Posts Tagged ‘psychologists’

Psychological Testing

Psychological Testing from Early Childhood through Adolescence. A Developmental and Psychodynamic Approach

By Miriam G. Siegel

Madison, CT, International Universities Press, Inc., 1987. 529 pp.

Although psychological testing has been around for some time, Miriam Siegel has written a refreshing and insightful guide to the testing of children and adolescents. Most notable is her illumination of the context in which such young subjects present themselves, specifically in terms of its effects on both administration and interpretation. Though the work is evidently written for clinicians, its clear style and case presentations make it a good introduction for interested students and other professionals.

The book is divided into two parts. Part I focuses on the setting in which testing is done and looks at qualitative impressions which the clinician should consider in approaching the child. For instance, the affective and cognitive style of the child, in addition to parental factors (both during and outside the session) form a composite of external effects on the test results. Certain age-specific factors are also relevant, and here Siegel points to developmental milestones (such as Piaget’s stages). Often, the way in which children enter the room, approach the test, and interact with parents, clinicians, and their own bodies will indicate much about their background. Part I advises the clinician to consider the test results with respect to these features, in addition to culture, environmental idiosyncrasies, and past experiences.

A general introduction is then given to several tests: Wechsler intelligence tests, Rorschach Inkblot, Thematic Apperception Test (TAT), Children’s Apperception Test (CAT), human figure drawings, and Bender Gestalt drawing. A brief history and introduction is provided, along with examples. Siegel then spells out age-specific features of administration, along with a guide to integrating the results. It is noteworthy that the author also talks about the clinician as well as the subject, warning, “the clinician’s unconscious attitudes toward mental health and illness may sometimes distort his judgment” (p. 140). Such a careful consideration of all features of testing underlies the entire work. The final chapters in Part I, on integration and presentation of results along with diagnosis, are especially thorough and insightful. Although Siegel writes about age-specific elements, there is a general lack of detail in terms of differentiating children versus adolescents. More information on developmental milestones, especially around the time of puberty, would have been extremely helpful.

Part II consists of eight case studies, and provides all test results (including all responses and relevant human figure drawings) with interpretations. The cases range in age and type of disorder. Siegel draws upon Part I to illustrate her holistic approach, showing how a battery of psychological tests is used to analyze a child. Although the cases are well presented, interesting, and easy to follow, they presume some experience with the tests and with clinical work in general. In addition, several of the analyses seem a bit contrived, especially since the reader knows only a little about the subjects’ backgrounds. It should be noted that the author relies upon a “developmental and psychodynamic approach,” which is appropriate, given the tests’ historical and theoretical basis (especially the projective tests). Again, background knowledge of psychoanalytic and/or developmental theory (Piaget in particular) is useful.

In all, Siegel has written an eloquent, masterful introduction to psychological testing of children and adolescents. The book’s holistic perspective with clear case studies presents a well-substantiated, thorough guide for numerous clinicians and test protocols.

Biological Psychology

Biological Psychology: An Introduction to Behavioral, Cognitive and Clinical Neuroscience (Book and CD-ROM), Third Edition

Mark R. Rosenzweig, S. Marc Breedlove, and Arnold L. Leiman

Sunderland, Massachusetts: Sinauer Associates, 2001. 651 pp.

Biological Psychology by the trio of Rosenzweig, Breedlove, and Leiman explains the biological foundations of evolution, development of the nervous system, regulation of behavior, emotions and mental disorders on a student-oriented textbook. Throughout the entire book lies a strong emphasis in the biological processes that produce and govern behavior and cognition with respect to the environment. The level of the text is geared to the beginning student in the discipline. With a colorful format, icons, key terms, boxes, and a CD-ROM, which contains quizzes and Sylvius, a module to learn neuroanatomy, a new student should consider purchasing or buying Biological Psychology.

The writing is clear and the illustrations that accompany it are not only attractive but illustrative as well. With CD-ROM links to several key illustrations, the book is undoubtedly tightly integrated and cross-referenced among its various modes of presenting information to the student. Because the text is geared for the beginner that would consider specializing in the discipline, it was general, yet technical enough that as a medical student I found it helpful in relearning some neuroanatomy structures such as the circle of Willis. Therefore, certain parts of the text can also be used by students who wish to become clinicians in addition to those who want to become specialized researchers. All chapters contain up-to-date research that would prove useful to both kinds of students. As an aside, the book actually contains photographs of current researchers such as Nancy Wexler, which connects a face with hot-off-the press research.

