). Horney’s thinking about women anticipated much of the work of more modern feminist critics of psychoanalysis but has been largely ignored for a long time, probably because of her later dissent and expulsion from mainstream psychoanalysis. The remainder of this volume includes a miscellaneous collection of essays, lecture notes, and fragments in which Am J Psychiatry 158:11, November 2001
Paris observes the development of Horney’s mature thinking about personality development and culture: “It represents Karen Horney speaking in her distinctive voice and developing her own theory” (p. 159). Paris includes here the letter written by Horney, Harmon S. Ephron, Sarah R. Kelman, Bernard S. Robbins, and Clara M. Thompson when they resigned from the New York Psychoanalytic Society in 1941. The central concept in this letter is a timeless statement that applies now as well as ever not only to psychoanalysis but to all of psychiatric education: Education in any field consists in a passing on from an older to a younger generation of the truth that the older generation believes it has learned, as well as a bequeathing to the younger generation of the problems left unsolved by their elders. In psychoanalysis as it is today, we cannot afford to subject the younger generation to any dogmatism; we should not mislead it with the illusion of certainty, where none actually exists. (pp. 304–305) In summary, this book represents the work of a dedicated literary researcher and bibliographer. Paris’s introductions to the two sections not only summarize the papers included but also present the development of Horney’s thinking in a concise and scholarly manner. The book will be most valuable to those who already have an interest in Horney’s work and want to see how her thinking developed. Those of our colleagues who want to make an acquaintance with her thinking would be best referred to her final book, Neurosis and Human Growth (5), which Paris notes represents her most mature thinking and which I would recommend to anyone as a very readable text and a useful one to any therapist who wants to work psychodynamically. References 1. Paris BJ: Karen Horney: A Psychoanalyst’s Search for Self-Understanding. New Haven, Conn, Yale University Press, 1994 2. Paris BJ: Imagined Human Beings: A Psychological Approach to Character and Conflict in Literature. New York, New York University Press, 1997 3. Karen Horney: The Therapeutic Process: Essays and Lectures. Edited by Paris BJ. New Haven, Conn, Yale University Press, 1999 4. Horney K: Feminine Psychology. New York, WW Norton, 1967 5. Horney K: Neurosis and Human Growth: The Struggle Toward Self-Realization. New York, WW Norton, 1950
MARIAM COHEN, M.D., PSY.D. Scottsdale, Ariz.
Ideas and Identities: The Life and Work of Erik Erikson, edited by Robert S. Wallerstein, M.D., and Leo Goldberger, Ph.D. Madison, Conn., International Universities Press, 1999, 430 pp., $65.00. This is a remarkable collection of essays by various authors who define and discuss the significant contributions of Erik Erikson to psychoanalytic theory, clinical practice, “psychohistory,” and social science from 1929 to 1994. The book is an outgrowth of an all-day symposium held in 1995 in San
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Francisco commemorating and celebrating Erikson’s life. Robert Wallerstein, long-time friend and colleague of Erikson’s, organized the symposium. The proceedings of the symposium were published in Psychoanalysis and Contemporary Thought. Wallerstein and Leo Goldberger, editor of that journal, constructed this volume from papers presented at the symposium, along with additional perspectives from other writers on Erikson’s influence on current psychoanalytic thinking. Several of Erikson’s most important contributions are also included. It is difficult to summarize in a brief review the remarkable richness of the chapters in this book, each of which addresses, from a different perspective, Erikson’s life and psychoanalytic contributions. A selection will be presented here in order to give a flavor of the whole book. The volume begins with a concise and informative chapter, “Erik H. Erikson, 1902–1994: Setting the Context,” in which Wallerstein reviews key aspects of Erikson’s life, the social/historical changes that occurred during his lifetime, and the evolution of psychoanalytic thinking. In the next chapter, “Erik Erikson and the Temporal Mind,” Marsha Cavell, Ph.D., of the University of California, Berkeley, gives an eloquent discussion of Erikson’s work in relation to philosophy. Cavell emphasizes the role of “doubt,” selfawareness, and the role of being the “doubter” in the field of philosophy. She presents a very informative discussion of the development of the “I” in the development of identification and an equally rich discussion of the significance of “shame and doubt” in the development of the sense of separateness and individuality. In “Erik Erikson as Social Scientist,” Neil J. Smelser, Ph.D., discusses Erikson’s role as a social scientist. Smelser emphasizes Erikson’s interdisciplinarian approach, some of the unresolved methodological issues in his approach, his diagnosis of Western culture, and his sociological idealism. Smelser, in a very concise and elegant critique, discusses in detail the strengths and weaknesses of Erikson’s approach as a social scientist, especially the difficulty in unifying or integrating into a whole Erikson’s multiple perspectives on human functioning and adaptation. In general, Smelser is quite positive about Erikson’s contributions, especially his discussion of the dangers of totalitarianism and the phenomenon of “pseudospeciation” and its detrimental effect on society. Walter H. Capps gives an eloquent discussion of Erikson’s contribution to the understanding of religion: Thus, when Erikson addressed the subject of religion, he concentrated on the quest for truth, and truth was always linked to integrity, and integrity to wholeness, and wholeness to “being well,” or as he put it sometimes, to “being all right.” In the end, his work stands as a testament to moral courage. Other chapters include interesting contributions from Elizabeth Lloyd Mayer, Ph.D. (“Erik Erikson on Bodies, Gender and Development”), and a chapter by Robert Jay Lifton on Erikson’s historical perspectives (“Entering History: Erik Erikson’s New Psychological Landscape”). Two papers are included in addition to those given at the 1995 symposium: “Erikson, Our Contemporary: His Anticipation of an Intersubjective Perspective,” by Stephen Seligman
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and Rebecca Shahmoon Shanok, and “Erik H. Erikson’s Critical Themes and Voices: The Task of Synthesis,” by Lawrence J. Friedman. The Seligman-Shanok chapter discusses in detail how Erikson’s emphasis on the significance and psychological power of the person’s environment, especially the complex relationships with important people in the environment, not only presaged but also predicted the gradual evolution of an “intersubjective” point of view that emphasizes the essential place of relationships in motivation, development, and clinical practice: We believe that Erikson’s insistence on the inclusion of broad social and historical conditions in psychoanalytic psychology challenges adherence to the two-person perspective to include a wider array of familial, institutional and cultural relationships in their project.…Erikson’s concept of identity provides a profound account of subjective experience in terms of processes of locating self and other representations in intersubjective space. Friedman’s chapter provides a remarkably clear and concise discussion of Erikson’s historical role in psychoanalytic thinking as well as his influence on current culture. He gives a very informed discussion of Erikson’s criticisms of Western culture, especially the culture in the United States, and a very lucid discussion of Erikson’s concept of “pseudospeciation” as “the arrogant placing of one’s nation, race or culture, and/or society ahead those of others.” Friedman discusses three of Erikson’s longstanding topical interests—American society, psychoanalysis, and the human life cycle—and talks about how difficult it is to integrate these interests into a coherent theory. One of the great treats of this book is the inclusion of four classic papers by Erikson: “The Dream Specimen of Psychoanalysis,” “The Problem of Ego Identity,” “The Nature of Clinical Evidence,” and “The Galilean Sayings and the Sense of ‘I’.” In addition, there is a very moving document, a position statement made by Erikson in 1950 (the McCarthy era) to the Committee on Privilege and Tenure of the University of California in which he resigns his position. He did so in protest of the University of California’s newly developed requirement that faculty sign, in essence, a loyalty oath, including a statement that they “are not a member of the Communist Party or any other organization which advocates the overthrow of the government by force and violence, etc.” Erikson refused to sign the loyalty oath but was found fit for continued tenure; he resigned his position in protest. All of the Erikson papers included in this volume are important contributions. In the ego identity paper, Erikson very thoughtfully elaborates his understanding of the development of ego identity with a rather extensive discussion of his definition of the term and the internal and external forces that play a role in the development of one’s ego identity. Wallerstein describes Erikson’s “The Dream Specimen of Psychoanalysis,” written in 1954, as “arguably the most important single paper on dream analysis since Freud’s Dream Book in 1900.” There is a moving and succinct epilogue by Goldberger and an excellent bibliography. One of the most impressive aspects of this book is that the extraordinary variety and intelligent and informed approaches of the various authors reflect ErikAm J Psychiatry 158:11, November 2001
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son’s remarkable diversity and his capacity to think in various domains of human existence. GRAEME HANSON, M.D. San Francisco, Calif.
