Book Forum
PSYCHOTHERAPY
Understanding Therapeutic Action: Psychodynamic Con-
cepts of Cure, edited by Lawrence E. Lifson. Hillsdale, N.J.,
The Analytic Press, 1996, 280 pp., $39.95.
As the title promises, the therapeutic action targeted in this
edited tome is limited to the scope of what Alonso calls “a
host of dynamic therapies,” targeting therapeutic action in
the context of broad-based psychoanalytic theories that em-
phasize relational and self psychological constructs. Lifson’s
choice of authors ranges from “heavy hitters” in the psycho-
analytic field (e.g., Meissner, Kernberg, Modell, Adler, Paul
and Anna Ornstein, Lichtenberg, Mitchell, and Alonso) to
lesser known authors (e.g., Teicholz, Herzog, Russell, Fish-
man, and Stark).
Two of the chapters stand on their own and have their own
direction—Kernberg’s on diagnosis in adolescence and the
Ornsteins on presenting a schema for psychoanalytic psycho-
therapy from a self psychological point of view. However, a
central theme of this book presents a paradox: that is, Mitch-
ell’s view that Freud’s influence on psychoanalytic theorists
has persisted despite the fact that “while Freud’s explana-
tions worked persuasively in his day it can no longer work
for us.”
A core theme of this book focuses on the relationship be-
tween patient and therapist and the use of that relationship
as the “curative” force in the therapy. Mitchell sees “cure” as
best occurring in the countertransference because “to study
something is to interact with it.” He views Freudian author-
ity as abusive and interpretations as not having as much
weight in contemporary psychoanalysis as does the emo-
tional response of the analyst and the struggle between pa-
tient and analyst “to find a different kind of emotional con-
nection.” A central message is that analysis has changed
from a patient-centered treatment to a patient-therapist rela-
tional matrix. Flexibility in method is de rigeur.
Alonso’s opening chapter gets right to the point by reinter-
preting the core psychoanalytic concept of “therapeutic neu-
trality.” Using a relational model, she views the therapist as a
“participant observer” or “interventionist.” In this model,
the clinician is more transparent than opaque, more flexible
than abstinent. The old psychoanalytic adage, “Don’t gratify
the patient and remain a blank screen,” is dismissed as possi-
bly increasing the patient’s shame and leading to a stalemate
in therapy. Meissner, viewing psychoanalytic cure as discov-
ered “in the therapeutic alliance versus the real relationship,”
emphasizes the importance of the real relationship with the
analyst in stimulating transference. At times, however, he
views the real relationship as becoming a resistance to
progress in treatment. He urges us not to give advice to pa-
tients because it “crosses the boundary between alliance and
reality and undermines the alliance.” Modell views transfer-
ence as an intersubjective process but warns us that “a rela-
tional view of the transference can be overdone.” His focus
on memory as retranscription highlights the problems of
what is remembered by analysands, especially those suffering
Am J Psychiatry 155:11, November 1998
from trauma. Adler focuses on how the patient with border-
line or narcissistic personality disorder uses the analyst as a
transitional object, “selfobject,” and real object for curative
purposes. The Ornsteins present a summary of Kohut’s self
psychological theory and demonstrate how psychopathology
may be the result of “a deficit in the structure of the psyche.”
For those patients, “the healing process involves the analyst’s
optimal empathic responsiveness to the patient’s subjective
experience.” The patient’s obstacle to “cure” is the fear that
“in the transference he/she will be retraumatized by his/her
openly expressed needs and wishes.” Structure building
through transmuting internalization replaces insight as the
curative force. Working from a self psychology model, “the
acquisition of empathic contact with selfobjects is the essence
of psychoanalytic cure.”
Less compelling arguments of what constitutes therapeutic
change include the following: 1) Lichtenberg’s concepts of
“self righting” (“the inherent tendency to rebound from a
deficit”), shared expanding awareness, and the rearrange-
ment or recategorization of symbolic representations, 2) Her-
zog’s cryptic statement that the analyst’s conclusion that “some-
thing has happened” provides an explanation for the
reconfiguration of the patient in the process of change or
“cure,” 3) Russell’s use of his dream to view “process and in-
volvement” as the curative force; and 4) Fishman’s “listening
to affect” (he gives a personal example of when he almost
cried in treatment and why not doing so was therapeutic)
and his statement that “the patient desires a response from
the therapist and feels that it comes from inside their mutual
attachment.” Moreover, Lichtenberg says, “psychoanalysis
leads not simply to knowing more but to reworking, recate-
gorizing and rearranging.”
Stark summarizes the three models of therapeutic action
outlined by Mitchell as representative of when and how ther-
apeutic action must occur. The three models include the
drive-conflict model, the deficiency-compensation model,
and the relational conflict model. She argues that counter-
transference “is now seen as inevitable and as offering the
therapist one of the most effective ways to understand the in-
ternal workings of the patient’s mind.” In this context, she
focuses on one type of patient (commonly seen in practice)
who needs to be in a relationship with a bad object and uses
the therapist by drawing him or her into the inevitable reen-
actments (with the analyst resisting getting lost in them) in
order to allow for change to take place. Mitchell sees “thera-
peutic action as involving correction for the internal presence
of bad objects by way of working through the negative trans-
ference.” The relational model helps us to understand why
the patient needs to remain attached to the bad objects and
why “we must be able to let the patient make us fail him.”
Many psychodynamic theorists and psychoanalysts have
placed their bets on a relational model of psychoanalysis.
The role of interpretation and insight in psychoanalytically
oriented therapy and psychoanalysis is changing rapidly.
There is no Holy Grail. For newcomers to the field, this book
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offers a glimpse into the problems and process of contempo-
rary psychoanalysis. It is worthwhile reading.
LESLIE M. LOTHSTEIN, PH.D.
Hartford, Conn.
The Inward Eye: Psychoanalysts Reflect on Their Lives and
Work, edited by Laurie W. Raymond and Susan Rosbrow-
Reich. Hillsdale, N.J., The Analytic Press, 1997, 504 pp.,
$55.00.
The last word in this remarkably good book is given to Ja-
nine Chasseguet-Smirgel, training analyst at the Paris Psy-
choanalytical Society: “There exists a struggle against psy-
choanalysis which is one with the struggle against thought
itself. A denial of the unconscious is in keeping with the de-
humanized world in which we live. A postgraduate student
in cognitive sciences, after a presentation of mine on halluci-
nation was over, told me: ‘We can’t measure it.’ Another
added, ‘Dreams do not interest us since computers don’t
dream.’ It was not a joke” (pp. 462–463).
