BOOK REVIEWS
, Editor
The Lobotomist and the Lobotomized
The Lobotomist: A Maverick Medical Genius and
His Tragic Quest to Rid the World of Mental Illness
by Jack El-Hai; New York, John Wiley & Sons, Inc., 2005, 368 pages, $27.95
The Pest Maiden: A Story of Lobotomy
by Penelope Scambly Schott; Cincinnati, Ohio, Wordtech
Communications, 2004, 132 pages, $17 softcover
Jeffrey L. Geller, M.D., M.P.H.
Y ears before I was a psychiatry res-
ident I worked as an aide in two
different psychiatric hospitals. At
each hospital I participated, in one
form or another, in procedures that I
thought had already become part of
psychiatry’s history. The first was
packing in a wet sheet, a procedure
about which there have been many
stories of horror but that the patient
later described as being remarkably
soothing and helpful. The second was
a lobotomy that the patient had
pleaded with her psychiatrist to re-
ceive. This procedure I found to be
crude, frightening, and bordering on
incomprehensible.
Interest in lobotomy, which has
been quiescent but has never entirely
gone away, seems to have erupted
with the publication of The Loboto-
mist: A Maverick Medical Genius and
His Tragic Quest to Rid the World of
Mental Illness, by Jack El-Hai. The
Lobotomist is the story of Walter
Freeman, a maverick physician, who
almost single-handedly brought lo-
botomy to the United States and per-
petuated its practice for decades.
The reawakened interest in loboto-
my is demonstrated by an editorial in
the New England Journal of Medicine
by Barron H. Lerner on July 14, 2005,
titled “Last Ditch Medical Therapy—
Revisiting Lobotomy” (1). The inter-
est is also evident in Associated Press
coverage in the print media and on
the Internet, with titles such as “Con-
troversy Over Lobotomies Resur-
faces,” an article that discusses the ef-
forts of relatives of lobotomized indi-
Dr. Geller is professor of psychiatry and
director of public-sector psychiatry at the
University of Massachusetts Medical
School in Worcester.
1318
Jeffrey L. Geller, M.D., M.P.H.
viduals to posthumously strip loboto-
my pioneer, Portuguese neurologist
Egas Moniz, of his Nobel Prize (2).
That lobotomies would stir up con-
troversy even decades after the inter-
vention passed from surgical practice
will surprise no one who reads The Lo-
botomist. Walter Freeman’s story is a
psychologically interesting one, as we
view a physician dealing with his pa-
ternal lineage and his own lifetime
quest to make a contribution and be-
come famous. Freeman, the grandson
of well-known physician William
Williams Keen and the son of a physi-
cian of no particular distinction, per-
formed his first lobotomy in the Unit-
ed States in September 1936. Before
venturing into the world of destroying
healthy brain tissue in the name of re-
mediating all manner of psychiatric
and neurologic symptoms, Freeman
had rather impeccable credentials, in-
cluding positions at Georgetown Uni-
versity, the U.S. Naval Medical School,
and George Washington University.
El-Hai does a credible job of weav-
ing through Freeman’s history the
impact of his early development, his
character traits, his quest for great-
ness, his profound desire to be taken
seriously as a scientist by his peers,
his record keeping, and his lifelong
interest in photography. The result-
ing tale is one that shows how devel-
opments in medicine are affected by
one individual and how the individ-
ual is affected by developments in
medicine. Celebrities who are known
for their lobotomies appear through-
out these pages, including Frances
Farmer and Rosemary Kennedy.
While acknowledging his role in lo-
botomizing Kennedy, Freeman de-
nied his involvement with Farmer
and her treatment.
PSYCHIATRIC SERVICES ♦ http://ps.psychiatryonline.org ♦ October 2005 Vol. 56 No. 10
The Lobotomist is also the tale of a
medical intervention gone awry. Po-
tential small successes in the begin-
ning are parlayed into a treatment
that has far broader application than
was conceivable at the outset. As has
been seen in psychiatry with many
other treatments, such as ovari-
otomies in the 19th century and elec-
troconvulsive therapy (ECT) in the
20th century, treatments became bas-
tardized and became so widespread
that it is almost impossible to ascer-
tain for whom, if anyone, they might
have worked. The public villainizes
these treatments, and what might be
successful for some has the potential
to be lost. Ovariotomies as a means of
treating insanity most probably never
made sense, whereas ECT has proven
to be an extremely effective treat-
ment when targeted at a narrow
range of psychopathology.
The Lobotomist is recommended
for anyone who is interested in the
history of psychiatry or even the more
general topic of how treatments in
medicine evolve.
There would, of course, be no his-
tory of and no controversy around lo-
botomies without patients who had
been lobotomized. There are few au-
tobiographies by individuals who had
lobotomies, and the authorship of
some of the more well-known, such
as Frances Farmer’s Will There Real-
ly Be a Morning? (3), is in question.
Nor are there very many biographies
about individuals who were the re-
cipients of lobotomies. With The Pest
Maiden: The Story of Lobotomy,
Penelope Scambly Schott has written
a book-length narrative as a series of
poems that is the story of her mater-
nal grandmother’s first cousin’s
daughter’s lobotomy.
