Book Reviews
Sidney Zisook (Ed.), Biopsychosocial Aspects of Bereavement. Washington, D.C.: American Psychiatric Press, 1987. 189 pages. Reviewed by Cynthia R. Pfeffer, MD, Associate Professor of Clinical Psychiatry, Cornell University Medical College; Chief, Child Psychiatry Inpatient Unit, New York Hospital-Westchester Division.
Bereavement is an inevitable and universal event that may be experienced at any time in one's life. As noted in this excellent review of the multidimensional responses to bereavement, grieving “is a prototypical life stress event which most often is associated with acute turmoil and distress, and, at times, may lead to substantial psychological and/or medical morbidity, possibly even to death” (p. xi). For the suicidologist, a text of this type is invaluable. It provides information about the processes of grief that must be understood by anyone who works with individuals bereft by suicide.
This book includes 11 chapters written by groups of clinicians and researchers who have experience with grieving individuals. The important issues raised in this volume repeatedly indicate that much more remains to be learned about responses to bereavement with regard to the type of death, the relation of survivors to the deceased, the age of survivors, and the longitudinal course of adapting to the finality of the loss. Throughout the text, the issue of distinguishing between normal and pathological grief is discussed. The various authors point out that this is not a resolved issue and that more research is needed to clarify it.
Among the points made in this book is that bereavement is associated with measurable distress in virtually everyone. “The distress, which can vary in intensity and in the extent of interference with function, is long lasting. … there is tremendous variation in individuals' reactions to bereavement” (p. 7). These responses include psychological, socialadaptational, and biological reactions, and the viscissitudes of these over time. It is a premise of this book that “everyone needs support, reassurance, and some education and information following bereavement” (p. 10).
This book is organized in such a way that chapters often overlap in content. This is probably a function of the fact that Sidney Zisook, the editor, is a coauthor of a number of chapters. Among some of the chapter titles are “Unresolved Grief,” “Adjustment to Widowhood,” “Psychological Distress of Bereavement,” “Psychoendocrine Aspects of Bereavement,” and “The Therapeutic Task of Grief.” These titles suggest the various aspects of grief covered in this text.
The book points out that “the boundaries between normal or noncomplicated grief and pathological mourning often remain unclear” (p. 23). “The frequency of unresolved grief is unknown and depends on [such] diverse factors as the population studied and definitions of the term, but reported estimates range from 10 to 25 percent” (p. 26). Thus, for grief following a suicide, the extent to which the outcome is normal versus pathological is particularly unclear. Another point made is that “the death of a spouse can precipitate some of the deepest anguish and most profound disruptions that human beings are likely to experience” (p. 37). The book describes data from longitudinal research on the process of grief after loss of a spouse.
Although not extensively discussed, issues concerning unnatural death—that is, suicide, homicide, and accidents—are raised. It is suggested that people “whose bereavement is associated with unnatural dying should be treated as a separate population” (p. 90). It is also suggested that bereavement following unnatural death, in contrast to that after natural death, involves “a greater incidence of symptoms of posttraumatic stress, victimization, and compulsive inquiry in subjects adjusting” (p. 90) to such death.
As noted earlier, the book stresses that there is a great need for research into processes of grief. One of the problems in the field of empirical investigation is the need for adequate instruments to measure features of grief. Some of the research instruments that have been developed are described. Another complex issue that requires additional study is that of the physiological factors associated with grief. Some investigations have focused on cortisol levels, catecholamines, prolactin, growth hormone, and other aspects of psychoendocrine functioning. Still another field of research endeavor has been the relations among depression, bereavement, and immune function.
Finally, one of the strong points of this book is its emphasis on therapeutic tasks of grief. It is suggested that these include “development of the capacity to experience, express, and integrate painful affects, utilization of the most adaptive means of modulating painful affects, integration of the continuing relationship with the dead spouse, maintenance of health and continued functioning, achievement of a successful reconfiguration of altered relationships, and achievement of an integrated, healthy self-concept and stable world view” (p. 177).
I highly recommend this book, which is easy to read, condenses the knowledge currently accumulated, and makes important suggestions for future research and clinical endeavors.