I approached this book with considerable trepidation for a
number of reasons. It was written by two women, a psychia-
trist and a psychologist, who shared the same analyst and
consists of interviews they carried out 8–10 years ago with a
number of noted psychoanalysts, most of whom were ap-
proaching or into their 80s. The editors’ choices of whom to
interview “were idiosyncratic and highly personal” (p. ix).
They describe their work as “an effort to learn more about
that inner dialogue, to see the world from the analyst’s inner
eye.…We undertook this study both as a complement and an
antidote to our training analyses” (p. ix). The editors do not
explain in their introduction why they felt that their training
analyses required an “antidote,” and I was at first concerned
that the whole project represented some kind of neurotic en-
actment based on issues that had not been worked through in
their training analyses with their shared analyst: “The
project enabled us metaphorically and actually to get up off
the couch, meet the analyst person to person, and formally
discuss the psychoanalytic process rather than live it” (p.
xvi). In addition, I wondered why these well-known analysts
agreed to be interviewed in this fashion, speculating on the
narcissistic roots of such an agreement and anticipating that
the responses and reminiscences would be repetitious and
boring.
I am happy to report that the work of these two faculty
members of the Psychoanalytic Institute of New England
East and staff members of Harvard University Health Ser-
vices turned out to be an excellent contribution and of great
interest in spite of the fact that both were in training at the
time. The correct common denominator of these 500 pages
of interview material is presented by the editors in their in-
troduction: “The qualities of these persons that affected us
most have to do with character. They include honesty and in-
tegrity, a commitment to learn from one’s experience, a deep
respect for another person no matter how ill, and a funda-
mental kindness and generosity toward others” (p. xvii). Al-
lowing for the rhetoric in this statement, on the whole I think
the book presents a good introduction to how reputable and
skilled psychoanalysts think and conduct their practices, so
the editors may indeed conclude, as does Rosbrow-Reich
(the psychologist), “I look at the body of psychoanalytic lit-
erature now less as gospel than as reflecting each individual
contributor’s highly subjective, carefully crafted, unique way
1618
of expressing what is most true and important for her or him,
each with an imagery shaped by life experience” (p. xx).
The best way to read this book is to savor it by studying
one interview and then putting the book down and picking it
up at another time to read another interview, rather than try-
ing to read it all the way through at once, as one does with
most books. In those few psychiatric residencies which still
teach psychodynamic psychiatry, this makes the book a good
choice for a monthly seminar for advanced residents, cover-
ing one interview each time. Read in this way, it avoids the
problem that the book tends to be somewhat repetitious in
the questions asked and could have used further editing; for
example, the editors present the same substantial quotation
from Ferenczi a number of times to different people they in-
terviewed, and I see no point to repeating the entire quota-
tion in the transcript of each of the interviews.
There is not time in a brief book review to discuss all 15 in-
terviews, so I will just mention a few high points that I found
exceptionally interesting. It is impossible to read this book
without learning quite a bit. For example, Arlow tells us,
“Everything that the analyst thinks and feels in the course
of listening to his patient is some commentary on the pa-
tient’s material” (p. 53), and he emphasizes how the pa-
tient’s production, in form and mode of presentation, “re-
sembles the creative process” (p. 53). He even compares
analytic sessions to works of art (p. 62). I was delighted to
read that the French psychoanalyst Green maintains, as I
do, that Freud’s concept of “drives” conveys something
metaphorically that should not be considered obsolete or
old-fashioned. Green reports that Lacan’s work has led
French psychoanalysts to “pay enormous attention to the
words of the patient” (p. 91).
Curiously, Rangell requested that his wife be present for
the interview. He emphasizes the issue of the patient’s re-
sponsibility in psychoanalysis, so that once insight is
achieved, he leaves it up to the patient whether to use the in-
sight or not. He cleverly calls this “the responsibility of in-
sight” (p. 194). Rangell is very conservative and betrays only
a foggy understanding of self psychology but, like Green and
me, he also wishes to retain Freud’s concept of “drives.” He
adds, “There is too much myth formation, cultism, and ‘fol-
low the leader’ in analysis” (p. 153). In contrast to those an-
alysts who try to interpret all the patient’s material in terms
of the transference, Rangell stresses the “extra-analytic
present,” a field of observation and data pertaining to the pa-
tient’s outside life and having an important effect on the
treatment.
Solnit and others emphasize the importance of the analyst
as a real person and the danger of pretending that the ana-
lyst’s behavior regarding such matters as the presentation of
the bill or the arrangement of the office has no significance or
existence. Gardner concentrates on the role of friction be-
tween the patient and the analyst in stirring up capacities for
adaptation, cooperation, and collaboration rather than the
perfect harmony that is searched for in an idealized vision of
empathy. He speaks of what one might call “optimal fric-
tion” as playing an important role in development and in the
analytic process.
Many of the authors, even though they are of an older gen-
eration of psychoanalysts, are aware of, as Gardner puts it,
“the complexity of the ways in which conscious and precon-
scious observations, insight, and corrective experience inter-
act” (p. 415). This awareness has led to a much more pro-
found understanding of the psychoanalytic process than is
often presented in the foolish stereotypes of Freud’s work
that are tendentiously attacked in the literature. It also has
Am J Psychiatry 155:11, November 1998

led to a greater tolerance for differences, although Gardner
suggests that this is more characteristic of the French analysts
than the American analysts, at least at the time of his inter-
view. He also suggests something that I have advocated for a
long time—namely, making the core of the training program
tutorial rather than a series of seminars. I have advocated
this even for psychiatric residents in order to, as Gardner
says, “shape our teaching with fuller regard for the specific
needs and strengths of our candidates and our teachers and
their individual ways of learning and teaching” (p. 433).
I hope that this little sampling gives the reader of this re-
view a taste of the many fascinating concepts, discussions,
and disagreements that are presented in this excellent book.
It deserves careful reading and, as few books do, careful re-
reading. I believe it will be more useful to those who have at
least a basic familiarity with psychoanalysis, because some of
the issues raised are quite sophisticated and presuppose a
knowledge of psychoanalytic terminology.
RICHARD D. CHESSICK, M.D., PH.D.
Evanston, Ill.
Deconstruction of Psychotherapy, by T. Byram Karasu.
Northvale, N.J., Jason Aronson, 1996, 160 pp., $27.50.
