In Two Minds: A Casebook of Psychiatric Ethics

BOOK REVIEWS Jeffrey L. Geller, M.D., M.P.H., Editor Handbook of Psychological Change: Psychotherapy Processes and Practices for the 21st Century edited by C. R. Snyder and Rick E. Ingram; New York, John Wiley & Sons, 2000, 768 pages, $110.95 Laurie Heatherington, Ph.D. Stephen Eyre I s there a provider of psychiatric services among us who has never said, “I wish I could take a focused, high-level course in what’s happened in the field of psychotherapy since I graduated”? Is there a graduate student among us who has never thought, “If only there were time, I would read up on the history and development of the psychotherapies—a history that my teachers know because they lived it, but that for me is a blur”? And is there an academic among us who has not fretted, “My work has become so specialized. . . . On my next sabbatical I should read up on the newer developments in areas outside my own”? We doubt it. Happily, Snyder and Ingram and their collaborators speak to each of these desires in a packed but highly readable volume, Handbook of Psychological Change. The book’s 34 chapters are organized into six parts: the history of psychotherapeutic change; research methods for studying the effectiveness of therapeutic change along with a critical analysis of these methods; the role of selected nonspecific factors in what makes interventions work, such as therapist variables, client variables, and stages of change; the basic mechanisms of change in and the empirical status of 13 different psychotherapeutic approaches; therapeutic approaches to use with special populations, such as abuse and incest survivors and older adults; and psychotherapy in the new millennium— a section that addresses, among other topics, prevention science, psycho- Dr. Heatherington and Mr. Eyre are affiliated with the department of psychology at Williams College in Williamstown, Massachusetts. 1036 therapy in American society, and the training of future psychotherapists. Given its deliberate focus on the future, the book devotes only a single, though inspiring, philosophical chapter to the history of psychotherapy and two chapters to research per se. The latter review and discuss—positively but not uncritically—the state of the art in psychotherapy outcomes research and the empirically supported treatment movement. Although these chapters may be tough going for readers not trained in psychotherapy research, they form an important foundation for the rest of the book, because research evidence (or the lack thereof) for the effectiveness of each therapeutic approach is infused in parts 3, 4, and 5. The chapters in parts 4, 5, and 6 are stand-alone articles. They do not all follow the same format, yet they manage to cover similar territory, and the text has a coherent feel to it. Despite its length, the book is not encyclopedic, in scope or in style, as the authors provide opinions and analyses as well as descriptive material; in this respect, reading it is much like attending a graduate seminar with the top scholars in each area. It is good to see the sometimes-marginalized marital therapies, constructivist and narrative therapies, group therapy, and other types of therapy treated in the main section of the text. While the individual chapters in parts 5 and 6 are excellent, they encompass a more eclectic, less coherent collection of topics. Handbook of Psychological Change is not a how-to manual, although readers will find ample references to resources for learning the various approaches. Rather it is an ambitious and demanding, but humble, work on the science of psychotherapy that places the person squarely within the frame of discussion. In Two Minds: A Casebook of Psychiatric Ethics by Donna Dickenson and Bill Fulford; New York, Oxford University Press, 2000, 382 pages, $45 softcover Donna T. Chen, M.D, M.P.H. T he authors of In Two Minds: A Casebook of Psychiatric Ethics set out to provide a framework for thinking through ethical aspects of situations commonly encountered by psychiatrists and other mental health clinicians. As longtime collaborators in addressing issues at the interface of philosophy, ethics, and mental health, Drs. Dickenson and Fulford achieve this objective superbly. In Two Minds is billed as a companion to Psychiatric Ethics (1), but appreciating this book does not depend on one’s familiarity with its sister publication. Rather, the two books are complementary, and each can stand alone. In Two Minds is written with the assumption that exposure to ethical PSYCHIATRIC SERVICES theory alone will not necessarily improve ethical thinking or problem solving. The authors distinguish between two levels of moral reasoning: everyday action and critical reflection. To be effective on the first level, mental health professionals must be decisive and unselfconscious. By engaging in critical reflection, individuals can improve their ethical thinking skills, which can help them act decisively. The authors aim to teach such Dr. Chen is a fellow in bioethics and psychiatry in the department of clinical bioethics of the National Institutes of Health and is on the psychiatry consultation-liaison service of the National Institute of Mental Health. ♦ http://psychservices.psychiatryonline.org ♦ August 2002 Vol. 53 No. 8 BOOK REVIEWS ethical thinking skills by engaging the reader in critical