reviews of the literature

REVIEWS OF THE LITERATURE

MEMORY AND INTELLIGENCE. Jean Piaget and Barbel Inhelder, in collaboration with Her- mine Sinclair-De Zwart. 1973. 414 pp. $12.50. Basic Books New York.

UNDERSTANDING CAUSALITY. Jean Piaget, in collaboration with R. Garcia. 1974. 192 pp. $10.00. Norton, New York.

THE O R M N OF THE IDEA OF CHANCE IN CHILDREN. Jean Piaget and Barbel Inhelder. 1975. 211 pp. $12.50. Norton, New York.

Some 25 years ago Piaget wrote that for 30 years his work had been dominated by the single idea that intellectual operations proceed in terms of structures-of-the-whole. Noting that such structures are a t once or- ganic, psychological, and social, he ex- pressed the hope of some day demon- strating relationships between mental structures and stages of nervous development, and eventually arriving at a general theory of structures.

The three volumes to be reviewed here represent different aspects of Piaget's life undertaking. The Origin of the Idea of Chance, originally published in French in I95 I , resembles earlier studies dealing with quantity, space, and time. In these studies children of varying ages are confronted with experiments designed to reveal the nature of their reasoning. Memory and Intelligence, first published in 1968, like its predecessor, Mental Imagery in the Child, shifts focus from specific areas of knowledge to specific aspects of cognitive functioning. The third and most recent volume, Understanding Causality, stems from the International Center for Genetic Episte- mology and brings the results from a hun- dred studies to bear on the question of explanations of causality.

Despite the integrity of each of these

I74

three volumes, their connections to Piaget's other work can hardly be ignored. Chance seems unlikely to have evolved had there not been the earlier works, The Child's Conception of the World and The Child's Conception of Physical Causality.

In turn, Chance draws on The Child's Conception of Space and The Child's Con- ception of Movement and Speed. Memory and Intelligence relies even more cornpre- hensively on previous work, including ex- tensive sections on logic, on causality, and on space, viewed from the standpoint of the child's memory. Unclerstanrling, Causality, which summarizes recent studies but provides few of their details, depends on its readers' knowledge of Piaget's ways of experimenting.

These formidable networks of as5ocia- tion may be seen as a barrier by the reader who has read more about Piaget than he has read Piaget. At the same time, they offer stimulating journeys of discovery for the less timorous.

The Origin of the Idea of Chnnce i n Children is quite readable, including lib- eral portions of protocols for the cxperi- ments in all but the introductory and con- cluding chapters. Essentially the book addresses the question of induction: what are the steps by which one sifts through ex- perimentation separating what is fortuitous from what is deducible, while a t the same time preparing for deduction itself? The experiments range from the child's predictions regarding the random mixture of balls of two colors during several tiltings of their container, through his inferences regarding the stopping of a pointer on a disc when it moves freely and when it is rigged to stop each time at the same place, and on to his calculations of the probabili-

REVIEWS OF T H E LITERATURE I75

ties for drawing pairs of marbles from a bag with a mixture of 20 red and 20 blue.

That chance is only gradually discovered, and that the discovery evolves through three stages will come as no sur- prise to Piaget’s readers.

Before seven or eight years, the child does not differentiate between what is possible and what is necessary.

His thought oscillates between the predictable and the unforeseen, but nothing for him is either predictable for certain or absolutely unforeseen.

When, however. the child becomes capa- ble of operational thought, and recognizes the logically necessary, he also develops an awareness of the fortuitous. Not until the onset of adolescence and the advent of the ability to understand proportion and the ability to consider systematically all the possible ways of grouping a set of elements does the child become able to manage problems dealing with probability.

Chance, unlike its companion volumes on which American researchers have based much work, has heretofore received minimal attention. In contrast, some of the ideas in Memory and Intelligence were previewed by Inhelder in the festschrift volume, Stirdies in Cognitive Development. edited by David Elkind and John Flavell. In the same year an excerpt from Memory and Intelligence appeared in Hans Furth’s Pinget and Knowledge. These have stimu- lated much discussion and considerable rc- search.

That Piaget welcomes the replication and extension of the studies reported in Memory and Intelligence is suggested in the preface. The authors note,

The reader will be presented not only with a number of experimental facts but also with several theoretical notions, the validity of which the future alone can decide.

Memory r i n d Intelligence begins with a consideration of the d a c e of memorv

tional schemata.* In the strict sense, memory focuses on the recognition, recall, or reconstruction of particular past events.

The experiments reported in Memory and Intelligence were designed to tap memory in the strict sense. Children of varying ages were asked to memorize different con- figurations. Some of these involve additive logical structures such as classification and seriation, others multiplicative structures such as double serial correspondence. Others involve the remembrance of causal processes, for example, those represented by levers, or in a transmitted motion. Still others focus on spatial structures.

The well known experiment in which the child is asked to represent the water levels in bottles that are standing upright, upside down, or inclined serves as a basis for one of the memory experiments, and illus- trates the kinds of procedures that were used. The child is presented with a drawing showing, for example, a bottle containing a portion of liquid inclined to an angle of 45”. The level of liquid is, of course, clearly parallel to the horizontal surface against which the bottle is suspended. The experimenter asks the child to memorize the drawing, and, after an hour, calls upon him to draw what he has seen. A week and, in some instances, six months later, another drawing of the bottle is requested. At these later sessions, questions related to his drawings are asked, or, in the case of a correct drawing, the questions may be directed to the levels of the liquid in other erroneous drawings.

The reader may recall that, in the earlier studies reported in The Child’s Conception of Space, most children under the age of nine were unable to predict what the level of the liquid in the bottle would be when it was rotated. At early stages the child thinks of the liquid as approaching or re- ceding from the neck of the bottle while remaining parallel to its base. At later

among the cognitive functions. A distinction is made between memory in i ts broad * The terms “schema” and “schemata” are

used throughout this translation, with the ap- sense and memory in its strict sense. The parent meaning of of genera,iza- former refers to the Of the tion” (p . 362). Such use runs counter to other past, and includes both the conservation translations, where the term “scheme” is used of biological mechanisms and the con- to refer to the gcrierd structure of actions and servation of pre-operational and opera- operations.