Usually, I devote the second or third paragraphs in the review to criticisms of the book. The terseness of this paragraph indicates how I feel this textbook is as close to a paragon for excellence for biological psychology textbooks that I have read.

Biological Psychology was clearly designed with the student in mind. I give it the highest recommendation and it should be welcome addition to your library.

The Hippocampal and Parietal Foundations of Spatial Cognition

The Hippocampal and Parietal Foundations of Spatial Cognition

Burgess N, Jeffery KJ, O’Keefe J, editors

Oxford: Oxford University Press; 1999. 490 pp. with index

ISBN 0-19-852452-8 (paper)

This well-organized volume has much of interest to basic researchers. The 3 roughly equal sections discuss, first, the parietal cortex, then the hippocampal formation and, finally, the interaction of the two in spatial learning and memory. Studies of rats, monkeys and humans are included. Among the techniques reviewed are behavioural, neuropsychological, electrophysiological, brain imaging and neural net computational modeling. Reading this book from cover to cover reveals a lot of repetition of similar material, such as anatomical details. It is often surprising to read about the same ideas in different chapters that do not cross-reference each other. However, for the reader who uses this book as a source of specific information about cortical regional specialization of function, the chapters provide independent and complete reviews of the latest relevant work.

The sophisticated studies of Milner and Goodale, identifying 2 streams of visual information processing with different functions, provide a useful basis for integrating much of the work presented in the first section on the parietal cortex and some of the studies presented in the third section on integration of parietal and hippocampal function. Goodale et al have argued that the dorsal stream of visual processing into the superior parietal lobe is concerned with the use of that information for the generation of motor actions; damage to this area leads to optic ataxia. The ventral stream projecting into the inferior parietal lobe and dorsal temporal cortex is concerned with what is being seen; damage here leads to spatial neglect. The chapter by Karnath, for example, presents results of studies showing that patients with damage to the right parietal cortex made exploratory eye movements consistent with an ipsilesional deviation of egocentric space representation. The same patients showed no deficit in goal-directed arm movements to targets around them. These findings are consistent with the idea that there are 2 streams of processing and that the damage in the patients studied affected the ventral but not the dorsal stream.

Colby presents fascinating electrophysiological data recorded in the ventral intraparietal area in monkeys. Cells were found to be responsive to both visual and so-matosensory stimuli; neurons with foveal visual receptive fields had somatosensory receptive fields on or around the muzzle. It was as if the mouth was the “fovea” of the facial somatosensory system! Furthermore, visual receptive fields moved across the retina in order to maintain spatial correspondence with somatosensory fields, suggesting that stimuli are coded in a head-centred reference frame. Patients with parietal cortical damage can be seen to suffer from a deficit in updating spatial representations for use by the motor system. Colby suggests that the remapping of visual fields observed in parietal cortical neurons provides the substrate for this updating.

In coaching students preparing for comprehensive examinations, one of my colleagues often counsels them to identify landmark papers that open whole new areas of investigation. Two such works in Spatial Cognition are Scoville and Milner’s paper and O’Keefe and Nadal’s 1978 book The Hippocampus as a Cognitive Map. The former is the first report of a role for the hippocampus in recent memory, and the latter identifies the place specificity of hippocampal cells. Juxtaposition of the ideas from these 2 classic works influences much of the thinking in Spatial Cognition. Some interesting ideas linking recent memory and place specificity can be found.

Mishkin et al, for example, discuss episodic and semantic memory. When a new item, association or fact is being encoded into memory, the relevant sensory information arrives as an episode that includes spatial information, as well as temporal cues and information about emotional and mental states. The amount of contextual information that is retained determines the nature of the stored memory: con-textually rich memories include spatial and other information and are, therefore, episodic; contextually poor memories record only the facts, and therefore constitute semantic memory. From this point of view, semantic memory is lower in a hierarchy of mnemonic sophistication than episodic memory. Mishkin et al argue that the hippocampus is necessary for episodic but not for semantic memory. Spatial information would be intrinsic to episodic memory. Rolls, Gaffan and Hornak make similar arguments in later chapters.

One distinction that guides some of the discussion of the interactions between parietal and hippocampal systems in space and memory is that between allocentric and egocentric frames of reference. Egocentric reference is putatively mediated by parietal circuits, and allocentric reference by hippocam-pal circuits. Rolls reported that 46% of the spatial cells of the hippocampus represented space in allocentric coordinates, versus 10% that, by comparison, were egocentric. Maguire reported that positron-emission tomographic (PET) images of people who walked mentally along a recently learned spatial route showed right hippocampal activation, suggesting that this region provides an allocentric representation of space. Parietal cortical regions seemed to play a role in egocentric movements through environments.