reflection of common clinical cases. The authors’ view is that good ethical thinking is required throughout the spectrum of mental health care— including in phenomenology, diagnosis, etiology, treatment, prognosis, and service delivery. In the first chapter they introduce both their framework for thinking about psychiatric ethics along this spectrum and the philosophical underpinnings of psychiatric ethics, including philosophy of science and philosophy of mind. A second introductory chapter lays out the authors’ practical skills approach for teaching ethical thinking. The practical skills approach frames the succeeding chapters, which collectively cover the spectrum of mental health care. Each chapter includes an introduction to the ethical and philosophical issues to be covered in the chapter, a case presentation, a discussion of the ethical issues embedded in the case, a commentary by a practicing clinician, and a discussion of recommended readings covering the basic philosophical and ethical concepts covered in the chapter. These chapters are followed by one describing how to use the authors’ method in a sample teaching seminar. Although a chapter covering research ethics and another providing an international perspective at the end of the book do not fit well into the otherwise tightly organized structure of the book, they do provide interesting discussions of important topics. Two chapters are relatively unusual for textbooks of bioethics and are of particular relevance to the readership of Psychiatric Services. Chapter 8, which discusses the importance of teamwork and good communication from an “ethics” standpoint, exemplifies how ethical care and good clinical care are frequently one and the same. The chapter also provides a forum for highlighting an approach to ethics called “perspectives,” which is introduced in chapter 2—an approach that many U.S. readers may not have encountered before. Chapter 10 tackles the issue of when evidence-based quality improvement efforts become PSYCHIATRIC SERVICES research and why this distinction might be important—a timely discussion of importance to all service providers charged with evaluating and improving their efforts. With the goal of teaching ethical thinking, the authors are careful to point out that they are not offering solutions to ethical dilemmas—and readers hoping to find solutions will be disappointed. Because the authors are British, the book cites legislation and legal cases primarily from the United Kingdom. For readers who are not governed by the laws described, this distancing can serve to focus attention squarely on ethical thinking rather than allowing the reader to look to the law for answers to ethical dilemmas. However, this feature of the book may frustrate readers who are unfamiliar with similarities to and differences from their own federal, state or provincial, and case law. Nevertheless, the topics discussed in In Two Minds have universal relevance. I recommend this book to anyone looking for an engaging and dynamic way to reflect critically on ethical aspects of common clinical situations. By engaging in the types of critical reflection covered, one can begin to learn and develop the ethical thinking skills required to act decisively and with confidence in difficult clinical situations. Reference 1. Bloch S, Chodoff P, Green S (eds): Psychiatric Ethics, 3rd ed. New York, Oxford University Press, 1999 Family Interventions in Family Illness: International Perspectives edited by Harriet P. Lefley and Dale L. Johnson; Westport, Connecticut, Praeger, 2002, 247 pages, $69 William Vogel, Ph.D. T his scholarly book is a muchneeded work in the field of family mental health. The editors of Family Interventions in Family Illness are both eminent scholars with extensive backgrounds in cross-cultural psychology and psychiatry. In this book they focus on “therapeutic interventions for families of adults with major mental illnesses in various countries throughout the world,” especially “on persons with severe psychiatric syndromes such as schizophrenia and major affective disorders.” The 13 chapters are written by authors working in various countries— the United States, Sweden, Austria, India, China, Japan, the Netherlands, and others—and with various cultural groups within those countries. Thus, for example, we get a chapter on work with various Hispanic groups in the United States. The book highlights the vast differences in approaches to work with Dr. Vogel is affiliated with the department of psychiatry at UMass Memorial Health Care in Worcester, Massachusetts. ♦ August 2002 Vol. 53 No. 8 families from country to country. For example, “Japanese psychiatric services are typically hospital based,” whereas in China, “it is impossible for the public purse to provide the care and welfare that families do,” and hence “the Chinese constitution of 1981 makes it mandatory for children to care for their elderly parents.” In India, “barriers exist to . . . programs of [behaviorally based] family work. Prominent . . . barriers are the biomedical model and expectations of care only from medication-oriented approaches.” In Great Britain, “biological modes . . . are seen as most important, with psychological approaches being seen as secondary or optional. Staff frequently comment that if family work is not affected, there are no adverse consequences.” Nevertheless, in all the societies surveyed, behavioral-based treatment interventions do exist, tailored to the need of various cultures. The book discusses the various approaches and the treatment efficacies of each. The book is a must-read for anyone in the mental health field. 