In this biography, Schott, who men-
tions that she has her own psychiatric
history, never met the subject of her
story. She did, however, have regular
contact with the subject’s aunt, Viola
Paradise, from whom she “inherited”
a file box that included letters from,
to, and about Jean, the young woman
who was lobotomized. The author
quotes from these letters and also
uses primary and secondary sources

in the neurologic and psychiatric lit-
erature, including Walter Freeman’s
description, “how to perform my new
transorbital lobotomy.” On one hand
Schott’s tale is a very personal one,
but on the other hand it provides in-
formation about not only the develop-
ment of lobotomies and their effects
on an individual patient but also their
ripple effects on an extended family.
Jean Heuser received her lobotomy
at Rockland State Hospital on Mon-
day, February 15, 1954. It is both
ironic and poignant that the following
month—March of 1954—the U.S.
Food and Drug Administration ap-
proved chlorpromazine for use
among psychiatric patients. It was this
first antipsychotic that heralded the
end of what Schott calls “the epic of
mass lobotomy.”
Psychological Treatment of Bipolar Disorder
edited by Sheri L. Johnson and Robert L. Leahy;
New York, Guilford Press, 2004, 339 pages, $40
Ellen B. Tabor, M.D.
B ipolar disorder is a common and
serious psychiatric disorder for
which successful treatment is an elu-
sive goal. The combination of
grandiosity, hopelessness, and ex-
treme lability make patients reluctant
to engage wholeheartedly in treat-
ment, leading to self-destructiveness
and, often, suicide. Pharmacologic ad-
vances have made symptom reduction
more possible than ever, but the psy-
chological concomitants of grandiosi-
ty, denial, and the real pleasure of the
manic and hypomanic state make
long-term medication compliance a
rarity. Psychological Treatment of
Bipolar Disorder attempts to bring a
psychotherapeutic framework back
into what has become a psychophar-
macologic morass. Although the num-
ber of medications available to treat
Dr. Tabor is medical director of adult in-
patient psychiatry at Kings County Hos-
pital Center and assistant professor in
psychiatry at the State University of New
York (SUNY)–Downstate Medical Center
in Brooklyn.
PSYCHIATRIC SERVICES ♦ http://ps.psychiatryonline.org ♦ October 2005 Vol. 56 No. 10
The power of Schott’s presentation
is no better appreciated than through
her words themselves: “The gray
women/in the long dayroom/of the
long ward/don’t think they are
bored/Who would believe/Jean can
still grieve?/Whenever she starts/look-
ing down/the attendants send her/to
have her hair/dyed brown/again/and
again/and curled/as if the world/or a
hot comb/or curlers/could ever re-
furl/those severed fibers.”
References
1. Lerner BH: Last Ditch Medical Therapy:
Revisiting Lobotomy. New England Jour-
nal of Medicine 353:119–121, 2005
2. Controversy over lobotomies resurfaces.
Available at www.cnn.com/2005/health/07/
14/lobotomy.debate.ap
3. Arnold W: Shadowland. New York, Mc-
Graw Hill, 1978
bipolar disorder continues to grow,
with the anticonvulsants playing an
ever more important role, patient fac-
tors frustrate psychiatrists and other
therapists. Can this book provide
some help?
Well, yes and no. The middle chap-
ters, describing various manual-guid-
ed psychotherapies, including cogni-
tive therapy, interpersonal and social
rhythm therapy, and the Life Goals
Program at Brown University, offer
novel and thoughtful additions to the
psychotherapeutic armamentarium,
never straying from psychopharma-
cologic compliance but adding depth
to the understanding of factors that
lead to relapse and to noncompli-
ance. In particular, the chapter on in-
terpersonal and social rhythm thera-
py, by Ellen Frank and Holly Swartz,
develops the important realization
that regularization of circadian
rhythms is essential to the mainte-
nance of a euthymic state and com-
bines cognitive-behavioral tech-
niques with the keeping of a social
rhythm diary to educate the patient
BOOK REVIEWS
about the complex interactions be-
tween biological rhythms (for exam-
ple, diurnal variations in sleep) and
social events and stressors (for exam-
ple, life changes and job stresses).
The inclusion of the emphasis on bi-
ological rhythms into the psychother-
apy is an important development.
The authors provide an example of a
chart for patients to record the bio-
logical and social events in their lives,
creating an archive of these interac-
tions, from which the patient can
learn important associations that can
lead to behavioral change.
The other truly excellent chapter
describes the Life Goals Program at
Brown University, which is headed by
Mark Bauer. In this chapter, Bauer
describes what he calls supporting
collaborative practice management,
in which the patient collaborates with
therapists and other patients to man-
age the illness better and to improve
his or her functional outcome. He fo-
cuses on the term “manic-depressive
illness,” which he believes better de-
scribes the illness than the newer
term, “bipolar disorder.” The Life
Goals Program encourages the for-
mation of personal goals and strate-
gies for reaching them, including
teaching oneself the negative reper-
cussions of one’s behavior while man-
ic or depressed. In addition, Bauer
recognizes that mere symptom re-
duction may not have an impact on a
patient’s functional level, so the pro-
gram goes beyond achieving remis-
sion and looks to living a life that the
patient finds fulfilling. It comprises
cognitive, behavioral, and group skills
and fosters individual accountability
and independence.
