Posts Tagged ‘mental health’

A Primer of Supportive Psychotherapy

A Primer of Supportive Psychotherapy

Pinsker H

Hillsdale (NJ): The Analytic Press; 1997. 278 pp. with index

ISBN 0-88163-274-0 (cloth)

Convincing evidence has accumulated that the supportive or nonspecific component, common to most forms of psychotherapy, is responsible for most of the change that results from psychotherapeutic interventions. This component appears to be both supportive — in that it is derived from the quality of the therapeutic relationship — and technical — in that it stems from the contract established with the patient and the use of nonspecific interventions. Specific interventions drawn from different schools of thought account for surprisingly little of the variance in outcome for most disorders, with the possible exceptions of panic and obsessive-compulsive disorders. The implications of these findings are clear. All mental health clinicians, regardless of their field, should be well versed in nonspecific interventions, and clinical training should emphasize integrated or so-called transtheoretical perspectives. Unfortunately, both practice and training tend to lag behind research. Many clinicians continue to rely on specific psychotherapeutic models, and training rarely gives nonspecific interventions the weight that they deserve, although there is some evidence that this is changing.

In this context, Dr. Pinsker’s very practical little volume is a useful addition to the growing number of texts on supportive therapy. Although one might disagree with some of the ideas and with the theoretical model that lies behind the volume, one must agree with the tone. This is the work of a sensitive and humane clinician who respects his patients. The approach emphasizes a conversational style and a responsive approach, rather than listening silently or interrogating the patient. The volume offers a model worth emulating. Anyone who adheres to the spirit of this work will not go far wrong, nor will his or her patients come to harm.

The value of this work lies in the large number of examples of the kinds of statements patients typically make and the clinician’s possible responses. The topics discussed include most of the key issues in therapy: increasing self-esteem, reducing and preventing anxiety, promoting adaptive skills, building a treatment alliance, and so on. These topics are explored through specific examples that include illustrations of helpful and less helpful responses that therapists may make. It is these examples that make this book especially helpful as an introductory text. Here is an experienced clinician talking in a common-sense way about the nuts and bolts of therapy. This makes for a style that is at times a little dull but replete with clinical wisdom. The simple practical examples will be helpful to a neophyte clinician who is learning how to conduct assessment and therapy interviews. They may also be worth a brief perusal by those who are much more experienced, who may be surprised to recognize bad habits unwittingly accumulated over the years.

The volume is not without limitations. Two issues are worthy of comment. First, some of the examples are a little sparse, and the discussion of alternative responses by the clinician is a little limited. Hence, the implications of the different possible therapist responses may not always be clear to the beginning therapist. More problematic is the theoretical perspective that runs through the volume. This is classically psychodynamic; hence, much is made of the distinction between supportive and expressive therapy. With increasing emphasis on integrated approaches, this distinction is less important. It may also be a little dated. The problem emerges on the first page when supportive therapy is differentiated from expressive therapy in terms of technical considerations. These are defined as using a conversational style, viewing the patient-therapist relationship as a real relationship that is not analysed, and supporting defences that are not maladaptive. Perhaps the important issue is not the distinction between supportive and exploratory therapy — which is important only to those who espouse the psychoanalytic tradition — but rather the degree of intrusiveness and the extent to which generic mechanisms are used to effect change. Dr. Pinsker describes these clearly, although in different terms. Consequently, it is easy to put theoretical issues to one side and concentrate on the practical component of the book. In this regard, the volume meets its goal of being a is a useful primer.

Pharmacology of Anxiolytic Drugs

Pharmacology of Anxiolytic Drugs. WHO Expert Series on Neuroscience, vol. 3

Racagni G, Masotto C, Steardo L

Seattle (WA): Hogrefe and Huber; 1997. 132 pp. with index

ISBN 0-88937-088-5 (cloth)

This monograph forms part of the World Health Organization’s expert series in neuroscience, which is intended to help prevent or control mental neurological disorders and psychosocial problems, as well as to ensure broad use of mental health knowledge in general health care within WHO member states. It is indeed a textbook of pharmacology and should be viewed as such.

The authors must be world renowned in the field of pharmacology and its clinical application, although I could find only one citation by one of the authors (a publication in Nature in 1979) through MEDLINE. As well, the authors do not cite themselves in the book, indicating either that they are modest or that their publications are now aged. The University of Milan, however, has a reputation for expertise in pharmacology.

