BOOK REVIEWS
Forensic Psychiatry
Management of the Mentally Disordered Offender in Prison. GN Conacher. Montreal: McGill University Press; 1996. 142 p. Can$39.95.
Review by
Guyon Mersereau, MD, CM, FRCPC
Hamilton, Ontario
Who says you can’t tell a book by its cover? Black, with the title and author in gold. We hardly need look behind the title page to learn that “this book was made possible by . . . Correctional Service Canada.” In the beginning was “THE PROBLEM: There is quite possibly no single area of human endeavour that poses a greater ethical challenge to a free society than safe control of mentally disordered persons whose behaviour represents a significant social danger.” At the outset, it does not take much imagination to guess where this book is headed, but just to make sure you know, it declares: “It is the purpose of this monograph to examine the essential elements of a complete service for the MDO that can provide for eventual and safe release of the offender to the community.”
Thus our first lesson is that those of us who work in prisons serve primarily as handmaidens to the agents of social control therein: agents of the agents—not of the patients? The book, which is about equally divided (not counting appendices) into 2 parts: one on “management” and the other on “special issues,” adds little to what is generally known—at least to that odd collection of those people who do this kind of work. One exception to this general observation is the chapter on self-mutilation, which concentrates on the genital variety.
The following chapter on suicide was eagerly awaited— and bound to be a disappointment, but did it need to be as empty as this? Virtually ignoring the general literature on the subject, the review of prison suicides concludes that it “has shown only how little we know. Prediction and prevention of suicides are extraordinarily difficult in this high-risk environment.”
The author’s own data from Kingston, however, are more, if cautiously, encouraging. A graph shows a drop from 19 suicides in the 4 years preceding the introduction of ambulatory services in 1987 to 8 in the succeeding 4 years. The 19 suicides include 10 in 1986 (a likely spur to getting those services started), so a more valid comparison would be with the 13 suicides between 1982 and 1985. The epidemiology of contagion in prison is discussed in general, but not the epidemic of 1986 in particular. One is left hungry for details. Instead, we’re given the “CONCLUSION . . . Suicides in prison come in clusters, not all of which may be possible to explain.”
The more general epidemiology of the several-fold over- representation of psychoses (schizophrenia x 7, bipolar x 4) in prison populations relies largely on the Canadian prevalence surveys of Hodgins and Porporino (1,2). These now well-validated and replicated findings are acknowledged along with the recognition that only a small fraction of those people who are in need are ever seen in treatment. We are spared any description of the conditions of confinement of the untreated remainder.
The main burden of the book, which is found especially in the chapters on preparation for release, community supervision, and “the predictably dangerous mentally disordered offender,” concerns the perils and trials at the interface: what to do when he’s “done his time.” It is here that the author, albeit politely and obliquely, takes issue with the bulk of his colleagues to state the case for transfer, involuntarily if necessary, to hospital. The case is forcefully made in a series of graphic vignettes.
Now we can only wonder how the author, having himself made the same geographic transition, will maintain these views. Indeed, the newly emerging findings on the actuarial prediction of violence are presented in such a way as to lead a naive reader to believe, contrary to the more clinical view, that these predictions are more valid than those of harm to oneself.
From this reviewer’s perspective, which is still immersed in the works of Bruno Cormier (1919–1991), this work cannot but pale in the inevitable comparison. Lacking any depth, the picture of the “offender” is flat and foreign. Neither psychodynamics (short of a bit in Appendix B) nor psychotherapy is mentioned. Having excluded “the ethics of social control” on page 5, the chapter on “ethical considerations” deals only with the relatively minor issues of confidentiality (but not, of course, with the current federal Bill C-46), reporting abuse, and use of force. A very few staff problems are mentioned en passant, but there is no sense of “the watcher and the watched” interaction any more than there is of interaction between doctor and patient (3).
Furthermore, the dominant preoccupation with “safe control,” if not a creature of the politically exploited general fear of crime, at least panders to it. If goats aren’t good enough, and witches and communists are out of fashion, couldn’t we pick on somebody less vulnerable? Say, people who speak the wrong language?