The Father of Canadian Psychiatry: Joseph Workman, by Christine I.M. Johnston. Victoria, B.C., Canada, Ogden Press, 2000, 332 pp., $19.95. This little book introduces Joseph Workman, M.D., 1805– 1894, an Irish immigrant who became the medical superintendent of the Provincial Lunatic Asylum of Toronto from 1853 to 1875. Reflecting changes in fashion, the name of this institution was changed in 1871 to the Toronto Asylum for the Insane, later to the Queen Street Provincial Psychiatric Hospital, then the Queen Street Mental Health Centre. Four years ago it became part of the Centre for Addiction and Mental Health. Compared with his student, C.K. Clarke (after whom the Clarke Institute, now also part of the Centre for Addiction and Mental Health, was named), Dr. Workman is not well-known in Canadian psychiatry and certainly deserves fuller treatment than is afforded by this book. We are told that Dr. Workman was a prolific writer and linguist and translated much European (especially Italian) psychiatric writing into English, but the content of what he translated is left to the reader’s imagination. We are told that he was an innovator, but the nature of his psychiatric innovations is very sketchy. He advocated good food, plenty of space, exercise, and fresh air for the mentally ill in his charge. He believed in moral treatment, and the patients in his institution were treated humanely in what is described as a supportive, structured social community. He believed in occupation, especially gardening. Initially involved in the temperance movement, Dr. Workman eventually came to believe in the health-giving potential of alcohol mixed with opium and quinine. As elsewhere during this period, such tonics were administered not only for therapeutic reasons but also because they kept the wards quiet and manageable. Insanity was understood as an outgrowth of predisposition (genetic endowment, for example) triggered by a stressful event (such as a blow to the head). Dr. Workman believed that injuries, illnesses and fevers, excessive smoking, defective diet, and “over lactation” could cause psychiatric illness. He also believed that overwork, sudden fright, “religious commotion,” and masturbation were to blame. His beliefs reflected those in vogue at the time. One senses, as the following quotation illustrates, that he was a kind man: Unvarying kindness, never-tiring forbearance, and undeviating truthfulness, are the cardinal moral agencies now [1858] employed in every well-conducted Lunatic Asylum; and surely no remedies could be found less expensive, or more easy of appliance. Unfortunately, this book does little more than allow the reader a very superficial sense of Workman’s character and tells relatively little about his life and his psychiatric philosophy. He remains, as before, unknown. MARY V. SEEMAN, M.D. Toronto, Ont., Canada Am J Psychiatry 158:11, November 2001
Memoirs of My Nervous Illness (1903), by Daniel Paul Schreber. New York, New York Review of Books, 2000, 454 pp., $14.95 (paper). This book, written a century ago by a man confined to an asylum, was selected by Amazon.com as one of the 100 finest nonfiction books of the 20th century. This must be the first time a madman has made a “Great Books” list. Psychiatrists know Schreber through Freud’s case study, but scholars of all types have read him. Memoirs of My Mental Illness is surely the most studied text ever written by a psychiatric patient. Daniel Paul Schreber was born in 1842 to an upper-class family in Leipzig. His father was a physician who was famous in Germany for his work in health and education. After finishing law school, the younger Schreber entered the service of the Saxon Ministry of Justice, where his career steadily advanced. At the age of 42, he ran for a place in the Reichstag but was overwhelmingly defeated. Shortly thereafter, he developed multiple depressive symptoms and admitted himself voluntarily to a psychiatric hospital run by Dr. Paul Flechsig, whom he later regarded as his persecutor. After a 6-month hospital stay and a convalescence, Schreber resumed his duties at court. No one reported psychotic symptoms during his illness. So far as we know, Schreber remained free of psychiatric disorder for almost 10 years after his first psychiatric hospitalization. Shortly after becoming a presiding judge, he became symptomatic and was readmitted to Flechsig’s asylum. Thereafter, Schreber developed a very rich, very complex, and very bizarre delusional system. He believed he was connected to God through nerves or “rays,” which, he thought, made up the human soul. He feared that his soul would be handed over to Flechsig, who would either abuse his body or let it rot. This was “soul murder.” Schreber developed an array of messianic ideas, including the belief that he was to be fertilized by God in order to create a new race of beings. Schreber wrote his manuscript in an attempt to win his freedom. He hoped it would demonstrate that he was sane enough to leave the hospital. In 1902, the court released him. No one thought that he was sane, but the judges believed he was harmless. (Ironically, he was freed by the same court in which he had served as a presiding judge.) Five years later, Schreber was readmitted and remained hospitalized until his death. Why has this book captured the attention of so many academics? First, it is a vivid and articulate description of psychosis. Schreber’s psychosis is manifest throughout, but he writes like a scholar; everyone who reads Schreber notes the peculiar combination of the most unbelievable delusions within a logical and eloquent literary form. When he can free himself from his more personal beliefs, he writes persuasively, as in his essay on why “cases of harmless insanity” should not be involuntarily hospitalized. After a time, reading Memoirs of My Nervous Illness becomes tedious because Schreber frequently repeats or contradicts himself. Few will want to read this book cover to cover, but anyone who picks it up will be fascinated by the author’s delusional symptoms. A second and more important reason for the popularity of this book is that Schreber offers penetrating insights, however bizarrely they are presented. The reader gains a deeper understanding of madness. Indeed, the reader gains a deeper understanding of whatever topic the man addresses.
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Schreber’s influence is evident, for example, in Freud’s interpretation of paranoia and Lacan’s views of paternal representations. As Professor Zvi Lothane (1) has pointed out, Schreber is a master thinker and interpreter who should be heard on his own terms. Freud (2) recognized this when he concluded at the end of his monograph on Schreber, It remains for the future to decide whether there is more delusion in my theory than I should like to admit, or whether there is more truth in Schreber’s delusion than other people are as yet prepared to believe. References 1. Lothane Z: In Defense of Schreber: Soul Murder and Psychiatry. Hillsdale, NJ, Analytic Press, 1992 2. Freud S: Psycho-analytic notes on an autobiographical account of a case of paranoia (dementia paranoides) (1912 [1911]), in Complete Psychological Works, standard ed, vol 12. London, Hogarth Press, 1958, pp 3–82
GLENN H. MILLER, M.D. Bethesda, Md.
