- Email: [email protected]
The Child and Adolescent Psychotherapy Treatment Planner
BOOK REVIEWS
objectives, as well as therapeutic interventions. The most helpful aspect is the cross-reference after each objective to the appropriate interventions. As an example, a short-term objective for sleep disturbances is to identifY stressors and associated sleep patterns, and three possible interventions are recommended: (1) assess the role of stressors in interrupting sleep. (2) utilize play therapy to assess and resolve emotional conflicts, and (3) meet with the family to assess the level of tension and conflict and their effect on the client's sleep. This "one from column A, two from column B ... " approach makes much of the text redundant, but it provides minor adaptations to suit varying therapeutic philosophies and styles among the selected audience. The authors have done an excellent job of including interventions appropriate to almost. every philosophical bent and level of training. This book arrived for review as our inpatient units were undergoing restructuring as well as "accreditation anxiety." The director was quite excited one day about finding a new resource to help organize the units more efficiently, and she pulled out a copy of this volume. It has proved very beneficial in defining the treatment plans, and the style is appropriate for all staff, regardless of level or nature of training. Despite its strong points, three aspects of the book are troubling. The authors recommend completing the list of objectives and interventions before making a DSM-IV diagnosis. While this works perfectly well, it reflects a difference in training. Suggesting a diagnostic trial of intravenous antibiotics to determine whether a patient has pneumonia would not be acceptable in medical realms, and I would prefer to begin with a presumptive diagnosis before treatment begins. That either approach works for the vast majority of patients in psychiatry speaks to the imprecision of our diagnostic tools and the need for more accurate definitions of the diagnoses in our field. The second problem is one of exclusion on the part of the authors. Overall they have done an excellent job using the jargon of managed care, but they omitted one catch phrase: "outcome measures." The book would have been more helpful if they had also provided a list of "targets" for each intervention. I find it difficult to phrase suitable goals, perhaps because I resist the implication that we are thereby compartmentalizing and quantifYing our patients. That brings up the third concern: the implied collusion with the third-party payers and review boards that is inherent in this book's existence. In the introduction, the authors discuss the need for "uniformity of documentation" to satisfY reviewers, but they neglect to emphasize the unique characteristics of our clientele. We continue to struggle between the desirability of predictability and the unpredictable nature that is the sine qua non of psychiatric illness. It was not the intent of this book to answer these larger questions about the future of mental health, but rather to pro-
true for non-Jewish therapists. They need a cultural understanding of the impact of this tragedy on the Jewish people. Although I have read a good deal of literature on the impact of trauma in general and the Holocaust in particular, this book has an emotional impact that enriches the understanding of these events. Clinicians can develop a different level of insight and perhaps enhance their ability to empathize with and to treat these patients. In summary, The Last Witness is a valuable addition to the literature not only on the Holocaust, but also on the impact of massive traumatic stress in general. Genocide is not as uncommon as we would like to think. The tragedies in Bosnia and Rwanda underscore the need to "witness" these horrible events and make them understandable and accessible to people. I recommend this book to anyone interested in the Holocaust and the impact of genocide and to clinicians undertaking the treatment of Holocaust survivors or their children. Steven P. Cuffe, M.D. Director, Residency Training Program William S. Hall Psychiatric Institute Associate Professor University of South Carolina, Columbia
The Child and Adolescent Psychotherapy Treatment Planner. By Arthur E. Jongsma. Jr.. L. Mark Peterson. and William P Mcinnis. New York: John Wiley & Sons. Inc.. 1996. 219 pp. $32.95 (softcover). In 1995 the first two authors produced The Complete Psychotherapy Treatment Planner and now, with the help of Dr. McInnis. have delivered the latest member of the family of managed care survival manuals. Their efforts will be much appreciated by anyone who must devise treatment plans to satisfY insurance reviewers. The purpose of this volume is to provide practitioners with a ready source of defined problems to serve as a focus of therapy, as well as proposed interventions for each problem. The target audience is essentially anyone who provides mental health services for children and adolescents. The layout is simple and straightforward, with a chapter devoted to each global problem, such as anxiety, attentiondeficit hyperactivity disorder, enuresis/encopresis, peer/sibling conflict, and suicidal ideation/attempt. There are 29 subdivisions, covering not only DSM-1V diagnostic groups, but also behaviors like fire-setting and attitudes such as low selfesteem. This system makes it easy to scan through the options and focus on the more specific items in each chapter. Each chapter is arranged to select long-term goals based on the overall behavior, followed by a list of detailed short-term
1156
J.