This is a well-crafted book by one of the leading figures on
the practice of psychotherapy. Dr. Karasu uses the “meta-
phor” of deconstruction theory to approach the question of
a modern understanding of psychotherapy. Although the ef-
fort of applying deconstruction theory to a nebulous enter-
prise such as psychotherapy is interesting, it seems a bit con-
trived as a means to gain a grasp of the issues in the field.
However, the reader should be willing to forgive this indul-
gence because Dr. Karasu does an excellent job of analyzing
psychotherapy and puts forward many salient and creative
notions.
There is an excellent chapter providing a concise and inci-
sive overview of the major theoretical paradigms in psycho-
therapy, i.e., psychodynamic, behavioral, and experiential.
These three paradigms are viewed from the perspectives of
the nature of man and his difficulties, how changes occur
(the therapeutic process), the nature of the therapeutic rela-
tionship, and techniques, methods, and variations on the ba-
sic paradigm. If there is a weakness in the first portion of the
book, it is the relative undertreatment of cognitive behavior
therapy under the behavioral paradigm. Cognitive behavior
therapy is enjoying increasing success as a clear manual-
guided treatment and is shown to be effective in a variety of
specific psychiatric illnesses.
Dr. Karasu begins to reach for a higher gear in his chapter
on the dilemma of specificity versus nonspecificity of cure.
He takes on several dualities of psychotherapy, including sec-
tarianism versus eclecticism, individuality versus universality,
and technique versus relationship. I found his account of a
definition of specificity to be particularly wise; he clearly un-
derstands the complexity of this seductively simple idea. He
develops the idea of specificity as meaning a determining
quality and as a mechanism for mediation of cure as opposed
to its meaning common or unique. Also, he notes that the
terms “specific” and “nonspecific” frequently refer to the
quality of being scientifically accessible or not, respectively.
One of the interesting features of his treatment of the sectar-
ianism versus eclecticism duality is a strong argument against
the value of eclecticism. Dr. Karasu very carefully notes that
a therapist’s belief in his or her preferred mode of therapy is
Am J Psychiatry 155:11, November 1998
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an element of its success. Eclecticism, by contrast, carries no
theoretical loyalty or passionate belief; instead, it can foster
confused therapists with marginal advances in treatment
success.
In his discussion of the dualities of individuality versus
universality, Dr. Karasu surmises that there are probably no
treatments that are universally good for everyone. Rather, he
argues persuasively that specific treatments have specialized
techniques that are valuable for treatment of different patient
groups. Therapeutic goals and therapeutic effects can mani-
fest themselves in a variety of different ways.
The chapter that deals with the problems of psychotherapy
research is also sagacious. Dr. Karasu identifies problematic
areas of research design, sample selection, methodologies, as-
sessment of change, cost effectiveness, costs versus benefits,
statistical issues, research strategies, and unresolved outcome
measurement issues. This is an excellent chapter on some of
the pitfalls in logic that have haunted the interpretation of
psychotherapy research.
In the last two chapters, Dr. Karasu attempts to achieve a
synthesis of commonalities or universal aspects of psycho-
therapies, but not in an effort to establish an eclectic ap-
proach. He identifies the dimensions of affective experienc-
ing, cognitive mastery, and behavioral regulation as important
features of the healing experience regardless of the school of
psychotherapy. He goes on to show that all of these elements
seem to be present in one way or another in all of the theo-
retical schools of psychotherapy but are emphasized differ-
entially. Dr. Karasu ends on a transcendent theme in his
construction of a notion of the therapeutic action of psycho-
therapy. Although this effort also seems to be something of a
metaphor that is perhaps appropriate for the high-sounding no-
tion of deconstructionism, this formulation certainly provides
an affective experience of hopefulness as well as a cognitive
reorientation of thinking beyond therapy theory and behav-
ioral regulation of learning to live without blind devotion to
theory.
There are some important aspects of modern psychother-
apy practice that are not addressed here but are necessary to
truly understand this complex endeavor. There are economic
issues, the nature of patients who seek psychotherapy, and
the nature of those who wish to provide it. Nevertheless, this
is an excellent book, very much rewarding the effort of its
reading. I highly recommend this book for both practitioners
and academics who seek an understanding of the practice
and theory of psychotherapy.
WILLIAM H. SLEDGE, M.D.
New Haven, Conn.
Art, Psychotherapy, and Psychosis, edited by Katherine Kil-
lick and Joy Schaverien. New York, Routledge, 1997, 267
pp., $69.95; $24.99 (paper).
This book is an engaging collection of 12 essays on the the-
ory, practice, and historical development of the field of art
therapy in Britain, specifically regarding the treatment of
psychosis. It is intended for a wide readership, internation-
ally as well as from diverse clinical fields. It is organized into
two sections. Part 1, Art, Psychotherapy, and Psychosis, con-
sists of six chapters discussing issues of theory and practice,
primarily from an analytic perspective, illustrated with case
examples and reproductions of artwork. Part 2, Context and
History, discusses the historical development of the profes-
sion. Most of the patients discussed are diagnosed as having
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schizophrenia, although some have diagnoses of manic-de-
pressive and paranoid psychosis. However, the case studies
will be of interest not only for clinicians who work with psy-
chotic patients but also for those who work with children,
adults with learning disabilities, or other nonverbal groups.
The authors included are all registered members of the
British Association of Art Therapists. Many have back-
grounds as visual artists, and several have Jungian training as
well. The two editors, Katherine Killick and Joy Schaverien,
are both Jungian analysts. Although sometimes the analysis
is a bit heavy-handed and the writing quality uneven, the au-
thors insightfully and inspirationally discuss the healing
power of using art to work with psychotic patients.
In the first essay, Schaverien speaks of the artwork as a
transactional object that allows the patient a safe way to es-
tablish an indirect relationship with the therapist. At first,
the artwork is used as a private fetish, invested with magical
meaning but not used to relate to the therapist. As trust de-
velops, the artwork is eventually used as a talisman, to com-
municate and relate to the therapist. Schaverien also explains
her theory of scapegoat transference, by which split-off ele-
ments of the psyche are externalized in an art piece. It is the
therapist’s role to gradually make the intolerable affect toler-
able so that the patient can reintegrate it.
In the next chapter, Killick uses case studies to emphasize
the importance of creating and maintaining a contained envi-
ronment when working with psychotic patients with fragile
ego boundaries. Many of the writers in this collection reiter-
ate this point, thoroughly describing their work environ-
ments and other frame issues. Killick, like many of the writ-
ers in this volume, bemoans the difficulty of providing a
stable frame in many community settings—the old asylums
that provided long-term placements for patients having
closed—and makes a plea for such sanctuaries, or, in the
words of one of her patients, “places that allow the mind to
heal.” This point is well-taken in the United States as well.