The rest of the book is not as inter-
esting and useful. The opening sec-
tion reviews the basic information
about bipolar disorder in an extreme-
ly inaccessible way. Nothing new is
offered, and the citation style of list-
ing all the authors rather than using
numbers creates large gaps between
material; I found the entire book awk-
ward to read for this reason. Much of
the book had little or nothing to do
with psychological factors in bipolar
disorder, let alone psychological
treatment of the disorder. There was
1319
BOOK REVIEWS
almost no mention of the manic de-
fense, a very important concept in
managing both phases of the illness
and in particular suicidality, despite
the fact that an entire chapter is de-
voted to suicidality. The chapter on
psychopharmacology, a curious inclu-
sion given the book’s title, is similarly
banal. Many of the authors quote
themselves extensively. Finally, the
research cited is not always the most
From Toxic Institutions to Therapeutic Environments:
Residential Settings in Mental Health Services
edited by Penelope Campling, Steffan Davies, and Graeme
Farquharson; London, Gaskell, 2004, 286 pages, $25 softcover
Timothy B. Sullivan, M.D.
I was eager for the opportunity to re-
view this book as soon as I saw the
title. It’s been a long time since I have
read anything thoughtful about thera-
peutic communities, which has
seemed strange, given that I am im-
pressed each day, in my work as a
community psychiatrist, with the im-
portance and clinical relevance of the
patient’s environment in his or her life.
To prepare myself to review From
Toxic Institutions to Therapeutic En-
vironments: Residential Settings in
Mental Health Services, I performed
a few on-line searches, through
PubMed, using keywords such as
“therapeutic community” and “resi-
dential treatment.” It probably will
not surprise readers that there has
been little American research in this
area in recent years, except for the
substance abuse (MICA) field. The
handful of articles I could find origi-
nated in the United Kingdom and
were authored, for the most part, by
the various contributors to this useful
and provocative volume.
The book includes reviews of his-
torical accomplishments and progress
in the development of therapeutic
Dr. Sullivan is chief of services for the
seriously mentally ill at Saint Vincent’s
Catholic Medical Center in Westchester,
New York, and assistant professor of
psychiatry at New York Medical College
in Valhalla.
1320
recent, given that the book was pub-
lished in 2004.
In sum, Psychological Treatment of
Bipolar Disorder offers too little
about psychotherapy and too much
that is available elsewhere. The chap-
ters “Interpersonal and Social
Rhythm Therapy” and “Supporting
Collaborative Practice Management”
provide a pleasant respite from an
otherwise redundant book.
communities; sociologic reflections on
the relationship of persons to their
physical and emotional environments;
unapologetic, psychoanalytically ori-
ented essays on group and communi-
ty processes; and reviews of research
and proposals for the future study of
issues raised by these well-written,
and occasionally poignant, essays.
The writing deals with a broad
range of topics, covering both inpa-
tient and community-based residen-
tial treatment, such as the physical
environment and use of space, con-
necting with the natural environ-
ment, a gender-sensitive therapeutic
environment for women, preventing
and managing violence and aggres-
sion in inpatient settings, the resi-
dential care and treatment of adoles-
cents, and measuring the therapeu-
tic environment.
The book’s contributors include
very well-known researchers, such as
Rudolf Moos of Stanford University
and Steffan Davies of the University
of Leicester, who is also one of the
book’s editors, as well as nurses and
T his book on participatory com-
other health care professionals work-
ing in a variety of clinical settings.
There are also two chapters written
from the perspective of “users” (the
British equivalent of “consumers”).
The book principally uses clinical
examples and models from health
care programs in the United King-
dom but is no less interesting for
PSYCHIATRIC SERVICES ♦ http://ps.psychiatryonline.org ♦ October 2005 Vol. 56 No. 10
American readers. In fact, readers
will likely find this element stimulat-
ing because of the different perspec-
tives and priorities evidenced in these
clinicians’ accounts of their work. It is
also axiomatic that subjective experi-
ence is not so different in the two
countries, especially when consider-
ing themes of alienation, helpless-
ness, and institutional bias.
In the preface, the editors note that
“the concepts of ‘asylum’ and ‘sanctu-
ary’—so obvious to laypeople—need
to be rediscovered by mental health
professionals.” They assert, and
demonstrate, that this topic is receiv-
ing renewed interest and support, at
least in the United Kingdom. It is
perhaps appropriate that this should
be so in the country where the first,
great asylums (1), which promoted
“moral treatment” in the 18th centu-
ry, were founded. Let us hope the en-
thusiasm and insight, demonstrated
in this very worthwhile book, travels
“across the pond.”
Reference
1. Morrissey JP, Goldman HH: Cycles of re-
form in the care of the chronically mentally
ill. Hospital and Community Psychiatry
35:785–793, 1984
Participatory Community
Research: Theories and
Methods in Action
edited by Leonard A. Jason,
Christopher B. Keys, Yolanda Suarez-
Balcazar, Renee R. Taylor, and
Margaret I. Davis; Washington, D.C.,
American Psychological Association,
2004, 320 pages, $49.95
Beth Hinden, Ph.D.
munity research informs, in-
structs, and may even inspire. The
work as a whole accomplishes several
goals that are important to the pro-
motion of participatory research as a
legitimate and powerful complement
to more traditional methods. Specifi-
Dr. Hinden is affiliated with the depart-
ment of psychiatry at Worcester State
Hospital in Worcester, Massachusetts.

