- Email: [email protected]
Handbook of psychotherapy for Anorexia Nervosa and Bulimia
BOOK REVIEWS
241
It is difficult to see how such a result can come about by combining chapters reporting on carefully designed, carried out and evaluated clinical trials, with purely speculative and assertive declarations of a psychoanalytic nature. When are we going to have some actual demonstration (as opposed to assertions) of all the wonderful things that these psychoanalytic theories and practices do to patients? The book fails to answer this question, and is disappointing as a consequence. Hopeful eclecticism is no reasonable alternative to careful empirical and experimental work, and mere repetition of cliches is no substitute for quantitative evaluation of clinical trials attempting to establish specific points of view. H. J. EYSENCK
E. KAUFMAN: Substance Abuse and Family Therapy. Grune & Stratton,
Orlando,
Fla (1985). xviii + 234 Pages.
$24.50.
This book is the second in a series entitled “Family Therapy: Theory, Practice and Techniques”, edited by Vincent D. Foley. In the introduction Dr Foley describes this book as an ‘*amalgam of psychodynamic systems and behavioral approaches. formed into a total picture of a critical problem in American society”. Whilst some sections of the book, particularly those dealing with family therapy techniques are good and would be beneficial to clinicians in the field of family therapy with substance abusers there are, I believe, some serious difficulties with this book. It appears that Dr Kaufman has attampted to provide a review of the literature relating to substance abuse and this is expressed by the title of the book. Unfortunately. this attempt results in large sections of the book reading rather like a disjointed bibliography and there are few attempts to describe the literature quoted and very little evidence is presented with which the reader can evaluate these references. In some instances, for example Chapter 1, “The Problem, Personality and Psychopathology” where a few studies were presented in greater depth, I found large claims and generalizations seemingly based on small uncontrolled studies. Not only were the literature-oriented sections unsatisfactory in the way I have outlined, they were also extremely difficult to read and of considerably less value to the British clinician than the American. Whilst Dr Kaufman’s descriptions of alcohol abusers were familiar, those of adolescent drug abusers described a more affluent group than is the current British experience, and seemed to me to be more descriptive of drug abusers in this country in the 60s. In this context I am referring only to his descriptions of behaviour, and not to the impact on families or to the type of family dynamics which the therapist encounters. As I have stated, the sections of the book that deal with therapy and treatment alone were informative and interesting, and made for much easier reading. I would recommend these sections to professionals in the abuse field interested in a systems approach to family therapy, and to students of family therapy in general. Whilst a useful book for libraries to stock I find it difficult to see any professional group in Britain to which this book would have significant use. Researchers with a behavioural bias may find some of the tools described in the research review sections interesting and useful, although again the strong American bias might preclude this. Su BURRELL
K. HAWTON: Sex Therapy: a Practical Guide. OUP,
Oxford
(1985). 273 Pages.
f7.95.