The book begins with a succinct history of the search for anxiolytics. The comprehensive contents of the book are then divided into 4 groups. Group 1, on benzodiazepines, is the most comprehensive of the chapters and includes a detailed description of each of the benzodiazepines, including their 2-dimensional chemical formulae. There is an extensive discussion of action, side effects, dependance and interactions. Group 2 discusses compounds with benzodiazepine-like activity, and details agonists, partial-agonists and antagonists. Group 3 reviews compounds that act on nonbenzodiazepine receptors and includes a large discussion of the role of serotonin in anxiety. Group 4 considers the role of antidepressants as anxiolytics and includes tricyclic antidepressants, selective serotonin reuptake inhibitors, monoamine oxidase inhibitors, α2-adrenergic blockers and β-blockers.

Only generic drug names are used throughout the book.

This book is a very comprehensive, well-organized and crisp discussion of anxiolytic drugs, and includes scientifically backed clinical use. Remember, the title is Pharmacology of Anxiolytic Drugs, and so the rather dry chemical formulae, pharmacokinetics and pharmacodynamics seem clinically sterile. The authors include substances that we prescribe routinely as well as medications that are not very commonly used in this country but may be in other parts of the world.

There are other texts, such as those by Goodman and Gilman or by Schatzberg and Nemeroff, that are more enjoyable to read, but they are not as complete as this book, and they cannot be held in one hand. This book is not a light read, but is a good, comprehensive reference.

My main criticism is that there is a lack of reference to the clinical situation, but then, this is a textbook of pharmacology.

The readership is meant to include nurse practitioners, social workers, family physicians, and others, but I believe they would use this book only as a reference text. Psychiatrists, residents in psychiatry and anesthetists would find this book quite valuable.

Neural Networks and Psychopathology

Neural Networks and Psychopathology: Connectionist Models in Practice and Research

Dan J. Stein, Jacques Ludik, editors

Cambridge (UK): Cambridge University Press; 1998. 371 pp. with index

ISBN 0-521-57163-4 (cloth)

Neural networks are mathematical models of how the mind processes information, just as mathematical equations can be seen to describe the universe. Neural networks can provide the theoretical framework that clinical science lacks for integrating psychological and neurobiological data. This theoretical framework is based on the idea that the brain functions by a process of pattern recognition. Each chapter in this collection, edited by Dan Stein and Jacques Ludik, looks at this process from a unique perspective and, taken as a whole, demonstrates the complexity of the mind arising from basic units and their interconnections.

This book is aimed at a very diverse audience including clinicians, researchers in psychopathology and those working in cognitive science and artificial intelligence. Its chapters are organized into 2 broad sections. The first part of the book presents general concepts. Each chapter demonstrates how neural network modelling can be used to understand clinical practice and research in areas such as diagnosis and psychotherapy. The second part of the book constructs neural network models of various clinical disorders and demonstrates their usefulness in helping improve one’s understanding of the pathologic process underlying these clinical disorders.

A number of important ideas are introduced in the first section. For example, neural network or connectionist models “rely on the idea that almost all knowledge is implicit in the structure of the device that carries out the task rather than explicit in the states of the units themselves.” This means that knowledge is stored in the strength of the connections between units or neurons and not in the units’ moment-by-moment activity. Nevertheless, this activity does affect the strength of synaptic connections through the process of learning. This leads to an important dilemma: How can the brain be plastic enough to learn new patterns as well as stable enough to remember old patterns? Knowledge is stored as patterns of activation of neurons, determined by synaptic connections. This leads to another important concept: the function of the brain is to recognize patterns; and the effectiveness of the brain is measured by how accurately it can match patterns and by how well it can generalize (find similar patterns). When the brain becomes faulty in its ability to correctly discriminate patterns, clinical symptoms such as delusions and hallucinations can arise. Delusional individuals interpret all inputs in the light of some false belief. Any bit of information is used to support this false belief no matter how ludicrous the connection. Conceptually, the delusional brain continually matches all inputs to a specific incorrectly matching pattern; or in other cases, one pattern becomes central in interpreting all inputs. With respect to hallucinations, perception involves the superposition of sensory input with higher cognitive expectations, but if the system is strongly focussed on expectations and ignores sensory input then the system will perceive objects that are not there. Again the brain is unable to correctly match incoming patterns (sensory information) with stored patterns (memory or expectations).