I76 AMERICAN JOURNAL OF ORTHOPSYCHIATRY

stages he recognizes that it will not always be parallel to the base, but cannot coordi- nate his predictions with the fixed reference system provided by the table on which it rests. To a striking degree, the children’s memory drawings, despite the fact that the child has been given all the information he needs for a correct reproduction, cor- respond to the kinds of predictions children of simialr ages made in the earlier studies. Furthermore, over the six-month period, some improvement in the memory drawings occurs among the seven-to-nine- year-olds.

From these and comparable findings, Piaget and Inhelder conclude that there is no clear line of demarcation between memory in the strict sense, and memory in the broad sense. Rather,

. . . memory in the strict sense is part of a general set of cognitive functions . . . and . . . the conservation of memories rests on special but related schematizations in certain cases, but participates directly in that of the intelligence in others.

Or, from the vicwpoint of information theory, the encoding of data during per- ception, their storage and decoding or re- coding depend on the code employed by the subject. The code itself is transformed as the child moves from pre-operational to operational thought.

Understanding Causality also deals with transformations in the child’s thought, but as they relate to causal relations among objects. To some extent it goes beyond the thought of children to consider how the thought of philosophers and scientists has evolved since Aristotle and Archimedes. The question it addresses, although posed in Genevan terms, is an old one: What is the relationship between the development of operational thought and the development of the understanding of causality? Do the logico-mathematical operations develop on their own, to be attributed by the subject in an a priori fashion to the objects he encounters? Or does the understanding of causality precede the development of operations, so that the latter are essentially a reflection of the causal notions imposed on the subject by reality?

Piaget rejects both of these hypotheses in favor of a third:

At every level the development of the understanding of causality proceeds by interacting with the development of the operations, which amounts to saying that each of these two developments helps the other.

The remainder of the first and major portion of the book is devoted to the examination of this hypothesis in the light of data from experiments in seventeen different areas, such as changes in the states of mat- ter, “weight” and its compositions with spatial dimensions, and the concept of work. The latter part of the book turns to an epistemological analysis of certain problems in theoretical physics, and “constitutes an attempt at interdisciplinary research. ”

The reader who is familiar with Piaget’s experiments in particular areas may find that the discussion clarifies certain tenets of his theory, such as the distinctions between logical and intralogical operations, and between physical and reflexive abstrac- tions. It also illuminates the problem of lag, or dhcalage, in the development of operational structures, with reference to different aspects of physical reality.

Understanding Causality demonstrates that Piaget’s “general theory of structures” is sufficiently comprehensive to incorporate physical reality. When it is read in conjunction with Chance and Memory and Intelligence, one can only marvel again at the genius of the man who so many years ago began the process of bringing empirical data to hear on philosophical issues that have long been discussed but seldom researched.

One suspects that for Piaget those issues have constituted an intellectual Everest that had to be conquered, regardless of consequence. Nevertheless, he has not been unaware of the variety of practical implications that may he drawn from his theory. H e has occasionally expounded on them, but has generally left the task of making pedagogical and other inferences to his followers.

The professional who wishes to apply Piaget’s theory in understanding a client


or teaching a child works in a setting considerably more complex than that involved in the typical Piagetian clinical interview. Yet it seems that the Piagetian method, with its concern for understanding the point of view of the child and its basic respect for the child’s thinking, constitutes an appropriate model for psychologist, social worker, pediatrician, nurse, and teacher. It should help the professional to understand the nature of the child’s thinking at different stages, as revealed in these three and other volumes written by Piaget. An appropriate application of theory, however, seems to this reviewer to demand not only the knowledge derived from Piaget’s investigations, but also the inquiring atti- tude of mind that characterizes them.- Millie AIrny. Ph .D. , School of Education, University of California, Berkeley.

PSYCHOANALYTIC SOCIOLOGY: An Essay on the Interpretation of Historical Data and the Phenomena of Collective Behavior. Fred Weinstein and Gerald M. Platt. 1973. 135 pp. $8.50 (paper, $2.50). Johns Hop- kins University Press, Baltimore.

For anyone involved with or attracted by the psychoanalytic method, one question that must be asked is how does one ac- count for change? Are we still to believe in Freud’s original metaphor of a differ- entiated psyche of ego, id, and superego? Do we continue to accept notions like the transformation of the ego, resolutions of oedipal trauma, the renunciation of instincts, and the power of identification? And d o we still put faith in psychoanalytic interpretations of significant social movements?

Weinstein and Platt have taken on perhaps the most profound theoretical issues facing students of human behavior. In light of individual psychological theories that advance notions of individual unique- ness and indeed idiosyncratic behavior, how does one explain concerted social action at various times in history, and then in- terpret the resulting patterns of individual development that follow from these changes? This volume represents a most

significant accomplishment. To my knowledge, no recent book has so profoundly argued for the interdependence of the psychic system and the social system, and in the process honored both individual action and the impact of social institutions, history, and, ultimately, cultural values.

Perhaps the central theoretical point of these authors is that the id, Freud’s old seething cauldron of instincts and source of drive energy, is

. . . structured to a significant degree by cultural and social influences so that codified expression of new standards and expectations derive from the external world . . . They derive, according to the authors, through the mechanisms of identification and internalization, the very mechanisms that early psychoanalytic theory claimed to function primarily in the realm of intra- psychic dynamics. Said more simply-although this volume’s concise arguments cannot easily be simplified-the idea that children are socialized to the extent that id drives are quelled, that parents are the major agents through which the internalization of cultural values happens, and, most importantly, that personalities are formed somewhere near the time of the resolution of the oedipal conflict, clearly d o not explain reality. Not until historical and social structural variables are consid- ered can we begin to understand the development of single human beings, the collective action of human groups, and the reasons behind an enduring social order.

