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BOOK REVIEWS
Insane Sisters: Or, the Price Paid
for Challenging a Company Town
by Gregg Andrews; Columbia, Missouri, University
of Missouri Press, 1999, 262 pages, $29.95
Patricia E. Deegan, Ph.D.
T his is the story of two women who
dared, early in the 20th century,
to step outside of prescribed gender
roles and challenge corporate pow-
er—and lost. The book takes us into
the lives and times of Mary (Mollie)
Heinbach and her sister Euphemia
(Feemy) Koller and their struggle
with the powerful Atlas Portland Ce-
ment Company in the small company
town of Ilasco, Missouri.
When Mollie inherited a tract of
land that was desirable to Atlas, the
company used its influence to per-
suade politicians and local lawyers to
challenge her ownership. Molly en-
listed the aid of her fiery and feisty
sister Feemy, and for 17 years the two
fought Atlas. Their case returned to
the Missouri Supreme Court four
times, but in the end the powers of in-
stitutional psychiatry were invoked as
juries found both sisters to be insane.
Molly was placed under guardian-
ship, and Feemy—alleged to be mon-
omaniacal in her 17-year pursuit of
litigation to protect her sister’s prop-
erty—was involuntarily committed to
the Insane Asylum in Fulton, Mis-
souri. Both women perished within a
few years of being stripped of their
liberty. Feemy was buried in an un-
marked grave. Atlas went on to claim
the land and, many mergers later,
continues to thrive.
Insane Sisters is well written and
has a compelling story line. It has
been meticulously researched and is
quite rigorous from a historical point
of view. Although this rigor is one of
the book’s strengths, the author’s em-
phasis on providing historical context
detracts from its usefulness for men-
tal health professionals. For instance,
he suggests that the sisters’ plight
raises some “questions about the use
Dr. Deegan is director of ex-patient stud-
ies in the Institute for the Study of Human
Resilience at Boston University.
PSYCHIATRIC SERVICES ♦ December 2001 Vol. 52 No. 12
Jeffrey L. Geller, M.D., M.P.H., Editor
of guardianships and insanity as
methods of social control,” but his
analysis never moves beyond the lives
of the two sisters. Hence we are left
to wonder about the breadth of the
powers of institutional psychiatry and
the fate of other unconventional
women in the early 20th century.
Nevertheless, the real value of In-
sane Sisters for mental health profes-
sionals is to be found in its caution
about the use of psychiatry to police
compliance with social, political, and
economic role expectations. The
greatest danger and the gravest re-
sponsibility of our professions lie in
our duty to refrain from locating so-
cial problems in individual brains. To-
day—like a century ago—angry, well-
educated women with unconvention-
al views who directly challenge male-
dominated power are—like their “in-
sane sisters”—likely to wind up la-
beled “madwomen.”
In this section . . .
The lead review this month is of
a book that describes how, with
the aid of psychiatry, two sisters
were deprived of their property
and their liberty to make way
for a growing cement company
early in the 20th century. Re-
views follow of books on the use
of family therapy in the treat-
ment of ADHD; psychological
debriefing and the evidence
that supports it; the science and
theory of anxiety, depression,
and emotion; the use of evi-
dence-based treatments in the
United Kingdom; the treatment
of suicidal behavior; the treat-
ment of substance use disor-
ders; and other topics.
Family Therapy for ADHD:
Treating Children,
Adolescents, and Adults
by Craig A. Everett and Sandra
Volgy Everett; New York, Guilford
Press, 1999, 270 pages, $35
Jason H. Edwards, Ph.D.
A ttention-deficit hyperactivity dis-
order (ADHD) is one of the
more common presenting problems
among children in psychiatric outpa-
tient settings. Because much has al-
ready been written about the disor-
der, one reasonable question about
any new book on the subject is
whether it contributes anything new
to the literature that may be helpful
to clinicians. The short answer in this
case is a definitive yes.
The significant clinical contribution
of this book lies in the emphasis it
places on a developmentally informed
family systems and family therapy per-
spective in the assessment and treat-
ment of ADHD. The primary message
of the book is that the assessment and
treatment of a person with ADHD
should occur in the context of the per-
son’s family system.
Family Therapy for ADHD is
thoughtful, readable, and clinician
friendly. The clinical wisdom the au-
thors have gleaned from many years
of practice is evident in their good use
of case studies to illustrate their cre-
ative ideas. The book has a strong
how-to quality that is helpful to clini-
cians who are interested in incorpo-
rating the authors’ ideas into practice.
The book is well organized overall,
and each of its nine chapters begins
with a helpful outline of what is to fol-
low. An introduction provides insights
into various families’ experiences with
ADHD through case studies, and the
first chapter covers background infor-
mation concerning ADHD, including
DSM-IV criteria, etiology, epidemiol-
ogy, and comorbid disorders.
Chapters 2 through 5 address as-
Dr. Edwards is associate professor of psy-
chology and codirector of the Center for
Children and Families at Frostburg State
University in Frostburg, Maryland.