In the second half of the book, specific clinical disorders are modelled, based on the basic principles from the first half of the book. The success of this modelling is both thought-provoking, in demonstrating how underlying neuropathology can result in complex symptomatology, and fascinating, by forcing one to reexamine previous views of psychopathology. The models very nicely integrate neurobiology and psychological data, and because the computer models are working models one can see how the brain might process information. Dan Lloyd looks in depth at how a new memory can affect previously learned related memories and vice versa. This process is addressed in the specific context of traumatic memories. He constructs a computer simulation, called Lucynet, that models human learning based on the most basic neural network theoretical principles. The simulation is exposed to the traumas of Sigmund Freud’s patient, Lucy R. The results of this recreation address several aspects of memory. They support the cognitive research showing that recall is the construction of a memory rather than its extraction from a form of storage. The results also show that repression can result from the inherent process of memory formation rather than requiring the hypothesis of a novel mechanism of the ego as proposed by Freud.

In another chapter, Ira Cohen gives an elegant working model of autism. Working from the neurobiological data, which suggests that autistic people have a greater number of synaptic connections, a greater number of neurons or abnormal wiring patterns in various brain regions, combined with the recognition that autistic children are very poor at generalization, the computer model runs several scenarios of either too few, an optimal number or too many neurons faced with a learning task. “With too few neurons, the computer simulation shows that overall learning and generalization are weak and responses are inconsistent. With an optimal number of neurons, both learning and generalization are good and correct responding is consistent and predictable. With too many neurons, learning is good but generalization is poor and shows relatively little variation.” This inflexibility relates to the typically stereotyped and inflexible responses of autistic children. There is more depth and complexity to these models when presented in their respective chapters, but this brief summary may convey the ability of these simulations to recreate psychopathology while functioning with only the basic rules of learning in connectionist theory.

Although the term “neural network” or “neural net” is becoming popularized, at least in science fiction, it is not a well-understood concept. There are few, if any, psychiatry programs or even psychology programs that include it as part of their teaching curriculum. I believe that it will become increasingly advantageous to know something of this area. The scope of this book is wide and it is aimed at a diverse audience. Nevertheless, it is an important attempt to make this area more understandable. Each chapter is written by a different expert, and this format requires a strong introduction to pull the pieces together. The lack of this kind of introduction is the major deficiency of the book. This format also runs the risk of becoming disjointed. Luckily, this does not happen because the structure of the book itself allows for a significant amount of redundancy, and the concepts from the first half of the book are expanded on in the second half. There was only one chapter that I found quite incomprehensible because it was so poorly written. Generally, all authors focus more on concepts than on the details of how to construct and run a neural network model. This approach keeps the book accessible to the diverse audience to which it is aimed.

As a non-expert in the field of neural network modelling, I found the book absolutely fascinating because there are many concepts and reconceptualizations that do not require an intimate working knowledge of neural network theory. Still, some knowledge of neural network modelling is of benefit in appreciating the complexity of the issues. And I must point out that the subject matter is dense.

The editors open the first chapter with the following statement “The recent shift in psychiatry from a predominantly psychodynamic model towards a neurobiological paradigm has led to advances in our understanding and management of many mental disorders. At the same time this shift has been characterized as a move from a brainless psychiatry to a mindless one.” Neural network modelling has the capacity to reintroduce the mind even if not in all its complexity. This makes the final chapter by David Forrest on the challenges facing clinicians and researchers, as well as some of the potential limitations of neurocomputational modelling, an especially appropriate and thought-provoking conclusion to a book that challenges one to think.

Emergencies in Mental Health Practice: Evaluation and Management

Emergencies in Mental Health Practice: Evaluation and Management

Kleespies PM, editor

New York, The Guilford Press; 1998. 450 pp

ISBN 1-57230-255-0 (cloth)