1037 BOOK REVIEWS Health Care in the Black Community: Empowerment, Knowledge, Skills, and Collectivism edited by Sadye L. Logan, D.S.W., and Edith M. Freeman, Ph.D.; New York, Haworth Press, 2000, 276 pages, $69.95 hardcover, $34.95 softcover Irma J. Bland, M.D. A s health care professionals, physicians have finally come to realize that the administering of our knowledge, the practice of our skills, and the prescribing of our medications often fall far short of our goals. This is particularly true when our practice of medicine fails to recognize the specific social issues and cultural realities that affect our patients’ lives. Research continues to bear out this reality, as reflected in the health statistics of African Americans and other ethnic minority populations. As the authors of Health Care in the Black Community point out, African Americans continue to suffer disproportionately from a number of diseases that result in chronic disability and cause premature death. In spite of the advances in medical science and the development of more effective treatments and innovations in health care delivery, substantial disparities remain between African Americans and the general population in physical and mental health and in the delivery of health care services. This book proposes a comprehensive approach to bridge this gap. The volume editors are eminently qualified professors of social work who have focused much of their scholarly work on the health and welfare of families in the interface of culture and community. For this book they brought together a distinguished and diverse group of academic scholars, researchers, and clinicians representing the fields of social work, psychology, and medicine. From the perspective of their disciplines, research, or clinical practices, the authors provide an overview of the most serious Dr. Bland is clinical professor of psychiatry at the Louisiana State University Health Sciences Center and regional administrator and chief executive officer of the Office of Mental Health, Region-1, in New Orleans. 1038 and persistent health problems affecting African Americans, identify and examine current issues that affect their health care, and offer solutions to these issues. They identify areas of knowledge, skills, and forms of collectivism that have traditionally supported the survival of blacks and illustrate how building on these strengths, values, and cultural traditions can foster more effective health education and enhance prevention and early intervention. How can we increase utilization, enhance medical compliance, promote health and wellness, and improve the health status of African Americans? The authors offer a number of innovative models. They illustrate the effectiveness of partnerships with the black church to provide health education and social support such as weight reduction programs and drug abuse prevention programs; use of mutual assistance groups to augment health care for people with chronic illnesses; other community-centered initiatives; and educational and behavioral strategies targeting health care utilization, medical compliance, and the promotion of wellness. Of particular interest to mental health professionals are models that focus on strengthening families and building social competence and emotional skills. These include competence development models to enhance the family’s capacity to build competence and self-esteem in their children and frameworks that assist families in examining relationships and understanding, alleviating, and preventing violence as a means of coping with stress. This book should be of interest to clinicians, faculty, and students in the social service and health care professions, persons involved in the delivery of health services to African Americans and other racially or ethnically diverse populations, and anyone interested in a multisystems approach to health care delivery. It is time for physicians to partner more effectively with colleagues from social work, psychology, and other health professions. In the empowerment framework of this book, the authors put forth innovative models that are culturally sensitive, that have been shown by research to be effective, and that can support and enhance all individuals, families, and communities in efforts to improve utilization, medical compliance, and physical and mental health. Principles and Practices of Behavioral Assessment by Stephen N. Haynes and William Hayes O’Brien; New York, Kluwer Academic/Plenum Publishers, 2000, 348 pages, $59.95 Nirbhay N. Singh, Ph.D. A t the core of this volume are the concepts and strategies of behavioral assessment, which is a subset of psychological assessment. The book goes beyond the simplistic behavioral assessment strategies that are widely employed in behavioral research and clinical practice today. For example, in much contemporary research and practice, behavioral assessment is al- PSYCHIATRIC SERVICES most synonymous with functional assessment, a method used to assess the generic conditions that purportedly maintain problem behaviors. As this book clearly shows, however, functional