Heinz Kohut: The Making of a Psychoanalyst, by Charles B. Strozier. New York, Farrar, Straus & Giroux, 2001, 495 pp., $35.00. The author of this meticulously documented biography is a professor of history at John Jay College and the Graduate Center, City University of New York, and a training and supervising psychoanalyst at the Training and Research Institute for Self Psychology. In his preface he says that, having finished a “psychoanalytic study of Lincoln,” he was looking for a new project and decided to write about Heinz Kohut (pp. xi–xii). Strozier tells us he was trained at the Chicago Institute for Psychoanalysis, where he became a convert to the Kohutian approach. In writing this book over several years, Strozier seems to have interviewed everyone he could find among the colleagues, students, patients, family, and friends of Kohut in an effort to write a portrait of this very complex man. He apparently leaned heavily on Kohut’s only son, Thomas, for certain assumptions that underlie the structure of this biography. The first of these assumptions is Thomas’s conviction that the famous case history of Mr. Z (1) is a disguised autobiographical study by Kohut (pp. 310–312). Strozier admits that it will never really be possible to know for certain if the famous paper on Mr. Z was autobiographical or not; “the proof is all circumstantial” (p. 314). Kohut never said that this case was autobiographical. Strozier amasses arguments for and against Thomas’s conviction at various places in the text. One must keep in mind that whether the case history of Mr. Z was autobiographical or not, it was written for rhetorical purposes. Kohut used it in an attempt to demonstrate the superior efficacy of a self psychological analysis over a traditional Freudian analysis. According to Kohut, Mr. Z’s first analysis, which was traditional, was unsuccessful and was superseded by a successful self psychological analysis. In the first hundred or so pages of this book, Strozier leans heavily on the Mr. Z publication as if it reliably gave details of Kohut’s life. The second assumption requires accepting a number of anecdotes about Kohut’s unpleasant behavior, including some reported by his son that are quite depreciating of his fa-
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ther. The philosopher and historian Collingwood warned us against historical study based on collecting and reporting statements and anecdotes; he called this “scissors-and-paste history” (2, p. 77). There is a great deal of mother-bashing at several places in the book, based on Kohut’s discussion of the cases of Mr. A and Mr. Z and Thomas Kohut’s remarks, as well as on the experiences of others that involved Kohut’s unusual mother, Else. Strozier concludes, for example, that Kohut “seemed unable to escape the toxic influences of his own ‘bad mother’ ” (p. 265). Mother-bashing is somewhat out-of-date in psychoanalytic thinking, as Strozier himself is aware, and he recognizes that Kohut’s mother was a remarkably capable woman. Like her son, she immigrated to the United States and built a successful life for herself. Kohut’s relationship with his mother was extremely complicated, and we do not have sufficient information about his early life to get a convincing picture of it. The assumption that the case history of Mr. Z is reliably autobiographical is not above suspicion, and so the first hundred pages of Strozier’s biography must be read with a certain skepticism. The issue of Kohut’s personality comes up repeatedly. At times Kohut seems so grandiose in this biography that he is almost psychotic, as, for example, in the description of his behavior in the hospital reported by a nurse (pp. 323–324) and his behavior at social gatherings, especially after he became ill (p. 234). In other situations described here he shows extraordinary empathy with patients and students. Kohut could be very cruel and destructive at times, and at other times he could be very empathic and supportive. Everyone seems to agree that he had a certain charisma; using this, he engaged in the questionable procedure of gathering disciples around him, many of whom were his analysands or students, and, at least in some cases, exploiting them rather ruthlessly and publicly humiliating them. When I saw him at meetings he appeared to be a self-satisfied and highly effective speaker. The central lesson of Strozier’s biography and of my own text on self psychology (3) is that no analyst or psychodynamically oriented psychotherapist who has studied self psychology will ever practice in quite the same way as before, even if he or she rejects the theoretical postulates and principles of infant development that Kohut evolved in his later life. There is something unique about Kohut’s writings and his approach that leaves a lasting impression when carefully studied. Strozier is right when he emphasizes again and again that Kohut’s influence loosened the shackles that bound traditional psychoanalysts of the mid-20th-century and allowed them to become more humane and empathic with their patients without guilt and without feeling they were violating technique or introducing “parameters.” Strozier mentions several issues that are certain to offend some readers. For example, there is no clear explanation of how Kohut evaded the draft in World War II. Also, Kohut’s attitude toward his Judaism can only be described as insulting to any person of Jewish faith. Strozier says that “Kohut began presenting himself ethnically as half-Jewish at most (and not Jewish at all if he thought he could get away with it)” (p. 75). His loud and arrogant demand for a ham sandwich in a kosher delicatessen as reported by Ornstein (p. 188) ought to offend everybody. This is an issue Kohut never resolved. We are told that “Kohut could be mean and insulting, but even at best he was exceedingly arrogant” (p. 86). His behavior with his Am J Psychiatry 158:11, November 2001
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first serious girlfriend, and his habit of never apologizing “for his rage, for his arrogance, or for hurting his friend” (p. 86), help to explain why he was such a controversial figure. His wife and his son implored him repeatedly not to be so narcissistic, but he replied that he could not help it. Nobody could deny that Kohut had an extraordinary mind, “arrogant and peculiar” (p. 139) as he was, but some of his disciples carried matters to an extreme in their idealization of him. He was an elitist (p. 114) who had no patience with those who had less education or culture than himself, and he aroused a great deal of envy among his colleagues. It did not help that “he was never open about himself, and was generally remote” (p. 128) and that “he was very impressed with himself” (p. 177). In summary, he manifested poor interpersonal relationships, especially in matters of intimacy, and one senses that he had difficulties with his only son. The greatest strength of Strozier’s book is in his description of Kohut’s publications, and it serves as a nice ancillary text for those who are interested in the study of self psychology. The book is divided into five sections, titled Vienna, In the Footsteps of Freud, Breaking Free, A Theory and a Movement, and The Birth of a Hero. Strozier’s cogent and relatively lucid analysis of Kohut’s publications also repeatedly announces that Kohut rejected “drive theory” and “demonstrated how ridiculous” (p. 222) it was. This is one of the areas where the reader will have to decide whether Strozier is right, especially by examining Kohut’s published comments on this matter directly. Kohut’s final years were characterized by advancing cancer, which, if we are to believe the reports in this book, resulted in an exacerbation of his worst qualities. He stopped reading the psychoanalytic publications of others. As his theories developed, Kohut, who was at one time the president of the American Psychoanalytic Association and regarded himself as “Mr. Psychoanalysis,” was subjected to ostracism and the loss of the friendliness of a number of his colleagues. The conditions for yet another split in the psychoanalytic movement were ripe, and some of his disciples urged him to form an institute separate from the Chicago Psychoanalytic Institute. He refused to do so, even though, according to Strozier, some of his power and prestigious positions at the Chicago Institute were taken away from him. Strozier tells us that, in his final years, Kohut’s “bragging and self-centeredness in social situations was nearly out of control, driving his son at times to distraction” (p. 323). Kohut was a refugee from Austria; he left at essentially the same time Freud escaped. He started out in the United States as a resident in neurology and a disciple of Richard Richter, the chairman of the Department of Neurology at the University of Chicago. Richter was an outstanding neurologist, and he was very disappointed when Kohut moved into the field of psychoanalysis, in a career somewhat parallel to that of Freud. In his final years, self psychology became Kohut’s total preoccupation, and he seemed to relegate almost all psychogenic difficulties to pathology of the self. His final work (4) was posthumously published, so Kohut was not able to have the work edited and to make final corrections and emendations. “Empathy” gained an increasing significance for Kohut, and he became convinced that empathy by itself had a curative effect (p. 347), stirring up a storm of controversy among psychodynamic psychiatrists and traditional psychoanalysts. Am J Psychiatry 158:11, November 2001
These controversies continue (3), but self psychology has certainly become one of the most important channels available to us for understanding patients (5). Regardless of whether one is convinced of the validity of self psychology, the importance of Kohut’s work cannot be overestimated because of the powerful personal impact that it has on anyone who takes the trouble to study it. Although I have raised some questions about the historical accuracy of this biography and I suspect that professional historians will have some complaints about it, I strongly recommend it to anyone who is interested in the practice of psychodynamic psychotherapy. It is an important contribution to the literature. References 1. Kohut H: The two analyses of Mr Z. Int J Psychoanal 1979; 60: 3–27 2. Collingwood C: The Principles of History. Oxford, UK, Oxford University Press, 1999 3. Chessick RD: Self Psychology and the Treatment of Narcissism. Northvale, NJ, Jason Aronson, 1985 4. Kohut H: How Does Analysis Cure? Chicago, University of Chicago Press, 1984 5. Chessick RD: Psychoanalytic Clinical Practice. London, Free Association Books, 2000
RICHARD D. CHESSICK, M.D., PH.D. Evanston, Ill.
