Textbook of Adolescent Psychiatry
edited by Richard Rosner, M.D.

Reviewed by Dominic Ferro.

Dr. Rosner has published a number of textbooks which have served as standards in their respective fields. In particular, his Principles and Practice of Forensic Psychiatry serves as an essential introductory text for the young Forensic Psychiatrist and a valuable resource for the experienced practitioner. The same can be said for this Textbook of Adolescent Psychiatry. It provides a broad overview of the issues and information relevant to the adolescent psychiatrist, and covers them at sufficient depth so as to provide a blueprint for more advanced study. The section editors and many of the authors are among the most experienced and knowledgeable adolescent psychiatrists.

The value of this book is greatly enhanced by the fact that the study of adolescent psychiatry has long lagged behind that of adult psychiatry. Adolescence itself has only been recognized as a developmental phase distinct from adulthood during the last century, and although the current concept of adolescence has been seen largely a social construction, there is growing evidence that the brain of an adolescent is indeed an evolving entity and that adolescents are in fact distinct from adults biologically, cognitively and psychologically (Steinberg, et al. in press). It has only been 35 years since Daniel Offer first published data challenging the belief that adolescence was necessarily stormy and conflict ridden. Much of the work done on the cognitive psychology of adolescence has taken place during the last few decades.

In a recent inventory of evidenced-based treatments in child and adolescent psychiatry, McClellan and Werry concluded, "Although the number of evidence-based treatments for child psychiatry is growing, much of clinical practice remains based on the adult literature and traditional models of care." The recent controversy regarding the safety and efficacy of the use of antidepressants in adolescents highlights the risks of extrapolating from the literature on the treatment of adults. The Textbook of Adolescent Psychiatry comes at an excellent time to summarize the field to date and to point the direction of future development.

The book is divided into seven sections, which reflect significant areas of concern for the practitioner treating adolescents. The first section, entitled Special Issues in Adolescent Psychiatry, provides an excellent background to the concept of adolescence, as well as pertinent ethical, medical and practice issues. Of particular value to the younger practitioner are the chapters addressing the history of adolescent psychiatry and the available paths to education and training in adolescent psychiatry.

The main body of the text consists of three sections dedicated to the assessment of adolescent patients, the psychiatric disorders prominent in adolescence and the psychiatric treatment of adolescent patients. Each of these sections is comprehensive and thorough. The three remaining sections cover Risk-Behavior, Development and Adolescent Psychiatry and the Law. Two of these sections, Risk-Behavior and Adolescent Psychiatry and the Law, are particularly strong and greatly enhance the value of the book.

Much of what distinguishes adolescents from adults is captured in their attitudes toward risk-behaviors. These are topics that are particularly valuable for the clinician working with adolescents. Adolescent risk-behavior is a topic which subsumes much of what distinguishes adolescent patients from adults. Risk-behaviors are an essential aspect of adolescent development, and this section edited by Lynn Ponton, Ph.D. is an excellent introduction into the research into this area. Similarly, the interface between Adolescent Psychiatry and the Law is an area of growing significance. Juvenile justice issues remain a prominent societal concern and are covered well in this section edited by Richard Ratner, M.D., with particular attention paid to the role of the adolescent psychiatrist. In addition, this section provides an excellent review of other areas in which the legal system impacts adolescents, such as findings of abuse and neglect, custody issues and involuntary hospitalization.

The Textbook of Adolescent Psychiatry is an excellent resource for child and adolescent psychiatrists who are interested in focusing more directly on adolescent issues. However, it is perhaps most valuable to general psychiatrists who are interested in expanding their practices to include the assessment and care of adolescents.

Footnotes:

McLellan, JM, & Werry, JS, Evidence-based Treatments in Child and Adolescent Psychiatry: An Inventory, J. Am. Acad. Child Adolesc. Psychiatry, 42:12 December 2003, 1388

Steinberg, L, Dahl, R, Keating, D, Kupfer, DJ, Masten, AS, Pine, D, The Study of Developmental Psychopathology in Adolescence: Integrating Affective Neuroscience with the Study of Context in Handbook of Developmental Psychopathology, Cicchetti, D, Ed., John Wiley & Sons, New York. Bullying, Peer Harassment and Victimization In The Schools, The Next Generation Of Prevention.