Violence, whether episodic, endemic, or epidemic, has written much, if not most, of our history and prehistory. We can fairly confidently expect it to be with us in some form for a little while yet. We should still strive to do less of it to our patients than they do to us, whether as individuals or as a community.
We still await a nice little book to introduce students and physicians to the work with those who “do time” and to update and amuse some of the older hands at the game.
References
1. Hodgins S, Coté G. Major mental disorder among Canadian penitentiary inmates. In: Webster CD, Stermac L, Stewart L, editors. Clinical criminology. Toronto: University of Toronto Press; 1992.
2. Motiuk LL, Porporino FJ. The prevalence, nature and severity of mental health problems among federal male inmates in Canadian penitentiaries [No. R-24]. Ottawa: Correctional Service Canada, Research and Statistics Branch; 1992.
3. Cormier BM. The watcher and the watched. Montreal: Tundra Press; 1975.
General Psychiatry
Disorders of the Self: New Therapeutic Horizons. The Masterson Approach. JF Masterson, R Kline, editors. New York: Brunner/Mazel; 1995. 448 p. US$51.95.
Review by
Paul Steinberg, MD, FRCPC
Edmonton, Alberta
This collaboration between Dr Masterson and his colleagues is divided into 4 parts. The first part deals with the self in exile, a developmental self, and the object–relations approach to the schizoid disorder of the self. Most of this section’s chapters are written by Dr Kline. Chapter 1 describes the evolution of the schizoid concept in a concise and useful manner, with an excellent critique of Fairbairn’s approach. Kline, however, includes Winnicott’s work without referring to it, as if it were Fairbairn’s work. He emphasizes Guntrip’s schizoid dilemma between striving to maintain relatedness in order to achieve security and distancing in order to maintain freedom and independence from the object. He also describes Guntrip’s schizoid compromise, the goal of which is to protect one from the twin dangers of closeness and distance. Chapter 2 expands on Guntrip’s 9 schizoid characteristics and identifies the “secret schizoid,” who presents with an engaging interactive personality style. There is an excellent description of 3 clusters of schizoid characteristics with case examples. Kline, like Akhtar and McWilliams, integrates descriptive and psychodynamic considerations (1,2). In a very condensed chapter 3, he justifies the use of developmental theory and makes a useful distinction between external and internal symbiosis. It would be useful to readers who are unfamiliar with Mahler’s and Stern’s work to expand more fully on their theoretical contributions. Chapter 4 describes the representational world of the schizoid patient, including the nature of the conditions of attachment and the “deal” made between the schizoid patient and his or her significant others. I understood the “deal” to describe the conditions under which a schizoid patient may become attached, which involves a compromise in the conflict between closeness and security. For the schizoid patient, there is no conviction that a communication network is possible without grave risk. Kline refers to the anxiety of complete isolation and believes that around the age of latency, the schizoid individual becomes consciously aware that, no matter what he does, he cannot rely on his parents for the acknowledgement, affirmation, and approval he needs. He adds useful illustrative vignettes and describes Masterson’s rewarding (RORU) and withdrawing (WORU) object–relations units (3). The schizoid patient’s RORU is a master and slave unit; the WORU is a sadistic object and self-in-exile unit. This chapter describes the schizoid patient’s inner world in a readable and succinct manner. Kline emphasizes the object as appropriator and suggests that there is an overlap between the experience of narcissistic and schizoid patients. Both experience themselves as extensions of their parents, but, in the schizoid’s case, the experience is more extreme, with no chance of receiving gratification for achievement. Rather, the future schizoid individual is dehumanized into a function.
