Book Reviews DEATHS OF MAN by Edwin S. Shneidman. New York, Quadrangle/The New York Times Book Co., 1973. 238 pp. Price $8.95. During the past decade the volume of literature relating to death and dying has expanded enormously. Psychiatrists, psy- chologists. and sociologists all have attempted to analyze the most empirically tested phenomenon of Iife-death. The vol- uminous literature on the subject is riddled with theorizing and experimental analysis, and an attempt at an explanation of this phenomenal contemporary interest in the subject would itself be worthy of scientific exploitation. Obviously, much of the literature-both books and articles-is relatively worthless when subjected to critical evaluation. The current fad is to identify oneself as an editor and compile a series of discon- nected articles under a title that includes the word "death" or "dying." In such a cultural climate, Shneidman's book appears both refreshing and stimulating. He is willing to shoulder the responsibility of one man's deliberations on the process of dying. One need neither agree with all of his hypotheses nor accept all of his conclusions, but at least they represent a point of view of what the actual process of dying is like. Reserving relatively few pages for theoretical considerations. the author is willing early on to present some of his own practical considerations of the death process. His primary and pervading hypothesis seems to be that one's own death as an event is other people's experience and, therefore, cannot be an experience of one's own. Thus, much of the material is survivor-oriented. The significance of "post-vention"- working with the survivors after the death of a loved one-is a unique principle or concept for consideration. Other prin- ciples are similarly unique to the best of my knowledge. He makes much of the idea of "partial death"- the loss before physical death of part of the self through either bereavement or alienation. Sub-intention-a state of mind leading the individual to play some unconscious role in hastening his own death-is another interesting conceptualization. His considera- tion of the "post-self' is indeed intrigung: to him, this means the generally pleasurable anticipation, while one is still alive, that after his demise his life will have a significant positive effect in the continuing world. In addition to these considera- tions, practical chapters deal with the medico-legal aspects of death, including the death certificate and the psychologic "autopsy." It is obvious at the outset that the writings of Herman Mel- ville (Moby Dick, in particular) have had a tremendous im- pact on Shneidman's own death attitudes. As Melville says of Captain Ahab, "... on life and death this old man walked," so says Shneidman of 20th·century man. The dust-bowl empiricist will find little hard data between the covers. The author's approach is indeed a rational one, including his frequent rather arbitrary listings of types, char- acteristics, and classifications of the death experience. The purpose of the book is clearly not to communicate scientific information about the death process in man but rather to try to bring together the multitude of interlacings of life experi- ences of death itself. Shneidman presents a point of view that brings clearly into focus the observation that Leonardo da Vinci once had: "All the time I thought I was learning how to live, I was learning Jan.lFeb./Mar .. 1974 how to die." WENDELL M. SWENSON, PH.D. MAYO CLiNtC AND MAYO FOUNDATtON ROCHESTER. MINNESOTA THE EFFECTIVE CLINICIAN. Philip A. Tumulty, M.D. W. B. Saunders, Philadelphia, 1973. The methods and approach to diagnosis and care are thor- oughly pursued in a most useful book by a superb teacher and clinician. The importance of knowing the patient as a person. inclusive of his problems and life circumstances, are not given mere lip service, but are shown to be more important than many esoteric laboratory tests. In addition to this ex- posure, the reader will gain many dividends in the form of clinical and therapeutic nuggets which flow effortlessly through- out the book. Section A deals with communication in which the patient, the family and the primary physician are all considered. The effective clinician must like people and must like to talk with them; talk, however, can only be of value if the patient has confidence in the physician. This, in turn, requires a genuine interest and warmth. understanding. empathy and the ability to clarify the situation and what must be done. As for the famly, explanations should be simple and not contain too many details, since this may lead to confusion and misinter- pretation. As for communication with the primary physician, it is essential among other considerations that the results of the consultation be transmitted as soon as possible. Section B covers the physical examination. This is done in detail and is replete with cues and clues which will improve the clinical acumen of both the neophyte as well as the seasoned physician. Section C deals with clinical management. Thoughtful analysis coupled with a complete and thorough knowledge of the patient's problem must precede the choice of a specific treatment for a specific patient under specific circumstances. A special chapter in which the patient with a functional dis- order is discussed is exceptionally clear and concise; the only possible critique one can make is that it might have been longer, since this is the testing ground where so many other- wise brilliant clinicians fall short. Nevertheless, it is packed with tact, coolness, wisdom and understanding. The import- ance of not being hurried is underscored. as is the need for firmness when diagnosis of a functional disorder is made. th:H are equivocal. esp:cially labo"atol y tests. should be ignored. Other chapters deal with fever of unknown origin and the patient with incurable, progressive or fatal illness and are similarly packed with clinical and therapeutic tidbits. Section D is entitled "Clinical Problem Analysis", a systema- tic approach to differential diagnosis in which all the evidence is first gathered, then organized. The selection of one or more key features for analysis in depth then follows, and this in turn by a listing of all the disorders which can produce them. The one (or ones) that best explains the clinical evidence is then selected. Examples are then provided which run the gamut of clinical medicine, each case study followed by a complete discussion and the post-mortem findings. An excellent bibli- ography follows each chapter. This reviewer thoroughly enjoyed this vivid, lucid and
Transcript
Book Reviews
DEATHS OF MAN by Edwin S. Shneidman. New York,Quadrangle/The New York Times Book Co., 1973. 238pp. Price $8.95.