Handbook of Adolescent Health Risk Behavior, Edited by Ralph J. DiClemente, William B. Hansen and Lynn E. Ponton. New York , Plenum Press, 1996, 440 Pages, $75.00

The Romance of Risk: Why Teenagers Do The Things They Do, Lynn E. Ponton, New York, Basic Books, 1997 307 pages, $25.00

"Risk taking is the major tool that adolescents use to shape their identities."

This is the thesis of both of these books, the first written for a professional audience and the second for lay readers. ASAP member Lynn Ponton has long been able to combine the perspective of a gifted clinician with the scientific approach of a disciplined researcher. Her work on risk behaviors has established her as one of the leading experts in adolescent psychiatry. She has been one of our most popular presenters at our meetings. The first book summarizes what is known about each of several serious problems prevalent in the adolescent period. The three authors worked together at the University of California in San Francisco, where Lynn is Professor of Psychiatry. Some of the work they did took place in adolescent inpatient unit, which Lynn directed, some in pediatric settings, and some in homeless shelters. There is no doubt that they know adolescents. They have introduced the concept of risk taking as a behavior that can be either positive or negative, but is a quintessential part of adolescence. It is the teenager's evaluation of likely outcomes, his or her cost-benefit analysis, that is the crucial factor in decision-making with regard to risk. Negative risk-taking, such as gang activity, illegal substance use, and unsafe sex, are more likely to occur in adolescents who have emotional problems that impair their decision-making ability and/or who lack opportunities for healthy risk-taking, such as team sports, intellectual pursuits, or artistic creation. Flying in the face of the "Just say no" chorus, the authors advocate that, instead of trying to keep adolescents from taking risks, we should be teaching them how to make decisions, and providing them with opportunities for healthy risk-taking.

The Handbook includes chapters on theories of adolescent risk-taking behavior, tobacco, alcohol and drug use, disordered eating, and suicide and unintentional injury. It is a well referenced and scholarly work that is at the same time readable and organized in such a way that it would be useful as a reference. The emphasis on problem behaviors rather than diagnostic nosology is useful and allows for the treatment of the full spectrum of problem behavior, including what are often called subclinical or subthreshold disorders. For example, dieting or unhealthy restriction of food intake is so prevalent among teenagers as to be normative behavior. It is this behavior, rather than full blown anorexia nervosa or bulimia, that is likely to be encountered in the pediatrician's office or school health clinic. Each chapter includes a careful assessment of various preventive interventions. It would be a useful resource for anyone called upon to speak to school personnel or primary health care providers, or to answer parents' questions about risks their children face.

The Romance of Risk is Lynn Ponton's first "cross-over" book; that is a book written by a professional author for a lay audience. We seem to be seeing a plethora of these lately. Many suffer from being in-between, too technical and difficult for the average reader, and too watered down for the professional. A bit like a recording of West Side Story I have, performed by operatic stars. The Romance of Risk falls into neither of these categories. Dr. Ponton's writing style is clear and highly readable. I thoroughly enjoyed this book, learned from it, and finished it with renewed inspiration for the field of adolescent psychiatry.

The book is organized into a series of chapters, each of which illustrates a particular clinical problem. Most of the chapters consist of detailed case studies, often of a single case. They are narratives of the author's work with individual adolescents and their families. They begin with the initial encounter over the phone or in the waiting room, and proceed through all the vicissitudes of the therapeutic work. They are rich in the descriptions of the author's own thoughts and reactions to her patients. The patients are a sampling of adolescents from many socioeconomic and ethnic backgrounds. Anyone who does work with adolescents will find the dilemmas and challenges presented by these youngsters familiar. Some of the scenarios are quintessentially Californian. Those who live in places such as Blue Bell, PA will probably not have encountered parents who say, as one mother did, when asked what she thought of her daughter's smoking marijuana, "Everyone does in California."