I found Kline’s references to Masterson somewhat off-putting, resembling a disciple quoting his prophet. I agree that the only place where a therapist can stand that feels safe to the schizoid patient before a therapeutic alliance is established is at a safe distance, but I find Kline’s terms rather dogmatic. He emphasizes the need for the patient to assume responsibility for his thoughts, behaviours, and actions, and he emphasizes the importance of the therapeutic frame. The frame sets forth a baseline of expectations that the therapist can use to respond to the patient’s attempt to distort those conditions of adaptation and responsibility to him or herself, others, and the demands of reality. I agree but feel that Kline seems to be rigid in suggesting, for example, that a therapist should refuse to distort reality by being a secretary in lending his patient a pen to write a cheque. One might lend the pen and explore the meaning of this to the patient afterwards. (This reminded me of when Dr Masterson said, during our public supervision in front of 150 people long ago, that he does not provide tissue for his patients; if they want to cry, they can bring their own. In my opinion, it is appropriate to temper justice with mercy. Public supervision with Dr Masterson was a useful, if bracing, experience.) Kline writes cogently about transference acting-out, the importance of interpreting the schizoid dilemma, and the struggle between the dread of appropriation and the dread of total isolation. He also deals with countertransference acting-out in which the therapist responds to the transference acting-out of a patient, during which the therapeutic alliance may be seriously compromised. Kline skillfully illustrates how the patient may project master and slave or sadistic object and self-in-exile images onto the therapist, which facilitates the countertransference acting-out. He underlines the importance of the schizoid compromise to settle for a semblance of a relationship to others without the reality of it.
A chapter on shorter-term treatment describes goals and techniques to be used with schizoid patients. Kline clearly shows himself to be an experienced and thoughtful therapist who can express his impressions to his patient without imposing them on him. A chapter on intensive long-term psych-otherapy describes a case history in considerable detail. Kline’s chapters are well written and clear, for the most part, and they display a consistent approach to the understanding and therapy of the schizoid patient. They fit together well and flow from one to another in a coherent and logical progression. Chapter 8 discusses how to approach the treatment of the schizoid patient. Its brief introduction adds nothing to the preceding chapters and is followed by several short case histories, which reinforce the points Kline made but add little that is new to the book. Chapter 9 describes a case that superficially looks like a narcissistic personality disorder. I found the repeated references to the Masterson approach slightly irritating. I admire Masterson’s work but feel that the repeated references to Masterson and Kline would be more appropriate in a hagiography than in a scientific text. The rehashing of the schizoid dilemma in this chapter was repetitious.
Part 2, Early Trauma and the Developing Self, comprises 4 chapters, 3 of which are by Dr Candace Orcutt. She describes the need to “titrate the abreactive work on trauma with work on the character defences” with traumatized patients. Chapter 10 describes the way in which traumatic events that are experienced during the formative years affect the development of the self. Orcutt applies Freud’s original trauma theory to Masterson’s work. She makes the important point that sometimes the patient’s need to be objectively understood is overshadowed by the therapist’s need to separate an abused child or formerly abused adult from a label which suggests that a degree of pathology may exist in the victim. Orcutt argues that it may be necessary for the therapist to use hypnotic technique to pass through the repression barrier and enter the dissociative level of the work. She indicates that the goal is to proceed with care and respect for resistances in order to bring through the abreactive material in a safe way and assist its transformation into a conscious verbal narrative. She presents 3 case vignettes to illustrate her approach. Some psychodynamic therapists would be averse to using this technique. I include myself in this group but admit that I have not attempted to treat the very disturbed patients who suffer from both severe character disorders and dissociative conditions which Orcutt describes. Given the present controversy about dissociative identity disorder, Orcutt comes across as knowledgeable and generally credible, although I am uncomfortable with terms such as “separation work” and “trauma work,” the meanings of which are unclear. Orcutt has some impressive support in this field (2). Chapter 11 deals with child abuse in borderline patients and describes issues raised by departures from classic dynamic technique. She asks, “Can Freud’s way of listening to the unconscious be reversed into a way of talking to it?” This is a new concept for me, and I am wary of it. I was impressed with Orcutt’s caution regarding hypnosis and the ambivalence