Killick discusses her countertransference feelings with im-
pressive honesty, specifically the potential for feelings of de-
spair and futility.
Fiona Foster, a sculptor, compellingly discusses the paral-
lels between sculpted objects and a body-like form and thus
the tendency of psychotic patients to project bad parts of
themselves onto the material and then avoid or flatten the
clay, perceiving it as a container of projected persecutory
forces. By talking about a sculpture outside of the self, the
patient slowly feels the safety to begin to re-own split-off
feelings and memories.
In a very well-written essay describing one patient with ex-
tensive sexual perversions, David Mann insightfully demon-
strates how the picture-making process can be used to up-
hold defensive structures. Mann also makes an interesting
distinction between the perverse use of sexuality in psychotic
art—wherein the “as if” quality is lost and the patients really
believe themselves to be engaged in a sexual act with the
painting—and the nonpsychotic use of sexual themes by fine
artists.
At this section’s end, Helen Greenwood makes the strong
point that in a supportive environment, the ego structures of
psychotic patients can be strengthened to enable them to use
the higher-level defenses of humor and sublimation.
Part 2 opens with a theoretical piece by David Maclagan
questioning the definition of psychotic art and arguing that
such a category is culturally defined and that psychotic art-
ists have been influenced in style by the currents of modern-
ism. This raises an interesting point: the thin line between art
we define as “psychotic” because it is made by institutional-
1620
ized individuals and the art that becomes defined as avant
garde, some of which is produced by now famous artists who
happen to have had a diagnosable mental illness. Maclagan
suggests that a transition in social role from psychiatric pa-
tient to artist would be healing for many patients.
Chris Wood provides a comprehensive historical overview
of the developing field of art therapy, tracing its roots from
the 1940s and 1950s, when artists began to work with pa-
tients and emphasized the intrinsic nature of art-making as
healing, to the antipsychiatry movement of the 1960s and
1970s, when psychotic processes were somewhat romanti-
cized by clinicians influenced by the theories of R.D. Laing
and patients’ art productions were viewed more in terms of
their creativity than their illness, to the professionalism of the
analytic 1980s and 1990s. John Henzell’s autobiographical
piece provides a longer discussion of the antipsychiatry
movement. It would have been interesting to hear more
about the specific therapeutic techniques of clinicians work-
ing during this time period, interested as they were in under-
standing the state of consciousness of their clients rather than
medicating it.
The next two pieces, by Claire Skailes and Sue Morter,
could have been placed in part 1 because they are more con-
cerned with theory and practice than history. Both rely on
case studies to illustrate the sensitivity, care, and respect de-
manded of clinicians who work with psychotic patients.
Skailes’s description of her patients, viewed through a non-
theoretical beginner’s mind, as the “walking undead” is par-
ticularly poignant for anyone who has worked with such pa-
tients. Morter takes an object relations approach in describing
the use of her own artwork to mirror one patient’s process.
Her piece is particularly illustrative of what an art therapist
does in the room with the patient, details of which are left
vague in some of the other essays.
Overall, this book convincingly illustrates the benefits of
art therapy treatment for psychotic patients and hence pro-
vides a strong argument for appropriating more resources for
these underserved and often written-off patients.
ALISSA J. HIRSHFELD, M.A., M.F.C.C.
San Rafael, Calif.
PSYCHOPHARMACOLOGY
American Psychiatric Press Textbook of Psychopharmacol-
ogy, 2nd ed., edited by Alan F. Schatzberg, M.D., and
Charles B. Nemeroff, M.D. Washington, D.C., American
Psychiatric Press, 1998, 1,095 pp., $120.00.
The first edition of this volume was published in 1995, and
I had the privilege of reviewing it for The American Journal
of Psychiatry (1). In the past 3 years, this textbook has be-
come a classic reference on the topic of psychopharmacology.
The second edition is not merely a cosmetic update but an
extensive revision of the initial edition. I am impressed that
the number of chapters has increased from 41 to 48. The
number of pages has increased from 896 to 1,095, and, inter-
estingly, the format is such that the amount of information
per page seems to be at least 30% greater. Thus, it would not
surprise me if the amount of the information in the second
edition were 30% to 50% greater than the first edition.
The Textbook of Psychopharmacology continues to have
four major sections: Principles of Psychopharmacology;
Classes of Psychiatric Treatments; Animal and Human Phar-
Am J Psychiatry 155:11, November 1998

macology, Clinical Psychobiology, and Psychiatric Syn-
dromes; and Psychopharmacological Treatment. The authors
of the individual chapters were carefully selected to provide
the most comprehensive and up-to-date versions of their top-
ics. The second edition also seems to be better illustrated
than the first edition, particularly in the Principles of Psy-
chopharmacology section, which has been expanded from
six to nine chapters. There are new chapters on animal mod-
els of Alzheimer’s disease and neuroendocrine and immune
system pathology in psychiatric disease. The second section
has two additional chapters, one on venlafaxine and one on
ECT. The latter chapter includes some information on rapid-
rate transcranial magnetic stimulation, an evolving experi-
mental treatment for depression. The third section has an ad-
ditional chapter on biology of personality disorders. The fi-
nal section has an additional chapter on treatment of
insomnia. Each chapter is well referenced, and the referenc-
ing includes citations through 1997. The treatment chapters
follow a similar format and include general principles of
treatment and approaches to treatment resistance. The index
is quite useful.
It is difficult to revise a textbook in a 3-year span. The up-
date, expansion, and revision of the second edition of the
Textbook of Psychopharmacology reflects a considerable ef-
fort by the editors, section editors, and contributors, and the
new edition incorporates all the updated research in these
last few years.
This textbook is a must for psychiatric residents and psy-
chiatrists who have recently completed training and those in-
terested in studying for their board examinations. It is of
considerable use for other mental health practitioners and
provides an update on the rapidly evolving field of psychop-
harmacology. There is much more to this volume than the
first edition, and I would encourage individuals who pur-
chased the first edition to look through this magnificent vol-
ume and consider updating their library.
REFERENCE
1. Dunner DL: Book review, AF Schatzberg, CB Nemeroff (eds):
The American Psychiatric Press Textbook of Psychopharma-
cology. Am J Psychiatry 1995; 152:1228–1229
DAVID L. DUNNER, M.D.
Seattle, Wash.
Pocket Handbook of Psychiatric Drug Treatment, 2nd ed.,
by Harold I. Kaplan, M.D, and Benjamin J. Sadock, M.D.