AM. ACAD. CHIl.D ADOLESC. PSYCHIATRY. 36:8. AUGUST 1997
BOOK REVIEWS
vide us as caregivers with a map to help us navigate through these times. To use another analogy, the authors have done an excellent job of showing us where the stones are to cross to the other side of the river without drowning. Their work will allow us to carryon and fight this battle another day. Mark Jennings, M.D. University of Arkansas for Medical Sciences Little Rock
,I . Minefields in Their Hearts: The Mental Health of Children in War and Communal Violence. Edited by Roberta j. Apfel, M.D., M. P.H. , and Bennett Simon, M.D. New Haven and London: Yale University Press, 1996, 230 pp., $30.00 (hardcover). This timely and sensitive portrayal of those children in the world who are the victims of communal violence emanates from an International Work Group focusing on Children of War and Communal Violence. The editors in their introduction describe their commitment "to try to change the conditions that allow the violence," to facilitate an understanding of the "amazing resiliency" of these children, to make us aware of the "resourcefulness and dedication" of those adults who work with these children, and to write a book that "will have emotional resonance" for those mental health professionals sensitized to the suffering of children through their own experiences in childhood. The introduction provides a careful and thoughtful exposition and definition of the concepts and terms associated with the child victims of violence, i.e., trauma, war and communal violence, normal and abnormal development, resiliency and interventions. The editors note that all the interventions to be described are informed by the basic values of psychoanalysis, i.e., "open ended listening, bearing painful affects, and doing what is in the best interests of those in our care." They stress the importance of the therapist's being genuine and nonjudgmental, respecting the child's capacities, recognizing the child's complexity, and being innovative and willing to try nontraditional approaches. An editorial introduction precedes each chapter, both providing a purposeful statement of the writer's intent and point of view and placing the chapter contextually in the tapestry of the overall presentation. As one would expect in such a global undertaking, there is considerable diversity and range of topics presented as well as variations in the quality of contributions. Contributions include such chapters as "Ethical Issues in Working With Children in War Zones"; "What Do We Need to Know to Understand Children in War and Communal Violence"; "Post-Traumatic Stress Disorder and Other Stress Reactions";
]. AM. ACAD. CHILD ADOLESC. PSYCHIATRY..~(':8. AUCUST 1997
"Refugee Children"; "Child Development and Adaptation to Catastrophic Circumstances"; "Youth and Violence: Trends, Principles, and Programmatic Interventions"; "Mobilizing Communities to Meet the Psychosocial Needs of Children in War and Refugee Crises"; "Attempting to Overcome the Intergenerational Transmission ofTrauma: Dialogue Between Descendants of Victims and Perpetrators"; "Who Takes Care of the Caretakers"; "Assessing the Impact of War on Children"; and "Practical Approaches to Research With Children in Violent Settings." A number of important lines of thought that are developed and amplified are particularly relevant to those interested in understanding and working with children exposed to communal violence: (1) it is important to give priority to the "best interests of the child" and avoid the matrix of political motivations and agendas within which these children are embedded; (2) communal violence is not only the product of systemically directed warfare but is endemic to our large urban areas; (3) children are not miniature adults, and our understanding of their responses to violence requires knowledge of their cognitive and psychosocial development and how these processes interface with complex social ecosystems; (4) knowledge of the spectrum of trauma-specific and stressrelated disorders and the role of acute and chronic traumatization as determinants of medical-psychiatric disease is essential; (5) the effects of communal violence on children extend beyond the actual trauma and reverberate throughout the inner life of the child as he or she struggles to integrate the perceived meaning of the violence into his or her own view of self, others, and the world at large; (6) intervention strategies, while guided by our concerns for the individual child, need to be interwoven with the family, community, and social infrastructure of the ecosystem to be able to mobilize the resources necessary to mitigate the impact of communal violence and to contribute to the lessening of further violence against children; (7) children who are victimized by violence will become the conduits through which a transgenerational transfer of the derivative effects of trauma will be passed on to succeeding generations of families; (8) the many caretakers who invest so much of their emotional lives in the children of violence become victimized themselves through the contagion of suffering and require succorance; and (9) it is imperative that we secure an empirical basis for our understanding of the effects of communal violence and that our intervention strategies be predicated on scientifically validated and proven procedures. Minefields in Their Hearts is a welcome and thoughtful introduction to those wanting to understand the magnitude and the role of communal violence in the world, its devastating effects on children and families, and the opportunities available for mental health professionals to contribute to the relief of suffering. The book is comprehensive and enriching,
