B R I T I S H J O U R N A L O F P S YC H I AT RY ( 2 0 0 6 ) , 1 8 8 , 9 4 ^ 9 7
Book reviews
EDITED BY SIDNEY CROWN, FEMI OYEBODE and ROSALIND R AMSAY
Mindfulness and Acceptance :
Expanding the Cognitive ^
Behavioral Tradition
Edited by Steven C. Hayes,Victoria M. Follette
& Marsha M. Linehan. New York: Guilford
Press. 20 04. 319pp. » 30.0 0 (hb).
ISBN159385
ISBN1593850662
0662
The vogue for the past three decades or so
has been to see the ‘correct’ treatment for
depression (as well as a host of other
psychiatric disorders) as being centred on
a combination of medication and CBT
(cognitive–behavioural therapy). Behaviour
therapists criticised the amazing flights of
psychoanalytic fancy that could be occasioned by the simplest phobias or other
clinical disorders. As a form of instructive
ridicule, behaviour therapists used to train
simple actions by direct shaping in people
with chronic mental illness and they
watched with amusement as psychoanalytic
colleagues concocted bizarre symbolic interpretations of behaviours that had known
and simple histories.
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Now we appear to be on the cusp of yet
another revolution in therapy which could
relegate CBT to the history books, rather in
the way it claimed to do in turn to
psychoanalysis. This new approach has not
yet achieved the status of a widely accepted
formal name but hinges on ‘mindfulness and
acceptance’, which are the key buzz words
that pop up again and again in this field.
The new perspective on human behaviour
borrows hugely from Zen Buddhism. Zen
has an exasperating tendency to appear
awfully meaningful from a cursory glance
and yet impenetrable and impracticable to
the clinician anxious to assist patients and
relieve suffering that is all too real.
However, this new multi-authored
tome edited by several distinguished US
professors of psychology is a rigorous
attempt to bring together what is known
empirically about this emerging therapeutic
approach, alongside a comprehensive stab
at demonstrating how it is pragmatically
different from conventional CBT.
Apparently, we learn that Zen teaches
that each moment is complete by itself, and
that the world is perfect as it is. So as a
result, Zen focuses on acceptance, validation and tolerance instead of change.
Finally, in contrast to the experimental
evidence required in psychology, Zen emphasises experiential evidence as a means of
understanding the world.
The clinicians among the many authors
in this text point out for their patients how
liberating it feels to be able to see that your
thoughts are just thoughts and that they are
not ‘you’ or ‘reality’. The simple act of
recognising your thoughts as thoughts can
free you from the distorted reality they
often create and allow for more clearsightedness and a greater sense of manageability in your life.
The idea that the solution to suffering is
to increase acceptance of the here and now,
and decrease craving and attachment that
inevitably keep one clinging to a past that
has changed already, is quite different from
behaviour therapy’s emphasis on developing skills for attaining one’s goals.
Yet, the notion that suffering results
from things not being the way one strongly
wants them to be, or insists they should be, is
very compatible with cognitive–behavioural
therapies; Albert Ellis is perhaps the clearest,
most consistent exponent of this viewpoint.
Even if this new advance overthrows or
fundamentally alters CBT, as this book
optimistically predicts, when are we going
to get an approach in psychiatry that
genuinely transforms the motivation of
our patients so they engage in therapeutic
work in the amazing way the examples in
these books seem to revel in? Or perhaps
my real issue is that such a fervent desire
just isn’t too Zen.
Raj Persaud Gresham Professor for Public
Understanding of Psychiatry,The Maudsley Hospital,
Westways Resource Centre, 49 St James Road,
Croydon CR0 2UR,UK.
E-mail: r.persaud@
r.persaud@iop.kcl.ac.uk
Compassion: Conceptualisations,
Research and Use
in Psychotherapy
Edited by Paul Gilbert. London: Routledge.
20 05. 4 08 pp. »19.99 (pb). ISBN158391983X
I am suspicious of the analysis of virtues.
There seems to me to be a real danger that
all that is best about people will be analysed
and summed up as ‘just’ (and the word
‘just’ is important here) a function of genes
for this or that, or evolutionary pressures,
B OOK R E V I E W S
or social structures, or anything that
diminishes individuality, agency and difference. It is as if a picture restorer were to
say, ‘Well, you realise that the Mona Lisa is
really just paint’; which is true in a sense,
but misses the point about looking at
pictures generally.