she expressed about using it. She refers to “age regression techniques” without explaining what they are. In chapter 12, Integration of Multiple Disorder, Orcutt describes attending her patient’s session with a hypnoanalyist. Such a parameter may be necessary, but I am not aware of therapists whose work I am familiar with and respect who do this. I was surprised that Dr Orcutt did not mention the controversy regarding recovered memories. She refers to the Internal Self Helper, which represents the spiritual aspect of the self and has been credited with paranormal abilities. I was not sure what to make of this reference, and I am not sure where the spiritual fits in a text about psychotherapy. I accept that Orcutt was able to help significantly the difficult cases she describes having treated, but I have difficulty with some of the concepts she employs. It is sometimes difficult to understand what appears to be a reification of psychic structures. I am unsure how the unfamiliar terms she uses are more useful than the traditional terminology of object relations. It is difficult to read some of Orcutt’s dramatic descriptions, such as the “frozen redundant nature of Tunnel region.” I wondered whether this treatment was described in more complicated terms than was necessary. I suggest this humbly, because I admire the heroic therapeutic work that apparently is necessary to help these severely damaged patients. Orcutt appears to have achieved an impressive result in the case described. I would expect to find her work, however, in a book about the treatment of dissociative conditions. She does describe an integration of the Masterson approach to the treatment of character pathology with hypnosis to deal with dissociative symptoms, but her chapters appear discontinuous with the flow of the book. Chapter 13 explains the basis of the effects of continuous incest on one’s relationship with parents and the development of the self, as opposed to just considering the traumatic behaviour. Also, Carla Clark does not introduce new terms like Orcutt does. This book appears to present 2 approaches to the treatment of the abused patient: 1 conventional treatment and 1 heroic combination of approaches with somewhat arcane interpretations of what transpires, without an explanation of why the latter is necessary.
Part 3, Perspectives on Treating the Narcissistic Disorder of the Self, begins with a chapter that consists of a clearly written description of a closet narcissist. It is easily understood and offers a consistent application of the concepts Kline introduced. Chapter 15, The Devaluing Narcissistic Patient, presents 3 patients who are still in treatment at the time the chapter is written. It would be more convincing to use patients for whom follow-up years after treatment could be presented. I found myself wondering what the effect on the treatment was, especially regarding the transference and countertransference, of publishing aspects of treatment while the work is still in progress. It is difficult to say whether this might be helpful or hurtful, and one wonders whether the patient really can give an informed consent to this, even if he or she is shown the manuscript. Chapter 16, on devaluation in the therapeutic relationship, describes the differentiation between schizoid, borderline, and narcissistic devaluations in terms of motivation. A very apt case history describes the necessity for the therapist to tolerate his or her own narcissistic imperfections and to interpret the motivation and consequences of the narcissistic patient’s devaluation. Chapter 17 offers short, illustrative vignettes that are convincing but frustratingly brief. The theme involves defences against awareness of disappointment in the self, with a demand, implicit or explicit, for help from the therapist.
Part 4, Other Treatment Strategies, begins with Group Psychotherapy and the Disorders of the Self. Richard Fischer emphasizes the need for collaboration between the referring individual psychotherapist and the group psychotherapist. This raises some questions regarding confidentiality and boundaries. In my opinion, the danger of splitting is undoubtedly present. Fischer does not suggest that group therapy supplants individual therapy but, rather, suggests it as an adjunct treatment. A chapter about couples therapy describes the need for assessment to decide if couples therapy is appropriate, with little indication of what the decision is based on. The author emphasizes the importance of therapeutic neutrality and indicates that the aim of his approach to couples therapy is to alter the couple’s defensive operations sufficiently so that they are able to maintain a working alliance. He emphasizes that this therapy is not a substitute for individual treatment but an ancillary treatment which could be a prelude to individual treatment. Chapter 20, Working with the Collective Marital Self, describes an integration of family-systems theory and object–relations theory in a much more accessible style than Orcutt did in her earlier chapters. She indicates that the working through in marital therapy consists of tracing the acting out transference projections from their beginnings in the early relationships. She adds that the larger part of this task in the working through phase lies in the individual treatment, which, ideally, should