1661
BOOK REVIEWS
sessment issues and are particularly
interesting in their presentation of a
family systems perspective. These
chapters include discussion of the
pragmatics of coordinating and col-
laborating with other professionals
and larger systems in the evaluation
process. The authors clearly articu-
late the intergenerational impact of
ADHD on the family system. An in-
teresting five-stage developmental
family systems model for assessing
child and adolescent ADHD is pre-
sented. The model integrates a family
life cycle perspective in assessing
ADHD symptoms and the impact
they have on the child and his or her
parents and siblings.
The last three chapters address
family systems treatment for chil-
dren, adolescents, and adults, respec-
tively. An interesting 12-session treat-
ment model for children and a ten-
session model for adolescents are
presented. The models are discussed
session by session, and goals for each
session are clearly delineated. This
book was published before the initial
reports of the Multimodal Treatment
Study of Children With ADHD (MTA)
(1). However, there appears to be
some empirical support for aspects of
the authors’ family systems treatment
approach with children. Given what is
currently known about treatment ef-
fectiveness, clinicians might consider
increasing the number of sessions de-
voted to parent management training
in the model.
The final chapter addresses treat-
ment for adults. Some useful sugges-
tions are presented, but certainly
more discussion of evaluation and
treatment would be required for cli-
nicians who intend to work with
adults with ADHD. The authors may
have tried to accomplish too much by
including this chapter.
Clinicians might obtain the most
benefit by integrating the authors’
family therapy approach with what
we know empirically about child
ADHD and adolescent ADHD. Clin-
icians who are less familiar with eval-
uation and effective treatment of
ADHD might consider reading
Barkley (2) and Robin (3) first, along
with reports about the MTA. This is
1662
not a criticism of the book but rather
an acknowledgment of its unique
contributions to the literature.
The family systems perspective
presented in Family Therapy for
ADHD enriches our current knowl-
edge about assessment and treatment
of ADHD. This very practical book is
likely to be useful for mental health
clinicians who work with individuals
who are experiencing ADHD, partic-
ularly with children and adolescents.
Psychological Debriefing: Theory, Practice, and Evidence
edited by Beverley Raphael and John P. Wilson; Cambridge, England,
Cambridge University Press, 2000, 376 pages, $59.95 softcover
Carol S. North, M.D., M.P.E.
David E. Pollio, Ph.D.
T his book tackles head-on the con-
troversial topic of psychological
debriefing—not a task for the faint of
heart. The introduction addresses the
current state of affairs in psychologi-
cal debriefing, acknowledging the
popular embracing of this interven-
tion as a “magic bullet” and the fact
that a “trauma industry” that has
emerged without the requisite sup-
port of scientific backing.
The all-star roster of contributors
represents a spectrum of opinions
about psychological debriefing. Au-
thors range from Jeffrey Mitchell and
George Everly, pioneers of critical in-
cident stress management—who are,
not unexpectedly, enthusiastic propo-
nents of debriefing—to Robert Ur-
sano and his group (“if it works, prove
it”), who caution that responsible ap-
plication of debriefing must follow sci-
entific research. Unfortunately, much
of the debriefing field today is charac-
terized by the enthusiastic application
of models in the absence of clear doc-
umentation of long-term benefits.
These prevailing practices and atti-
tudes constituted a substantial chal-
Dr. North is with the department of psy-
chiatry in the School of Medicine and Dr.
Pollio is with the George Warren Brown
School of Social Work at Washington Uni-
versity in St. Louis, Missouri.
PSYCHIATRIC SERVICES
References
1. MTA Cooperative Group: A 14-month ran-
domized clinical trial of treatment strate-
gies for attention-deficit/hyperactivity dis-
order. Archives of General Psychiatry 56:
1073–1086, 1999
2. Barkley RA: Attention-Deficit Hyperactivi-
ty Disorder: A Handbook for Diagnosis and
Treatment, 2nd ed. New York, Guilford,
1998
3. Robin AL: ADHD in Adolescents: Diagno-
sis and Treatment. New York, Guilford,
1998
lenge to the preparation of this vol-
ume. Balanced and well-referenced
discussions of the scientific, experien-
tial, and ethical merits and potential
drawbacks of debriefing appear along
with theoretical models, definitions
and descriptions of applications, an-
ecdotal accounts, and reviews of eval-
uation studies. Pulling together such
disparate material into a single coher-
ent document that synthesizes and
summarizes the current field re-
quired a masterful understanding of
the issues, political sensitivity to dif-
ferent kinds of experience and values,
and the ability to mesh seemingly di-
vergent models and systems. The
book accomplishes the task nicely.
At first glance, we were concerned
that the book’s attempt to focus on
empirical evidence and careful appli-
cation of debriefing might be lost in
the middle chapters’ detailed discus-
sions of debriefing for such diverse
populations as children and adoles-
cents, hospital staff, victims of motor
vehicle accidents, survivors of trau-
matic childbirth, and Australian Abo-
riginal people. This concern was dissi-
pated as we read the chapters, how-
ever; most provide candid discussions
of the scientific evidence for debrief-
ing with the population described.
