Scharff, J. S. (2013). Book review of Shrink Rap. In Psychodynamic Psychiatry 41(3): 473-477. Posted by permission of Guilford Press.
Shrink Rap, by Dinah Miller, Annette Hanson, and Steven Roy Daviss, Johns Hopkins University Press, Baltimore, MD, 2011, 255 pp.
As a psychoanalyst, I was not drawn to the title of this book, Shrink Rap, or to its focus on psychiatry with barely a mention of psychoanalysis. As a psychiatrist, I was not drawn to it either, given I had already been immersed in psychiatry and had left it behind. Once into the book, I found plenty of useful information, and I quite enjoyed its survey of the field. This book, however, is not intended for professionals. It is for consumers of psychiatric services. A trade book! Surely an unconventional choice for an academic press, I thought, until I realized that Johns Hopkins Press includes similar titles in its catalogue. As an academic publication, Shrink Rap falls short in that, although there is an index, a list of further reading, and any research or literature drawn from is mentioned in the text, there is no bibliography as one might expect in a book from an academic press. Nevertheless, as a trade book, Shrink Rap is well written, well crafted, accurate, and forthright. In being clear, comprehensive, informative, and impartial, it is scholarly in its own way. True to their mission, the authors write as thoughtful friendly guides to the psychiatric system, respectfully explaining the competencies of various mental health professionals in relation to the book’s main focus—the practice of psychiatry from outpatient to inpatient setting, clinic to private practice, voluntary to involuntary treatment, severe mental illness to personality disorder. It interested me to read the book from the point of view of patients who face this array when they present with a problem, as well as from my own perspective as an analyst. Where would psychoanalysis fit in the scheme of things?
Written for patients and their families, Shrink Rap is a wealth of information, clearly presented. After years of experience writing a blog and creating podcasts, three Maryland physicians—Dinah Miller, a general outpatient psychiatrist, Annette Hanson, forensic psychiatrist, and Steven Roy Daviss, consultation-liaison psychiatrist and specialist in clinical informatics—know the needs and concerns of patients and their families and how to address them clearly and simply. Now they have distilled their collective wisdom and experience in this book. Readers can ask questions and post comments about the book and engage with the authors and other patients and families on the authors’ blog. The authors, who express their academic authority in a friendly professional voice, have constructed a really well written, easily accessible, reliable consumer guide with access to follow-up discussion. In short, Shrink Rap is a well-supported trade book, offered, however, by an academic press.
Accompanying the authors on this walk through the system are fictional patients. I always have a problem with this device because it cannot accommodate the movement of the unique individual unconscious. The “patients” are composites put to the service of representing types of illness such as attention deficit disorder, delinquency, depression, addiction to drugs and pornography, panic and eating disorders, bipolar depression, and schizophrenia, and illustrating various approaches by psychiatrists who vary from remote to effusive, respectful to exploitative. Patients and psychiatrists working in treatment demonstrate the strengths and weaknesses of the system, the therapeutic relationship, pharmaceuticals, and newer invasive therapies. At one end of the spectrum of satisfactory care, there’s Tara, her panic disorder treated successfully with drugs and weekly supportive and exploratory psychotherapy, and at the other end there’s Becca who bounces from one psychiatrist to another, feeling misunderstood, rejected, embraced, and eventually betrayed. There’s the fictive Brandt family whose members are given to suffer individually—Stuart from grief reaction, Jack with hallucinosis found to be caused by a brain tumor, rapid cycling bipolar disorder (that’s Becca), Richard addicted to pornography, and Frank who is simply in a developmental transition. Later we meet Mitchell who is receiving hospital care for relapsing schizophrenia, and orphaned, hyperactive Eddie who is followed from the juvenile justice system to his incarceration as an adult drug user and sex offender in a setting where at last he could develop into a responsible adult.
