- Email: [email protected]
The Adolescent Molester, Second Edition
BOOK REVIEWS
out. There is no discussion about substance abuse and bipolar disorder, and anxiety disorders are hardly mentioned. The authors briefly note that youngsters with attentiondeficit hyperactivity disorder (ADHD) and conduct disorder use substances at a very high rate, but they do not explore the differences between ADHD teenagers with and without conduct disorder. Also, a more lengthy discussion of learning and school difficulties related to substance use and dual diagnosis would have been helpful. The authors describe how alcohol and substances affect memory and learning. Information concerning collaborative teamwork between therapists, substance abuse counselors, and educators would be most helpful. The authors describe well the Catch-22 of dual diagnosis: that our mental health institutions do not want adolescents with coexisting severe chemical dependency disorders and that our substance abuse programs are similarly ill-equipped to deal with the mental health issues of these youngsters! They do mention that appropriate treatment services for adolescents with dual diagnoses have increased in recent years, but descriptions of successful programs would have been helpful. Prevention and treatment options are well reviewed. The authors cautiously give some credit to social environmental/ learning-type programs such as DARE, which trains children to stay away from substances and dangerous social situations. However, they also point out that no prevention strategy has had proven long-term success or effectiveness. A recent comprehensive review of the DARE program supports this conclusion. It seems that although we have much to learn about treatment, we know even less about prevention! In summary, this book has some stimulating thoughts concerning prenatal and early childhood exposure; accidents, crime, violence, and other social factors; as well as prevention and treatment issues. It gives many nice clinical vignettes. Yet, it often lacks sufficient detail to comprehensively cover these important areas. Marvin Rosen, M.D. Assistant Clinical Professor Oregon Health Sciences University, Portland
The Adolescent Molester, Second Edition. By WilliamBreer.
Sprinfield IL: Charles C Thomas, 1996 224 pp., $49.95 (hardcover), $34.95 (softcover). As funds for traditional mental health services appear to be shrinking, resources for correctional facilities are undergoing a rapid expansion in my state. Incarcerating young people is now a growth industry! I recently took on a
J. A M . A C A D . C H I L D A D O L E S C . P S Y C H I A T R Y , 3 6 : 3 , M A R C H 1997
psychiatric consulting position at a state correctional facility. I quickly learned that more than 100 youths in that institution are there for sexual offenses and that the sexual offender treatment program is important and well established. Embarrassed by my lack of knowledge in this field, I went scurrying off in search of material on sexual offenders. As luck would have it, I found William Breer’s excellent new volume. There is now a “standard model” for treating sexual offenders as recommended in 1988 by The National Task Force on Adolescent Sex Offending. This model is based on cognitive-behavioral principles. Cognitive restructuring, that is, making explicit the erroneous ideas underlying sexually assaultive behavior, is a cornerstone of this model. An important technique of this model is to extinguish or suppress deviant sexual interests by having the offender masturbate repeatedly, first with a healthy and appropriate fantasy and subsequently to deviant fantasies. The goal is to extinguish the deviant erotic response. Also incorporated in many treatment programs are anger management and social skills interventions. The author carefully reviews and describes these programs in detail; then he points out their deficiencies and subsequently gives a detailed description of his own more psychodynamically oriented treatment protocol. He calls this the “developmental model.” His strategy relies heavily on the prior lack of male models for identification in the lives of these young offenders. Therapy thus needs to incorporate a strong and authoritative but patient and compassionate male group leader. The author stresses that most sexual offenders in his group are not homosexual youths or rapists, but adolescent males who molest younger children. He reports a recidivism rate of less than 5% among more than 300 youths he has treated over the past 15 years. Thus, this kind of intervention, although stressful, is rewarding. Breer carefully covers the role of victimization in the life of the offender. The danger in overemphasizing the victim’s role in therapy is that the offender can easily take refuge in this role and thus not deal with his offenses. The author reports that in his own caseload, about 60% of boys have been sexual victims. He believes that being molested by another male (rather than female) is more traumatic and sets in motion homosexual conflicts. He also believes that the age at which a victimization experience occurs is equally important for the male. A sexual experience prior to the age of 6 years is usually less conflicted than one occurring after that time. In describing some of the dynamics of his groups for sexual offenders, Breer emphasizes the need for a climate of uniformity and freedom, including the need for openness in describing why the boy is there (i.e., his sexual offenses). “Each boy must learn abut the impact of molesting on victims, why he committed his offenses and what will keep him from offending in the future” (p. 144). The author
