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The patient-therapist relationship: Its many dimensions
276
Book Reviews
they the choice, to "go out like a light", the question whether and how a slow death can be a good death will assume increasing importance. To answer this question, Michael Young and Leslie Cullen identified fourteen East Londoners with cancer who were diagnosed as having 3-4 months left to live; some actually lived much longer. The aim was to talk to, and perhaps learn from, those facing what will increasingly be our future: dying slowly. The researchers met them in their homes repeatedly (38 times in one case), becoming their friends as well as their interviewers. Young, at least, was as much a participant in as an observer of dying--he himself has cancer, and his wife died of the same disease during the writing of the book. An in-depth, repeated, prospective interview study of those dying at home is unusual, if not unique. Their experiences are well captured not only because of the methodology, but also because few sociologists can write as beautifully, sensitively and clearly as Young. The cover claims the book is for the dying, their carers and student doctors, nurses and social workers; it should certainly help student professionals to see things from the viewpoint of patients and their unpaid carers. For example, Chapter 5 on "The Doctor" reveals the consequences--not only for patients' morale but also for their physical health--of hospitals valuing the doctor's but not the patient's time. Chapter 8 on "The Afterlife" is one of the best accounts I have read of how, even in a modern secular city, the living interact with the dead; the account neither medicalises nor pathologises these interactions. Clearly the book is a sensitive and readable account of what it is like to die of cancer in London today; but it is also a profound, though implicit, essay on three of modernity's goals: liberty, equality and fraternity (for which latter term read "community" or "solidarity"). Michael Young has been passionately devoted to these ideals all his long life. As founder of the Consumers Association he has helped consumers exercise informed choice and thus promoted real liberty; as a shaper of the Labour Party's 1945 election manifesto and founder of the Open University, he has done much to promote equality; and as a sociologist he has been centrally concerned with the basis of community ever since his classic book Family and Kinship in East London. One might presume that for Young the good death would too--against the odds--reflect or even promote liberty, equality and solidarity. But how can that be? Libero'. This is perhaps the most conventional aspect of the book. Young and Cullen's research has convinced them of the value of home-based palliative care, their book documenting the benefits wrought by the hospice movement. Central to this is the authority not of the doctor but of the patient. With good medico-nursing care and information, dying people can make their own choices how to live their final months. In particular, pain is more bearable if the sufferer controls the medication.
Equalio,. Much sociological research has explored death's inequality: why do the poor die sooner than the rich, males sooner than females? But this book argues from death's equality--the fact that we all must die. And from this, in their final and, for me, most intriguing pages, Young and Cullen mount their argument about solidarity. Solidario'. Hume noted the strong human sentiment of self-love and the weaker sentiment of love for humanity-which "being common to all men, can alone be the foundation of morals". Young and Cullen argue, on the basis of the self-giving love shown by family, friends and neighbours to those dying in East London, that "death, being also common to all men, is the ever-available assistant to fellow feeling." While Zygmunt Bauman has pointed in Modernity and the Holocaust to the potential of physical proximity to generate ethical behaviour, Young suggests that it is death in conjunction with proximity that can transform a society of individuals into community. Death can bring people together as well as tear them apart. "The perpetual fund of good will which death can generate is t h e r e . . . The failing of the collective arrangements we now make is that we draw so parsimoniously on the fund and fail so often to top it up." Well-funded community care has to be the way forward. This argument also points to the importance of the funeral in reinforcing human solidarity at this critical time: the shame of so many British funerals is that they fail in this, miserably. This thesis about death and solidarity may turn out to be among the most important of Young's many contributions to sociology and to British society. Having documented 40 years ago the basis of community in London's East End and its erosion by affluence and mobility, his latest research with people dying of cancer may yet have uncovered an enduring base for community. It is often said that modernity cannot handle death, except by conquering it through medicine. But using the sociology not of medicine but of family and community, this book concludes that the slow deaths of the future may actually have some power to sustain the Enlightenment ideals of liberty, equality and solidarity. Good deaths can lead to a good society, but paradoxically they also require the good society we do not have, or are in danger of losing.
The Patient-Therapist Relationship: Its Many Dimensions, edited by Stefania Borgo and Lucio Sibilia. Consiglio Nazionale delle Ricerche, Roma, 1994, 140 pp.