Another work that strongly influences many authors writing in Spatial Cognition and could be added to the comprehensive reading list that I mentioned earlier is The Visual Brain in Action by Milner and Goodale. This is the source of the idea, mentioned above, that the dorsal stream guides visuomotor actions and the ventral stream identification of what is seen. In the final chapter, Milner et al suggest that, if a participant was required to perform a delayed motor act, accurate performance would depend on the ventral stream because the egocentric coordinates that are tracked by the dorsal stream will have changed during the delay (assuming the participant moves). Thus, visually guided motor acts like pointing should be impaired after a delay in people with damage to the ventral stream. Results supported this conclusion.

One interesting contrast that I found in Spatial Cognition was between Rolls’ and Maguire’s view of imaging studies. Rolls reported the results of electrophysiological studies in rats and monkeys showing that hippocampal cells in rats were place cells, responding when the rat was in that place; in monkeys, hippocampal cells fired when the monkey looked to a particular place, even if it didn’t go there. Rolls argues that imaging studies could not make this distinction; they did not provide a full description of what was being represented in the brain. Maguire reports differences in regional activation assessed by PET imaging, as described above, and concludes that PET offers a means to pursue many outstanding questions in understanding neuronal control of spatial cognition. I suspect that they are both right. The breadth of techniques reported in this book and the emerging clarity of the knowledge about the cognitive functions of these brain regions attests to the power of multiple empirical approaches to the study of the brain for discovering the mechanisms underlying the amazing abilities of this structure.

Psychiatry

Psychiatry. Second edition. Oxford Core Texts series

Gelder M, Mayou R, Geddes J

New York: Oxford University Press; 1999

ISBN 0-19262-888-7

The first edition of this book was called The Concise Oxford Text of Psychiatry, and the title change implies that the authors and publishers are attempting to broaden the book’s appeal. The 3 authors are senior academic psychiatrists from the University of Oxford.

Before reviewing the book, I made a list of the key requirements of a textbook for medical students: clarity, comprehensiveness, conciseness, cost, practicality and pertinence. This book scores high on all these items with the exception of cost and pertinence. It emphasizes strongly the integration between psychiatry and general medicine, yet the psychosocial aspects of medicine and psychiatry are also underlined. An appropriate balance between comprehensiveness and overinclusive detail is maintained, and liberal use is made of tables, diagrams lists and summaries. Many chapters also include “screening questions” — a list of questions that can be asked of a patient to rule out a specific diagnosis. The chapters on suicide, pharmacotherapy and “psychological” treatment (as the psychotherapies are called in the quaint British tradition) are particularly well written.

The book has its limitations. The chapter on psychiatry and the law is written for British readers and has limited relevance to other jurisdictions. For a soft cover, this book is not cheap. Finally, there are few references, although each chapter concludes with a recommended reading list.

With these provisos, the book can be highly recommended to medical students and to non-psychiatric residents who are interested in a readable and practical introduction to psychiatry.

Psychosocial Factors in Pain

Psychosocial Factors in Pain: Critical Perspectives

Gatchel RJ, Turk DC, editors

New York: The Guilford Press; 1999. 510 pp. with index

ISGN 1-57230-285-2

The preface to this book stakes out its claim. We are told that 4 main developments, each involving psychologists, served as the impetus for a revolution in thinking about pain. This revolution consists in the rejection of a “medical model” in favour of a “bio-psychosocial approach.”

The volume comprises 30 chapters. Of these, the first 9 make up Part I, on biopsychosocial context. In Part II 11 chapters deal with special topics and populations, and Part III provides 10 more on issues in prevention and management. The book finishes with an overview on resolution and evolution. Three out of the 43 authors of the 30 chapters are physicians dealing with pain and AIDS (a magnificent review), the epidemiology of low-back pain, and work style and work-related upper extremity disorders. There is an epidemiologist or two, a dentist with qualifications in psychology, and almost all the rest are psychologists dealing with pain. These include 3 Canadians (Gagliese, Katz and Melzack), Flor from Germany, and Main (from Glasgow and now Manchester).

The great bulk of the material reflects the work and views of US psychologists and their special psychosocial context.

This is a long volume, well produced and full of information, often very well worked out. The text itself is easy to read and very solidly written for the most part. Some chapters are excellent in whole or in part, while others seem to exist only to disappoint.