So I was not minded to like this book
on first sight. But Professor Paul Gilbert is a
serious player in the field of the study of
affective experience and regulation, both as
a clinician and a researcher; and if he says
that compassion is worth empirical study,
in terms of understanding behaviour and
developing effective treatments, then it
probably is. By the end of the book, I
found myself in agreement: compassion is a
human experience that is of immense
relevance to psychiatrists and psychological
therapists, especially at a time when psychiatry is under pressure to prevent patients
from being violent. My work with patients
has taught me that most violence begins
with the capacity for cruelty, both to the
self and others; and I was fascinated to find
comprehensive theoretical accounts of the
concept of both compassion and cruelty in
this book.
The conceptual part of the book draws
on a wide variety of paradigms: evolutionary psychology, attachment theory, social
learning and Buddhism. The second half of
the book describes compassion as ‘caregiving mentality’, and as an essential for
therapy and therapists. Again, to begin
with, I was sceptical: surely compassion is
something that is essential for everyone, not
just for therapists. Further, I think that
there is a danger of conflating compassion,
empathy and sympathy, and of presenting
the therapeutic encounter as being a warm
and pleasurable experience. As with any
form of psychological development, one
hopes that overall the therapy experience
will ultimately be seen as being positive and
rich, but often the process will involve real
pain, anger, hatred and cruelty in the
therapeutic space between the participants.
It is the negative aspects of the patient that
the therapist must have compassion for,
which in turn means compassion for his or
her own anger, cruelty and pain.
Professor Gilbert and his co-authors
describe this issue well, and by the end of
the book I was convinced that a lack of
compassion for the self is an important
aspect of conditions such as chronic depression and post-traumatic stress disorder, and
of destructive behaviours such as repeated
self-harm. A nice chapter by Lee describes
the effectiveness of identifying a cruel
aspect of the self, and, interestingly, the
lack of effectiveness of standard cognitive
therapy for people who lack compassion
for themselves. I also enjoyed a chapter by
Bates about compassion in group therapy,
not least because it rang so true for me and
my experience of working with forensic
patients in groups.
I came away from the book wanting to
recommend it to colleagues, especially
those working with violent patients or with
patients who self-harm or are cruel to their
bodies in some way. It is a compassionate
book, written in a warm and accessible
style, and I am more convinced now that
understanding the good parts of our nature
is essential for managing the less good
parts. I hope Professor Gilbert and his
colleagues will write more about the virtues
in future.
Gwen Adshead Broadmoor Hospital,
Crowthorne RG45 7EG,UK. E-mail:
gwen.adshead@
gwen.adshead@wlmht.nhs.uk
CANE : Camberwell Assessment
of Need for the Elderly
Edited by Martin Orrell
& Geraldine Hancock.Gaskell: London. 20 04.
208pp. »8 0.0 0 (pb). ISBN1904671063
ISBN1904 671063
Needs assessment has become an imperative for commissioning authorities in
healthcare systems as a way of ensuring
that informed judgements are made on
providing appropriate healthcare for local
populations. The Camberwell Assement of
Need for the Elderly (the CANE) was
developed as a tool to assess the needs of
older people, especially those with mental
health problems.
This is a multi-author volume describing the development and use of the CANE
in different settings. Surprisingly, parts of
the book are highly readable, I suspect
because of the choice of authors. It begins
with a pithy foreword in which Professor
Grimley Evans gives some of the background to the development of needs assessment tools and aims some barbed
comments at the politicians who run the
National Health Service.
As I read the book I realised that needs
assessment has become part of common
medical terminology but previously I had
not fully understood the concept. The
editors provide a helpful introduction in
which they describe the principles of needs
assessment and how definitions have changed. There are chapters on the validation of
the CANE in different settings and interesting asides, for instance explaining the
funding of the German healthcare system.
The CANE itself is available in long
and short forms and needs are determined
in a variety of domains by patients, carers
and professional. It is aimed at multidisciplinary assessment. When I gave the
staff in my day hospital a copy they were
not over-impressed by it, although they did
only use it on a few patients and the
concept of needs assessment is a new one
for them as well. What did strike me was
that the CANE is an ideal way to determine
needs in order either to develop services or
to defend already existing services.
So should you buy this book? Well, it
depends on who you are. I would suggest
that it’s a book that all departments of old
age psychiatry should have and that clinical
directors and managers of old age services
should have access to. Although most
clinicians who pick it up are unlikely to
read it all the way through, the discussion
of needs assessment in itself make purchase
justifiable and once one gets beyond the
bland (although necessary) statistics there is
enough stimulating material to make it a
worthwhile read.
