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Dynamic psychiatry: Explorations in psychotherapy, psychoanalysis, and psychosomatic medicine
Book Reviews
Dynamic Psychiatry: Explorations in Psychotherapy, Psychoanalysis, and Psychosomatic Medicine. By Pietro Castelnuovo-Tedesco. Madison, CT, International Universities Press, Inc., 1991 ($50.001, 474 pp. What a treat to share the experiences of 30 years of Dr. Pietro Castelnuovo-Tedesco! Hearing how it went for him gives us specific ideas about how we want to work today. In today’s climate, with psychiatry trying to be more scientific through standardized diagnoses and rigorous data analysis, a careful clinical approach is more important than ever. Science is important in our field, but it must be driven by sound clinical understanding and reflection on the psychological significance of case material. Dr. Castelnuovo-Tedesco’s work exemplifies the best of careful history-taking, observation of the patient, attention to psychological detail, and pondering the meaning of events to a person at a particular time in his or her life so that we can make psychological sense of what we see. This selection of papers reflects changes and developments in American psychiatry from the 1960s’ dominance of psychoanalysis and psychosomatic medicine to the 1970s’ social and community psychiatry to the 1980s’ biological focus, which continues to dominate our field. There are three sections: “Psychotherapy,” “Psychoanalysis,” and “Psychosomatic Medicine.” In all of them there is deep commitment to the idea of psychiatry remaining an integral part of comprehensive medicine. The psychotherapy section considers such “hot” topics as 1) brief psychotherapy, 2) broadening the reach of psychotherapy to wider segments of the population using relatively untrained counselors and general physicians, 3) the famous “twenty-minute hour,” and 4) combining drugs and psychotherapy. Dr. Castelnuovo-Tedesco was ahead of his time. What could be more topical than “The Twenty-Minute Hour” designed specifically for nonpsychiatrist physicians to do supportive psychotherapy? This
420 ISSN 0163-8343/93/$6.00
creative approach was developed by Dr. Castelnuovo-Tedesco in 1960 with medical residents at the Harbor General Hospital in Los Angeles. How timely this approach is in view of data indicating that psychological services reduce the cost of medical care with the cost of medical care being a current obsession of our society. Teaching psychiatry to nonpsychiatrists is “in” again, fostered by issues of cost and drug companies’ promotion of new psychotropic agents. Whereas many writers are enthusiastic and optimistic, of particular value is Dr. Castelnuovo-Tedesco’s willingness to speak candidly of failures and difficulties. If you want to work with medical residents, Dr. CastelnuovoTedesco’s experience will help you teach them that they can “do something for a patient” without doing “something to him.” Dr. Castelnuovo-Tedesco traces the development of brief psychotherapy from its earliest beginnings in Vienna in the 1880s when Dora was treated for 3 months and the Wolf-Man had a time limit, to current models of applying psychoanalytic concepts, a crisis orientation, or a behavioral approach. Characteristic of Dr. Castelnuovo-Tedesco is the focus on what works, not primarily on whether or not it uses predominantly interpretive or manipulative techniques. Although interest in brief psychotherapy in the 1960s was based on an awareness of its social significance and its potential for broadening the delivery of psychiatric care, today the focus is often on cost containment. The papers on psychoanalysis do not deal with “traditional” analytic theory, but rather with clinical topics that “have not been sufficiently explored in the analytic literature” such as “stealing as revenge.” It is remarkable that the psychology of organ transplantation appears under “psychoanalysis” as well as under “psychosomatics.” In this view, psychosomatic and psychoanalytic overlap, and psychology, psychodynamics, and medical-surgical psychiatry are blended together. “Fear General Hospital Psychiatry 15,42M21,1993 0 1993 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010
Book Reviews
of change” is a compelling notion which is addressed in two chapters. Whereas traditional resistance is framed in terms of drives and defenses (i.e., the patient resists becoming aware of drives), patients also direct strong efforts to try to prevent change which they perceive as a threat to the organization of the self. Fear of change is presented “as a specific entity that powerfully affects the course of treatment” and which “has not received the attention it deserves. . . because it has been bracketed under the general rubric of resistance.” The medical-surgical psychiatry section contains a fascinating chapter on the dramatic complications of peptic ulcer, perforation or hematemesis, which have received hardly any psychiatric attention. Referencing here is outstanding. Although this clinical report was written in 1962, it utilizes the biopsychosocial model in its emphasis on a spectrum of etiologic factors, from alcohol abuse and genetic predisposition to psychological conflict and stressful life events. The classic paper on chronic pelvic pain illustrates both the value of a careful clinical approach and the dangers of prematurely accepting etiologic assumptions. Despite much subsequent study, we have yet to disentangle the contribution of organic and psychological factors here.
Limitations of this book include its failure to address the dilemma of the discrepancy between the outcry for “talking” between doctors and patients and the lack of commitment on the part of academic institutions to teaching these skills. Another limitation is the pre-DSM-III deemphasis on diagnostic labels. Whereas overemphasis on diagnosis easily leads to a nonpsychological approach, avoidance of diagnosis leaves us unclear about what we are dealing with and specific indications for psychotropic agents. Some chapters stand the test of time better than others; for example, the chapter on anxiety seems not as fresh as the chapters on the fear of change. In times when students seem to have less time and may read less, any of these articles will provide a classic, clear, well-referenced, readable review of an interesting and pertinent topic. In sum, this book should be read by both students and teachers of psychotherapy and medical-surgical psychiatry who will find it easy to read and clinically useful.