Second, the therapist is expected to act simultaneously in a professional role, characterized by task orientation and the recognition that the interaction will eventually be terminated, and in a supportive and empathic role that reflects acceptance and genuine concern for the patient. Third, he/she is expected to encourage the patient both to accept his or her help and to become independent of him or her. It is probably because of these conflicting demands that the book emphasizes the role of the therapist in the dyad. The volume is the product of the collaboration of well-known researchers and clinicians--seven from Italy and five from other European countries--working on the application of interpersonal communication to clinical
Cognitive psychotherapy is one of the applicative domains of cognitive psychology. This book offers a historical overview of the patient-therapist relationship in psychotherapy from the cognitive-behavioral perspective. The therapeutic relationship is distinguished from other close relationships by apparently contradictory requirements, asserts the only American contributor in the introductory chapter of this volume. First, the therapist has a dual role in the relationship, as a participant and observer.
Department of Sociology Universi O" of Reading Reading R68 2AA U.K.
Tony Walter
REFERENCES Bauman, Z. (1989) Moderni o, and the Holocaust. Polity, Oxford. Young, M. and Willmott, M. (1957) Family and Kinship in East London. Routledge & Kegan Paul, London.
Book Reviews
277
problems. Although the collection illuminates several aspects of the patient-therapist relationship, it focuses mainly on the affective emotional dimension which has been neglected in cognitive-behavioral thinking. Recent assertions of the need to give adequate attention to emotions in cognitive psychotherapy has led to the development of several approaches. Among them, the application of attachment theory by cognitive psychotherapists and researchers has apparently resulted in bringing the clinical realities of the patient's behavioral systems to a metacognitive level, on the one hand, and in the consideration of the therapist's own relational behavior as a possible contributor to the interaction, on the other hand. The chapters that attempt to examine the patienttherapist relationship empirically are especially interesting. For example, the results of a quasi-experimental study on the outpatient treatment of obsessive-compulsive neurosis in the Netherlands show that a positive evaluation of the relationship by the therapist was not necessarily associated with a significantly better treatment outcome. The findings of a German study suggest that patients view therapists more positively than they view their relatives, that patients" views of the therapist
and the relatives are barely correlated, and that the patients" view of therapist is associated with their psychopathology. Considering the acknowledgment in the introductory chapter that the therapeutic role involves more than the direct application of knowledge, the lack of discussion on the ethical aspects of the patient-therapist relationship (such as paternalism, coercion, etc.) in the volume is noticeable. It should also be noted that, for the sake of precision, the title of the book should state that it concerns the many dimensions of the patient therapist relationship within the framework of the cognitive perspective. Despite these shortcomings, this book provides readers working in clinical settings in many parts of the world not only with an insight into the cognitive-behavioral perspective on therapist's role, but also with the opportunity to critically rethink their own perception of the therapist's role in the patient therapist dyad.
Reproduction, Technology, and Rights, edited by James M.
allocation of limited resources, he concludes that IVF can claim a high priority only as a treatment for obstructed Fallopian tubes. The third essay is by Walter Gannon, from the Department of Philosophy at Yale University, who argues for "the morality of selective termination," in part, on the grounds that numbers have "'moral import." Part IIi contains 2 essays. The first essay is by Bambi E. Robinson, from the Department of Philosophy at Southeast Missouri State University. She argues for "'a woman's obligation to have an abortion" in the case of fetal defects certain to cause very premature death or great suffering, and, in general, where ""life is a fate worse than death" (p. 120). In the final essay of the book, Richard T. Hull, from the Department of Philosophy of the State University at Buffalo, argues for the "'just claims of dyslexic children." In general, this is a collection of papers that clearly summarizes well-known ethical arguments or provocatively presents interesting new lines of argument. A minor or major criticism, depending on readers" expectations for a book, is that its elements are not well linked or synthesized. Indeed, the essays in Part I are the most useful because they are arranged according to an argument-counterargument rejoinder logic. The other Parts might have been written, arranged, or otherwise editorially linked according to a similar or different logic. For example, there is a recurring "numbers-are-morally-important" motif, wholly distinctive to the new reproductive technologies, which could have been featured more effectively and, thereby, suggest new directions for ethical argument. There is also a vantagepoint theme here that remains unexploited; authors variously foreground and justapose women, men, and children, again, in a way that seems distinctive to addressing reproductive ethics. As is, although the essays all have something to do with reproductive rights and obligations, their assembly in book format seems accidental. The editors' empirical grouping of the essays in Parts II and Ill (that is, essays to do with IVF and essays to do with children) seems less effective than a more thematic or conceptual grouping might have been. Indeed, an innovative
