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Massachusetts General Hospital: Psychiatric Aspects of General Hospital Pediatrics
BOOK REVIEWS
child to the area of physical surrounds and, if possible, make the surroundings fit the child . However, the most important point to be derived from the aforementioned example about the book is the need for a more specific delineation of diagnostic interviews from treatment sessions. The setup of the room described in the book is much more appropriate to an ongoing treatment experience than for a diagnostic assessment. I also have some serious questions regarding the idea of matching or pacing behavior as a means to establish rapport. Although this process may help some children , it is the antithesis of what should be done with others. A disorganized hyperactive child does not need matching behavior; what is needed is a calm, relaxed, consistent approach that may serve as a model for the child or adolescent. In summary, I find this book to be good, and it achieves its purpose of guiding newcomers to the profession that aims to work with and help children and adolescents . JOHN D. O'BRIEN , M.D .
Clinical Associate Professor of Psychiatry Director, Training & Education for Child and Adolescent Psychiatry New York University Medical Center
Massachusetts General Hospital: Psychiatric Aspects of General Hospital Pediatrics. Edited by Michael S. Jellinek and David B. Hertzog. Chicago, IL: Year Book Med ical Publishers, Inc., 1990, 421 pp ., $24 .95 (soft cover). This is a small book, but it is by no means an inconsequential one . It is about the size of the usual paperback mystery and deliberately designed so that it can be carried about easily by its primary target audience: pediatric house officers . It is intended to be a companion to The Harriet Lane Handbook, the popular and well-established volume that has been so useful to pediatric residents for many years. I agree with the editors' preface and with the introductory comments by Donald Medearis, Chief of the Children's Services at the Massachusetts General Hospital, that this book fills an important niche in the literature regarding child psychiatric care. Although there are several very substantial texts regarding the psychological aspects of pediatric illnesses and care and an increasing number of textbooks in child and adolescent psychiatry, none so directly deals with the psychiatric aspects of pediatric hospital care as does this one. There are several things that this book is not. As acknowledged in the preface, this is not a comprehensive textbook . And, it is not a resource for extensive bibliographic information regarding any of the topics addressed . It is, rather, a compact, practical guide that addresses a multitude of issues that arise with relative frequency on a pediatric service in a general hospital or in a children's hospital. Although it is clearly directed to the pediatric house officer, I believe its value goes well beyond and that it will
512
prove useful to child and adolescent psychiatrists and residents and to other caretaking staffs of pediatric services. For instance, I believe this book may be nearly as valuable to pediatric nurses as it is to physicians . The book is comprised of 53 chapters to which over 4 dozen authors have contributed. Several chapters address generic issues, such as interviewing, caring for children in the hospital, obtaining psychiatric consultation, legal issues, and ethical considerations. Several of these particularly caught my attention . The chapter on " House Staff Stress" is a compact and quite comprehensive brief essay on the sources of stress , the signs of excessive stress, and the means by which stress may be reduced . The subsequent chapter, "The Difficult Parent," describes a source of difficulty for many pediatric residents. It, too, is quite thorough despite its brevity, and it provides some rather specific and helpful suggestions for the pediatric resident in dealing with the often perplexing and demanding situations. Most of the chapters address particular medical problems. Although there is no standard format for these chapters, most describe more frequent psychiatric or psychological reactions to the specific illness or injury, and most include specific suggestions for evaluation and/or management. Specific suggestions are provided that help define the role of the pediatric resident and possible reactions of the residents to these often difficult situations. Some chapters include brief clinical vignettes, which add interest and reinforce the practical suggestions made in the narrative. Although compactness and practicality clearly were priorities in compiling these chapters, there is a continuing recognition of complexity , ambiguity , and seriousness that go beyond the material included. Despite the brevity of the chapters and the almost telegraphic quality of some of the lists of suggestions and principles, this is a very readable book. As one might expect, with so many authors, there is some unevenness of style, but its overall directness and its emphasis on the potential roles, functions, and contributions of pediatric house staff should make it a most useful and well-received volume. A unique attribute is the attention to the reactions of the house officer to the clinical situations . Although clearly not the major focus, these brief discussions can be reassuring to the resident, and the suggestions for coping with stress and ambiguity may prove helpful. I was impressed that psychological reactions described in this volume were so similar to those presented by Cohen that were derived directly from residents (Cohen, 1988). Its size and its cost also make it an attractive book. It is printed on relatively good paper, but the print is rather small. The index is well done, making it relatively easy to identify the particular sections of the book that may be helpful in any point in time when easy access to the narrative information is needed. I believe this book achieves its goals rather well. I do wish that there had been a little more uniformity in providing reference material that might be helpful to those who wish to pursue any of the topics in somewhat more depth. Despite this, I believe the editors and the authors .are to be complimented. J . Am .Acad. Child Adolesc . Psychiatry, 30:3 , May 1991
BOOK REV IEWS REFERENCE
Cohen, R. L. , (1989) , House Officer: Becoming a Medical Specialist . New York: Plenum .