cally, Participatory Community Re-
search: Theories and Methods in Ac-
tion effectively defines and distin-
guishes participatory research ap-
proaches, relates participatory com-
munity research to other theoretical
approaches (such as feminism and
multiculturalism) and methodologic
approaches (such as epidemiologic
studies and randomized controlled
trials), and provides examples of cut-
ting-edge research across a range of
compelling public health problems,
such as AIDS, smoking, alcoholism,
and youth violence.
To the book’s credit, it is a partici-
patory work itself. That is, the entire
“community of researchers”—aca-
demic faculty, graduate students,
and community members—are re-
flected across chapters that delin-
eate both strengths and weaknesses;
an entire section is devoted to
“stakeholder perspectives.” As a
whole, the book both reflects the
Brief Therapy for Couples:
Helping Partners Help Themselves
by W. Kim Halford, Ph.D.; New York, Guilford
Press, 2001, 279 pages, $31.50 softcover
Nathan S. Keedy, L.I.C.S.W.
I f you are a couples therapist seeking
an enduring and rewarding relation-
ship with a book that provides a fresh
model for flexible short-term couples
therapy, Brief Therapy for Couples:
Helping Partners Help Themselves
may be a very eligible match for you.
The author is W. Kim Halford, Ph.D.,
professor of clinical psychology in the
School of Applied Psychology at Grif-
fith University in Brisbane, Australia.
Halford brings to this book many years
of research and direct clinical practice
with couples. Halford’s experience is
evident in the richness of detail and
comprehensiveness of his work. Al-
though I am an older and skeptical cli-
nician, after reading his book I was ea-
Mr. Keedy is a staff psychotherapist and
supervisor in the outpatient psychiatry
department of UMass Memorial Medical
Center in Worcester.
PSYCHIATRIC SERVICES ♦ http://ps.psychiatryonline.org ♦ October 2005 Vol. 56 No. 10
current state of the art and sets the
stage for the future of participatory
community research.
The data presented in this book are
compelling. Participatory community
research represents a research ap-
proach dedicated to empowering in-
dividuals and communities through
research partnerships. It prioritizes
academic-community partnership
and power sharing such that research
questions and study designs are de-
veloped collaboratively and reflect
the complex qualities and needs of
the communities from which re-
search participants are recruited and
interventions targeted. Although
these priorities create difficult chal-
lenges, they are also likely to generate
stronger community commitment to
research participation and to result in
more appropriate, effective, and sus-
tainable interventions—goals on par,
it seems to me, with scientific objec-
tivity and control.
ger to begin applying Halford’s model
to my practice.
Working within the general school
of behavioral and cognitive therapies
for couples, the author calls for a
“new model of couple therapy,” one
that does not simply apply behavioral
and cognitive skills to couples but that
enables couples to change them-
selves. Building on behavioral self-
control theory, Halford calls this self-
change approach “self-regulatory
couples therapy” (SRCT). He propos-
es, with some research support, that
self-change produces greater rela-
tionship satisfaction than when
change is directed by the therapist.
Self-change is an exciting idea in this
book, and Halford takes it and seems
to transform much of the tenor of be-
havioral and cognitive therapies.
The book begins with a research-
based description of the nature of
BOOK REVIEWS
couple’s problems and the life events,
individual characteristics, and contex-
tual factors that can affect a couple. A
useful review of several evidence-
supported couples therapies follows.
Halford has adapted many of these
methods to his own approach. Then,
after a clear and detailed description
of his approach, Halford takes the
reader step by step through applying
it to clinical practice, and he includes
a sufficient number of case examples.
From the beginning of therapy,
SRCT “shapes the couple’s attention
to self-directed change” and offers
three different levels of therapy, de-
pending on how capable the couple is
for self-change. Self-change depends
on what Halford calls “metacompen-
tencies” within a couple. Metacompe-
tencies include such things as “self-
appraisal, setting self-change goals,
implementing self-change strategies,
and evaluating the effects of the self-
change efforts.” If a couple has suffi-
cient metacompetencies, brief (two
to six sessions) self-directed therapy is
offered. For couples who cannot self-
appraise and self-select goals or who
lack certain relationship skills, one or
two additional levels of therapy are
offered first. Halford’s chapters on
these other levels are rich in invalu-
able methods and techniques for
working with more distressed cou-
ples. However, the ultimate goal of
therapy for any couple is the develop-
ment of adequate metacompetencies
for self-change.
Brief Therapy for Couples suc-
ceeds nicely in being an understand-
able presentation of SRCT theory
and in providing a very user-friendly
clinician’s manual. Numerous details,
common therapy pitfalls, and prob-
lem areas—for example, domestic vi-
olence and affairs—are well covered.
Many self-report inventories are rec-
ommended. This book leaves little
for the reader to fill in. One could use
the book just for its richness of tech-
niques. But that would be missing its
greater value, which is a clear pres-
entation of a brief but comprehen-
sive and flexible form of couples
therapy that aims to develop in two
people their own ability to change
their relationship.