In chapter after chapter, the au-
thors find insufficient scientific evi-
♦ December 2001 Vol. 52 No. 12

dence and cite recent negative stud-
ies that fail to show that debriefing
“works”—that is, that it prevents or
reduces psychopathology or improves
outcomes. Some authors level criti-
cism at the research for its method-
ological limitations and for applying
the intervention improperly, such as
when implementation lacked fidelity
to the model or when debriefing facil-
itators lacked sufficient qualifications.
Throughout the book, the editors
Anxiety, Depression, and Emotion
edited by Richard J. Davidson; New York, Oxford
University Press, 2000, 291 pages, $60
John R. Walker, Ph.D.
T his volume is based on papers
presented in 1995 at the First
Wisconsin Symposium on Emotion at
the University of Wisconsin at Madi-
son. Initially I was concerned that the
material might be somewhat out of
date, but a review of the chapters in-
dicated that the contributors have
added many references to recent
work, including their own. The chap-
ter authors provide overviews of their
area of study and a perspective on
some of the most up-to-date research
and theories in each area.
The symposium’s coverage of the
field and the resulting book were in-
tended to be broad, and the book re-
flects this goal. The chapters cover a
range of topics, including animal
models of anxiety and depression;
neuroimaging; cognitive functioning
in depression; mood, personality, and
personality disorder; and normal de-
velopment of emotion in children. Six
researchers, all authorities in their
fields, present research on the rela-
tionship between emotion and psy-
chopathology. Each of their chapters
is followed by a chapter containing
commentary that is based on the dis-
cussion that took place among other
Dr. Walker is professor of clinical health
psychology at the University of Manitoba
and director of the anxiety disorders pro-
gram at St. Boniface General Hospital in
Winnipeg, Manitoba, Canada.
PSYCHIATRIC SERVICES ♦ December 2001 Vol. 52 No. 12
carefully maintain a firm grasp on the
book’s central issue: determining the
utility of debriefing and describing its
applicability. “Do we need debriefing
at all?” they ask in the end. “This is
the real question—and it has not yet
been fully answered.” To date, this
book is the definitive source on de-
briefing. It provides a vast amount of
information as well as balanced scien-
tific discussion of potential merits and
shortcomings.
researchers and students who attend-
ed the symposium.
I work in a setting in which the fo-
cus is on clinical service, teaching,
and applied research. I regularly read
reports of applied research but am
able to devote less time to keeping up
with basic research. I hoped that this
book might help me reconnect with
the basic research in these fields. The
chapters on animal models were
heavy going at first, but with persist-
ence I was rewarded with valuable in-
sights about our understanding of
anxiety that is related to defensive be-
haviors and depression that is related
to deficiencies in appetitive behaviors
from the broader perspective of basic
behavioral research.
The chapter on cognitive function-
ing in depression provides a helpful
summary of the wide range of studies
in this area and realistic suggestions
for future research. The chapter on
mood, personality, and personality
disorder presents a very broad per-
spective relating the distinct—and of-
ten isolated—literatures from these
three areas to one another. The au-
thor offers a clear summary of the re-
lationships among these fields and
helps tie together much of the basic
research on emotion and the field of
psychopathology.
The chapter on the development of
complex emotions in children offers a
developmental perspective on psy-
BOOK REVIEWS
chopathology. The views expressed in
this chapter are more speculative, but
it is clear that future research on
emotional development in children
will be essential to our understanding
of adult psychopathology.
I came away from Anxiety, Depres-
sion, and Emotion with many new
perspectives from which to view psy-
chopathology and our efforts to treat
anxiety and mood disorders. I would
highly recommend the book to col-
leagues and students working in the
field of anxiety and depression. The
insights it provides will help strength-
en their understanding of these cen-
tral clinical problems.
The Heroic Client: Doing
Client-Directed, Outcome-
Informed Therapy
by Barry L. Duncan and Scott D.
Miller; San Francisco, Jossey-Bass,
2000, 292 pages, $38
Catherine Pemberton, M.S.W.,
L.I.C.S.W.
T he aim of this book is to urge both
mental health clinicians and per-
sons receiving treatment to step back
and examine how the client is margin-
alized in today’s system of managed
care. The authors, both psychologists,
have devoted their careers to working
as educators, trainers, authors, and
therapists. Together they founded the
Institute for the Study of Therapeutic
Change, a private group of clinicians
and researchers dedicated to studying
“what works” in treatment.
The book opens with a chapter on
challenges to clinical practice in the
21st century. The authors then look
critically at the “mythology” of mental
health and challenge the myths of the
magic pill, psychiatric diagnosis, and
the guru therapist. They ask mental
health professionals to examine their
work and the outside influences that
affect their practice and beliefs and to
develop an approach that extends be-
yond the limits of the medical model.
