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Childhood abuse and chronic pain: a curious relationship?
Book Reviews
305
The guide also takes a creative and expansive view of learning opportunities that extends far beyond the traditional definition of attendance on training courses. The 14 examples of various learning opportunities mentioned in the guide demonstrate that the acquisition of skills in child protection work does not depend solely on what takes place between the newly qualified worker and their front line manager.
GRETCHEN PRECEY Clermont Child Protection Unit Brighton and Hove Social Services 251 Preston Road Brighton East Sussex BN 6SE, UK
PII S0145-2134(99)00136-2
Childhood Abuse and Chronic Pain: A Curious Relationship? by Ranjan Roy. University of Toronto Press, 1998, 160 pp. $40 & £27 (cloth); $16.95 & £11 (paperback). Maltreatment can interfere with the whole spectrum of a child’s developmental process and intrude into many aspects of later functioning. There has been considerable interest in the link between childhood abuse and psychological symptoms in adult life, with convincing evidence that childhood maltreatment features prominently in the histories of mental health service patients. Ranjan Roy’s contribution is in an area that has received relatively less attention, that of psychogenic pain. He is professor in the University of Manitoba’s Faculty of Social Work and Department of Clinical Health Psychology, a practicing clinician with a background in psychodynamic psychotherapy. In this book, he describes his experiences of treating patients who had presented to a pain clinic with a range of bodily pains, which appeared to be linked to physical, sexual or emotional abuse in childhood. Roy first reviews evidence that childhood abuse may lead to later problems such as psychiatric breakdowns, eating disorders, and psychosomatic complaints. This is not intended as an exhaustive trawl through the literature on these topics and his focus remains psychosomatic pain, with an emphasis on what Engel has described as “pain-proneness.” While the reviews are succinct and instructive, I did wish for somewhat fuller discussions of the psychological mechanisms that might underlie the translation of abusive experiences into physical pain many years later. This is because the material in the numerous clinical vignettes appear to have been selected on the assumption that the presenting symptoms were based on the patient’s abuse history and some skeptical readers are likely to posit other explanations. A whole chapter is devoted to psychogenic pain associated with spouse abuse because of Roy’s concern that it is grossly under-recognized clinically and under-reported in the literature. This is, above all, a clinical book and the comments which accompany the case examples expand on common patterns between them, such as the symptoms of pain which took on a meaning of their own, beyond the original psychological conflict, and seemed to represent an atonement for past “misdeeds,” of a search for care. Also, a number of patients were referred after being involved in road traffic accident, which appeared to have reawakened their earlier sense of helplessness. Another point of interest was the often repeated comments by those patients emotionally abused as children that they would have preferred to have been beaten rather than humiliated, criticized, or ignored, which adds weight to observations of others that it is the psychological assaults of abuse that are the most traumatizing. Issues of engagement are not specifically highlighted, even though this is notoriously difficult with those who have histories of abuse. Some of the patients described only came to a few sessions or remained intellectualizing throughout, saying that no psychological help was necessary. Reder and Fredman (1996) have discussed such difficulties as representing a conflictual “relationship to help,” in which childhood experiences— the wish to be rescued and helped, tempered with the realization that no one was prepared to notice or believe their plight—are repeated in the process of seeking and rejecting therapy as an adult. We suggest that the risk of such a repetition needs to be overt early in the therapeutic contact. The crisis of disclosure is addressed through a dedicated chapter, which describes vividly how some adult patients re-experience the affect that accompanied the original childhood abuse. Disclosure during therapy may then become a crisis requiring intensive support and active treatment. A further chapter outlines the process of therapy through selected vignettes. Roy’s review of outcome literature leads him to conclude that there is room for further evidence of the efficacy of the various approaches. However, his preferred
306
Book Reviews
psychotherapeutic technique is based on brief psychotherapy models described by Malan and Sifneos, which have been shown to be effective for a range of presentations. This is a succinct and readable book, which will hopefully, of influence to physicians and surgeons. DR. PETER REDER Consultant Child Psychiatrist Child & Family Consultation Center 1 Wolverton Gardens London, W6 7DY, UK
PII S0145-2134(99)00140-4
REFERENCE Reder, P., & Fredman, G. (1996). The relationship to help: Interacting beliefs about the treatment process. Clinical Child Psychology & Psychiatry, 1, 457– 467.