LESLIE HARTLEY New
GISE, M.D.
York, New York
Dynamic Psychiatry: Explorations in Psychotherapy, Psychoanalysis, and Psychosomatic Medicine. By Pietro Castelnuovo-Tedesco. Madison, CT, International Universities Press, Inc., 1991 ($50.001, 474 pp. What a treat to share the experiences of 30 years of Dr. Pietro Castelnuovo-Tedesco! Hearing how it went for him gives us specific ideas about how we want to work today. In today’s climate, with psychiatry trying to be more scientific through standardized diagnoses and rigorous data analysis, a careful clinical approach is more important than ever. Science is important in our field, but it must be driven by sound clinical understanding and reflection on the psychological significance of case material. Dr. Castelnuovo-Tedesco’s work exemplifies the best of careful history-taking, observation of the patient, attention to psychological detail, and pondering the meaning of events to a person at a particular time in his or her life so that we can make psychological sense of what we see. This selection of papers reflects changes and developments in American psychiatry from the 1960s’ dominance of psychoanalysis and psychosomatic medicine to the 1970s’ social and community psychiatry to the 1980s’ biological focus, which continues to dominate our field. There are three sections: “Psychotherapy,” “Psychoanalysis,” and “Psychosomatic Medicine.” In all of them there is deep commitment to the idea of psychiatry remaining an integral part of comprehensive medicine. The psychotherapy section considers such “hot” topics as 1) brief psychotherapy, 2) broadening the reach of psychotherapy to wider segments of the population using relatively untrained counselors and general physicians, 3) the famous “twenty-minute hour,” and 4) combining drugs and psychotherapy. Dr. Castelnuovo-Tedesco was ahead of his time. What could be more topical than “The Twenty-Minute Hour” designed specifically for nonpsychiatrist physicians to do supportive psychotherapy? This
420 ISSN 0163-8343/93/$6.00
creative approach was developed by Dr. Castelnuovo-Tedesco in 1960 with medical residents at the Harbor General Hospital in Los Angeles. How timely this approach is in view of data indicating that psychological services reduce the cost of medical care with the cost of medical care being a current obsession of our society. Teaching psychiatry to nonpsychiatrists is “in” again, fostered by issues of cost and drug companies’ promotion of new psychotropic agents. Whereas many writers are enthusiastic and optimistic, of particular value is Dr. Castelnuovo-Tedesco’s willingness to speak candidly of failures and difficulties. If you want to work with medical residents, Dr. CastelnuovoTedesco’s experience will help you teach them that they can “do something for a patient” without doing “something to him.” Dr. Castelnuovo-Tedesco traces the development of brief psychotherapy from its earliest beginnings in Vienna in the 1880s when Dora was treated for 3 months and the Wolf-Man had a time limit, to current models of applying psychoanalytic concepts, a crisis orientation, or a behavioral approach. Characteristic of Dr. Castelnuovo-Tedesco is the focus on what works, not primarily on whether or not it uses predominantly interpretive or manipulative techniques. Although interest in brief psychotherapy in the 1960s was based on an awareness of its social significance and its potential for broadening the delivery of psychiatric care, today the focus is often on cost containment. The papers on psychoanalysis do not deal with “traditional” analytic theory, but rather with clinical topics that “have not been sufficiently explored in the analytic literature” such as “stealing as revenge.” It is remarkable that the psychology of organ transplantation appears under “psychoanalysis” as well as under “psychosomatics.” In this view, psychosomatic and psychoanalytic overlap, and psychology, psychodynamics, and medical-surgical psychiatry are blended together. “Fear General Hospital Psychiatry 15,42M21,1993 0 1993 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010
Book Reviews
of change” is a compelling notion which is addressed in two chapters. Whereas traditional resistance is framed in terms of drives and defenses (i.e., the patient resists becoming aware of drives), patients also direct strong efforts to try to prevent change which they perceive as a threat to the organization of the self. Fear of change is presented “as a specific entity that powerfully affects the course of treatment” and which “has not received the attention it deserves. . . because it has been bracketed under the general rubric of resistance.” The medical-surgical psychiatry section contains a fascinating chapter on the dramatic complications of peptic ulcer, perforation or hematemesis, which have received hardly any psychiatric attention. Referencing here is outstanding. Although this clinical report was written in 1962, it utilizes the biopsychosocial model in its emphasis on a spectrum of etiologic factors, from alcohol abuse and genetic predisposition to psychological conflict and stressful life events. The classic paper on chronic pelvic pain illustrates both the value of a careful clinical approach and the dangers of prematurely accepting etiologic assumptions. Despite much subsequent study, we have yet to disentangle the contribution of organic and psychological factors here.
Limitations of this book include its failure to address the dilemma of the discrepancy between the outcry for “talking” between doctors and patients and the lack of commitment on the part of academic institutions to teaching these skills. Another limitation is the pre-DSM-III deemphasis on diagnostic labels. Whereas overemphasis on diagnosis easily leads to a nonpsychological approach, avoidance of diagnosis leaves us unclear about what we are dealing with and specific indications for psychotropic agents. Some chapters stand the test of time better than others; for example, the chapter on anxiety seems not as fresh as the chapters on the fear of change. In times when students seem to have less time and may read less, any of these articles will provide a classic, clear, well-referenced, readable review of an interesting and pertinent topic. In sum, this book should be read by both students and teachers of psychotherapy and medical-surgical psychiatry who will find it easy to read and clinically useful.
LESLIE HARTLEY New
GISE, M.D.
York, New York