Baltimore, Williams & Wilkins, 1996, 275 pp., $35.00.
“Psychiatrists don’t know a benzene ring from a hole in
the wall” was the response of one colleague to whom I
showed this book. Although some of my clinical friends may
dispute this statement, it is certainly questionable whether
chemical structures really constitute useful information in a
pocket handbook of drug treatment. The critical reader will
find superfluities, deficits, and inaccuracies in almost any
text, and this book is certainly no exception. Thirty-five of
the 41 chapters provide an alphabetized listing of drugs,
from β-adrenergic receptor antagonists to yohimbine, with a
somewhat idiosyncratic classification according, in theory, to
pharmacological activity and mechanism of action. This
avoids the complications associated with the fact that the
same drugs are used in the treatment of different disorders
(e.g., depression and anxiety). Although there are some ad-
vantages to this classification, it assumes that the mecha-
Am J Psychiatry 155:11, November 1998
BOOK FORUM
nisms of action of psychiatric drugs are understood. This is
an assumption that the most able psychopharmacologist
would be loath to make. In practice, there are so many ex-
ceptions that most of the chapters address individual drugs,
and several others define a drug class on the basis of chemical
structure (e.g., tricyclics, benzodiazepines). Dividing the an-
tipsychotics into separate chapters on “dopamine receptor
antagonists” and “clozapine” also appears arbitrary.
As one uses the book, however, these idiosyncrasies be-
come less annoying, even endearing, and the fact that the
classification is, well, unusual, does not mean that the work-
ing psychiatrist could not rapidly come to grips with its use.
There is a comprehensive index for rapid identification of the
drug or indication wanted, and this is supplemented by two
useful tables in chapter 1, each with chapter cross-references,
one of which lists both generic and U.S. trade names of psy-
chiatric drugs while the other gives major psychiatric indica-
tions and the drug classes used in their treatment. In addi-
tion, if you do not know what they look like, the tablets and
capsules of many of these drugs are shown in color in a 5-
page section at the beginning of the book.
The book contains much to justify the inclusion of medical
students and nonphysician clinical staff, as well as psychia-
trists and primary care physicians, in its target readership.
The first chapter provides a brief introduction to the basic
principles of psychopharmacology. Other useful sections in-
clude an emergency intoxication and overdose table and a
chapter on laboratory diagnostic tests. Intriguingly, there is a
chapter on combined psychotherapy and pharmacotherapy.
There are some disappointments, however. The authors have
tried to overcome the inevitable limitations of a book pub-
lished in a rapidly developing field by including a chapter
on investigational drugs, although having a table of such
drugs dated from 1992 does not provide much help. Some
other problems are apparent, including the extension of the
unsatisfactory term “nootropics” to include all drugs in de-
velopment for treatment of dementia. Tacrine gets its own
chapter, but the statement that this drug “has inhibition of
acetylcholine as its primary mechanism” is worryingly inac-
curate, which brings me to wonder, not wholly facetiously,
When will a handbook on drug treatment include a section
on litigation?
GAVIN P. REYNOLDS, PH.D.
Sheffield, U.K.
SUICIDE
The Suicidal Patient: Principles of Assessment, Treatment,
and Case Management, by John A. Chiles, M.D., and Kirk
D. Strosahl, Ph.D. Washington, D.C., American Psychiatric
Press, 1995, 282 pp., $42.50.
In the opening lines of Moby Dick, Ishmael states, “When-
ever it is a damp, drizzly November in my soul; whenever I
find myself involuntarily pausing before coffin warehouses,
and bringing up the rear of every funeral I meet…I count it
high time to go to sea as soon as I can. This is my substitution
for pistol and ball.” Ishmael’s suicidal rumination reflects
Camus’s contention: “There is but one truly serious philo-
sophical problem and that is suicide. Judging whether life is
or is not worth living amounts to answering the fundamental
question of philosophy” (1). To assist frontline clinicians
“with a sense of what to do with the suicidal patient” as they
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deal with patients’ suicidal behavior, Drs. Chiles and Strosahl
have authored a very valuable and practical guide in The Sui-
cidal Patient.
With their recognizing that suicidal behaviors—rumina-
tion, attempt, and completion—may not represent a contin-
uum (most of those who ruminate about suicide do not at-
tempt suicide and most of those who attempt do not die), the
authors devote most of their book to expanding their under-
lying and fundamental observations. They “treat suicidal be-
havior as a method of solving problems and…focus on non-
fatal forms of the behavior.”
The book is divided into three sections. Section 1 includes
four chapters on understanding suicidality. In chapter 2, for
example, I found an excellent discussion of the affective, eth-
ical, and legal issues confronting the clinician who is treating
a suicidal patient. Most clinicians fear that no matter what
was done, they will somehow be both blamed and sued if
there is a suicide. The authors’ advocacy of reducing the vol-
ume of potential litigation regarding alleged negligence in
treatment by “moving suicide into the realm of nonculpabil-
ity…[and thereby] more accurately represent[ing] the nature
of the act itself and specifically honor[ing] the fact that the
mental health profession does not currently possess the tech-
nology for accurate prediction or prevention of the act” is
both timely and reassuring in the litigious climate that over-
shadows current clinical practice.
Key to an understanding of the suicidal crisis is to accept
the authors’ conviction that suicidal behavior is a learned
method of problem solving. Thus, in chapter 4, Drs. Chiles
and Strosahl define the “three Is”: anyone can become sui-
cidal if a situation produces emotional pain and is believed to
be inescapable, interminable, and intolerable. Consequently,
if a patient sees that all other reasonable, problem-solving
options have become ineffective or have been tried and
failed, then the option of suicide becomes increasingly more
desirable. Rather than convince the patient that the suicidal
act is wrong, it is preferable to intervene by getting the pa-
tient to acknowledge his or her ambivalence and to discover
overlooked, alternative problem-solving options.
In section 2, which also includes four chapters, the authors
provide the reader with the basic message and details of their
learned behavior treatment model. Drs. Chiles and Strosahl
use clinical vignettes to proffer goals and strategies in making
interventions with inpatients and outpatients manifesting
suicidal behavior and demonstrate both crisis and case man-
agement expertise as they address the more clinically chal-
lenging patients who evidence recurrent suicidal behavior.
With the latter, the authors provide five central principles for
successful intervention: 1) Suicidal behavior is designed to
solve specific problems that are enmeshed in the “three Is.”