1321
BOOK REVIEWS
Open Heart: A Patient’s Story of Life-
Saving Medicine and Life-Giving Friendship
by Jay Neugeboren; Boston, Houghton
Mifflin Company, 2003, 371 pages, $24
Jeffrey Geller, M.D., M.P.H.
O pen Heart: A Patient’s Story of
Life-Saving Medicine and Life-
Giving Friendship, by Jay Neuge-
boren, is an incredibly heartwarming
tale by an author who is perhaps best
known to the readers of this journal
for his books Imagining Robert and
Transforming Madness. Neugeboren
focuses on three relationships in
Open Heart: his heart, his friends,
and his penis. The real value of the
book is a description of the relation-
ships between Neugeboren and four
lifelong friends. The relationships get
played out around Neugeboren’s car-
diac disease. The penile relationship,
most of which relates to medical and
physiological disorders of the organ,
is one that is obviously important to
Neugeboren and true to the chronol-
ogy but was mostly a diversion for
this reader.
Four of Neugeboren’s friends work
with him and with each other to save
his life. All five of these guys grew up
together in Brooklyn. Three are physi-
cians: one is director of the AIDS pro-
gram at Yale–New Haven Hospital;
another, a neurologist in Denver, Col-
orado; and another, a cardiologist at
Cedars Sinai Medical Center in Los
Angeles. The fourth is a psychologist
in private practice. Before going any
further I state without any reservation
that every literate male in America
should read this book; those for whom
the book’s reading level is beyond
their capacity should have somebody
read it to them.
Why? Open Heart is the story of
men with open hearts. It is the story
of sweet, caring, supportive, lifelong
relationships among a cohort of
American men that is so rarely the
subject in any American media and so
outside the experience of such a large
proportion of American men that
Dr. Geller is professor of psychiatry and
director of public-sector psychiatry at the
University of Massachusetts Medical
School in Worcester.
1322
some readers of Open Heart might
think it a work of fiction.
There is much in Open Heart about
the state of American medicine, the
doctor-patient relationship, the inter-
action of compassion and technical
skills, and what it means to care for
the person beyond the patient that
makes this useful reading for all
physicians. The good doctor as per
Neugeboren: “It is only by carefully
listening to and examining a patient,
by putting a patient’s symptoms and
concerns into the larger context of the
patient’s individuality and history, and
by considering the individual patient
in the context of their own knowledge
and clinical experience that they be-
lieve they have a good shot at an ac-
curate diagnosis and a beneficial
treatment plan.” Neugeboren visits
the issue of the physician’s role when
the best he or she can do is care and
not cure. Neugeboren quotes one of
his friends: “I think one of the main
things in being a doctor these days is
making sure the technology doesn’t
overrun your judgment.” Neuge-
D epression is one of the signifi-
boren stresses the importance of
keeping the patient as fully informed
as possible and talks about his own
ease and uneasiness when left with-
out an understanding of his disease.
Men and medicine have much to
learn from Neugeboren. One of his
resonant messages: “The things peo-
ple want from their doctors, and that
they are, in recent years, getting less
of, have much in common with what
they want from friendship.” Some
might say it’s just too late for Ameri-
can medicine. To that I would re-
spond with an African proverb that
Neugeboren quotes: “The best time
to plant a tree is 20 years ago. The
second best time is now.”
The only aspect of Open Heart that
disappointed me was Neugeboren’s
failure to draw parallels between his
situation and that of his brother
Robert, his younger sibling about
whom he has written extensively. Per-
PSYCHIATRIC SERVICES ♦ http://ps.psychiatryonline.org ♦ October 2005 Vol. 56 No. 10
haps that is Neugeboren’s next book;
I look forward to it.
Finally, I have a suggestion for how
we might use Open Heart to improve
the practice of medicine. If the Amer-
ican Medical Association (AMA)
stopped sending me and all other
physicians the multitude of junk mail-
ings they send out to members and
nonmembers alike, it could probably
cut a deal with Houghton Mifflin, the
publishers of Open Heart, to send a
copy of the book to every physician in
the United States and to do so in a
cost-neutral fashion. The AMA would
probably get more new members
than they do with their current cam-
paign, and physicians in the United
States might be much better able to
practice medicine with an open heart.
Late-Life Depression
edited by Steven P. Roose and
Harold A. Sackeim; New York,
Oxford University Press, 2004,
388 pages, $89.50
Michael B. Sheikman, M.D.
cant causes of morbidity and
mortality among older people and
consumes an increasing share of
health care resources. This illness has
a particularly devastating impact on
elderly persons because it is often un-
derdiagnosed and, in many cases, is
inadequately treated. Depression not
only has a profound effect on the
quality of life but also is associated
with an increased risk of mortality
from suicide and vascular disease.
Practicing geriatric psychiatrists un-
derstand what a difficult task it is to
treat depression in this population.
Late-Life Depression is an up-to-
date book that helps illuminate the
deleterious relationship between
depression in late life and other ill-
nesses. This book is targeted to psy-
chiatrists and other health profes-
sionals who work with older adults
and have to deal with the rapid ex-
Dr. Sheikman lives in Shrewsbury,
Massachusetts.