They encourage clients to be active in
the treatment relationship by ques-
tioning, challenging, and reviewing
1663
BOOK REVIEWS
treatment goals and outcome. Using
an approach based on clinical re-
search and field-tested experience,
the authors lead readers on a search
for meaning and effectiveness in
treatment that is always centered on
the client.
How is it that psychiatrists, psychol-
ogists, social workers, family thera-
pists, and others who provide mental
health support and treatment lose
sight of the human being behind the
symptoms? One datum the authors
offer is that the number of categories
in the American Psychiatric Associa-
tion’s DSM jumped from 66 in the
first edition to 286 in the fourth edi-
tion. With so many categories avail-
able, it has become easier for the
client to become identified by a label,
which all too often then dominates
discussion and direction in treat-
ment. Given the time-limited treat-
ment and brief sessions covered by
payers, little time is available for the
client to disagree or debate with the
professional’s formulation and diag-
nosis. Thus we lose the human being
and are left with treatment that is
driven by diagnosis and by medica-
tion. The therapist and the client
both lose when this happens.
Another point Duncan and Miller
offer for consideration is the number
of theories, techniques, and schools
of therapy available to “apply to the
person.” The authors inform us that
the number of available talk therapies
has risen from 60 in the 1960s to
more than 250 today. One can see in
such growth a formula for leaning
away from a focus on the client’s re-
sources, perceptions, and participa-
tion and toward DSM diagnosis and
application of a treatment chosen by
the practitioner.
The authors use case examples to
describe ways to move from a largely
medical model of care to one in which
the client is at the center, taking an
active role—client-directed rather
than theory-directed change, using a
relational rather than a medical mod-
el of change, focusing more on the
desired outcome than on the services.
Some professionals might find The
Heroic Client provocative because of
the extent to which it calls into ques-
1664
tion the managed care structures
within which they practice. Many
who feel that they have been forced
to accommodate to managed care sys-
tems may be skeptical that it is possi-
ble to give the client such a strong po-
The Advanced Handbook of Methods
in Evidence Based Healthcare
edited by Andrew Stevens, Keith Abrams, John
Brazier, Ray Fitzpatrick, and Richard Lilford; London,
Sage Publications, 2001, 507 pages, $99.95
Evidence-Based Counselling and Psychological
Therapies: Research and Applications
edited by Nancy Rowland and Stephen Goss; London,
Routledge, 2000, 216 pages, $29.95 softcover
Scott E. Provost, M.M., L.I.C.S.W.
T hroughout the history of psychia-
try, critics have questioned the ef-
fectiveness of and the need for certain
treatments. Well-known examples in-
clude hydrotherapy, insulin shock
therapy, frontal lobotomy, and long-
term psychoanalytic therapy. While
many such controversies have been re-
solved, psychiatry and medicine over-
all face new challenges amid growing
concerns about the prevalence of
medical errors, variations in practice
patterns, and the fragmentation of
care. These concerns have fueled ef-
forts nationwide to monitor and im-
prove the quality of health care and
have formed part of the impetus for
the use of evidence-based treatment.
Quality-of-care issues are familiar
to readers of this journal. Its articles
typically cover the organization, fi-
nancing, and delivery of care, includ-
ing the underuse, overuse, and mis-
use of treatment. Although the jour-
nal has been at the forefront of efforts
to provide information about evi-
dence-based mental health services,
evidence-based medicine is a rela-
tively new concept in the field.
The publication of these two books,
Mr. Provost is associate director for re-
search at the Center for Quality Assess-
ment and Improvement in Mental Health
in Cambridge, Massachusetts.
PSYCHIATRIC SERVICES
sition in treatment. This book should
provide all readers with hope, howev-
er. The authors illustrate many ways
for the therapist and the client to
work together toward effective and
meaningful treatment.
The Advanced Handbook of Methods
in Evidence Based Healthcare and
Evidence-Based Counselling and Psy-
chological Therapies, seems especial-
ly timely given that Psychiatric Ser-
vices has devoted the 2001 volume to
the principles and practice of evi-
dence-based psychiatry. Both books
examine the theory, methods, and ap-
plication of evidence-based treat-
ment in the context of the United
Kingdom’s National Health Service;
in so doing, they offer a lens through
which to view evidence-based medi-
cine in other contexts. In addition,
the material covered in these books
encourages professionals to question
customary practice, systematically as-
sess research findings, and incorpo-
rate the best available evidence into
clinical care.
The Advanced Handbook of Meth-
ods in Evidence Based Healthcare is
organized into six general themes: the
quantitative and the qualitative meth-
odologies used to generate clinical ev-
idence; cost-benefit analyses; consen-
sus guideline development; meta-
analyses; and the identification of
emerging health care technologies.
Contributors include well-respected
methodologists, economists, and ethi-
cists. The book is intended for re-
searchers and managers, but it is
more suitable for use as a primary text
♦ December 2001 Vol. 52 No. 12

or as a supplemental resource for sea-
soned health services researchers and
graduate students in epidemiology
and health services research. Most
managers and policy makers are like-
ly to find the book too long and dense
to read cover to cover.