One of the many criticisms leveled at Talcott Parsons, particularly in his works on the family and personality, has been that his sociological theory does “nothing more” than turn psychological words into sociological words. Nothing could be farther from the truth, as a close reading of Psychoanalytic Sociology reveals. Wein- stein and Platt, while preserving many of Freud’s and Erikson’s original statements, turn Freud totally around. It is not, they argue, that

. . . social organization is merely a reflection of internal conflict and its resolution in the family, and that the types of conflict which occur within the individual because of life in


the family will be displaced on to the wider world. [Rather,] changes at the level of social structure have prompted systematic changes at the psychic level. [Thus,] there is a sociological side to psychoanalytic problems.

Once again, the implication of such statements is that personality develops at all ages because, throughout the life cycle, the person confronts aspects of the social system as well as changes in it . Moreover, he or she is born into a social system in which symbols and objects, political and economic structures, and patterns of mor- ality already exist in elaborately codified forms. The family represents but one such social system, hardly the only one. Images and their perceptions, objects lost and recovered, will remain as part of the ego's mastering of reality. They will also remain as part of the content of the id. Thus, one may draw in this new theoretical statement a direct experiential union of social structure and the unconscious, although this union must itself be placed in appropriate historical contexts. In the authors' words,

We may conclude that socialization occurs at all levels of the personality and that the consequent thoughts and behaviors are linked to the common culture. There are no actions which do not have sociuf significance, and there are no thoughts which are not to some recognizable degree structured by particular historical and social circumstances.

Taking the argument one step further, unconscious wishes and repressed fantasies may be brought not only to consciousness, but may be further transformed into a shared ideology which then forms the basis for new action at both personal a n d collective levels. It is not accurate to suggest, therefore, that the traits or behavior of great historical figures change the course of human events, as many writers seem to suggest in their biographies and especially psychobiographies. Indeed, one of the many problems facing contemporary psy- cohistorians, the authors claim,

. . . stems in part from an implicit but mis- taken assumption that the behavior of the mass can be inferred from the behnvior of the leader.

It should not be inferred from all this

that Weinstein and Platt would d o away with the theoretical and methodological components of psychoanalysis. To the con- trary, what Freud demonstrated in Civiliza- tion and its Discontents, is precisely the need to look a t individual reactions to sociological events: Without psychoanalytic theory the variety of human responses to social change cannot be explained in any comprehensive way.

Still, psychoanalysts and historians must be careful not to view innovative behavior eternally as repressive, neurotic, or inappropriate, or to define behavior always in terms of libido, the control of anxiety, or the resolution of guilt. Always the criteria for evaluating personal and social action as rational or irrational must be examined. When they are not, one is left with a plethora of studies constantly explaining revolutionary movements in terms of oedipal rebellion, narcissism, or the re- sponse to abandonment and betrayal. At a11 moments in history, tangible political and social inequities must be redressed and contemporary forms of grievance internal- ized. To consistently psychoanalyze social movements is not only to neutralize them, it is to miss completely the points of their origin, object, and meaning. In the end, a psychoanalytic sociology is required to understand and honor momentous social and psychological transformations.- Thomas J . Cottle, Children's Defensc Fund, Washington Research Project, Cam- bridge, Mass.

ATTITUDES TOWARD MENTAL PATIENTS: A Study Across Cultures. Alexander Askenasy. 1974. 322 pp. $16.00. Mouton, The Hague (U.S. distributors MacFarland Co., Scotch Plains, N.J.; Humanities Press, Atlantic Highlands, N.1.)

Two complementary studies are reported in this book, both concerning attitudes relevant to the rehabilitation of former mental patients and both using a cross-cultural perspective. The first concerns attitudes of mental health workers toward mental illness, characteristics of mental patients, their subsequent employment and related issues. The second. co-authored by


Marisa Zavalloni, concerns attitiides of the working public toward the occupational rehabilitation of former mental patients. In the first study, over 1000 staff members of hospitals in Delaware, Hawaii, and two hospitals in England were surveyed; in the second, I170 residents in the catchment areas of these four hospitals were selected for study.

The first investigation, concerning attitudes of mental health personnel, com- prises two-thirds of the book. After a brief presentation of factors previously found to be associated with attitudes toward mental illness, and a selective literature review of some major previous studies, the instru- ment development and subject selection for the present undertaking are described in detail. Respondents from the four hospitals were drawn from six occupational categories, ranging from attendants to psychiatrists and including counselors who serve patients in the community after their hospital discharge. In 1960 and 1961, all were asked to complete a four-part ques- tionnaire that included items from Cohen and Strucning’s OM1 Scale, semantic differential scales, and multiple-choice and open-ended questions devised for this study. The hospitals were ranked along a progressive-conservative dimension with respect to their official policies and prac- tices regarding use of open wards, amount of responsibility given to patients, emphasis on prompt discharge, and amount of post-hospitalization support provided. The two English hospitals occupied the extreme positions on this dimension, the American hospitals the intermediate ones. In 1955, five years before the currcnt study, the most progressive hospital discharged 37% of patients treated in a given year, compared to 26% or 27% for the other three hospitals.

Results gathered with this complex ques- tionnaire are presentcd in meticulous detail in five subsequent chapters. Fortu- nately for the reader who is not concerned with the nuances of the data analyses, which are presented in 91 tables and the text, each chapter is effectivcly summar- ized. Following presentation of results, major findings regarding variablcs influ- encing attitudes of mental health workers

are discussed and integrated, and recom- mendations for future research and rehabilitation programs are offered.

The major variables that Askenasy worked with-occupation, hospital setting, and cultural m e m b e r s h i p w e r e found to be significant attitudinal determinants both separately and in interaction. For example, the less formal training a respondent had received, the stronger were the effects of cultural traditions on his attitudes. Hos- pital policy was found more strongly related to attitudes of psychiatrists than other occupational groups, perhaps because psychiatrists are most influential in determin- ing such policies. Occupation was strongly related to attitudes, but its effect was modi- fied by the hospital and cultural settings. In general, these results serve to replicate and thus reinforce conclusions derived from earlier studies concerning the impact of occupation, amount of training, social class and other respondent characteristics on attitudes about mental illness and patient rehabilitation. As such, they serve to consolidate, strengthen, and extend our knowledge about attitudes of different groups of mental health workers and factors that help determine them.