1157
objectives, as well as therapeutic interventions. The most helpful aspect is the cross-reference after each objective to the appropriate interventions. As an example, a short-term objective for sleep disturbances is to identifY stressors and associated sleep patterns, and three possible interventions are recommended: (1) assess the role of stressors in interrupting sleep. (2) utilize play therapy to assess and resolve emotional conflicts, and (3) meet with the family to assess the level of tension and conflict and their effect on the client's sleep. This "one from column A, two from column B ... " approach makes much of the text redundant, but it provides minor adaptations to suit varying therapeutic philosophies and styles among the selected audience. The authors have done an excellent job of including interventions appropriate to almost. every philosophical bent and level of training. This book arrived for review as our inpatient units were undergoing restructuring as well as "accreditation anxiety." The director was quite excited one day about finding a new resource to help organize the units more efficiently, and she pulled out a copy of this volume. It has proved very beneficial in defining the treatment plans, and the style is appropriate for all staff, regardless of level or nature of training. Despite its strong points, three aspects of the book are troubling. The authors recommend completing the list of objectives and interventions before making a DSM-IV diagnosis. While this works perfectly well, it reflects a difference in training. Suggesting a diagnostic trial of intravenous antibiotics to determine whether a patient has pneumonia would not be acceptable in medical realms, and I would prefer to begin with a presumptive diagnosis before treatment begins. That either approach works for the vast majority of patients in psychiatry speaks to the imprecision of our diagnostic tools and the need for more accurate definitions of the diagnoses in our field. The second problem is one of exclusion on the part of the authors. Overall they have done an excellent job using the jargon of managed care, but they omitted one catch phrase: "outcome measures." The book would have been more helpful if they had also provided a list of "targets" for each intervention. I find it difficult to phrase suitable goals, perhaps because I resist the implication that we are thereby compartmentalizing and quantifYing our patients. That brings up the third concern: the implied collusion with the third-party payers and review boards that is inherent in this book's existence. In the introduction, the authors discuss the need for "uniformity of documentation" to satisfY reviewers, but they neglect to emphasize the unique characteristics of our clientele. We continue to struggle between the desirability of predictability and the unpredictable nature that is the sine qua non of psychiatric illness. It was not the intent of this book to answer these larger questions about the future of mental health, but rather to pro-
true for non-Jewish therapists. They need a cultural understanding of the impact of this tragedy on the Jewish people. Although I have read a good deal of literature on the impact of trauma in general and the Holocaust in particular, this book has an emotional impact that enriches the understanding of these events. Clinicians can develop a different level of insight and perhaps enhance their ability to empathize with and to treat these patients. In summary, The Last Witness is a valuable addition to the literature not only on the Holocaust, but also on the impact of massive traumatic stress in general. Genocide is not as uncommon as we would like to think. The tragedies in Bosnia and Rwanda underscore the need to "witness" these horrible events and make them understandable and accessible to people. I recommend this book to anyone interested in the Holocaust and the impact of genocide and to clinicians undertaking the treatment of Holocaust survivors or their children. Steven P. Cuffe, M.D. Director, Residency Training Program William S. Hall Psychiatric Institute Associate Professor University of South Carolina, Columbia
The Child and Adolescent Psychotherapy Treatment Planner. By Arthur E. Jongsma. Jr.. L. Mark Peterson. and William P Mcinnis. New York: John Wiley & Sons. Inc.. 1996. 219 pp. $32.95 (softcover). In 1995 the first two authors produced The Complete Psychotherapy Treatment Planner and now, with the help of Dr. McInnis. have delivered the latest member of the family of managed care survival manuals. Their efforts will be much appreciated by anyone who must devise treatment plans to satisfY insurance reviewers. The purpose of this volume is to provide practitioners with a ready source of defined problems to serve as a focus of therapy, as well as proposed interventions for each problem. The target audience is essentially anyone who provides mental health services for children and adolescents. The layout is simple and straightforward, with a chapter devoted to each global problem, such as anxiety, attentiondeficit hyperactivity disorder, enuresis/encopresis, peer/sibling conflict, and suicidal ideation/attempt. There are 29 subdivisions, covering not only DSM-1V diagnostic groups, but also behaviors like fire-setting and attitudes such as low selfesteem. This system makes it easy to scan through the options and focus on the more specific items in each chapter. Each chapter is arranged to select long-term goals based on the overall behavior, followed by a list of detailed short-term
1156
J.
