thors present a concise summary of the physiology and psychology of pain, including concepts of pain tolerance and pain threshold, and differentiating hypnotic suggestions for pain reduction from ef- fects of anxiety reduction through medication or other behavioral techniques including the more nonspecific use of hypnosis. Anxiety reduction can increase pain tolerance and decrease suffering, but does not alter the feeling of pain.

The clinical sections deal with specific pain topics and review the hypnotic strategies that have been employed along with published results of the hyp- notic treatment of conditions generally considered “organic.” These selected topics were chosen to avoid types of pain presentations that are often modifiable with other psychologic and behavioral interventions, and the authors are well aware of the pitfalls of such an arbitrary division of concepts and topics. The sections on the hypnotic applications to specific pain syndromes are likely to be more inter- esting to specialized clinical practitioners.

There are sections dealing specifically with hyp- nosis with cancer pain, childbirth and labor, general surgery, and its uses in dentistry. Strategies for the combined and coordinated use of hypnosis and clinical anesthesia are presented, as well as the broader nonpain usage of hypnosis in these condi- tions. Specific hypnotic approaches and strategies for pain are presented including techniques for the direct suggestions of pain reduction, e.g., reduction of pain sensitivity to a body part not experiencing pain and then transferring the felt pain (such as the technique of “glove anesthesia”) to that area in or- der to reduce the felt pain when touched by the anesthetic hand; techniques for altering the experi- ence of pain and not necessarily reducing it, useful for pain that is not localized but is diffuse (e.g., a hypnotic strategy for concentrating the pain into some smaller area and then perhaps moving it to another location); techniques for redirecting atten- tion away from the pain that involve hallucinatory experiences, such as that of an absent limb or body part, and use of amnesia techniques for intermittent pain which is often associated with the negative effects of anticipatory pain. The authors highlight the important differences between nonpatients in the laboratory undergoing experimental proce- dures vs real patients presenting with painful con- ditions associated with discrete medical conditions.

The book ends with some discussion of theoreti- cal issues, including the roles of suggestibility, imagination, amnesia, and “splits” in conscious- ness. A key contribution of the Hilgards has been

the concept of the role of the “hidden observer,” a metaphor for the still-obscure process by which a person does not feel overt pain yet indicates via the technique of automatic writing/talking that sen- sory pain and suffering have registered at some level outside of usual consciousness and awareness.

This book is recommended for those who are in- terested in a recent classic and want to review basic hypnotic concepts and clinical data pertaining to the treatment of medically based painful conditions with hypnotic techniques used often as adjuncts to conventional medical treatments. This book has the advantage of textbook breadth and depth, yet re- mains practically focused.

J. PETER STRANG, M.D.

Boston, Massachusetts

PI1 SOl63-8343(96)00058-8

Keeping Boundaries: Maintaining Safety and integrity in the Psychotherapeutic Process. By Richard S. Ep- stein. Washington, D.C., American Psychiatric Press, Inc., 1994 ($35.00), 318 pp.

The concept of boundaries is a nebulous one even for experienced psychiatrists. Dr. Epstein starts from a broad perspective of defining boundary vio- lations as “any behavior that infringes upon the primary goal of providing care, and that might harm the patient, the therapist, or the therapy it- self.” After developing the empirical basis for these concerns, he proceeds fairly rapidly to catalogue a number of interpersonal and intrapsychic markers of boundary violations. These markers are de- scribed using psychodynamic and social constructs. As an example, he discusses Goffman’s model of social frames and how this can be used as a model for boundaries in the clinical process. This model suggests that social and psychological expectations frame human interaction and that coherent experi- ence is optimal when these experiences are congru- ent with the expectations.

My only problem with this book is a relatively minor one as it applies to medical psychiatrists. There are special clinical circumstances that arise for psychiatrists who perform their own physical examinations, medically assess patients with inad- equate resources, or accept tertiary referrals from a wide geographic area. There are some psychiatrists who treat multiple family members because they

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are skilled in treating a specific heritable disorder or psychiatric disorder in patients with significant medical illness. Epstein discusses how all of these situations may be problematic and lead to potential boundary problems in a psychotherapeutic setting but provides little guidance for medical psychia- trists and psychiatrists who regularly need to ad- vocate for their patients such as those in commu- nity mental health centers and managed care set- tings.

This book is outstanding and should be read by every psychiatrist and psychiatric resident. It is the first book I have seen that adequately addresses the problem of appropriate behavior on the part of the psychiatrist. Specific problems are explicit, well il-

lustrated by clinical examples, supported by cur- rent literature, and preventive strategies are dis- cussed. It also gave me the opportunity to think about a question one of my psychoanalyst psycho- therapy supervisors asked me, “Do you think that boundaries’ is a technical term that a psychiatrist should use?” Back then I groped for the appropriate answer. After reading this book, the answer is an unequivocal “yes.” Dr. Epstein has provided a trea- tise in this area that will be useful for years to come.

GEORGE DAWSON, M.D.

Mahtomedi, MN

PI1 SOl63-8343(96)0(~61-8

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