Critical Issues in Psychiatry – serie

This volume is about the normal development of adulthood, as weIl as its vieissitudes and the contributions of such development to psycho- pathology. The authors are psychoanalysts of great dinieal skill and perceptiveness, but while their focus is consistently a psychodynamie one, their conceptualizations about adult developmental processes are applicable to virtually all kinds of therapy. It is extraordinary how little attention has been paid to the effects of adult developmental experience on mental development. Obviously mental structures are not statie after the profound experiences of child- hood and adolescence, nor are they merely a template upon whieh adult experiences are processed. The authors dearly demonstrate that current adult experience always adds to, and interacts with, existing mental structure, whieh is itself the result of all preceding develop- ment. After a first section in whieh they examine life cyde ideas on de- velopment from antiquity to the present, they present their own work as it relates to adult experience and adult development.Their hypoth- eses about the psychodynamie theory of adult development are partie- ularly creative and an enormous contribution to the psychiatrie litera- ture and the dinical understanding of patients. Consistent with their views that development in adulthood is an ongoing and dynamic process, they elaborate their ideas that childhood development is fo- cused primarily on the formation of psychie structure while adult de- velopment is concerned with the continued evolution of existing struc- ture and its use.

When Ifirst read this manuscript, Iexclaimed to a colleague: "This is the most important and clinically relevant book on schizophrenia since Bleuler!" Time has not altered my initial enthusiastic evaluation. Drs. Strauss and Carpenter are among the most distinguished researchers in the field ofschizophrenia,butthey are also clinicians ofgreat experience, breadth, sensitivity, and flexibility. It is from this expertise, as well as theirwide familiarity with the world literature, thattheyhavebeenable to distill the essence of an exceedingly practical and comprehensive approach to the understanding, evaluation, diagnosis, and treatment of schizophrenia. They begin by unequivocally stating the inadequacy and futility of approaching schizophrenia via a single model. Standingalone, neither a biomedical, a social, nor a psychological model can adequately account for the complexities of this illness with regard to etiology, phenomenol­ ogy, course, or optimum treatment. While the advent of psychophar­ macologicalinterventionhas made a profound impact on both individual treatment and the responsive support systems, and is an important aspect ofmosttreatmentplans, to view schizophrenia as a phenothiazine deficiency disease is not only bad science but bad therapeutics. Their conceptualization of an "interactive developmental systems model" provides a framework upon which to build a broad medical approach to schizophrenia. This model relates variables drawn from different systems, interactive with one another, and contributing to a pathogenetic process across time. Within this bio-social-psychological matrix, one can then organize information relative to vulnerability, the manifest illness per se, the course of the disorder, and the multiplicity of factors relative to treatmentplanning.

In order to complete training successfuIly, every psychoanalyst has to be a supervisee. This experience leads each analyst to want to become a supervisor. Until recently, very little has been discussed about wh at supervision is, how it is done, and how it is related to the various theories of psychoanalysis that are held as articles of faith. The 1980-1981 program of the William Alanson White Psychoanaly- tic Society was devoted to supervision-with representatives of various "schools" demonstrating their ways of doing consultations with ana- lysts about patients. This book is an extension of that endeavor. In it, supervisors of various persuasions discuss this topic. The editors-Leopold Caligor, Philip M. Bromberg, and James D. Meltzer-are to be congratulated for the high level of discourse repre- sented by the various chapters. They are to be commended as weIl about the eloquent statement this book makes-namely, there are many an- swers and approaches and no final answer to the questions raised by the volume.

This is the second book in the pioneering investigation of adult develop­ ment by Robert A. Nemiroff and Calvin A. Colarusso. The first, Adult Development: A New Dimension in Psychodynamic Theory and Practice, ar­ rived to critical acclaim in 1981. It presented a psychodynamic theory of development during the second half of life and a model of normal adult functioning. This book is the logical sequel, expanding and elaborating the original formulations and applying them to the clinical practice of psychotherapy and psychoanalysis. Nemiroff and Colarusso demonstrate that these are appropriate techniques for patients in the second half of life, regardless of age. They lay to rest many stereotypes and myths that have long interfered with the dynamic treatment of older patients, and they propose exciting new conceptualizations such as that of adult develop­ mental arrests. The genetic approach reaches beyond childhood and adolescence and takes on important new meaning by incorporating an adult developmental past that influences both psychopathology and transference. The relationship between theory and therapy is richly demonstrated in the clinical presentations, including ten detailed case histories of pa­ tients between the ages of 40 and BO. These and other clinical discussions provide ample evidence that a psychodynamic approach that is based on a sound adult developmental psychology can be extraordinarily effective. They also demonstrate both the similarities and differences in working with older versus younger patients. This work is a major contribution in a long-neglected dimension of clinical psychiatry. SHERWYN M.