WOMEN
AND
MEN: GENDER ISSUES
Mothers at Work: Effects on Children’s Well-Being, b y Lois W. Hoffman and Lise M. Youngblade. New York, Cambridge University Press, 1999, 352 pp., $54.95; $19.95 (paper). Hoffman and Youngblade point out that one of the major social changes in the United States is the increased employment of women, but especially women with children. In 1940, 8.6% of mothers with children under 18 worked outside the home. By 1996 that percentage had risen to 70%. Obviously the dual demands of employment and parenting affect the father’s role, which in turn affects family structure, functioning, interaction patterns, and child-rearing orientation. However, as Hoffman and Youngblade state in this book, we know amazingly little about how the mother’s employment status affects families and children. The authors researched 465 families with elementary-age children who attended public school in an industrialized city in middle America with lowto-moderate unemployment rates. Their sample consisted of middle-class and working-class families; an estimated 20% of the families were classified as living in poverty. It is important to note that the researchers had a complete data set for 369 of these families. The structure of Mothers at Work can be described as a 300page research article. The book opens with an introduction and review of the literature (chapter 1) followed by a chapter on methodology. Chapters 4 through 11 analyze data obtained from mothers, fathers, children and their peers, teachers, and school records. Each chapter concentrates on a theme and places findings within the context of the broader literature. Themes covered include the husband-wife rela-
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tionship, maternal employment and child outcomes, child rearing, and the mother’s well-being. Chapter 12 offers a summary and review of the research findings. This book also includes a special chapter by Hoffman and Allison Sidle Fuligni (chapter 3) describing what researchers learned about family life from interviews with children. The combined data analysis and literature review is at times overwhelming. Hoffman and Youngblade summarize their findings by noting, Twenty years ago, it would have seemed strange to do a study of maternal employment and not focus on it as a social problem, but there is little in these data to suggest that it is. The bulk of what we have found is that most families accommodate well to the mother’s employment and in doing so provide a family environment that works well. (p. 292) In fact, one is left with the impression that families with stay-at-home moms might be a social problem. As one example, daughters of employed mothers displayed better social and academic competence, had a greater sense of efficacy, scored higher on three achievement tests, and were rated by teachers as showing fewer learning problems (p. 289). In spite of the vast array of data collected the reader is at times left thinking, What about…? For example, what about the mother’s work environment? No data were collected on hours worked per week, job stresses, degree of autonomy, salary ranges, and so on. Of course, one must realize researchers have to make choices about what to study. They can’t study everything.
and related diagnoses, including bereavement and grief, personality disorders, eating disorders, and alcohol and drug abuse; adolescent, premenstrual, and postpartum mood changes; gender issues in psychopharmacological and psychotherapeutic treatment; and feminist perspectives on the etiology, manifestations, and treatment of mood disorders in women. Myths are countered with empirical evidence: women’s alcohol dependence is not less serious than men’s; mood disorders and substance abuse are distinct and not different manifestations of the same underlying condition. The book is replete with interesting data and theories, such as why women with premenstrual dysphoria and eating disorders crave carbohydrates. The identification of gaps in the literature should be an inspiration for researchers. Most chapters cite and summarize large numbers of relevant studies, although some analyze the literature more critically than others. There is similar variability in the degree to which chapters integrate psychosocial with physiological perspectives and in the inclusion or omission of tables of information such as medication doses and attributes, with more information about hormones than about antidepressants. There is significant content overlap among chapters, but the overlap enables each chapter to stand on its own as a reference or material for a didactic course. This is a purpose for which this volume is apt; it offers a wealth of information for the general professional reader as well. NADA L. STOTLAND, M.D., M.P.H. Chicago, Ill.
Masculinity and Sexuality: Selected Topics in the Psychology of Men, edited by Richard C. Friedman, M.D., and
JOAN FERRANTE, PH.D. Highland Heights, Ky.
Jennifer I. Downey, M.D. Washington, D.C., American Psychiatric Press, 1999, 200 pp., $31.50 (paper).
Mood Disorders in Women, edited by Meir Steiner, M.D., Kimberly A. Yonkers, M.D., and Elias Eriksson, M.D. London, Martin Dunitz, 2000, 558 pp., $135.00.
This compact book is part 5 of the 18th volume of the popular annual Review of Psychiatry series edited by Drs. John Oldham and Michelle Riba. It does well as a stand-alone book because it is very specific in focus and greatly appealing in content. As the subtitle suggests, Drs. Friedman and Downey, both psychiatrists, have earmarked areas of clinical inquiry in the huge field of men’s studies. For each of these areas they found authors who write well and generally uniformly. Friedman and Downey’s purpose, noted in the foreword, is to “remind us that the practice of psychiatry is a human enterprise, a fact sometimes overlooked because of recent economic pressures on health care delivery.” How true! Chapter 1, “Sexual Fantasy and Behavior: Selected Clinical Issues,” is written by the editors. This is a beautifully crafted chapter with lots of distilled wisdom and decipherable language and concepts. A pithy sentence from their conclusion speaks volumes: “Human sexuality tends to be neglected by modern mental health clinicians.” Friedman and Downey remind us of the importance of sexual fantasy in our patients, including common differences between men and women and the close association of erotic fantasy in men with masculine self-esteem and, at times, shame. Restricting their exposition to psychodynamic psychotherapies, they outline sexual history-taking from the initial visit to later in treatment. Particularly illuminating are their insights into how our countertransference inhibits male patients from disclosing sexual fantasies and their thoughts about how disguised sexual conflicts may
Why is the incidence of depression twice as great in women as in men? Is this true in every culture and every stratum of society? What does it have to do with gender roles and the position of women in a given society? What are the connections between changes in mood and changes in women’s hormones premenstrually and postpartum? Why does the gender difference begin at puberty and taper off after menopause? With depression a predominantly women’s disease, what do we know about sex differences in risk factors, symptoms, presentation, comorbidity, and responses to treatments? We have only recently begun to raise these questions, but the neurohormonal, social, and psychological research they have engendered has fascinating implications for both men and women. We do not have definitive answers to any of the questions, but we may now have the definitive resource for those scientists and clinicians interested in the current state of knowledge. This book is hefty in both size and substance. The content is divided into 31 compact, discrete chapters, encompassing every facet of the issue, from epidemiology through evolution, neuroanatomy, neurochemistry, and psychoneuroimmunology. The book deals with the effects of female-sex and male-sex steroids on brain and behavior; comorbid disorders
