Book Reviews 181

in children with organismic defect, since stress can be imposed by normalenvironmental demands upon a child who is developmentally immature.This thesis is supported by a clearly written report of the group studied, theinstruments used to identify behavioral problems, and the tests of perceptual­motor functioning employed. Thus, not only is replicability of data possi­ble, but this volume also provides assistance to the educator or worker inthe mental health field who may not be sufficiently knowledgeable regard­ing useful diagnostic or screening instruments.

There is an excellent discussion of motivation and self-esteem in the chil­dren described. The distinction made between school failure in general andcognitive-perceptual-motor dysfunction in particular is of special importance.The discussion of possible levels of intervention is practical and useful.

Neurology of Childhood Learning Disorders deals with the neurologicalsubstratum of learning disorders. It includes a step-by-step neurologicalstudy (history and examination), with definitions of positive findings anddiscussion of their implications. The authors emphasize the important andoften overlooked fact that "no behavioral syndrome is pathognomic of thepresence of brain damage," and make the needed distinction between tem­peramental developmental hyperactivity and that resulting from brain dam­age. Scholarly critical reviews are given of the various at-risk factors and ofthe concept of minimal brain dysfunction. Each chapter is, in fact, a schol­arly review. Additional topics included are developmental dyslexia, cerebralpalsy syndrome, seizure disorders, progressive diseases of the brain, psychi­atric disorders, and others. This book is written so clearly and tightly thatits 142 pages cover a wealth of information that make it an unusually richreference source. Very impressive is Schain's concept of responsibility: "in­sofar as the neurological consultant wishes to assist the child with a learn­ing disorder beyond clarification of specific neurological issues, he must de­velop the attitudes of a physician aware of family and community pro­cesses" (p. 129).

Shame and Guilt in Neurosis. By Helen Block Lewis. New York: Inter­national Universities Press, Inc., 1971,525 pp., $15.00.

Reviewed by Robert L. Leon) M.D.

Shame is a relatively neglected issue in psychoanalysis and is generally sub­sumed under guilt. Yet shame as a specific superego function, separate fromguilt, can be analyzed with resultant symptom reduction. "Identificationwith the threatening parents stirs an 'internalized threat' which is experi­enced as guilt. Identification with the beloved or admired ego-ideal stirspride and triumphant feeling; failure to live up to this internalized admiredimago stirs shame" (p. 23).

Dr. Leon is Professor of Psychiatry, University of Texas, San Antonio, Texas.

182 Book Reviews

Shame and guilt, having many qualities in common, are difficult for thetherapist to distinguish from one another. To complicate matters, shame isnot necessarily overt. Shame can be masked by guilt or fused with guilt orit can be by-passed. In by-passed shame the affective component is not ex­perienced directly but may be experienced as "wordless 'shock' in feeling,followed by or accompanying ideation about the self from the 'other's' view­point" (p. 233).

Couple the complexities of distinguishing between and understanding thedifferential origins of shame and guilt with the "differentiation construct"(the latter referring primarily to whether a person is field-dependent orfield-independent), and we have the basis of an intriguing book that relatesthe above elements to superego style. There are even some fine targets forwomen's lib in the author's discussions of sex differentiation in perceptualstyles. Women of course are more field-dependent, and this relates in partto their sexual role.

The entire book is scholarly and well written. Reading is at times slowand tedious, but this is more because of the nature of the subject matterand the thoroughness with which the subject is treated rather than theauthor's style. The chapter on the differentiation construct presents a goodreview of the literature as it relates to the author's attempt to develop "anintegrated view of man's cognitive and affective functioning" (p. 131). Thischapter is followed by an experimental investigation of the hypothesis thatfield-dependent patients are more subject to shame and field-independentpatients are more subject to guilt. A significant portion of the book isdevoted to case studies illustrating how shame and guilt appear in therapy.The author also reexamines some of Freud's clinical material, with specialattention to evaluation of shame phenomena.

For the psychoanalyst and the analytically oriented psychotherapist, thebook should prove helpful in what the author terms the "therapeutic 'dailychore' " that is oriented to understanding the relationship of the shame ex­perience to imagery and ideation. The author contends that therapy isshortened by a phenomenological stance toward shame and guilt. Psycho­analytic work is shifted away from generalized character analysis and moretoward the understanding of shame and guilt in actual symptom formation.Admittedly, this is impressionistic and requires further research. For thoseinterested in research into some technical aspects of the relationship of per­ceptual styles and psychoanalytic theory, the book offers interesting ideasand suggestions for methodology.

This is not a book for child psychiatrists qua child psychiatrists, nor is itparticularly useful in the fast-moving arena of community psychiatry whereunraveling the intricacies of guilt and shame in relation to perceptual styleis not an immediate issue, or at least not as immediate as some sort of crisisintervention to bolster the adaptive capacity of a family. Some who arecaught up in this world of immediate problems might want to take an op­portunity to step back and contemplate some of the nuances of psychoana­lytic theory and therapy.