The psychiatric view of homosexuality has undergone a fascinating evo­ lution in recent years. This includes not only the change from viewing homosexuality as a diagnosable illness, as opposed to an alternative life style, but also the development of considerable professional concern for providing appropriate mental health services to this previously under­ served minority community. There has been an increasing recognition of the need for comprehensive services including, but not limited to, counseling, individual psychotherapy, and couples therapy. This book is written for the practicing clinician, and offers a compre­ hensive survey of the important clinical issues involved in the counsel­ ing and psychotherapy of gay men and lesbian women. It is an extraor­ dinarily practical book and its breadth and depth make it appropriate for both the novice and the experienced therapist. SHERWYN M. WOODS Series Editor ix Preface We hear our mentors but do not often heed them. Freud's supportive, nonjudgmental approach to homosexuality provided an ambience with­ in which discoveries could be made, that is, the discovery that homosex­ uality was not a disease of mental degeneration and that sexuality, in the sense of a fundamental human propensity to find pleasure in social and physical attachments, was at its root directed to both sexes. The ad­ herence to a nonjudgmental approach was short-lived, suffered repres­ sion by homophobic defenses, and scientific zeal was directed toward "cure" rather than comprehension of the homosexual state.

If ever a book could be called timely, this is it. Sleep disorders medicine has made rapid advances in recent years. The field has attained growing respectability, with a textbook recently published, a congressionally man­ dated National Commission on Sleep Disorders Research, and a growing public awareness of the importance of sleep disorders. However, this rapid growth has made the discrepancy among certain components of the field all the more obvious. Thus, we find that patients who complain of insom­ nia are almost never in the majority of those seen in sleep disorders centers, in spite of the well-known fact that the prevalence of such individ­ uals in our society is by far the largest. Current articles on insomnia abound, but they tend to be facile recitations of diagnosis and impractical global recommendations for treat­ ment, without providing the essential details. Indeed, the clinical profes­ sions really do not know what to do about insomnia. This is reflected in a number of observations I have made in the recent past. For example, the majority of individuals who complain of insomnia take alcohol, aspirin, over-the-counter medications, hot baths, and a host of other nostrums, but rarely seek a physician. In the unlikely event that a physician is consulted, he is likely to prescribe a sleep medication but without any particular consistency, or any clear instructions on its use.

This multiauthored textbook is directed to the psychiatric resident and other professionals who are interested in the issues, strategies, and methods of psychiatric research. Although the field of psychiatry has not attained the scientific rigor and clinical sophistication of some of its sister disciplines in the medical arena, considerable progress has been made in the last decade or two, and a full understanding of the types of articles that now appear in such publications as the American Journal of Psychiatry, the Archives of General Psychi­ atry, and the Journal of the American Academy of Child and Adolescent Psychiatry requires a fair amount of knowledge about research design and strategy. Whereas articles in psychiatric journals 20 years ago dealt mainly with psycho­ dynamic topics and utilized nonexperimental observations, today their counter­ parts are concerned mostly with psychobiology, clinical features, diagnosis, and treatment, and employ scientific experimental designs. The trend of applying scientific methodology to research in psychiatry is increasing and undoubtedly will continue to do so in the future.

Focusing on patients with severe impairments, including mixed and multiple diagnoses, this volume describes how behavior therapy fits into the clinical environment. Psychiatrists, medical clinicians, and residents will appreciate the in-depth coverage of a broad range of difficult issues.