The second study reported in this volume explores relatively uncharted ground. The authors sought to determine whether public attitudes are generally positive or ncgative toward mental patients, how they feel about their employment, and how they define the term “mental illness.” To obtain answers to these issues, respondents were asked whether properly trained, formerly hospitalized people could be trusted in 23 different categories of occupation; a social distance scale was administered, OM1 items werc presented, and respondents were asked to define “nervous breakdown” and “mental illness.”

The 23 different occupations were ranked according to the percent of respondents who trusted ex-patients to work in them. They were most willing to trust ex- patients in jobs entailing little skill o r prestige, and least willing to trust them in positions of power, prestige, and responsibility.

In general, strong relationships were found between various beliefs, attitudes


and perceptions regarding the mentally ill. Thus, one group of respondents perceived mental patients as indistinguishable from other people, able to succeed, and trust- worthy in positions of power and responsibility. Another group of respondents, a minority like the first, were characteris- tically intolerant, perceiving mental patients as qualititatively different from other pcople, as dangerous, untrustworthy, probably incurable and always liable to relapse. Members of the latter groups were apt to be less educated and of lower occupational status than members of the former.

The authors also explored the relatively uncharted area of how people define the term “mental illness.” It is usually assumed by investigators in the field that the layman associates psychiatric hospitalization with the label of mental illness, but the issue has received little empirical study. Zavalloni and Askenasy found that, for their sample, there exists an intermediate category between health and illness, which is a nervous breakdown. It is perceived as the product of environmental pressures, as temporary and curable, and requiring only brief hospitalization. In contrast, mental illness is seen as essentially incurable, af- fecting all areas of functioning, requiring long hospitalization, and as more handi- capping with respect to future vocational activities.

In general, these two studies are care- fully formulated, well-executed, and in- telligently presented. The first serves to consolidate findings suggested by earlier research, while the second is more explor- atory in nature. Both contribute to a n understanding of professional and public attitudes about mental illness. An additional contribution might have come out of greater attention to the nature of the rcla- tionships and interactions between the findings of the two studies, since the correspondence between public and professional attitudes is a subject that warrants more systematic scrutiny than it has received in the literature. The authors also raised, but did not fully answer, several interesting questions regarding inconsistencies in previous results reported in this area. For example, they wonder whether optimistic or pessimistic public views about mental ill-

ness prevail, and whether the context of deviancy vs. illness influences respondents’ attitudes about mental patients. Some findings are related to these questions, but a more extended, focused discussion would be valuable. Nevertheless, the book is in- formative and complete as it stands, and is highly recommended to students and researchers interested in attitudes about mental illness and the vocational rehabilitation of mental patients.-Judith G . Rab- kin, Associate Research Scientist, Epidemi- ology of Mental Disorders Research Unit, New York State Department of Mental Hygiene.

THE DEPRESSED WOMAN: A Study of Social Relationships. Myrna M. Weissrnan and Eu- gene S. Paykel (foreword by Gerald L. Kler- man). 1974. 289 pp. $10.00. University of Chicago Press, Chicago.

This is a book whose importance goes far beyond the data gathered on 40 depressed women outpatients and their 40 matched control neighbors. The authors add significantly to the current interest in depression, by focirsing on “what depressed people are like in their daily lives,” both during and after an acute depressive episode.

The book itself is well written, amaz- ingly concise for its richness of conceptual sophistication, and provides a thoughtful integration of biological, social, intra- psychic, and treatment variables. In this, the authors of the book and its foreword reflect the findings not only of the present study, but of a large body of previous work in the same area, by themselves and others.

The findings are worth summarizing. Not surprisingly, the patients showed problems in performance of, and satisfaction with, social roles persisting after recovery from the acute episode. This dysfunction cut across a variety of social roles, and was more marked in work and in intimate relationships of marriage and parenthood, than in relationships with extended family, friends, and acquaintances. Work impairment was less for employed women than for housewives. Depressed mothers tended to have problems with their children, which varied in expression with the age of the child: discussion of this topic i n detail is

REVIEWS OF THE LITERATURE 181

one of the most important parts of the work.

In the marriages, these depressed women were more reticent in communication, more submissive and dependent, felt less affection towards and more friction with their spouses, and had very little interest in sexual relationships-all in marked contrast to the controls. Impaired autonomy, intimacy, and communication were striking. These findings were particularly strong where there was premorbid marital unhappiness.

In the mother-child relationships, dis- turbances were particularly severe at transition stages in children’s lives, such as postpartum stage ( a small number), in- fancy, and adolescence of the children.

Factor analysis of impairment indices yielded six factors, interpreted as work performance, interpersonal friction, inhibited communication, submissive dependency, family attachment, and anxious rumination. These factors cut across particular social roles and social fields.

Reevaluation of treated patients was provided at two, four, and eight months of treatment, and at twenty-month follow-up. Patients who were recovering from the acute episode showed most improvement in the factors of work impairment and anxious rumination. Inhibited communication and interpersonal friction continued to distinguish patients from controls. Patients showing clinical relapse worsened most dramatically on work performance, family attachment, and submissive dependency. Social recovery occurred most rapidly in the first two months, but lagged far behind recovery from symptoms. The patient was still likely to be considerably impaired in social function at a time when she was symptom-free. Symptom intensity and SO- cia1 maladaptation correlated poorly at the height of the illness (within the clinical sample) but showed considerable overlap during the residual period.

The authors are appropriately cautious about drawing conclusions about treatment efficacy. All patients were on tricyclic an- tidepressants; half also received psychotherapy, consisting of one to three 45- minute sessions per week with an experienced woman social worker (the kind of

therapist also found most helpful to depressed women by Orlinsky and How- ard ”), while half received assessment and medication interviews only. Symptomatic remission did not vary with intensity of psychotherapy contact, but improvement of social impairment did. At two months, patients receiving psychotherapy showed significantly less interpersonal friction, family attachment, and anxious rumination; they dealt better with role areas of nuclear family and parenthood, while being a little more impaired in the work role (possibly reflecting the emphasis of the therapy). After eight months of therapy, for those who had not relapsed, psychotherapy patients were significantly better than low-contact patients, and closer to normal controls, in work performance, interpersonal friction, and communication. Submissive dependency was apparently harder to reverse in this relatively brief therapy. Therapy patients, after recovery, did not differ significantly from controls in work, extended family relationships, marriages, or with their children. They were still significantly impaired in social and leisure activities. In other words, psychotherapy appeared to be relatively ineffec- tive in treating the acute illness, or in pre- venting relapse, but it did appear to lessen the residual social impairment in those who recovered from symptoms.