Humber and Robert F. Almeder. Humana Press, Totowa, New Jersey, 1996. 157pp., $44.50. Reproduction, Technology, and Rights is a well-written, but very loosely organized and minimally edited collection of essays addressing ethical issues in the domain of human reproduction and reproductive technology. The appropriate audience for this book includes ethicists, clinical practitioners, and students able to read and interpret complex ethical arguments. Part 1 includes 3 essays. The first essay is by Steven D. Hales, from the Department of Philosophy at Bloomsburg University in Pennsylvania. Addressing "'abortion and fathers' rights," Hales juxtaposes a woman's right to abortion with a man's obligation to provide support for his child to argue that men have no such absolute obligations. If women can escape future duties to their progeny via abortion, then men can escape future duties to their progeny via refusal (p. 24). In the second essay on "maternity, paternity, and equality," James M. Humber, from the Department of Philosophy at Georgia State University, compares pregnancy to disability to refute Hales' argument that a woman's right to abort necessarily absolves a man of responsibility for his child. In the third essay offering "more on fathers' rights," Hales responds to Humber's critique by undermining the pregnancy-asdisability analogy. Part II includes 3 essays. The first essay is by Kathleen Ganss Gibson, also from the Department of Philosophy at Georgia State University, and Joe B. Massey, from the Infertility, Reproductive Endocrinology, and Gynecology Clinic in Atlanta. In "ethical considerations in the multiplication of human embryos," they survey the moral principles and medical and psychological perspectives that either support or reject such procedures as morally justified. The second essay is by Leonard J. Weber, from the Ethics Institute at the University of Detroit. He considers "in vitro fertilization (IVF) and the just use of health care resources." Drawing from principles of patient rights, consumer sovereignty, and rationing and the
Paul Baerwald School of Social Work The Hebrew Unieersity of Jerusalem Mount Scopus Israel
Ruth Landau
Book Reviews
they the choice, to "go out like a light", the question whether and how a slow death can be a good death will assume increasing importance. To answer this question, Michael Young and Leslie Cullen identified fourteen East Londoners with cancer who were diagnosed as having 3-4 months left to live; some actually lived much longer. The aim was to talk to, and perhaps learn from, those facing what will increasingly be our future: dying slowly. The researchers met them in their homes repeatedly (38 times in one case), becoming their friends as well as their interviewers. Young, at least, was as much a participant in as an observer of dying--he himself has cancer, and his wife died of the same disease during the writing of the book. An in-depth, repeated, prospective interview study of those dying at home is unusual, if not unique. Their experiences are well captured not only because of the methodology, but also because few sociologists can write as beautifully, sensitively and clearly as Young. The cover claims the book is for the dying, their carers and student doctors, nurses and social workers; it should certainly help student professionals to see things from the viewpoint of patients and their unpaid carers. For example, Chapter 5 on "The Doctor" reveals the consequences--not only for patients' morale but also for their physical health--of hospitals valuing the doctor's but not the patient's time. Chapter 8 on "The Afterlife" is one of the best accounts I have read of how, even in a modern secular city, the living interact with the dead; the account neither medicalises nor pathologises these interactions. Clearly the book is a sensitive and readable account of what it is like to die of cancer in London today; but it is also a profound, though implicit, essay on three of modernity's goals: liberty, equality and fraternity (for which latter term read "community" or "solidarity"). Michael Young has been passionately devoted to these ideals all his long life. As founder of the Consumers Association he has helped consumers exercise informed choice and thus promoted real liberty; as a shaper of the Labour Party's 1945 election manifesto and founder of the Open University, he has done much to promote equality; and as a sociologist he has been centrally concerned with the basis of community ever since his classic book Family and Kinship in East London. One might presume that for Young the good death would too--against the odds--reflect or even promote liberty, equality and solidarity. But how can that be? Libero'. This is perhaps the most conventional aspect of the book. Young and Cullen's research has convinced them of the value of home-based palliative care, their book documenting the benefits wrought by the hospice movement. Central to this is the authority not of the doctor but of the patient. With good medico-nursing care and information, dying people can make their own choices how to live their final months. In particular, pain is more bearable if the sufferer controls the medication.