During the past decade the volume of literature relating todeath and dying has expanded enormously. Psychiatrists, psychologists. and sociologists all have attempted to analyze themost empirically tested phenomenon of Iife-death. The voluminous literature on the subject is riddled with theorizing andexperimental analysis, and an attempt at an explanation ofthis phenomenal contemporary interest in the subject woulditself be worthy of scientific exploitation. Obviously, much ofthe literature-both books and articles-is relatively worthlesswhen subjected to critical evaluation. The current fad is toidentify oneself as an editor and compile a series of disconnected articles under a title that includes the word "death" or"dying." In such a cultural climate, Shneidman's book appearsboth refreshing and stimulating. He is willing to shoulderthe responsibility of one man's deliberations on the processof dying. One need neither agree with all of his hypotheses noraccept all of his conclusions, but at least they represent a pointof view of what the actual process of dying is like.
Reserving relatively few pages for theoretical considerations.the author is willing early on to present some of his ownpractical considerations of the death process. His primaryand pervading hypothesis seems to be that one's own deathas an event is other people's experience and, therefore, cannotbe an experience of one's own. Thus, much of the materialis survivor-oriented. The significance of "post-vention"working with the survivors after the death of a loved one-isa unique principle or concept for consideration. Other principles are similarly unique to the best of my knowledge. Hemakes much of the idea of "partial death"- the loss beforephysical death of part of the self through either bereavementor alienation. Sub-intention-a state of mind leading theindividual to play some unconscious role in hastening his owndeath-is another interesting conceptualization. His consideration of the "post-self' is indeed intrigung: to him, this meansthe generally pleasurable anticipation, while one is still alive,that after his demise his life will have a significant positiveeffect in the continuing world. In addition to these considerations, practical chapters deal with the medico-legal aspects ofdeath, including the death certificate and the psychologic"autopsy."
It is obvious at the outset that the writings of Herman Melville (Moby Dick, in particular) have had a tremendous impact on Shneidman's own death attitudes. As Melville saysof Captain Ahab, "... on life and death this old man walked,"so says Shneidman of 20th·century man.
The dust-bowl empiricist will find little hard data betweenthe covers. The author's approach is indeed a rational one,including his frequent rather arbitrary listings of types, characteristics, and classifications of the death experience. Thepurpose of the book is clearly not to communicate scientificinformation about the death process in man but rather to tryto bring together the multitude of interlacings of life experiences of death itself.
Shneidman presents a point of view that brings clearly intofocus the observation that Leonardo da Vinci once had: "Allthe time I thought I was learning how to live, I was learning
Jan.lFeb./Mar.. 1974
how to die."WENDELL M. SWENSON, PH.D.MAYO CLiNtC AND MAYO FOUNDATtON
ROCHESTER. MINNESOTA
THE EFFECTIVE CLINICIAN. Philip A. Tumulty, M.D.W. B. Saunders, Philadelphia, 1973.
