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Compliance with treatment in schizophrenia. Maudsley monograph no. 37
Behav. Res. Ther. Vol. 35, No. 5, pp. 485-489, 1997 Published by Elsevier Science Ltd. Printed in Great Britain 0005-7967/97 $17.00 + 0.00
Pergamon
BOOK REVIEWS H. C. PHILIPS and S. R A C H M A N : The Psychological Management of Chronic Pain: A Treatment Manual (2nd edn). Springer Publishing, New York (1996). xiv + 286 pp. $42.95. Eight years after the successful first edition of this book, Philips has combined her expertise in pain management with Rachman's scholarship on psychological therapy and emotions to produce an even more valuable monograph on pain. This comes in the form of two handy volumes: a treatment manual with well-reasoned suggestions to the pain clinician, and a patient manual with verbatim instructions to the pain sufferer. The first six chapters of the treatment manual take the reader on an interesting survey of biopsychosocial interactions in pain. In the process, the myth of equivalence between tissue damage and pain is systematically brought down with support from empirical observations of medical abnormalities, sporting injuries, religious rituals, complexities of memory, and various treatment conundrums. The core of the manual is a set of nine chapters, one for each of the weekly sessions in the outpatient pain management program. What is found here is not just an assortment of treatment ideas but an exposition of concrete psychological 'tactics' for the self-regulation of pain. The sessions share a common structure of goal setting, brief didactic presentations, demonstration and practice, and homework assignments. Remarkable sensitivity is also shown to the transitional steps between sessions and to the many nuances in treatment implementation---e.g, timing of each tactic, preparation of the patient, tailoring of treatments to individual needs, and keeping the momentum of change. The manual is as impressive in breadth of coverage as it is in richness of detail. Attention is paid not only to pain but to varied aspects of the functional status of patients. Cognitive, behavioral, and affective domains of functioning are all considered. Very convincingly, the authors demonstrate the interdependence between behavior modification and cognitive change. With regard to affect, there is discussion of depression and anxiety as well as reference to the pervasive problem of anger. A sound case is made for the psychologist as director of the treatment team which also relies on the consultative services of the physician, pharmacist, and physiotherapist. The authors acknowledge that their list of assessment instruments is far from exhaustive. Fortunately, other sources devoted to this subject are now available, as indicated in the authors' list of suggested readings. The final section of the manual addresses the vital question of treatment outcome. Describing a series of case studies and nomothetic investigations, it is revealed that more than 80% of patients following the authors' treatment plan evidence significant clinical improvement. The program is also cost-efficient, although more data on this would be helpful. In sum, Philips and Rachman have delivered a blueprint for a highly effective outpatient pain management program for groups (of six to eight patients) over a period of 14 hours of treatment distributed over nine weekly sessions. In a very clear and streamlined format, the material on this program is partitioned between an elaborate clinician's manual and a concise and equally readable manual for the pain patient. EPHREM F E R N A N D E Z
GWEN HOWE: x + 195 pp. £9.95.
Working with Schizophrenia--A
Needs Based Approach. Jessica Kingsley, London
(1995).
This is intended as a practical handbook for professionals working with schizophrenia, especially those based in the community. It briefly reviews the current 'state of play' with regard to this disorder, and then focuses on the experience of both sufferers and their families. Having identified the needs of sufferers and their families, the author considers ways of meeting these needs. These include various ways of intervention, including group work. This is clearly a valuable book and, in the present climate of concern about the wisdom or otherwise of caring for schizophrenic patients in the community, it has particular relevance. Many professionals in this challenging area will find this book useful, and a good basis for discussing relevant issues with colleagues and trainees. The discussion of resources, unusual in books in this area, is very welcome. More detailed discussion of violence would have been useful, but I can see the point in not overemphasising this issue. This is not a textbook on schizophrenia, and does not pretend to be one, so the reader has to go elsewhere for basic information. What this book does is to provide a very sensible discussion of a way of managing, and working with, schizophrenic patients and their families in the community. Thus it complements, very effectively, the existing technical literature. OLWEN M c G R E G O R
A. BUCHANAN: Compliance with Treatment in Schizophrenia. Maudsley Monograph No. 37. Psychology Press, Hove (1996). xii + 75 pp. £19.95. This book reports a prospective study of 61 inpatients diagnosed with 'schizophrenia'. Their compliance with medication and attendance at outpatient psychiatric clinics were measured at 1 and 2 years following hospital discharge in 1988. The book is neatly organised in the style of a project report. The aims were to test predictions from the literature including a relationship between good compliance and 'insight', and poor compliance and 'low socioeconomic status', 'complex drug 485
486
Book Reviews
