- Email: [email protected]
Troubled Families: A Treatment Program
636
BOOK REVIEWS
the patient suffered from a process or a reactive disorder also predicted outcome, as did the patient's intelligence and the degree of family psychopathology . On the positive side, if the patient completed all recommended inpatient treatments and continued some form of psychotherapy after hospital discharge, the outcome was significantly improved. The authors also conclude that patients do better if treated on a specialized, semiautonomous hospital unit. There seems little doubt that this study, combined with the earlier ones, demonstrates that long-term hospital treatment of severely ill adolescents can be and often is successful. The less severe diagnoses do well even if they have not done well on previous outpatient or brief hospital treatment. As with earlier studies, Gossett's .data shows two-thirds of chronic personality disorders are functioning well at the time of followup. Less than one-third of the psychotic adolescents, however, are doing well at follow-up. In addition to these research results and clinical impressions deriving from the study, there are also a number of provocative observations. Gossett used the Locus of Control Questionnaire on a subgroup of patients and discovered that this 10-minute self-administered instrument, which has been validated in numerous previous studies, predicted those who would do well vs. poorly at the time of follow-up. It is recommended as part of a predictive test battery which might be used in the future . The fact of having finished high school and having gained remunerative employment during the followup period correlated highly with the patient's adaptive
level. The authors make a valuable comment about the significance of psychotherapeutic work in the hospital focussed on the adolescent's sources of anger. For example, adolescents may correctly perceive the unfairness of their being in the hospital while other also-disturbed family members remain unhospitalized; such adolescents tend to see their own hospitalization as a victory for others. Anger may be used intrapsychically as a defense against separation panic. Or anger may serve to cover feelings of self-accusation at having failed one's parents. If these sources of anger are insufficiently worked through, the authors believe that a poorer long-term adaptation may result. Finally, the report comments upon the high number of illegitimate pregnancies in discharged adolescent females and recommends more attention to contraceptive education in the hospital. In a sense, this report marks the end of an era in this research field. New theoretical and methodological work is needed in two directions. With the arrival of DSM-III, future research reports will be looked upon as less than adequate if they do not use more precise measures of severity of disorder and of diag-
nosis. Secondly, new methods for tracing and quantifying a specific therapeutic process over the course of . hospitalization are needed. We need to extend the field of adolescent diagnosis. It is clear that differences in personality structure and psychodynamic processes are relevant to treatment planning and to prognosis. In formulating more precise diagnostic subgroups, one needs to attend not only to forms of family pathology and to the processreactive dimension but also to whether the patient identifies with a psychotic parent and whether a chaotic home environment is promoting personality disorganization. With respect to treatment processes which need more precise descriptions and assessments, one can easily point to the significance of the separationindividuation process, the giving up of the helpless or omnipotent self, the containment of aggressive or sexual impulses leading to more regulated self-expression, the amelioration of cognitive disorder or the development of new powers of self observation and insight. The next generation of treatment studies will need to combine the strengths of this Timberlawn study with newer research specificity with respect to diagnosis and treatment process. Reference SMITH, M. L. & GLASS , G. V. (1977), Meta-analysis of psych otherapy outcome studies. Amer. Psychol., 32:752-760.
Troubled Families: A Treatment Program. By Mathew J. Fleischman, Arthur M. Horne, and Judy L. Arthur. Champaign, Ill.: Research Press Co., 1983, 284 pp., $18.95. Parents' Survival Handbook. By L. Eugene Arnold, M.D. Sunbury, Ohio: LAMMP Publishing Co., 1983, 137 pp., $5.95 (paper). Helping Families with Special Problems. Edited by Martin R. Textor, Dipl-Paed. New York: Jason Aronson, 1983, 246 pp., $25.00. Reviewed by Yolande B. Davenport, M.S. W.* Changes in societal and family structure (e.g., isolated and single parent households, working women, changing sex roles, etc.) have contributed to an increase in family stress at a time when many adults are unprepared to fill their roles as parents. The first two books represent an acknowledgement of an ongoing need for education in parenting skills. They rely heavily upon instruction in techniques of behavior modification therapy. Troubled Families: A Treatment Program written primarily for the novice therapist presents a systematic approach to treatment of difficult parent * Mrs. Davenport is Chief, Unit of Family Studies, Laboratory of Clinical Studies, NIAAA, Bethesda, Maryland.
