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Handbook of behavioral interventions. A clinical guide
UOOK RbVlhWS
1x9
authors. with occasional collaboration of others) on the anatomy. physiology and endocrinology, the relationship (of erectile dysfunction) with various medical conditions and with alcohol, theories. diagnostic methods and different forms of treatment. Each chapter is well-referenced (though unfortunately there is no author index). and --where relc~lnt-illustrated with photo~r~lphs and line drawings. The real value of this book, in my view. is that it integrates a large amount of new research-usually appearing in widely-scattered journals not always regularly read by practising therapists. It also reports previously unpublished data and presents both types of empirical evidence in one coherent text. It thus succeeds in being a useful reference book for the clinician/student on the subject of impotence. One problem with this otherwise excellent text is that the discussions are at times all too brief. For example. the chapter on psychological theories could have been more comprehensive. The same applies to the chapter on psychological therapies. The order of chapters, too, leaves something to be desired. 1 am also not convinced that the presentation of case vignettes in split form (presenting problem and background data at the beginning of the book. management and outcome at the end) achieves any usefulend. Despite these reservations, Wagner and Green have produced a book that goes a long way toaards ful~llin~ a serious need. One hopes they will expand and update therr volume at a later date. PADMAL DE SILVA
0. POMERLEAL and J. P. BRADY: ~~~~~j~~r~~~ Medicine: 308 pp.
Thrmy
ad
Pracriw.
Williams
& Wilkins,
Baltimore
(1980).
The subject that is known in America as behavioural medicine and more often in this country as medical psychology, has achieved rapid if belated popularity. In the manner to which we have become accustomed. publications on this new topic have begun to appear with a rapidity that over-reaches the accumulation of new facts or ideas. In the midst of this stream. which threatens to become a flood, the book edited by Pomerleau and Brady is of superior quality. The 12 chapters, each written by an authority on his subject, are divided into one section devoted to basic concepts, and another section which deals with the clinical applications. As might be expected, the section on basic concepts is more solidly estabhshed than the applications which at this stage are far too often potentialities dressed up as practical procedures of known effectiveness. While few of the chapters deal with material that is not already at least partly familiar to readers of this subject, some arc sufIiciently navel to warrant particular attention. A chapter on behavioural epidemiology by Sexton. while containing material that fits easily into the conventional notion of epidemiology, does make some tentative steps in the direction of the title of her article. It is stimulating and well worth looking at. Brady on learning and Shapiro and Surwit on biofeedback present their usual authoritative and concise contributions. and the same can he said of Mahoney and Arnkoff on self-management. In the clinicial applications section there is a good chapter on behavioural pediatrics, a clear restatement by Fordqce of his approach to chronic pain and an updated review by Bernstein of his incisive and constructive analysis of smoking research. Stunkard on obesity is reliable and interesting. Nathan and Goldman are equally stimulating on the ancient problem of alcoholism. but some of their judgements give the impression that there exists greater certainty on certain subjects than is the case. Agras and Jacob give an excellent chapter on the psychology of hypertension, c~~rnbinin~ a healthy scepticism with clarity and cautious optimism. Two of the best chapters are those provided by Stoqva on stress-related disorders, and by Lo Piccolo and Ho_pan on sexual dysfunction. As these are subjects that have been Lvritten about so frequently. compiling a fresh and interesting chapter on the subject presents a challenge. The contributors have in this case succeeded admirably well and readers wishing to have a thoughtful review of these subjects could do no better than search out these chapters. At this early staze of the development of behavioural medicine, reviewers have little option but to note the steadily-accumulating literature on the subject and attempt to point readers in the directions that might benefit them. The subject is well launched, but even in the presence of such well compiled and useful books as the one by Pomerleau and Brady. it is difficult to avoid worrying about the possibility of yet another publication flood. Leaving aside one’s worry about wastage. there is the danger that potent~ll~-interested psychologists and others might react pa~doxic~~lly to the rapidly expanding literature by withdr~l~vin~ in a state of satiation. If the correct balance is to be found. the present book by Pomerleau and Brady should succeed and be read widely and with profit.