support intensive marital therapy. The key word here is “ideally.” How much treatment can one family be expected to absorb? In the United States, it depends on how much they can afford to pay; this may soon be true in Canada as well. A chapter on antidepressants in psychotherapy describes the problems in terms of transference implications with prescribing antidepressants to borderline patients. In my opinion, the use of “endogenous depression” is anachronistic and not appropriate to the late 1990s. The author suggests that only 40% of patients admitted to psychiatric hospitals with a diagnosis of depression are helped by antidepressants. This appears to be a low figure, and no reference is given. The author could have elaborated on the important point that the prescription of antidepressants should be based on the clinical presentation of the patient: the more the patient’s state resembles a major depressive episode, the more an antidepressant is indicated. This is independent of psychodynamic factors, which, of course, need to be taken into consideration in the prescription of the medication. If a borderline patient has persistent depressive symptoms, it is highly questionable whether an antidepressant can be withheld ethically. A chapter describing the boundary between bipolar disorders and disorders of the self suggests an association between bipolar illness and narcissistic disorder of the self. It is unclear why the author seems to presume that bipolar affective disorder is a completely inherited disorder, as opposed to being a multifactorial condition which involves environmental factors. This chapter demonstrates a useful integration of biological and psychological approaches, more honoured in the breach than in the observance. The author emphasises that patients need to be helped to manage their feelings about medications and to work with them, rather than the physician insisting that they do or do not take medication a certain way. He adds that the regulation of affect by medication may allow psychotherapy to proceed and, therefore, permit change in psychic structure.
Overall, I found this to be a useful, well-organized text, which, for the most part, adumbrates Masterson’s theories in a readable way. The book fulfils the purpose for which it was written quite well. The authors are all competent on the subject, and the book is of considerable topical interest. For the most part, it is written clearly and, although not brief at 435 pages, it is economical in its use of space. The volume is attractive in layout, free from production errors, and fairly reasonably priced. I find the Masterson approach a trifle restrictive compared with Akhtar’s and McWilliams’ work, although these authors integrate many sources in their work, whereas Masterson’s work, based on Mahler’s theories, involves a more specific approach (1,2).
References
1. Akhtar S. Broken structures: severe personality disorders and their treatment. Northvale (NJ): Jason Aronson; 1992.
2. McWilliams N. Psychoanalytic diagnosis: understanding personality structure in the clinical process. New York: Guilford; 1994.
3. Masterson JF. Psychotherapy of the borderline adult. New York: Brunner/Mazel; 1978.
The American Psychiatric Press Textbook of Consultation–Liaison Psychiatry. JR Rundle, MG Wise, editors. Washington (DC): American Psychiatric Press; 1996. 1171 p.
Review by
David Attwood, MD
J Robert Swenson, MD, FRCPC
Ottawa, Ontario
The Textbook of Consultation–Liaison Psychiatry grew out of the Concise Guide to Consultation Psychiatry, which was published in 1987. While this proved to be a popular and clinically practical publication, there remained the need to create a comprehensive text that would fill the void at the interface of medicine and psychiatry. By the very nature of this area, professionals who choose to work in consultation–liaison psychiatry are required to access and coordinate a very broad range of information from multiple disciplines. This compilation attempts to be that resource. I (DA) had the opportunity to use and evaluate this book during a 3-month rotation in consultation–liaison (CL) psychiatry during my third year of psychiatric residency. The book itself is relatively large at 1171 pages, and its 44 chapters are divided into 4 sections: 1) General Principles, 2) Psychiatric Disorders in General Hospital Patients, 3) Clinical Consultation–Liaison Settings, and 4) Treatment. There are approximately 100 contributors, and each chapter is extensively referenced.
Section 1, General Principles, provides an overview of the background and practical setting of CL psychiatry. Most topics are covered in standard psychiatric references, including neuroimaging, mental status examination, neuropsychological and psychological perspectives, and suicidality. The section about economics is generally irrelevant for psychiatric practice in Canada, and it is also in this section that the book’s political motivation becomes apparent. A large amount of text is dedicated to documenting CL psychiatry as a psychiatric subspecialty. Furthermore, there is a suggestion that CL psychiatrists more closely resemble medical doctors than their non-CL colleagues. This is perhaps a reflection of the American experience and the battle for funding that is unfolding in that country (and on the horizon in Canada).