Christopher A.Vassilas Queen Elizabeth
Psychiatric Hospital, Mindelsohn Way,
Edgbaston, Birmingham B15 2QZ,UK.
E-mail: c.a.vassilas@
c.a.vassilas@bham.ac.uk
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B OOK R E V I E W S
Values and Psychiatric Diagnosis
By John Z. Sadler.Oxford: Oxford University
Press. 20 04. 54 0 pp. » 34.95 (pb).
ISBN 0198526377
019852637 7
For more than ten years Sadler has been
thinking about the ways in which psychiatric classification is imbued with judgements of value, even when it purports to be
objective. Operational definitions of psychiatric disorders are intended to be universal, in some sense scientific, and as such
should do away with value judgements.
Sadler, whose massive scholarship is demonstrated in this book, shows the extent
to which such judgements persist and why
this is inevitable.
‘Massive’ is not hyperbole. The message
that psychiatric diagnosis involves values is
not too difficult to convey. What Sadler
shows, however, is how values are involved, not just in the wording of particular
diagnostic categories, but at every step of
the way. They are involved in the very idea
of pinning down psychiatric illnesses and
placing them in categories: the determination that this can be done in a scientific
manner involves ‘value-commitments’.
How the enterprise of creating a classificatory system is undertaken (e.g. with openness to non-psychiatric participation) is
itself a political matter involving ethical
and pragmatic values. Sadler lays bare the
ways in which our world views – involving
culture, religion, sex and gender – can
shape our definitions of mental disorder.
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This was most starkly shown in 1973 when,
in America, homosexuality was voted not
to be a mental disorder. How this is
squared with the underpinning essentialism
of nosology – according to which diseases
have an invariant nature – shows the
complexity of things; because an essence
should be found, not voted in or out (which
sounds more like the social construction of
disorder). What emerges is the importance
of our ontological assumptions: where we
stand on how things are in the world.
It has to be said that this is a long book.
Nevertheless, its individual chapters could
be highly recommended to specific groups
for various purposes – none more so than
the chapter on technology, in which the
need for a balance between technological
practice (which is efficient, productive and
economical) and poietic practice (to do
with creativity, tradition, nature, connectedness) is suggested. Sadler, who is one of
the main movers in the field of the
philosophy of psychiatry, emphasises the
need for balance between scientific and
philosophical understandings, which is
crucial if clinical practice is to aspire to
excellence.
Julian C. Hughes Consultant in Old Age
Psychiatry and Honorary Clinical Senior Lecturer,
NorthTyneside General Hospital and the Institute
for Ageing and Health,University of Newcastle,
NorthTyneside General Hospital, Rake Lane,
North Shields NE29 8NH,UK.
E-mail: j.c.hughes@
j.c.hughes@ncl.ac.uk
Manual of Psychiatric Care
for the Medically Ill
Edited by Antoinette Ambrosino Wyszynski
& Bernard Wyszynski.Washington, DC:
American Psychiatric Publishing. 20 05. 416
pp.US $6
$64.0
4.0 0 (pb). ISBN1585621188
This is a good book. Don’t be deterred by
the flimsy cover and coil binding, which I
viewed with great sceptism on its arrival. It
seemed an unlikely candidate to survive the
rigours of life chez Garden. However, soon
the advantages of the design become
apparent; it is very compact and pages with
useful scales and instruments could be
reproduced with ease (subject to copyright).
You can find your way around. The logical
structure, with largely predictable and
systematic coverage of different systems, is
an advantage both for psychiatrists with
limited medical knowledge and for physicians with little mental health experience.
It is indeed a manual. In each section
there is a useful clinical summary of
conditions described. It combines basic
background medical information, summaries of psychiatric aspects of conditions
with practical ‘how do I . . . ?’ questions
about psychotropic medication, and relevant scales, their uses and limitations in
each clinical setting. Inclusion of a section
on obstetric patients, for whom rapid,
relevant and safe response may be crucial,
is particularly useful for psychiatrists without the luxury of a perinatal mental health
service. The section on capacity is a timely
bonus for UK practitioners, since objective
assessment of capacity will become highly
topical when the Incapacity Act comes into
force.
However, the book does have limitations for the UK reader. There is information about drugs that are unavailable in
the UK, and the use of many abbreviations
unfamiliar to the non-US practitioner requires the reader to make frequent reference to the key. Furthermore, several
important subjects are not covered. For
example, medically unexplained symptoms,
particularly topical in British liaison psychiatry, are addressed by system rather than
as a collective problem, and relevant
psychotherapeutic interventions, such as
reattribution, receive little if any mention.
