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THE PSYCHIATRISTS. By Arnold A. Rogow.
New York: G.P. Putllam's Sons, pg. 317, $7.95.
This book is based on a truly objective review
of the psychiatric and psychoanalytic literature
and on a total of 490 questionnaires mailed to
every thirtieth name in the directories of the
American Psychiatric Association and the Ameri
can Psychoanalytic Association. Although only
184 questionnaires were returned (149 from the
APA and 35 from the analytic group), a remark
able portrait of the current status of American
psychiatry is provided. The author is not blind to
the limitations produced by his sample, yet wisely
notes that "absolute facts, like absolute virtue and
absolute truth" are difficult indeed to ascertain.
In considering the "Crisis in American Psy
chiatry", evidence is provided that psychiatry has
been oversold in America, both as a therapy and
as a panacea for many problems. Quoting Roy
R. Grinker: "Psychoanalysis, for which many
have sacrificed so much, has not become the ther
apeutic answer; it seems to be mired in a theo
retical rut vigilantly guarded by the orthod0x.
and except for relatively few exampes, prevented
from comingling with science". .Laurence S.
Kubie echos Grinker in commenting: "each de
viant (from an analytic school) tends to create
his own orthodoxy and ultimately to become his
own messiah". Each group tends to push aside the
theories of the others; Freud, however, was a
"?artial" exception in that he cont:nually criti
cIzed and altered his own theories - yet did not
welcome those of others. Additional criticisms
point up that little is known why one patient gets
well and another fails to do so, or why a particular
p~tient succeeds with one therapist after failing
wIth many others. Still others are critical of the
stark reality that psychoanalysis is for the few
and offers little help for the many. A realization
that mental illness may be related to biochemical
or neurophysiological disturbances is on the hori
zon; even the neuroses may eventually yield to
drug therapy and thus require less psychotherapy.
It is interesting to note that almost a third of
the entire study population were involved in a
different occupation before choosing psychiatry
as a career. The great majority were recruited
from some other branch of medicine.
Psychoanalyst Theodore Reik is quoted: "Let
me freely admit that in these 35 years of psy
choanalytic practice, I have had this wish (to
change professions) more than once. I have had
moods in which being a psychoanalyst appeared
to me less a profession than a calamity." It is
probable that most psychiatrists and psycho
analysts have shared such feelings at one time
or another, yet few leave psychiatry. If any change
is made, it is from practice to teaching, research
or administration, or in the reverse direction.
Feelings of inadequacy seem to plague at least
a few of the profession who have the courage to
admit this to themselves. The loneliness and soli
tude of practice is cited as well as the awareness
of the gap between one's limited efforts with a
small number of patients in the face of vast social
When asked to identify the most significant
developments in psychiatry during the past twenty
years, 77 (92 (j) who replied to the questionnaire
named psychopharmacology. In second place, yet
considerably behind, was the rise of community
and social psychiatry, and of equal importance,
the emphasis on ego psychology. These two were
mentioned only 11 times. Only psychopharmaco
logy ranked high among both psychiatrists and
analysts and it is the only development that re
ceived more than half the vote for first place by
the psychiatrists. When asked to identify the most
outstanding psychiatrists and psychoanalysts,
Anna Freud was at the top of the list for both
psychiatrists and psychoanalysts. Among psy·
chiatrists she is foilowed by Karl Menninger, Erik
Erikson, Heinz Hartman and Lawrence Kubie.
For the analysts the only significant order of
mention following Anna Freud was: Heinz Hart
man and Lawrence Kubie. There was then a sharp
drop for the rest in both categories. It is worthy
of comment that almost all the high ranking
figures mentioned by both psychiatrists and
analysts are analysts. This certainly suggests
that there is as yet no replacement for psycho
analytic theory, despite the "drug revolution" and
other innovations in therapy.
The view that society itself may be sick, rather
than human nature, expresses the feelings of many
psychiatrists and psychoanalysts. It is their view
that it is becoming more and more difficult to
remain healthy even if one had excellent parents
and a truly happy childhood. They see no alter
natives but to base one's life on love and work.
Incidentally, this was suggested by Freud.