A number of the chapters in this
book may be of value for producers
and consumers of mental health serv-
ices research. For researchers, the
chapters “The Potential Use of Rou-
tine Data Sets in Health Technology
Assessment” and “Methods for Evalu-
ating Organization- or Area-Based
Health Interventions” offer useful
methodological strategies for conduct-
ing research in naturalistic settings.
For readers of research, the chapters
entitled “Assessing the Quality of Re-
ports of Randomized Trials Included
in Meta-Analyses: Attitudes, Practice,
Evidence and Guides” and “Identify-
ing New Healthcare Technologies”
provide useful guides for evaluating
research evidence and forecasting
trends in health care technology.
Each chapter includes useful refer-
ences, and as a whole the book is
comprehensive. However, it is weak-
ened by the fact that it emphasizes
breadth over depth, does not in-
clude a concluding chapter to sum-
marize the book’s content, and does
not examine how evidence-based
treatments are applied in clinical
practice.
Readers will find Evidence-Based
Counselling and Psychological Thera-
pies to be more readable and applica-
ble to mental health research, policy,
and practice. Contributors include
researchers and clinicians from psy-
chology, psychiatry, epidemiology,
and economics. The book is organ-
ized into three sections. The chapters
in the first section provide meaning-
ful definitions of evidence-based
health care, and those in the second
debate the merits of quantitative and
qualitative research methods. The
third section describes how research
evidence can be synthesized and dis-
seminated into clinical practice.
The introductory and concluding
chapters, written by the volume edi-
tors, are clear and concise, and they
can provide less ambitious readers
PSYCHIATRIC SERVICES ♦ December 2001 Vol. 52 No. 12
with an overview and a thoughtful
summary of evidence-based counsel-
ing and mental health care. Clini-
cians, clinician-managers, research-
ers, and policy makers will find this
book to be a practical introduction to
evidence-based mental health care.
It would also serve as a useful sup-
plemental text for graduate courses
in psychology, mental health policy,
and mental health services research.
As concerns mount about quality of
care and health care costs, it is impor-
tant that the profession balance the
science of evidence-based practices
and the art of tailoring treatment to
individual patients. Although both of
these books shed light on the meth-
ods used to produce, assess, and dis-
seminate evidence, they do not re-
view the clinical, management, and
policy challenges that are required to
translate evidence-based research
Treating Suicidal Behavior: An
Effective, Time-Limited Approach
by M. David Rudd, Thomas Joiner, and M. Hasan
Rajab; New York, Guilford Press, 2001, 274 pages, $32
Andrew Edmund Slaby, M.D., Ph.D.
D espite our growing knowledge of
the factors that contribute to self-
destructive behavior, the number of
persons who die by suicide remains
high. The need for a better under-
standing of how to manage persons
who have suicidal behavior is high-
lighted by the fact that for every sui-
cide completion, there are eight to 25
more attempts.
Clearly, depression, hopelessness,
and impulsivity play a role in suicidal
behavior. Genetic factors can predis-
pose an individual to neurotransmitter
dysfunction during times of stress,
which can result in recurrent symp-
toms of affective illness and other psy-
chiatric disorders that are associated
with suicide. Psychopharmacotherapy
and electroconvulsive therapy can of-
Dr. Slaby is clinical professor of psychia-
try at New York University and New York
Medical College.
BOOK REVIEWS
into routine practice settings—a
fruitful topic for future books.
These books are also useful texts for
comparing and contrasting the cen-
tralized health system in the United
Kingdom with the decentralized sys-
tem in the United States. The use of
evidence-based medicine is likely to
increase in both countries (1) as long
as the current call for reducing vari-
ability in the quality of care is sus-
tained. However, differences between
the experiences in the two countries
may ultimately reveal worthwhile les-
sons for ensuring that evidence-based
practices remain on the research, poli-
cy, and practice agendas.
Reference
1. Ferlie EB, Shortell S: Improving the quali-
ty of health care in the United Kingdom
and the United States: a framework for
change. Milbank Quarterly 79:281–315,
2001
ten effectively mollify if not ameliorate
symptoms, but such therapies alone
are not enough. Additional interven-
tions should address the skill building
and interpersonal change that are re-
quired to raise the suicide threshold
during times of stress.
Suicidal patients suffer cognitive
distortions and a poverty of skills. At
their moments of greatest risk, they
feel hopeless about the future, unlov-
able and worthless, and helpless to
change their situation enough to make
a difference. They often perceive
those around them as critical, judg-
mental, rejecting, or abusive. Lacking
in problem solving and interpersonal
skills, they focus on their despair.
Although a number of guidelines
have been published on the treatment
of disorders that are associated with
suicide, such as bipolar illness, major
depression, schizophrenia, and bor-
derline personality disorder, few au-
1665
BOOK REVIEWS
thors have systematically enumerated
strategies for addressing suicidal
ideation itself. In this clearly written
and well-documented volume, Rudd,
Joiner, and Rajab elaborate an ap-
proach to the psychotherapeutic man-
agement of suicidal behavior regard-
less of diagnosis.