It is an irritating pity that what could have been a superb volume is marred by 2 faults of emphasis. One is needless special pleading and the other is an ill-founded, albeit highly sophisticated, tendency to revise the understanding of what it means to favour a back-pain disability model.

The special pleading begins with the listing of 10 contributors to the psychological approach. Three of these were actually physicians but not identified as such. More important, and tellingly, there is a lack of understanding or recognition that psychosocial factors have always been strong in medicine. Psychologists now dwell in a field long inhabited and not relinquished by internists, family doctors, neurologists, psychiatrists and a host of others.

Psychologists are much more numerous than psychiatrists in the field of pain and have made great contributions, starting with Hebb and Melzack. But some of their contributions (e.g., behavioural therapy of pain) remain controversial, and the field in which they have gained most recognition and added most to the subject appears to be cognitive treatment, which, incidentally, was applied to pain by a psychiatrist, A.T. Beck. Thus, what should have been a friendly and sociable claim to have made a large contribution has been spoiled by exaggeration.

More important, the way in which the biopsychosocial construct is now treated serves to reduce the biological element and to suggest that pain is largely due to psychological causes. I partly made that mistake myself and can sympathize, but the fact is that we have very few genuine indications that pain for which physical explanations are lacking is due to psychological causes except when it occurs with or after the onset of an obvious affective disorder. In other cases, and especially with musculoskeletal pain that arises with questionable indications of psychological difficulty, there is insufficient evidence to support the view that pain is due to vaguely alleged “behavioural factors,” but there is growing evidence from systematic controlled investigations that the determining factor is the state of the facet joints or degeneration (not prolapse) of intervertebral disks.

One of the most insidious practices connected with rejecting the patient’s pain consists in describing correlated information as “predictive.” Every psychologist knows that correlations do not demonstrate a causal link, except when there is a serial position, and should not be thought of as a causal consequence. Yet the insinuating word “prediction” is used repeatedly to corroborate some argument for psychological causation.

I do not want to leave the impression that Gatchel and Turk, as editors, make no attempt to acknowledge evidence that complicates their message. They recognize much of it. However, overall the book states the problems softly when they relate to weaknesses in psychological achievement, and overstates the failures of the organic approach. This is the more distressing because the authors and editors have all made significant contributions in the past, and continue to do so. Unfortunately, as one of my colleagues puts it, those who state their adherence to the biopsychosocial approach most loudly do not appear to be as serious about the “bio-” element.

The American Psychiatric Press Textbook of Psychiatry

The American Psychiatric Press Textbook of Psychiatry, 3rd ed

Robert E. Hales, Stuart C. Yudofsky, John A. Talbott, editors

Washington (DC): American Psychiatric Press; 1999. 1762 pp. with index

ISBN 0-88048-819-0 (cloth)

As would be expected of both the American Psychiatric Press and the American Psychiatric Association as an organization, the latest edition of the Textbook of Psychiatry, edited by Hales, Yudofsky and Talbott, is an impressive book. Members of the editorial board, the international advisory board and the individual chapter authors, make up a Who’s Who of modern psychiatry, although with a strong American bias. As examples, the chapter entitled “Psychiatric education” is written by Jonathan Borus, “Clinical neuropsychiatry” by Jeffrey Cummings, contributions on hypnosis and dissociation are provided by David Spiegel, and “Group therapy” is by Irvin Yalom. Thus, in most cases, the chapters have been prepared by leading experts in a particular field.

But there is a problem. In many ways, it is one that is illustrated, in parallel fashion, by the inclusion of DSM-IV on CD-ROM in a kind of “book within a book.” The CD-ROM is fun — easy to load on the computer and browse through but, in the end, not particularly useful. It comes on a CD-ROM, so cannot be downloaded, which means I have to choose whether to leave it at home or at work. More important, apart from providing another way to look up something (and I still think picking up my well worn mini DSM, which opens automatically to the Global Assessment of Functioning Scale is quicker), it really doesn’t do much. You can search key words on it, and find out how many diagnoses include anhedonia in the description of symptoms, and you could cut and paste sections from the DSM into other documents, but apart from that relatively restricted use, it just doesn’t seem to have a role.

Similarly, the question arises: What is the purpose of a large textbook like this now? Is it to provide a quick reference source for the field of psychiatry, a state of the art presentation of the field or a study tool for residents preparing for their fellowship examinations? Should it provide sufficient depth of discussion of topics to allow clinicians to expand their practical skills and knowledge substantially, making the book a large one indeed, or is it designed to provide overviews of complex fields?