assessment is simply one method of assessment that, by itself, provides an incomplete picture of the behavior of interest. In Principles and Practice of Be- ♦ http://psychservices.psychiatryonline.org ♦ August 2002 Vol. 53 No. 8 BOOK REVIEWS havioral Assessment, Haynes and O’Brien eschew the current myopic view of behavioral assessment and suggest a much broader array of methods that researchers and clinicians can use to develop a more informed view of why a person may be behaving in a certain way. The authors also emphasize that the beliefs and values of the person who is doing the assessment greatly influence which assessment paradigm is used, which in turn affects the selection of an assessment, of the variables for assessment, of the assessment strategies for examining the behavior, and of the measures to be obtained. These choices in turn affect the case formulation and the treatment decisions. The authors rightly note that behavioral assessment, like psychological assessment itself, involves the use of quantitative as well as qualitative methods to obtain a coherent picture of the multiple motivations that underlie the repeated occurrence of a problem behavior. Haynes and O’Brien discuss the characteristics and applications of behavioral assessment and how these variables are related to the critical issue of clinical judgment. They note that practitioners have few empirically derived guidelines for making clinical judgments, and virtually no guidelines for designing effective intervention programs. The authors discuss how to avoid the oversimplification strategies that clinicians use to make sense of the large data sets that behavioral assessments produce. Many behavioral researchers and clinicians hold the view that behavioral assessment and therapy are part of a science that is based on reliable and observed behavior. However, they forget that even in behavioral therapy, case formulation is an art that is ultimately based on the therapist’s hypotheses and judgments about the problem behaviors, causal variables, and functional relations among multiple behaviors, environments, and so Dr. Singh is professor of psychiatry, pediatrics, and psychology at the Medical College of Virginia of Virginia Commonwealth University in Richmond. PSYCHIATRIC SERVICES on. Moreover, as Haynes and O’Brien point out, case formulation affects clinical intervention, and many uncontrolled factors moderate treatment effects. These moderator variables include the person’s goals and strengths, presence of medical and psychiatric problems, characteristics of the treatment environment, use of recreational and prescribed drugs, social support, and others. To their credit, the authors present a clinically astute model that relates behavioral assessment to good case formulation, which leads to appropriate clinical intervention that will result in en- hanced treatment outcomes. I enjoyed reading this book. It presents a wealth of information in a very readable format. The authors amply demonstrate the merits of taking a broad approach to behavioral assessment, as it is a powerful method for assessing and making sense of complex human behavior. They also emphasize the need for good case formulation—a topic rarely taught in university courses and usually ignored in textbooks on behavioral assessment. If I could have only one book on behavioral assessment, this would be it. The Forgotten Generation: The Status and Challenges of Adults With Mild Cognitive Limitations edited by Alexander J. Tymchuk, Ph.D., K. Charlie Lakin, Ph.D., and Ruth Luckasson, J.D.; Baltimore, Paul H. Brookes Publishing Co., 2001, 387 pages, $32.95 softcover Barbara Haskins, M.D. T his book boldly addresses the societal plight of persons with mild cognitive limitations. Begun in 1999 as The Forgotten Generation: A Report to the President, this volume contains the final revisions of the papers that first appeared in that report. Its focus is on the plight of all persons who require supports, not just those who meet diagnostic criteria for mild mental retardation. This group includes people who have lower than average learning, communication, judgment, or understanding abilities, and thus includes people who as children were learning disabled or emotionally disturbed and are now grown up. The book is largely directed to those responsible for planning human services delivery systems. Its analysis of the many barriers in service models can benefit college students and faculty in sociology, education, social work, law, and public health. Legislators and their aides could glean much useful information. Any advocacy group can use chapters from the book to bolster their arguments and supplement their data. However, because the book focuses on systems, it would not be useful to the average clinician. Chapters address community sup- ♦ http://psychservices.psychiatryonline.org ♦ August 2002 Vol. 53 No. 8 ports, outcome studies, employment, parenting, access to health care, spirituality, citizenship, the criminal justice system, and mental health. There is very little linkage among service systems, and little advocacy or outreach for the cognitively disabled, which leaves them marginalized in society and overrepresented among the poor, the unemployed, the incarcerated, and those who are charged with child abuse. The broad net of cognitive limitation sweeps in many