BOOK REVIEWS
child relationships. Parents' Survival Handbook is addressed to parents who want to learn more about how to respond to their children at various stages of development. Helping Families with Special Problems joins the ranks of family therapy literature focused on the treatment of families with severe emotional and behavioral disturbances. Troubled Families: A Treatment Program
This manual outlines a social learning program which utilizes cognitive and behavioral therapy to teach parents new interactive approaches to managing family relationship problems. Intervention techniques are described for children between the toddler period and latency stages when the presenting complaint is the child's aggressive behavior, conduct problems, or parent-child conflicts. The training program relies heavily upon a somewhat mechanistic, structural approach to treatment of families with child management problems in outpatient settings either individually, or in groups. Detailed instructions and handouts for both parents and therapists are included in the text, making this a manual which could be used by a beginning therapist assuming the modeling, teaching role once performed for parents by an available extended family. Parents' Survival Handbook Dr. Arnold's delightful book can be enthusiastically recommended for parents who need support in maneuvering the many pitfalls along the path to successful parenthood. While the author utilizes learning behavior theory throughout the text, he approaches sound principles of child development and child rearing with a warm point of view, relying upon the common sense and good intent of parents interested in improving parenting skills. Proceeding from a chapter captioned "Organizing the Campaign for the Long Haul," practical and valuable instruction is offered in coping with a variety of parent-child struggles from managing the tantrums of a 2-year-old to survivorship techniques with grown children and grandchildren. This book is a find. It is unpretentious, written for parents rather than the specialist, and is modestly priced. Helping Families with Special Problems
In his preface, the editor of this book refers to the likelihood that many family therapists will object to the differential diagnosis made of the 11 pathological family types described in the book's 12 chapters, since a medical, psychiatric or psychological diagnosis of
637
one family member tends to focus blame for the family's dysfunctional behavior on the identified patient rather than on maladaptive family interaction patterns which operate to support the behavior. He suggests that still other family therapists may find diagnoses unwarranted and intrusive, because of the similarity of pathogenic mechanisms noted in different pathological family types. This seems a specious issue. If there is concern regarding the tendency to blame the diagnosed patient and the presence of an illness for all of the upheaval in the family, this might be better construed as grist for the therapeutic mill rather than rationale for dispensing with a diagnosis. Identification of a syndrome does not diminish the desirability of involving the family in a treatment approach which may well include pharmacotherapy for the identified patient, as well as intervention in the family system. Fortunately, the editor and authors have chosen to ignore this possible controversy. It is $.e precise delineation of diagnostic entities that gives t.his book its validity as an informative addition to t1lJ.e sparse literature which considers the relationship between the complexities of family psychodynamics and pathology. Overall, the quality of the papers is good. The book offers clinical material as well as treatment approaches for families with a schizophrenic, hospitalized, chronically ill, dying, neurotic, sexually dysfunctional, or alcohol- or drug-addicted member. These chapters provide a broad spectrum of treatment perspectives, although the reader hoping for new theoretical formulations or treatment concepts may be disappointed. A brief but sensitively written chapter addresses issues related to incest in families. Other chapters focus on family therapy for families struggling with contemporary interactional and behavioral problems related to separation and divorce, the reconstituted family or remarried family constellations, delinquency' and various adjustment problems of childhood. These chapters, which address the field of rapidly changing family patterns, are thoughtful but the professional wishing to pursue in depth dynamic constructs and therapeutic approaches would have to go beyond what is available here. Most of the contributors included concise literature reviews of family therapy theories and the specific entity about which they have written, providing easy access to comprehensive information on the evolution of the family therapy movement and family psychopathology. If for no other reason, this makes this book a worthwhile reference for any practitioner working with families.