Lost Childhoods, The Plight of the Parentified Child, by Gregory J. Jurkovic. Brunner/Mazel Publishers, New York, 1997. Parentification is an overlooked problem of family dynamics, and in association to child abuse neglect, an inadequately treated and overlooked topic. Few articles have been written and the literature is surprisingly sparse. Many children will grow up experiencing a more or less permanent role-reversal pattern sacrificing their childhood, while others will experience the plight during periods of family life, for example, during marital conflicts, divorce, periods of parental drug abuse, and other forms of family stress and dysfunction. At the other end of the spectra children learn and grow by taking responsibility while growing up. In this book the author has tried to summarize underlying theories behind the parentification process, earlier publications on the subject, and many years of their own experiences as psychotherapist and supervisor. In the introductory chapters (Chapters 1–3), the author tries to map the territory or define the construct of parentification and other interrelated constructs, outlines the possible pathways causing destructive forms of parentification, and consequences of parentification. Throughout the book the author stresses the importance of the multivariate nature of causality, transgenerational transmission patterns, and the ecological-ethical perspective. This stance becomes very evident in the subsequent chapters dealing with evaluation and treatment issues (Chapters 4 – 6). Examples of questions that can be asked of parents, children, and siblings are helpfully given. The therapeutic tasks are clearly outlined and illustrated with case reports. In Chapter 7, the author focuses on treating destructive parentification in couples which also highlights the transgenerational patterns that parents so often are burdened with. Patterns can be subtle and vague if not focused on in the evaluation or in the therapeutic process. In the next chapter, Dr. Jurkovic addresses the problems and strengths with therapists who themselves have a history of parentification. Finally, the last chapter deals with the question of how to prevent parentification? In summary, Professor Jurkovic has written an important book and contributed to a better knowledge and understanding of the psychodynamics behind parentification. The book also gives approaches to treatment interventions required by family therapists. The book highlights the knowledge that every professional working with children needs and the book can be recommended, especially for practitioners of family therapy and family counseling. For readers of Child Abuse & Neglect, I would recommend reading the chapter of evaluation and treatment, but especially the chapter “Wounded Healer” that emphasize both the risk for professional burnout among therapists, and especially parentified therapists working in the field of child abuse and neglect. CARL GORAN SVEDIN Department of Child and Adolescent Psychiatry Faculty of Health Sciences University Hospital S-581 85 Linkoping Sweden
PII S0145-2134(99)00139-8
305
The guide also takes a creative and expansive view of learning opportunities that extends far beyond the traditional definition of attendance on training courses. The 14 examples of various learning opportunities mentioned in the guide demonstrate that the acquisition of skills in child protection work does not depend solely on what takes place between the newly qualified worker and their front line manager.
GRETCHEN PRECEY Clermont Child Protection Unit Brighton and Hove Social Services 251 Preston Road Brighton East Sussex BN 6SE, UK
PII S0145-2134(99)00136-2
Childhood Abuse and Chronic Pain: A Curious Relationship? by Ranjan Roy. University of Toronto Press, 1998, 160 pp. $40 & £27 (cloth); $16.95 & £11 (paperback). Maltreatment can interfere with the whole spectrum of a child’s developmental process and intrude into many aspects of later functioning. There has been considerable interest in the link between childhood abuse and psychological symptoms in adult life, with convincing evidence that childhood maltreatment features prominently in the histories of mental health service patients. Ranjan Roy’s contribution is in an area that has received relatively less attention, that of psychogenic pain. He is professor in the University of Manitoba’s Faculty of Social Work and Department of Clinical Health Psychology, a practicing clinician with a background in psychodynamic psychotherapy. In this book, he describes his experiences of treating patients who had presented to a pain clinic with a range of bodily pains, which appeared to be linked to physical, sexual or emotional abuse in childhood. Roy first reviews evidence that childhood abuse may lead to later problems such as psychiatric breakdowns, eating disorders, and psychosomatic complaints. This is not intended as an exhaustive trawl through the literature on these topics and his focus remains psychosomatic pain, with an emphasis on what Engel has described as “pain-proneness.” While the reviews are succinct and instructive, I did wish for somewhat fuller discussions of the psychological mechanisms that might underlie the translation of abusive experiences into physical pain many years later. This is because the material in the numerous clinical vignettes appear to have been selected on the assumption that the presenting symptoms were based on the patient’s abuse history and some skeptical readers are likely to posit other explanations. A whole chapter is devoted to psychogenic pain associated with spouse abuse because of Roy’s concern that it is grossly under-recognized clinically and under-reported in the literature. This is, above all, a