The book is divided into two parts;
the first provides a theoretical founda-
tion, and the second is an elaboration
of specific tasks in assessment and
treatment. Research indicates fairly
consistently that the most effective in-
terventions for managing suicidal pa-
tients in the short term entail cogni-
tive-based therapy in which problem
solving is integrated as a core compo-
nent to reduce depression, hopeless-
ness, and suicidal ideation. Reduction
of subsequent suicide attempts and re-
current suicidal ideation requires
longer-term treatment in which a vari-
ety of modalities are used to target
poor stress tolerance, distortions of
self-image, anger management, im-
paired social skills, and dysregulation
of emotion.
The authors discuss how to teach pa-
tients to effectively solve problems by
not avoiding them or responding im-
pulsively to them but by taking a step-
by-step approach and by acquiring
skills that will increase patients’ flexibil-
ity, such as emotion regulation and as-
sertiveness. Principles of cognitive ther-
apy are used, such as adopting a present
time frame and developing awareness
of how individuals actively participate
in construction of their reality.
Acutely suicidal patients are often
unaware that emotional intensity natu-
rally changes over time and that they
may feel better after a while. Their
pervasive sense of hopelessness and
helplessness overwhelms any sense
that they may proactively affect their
destiny. Often they cannot see how
their behavior may intensify rather
than diminish their despair.
The authors emphasize that the
therapeutic relationship is a mecha-
nism for modeling support, trust, ac-
ceptance, attachment, and, ultimately,
separation and growth. For the vast
majority of chronically suicidal pa-
tients and repeated attempters, inter-
personal issues are at the core of their
1666
suicidality. The therapeutic alliance is
the vehicle for change. The quality of
the relationship, the authors empha-
size, is the single most significant fac-
tor in predicting therapeutic outcome
and assessing risk. Without a strong
therapeutic relationship, it is unlikely
that the patient will invest the energy
and endure the pain that are often re-
quired for productive change.
At times the attachment in therapy
may be all a patient can rely on to sur-
vive a particular emotional crisis. The
ultimate goal of both brief and longer-
Learning Disabilities: Implications
for Psychiatric Treatment
edited by Laurence L. Greenhill, M.D.; American Psychiatric Association
Review of Psychiatry Series, volume 19, number 5; Washington, D.C.,
American Psychiatric Press, Inc., 2000, 182 pages, $32.50 softcover
Barbara G. Haskins, M.D.
T his book provides a valuable de-
piction of the complexity and co-
morbidity associated with learning dis-
abilities, which can affect educational,
social, and occupational performance.
Learning disabilities, although tradi-
tionally the purview of child clinicians,
have relevance for clinicians who serve
adults and for physicians who are in-
terested in neuropsychiatry. The Am-
ericans With Disabilities Act has
heightened our culture’s awareness of
the need for accommodation, and
since the law was enacted more and
more situations have arisen in which
persons with disabilities request ac-
commodation. How to conceptualize
learning disabilities and to appropri-
ately manage their accommodation
may interest clinicians who serve colle-
giate populations as well as forensic
psychiatrists.
Learning Disabilities takes the read-
er through epidemiological and longi-
tudinal research findings, neuroimag-
ing findings that anchor disabilities in
discrete brain areas, and overall psy-
chiatric comorbidity. Specific disor-
Dr. Haskins is associate professor of clini-
cal psychiatry at the University of Vir-
ginia and attending psychiatrist at West-
ern State Hospital in Staunton, Virginia.
PSYCHIATRIC SERVICES
term therapy is to raise the threshold
of becoming suicidal when the patient
is no longer highly symptomatic by in-
stilling hope for the future, improving
stress tolerance, enhancing self-image,
and improving interpersonal skills.
The authors of this richly illustrated
practical manual offer psychiatric cli-
nicians, regardless of professional
background, empirically based guide-
lines to supplement their unique ex-
pertise and judgment for the manage-
ment of acutely and chronically suici-
dal patients and those who recurrently
ders that co-occur with attention-
deficit hyperactivity disorder (ADHD)
are addressed in several of the book’s
five chapters. The text offers only
scant discussion of right hemisphere,
or nonverbal, learning disorders.
The chapter on comorbid psychi-
atric disorders among children with
learning disabilities is somewhat weak
in that it makes many impressionistic
or intuitive statements without critical-
ly analyzing the data to support those
statements. The results of longitudinal
studies, although sometimes contra-
dictory, do suggest excessive psychi-
atric comorbidity among persons with
learning disabilities. There is no clear
link between early learning disabilities
and later development of conduct dis-
orders or ADHD.
The chapter detailing cognitive and
neurobiological studies of dyslexia
does a good job of explaining the vari-
ous components of the processes by
which we derive meaning from print-
ed language. Good evidence suggests
that deficits in phonological aware-
ness—a strongly heritable trait—are
the core deficit in dyslexia. Affected
persons cannot master the task of
mapping alphabetic cues onto sounds.