AM. ACAD. CHIl.D ADOLESC. PSYCHIATRY. 36:8. AUGUST 1997
BOOK REVIEWS
vide us as caregivers with a map to help us navigate through these times. To use another analogy, the authors have done an excellent job of showing us where the stones are to cross to the other side of the river without drowning. Their work will allow us to carryon and fight this battle another day. Mark Jennings, M.D. University of Arkansas for Medical Sciences Little Rock
,I . Minefields in Their Hearts: The Mental Health of Children in War and Communal Violence. Edited by Roberta j. Apfel, M.D., M. P.H. , and Bennett Simon, M.D. New Haven and London: Yale University Press, 1996, 230 pp., $30.00 (hardcover). This timely and sensitive portrayal of those children in the world who are the victims of communal violence emanates from an International Work Group focusing on Children of War and Communal Violence. The editors in their introduction describe their commitment "to try to change the conditions that allow the violence," to facilitate an understanding of the "amazing resiliency" of these children, to make us aware of the "resourcefulness and dedication" of those adults who work with these children, and to write a book that "will have emotional resonance" for those mental health professionals sensitized to the suffering of children through their own experiences in childhood. The introduction provides a careful and thoughtful exposition and definition of the concepts and terms associated with the child victims of violence, i.e., trauma, war and communal violence, normal and abnormal development, resiliency and interventions. The editors note that all the interventions to be described are informed by the basic values of psychoanalysis, i.e., "open ended listening, bearing painful affects, and doing what is in the best interests of those in our care." They stress the importance of the therapist's being genuine and nonjudgmental, respecting the child's capacities, recognizing the child's complexity, and being innovative and willing to try nontraditional approaches. An editorial introduction precedes each chapter, both providing a purposeful statement of the writer's intent and point of view and placing the chapter contextually in the tapestry of the overall presentation. As one would expect in such a global undertaking, there is considerable diversity and range of topics presented as well as variations in the quality of contributions. Contributions include such chapters as "Ethical Issues in Working With Children in War Zones"; "What Do We Need to Know to Understand Children in War and Communal Violence"; "Post-Traumatic Stress Disorder and Other Stress Reactions";
]. AM. ACAD. CHILD ADOLESC. PSYCHIATRY..~(':8. AUCUST 1997
"Refugee Children"; "Child Development and Adaptation to Catastrophic Circumstances"; "Youth and Violence: Trends, Principles, and Programmatic Interventions"; "Mobilizing Communities to Meet the Psychosocial Needs of Children in War and Refugee Crises"; "Attempting to Overcome the Intergenerational Transmission ofTrauma: Dialogue Between Descendants of Victims and Perpetrators"; "Who Takes Care of the Caretakers"; "Assessing the Impact of War on Children"; and "Practical Approaches to Research With Children in Violent Settings." A number of important lines of thought that are developed and amplified are particularly relevant to those interested in understanding and working with children exposed to communal violence: (1) it is important to give priority to the "best interests of the child" and avoid the matrix of political motivations and agendas within which these children are embedded; (2) communal violence is not only the product of systemically directed warfare but is endemic to our large urban areas; (3) children are not miniature adults, and our understanding of their responses to violence requires knowledge of their cognitive and psychosocial development and how these processes interface with complex social ecosystems; (4) knowledge of the spectrum of trauma-specific and stressrelated disorders and the role of acute and chronic traumatization as determinants of medical-psychiatric disease is essential; (5) the effects of communal violence on children extend beyond the actual trauma and reverberate throughout the inner life of the child as he or she struggles to integrate the perceived meaning of the violence into his or her own view of self, others, and the world at large; (6) intervention strategies, while guided by our concerns for the individual child, need to be interwoven with the family, community, and social infrastructure of the ecosystem to be able to mobilize the resources necessary to mitigate the impact of communal violence and to contribute to the lessening of further violence against children; (7) children who are victimized by violence will become the conduits through which a transgenerational transfer of the derivative effects of trauma will be passed on to succeeding generations of families; (8) the many caretakers who invest so much of their emotional lives in the children of violence become victimized themselves through the contagion of suffering and require succorance; and (9) it is imperative that we secure an empirical basis for our understanding of the effects of communal violence and that our intervention strategies be predicated on scientifically validated and proven procedures. Minefields in Their Hearts is a welcome and thoughtful introduction to those wanting to understand the magnitude and the role of communal violence in the world, its devastating effects on children and families, and the opportunities available for mental health professionals to contribute to the relief of suffering. The book is comprehensive and enriching,
1157