This is an extremely useful and interesting book. It is a collection of contributions on behavioural techniques and on the clinicial process of behaviour therapy. The book begins with a short contribution on behaviour analysis by Wolpe which consists. in the main. of a transcript from one of Wolpe’s well-known workshops. Giving pride of place to Wolpe is significant as there is no doubt that the contributions in this book in one way or another owe a great debt to Wolpc’s pioneering work on the treatment of adult neurosis. Disappointingly, Wolpe’s introductory chapter offers very
I90
little more than can be found in other examples of his approach to behaviour analysis. Moreover. the v.orkshop format is not the best way of communicating the essential complexity of that enterprise. The handbook is then divided into t%o distinct sections. Six contributions which illustrate the application of behavioural techniques, namely systematic desensitization. imposive therapy. covert conditionillg. biofeedback tecbniyues and p~lradoxi~~~l intention. The second section contains live very lengthy chapters illl~str~~ting in considerable clinical detail beh~lvioLlr~~l interv~l~ti~~lls in the treatment of agoraphobia, obsessive-compulsive neurosis. unassertivcnrss. sexual deviation and stuttering. It will be immediately obvious that the emphasis on the book is on adult neurotic problems, in particular those in \\iich anxiety is a significant feature. Notable omissions from the compendium are anything on the trentmcnt of depression. psychosexual counselling and the treatment of sexual disfunction. the treatment of antisocial and agressive bchaviour as well as the vast area on children and adolescents. However. the book is long enough as it stands and it is clear that the editors have chosen to focus on a particular section of the psychiatric population and provide cons&rable detail on how these disorders might be treated. If the potential reader is aware of the specific focus of the book and work5 predominantly with anxiety-based neurotic problems, then there is no doubt that this \olumc has a lot to other to the practitioner. As \vith all edited ~o~~pe~~di~~rns. some ~ontr~biiti~~ils are much better than others. But tIw ov~mll stnnd;lrd is gencratlq vary high and the editors are to he commended for ensuring that each contributor keeps uithin ;I standard, but still flexible format in their presentation. The strength of the book lies in the considerable :ittention to detzii of thtz clinical process of behaviour therapy. Very few books on hehaviour therapy-indeed I cannot think of any that quite matches this once have been so revealing BS to \+hat hehaviour therapists actually do in climcal practice. C‘ase material about and detailed segments of transcripts of cases can be found in all the chapters. Not only does this make the lengthy chapters much more readable. but IS parl~cularly useful fat, the practitioner to see how others. often leading experts in the field. carry out their behavioural Icork. Selection of chapters of particular interest is mevitably a personal choice. But I was greatly encouraged to read the lengthy exposition bv Dlnnnc C‘hamblcss and Alan
intrapersonal and interpersonal factors define the conditio;,. Thus. tl& see complex agoraphobics as being pcoplr with low levels of self-sutticiency. usually in some form of interpersonal confiict with ;t spouse or others. Uith a tendency to misinterpret the antecedents of their anxiety. and with a “fear of fear” iisthe central phobic clement. This recognition of the cognitive and interpersonal aspect of agoraphobia has Icad them to develop a clinical treatment in which bchavioural procedures are rightly subsumed to the personal aspects of the thcrapq process. Ch;tmbless and Goldstein acknowledge: “Agoraphohics are particularly sensitive to the interpersonal environment of psychotherapy. They respond strongly to a therapist as a person. and the success of the therapy often hinges on the relationship.” (p. 409) It is heartening to see behaviour therapists linally acknowledge the interpersonal aspects of the!