Book Reviews

This book offers a re-examination of the place of psychotherapy in the treatment of schizophrenia. As the authors state "the total picture from research, as far as psychotherapy of schizophrenia is concerned, is of one unimpressive result after another," but go on to state "psychosocial intervention can demonstrably affect some schizophrenic patients" and "there is broad evidence that psychotherapy as an endeavour is worthwhile . reports of the demise of psychotherapy of schizophrenia may be premature. " The authors then present reconstructed case histories of four schizophrenic patients, all of whom received extensive psychotherapy as part of their treatment at Chestnut Lodge. All were treated many years ago when neuroleptics were either not available or only recently introduced, and all were part of the Chestnut Lodge follow-up studies. In part two of the book each of the cases is subjected to a critique dealing with common and disparate illness features and discussing onset, course, affect, and severity and the personality, developmental aspects and premorbid features of each case. This is followed by a description of a model of the psychotherapeutic process, which is then related to each of the cases presented earlier, and which is then elegantly put into the context of the effects of the natural history of the disorder on the outcome, and treatment effects on outcome. Many attempts are made to relate these to a potential model for future research. It is obvious that Chestnut Lodge is not typical of institutions for patients with schizophrenia. All the cases illustrated come from families with considerable economic resources. The intensity of care and psychotherapy afforded these patients was and is beyond the resources of most families or treatment facilities. Thus the cases are not typical. The authors clearly recognize this and offer some interesting speculation about what would perhaps happen to these same patients today. Obviously they would have received much more neuroleptic medication, but would this have altered the overall outcome? As is clearly pointed out, for many cases the natural history of schizophrenia is chronic and lifelong, and perhaps at the least complex relationship a therapist can offer is asylum, an aspect that the authors consider at least as important as interpretation. As is stated "in other economic circumstances and at other times, Betty and Mark might have become semipermanent state hospital residents. Today they might well be among the homeless and it is for this reason that we regard asylum as treatment" and "day patient and outpatient asylums sufficient for the need cannot become realities without more solid commitment of social resources and less paranoid regard of social paternalism. " Much of the problem in both the treatment of schizophrenia and in the way society relates to the patient may be ascribed to a perceived lack of cooperation and disinterest on the part of the patient. The authors eloquently state "what seems to be freely chosen behaviour may be paralysis of the capacity to self-determine, a paralysis of will. Taking this perspective seriously may lead us to think twice about allowing our bag lady her' freedom' to freeze to death on the stairs of the train station. " As Allen Frances states in his Foreword, "We have in