There is a bewildering choice of sex books in print at the moment. Any new book on sexuality, sexual dysfunction or specific sex therapy has to offer a unique feature and Keith Hawton has managed to do this with his immensely practical guide to current sex therapy. He has recognized that there are now a wide range of health-care professionals who practise sex therapy and whose theoretical background and training are quite disparate. He argues well the need for a practical text that provides a detailed and straightforward account of sex problems and sex therapy. Part I is devoted to the nature of sexual problems, their prevalence and effects and causes. Of particular help are the extensive tables at the end of this section outlining the effects of physical illness, surgery and medication on sexual dysfunction. Part II is concerned with therapy. Assessment is divided into the formal work of the clinician, and the communication of a formulation with the prospective couple in therapy. There follow chapters on homework assignments, psychotherapeutic aspects of therapy, educational measurers, helping with relationship issues and, finally, the termination of treatment. The particular emphasis given to difficulties met during home assignments is innovative and imaginative. There are numerous worked examples, clear tables and checklists for anyone wishing to use this manual as a beginners’ text or as an update on clinical methodology. The last part of the book looks at research and assesses the current and future developments needed. There are also chapters on patients without partners, those with associated physical disorders and those not needing a full therapy programme. Only passing reference is made to cultural differences, which is a pity, and could be extended in future editions. I see this book as the ideal text for the therapist, beginner or advanced, who does not have the time to approach a more comprehensive tome, but who is seeking a pragmatic and accessible handbook for daily clinical practice. PATRICIAD’ARDENNE
D. M. GARNER and P. E. GARFINKEL(Eds): Handbook qf Ps.vchotherapy.for Anorexia Nervosa and Bulimia. Guilford New York (1985). xvi + 592 Pages. f39.95. This book assembles contributions centres in North America, England
Press,
to the treatment of anorexia nervosa and bulimia from a number of major treatment and Australia. The editors aimed to provide the practising clinician with some insight
24%
BOOK REVIEWS
into both the range and content of the psychotherapeutic approaches currently in use in the field of eating disorders. Some authors have presented theoretical models and then gone on to describe their overall approach to treatment. Others have chosen to concentrate on giving a flavour of what takes place in individual sessions, with occasional biow-by-blow dialogue and case illustrations. The book provides an ideal opportunity to compare and contrast the various philosophies and methods described, although the editors’ suggestion that these chapters could be used for ~plication in clinical trials would in many cases be overoptimistic. The material is organized into eight sections, with a foreword by Russell. Part I, “The Context for Psychotherapy”, contains three chapters. The first is an intr~uctjon by the editors, giving an overview of the book. In the second, Bruch comments on ‘four decades of eating disorders’, and makes intriguing predictions for future trends in the clinical presentation of anorexic illness. Johnson describes an extremely detailed checklist which he suggests should be used as a database for both research and clinical assessment. Part II, “Psychoanalytic Approaches*‘, contains a theoretical and treatment account by Goodsitt, and a feminist psychoanalytic account by Grbach. In Part III. “Cognitive and Behavioral Therapies”, chapters by Garner and Bemis, Hatmi, Fairburn , and Rosen and Leitenberg all extend their previous writings on therapy to give a fulter account of how they actuahy carry out their treatments and of the clinical issues addressed. Part IV, *‘Group Treatment”, contains accounts of two contrasting group models. Hail describes an open-ended long-term approach focusing on psychologi~l development for anorexic patients, whilst Mitchell and colleagues describe short-term groups advocating an abstinence model to address bulimic disorders. In Part V, “Family Therapy”, Sargent and co&agues present a clear description of a M~nucbin-st~ie structuraI family approach, whilst Schwartz and colleagues give a comprehensive, if overinclusive, view of bulimic treatment. Part VI, “Inpatient Treatment”, provides a detailed .account by Andersen of a unit programme which is probably broadly typical of most inpatient programmes in major centres now. Garfinkel and colleagues focus on speciaf management problems which often do not get sufficient attention. In Part VII, “Multicomponent Treatment Programmes”, chapters by Strober and Yager, Wooley and Wooley, Lacey and Kalucy and colleagues, describe more eclectic approaches which contain elements of cognitive-behavioural and dynamic individual and group methods, applied in packages to the treatment of anorexia or bulimia. In Part VIII, “Support and Educative Methods”, Enright and colleagues give a useful breakdown of the various models of support and self-help groups in existence. Gamer and coIIeagues bring together a wide range of facts reiated to weight control and eating, and this chapter may provide useful information to patients as well as staff. Overall this book contains a wealth of clinical wisdom which becomes repetitive in parts, but conveys a clear vote of coniidenoe that we now have the experience to tackle the treatment of eating disorders largely from an outpatient perspective, using bospitali~tion as an important resource where appropriate but not as the primary focus of treatment. Needless to say, there is plenty of room for future research to evaluate the efficacy of contrasting principles of treatment, but there is also a remarkable similarity in the basic details of treatment based on divergent theoretical models. There is also a clear need to examine the cases where treatment fails, and the management of chronic anorexia which is touched on briefly in this book. S5n3_tr3 CHANN~N