The strength of this book lies in the 2 middle sections. In Section 2, the discussions about psychiatric disorders in general hospital settings are informative, comprehensive, and clinically practical. Especially good coverage of delirium, somatoform disorders, and approaches to substance-related disorders is provided. Here, and throughout, the differences in minimal practice standards between the United States and Canada are evident. Eating disorders are covered from an essentially medical perspective, and psychological treatments are covered briefly and superficially. The chapters on mood and anxiety disorders, sexual dysfunctions, sleep disorders, and factitious disorders provide good information and make an effort to illustrate specific problems encountered in the CL setting.
Section 3 is a discourse on psychiatric illness found in patients with specific medical and surgical illnesses and also the settings within which CL psychiatrists must work. The sections devoted to specific medical and surgical conditions make no effort to be comprehensive. Rather, they remind this reviewer of lessons lost since medical school, such as terminology, course, prognosis, and comorbidity. The goal is to provide sufficient background to enable meaningful discussions between professionals and to offer a level of perspective to the psychiatrist (or resident) who is often swamped by “unreasonable” consultations. The chapter on geriatrics, while brief, attempts to point out the unique difficulties seen in this population, without repeating what is covered elsewhere in the book. There is a discussion on medical–psychiatric units which focuses on the administrative difficulties in defining and operating such a unit.
Finally, Section 4 attempts to cover treatment issues in approximately 140 pages. Obviously, the book has shortcomings. A chapter on psychopharmacology gives only minimal coverage of the serotonergic antidepressants, valproic acid, and the novel antipsychotics. The role of psychotherapy is covered from the “medical” model and advocates a brief, vaguely interpersonal style with an emphasis on understanding the “personality type.” The need to be eclectic and flexible is emphasized. The chapter on electroconvulsive therapy goes into slightly greater detail on topics that are usually listed merely as “relative” and “absolute” contraindications in other texts. The jewel in this section is the chapter on the management of chronic pain—the terminology, epidemiology, pathophysiology (which requires close reading), and comorbidity with other psychiatric conditions are all presented. The information on pharmacotherapy of chronic pain is inclusive but brief, and, appropriately, a multidisciplinary approach to the treatment of chronic pain is advocated.
Overall, this book is an admirable attempt to unify and define what has been a fragmented field in psychiatry. The quality of the writing is very good, and the authors are all well known. In many ways, it is a valuable contribution to the literature, and it may assist in further establishing CL psychiatry as a subspecialty in its own right. I would have to think twice before buying it, however. It is expensive, and similar information is available from other books on my shelf. Furthermore, its comprehensiveness has come at the expense of the utility that made its predecessor a success. Consultation–liaison psychiatry is practised on the run, and a book this size stays in the office. While it does not stand alone, I would recommend the Textbook of Consultation–Liaison Psychiatry to fellows or staff who are specifically involved in CL psychiatry and to general psychiatrists who struggle to provide comprehensive care in underserviced areas. For psychiatric residents, it is perhaps best accessed via the library on an “as needed” basis, at least until the second edition is published.
From the perspective of a full-time CL psychiatrist who works in a teaching hospital, I (JRS) believe this book is an excellent resource for medical students and psychiatric residents, and it is also useful for patient care. I was disappointed that the chapter on international perspectives did not have a section devoted to Canada, despite sections on the status and development of CL psychiatry in several European countries, Australia, and Japan. Notably, the introductory chapter on the history of CL psychiatry is written by Dr Zbigniew Lipowski, a Canadian psychiatrist who is considered by many to be the father of modern CL psychiatry, and 2 other chapters are written by well-known Canadian CL psychiatrists, Dr Susan Abbey and Dr Mark Halman. I agree with Dr Attwood that this book may not be essential for all psychiatric residents to buy, but I would recommend its purchase by residents who have a strong interest in CL psychiatry and by psychiatrists who work in general hospitals and are involved in treating patients with comorbid medical and psychiatric illnesses.
The Prevention of Mental Illness in Primary Care. T Kendrick, A Tylee, P Freeling. New York: Cambridge University Press; 1996. 398 p. US$49.95.
