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The Original Sin: Incest and Its Meaning
BOOK REVIEWS
sis, tactics and strategy of clinical reasoning, and "the hypothetico-deductive reasoning in the clinical process." The authors describe how a clinician thinks and give basic descriptions of how humans think, e.g., "the human computer is overimpressed with evidence appearing early in the reasoning process and relatively less efficient in considering later information, especially if it runs counter to earlier material." Appendix I supplements part two in that it is a typescript of the diagnostic reasoning of an experienced clinician while interviewing a patient. Part three addresses clinical procedures. The authors explain how to obtain a psychiatric history and begin with how the physician should introduce him or herself to the patient. The chapter includes, in obtaining a psychiatric history, everything from three interview seating arrangements to transference and countertransference, with the suggestion to get help from a colleague when necessary. The chapter on mental status examination, in addition to the usual examples of the examination, contains several brief tests including a test of language function. The chapter on the physical examination and special investigations notes that 75 non psychiatric disorders can be present with depression but also that the history should determine the direction of the physical examination and laboratory investigation. The authors do not hesitate to state their opinion, e.g., they do not think the DST is reliable or cost-effective and they give their reasons. Chapter II is a discussion of categorical diagnosis and DSM-III. The following chapter, 12, describes various treatment modalities, unresolved controversies, and the need for a comprehensive approach. The various psychological therapies, psychopharmacology, ECT, and issues relating to the various therapies are discussed in a lucid manner. Part four addresses diagnosis and planning. The authors describe the limitations of the problem-oriented record. It "pays little heed to the sophisticated clinical reasoning required for effective problem-solving." This review concurs. They then emphasize the need for a comprehensive approach to diagnosis and rational management planning. Part five concerns itself with special situations from emergency psychiatry to child psychiatry. A large section, 135 pages, is devoted to child psychiatry. The authors clearly delineate basic issues in child psychiatry including referral sources, collaboration, emergencies, desirability of interviewing both parents, the suspicious child or adolescent, and intake questionnaires and checklists. A developmental perspective is emphasized. The world of the child and how to conduct an interview are elaborated extensively. Here again, attention to detail is characteristic of the authors. For example, they state "Do not ask 'why" and give their reasons with alternative phrases. A number of protocols are presented to be used at the clinician's discretion, but the clinician is cautioned not to use them in a mindless fashion. The chapter on physical examination of the child and special examinations focuses on the special needs of the child or adolescent and includes a large number of suitable developmental and psychological tests. Other chapters discuss diagnosis, the developmental axis, treatment, and comprehensive planning in child psychiatry. The chapter on treatment planning describes one case in detail as an example of the need to consider multiple factors. The last chapter is on clinical reasoning in psychiatry and
605
how it can be taught. The four appendices include the diagnostic reasoning of the experienced clinician, child and adolescent mental status rating scales, glossary for child and adolescent mental status rating scales, and child information form. All would be useful for the medical student and resident. The references, author index, and subject index are complete and helpful. This book is very readable. It is scholarly but not weighty. What is important is highlighted and the authors give reasons for their views but also note where it is not possible to come to definitive conclusions. I highly recommend this text for medical students and psychiatric residents.
The Original Sin: Incest and Its Meaning. By W. Arens. New York: Oxford University Press, 1986, 190 pp., $19.95.