NORBERT B. ENZER, M.D. Professor and Chairperson Department of Psychiatry Michigan State University
The Bad Object: Handling the Negative Therapeutic Reaction in Psychotherapy. By Jeffrey Seinfeld , Ph .D . Northvale , New Jerse y: Jason Aronson, Inc. , 1990, 336 pp ., $40.00 (hardcover). This book is about the psychodyn amics and treatment of the negative therapeutic reaction-the patient 's inability to tolerate progress in treatment. It certainly achieves what it sets out to do . This is a very technic al book on a very technical, complex psychoanalytic subject. I must share with you the feeling I had throughout the reading of the first part of this book, the theoretical part: it was a feeling of having to struggle with it and finally attack it! However, I felt rewarded upon completion of it, as the last half (probably 60%) is rich with clinical description s and astute observations as well as well thought-out and explained interventions; the beginning is difficult reading , but the latter part is not. The book does not have a whole lot to do with the treatment of children; it is mostly about the long-term intense psychotherapy of borderline and other severely disturbed young and older adults. However , the few descriptions of the treatment of chaotic, disorganized, disturbed children are rich and valuable . Chapter Six, " Handling the Negative Therapeutic Reaction in Children, " is grand on how to understand and intervene with such children. I take exception with the author calling the children described as " borderline" because their personalities are still so fluid, plastic , changing, and changeable that I don't think their personalities could yet be crystallized into what would be called a personality disorder. Better that these children ju st described be thought of as the chaotic , disorganized , impulsive , low frustration tolerance , depressed , angry, etc . children that they are. The book contains man y useful suggestions, understandings, interventions, and " how-tos " in the clinical descriptions of the treatment of such children. I also disagree with the author because he does not address and therefore, by omission, seems to deny the biological substrate for the problems of most of these children and adults . The book also focuses on object (especially American object) relation s theory . In the first part of the book , the author expects the reader to be familiar with its language and literature. The author sorts out, elaborates on, and synthesizes the contributions of various theoreticians, such as Edith Jacobson, Searles , Kohut , Kernberg, Melanie Klein , Abraham, Fairbairn, Winnicott , Mahler, and Masterson as well as his own . One sometimes has to do some mental J. Am. Acad . Child Ado/esc .Psychiatry, 30 :3, May 1991
gymnastics wading through the language, read ing and rereading to keep straight who is saying what and to keep straight the complex psychoanalytical language; for instance, on page 26 , " The selfcomponent feeling rejected will then reject the exciting object. The self then becomes a rejecting self, the object a rejecting object. The rejecting self-rejected object leads to the inevitable depression associated with object loss , result ing in the wish for merger with the hoped-for good object , resulting in the exciting and then rejecting-rejected object configuration ." The author is literate and knowledgeable with metaphors from quantum physics , atomic physics, and classical and object-relations psychoanalytical literature . However, the author sometimes obfuscate s the intended message. The volume sets out with the intent of showing, •'how to help the patient overcome what has been described by Freud as the most serious obstacle to psychotherapy: the negative therapeutic reaction. " It is the bad object that is predominantly responsible for this reaction. The bad object comprises the real and fantasied negative attributes of parental figures that become distorted and more powerful than the actual parents. The y get split off, and when the therap y process threatens the patient, the patient projects the bad object onto the therapist. In the second part of the book , the author guides the reader through Searles' " phases of patient-therapist interreaction : (l) Out-of-Contact; (2) Ambiv alent (pathological) symbiosis; (3) Therapeuti c symbiosis, and (4) resolution of the symbiosi s with scintillating case studies." The author outlines both the principles of intervention and the interventions themsel ves very well. The interventions are explained with utmost clarity. They mentioned both the com plexities and the confusions discussed above . The case discussions are as lucid as can be; the interventions mentioned are both useful and practical. The author as a clinician and therapist is very sensitive to the patients ' communication s and is empathetic , patient , a good listener, and yet an active therapist when it is time to intervene . He explains all this well, and he ably shows how the severely disturbed patient induces the therapist into using generalized limit setting and ego supportive techniques in order to transform the therap ist into the bad object. There is an outstanding description of the treatment process in the case study of the treatment of a chaotic , provocat ive , disorg anized , angry, depressed 9-year-old boy. This book is worth reading ; fight your way through the jargon and the complexities and enjoy the latter part of the book and learn a great deal in the process. RICHARD L. GROSS , M.D . Clinical Professor of Psychiatry George Washington University Medical Center Medical Director of Fairbridge Residential Treatment Center Rockville , Maryland
513
child to the area of physical surrounds and, if possible, make the surroundings fit the child . However, the most important point to be derived from the aforementioned example about the book is the need for a more specific delineation of diagnostic interviews from treatment sessions. The setup of the room described in the book is much more appropriate to an ongoing treatment experience than for a diagnostic assessment. I also have some serious questions regarding the idea of matching or pacing behavior as a means to establish rapport. Although this process may help some children , it is the antithesis of what should be done with others. A disorganized hyperactive child does not need matching behavior; what is needed is a calm, relaxed, consistent approach that may serve as a model for the child or adolescent. In summary, I find this book to be good, and it achieves its purpose of guiding newcomers to the profession that aims to work with and help children and adolescents . JOHN D. O'BRIEN , M.D .