Developmental theory is the essence of any psychodynamic psychother­ apy, and certainly of psychoanalysis. It is through an understanding of progressive life events, and the way these events relate to associated biological and social events, that we come to understand both psycho­ pathology and psychological strengths. For a long time we have needed a clinically oriented book that surveys normal development in both childhood and adulthood. This book should be particularly helpful to all mental health professionals whose daily work requires a constant awareness and appraisal of devel­ opmental issues. Dr. Colarusso has integrated and summarized a tremen­ dous amount of theoretical, empirical, and clinical material in a format that makes it come alive through clinical examples. This book should be of great interest to all students of human behav­ ior as well as to seasoned clinicians. SHERWYN M. WOODS, M. D. , PH. D. vii Preface Each year as I gave a lecture series on child and adult development to the adult and child psychiatric residents at the University of California at San Diego, someone inevitably would ask, "Is there a book that I could understand that has all of this information in it?" I would reply that I did not know of any single source, but I could refer the person to many articles and books on development.

The author has written an unusually fresh work, applying a biopsychosocial approach to the diagnosis and treatment of a wide range and degree of disorders. The book will provide mental health professionals and graduate students with a trustworthy, sophisticated introduction to sexual health and its problems.

At the time of this writing, there is much uncertainty about the form of this country's future healthcare system and the role of psychiatry and other mental health disciplines in that system. Current experience with various managed healthcare programs is not encouraging. Most often patients with severe psychiatrie disturbances receive, at best, so me form of crisis intervention or brief treatment. Marital and family approaches to treatment receive even less support. This discouraging socioeconomic context makes the work of John Schwab and his colleagues even more important than it would be in more favorable times. Their message is clear: The family is crucial to an understanding of psychiatrie disorders and must often be the major focus in the treatment of these disorders. This book is unique in its direct reflection of the senior author's long-term professional interests-the family, epidemiology, and history. A careful reading provides family therapists and researchers with won­ derful opportunities to examine the ways in which history, socio­ economie and politieal contexts, and epidemiology can be used to in­ crease understanding of the family. This his tory of the family is unusually thorough; in particular, I found fascinating the information about early Egyptian families (3000 B.C.) and their accordance of high status of women.

`[This] volume provides a unique and advantageous perspective to the trainees and practitioners in the adolescent substance abuse field. It offers a sophisticated perspective on addiction treatment techniques developed in recent years, with a sensitivity to the social and developmental needs of the adolescent.'Marc Galanter, from the Foreword.

The family, that most fundamentalof human groups, is currently perceived to be changing in response to social, biological, cultural and technological developments in our postmodernsociety. While the observed changes in families have been considered by some sociologists to be evidence of adaptation and, therefore, normal, the authors of this volume, consider them maladaptive. Viewing society from the point of view of clinical psychiatry, they point to greatly increased numbers of children born to single mothers, soaring rates of divorce, a statistically confirmed increase in mental disorders, increase in reported incest, high rates of depression in younger people and escalation of the amount of reported family violence as evidence that the family, as a social institution, is in crisis and can either move toward renewed vitality or continued deterioration. Perceiving a need to obtain information about family functioning that might lead to the increased stability and well-being of this critically important type of system, Dr. John Schwab and his associates designed and camed out a research program that began with a thorough review of relevant literature beginning with LePlay’s study of 300 families in the 1850’sand including important recent statistical studies. They found that although these studies represent advances in understanding the family system, some serious problems with the research remain, one of which is confounding variables such as family function and mental or substance abuse disorders so that if a family member has a problem, such as drug abuse, the family is classifiedasdysfunctional.

Today there is an overall greater awareness and acceptance of ethnic diversity in American society and a clearer definition of the United States as a pluralistic nation. The last U.S. census showed that well over 100 million Americans, white and non­ white, identify with an ethnic group. Ethnicity is indicative of more than the personal distinc­ tiveness derived from race, religion, national origin, or ge­ ography. It denotes the culture of people-that powerful yet subtle factor that shapes values, attitudes, perceptions, needs, modes of expression, patterns of behavior, and identity. From a clinical perspective ethnicity involves conscious and uncon­ scious processes that fulfill deep psychological needs for se­ curity, a sense of one's own proper dignity, and a sense of historical continuity as well. These functional aspects of eth­ nicity reinforce the notion that culture is of significant value to the quality of life and the mental health of all individuals. In the preventive and therapeutic sense, ethnicity sustains a capacity for coping with stress by providing communal support systems which serve to buffer the excessive indi­ vidualism, alienation, and anomie of modem mass culture. Hence, to ensure appropriate delivery of mental health ser­ vices to a particular ethnic population, mental health profes­ sionals must first become cognizant of the positive aspects vii FOREWORD viii and strengths to be drawn from a particular group identity and then incorporate these elements into their treatment strat­ egies or techniques.