pansion of scientific knowledge
about aging.
Late-Life Depression is devoted to
the epidemiology, phenomenology,
psychobiology, and consequences of
late-life depression and describes
current attitudes to treatment. The
contributors to this book point out
that the current DSM criteria have
not been modified to reflect the clin-
ical features unique to the depressed
elderly, who tend to report more so-
matic and cognitive symptoms than
affective symptoms. Neurocognitive
presentation of depression among
elderly individuals who are experi-
encing forgetfulness and distractabili-
ty is a part of the phenomenology of
depression. Depression may also play
a role in the development of vascular
disease. Elevations in the hypothala-
mic-pituitary-adrenal axis play an in-
tegral role in the expression and out-
come of depression as well as in co-
morbid diseases among the elderly.
Subclinical endocrinopathies—for
example, mild testosterone deficien-
cy—are etiologically important in the
development of subthreshold neu-
ropsychiatric problems.
Suicide is more frequent among
elderly persons than in any other pop-
ulation. Suicide in later life is a signif-
icant public health problem that in
the coming decades is likely to ac-
Handbook of Racial and Ethnic Minority Psychology
edited by Guillermo Bernal, Joseph E. Trimble, A. Kathleen
Burlew, and Frederick T. L. Leong; Thousand Oaks, California,
Sage Publications, 2003, 780 pages, $99.95
Shanta Henderson, M.D.
H andbook of Racial and Ethnic
Minority Psychology is the
fourth volume in the Racial and Eth-
nic Minority Psychology series. It is a
collection of papers divided into six
parts: conceptual, professional, and
training issues; ethnic minority re-
Dr. Henderson is a chief resident in the
department of psychiatry of the Universi-
ty of Maryland/Sheppard Pratt and a mi-
nority fellow of the Substance Abuse and
Mental Health Services Administration
and the American Psychiatric Association.
PSYCHIATRIC SERVICES ♦ http://ps.psychiatryonline.org ♦ October 2005 Vol. 56 No. 10
count for an even larger number of
deaths. Substance use and abuse in
late life are also currently growing
public health issues.
Age-associated pharmacodynamic
changes result in higher and more
variable drug concentrations in the
elderly. Older patients also take
longer to respond to antidepressants
and require extended treatment tri-
als. These medications are also associ-
ated with a higher rate of side effects.
Selective serotonin reuptake in-
hibitors are the most frequently pre-
scribed, and elderly persons are more
likely than younger individuals to ex-
perience adverse events due to anti-
depressants. Atypical antipsychotics
are preferred over conventional
agents for elderly patients who have
psychotic disorders.
The authors show that late-life de-
pression is an entity that is meaning-
fully distinct from depression among
younger adults and presents distinct
clinical challenges in terms of assess-
ment, treatment optimization, and
the frequency and management of
side effects. The care of the patient
with late-life depression must address
different issues and needs from those
encountered in the treatment of
younger adults, and Late-Life De-
pression will be a helpful aid for psy-
chiatrists treating late-life depression.
search and methods; social and devel-
opmental process; stress and adjust-
ment; clinical interventions; and ap-
plied and preventive psychology. It
aims to provide “the needed concep-
tual and theoretical foundations, nor-
mative data, research findings, and
pragmatic strategies distinctive to
work with persons of color.”
At first glance, the term “handbook”
does not seem like an accurate descrip-
tion for this 780-page volume. Howev-
er, from the start the book clearly
BOOK REVIEWS
meets the definition of a handbook as a
guidebook for travelers, for it skillfully
guides seasoned explorers and novices
alike on a journey of discovery through
a rich landscape of psychological theo-
ry, research, and practice.
Part 1—Conceptual, Professional,
and Training Issues—is an excellent
representation of the text. Each part
offers “resources for teaching, re-
search, and action” through general
overviews and issue-specific chapters.
The stage is set with the chapter “A
Tale of Challenge and Change: A His-
tory and Chronology of Ethnic Mi-
norities in the United States.” The au-
thors honestly portray psychology’s
role in perpetuating “scientific
racism,” describe the impact of so-
ciopolitical forces on psychology, and
summarize the involvement of mi-
norities in the field from 1869 to
2002. This chapter is a sound intro-
duction to chapters that follow in Part
1, such as the brave and commend-
able paper “The Psychology of To-
kenism: Psychosocial Realities of Fac-
ulty of Color.”
This book is a tool not only for
mental health researchers and clini-
cians but also for students and profes-
sionals in other fields. The chapters
avoid esoteric discourse and clearly
describe basic principles and termi-
nology. For example, in “Ethnic Re-
search is Good Science,” the authors
make an effort to define terms such as
“translation” and “conceptual equiva-
lence” before discussing them in
more detail.
Although the book could not focus
on all issues or populations, even the
culture-specific chapters provide con-
cepts that can be applied to research
and practice with other groups. For
example, “Infant Mental Health in
African-American Families: A Socio-
cultural Perspective” looks specifically
at African Americans but illustrates
“how culture might influence parent-
ing behaviors, attitudes toward mental
health, and children’s mental health
outcomes” across populations.