The creativity involved in effective psychotherapy is well illustrated. I am reminded of Ev. Dulit's Schoenfeld address several years ago comparing psychotherapy with adolescents with musical improvisation in jazz-both involve reacting on a moment to moment basis to the productions of another person to produce a creation that enhances experience. I have seldom seen the experience of doing psychotherapy from the point of view of the psychotherapist described so beautifully and richly.

This book is a reminder that there is still much we can learn from adolescent patients about normal development. There is a considerable emphasis on identifying strengths in both patients and families and working towards using these to enhance healthy growth and development. All of the patients are outpatients, and all have successful outcomes, so they are not at the far end of the developmental psychopathology spectrum. Of note, only one of the patients is treated with medication, a depressed girl who mutilates herself. There is a lot to be said for psychotherapy done well.

I have suggested this book to the residents I supervise. I would certainly recommend it to all adolescent psychiatrists. I hope that parents and other adults who have responsibility for adolescents will read it.

Lois T. Flaherty, MD

Marriage as a Search for Healing: Theory, Assessment and Therapy, by Jerry M. Lewis, M.D. New York: Bruner/ Mazel, 1997, 274 Pages; $34.95.

Jerry M. Lewis is a long time ASAP member who has been a prolific author in the field of family therapy. He was for many years is the the Psychiatrist in Chief at Timberlawn and is currently Senior Researcher at the Timberlawn Foundation in Dallas. The book, To Find a Way, co-authored with Gossett and Barnhart (Bruner/Mazel, 1983), a study of the outcome of hospital treatment of disturbed adolescents, is a classic that should be read by all adolescent psychiatrists.

This book could serve as a primer for those wishing to know about marital and couples therapy. The authors review of the literature on the subject is very complete and reflects the fact that this is a field in which many new developments have taken place in recent years. One example is the research on adult attachment, which has produced an extensive body of literature. As many of the leading workers in this area publish in family therapy journals rather than those routinely subscribed to by adolescent psychiatrists, those of us who do not specialize in this area are unlikely to be familiar with recent work.

In addition to a detailed discussion of theories of family and couples therapy, the author provides many illuminating case studies from his own clinical work with couples. These add richness to the book and will be enjoyable for experienced therapists as well as novices to read. I wish that there had been more examples of families with adolescent or young adult children. Maybe Dr. Lewis would consider writing a book on this topic. It would be an important service to the field.

Some of the examples involve a partner who in all likelihood would meet DSM IV criteria for some type of depression. The author provides an understanding of depression in the context of the relationship, and as a maladaptive response to problems in the relationship. At the same time, he does not negate the reality of biological vulnerability. This is a true biopsychosocial model of psychiatric disorder, one that often receives lip service but is not truly articulated.

Dr. Lewis is clear about his commitment to upholding standards of psychotherapy and teaching and equally clear about his views about what is happening to both in today's world. He states, for example, .... "teaching psychotherapy has all but disappeared from some training programs. Indeed, the crunch of managed health care has been augmented immeasurably by the brain disease model of psychopathology. From the brain disease perspective, psychosocial variables are mostly epiphenomenal and, as a consequence, the psychotherapies are all too often seen as tangential, at best. [p. 182]"

I particularly liked Dr. Lewis' comments about the resistance on the part of supervisees to writing a formulation. I share his belief that this impedes the progress of treatment and reflects a lack of commitment to well thought out plan of action. I too, have struggled with residents over this. I believe that the formulation is a crucial part of the diagnostic process. But where is the opportunity to learn it found, when trainees are harried, and diagnostic evaluations consist of the filling out of forms, a hurriedly dictated summary, or a few handwritten lines in a chart? Perhaps this book will help to remind us all of the richness of our field and the importance of passing along the knowledge we have learned to new generations.

Lois T. Flaherty, M.D.

Treating Abused Adolescents by Eliana Gil, New York: Guilford, 1996. 228 pages, $42.00 hardcover, $18.95 softcover.