Reviewed by Marc W. Reitman. M.D.· Scholars of the natural and social sciences, such as Freud, Darwin, Marx, Durkheim, and Levi-Strauss have discussed the origins of incest and its prohibitions for over 100 years. More recently there has been a surge in the number of books published that pertain to the evaluation and treatment of incest victims, families, and perpetrators. Professor Arens' scholarly study of incest, The Original Sin, offers a unique approach to this topic, systematically examining this complex clinical issue from a biological, sociological, and anthropological perspective. He draws from his own research among the Shilluk of the Sudan and uses his diverse experiences as a professor of anthropology to present a provocative and challenging position: that incest is an invention of human culture rather than a suppressed innate tendency of man. Professor Arens has methodically presented his extensive research, dividing his essay into 10 chapters. The first chapter sets forth the course of exploration of this topic through the findings of various academic disciplines. He discounts the universality of the incest taboo and recognizes its origins and functions served in various cultures. The biological implications and consequences of close inbreeding are examined in the second chapter. Of particular interest is a review of McKusick's study of the Amish in Pennsylvania and the genetic effects of consanguineous reproduction. In this chapter, Arens hypothesizes that incest may produce a "cleansing" process, by eliminating the deleterious recessive gene pool through the mortality of offspring, thereby rendering these maladaptive characteristics unavailable for further transmission. The basis for such a conclusion is weakly established and his reasoning is difficult to follow. The third chapter compares the functionalist ideas of incest prohibition presented by Morgan in 1877 with those of Taylor, who in 1889, explained the taboo from the sociological perspective. Arens reviews the work of Levi-Strauss in this century, who merged both perspectives by conceptualizing the prohibition as a transition from nature to culture. The next chapter pursues the sociological viewpoint in the twen* Dr. Reitman is the Director of the Family Crisis Program for Sexually Abused Children, Assistant Director of the General Child Psychiatry Clinic at New England Medical Center and Assistant Professor of Psychiatry at Tufts University School of Medicine.
606
BOOK REVIEWS
tieth century and superficially begins to examine incest from a family dynamics perspective. The fifth and sixth chapters explore Westermack's aversion hypothesis that inbreeding was naturally avoided rather than prohibited. In other words, familiarity breeds sexual disinterest. Professor Arens provides logical examples of Israeli kibbutz children reared together and arranged marriages in China to support Westermack's theory. Arens further illustrates this point through several detailed examples of animal species of lower orders that naturally avoid inbreeding. The seventh chapter uses examples from many royal incestuous societies of archaic Egypt, Hawaii, Peru, Thailand, and some African societies to demonstrate how sanctioned incest presages the emergence of a new social order. The eighth and ninth chapters focus on the power of incest. Professor Arens discusses the current political and social hierarchy of the Shilluk of the southern Sudan in Egypt. Although incest is prohibited in this society, the potential ruler commits a form of incest as part of his passage to power. By surviving this prohibited and dangerous act, his deity is established. This is the most interesting and clearly written chapter in the book, perhaps because it is his own area of research. Unfortunately, the ninth chapter is the weakest of the book, as Arens attempts to bridge the gap between this royal incestuous society to the occurrence of incest in Western society through the common theme of power. In fatherdaughter incest, Arens focuses upon the emergence of the father as the sole arbiter of morality and power within the family. Just as the prohibited sexual act bestows power to the political elite of the Shilluk, so, too, does the act in our society confer power to the father over the daughter. The drawback to this chapter is that the clinical impact of incest is described from a unidimensional viewpoint and is therefore naive. Arens does not explore the power differential in homosexual, sibling, or mother-child incest, the dynamics of which are quite different from that of father-daughter incest. The final chapter restates and elaborates upon the two basic conclusions of the essay. The first is that exogamy is derived from an original innate avoidance of inbreeding, and the second is that incest is cultural in origin, not an expression of heritage but of potency, linked up with the indigenous nature of power. These conclusions are somewhat controversial but are well supported in his essay. Dr. Arens' essay is followed by an extensive and comprehensive bibliography. Although The Original Sin provides little direct and immediate application to clinicians working with victims of incest and their families, Professor Arens offers mental health professionals and social scientists alike an understanding and deeper appreciation of incest as an element of cultural development.