Clearly, a textbook, no matter how well produced, is not going to be a state of the art presentation for long, although this one does an admirable job. As a reference tool, the textbook varies in its ability to deliver. The depth of discussion is limited by size constraints so, for example, important advances such as Linehan’s work on dialectical behaviour therapy for personality disorder, are presented and described, but not in sufficient depth to do more than stimulate interest. Autistic disorders are discussed fairly thoroughly, but little useful discussion of autism in adults is provided, even though the section is clear and well written. Finally, the chapter on group therapy restricts most of its content to a focus on the interpersonal orientation of Yalom, without providing a broad overview of writing on psychodynamic groups, cognitive behavioural groups or psychoeducation groups and the roles of these in various illnesses.

This limits to some degree the value of the book as either a quick reference or a study tool for residents, and yet this limitation, with some minor exceptions, stems more from the restrictions of the art of the textbook in current medicine than from the limitations of the authors. The expansion of knowledge in any field may have pushed the limits beyond that which is practically encompassed in a comprehensive textbook. Despite my earlier comments, overall, this is a good textbook. Chapters are generally very well written and ideas presented clearly. In most cases, key, up-to-date references are included. Clearly, the editors have run a tight ship to ensure publication of a textbook as up-to-date as possible.

Organization is fairly standard, with chapters on the theoretical foundations of psychiatry, a section on assessment, a section focussing on the disorders of psychiatry (following the DSM system of classification) and one on treatments. The editors avoided the pitfall of excessive reliance on DSM by setting chapters in the final section on topics such as violence, an area not well classified in DSM.

There are some excellent sections. Despite the loss of prominence of psychoanalytic theory politically, there is an excellent chapter by Robert Ursano and Edward Silberman on psychoanalysis, psychoanalytic psychotherapy and supportive psychotherapy. It reviews important writings and research and includes an extremely useful section looking at a comparison of psychodynamic, interpersonal and cognitive therapies, and pointing out the similarities and common roots that are often forgotten or ignored in debates between proponents on the relative merits of each.

The one main drawback for an international audience, is that this text is ultimately an American one. The chapters on psychiatric education, and law and psychiatry are about medicolegal psychiatry and education in the United States. “Public psychiatry,” “Managed care and psychiatry” and “Psychiatry and primary care” are written about US models and experiences of these fields; therefore, for example, the work by Kates and others on a shared care model for psychiatry and primary care is not included. This is unfortunate because the discussion on any of these areas could, with relatively little expansion of content, be greatly enriched by the inclusion of the experience in other countries. Including differing perspectives on the legal handling of dangerousness in the psychiatrically ill, or different models of postgraduate education in psychiatry, would not only benefit readers from other countries but could expand the dialogue on these issues through contrast and comparison. After all, many of these systems evolve in a particular way for historical reasons that may not always reflect the only or the best solution. Given the inclusion of an expert international advisory panel, it is unfortunate that the textbook falls short in this way.

Textbook of Psychiatry from the American Psychiatric Press is ultimately a pretty good textbook. It is comprehensive, well written and up-to-date. It is limited by its very nature, but if one feels that one does need such a book, then this book is competitive with any other in the field. It is unfortunate that it is limited by being essentially an American textbook. Relatively minor changes could have made it a truly international one, of use to both an American and an international audience.

Obsessive-Compulsive Disorder: Theory, Research and Treatment

Obsessive-Compulsive Disorder: Theory, Research and Treatment

Swinson RP, Antony MM, Rachman S, Richter MA, editors

New York: The Guilford Press; 1998. 478 pp with index

ISBN 1-57230-335-2 (cloth)

This book, as its subtitle indicates, sets out to review all aspects of obsessive-compulsive disorder. It is comprehensive, consisting of 18 chapters by 41 contributors, and is divided into 3 major sections. The first is on psycho-pathology and theoretical perspectives, the second on assessment and treatment, and the third on obsessive-compulsive spectrum disorders.

There is also a 6-page appendix of information on national organizations concerned with obsessive-compulsive disorder, anxiety disorders, and obsessive-compulsive spectrum disorders, both in and outside North America, as well as supplementary material intended for both the public and professionals.

The writing is consistent and clear, a tribute to the authors and the 4 editors — 2 of whom are psychiatrists and 2 psychologists. Each chapter is followed by a list of references that includes both those of historical interest and those that are refreshingly current, published as recently as 1998.

The first part, on psychopathology and theoretical perspectives, both psychological and biological, constitutes about half the book.

The presentations in this section are balanced and critical. The evidence in support of prevailing hypotheses is mainly from controlled studies, with suggestive evidence from case reports and clinical experience. Areas of uncertainty in theorizing about obsessive-compulsive disorder are clearly indicated, and arguments favouring or opposing prevailing theoretical positions are clearly set out.

