Handbook of behavioral medicine

Handbook of behavioral medicine

Journal of Psychosomoric Printed in Great Britain. Research. Vol. 30, No. 1, PP. 105-109, Pergamon 1986 Press Ltd. BOOK REVIEWS The Patient-Doct...

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Journal of Psychosomoric Printed in Great Britain.


Vol. 30, No. 1, PP. 105-109,



Press Ltd.

BOOK REVIEWS The Patient-Doctor Bristol, 1984. f20.

Relationship. T.



Health Science Press, Sidney, Australia,

216~~. Wright,

THIS book is translated from the original Finnish having been written by a leading Finnish professor of psychiatry, its production supported by the Finnish Medical Association. In the preface the author specifically spells out that it is intended primarily as a textbook for medical students. It is a readable book, clearly structured and in the opinion of the reviewer it stands up well to the process of translation, particularly given the psycho-social clinical subtleties which are its major subject-matter. It must be evaluated in the acknowledged context that it is aimed at undergraduate medical student8 rather than at clinical psychologists, psychiatrists or other professions with more detailed and intensive training in the field in question. It does not attempt to provide a detailed review of scientific evidence available concerning the patientdoctor relationship, nor does it attempt to ‘dissect’ individual studies in the field in any detail. It does not describe or compare the various methodologies or experimental design strategies used by researchers in the field. Similarly, it does not identify and compare the various measuring instruments now available to examine such topics as patients perceptions of their health, their health-care or their self-image. If the potential reader is seeking this sort of information, it will not be found in this book. Despite the above, acknowledged, limitations of the book it is interesting in terms of the framework which is uses to consider the patient-doctor relationship. As well as sections which consider ‘The Medical Interview’, ‘Examining the Patient’, ‘Informing the Patient’, and ‘Treating the Patient’ it specifically views the situation from the ‘Point of Departure’ of the patient and the doctor. It draws attention to the relevance of patient expectations, the effects of the setting in which the encounter occurs and broader cultural influences on the situation. There is a tendency for the statements made to be rather of the nature of ‘thou shalt’ instructions rather than ‘you might do well to think about’ advice. The reviewer did, however, find himself agreeing with most of the points of emphasis of the author. The most limited and disappointing section was that brief one which specifically refers to the psychological treatment of patient problems. This was, perhaps not surprisingly in a book such as this, too brief and limited to be of a great deal of value. The final point to bear in mind is that this book was first published in 1977 and that references after the mid-1970’s are therefore not included. Despite the above limitations it is still a book which the interested medical student might do well to read in order to identify and consider some important aspects of the doctor-patient relationship. JOHN KINCEY Royal Infirmary Manchester


of Behavioral Medicine. Edited by W. DOYLE CENTRY.The Guilford


1984. 530 pp. f33.

THIS volume is intended to serve as a source book for researchers, practitioners and educators concerned with understanding and dealing with psychological, social and behavioural factors as they contribute to physiological disturbances and diseases. The 12 chapters by 19 contributors, mainly psychologists, cover conceptual and methodological problems; reviews of certain bodily system disorders, immune, gastrointestinal and cardiovascular; psychological defenses with emphasis on coping; treatments and preventive strategies. Each of the chapters is carefully constructed, clearly written and, for the most part, thorough. Two of them deal with compliance in therapeutic regimens and other aspects of patients’ behaviour in the context of efforts to cure or prevent disease. These considerations, that get very little attention in present day medical practice, are highly pertinent to the work of a conscientious physician. The editor, in his introductory chapter, traces the use of the term Behavioural Medicine. Originally applied to biofeedback, it was later used to describe various cognitive treatment modalities not requiring the conceptual framework of psychoanalysis. The focus was then broadened to include etiologic concepts and research approaches, mainly psychological and epidemiological in the beginning, but ultimately encompassing psychophysiological and neurobiological methods of inquiry. In the end the definition of Behavioral Medicine proposed at the Institute of Medicine Conference in 1978 approached closely that applied to Psychosomatic Medicine in 1942 at the inauguration of the American Society for Research in Psychosomatic Problems. 105


