Family Therapy in Clinical Practice

BOOK REVIEWS apy" for each model. It is impossible to segregate one from the other; they do overlap. But the attempted separation of the two does serve to clarify for the reader the conceptual base upon which the therapist in each model would build his therapeutic approach. The reviewers are reluctant to promote another, perhaps unconscious, goal of the editors: the idea that marital therapy be identified as yet another area of specialization. Our feeling is that the fragmentation in psychotherapy has already exceeded productive limits, and that a therapist well grounded in psychodynamics, who has had a personal analysis with experienced supervision, should generally be capable of doing adequate marital therapy. The editors are well aware that marital therapy has developed empirically, and that much research is necessary in order to move toward a firmer scientific foundation. Variations of marriages and marital disorders are so complex as to raise the question of whether one can confine oneself to the conceptual framework of just one theoretical perspective. In the final chapter, Alan S. Gurman analyzes contemporary marital therapies and suggests that in theory, as in life, all too often our most valued strengths are also our biggest problems. Experience from past relationships can be transferred into present marriages in very disruptive and deceptive ways. Whereas the systems and behavioral theories are better prepared, perhaps, for analyzing present functioning, they may overlook ways in which conceptual distorMAY 1980· VOL 2\ • NO 5

tions, due to transference phenomena, can disrupt current interactions. Freud said once that there are many ways and means of practicing psychotherapy; all that lead to recovery are good. This volume is well worth reading for the psychiatrist, psychologist, social worker, or advanced-degree professional psychiatric nurse. Irving Frank. M.D.• Ed.D. Rosanne K. Frank. R.N.. M.S. Sycamore. 1/1.

Family Therapy in Clinical Practice By Murray Bowen. 565 pp. $30. New York. Jason Aronson.

• Murray Bowen's work is an integral part of family therapy's foundation. This collection of his papers provides a conceptual outline for work with families and simultaneously emerges as a history of family therapy. Bowen's papers are carefully and clearly written. The book is useful for a whole range of readers, from experienced family therapists to those seeking an introduction to family therapy. Because the author is a physician/ psychiatrist with six years of psychoanalytic training, it is of special value to those physicians desiring an introduction to family therapy theory. Despite wide use among mental health professionals, family therapy has never found a place in psychiatry. The physician is apt to stumble over problems such as his deeply ingrained protective responsibility for the symptomatic person, how to fit standard diagnostic procedures into a multiperson emotional system, and how to

transcend the cause-effect idea of etiology and move toward the notion of circular causality. These are not easy transitions for the physician to make. An exciting component of this book is Bowen's early struggle with the transition from conventional psychiatrist to family researcher/ therapist. He explains that early in his psychiatric work, he developed the notion that "emotional illness is a deeper phenomenon than can be explained by disturbed relationships in a single generation." Gradually, the gestalt of human experience took on a different look for him. Instead of trees, he began to see a forest. He saw an emotional relationship system that spanned three generations. These papers represent the author's effort to get a conceptual hold on the system's perspective. Bowen's ideas are extensively developed in this collection. They include such concepts as undifferentiated family ego mass, triangulation, individuation, family projection process, emotional divorce, circular causality, symptom evolution through multiple generations, and reciprocal functioning in marriage. While much of his wntmg focuses on the family with a schizophrenic member, many of the ideas are being applied to families with psychosomatic problems. When illness is viewed from the family dynamics point of view, the troublesome body-mind dichotomy is transcended and, thereby, resolved. A standard criticism of family therapy by conventional psychiatrists is that it lacks a cohesive theoretical base. The next time I hear 439

BOOK REVIEWS that cntlclsm, I will recommend reading this book, to be followed closely by Minuchin's Families and Family Therapy. David V. Keith, M.D. University of Wisconsin

The Woman Patient: Medical and Psychological Interfaces, vol 1 Edited by Malkah T. Notman and Carol C. Nadelson. 363 pp. $19.50. New York. Plenum Press.

• This volume, subtitled "Sexual and Reproductive Aspects of Women's Health Care," is the first in a series designed to evaluate current knowledge of female reproductive functioning. The book has 25 chapters, nearly all by women, many of them physicians and all experts in those areas of health care-reproduction and sexualityin which a woman's experience differs vastly from that of a man. Among the subjects covered are prenatal influences, genetic counseling. pregnancy, adolescent sexuality, infertility, contraception, abortion, gynecology, breast disorders, cosmetic surgery, sexual dysfunctions, rape, and menopause. The woman, often submissive and uninformed, is usually treated by a male physician, often authoritative and paternalistic. Thus, many decisions, e.g., those regarding hysterectomy and radical mastectomy. are made by the physician without consideration of the woman's wishes. Furthermore, the intensity of the physician-patient relationship may evoke sexual feelings in response to anxiety proMAY 1980' VOL 21 • NO 5

duced by illness, as well as depression, anger, and homosexual feelings. Among old myths that are refuted is the viewpoint that childbirth is more hazardous after age 30, since statistics do not substantiate the contention that healthy older women have longer, more difficult labors. As Nadelson points out, pregnancy may be compared with other critical life periods, which Erikson called developmental crises. Pregnancy is an opportunity for mastery and maturation, as well as a time of major life stress. Childbearing and child rearing are aggressive and libidinal tasks. Infantilization of a pregnant woman decreases her sense of mastery and does not encourage confident parenting. Seiden reminds us that our language reveals our attitude: "The physician is the one who 'delivers the child'; he does not attend the mother, who delivers the child.... To infantilize women, after all, is to rear children by infants." In "The COPE Story," Turner and Izzi beautifully describe the psychological stages of pregnancy and the postpartum period. This is the theoretical framework for COPE (Coping with the Overall Pregnancy / Parenting Experience) support groups, which operate in 16 metropolitan Boston communities. Over 600 women have participated in peer-led support groups, using a problem-solving format to decrease anxiety. The relationship between the woman patient and her male surgeon is discussed from a psychodynamic standpoint. Surgeons are doers, not empathic listeners. For

self-protection, they often distance themselves from a patient's feelings. Some of them react to a patient in terms of their own personal value systems. Patients regress because of illness as well as passivity. Some of them "bargain" with the physician, viewing him or her as omnipotent, with the power of life and death. Such women feel they must appease the caretaker to prevent fantasied retaliation or rejection, as well as to attain their goal of cure. Their reluctance to ask questions intensifies their anxiety. The chapter on gynecologic surgery clarifies the factors involved in the prognosis for mental health after hysterectomy: organic pathology, age, socioeconomic class, significant close personal relationship, satisfaction with children, and vocational and avocational absorption. The operation does not lead to significant psychopathology in healthy women, but a mourning process is inevitable as the woman consciously and unconsciously reintegrates her gender identity. These are only a few of the highlights of this book, which I recommend to physicians and [0 those consumers who are interested in a greater understanding of women's relationships with their physicians as well as their bodies. Although there is some repetitiveness and an occasional contradiction, this must be expected in a book with so many authors. There is a wealth of clinical material to reinforce the didactic. The editors are to be complimented for this timely and valuable, pioneer work. Ann Ruth Turkel, M.D. New York