Chapter 4 contains an intriguing discussion of the comorbidity of obsessive-compulsive disorder with various personality disorders and a preliminary consideration of possible subtypes of obsessive-compulsive disorder. The effect on the patient’s family is dealt with as well.

Chapter 9 mentions that resistance to obsessive thoughts and compulsive acts is not always found. To my knowledge, a paper by British psychiatrist Valerie Walker1 was the first to report this in the literature, but she is not given credit.

Discussion of the relation between obsessive-compulsive disorder and generalized anxiety disorder includes a description of worry, but does not include worries about possible but highly improbably occurrences (as one patient termed it, “the what ifs”).

Chapters 10 to 15 include a critical review of the instruments useful in establishing the diagnosis and a helpful section, in chapter 10, on clinical considerations. Both psychosocial and biological treatments are discussed thoroughly. The sections on clinical applications of treatment will be especially helpful to practitioners.

Chapter 16 covers comprehensively the subject of obsessive-compulsive disorder in children and adolescents, and chapters 17 and 18 deal with the subject of obsessive-compulsive spectrum disorders, including screening questions for patients and useful assessment instruments.

This is an excellent book. It contains a critical discussion of controversial issues, a challenge to our current classification of obsessive-compulsive disorder as an anxiety disorder, and evidence that obsessive-compulsive disorder is not a homogeneous disease entity — which should lead to more effective treatments.

I recommend it highly to all personnel who care for patients with mental disorders.

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.

Recovered memories and false memories

Recovered memories and false memories

Conway MA, editor

Don Mills (ON): Oxford University Press; 1997. 313 pp

ISBN 0198523866 (paper)

Freud’s theory of repression is a less homogeneous concept than one might think. Erdelyi, for instance, has shown that Freud used a wide range of descriptive terms in writing about the mechanisms of repression, ranging from unconscious to conscious suppression. Yet for more than 100 years Freud’s theory, or something similar, was accepted, at first quite gradually, then vigorously until it dominated the nonbiological half of psychiatry in the form of “dynamic psychiatry.” The theory has now suffered a precipitous decline in prestige and importance outside psychiatry, and seems likely to go the same way inside psychiatry, except that many psychiatrists — possibly the majority — have not yet recognized the bombshell about to explode, or do not appreciate its potential impact. This bombshell is the rejection of the main ideas of repression and dissociation as conceived to date, which has developed from 2 very different lines of enquiry.

The first line, which is less well known among psychiatrists, is the new Freud scholarship. This comprises a variety of biographical studies of Freud’s publications; accounts of his dealings with his patients as they saw themselves and as others saw them; important segments of his correspondence, which has shed quite a different light on his techniques and activities, compared with the impression conveyed by Ernest Jones in his famous (and sometimes very misleading) biography; the failure of scientific studies to demonstrate the occurrence of repression; and the close study of what Freud actually said rather than what he led his readers to believe. Taken together, the material is devastating to Freudian theory and to our belief in repression.

Little note of these changes has been taken by psychiatrists. Those already disillusioned with psychoanalysis have focused on the increasing number of alternatives, such as biological psychiatry, which has increased inexorably in strength and in clinical usefulness on cognitive and social measures as well as on some behavioural techniques. However, the multivolume multi-authored textbooks in English continue to favour dynamic ideas, even though psychoanalysis has long had problems demonstrating its value as a treatment.

The issue that is making medicine recognize that literary, historical, semantic and philosophical studies are relevant to psychiatry is the phenomenon of recovered memory of childhood sexual abuse.

The theory of recovered memory relied heavily on psychoanalytic ideas, and differed in only one major respect. Advocates of recovered memory therapy for childhood sexual abuse were unabashed in their suggestive efforts to find repressed memories of sexual abuse, and naturally succeeded. After a few years, the result was an eruption of false accusations, reports of multiple personality disorder (because only repressed childhood sexual abuse could explain it), memories of satanic ritual abuse, recollections from early childhood before the brain could fix permanent episodic memories, discoveries of past lives, alien abductions, criminal charges, civil lawsuits, a series of witch hunts in the US (and 1 or 2 in Canada) and an epidemic of needlessly broken families.

The necessary correction came from accused parents and their spouses, who were assisted by psychiatry and cognitive psychology professionals. In March 1992 the False Memory Syndrome (FMS) Foundation was founded, leading the way in a critical examination of the recovered memory phenomenon on which the theory of repression is based.