Multidisciplinary Assessment of Children with Learning Disabilities and Mental Retardation. By David L. Wodrich and James E. Joy. Baltimore: Paul H. Brookes, 1986, 348 pp., $22.95. Neuropsychological Assessment of Children: A TreatmentOriented Approach. By Byron P. Rourke, John L. Fisk,
and John D. Strang. New York: Guilford Press, 1986, 285 pp., $30. Reviewed by Richard E. Mallison. M.D.· The editors of Multidisciplinary Assessment ofChildren with Learning Disabilities and Mental Retardation wish to give an overview to clinicians who are interested in the various professionals' roles in the multidisciplinary evaluation of such special children. The contributors include a psychologist, special educator, audiologist, speech-language pathologist, occupational therapist, developmental pediatrician, child psychiatrist, and pediatric neurologist. Each specialist discusses his or her function in the multidisciplinary assessment process in terms of professional training, diagnostic and assessment techniques (and their empirical basis), and appropriate referrals. The last chapter discusses the vital collaborative process of multidisciplinary assessment. The illustrated cases bring alive the process with well-chosen common examples. The book does provide a practical and informative overview. In general, each contributor kept to the editors' outline. At the conclusion of the chapter on neurological assessment, the actual format of a learning disorders unit is provided. Such a practical appendix might have proved valuable at the end of each contributor's section. The chapters that focus on the developmental pediatrician, child psychiatrist, and pediatric neurologist delineate well the specific contributions of each specialist, a separation that is too often blurred. The chapter describing the work of a child psychiatrist is well presented; however, objective instruments used commonly by child psychiatrists-for example, mental state examinations, self-report instruments, and parent and teacher behavior checklists-could have been provided as was done by each other specialist. Conduct disorders and school refusal could have been added as disorders that are not uncommon in children and adolescents with learning disabilities. Finally, the discussion of depression in childhood could easily mislead readers to believe that we now feel most depression is neurochemical in nature, and all depressive disorders should be treated with antidepressant medication as part of the overall treatment plan. Overall, clinicians from various backgrounds who wish to learn more about multidisciplinary assessment will find this book very helpful in understanding the individual roles and the collaborative process. However, child psychiatrists will only find this book to be a simplified condensation of their extensive training on multidisciplinary teams. Further, I don't believe a child psychiatry resident would gain much from reading this book in contrast with participation on such teams and the extensive course work provided by multidisciplinary specialists. Neuropsychological Assessment of Children: A TreatmentOriented Approach focuses on an even more specialized area of assessment. The authors, a prominent group of neuropsychologists, present many common cases that they evaluated with their specific assessment battery. The components include specific tactile-perceptual, visual-perceptual, auditoryperceptual, and language related tests; problem-solving; concept formation; reasoning; motor and psychomotor tests; and ·Dr. Mattison is Associate Professor in the Department of Psychiatry, Pennsylvania State University ColIege of Medicine, Hershey, Pennsylvania.
sis, tactics and strategy of clinical reasoning, and "the hypothetico-deductive reasoning in the clinical process." The authors describe how a clinician thinks and give basic descriptions of how humans think, e.g., "the human computer is overimpressed with evidence appearing early in the reasoning process and relatively less efficient in considering later information, especially if it runs counter to earlier material." Appendix I supplements part two in that it is a typescript of the diagnostic reasoning of an experienced clinician while interviewing a patient. Part three addresses clinical procedures. The authors explain how to obtain a psychiatric history and begin with how the physician should introduce him or herself to the patient. The chapter includes, in obtaining a psychiatric history, everything from three interview seating arrangements to transference and countertransference, with the suggestion to get help from a colleague when necessary. The chapter on mental status examination, in addition to the usual examples of the examination, contains several brief tests including a test of language function. The chapter on the physical examination and special investigations notes that 75 non psychiatric disorders can be present with depression but also that the history should determine the direction of the physical examination and laboratory investigation. The authors do not hesitate to state their opinion, e.g., they do not think the DST is reliable or cost-effective and they give their reasons. Chapter II is a discussion of categorical diagnosis and DSM-III. The following chapter, 12, describes various treatment modalities, unresolved controversies, and the need for a comprehensive approach. The various psychological therapies, psychopharmacology, ECT, and issues relating to the various therapies are discussed in a lucid manner. Part four addresses diagnosis and planning. The authors describe the limitations of the problem-oriented record. It "pays little heed to the sophisticated clinical reasoning required for effective problem-solving." This review concurs. They then emphasize the need for a comprehensive approach to diagnosis and rational management planning. Part five concerns itself with special situations from emergency psychiatry to child psychiatry. A large section, 135 pages, is devoted to child psychiatry. The authors clearly delineate basic issues in child psychiatry including referral sources, collaboration, emergencies, desirability of interviewing both parents, the suspicious child or adolescent, and intake questionnaires and checklists. A developmental perspective is emphasized. The world of the child and how to conduct an interview are elaborated extensively. Here again, attention to detail is characteristic of the authors. For example, they state "Do not ask 'why" and give their reasons with alternative phrases. A number of protocols are presented to be used at the clinician's discretion, but the clinician is cautioned not to use them in a mindless fashion. The chapter on physical examination of the child and special examinations focuses on the special needs of the child or adolescent and includes a large number of suitable developmental and psychological tests. Other chapters discuss diagnosis, the developmental axis, treatment, and comprehensive planning in child psychiatry. The chapter on treatment planning describes one case in detail as an example of the need to consider multiple factors. The last chapter is on clinical reasoning in psychiatry and
605
how it can be taught. The four appendices include the diagnostic reasoning of the experienced clinician, child and adolescent mental status rating scales, glossary for child and adolescent mental status rating scales, and child information form. All would be useful for the medical student and resident. The references, author index, and subject index are complete and helpful. This book is very readable. It is scholarly but not weighty. What is important is highlighted and the authors give reasons for their views but also note where it is not possible to come to definitive conclusions. I highly recommend this text for medical students and psychiatric residents.