Israel Orbach, Children Who Don't Want to Live. San Francisco: Jossey-Bass, 1988. 267 pages. Reviewed by Carol A. Siefker, MA, Research Associate, New York Hospital-Westchester Division.
Israel Orbach is currently senior clinical psychologist at the Adolescent Suicide Clinic of Albert Einstein School of Medicine, Yeshiva University, New York, while on leave from his position as associate professor at Bar-Ilan University in Israel. Orbach has been clinically researching suicide for the last 13 years, has developed several suicide prevention programs, and has been published extensively. Children Who Don't Want to Live was first published in Hebrew in 1987. The author's goal is to assist in the understanding of the underlying reasons for and the process of child suicide, in order to better recognize signs of suicidal behavior and to help children deal with their “unresolvable problems.”
The text material is presented in an organized manner, systematically moving from case examples to discussions of adult suicide; child suicide; children at risk; concepts of death; family dynamics; theoretical perspectives; and recommendations for treatment. The author provides a rich selection of past and current findings throughout the literature on child suicide. Orbach also supplies glimpses of his own research throughout the text, specifically in the areas of depression and suicide; cognitive rigidity as a potential factor in suicide; the influence of parental suicidal behavior; the relation of anxiety, age, and intelligence to children's concepts of death; children's play and their levels of pain and distress; attraction and repulsion to life and death; and death and children's religious attitudes.
In a very sensitive and compassionate manner, Orbach portrays the vexing life circumstances that often plague the lives of children who contemplate death. Insightfully generating new conceptualizations of the dynamics of child suicide, the author examines children's life management and problem-solving strategies in relation to their personal concepts of death.
The book is slightly disappointing, however, in that the buildup to Chapter 9 does not measure up to what had been promised in the initial chapters. What was to have been a new theory explaining child suicide is really little more than a recapitulation of the early work of Ticher and Jacobs. Ticher and Jacobs describe suicide as a gradual decline into social isolation, beginning with the pain of long-term life problems that are perceived as insoluble, and ending with death as the only possible relief. What Orbach refers to in Chapter 9 (pp. 188–189) as an approach that he calls “the thesis of the unresolvable problem” is, in truth, the same theme.
In the same chapter, (p. 183), Orbach describes the premise of Sabbath's “expendable child” theory, wherein suicide is the result of a child's inner feeling that he or she is the expendable part of a rejecting family. Death becomes a way in which to avoid coping with the painful rejection of the parents, and serves as a means of pulling the family together. The child subconsciously hopes that in death, he or she can finally win the affections of the parents, which had been denied to the child in life. It is also difficult to see any clear distinction between Sabbath's theory and the author's “thesis of the unresolvable problem.”
The author describes Pfeffer 's (1986) perception of child suicide as a “product of a complex family system in which both parents are still dependent on their own parents.” Boundaries are broken because of such dependencies, and conflicts from the original family are “interjected into the daily life of the new one.” Because the parents are not in harmony, the child becomes the bearer of negative feelings in order to preserve the family unit. The child becomes trapped between feelings of love and dependency on the parents, and feelings of hate. There is a splitting between the child's perceptions of good and bad and of self and the world. The child tries to internalize the anger and hate, thereby denying its existence. When the anger mounts beyond control, the child turns against the self, in order to preserve the positive perception of the parents. Orbach criticizes such an object relations theory, stating that it seems “more appropriate to the interpretation of adolescent suicide,” because “at younger ages, personality has not sufficiently matured.” Such a position seems to be in opposition to his own borrowed thesis—namely, that children want to die because they are faced with an unresolvable problem that is too great for them to handle. This is of additional interest in light of the author's own research with children indicating quite realistic perceptions of death at young ages (p. 106).
The most provocative component of the text is the author's discussion of treatment of suicidal children (p. 241). He states that “in high-risk cases of suicide, the major therapeutic breakthrough comes when the therapist participates in examining suicide as a possible solution.” Orbach suggests that the patient then learns, through discussion of his or her wish to die, that “simply contemplating suicide does not automatically categorize him as crazy or immoral.” Recognizing that such a view may “go against the grain,” Orbach highlights how such a partnership between therapist and patient can replace feelings of isolation and alienation with feelings of comradeship and mutual understanding. The patient can, as a result, go on living, knowing that he or she has the freedom to choose the option of death. The role of the therapist is to “reflect back to the child how such emotional turmoil developed into the wish for suicide” (p. 241).
