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Crisis at Adolescence: Object Relations Therapy with the Family
BOOK
REVIEWS
Crisis at Adolescence: Object Relations Therapy with the Family. Edited by Sally Box, Beta Copley, Jeanne Magagna, and Errica Moustaki Smilansky. Northvale, N]' Jason Aronson, Inc., 1994, 296 pp., $40.00 (hardcover). Every human being ought to be sentenced monthly, to review-for publication in one's local paper-a book about a topic he or she stands against or abhors. I bet you my Managed Care membership card that it will cut half of the world's nonsense and make "utopia" more realizable and realisticallydesignable. Unlike John Updike's view of literary criticism as "hugging the shore"-meaning that critics are usually shrill, mean-tempered, cajonesless Monday morning quarterbacks-I take the challenge of book reviewing very seriously. My paradigm mirrors Vaclav Havel's reverence of the potential nuclear, radioactive power of a word especially when one is forced to examine where one stands and what one stands for as one examines where one thinks another stands and what that other person stands for. This is a cold, drizzling N ovember morning of the American psychiatric soul. An atmosphere of cynicism and hopelessness grips our hearts as we see our autonomy to practice our profession being ripped from our hands by managed care groups who make us justify our diagnoses and treatment plans in rigid, prefabbed, multiple-choice questionnaire check boxes. In my neck of the woods, only one or two of us practice individual or family psychotherapy. Why? We are not supposed to. It is not economically feasible. Not only that, there is an aura of psychotherapeutic nihilism that has made the majority of us into pill-pushers and "biological psychiatrists." Most psychiatrists nowadays are not happy campers. Collegiality is as rare as a house call. We are like adolescents in crisis-and this is what this book is about. Of the 11 or so nuances of the word "doctor," one is as a fresh sea breeze that sweeps through a musty room. This book certainly doctored me in that sense. Also, in an aleatory way. For it forced me to identify for myself who I thought I was and was for. Coming from an almost mythical kingdom called "T he Tavistock," in England , Sally Box and her 11 colleagues sally forth into our living rooms and reintroduce us to our old selves. And it feels good. Lest I forget, Susan Carvallo ("History of Family Therapy") pins a "Hello, I am . . . " badge on me saying that I am, indeed, a "conductor-psychodynamic-directive therapist."
J . AM . ACAD. CHILD ADOL ESC . PSYCHIATRY. 34 :6. JUN E 1995
Assistant Editor: William Sack, MD.
Then Sally Box gives us a brief introduction to Kleinian and post-Kleinian object relations theory. It quickly emerges that these are bionic (after Wilfred Bion) men and women who are bright, compassionate, and amazingly open to exposing themselves to self-criticism in that scary area of the countertransference. In fact, it was at this point that I noticed a copious drooling incontinence of envy knowing that , somewhere out there, therapists do like each other enough (and are allowed by third-party payers) to sit down regularly each week to analyze transference/countertransference issues without wondering whether these are "billable" hours! Ronald Britton's chapter on "Reenactment as an Unwitting Professional Response to Family Dynamics" is like a quick dip in Lake Michigan in mid-December. Shocking, eye-opening, and brisk. It forces us to look at our own responses as professionals in the mental health field to the dynamics of the sick families we serve. It forces us to view ourselves as the "Wounded Healers" Thomas Maeder referred to in his 1989 Atlantic Monthly jeremiad . My personal favorite in terms of its boldness and charming eclecticism is "The Significance of the Outsider in Families and Other Social Groups ," by Anna (Halton) Darrington. Perhaps because her ebullience and bibliographical watering holes mirror mine, Darrington feels like a mint julep in July: the compleat therapist comfortable in the semiosis of any discipline that helps one explain and enjoy the human person. Her exposition of the outsider role being of the group and definitely performing some function for the group yet taking a position on the fringe or the edge of that group piquantly describes the role of the adolescent patient. And the therapist. Both have to go through a phase of "necessary skepticism" to find a space for independent thought. Both have to wade through the jetsam and flotsam of hypocrisy and malignancy (the "nameless dread") to uncover truth and health. Both have to learn how to celebrate the self and his place in th is world which is, as George E. Woodbury would have it, to solve half the problem of contentment. It also empowers us to overcome what Herbert Rosenfeld referred to as "the narcissistic gang of the mind" and (Meltzer's) "gang families." This is a book which, I must confess, I approached with a jaundiced view, partly because I came from a training
825
BOOK REVIEWS
background where to admit a more than nodding acquaintance with Klein and Bion would be like standing up at a Senator McCarthy hearing in the 1950s and waving a Communist membership card. More importantly, though, it admits having the disillusioned tears of a closet psychotherapeutic romantic who believes that somewhere outside of Tavistock patients are taken care of first by caring for them rather than caring first about what insurance plan they belong to. For a book written by 12 authors, this volume certainly allows a lot of space for individual thinking and writing style. I found only five syntactical errors in the whole book. The cover art by Shirra Smilansky (who I assume, is a child of Errica, one of the coeditors and authors) is a sight to behold. It is a stirring confection of Chagall and Picasso that captures the essence of family psychopathology. It gives one the impression that Shirra must have read this book before embarking on the trip through her canvas sea. Truce T. Ordofia, M.D. Davenport, IA
The Management of Visual Impairment in Childhood.