In addition, the emphasis is on medical
rather than psychotherapeutic intervention,
perhaps reflecting differences in practice on
either side of the Atlantic. It is notable that
the chapter addressing psychological issues
in medical patients is only three pages long.
B OOK R E V I E W S
To be fair, the editors acknowledge these
omissions and others in the preface.
Two chapters deserve a special mention: that on dealing with spiritual matters,
and the epilogue ‘The physician as a
comforter’. I think these chapters reflect
that the book has been written for practitioners at the ‘coalface’, who are asked
regularly about issues associated with dying,
about the veracity of belief systems, be they
religious or otherwise, and may have their
own belief systems challenged by this work.
Here, the book departs from being a
manual, but perhaps fittingly so, since it
reminds clinicians that however expert their
knowledge, medical management and monitoring, their care is incomplete without
consideration and respect for their patients’
feelings and beliefs.
Gill Garden Consultant in Psychological
Medicine, Pilgrim Hospital, Boston PE21 9QS,UK.
E-mail: Gillian.Garden@
Gillian.Garden@ulh.nhs.uk
Textbook of Psychosomatic
Medicine
Edited by James L. Levenson.Washington, DC:
American Psychiatric Publishing. 20 05. 1120
pp.US $169.0 0 (hb). ISBN1585621277
ISBN158562127 7
Isn’t psychosomatic medicine meant to be
defunct, an obsolete term abandoned in the
wake of unproven aetiological theories of
medical illness? Hasn’t it been superseded
by the more practical and evidence-based
subspecialty of liaison psychiatry, or consultation–liaison psychiatry as some prefer
to call it? The speculative formulations of
Alexander and Dunbar have indeed been
discarded but psychosomatic medicine has
enjoyed a recent resurrection, courtesy of
the American Board of Medical Specialties.
In 2001 the American Academy of Psychosomatic Medicine applied successfully to
the American Board of Psychiatry and
Neurology for psychosomatic medicine to
be recognised as a subspecialty of psychiatry. Formal approval was subsequently
obtained from the required professional
bodies and the first certifying examinations
are due to be held in the summer of 2005.
Quite why ‘psychosomatic medicine’ was
chosen as the term to define the subspecialty is not clear, given its association with
dubious historical baggage. However, when
one looks at the scope of the subject, and
the content of this book, the range of
problems is immediately familiar. The
editor has adopted the definition of psychosomatic medicine as the area of psychiatry where practitioners have particular
expertise in the diagnosis and treatment of
psychiatric disorders and difficulties in
medically ill patients. Three groups of
clinical problems are said to fall within its
remit: comorbid psychiatric and general
medical illnesses complicating each other’s
management; somatoform and functional
disorders; and psychiatric disorders that are
a direct consequence of a medical condition
or its treatment. In other words, this is
what most of us in the UK still call ‘liaison
psychiatry’.
New examinations are a gift to academic publishers. In the light of American
Board recognition it is not surprising that
some large textbooks have been published
recently and these will undoubtedly become
required reading for examination candidates. This is the third substantial book in
the field to appear since the millennium. It
is a book on the grand scale and James
Levenson has achieved a considerable
success in bringing it to fruition. This has
been a Herculean task, supported by an
editorial board which has a multinational
membership, with the intention of providing a broadly based perspective.
The book has a conventional format,
being organised into four parts which cover
general principles, clinical symptoms, medical specialties and treatment. By far the
largest part is taken up with a review of
psychiatric disorders in various medical
specialties such as gastroenterology, oncology, cardiology, neurology and paediatrics.
The standard is consistently high. The text
is accompanied by many helpful tables and
there is an emphasis on practical advice
about how to manage difficult clinical
problems. Particularly interesting are the
chapters on ethical and legal issues. Liaison
psychiatrists are becoming increasingly involved in helping resolve ethical dilemmas
in clinical practice and in assessing a
patient’s capacity to refuse or consent to
medical treatment. The problems discussed
in these chapters will be universally familiar
to clinicians, but statutory and case law will
vary considerably from one country to
another.
This is a book for the specialist in
liaison psychiatry or, as the editor would
prefer, psychosomatic medicine. It is therefore likely to have limited appeal, but it will
be an invaluable source of information for
psychiatrists and psychologists whose work
brings them into frequent contact with
general hospital patients. Outside the USA
it will probably be a book for the
institutional library rather than the
personal bookshelf.
Geoffrey Lloyd Visiting Consultant Psychiatrist,
Priory Hospital North London, London
N14 6RA,UK. E-mail: g.glloyd@
g.glloyd@btinternet.com
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