In this book we present a conceptually integrated approach to disorders of mood. These disorders are defined narrowly as the clinical syndromes of mania and melancholia. The latter is our particular focus, for the simple reason that it is more common and thus more is known about it. Our approach owes much to Adolf Meyer, who first used the term psychobiology. It was he who emphasized in a practical way the importance of the clinician consider­ ing the joint contribution of psychosocial and biological factors in the genesis of mental disorders. However, until the 1960s, our relative ignorance of basic mechanisms that link brain and behavior prevented the development of a genuine psychobiological perspective. Thus Meyer's work was concerned largely with teaching the importance of the personal biography and a consideration of social history in the development of mental disorder. We feel that sufficiently rigorous data have now emerged in psychia­ try to permit tentative but real psychobiological integration. Affective illness is proba­ bly the most promising area for an attempt at such a synthesis. It is our belief that the theory and clinical practice of psychiatry now can be woven into a coherent theme, integrating insights and evidence generated by the psychodynamic, biological, and behavioral methods; hence in part we review the emerging psychobiology of mood disorders with the hope that it can serve as a generic paradigm for other psychiatric syndromes.

Some will wonder why this book, with its specific focus on the pro­ cess of change in psychotherapy, was chosen for inclusion in "Crit­ ical Issues in Psychiatry: A Series for Residents and Clinicians" as our books are generally devoted to a broad topical survey of some im­ portant clinical area in the practice of psychiatry or a related mental health discipline. The answer will become rapidly apparent to the reader, for Dr. Horowitz has developed an exciting, creative, and practical method whereby any psychotherapist can understand, monitor, conceptualize, and evaluate the process of change in psychotherapy. His method of "configurational analysis" utilizes direct clinical observations of emotional states, role relationships, and information processing to systematically, in a step-by-step fashion, organize and describe clinical data. It can be employed at any point in the therapeutic transaction, from the time of initial presentation to the time of termina­ tion or follow-up. This method of organizing information about a person, his problems and resources, and the nature of the psychotherapeutic transaction provides the therapist with a powerful tool with which to both understand and communicate how and why change occurs, or does not occur, in psychotherapy. It can be applied all the way from the description of large-scale patterns to the microanalytic dissection and understanding of a small segment of a therapy session.

It is sobering to reflect that it has been nearly fifty years since Thomas French's article on the "Interrelations between Psychoanalysis and the Experimental Work of Pavlov," representing the first psychoanalyst to bridge the gap between the theories of conditioning, was published. In hjs paper French clearly delineated the manner and directions in which these two points of view might enrich each other. Regrettably, his open­ ness to new ideas has not been characteristic of most "schools" of psychiatry thought, which have tended instead to develop an unfortu­ nate degree of insularity. This has occurred despite the obvious reality that the bio-social-psychological nature of man is such that no one theory or discipline is likely, in the foreseeable future, to explain, much less predict, all of the complexities of human behavior. All too often disputing theoreticians, like the fabled blind men describing the elephant, assume that the whole is just a gigantic magnification of the parts with which they are in contact. When treatment strategies are extrapolated from such narrow views, more often than not they fail to achieve the parsimony of effort, the breadth of application, and the maximum of efficiency that one would hope for. In our opinion, it is impossible adequately to conceptualize person­ ality development, symptom formation, or responses to psychotherapy, without taking into consideration theories of conflict as well as those of learning.