In the introduction to this book, the editor points out that most training sites for psychology interns provide limited or no training at all in emergency psychological services, reflecting a general inattention to such services in the field of professional psychology. However, the editor suggests, if clinicians are to regard themselves as independent practitioners, they must be prepared to assist patients in the event of a life-threatening behaviour or a psychological emergency, whether in the office, the emergency department or elsewhere. Referring to psychiatry as a paradigm, he recommends that mental health disciplines incorporate training in the management of emergencies as a professional requirement. For the purpose of such training, the editor offers the structure of this book as “a proposed curriculum for a knowledge base in emergency psychological services/’ The book is structured into 6 parts consisting of 19 chapters. Most of the chapters have been written from the perspective of the mental health professional who must evaluate and manage a behavioural emergency in the emergency department or, occasionally, in another setting. Some of these chapters are excellent, offering useful and practical advice. This is especially true of the chapters on emergency interviews, evaluation and management of suicidal patients and potentially violent patients, and emergency telephone calls. The 2 chapters on risk management offer helpful reminders of the importance of consultation and proper documentation in dealing with suicidal or violent patients. A laudable feature, not found in other comparable books, is the devotion of 3 chapters to the stressful impact on the clinician of patient suicidal behaviour, violent behaviour and disaster. The weaknesses of the book are likely the result of the large number of contributors — 33 in all — with 2 to 5 authors in 15 of the 19 chapters. There is duplication between chapters, the writing style is variable, and even the perspective from which the chapters are written differs. For instance, the last chapter is written from the point of view of the psychologist. The entire Part 5, consisting of nearly 100 pages, is not about emergencies but about syndrome psychiatry and pharmacotherapy, which are best covered in a traditional text-book. Inconsistencies also occur. A notable example is that considerable effort is expended in the first 2 chapters to distinguish “crisis” and “crisis intervention” from “psychological emergency” and “emergency intervention,” and to dissuade the reader from using these terms interchangeably. However, in chapters 3, 4 and 6, either these terms are used interchangeably or new definitions are given. Some chapters would benefit from increased succinctness and decreased preoccupation with referencing every statement.

The inspiration for this book came from the editor’s considerable clinical and supervisory work with psychology interns in emergencies at the Boston Veteran Affairs Medical Center. The editor and the chapters’ authors, most of whom are psychologists, have created a book that will serve well psychology interns, their supervisors, and students and staff of other mental health professions in the evaluation and management of emergencies in mental health practice. I hope that this book will be a catalyst for increased training in this important but rather neglected field of mental health practice.

Women’s Health: Hormones, Emotions and Behavior

Women’s Health: Hormones, Emotions and Behavior

Regina C. Casper, editor

Cambridge (UK): Cambridge University Press; 1998. 328 pp

ISBN: 0-52156-341-0 (hardcover)

Cambridge University Press has initiated a very useful series of clinical texts in the area of psychiatry and medicine. The editorial board of this series is to be congratulated for its selection of books and for its uniformly high standard of publication. This book is no exception. It is a “must read” for all mental health professionals, both women and men.

Women’s Health: Hormones, Emotions and Behavior is well written and informative, but not overly detailed. It covers the important areas and keeps the reader’s attention throughout. Women’s health has become a popular topic and there has been a recent spate of books in this area. This is the best one. Although it is multi-authored, the editor has kept a strict rein on the contributors, has participated actively in each of the chapters and has ensured a high level of readability, comprehensiveness and up-to-date thinking on a common theme.

She has done what is very difficult to do — she has interwoven highly sophisticated neuroendocrine and neuropharmacological information and recent thinking about the impact of roles, functions, supports and losses in women’s lives so seamlessly that perspectives from many different fields are integrated into a complex framework. The readership will emerge not only with knowledge but also with wisdom.

The field of women’s health is evolving so quickly that the book is already a little out of date. The discovery of a second estrogen receptor and of several ways in which selective estrogen receptor antagonists affect and protect different body tissues all promise new insights and new therapies. The role of estrogens in Alzheimer’s disease is attracting new attention. Our increasing awareness of autosomal differences between the sexes, and of immune differences, will incrementally contribute to this field. As all this happens, women’s (and men’s) roles will change and diversify, and will no doubt induce hormonal and neurotransmitter changes, which perhaps will stand all the old findings on their heads. As we have recently learned, the expansion of the universe we inhabit is accelerating. So is knowledge in this field of study. This is a book we should all read to try to keep up.

Thérapie brève et intervention de réseau

Thérapie brève et intervention de réseau: une approche intégrée

Jérôme Guay

Montréal : Les Presses de l’Université de Montréal; 1992. 189 pp

ISBN 2-7606-1556-1 (papier)

L’auteur de ce livre de base souligne l’importance de la multidisci-plinarité pour traiter les personnes souffrant de troubles psychiques en pointant les interventions psychosociales comme composante indispensable des soins aux malades.

Dans le premier chapitre, il affirme que la psychothérapie est seulement efficace pour régler des problèmes mineurs. Malheureusement, ses références sont limitées et datent de plus de 10 ans. Au cours de la dernière décennie, de nombreuses études de recherche ont prouvé l’efficacité de la psychothérapie brève (thérapie cogni-tive du comportement, psychothérapie interpersonnelle et dynamique) pour des troubles mentaux sérieux.1 La psychothérapie à long terme, la psychothérapie de groupe et l’hospitalisation à temps partiel sont essentielles pour les patients souffrant de troubles psychopathologiques plus sévères qui manquent de soutien social.

