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Moments of Engagement—Intimate psychotherapy in a technological age
BOOK REVIEWS
November 1989
Volume 15 is hugely procedural, with chapters on sedation for the child and others that stress techniques for facilitating gastrointestinal endoscopy and panendoscopy. One particular valuable section deals with modifications in endoscopic retrograde cholangiopancreatography for children under 5 yr of age in whom the standard instruments are cumbersome or simply too large. Liver biopsy, small bowel biopsy, esophageal dilation, and sclerosis of esophageal varices are well discussed. Nearly half of this text is devoted to radiologic and nuclear medicine studies of the gastrointestinal tract and hepatobiliary system. Volume 16 discusses the diagnostic tests available for evaluating motor function of the esophagus and gastrointestinal tract, nutritional status, carbohydrate and fat absorption, and scanning electron microscopy findings in small bowel tissue. Newer techniques for measuring enteric protein loss as well as macromolecular absorption are also described. A fine chapter by Boedeker and McQueen reviews the laboratory investigations of childhood enteric infections and resurrects the old pathogenic Bscherichia coli serotypes as those now associated with “enteroinvasive E. coli.” A chapter describing the value of serum bile acid measurements for the determination of liver disease and of ileal dysfunction as well as the caffeine clearance test as a measure of quantitative hepatic function provides us with new vistas in the evaluation of liver function. In conclusion, there are sections on electron microscopy of liver biopsy tissue and new noninvasive tests to measure pancreatic function. These are impressive small volumes that contain a wealth of information and should be in every reference library. The cost however is extremely high, which will influence individual purchases. JOYCE D. GRYBOSKI, M.D.
New Haven, Connecticut
Moments of Engagement-Intimate Psychotherapy in a Technological Age. By P. D. Kramer. $24.95. W. W. Norton, New York, New York, 1969. ISBN: o-393-70075-5. There is a whole movement out there that escapes most gastroenterologists and has to do with storytelling as a form of diagnosis and therapy. This does not seem to make much sense to many of our ilk, engaged as we are in colonoscopic surveillance for inflammatory bowel disease or Barrett’s esophagus, and besieged by attorneys demanding to know why we did not make the diagnosis of metestatic colon cancer earlier. But over the past 5-10 yr, as deconstructionists in English (and French) departments have looked behind the story in literature to engage in a psychoanalytic dissection of what authors have said-and not said-psychiatrists and some general physicians have begun to recognize that hearing the patient’s story, retelling that story, and reframing it can provide therapy for many of their patients. Trained in literature before he became engaged in psychotherapy and psychoanalysis, Peter Kramer does more than just add to the genre. He tells his own stories of how he made contact with patients in more than one epiphany
1351
of understanding, and as we read the different techniques he has learned to use, we come to understand why such a sensitive psychotherapist works in the Brown University medical program: he likes to teach as well as to care for patients. Kramer uses analytic techniques that he learned both as a patient and as a therapist. As frank about issues of control and power as he is about the pleasures in treating someone, he has gradually moved, I think, from pure psychoanalytic technique to ones far more eclectic. But his catholic approach was always there, I think, from the time he rushed to wake up and put under a shower a patient who had received too much sedation, to visiting patients in their houses and to being, in a sense, a friend as well as a therapist. Indeed, his chapter on “Rent-a-Friend” raises questions, not always answered, about whether it is the technique or the time for the technique that leads to improvement. In a wise dissertation on psychotropic medications Kramer, like most modern psychiatrists, finds them important and helpful, but his ideas and interpretations come as unique revelations: “Medications can function as, or provide, interpretations . . . to be prescribed for has meaning . . . the act may be seen as nurturant or sadistic or both . . . the act of prescribing affects how the patient sees us and how he imagines we see him. I would say there is a new requirement in therapy, namely that we know the meaning of medications for ourselves, because thoughts about medications have inevitably become part of the way we communicate with ourselves.” Kramer has good and sensible observations about how medicine has been turned topsy-turvy: the young have advantages over the old so that wisdom and patience are “gravy,” but no longer the “meat” of the hospital. Would it were otherwise. There is a fine chapter on empathy in which Kramer interweaves thoughts on how retelling the patient’s story changes the patient’s appreciation of himself. In his final sections on the “Ambiguous Profession” discussing what psychotherapy is, Kramer identifies it as an art. But you must read how much more he would make of it. As he tells us of his pilgrimage so far, he finds that the stories of his youth turn out to be refractions through a lens that no longer exists when he confronts them a second time. Judging from the picture on the jacket, Kramer is doubtless a young man, posed somewhat ambiguously in front of a fence, but he is already wise and sensitive. One hopes a wide readership for his book, which I recommend to all students-and they are many-who are considering the field of psychiatry. I will also wish that as he grows older and refills the cornucopia of books we can expect, he will somehow keep his sensitivity to the new and his willingness to experiment. Kramer feels deeply and writes freely and we are lucky to have him write for us. HOWARD SPIRO, M.D.
New Haven, Connecticut
The Autopsy-Medical Pmctice and Public Policy. By R. B. Hill and R. E. Anderson. 320 pp., $39.95. Butterworth, Boston, Massachusetts, 1988. ISBN: O-409-90137-7.