In summary, Orbach provides a good review of the literature; asks some interesting questions; and seeks to further clarify our understanding of the suicidal child in relation to the obstacles that hinder his or her very survival. I recommend this book as a valuable contribution to the already existing literature.
Paul G. Quinnett, Suicide: The Forever Decision. New York: Continuum, 1987. 151 pages. Reviewed by Ronald L. Bonner, PsyD, Staff Psychologist, Division of Forensic Psychiatry, 45th Street Mental Health Center, West Palm Beach, Florida.
Those of us who engage with people who are struggling with the thought of ending their lives have the constant agonizing awareness of how difficult it is to reach and touch a suicidal person. It is as if the suicidal person, in his or her world of emotional pain and hopelessness, is paralyzed, unable to see possibilities of change and an end to his or her despair. Blinded by tunnel vision, overwhelmed with life stress and problems of living, and anguished by feelings of loneliness, depression, hopelessness, and despair, the person often comes to see suicide as the only way out of a never-ending world of intolerable pain. In a very powerful way, Paul G. Quinnett has written Suicide: The Forever Decision to the suicidal person, empathizing and validating the painful experience of being suicidal. In so doing, Dr. Quinnett connects with the suicidal person, developing a relationship where in print he walks along with the person in his or her seemingly hopeless world. Once achieved, he gently and effectively pushes the suicidal person to consider that his or her world may change; the pain may leave; there may in fact be an alternative solution to his or her problem of living; and in fact suicide may not resolve the problem as the person would like.
For me, Dr. Quinnett's approach epitomizes a therapeutic and interpersonal style that is necessary and sufficient for touching and helping the suicidal person. First, he effectively confronts the dehumanizing myth that suicide is a result of being “crazy,” and then normalizes it as a coping response to solve problems of living. By so doing, he sets the stage for a phenomenological approach that allows him and the suicidal person to be part of the human experience and then to understand why suicide comes to make sense in the person's experience. In addition, Dr. Quinnett powerfully confronts the suicidal experience of the individual by encouraging the person to deal directly with his or her suicidal intention; his or her wish to live or wish to die; and ultimately death itself and whether or not it in fact will work as a solution for the individual's problem And, again, by so doing, he humanizes the experience—not masking or pathologizing it, but allowing, encouraging, and supporting the person to see his or her suicidal intentions for what they are and why they have come about.
In this process, Dr. Quinnett discusses a number of common experiences and problems of living that allow suicide to come to make sense, including loneliness, depression, anger, stress, substance abuse, and hopelessness. He does an excellent job of describing what it must be like to feel these painful emotions and encounter seemingly unsolvable problems of living. However, he also goes the critical step further by respectfully and gently asking the reader to think about and examine the actual permanence of the situation. Will suicide really solve the person's problems, achieve what he or she wants, and have the effect on significant others that the person wishes to achieve? Most importantly, at no time does Dr. Quinnett guarantee or promise that it will not; he only suggests that something as serious and permanent as suicide should be well considered. Through this process, Dr. Quinnett allows the suicidal person to have control of his or her destiny in a seemingly uncontrollable world, permitting him or her then to freely consider suicide, its consequences, and ultimately alternative possibilities. With thinking and possibilities comes hope, which always makes suicide seem less of a possibility.
In conclusion, I wish to recommend Dr. Quinnett's Suicide: The Forever Decision most highly. I have found it most useful as bibliotherapy in my clinical work with suicidal persons. Furthermore, I have found it to powerfully teach and sensitize me as a therapist, researcher, and participant of the human experience that suicide is not merely a pathological symptom or the outcome of an environmental prompt or intrapsychic impulse, but is in fact a solution that comes to make experiential sense for solving problems of living. I believe that approaching the suicidal person with genuine respect, empathy, love, honesty, and faith in life, as Dr. Quinnett has so eloquently done, will make suicide come to make less sense for the suicidal person.
Rachel Gittelman (Ed.), Anxiety Disorders of Childhood. New York: Guilford Press, 1986. 255 pages. Reviewed by Mae S. Sokol, MD, Instructor in Psychiatry, Cornell University Medical College.