2) Approach the suicidal crisis in a candid, easygoing, nonap-
prehensive manner. 3) Remember that most suicidal crises
are nonlethal, and that no form of intervention can prevent a
determined suicide. 4) Actual suicide crises are self-limiting,
of short duration, and can usually last no more than 48
hours. 5) The goal of intervention is to help patients solve
their existential problems in nonlethal ways.
The third and final section devotes its three chapters to
special clinical problems. Included in this group are chapters
on the repetitiously suicidal patient; the suicidal patient in
general health care; and special populations, settings, and
techniques. This last chapter examines such diverse but at-
risk populations as the patient who is taking psychoactive
medication, the substance-abusing patient, the psychotically
ill patient, and the high-risk groups of adolescents and the
elderly.
1622
In sum, I find this book both well written and clinically rel-
evant for all practitioners who may see a suicidal patient in
their practice. Although the twin crisis intervention skills of
validating emotional pain and forming an effective problem-
solving plan with the patient are still germane, one popula-
tion underrepresented in this work is the jail inmate. Here
the core issue of the “suicide bind” is amplified in the mental
health practitioner who provides services to this population,
which is growing with the underfunding of community men-
tal health services and the redirection of the mentally ill into
the less clinically sophisticated criminal justice system. The
authors define the “suicide bind” as “the inescapable fact
that the power to commit suicide or engage in suicidal behav-
ior is finally and completely in the hands of your patient. No
amount of coercion, restraint, persuasion, or pleading is go-
ing to change the fact that your patient in the long run con-
trols destiny. The suicidal bind can leave you feeling power-
less and simultaneously feeling responsible for doing something
miraculous.” I hope the authors will add the jail inmate to their
chapter on special populations or settings in future editions.
Finally, as Dr. Stelzner writes,
No matter how much we may try to categorize sui-
cide…there is…a characteristic shared by all: a general
diminution of psychological capacity; an inability to use
the will, the understanding, or the imagination to con-
ceive of alternatives or a change in the intolerable situa-
tion and to use the alternative to tear oneself from the sui-
cidal obsession.…Goethe puts these words in the mouth
of Werther: “Nature finds no exit from the labyrinth of
confused, contradictory forces, and the human being
must die.”(2)
REFERENCES
1. Camus A: The Myth of Sisyphus. New York, Vintage Books,
1953
2. Friedman P (ed): On Suicide. New York, International Univer-
sity Press, 1967, pp 85–86
MICHAEL F. HEIMAN, M.D.
Sonoma, Calif.
The Suicidal Mind, by Edwin S. Shneidman, Ph.D. New
York, Oxford University Press, 1996, 181 pp., $35.00;
$12.95 (paperback published in 1998).
Dr. Shneidman has spent decades studying suicidal behav-
ior. This book offers the reader an account of his thoughts
and observations about the psychology of suicide. The major
theme of this book is that suicide is the result of “psych-
ache,” or psychological pain. He suggests that the most im-
portant issue to assess in a suicidal person is, “Where do you
hurt?” He states that this is more important than asking
about family history or examining blood or spinal fluid
chemistry.
Much of this text is devoted to personal histories or writ-
ten materials from suicidal patients. These are used to illus-
trate features of suicidal behavior that Dr. Shneidman be-
lieves are important for clinicians to learn. For example, he
suggests that most suicides fall into five categories of psycho-
logical needs: thwarted love, fractured control, shame, rup-
tured relationships, and excessive anger. Dr. Shneidman lists
and discusses what he believes are the 10 commonalities of
suicide: search for a solution, cessation of consciousness, un-
bearable psychological pain, frustrated needs, hopelessness,
Am J Psychiatry 155:11, November 1998

ambivalence, constricted thinking, escape, communication of
intention, and extension of lifelong personality styles.
One section of the book offers the reader recommenda-
tions of psychotherapeutic interventions that can be used in
working with suicidal patients. Dr. Shneidman suggests sev-
eral examples of techniques he has found useful in therapy
sessions.
Throughout the book, Dr. Shneidman reminisces about
past studies he has done and the geographical location of the
studies. (Caution: the reader must resist prolonged day-
dreaming about the beautiful places in California that are
mentioned.) From time to time, he also reflects on scholars
who have impressed him or influenced his thinking.
This book is recommended to the reader who would like
an introduction to the thoughts of a respected pioneer of the
study of suicide. Those of you wishing to explore some of the
early research of Dr. Shneidman, pull out your Internet ad-
dress for MEDLINE. If you want a comprehensive review of
suicide, including biological and psychiatric research with
references, put on your walking shoes and head for the li-
brary to find other books.
MICHAEL GARVEY, M.D.
Iowa City, Iowa
FORENSICS AND ETHICS
Psychological Evaluations for the Courts: A Handbook for
Mental Health Professionals and Lawyers, 2nd ed, by Gary
B. Melton, John Petrila, Norman G. Poythress, and Christo-
pher Slobogin. New York, Guilford Publications, 1997, 792
pp., $75.00.
A large number of factors have produced a marked up-
welling of interest in forensic psychiatry. These factors in-
clude the intrinsic fascination of the field; the visibility of
controversial, high-profile cases; the intellectual challenge of
reconciling two such diverse disciplines as psychiatry and
law; the desire for freedom from managed care’s intrusions
on sound clinical work; and many others.
In the accompanying proliferation of literature in this sub-
specialty field, only a handful of textbooks have achieved es-
sential or core status in that they are found in every forensic
library and used in every forensic fellowship. The first edi-
tion of this text was one of those few. The second edition,
therefore, has, figuratively, large shelves to fill. I suggest that
it fills them.
The authors define the book’s purpose as “to provide
[mental health professionals who perform psychological
evaluations for the courts and lawyers and judges] with a
comprehensive guide to the issues the legal system has most
commonly asked clinicians to address” (p. vii). The new ma-
terial in this edition includes such recently expanding areas
as discrimination and entitlement law and education and ha-
bilitation topics.
For those unfamiliar with the authors’ approach, each
topic begins with the legal background; this is followed by
discussion of relevant research that may support opinions on
the subject; finally, guidance is provided on the particular
evaluation in question. As before, the book is pervaded by
ethical concerns and tensions and a laudable bias toward re-
search-based assessment methods.
The second edition is divided into 18 substantive chapters,
a penultimate chapter providing extensive examples of cases
Am J Psychiatry 155:11, November 1998
BOOK FORUM
and case reports, and a large glossary. These are uniformly
excellent: thorough, logically organized, and clearly written.