J. C. CLARKE and W. WARDMAN: Ag~rapkobiff:u Clinfcaiand PersonalACC~KW. Pergamon Press, Oxford (1985). xiv + 189 Pages E9.50 (Pa~r~ck)~ ft?SO (Hardback). Tbis book is unusual in that it was written by both the therapist and the agoraphobic patient under treatment. The second author, a medical practitioner, suffered from agoraphobia for 10 years before en~untering the first author, a clinical psychologist, who proceeded to apply behavioural treatment to good effect. The book conveys the various stages of therapy. starting with the numerous mi~ja~oses the patient had received over the years, together with the medj~tion of the day. The behavioural treatment extended over some time progressing from the initial cautious steps of accompanied exposure. together with strategic homework assignments, to the giving of ambitious tasks, such as a brief trip on a ‘plane. As the patient suffered from spontaneous panic attacks and excessive ant~~patory anxiety in addition to his agoraphob~. the therapist also tackled concurrently what he considers to be the three maladaptive fears of agoraphobia-namely, phobic anxiety, panic anxiety and ‘worry’. Thus, together with exposure tr~tment the patient was also trained in meditation and distraction techniques, each of which is described in detail. A book like this could easily have been anecdotal and self-indulgent, familiar to anybody who has ploughed through therapy accounts with pages of verbatim quotations (‘ . , . and then the therapist said: . . . , to which the patient replied: . _‘f. This book, however, retains a crisp pace giving justifications for each intervention method and a discussion of current research positions and alternative notions. But the greatest value of the book lies in the consideration of the many decisions therapists must make unaided by research data, such as the amount of pressure to put on patients, how to deal with setbacks. how much support to give without en~ndering dependence or which props to allow. to give but a few examples. The clear-minds discussion of these issues reveals a Iirm yet sympathetic attitude which results from a good understanding of anxiety mechanisms, and is likely to be of great help to therapists in training. The patient’s account conveying the distress caused by this psychological disorder (with all its ramifications) is all the more valuable because it is clearly an ‘informed’ account. This book should be recommended reading for trainee clinical psychologists and psychiatrists, as well as anybody else who is dealing with agoraphobic patients, GUDRUN SARTORY
241
It is difficult to see how such a result can come about by combining chapters reporting on carefully designed, carried out and evaluated clinical trials, with purely speculative and assertive declarations of a psychoanalytic nature. When are we going to have some actual demonstration (as opposed to assertions) of all the wonderful things that these psychoanalytic theories and practices do to patients? The book fails to answer this question, and is disappointing as a consequence. Hopeful eclecticism is no reasonable alternative to careful empirical and experimental work, and mere repetition of cliches is no substitute for quantitative evaluation of clinical trials attempting to establish specific points of view. H. J. EYSENCK
E. KAUFMAN: Substance Abuse and Family Therapy. Grune & Stratton,
Orlando,
Fla (1985). xviii + 234 Pages.
$24.50.
This book is the second in a series entitled “Family Therapy: Theory, Practice and Techniques”, edited by Vincent D. Foley. In the introduction Dr Foley describes this book as an ‘*amalgam of psychodynamic systems and behavioral approaches. formed into a total picture of a critical problem in American society”. Whilst some sections of the book, particularly those dealing with family therapy techniques are good and would be beneficial to clinicians in the field of family therapy with substance abusers there are, I believe, some serious difficulties with this book. It appears that Dr Kaufman has attampted to provide a review of the literature relating to substance abuse and this is expressed by the title of the book. Unfortunately. this attempt results in large sections of the book reading rather like a disjointed bibliography and there are few attempts to describe the literature quoted and very little evidence is presented with which the reader can evaluate these references. In some instances, for example Chapter 1, “The Problem, Personality and Psychopathology” where a few studies were presented in greater depth, I found large claims and generalizations seemingly based on small uncontrolled studies. Not only were the literature-oriented sections unsatisfactory in the way I have outlined, they were also extremely difficult to read and of considerably less value to the British clinician than the American. Whilst Dr Kaufman’s descriptions of alcohol abusers were familiar, those of adolescent drug abusers described a more affluent group than is the current British experience, and seemed to me to be more descriptive of drug abusers in this country in the 60s. In this context I am referring only to his descriptions of behaviour, and not to the impact on families or to the type of family dynamics which the therapist encounters. As I have stated, the sections of the book that deal with therapy and treatment alone were informative and interesting, and made for much easier reading. I would recommend these sections to professionals in the abuse field interested in a systems approach to family therapy, and to students of family therapy in general. Whilst a useful book for libraries to stock I find it difficult to see any professional group in Britain to which this book would have significant use. Researchers with a behavioural bias may find some of the tools described in the research review sections interesting and useful, although again the strong American bias might preclude this. Su BURRELL
K. HAWTON: Sex Therapy: a Practical Guide. OUP,
Oxford
(1985). 273 Pages.