BOOK REVIEWS
the patient suffered from a process or a reactive disorder also predicted outcome, as did the patient's intelligence and the degree of family psychopathology . On the positive side, if the patient completed all recommended inpatient treatments and continued some form of psychotherapy after hospital discharge, the outcome was significantly improved. The authors also conclude that patients do better if treated on a specialized, semiautonomous hospital unit. There seems little doubt that this study, combined with the earlier ones, demonstrates that long-term hospital treatment of severely ill adolescents can be and often is successful. The less severe diagnoses do well even if they have not done well on previous outpatient or brief hospital treatment. As with earlier studies, Gossett's .data shows two-thirds of chronic personality disorders are functioning well at the time of followup. Less than one-third of the psychotic adolescents, however, are doing well at follow-up. In addition to these research results and clinical impressions deriving from the study, there are also a number of provocative observations. Gossett used the Locus of Control Questionnaire on a subgroup of patients and discovered that this 10-minute self-administered instrument, which has been validated in numerous previous studies, predicted those who would do well vs. poorly at the time of follow-up. It is recommended as part of a predictive test battery which might be used in the future . The fact of having finished high school and having gained remunerative employment during the followup period correlated highly with the patient's adaptive
level. The authors make a valuable comment about the significance of psychotherapeutic work in the hospital focussed on the adolescent's sources of anger. For example, adolescents may correctly perceive the unfairness of their being in the hospital while other also-disturbed family members remain unhospitalized; such adolescents tend to see their own hospitalization as a victory for others. Anger may be used intrapsychically as a defense against separation panic. Or anger may serve to cover feelings of self-accusation at having failed one's parents. If these sources of anger are insufficiently worked through, the authors believe that a poorer long-term adaptation may result. Finally, the report comments upon the high number of illegitimate pregnancies in discharged adolescent females and recommends more attention to contraceptive education in the hospital. In a sense, this report marks the end of an era in this research field. New theoretical and methodological work is needed in two directions. With the arrival of DSM-III, future research reports will be looked upon as less than adequate if they do not use more precise measures of severity of disorder and of diag-
nosis. Secondly, new methods for tracing and quantifying a specific therapeutic process over the course of . hospitalization are needed. We need to extend the field of adolescent diagnosis. It is clear that differences in personality structure and psychodynamic processes are relevant to treatment planning and to prognosis. In formulating more precise diagnostic subgroups, one needs to attend not only to forms of family pathology and to the processreactive dimension but also to whether the patient identifies with a psychotic parent and whether a chaotic home environment is promoting personality disorganization. With respect to treatment processes which need more precise descriptions and assessments, one can easily point to the significance of the separationindividuation process, the giving up of the helpless or omnipotent self, the containment of aggressive or sexual impulses leading to more regulated self-expression, the amelioration of cognitive disorder or the development of new powers of self observation and insight. The next generation of treatment studies will need to combine the strengths of this Timberlawn study with newer research specificity with respect to diagnosis and treatment process. Reference SMITH, M. L. & GLASS , G. V. (1977), Meta-analysis of psych otherapy outcome studies. Amer. Psychol., 32:752-760.
Troubled Families: A Treatment Program. By Mathew J. Fleischman, Arthur M. Horne, and Judy L. Arthur. Champaign, Ill.: Research Press Co., 1983, 284 pp., $18.95. Parents' Survival Handbook. By L. Eugene Arnold, M.D. Sunbury, Ohio: LAMMP Publishing Co., 1983, 137 pp., $5.95 (paper). Helping Families with Special Problems. Edited by Martin R. Textor, Dipl-Paed. New York: Jason Aronson, 1983, 246 pp., $25.00. Reviewed by Yolande B. Davenport, M.S. W.* Changes in societal and family structure (e.g., isolated and single parent households, working women, changing sex roles, etc.) have contributed to an increase in family stress at a time when many adults are unprepared to fill their roles as parents. The first two books represent an acknowledgement of an ongoing need for education in parenting skills. They rely heavily upon instruction in techniques of behavior modification therapy. Troubled Families: A Treatment Program written primarily for the novice therapist presents a systematic approach to treatment of difficult parent * Mrs. Davenport is Chief, Unit of Family Studies, Laboratory of Clinical Studies, NIAAA, Bethesda, Maryland.