L’auteur identifie les compétences essentielles du thérapeute pour améliorer l’alliance thérapeutique, p.ex., se montrer sincèrement intéressé, écouter et avoir de l’empathie envers les patients. Les principes de base de la psychothérapie sont abordés. Cependant, l’auteur a omis de définir clairement des concepts principaux, comme la résistance, le transfert et le contre-transfert. L’importance de garder des «limites» à l’intérieur de la relation thérapeutique est décrite brièvement mais elle n’est pas expliquée. Cela est inquiétant, compte tenu que la violation des limites est plus souvent initiée par le thérapeute et qu’elle cause des dommages psychologiques aux patients.

Le deuxième chapitre renferme un guide d’évaluation avec des questions utiles pour évaluer le degré de motivation du patient, le type de crise, la stratégie d’adaptation, les aspirations et le réseau de soutien. L’auteur, qui mène un rôle actif dans la promotion des programmes communautaires, souligne l’utilité de rencontrer les membres de la famille et les amis qui constituent le réseau de soutien social du patient. Cinq types de thérapie sont résumés. Parmi les faiblesses dans ce chapitre, je remarque l’absence d’une évaluation de la force du Moi, qui est un outil utile pour déterminer les contre-indications pour des psychothérapies brèves. De plus, à l’intérieur du guide d’évaluation, on ne fait pas mention du besoin d’éliminer les troubles médicaux qui peuvent simuler et (ou) compliquer des symptômes psychologiques. L’auteur n’a également pas abordé l’importance d’un renvoi à un psychiatre pour les patients qui ont besoin de phar-macothérapie pour traiter des symptômes graves.

Les troisième et quatrième chapitres sont intéressants et ils atteignent vraiment les objectifs fixés par l’auteur. Il encourage les praticiens à développer une confiance dans la pratique d’interventions psychosociales. Il élabore sur les jumelages entraidants, les groupes d’entraide, les groupes communautaires et d’autres ressources précieuses. L’annexe comprend des tableaux détaillés, des diagrammes et des questions qui sont pratiques et bien organisés.

Ce livre facile à lire est une bonne introduction pour les professionnels de la santé qui sont intéressés à connaître les évaluations et les interventions psychosociales. Les lacunes principales de ce livre sont l’absence de concepts essentiels de psychothérapie et le manque d’explication sur le moment opportun pour envoyer un patient recevoir des consultations médicales et (ou) psychiatriques.

J’apprécie le commentaire de l’auteur affirmant que la pratique de la psychothérapie requiert une formation clinique. Toutefois, en tant que psychiatre spécialisé en psychothérapie psychodynamique, je crois que nous devons maintenir les normes sociales et morales, chercher à obtenir la supervision d’experts qualifiés et obtenir beaucoup plus que deux ans d’expérience clinique. La compétence clinique est essentielle et fondamentale à la pratique de la psychothérapie.

Problem Drinking

Problem Drinking, 3rd edition

Heather N, Robertson I

New York: Oxford University Press; 1997. 226 pages

ISBN 0-19-262861-5 (paper)

This book was somewhat of a challenge to review. Increasingly, recent empirical literature on substance-related cravings and relapses transcends the ideological boundaries and rivalries among 2 schools of thought: one characterizing addiction as a disease and one characterizing it as a learned behaviour. Recently, there has been increased recognition of the complementary nature of these approaches and a promise of improved patient outcome; Problem Drinking is a setback from this position. The authors, Nick Heather and Ian Robertson, are well-known exponents of a social-learning theory in the United Kingdom, although, surprisingly, their credentials are not mentioned in the book. They present a sustained argument that problem drinking is best regarded as a learned behavioural disorder rather than a disease.

The book is divided into 2 parts: the first is “unapologetically destructive” and reviews the current evidence countering the position that problem drinking is a disease. This is accomplished in 4 chapters, which account for 60% of the book. The first chapter reviews the changes in alcohol consumption in Britain and the influence of the temperance and prohibition movements on the disease concept. The second chapter presents a critical overview of selected literature in which alcoholism is looked upon as a physical shortcoming, a mental illness or psychopathology, or an acquired addiction or dependence. The possibility that recovering alcoholics can drink normally is addressed in the third chapter, and evidence derived from epidemiological surveys and laboratory investigations is presented. The fourth chapter outlines the potential detrimental effects of considering problem drinking a disease, including the licence to abrogate responsibility, the labelling of problem drinkers and the requirement for abstinence, and discusses the legal and preventive implications.