The authors are appropriately cautious in generalizing from this sample (predom- inantly white, married, working-class WO-

men of Italian Catholic background, typical in the New Haven community studied). They are to be commended for the thor- oughness of the study and its associated literature review and theoretical discussion, and the modesty of their claims to gen- eralizability. An incidental finding of considerable interest was the relatively good adaptation of their nonclinical “normal neighbor” control sample-in contrast to some community studies showing high prevalence of disturbing symptoms among nonclinical populations,’ I 4 but in agree- ment with other studies of “normal” populations.2

A brief summary does not d o justice to the richness of this short book. It is a veritable model for presentatioll of clinical


research, in terms of the importance of topic, careful design of the study, and clear description of methods (unobtrusive to the student who does not read research language well, but amply documented for the benefit of the more research-oriented reader). This book would be highly appropriate for beginning or advanced clinicians. or as reading in courses in research methods in clinical mental health disciplines. The simplicity of the language belies the sophistication of the concepts. Unfortu- nately, it is still rare to find a short book with such widespread usefulness for both clinical and research-oriented audiences of varying levels of experience.-Anne M. Seiden, M.D., Director of Research, Insti- tute f o r Juvenile Research, Chicago.

REFERENCES 1. LEIGHTON, D. A N D ALEXANDER, H . 1967. 111

Comprehensive Textbook of Psychiatry, A. Freedman and H. Kaplan, eds. Williams and Wilkins, Baltimore.

2. OFFER, D. 1969. The Psychological World of the Teenager. Basic Books, New York.

ties of Psychotherapeutic Experience: Mul- tivariate Analyses of Patients’ and Thera- pists’ Reports. Teachers College Press (Co- lumbia University), New York.

4. SROLE, L. ET AL. 1962. Mental Health in the Metropolis. McGraw-Hill, New York.

3. ORLINSKY, D. AND HOWARD, K . 1975. Varie-

ADOLESCENT PSYCHIATRY Volume II: Develop- mental and Clinical Studies. Sherman C. Feinstein and Peter L. Giovacchini, eds. 1973. 450 pp. $15.00. Basic Books, New York.

ADOLESCENT PSYCHIATRY, Volume 111: Develop- mental and Clinical Studies. Sherman C. Feinstein and Peter 1. Giovacchini, eds. 1974. 456 pp. $17.50. Basic Books, New York.

When Volume I of this series of annual publications sponsored by the American Society for Adolescent Psychiatry was discussed, * this reviewer was extremely criti- cal of its narrow focus. its chauvinistic theoretical orientation (mostly early psychoanalytic thought), and its minimal repre- sentation of the multidisciplinary views of

* Amer. J . Orthopsychiat. 1972, 42(5):884- 887.

many young. creative mental health workers. The two subsequent volumes are a major improvement over Volume I. In fact, Volume 111 comes closest to what the editors described as their aim: “encouraging communication among behavioral scientists of different backgrounds” in the area of adolescent growth, development, pathology and treatment ( p . xi, preface to Vol. 111).

In these volumes well-known names are present, appearing sometimes for a second or even a third time-E. J . Anthony (with an excellent article on self therapy in adolescence. stressing the creative growth processes of that developmental stage), Na- gera. Winnicott, Salzman. Offer, Farns- worth, and Josselyn. But there is a major effort, particularly in Volume 111, to broaden the areas of interest. Included are chapters on medical settings (Schildkrout: Reich and Feinberg) ; family therapy (Stier- l in , Levi and Savard: Offer and Van- derstoep) ; the disadvantaged adolescent ( Kohen-Raz. who descrihes his research on disadvantaged Israeli youth) : psychiatric hospitalizstion (Nichtern; Greenwood; Rinsley) ; war and youth (Rascovsky); de- linquency and violence (Copeland; Kalog- crakis: Marohn) . There is an article on the use of non-treatment oriented group process in a high school crisis (Sugar) . and one on mental health services for adoles- cents by Judge Justine Wise Polier. There is even an attempt to bring an international scope to the series (chapters by South American psychiatrists, and a short but valuable article on Israeli youth). Otto Pollack. a sociologist, and Ludwig von Bertalanffy, the leader in general systems theory. are both represented.

The clinical articles still comprise the ma- jority of ch:ipters. Although thcy are often exciting. thcy sometimes appear too short or seem to resemble lectures that were transferred to print. rather than scholarly art ides.

Yet I canie away from these volumes with a number of dissatisfactions. One is struck by thc dearth of research studies and the absence of discussion of research issues in adolescence. For example, longitudinnl studies arc not even nicntioned. There is also an extraordinary amount of repetition ( the psychosocial issues of adolescence are


defined over and over again, albeit in different words). Moses Laufer ( a nonmedical psychoanalyst who is doing some very creative work in London), in his article in Vol- ume 11. best summarizes the feelings I had:

These views avoided a much more basic fact, that is. that the psychological process of adolescence is itself inadequately understood. A glance at the literature soon confirms this. The most recent contributions repeat a few basic assumptions about the tasks of adolescence. We felt that the level and the quality of investigations being reported were not ex- amining anything beyond our present knowledge, nor did we feel that such generalized umbrella concepts, which are used both in psychoanalytic thinking and in sociological studies. helped (for example. identity crisis. conflict of generations, role reversal) in any further understanding of the process of adolescence itself or of psychopathology. (p. 5 7 )

Laufer has posed the challenge for the future volumes of this series. From the development of this set of volumes, it appears more and more possible that the editors may rise to the challenge in the future with articles on prevention (consulta- tion and education. for example. or family planning in adolescence). on the mentally retarded adolescent, on the brain damaged adolescent. and on the abused adolescent, as well as more substantive articles on those economic. cultural. and social factors that must be understood i f we arc indeed to develop programs that can go beyond the repetition of stock phrases (which often result only in the illusion of understanding) towards practical and sophisti- cated suggestions for a well planned national social policy for youth.-Milton F. Shore, Ph .D . . Mentcrl Hcaltli Stridji Ceuter. National Itistittrtc ol Mentcil Heal th

WHAT TO DO ABOUT YOUR BRAIN-INJURED CHILD: Or Your Brain-damaged, Mentally Retarded, Cerebral Palsied, Spastic, Flaccid, Rigid, Epileptic Autistic, Athetoid, Hyperac- tive Child. Glenn Dornan. 1974. 291 pp. $7.95. Doubleday, New York.