419
BOOK REVIEWS
finds great utility in the use of dreams in group discussions. He also uses drawing and poetry. Breer cautions that his methods work best for adolescents in outpatient settings and acknowledges the need for use of the “standard model” in residential settings with those whose overall delinquency is at a much higher level. There are in this volume chapters on individual and family therapy as well, although the author asserts that group therapy is the preferred mode of treatment for most offenders. In addition to detailed description of the therapeutic framework and procedures, Breer also develops a dynamically oriented hypothesis as to why teenage boys molest. He finds the adolescent molester has deep conflict abut his own sexuality, most often because of the paucity of adequate male role models in his life. The teenage boy feels, “I might be gay and I don’t like that.” Thus, the act of molestation is, in part, a defense against this conflict. The clinical experience gleaned over an extended time has led Breer to develop a psychodynamic model of male development itself, integrating the new psychoanalytic theories (of Kohut, Blos, etc.) with neurodevelopmental studies (of Money, Young, Joy, and Phoenix); this model is described in one of his chapters. However, the author’s extensive clinical descriptions remain the strongest aspect of this book. What Breer achieves in this volume is all too rare in our age of edited books and rapid publication deadlines. We have here a single author, a seasoned clinician, reporting on his own experience with a particularly challenging group of patients. He successfully integrates and contrasts his own experience with the prevailing empirical literature as well as the underlying theoretical foundations of his work. The result is an eminently readable volume, lucid, candid, informed, and yet humble in tone. As I finished the The Adolescent Molesters, I felt I had not only learned a great deal but met a rewarding professional colleague as well. William H. Sack, M.D. Professor of Psychiatry Oregon Health Sciences University, Portland
The Best Intentions: Unintended Pregnancy and the WellBeing of Children and Families. Edited by Sarah Brown and Leon Eisenberg. Washington, DC: NationalAcademy Press, 1995, 225 pp., $24.95 (softcover).
s.
This book is the report of a study of unintended pregnancy done by the Institute of Medicine, National Academy of Sciences. It opens with the bold statement that almost 60% of pregnancies in the United States are unintended-either mistimed or unwanted altogether. This percentage is much
420
higher than that in most other Western democracies. Why is this so? What are the consequences? What can be done about it? These are the focal questions. The goal of this publication is to draw attention to this wide-reaching social problem and to stimulate research, corrective policies, and public interest. The text is well organized and easy to read. Terms are clearly defined. Numerous graphs, tables, and diagrams help one visually integrate the data. The early chapters offer a compilation of data, drawing substantially on the National Survey of Family Growth conducted by the National Center for Health Statistics. In chapter 3, the social, medical, and economic consequences of unintended pregnancy are examined. Attention is given to sorting out what is known from what is suspected and in need of further research. Chapters 4 and 5 deal with contraceptive use (or non-use) and look at possible reasons why, in a country where citizens supposedly have easy access to contraception, there are such high rates of contraceptive (or user) failure. Of particular interest to child psychiatrists in clinical practice is chapter 6, which gives us a look at the personal and interpersonal determinants of contraceptive use. The authors seek to examine this complex web of emotions and behavior and do a very good job of describing the dilemmas young females face in today’s world. Those of us who sit and talk with adolescent patients who are attempting to master their sexuality and fertility in a society fraught with choices will especially appreciate this section. Chapter 7 moves from the individual to a societal focus and gives us a wide-ranging discussion of economic, cultural, political, and media influences operating in contemporary America. Chapter 8 describes and reviews a number of programs that have been targeted at reducing unintended pregnancies. Additional detail on specific programs is given in the appendix. I would strongly recommend this section to educators and social program administrators, and it is quite interesting to a larger audience as well. Controversies over abortion, contraception, and abstinence-based versus comprehensive sex education have made it difficult to reach a national consensus. The authors of this book do an excellent job of describing how ideological differences stand in the way of progress. The authors recommend that the emphasis be placed on the premise that all pregnancies should be intended. Certainly some common ground can be found here. The study group proposes a national campaign (comparable to others in recent years focusing on drunk driving, seat belt use, and drug abuse) aimed at establishing a new social norm that all pregnancies be consciously desired at the time of conception. There are detailed recommendations regarding government and economic policy, physician training, insurance coverage, research funding, and the role of the media.