By 1996 more than 6 professional societies had issued guidelines of varying degrees, had warned against suggestive treatment and effectively rejected the recovered memory phenomenon. Over time, there was a tendency for the admonitions against recovered memory therapy to become stronger. The Canadian Psychiatric Association adopted a very firm position in 1996, and the Royal College of Psychiatrists outdid us in 1997 with stronger guidelines and in 1998 published a very critical report by Brandon et al. Of course, not everyone is convinced and a rearguard action continues at different levels.

The story has been superbly documented by Pendergrast, and now psychiatry and psychology may begin to look again at dissociation and repression to understand where psychiatric theory is going. Recovered Memories and False Memories belongs to the first half of the recent story rather than to the second half. An introduction and 10 chapters express concern about what exists rather than where things might be going, not recognizing that the controversy is past its peak, if not over. The editor’s introduction paints the picture of a dialogue between psychiatrists and memory researchers, tactfully, but not very convincingly, praising the merits of such disparate contributors as Christine Courtois and Daniel Schacter.

The main proponents of recovered memory refer to partial or fragmentary memory as well as delayed disclosure in normal and traumatized people, and say that abuse memories may emerge in response to a wide array of cues or triggers, some of which might occur in therapy. In contrast, Schooler, Norman and Koutstaal, who seem to approve of the recovered memory theory, conclude that the recovery of highly traumatic incidents over a period of years is very unlikely to occur in the absence of previous dissociative pathology.

Some chapters reflect a patchwork, such as the ones by Yapko and by Fivush et al dealing with the “troublesome unknowns.” Fivush et al, considering children’s memories, leave a door partly open for some of the recovered memory ideas, as does the editor in his chapter on the past and present. Kihlstrom is the only contributor who is on the Scientific Advisory Board of the FMS Foundation, but he is joined to a considerable extent by Schacter et al and Roediger et al in his skepticism of recovered memory phenomenon. In other chapters, such as the ones by Brewin and Andrews, and by Christianson and Engelberg, the authors appear unconverted but much more cautious than in the recent past.

The final chapter by Schooler et al on “taking the middle line” tries to show that psychological causes of recovered memory have been corroborated. These authors identify 4 features that require attention to appraise and corroborate memories: the recovery experience; the subject’s perception of the extent of prior forgetting; the existence of sources corroborating the event; and the existence of sources corroborating the forgetting. All 4 cases they present are strikingly similar in that the recovery is reported as a private emotional experiential state. The authors compare this state with insight experiences that sometimes occur during problem solving and make a weak analogy with flashbacks. Three of their subjects had actually indicated previous memories, which later appeared to them to be new. Correspondingly, the actual corroboration of abuse appears quite good (but perhaps weakest in the case without prior recall). The authors believe that they have found corroboration of the phenomenology of the recovered memory experience. They discuss alternative possibilities for the special emotional experience they attribute to discovering a memory. Altered mood states are known to cause vivid emotional experiences, which may not persist (whether pleasant or unpleasant); so too are drugs. One of the cases that occurred after sleep raises the possibility of cataplexy (with hallucinatory experience founded on a known past event producing heightened emotion). This is particularly plausible in the light of Peter Hays’s4 description of false but sincere accusations of abuse related to narcolepsy. But a special feeling called a flashback may have nothing to do with their views.

Overall this book is a mixed bag. The emphasis of some chapters is seriously misdirected or simply cannot be relied upon. Other chapters, particularly the ones by Kihlstrom, and by Schacter and Roediger, contain solid material, and Schooler’s is at least interesting. Anyone wishing to find their way around the false memory story would be better advised to read the book by Mark Pendergrast, which still provides an outstanding overall account of the topic. Recovered Memories and False Memories provides significant information on both approaches to the topic; but only one of these approaches is likely to be reliable and accurate.

The Millon Inventories: Clinical and Personality Assessment

The Millon Inventories: Clinical and Personality Assessment

Millon T, editor

New York: The Guilford Press; 1997. 552 pp

ISBN 1572301848 (hard cover)

This book provides an overview of the growing family of personality inventories developed by Theodore Millon and members of the Institute for Advanced Studies in Personology and Psychopathology. Chief among these instruments is the Millon Clinical Multiaxial Inventory (MCMI), which is one of the 2 or 3 of the most widely used personality assessment methods in the world; 16 chapters of the book are devoted to it. While there are 6 books describing the inventory, this is the only one edited by Millon himself. The introductory chapter reviews Millon’s theoretical approach to personality assessment, which balances the nomothetic and idiographic traditions; the chapter illustrates how this theory guided the design of the assessment inventories.