Book Reviews

Behavioral Medicine, then, like the Psychosomatic movement of the 194Os, emphasized the need for interdisciplinary thinking and collaborative research. Unfortunately, both enterprises, launched 40 yr apart with closely similar aims, have had difficulty shaking off a parochial identity. Neither has thus far been able to penetrate the mainstream of discourse in medical research or practice. This book, as thoughtful and well crafted as it is, does not speak to the medical practitioners. This is a pity because it contains much that a physician needs to sharpen his awareness of his patients’ motivations and behavior. Moreover it may help clarify some of the reasons for illness and for a successful or unsuccessful outcome of treatment. STEWART WOLF St. Luke’s Hospital Bethlehem U.S.A.

Psychological 354 pp. f33.

Control of Pain. D. ELTON, G. STANLEYand B. GRAHAM. Grune & Stratton,



No CONTEMPORARYtext book on psychological control of pain has attempted to span such a wide range of theories, disciplines and therapies as this book. Divided into three parts, the first part covers definitions and models of pain, neurophysiology, biochemistry, personality, psychosocial variables and methodology. The second part deals with psychological methods of pain control, including placebo, behavioural psychotherapy, hypnotherapy, biofeedback, relaxation, operant conditioning, group therapy, as well as a final chapter on clinical pain measurement and comparative study. The third and final part of the book deals with medical and paramedical approaches t6 pain, and covers medication, surgery, acupuncture and transcutaneous stimulation, as well as a final chapter on the psychology of medical and paramedical approaches. This impressive breadth of interest has proaucea a book which, it tor no other reason, is usetul as a source of references in areas with which readers familiar with pain literature only in journals related to their own discipline, might well find useful. There is a refreshing clarity about much of the writing in this book, and some complex theories are very well summarised and explicated, (‘Gate-control’ theory, and the role of endorphins in pain being just two such examples). It is perhaps telling however, that I was most impressed by those sections of the book dealing with areas which were outside my discipline and expertise. My first misgivings came on reading Chapter 6, which deals with methodology in pain research. In an area dismally short of adequately controlled trials of various treatment strategies, the authors’ coverage of issues in controlled trials and single case study design was woefully inadequate. For instance, the authors come to the conclusion that matched subject designs for psychological research are more acceptable than randomisation designs, and their justification for arguing this is by referring not to any of the many worthy and standard texts on experimental design which are available, but rather to a somewhat obscure chapter on research strategies in hypnosis. As 1 began to read Section 2, the area of psychological methods of pain control with which I am more familiar, the misgivings which had arisen were unfortunately borne out. Certainly, the authors give a very clear and useful explication of a wide range of different therapeutic strategies. They include interesting and illuminating case histories, and give practical guidelines for the administration of diverse therapies which, even though any good empirical basis for giving such guidelines may be lacking, are nevertheless welcome starting points for those who may not have had any experience with these types of therapy. What was most lacking in all of these chapters was a critical reading of the outcome literature. In glancing at two reviews of psychological treatment of chronic pain published in 1982, 1 found at least six studies which were either randomised control studies or carefully controlled single case design studies, which were not referred to in this book. This is far from a trivial point, and there are hardly any properly controlled studies of the treatment of chronic pain by psychological methods. The enthusiasm with which the authors launch into descriptions and prescriptions for therapies from hypnotherapy to biofeedback is infectious, but it is clear that the authors are guided more by clinical intuition than they are by good scientific research. Perhaps in an attempt to make up for this, the authors provide a detailed account of a comparative study of four different types of psychological intervention, plus one control procedure, which they carried out themselves, and in which they incautiously conclude that ‘this study showed that behavioural techniques were effective in attaining pain relief in chronic pain patients, but their effect was greatly augmented if hypnosis and biofeedback were used in conjunction with behavioural modification’ (p. 226). The authors’ poor grasp of experimental design and research methodology is confirmed here, where they draw such certain conclusions for such uncertain data, where there was no follow-up after the end of treatment, nor was there any blind assessment. Furthermore, no statistical analysis was carried out, and it was asserted that differences existed between groups without providing any statistical justification for this.