There has been an explosion of interest in trauma and abuse in recent years. There are journals devoted exclusively to this topic and new books seem to be appearing almost daily. Nearly all are focused on adult survivors, some on children (or although the title may mention adolescents, the emphasis is really on children). Yet, adolescents are the group most at risk for abuse. As in so many other ways, they have been relatively neglected in the literature. We are beginning to see research reports of the dismal adolescent outcomes of childhood abuse, but we still have a ways to go in understanding how to intervene effectively with this population. There are currently two self-help books out for adolescents, How Long Does It Hurt? : A Guide to Recovering from Incest and Sexual Abuse for Teenagers, Their Friends, and Their Families, by Cynthia L. Mather, Kristina E. Debye, Judy Wood (Illustrator), Eliana Gil (Designer) Paperback - 265 pages (1994), Jossey-Bass Publishers; and The Me Nobody Knows: A Guide for Teen Survivors, by Barbara Bean, Shari Bennett, Paperback - 155 pages (1997) Jossey-Bass Publishers; but Treating Abused Adolescents by Eliana Gil is the only one I have seen for therapists.

Treating Abused Adolescents is one of several books published by this author, a marriage and family therapist. It is her first book on adolescents, and the only one I have seen that focuses on the treatment of adolescent victims of physical and/or sexual abuse. Others include Systemic Treatment of Families Who Abuse (Jossey-Bass; 1995), The Healing Power of Play: Working with Abused Children (Guilford, 1991) and Play in Family Therapy (Guilford, 1991).

This is a book by a clinician for clinicians. Its main emphasis is on psychotherapy techniques. The book offers brief overviews of the developmental psychopathology of abuse, in such chapters as "Current Versus Cumulative Abuse of Adolescents" blending her own clinical observations and opinions with citations of relevant literature. But its real strength is in the clinical vignettes, which form the backbone of the book. These include detailed descriptions of adolescent-therapist and family-therapist interactions, which are delightful to read.

The language is straightforward, to the point and refreshingly free of jargon, for example: "Many abused adolescents do not see how past abuse relates to current problems. Others however, have learned to use past abuse as an explanation for every problem they face. Yet other adolescents seem to reenact abuse dynamics, exhibiting either identification with aggressors, or experiences of victimizations." (pp 117-118). Gil advocates for a flexible approach to treatment depending on individual needs. She recommends beginning with individual sessions and subsequently incorporating group and/or family work. Her description of a family session with parents of a 16 year old boy whose father has resorted to hitting him to try to get the boy to "pay more attention to what I say" illustrates an a approach to therapy in which considerable support is provided along with a clear expectation for individual responsibility for behavior. After a discussion with the parents of what has happened since "Mr. W hit him on his face with the belt," she summarizes, saying, "So it probably wasn't effective as a teaching tool." (pp 57-58). She then goes on to empathize with the father's frustration and feelings of remorse.

One of the most useful chapters describes "Structured Processing of Trauma," an approach utilized in selected cases in which there are persistent PTSD symptoms, behavioral reenactments, or for youngsters who are, in the author's words "immersed in their past to the exclusion of their present or future." This is a time-limited approach of 5-6 90-minute sessions in which the trauma is talked about in incremental stages, beginning with aspects that are less emotionally upsetting. The memories of trauma with their affective and sensory components are reexamined in the light of understanding, with one of the goals being to reduce the level of self-blame associated with them. The use of this technique occurs only when therapy has progressed sufficiently for a variety of conditions to be met, including a sufficient level of impulse control and trust of the therapist.

The impact of trauma and abuse is truly a biopsychosocial one. There is evidence that severe trauma has lasting effects on brain functioning through disruptions of neural mechanisms. At the same time the impact of trauma cannot be addressed without reference to the psychological and social sphere. It is through its effect on meaning that is central to the understanding of both the psychological effects of trauma and its effective treatment. Psychologically, its most devastating impact is perhaps the loss of innocence, the damage to basic trust and sense of being out of harm's way that most of us carry with us throughout our lives. Socially, it involves a loss of community and connectedness, the converse of which is isolation. For adolescents, the developmental outcomes may involve depression, suicidality, self-mutilation, eating disorders, dissociative disorders, violent aggression or all of the above. The evolution of a "victim identity" is a particularly salient feature given the importance of identity consolidation during adolescence and it is probably to this pathological transformation that the helping professions stand the most to contribute through inadequate or mistaken assessment and treatment. "In other words, mental health professionals can exacerbate the development of a victim identity by misguided efforts. "Given the frequency with which adolescent trauma victims populate our treatment and correctional facilities, become perpetrators of abuse themselves, and challenge our diagnostic and therapeutic skills, it behooves us to learn as much as we can about how to help them.