Doman’s book on the child who is brain injured (or brain damaged. mentally retarded, etc.) is distinctly encouraging. H e makes some points which clearly need to be made, such as that parents arc not stupid or so emotionally involved that they

cannot recognize when therc is a problem with their child. They can also prove ef- fectual in remediation. H c believes help is possible and that we can deal with the problem through channels other than hand-wringing and prayer.

The method he proposes-the oft-discussed Doman-Delacato approach-is not universally accepted by those who work in the field. But there is much more in the book than sharing how their particular theory evolved, although that, in itself, is fascinating. We see at work a creative mind brave enough to follow intuitions, test even seemingly hair-brained hypotheses, follow through with dogged detcrmina- tion-all the characteristics current work in the field of creativity suggests differentiate the mere highly intelligent from the highly intelligent and creative individual. Doman describes the semi-ridicule he and his associates had to endure from the es- tablishment, but also shows the sort of dedication and willingness to push on that arc essential for genuine innovation or original production in any field.

The reader will see the gradual refine- ment of tools which permit more and more precise evaluation of progress for these “hurt children,” to employ the phrase he so often applies. It is not especially scien- tific to say children, after therapy, are better. Better how? To what degree better? Incontrovertibly? Or-more succinctly- scz who? Just this emotionally-involved parent and ego-involved therapist? We see each of the tasks which distinguish us as being human broken down into separate testable components so that thc distance from here to therc, and the rapidity of movement, can be generally agreed upon.

The folly of treating symptoms is demonstrated. This seems so obvious now, but. actually it was not so long ago that physi- cianc trcated affected parts rathcr than the dysfunctional brain which caused the problem farther away in the body. As with carlier polio victims, we see patients en- cased in braces and supports which would inevitably cause further atrophication and loss of function.

Wc also may understand more completely why children with reading difficul- tics arc required to crawl, though thcy may


be well up in years. Mobility is described as being the result of four stages (movement without mobility, crawling, creeping, and walking). If any stage is short- changed, problems arise later, because creeping and crawling were presented as being essential for proper programming of the brain. The two hemispheres of the brain could not work together as they should, the result being either a major or minor neurological problem. Better late than never, or insufficiently, if this stage in the acquisition of mobility had not run its course and accomplished its prescribed function.

Doman clearly believes that structure follows function, instead of the reverse. Undeveloped chests expand with application of breathing exercises which necessi- tate growth. Doman didn’t say it, but his line of reasoning would support those who assert that man did not think because of his larger brain, but developed the larger brain due to his thinking.

The book is exciting. A basic optimism regarding the growth and development of all children comes through. The extreme competence of young children is illustrated time and again, from accelerated swim- ming in Australia to Suzuki violin playing in Japan to easy mastery of reading at age two or three, if we print large enough. Plus the sheer joie de vivre that the child -or adult stroke patient-experiences as he is assisted to progress to ever higher levels of performance. The capacity is in- herent, and utilization of that ability must be a delight to experience as well as to observe in others. Just as entrapment of ability through lack of understanding or technique is overwhelmingly frustrating for both those who feel and those who see it in fellow human beings.

So the book, though it is more specifi- cally related to these particular “hurt children,” has far wider implications than the title might suggest. Also, as the author documents, more readers might be classi- fied as brain-injured than they compla- cently might first assume. The book, then, is about and for us-not them.-Ann Trabue Bass, Profesror of Educational Psychology, Indiana Stare University, Terre Haute, Ind.

THE VICTIM IS ALWAYS THE SAME. I.S. Cooper. 1973. 165 pp. $7.95. Harper & Row, New York.

Two nights after reading this book I had a nightmare. I dreamt my wife and I visited a mental hospital to see our children. Filled with anxiety and dread, we walked down long, painted brick corridors to a day-room. The whole place was cold and institutional, more like a prison than a hospital. Our kids weren’t in the day- room. When I asked the person in charge where they were, the answer came, “They’re in the punishment room.’’ Shak- ing with rage, I demanded that they be released at once, and announced that we were going to take them out of the hospital.

After waking I realized that I wasn’t just shaking from rage. I felt terribly guilty that I had allowed my children t o be taken from me only to be treated so badly. Whatever else this dream reflects about my life, the immediate stimulus was, without doubt, the book I had so recently finished.

I.S. Cooper is a neurosurgeon. His book deals with the neurosurgical treatment of several patients suffering from dystonia musculorum deformans, a severely incapa- citating, genetically linked disease char- acterized by body contortions, rigidity, spasms, and grotesque deformity. His book examines what it feels like to be a patient, and what it feels like to be a pioneering surgeon. Cooper is also something of il philosopher. H e confronts the agonies of deciding what is ethical and proper behavior for a surgeon working on the leading edge of medical knowledge. H e also ex- poses some of his colleagues’ medical and psychological malpractice, and the awful arrogance of some members of the helping professions.