Edited by Alistair R. Fielder, Anthony B. Best, and Martin Co. Bax. Clinics in Developmental Medicine No. 128: Mac KeithPress. DistributedbyCambridge University Press, London, England, 1993, 213 pp., $64.95 (hardcover). This book addresses a topic that is not adequately represented in the literature. It provides an updated review on the subject of visual impairment in children. Visual impairment in children younger than the age of 15 is present in less than 1 in evety 1,000. Although the child psychiatrist is not the first physician to encounter the patient, the problem is occasionally met in the course of one's practice. While the book is geared more toward the pediatrician, who is usually the first to see children with visual impairment, it could be a valuable source of information for the child psychiatrist, especiallyone who works with visually impaired children. The authors of the various chapters represents both sides of the Atlantic: England, the Netherlands, the United States, and Canada. Although some chapters discuss local situations, especially when reference is made to availability of resource centers, the basic issues are essentially the same for most countries. The first chapter provides a brief review of the epidemiology of blindness and visual impairment in children. While there are an estimated 1 million blind children in the world today, many more present with visual impairment to various but significant degrees.
826
The book also includes chapters on visual assessment, the ophthalmology of visual impairment, neurological causes, management, prevention, and education. Two of the chapters are closer to the interests of the child psychiatrist: chapter 5, "The Effects ofVisual Disability on Behavior and the Family," and chapter 6, "The Effects of Severe Visual Impairment on Development." In chapter 5, Maryke Groenveld points out the basic principle that children behave to a large extent the way we expect them to behave, i.e., if society expectsvisuallyimpaired children to be helpless, this increases their chances of behaving that way. Also, the visually impaired child has a serious impact on the family. Usually the mother has to stay home with the child. At times, parents feel that their visually impaired child brings them closer together. Also, the presence of such a child has an effect on siblings, in that they are frequently asked to take on adult roles and their resentment is not always freely expressed. Visually impaired children are generally less active, but engage in some form of selfstimulation (rocking, hand-flapping, or other mannerisms). When these children are integrated in the school system, these mannerisms subside. Therefore, in most countries, full integration in regular schools is becoming the norm. In chapter 6, Patricia Sonksen describes her experience with more than 600 severely visually impaired babies and preschool children. Since all five senses interact in the process of development, the impact of severe visual impairment is an important factor as it could potentially interfere with the developmental process if appropriate intervention is not provided. These children are less equipped to learn about themselves and the world, and they require additional assistance. Although the book is well organized and in many aspects very informative, it does not include any topic on the child psychiatric aspects of these children. It would have been more helpful if it had covered areas such as the psychiatric epidemiology of this population and to what extent visual impairment contributes to their psychopathology. It would also have been helpful to have a chapter on how the available psychotherapeutic approaches in child psychiatry need to be modified to meet the special needs of the visually impaired child. Although the child psychiatric input is very limited, the book can serve as a useful resource and stimulate the interest of the child psychiatrist in this area. Paul Kymissis, M.D. Associate Professor, Psychiatry and Pediatrics Director, Division of Child and Adolescent Psychiatry New York Medical College/Westchester County Medical Center Valhalla, NY
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 34:6, JUNE 1995
REVIEWS
Crisis at Adolescence: Object Relations Therapy with the Family. Edited by Sally Box, Beta Copley, Jeanne Magagna, and Errica Moustaki Smilansky. Northvale, N]' Jason Aronson, Inc., 1994, 296 pp., $40.00 (hardcover). Every human being ought to be sentenced monthly, to review-for publication in one's local paper-a book about a topic he or she stands against or abhors. I bet you my Managed Care membership card that it will cut half of the world's nonsense and make "utopia" more realizable and realisticallydesignable. Unlike John Updike's view of literary criticism as "hugging the shore"-meaning that critics are usually shrill, mean-tempered, cajonesless Monday morning quarterbacks-I take the challenge of book reviewing very seriously. My paradigm mirrors Vaclav Havel's reverence of the potential nuclear, radioactive power of a word especially when one is forced to examine where one stands and