Clinical Associate Professor of Psychiatry Director, Training & Education for Child and Adolescent Psychiatry New York University Medical Center
Massachusetts General Hospital: Psychiatric Aspects of General Hospital Pediatrics. Edited by Michael S. Jellinek and David B. Hertzog. Chicago, IL: Year Book Med ical Publishers, Inc., 1990, 421 pp ., $24 .95 (soft cover). This is a small book, but it is by no means an inconsequential one . It is about the size of the usual paperback mystery and deliberately designed so that it can be carried about easily by its primary target audience: pediatric house officers . It is intended to be a companion to The Harriet Lane Handbook, the popular and well-established volume that has been so useful to pediatric residents for many years. I agree with the editors' preface and with the introductory comments by Donald Medearis, Chief of the Children's Services at the Massachusetts General Hospital, that this book fills an important niche in the literature regarding child psychiatric care. Although there are several very substantial texts regarding the psychological aspects of pediatric illnesses and care and an increasing number of textbooks in child and adolescent psychiatry, none so directly deals with the psychiatric aspects of pediatric hospital care as does this one. There are several things that this book is not. As acknowledged in the preface, this is not a comprehensive textbook . And, it is not a resource for extensive bibliographic information regarding any of the topics addressed . It is, rather, a compact, practical guide that addresses a multitude of issues that arise with relative frequency on a pediatric service in a general hospital or in a children's hospital. Although it is clearly directed to the pediatric house officer, I believe its value goes well beyond and that it will
512
prove useful to child and adolescent psychiatrists and residents and to other caretaking staffs of pediatric services. For instance, I believe this book may be nearly as valuable to pediatric nurses as it is to physicians . The book is comprised of 53 chapters to which over 4 dozen authors have contributed. Several chapters address generic issues, such as interviewing, caring for children in the hospital, obtaining psychiatric consultation, legal issues, and ethical considerations. Several of these particularly caught my attention . The chapter on " House Staff Stress" is a compact and quite comprehensive brief essay on the sources of stress , the signs of excessive stress, and the means by which stress may be reduced . The subsequent chapter, "The Difficult Parent," describes a source of difficulty for many pediatric residents. It, too, is quite thorough despite its brevity, and it provides some rather specific and helpful suggestions for the pediatric resident in dealing with the often perplexing and demanding situations. Most of the chapters address particular medical problems. Although there is no standard format for these chapters, most describe more frequent psychiatric or psychological reactions to the specific illness or injury, and most include specific suggestions for evaluation and/or management. Specific suggestions are provided that help define the role of the pediatric resident and possible reactions of the residents to these often difficult situations. Some chapters include brief clinical vignettes, which add interest and reinforce the practical suggestions made in the narrative. Although compactness and practicality clearly were priorities in compiling these chapters, there is a continuing recognition of complexity , ambiguity , and seriousness that go beyond the material included. Despite the brevity of the chapters and the almost telegraphic quality of some of the lists of suggestions and principles, this is a very readable book. As one might expect, with so many authors, there is some unevenness of style, but its overall directness and its emphasis on the potential roles, functions, and contributions of pediatric house staff should make it a most useful and well-received volume. A unique attribute is the attention to the reactions of the house officer to the clinical situations . Although clearly not the major focus, these brief discussions can be reassuring to the resident, and the suggestions for coping with stress and ambiguity may prove helpful. I was impressed that psychological reactions described in this volume were so similar to those presented by Cohen that were derived directly from residents (Cohen, 1988). Its size and its cost also make it an attractive book. It is printed on relatively good paper, but the print is rather small. The index is well done, making it relatively easy to identify the particular sections of the book that may be helpful in any point in time when easy access to the narrative information is needed. I believe this book achieves its goals rather well. I do wish that there had been a little more uniformity in providing reference material that might be helpful to those who wish to pursue any of the topics in somewhat more depth. Despite this, I believe the editors and the authors .are to be complimented. J . Am .Acad. Child Adolesc . Psychiatry, 30:3 , May 1991
BOOK REV IEWS REFERENCE
Cohen, R. L. , (1989) , House Officer: Becoming a Medical Specialist . New York: Plenum .