Cooper records through the words of his patients the damage done by professionals who didn’t recognize dystonia, or recognized it but didn’t know it could be treated. Yet it wasn’t their ignorance that did the damage; i t was their refusal to acknowledge i t . Rather than admit being bam.ed by the symptoms, they accused the families of the patients (and i t was heard as an accusation even if not offered that way) of being too demanding, too rigid,


too perfectionistic, too sornerhing-anything that would relieve the professional of the burden of saying “I don’t know.” The sufferers themselves were accused of seek- ing attention, were dismissed as hysterics, or were heaped with psychiatric jargon. They were prodded into psychiatric hospitals by psychiatrists, and pushed into small, unadorned rooms in these hospitals by psychologists.

It’s worth noting that neither orientation nor field of specialization saved the professionals from the clutches of ignorance and arrogance. Patients were misdiagnosed by neurologists, general practitioners, and pediatricians; mistreated by psychiatrists, psychologists, hypnotherapists, and ortho- pedists; mishandled by Freudians and be- haviorists; and mystified by dynamic theo- rists and family therapists.

One example. Confronted with a case of dystonia, a hospital psychiatrist initiated psychotherapy three times a week for 146 sessions. In his closing summary he wrote:

When this seventeen-year-old single, white male was admitted, he had a severe motor disturbance in walking, giving him a grotesque, unco-ordinated gait so that his arms and legs and trunk seemed to have no control. . . His right hand, when in use, would be flexed at the wrist and his hand would be formed in a fist. . . Whenever he touched his penis with his right hand, he lost his sexual desire. This was obviously related to his cas- tration anxiety and he was behaving as though he was castrated and had no penis. He learned in good time a good deal about the meaning of his symptoms, how his stick- ing his stomach out was, on the one hand, imitating his mother’s pregnancy with his younger sister, whereas, on the other hand, it was putting his penis forward and asserting himself as a man. . . He gained a good deal of insight into his feminine identification and his attraction to men. His forward movement of the penis tells us that it also had the pur- pose of closing off his anus from attack from the rear. Although the patient’s gait didn’t improve during his stay, his relationship with his family was much better, so that he was more comfortable being with his parents and sister at the time he left the hospital. It seems he wasn’t at all ready to give up his symptoms as yet because they were giving him much too much gratification to be relinquished. This would be the area that had to be worked on a great deal in his future treatment.

DAVID

DIAGNOSIS ON DISCHARGE: psychoneurosis, Con- version hysteria

53 1

Given case after case of this kind of treatment, and given the tendency among some neurosurgeons to equate a disor- dered life with a diseased brain, one might expect Cooper to conclude that psychiatry is more madness than medicine. But he makes instead the oft-neglected distinction between psychiatry and bad psychiatry. In Cooper’s words,

I should like to state without qualification that an indictment of psychiatry and the behavioral sciences is neither intended nor im- plied. In certain instances, which are cited, this discipline was abused. This is sometimes true of other disciplines as well-my own included. The developing behavioral sciences, however, now and in the future, are among the great comforts and hopes of mankind. (pp. xviii-xix)

The book raises issues of medical ethics confronting the profession today. It dis- cusses at some length the effects of tech- nology on medicine, and takes a long glance at the issues of informed consent, the need for preliminary animal experi- mentation, the weighing of risk and gain, and the all important question of who is to gain from experimental research.-Jules Older, Ph.D., University of Otago. Dune- din, New Zealand

CONDITION ON DISCHARGE: improved. (pp. 51-

FRITZ: An Intimate Portrait of Fritz Perls and Gestalt Therapy. Martin Shepard. 1975. $9.50 (paper, $3.95). Saturday Review Press, New York.

A basic tenet of Gestalt psychology is that the whole is greater than the sum of its parts. The author of this biography, tries to construct a total picture of his subject by bringing to the foreground a few specific elements and unifying the mosaic with his own analytic interpretation. Although many of the elements of Frederick S. Perk’s life are present, the book fails to portray a complete image of Fritz as therapist and theoretician, man and lover.

This “intimate portrait” is a collection of memories twice removed from the actual events, and it leaves one longing for a


sense of now, so central to Gestalt Therapy. In his own rhetoric, Shepard says,

To best understand Fritz requires that we dis- pense with explanations offered by analysts and mystics alike. Pure description of what occurred is sufficient.

However, much of what Shepard writes is interpretation and analysis of only a lim- ited number of transactions and experiences that may have led to Fritz’s acting out his script. Shepard separates the reader from the biography and stumbles into spec- ulation with an attempt to reconstruct the historical, familial, and cultural roots of Fritz’s personality. Disappointingly little attention is paid to Fritz’s theoretical contributions and to their impact on the field of psychotherapy. The book dwells heavily on Fritz’s relationships with various lovers and gives only cursory coverage to his relationships with others who had significant impact on his life-including his wife, Laura, who first introduced him to the prin- ciples of Gestalt psychology.

Shepard’s portrait of Fritz is a caricature of a rascally old man who looks like a bald- headed Santa Claus, with a large mouth sometimes containing an inserted foot. Much of the body is dwarfed by a robust belly housing unusual insight and sensitiv- ity, while stallion-like genitals are ever in search of fair maidens. What is missing in this caricature is the image of the actual person. The overdetailing of some aspects and the minimizatjon of others do not represent the Fritz I and others knew. Shepard produces a recognizable image but much is missing.

The frequent references to Fritz’s sexu- ality seem to be a flaunting of only one as- pect of a brilliant and unpredictable personality. The analytical side of Fritz, as well as the impact he had on people’s lives, is underplayed, while his dislike for banal- ity becomes a central focus. Only on close examination does the reader see that Fritz could be lewd or loving, nasty or funny, cheap or extravagant, crude or kind-none of which he bothered to hide. He didn’t hide because he was the living example of Gestalt Therapy-an approach which he refined for himself, to contend with the conflicts of his own polarities.

Fritz learned from the school of life what it means when a parent doesn’t love his child, and how people tend to perpetu- ate antagonistic relationships. He learned what it felt like to be an outsider and to be discriminated against. He learned heroism, felt pain, knew how to endure loneliness and isolation. As a child he acquired an appreciation so strong that he perpetually strove to make living simultaneously artis- tic, dramatic, and exciting. If you take Fritz’s childlike curiosity, add a great capacity to synthesize and integrate the ideas and techniques of others with his in- tuitive sense of life, and mix thoroughly, you will have discovered the recipe for Fritz’s abilities as both therapist and teacher, for whatever he learned of value he immediately passed on to others.