Equalio,. Much sociological research has explored death's inequality: why do the poor die sooner than the rich, males sooner than females? But this book argues from death's equality--the fact that we all must die. And from this, in their final and, for me, most intriguing pages, Young and Cullen mount their argument about solidarity. Solidario'. Hume noted the strong human sentiment of self-love and the weaker sentiment of love for humanity-which "being common to all men, can alone be the foundation of morals". Young and Cullen argue, on the basis of the self-giving love shown by family, friends and neighbours to those dying in East London, that "death, being also common to all men, is the ever-available assistant to fellow feeling." While Zygmunt Bauman has pointed in Modernity and the Holocaust to the potential of physical proximity to generate ethical behaviour, Young suggests that it is death in conjunction with proximity that can transform a society of individuals into community. Death can bring people together as well as tear them apart. "The perpetual fund of good will which death can generate is t h e r e . . . The failing of the collective arrangements we now make is that we draw so parsimoniously on the fund and fail so often to top it up." Well-funded community care has to be the way forward. This argument also points to the importance of the funeral in reinforcing human solidarity at this critical time: the shame of so many British funerals is that they fail in this, miserably. This thesis about death and solidarity may turn out to be among the most important of Young's many contributions to sociology and to British society. Having documented 40 years ago the basis of community in London's East End and its erosion by affluence and mobility, his latest research with people dying of cancer may yet have uncovered an enduring base for community. It is often said that modernity cannot handle death, except by conquering it through medicine. But using the sociology not of medicine but of family and community, this book concludes that the slow deaths of the future may actually have some power to sustain the Enlightenment ideals of liberty, equality and solidarity. Good deaths can lead to a good society, but paradoxically they also require the good society we do not have, or are in danger of losing.
The Patient-Therapist Relationship: Its Many Dimensions, edited by Stefania Borgo and Lucio Sibilia. Consiglio Nazionale delle Ricerche, Roma, 1994, 140 pp.
Second, the therapist is expected to act simultaneously in a professional role, characterized by task orientation and the recognition that the interaction will eventually be terminated, and in a supportive and empathic role that reflects acceptance and genuine concern for the patient. Third, he/she is expected to encourage the patient both to accept his or her help and to become independent of him or her. It is probably because of these conflicting demands that the book emphasizes the role of the therapist in the dyad. The volume is the product of the collaboration of well-known researchers and clinicians--seven from Italy and five from other European countries--working on the application of interpersonal communication to clinical
Cognitive psychotherapy is one of the applicative domains of cognitive psychology. This book offers a historical overview of the patient-therapist relationship in psychotherapy from the cognitive-behavioral perspective. The therapeutic relationship is distinguished from other close relationships by apparently contradictory requirements, asserts the only American contributor in the introductory chapter of this volume. First, the therapist has a dual role in the relationship, as a participant and observer.
Department of Sociology Universi O" of Reading Reading R68 2AA U.K.
Tony Walter
REFERENCES Bauman, Z. (1989) Moderni o, and the Holocaust. Polity, Oxford. Young, M. and Willmott, M. (1957) Family and Kinship in East London. Routledge & Kegan Paul, London.
Book Reviews
277
problems. Although the collection illuminates several aspects of the patient-therapist relationship, it focuses mainly on the affective emotional dimension which has been neglected in cognitive-behavioral thinking. Recent assertions of the need to give adequate attention to emotions in cognitive psychotherapy has led to the development of several approaches. Among them, the application of attachment theory by cognitive psychotherapists and researchers has apparently resulted in bringing the clinical realities of the patient's behavioral systems to a metacognitive level, on the one hand, and in the consideration of the therapist's own relational behavior as a possible contributor to the interaction, on the other hand. The chapters that attempt to examine the patienttherapist relationship empirically are especially interesting. For example, the results of a quasi-experimental study on the outpatient treatment of obsessive-compulsive neurosis in the Netherlands show that a positive evaluation of the relationship by the therapist was not necessarily associated with a significantly better treatment outcome. The findings of a German study suggest that patients view therapists more positively than they view their relatives, that patients" views of the therapist
and the relatives are barely correlated, and that the patients" view of therapist is associated with their psychopathology. Considering the acknowledgment in the introductory chapter that the therapeutic role involves more than the direct application of knowledge, the lack of discussion on the ethical aspects of the patient-therapist relationship (such as paternalism, coercion, etc.) in the volume is noticeable. It should also be noted that, for the sake of precision, the title of the book should state that it concerns the many dimensions of the patient therapist relationship within the framework of the cognitive perspective. Despite these shortcomings, this book provides readers working in clinical settings in many parts of the world not only with an insight into the cognitive-behavioral perspective on therapist's role, but also with the opportunity to critically rethink their own perception of the therapist's role in the patient therapist dyad.