persons struggling to survive in a society increasingly ruled by technology and information services. The mildly cognitively impaired are unlikely to advocate for accessible services or to locate currently available services. They are a constituency with few natural advocates. Their efforts to blend in, especially after being labeled in school systems as deficient, often leads case managers in human services fields to miss or minimize their Dr. Haskins is associate professor of clinical psychiatry at the University of Virginia and chair of the committee on developmental disabilities of the American Academy of Psychiatry and the Law. 1039 BOOK REVIEWS needs for supports. (As a forensic psychiatrist, I have seen this subtle factor lead prosecutors to assume a higher level of criminal intent than the retarded individual actually had.) Deficits in the use of written or spoken language recurrently pose enormous barriers to gaining access to service systems; for example, to fill out the 11-page MediCal application requires 14 years of education. A weakness of the dual diagnosis section is the lack of medical and biological information on the etiology of mental illness. Instead, the causes are cited as “negative contingencies. . . negative environments . . . and unusual motivation.” This chapter is unacceptably sparse after the Decade of the Brain. The spirituality section is well written and inspirational. Congregations need to appreciate the role a spiritual community offers to the cognitively limited—namely, inclusion—and initiate outreach efforts. Overall, this book is a useful compendium of aggregated data on the status of cognitively disabled people over time and across multiple domains. Personnel Preparation in Disability and Community Life: Toward Universal Approaches to Support by Julie Ann Racino; Springfield, Illinois, Charles C. Thomas, 2000, 330 pages, $65.95 hardcover, $51.95 softcover training, and academic theories of disability. In reading these chapters I learned that a brokerage model of community support, which unbundles the generic support role from specific services, remains a viable and even favored model in nonmedical community support theory. This is not the case in the current psychiatric case management and community support literature, in which the brokerage model seems to be in the process of being discarded. It is particicularly helpful to understand this difference if one is seeking to create a liaison between these different systemic points of view. I will use this book as a resource to guide my introduction to the literature of the disability and community support movements. Benjamin Crocker, M.D. T his wide-ranging book is built on the author’s experience as an educator, manager, and consultant in the fields of disability policy and theory and community support. It does not appear to have been intended as an introduction to these fields but rather as a resource book as well as a reference book for use in the development of training related to the support of broad community participation by people with disabilities. Although the author’s focus is on people with developmental disabilities, she makes it clear that she is advocating for training, education, and information diffusion that will encourage the development of generic or generalist community development workers who, while sensitive to the mode of person-specific planning, also look beyond individual needs to consider the needs of the community as a whole. In the concluding chapter, she emphasizes that “universal” support services should be generic and broadly competent and inclusive rather than categorical. This is not an easy book to read, and the chapters at times seem amorphous and redundant. The writing Dr. Crocker is affiliated with the Maine Medical Center in Portland. 1040 style is notable for long, poorly punctuated sentences, with many lists of examples following any abstraction. The text is densely referenced, which well serves the book’s role a reference text, but the frequent use of parenthetical citations instead of footnotes can be distracting to the reader who is pursuing the material more than its sources. Part of my problem in following the text was that I am not familiar with the literature it covers. I was struck by the absence of citations from the psychiatric literature, although it is consistent with the author’s position that professional services in the medical model, driven by federal health care dollars, are competitive with and suppressive of the development of a broadly competent community support and development workforce. The heart of the book lies in several chapters that describe various training and academic curricula. These chapters contain a great deal of detail, and they might have been better edited to suit the purpose of description, but they present an interesting variety of approaches. The other chapters are more readable. They cover systems change, research paradigms, the role of universities in technical assistance and field PSYCHIATRIC SERVICES The Practice of Electroconvulsive Therapy: Recom mendations for Treatment, Training, and Privileging, second edition by the American Psychiatric Association Committee on Electroconvulsive Therapy; Washington D.C., American Psychiatric Association, 355 pages, $52 Max Fink, M.D. M uch energy is spent seeking to increase the acceptance of