Shepard has shown that Fritz Perk was cognizant of the fact that emotional suffering is related to the degree to which people are not sufficiently aware of what is oc- curring in the ever-present now-that un- met needs and undischarged tensions cause stress and, in sufficient quantity, are re- sponsible for mental illness. He recognized that some people live perpetually in the past, ruminating about “what I should have done . . . what I should have said,” or blame their parents or spouses for their lack of present-day fulfillment. Others miss out on life’s riches by being future oriented, always preparing and daydream- ing for a tomorrow that never occurs.

Fritz taught people that it was all right to put their needs first, because he would invariably put his desires first. He per- mitted, by his example, honest self-interest and self-expression, as opposed to un- happy martyrdom, false compassion, or tortured retroflected accusations of selfish- ness. He taught courage by holding to his convictions and, with skill and tenacity, getting a hostile and indifferent psychiatric community to give him a fair and important hearing.

Like Emerson, Fritz believed that the only thing that made sense, in the end, is for each of us to follow our own intuition and interests, to fully experience the process of being alive, and to live in the now. -Richard G . Erskine, Ph.D., Assistant Professor, University of Illinois, Urbana- Champaign, Ill.


INTEGRATE0 PSYCHIATRIC TREATMENT. Julian Lieb and Andrew Edmund Slaby. 1975. 190 pp. $9.75. Harper & Row, Hagerstown, Md.

Early on in one’s development as a mental health professional, an orientation toward the assessment and treatment of patients is chosen which consumes one‘s academic and clinical time and energy at the expense of other equally valid and often complementary orientations. There are no “renais- sance men” or women in the various mental health fields simply because a complete knowledge of human functioning entails so much. One’s orientation to and understanding of human functioning are prod- ucts not only of the profession chosen- social work as opposed to psychology or psychiatry-but also of one’s particular institutions of academic training and early professional experiences. The result is a tendency to view patients with a kind of “tunnel vision,” according to one’s own personal approach to the possible reasons why people suffer psychic pain. The use of a particular model, say the authors of this volume, implies a particular reference to etioIogy. Since the etiology of any given disorder is usually multi-determined, a rigid adherence to one model is really inappropriate. This manual is a plea for awareness of other models of personality, deviance, and intervention outside of one’s areas of interest and competence.

The cornerstone of the book is its synthesis of several approaches to psychiatric practice, There are many excellent sections which present a blend of relevant literature and practical advice in the areas of epide- miology, psychopharmacology, psychology, medicine, and psychoanalysis. How- ever, the authors seem to lean more toward the medical model, while giving compara- tively less attention to psychodynamic theory. Psychoanalytic explanations of certain disorders are often overly simplified and important developments in psychoanalytic theory, such as Bibring‘s contribution to the theory of depression, are omitted. Lieb and Slaby more than make up for this with their many references to lesser known areas of psychiatry, as in their discussions of the differences between British and American notions of schizo-

phrenia and the nosology and etiology of some disorders.

Great pains are taken by the authors to instruct their readers to base treatment planning on a thorough understanding of all facets of human functioning-psychological, biological, and sociological. The treatment planning itself is a blend not only of theory, but also of plain common sense and sound clinical judgment that can only be a product of the authors’ experience. This is especially evident in their fine chapters on schizophrenia, mood disorders, alcoholism, and chronic brain syndromes. The relationship between a patient’s total history in conjunction with the presenting picture is well handled in these chapters. One would have wished for a similar discussion of borderline states-a most confusing entity for most neophyte and many experienced clinicians.

The chapter on schizophrenia deserves special mention here. There is an excellent description of symptoms and types of schizophrenia, which provides a good in- troduction to these disorders for those new to the field, as well as a fine overview for those professionals whose recent experience has not brought them into close contact with a significant number of persons so afflicted.

This manual will prove to be very useful for those mental health professionals and para-professionals whose training has not included such basic and important areas as the early detection of pyschoactive drug side effects, the assessment of suicidal po- tential, differential diagnosis and treatment planning, and the handling of a variety of resistances to treatment. The clinician is given many useful caveats to take into ac- count day-to-day problems of living, such as living arrangements and financial problems, of persons presenting themselves for psychiatric help.

The chapter on psychoactive medication will be very useful to all psychiatric clinicians, but especially to non-medical therapists who deal with patients who take these drugs. However, the use of trade names of common drugs is not uniform throughout the book, raising questions as to the audience for whom these discussions were

I88 AMERICAN JOURNAL OF ORTHO PSYCH I ATRY

intended. Since most nonmedical clinicians are more familiar with trade names than with generic names, trade names of drugs should have been used uniformly throughout the text, perhaps with generic names in parenthesis.

In view of the many physical diseases whose early symptoms appear to be of a psychological nature, probably few would argue that it may be preferable for a psychiatric clinician with training in medicine and neurology to examine all persons ap- plying for help for what they perceive to be psychological problems. In most sit- uatioils this is simply not possible and, indeed, it may not even be necessary if nonmedical psychiatric clinicians are alerted to the early symptom constellations and characteristic histories of such entities as Huntington’s chorea, hyperthyroidism, and certain chronic brain syndromes. If more nonmedical psychiatric clinicians were alerted to these kinds of symptoms and his-

tories, perhaps many more persons with these masked diseases could be screened and referred for further diagnostic work and appropriate treatment. Lieb and Slaby take steps in the direction of making clinicians aware of this crucial area of diagnosis and referral.

This book is packed with many useful reviews of the literature and references. An unfortunate omisson was that several works cited in the text were not listed in the bibli- ography.

Even with its few shortcomings, this concise and clearly written book makes a worthwhile contribution to the psychiatric manual genre, particularly when it delves into often neglected areas such as epidemi- ology, and in its striving toward synthesis. The volume deserves a wide audience among the several mental health professions.-Stephen L. White, M.S. W., Cam- bridge Court Clinic, Cambridge, Mass.

reviews of the literature

Documents