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In reading Rasch’s first chapter and Cormier’s last one (Dannemora Revisited), one wonders why and how this is possible. Cormier gives us a clue. On revisiting the institution he says: “The initial physical impression created an almost surrealistic feeling of being in a place which was familiar and at the same time foreign.” On meeting former inmates: “it was a joyous reunion, replete with back slapping, hugging and the wordless exchange of broad grins.” Institu- tions revert to their socially affixed destiny; maybe not quite, but even the marginal differences become problematic since they tend to give a human face to a non-human (if not inhuman) structure. But those who have seen people behind labels and bars, and have seen them resuscitated and revived, cannot abandon this human condition but must go on to push the stone uphill. The real mistake that Rasch made, and still makes in the book, is the hope that this human ideal can be systematized and institutionalized. In the absence of a real community, and in the presence of the possibility, through the criminal law, of rejecting uncomfortable members and banishing them to places like prisons, such an attempt remains more than doubtful.

If we could conceive of law and psychiatry as the praxis of human actors rather than the fulfillment of institutional demands, Camus may be right when he asks us to assume that Sysiphus is happy in spite of the absurd. If we are seduced (as we often are) to offer technical perfection to a system (be it punish- ment or treatment), we only contribute to the surrealism in the landscape around us; and Furensische Sozialtherapie painfully documents this juncture. Forensische Sozialtherapie is still the main title of the book, and Erfahrungen in Diiren (Experiences in Duren) is the sub-title in small print. What makes the book worth reading, and in fact mandatory reading for those who contemplate therapeutic regimens in prisons, are the accounts of the experiences in Diiren for which the concept of social therapy only provides the structural frame.

TREATMENT OF PRIMITIVE MENTAL STATES By Peter Giovacchini. New York: Jason Aronson Press, 1979, xi + 536 pp.

Reviewer; Frank Summers, Assistant Professor, Department of Psychiatry and Behavioral Sciences, Northwestern University Medical School, Chicago, U.S.A.

Contemporary psychiatry has become increasingly attracted to biological con- ceptions of and treatment for major mental disorders. When psychotherapeutic interventions are considered, supportive approaches in conjunction with medication are most commonly recommended. Growing as these trends are, a few intrepid clinicians have not wavered from the view that severely emotional- ly disordered patients can use, and ought to have, psychoanalytic treatment. Foremost among these is Dr. Peter Giovacchini, who for many years has taken an often lonely stand in favor of the efficacy of psychoanalysis for such pa- tients. This stance is in stark opposition to not only the biological movement in psychiatry, but also the dominant trend in psychoanalytic concepts of treatability, according to which psychoanalysis is best suited for the “healthier”

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patient who can withstand the strong regressive pull of the analytic setting. Dr. Giovacchini may be said to be in the forefront of a recent tendency

among some psychoanalytic thinkers to extend the analytic process to characterological difficulties. Indeed, the past decade has seen an increasing number of analytic theorists, such as Drs. Otto Kernberg and Dr. Heinz Kohut, move toward the view that psychoanalysis can be profitably employed with characterologically defective individuals as well as neurotic conditions. Often lost in the encomiums with which this work has at times been received have been the pioneering efforts of Dr. Giovacchini.

Giovacchini’s work as a whole presents interesting and difficult challenges to entrenched assumptions of both biological psychiatry and psychoanalysis. While not contending that ail patients are treatable psychoanalytically, Giovac- cini refuses to assume apriori that any patient is not analyzable and makes the bold claim that many characterologically defective and even some psychotic in- dividuals who appear to lack the motivation, “ego strength,” and introspective capacity for “insight” therapy not only can be successfully psychoanalyzed, but also may require the psychoanalytic setting as a necessary condition for their improvement.

This view, substantiated although not proved in Dr. Giovacchini’s most re- cent book, raises critical issues not only for therapeutic work, but also for a broad range of legal, ethical, social, and public policy questions. To take one example: the community mental health movement is based on the claim that medication in conjunction with other forms of diluted intervention, such as group approaches, support, or skill-building, is the treatment of choice for the post-hospitalized patient. However, if Dr. Giovacchini’s claim is accepted that only the psychoanalytic setting provides the proper environment in which such patients can experience personality growth, then the treatment provided by many public facilities might be viewed as an efficacious maneuver to withhold public resources, rather than the provision of optimal treatment. This possibili- ty raises an ethical and legal issue for public health. If it is neither legal nor ethical for a public hospital to refuse the treatment of choice for a physical ill- ness, is such a policy defensible for emotional disorders? This is the type of public policy question which is both stimulated by Giovacchini’s work and sets the context for its evaluation.

