by Dan J. Stein. New York, Cambridge University Press, 2008, 224 pp., $60.00.
STEVEN L. DUBOVSKY, M.D.Buffalo, N.Y.
Developing effective psychiatric interventions depends on identifying specific targets for these interventions. Traditionally, such targets have been diagnoses, but most of the treatments we have work for more than one disorder. The more data we have on the features of diverse disorders on which a particular treatment acts, the more precise our treatments become.
This book, written by the chair of the Department of Psychiatry at the University of Cape Town, who is also—or perhaps primarily—a philosopher, expands the question of who should get what treatment by addressing several fundamental questions. Among the issues raised are: To what degree are psychiatric disorders valid independent constructs versus culturally defined misalignments between the individual and society? What happens to the identity of the person whose point of view is changed by medications or psychotherapy? What are the borders at which psychiatric treatment becomes cosmetic rather than clinical? Although it is advertised as a book on psychopharmacology, there are coordinated discussions of the nature and meaning of psychotherapy as well as nonpsychiatric treatments such as meditation.
The book contains extensive scholarly syntheses of the psychiatric and philosophical literature. Mercifully for those of us who are less informed about the philosophical concepts that are discussed, each new chapter summarizes what was said in the last one. The only issue that is missing is whether current categorical concepts of diagnosis will ultimately prove useful in guiding treatment or whether discrete dimensions such as endophenotypes or specific traits will turn out to be more useful in choosing a particular treatment.
This book will be especially appealing to people who liked college philosophy and want to have another go at it in a more condensed format that is a little more relevant to their work.
For many clinicians, delving into the ultimate meaning of making diagnoses, prescribing treatment, and changing people may feel a bit like driving a car on a busy freeway while contemplating why the road has eight lanes, what the laws of physics are that make the car run, whether an alternative-fuel vehicle would work better, what forces led to our insistence on driving everywhere ourselves and using up so much oil, and so on. These are important questions that may have an impact on where we will drive next, but if we reason all this out while negotiating traffic, we may feel distracted and might even miss our exit.
The gap between everyday practice and the ultimate meaning of what we do as clinicians was brought home to me when a very capable neurologist friend of mine told me about a patient he had just referred. "Perhaps you can explain the question she asked me," he said. "She wanted to know what your philosophy was. ‘Is he a psychopharmacologist, a behaviorist, a Freudian, a Jungian, or a cognitive therapist? What is his orientation toward mental illness?’"
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