J . AM. ACAD. C H I L D ADOLESC. PSYCHIATRY, 3 6 : 3 , MARCH 1997
out. There is no discussion about substance abuse and bipolar disorder, and anxiety disorders are hardly mentioned. The authors briefly note that youngsters with attentiondeficit hyperactivity disorder (ADHD) and conduct disorder use substances at a very high rate, but they do not explore the differences between ADHD teenagers with and without conduct disorder. Also, a more lengthy discussion of learning and school difficulties related to substance use and dual diagnosis would have been helpful. The authors describe how alcohol and substances affect memory and learning. Information concerning collaborative teamwork between therapists, substance abuse counselors, and educators would be most helpful. The authors describe well the Catch-22 of dual diagnosis: that our mental health institutions do not want adolescents with coexisting severe chemical dependency disorders and that our substance abuse programs are similarly ill-equipped to deal with the mental health issues of these youngsters! They do mention that appropriate treatment services for adolescents with dual diagnoses have increased in recent years, but descriptions of successful programs would have been helpful. Prevention and treatment options are well reviewed. The authors cautiously give some credit to social environmental/ learning-type programs such as DARE, which trains children to stay away from substances and dangerous social situations. However, they also point out that no prevention strategy has had proven long-term success or effectiveness. A recent comprehensive review of the DARE program supports this conclusion. It seems that although we have much to learn about treatment, we know even less about prevention! In summary, this book has some stimulating thoughts concerning prenatal and early childhood exposure; accidents, crime, violence, and other social factors; as well as prevention and treatment issues. It gives many nice clinical vignettes. Yet, it often lacks sufficient detail to comprehensively cover these important areas. Marvin Rosen, M.D. Assistant Clinical Professor Oregon Health Sciences University, Portland
The Adolescent Molester, Second Edition. By WilliamBreer.
Sprinfield IL: Charles C Thomas, 1996 224 pp., $49.95 (hardcover), $34.95 (softcover). As funds for traditional mental health services appear to be shrinking, resources for correctional facilities are undergoing a rapid expansion in my state. Incarcerating young people is now a growth industry! I recently took on a
J. A M . A C A D . C H I L D A D O L E S C . P S Y C H I A T R Y , 3 6 : 3 , M A R C H 1997
psychiatric consulting position at a state correctional facility. I quickly learned that more than 100 youths in that institution are there for sexual offenses and that the sexual offender treatment program is important and well established. Embarrassed by my lack of knowledge in this field, I went scurrying off in search of material on sexual offenders. As luck would have it, I found William Breer’s excellent new volume. There is now a “standard model” for treating sexual offenders as recommended in 1988 by The National Task Force on Adolescent Sex Offending. This model is based on cognitive-behavioral principles. Cognitive restructuring, that is, making explicit the erroneous ideas underlying sexually assaultive behavior, is a cornerstone of this model. An important technique of this model is to extinguish or suppress deviant sexual interests by having the offender masturbate repeatedly, first with a healthy and appropriate fantasy and subsequently to deviant fantasies. The goal is to extinguish the deviant erotic response. Also incorporated in many treatment programs are anger management and social skills interventions. The author carefully reviews and describes these programs in detail; then he points out their deficiencies and subsequently gives a detailed description of his own more psychodynamically oriented treatment protocol. He calls this the “developmental model.” His strategy relies heavily on the prior lack of male models for identification in the lives of these young offenders. Therapy thus needs to incorporate a strong and authoritative but patient and compassionate male group leader. The author stresses that most sexual offenders in his group are not homosexual youths or rapists, but adolescent males who molest younger children. He reports a recidivism rate of less than 5% among more than 300 youths he has treated over the past 15 years. Thus, this kind of intervention, although stressful, is rewarding. Breer carefully covers the role of victimization in the life of the offender. The danger in overemphasizing the victim’s role in therapy is that the offender can easily take refuge in this role and thus not deal with his offenses. The author reports that in his own caseload, about 60% of boys have been sexual victims. He believes that being molested by another male (rather than female) is more traumatic and sets in motion homosexual conflicts. He also believes that the age at which a victimization experience occurs is equally important for the male. A sexual experience prior to the age of 6 years is usually less conflicted than one occurring after that time. In describing some of the dynamics of his groups for sexual offenders, Breer emphasizes the need for a climate of uniformity and freedom, including the need for openness in describing why the boy is there (i.e., his sexual offenses). “Each boy must learn abut the impact of molesting on victims, why he committed his offenses and what will keep him from offending in the future” (p. 144). The author