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contribute to disorders on both axis I and axis II. They challenge the term “sexual addiction” and define sexual impulsivity and compulsivity as more accurate representations of this behavior. The remainder of the chapter reviews such important matters as internalized homophobia, sexual symptoms (fantasy and activity) in men with severe personality disorders, and the controversial area of sexual orientation conversion. “Male Heterosexuality” is the title of chapter 2 by Stephen Levine, M.D., who provides an exhaustive analysis. He defines male heterosexuality as “an evolving mental organization that directs the sexual and romantic interests and behaviors of males toward females for the vast majority of their life span” and describes four stages in its evolution: proto-heterosexuality (before puberty), adolescent heterosexuality, adult heterosexuality, and the final accomplishment (i.e., genuine nonsexual appreciation of the capacities, roles, and styles inherent in women’s lives). Although his biopsychosocial explanations of sexual drive, motive, and wish are very good, Levine’s discussion of psychological intimacy in men and its relationship to eroticism is brilliant. He argues that impediments to a mature capacity to love sexually can lead to psychiatric difficulties. Stanley Althof, Ph.D., a psychologist, and Allen Seftel, M.D., a urologist, are the authors of “Evaluation and Treatment of Erectile Dysfunction.” In this age of “Viagra overkill,” it is refreshing to have a scholarly review and update of the subject. Their chapter reviews definitions, prevalence, medical risk factors, physiology, and cutting-edge gene therapy. Their model of evaluation integrates biological and psychiatric theories, as does their multidisciplinary treatment approach. Their process of care model has six phases, in which diagnostic tests, oral agents, interventional approaches, and individual and couple counseling are outlined. “Fatherhood as a Transformation of the Self: Steps Toward a New Psychology of Men” is written by William Pollack, Ph.D., a prolific author in the field of men’s studies. He calls for a rethinking of male development and reviews much of the classic and recent work in this field. He argues that many boys and, later, men are at risk for empathic disruptions in their affiliative connections because of the “push” for autonomy in childhood and traumatic separation from their mother with no alternative nurturance provided by their fathers. He calls for a balance of the “I” (autonomy) and “We” (affiliation) in men, not an either/or dichotomy. He celebrates fatherhood and sees this as a second chance, an opportunity to repair the psychic damage secondary to a forced disidentification from early maternal love objects. Extending beyond the self, a nurturant fatherhood will be a benefit for a man’s children, his partner, and society in general. The concluding chapter, “Casualties of Recovered Memory Therapy: The Impact of False Allegations of Incest on Accused Fathers,” by Harold Lief, M.D., and Janet Fetkewicz, M.A., addresses a current and painful subject. These authors provide an overview of the phenomenon of recovered memories and discuss the role of suggestion and their results from interviews with accused fathers from the False Memory Syndrome Foundation in Philadelphia. The impact of a false accusation cannot be underestimated—it becomes a defining feature of a man’s life. The authors share with the reader how men are affected emotionally, their typical coping mechanisms, and the implications for their work, marriages, and parenting. This Am J Psychiatry 158:11, November 2001
study is a beginning—we can expect more scholarly work on this group of men. All psychiatrists who treat men can learn something from this small book, whether their patients live with psychoses or V codes. The text builds on other more general works of the past decade (1). The editors and authors are to be commended for their lucidity, richness of detail, and keen sensitivity toward men. This book is highly recommended! Reference 1. Fogel GI, Lane FM, Liebert RS (eds): The Psychology of Men: Psychoanalytic Perspectives. New Haven, Conn, Yale University Press, 1996
MICHAEL F. MYERS, M.D. Vancouver, B.C., Canada
The Adonis Complex: The Secret Crisis of Male Body Obsession, by Harrison G. Pope, Jr., M.D., Katherine A. Phillips, M.D., and Roberto Olivardia, Ph.D. New York, Free Press (Simon & Schuster), 2000, 288 pp., $25.00. The enjoyment and frustration of this book start from the very beginning. As a lay book, it is fascinating. As a book for the scientific community, it has some problems. Adonis was a beautiful Greek youth who was a source of jealousy between the goddesses Aphrodite and Persephone, a being of incestuous origin whose death came by pathological jealousy. Adonis was more appropriately a character for a Dallas-type soap opera than an individual in crisis because of his search for an ideal male body. He is known for his beauty, a quality greater than the more limited current ideal of pure muscularity. That having been said, the authors are truly experts in the issue of males and their body image concerns. They are most persuasive with the first half dozen or so case histories. It is apparent, from multiple sources, that men today are more concerned with their body image, their weight, and their shape than they were during the 1950s and the 1960s. This is supported by the increased degree of skin exposure in ads, by the evolution of action toys to more V-shaped mesomorphic bodies, and by measurements of Playgirl centerfolds. The book has 11 chapters with appendixes on calculation of fatfree mass index and diagnostic criteria for body image disorders as well as sources of help and an extremely well-documented set of references. The major point of chapter 2, “The Rise of the Adonis Complex,” is that fatness and body image issues are not only feminine issues. The visual depiction of males who are or are not taking steroids, the pictures of action toys, and changes in Playgirl centerfolds speak volumes. Although recent magazine advertisements are more likely to feature male bodies with minimal clothing, the implication that this ideal began around 1960 is problematic in view of the history of male body image as revealed in what we know about Sparta, the Roman Empire, the Renaissance (the statue of David is actually more like Adonis in the book’s concept than Adonis), and, as recently as 1900, Theodore Roosevelt’s promotion of masculine muscular development. Historically, the male ideal revealed a more global view of masculinity than mere muscularity (1–5). Chapter 3 gives a simple test to assess the presence of the Adonis complex. Chapter 4 progresses to the area of muscle dysmorphia, an area almost exclusively mined by these experi-
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enced authors. The dangers of anabolic steroids are described in chapter 5, fear of fatness in chapter 6, and other body obsessions such as hair, breasts, and genitals in chapter 7. Perhaps of greater concern in terms of public health is the “bleeding down” of typical adolescent and young adult male concerns to young boys who no longer have the option of waiting until puberty to deal with their body image. Heterosexuals versus homosexuals are discussed in chapter 10. The idea that “the Adonis Complex may just be more announced in the gay community, not necessarily more pronounced” is not supported by the findings in other studies that gay men are just behind heterosexual women in terms of desire for thinness. Chapter 11 helpfully guides men with the Adonis complex and their loved ones to getting help. The emphasis in the help section is on cognitive behavior therapy and selective serotonin reuptake inhibitors, both validated forms of treatment. Somewhat lacking is a clear definition of what exactly the Adonis complex is, whether an overvalued belief, an obsessive-compulsive disorder, or a kind of delusional state. These authors are probably the most experienced team in the United States in dealing with these disorders. At a minimum their book is enjoyable reading. Enjoy the book with your noncritical eyes and brain, accepting the jazziness of the title as conveying sex appeal more than accuracy. Poor Adonis has been gored again, but his spirit will certainly rise once more. References 1. Holtsmark E: Ancient societal fascination with appearance much like our own. Daily Iowan, Sept 21, 1993 2. Drewnowski A, Yee D: Men and body image: are males satisfied with their body weight? Psychosom Med 1987; 49:626–634 3. Siever M: Sexual orientation and gender as factors in socioculturally acquired vulnerability to body dissatisfaction and eating disorders. J Consult Clin Psychol 1994; 62:252–260 4. Bullfinch T: The narcissist, in What Is a Man? 3000 Years of Wisdom on the Art of Manly Virtue. Edited by Newell W. New York, Harper, 1999, pp 56–58 5. van Deth R, Vandereycken W: The striking age-old minority of fasting males in the history of anorexia nervosa. Food and Foodways 1997; 7(2):119–130
ARNOLD ANDERSEN, M.D. Iowa City, Iowa
DEMENTIAS Practical Dementia Care, by Peter V. Rabins, M.D., M.P.H., Constantine G. Lyketsos, M.D., M.H.S., and Cynthia D. Steele, R.N., M.P.H. New York, Oxford University Press, 1999, 278 pp., $34.95. The title of this book is most appropriate because the authors reveal in their work the importance of psychiatric care for demented patients and their commitment to this care. Demented patients are not just medical cases with particular diseases, but patients with a disease who have specific and practical needs for care. As patients with dementia become ill,
