- Email: [email protected]
Treating Attachment Disorders: From Theory to Therapy
Assistant Editor: Christopher R. Thomas, M.D.
BOOK REVIEWS
Treating Attachment Disorders: From Theory to Therapy. By Karl Heinz Brisch, translated by Kenneth Kronenberg. New York: The Guilford Press, 2002, 294 pp., $36.00 (hardcover). The book Treating Attachment Disorders by Dr. Karl Heinz Brisch is profoundly innovative, offering a concise and useful review of attachment theory evolution and research into the attachment theory. It also presents a therapeutic approach using our knowledge of attachment theory and implements this knowledge in treating patients. One of the strengths of this book is the wide-ranging experience of Dr. Brisch, who not only gives a European child and adolescent psychiatrist’s perspective, but also melds this with the perspectives of an adult psychiatrist and neurologist and training psychoanalyst. He has the experience of leading the Division of Pediatric Psychosomatic Medicine and Psychotherapy at the Ludwig Maximilians University in Munich, Germany, and has used his experience from a career of researching attachment disturbances and early psychotherapeutic intervention. Treating Attachment Disorders is clearly organized. The first parts of the book, Sections I through III, review the history of attachment theory and clearly compare this to other psychotherapies. The second part of this book, Sections IV and V, builds on this foundation, integrating it in clinical examples to illustrate how attachment theory is beneficial in actual treatment cases. The conclusion proceeds to speculate on how attachment theory may be integrated into several different areas for prevention of mental illness. Each section is quite readable on its own, but it is beneficial to understand the underlying history and theory before moving on to case studies. Section I, “Attachment Theory and Its Basic Concepts,” gives a good historical overview of the progression of attachment research from Bowlby’s early work in 1936 through the development of Ainsworth’s ‘Strange Situation Protocol’ and George’s “Adult Attachment Interview (AAI)” to an understanding of current psychotherapy (in relationship to attachment theory), such as Kohut’s self-psychology and behavioral therapy. Most readers familiar with attachment theory will be familiar with the Strange Situation protocol and the AAI, but the depths used in discussing their development give these familiar tools new life and new understanding to the reader. Enough details of each interview process are given that a newcomer can begin to feel comfortable with them. There is even a discussion of attachment with working mothers that should be reassuring to those mothers returning to work with young children. Dr. Brisch presents material acknowledging several psychological theories, including psychodynamic models, psychoanalytic models, the learning 1530
theory model, and the self-psychology model, making this a very well-rounded section. Terms used are explained in simple yet rich detail, such as “sensitive behavior,” laying a good foundation for the attachment theory novice as well as providing a review and enrichment for the expert reader. Section II, “Attachment Disorders,” focuses on understanding the correlation between attachment and psychopathology. Modern concepts of the immune response and neurohormonal regulation in response to attachment patterns and psychosomatic illness are raised. The information is derived from recent sources in the world literature. The remainder of this section is devoted to explaining the different types of attachment disorder and how this fits into the current classification schemes for psychiatric illness. Dr. Brisch proposes his description of attachment disorders as a clinical classification with the hope that it will be “a first step toward a more differentiated diagnosis of attachment disorders” (p. 64). Section III, “Attachment Therapy,” examines how attachment theory can be used in treatment and departs from a more traditional psychodynamic “one-person” approach to treatment. This section goes into point-by-point detail about how to build a “secure base” in therapy, both in adult and child/adolescent therapy. This can be referenced when reviewing case reports. Section IV, “Treatment Cases from Clinical Practice,” discusses several actual cases. This section begins with preconception difficulties in attachment and continues full circle with cases illustrative of attachment disorders in the geriatric population. The primary focus is the development of the patient–therapist relationship from an attachment theory perspective, and how this can be used to decrease mental illness of all types. Cases are grouped together, headed by an interesting conceptual discussion as well as specific techniques to help the clinician. Other psychodynamic explanations are explored, showing a willingness of the author to incorporate different points of view. This section is a powerful account of how to apply attachment knowledge in clinical practice. Especially helpful is the discussion on aggressive attachment behavior and how this behavior can serve to establish and maintain attachment. If the need for attachment or the expression of attachment is not understood, it may result in a complete failure of any psychotherapeutic approach. The discussion of attachment and self-reliance is particularly significant in problems such as teenage addiction. Selective disorders in adults, such as anxiety, antisocial personality disorders, depression, and narcissistic symptoms, are used to
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 42:12, DECEMBER 2003