The Original Sin: Incest and Its Meaning. By W. Arens. New York: Oxford University Press, 1986, 190 pp., $19.95.
Reviewed by Marc W. Reitman. M.D.· Scholars of the natural and social sciences, such as Freud, Darwin, Marx, Durkheim, and Levi-Strauss have discussed the origins of incest and its prohibitions for over 100 years. More recently there has been a surge in the number of books published that pertain to the evaluation and treatment of incest victims, families, and perpetrators. Professor Arens' scholarly study of incest, The Original Sin, offers a unique approach to this topic, systematically examining this complex clinical issue from a biological, sociological, and anthropological perspective. He draws from his own research among the Shilluk of the Sudan and uses his diverse experiences as a professor of anthropology to present a provocative and challenging position: that incest is an invention of human culture rather than a suppressed innate tendency of man. Professor Arens has methodically presented his extensive research, dividing his essay into 10 chapters. The first chapter sets forth the course of exploration of this topic through the findings of various academic disciplines. He discounts the universality of the incest taboo and recognizes its origins and functions served in various cultures. The biological implications and consequences of close inbreeding are examined in the second chapter. Of particular interest is a review of McKusick's study of the Amish in Pennsylvania and the genetic effects of consanguineous reproduction. In this chapter, Arens hypothesizes that incest may produce a "cleansing" process, by eliminating the deleterious recessive gene pool through the mortality of offspring, thereby rendering these maladaptive characteristics unavailable for further transmission. The basis for such a conclusion is weakly established and his reasoning is difficult to follow. The third chapter compares the functionalist ideas of incest prohibition presented by Morgan in 1877 with those of Taylor, who in 1889, explained the taboo from the sociological perspective. Arens reviews the work of Levi-Strauss in this century, who merged both perspectives by conceptualizing the prohibition as a transition from nature to culture. The next chapter pursues the sociological viewpoint in the twen* Dr. Reitman is the Director of the Family Crisis Program for Sexually Abused Children, Assistant Director of the General Child Psychiatry Clinic at New England Medical Center and Assistant Professor of Psychiatry at Tufts University School of Medicine.