In his most recent book, Giovacchini provides a comprehensive concep- tualization of psychoanalytic treatment for a broad range of severe psychopathological conditions which are designated “primitive mental states.” Indeed, this book may be seen as the culmination of Giovacchini’s work in this area. Thoughts and ideas mentioned or sketched out in the previous books have been brought together in more integrated fashion in the present work. This volume may be said to make major contributions to theory in psychopathology and nosology as well as psychoanalytic technique. Insights in both areas abound throughout the text.

Dr. Giovacchini provides a comprehensive schema for the division of character problems into five categories: schizoid (the hopeless patient), borderline (the helpless patient), character and narcissistic (the alienated pa- tient); affective (the miserable patient); and psychotic (the delusional patient). He undertakes a theoretical analysis of each type of disorder which concludes

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with a formulation regarding its essential psychopathology. Giovacchini pro- vides ample clinical material to illustrate each disorder, focusing on a single pa- tient to represent each condition. The discussions of the case material, however, go beyond the illustration of. theory; in themselves, they also provide keen in- sights into the nature of the psychoanalytic process. These insights, elaborated in the book’s concluding chapter into a rich and detailed analysis of treatment techniques, are Giovacchini’s most controversial notions and may ultimately prove to be his most unique and lasting contribution.

Central to Giovacchini’s approach is his concept of a “pre-mentational” phase of development prior to the stage of primary narcissism. The latter is the phase of infancy in which the infant shows no recognition of the outside world, directs all its energies toward itself, and appears to exist in a state of blissful isolation in which no awareness of external sources of gratification or frustra- tion exists. Giovacchini points out that the pre-narcissistic state is pre- mentational, a purely physiological state of needs and their gratification or frustration, without corresponding psychological registration. The infant is simply too disorganized and primitive for mentational phenomena. Conse- quently, although traumata at this time may have profound psychological con- sequences, they cannot be experienced as such by the infant. This point is not an arcane, academic matter lost in the refinement of psychoanalytic theory, but rather the turning point upon which much of Giovacchini’s theory of technique rests. The concept of “pre-mentational” phase also allows Giovacchini to main- tain his developmental perspective without being guilty of “adultomorphism,” an error he sees in the work of other analytic theorists, such as Kohut and Melanie Klein.

If the most primitive psychopathology originates in the pre-mentational state, its treatment need not consist solely in the recall of traumatic memories, nor can the verbalized mental states of such patients alone be presumed to repeat the early traumatic state. Given these conditions, how is psychoanalytic treatment possible? Giovacchini’s answer to this question goes to the heart of his views on treatment and includes an expanded view of the therapeutic poten- tial of the psychoanalytic process. Rather than focusing exclusively on the un- covering of verbal memories, the psychoanalysis of such patients allows the pa- tient to repeat the early, nonremembered trauma. The analyst, by understand- ing rather than colluding in, the repetition makes possible the mastery of such trauma in a new relationship. The task of the analyst is to understand, allow, and contain this process, but not necessarily to interpret it. The very process of psychoanalysis, rather than the content of particular interpretations, is the primary therapeutic factor.

One of Giovacchini’s most valuable contributions to the theory of psychoanalytic technique is his concept of the “analytic introject.” By this term, Giovacchini refers to the patient’s adoption of the analyst’s calm, understand- ing, and neutral attitude toward the patient’s psychopathology. The maintenance of a consistent analytic stance, that is, that all the patient’s therapeutic material is welcomed and understandable, never feared as alien, strange, or “crazy,” in itself has therapeutic value, for the patient will eventual- ly begin to take this attitude toward his/her own conflicts. Not only is this at- titude in itself comforting, but also this way of viewing himself/herself already

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implies a change in the patient’s self-representation and ways of handling his own problems. If such an attitude is maintained, the possibility exists for pa- tients to begin to view the source of their anxiety as an understandable compo- nent of their own very human process, rather than an alien terror which must be avoided or suppressed. Thus, at the points in treatment when many clinicians would utilize “extra-analytic” methods, such as reassurance, advice, or medica- tion, Giovachini would insist that the analytic process is most necessary.

This treatment approach has important implications for countertransference. According to the mainstream of psychoanalytic theory, countertransference refers to the difficulties of the therapist, stemming from his/her own background, in handling patient material. Consequently, countertransference reactions are to be understood, controlled, and removed from the treatment situation. Giovacchini contends that such a view eliminates a critical source of understanding of any patient, and especially of the more primitive mental states. Since severely disturbed individuals suffer from preverbal infantile trauma, their most accessible means of communication of these phenomena in psychoanalysis is often to make the analyst feel their early conflicts. The analyst’s emotional reactions are often the most important source of understanding of primitive mental states, and it is the analyst’s responsibility not only to be aware of his/her reactions, but also to examine them for what they reflect about the patient, and often to relate them to the patient to further the analytic process.