BOOK REVIEWS
illustrate how the issue of attachment continues to retain its importance in adult symptomatology. The process of establishing a “secure base” is emphasized and illustrated throughout these examples as a prerequisite for enabling the patient to change the pathological childhood representation of self and attachment figures through work in the transference or the “secure attachment relationship” between therapist and patient. Section V, “Prospects for Further Application’” is the book’s conclusion and describes the possibilities of using the attachment model to help prevent attachment problems by using this theory in family therapy, group therapy, and education. The use of attachment theory in mental illness prevention is discussed, citing Parens’ work. This is a book that is enjoyable to read even in its translated form, yet provides a great deal of information. It can be a reference book for help in treating therapy cases. There are interesting ideas presented that may give way to further research directions and new systems of classification. Treating Attachment Disorders will be enriching for all who read it. Many of the ideas are applicable to a wide range of psychotherapy, such as Dr. Brisch’s words of advice that we must all be careful of using patients’ therapy to treat our own attachment needs. The overall strength of this book lies in the firm theoretical and historical groundwork and its application to a great variety of clinical issues. Karam Radwan, M.D. Department of Child and Adolescent Psychiatry University of Michigan, Ann Arbor Sharon L. Hirsch, M.D. Feinberg School of Medicine Northwestern University, Chicago DOI: 10.1097/01.chi.0000091941.28938.9a
Infanticide: Psychosocial and Legal Perspectives on Mothers Who Kill. Edited by Margaret G. Spinelli. Arlington, VA: American Psychiatric Publishing Inc., 2003, 272 pp., $49.95 (hardcover). Infanticide is regarded as a ghastly, unimaginable crime, particularly when performed by the infant’s mother, whom the infant relies on for comfort, love, and support. Recent media coverage of this horrible act has sent disbelief and dread into the minds of laypeople and practitioners alike. Infanticide: Psychosocial and Legal Perspectives on Mothers Who Kill enables the reader to look further than the initial horror of the act and examine the feelings and situation of the mother, who is most often a victim. Additionally, it educates and challenges the reader to consider how such an
act might be prevented. The editor outlines two major goals for the book: (1) to develop a framework in educating the reader on early identification, treatment, and prevention of infanticide, and (2) to assist professionals in understanding the women who commit these crimes. Therefore, the book is mainly directed to mental health professionals for early identification and treatment methods. The book is written in a clear and concise manner, with illustrating cases and definitions of legal and medical terms so that other professionals and laypersons can enjoy this interesting topic. Although the book is written in the context of a British editor to illustrate British cultural and legal issues, the book certainly applies to America and other societies. The book’s objectives are well met as the reader is led on a journey through the history, epidemiology, cultural perspectives, legislation, and treatment methods of infanticide. The book is divided into four parts, with 13 chapters in all. The first part, “Epidemiology and Historical Legal Statutes,” traces the history of infanticide cases from ancient cultures and religions to the present. The book illustrates various cultural and religious reasons for infanticide, including population control, sickly or disabled infants, and less valuable female offspring. The history of legal proceedings is also presented from the Roman empire to contemporary proceedings. Additionally, the chapter provides education on the types of infanticide (neonaticide, assisted infanticide, neglect-related infanticide, abuse-related infanticide, and mental illness-related infanticide). The second chapter describes the epidemiology of infanticide, including the cause of death and the perpetrators. The book describes the limitations of epidemiological studies, such as the question of live birth, prematurity, extensive deterioration of the body, and fetal deaths occurring outside of clinical settings. Therefore, it is estimated that the prevalence rates for infanticide are grossly underestimated. The second part of the book, “Biopsychosocial and Cultural Perspectives on Infanticide,” begins with a description of postpartum disorders. It outlines the epidemiology of postpartum disorders and their surprisingly common occurrence in the medical setting. Chapter 3 describes the symptoms present during the postpartum period and the time frame, comparing the criteria in DSM-IV and ICD-10. The chapter helps to illustrate the difference in symptoms between postpartum “blues,” depression, and psychosis. Treatment methods are described, including psychotherapy and pharmacology, as well as their limitations. Chapter 4 outlines the neurohormonal aspects of postpartum depression and psychosis. It presents a detailed description of neurotransmitters and different hormonal axes to illustrate the biological changes occurring during the postpartum period. Chapter 5 introduces the reader to the feelings of denial in certain pregnant females and how denial is a pertinent risk factor for infanticide. Chapter 6 presents various cases of neonaticide to illustrate pertinent risk factors leading to neo-