electroconvulsive therapy (ECT) in the treatment of severe psychiatric illness. ECT’s efficacy in providing relief to patients for whom medications have not worked is well documented. In response to proscription of ECT by the California legislature in 1973, the American Psychiatric Association (APA) established its first task force on ECT to understand why the public was hostile to this treatment. The task force’s 1978 report (1) recognized that the efficacy and safety of ECT warranted its use. In response to the charges of abuse of ECT, the task force introduced informed and per- Dr. Fink is professor of psychiatry and neurology emeritus at the State University of New York at Stony Brook. ♦ http://psychservices.psychiatryonline.org ♦ August 2002 Vol. 53 No. 8 BOOK REVIEWS sonally signed consent as the new standard of care; that standard is now firmly established. However, the 1978 report did not give adequate attention to the technical details of ECT, and numerous texts on ECT soon appeared. APA commissioned a 1990 update (2), which quickly became the standard for care. The volume reviewed here is a revised edition of that update, commissioned to accommodate new knowledge. The most investigated question in ECT is electrode placement. The 1978 report recognized, and the 1990 report encouraged, the use of right unilateral electrode placement (RUL) for patients with depression. This recommendation was based on evidence that its efficacy seemed equal to that of bitemporal electrode placement (BT), with lesser immediate and short-term cognitive deficits. But more recent studies have questioned the equivalence of RUL and BT. It was thought that any stimulus sufficient to elicit a grand mal seizure would be clinically effective, regardless of electrode placement. While that concept is true for BT, the efficacy of RUL depends on the level of energy above a measured seizure threshold. Indeed, effective RUL required six times the seizure threshold to approximate the efficacy of BT (3). Unfortunately, increasing the energy level increases immediate cognitive deficits, vitiating any vaunted advantage for RUL (4). Despite these findings, the revised report recommends the preferential use of unilateral electrode placement with the energy level at six times the seizure threshold. This recommendation does not have secure grounding and does not warrant the APA imprimatur. The recommendation also requires that practitioners assess seizure thresholds by titration for RUL. But neither the safety nor the merits of this procedure compel its use. The report is extensively referenced, reflecting the increasing number of publications about ECT as interest has grown in the past two decades. In format, the revision folPSYCHIATRIC SERVICES lows the 1990 report closely. As a guide for ECT practitioners, this revision adds little to the earlier version. The ECT practitioner will be better served by one of the smaller technical handbooks available (5,6) or by Abrams’ definitive text (7). For clinicians who do not actively practice ECT, the Abrams textbook or the trade book by Fink (8), designed for patients and their families, would make better reading. 3. Sackeim HA, Prudic J, Devanand DP, et al: A prospective, randomized, double-blind comparison of bilateral and right unilateral electroconvulsive therapy at different stimulus intensities. Archives of General Psychiatry 57:425–434, 2000 References 6. Beyer JL, Weiner RD, Glenn MD: Electroconvulsive Therapy: A Programmed Text. Washington, DC, American Psychiatric Press, Inc, 1998 1. American Psychiatric Association: Electroconvulsive Therapy. Task Force Report 14. Washington DC, American Psychiatric Association, 1978 2. American Psychiatric Association: Electroconvulsive Therapy: Treatment, Training, and Privileging. American Psychiatric Association, Washington, DC, 1990 4. McCall WV, Reboussin DM, Weiner RD, et al: Titrated moderately suprathreshold vs fixed high-dose right unilateral electroconvulsive therapy. Archives of General Psychiatry 57:438–444, 2000 5. Kellner CH, Pritchett JT, Beale MD, et al: Handbook of ECT. Washington, DC, American Psychiatric Press, Inc, 1997 7. Abrams R: Electroconvulsive Therapy. New York, Oxford University Press, 1988; rev ed, 1997 8. Fink M: Electroshock: Restoring the Mind. New York: Oxford University Press, 1999 The Notorious Astrological Physician of London: Works and Days of Simon Forman by Barbara Howard Traister; Chicago, University of Chicago Press, 2001, 250 pages, $30 Kenneth E. Fletcher, Ph.D. I n April 1613, two years after Simon Forman’s death, Sir Thomas Overbury was committed to the Tower of London for refusing King James’ offer of an ambassadorship to Russia. One month later, still a prisoner in the tower, he died. By the summer of 1615, rumors that Overbury had been poisoned prompted King James to have the death investigated. The investigation revealed a convoluted plot that involved the young wife of the earl of Essex, who had been carrying on an affair with one of King James’ favorite courtiers, to whom Overbury acted as adviser. When Overbury advised the courtier against involvement with the young woman, and after he refused the ambassadorship that was intended to remove him from the scene, she plotted Dr. Fletcher is associate professor of psychiatry and director of the behavior sciences research core in the Graduate School of Nursing