With training, children can conscious-
ly perform such mapping, but the
♦ December 2001 Vol. 52 No. 12

process never becomes truly automat-
ic, and hence these persons will always
read more slowly than do persons who
are not affected. Once the diagnosis of
dyslexia has been confirmed, there is
no need for retesting after high school.
A valid diagnosis mandates accommo-
dation—that is, giving students more
time to perform tasks.
Dyslexia affects children of all intel-
ligence levels. The book devotes many
pages to the debate about screening
methods—the simple-difference meth-
od versus the predicted-achievement
method. Although discussion of the
debate will no doubt seem highly rele-
vant to specialists, generalists will be
more interested in how to manage
children and adults who have learning
disabilities. Much of the methodologi-
cal material would have been better
placed in an appendix.
I found Tannock’s chapter on lan-
guage, reading, and motor control
Community Treatment of Drug
Misuse: More Than Methadone
by Nicholas Seivewright; Cambridge, England, Cambridge
University Press, 2000, 243 pages, $90 hardcover, $39.95 softcover
The Addiction-Prone Personality
by Gordon E. Barnes, Robert P. Murray, David Patton,
Peter M. Bentler, and Robert E. Anderson; New York, Kluwer
Academic/Plenum Publishers, 2000, 320 pages, $65
William Kadish, M.D.
I n the United States, the world of
methadone maintenance therapy is
foreign to almost all mental health pro-
fessionals who are not directly involved
in the provision of services at federally
regulated clinics. This is an unfortu-
nate consequence of the unique regu-
latory structure that separates meth-
adone therapy from the mainstream of
both medical and psychiatric care.
It is therefore most interesting to
read Dr. Seivewright’s Community
Treatment of Drug Misuse, a detailed
and informative book about the deliv-
ery of drug treatment services in Great
Britain, where methadone treatment is
Dr. Kadish practices psychiatry in Shrews-
bury, Massachusetts.
PSYCHIATRIC SERVICES ♦ December 2001 Vol. 52 No. 12
problems in ADHD the most fascinat-
ing in the book. Clinicians in Scandi-
navian countries note a syndrome of
deficits in attention, motor control,
and perception—DAMP. In ADHD,
expressive language is particularly im-
paired. Recent studies indicate that
problems in naming speed are found
in autism and spina bifida as well,
which suggests involvement of the
cerebellum in cognitive processing.
Neuropsychiatrists will be most inter-
ested in this chapter.
Parsimonious diagnosis and our in-
complete understanding of the comor-
bidity that results from dysfunctional
neuronal systems have produced an
underdeveloped view of the range of
impairments associated with learning
disabilities. This book provides useful
information for enhancing our appre-
ciation of the multiple domains affect-
ed by learning disabilities and, to a
lesser extent, for managing them.
not diverted from the mainstream. Al-
though the subtitle of the book is
“More Than Methadone,” it is clear
that the author’s greatest clinical ex-
pertise and the subject about which he
has the most to offer is methadone
treatment. He has worked in the field
for more than a decade and is consid-
ered one of Great Britain’s leading au-
thorities on drug treatment.
The book is divided into two sec-
tions, the first entitled “Treatments”
and the second “Providing Clinical
Services.” The first section presents a
thorough discussion of the clinical real-
ities of methadone treatment as well as
other treatments for opiate addiction
and other drug problems. Much atten-
tion is paid to the differences between
BOOK REVIEWS
using methadone for long-term main-
tenance and using it for shorter peri-
ods, including for acute detoxification.
The author wrestles with the problem
of young users who have not been de-
pendent for very long and how best to
avoid getting them onto maintenance
therapy. Other special populations are
considered in turn, with illustrative
case examples.
The second section will be of partic-
ular value to those involved in the plan-
ning, organization, and administration
of drug treatment services. Seivewright
reviews the history of service delivery
in the United Kingdom and describes
the current system in detail. He then
addresses the issues of treatment in
primary care settings and the problems
related to dual diagnosis. His rich clin-
ical experience, thoughtful analysis,
and abundant common sense make
these chapters well worth reading. I
would strongly suggest that anyone in-
volved in the provision of drug treat-
ment services obtain this book, espe-
cially those who work with patients us-
ing methadone. The book would also
be interesting to those who work regu-
larly with substance abusers and to
anyone who is interested in methadone
treatment.
In contrast to the first book, The Ad-
diction-Prone Personality is pure re-
search. The lead author has more than
20 years’ experience in personality re-
search as it applies to alcoholism and
drug abuse, and his coauthors have
written numerous papers on the sub-
ject as well. Whereas the first book re-
viewed here focuses almost exclusively
on drug abuse, this work gives much
more attention to alcohol abuse. The
“prealcoholic personality” is covered in
detail, as is the personality of the alco-
hol user and of the person who is clini-
cally dependent on alcohol. Perhaps
the book would have been better titled
“The Prealcoholic and Alcoholic Per-
sonalities.”