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their reliance on others increases significantly. The quality of the response to these patients often determines whether their capacities and emotional balance can be enhanced. These patients can be helped substantially. The authors write well, mostly without jargon and in direct, clear statements, so reading this book is easy and inviting. They are interested in patients with dementia and have something to say about how they can be helped. The first third of the book covers definitions, evaluations, and formulations of dementias. Dementia is considered a syndrome associated with a decline in cognitive capacity; multiple areas of cognition are affected, but there is a normal level of consciousness. Two types of dementia-based patterns of cognitive impairment are recognized, cortical and subcortical. Cortical dementias are distinguished by the loss of cognitive capacities and the capacity “to do.” Patients with subcortical dementia lose the ability to coordinate cognition but often can “do it.” For example, a patient with cortical dementia can’t remember and can’t do things, but a patients with subcortical dementia may think slowly and need clues but can remember or “do” with aids. The dementias associated with cortical syndromes are described in one chapter: Alzheimer’s, frontotemporal degeneration, disseminated Lewy body disease, and the prion dementias, along with their distinct clinical picture, epidemiology, and pathology/etiology. In the following chapter, the diseases associated with a subcortical or mixed pattern of dementia are described: Parkinson’s, progressive supranuclear palsy, Huntington’s, normal pressure hydrocephalus, multiple sclerosis, HIV and AIDS, cerebrovascular disease, depression-induced cognitive impairment, traumatic brain injury, and various toxicities. The authors stress the importance of making a specific diagnosis of the cause of dementia because this conveys important knowledge about prognosis and, therefore, more effective treatment. There are good chapters on supportive care for demented patients and on supporting the family caregiver. Following this is an excellent discussion of common behavioral and psychiatric problems seen in the dementias (catastrophic reactions, resistance to care, apathy, aggression, wandering and pacing, hoarding, yelling, mood disorders, and hallucinations and delusions) and their understanding and suggested treatments. There is a good discussion on pharmacological treatment of the dementias that covers cholinesterase inhibitors (tacrine and donepezil), antipsychotics (atypical agents are usually preferable because of fewer and milder side effects), and antidepressants and mood stabilizers. Selective serotonin reuptake inhibitors are usually preferable to tricyclics. The book ends with very useful and thoughtful suggestions for handling the terminal phase of dementia and about ethical and legal problems. For example, should a severely demented patient be told of their spouse’s death? Probably not, because it may lead quickly to the patient’s own death and it serves no purpose. This is a very good book for those of us working with demented patients. I strongly recommend it. MICHAEL R. BIEBER, PH.D. Dallas, Tex. Am J Psychiatry 158:11, November 2001
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Diagnosis and Management of Dementia: A Manual for Memory Disorders Teams, edited by Gordon K. Wilcock, Romola S. Bucks, and Kenneth Rockwood. New York, Oxford University Press, 1999, 391 pp., $39.95 (paper). This is a highly specialized book, and for those in the process of setting up dementia clinics or memory disorder programs it will be very useful. With the increasing longevity of the world population, there is a clear need for clinical programs that can assess, diagnosis, and treat people with dementia and memory impairments. The care of the patient with dementia is similar to that of the patient with schizophrenia in that it is best to have a team involved in diagnosis and management. Members of the team include a medical dementia specialist (usually a geriatrician, neurologist, or psychiatrist), primary care physician, radiologist, neuropsychologist, psychologist, social worker, nurse, occupational and speech therapist, and, often, clergy. It is to potential members of this multidisciplinary team that the book is directed. Each of the chapters is well written, complete, and informative. However, the chapters that concern specific specialists will serve as nice but unnecessary reviews for them. For example, “Differentiation of the Common Dementias” will be of little interest for a dementia specialist but would be very informative for a social worker, nurse, radiologist, etc. In this sense, the book would be very educational for the staff of a dementia clinic because it would assure a similar critical knowledge base for the whole staff. There are chapters on administration and organization; information management; medical assessment; psychiatric assessment; laboratory, radiological, and neurophysiological investigations; neuropsychological assessment; the role of the speech and language therapist; functional assessment; and computerized cognitive assessment. There is an excellent chapter on age-related memory impairment. Management is covered by nice chapters on the role and support of the caregiver, pharmacological treatment, and nonpharmacologic treatment as well as a fairly comprehensive overview of the management of common problems such as aggression, wandering, sleep disturbance, and ethical issues. Each chapter has a comprehensive bibliography. There is a very interesting and useful appendix, which consists of demographic data about the dementia clinics of the contributors to the book. As the contributors represent 12 clinics in North America, nine in the United Kingdom, and six from the rest of Europe, the data on clinic staffing, data and assessment instruments, and patient load and characteristics are very useful for those planning a new clinic. This book would be of use to any dementia or geriatric clinic; it is directed at a multidisciplinary audience and in this sense would also be a good text for trainees who are thinking of working with geriatric populations. GARY J. TUCKER, M.D. Seattle, Wash.
Drug Treatment in Dementia, by Roy Jones, M.D. Malden, Mass., Blackwell Science, 2000, 115 pp., $29.95 (paper). This book is a concise compilation of the latest findings regarding the diagnosis and treatment of dementia. Roy Jones successfully reviewed a number of publications in geriatric medicine, neurology, psychiatry, and other fields to compile Am J Psychiatry 158:11, November 2001
the book. The scope of the book includes epidemiology, diagnosis, evaluation of treatment response, drug treatment for cognitive and behavioral symptoms, and other issues that govern use of drugs in these patients. This pocket-sized book was written for doctors working in primary and specialty care, but it will be most useful for primary care physicians, residents, medical students, and nurses. It is easy to read, with judicious use of epidemiology and research findings, and clinicians will find it practical and useful. This review will describe the book’s highlights and key contents and will make suggestions for future editions. The book offers much practical information for clinicians, particularly those who would like to read a quick summary of information on a given topic. The organization of material is generally helpful in terms of the style, organization, and methods of communicating information. The cover is attractive and tables in chapters 1 and 2 are efficient in summarizing symptoms, diagnostic criteria, and epidemiology of dementia. Chapter 3 has a concise summary of scales used to identify and monitor cognitive deficits and problems with activities of daily living in preparation for and in response to treatment. Chapter 4 has a concise review of the pharmacology and clinical trials of acetylcholinesterase inhibitors and other medications being evaluated for use in dementia. The book succeeds in outlining many important issues that provide the context for good clinical care. The principle of evaluating a patient’s baseline and continuing evaluation (e.g., with scales) is clearly outlined. The author also addresses when to start and stop therapy, use of guidelines and treatment protocols, ethical issues, and pharmacoeconomic considerations. In addition, psychosocial interventions and treatments for behavioral symptoms are reviewed; these interventions are critical because behavioral symptoms are the strongest determinant of institutionalization. Finally, aspects are offered in chapter 7 to address common medical problems that affect symptoms and delivery of care (e.g., pain, nutrition, vision and hearing difficulties, diabetes, and terminal care). A few changes should be included in the next volume. It would be helpful to have illustrative cases to demonstrate how one literally uses cognitive tests, laboratory tests, and imaging to diagnose patients rather than offering a compilation of information about the tests. The primary care physician’s difficulty in diagnosis is acknowledged in the introduction, and this book could address this difficulty further in future editions. Algorithms and tables could also be used to synthesize information and guide treatment (e.g., a table in chapter 4 for comparing the dose, side effects, cost, and other practical tips of the acetylcholinesterase inhibitors in order to get beyond facts and provide more useful information on using the drugs). In addition, headings are not easy to follow because of the formatting (e.g., chapter 4), and the use of bullets in many chapters is ineffective because of the margins used and the lack of spacing, which prevents quick review of the bulleted items. Finally, space permitting, it would be relevant to provide information on the pros and cons of evaluation and treatment of age-related cognitive decline and mild cognitive impairment, since early detection and treatment may push back the onset of Alzheimer’s disease. DONALD M. HILTY, M.D. ELMER E. GURMAI, M.D. Sacramento, Calif.