regimens', 'side effectes', "compulsory detention' and 'previous history of poor compliance'. There is surprisingly no reference to these clients' exposure to psychological treatment. Following a standard literature review, the study replicated the correlation between poor compliance and low socioeconomic status and stability, compulsory admission and poor previous compliance. This addressesd 'what' but not 'why', and the author himself noted that a qualitative, interview-based study would be more suited to understanding patients' decision-making. I feel another main difficulty was his reliance on the medical definition of the two central concepts: 'Compliance' (by implication, with the will of another), and 'Insight' (which here refers to the acceptance of a simple 'illness' label). Psychotherapy process research and phenomenology show that the client's wishes regarding outcome of treatment, and their cost/benefit analysis of involvement, are major components of co-operation. By the same token, a client's 'insight' refers to subjective evaluation of their state, and by definition, the client has access to a more complex data set than does anyone observing a clinic snapshot. These were not measured. Here, a client was considered to have insight if his answer to the question "why were you in hospital" was "because I got ill", and not "because my family don't like me" (p. 28). A fleeting glance at, for example, the Expressed Emotion literature would begin to illustrate the complexity of this concept. This book is short, simply organised and easy to access. Whilst it does not itself address an understanding of 'compliance', it does recommend this for future research. CAROLYN JOHN
B. E. L E O N A R D and K. MILLER: Stress--The Immune System and Psychiatry. Wiley, Chichester (1995). 252 pp. £50.00. The importance of psychosocial factors in major diseases like cancer and coronary heart disease has been recognized for over two thousand years, but scientific verification of ancient theories has only come quite recently. The cancer-prone personality--unable to express emotions, unable to cope with stress, given to feelings of hopelessness and helplessness, and the CHD-prone personality--given to feelings of anger, hostility and aggression, are now widely recognized as important risk factors for disease, more powerful than smoking, drinking, and many other risk factors, and interacting synergistically with these physical risk factors. Descriptive, correlational and prospective studies have established quite strong correlations between disease and stress/personality, but science is concerned with causation; it looks for physical connecting links between psychological factors and physical results. The most likely candidate has always been the immune system, ever since it has been shown to be responsive to CNS innervations. This book presents chapters dealing with recent advances in psychonueroimmunology, the unlikely name of this speciality. Unfortunately, the only psychosocial factor considered is stress, and there is a very brief note on the desirability of including personality measures (other than ratings) in the experiment. The large literature on personality, disease and the immune system is neglected, as is the important fact that stress is only converted into strain through interaction between situation and personality--one person's stress is another person's motivation! The book will be of interest to people working in this field, but it could have been better if it had been more inclusive. H. J. EYSENCK
W. P. T. JAMES (Ed.): The Origins and Consequences of Obesity. Wiley, Chichester (1996). 288 pp. £52.50. My first impression on being asked to review this book was that it was rather unusual to be given a book which details epidemiology, clinical features and aetiology of obesity, with not even a mention of treatment, for a journal which has as its focus behaviour change. I accepted the task mainly to please the book editor. Later I could see the wisdom in it. As therapists we analyse problems and synthesise models to understand and help tackle the difficulties our clients face. Our task is helped and rests upon surer foundations if we use the basic building blocks of science in our constructions. This book is a warehouse of such ideas and also allows you the privilege of eavesdropping upon the discussion amongst the tradesmen. Each chapter is short and focuses upon one issue or new piece of research and is followed by several pages of transcripts of the discussion held between the small group of participants. Three of the 30 members of the group were from departments of psychiatry or psychology. Why should Behaviour Research and Therapy be interested in obesity? This book will, in part, answer that question. Obesity is a global problem but some genetic stock, for example the Micronesians and certain environments i.e. Western cultures have a greater risk. Obesity is associated with a variety of health risks which differ amongst the races. Thus obesity is a paradigm of a new approach to psychosomatic medicine in which genes and lifestyle intertwine. The rapid changes in prevalence of obesity suggest that noxious environments have a causal role. A parallel pattern is occurring at the other end of the spectrum, in particular, bulimia nervosa. Although an approach through public health may be needed, experts in changing in behaviour should advise about political strategy in addition to helping the individual to adapt his/her lifestyle to give a healthier balance between genes and environment. Now is a time of rapid changes in our understanding of body composition and metabolism. Genes for proteins in pathways which we never dreamed were of relevance are being discovered. For example, maturity onset diabetes of the young is linked to genes that encode hepatocyte nuclear factors. This book therefore lets us keep within sight of the front runners in the field. It is of relevance for those of us who deal with all forms of eating disorders from the lean to the not so lean. It is not basic fare for the beginner but offers interesting appetizers for the gourmet. JANET T R E A S U R E