It is difficult to believe the author's confession that she avoided treating adolescents for a long time, favoring younger children and adults, because of concern that her own unresolved adolescent problems would interfere with her ability to treat adolescents effectively. It is a good thing for adolescents and her readers that she was able to come to terms with this issue, or perhaps to recognize that adolescent conflicts live in the psyches of many successful adolescent therapists. I hope this not her last book on adolescents.

Lois Flaherty

Psychoanalytic Therapy and The Gay Man, by Jack Drescher, New York: Analytic Press, 384 pp., $55.00, 1998.

"How can you be a psychiatrist and not know what causes homosexuality?" a gay patient asks his therapist in Jack Drescher's book. This question highlights the fact that psychiatry as a profession has not shied from making assertions that this or that was the cause (or causes), and therefore this or that was the cure of what until recently was defined as a mental illness. That gay men come into treatment asking this question is a testament to how much they themselves have accepted conventional societal views.

I saw my first gay patient as a Georgetown psychiatry resident. Feeling unprepared for how to treat him with psychoanalytic psychotherapy, I read everything I could about psychiatric treatment of gay men. What I found were in the library were books by Socarides and others with explanations that male homosexuality was caused by overbearing mothers and absent or uninvolved fathers, that it was essentially a phobia of heterosexual behavior. Fortunately I had a wise supervisor who helped me focus on the problems that had brought the patient into treatment rather than telling him what was wrong with him. I don't remember too many details about the treatment, but mainly that it focused on the patient's relationship with his dying father. When I completed my residency, he elected to continue treatment with another resident, feeling it had been helpful.

Later, I began to work with a 17-year-old young woman, who over the course of the next several years of therapy proceeded to come out, first to herself, then to others including her family. Having had virtually no experience or teaching that would have helped me cope with my own feelings about her developmental trajectory, I felt I could do little more than watch it unfold. I managed by being able to relate to her basic human experience, but certainly had no knowledge of gay or lesbian culture or lifestyle to guide me. Subsequently she and her partner came back to see me for help in dealing with problems in their relationship, telling me that I was one of the few people they felt qualified to help them.

These experiences were humbling for me and I was acutely aware of how little I knew about these patients' typical life struggles. Reading this book made me realize how much more helpful I could have been had I had it to read. At least, I don't think I harmed these patients. Perhaps my early exposure and to the work of Harry Stack Sullivan and the influence of the interpersonal theoretical view on Georgetown, where Sullivan had taught, were influential and helped us to avoid more doctrinaire approaches. It is this perspective that informs Dr. Drescher's thinking as well. And, as Dr. Drescher himself points out, Sullivan's identity as a closeted gay man may have made him acutely sensitive to the inseparability of personality and interpersonal relationships, and the effects of having to live dissociated from one's true self.

The first five chapters of this book provide a thorough, scholarly, extensively referenced, background and summary of the historical thinking about homosexuality, and the evolution of contemporary psychoanalytic thinking. The author concludes and makes the point repeatedly that we do not know what causes homosexuality or heterosexuality. He considers that homosexuality is a normal variant on a continuum of sexual orientation, and urges abandonment of a binary view of sexuality. If anyone has doubts about the damage done by the application of techniques based on conventional views promulgated as scientific theory, reading these sections should dispel them. Over and over again, one is struck by how the very institutions that most people grow up expecting they can derive support from: families; schools; organized religion; have let down gay men and women. A chapter on reparative therapies, the attempts to cure homosexuality, often with Christian fundamentalist beliefs, exposes the fallacies of these therapies and their inflated claims of success, as well as their potential to harm those they purport to help. The second part is a detailed analysis of how the gay man actually survives and succeeds in many cases despite the enormous obstacles he faces in school, career and socially. One is left with a renewed respect for the resiliency of the human spirit. Chapters titled "The Therapist's Stance," "Developmental Narratives of Gay Men," The Closet" and "Coming Out" provide a practical compendium for the therapist to understand development and provide what Dr. Drescher terms "respectful care." The clinical chapters in the book are amply illustrated by clinical vignettes, which make for engrossing reading.