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Concepts of Alzheimer Disease: Biological, Clinical, and Cultural Perspectives, edited by Peter J. Whitehouse, M.D., Ph.D., Konrad Maurer, M.D., Ph.D., and Jesse F. Ballenger, M.A. Baltimore, Johns Hopkins University Press, 2000, 312 pp., $55.00. Alzheimer’s disease has been dubbed “the disease of the 20th century,” an appropriate if dubious honor for an illness that at the close of the century was diagnosed in 4 million living North Americans, including a former president of the United States. Interest in the disease described by Alois Alzheimer in 1907 largely fizzled out in the first 50 years of its life. Alzheimer’s disease was considered a rare cause of presenile cognitive decline until the penny dropped in the 1960s and 1970s, when clinicians who were seeing older people with dementia noticed that most of this group had neuropathological features of the condition. This “rediscovery” of Alzheimer’s disease and the subsequent exponential growth in both the number of people afflicted by it and academic and commercially sponsored research makes for a fascinating story. How ironic that a disease whose main feature is loss of memory should itself be forgotten for so many years. Just as our amnestic patients may painfully rediscover the death of their parents and changes in their neighborhood since their childhood, the story of Alois Alzheimer has also been the subject of some remarkable recent rediscoveries. Peter Whitehouse and the other editors of this book have put together what I am sure will prove the definitive account of exactly what happened to Alzheimer’s disease in the last century. The book arose from the collected proceedings of a symposium held in 1997 to celebrate the life and legacy of Alois Alzheimer and the neuroscientists of his generation. Fittingly, the symposium was held in Alzheimer’s birthplace and childhood home in Marktbreit, Germany; the house itself was another rediscovery, made in 1989. The house was purchased by Eli Lilly and Company and converted into a museum and conference center. Within 2 days of the opening of the restored and converted Alzheimer Haus, Konrad Maurer and colleagues, searching the dusty basement of the Johann Wolfgang Goethe University Hospital, rediscovered the case notes of Auguste D, Alzheimer’s famous first case. The details of that case, with photographs of Auguste D, her case file, and her handwriting, plus, for the morbidly curious, a picture of Alzheimer’s grave can be found in the book’s first chapter. The contributions that follow cover everything else, from the history of the Alzheimer’s Association to the latest developments in molecular biology. I read this book with great pleasure, and it will share a special place on my bookshelves with the other books that I don’t really want to lend to my colleagues in case they don’t return them. The contributors were well chosen, and the editors took their responsibilities very seriously to ensure that there are no false notes among the chapters. Anybody who works with people with dementia will find that this book enriches their perspective on the disorder. We still have pathetically little to offer patients with Alzheimer’s disease in the way of disease-modifying treatments. Perhaps in 2100 the great-grandchildren of the contributors to this book will be writing more optimistically about this area. ROBERT HOWARD, M.D., M.R.C.PSYCH. London, U.K.
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FORENSIC TOPICS The Hidden Prejudice: Mental Disability on Trial, b y Michael L. Perlin. Washington, D.C., American Psychological Association, 2000, 400 pp., $49.95. The hidden prejudice is sanism. Other prejudices like racism, sexism, ageism, anti-Semitism, etc., are no longer hidden. It is the task of Michael Perlin in this book to expose sanism (again). The book is both scholarly and passionate, as befits a long-time writer, educator, and polemicist. Perlin is a professor at New York Law School and has served as director of public advocacy in New Jersey. He is the winner of the Manfred Guttmacher award for his book The Jurisprudence of the Insanity Defense (1), which I had the opportunity to review for the Journal (2). Sanism stays hidden because the most liberal advocates for eliminating the other “-isms”—lawyers, judges, psychologists, and psychiatrists—perpetuate sanism. We base our actions on ordinary common sense in the face of substantial statistical evidence to the contrary. For instance, there is a common belief that many individuals are allowed to commit crimes of violence because of the insanity defense. The use of pretexts (“pretextuality”) is widespread through the legal system. For instance, states pass laws to treat offenders in prisons but fail to hire professionally competent people to provide the treatment. Passing the law, consequently, is a pretext. Having established his basic premises of sanism and pretextuality, Perlin goes on to demonstrate how each area of mental disability law is affected by their presence. He starts with civil commitment. The landmark cases of O’Connor v. Donaldson (3), Jackson v. Indiana (4), and Lessard v. Schmidt (5) are revisited. None of these decisions is sanist or pretextual, but the reality has not been a “robust” interpretation of these cases and is fraught with sanism and pretextuality. Perlin deplores the “morality” of mental health professionals, citing Paul Chodoff for “benevolent paternalism” and David Lamb for interpreting civil commitment laws too “literally.” Perlin goes on to review the right to treatment, right to refuse treatment, right to sexual interaction (brave man), the Americans With Disabilities Act (too soon to evaluate), competence to plead guilty and to waive counsel (fine points for a forensic psychiatrist), and, in due course, the insanity defense. He notes the powerful effect of high-profile cases. Here’s an example of Perlin’s range. I chose it from the chapter titled “The Right to Refuse Treatment,” in my state known as medication over objection, an area in which the practicing psychiatrist is frequently called upon to testify. • Consider all the right to refuse treatment issues that are touched on by sanism and pretextuality. • The attitudes of trial judges toward patients. • The attitudes of counsel toward patients. • The implication of courts articulating expansive remedies in class action litigation without providing counsel to represent patients in individual cases. • The assignment of non-specialized counsel and uneducated judges. • The failure of appellate courts to take seriously the pro forma quality and nature of hearings in many instances. Am J Psychiatry 158:11, November 2001
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• The propensity of decision makers to make incompetent equivalent with makes bad decisions. • The perception of positive relationship between implementing the right to refuse and failed deinstitutionalization policies. • The perception of drugs as the only “cure” for “dangerousness.” All psychiatrists should read Professor Perlin. We have a great deal to learn, and he is a superb teacher. Many of us may be infuriated by his polemics and feel for our illustrious colleagues who are portrayed in unflattering ways. However, which one of us is never a secret sanist or practitioner of pretextuality? References 1. Perlin ML: The Jurisprudence of the Insanity Defense. Durham, NC, Carolina Academic Press, 1994 2. Bluestone H: Book review, ML Perlin: The Jurisprudence of the Insanity Defense. Am J Psychiatry 1996; 153:284–285 3. O’Connor v Donaldson, 422 US 563, 573 (1975) 4. Jackson v Indiana, 406 US 715, 32 L Ed 2d 435 (1972) 5. Lessard v Schmidt, 349 F Supp 1078 (ED Wis 1972)
HARVEY J. BLUESTONE, M.D. Bronx, N.Y.