Pergamon
BOOK REVIEWS H. C. PHILIPS and S. R A C H M A N : The Psychological Management of Chronic Pain: A Treatment Manual (2nd edn). Springer Publishing, New York (1996). xiv + 286 pp. $42.95. Eight years after the successful first edition of this book, Philips has combined her expertise in pain management with Rachman's scholarship on psychological therapy and emotions to produce an even more valuable monograph on pain. This comes in the form of two handy volumes: a treatment manual with well-reasoned suggestions to the pain clinician, and a patient manual with verbatim instructions to the pain sufferer. The first six chapters of the treatment manual take the reader on an interesting survey of biopsychosocial interactions in pain. In the process, the myth of equivalence between tissue damage and pain is systematically brought down with support from empirical observations of medical abnormalities, sporting injuries, religious rituals, complexities of memory, and various treatment conundrums. The core of the manual is a set of nine chapters, one for each of the weekly sessions in the outpatient pain management program. What is found here is not just an assortment of treatment ideas but an exposition of concrete psychological 'tactics' for the self-regulation of pain. The sessions share a common structure of goal setting, brief didactic presentations, demonstration and practice, and homework assignments. Remarkable sensitivity is also shown to the transitional steps between sessions and to the many nuances in treatment implementation---e.g, timing of each tactic, preparation of the patient, tailoring of treatments to individual needs, and keeping the momentum of change. The manual is as impressive in breadth of coverage as it is in richness of detail. Attention is paid not only to pain but to varied aspects of the functional status of patients. Cognitive, behavioral, and affective domains of functioning are all considered. Very convincingly, the authors demonstrate the interdependence between behavior modification and cognitive change. With regard to affect, there is discussion of depression and anxiety as well as reference to the pervasive problem of anger. A sound case is made for the psychologist as director of the treatment team which also relies on the consultative services of the physician, pharmacist, and physiotherapist. The authors acknowledge that their list of assessment instruments is far from exhaustive. Fortunately, other sources devoted to this subject are now available, as indicated in the authors' list of suggested readings. The final section of the manual addresses the vital question of treatment outcome. Describing a series of case studies and nomothetic investigations, it is revealed that more than 80% of patients following the authors' treatment plan evidence significant clinical improvement. The program is also cost-efficient, although more data on this would be helpful. In sum, Philips and Rachman have delivered a blueprint for a highly effective outpatient pain management program for groups (of six to eight patients) over a period of 14 hours of treatment distributed over nine weekly sessions. In a very clear and streamlined format, the material on this program is partitioned between an elaborate clinician's manual and a concise and equally readable manual for the pain patient. EPHREM F E R N A N D E Z
GWEN HOWE: x + 195 pp. £9.95.
Working with Schizophrenia--A
Needs Based Approach. Jessica Kingsley, London
(1995).
This is intended as a practical handbook for professionals working with schizophrenia, especially those based in the community. It briefly reviews the current 'state of play' with regard to this disorder, and then focuses on the experience of both sufferers and their families. Having identified the needs of sufferers and their families, the author considers ways of meeting these needs. These include various ways of intervention, including group work. This is clearly a valuable book and, in the present climate of concern about the wisdom or otherwise of caring for schizophrenic patients in the community, it has particular relevance. Many professionals in this challenging area will find this book useful, and a good basis for discussing relevant issues with colleagues and trainees. The discussion of resources, unusual in books in this area, is very welcome. More detailed discussion of violence would have been useful, but I can see the point in not overemphasising this issue. This is not a textbook on schizophrenia, and does not pretend to be one, so the reader has to go elsewhere for basic information. What this book does is to provide a very sensible discussion of a way of managing, and working with, schizophrenic patients and their families in the community. Thus it complements, very effectively, the existing technical literature. OLWEN M c G R E G O R
A. BUCHANAN: Compliance with Treatment in Schizophrenia. Maudsley Monograph No. 37. Psychology Press, Hove (1996). xii + 75 pp. £19.95. This book reports a prospective study of 61 inpatients diagnosed with 'schizophrenia'. Their compliance with medication and attendance at outpatient psychiatric clinics were measured at 1 and 2 years following hospital discharge in 1988. The book is neatly organised in the style of a project report. The aims were to test predictions from the literature including a relationship between good compliance and 'insight', and poor compliance and 'low socioeconomic status', 'complex drug 485
486
Book Reviews