Nearly a century ago, Emile Durkheim founded the sociology of educa­ tion on the French cultural and structural premise that the function of educators is to transmit culture from one generation to the next. The clarity of his vision was aided by the era, the place, and the actors in the learning environment. His was an era when the relatively seamless web of western culture, although ripping and straining, was still intact. The place, post-Napoleonic France, was vertically stratified and elaborately structured. And the teachers had reason to think they were agents of authority, whereas most students, during school hours at least, behaved as if they were the objects of that authority. Underlying the very notion of a sociology of education, then, was a visible and pervasive aura of a system and order that was culturally prescribed. Scholars of American education have yearned for such systems before and since Durkheim. Every European and English model has been emulated in a more or less winsome manner, from the Boston Latin School of the 1700s to the Open Education programs of the 1960s. In the last quarter century of research, it has begun to dawn on us, however, that no matter how hard American educators try, they do not build a system.

Building on the work of Janet, Jung, and Fairbairn, the author details a comprehensive theory of pathology and integrates the major schools of treatment into a holistic outpatient milieu therapy. Abroms emphasizes the role of personality dissociation in depressive pathologies, and works toward unifying the self into a more aware, spiritually connected whole. Clinicians working from a variety of viewpoints will find fruit in his work.

This is the inaugural volume of the new series: Critical Issues in Psychiatry: An Educational Series for Residents and Clinicians. It is an appropriate beginning, for this book represents a milestone in the evolution of psychiatric education. For the first time, there will now be a single place where one can find a compre­ hensive collection of educational goals and objectives to define the broad spectrum of knowledge and skills essential for general and child psychiatry. This collection does not represent the bias of a single educator or program. Rather, it consists of a consensually validated ranking of relative importance for each educational goal and objective as determined by a large and international sampling of ex­ perienced psychiatric educators, as well as an editorial board with some of the most distinguished names in psychiatric education. It is even possible to tell at a glance whether the ranked level of importance is the same or different within several national groups, for example Canadians vs. Americans. This book is intended for all students of psychiatry. It is particularly valuable to residents in training, but equally so for experienced clinicians preparing for Board examination or simply attending to the process of continuing education and intellectual renewal. While it might well be used by an institution to delineate the dimensions of a training program in psychiatry, it is intended primarily for the self-evaluation and self-monitoring of one's growth as a psychiatrist.

Clinicians have long been fascinated by the rare and exotic in med­ icine. Similarly, psychiatrists and mental health professionals have been intrigued by the uncommon and extraordinary syndromes which, despite their rarity, have much to teach us about the limitless forms of human adaptation. Of particular interest is the fact that fragments and partial expressions of these rare disorders are often encountered in the dreams and fantasies of the "ordinary" patient. For this reason, the understanding and insights collected in this volume are likely to have clinical usefulness far beyond those rare occasions when we encounter the exotic in its fully developed form. These disorders demonstrate the complex interplay between intra­ psychic dynamic forces and the cultural influences which act to shape overt symptomatology. The section on extraordinary syndromes from non-Western cultures demonstrates the universality of the psychody­ namic roots of human suffering, despite the seemingly strange furms in which this suffering is expressed. As clinicians we are too often restricted by ethnocentric attitudes and culturally determined stereotypes. This volume provides a stimulating and enjoyable opportunity to reach beyond those limitations.

When this series was conceived, a book on substance abuse, including alcohol and alcoholism, was to be of the highest priority. This priority was a reflection of my view that the subject is often inadequately or insufficient­ ly taught in many training programs. Few clinicians have had comprehen­ sive didactic education in this area, despite the frequency with which these problems are encountered in practice. All too often these encounters are in situations in which accurate diagnosis and rapid treatment are of critical im­ portance. We wanted a book that would be concise and easily readable but also comprehensive in its presentation of the basic principles underlying clinical manifestations, diagnosis, and management. It was of particular im­ portance that the book also serve as an easy reference guide in emergency situations. Marc Schuckit, a man with impeccable credentials as a scholar and an experienced clinician in this field, produced just such a book with his critically acclaimed first edition. That volume rapidly became a resource of great significance for psychiatrists, psychotherapists, and physicians in general. It has been adopted as a text in medical schools and residency train­ ing, as well as for courses in psychology, emergency medicine, social work, and nursing. The entire volume has been revised and updated to reflect changes in knowledge and clinical practice since the publication of the first edition and in order to keep the comprehensive references current. There is a new chapter on phencyclidine and another on caffeine and nicotine.