This literature review is a selective one. Of note is the limited reference to the neuroscientific research supporting the disease concept. Much work has been conducted on the notion of acquired addiction or dependence since the publication of works by E.M. Jellinek and G. Edwards. The findings of the current systematic research program, backed by neuroimaging and largely funded by National Institute on Drug Abuse, are not mentioned. Regarding the presence of a possible physical marker of vulnerability, the work of investigators such as Begleiter and Schuckit are omitted. Of particular interest to psychiatrists, the review of the evidence of alcoholism as a psychopathology is limited to the conclusions of Freud, Adler and Menninger. Has anybody made a more recent contribution? This portion of the book does not shy away from statements against phenomena such as “12 step hysteria” and “medical imperialism.” The perception of a conspiracy theory emerges from this book, where holders of the truth are ignored by the field at large, if not victimized.

Feeling somewhat chastised, one looks forward to the book’s briefer second part where the new paradigm is described: the social-learning theory. After a brief historical introduction, the applications of several types of learning theory to alcohol use are described. In classical conditioning, for example, new stimuli or “cues” evoke the desire to consume alcohol. Problem drinking arises when people interpret manifestations of withdrawal as cues to drink. Tolerance arises because of the homeostatic processes produced by the body to counter the action of drinking. Cue-exposure treatments owe their effectiveness in part to the extinction of conditional tolerance and withdrawal. Alcohol, by acting as either a positive or negative rein-forcer, also exposes a person to instrument learning. Community-reinforcement programs and aversive treatment harness this form of learning to promote abstinence. Higher forms of learning include modelling after, say, a parent’s behaviour, and self-regulation, lack of which prevents the person from stopping drinking. Higher cognitive processes, such as expectations, learned helplessness and the reasons for helplessness, also determine how alcohol is abused. Popular therapeutic approaches such as Marlatt’s relapse prevention and Beck’s cognitivenbehavioural therapy have focused on countering these effects.

The last chapter outlines other potential applications of social-learning theory: treatment programs, non-medical staffing, counselling and social policies. Even the results of Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity), which showed no difference between 12-step facilitation, cognitivenbehavioural coping skills and motivational enhancement therapy are interpreted in support of a more cost-effective social-learning theory. In fact, the media in North America have opted to perceive the results as a vindication of Alcoholics Anonymous!

My overall concern about this book is the deliberate effort to present evidence against the disease model and in support of the social-learning theory. In effect, most of the clinical programs I know have incorporated quite successfully therapeutic approaches from both schools of thought. Currently, moderate problem drinkers are likely to be advised by their physicians to set a “sensible drinking” goal, whereas heavy drinkers will be counselled to abstain. The spectrum of alcohol-related disorders is well recognized. Most therapists will not exclusively use 12-step facilitation, cognitivenbehavioural coping skills or motivational enhancement therapy, but will use each of these approaches at different phases of treatment. The case for polarization may not be as excessive as the authors purport, and the complementary nature of these approaches is not addressed.

In 1993, the Sobells published a book entitled Problem Drinkers. In the first 30 pages they discussed the lack of differentiation between problem drinkers and chronic alcoholics and for the rest of the book described useful treatment approaches for problem drinkers. I found this publication much more clinically relevant, but would recommend Heather and Robertson’s Problem Drinking to students who are eager to steep themselves in one of our field’s controversies. The price is appropriate for a library.

Neurobiology of Violence

Neurobiology of Violence

Volavka J

Washington (DC): American Psychiatric Press; 1995. 397 pp with index

ISBN 0-88048-343-4 (cloth)

Human behaviours are extremely complex; human aggression and violence toward other human beings are the most complex of them all. Neurobiology of Violence by Jan Volavka is an important contribution to the understanding of this most complex of human behaviours. If you are a practising clinician (psychiatrist, physician, psychologist or other mental health professional), I recommend that you order this book immediately. If you are a psychiatric resident preparing for the specialist examination, I recommend that you beg, borrow, steal or preferably buy a copy of this book, as it should be an essential part of your reading list.

In the preface the author talks about her imprisonment in a Nazi prison at the age of 10, an experience that inspired her to study and understand the roots of violence. In the introductory chapter she discusses the concepts of biological and environmental reductionism and the 3 models of the nature-versus-nurture debate: the either/or model, the combined model and the transactional model.