November 1989
Volume 15 is hugely procedural, with chapters on sedation for the child and others that stress techniques for facilitating gastrointestinal endoscopy and panendoscopy. One particular valuable section deals with modifications in endoscopic retrograde cholangiopancreatography for children under 5 yr of age in whom the standard instruments are cumbersome or simply too large. Liver biopsy, small bowel biopsy, esophageal dilation, and sclerosis of esophageal varices are well discussed. Nearly half of this text is devoted to radiologic and nuclear medicine studies of the gastrointestinal tract and hepatobiliary system. Volume 16 discusses the diagnostic tests available for evaluating motor function of the esophagus and gastrointestinal tract, nutritional status, carbohydrate and fat absorption, and scanning electron microscopy findings in small bowel tissue. Newer techniques for measuring enteric protein loss as well as macromolecular absorption are also described. A fine chapter by Boedeker and McQueen reviews the laboratory investigations of childhood enteric infections and resurrects the old pathogenic Bscherichia coli serotypes as those now associated with “enteroinvasive E. coli.” A chapter describing the value of serum bile acid measurements for the determination of liver disease and of ileal dysfunction as well as the caffeine clearance test as a measure of quantitative hepatic function provides us with new vistas in the evaluation of liver function. In conclusion, there are sections on electron microscopy of liver biopsy tissue and new noninvasive tests to measure pancreatic function. These are impressive small volumes that contain a wealth of information and should be in every reference library. The cost however is extremely high, which will influence individual purchases. JOYCE D. GRYBOSKI, M.D.
New Haven, Connecticut
Moments of Engagement-Intimate Psychotherapy in a Technological Age. By P. D. Kramer. $24.95. W. W. Norton, New York, New York, 1969. ISBN: o-393-70075-5. There is a whole movement out there that escapes most gastroenterologists and has to do with storytelling as a form of diagnosis and therapy. This does not seem to make much sense to many of our ilk, engaged as we are in colonoscopic surveillance for inflammatory bowel disease or Barrett’s esophagus, and besieged by attorneys demanding to know why we did not make the diagnosis of metestatic colon cancer earlier. But over the past 5-10 yr, as deconstructionists in English (and French) departments have looked behind the story in literature to engage in a psychoanalytic dissection of what authors have said-and not said-psychiatrists and some general physicians have begun to recognize that hearing the patient’s story, retelling that story, and reframing it can provide therapy for many of their patients. Trained in literature before he became engaged in psychotherapy and psychoanalysis, Peter Kramer does more than just add to the genre. He tells his own stories of how he made contact with patients in more than one epiphany
1351
of understanding, and as we read the different techniques he has learned to use, we come to understand why such a sensitive psychotherapist works in the Brown University medical program: he likes to teach as well as to care for patients. Kramer uses analytic techniques that he learned both as a patient and as a therapist. As frank about issues of control and power as he is about the pleasures in treating someone, he has gradually moved, I think, from pure psychoanalytic technique to ones far more eclectic. But his catholic approach was always there, I think, from the time he rushed to wake up and put under a shower a patient who had received too much sedation, to visiting patients in their houses and to being, in a sense, a friend as well as a therapist. Indeed, his chapter on “Rent-a-Friend” raises questions, not always answered, about whether it is the technique or the time for the technique that leads to improvement. In a wise dissertation on psychotropic medications Kramer, like most modern psychiatrists, finds them important and helpful, but his ideas and interpretations come as unique revelations: “Medications can function as, or provide, interpretations . . . to be prescribed for has meaning . . . the act may be seen as nurturant or sadistic or both . . . the act of prescribing affects how the patient sees us and how he imagines we see him. I would say there is a new requirement in therapy, namely that we know the meaning of medications for ourselves, because thoughts about medications have inevitably become part of the way we communicate with ourselves.” Kramer has good and sensible observations about how medicine has been turned topsy-turvy: the young have advantages over the old so that wisdom and patience are “gravy,” but no longer the “meat” of the hospital. Would it were otherwise. There is a fine chapter on empathy in which Kramer interweaves thoughts on how retelling the patient’s story changes the patient’s appreciation of himself. In his final sections on the “Ambiguous Profession” discussing what psychotherapy is, Kramer identifies it as an art. But you must read how much more he would make of it. As he tells us of his pilgrimage so far, he finds that the stories of his youth turn out to be refractions through a lens that no longer exists when he confronts them a second time. Judging from the picture on the jacket, Kramer is doubtless a young man, posed somewhat ambiguously in front of a fence, but he is already wise and sensitive. One hopes a wide readership for his book, which I recommend to all students-and they are many-who are considering the field of psychiatry. I will also wish that as he grows older and refills the cornucopia of books we can expect, he will somehow keep his sensitivity to the new and his willingness to experiment. Kramer feels deeply and writes freely and we are lucky to have him write for us. HOWARD SPIRO, M.D.
New Haven, Connecticut
The Autopsy-Medical Pmctice and Public Policy. By R. B. Hill and R. E. Anderson. 320 pp., $39.95. Butterworth, Boston, Massachusetts, 1988. ISBN: O-409-90137-7.