BOOK REVIEWS
child relationships. Parents' Survival Handbook is addressed to parents who want to learn more about how to respond to their children at various stages of development. Helping Families with Special Problems joins the ranks of family therapy literature focused on the treatment of families with severe emotional and behavioral disturbances. Troubled Families: A Treatment Program
This manual outlines a social learning program which utilizes cognitive and behavioral therapy to teach parents new interactive approaches to managing family relationship problems. Intervention techniques are described for children between the toddler period and latency stages when the presenting complaint is the child's aggressive behavior, conduct problems, or parent-child conflicts. The training program relies heavily upon a somewhat mechanistic, structural approach to treatment of families with child management problems in outpatient settings either individually, or in groups. Detailed instructions and handouts for both parents and therapists are included in the text, making this a manual which could be used by a beginning therapist assuming the modeling, teaching role once performed for parents by an available extended family. Parents' Survival Handbook Dr. Arnold's delightful book can be enthusiastically recommended for parents who need support in maneuvering the many pitfalls along the path to successful parenthood. While the author utilizes learning behavior theory throughout the text, he approaches sound principles of child development and child rearing with a warm point of view, relying upon the common sense and good intent of parents interested in improving parenting skills. Proceeding from a chapter captioned "Organizing the Campaign for the Long Haul," practical and valuable instruction is offered in coping with a variety of parent-child struggles from managing the tantrums of a 2-year-old to survivorship techniques with grown children and grandchildren. This book is a find. It is unpretentious, written for parents rather than the specialist, and is modestly priced. Helping Families with Special Problems
In his preface, the editor of this book refers to the likelihood that many family therapists will object to the differential diagnosis made of the 11 pathological family types described in the book's 12 chapters, since a medical, psychiatric or psychological diagnosis of
637
one family member tends to focus blame for the family's dysfunctional behavior on the identified patient rather than on maladaptive family interaction patterns which operate to support the behavior. He suggests that still other family therapists may find diagnoses unwarranted and intrusive, because of the similarity of pathogenic mechanisms noted in different pathological family types. This seems a specious issue. If there is concern regarding the tendency to blame the diagnosed patient and the presence of an illness for all of the upheaval in the family, this might be better construed as grist for the therapeutic mill rather than rationale for dispensing with a diagnosis. Identification of a syndrome does not diminish the desirability of involving the family in a treatment approach which may well include pharmacotherapy for the identified patient, as well as intervention in the family system. Fortunately, the editor and authors have chosen to ignore this possible controversy. It is $.e precise delineation of diagnostic entities that gives t.his book its validity as an informative addition to t1lJ.e sparse literature which considers the relationship between the complexities of family psychodynamics and pathology. Overall, the quality of the papers is good. The book offers clinical material as well as treatment approaches for families with a schizophrenic, hospitalized, chronically ill, dying, neurotic, sexually dysfunctional, or alcohol- or drug-addicted member. These chapters provide a broad spectrum of treatment perspectives, although the reader hoping for new theoretical formulations or treatment concepts may be disappointed. A brief but sensitively written chapter addresses issues related to incest in families. Other chapters focus on family therapy for families struggling with contemporary interactional and behavioral problems related to separation and divorce, the reconstituted family or remarried family constellations, delinquency' and various adjustment problems of childhood. These chapters, which address the field of rapidly changing family patterns, are thoughtful but the professional wishing to pursue in depth dynamic constructs and therapeutic approaches would have to go beyond what is available here. Most of the contributors included concise literature reviews of family therapy theories and the specific entity about which they have written, providing easy access to comprehensive information on the evolution of the family therapy movement and family psychopathology. If for no other reason, this makes this book a worthwhile reference for any practitioner working with families.