what one stands for as one examines where one thinks another stands and what that other person stands for. This is a cold, drizzling N ovember morning of the American psychiatric soul. An atmosphere of cynicism and hopelessness grips our hearts as we see our autonomy to practice our profession being ripped from our hands by managed care groups who make us justify our diagnoses and treatment plans in rigid, prefabbed, multiple-choice questionnaire check boxes. In my neck of the woods, only one or two of us practice individual or family psychotherapy. Why? We are not supposed to. It is not economically feasible. Not only that, there is an aura of psychotherapeutic nihilism that has made the majority of us into pill-pushers and "biological psychiatrists." Most psychiatrists nowadays are not happy campers. Collegiality is as rare as a house call. We are like adolescents in crisis-and this is what this book is about. Of the 11 or so nuances of the word "doctor," one is as a fresh sea breeze that sweeps through a musty room. This book certainly doctored me in that sense. Also, in an aleatory way. For it forced me to identify for myself who I thought I was and was for. Coming from an almost mythical kingdom called "T he Tavistock," in England , Sally Box and her 11 colleagues sally forth into our living rooms and reintroduce us to our old selves. And it feels good. Lest I forget, Susan Carvallo ("History of Family Therapy") pins a "Hello, I am . . . " badge on me saying that I am, indeed, a "conductor-psychodynamic-directive therapist."
J . AM . ACAD. CHILD ADOL ESC . PSYCHIATRY. 34 :6. JUN E 1995
Assistant Editor: William Sack, MD.
Then Sally Box gives us a brief introduction to Kleinian and post-Kleinian object relations theory. It quickly emerges that these are bionic (after Wilfred Bion) men and women who are bright, compassionate, and amazingly open to exposing themselves to self-criticism in that scary area of the countertransference. In fact, it was at this point that I noticed a copious drooling incontinence of envy knowing that , somewhere out there, therapists do like each other enough (and are allowed by third-party payers) to sit down regularly each week to analyze transference/countertransference issues without wondering whether these are "billable" hours! Ronald Britton's chapter on "Reenactment as an Unwitting Professional Response to Family Dynamics" is like a quick dip in Lake Michigan in mid-December. Shocking, eye-opening, and brisk. It forces us to look at our own responses as professionals in the mental health field to the dynamics of the sick families we serve. It forces us to view ourselves as the "Wounded Healers" Thomas Maeder referred to in his 1989 Atlantic Monthly jeremiad . My personal favorite in terms of its boldness and charming eclecticism is "The Significance of the Outsider in Families and Other Social Groups ," by Anna (Halton) Darrington. Perhaps because her ebullience and bibliographical watering holes mirror mine, Darrington feels like a mint julep in July: the compleat therapist comfortable in the semiosis of any discipline that helps one explain and enjoy the human person. Her exposition of the outsider role being of the group and definitely performing some function for the group yet taking a position on the fringe or the edge of that group piquantly describes the role of the adolescent patient. And the therapist. Both have to go through a phase of "necessary skepticism" to find a space for independent thought. Both have to wade through the jetsam and flotsam of hypocrisy and malignancy (the "nameless dread") to uncover truth and health. Both have to learn how to celebrate the self and his place in th is world which is, as George E. Woodbury would have it, to solve half the problem of contentment. It also empowers us to overcome what Herbert Rosenfeld referred to as "the narcissistic gang of the mind" and (Meltzer's) "gang families." This is a book which, I must confess, I approached with a jaundiced view, partly because I came from a training
825
BOOK REVIEWS
background where to admit a more than nodding acquaintance with Klein and Bion would be like standing up at a Senator McCarthy hearing in the 1950s and waving a Communist membership card. More importantly, though, it admits having the disillusioned tears of a closet psychotherapeutic romantic who believes that somewhere outside of Tavistock patients are taken care of first by caring for them rather than caring first about what insurance plan they belong to. For a book written by 12 authors, this volume certainly allows a lot of space for individual thinking and writing style. I found only five syntactical errors in the whole book. The cover art by Shirra Smilansky (who I assume, is a child of Errica, one of the coeditors and authors) is a sight to behold. It is a stirring confection of Chagall and Picasso that captures the essence of family psychopathology. It gives one the impression that Shirra must have read this book before embarking on the trip through her canvas sea. Truce T. Ordofia, M.D. Davenport, IA
The Management of Visual Impairment in Childhood.