As a clinician I found little in this
book that I could use in my work. Al-
though the psychological research the
book covers is extensive, and although
many studies are discussed and re-
viewed, it was difficult for me to syn-
thesize the information into clinically
useful constructs. I would guess that
1667
BOOK REVIEWS
readers who are involved in personality
research would benefit a great deal
from the comprehensive assessment of
a vast body of research data that the au-
thors present in this book. Use of psy-
chometric tools is the primary research
method of the studies discussed, and
some familiarity with these instru-
ments is probably required to under-
stand the meaning of the results.
I would recommend this book only
to those involved in basic psychological
research on personality variables in al-
coholism and drug abuse. Today’s busy
clinicians can find much more relevant
literature elsewhere to guide or inform
their practice.
Adult Attachment and
Couple Psychotherapy:
The “Secure Base” in
Practice and Research
edited by Christopher Clulow;
Philadelphia, Brunner-Routledge,
2001, 228 pages, $29.95
William Vogel, Ph.D.
T his work is a study of couples re-
lationships, from the point of
view of attachment theory, which it-
self is derived primarily from psycho-
analysis. One aim of the book is to
reconcile attachment and object-rela-
tions views of the couple relationship.
This is an interdisciplinary work,
with psychologists, psychiatrists, so-
cial workers, and psychoanalysts
among its 17 contributors. Most of
them are or have been associated
with London’s Tavistock Marital
Studies Institute, and the book cele-
brates 50 years of work there.
The text has a unique format in
which clinical and research projects
reinforce and nourish each other. The
12 chapters deal with such topics as
assessment and measurement of cou-
ples relationships; determinants of
stability of relationships; how attach-
ment security is mediated across gen-
Dr. Vogel is associate professor of psychi-
atry at the University of Massachusetts
Medical School in Worcester.
1668
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erations; marital violence; same-sex
couples relationships; and training,
institutional, and social issues that are
related to couples work.
The writing is of a uniformly high
quality, and the issues that are ad-
dressed are far-reaching and impor-
tant. Although the text addresses
complex theoretical issues, it largely
avoids the theoretical jargon that so
Death of the Good Doctor: Lessons
From the Heart of the AIDS Epidemic
by Kate Scannell; San Francisco, Cleis
Press, 1999, 194 pages, $14.95 softcover
Francine Cournos, M.D.
I n 1985 Kate Scannell, M.D., left an
academic position at San Francisco
General Hospital to work as a general
internist at a community-based coun-
ty hospital 20 miles away. She hoped
to escape the emerging plague of
AIDS, which had increasingly come
to dominate her San Francisco prac-
tice. But when, to her dismay, she was
appointed clinical director of the
newly developed AIDS ward at Fair-
mont Hospital, she did not run away,
and for the next five years she experi-
enced the deep personal rewards of
tending to the dying as scores of her
patients exhausted the limited num-
ber of medical options that were then
available.
Death of the Good Doctor details a
period in the history of the AIDS epi-
demic in the United States when
there were no effective treatments for
HIV infection and when discrimina-
tion, ignorance, and denial were near-
ly universal responses to those who
were infected. Of course more thor-
ough accounts of this history can be
found elsewhere, and for many
younger health care professionals it
may no longer even seem relevant.
But the essence of this book is the
timeless theme of how we engage
with our dying patients, how we help
them despite our own helplessness to
make them better, and how intimate
we become with them in the process.
In Death of the Good Doctor, we gain
insight into this final stage of life
PSYCHIATRIC SERVICES
often mars books of this type. In sum,
Adult Attachment and Couple Psy-
chotherapy is an enjoyable read, and
it should be of interest to mental
health professionals who are interest-
ed in couples and family issues. While
it is of general interest, it should be of
particular interest to family workers
whose training and interests touch on
or involve psychoanalytic theory.
through Dr. Scannell’s emotional
struggles and those of some of her
most memorable patients. There’s
Jay, a threatening homeless injection
drug user who settles down when Dr.
Scannell learns what he most cares
for and buys it for him: a bowl of gold-
fish. And there’s Elton, an obsession-
al man who is convinced that there
must be a proper etiquette to dying
and wants to discuss the steps with
her. There’s gravely ill Eric and his
belligerent mother, who were es-
tranged for 11 years and now are
helped by the reluctant Dr. Scannell
to reconcile with one another and
thereby permit a peaceful good-bye.
And there’s Marvin, whose last re-
quest is granted: a purchase-free trip
to a Target department store. A host
of other characters, nearly all of them
men, populate this narrative.
It is then all the more remarkable
to learn at the end of the book that
Dr. Scannell has herself coped with
discrimination as a lesbian physician
and that she is now facing her own
premature life-and-death battle with
cancer. This highly readable book is
an engaging account of how much
healing is possible even when our
only task is to help our patients make
life’s inevitable final transition.
Dr. Cournos is director of the Washington
Heights Community Service at the New
York State Psychiatric Institute in New
York City.
♦ December 2001 Vol. 52 No. 12