The chapters move from general background issues to meth-
ods of assessment, agency issues, and forensic services; an ex-
tensive section on the criminal process; noncriminal issues
such as civil commitment and compensations systems; and
children and families. An entire portion is wisely devoted to
report writing and testimony under the rubric “Communi-
cating with the courts.” The sample reports and glossary
chapters round out the text. Each chapter is followed by a
useful list of references, presumably for further reading, since
they are not tied to the chapter content. Instead, each chap-
ter’s citations, notes, and references are placed in an end-
notes section at the back of the book, making for some awk-
ward book-balancing (and it is a big book!) to keep track of
these often useful comments and citations. I found the sec-
tions on courtroom techniques to be especially witty, realis-
tic, and useful. Although I cannot speak to forensic psychol-
ogy certification, I believe this text should serve as a valuable
resource for those clinicians seeking board certification in fo-
rensic psychiatry.
At the risk of seeming to pick nits, I noted that the index is
somewhat shorter than might be expected and somewhat cu-
riously arranged. To pick an example at random, looking for
competency to make a contract, a fairly basic topic, one finds
nothing under “contract”; looking under “competency,” one
finds “Competency to make a contract (see Guardianship)”;
looking under “Guardianship,” one finds no mention of con-
tracts. The glossary completely omits any form of the term
“reasonable medical (or psychological) certainty,” perhaps
the most significant concept to be grasped by any expert wit-
ness; the term is referenced in the index, however.
Overall, this second edition is every bit as valuable as
the first and, similarly, deserves a place on every forensic
bookshelf for its comprehensiveness, clarity, utility, and
soundness.
THOMAS G. GUTHEIL, M.D.
Boston, Mass.
Creating Born Criminals, by Nicole Hahn Rafter. Urbana,
University of Illinois Press, 1997, 284 pp., $36.95; $17.95
(paperback published in 1998).
It is amazing how many mistakes are made by mental
health professionals: psychologists, psychiatrists, social
workers, etc. We learn this mainly by looking to the past and
seeing the errors previously made. This book does an excel-
lent job of showing how the concept of the “born criminal”
was created and used, mostly on little more evidence than the
prejudices and inaccurate assumptions of the times. Those
prejudices and misunderstandings led to what Rafter calls
“eugenic criminology,” whereby criminals were often seen as
inherently defective, both intellectually and morally. The so-
lution arrived at was to have institutions for such people
where they might be confined for the rest of their lives and to
practice sterilization to prevent them from creating offspring
who would be, themselves, “defective delinquents.”
These outlooks and solutions gave incredible, often un-
checked, power to the administrators and professionals in-
volved with these alleged born criminals. Often a person
could be committed to an institution for “hereditary defec-
tives” without anything resembling due process. The person
may have been convicted of no crime but seen as a “defective
delinquent” and sent to an institution, possibly for life. Alter-
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natively, a prison might house a person who, deemed a “de-
fective delinquent,” was then sent to an institution designed
for “hopeless incurables.” The prisoner’s sentence, in effect,
was changed to a possible life sentence. In the United States,
sterilization was practiced on such people into the 1960s. In
fact, in the 1960s I worked at a state mental hospital where I
gave an IQ test to a 14-year-old African American youth. He
scored at or near the normal range of intelligence when I
tested him. His records, however, showed that, years earlier,
he had scored in the mentally retarded range and conse-
quently had been sterilized.
The misuse of eugenics (as with the youth I tested), Adolph
Hitler’s misuse during the Nazi regime, and the faulty think-
ing pointed out by Rafter all combine to give eugenics a bad
name. In contrast, Miller (1) defined eugenics as “efforts to
improve the gene pool…” (p. 391) and provided an argu-
ment for such efforts. Ellis (2) pointed out the irrational re-
sistance of many to evidence that humans differ in innate
abilities and to ways of dealing with these differences. What
the Rafter book reminds us of is the danger of misguided ef-
forts based on inaccurate concepts. When dealing with peo-
ple’s lives, it is vitally important not to make decisions based
on faulty knowledge, even if that knowledge has the stamp of
professional or scientific approval. On the other hand, there
are dangerous people in the world, people do demonstrate
differences in ability, and biology, evolution, and genetics
may have a lot to say about these things. Rafter’s book
sounds a warning about what not to do, but if it leads to re-
jection of all comparisons between people it will not help sit-
uations where decisions need to be made.
Much of what Rafter is writing about could be understood
by means of the concept of deviance. Deviance is often so-
cially created, but once the stigmatizing label of some kind of
deviance is applied to an individual, the label tends to stick,
whether valid or not. The “deviant” then has various un-
pleasant sanctions imposed. Unfortunately, sociologists have
been about the only professional group to write about devi-
ance. My book on deviance (3) is one of the few that is not
by a sociologist.
Rafter shows how inaccurate conceptions of the born
criminal were shared by many professionals and had horrible
consequences. This does not mean that there are no biologi-
cal bases of crime, but it means that the ones once believed in
were faulty. As intelligence tests were refined, people were
able to see that crime could not be explained by feeblemind-
edness, as many of the eugenic criminologists believed. Thus,
a new view was demanded, and the concept of the born crim-
inal or defective delinquent grew weaker. Thus, scientific and
professional advances can help us avoid misapplying our
knowledge. It would be healthy to reflect on this: if so many
professionals were once so inaccurate in their conceptions of
crime, what misconceptions might we harbor today about
crime, mental illness, and other topics?
REFERENCES
1. Miller EM: Eugenics: economics for the long run, in Research
in Biopolitics, vol 5. Edited by Peterson SA, Somit A. Green-
wich, Conn, JAI Press, 1997, pp 391–416
2. Ellis L: The evolution of attitudes about social stratification:
why many people (including social scientists) are morally out-
raged by The Bell Curve. Personality and Individual Differ-
ences 1998; 24:207–216
1624
3. Eisenman R: From Crime to Creativity: Psychological and So-
cial Factors in Deviance. Dubuque, Iowa, Kendall/Hunt, 1991
RUSSELL EISENMAN, PH.D.
Owensboro, Ky.
Research Ethics: A Psychological Approach, edited by Bar-
bara H. Stanley, Joan E. Sieber, and Gary B. Melton. Lin-
coln, University of Nebraska Press, 1996, 256 pp., $35.00.