Given the fact that sexuality and sexual orientation are lifelong issues, developmental aspects of homosexuality are emphasized. What will be particularly satisfying for adolescent psychiatrists is that the adolescent development of gay men is treated in detail and with an appreciation for the developmental processes of coming out and the complex meaning of the closet (actually many closets). For most males, the awareness of their sexual orientation is heightened during adolescence, and this is a time when therapy that is appropriate and culturally sensitive could be particularly important. The book is not about the psychiatric treatment of adolescents, but it offers much invaluable information for adolescent psychiatrists. Gay adolescents, in addition to bring faced with all the developmental tasks of adolescents, also are confronted with an extraordinary complex panoply of issues having to do with their identity and relationships with their families and significant others. That the level of suicidal thinking and actual suicide is high among these teenagers (around 20%) is an indication of how stressful their lives are. One important pointer offered by the author is that although the process of coming out is one that should be an important focus of therapy, the therapist must let the patient reach this goal at his own speed. In a similar vein, although meeting with the patient and his family may be very useful the therapist should never serve as an intermediary to inform families about their children's homosexuality.

The author is careful to point out that not all psychopathology in gay men can be explained by their victimization by a homophobic society, and the task of distinguishing that which is and that which isn't can be therapeutically challenging. Indeed, he emphasizes the need for the gay patient to take personal responsibility for having a satisfying life and not retreating into self-destructive behaviors.

In summary, this is a beautifully written book by a sensitive therapist. All psychiatrists should read it. Adolescent psychiatrists should hope for a similar book on gay adolescents to guide them.

Lois T. Flaherty

The Merck Manual, The Centennial Edition, The 17th Edition. Merck Manual of Diagnosis and Therapy, $35/, hardcover. Mark H. Beers, Robert Berkow Editors; with more than 300 experts contributing, publ. by Merck Publishing Company.

Usually published every 5 years for the past 100 years, this edition has been overdue and long awaited. The Centennial edition of this classic reference for physicians, residents, and nurses was published this past year updated in all areas. Bundled with it is a 192 page facsimile of the first edition of the Merck Manual which was first published in 1899, "A Ready Reference Pocket Book for the practicing physician." It lists every agent thought to be therapeutic at that time. Browsing this provides a fascinating view of agents in the pharmacopoeia of the time, such as cod liver oil for hysteria, cannabis for impotence, ergot in recurrent mania, and a pillow of hops for 'nervousness.'

The Merck Manual of Diagnosis and Therapy has been published for the past 100 years on a not-for-profit basis providing reliable, easy-to-use medical information. It has become the world's most widely used general medical text as well as being the hypochondriac's bible. The Manuals are also available for purchase in a variety of electronic editions and the 17th edition is available on Merck's web site free of charge along with the entire 2nd edition of The Merck Manual of Geriatrics and part of The Merck Manual of Medical Information, Home Edition, as well. With each printing, published on paper, corrections or additions can be made quickly in the electronic versions for one's personal use. This edition sports a larger type face than the previous. Merck Manual is most useful when time is a factor to consider, providing an exceptional reference. It consists of 2833 very thin pages which cover the whole of medicine as we know it. It has sections covering the DSM disorders in non-DSM language with a description of the entity, a symptoms and signs and a treatment section. Tables are present differentiating confusing diagnoses. Coverage is by thumbnail sketches useful for jogging the memory. But the main advantage lies in the coverage of the somatic illnesses which provides satisfying, detailed and up-to-date information for those who long or even not so long ago graduated from medical school, yet who must deal with the patients suffering from various disorders.

Leonard Henschel