When this series was conceived, a book on substance abuse, including alcohol and alcoholism, was to be of highest priority. This priority was a reflection of my view that the subject is often taught inadequately or insufficiently in many training programs. Yet these problems are com­ monly encountered in clinical practice, and all too often in situations where accurate diagnosis and rapid treatment are of critical importance. We wanted a book that would be concise and easily readable but also comprehensive in its presentation of the basic principles underlying clinical manifestations, diagnosis, and management. It was of particular importance that the book also serve as an easy reference guide in emergency situations. Marc Schuckit, a man with impeccable credentials as a scholar and an experienced clinician in this field, has produced just such a book! Few psychiatrists, psychotherapists, or physicians will want to be without it. The presentation is comprehensive and in depth, yet so clear and well organized that it will also likely be of interest to medical students, nurses, and emergency personnel.

When Critical Issues in Psychiatry was conceived, there were several sub­ jects I considered to be of crucial importance in a series devoted to residents and clinicians in psychiatry, as well as to other mental health professionals. Of prominence was the pressing need for an in-depth and scholarly exam­ ination of the interface between medicine and psychiatry. I had been amazed to find that not a single book, to my mind, adequately addressed the psy­ chological symptoms and manifestations of both common and rare medical illness. It seemed to me that there was a need for a work which would achieve the following goals: First, it would assist in the differential diagnosis of functional psychiatric symptoms versus symptoms secondary to recog­ nized or unrecognized medical illness; second, it would elucidate the psy­ chological symptoms resulting from pharmacologic and other therapeutic interventions in medical illness; and third, it would examine the use of psychopharmacological agents in the presence of medical illness and the drugs used to treat that illness. Dr. Jefferson is Board Certified in both internal medicine and psychiatry, and both Drs. Jefferson and Marshall have extensive clinical experience from their many years of consultation/liaison work in psychiatry. Their experience and expertise have resulted in what I believe to be a monumental contri­ bution to the literature.

This book is welcomed to the series as a truly unique contribution to the literature on marital therapy. It is written for the empirically oriented psychotherapist, regardless of his or her discipline, who encounters patients with marital discord and has been distressed by the absence of an acceptable conceptual model for treatment. Psychoanalysis, behavior therapy, general system theory, and social learning theory have all made important contributions to treatment. But all too often these approaches have focused either on individual psychopathology or on the formal elements of marital interaction. This volume is the first to propose an approach to marital therapy which is clinically sophisticated, empirically based and which integrates important elements of seemingly disparate theoretical systems. The result is a cognitive-behavioral model for the treatment of marital discord which borrows from both psychoanalytic and behavioral contributions by translating them into the language of cognitive social psychology. The author documents the toll in human suffering as well as the ubiquitous nature of marriage-related problems. Despite the frequency with which marital dissatisfaction and discord are encountered in clinical practice, an amazingly high percentage of mental health professionals have received inadequate training in either the theory or technique of effective clinical intervention. The absence of a conceptual framework linking individual psychopathology to interactional difficulties has wors­ ened the problem for clinicians interested in conjoint treatment.

Despite much progress in the past ten years, American medical schools have woefully inadequate sex education curricula. While some have a reasonable amount of lecture time, few have clinical opportunities for students to develop practical skills in working with patients who are struggling with sexual problems. It is my impression that the same is true in medical and gynecological residencies, as well as in graduate schools of psychology, counseling and social work. This book was specifically written to help fill that gap. This is a book for clinicians, and it will provide a wealth of practical clinical knowledge and skills in dealing with the gamut of patient's sexual concerns, problems and dilemmas. Twenty-four experts have contributed eighteen chapters which address both the common and unusual sexual issues encountered in practice. These include sexual concerns from childhood to old age; gender identity and sexual preference; sexual dysfunction, including that of the physically ill and disabled; counseling with students, premarital, marital, and divorced patients; fertility and infertility; and chap­ ters dealing with rape, incest and other sexual contacts between adults and children. Of particular importance are chapters on human sexuality in American minority popula­ tions, a chapter on alcohol, medication and other drugs, and a chapter on medical management of sexual problems in the gay population, a subject long-ignored by the profession. The focus on practical intervention and skill development is amplified by the concluding four appendixes devoted to patient management problems.