regimens', 'side effectes', "compulsory detention' and 'previous history of poor compliance'. There is surprisingly no reference to these clients' exposure to psychological treatment. Following a standard literature review, the study replicated the correlation between poor compliance and low socioeconomic status and stability, compulsory admission and poor previous compliance. This addressesd 'what' but not 'why', and the author himself noted that a qualitative, interview-based study would be more suited to understanding patients' decision-making. I feel another main difficulty was his reliance on the medical definition of the two central concepts: 'Compliance' (by implication, with the will of another), and 'Insight' (which here refers to the acceptance of a simple 'illness' label). Psychotherapy process research and phenomenology show that the client's wishes regarding outcome of treatment, and their cost/benefit analysis of involvement, are major components of co-operation. By the same token, a client's 'insight' refers to subjective evaluation of their state, and by definition, the client has access to a more complex data set than does anyone observing a clinic snapshot. These were not measured. Here, a client was considered to have insight if his answer to the question "why were you in hospital" was "because I got ill", and not "because my family don't like me" (p. 28). A fleeting glance at, for example, the Expressed Emotion literature would begin to illustrate the complexity of this concept. This book is short, simply organised and easy to access. Whilst it does not itself address an understanding of 'compliance', it does recommend this for future research. CAROLYN JOHN
B. E. L E O N A R D and K. MILLER: Stress--The Immune System and Psychiatry. Wiley, Chichester (1995). 252 pp. £50.00. The importance of psychosocial factors in major diseases like cancer and coronary heart disease has been recognized for over two thousand years, but scientific verification of ancient theories has only come quite recently. The cancer-prone personality--unable to express emotions, unable to cope with stress, given to feelings of hopelessness and helplessness, and the CHD-prone personality--given to feelings of anger, hostility and aggression, are now widely recognized as important risk factors for disease, more powerful than smoking, drinking, and many other risk factors, and interacting synergistically with these physical risk factors. Descriptive, correlational and prospective studies have established quite strong correlations between disease and stress/personality, but science is concerned with causation; it looks for physical connecting links between psychological factors and physical results. The most likely candidate has always been the immune system, ever since it has been shown to be responsive to CNS innervations. This book presents chapters dealing with recent advances in psychonueroimmunology, the unlikely name of this speciality. Unfortunately, the only psychosocial factor considered is stress, and there is a very brief note on the desirability of including personality measures (other than ratings) in the experiment. The large literature on personality, disease and the immune system is neglected, as is the important fact that stress is only converted into strain through interaction between situation and personality--one person's stress is another person's motivation! The book will be of interest to people working in this field, but it could have been better if it had been more inclusive. H. J. EYSENCK
W. P. T. JAMES (Ed.): The Origins and Consequences of Obesity. Wiley, Chichester (1996). 288 pp. £52.50. My first impression on being asked to review this book was that it was rather unusual to be given a book which details epidemiology, clinical features and aetiology of obesity, with not even a mention of treatment, for a journal which has as its focus behaviour change. I accepted the task mainly to please the book editor. Later I could see the wisdom in it. As therapists we analyse problems and synthesise models to understand and help tackle the difficulties our clients face. Our task is helped and rests upon surer foundations if we use the basic building blocks of science in our constructions. This book is a warehouse of such ideas and also allows you the privilege of eavesdropping upon the discussion amongst the tradesmen. Each chapter is short and focuses upon one issue or new piece of research and is followed by several pages of transcripts of the discussion held between the small group of participants. Three of the 30 members of the group were from departments of psychiatry or psychology. Why should Behaviour Research and Therapy be interested in obesity? This book will, in part, answer that question. Obesity is a global problem but some genetic stock, for example the Micronesians and certain environments i.e. Western cultures have a greater risk. Obesity is associated with a variety of health risks which differ amongst the races. Thus obesity is a paradigm of a new approach to psychosomatic medicine in which genes and lifestyle intertwine. The rapid changes in prevalence of obesity suggest that noxious environments have a causal role. A parallel pattern is occurring at the other end of the spectrum, in particular, bulimia nervosa. Although an approach through public health may be needed, experts in changing in behaviour should advise about political strategy in addition to helping the individual to adapt his/her lifestyle to give a healthier balance between genes and environment. Now is a time of rapid changes in our understanding of body composition and metabolism. Genes for proteins in pathways which we never dreamed were of relevance are being discovered. For example, maturity onset diabetes of the young is linked to genes that encode hepatocyte nuclear factors. This book therefore lets us keep within sight of the front runners in the field. It is of relevance for those of us who deal with all forms of eating disorders from the lean to the not so lean. It is not basic fare for the beginner but offers interesting appetizers for the gourmet. JANET T R E A S U R E