Edited by Alistair R. Fielder, Anthony B. Best, and Martin Co. Bax. Clinics in Developmental Medicine No. 128: Mac KeithPress. DistributedbyCambridge University Press, London, England, 1993, 213 pp., $64.95 (hardcover). This book addresses a topic that is not adequately represented in the literature. It provides an updated review on the subject of visual impairment in children. Visual impairment in children younger than the age of 15 is present in less than 1 in evety 1,000. Although the child psychiatrist is not the first physician to encounter the patient, the problem is occasionally met in the course of one's practice. While the book is geared more toward the pediatrician, who is usually the first to see children with visual impairment, it could be a valuable source of information for the child psychiatrist, especiallyone who works with visually impaired children. The authors of the various chapters represents both sides of the Atlantic: England, the Netherlands, the United States, and Canada. Although some chapters discuss local situations, especially when reference is made to availability of resource centers, the basic issues are essentially the same for most countries. The first chapter provides a brief review of the epidemiology of blindness and visual impairment in children. While there are an estimated 1 million blind children in the world today, many more present with visual impairment to various but significant degrees.
826
The book also includes chapters on visual assessment, the ophthalmology of visual impairment, neurological causes, management, prevention, and education. Two of the chapters are closer to the interests of the child psychiatrist: chapter 5, "The Effects ofVisual Disability on Behavior and the Family," and chapter 6, "The Effects of Severe Visual Impairment on Development." In chapter 5, Maryke Groenveld points out the basic principle that children behave to a large extent the way we expect them to behave, i.e., if society expectsvisuallyimpaired children to be helpless, this increases their chances of behaving that way. Also, the visually impaired child has a serious impact on the family. Usually the mother has to stay home with the child. At times, parents feel that their visually impaired child brings them closer together. Also, the presence of such a child has an effect on siblings, in that they are frequently asked to take on adult roles and their resentment is not always freely expressed. Visually impaired children are generally less active, but engage in some form of selfstimulation (rocking, hand-flapping, or other mannerisms). When these children are integrated in the school system, these mannerisms subside. Therefore, in most countries, full integration in regular schools is becoming the norm. In chapter 6, Patricia Sonksen describes her experience with more than 600 severely visually impaired babies and preschool children. Since all five senses interact in the process of development, the impact of severe visual impairment is an important factor as it could potentially interfere with the developmental process if appropriate intervention is not provided. These children are less equipped to learn about themselves and the world, and they require additional assistance. Although the book is well organized and in many aspects very informative, it does not include any topic on the child psychiatric aspects of these children. It would have been more helpful if it had covered areas such as the psychiatric epidemiology of this population and to what extent visual impairment contributes to their psychopathology. It would also have been helpful to have a chapter on how the available psychotherapeutic approaches in child psychiatry need to be modified to meet the special needs of the visually impaired child. Although the child psychiatric input is very limited, the book can serve as a useful resource and stimulate the interest of the child psychiatrist in this area. Paul Kymissis, M.D. Associate Professor, Psychiatry and Pediatrics Director, Division of Child and Adolescent Psychiatry New York Medical College/Westchester County Medical Center Valhalla, NY
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 34:6, JUNE 1995