Shrink Rap is such an omnibus of information and possible scenarios that it is surprising to note a few omissions. The next edition might include telepsychiatry in which psychiatrists deliver quality mental health care direct to patients who live remote from specialist centers and provide consultation or supervision to their local physicians and therapists via videoconference. Perhaps the authors do not endorse this innovation, but it is a growing part of the field of psychiatry and therefore a significant omission. Conjoint therapies are also overlooked. Why, I wonder, did no psychiatrists recommend couple therapy for Richard and his wife, or family therapy for the whole Brandt family? Readers are not given enough information about the parents, the previous generation, and the current sociocultural setting to guess at the Brandt family unconscious that connects to individual psychopathology. There is little but a passing mention of psychoanalysis, the foundation for understanding human conflict that underlies symptoms. The authors do refer to the childhood history of each patient and its effect on perception and feeling toward the treating psychiatrist but they do not apply this knowledge fully in their clinical narratives. I regret that patients and their families cannot use this book to learn how their situation has arisen or how to work through to a better adjustment. To be fair, the authors do not claim to write a guide to self-help treatment, only a guide to the system. Their fictional patients and treatment situations do serve to illustrate what can happen to people who must traverse the ins and outs of psychiatric services. But the authors could have done more to encourage reflection on the patient’s self.
I appreciate that the authors are scrupulously and refreshingly honest. Their chapter featuring Becca and her troubled course of treatment with a series of psychiatrists—of whom none were quite right and one of whom broke professional boundaries to feed her own narcotic habit—is so chilling that they might have excluded it to save face, but they wisely left it in as a cautionary tale. They present and illustrate the ethics of psychiatry even-handedly, acknowledge ethical dilemmas candidly, and discuss questionable decisions in a nonjudgmental way, always recognizing the grey areas. They acknowledge areas of debate and controversy in psychiatry. Their examples show that any of the psychotherapies for mental illness take second place to the prescription and management of psycho-pharmaceutical agents, and they ac- knowledge that drug management earns the doctor much more money in 15-minute increments than can be made in a 50-minute therapy hour. The authors admit to not knowing. They confront ignorance and uncertainty in many aspects of this new and inexact science. They mention inadequacies among practitioners, limitations of research, discrimination in insurance reimbursement policy, and difficulties arising in diagnosis and treatment. They discuss the risks and benefits of a national health information data storage system. In short, they give an accurate, comprehensive, unvarnished overview of the medico-legal-psychiatric system.
Reading as a mature psychiatrist I came away with a refresher on areas of the field from which my subspecialty has taken me away. Reading as a psychiatry trainee, one would find Shrink Rap useful in that it provides a detailed, comprehensive view of the field, a description of many of the psychoactive drugs in use, and a nonjudgmental account of the three major forms of psychotherapy. Trainees who identify with the authors’ approach will come away with a broad perspective on issues in the field and a humane, respectful, ethical stance. They will be encouraged to develop curiosity about the emotional life of their patients and their histories, but they will not develop any analytic sensibility or deep understanding of the human condition.
Reading as a psychoanalyst, I was sad, but not surprised to note the tiny place psychoanalysis has in the mind-set of the general psychiatrist. Shrink Rap reflects current perceptions that drive psychiatric residency training and mental health insurance policy. Psychoanalytically informed treatment has been slow to subject itself to research because the psychodynamic therapeutic relationship is too complex to reduce to simple criteria ready for measurement, but attachment research and neuroscience are now showing how the therapist’s capacity for empathy, containment, and attunement provide conditions conducive to affect regulation and brain growth. Intensive psychotherapy, however, calls for a big investment of time and money by patient and therapist in training. Consequently, psychodynamic or insight-oriented psychotherapy, once the staple of psychiatry, is now less often prescribed than quicker, evidence-based, results-focused methods with circumscribed goals that can be subjected to quantitative research. As a psychoanalyst, having been an analysand myself, I know from professional and personal experience that an open-ended psychodynamic, interpretive approach that takes account of the dynamic unconscious and its effect on the therapeutic relationship offers insight out of which personal growth develops. But I do not find this value embodied in this book. Psychoanalysis receives a mention as an option for those who seek to know themselves better to fulfill their potential, especially as psychotherapists, but it is not fully described, illustrated, or applied to the discussion of vignettes.
Psychoanalysis is most visible by its absence in Shrink Rap. Reading this book is a hard lesson for the psychoanalyst and psychodynamic psychotherapist. It serves up a sharp dose of reality and a painful reminder of how society has come to view mental illness and the means to wellness.
Jill Savege Scharff, M.D.
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