The child psychiatry literature has recently focused on anxiety disorders. This is due to the increasing awareness of treatment efficacy in adults and of the childhood genesis of adult anxiety disorders. Gittelman's book provides a comprehensive account of childhood anxiety disorders, in which various aspects are examined by experts in diverse areas of the field. The result is a comprehensive volume that accurately represents the different phenomenological viewpoints.
This book will interest those involved in the diagnosis and treatment of suicidal youngsters. It thoroughly delineates current knowledge of anxiety disorders. However, models for study of the interface between suicidal behavior and anxiety in children would have made this book even more relevant. Suicide can represent the failure to resolve psychological problems through normal channels. In this respect, the connection between depression and suicide is well recognized. Anxiety disorders are similarly relevant to suicidal behavior, though less well studied.
The relation of depressive, obsessive-compulsive, and anxiety disorders in childhood is cogently addressed. Joaquim Puig-Antich and Harris Rabinovich discuss the connection between depressive and anxiety disorders. Although the association appears to be significant, their coexistence in children does not seem to have practical clinical implications or psychobiological correlates. Research findings on children with major depression are presented to elucidate the distinctions and commonalities of these disorders. Further data suggest that children whose parents suffer from major depression may be predisposed to separation anxiety disorder. They note that most depressed children present with anxiety symptoms, although children with anxiety disorder do not necessarily have affective symptoms. Thus, the anxious and not apparently depressed child may be at risk for suicide.
Stephen Suomi describes animal models of anxiety. Behavioral and physiological individuality is shown to exist in infant monkeys' response to stress. Environmental and genetic factors affecting differences in stress reactivity are discussed. Rhesus monkey infants were observed with different frequencies of distress vocalizations immediately following separation from their mothers. Paradoxically, those infants with a low frequency of distress vocalizations were found to behave in a more anxious manner and were more prone to depression following prolonged social separations; they also displayed an increased adrenocorticoid response, compared with their high-vocal-distress counterparts.
Reactivity to stress is shown to be relatively stable throughout major periods of development in monkeys. Suomi emphasizes the need for prospective study of the developmental antecedents of various components of the reaction to stress. Stimulating ideas for future research are also provided in Susan Campbell's excellent discussion of developmental stages of anxiety in children.
Judith Rapoport and her associates present evidence that obsessive-compulsive disorder in children may be more independent of anxiety or depression than in adults. Preliminary results from their continuing study of obsessive-compulsive children and adolescents reveal that only 17% of the obsessive-compulsive adolescents in the study had a concomitant anxiety disorder diagnosable by DSM-III. Family loading for anxiety disorder was not demonstrable.
Epidemiology, assessment, clinical correlates, and prognosis of anxiety disorders are discussed in a systematic yet eclectic fashion. Chapters on the treatment of anxiety disorders provide a review of pertinent studies and a lucid overview of the current approaches.
The discussion of pharmacotherapy as an adjunct to treatment of anxiety disorders by Rachel Gittelman and Harold Koplewicz is particularly informative. Although additional controlled investigations of various drug treatments are needed, it is clear that tricyclic antidepressants, and possibly benzodiazepines, have a role in treatment of these disorders.
Chapters reviewing models of psychopathology blend nicely with discussions of the treatment approaches that derive from these theories. For instance, Paul Trautman astutely reviews in historical perspective the various psychoanalytic theories of anxiety. This leads naturally to Melvin Lewis's description of principles for individual psychoanalytic therapy in children's anxiety disorders. He notes the ambiguity of anxiety in psychiatric conditions of childhood and gives criteria for the use of psychoanalytic therapy in anxiety disorders.
Gittelman has succeeded in editing a comprehensive and superior text on anxiety disorders in childhood. The work will prove useful to professionals involved in the care of children with psychiatric disorders, specifically those who treat suicidal youngsters. Clinically, anxious behavior and anxiety disorders are seen in children with suicidal proclivities. The relationship between depression (a well-known risk factor for suicidal behavior) and anxiety disorders is well delineated in this volume. It is instructive to note the spectrum of approaches to the study of anxiety disorders. It is hoped that future research will more clearly delineate the relationship between anxiety disorders and suicidal behavior.