Beyond the use of the countertransference, Giovacchini advocates respond- ing to patient’s needs for non-interpretive interventions at certain points in treatment. Giovacchini, in this book perhaps more than any other, challenges the traditional boundaries of the psychoanalytic process. Rather than defining psychoanalysis as the maintenance of a particular technical stance, he appears to be arguing for an expansion of psychoanalysis with the severely disturbed pa- tient to include non-interpretive interventions at particular points in treatment.

But at what points? Here, I believe, one arrives at the limit of Giovacchini’s work up to the present. He has not yet offered criteria for the use of either type of extra-interpretive intervention. Yet such criteria are crucial. Without them, Giovacchini’s advocated extensions of the analytic method are in danger of sanctioning analytic license. Clearly, Giovacchini has no such intention. Nonetheless, until this innovative and challenging author can offer criteria for the points in treatment when the analyst can and cannot proceed extra- interpretively, the charge of “wild analysis” can be made. It is true that Dr. Giovacchini does suggest certain criteria for non-interpretive intervention: the initiative must be from the patient and the analyst must feel the desire to re- spond. Nonetheless, these criteria can easily be seen as inadequate. Clearly, the analyst should not express every feeling or thought which occurs to him/her during the course of treatment. But, when is such expression permissible or desirable, and when would it be an interference with the analytic processs? This is the question to which Giovacchini must still provide an answer.

Furthermore, one wonders how the advocacy of extra-interpretive interven- tion is consistent with the sanctity of the analytic attitude, the maintenance of which is so crucial to Giovacchini’s theory of treatment. Clearly, these in-

teresting and useful ideas further refinement.

Giovacchini also makes

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regarding the expansion of psychoanalysis beg for

significant contributions by elucidating certain uni- que treatment situations in which the analyst of the severely disturbed patient inevitably finds himself/herself. In this work, as in others, Giovacchini distinguishes himself from other commentators on the psychoanalysis of primitive mental states by formulating particular types of patient-analyst in- teraction which distinguish the analytic treatment of such patients from the psychoanalysis of neurotic conditions. An illustration of this is the “therapeutic paradox.” At times, patients will have to behave in ways that are in conflict with the analytic process itself. Rather than draw the conlusion that such a pa- tient is not analyzable, Giovacchini stresses the importance of the analyst’s understanding of both the patient’s need to involve him/her in the paradox and the analyst’s reaction to it as the critical component of the therapeutic process, and the issue which must be addressed in treatment. Giovacchini’s message seems to be that if the analyst is willing to maintain an observational stance, scrutinize his own affective reactions to primitive material, and understand these reactions as part of the analytic process which the patient needs to pro- duce, the fruits of their efforts will be borne by the people who need them most.

If Giovacchini is right, critical questions for public policy are inevitably raised. Can the public sector which bears the burden for the treatment of most primitive psychopathology afford the lengthy, intensive treatment involved in the psychoanalytic process? If not, can compromises with optimal treatment be justified legally and ethically? Are such justifications merely rationalizations for economically-motivated treatment decisions? Conversely, can the public realistically be expected to bear the economic burden of costly treatment for primitive mental states? However these questions may be addressed in public policy debates, Giovacchini’s work suggests that such debates should not con- fuse good treatment with good economics.

THE REGULATION OF PSYCHOTHERAPISTS By Daniel B. Hogan. Cambridge, Mass.: Ballinger, 1979. Vol. 1: A Study in the Philosophy and Practice of Professional Regulation, pp. xxiv -t 431; Vol. 2: A Handbook of State Licensing Laws, pp. xxvi + 519; Vol. 3: A Review of Malpractice Suits in the United States, pp. xx i- 442; Vol. 4: A Resource Bibliography, pp. xxii + 181.

Reviewer: Leonard L. Riskin, Professor of Law, University of Houston, Col- lege of Law, Houston, Texas, U.S.A.

Some American lawyers writing on the regulation of psychotherapy have con- centrated on the role of malpractice law. After laying bare its weaknesses, they have sought to reinforce. restructure or reconceptualize the civil action.’ In his

‘E.g., Furrow, Defective Medical Treatment: A Proposal for the Application of Strict Liability to Psy- chiatric Services, 58 B.U.L. REV. 391, 434 (1978); Riskin, Sexual Relations Between Psychotherapists and