The first chapter deals with semantics: definitions of aggression, violence and destructive behaviour, and the difficulties with these definitions. The author goes on to define crime and criminality and points out the flaws in the studies of crime rates, incidence and prevalence; she also discusses instruments for assessing aggression and hostility. Thus, in chapter 1 the author primes the reader for a critical review of various research studies on violence. Chapters 2 and 3 review studies of aggression in animals and human beings, especially the role of neurotransmitters and hormones. Chapter 4 deals with neurological, neuropsychological and electro-physiological correlates of violence. Chapter 5 covers congenital and demographic factors in the causation of violence. Chapter 6 deals with developmental antecedents of violent behaviour, including early childhood factors such as inappropriate parenting, attention deficit with hyperactivity disorder and physiological traits that interfere with the child’s ability to learn the inhibition of antisocial and aggressive behaviour. Chapter 7 moves on to the clinical area of personality disorders and impulse control. Specific types of impulse control disorders, such as intermittent explosive disorder and pyromania, are explained. Relevant research on the serotonergic system, glucose metabolism and electrical brain activity are reviewed. Chapter 8 deals with the important area of violence and psychoactive substance abuse. The effects of both acute and chronic use of alcohol and cocaine and other drugs — alone and in combination with alcohol — are discussed. The review of research on the effects of cannabis is topical, as there is renewed discussion of the decriminalization of the use of marijuana, especially for medical purposes.

Chapter 9 is probably the most clinically relevant chapter in this book. It deals with the violent behaviour of persons with mental disorders outside the hospital setting. The relation between major mental disorders, arrest rates (criminal behaviour) and violence is discussed. The author reviews various studies and evaluates the strengths and weaknesses of their methodologies and, consequently, of their findings. The author also discusses the concepts of criminalization of mental illness and “psychiatricization” of criminal behaviour. Prediction of violence and risk assessment are examined with findings from relevant studies. The author compares and contrasts the concepts of prediction of violence using clinical methods and actuarial methods. (There is an appendix on “Statistical explanation of the actuarial method: Bayes decision.”) The author goes on to analyze critically the limited number of studies and points out the “failure of psychiatric prediction of dangerousness.” Clinicians face the task of predicting violence in individual patients daily, in hospitals, emergency department and other clinical settings. This chapter describes the strengths and weaknesses in this task. The author’s willingness to state her opinion on controversial and complex issues is very evident in her review and analysis of findings from various studies of the prediction of violence.

Chapter 10 deals with the violent behaviour of psychiatric patients in the hospital setting. Chapter 11 discusses the pharmacological treatment of violence and problems in conducting research in this area. The use of drugs — including antipsychotics, benzodiazepines, 6-adrenergic blockers, lithium, antidepressants and anxiolytics — is adequately covered. Chapter 12 is a summary of the subjects dealt with in the previous 11 chapters. There are also 60 pages of references of all the studies referred to in the main text. This is followed by an 28-page index that helps the reader to locate information readily.

The author’s writing style is very enjoyable, and her ability to synthesize information from a large number of studies and arrange them in a clinically relevant sequence is very evident. The author has made an excellent contribution through this important book on the study and understanding of violence.

This book deals only with the biological aspects of violence. Any reader who wishes to understand the other facets of violence must rely on books dealing with nonbiological factors.

I hope that every clinician will get a copy of this book, since dealing with and predicting violence in psychiatric patients is an unavoidable task and this book helps immensely in fulfilling that task as an informed and erudite practitioner.

The Insider’s Guide to Mental Health Resources Online

The Insider’s Guide to Mental Health Resources Online

Grohol JM

New York: The Guilford Press; 1997. 326 pp with index

ISBN 1-57230-262-3 (cloth)

ISBN 1-57230-229-1 (paper)

This book is the sixth in the “Clinician’s Toolbox” series. The author, John M. Grohol, is a psychologist whose credentials and training are not specified but who has developed a reputation as an expert in psychological informatics. At his Web site (grohol.com), he informs consumers and answers simple questions about mental disorders and treatment. He apparently has a broad, in-depth knowledge of mental health resources on the Internet.

The author’s objective is to initiate the busy clinician to the World Wide Web; he guides the reader to what’s available and where to find it online so as to avoid surfing aimlessly. He critically evaluates numerous Web sites, making our journey into cyberspace easier.