In looking at the future, it is apparent that
the demand for psychiatrists and allied profes
sionals will unquestionably exceed the poten-
tial supply. The author suggests that additionalmental health personnel must be found in fieldsother than medicine, clinical psychology and social work. He expresses the opinion that peoplecan be trained to provide some help to otherswhile working under supervision in communitymental health centers.
In addition to its most thorough dissection ofthe problems, dilemmas and enigmas of psychiatry, this book supplies a fairly accurate portraitof both the psychiatrist and the psychoanalyst.In addition, dividends are provided in the appendices which identify famous people in the specialty as well as a glossary of psychiatric tenns.The final "Notes" include much pertinent materialand the bibliography is profuse.
This book is highly recommended to thereaders of Psychosomatics. It will provide rareinsights for many of the readers' unasked questions about psychiatry and those who try tohelp the emotionally ill. Incidentally, both the psychiatrist and the analyst emerge as humanbeings, with human frailities, rather than withomnipotent halos which frequently become tootight.
THE ROLE OF LEARNING IN PSYCHOTHERAPY. (A Ciba Fou1ldation Symposium) Editedby Ruth Porter. Little, Brown and Co. Boston.1968, 340 page8.
The Ciba Foundation, opened in 1949, was organized to promote international cooperation inmedical and chemical research. Every year theFoundation oganizes six to ten three-day symposiaand three or four shorter study groups, all ofwhich are published in book form.
"This symposium grew from discussions, in1964, with Dr. Issaac Marks about the paucityof objective, and particularly of controlled studiesassessing the results of psychotherapy, and thelack of information about the factors that affectthese results".
Unlearning and new learning are basic factorsin psychotherapy. The underlying learningtheories and techniques must be studied as approaches to unlearning and new learning. Thisbook is an attempt to examine and assess suchstudies. The objectives are simply stated: to arrive at the truth and to help people.
The first studies dealt with Dr. Harry F. Harlow's work with socially deprived rhesus monkeysusing such monkeys who did have access to theirpeers as controls. One of the important findingswas that animals deprived of physical peer contact during the first three to six months of lifefailed to perform socially at levels comparable to
those achieved by animals reared with peer experience. This type of isolation produced behaviorthat was totally inadequate and failed to improveafter repeated social experiences after the experimental time period. Thus, pennanent anomaliesare produced which persist regardless of the degree of adaptation to post-rearing test situations.Early learning, even in the first month of life, canproduce social traits that persist into adult life.
Another section of this symposium deals withmethods of assessing the results of psychotherapy. The problem of what is psychotherapy, itspurposes and its techniques, produces a highlyadequate discussion well worth reading. Despitethe range of human misery with which one attempts to deal, a common denominator is failureto cope with some aspect of living.
Every kind of therapy involves learning andthe assessment of change in the patient dependsto a very great extent on the values of society,the patient and the therapist, and what they consider to be a desirable change. The designs of alltherapies hinge on these factors.
Two questions arise: first. is the therapyoffered superior to no therapy at all and, second,does the therapy depend on a specific techniqueor on an interpersonal relationship?
The discussion of these questions is sincereand indeed penetrating. Most efforts to show thatpsychotherapy was effective have been inconclusive. Newer studies which evaluate which typeof therapist produces what type of change in whattype of patient may be more meaningful and helpful. Criteria for assessing improvement must beestablished. How does one measure personalitychange?
Psychotherapy is still considered worthwhileeven if it produces short-term benefits.
From the Tavistock Clinic, London, the twoquestions which arose regarding the psychodynamic assessment of therapy were: is it reliableand is it valid? Their studies answer both questions in the affirmative. Using the controlledtechniques of Behavior Therapy one learns thatdesensitization is superior only with patients witha circumscribed phobia but less than 2'/r of psychatric patients are suitable for this lengthy andboring procedure.
What of the anxiety-provoking techniques?Most of the patients responded with only moderate symptomatic relief and described "a newlearning experience".
Learning in the child is carefully presented.Placebo effects and learning are discussed. Behavior Therapy and the psychotherapeutic ingredients in the learning processes are ably presented. Each of the chapters includes a rewardingand stimulating discussion.