A poorly arranged retainer contract or inappropriate fee arrangement can set the expert witness up for damaging attacks on his or her credibility later in the case or failure to be properly compensated. The book provides a full treatment of the attitudes, practices, and qualifications of medical and mental health expertise in the legal arena. The book devotes several chapters to content areas, including forensic aspects of alcoholism and drug abuse, brain injury, photographic evidence, and a review of the infamous O.J. Simpson trial. Current standards for the admissibility of scientific evidence are also reviewed in detail. Physicians appearing in court who expect judges, attorneys, and juries to accept opinions based on medical authority may be set up for a rude, ego-bruising awakening. Post-Daubert v. Merrill-Dow Pharmaceuticals, Inc. (1), criteria for admissibility of scientific evidence are now the standard in federal and some state jurisdictions. Finally, the last chapter outlines the code of professional conduct of the National Forensic Center. This guide provides a framework for avoiding hazards and missteps and promoting high-quality expert witness services. Although Ethics in Forensic Science and Medicine is not a substitute for proper training and established competence, it provides comprehensive and in-depth coverage, integrating the wide range of issues within the covers of a single volume. Reference
Ethics in Forensic Science and Medicine: Guidelines for the Forensic Expert and the Attorney, edited by Melvin
1. Daubert v Merrill-Dow Pharmaceuticals, Inc, 509 US 579 (1993)
MARVIN W. ACKLIN, PH.D. Honolulu, Hawaii
A. Shiffman, M.D., J.D. Springfield, Ill., Charles C Thomas, 2000, 305 pp., $62.95; $47.95 (paper). Few would argue with the proposition that increasing numbers of medical and mental health professionals find themselves involved in the legal system. Wittingly or unwittingly, doctors may find themselves serving as witnesses in civil or criminal proceedings. One may end up in court as a result of having provided medical or mental health services to a litigant. Or one may more deliberately engage with the legal system as an expert consultant or witness. In either case, the legal arena is fraught with opportunities and risks for the nonlegal professional. Because of threats to one’s license and malpractice insurance, the old adage “forewarned is forearmed” is fitting for the physician facing a court appearance. Fear of injury in the legal arena is not, of course, the only reason for training and competence in the area. Work as a forensic expert is both professionally satisfying and lucrative. Reflecting the trend of increasing medical and mental health involvement in the courts, a plethora of books has been published in the last decade. These publications tend to provide varying quality and coverage of the subject matter. Ethics in Forensic Science and Medicine provides a comprehensive and in-depth treatment of laws, rules, procedures, and illustrative case material for the expert consultant/witness. It is not a book about professional ethics and risk management in general medical or mental health practice. The book addresses the issue of expert testimony across the full gamut from selection of an expert, legal rules and regulations governing expert testimony, ethical practice, the attorney-expert relationship, business and contractual arrangements, standards for the admissibility of testimony, report writing, and professional and ethical conduct. The area of business and contractual relations is especially detailed and rightly so. Am J Psychiatry 158:11, November 2001
Forensic Neuropsychology: Fundamentals and Practice, edited by Jerry J. Sweet. Royersford, Pa., Swets & Zeitlinger, 1999, 535 pp., $119.00. Litigation in recent decades has been a growth industry, so to speak, and forensic neuropsychology has grown along with it. The development of neuropsychology over the past 30 years as a subspecialty of psychology owes a great deal to its participation in legal proceedings in evaluating cognitive processes. Some say that lawyers more than hospitals or psychiatrists use the services of neuropsychologists, but the empirical data on it are limited (1). At Henry Ford Hospital, the major medical center in Detroit, approximately 25% of referrals for neurological testing come from medical clinics, 25% from neurology, 20% from psychiatrists, and 30% from lawyers and others (personal communication from K. Potel, head of neurological services at Henry Ford Hospital, Oct. 16, 2000). Since many of the cases end up in litigation, medical people ask for a neurological evaluation for that purpose. Attorneys avoid paying for the evaluation when the referral comes from medical services. Neurologists serve as expert witnesses in a variety of civil and criminal cases but mainly in personal injury cases dealing with alleged brain injury. The more than 200,000 annual automobile accidents in the United States generate much of the litigation involving head injury. For lawyers, the testbased nature (rather than interviews) of neuropsychology testing is appealing. The neuropsychological evaluation is a psychometric investigation of the behavioral manifestation of brain dysfunction. The testing is so sensitive that it always finds brain damage, much to the delight of plaintiff lawyers or
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defense counsel in criminal cases. By and large, proclaiming the “objectivity” of their testing, neuropsychologists have been more effective than psychiatrists in marketing their services in the legal area. This book provides up-to-date coverage of issues with which the clinical neuropsychologist must deal in the forensic setting. It is edited by Jerry Sweet, director of the Neuropsychology Service at Evanston Hospital and associate director of clinical training in the psychology department of Northwestern University. There are 15 chapters by 20 neuropsychologists, all of them highly regarded, and two legal experts. The text is organized into four sections: Fundamentals, Practice Expertise, Relevant Populations, and Parameters of the Forensic Arena. Sweet writes, There is little question that the strong scientist-practitioner foundations of clinical neuropsychology have provided essential empirical support for the development of the field, and, in particular, the development of clinical procedures that attract the attention of adversarial parties in need of relevant objective findings. (p. 469) He notes that the decision of the U.S. Supreme Court in 1993 in Daubert v. Merrill-Dow Pharmaceuticals (2) has established a new threshold for admission of information from experts. He adds, “No other healthcare field is better able, because of the strong connection between science and practice, to meet the consensual professional demands of the Daubert decision than clinical neuropsychology” (p. 469). Actually, neuropsychology may have no advantage in this regard in the courtroom. The Daubert decision has been found to have little or no applicability to the “soft sciences” (psychiatry and psychology), but it may work to the disadvantage of neuropsychology, as David Hartman of Rush University points out (p. 339). Daubert tightens the standard for “scientific testimony,” that is, the “hard sciences,” which may include neurology, given its reliance on quantitative measurements (3). The law puts fields of knowledge in one camp or the other (hard versus soft science) rather than on a continuum. Lawsuits require evidence regarding the cause, nature, and extent of any alleged injury. The questions are, What was the condition of the plaintiff prior to the wrongful act of the defendant? and What was the condition of the plaintiff afterward? Without adequate records of the plaintiff before the injury, it is difficult to make a judgment of the plaintiff’s deficits antedating the injury. Then, too, how is the cause of the injury assessed? A combination of factors, only one of which is brain functioning, determines an individual’s level of neuropsychological functioning. In a statement in 1996, the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology (4) warned,
Neuropsychological information is subject to intensive scrutiny in forensic proceedings and can be successfully challenged if it is over interpreted, obtained during the acute phase of an injury or when the patient is taking medications that might affect performance, ignores the presence of depression or anxiety when the tests were performed, or fails to take premorbid characteristics, developmental irregularities, and substance abuse into account. Over the years the courts have split over the question whether a neuropsychologist may give testimony on the issue of causation of brain injury. The majority of the states that have ruled on the issue have permitted such testimony, but others have ruled against admissibility of the testimony as falling “wholly in the realm of conjecture, speculation, and surmise.” A few courts have allowed it when presented in conjunction with medical testimony, and still others have said that the testimony is superfluous when “the disability followed the accident in an obvious sequence.” A few years ago, the Iowa Supreme Court set out a review of decisions allowing or disallowing the testimony (5). Notwithstanding quantitative testimony, neuropsychological reports submitted in litigation have presented conflicting views not only on cause of an injury but also on the nature and extent of the injury. The reports of neuropsychologists are dense, resembling those of radiologists; the details often result in an obfuscation of the truth (6). The various contributors in this book, as do other experts, attribute the conflicts in testimony to the pressures exerted in the adversarial setting. As is well-known, lawyers vary in how blatantly they communicate what they would like their expert to find. Not only neurologists but also psychiatrists will find the suggestions presented in this book helpful in preparing for the courtroom. Attorneys will also find the book helpful in understanding the practices, scope, and limitations of neuropsychologists. References 1. Lees-Haley PR, Smith HH, Williams CW, Dunn JT: Forensic neuropsychological test usage: an empirical survey. Arch Clin Neuropsychol 1996; 11:45–51 2. Daubert v Merrill-Dow Pharmaceuticals, Inc, 509 US 579 (1993) 3. Chapple v Granger (1994), 851 F Supp 1481 (ED Wash) 4. Assessment: neuropsychological testing of adults: consideration for neurologists: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 1996; 47:592–599 5. Hutchinson v American Family Mutual Ins Co, 514 NW 2d 881 (Iowa 1994) 6. Guilmette TJ, Hagan LD: The ethical neuropsychologist: courting the clinician. Clin Neuropsychol 1997; 11:287–290
RALPH SLOVENKO, J.D., PH.D. Detroit, Mich.
Reprints are not available; however, Book Forum reviews can be downloaded at http://ajp.psychiatryonline.org. Correction The third author’s middle initial was incorrect in the article “Limbic Responsiveness to Procaine in Cocaine-Addicted Subjects,” by Bryon Adinoff, M.D., et al., (Am J Psychiatry 2001; 158:390–398). The author’s name is Susan E. Best.
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Am J Psychiatry 158:11, November 2001