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 42:12, DECEMBER 2003
1531
BOOK REVIEWS
Treating Attachment Disorders: From Theory to Therapy. By Karl Heinz Brisch, translated by Kenneth Kronenberg. New York: The Guilford Press, 2002, 294 pp., $36.00 (hardcover). The book Treating Attachment Disorders by Dr. Karl Heinz Brisch is profoundly innovative, offering a concise and useful review of attachment theory evolution and research into the attachment theory. It also presents a therapeutic approach using our knowledge of attachment theory and implements this knowledge in treating patients. One of the strengths of this book is the wide-ranging experience of Dr. Brisch, who not only gives a European child and adolescent psychiatrist’s perspective, but also melds this with the perspectives of an adult psychiatrist and neurologist and training psychoanalyst. He has the experience of leading the Division of Pediatric Psychosomatic Medicine and Psychotherapy at the Ludwig Maximilians University in Munich, Germany, and has used his experience from a career of researching attachment disturbances and early psychotherapeutic intervention. Treating Attachment Disorders is clearly organized. The first parts of the book, Sections I through III, review the history of attachment theory and clearly compare this to other psychotherapies. The second part of this book, Sections IV and V, builds on this foundation, integrating it in clinical examples to illustrate how attachment theory is beneficial in actual treatment cases. The conclusion proceeds to speculate on how attachment theory may be integrated into several different areas for prevention of mental illness. Each section is quite readable on its own, but it is beneficial to understand the underlying history and theory before moving on to case studies. Section I, “Attachment Theory and Its Basic Concepts,” gives a good historical overview of the progression of attachment research from Bowlby’s early work in 1936 through the development of Ainsworth’s ‘Strange Situation Protocol’ and George’s “Adult Attachment Interview (AAI)” to an understanding of current psychotherapy (in relationship to attachment theory), such as Kohut’s self-psychology and behavioral therapy. Most readers familiar with attachment theory will be familiar with the Strange Situation protocol and the AAI, but the depths used in discussing their development give these familiar tools new life and new understanding to the reader. Enough details of each interview process are given that a newcomer can begin to feel comfortable with them. There is even a discussion of attachment with working mothers that should be reassuring to those mothers returning to work with young children. Dr. Brisch presents material acknowledging several psychological theories, including psychodynamic models, psychoanalytic models, the learning 1530
theory model, and the self-psychology model, making this a very well-rounded section. Terms used are explained in simple yet rich detail, such as “sensitive behavior,” laying a good foundation for the attachment theory novice as well as providing a review and enrichment for the expert reader. Section II, “Attachment Disorders,” focuses on understanding the correlation between attachment and psychopathology. Modern concepts of the immune response and neurohormonal regulation in response to attachment patterns and psychosomatic illness are raised. The information is derived from recent sources in the world literature. The remainder of this section is devoted to explaining the different types of attachment disorder and how this fits into the current classification schemes for psychiatric illness. Dr. Brisch proposes his description of attachment disorders as a clinical classification with the hope that it will be “a first step toward a more differentiated diagnosis of attachment disorders” (p. 64). Section III, “Attachment Therapy,” examines how attachment theory can be used in treatment and departs from a more traditional psychodynamic “one-person” approach to treatment. This section goes into point-by-point detail about how to build a “secure base” in therapy, both in adult and child/adolescent therapy. This can be referenced when reviewing case reports. Section IV, “Treatment Cases from Clinical Practice,” discusses several actual cases. This section begins with preconception difficulties in attachment and continues full circle with cases illustrative of attachment disorders in the geriatric population. The primary focus is the development of the patient–therapist relationship from an attachment theory perspective, and how this can be used to decrease mental illness of all types. Cases are grouped together, headed by an interesting conceptual discussion as well as specific techniques to help the clinician. Other psychodynamic explanations are explored, showing a willingness of the author to incorporate different points of view. This section is a powerful account of how to apply attachment knowledge in clinical practice. Especially helpful is the discussion on aggressive attachment behavior and how this behavior can serve to establish and maintain attachment. If the need for attachment or the expression of attachment is not understood, it may result in a complete failure of any psychotherapeutic approach. The discussion of attachment and self-reliance is particularly significant in problems such as teenage addiction. Selective disorders in adults, such as anxiety, antisocial personality disorders, depression, and narcissistic symptoms, are used to
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 42:12, DECEMBER 2003
BOOK REVIEWS