The methods and approach to diagnosis and care are thoroughly pursued in a most useful book by a superb teacherand clinician. The importance of knowing the patient as aperson. inclusive of his problems and life circumstances, arenot given mere lip service, but are shown to be more importantthan many esoteric laboratory tests. In addition to this exposure, the reader will gain many dividends in the form ofclinical and therapeutic nuggets which flow effortlessly throughout the book.
Section A deals with communication in which the patient, thefamily and the primary physician are all considered. Theeffective clinician must like people and must like to talk withthem; talk, however, can only be of value if the patient hasconfidence in the physician. This, in turn, requires a genuineinterest and warmth. understanding. empathy and the abilityto clarify the situation and what must be done. As for thefamly, explanations should be simple and not contain toomany details, since this may lead to confusion and misinterpretation. As for communication with the primary physician,it is essential among other considerations that the results ofthe consultation be transmitted as soon as possible.
Section B covers the physical examination. This is done indetail and is replete with cues and clues which will improvethe clinical acumen of both the neophyte as well as the seasonedphysician.
Section C deals with clinical management. Thoughtfulanalysis coupled with a complete and thorough knowledge ofthe patient's problem must precede the choice of a specifictreatment for a specific patient under specific circumstances.
A special chapter in which the patient with a functional disorder is discussed is exceptionally clear and concise; the onlypossible critique one can make is that it might have beenlonger, since this is the testing ground where so many otherwise brilliant clinicians fall short. Nevertheless, it is packedwith tact, coolness, wisdom and understanding. The importance of not being hurried is underscored. as is the need forfirmness when diagnosis of a functional disorder is made.R~sllh th:H are equivocal. esp:cially labo"atol y tests. should beignored. Other chapters deal with fever of unknown originand the patient with incurable, progressive or fatal illness andare similarly packed with clinical and therapeutic tidbits.
Section D is entitled "Clinical Problem Analysis", a systematic approach to differential diagnosis in which all the evidence isfirst gathered, then organized. The selection of one or morekey features for analysis in depth then follows, and this in turnby a listing of all the disorders which can produce them. Theone (or ones) that best explains the clinical evidence is thenselected. Examples are then provided which run the gamutof clinical medicine, each case study followed by a completediscussion and the post-mortem findings. An excellent bibliography follows each chapter.
This reviewer thoroughly enjoyed this vivid, lucid and
PSYCHOSOMATICS
brilliant portrayal of what it takes to be an effective clinician.It should be read slowly. to permit adequate digestion andabsorption of the wealth of material presented. Those readerswho are given to underlining pertinent passages, wilI be welIoccupied.
w.o.
THE THEORY AND PRACTICE OP PSYCHOTHERAPYWITH SPECIFIC DISORDERS. Max Hammer, Ph.D.Edi/or, Charles C. Thomas. Publisher, Sprint:!field. 111. 432pt:!S, Index
This book is designed as a reference source for professionalpsychotherapists and as a text for a course in psychotherapy.Its purpose is to reach students of psychology. psychiatry andsocial work. It claims "to provide the reader with the newest.most creative and most effective" guidance in psychotherapeuticmethod. The approach is psychodynamic with due recognitionof the person and emphasis on interpersonal relationship asa major healing vehicle. The writers are outstanding membersin the fields of psychology and psychiatry. Included are Drs.Salzman. Chrzanowski. Schiffer. Rose Spiegel and Wolman.
Discussions survey a broad group of psychiatric syndromes.The first chapter by the editor consists of an informative andinteresting analysis of motivation "to students interested inbecoming psychotherapists." Succeeding chapters deal withanxiety reaction. phobias. obsessive-compulsive reactions, hysterical disorders. depression. suicidal patients. psychosomaticdisorders. acting-out. sexual disorders. schizophrenia and theaged.
There is an abundance of meaty material in these pages.Much is controversial and while the theoretical considerationsmake interesting reading, there is no concrete evidence supporting their applicability. Clinical samples are anecdotal withoutstatistical support and with meager folIow-up. I get the impression from most papers that whatever "cure" develops is reallythe "transference remission" which can be effected by anytheraoeutic approach. yet the basic conflict remains. "Musts"are plentiful as is the magic word.