This slim volume is the product of a symposium convened
by the American Psychological Association Committee for
the Protection of Human Participants in Research at the Uni-
versity of Nebraska–Lincoln to examine the role of empirical
study on ethical issues on research. At the meeting, leading
psychologist-researchers reviewed recent empirical studies of
1) ethical decision-making bodies (institutional review
boards), 2) privacy protection, 3) subject and experimenter
bias, 4) communication in research settings, and 5) informed
consent and competency. The editors note that the field has
now progressed to empirical studies providing empirical data
on how research is really conducted and how and whether
researchers adhere to formally articulated standards with re-
gard to the conduct of psychological research in their profes-
sional ethical code. Although this volume focuses primarily
on research by psychologists, it also deals with biomedical
research.
In the introduction, Dr. Sieber, Professor of Psychology at
California State University, Hayward, and a senior research
scholar, notes that an academic telling psychologists what is
ethical conduct in research is different from a researcher
knowing how to do ethical research and using that body of
knowledge to conduct ethical research. She observes that a
researcher must know the answers to the following ques-
tions: 1) What are the perspectives of the research partici-
pants? (that is, their expectations, concerns, and beliefs
about the research); 2) How can one communicate with par-
ticipants about the research in terms they understand? 3) How
can one respect those privacies that are important to the partic-
ipants? 4) How can one conduct the most valid research possi-
ble at the least risk to participants and society? and 5) What
are the researcher’s own scientific perspectives and those of
other scientists? The researcher then must demonstrate em-
pirically that the answers to these questions are applicable. In
summary, she concludes that these are all areas that can and
have been studied.
In part 1, major areas of empirical research on basic is-
sues of consent, risk-versus-benefit assessment, rapport,
privacy, and confidentiality are summarized by conference
participants. Of particular interest to psychiatrists is the
chapter by Dr. Sieber on the subtleties of nonverbal commu-
nications that occur in the research setting and strongly af-
fect the rapport between investigators and research partici-
pants. Although as psychiatrists/clinicians we are ever
watchful with regard to the nonverbal communications of
our patients, when wearing the hat of researcher, I wonder
if we attend to nonverbal communication in the same way?
The skills, sensitivities, and nonverbal communication so
important in psychotherapy may be lost when doing re-
search that must be squeezed into the busy clinical day. Dr.
Sieber reminds the researcher of the constant attention that
must be paid to the subtleties of communication in research
and to their implications for the outcome of the research.
She also reviews a number of empirical studies in this area.
Am J Psychiatry 155:11, November 1998

In my opinion, this chapter is particularly important for the
beginning researcher.
In another chapter, Dr. Stanley and Jeannine R. Guido re-
view research on informed consent, including voluntariness,
competency, disclosure, comprehension, participants’ reac-
tions to being informed, the decision-making progress, and
public opinion regarding informed consent research and the
use of deception. I personally was surprised by the amount of
deception these authors report in psychological research con-
ducted at the undergraduate level in American universities. I
always thought subjects’ participation was voluntary and
never imagined that they might be part of a research pool by
virtue of their enrollment in an elementary psychology
course. I certainly was naive, or perhaps I just read contem-
porary psychological research using undergraduates as re-
search subjects with an uncritical eye. Recently I have been
reviewing research on the effects of explicit pornography on
college students’ attitudes toward women and sexuality. Re-
thinking my literature review in the light of Dr. Guido’s com-
ments about deception, I wonder how much deception was
used in the recruitment of these students regarding their in-
formed consent, voluntariness, and knowledge of the use to
which the research might be put.
The next section of the book deals with ethical issues in-
volved in doing psychological research on special popula-
tions or in special contexts such as hospitals and prisons. It
describes populations that are especially vulnerable, which
include people with mental illness or mental retardation,
children, the elderly, people who have been abused or ne-
glected, those with HIV infection, criminals, the homeless,
delinquent youngsters, and troubled families. As psychia-
trists doing research, we must recognize that we work with
populations that are particularly vulnerable in that they lack
resources or autonomy and are often unable to speak for
themselves. Their informed consent, while appearing volun-
tary, may be neither voluntary nor truly informed.
Drs. Melton and Stanley examine the ethical issues sur-
rounding research on populations of uncertain competence
to consent. Review of the empirical research in this area re-
veals that individuals of uncertain competence are often
more capable of rational consent than has been previously
supposed, particularly if a researcher makes a concerted ef-
fort to maximize autonomy. Thomas Grisso examines the
way in which institutional and organizational settings may
influence the degree of coercion, threat, and candor of re-
search participants. He focuses on such diverse institutions
Reprints of Book Forum reviews are not available.
Am J Psychiatry 155:11, November 1998
BOOK FORUM
as public schools, colleges, hospitals, and prisons and re-
views the extensive literature with regard to constraints such
institutions place on the voluntariness of decision making.
Finally, in a thought-provoking chapter, Michael J. Saks
and Dr. Melton ask, Is it possible to legislate morality? En-
couraging psychological research contributions to problems
of research ethics, Drs. Melton and Saks suggest a novel so-
lution to the problem of encouraging, supporting, and re-
warding adherence to ethical principles when conducting re-
search. First, they examine the stick approach; that is, using
sanctions imposed by professional ethics boards and the
courts in a punitive fashion to enforce ethical principles
when conducting research. They conclude that although a
few offenders might be “caught” and a few potential offend-
ers deterred, the stick approach will not ultimately change
behavior. They suggest that university departments of psy-
chology (supported by the American Psychological Associa-
tion) site-visit one another specifically for the purpose of re-
viewing each other’s research projects with a focus on
research ethics. The site visitor would offer friendly sugges-
tions to correct perceived ethical problems. The visitor’s as-
signment would be to discuss potential ethical concerns and
to help solve perceived problems. Site visitors would not visit
departments to formally evaluate or file charges if ethical vi-
olations were observed. They would be expected to send a re-
port on their visit to the American Psychological Association.
Dr. Melton recognizes that such a program would require
salary and support for a new staff position at the American
Psychological Association. He believes that attitudes and
then behavior can be changed by using “social influence
aimed by friendly strangers at people who are in the business
of doing research.” Saks and Melton conclude that this is one
strategy among a potentially large number of strategies for
improving ethics among researchers, and it is offered as an il-
lustration of one quiet way to advance ethical behavior and
knowledge of ethical issues in research “and begin to create
an ethos in which ethical concerns are an inherent part of the
research enterprise.”
This was not an easy book to read. It requires concentra-
tion and a serious consideration of the ideas presented. It is a
book I suspect I will continue to use, a book I certainly will
recommend to young researchers and more mature research
colleagues. It forces one to examine attitudes and behavior
and leads to insights and changes.
ELISSA P. BENEDEK, M.D.
Ann Arbor, Mich.
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