f7.95.
There is a bewildering choice of sex books in print at the moment. Any new book on sexuality, sexual dysfunction or specific sex therapy has to offer a unique feature and Keith Hawton has managed to do this with his immensely practical guide to current sex therapy. He has recognized that there are now a wide range of health-care professionals who practise sex therapy and whose theoretical background and training are quite disparate. He argues well the need for a practical text that provides a detailed and straightforward account of sex problems and sex therapy. Part I is devoted to the nature of sexual problems, their prevalence and effects and causes. Of particular help are the extensive tables at the end of this section outlining the effects of physical illness, surgery and medication on sexual dysfunction. Part II is concerned with therapy. Assessment is divided into the formal work of the clinician, and the communication of a formulation with the prospective couple in therapy. There follow chapters on homework assignments, psychotherapeutic aspects of therapy, educational measurers, helping with relationship issues and, finally, the termination of treatment. The particular emphasis given to difficulties met during home assignments is innovative and imaginative. There are numerous worked examples, clear tables and checklists for anyone wishing to use this manual as a beginners’ text or as an update on clinical methodology. The last part of the book looks at research and assesses the current and future developments needed. There are also chapters on patients without partners, those with associated physical disorders and those not needing a full therapy programme. Only passing reference is made to cultural differences, which is a pity, and could be extended in future editions. I see this book as the ideal text for the therapist, beginner or advanced, who does not have the time to approach a more comprehensive tome, but who is seeking a pragmatic and accessible handbook for daily clinical practice. PATRICIAD’ARDENNE
D. M. GARNER and P. E. GARFINKEL(Eds): Handbook qf Ps.vchotherapy.for Anorexia Nervosa and Bulimia. Guilford New York (1985). xvi + 592 Pages. f39.95. This book assembles contributions centres in North America, England
Press,
to the treatment of anorexia nervosa and bulimia from a number of major treatment and Australia. The editors aimed to provide the practising clinician with some insight
24%
BOOK REVIEWS
into both the range and content of the psychotherapeutic approaches currently in use in the field of eating disorders. Some authors have presented theoretical models and then gone on to describe their overall approach to treatment. Others have chosen to concentrate on giving a flavour of what takes place in individual sessions, with occasional biow-by-blow dialogue and case illustrations. The book provides an ideal opportunity to compare and contrast the various philosophies and methods described, although the editors’ suggestion that these chapters could be used for ~plication in clinical trials would in many cases be overoptimistic. The material is organized into eight sections, with a foreword by Russell. Part I, “The Context for Psychotherapy”, contains three chapters. The first is an intr~uctjon by the editors, giving an overview of the book. In the second, Bruch comments on ‘four decades of eating disorders’, and makes intriguing predictions for future trends in the clinical presentation of anorexic illness. Johnson describes an extremely detailed checklist which he suggests should be used as a database for both research and clinical assessment. Part II, “Psychoanalytic Approaches*‘, contains a theoretical and treatment account by Goodsitt, and a feminist psychoanalytic account by Grbach. In Part III. “Cognitive and Behavioral Therapies”, chapters by Garner and Bemis, Hatmi, Fairburn , and Rosen and Leitenberg all extend their previous writings on therapy to give a fulter account of how they actuahy carry out their treatments and of the clinical issues addressed. Part IV, *‘Group Treatment”, contains accounts of two contrasting group models. Hail describes an open-ended long-term approach focusing on psychologi~l development for anorexic patients, whilst Mitchell and colleagues describe short-term groups advocating an abstinence model to address bulimic disorders. In Part V, “Family Therapy”, Sargent and co&agues present a clear