Review by
George Voineskos, MD
Toronto, Ontario
This book is the creation of the departments of General Practice and of Psychiatry at the well-known St George’s Hospital Medical School in London, England. The 3 editors are senior academic staff members of the Department of General Practice, and 13 of the 23 contributors are members of either the General Practice or Psychiatry departments.
The book was published shortly after the fundamental reforms of the British National Health Service were introduced in the early 1990s. Briefly, these reforms have included the closure of mental hospitals and a shift of the care of mentally ill patients into the community; the movement of psychiatrists, psychologists, psychiatric nurses, and social workers out of the hospitals and into general practice settings; and payments to general practitioners for health promotion. Thus the traditional general practice has become multidisciplinary, namely, the primary-care team, and general practitioners are more involved in prevention. Consequently, the book is topical because, as the editors state, it is intended for general practitioners, other members of the primary health care team, mental health professionals working in primary care, and academics and educationalists.
The book consists of an introduction by the editors and 20 chapters, which are organized into 3 parts. Part 1, titled At-Risk Groups, consists of 7 chapters, which are devoted to primary prevention in childhood, the relevance of life-events, prevention of depression, bereavement, prevention in ethnic minorities, prevention in people with learning disabilities, and the role of counselling in primary prevention. Part 2, designated Early Detection in Primary Care, contains 6 chapters, which deal with secondary prevention in childhood, the prevention of depression, of anxiety disorders, of eating disorders, of alcohol and drug misuse, and the early detection of psychosis in primary care. Part 3, named Limiting Disability and Preventing Relapse, includes the last 7 chapters of the book, which are dedicated to tertiary prevention in childhood, tertiary prevention of depression through drug treatment, cognitive therapy and psychological treatments, the regular review of patients with schizophrenia in primary care, the prevention of social disability in schizophrenia, the continuing care of long-term mentally ill patients, and the prevention of suicide.
The book has been written in a clear, concise, and didactic manner, and it is based on sound research. The references are well selected and useful for further reading. The references for the chapter about the prevention of anxiety disorders are preceded by a list of 8 “useful texts for patients,” which constitutes a helpful paradigm for patient education that, unfortunately, is not followed by the other chapters. Each chapter contains practical suggestions, which are highlighted in boxes. The book is nearly free of production errors, and the subject index is very useful.
In any book with so many contributors, it is inevitable that there will be some variability among the chapters. Some chapters are excellent. The chapter on life-events admirably summarizes the relevant research and its application to prevention, the chapter on bereavement is a superb account of this universal topic, the chapters on secondary and tertiary prevention of depression and that on the secondary prevention of anxiety disorders are very good. The chapter on the prevention of suicide, although very useful, could have been longer, and the section on the aftermath of suicide deserved expansion.
The prevention of mental illness is fraught with a myriad of problems, a reality of which the editors are well aware, especially in primary prevention. Thus, in the introduction, the editors acknowledge that “many of the predisposing factors, such as poor housing or unemployment, seem beyond the control of professionals in primary care,” and they quote another investigator “the mental health of society . . . reflects its social economic and political structure.” At this point psychiatric epidemiology and prevention merge into social policy.” Earlier in the foreword, Professor David Goldberg, citing as an example the unexplored possibilities for primary prevention of the systematic education of school children in child-rearing and parenthood, suggests that little has been done in primary care through health-promoting information. Professor Goldberg thus concludes that “the authors of this book have therefore confined themselves to high-risk groups.” This conclusion is articulated in detail by the editors, whose aims of the book are to illustrate the available preventive strategies in mental health and to give specific practical advice to primary health care teams (p 4,8). The book fulfils its aims when the reader takes into consideration that prevention is mostly confined to high-risk groups.
While the book has been written for the British scene, it nevertheless contains a wealth of information and practical advice, which will be very useful to practitioners and students in this country, specifically family physicians, psychiatrists, family practice or psychiatry residents, medical students, and people of other mental health professions, especially those who practise in the community. The price of the book is reasonable.