NORBERT B. ENZER, M.D. Professor and Chairperson Department of Psychiatry Michigan State University
The Bad Object: Handling the Negative Therapeutic Reaction in Psychotherapy. By Jeffrey Seinfeld , Ph .D . Northvale , New Jerse y: Jason Aronson, Inc. , 1990, 336 pp ., $40.00 (hardcover). This book is about the psychodyn amics and treatment of the negative therapeutic reaction-the patient 's inability to tolerate progress in treatment. It certainly achieves what it sets out to do . This is a very technic al book on a very technical, complex psychoanalytic subject. I must share with you the feeling I had throughout the reading of the first part of this book, the theoretical part: it was a feeling of having to struggle with it and finally attack it! However, I felt rewarded upon completion of it, as the last half (probably 60%) is rich with clinical description s and astute observations as well as well thought-out and explained interventions; the beginning is difficult reading , but the latter part is not. The book does not have a whole lot to do with the treatment of children; it is mostly about the long-term intense psychotherapy of borderline and other severely disturbed young and older adults. However , the few descriptions of the treatment of chaotic, disorganized, disturbed children are rich and valuable . Chapter Six, " Handling the Negative Therapeutic Reaction in Children, " is grand on how to understand and intervene with such children. I take exception with the author calling the children described as " borderline" because their personalities are still so fluid, plastic , changing, and changeable that I don't think their personalities could yet be crystallized into what would be called a personality disorder. Better that these children ju st described be thought of as the chaotic , disorganized , impulsive , low frustration tolerance , depressed , angry, etc . children that they are. The book contains man y useful suggestions, understandings, interventions, and " how-tos " in the clinical descriptions of the treatment of such children. I also disagree with the author because he does not address and therefore, by omission, seems to deny the biological substrate for the problems of most of these children and adults . The book also focuses on object (especially American object) relation s theory . In the first part of the book , the author expects the reader to be familiar with its language and literature. The author sorts out, elaborates on, and synthesizes the contributions of various theoreticians, such as Edith Jacobson, Searles , Kohut , Kernberg, Melanie Klein , Abraham, Fairbairn, Winnicott , Mahler, and Masterson as well as his own . One sometimes has to do some mental J. Am. Acad . Child Ado/esc .Psychiatry, 30 :3, May 1991
gymnastics wading through the language, read ing and rereading to keep straight who is saying what and to keep straight the complex psychoanalytical language; for instance, on page 26 , " The selfcomponent feeling rejected will then reject the exciting object. The self then becomes a rejecting self, the object a rejecting object. The rejecting self-rejected object leads to the inevitable depression associated with object loss , result ing in the wish for merger with the hoped-for good object , resulting in the exciting and then rejecting-rejected object configuration ." The author is literate and knowledgeable with metaphors from quantum physics , atomic physics, and classical and object-relations psychoanalytical literature . However, the author sometimes obfuscate s the intended message. The volume sets out with the intent of showing, •'how to help the patient overcome what has been described by Freud as the most serious obstacle to psychotherapy: the negative therapeutic reaction. " It is the bad object that is predominantly responsible for this reaction. The bad object comprises the real and fantasied negative attributes of parental figures that become distorted and more powerful than the actual parents. The y get split off, and when the therap y process threatens the patient, the patient projects the bad object onto the therapist. In the second part of the book , the author guides the reader through Searles' " phases of patient-therapist interreaction : (l) Out-of-Contact; (2) Ambiv alent (pathological) symbiosis; (3) Therapeuti c symbiosis, and (4) resolution of the symbiosi s with scintillating case studies." The author outlines both the principles of intervention and the interventions themsel ves very well. The interventions are explained with utmost clarity. They mentioned both the com plexities and the confusions discussed above . The case discussions are as lucid as can be; the interventions mentioned are both useful and practical. The author as a clinician and therapist is very sensitive to the patients ' communication s and is empathetic , patient , a good listener, and yet an active therapist when it is time to intervene . He explains all this well, and he ably shows how the severely disturbed patient induces the therapist into using generalized limit setting and ego supportive techniques in order to transform the therap ist into the bad object. There is an outstanding description of the treatment process in the case study of the treatment of a chaotic , provocat ive , disorg anized , angry, depressed 9-year-old boy. This book is worth reading ; fight your way through the jargon and the complexities and enjoy the latter part of the book and learn a great deal in the process. RICHARD L. GROSS , M.D . Clinical Professor of Psychiatry George Washington University Medical Center Medical Director of Fairbridge Residential Treatment Center Rockville , Maryland
513