clinical book and the comments which accompany the case examples expand on common patterns between them, such as the symptoms of pain which took on a meaning of their own, beyond the original psychological conflict, and seemed to represent an atonement for past “misdeeds,” of a search for care. Also, a number of patients were referred after being involved in road traffic accident, which appeared to have reawakened their earlier sense of helplessness. Another point of interest was the often repeated comments by those patients emotionally abused as children that they would have preferred to have been beaten rather than humiliated, criticized, or ignored, which adds weight to observations of others that it is the psychological assaults of abuse that are the most traumatizing. Issues of engagement are not specifically highlighted, even though this is notoriously difficult with those who have histories of abuse. Some of the patients described only came to a few sessions or remained intellectualizing throughout, saying that no psychological help was necessary. Reder and Fredman (1996) have discussed such difficulties as representing a conflictual “relationship to help,” in which childhood experiences— the wish to be rescued and helped, tempered with the realization that no one was prepared to notice or believe their plight—are repeated in the process of seeking and rejecting therapy as an adult. We suggest that the risk of such a repetition needs to be overt early in the therapeutic contact. The crisis of disclosure is addressed through a dedicated chapter, which describes vividly how some adult patients re-experience the affect that accompanied the original childhood abuse. Disclosure during therapy may then become a crisis requiring intensive support and active treatment. A further chapter outlines the process of therapy through selected vignettes. Roy’s review of outcome literature leads him to conclude that there is room for further evidence of the efficacy of the various approaches. However, his preferred
306
Book Reviews
psychotherapeutic technique is based on brief psychotherapy models described by Malan and Sifneos, which have been shown to be effective for a range of presentations. This is a succinct and readable book, which will hopefully, of influence to physicians and surgeons. DR. PETER REDER Consultant Child Psychiatrist Child & Family Consultation Center 1 Wolverton Gardens London, W6 7DY, UK
PII S0145-2134(99)00140-4
REFERENCE Reder, P., & Fredman, G. (1996). The relationship to help: Interacting beliefs about the treatment process. Clinical Child Psychology & Psychiatry, 1, 457– 467.
Lost Childhoods, The Plight of the Parentified Child, by Gregory J. Jurkovic. Brunner/Mazel Publishers, New York, 1997. Parentification is an overlooked problem of family dynamics, and in association to child abuse neglect, an inadequately treated and overlooked topic. Few articles have been written and the literature is surprisingly sparse. Many children will grow up experiencing a more or less permanent role-reversal pattern sacrificing their childhood, while others will experience the plight during periods of family life, for example, during marital conflicts, divorce, periods of parental drug abuse, and other forms of family stress and dysfunction. At the other end of the spectra children learn and grow by taking responsibility while growing up. In this book the author has tried to summarize underlying theories behind the parentification process, earlier publications on the subject, and many years of their own experiences as psychotherapist and supervisor. In the introductory chapters (Chapters 1–3), the author tries to map the territory or define the construct of parentification and other interrelated constructs, outlines the possible pathways causing destructive forms of parentification, and consequences of parentification. Throughout the book the author stresses the importance of the multivariate nature of causality, transgenerational transmission patterns, and the ecological-ethical perspective. This stance becomes very evident in the subsequent chapters dealing with evaluation and treatment issues (Chapters 4 – 6). Examples of questions that can be asked of parents, children, and siblings are helpfully given. The therapeutic tasks are clearly outlined and illustrated with case reports. In Chapter 7, the author focuses on treating destructive parentification in couples which also highlights the transgenerational patterns that parents so often are burdened with. Patterns can be subtle and vague if not focused on in the evaluation or in the therapeutic process. In the next chapter, Dr. Jurkovic addresses the problems and strengths with therapists who themselves have a history of parentification. Finally, the last chapter deals with the question of how to prevent parentification? In summary, Professor Jurkovic has written an important book and contributed to a better knowledge and understanding of the psychodynamics behind parentification. The book also gives approaches to treatment interventions required by family therapists. The book highlights the knowledge that every professional working with children needs and the book can be recommended, especially for practitioners of family therapy and family counseling. For readers of Child Abuse & Neglect, I would recommend reading the chapter of evaluation and treatment, but especially the chapter “Wounded Healer” that emphasize both the risk for professional burnout among therapists, and especially parentified therapists working in the field of child abuse and neglect. CARL GORAN SVEDIN Department of Child and Adolescent Psychiatry Faculty of Health Sciences University Hospital S-581 85 Linkoping Sweden
PII S0145-2134(99)00139-8