A refreshing aspect of this book was
the passionate tone that permeated
the text. Papers such as “Examining
the Impact of Violence on Ethnic Mi-
nority Youth, Their Families, and
1323
BOOK REVIEWS
Communities: Issues for Prevention
Practice” and “Science and Chal-
lenges of HIV Prevention in Diverse
Communities: Sex, Culture, and Em-
powerment” describe interventions
that were scientifically evaluated and
theoretically sound. However, the
chapters still conveyed a sense of the
emotional backdrop that makes this
The Birth of the Mind: How a Tiny Number of
Genes Creates the Complexities of Human Thought
by Gary Marcus; New York, Basic Books, 2004, 278 pages, $26
Thomas A. Simpatico, M.D.
T he mind is what the brain does.”
So wrote Massachusetts Institute
of Technology psychologist Steven
Pinker in his celebrated 1997 book,
How the Mind Works (1). Today, and
in the wake of the ongoing genetics
revolution, Pinker’s former student
Gary Marcus takes a stab at answering
the lofty question, What do our minds
owe to nature, and what to nurture?
Until recently, we knew relatively lit-
tle about how genes work and what
they bring to the biological structures
that underlie the mind. Marcus re-
minds us that now, 50 years after the
discovery of the molecular structure
of DNA, we are for the first time in a
position to understand directly DNA’s
contribution to the mind.
Marcus is a cognitive psychologist
and is currently an associate professor
in the department of psychology at
New York University and director of
New York University’s infant language
center. He understands genes and has
researched his topic well, taking us on
a complex journey in an entertaining
and absorbing way. He does a particu-
larly good job of framing the issues
with crystal clarity and making rele-
vant scientific concepts accessible to
even the lay reader without diluting
his logic or the power of the story for
more knowledgeable readers.
Dr. Simpatico is associate professor of psy-
chiatry and director of public-sector psy-
chiatry at the University of Vermont Col-
lege of Medicine in Burlington and med-
ical director of the Vermont State Hospital.
1324
field of study so rewarding. In the ac-
knowledgments, the editors thank
their ancestors for nurturance and
wisdom and express a hope that their
experiences will live on through their
families. With this book, the authors
will themselves inspire a family of re-
searchers, practitioners, and students
to take the field to new levels.
Marcus explains how the emerging
picture of nature’s role in the forma-
tion of the mind is at odds with a con-
ventional view that suggests a much
more limited role for genes. He de-
scribes two key arguments that pro-
vide the basis for this view. The first is
Stanford anthropologist Paul Ehrlich’s
“gene shortage” view, which states
that genes can’t be very important to
the birth of the mind, because the hu-
man genome contains only about
30,000 genes, which is simply too few
to account for the brain’s complexity
(2). The second is the brain plasticity
argument, which posits that genes
can’t be very important because the
developing brain is so flexible—for
example, a child who loses a left
cerebral hemisphere may recover the
ability to speak.
As a compelling alternative to this
T rainees in psychiatry spend com-
static “gene as blueprint” model,
Marcus describes a vital dance be-
tween nature and nurture in which
genes provide us with options, and
the environment—as well as the
genes themselves through their pro-
tein products—influence which op-
tions are taken. Seen in this light,
there is no “gene shortage”; the hu-
man genome provides a wide range of
tools, but genetic expression is ulti-
mately context dependent. This dy-
namic interaction between nature
(genes) and nurture (environmental
opportunities and options) sets the
stage for powerful cascading effects
that allow an enormous range of pos-
sible outcomes.
PSYCHIATRIC SERVICES ♦ http://ps.psychiatryonline.org ♦ October 2005 Vol. 56 No. 10
This highly readable book will ap-
peal to anyone who has pondered
mind-body dualism; its ample appen-
dices will allow the more scientifical-
ly minded to drill down to greater lev-
els of detail. By making the elegant
argument that the brain and the body
are assembled in exactly the same
way, Marcus helps psychiatry assume
a more enlightened position that can
help lead to intellectual and financial
parity with the rest of medicine. He
concludes by giving us examples of
how our greater understanding of the
relationship between nature and nur-
ture will likely lead to advances in the
treatment of mental illness. In doing
so, this book provides us a glimpse
into what promises to be a pivotal
next century.
References
1. Pinker S: How the Mind Works. New York,
Norton, 1997
2. Ehrlich P: Human Natures: Genes, Cul-
tures, and the Human Prospect. Washing-
ton, DC, Island, 2000
Aggression: Psychiatric
Assessment and Treatment
edited by Emil F. Coccaro;
New York, Marcel-Dekker,
2003, 397 pages, $150
John R. Lion, M.D.
paratively little time learning
about aggression. In contrast, depres-
sion and schizophrenia consume
much more didactic time. Generally
speaking, behavioral disturbances,
save for childhood disorders, are
somehow viewed as ancillary to the
major thought and affective distur-
bances rather than primary condi-
tions to be treated in their own right.
Aggression: Psychiatric Assessment
and Treatment, an edited book that
covers theory and practice, is a wel-
come addition to the literature. For
the practitioner, the fourth section of
the volume is most useful in review-
Dr. Lion is in private practice and is clinical
professor of psychiatry at the University of
Maryland School of Medicine in Baltimore.