Reproduction, Technology, and Rights, edited by James M.
allocation of limited resources, he concludes that IVF can claim a high priority only as a treatment for obstructed Fallopian tubes. The third essay is by Walter Gannon, from the Department of Philosophy at Yale University, who argues for "the morality of selective termination," in part, on the grounds that numbers have "'moral import." Part IIi contains 2 essays. The first essay is by Bambi E. Robinson, from the Department of Philosophy at Southeast Missouri State University. She argues for "'a woman's obligation to have an abortion" in the case of fetal defects certain to cause very premature death or great suffering, and, in general, where ""life is a fate worse than death" (p. 120). In the final essay of the book, Richard T. Hull, from the Department of Philosophy of the State University at Buffalo, argues for the "'just claims of dyslexic children." In general, this is a collection of papers that clearly summarizes well-known ethical arguments or provocatively presents interesting new lines of argument. A minor or major criticism, depending on readers" expectations for a book, is that its elements are not well linked or synthesized. Indeed, the essays in Part I are the most useful because they are arranged according to an argument-counterargument rejoinder logic. The other Parts might have been written, arranged, or otherwise editorially linked according to a similar or different logic. For example, there is a recurring "numbers-are-morally-important" motif, wholly distinctive to the new reproductive technologies, which could have been featured more effectively and, thereby, suggest new directions for ethical argument. There is also a vantagepoint theme here that remains unexploited; authors variously foreground and justapose women, men, and children, again, in a way that seems distinctive to addressing reproductive ethics. As is, although the essays all have something to do with reproductive rights and obligations, their assembly in book format seems accidental. The editors' empirical grouping of the essays in Parts II and Ill (that is, essays to do with IVF and essays to do with children) seems less effective than a more thematic or conceptual grouping might have been. Indeed, an innovative
Humber and Robert F. Almeder. Humana Press, Totowa, New Jersey, 1996. 157pp., $44.50. Reproduction, Technology, and Rights is a well-written, but very loosely organized and minimally edited collection of essays addressing ethical issues in the domain of human reproduction and reproductive technology. The appropriate audience for this book includes ethicists, clinical practitioners, and students able to read and interpret complex ethical arguments. Part 1 includes 3 essays. The first essay is by Steven D. Hales, from the Department of Philosophy at Bloomsburg University in Pennsylvania. Addressing "'abortion and fathers' rights," Hales juxtaposes a woman's right to abortion with a man's obligation to provide support for his child to argue that men have no such absolute obligations. If women can escape future duties to their progeny via abortion, then men can escape future duties to their progeny via refusal (p. 24). In the second essay on "maternity, paternity, and equality," James M. Humber, from the Department of Philosophy at Georgia State University, compares pregnancy to disability to refute Hales' argument that a woman's right to abort necessarily absolves a man of responsibility for his child. In the third essay offering "more on fathers' rights," Hales responds to Humber's critique by undermining the pregnancy-asdisability analogy. Part II includes 3 essays. The first essay is by Kathleen Ganss Gibson, also from the Department of Philosophy at Georgia State University, and Joe B. Massey, from the Infertility, Reproductive Endocrinology, and Gynecology Clinic in Atlanta. In "ethical considerations in the multiplication of human embryos," they survey the moral principles and medical and psychological perspectives that either support or reject such procedures as morally justified. The second essay is by Leonard J. Weber, from the Ethics Institute at the University of Detroit. He considers "in vitro fertilization (IVF) and the just use of health care resources." Drawing from principles of patient rights, consumer sovereignty, and rationing and the
Paul Baerwald School of Social Work The Hebrew Unieersity of Jerusalem Mount Scopus Israel
Ruth Landau