-spy a\ being crucial \zriables in the success of their interventions. In the case of Chambless and Goldstein’s chapter this is exemplified in detailed and sopllistic~lted accounts of their therapy operation. Not all contributions to this volume are of a good clinical or theoretical standard and some raise rather disturbing ethical questions concerning the use of certain techniques, I pcrsonaliy found the exaggerated imagery that Levrs uses in his version of implosive therapy to be seriously questioned as an ethical therapeutic technique. It may be the CLISC that exaggerated imager) is successful in reducing anxiet) (although I am less sanguine than Levts in this respect). but the semipornopraphic descriptions of imagery used in the case of a 45-year-old depressed man who was apparently unable to express feelings of anger (pp. 13X 139) and the scatological descriptions of the patient \vith a fear of being contaminated by dog facces (pp. 126134) are disturbing to read let alone be subjected to as part of a therapeuuc approach. Levis suggests that these imagery-based approaches are designed to lend to the extinction of anxiety. but the crude analogy from the laboratory extinction procedures to the rich and complex anxieties found in clinical patients will just not do. It seems that Levis. and he is not the only one in this book. is prepared to ignore the cognitive content of emotional disorders. or treat that content as just another example of the conditioned stimuli that need to be extinguished by implosion or other means. The irony of this book is that practically all the contributions are prefaced by a brief sketch of conditioning or learning theories presumed to underlie the treatments used and to justify their application. But it is obvious to all except the most blinkered hehaviour therapist that the gap between the conditioning and learning theories in the laboratory and the therapeutic practices in the clinic. so liberally and extcnslbely illustrated in this volume, is enormous. Precisely because this is evident in this volume. I believe that it is \+ell worth while behaviour therapists. particularly those whose clinical practice has not been very extensive ober the years. should examine the material in this book and see how different the therapeutic practice is from the theories that are expounded in academic .journals. It is of course an expensive book for individuals to buq. But I beliecr that it well repays the outlay of just over El5 to gain the practical knowledge of clinical cases that cannot be found in any depth elsewhere.
This British paperback edition of An Altrrnafice Apyrocrcit to AUrryir.s (New York, Lippincott & Crowcll, 19110) will be a welcome addition to the library of therapists who prefer not to give up on patients who fail to respond to the orthodox panoply of drugs, behaviour therapy and palliative chat. The authors present a popular summary of Randolph’s 50 years of effort to elucidate the environmental origins of an enormous range of mental and physical disturbances.
1x9
authors. with occasional collaboration of others) on the anatomy. physiology and endocrinology, the relationship (of erectile dysfunction) with various medical conditions and with alcohol, theories. diagnostic methods and different forms of treatment. Each chapter is well-referenced (though unfortunately there is no author index). and --where relc~lnt-illustrated with photo~r~lphs and line drawings. The real value of this book, in my view. is that it integrates a large amount of new research-usually appearing in widely-scattered journals not always regularly read by practising therapists. It also reports previously unpublished data and presents both types of empirical evidence in one coherent text. It thus succeeds in being a useful reference book for the clinician/student on the subject of impotence. One problem with this otherwise excellent text is that the discussions are at times all too brief. For example. the chapter on psychological theories could have been more comprehensive. The same applies to the chapter on psychological therapies. The order of chapters, too, leaves something to be desired. 1 am also not convinced that the presentation of case vignettes in split form (presenting problem and background data at the beginning of the book. management and outcome at the end) achieves any usefulend. Despite these reservations, Wagner and Green have produced a book that goes a long way toaards ful~llin~ a serious need. One hopes they will expand and update therr volume at a later date. PADMAL DE SILVA
0. POMERLEAL and J. P. BRADY: ~~~~~j~~r~~~ Medicine: 308 pp.
Thrmy
ad
Pracriw.
Williams
& Wilkins,
Baltimore
(1980).