ing pharmacologic methods of reduc-
ing violence. Working backward, the
third section of the book focuses on
the methods of measuring aggression
and would be of utility to researchers
planning to assess, say, the effects of a
drug study on aggressive outbursts on
a psychiatric inpatient unit. Clinical
models are discussed in the second
section of the book, which reviews
anger outbursts—currently concep-
tualized in the nomenclature as inter-
mittent explosive disorder—an illness
listed on axis II. The phenomenology
of impulsivity—a trait commonly
linked with aggression—is thoroughly
described by various authors seeking
to more precisely clarify the fact that
when violence occurs, it is often
paroxysmal and repetitive.
I had less patience with the first
section of this book, which seeks to
study animal and human types of ag-
Brain Gender
by Melissa Hines; New York, Oxford
University Press, 2004, 307 pages, $38.25
Susan E. Bailey, M.D.
B rain Gender is a fascinating book,
clearly written and well organized.
The author, Melissa Hines, professor
of psychology and current director of
the Neuroendocrinology Research
Unit at London’s City University, traces
her interest in sex differences and their
origins to her freshman year in college,
when she and other women, the first to
be admitted to Princeton, were as-
signed to “two-man rooms” and were
routinely addressed as “Mr.” by un-
thinking preceptors. Hines trained at
UCLA and the University of Wisconsin
in personality theory, developmental
psychology, and neuroendocrinology.
Brain Gender reflects not only the au-
thor’s mastery of developmental biolo-
gy—particularly in relation to hormon-
al influences on brain development
and plasticity, developmental anatomy,
and sex-related behaviors in multiple
Dr. Bailey is an instructor in psychiatry at
the Johns Hopkins University School of
Medicine in Baltimore.
PSYCHIATRIC SERVICES ♦ http://ps.psychiatryonline.org ♦ October 2005 Vol. 56 No. 10
gression, from developmental models
to the effects of genetic and environ-
mental factors. Some of the contribu-
tors here discuss theories seemingly
far removed from clinical practice.
Missing from this volume is a dis-
cussion of the relationship between
depression and aggression and be-
tween homicide and suicide (suicide is
not even indexed). It is often difficult
for clinicians to predict which vector
aggression will take for a specific pa-
tient who is both violent toward others
and self-destructive. Although the lit-
erature on serotonin deficiencies is
mentioned, the destructive pathways
violence can take is an important top-
ic, as are the ways in which at least
short-term prediction of outcome can
proceed, and perhaps should have
been included in the book. That said,
Coccaro’s edited text remains a useful
primer for learning about this topic.
species—but also her understanding of
the social and cultural implications of
sex and gender differences for the hu-
man species.
Hines reviews carefully and lucidly
the research to date on sex differences
in humans, starting with genital ambi-
guity and its relationship to genetic and
hormonal abnormalities. She establish-
es that gonadal hormones play a major
role in tissue organization and the
structural development of genitalia in
human sexual differentiation; she then
examines the influence of gonadal hor-
mones on neural and behavioral devel-
opment in other mammals. Hines sup-
plies an admirable summary of intrigu-
ing animal research illustrating both
the “organizing” and the “activating”
nature of hormones. For example, fe-
male rats located “downstream” in
terms of uterine blood flow from male
littermates show as adults more male-
typical behaviors, such as mounting,
than females located “upstream.”
Hines also notes the importance of
BOOK REVIEWS
feedback loops and regulatory mecha-
nisms, some of which are environ-
mentally triggered and many of which
are time dependent: removing testic-
ular hormones from a male rat on
postnatal day 3 results in a behavioral-
ly “asexual” adult; adding testicular
hormones to a female rat on the same
postnatal day creates a behaviorally
“bisexual” adult. Prenatal stress—
such as crowding, physical restraint,
and bright light—later decreases the
adult female rat’s fertility and engen-
ders male-like courtship behavior in
the adult female guinea pig.
The most satisfying aspect of Hines’
work is her emphasis on the many ways
in which sex and gender research can
go wrong and her insistence on recog-
nizing the complexity of the subject.
She particularly warns against general-
izing from animal models to human be-
ings. In bird species that rely on song to
attract mates, several brain regions in
the singing male are larger and more
densely synapsed than in the silent fe-
male. Some studies suggest that rising
testosterone levels during the mating
season induce more dendrites in the
songbirds’ brains, allowing for more
complex songs as the season progress-
es; when the season ends and testos-
terone levels fall, the dendrites regress.
Other studies, however, suggest that
birds increase their dendrite number
through the act of singing itself—an in-
creasingly complex neural organization
both causes and results from the
singing behavior. In summarizing what
we know about human sex differences,
Hines writes that “a relationship be-
tween a brain structure and a behavior
does not imply, on its own, either a
causal relationship or, even if causal,
that the behavior is innately deter-
mined or cannot be changed.”
Hines examines what we know
about gonadal hormones and human
sexuality, sex differences in children’s
play, and the relationships among an-
drogens, estrogen, aggression and
cognition. In doing so, she finds that
human gender identity is more flexi-
ble than we may have thought and
that the human brain is more respon-
sive to experience than our sexual
stereotypes would suggest. Her book
is well worth reading.
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