illustrate how the issue of attachment continues to retain its importance in adult symptomatology. The process of establishing a “secure base” is emphasized and illustrated throughout these examples as a prerequisite for enabling the patient to change the pathological childhood representation of self and attachment figures through work in the transference or the “secure attachment relationship” between therapist and patient. Section V, “Prospects for Further Application’” is the book’s conclusion and describes the possibilities of using the attachment model to help prevent attachment problems by using this theory in family therapy, group therapy, and education. The use of attachment theory in mental illness prevention is discussed, citing Parens’ work. This is a book that is enjoyable to read even in its translated form, yet provides a great deal of information. It can be a reference book for help in treating therapy cases. There are interesting ideas presented that may give way to further research directions and new systems of classification. Treating Attachment Disorders will be enriching for all who read it. Many of the ideas are applicable to a wide range of psychotherapy, such as Dr. Brisch’s words of advice that we must all be careful of using patients’ therapy to treat our own attachment needs. The overall strength of this book lies in the firm theoretical and historical groundwork and its application to a great variety of clinical issues. Karam Radwan, M.D. Department of Child and Adolescent Psychiatry University of Michigan, Ann Arbor Sharon L. Hirsch, M.D. Feinberg School of Medicine Northwestern University, Chicago DOI: 10.1097/01.chi.0000091941.28938.9a
Infanticide: Psychosocial and Legal Perspectives on Mothers Who Kill. Edited by Margaret G. Spinelli. Arlington, VA: American Psychiatric Publishing Inc., 2003, 272 pp., $49.95 (hardcover). Infanticide is regarded as a ghastly, unimaginable crime, particularly when performed by the infant’s mother, whom the infant relies on for comfort, love, and support. Recent media coverage of this horrible act has sent disbelief and dread into the minds of laypeople and practitioners alike. Infanticide: Psychosocial and Legal Perspectives on Mothers Who Kill enables the reader to look further than the initial horror of the act and examine the feelings and situation of the mother, who is most often a victim. Additionally, it educates and challenges the reader to consider how such an
act might be prevented. The editor outlines two major goals for the book: (1) to develop a framework in educating the reader on early identification, treatment, and prevention of infanticide, and (2) to assist professionals in understanding the women who commit these crimes. Therefore, the book is mainly directed to mental health professionals for early identification and treatment methods. The book is written in a clear and concise manner, with illustrating cases and definitions of legal and medical terms so that other professionals and laypersons can enjoy this interesting topic. Although the book is written in the context of a British editor to illustrate British cultural and legal issues, the book certainly applies to America and other societies. The book’s objectives are well met as the reader is led on a journey through the history, epidemiology, cultural perspectives, legislation, and treatment methods of infanticide. The book is divided into four parts, with 13 chapters in all. The first part, “Epidemiology and Historical Legal Statutes,” traces the history of infanticide cases from ancient cultures and religions to the present. The book illustrates various cultural and religious reasons for infanticide, including population control, sickly or disabled infants, and less valuable female offspring. The history of legal proceedings is also presented from the Roman empire to contemporary proceedings. Additionally, the chapter provides education on the types of infanticide (neonaticide, assisted infanticide, neglect-related infanticide, abuse-related infanticide, and mental illness-related infanticide). The second chapter describes the epidemiology of infanticide, including the cause of death and the perpetrators. The book describes the limitations of epidemiological studies, such as the question of live birth, prematurity, extensive deterioration of the body, and fetal deaths occurring outside of clinical settings. Therefore, it is estimated that the prevalence rates for infanticide are grossly underestimated. The second part of the book, “Biopsychosocial and Cultural Perspectives on Infanticide,” begins with a description of postpartum disorders. It outlines the epidemiology of postpartum disorders and their surprisingly common occurrence in the medical setting. Chapter 3 describes the symptoms present during the postpartum period and the time frame, comparing the criteria in DSM-IV and ICD-10. The chapter helps to illustrate the difference in symptoms between postpartum “blues,” depression, and psychosis. Treatment methods are described, including psychotherapy and pharmacology, as well as their limitations. Chapter 4 outlines the neurohormonal aspects of postpartum depression and psychosis. It presents a detailed description of neurotransmitters and different hormonal axes to illustrate the biological changes occurring during the postpartum period. Chapter 5 introduces the reader to the feelings of denial in certain pregnant females and how denial is a pertinent risk factor for infanticide. Chapter 6 presents various cases of neonaticide to illustrate pertinent risk factors leading to neo-
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 42:12, DECEMBER 2003
1531