419
BOOK REVIEWS
finds great utility in the use of dreams in group discussions. He also uses drawing and poetry. Breer cautions that his methods work best for adolescents in outpatient settings and acknowledges the need for use of the “standard model” in residential settings with those whose overall delinquency is at a much higher level. There are in this volume chapters on individual and family therapy as well, although the author asserts that group therapy is the preferred mode of treatment for most offenders. In addition to detailed description of the therapeutic framework and procedures, Breer also develops a dynamically oriented hypothesis as to why teenage boys molest. He finds the adolescent molester has deep conflict abut his own sexuality, most often because of the paucity of adequate male role models in his life. The teenage boy feels, “I might be gay and I don’t like that.” Thus, the act of molestation is, in part, a defense against this conflict. The clinical experience gleaned over an extended time has led Breer to develop a psychodynamic model of male development itself, integrating the new psychoanalytic theories (of Kohut, Blos, etc.) with neurodevelopmental studies (of Money, Young, Joy, and Phoenix); this model is described in one of his chapters. However, the author’s extensive clinical descriptions remain the strongest aspect of this book. What Breer achieves in this volume is all too rare in our age of edited books and rapid publication deadlines. We have here a single author, a seasoned clinician, reporting on his own experience with a particularly challenging group of patients. He successfully integrates and contrasts his own experience with the prevailing empirical literature as well as the underlying theoretical foundations of his work. The result is an eminently readable volume, lucid, candid, informed, and yet humble in tone. As I finished the The Adolescent Molesters, I felt I had not only learned a great deal but met a rewarding professional colleague as well. William H. Sack, M.D. Professor of Psychiatry Oregon Health Sciences University, Portland
The Best Intentions: Unintended Pregnancy and the WellBeing of Children and Families. Edited by Sarah Brown and Leon Eisenberg. Washington, DC: NationalAcademy Press, 1995, 225 pp., $24.95 (softcover).
s.
This book is the report of a study of unintended pregnancy done by the Institute of Medicine, National Academy of Sciences. It opens with the bold statement that almost 60% of pregnancies in the United States are unintended-either mistimed or unwanted altogether. This percentage is much
420
higher than that in most other Western democracies. Why is this so? What are the consequences? What can be done about it? These are the focal questions. The goal of this publication is to draw attention to this wide-reaching social problem and to stimulate research, corrective policies, and public interest. The text is well organized and easy to read. Terms are clearly defined. Numerous graphs, tables, and diagrams help one visually integrate the data. The early chapters offer a compilation of data, drawing substantially on the National Survey of Family Growth conducted by the National Center for Health Statistics. In chapter 3, the social, medical, and economic consequences of unintended pregnancy are examined. Attention is given to sorting out what is known from what is suspected and in need of further research. Chapters 4 and 5 deal with contraceptive use (or non-use) and look at possible reasons why, in a country where citizens supposedly have easy access to contraception, there are such high rates of contraceptive (or user) failure. Of particular interest to child psychiatrists in clinical practice is chapter 6, which gives us a look at the personal and interpersonal determinants of contraceptive use. The authors seek to examine this complex web of emotions and behavior and do a very good job of describing the dilemmas young females face in today’s world. Those of us who sit and talk with adolescent patients who are attempting to master their sexuality and fertility in a society fraught with choices will especially appreciate this section. Chapter 7 moves from the individual to a societal focus and gives us a wide-ranging discussion of economic, cultural, political, and media influences operating in contemporary America. Chapter 8 describes and reviews a number of programs that have been targeted at reducing unintended pregnancies. Additional detail on specific programs is given in the appendix. I would strongly recommend this section to educators and social program administrators, and it is quite interesting to a larger audience as well. Controversies over abortion, contraception, and abstinence-based versus comprehensive sex education have made it difficult to reach a national consensus. The authors of this book do an excellent job of describing how ideological differences stand in the way of progress. The authors recommend that the emphasis be placed on the premise that all pregnancies should be intended. Certainly some common ground can be found here. The study group proposes a national campaign (comparable to others in recent years focusing on drunk driving, seat belt use, and drug abuse) aimed at establishing a new social norm that all pregnancies be consciously desired at the time of conception. There are detailed recommendations regarding government and economic policy, physician training, insurance coverage, research funding, and the role of the media.
J . AM. ACAD. C H I L D ADOLESC. PSYCHIATRY, 3 6 : 3 , MARCH 1997