The subject that is known in America as behavioural medicine and more often in this country as medical psychology, has achieved rapid if belated popularity. In the manner to which we have become accustomed. publications on this new topic have begun to appear with a rapidity that over-reaches the accumulation of new facts or ideas. In the midst of this stream. which threatens to become a flood, the book edited by Pomerleau and Brady is of superior quality. The 12 chapters, each written by an authority on his subject, are divided into one section devoted to basic concepts, and another section which deals with the clinical applications. As might be expected, the section on basic concepts is more solidly estabhshed than the applications which at this stage are far too often potentialities dressed up as practical procedures of known effectiveness. While few of the chapters deal with material that is not already at least partly familiar to readers of this subject, some arc sufIiciently navel to warrant particular attention. A chapter on behavioural epidemiology by Sexton. while containing material that fits easily into the conventional notion of epidemiology, does make some tentative steps in the direction of the title of her article. It is stimulating and well worth looking at. Brady on learning and Shapiro and Surwit on biofeedback present their usual authoritative and concise contributions. and the same can he said of Mahoney and Arnkoff on self-management. In the clinicial applications section there is a good chapter on behavioural pediatrics, a clear restatement by Fordqce of his approach to chronic pain and an updated review by Bernstein of his incisive and constructive analysis of smoking research. Stunkard on obesity is reliable and interesting. Nathan and Goldman are equally stimulating on the ancient problem of alcoholism. but some of their judgements give the impression that there exists greater certainty on certain subjects than is the case. Agras and Jacob give an excellent chapter on the psychology of hypertension, c~~rnbinin~ a healthy scepticism with clarity and cautious optimism. Two of the best chapters are those provided by Stoqva on stress-related disorders, and by Lo Piccolo and Ho_pan on sexual dysfunction. As these are subjects that have been Lvritten about so frequently. compiling a fresh and interesting chapter on the subject presents a challenge. The contributors have in this case succeeded admirably well and readers wishing to have a thoughtful review of these subjects could do no better than search out these chapters. At this early staze of the development of behavioural medicine, reviewers have little option but to note the steadily-accumulating literature on the subject and attempt to point readers in the directions that might benefit them. The subject is well launched, but even in the presence of such well compiled and useful books as the one by Pomerleau and Brady. it is difficult to avoid worrying about the possibility of yet another publication flood. Leaving aside one’s worry about wastage. there is the danger that potent~ll~-interested psychologists and others might react pa~doxic~~lly to the rapidly expanding literature by withdr~l~vin~ in a state of satiation. If the correct balance is to be found. the present book by Pomerleau and Brady should succeed and be read widely and with profit.
This is an extremely useful and interesting book. It is a collection of contributions on behavioural techniques and on the clinicial process of behaviour therapy. The book begins with a short contribution on behaviour analysis by Wolpe which consists. in the main. of a transcript from one of Wolpe’s well-known workshops. Giving pride of place to Wolpe is significant as there is no doubt that the contributions in this book in one way or another owe a great debt to Wolpc’s pioneering work on the treatment of adult neurosis. Disappointingly, Wolpe’s introductory chapter offers very
I90
little more than can be found in other examples of his approach to behaviour analysis. Moreover. the v.orkshop format is not the best way of communicating the essential complexity of that enterprise. The handbook is then divided into t%o distinct sections. Six contributions which illustrate the application of behavioural techniques, namely systematic desensitization. imposive therapy. covert conditionillg. biofeedback tecbniyues and p~lradoxi~~~l intention. The second section contains live very lengthy chapters illl~str~~ting in considerable clinical detail beh~lvioLlr~~l interv~l~ti~~lls in the treatment of agoraphobia, obsessive-compulsive neurosis. unassertivcnrss. sexual deviation and stuttering. It will be immediately obvious that the emphasis on the book is on adult neurotic problems, in particular those in \\iich anxiety is a significant feature. Notable omissions from the compendium are anything on the trentmcnt of depression. psychosexual counselling and the treatment of sexual disfunction. the treatment of antisocial and agressive bchaviour as well as the vast area on children and adolescents. However. the book is long enough as it stands and it is clear that the editors have chosen to focus on a particular section of the psychiatric population and provide cons&rable detail