Book Reviews

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

March-April 1970

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

problems.

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-

137

BOOK REVIEWS

.,

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.

W.D.

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

138

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.

Volume XI