description of a M~nucbin-st~ie structuraI family approach, whilst Schwartz and colleagues give a comprehensive, if overinclusive, view of bulimic treatment. Part VI, “Inpatient Treatment”, provides a detailed .account by Andersen of a unit programme which is probably broadly typical of most inpatient programmes in major centres now. Garfinkel and colleagues focus on speciaf management problems which often do not get sufficient attention. In Part VII, “Multicomponent Treatment Programmes”, chapters by Strober and Yager, Wooley and Wooley, Lacey and Kalucy and colleagues, describe more eclectic approaches which contain elements of cognitive-behavioural and dynamic individual and group methods, applied in packages to the treatment of anorexia or bulimia. In Part VIII, “Support and Educative Methods”, Enright and colleagues give a useful breakdown of the various models of support and self-help groups in existence. Gamer and coIIeagues bring together a wide range of facts reiated to weight control and eating, and this chapter may provide useful information to patients as well as staff. Overall this book contains a wealth of clinical wisdom which becomes repetitive in parts, but conveys a clear vote of coniidenoe that we now have the experience to tackle the treatment of eating disorders largely from an outpatient perspective, using bospitali~tion as an important resource where appropriate but not as the primary focus of treatment. Needless to say, there is plenty of room for future research to evaluate the efficacy of contrasting principles of treatment, but there is also a remarkable similarity in the basic details of treatment based on divergent theoretical models. There is also a clear need to examine the cases where treatment fails, and the management of chronic anorexia which is touched on briefly in this book. S5n3_tr3 CHANN~N
J. C. CLARKE and W. WARDMAN: Ag~rapkobiff:u Clinfcaiand PersonalACC~KW. Pergamon Press, Oxford (1985). xiv + 189 Pages E9.50 (Pa~r~ck)~ ft?SO (Hardback). Tbis book is unusual in that it was written by both the therapist and the agoraphobic patient under treatment. The second author, a medical practitioner, suffered from agoraphobia for 10 years before en~untering the first author, a clinical psychologist, who proceeded to apply behavioural treatment to good effect. The book conveys the various stages of therapy. starting with the numerous mi~ja~oses the patient had received over the years, together with the medj~tion of the day. The behavioural treatment extended over some time progressing from the initial cautious steps of accompanied exposure. together with strategic homework assignments, to the giving of ambitious tasks, such as a brief trip on a ‘plane. As the patient suffered from spontaneous panic attacks and excessive ant~~patory anxiety in addition to his agoraphob~. the therapist also tackled concurrently what he considers to be the three maladaptive fears of agoraphobia-namely, phobic anxiety, panic anxiety and ‘worry’. Thus, together with exposure tr~tment the patient was also trained in meditation and distraction techniques, each of which is described in detail. A book like this could easily have been anecdotal and self-indulgent, familiar to anybody who has ploughed through therapy accounts with pages of verbatim quotations (‘ . , . and then the therapist said: . . . , to which the patient replied: . _‘f. This book, however, retains a crisp pace giving justifications for each intervention method and a discussion of current research positions and alternative notions. But the greatest value of the book lies in the consideration of the many decisions therapists must make unaided by research data, such as the amount of pressure to put on patients, how to deal with setbacks. how much support to give without en~ndering dependence or which props to allow. to give but a few examples. The clear-minds discussion of these issues reveals a Iirm yet sympathetic attitude which results from a good understanding of anxiety mechanisms, and is likely to be of great help to therapists in training. The patient’s account conveying the distress caused by this psychological disorder (with all its ramifications) is all the more valuable because it is clearly an ‘informed’ account. This book should be recommended reading for trainee clinical psychologists and psychiatrists, as well as anybody else who is dealing with agoraphobic patients, GUDRUN SARTORY