606
BOOK REVIEWS
tieth century and superficially begins to examine incest from a family dynamics perspective. The fifth and sixth chapters explore Westermack's aversion hypothesis that inbreeding was naturally avoided rather than prohibited. In other words, familiarity breeds sexual disinterest. Professor Arens provides logical examples of Israeli kibbutz children reared together and arranged marriages in China to support Westermack's theory. Arens further illustrates this point through several detailed examples of animal species of lower orders that naturally avoid inbreeding. The seventh chapter uses examples from many royal incestuous societies of archaic Egypt, Hawaii, Peru, Thailand, and some African societies to demonstrate how sanctioned incest presages the emergence of a new social order. The eighth and ninth chapters focus on the power of incest. Professor Arens discusses the current political and social hierarchy of the Shilluk of the southern Sudan in Egypt. Although incest is prohibited in this society, the potential ruler commits a form of incest as part of his passage to power. By surviving this prohibited and dangerous act, his deity is established. This is the most interesting and clearly written chapter in the book, perhaps because it is his own area of research. Unfortunately, the ninth chapter is the weakest of the book, as Arens attempts to bridge the gap between this royal incestuous society to the occurrence of incest in Western society through the common theme of power. In fatherdaughter incest, Arens focuses upon the emergence of the father as the sole arbiter of morality and power within the family. Just as the prohibited sexual act bestows power to the political elite of the Shilluk, so, too, does the act in our society confer power to the father over the daughter. The drawback to this chapter is that the clinical impact of incest is described from a unidimensional viewpoint and is therefore naive. Arens does not explore the power differential in homosexual, sibling, or mother-child incest, the dynamics of which are quite different from that of father-daughter incest. The final chapter restates and elaborates upon the two basic conclusions of the essay. The first is that exogamy is derived from an original innate avoidance of inbreeding, and the second is that incest is cultural in origin, not an expression of heritage but of potency, linked up with the indigenous nature of power. These conclusions are somewhat controversial but are well supported in his essay. Dr. Arens' essay is followed by an extensive and comprehensive bibliography. Although The Original Sin provides little direct and immediate application to clinicians working with victims of incest and their families, Professor Arens offers mental health professionals and social scientists alike an understanding and deeper appreciation of incest as an element of cultural development.
Multidisciplinary Assessment of Children with Learning Disabilities and Mental Retardation. By David L. Wodrich and James E. Joy. Baltimore: Paul H. Brookes, 1986, 348 pp., $22.95. Neuropsychological Assessment of Children: A TreatmentOriented Approach. By Byron P. Rourke, John L. Fisk,
and John D. Strang. New York: Guilford Press, 1986, 285 pp., $30. Reviewed by Richard E. Mallison. M.D.· The editors of Multidisciplinary Assessment ofChildren with Learning Disabilities and Mental Retardation wish to give an overview to clinicians who are interested in the various professionals' roles in the multidisciplinary evaluation of such special children. The contributors include a psychologist, special educator, audiologist, speech-language pathologist, occupational therapist, developmental pediatrician, child psychiatrist, and pediatric neurologist. Each specialist discusses his or her function in the multidisciplinary assessment process in terms of professional training, diagnostic and assessment techniques (and their empirical basis), and appropriate referrals. The last chapter discusses the vital collaborative process of multidisciplinary assessment. The illustrated cases bring alive the process with well-chosen common examples. The book does provide a practical and informative overview. In general, each contributor kept to the editors' outline. At the conclusion of the chapter on neurological assessment, the actual format of a learning disorders unit is provided. Such a practical appendix might have proved valuable at the end of each contributor's section. The chapters that focus on the developmental pediatrician, child psychiatrist, and pediatric neurologist delineate well the specific contributions of each specialist, a separation that is too often blurred. The chapter describing the work of a child psychiatrist is well presented; however, objective instruments used commonly by child psychiatrists-for example, mental state examinations, self-report instruments, and parent and teacher behavior checklists-could have been provided as was done by each other specialist. Conduct disorders and school refusal could have been added as disorders that are not uncommon in children and adolescents with learning disabilities. Finally, the discussion of depression in childhood could easily mislead readers to believe that we now feel most depression is neurochemical in nature, and all depressive disorders should be treated with antidepressant medication as part of the overall treatment plan. Overall, clinicians from various backgrounds who wish to learn more about multidisciplinary assessment will find this book very helpful in understanding the individual roles and the collaborative process. However, child psychiatrists will only find this book to be a simplified condensation of their extensive training on multidisciplinary teams. Further, I don't believe a child psychiatry resident would gain much from reading this book in contrast with participation on such teams and the extensive course work provided by multidisciplinary specialists. Neuropsychological Assessment of Children: A TreatmentOriented Approach focuses on an even more specialized area of assessment. The authors, a prominent group of neuropsychologists, present many common cases that they evaluated with their specific assessment battery. The components include specific tactile-perceptual, visual-perceptual, auditoryperceptual, and language related tests; problem-solving; concept formation; reasoning; motor and psychomotor tests; and ·Dr. Mattison is Associate Professor in the Department of Psychiatry, Pennsylvania State University ColIege of Medicine, Hershey, Pennsylvania.