Two major weaknesses should not be overlooked. Althougha team reference is expressed, considering the seriousness ofschizophrenia. depression and suicide, for example, no recommendation exists that a psychiatrist be consulted for guidanceand responsibility sharing. Moreover. in the light of the stridesmade in psychopharmacology and shock therapy when indicated, in my opinion, any treatise on psychotherapy should befaulted for not including an educated reference to thesemodalities.
On the whole. however. I do not wish to depreciate thiscontribution. Its papers are dynamic, well-written, sincere andinformative. Much of it is to be studied carefully. It hasindeed much to offer psychologists, social workers and nurses.both in training and in practice. interested in psychotherapy.Too, it is useful for the psychiatrist who wishes to furtherand broaden his grasp of psychotherapy.
GEORGE J. TRAIN M.D.
BROOKLYN
THE DOCTOR, HIS PATIENT AND THE ILLNESS. Michael Balint. Revised (Third) Edition, New York, International Universities Press, 1972. p. 395, $
The last two decades have witnessed a considerable changein the role played by the primary physician in the care ofpsychiatric patients in the community. Reliance on intuitiveefforts and common sense alone has been replaced by morescientific techniques. To effect this change various methodsof training have been devised here and abroad, but it was
44
Michael Balint who established the now-famous "ResearchCum-Training Seminars" in the Tavistock Clinic, which became the basis of "Balint Groups." These are now used allover the world for the training of primary physicians in thenuances of office management of psychiatric patients.
Balint's arguments for the treatment of seriously ill neuroticpatients by family physicians seem, at first glance. unconvincing. But a careful reading of his slowly developed thesis, aspresented in The Doctor. His Patient and the Illness. compelsone to share the author's conviction.
The family physician reading this book will find an answerto his often repeated question: "Why has a faithful adherenceto the medical model failed to help so many of his patients?"With an answer now supplied. the doctor will probably striveto change his orientation from the purely medical model toone which we should perhaps call psychosomatic, since italso embraces the psychosocial determinants of health and illness. Such a reorientation will result in a change in the meaningfulness of the doctor-patient relationship and constructivelyalter medical management.
Numerous case histories serve as instructive clinical examples;thorough interpretations of cases with a minute follow-up.facilitate the selection of patients. the decision regarding theuse of therapy and its termination. The author vividly describesan approach to handling resistances by the doctor who isconcurrently family practitioner and psychotherapist, a position which may facilitate. yet at times complicate his psychotherapeutic role.
The book touches on practically all aspects of the doctor'spart of the doctor-patient relationship as well as the patient'sreactions to his illness. Special attention is given to the subjectof "training" which is valuable both to the doctor who desiresto do this work, as well as to the psychiatrist who is involvedin the "training" or "teaching."
In recommending this book to prospective readers of boththe above groups, this reviewer wishes to stress that althoughit is one of the first books ever written on this subject it isassuredly a very valuable text. It is not a collection of "doit-yourself' recipes. nor a handbook of instructions; ratherit is an excellent model for teaching as well as learning andshould be used as such by both the "teachers" and the "students."
ADAM J. KRAKOWSKI. M.D.
CHAMPLAIN VALLEY
PHYSICIANS HOSPITAL MEDICAL CENTER,
PLATTSBURGH. NEW YORK
"THE NEUROSIS OF OUR TIME: ACTING OUT" Compiled and Edited by Donald S. Milman, Ph.D. and GeorgeD. Goldman, Ph.D. Charles C. Thomas, Sprint:!field, Illinois1973,365 pat:!es.
The editors have succeeded in compiling a collection of some20 clear and concisely written chapters spanning a wide rangeof thought and experience. The 23 authors represent a broadspectrum of clinical, analytical, theoretical. and philosophicalorientations. The first chapter is a scholarly presentation ofthe semantic incongruity of the title of the book. It proposesthat the concept of "acting out" be dropped and replaced bythe terms "constructive" as contrasted with "destructive" action.Other authors in the book also wrestle with the definition andmeaning of "acting out." Nevertheless, the provocative natureof the title succeeds in evoking a brilliant melange of professional writing.
Nosologically, the clinical and theoretical discussions focuson a large sector of human pathology which, in psychiatricclassification. would come under the Personality Disorders.