The book is well organized and is divided into 4 parts: the first contains basic maps and tools for finding mental health information online; the second involves getting answers to your professional questions; the third is on patient education resources; and the fourth contains appendices and a useful glossary. For the novice Web-surfer, the first part is a very helpful introduction to the major resources online and the way search engines work. (Formulating a search question properly is essential to obtaining relevant information, whether it is a MEDLINE literature search or a search for a specific self-help group.) The second and main part of the book has specific chapters on finding information about disorders, treatments, employment opportunities and continuing education as well as on researching, networking and finding useful books, journals and software online. In one chapter, the author discusses psychotherapy and counselling online, and he clearly states the ethical issues involved. The third part contains 3 chapters listing patient-education resources and includes consumer mailing lists and news-group discussion and support groups. The fourth part has 4 appendices, one of which is a brief introduction to creating your own Web site.

I found the book to be free of errors (except for 2 minor ones) and easy to read. As a psychiatrist, though, I take exception with the author’s bias against electroconvulsive therapy. On page 195 he writes, “radical treatments such as electroconvulsive therapy (ECT)” and, on the next page, “About the only useful thing this site does offer is information on the pitfalls of ECT.” Elsewhere, he states his own biases clearly and reasonably.

One of the redeeming qualities of the book is the frequent reference to the “Insider’s Guide” online update page, which at the time of writing contained 3 pages of updates — mainly changes to uniform resource locators (URLs) and notices of “bad” links. Without such an update, this book would become outdated very quickly.

In conclusion, this book can help allay a middle-aged novice’s fears of the Internet and add another dimension to the communication of information, both among doctors and between doctors and patients. Although the book is targeted to a larger readership than the subscribers of this journal, it contains enough relevant material for me to recommend it to psychiatrists as well as allied health professionals interested in “psych” online.

Ethnicity and Family Therapy

Ethnicity and Family Therapy, 2nd edition

Monica McGoldrick, Joe Giardano, John K. Pearce, editors

New York: The Guilford Press; 1996. 717 pp with index

ISBN 8-89862-959-4 (cloth)

This is the much-anticipated second edition of this monumental work, which is the most comprehensive effort to date to review the particular features of families with different ethnic origins.

Different cultures lead human development in different directions. For instance, Eastern cultures have traditionally promoted the social human being, emphasizing each person’s capacity for empathy and social connection. Western culture tends to emphasize individuation and differentiation. Ethnic groups from other parts of the world also have important patterns of behaviour inherited from their culture. As they integrate into society, families remain rooted in cultural norms and therefore evolve in a larger context than can be accounted for by individual intrapsychic, interpersonal or socioeconomic influences. The authors of this book provide a kind of “road map,” guiding us through these cultural nuances, especially those that can cause difficulties: the book is not an assemblage of truths, but an accentuation of values.

The book is divided into 9 major chapters on American Indian families, families of African origin, Latino families, Asian-American families, Middle-Eastern families, Asian Indian families, families of European origin, Jewish families and Slavic families. Each chapter contains many more specific ethnic backgrounds. For example, a total of 19 different European origins are described in 3 of the chapters. Each major chapter begins with an overview covering immigration, demographic aspects, religion, similarities to and differences from other groups, specific studies in the group, family structure, etc. The contributors are themselves members of the ethnic groups discussed. The book presents factual information in politically correct language; controversies are sometimes mentioned but are generally avoided, as are stereotypes, reductionist views and oversimplifications. Each chapter is followed by a solid bibliography.

In the opening chapter, Mc-Goldrick and Giordano explore the clinical factors influenced by ethnicity. These include discussion and communication about symptoms, understanding of the causes of illness, attitudes toward health care providers, and expectations and wishes about treatment as well as the way that patients experience pain. These factors affect all of the relationships in the family, especially during times of distress and suffering when help is needed. Racism, social class, religion, the family life cycle and intercultural marriage are some of factors analyzed with experience and respect. The need for adequate ethnicity training in family therapy is stressed, and sound guidelines are offered that emphasize the need for therapists to come to terms with their own ethnic identity. Similar guidelines could be proposed for research, as the understanding of ethnicity in this field remains slow to emerge.

This book reflects a rich vision. It stimulates us to open our eyes and understand ethnicity in our practices. As a result, readers will recognize striking differences among families from different milieus, cities or countries. The second edition is an excellent revision and addition to the first edition. Its remarkable accumulation of insights makes it a must for any clinician (not only family therapists) confronting a world of individuals and families with different backgrounds.