A distinguishing feature of the MCMI and the more recent Index of Personality Styles is that they are systematically linked to a comprehensive theory of personality. This has an evolutionary base that draws parallels between the phylogenetic evolution of a species and the development of adaptive strategies for a person or a group, including personality style. The evolution of personality style is honed by a formative process involving biological endowment, social experience and interaction with the environment, both at the personal level and as a facet of culture. Millon identified 3 “motivating aims” that prompt and direct human behaviour: preservation of life, adaptation to change, and reproduction or replication. In this model, personality is dynamic; it includes behavioural elements (expressive behaviour and interpersonal conduct), phenomenological aspects (cognitive style, self-image and object representations), intrapsychic elements (covering the person’s regulatory mechanisms such as projection, exaggeration or acting out) and, at a biophysical level, mood and temperament.

The MCMI translates these theoretical insights into a diagnostic instrument suited for clinical populations; it is not intended for use as a general personality assessment. Rather than classify people into set personality types, the MCMI follows a prototypal approach that scores them along 11 personality dimensions, such as schizoid, avoidant, depressive, dependent or narcissistic. The emphasis is on identifying elements of multiple patterns that may co-exist in the person; the goal is to emphasize quantitative gradations rather than qualitative, all-or-none distinctions. Of the many theoretically possible permutations of personality types, about 20 cover over 80% of cases. Assessments can be linked to the DSM taxonomy of personality disorders. The MCMI is heuristic and seeks to provide clinicians with a “means for understanding the principles that underlie their patients’ functional and dysfunctional behaviors, thoughts and feelings.” The dynamic formulation of personality addresses the question “what functional processes and structural attributes are necessary for the client’s personality pattern to exist as an organic whole?” The process of interpreting the MCMI is complex (and is illustrated rather than explained in full in this book); it also takes account of scores indicating severe personality pathology and clinical syndromes. As well, the MCMI includes items designed to identify various response biases.

In addition to covering the MCMI, the book devotes 6 chapters to reviewing other scales developed by Millon’s group. These include the Millon Adolescent Clinical Inventory, intended for measuring adolescent personality and adjustment, and the Behavioral Health Inventory, which covers styles of coping with physical illness. The book also briefly describes 3 other personality scales: the Millon Personality Diagnostic Checklist, the Personality Adjective Check List and the Index of Personality Styles. Each assessment inventory is described only in general terms and the scales themselves are not shown. For this the reader would have to turn to the existing manuals for each instrument; this book does not address any of the practical details of how to obtain copies of the instruments. Somewhat more attention is paid to the clinical interpretation of scores, which is illustrated by case reports. Summary information on reliability and validity is provided and fairly extensively referenced.

The book is written for people who are already familiar with the Millon Inventories. Indeed, one weakness of the book may be that it assumes undue familiarity with the scales: the chapter headings refer to abbreviated titles of the scales, which are, in some instances, not spelled out in the chapter. The reader is assumed to understand chapter titles such as “The Role of Psychological Assessment in Health Care: the MBHI, MBMC, and Beyond.” Furthermore, descriptions of the purpose of each instrument are often sketchy. The chapter on the Millon Behavioral Health Inventory, for example, describes it as “a standardized, objective psychological assessment tool that offers significant utility in the assessment of medical patients and as such may be a significant addition to the assessment technologies of the primary care physician” (page 389). Later clarification doesn’t help very much: the MBHI is “designed to assess the personologic and psychological coping factors related to the physical health of adult medical patients” (page 391). One has the impression that the authors were perhaps too close to their subject, and there seems a risk that this book may fall between the cracks: it does not provide sufficient information for the neophyte to decide whether a scale will suit a particular purpose, nor does it offer a full review of the latest information on each scale for the experienced user seeking an update.

Nonetheless, the book is useful in drawing together in one source a wide range of general information on these scales. The book is technical and scholarly but still very readable. Although it is an edited volume, the style and content are successfully integrated, and one can sense Millon’s guiding hand in each of the chapters. The book offers useful background reading for practising psychometricians; it will provide a good introduction to Millon’s approach for students taking courses on psychological assessment. The book might also benefit the reader with a general interest in psychological and health measurement: many insights lie in these pages. The introductory discussion on the role of theory in developing personality assessments, for example, is excellent, and so is the discussion in chapter 14 on issues in assessment in different cultural settings. This is a book to encourage your library to buy as a general reference rather than a “must have” for your own bookshelf.