at the University of Massachusetts Medical School in Worcester. ♦ http://psychservices.psychiatryonline.org ♦ August 2002 Vol. 53 No. 8 his death by poisoning. During the ensuing trials, Simon Forman was accused of aiding and abetting the plot in some unspecified manner, perhaps by supplying the poison or by working black magic. Traister finds the evidence for this vague at best. However, the insinuations of the royal prosecution were enough to tarnish Forman’s reputation for the next four centuries. Writers from Ben Jonson to Nathaniel Hawthorne came to characterize him as either a silly fool or an evil magician in league with the devil. The reality of Simon Forman’s life is much more mundane, but it still makes for a good story for what it tells us about daily life during Shakespeare’s times, especially the life of a successful physician. Forman was perhaps the first physician to keep detailed notes on the patients he saw. Although Forman was largely selftaught, as were many physicians of his day, he was also well read in the medical literature of the time. He did not 1041 BOOK REVIEWS read it uncritically, however. In his maturity, he took a practical, “experimental” approach to his practice, always trying to evaluate the efficacy of both diagnostic methods and treatment procedures. His casebooks were particularly useful to him in this regard. He was a careful observer, made meticulous notes, and learned from his experiences. His conclusions frequently put him at odds with accepted medical practice of the time. He was, for example, vehemently opposed to the popular medical reliance on uroscopy, the use of urine samples to diagnose medical problems. At a time when little distinction was made between physical and mental disorders, Forman wrote a detailed treatise on melancholy. Still, according to Traister, his treatments were fairly conservative for the period, and “if they frequently did not cure, they probably did not do much harm either.” Like many of his colleagues, Forman’s approach to medicine relied heavily on Galenic humoral theory, spiced with doses of Paracelsian drug and herbal theory. He was an accomplished astrologer and relied heavily on the art not only for making diagnoses and considering prognoses but also to guide his own daily life. He also did a good business in magical sigils, which are engraved metals or amulets that are meant to be worn to help ward off evil and illness or to attract good fortune or love. He wrote private manuscripts about astrology, alchemy, magic, and witchcraft. He engaged in experiments similar to those of John Dee, Queen Elizabeth’s astrologer and the most accomplished English mathematician of his day, in which he tried to summon magical spirits—and he believed he had succeeded. Forman built up a lucrative practice in London over the years. Unfortunately, his success did nothing to endear him to the College of Physicians of London, which was charged with licensing physicians in the London area. Although the majority of practitioners in London were unlicensed, the College seems to have concentrated its efforts at censorship on the most notorious—or most successful—of these practitioners. Forman came to their attention early in his career in London. He was imprisoned then and many times thereafter. Aside from leaving the London area for a few years at a time, however, Forman defied the College, and in 1603 he managed to receive a university license from Cambridge. This did not stop the College from harassing him, but it appears that he was never imprisoned again. This book is filled with interesting details about Forman’s practice as well as about his daily life. The narrative is written in fairly dry scholarly prose, but Forman himself manages to help the reader overlook this. There was more to the man than the conscientious physician. He could be exceedingly vain, trivial, and a bit of a whiner, but these faults add a humorous quality to his story. Anyone who is interested in the way medicine was practiced in its early years will want to read this book. Psychiatric Services Launches Web-Based Manuscript Submission and Peer Review System Psychiatric Services has implemented a Web-based manuscript submission and peer-review system, called Manuscript Central, designed by ScholarOne. Since 1998 more than 150 top-tier scholarly peer-reviewed journals have turned to Manuscript Central to conduct a virtually “paperless” peer review. Authors of papers for Psychiatric Services: Please do not submit manuscripts by mail. Instead please visit http://appi.manuscriptcentral.com and follow the instructions to open your account and upload your paper and a cover letter. After submission, you can check the status of your paper on-line at any time. Peer reviewers for Psychiatric Services: You will be notified by e-mail when a paper has been assigned to you. The e-mail will contain instructions about visiting the Web site, locating the paper in your existing account, and submitting your review on-line. The journal staff and the technicians at ScholarOne have worked hard to make the system as user-friendly as possible. For users who need assistance, Manuscript Central offers prompt telephone support and other types of support, such as by e-mail and by “live chat” with a technician. 1042 PSYCHIATRIC SERVICES ♦ http://psychservices.psychiatryonline.org ♦ August 2002 Vol. 53 No. 8