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Book Reviews |
Key Words: Books Reviewed
Ask yourself what images you conjure up when you think of treatment for the chronically and severely mentally ill. If the best you can picture revolves around a lifetime of medications and prospects of gloom, then Rowan and O'Hanlon's new text could be the best prescription of the year. The authors offer decades of experience in the field and have created a power-packed, practical resource for working effectively with our most challenging clients. Its introduction describes its task of presenting "an optimistic set of methods...to foster competence, empower individuals and families, instill a sense of control, communicate acceptance, create a context of cooperation, and transform problems into opportunities." Not only do they achieve these goals, but they may even transform the clinician in the process.
With the exception of glimmers of optimism inspired by newer biological treatments, traditional psychiatry has led us into a dead end of treatment options for the severely mentally ill. The traditional expectation is "Don't expect much change; the best we can do is manage the illness." Rowan and O'Hanlon note that our pessimism about achieving real improvement may create a self-fulfilling prophecy with patients. They provide concrete, step-by-step examples that inspire optimism. As the book's title suggests, their approach concerns finding solutions to our clients' problems, not merely managing them.
Many of their techniques are based on a partnership model between client and therapist and use methods that help clients summon their own resources to solve their own problems. In the chapter Challenging Ideas That Disempower Clients, they propose that a partnership in treatment helps the client feel like "an active agent in life, rather than a passive victim of life." They challenge the notion that clients are not accountable for any aspects of their behavior, or that any concerns or insights they may have "are only another manifestation of the illness and have no basis in reality.... Clients, and families, do have their own areas of expertise, which therapists tend to ignore and stifle. They are experts on their experience with the problem.... The expertise of clients and family members is the keystone of the solution-oriented approach to working with `tough' clients."
Another way that traditional psychiatry devalues clients is by labeling them. It views our client as "a schizophrenic" instead of a person suffering from schizophrenia. In the chapter Rewriting Spoiled Identity Stories, the authors guide the clinician to search for evidence of the person beyond the illness, to evoke recognition of that other, healthier identity. For example, they suggest inviting someone to a meeting who does not view the client as disabled, or someone who knew the client before the problems began. If someone like this is not available, they suggest asking the client to imagine what the "valuing witness" would say: "If your best friend were here, what would he be able to tell me about the Jim who was here long before schizophrenia arrived in your life? What kind of person is that Jim?"
Furthermore, they describe the technique of externalizing problems to remind clients and their families that "the person is never the problem; the problem is the problem." They suggest naming and personifying the problem to externalize it from the person (e.g., "When Paranoia whispers in your ears, do you always listen?")
Nearly half of the text consists of detailed case examples intended to illustrate the authors' ideas. These examples make it unusually easy to translate their ideas into practice.
Although the text may be criticized as being overly anecdotal, it offers a treasure chest of ideas that may inspire even the most cynical clinician. It is a must-read for anyone who works with this population.
Footnotes
Dr. Daroff is Assistant Clinical Professor of Psychiatry, University of California at San Francisco, and is on the staff of the San Francisco Department of Veterans Affairs Medical Center.
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