on how these disorders might be treated. If the potential reader is aware of the specific focus of the book and work5 predominantly with anxiety-based neurotic problems, then there is no doubt that this \olumc has a lot to other to the practitioner. As \vith all edited ~o~~pe~~di~~rns. some ~ontr~biiti~~ils are much better than others. But tIw ov~mll stnnd;lrd is gencratlq vary high and the editors are to he commended for ensuring that each contributor keeps uithin ;I standard, but still flexible format in their presentation. The strength of the book lies in the considerable :ittention to detzii of thtz clinical process of behaviour therapy. Very few books on hehaviour therapy-indeed I cannot think of any that quite matches this once have been so revealing BS to \+hat hehaviour therapists actually do in climcal practice. C‘ase material about and detailed segments of transcripts of cases can be found in all the chapters. Not only does this make the lengthy chapters much more readable. but IS parl~cularly useful fat, the practitioner to see how others. often leading experts in the field. carry out their behavioural Icork. Selection of chapters of particular interest is mevitably a personal choice. But I was greatly encouraged to read the lengthy exposition bv Dlnnnc C‘hamblcss and Alan
intrapersonal and interpersonal factors define the conditio;,. Thus. tl& see complex agoraphobics as being pcoplr with low levels of self-sutticiency. usually in some form of interpersonal confiict with ;t spouse or others. Uith a tendency to misinterpret the antecedents of their anxiety. and with a “fear of fear” iisthe central phobic clement. This recognition of the cognitive and interpersonal aspect of agoraphobia has Icad them to develop a clinical treatment in which bchavioural procedures are rightly subsumed to the personal aspects of the thcrapq process. Ch;tmbless and Goldstein acknowledge: “Agoraphohics are particularly sensitive to the interpersonal environment of psychotherapy. They respond strongly to a therapist as a person. and the success of the therapy often hinges on the relationship.” (p. 409) It is heartening to see behaviour therapists linally acknowledge the interpersonal aspects of the!-spy a\ being crucial \zriables in the success of their interventions. In the case of Chambless and Goldstein’s chapter this is exemplified in detailed and sopllistic~lted accounts of their therapy operation. Not all contributions to this volume are of a good clinical or theoretical standard and some raise rather disturbing ethical questions concerning the use of certain techniques, I pcrsonaliy found the exaggerated imagery that Levrs uses in his version of implosive therapy to be seriously questioned as an ethical therapeutic technique. It may be the CLISC that exaggerated imager) is successful in reducing anxiet) (although I am less sanguine than Levts in this respect). but the semipornopraphic descriptions of imagery used in the case of a 45-year-old depressed man who was apparently unable to express feelings of anger (pp. 13X 139) and the scatological descriptions of the patient \vith a fear of being contaminated by dog facces (pp. 126134) are disturbing to read let alone be subjected to as part of a therapeuuc approach. Levis suggests that these imagery-based approaches are designed to lend to the extinction of anxiety. but the crude analogy from the laboratory extinction procedures to the rich and complex anxieties found in clinical patients will just not do. It seems that Levis. and he is not the only one in this book. is prepared to ignore the cognitive content of emotional disorders. or treat that content as just another example of the conditioned stimuli that need to be extinguished by implosion or other means. The irony of this book is that practically all the contributions are prefaced by a brief sketch of conditioning or learning theories presumed to underlie the treatments used and to justify their application. But it is obvious to all except the most blinkered hehaviour therapist that the gap between the conditioning and learning theories in the laboratory and the therapeutic practices in the clinic. so liberally and extcnslbely illustrated in this volume, is enormous. Precisely because this is evident in this volume. I believe that it is \+ell worth while behaviour therapists. particularly those whose clinical practice has not been very extensive ober the years. should examine the material in this book and see how different the therapeutic practice is from the theories that are expounded in academic .journals. It is of course an expensive book for individuals to buq. But I beliecr that it well repays the outlay of just over El5 to gain the practical knowledge of clinical cases that cannot be found in any depth elsewhere.
This British paperback edition of An Altrrnafice Apyrocrcit to AUrryir.s (New York, Lippincott & Crowcll, 19110) will be a welcome addition to the library of therapists who prefer not to give up on patients who fail to respond to the orthodox panoply of drugs, behaviour therapy and palliative chat. The authors present a popular summary of Randolph’s 50 years of effort to elucidate the environmental origins of an enormous range of mental and physical disturbances.