Journal of Psychiatric and Mental Health Nursing, 2001, 8, 373–378

© 2001 Blackwell Science Ltd 373

with constructing a model for understanding

dementia based on psychological ideas. Part three

shows how such a person-focused approach could

be applied to services for people with dementia.

Part four establishes an agenda for change and the

future for dementia care.

Part one employs a historical approach to bring

to life contentious concerns, such as the creation

and recreation of Alzheimer’s disease as a psychi-

atric disorder and the research funding this

attracted determining the caring attitude. The

historical understanding of dementia is brought to

life via a case study by Dr Alois Alzheimer of

Frau Auguste D. The essential thrust of this section

argues that the organic disease model has been

accepted, wrongly, as the principle paradigm for

explanation, leaving no room for other perspec-

tives. For Cheston and Bender, such an over reliance

on the diseased brain explanation has set the ther-

apeutic boundaries of work with this client group

too narrowly. For example, to achieve a diagnosis

of dementia, all physical explanations are excluded

and what cannot be accounted for or explained is

termed dementia.

To add credence to such a perspective, sweeping

generalizations are made to imply that services

are generally poor for dementia sufferers across

the United Kingdom. This to the reviewers is not

factual. There are an increasing number of excel-

lent services where the fundamental work of

Kitwood has been utilized, built upon, and cus-

tomized to meet local needs. Dementia care has

moved forward. There are areas where person-

centred care forms a foundation for practice, where

quality is measured in terms of well–ill being and

where services are delivered by a professional

multidisciplinary team who are both person and

disease focused.

Parts two and three of the book provide the

reader with a variety of alternative explanations

and psychological models for understanding

dementia, from a person-focused approach. This is

Understanding Dementia

R. Cheston & M. Bender Jessica Kingsley Publishers, London1999, 240 pages, £16.95ISBN: 185302 479

First impressions

As a clinician and an educationalist with deep inter-

est in dementia care, it is heartening to see how far

we have come in the last 12 years in understanding

the lived experience of those with dementia. Let

us remember that it was as recently as 1988 that

people with Alzheimer’s were referred to as ‘the

living dead’ (Miller 1988).

Cheston and Bender in this work continue the

important task of developing ways of knowing of

the personal experience of dementia. Taking us

further back from the brink when we actually con-

templated denying the psychological existence of

those with dementia with the ever-present potential

to deny them physically.

The whole tenor of the book emphasizes the sub-

jective experience and personhood of the dementia

sufferer rather than just preoccupation with the

needs of caregivers, both familial and professional.

More meaningful emphasis on the person with

dementia is discussed, rather than focusing on those

around them. After reading the chapter on thera-

peutic interventions we were excited to see that

seminal work of Kitwood (1997) has been devel-

oped further to make use of other psychological

theories. For example, Bowlby’s (1988) attachment

theories.

Structure of the book

The book is divided into four parts, which help the

reader to first understand how the organic model

has become the current dominant explanation for

the progression of dementia. Part two is concerned

Book reviewsEditor:Professor Philip Burnard

Submissions address:School of Nursing and Midwifery Studies, University of Wales College of Medicine, Heath Park, Cardiff CF14 4XN, Wales, UK

not to say that Cheston and Bender shun the

organic perspective, they merely attempt to help us

acknowledge the wider picture. The move is one

from no cure, therefore no point, to actively seeking

to understand and offer help and most of all hope

to those with dementia. Within part three, attach-

ment theory (Bowlby 1988), generally associated

with childhood behaviour, is illustrated and applied

to dementia sufferers. The reader is helped to

understand that the fearfully strange and confusing

consequences of dementia can activate deep fears

and trigger unconscious defence mechanisms,

resulting in the portrayal of attachment behaviour,

often clinically displayed as parent fixation. We

expect that readers will identify with the clear

scenarios presented regarding respite care, and its

sometimes dire, consequences. The reviewers con-

sider these inclusions, among many others, as prac-

tically helpful considerations that enable a deeper

understanding of the subjective experience of the

person with dementia.

Service implications in relation to increasing

emotional security and maintaining self-worth and

a sense of identity are examined and examples are

given of the types of therapeutic interventions and

evaluations that could be effective. These include

developing dementia care mapping, listening skills,

knowledge of attachment needs, and viewing the

impact of care from the person with dementia’s

viewpoint.

In concluding the book, part four presents a

gloomy picture and a ‘restless farewell’. Readers

are forced to come to terms with the fact that

unless they, or people the authors refer to as the

‘young–old’, convince those in positions of power

that services are not adequate, then all is lost. The

suggestion is made that inadequacies in service pro-

vision have to be shouted about loud and clear or

the homes and facilities we visit as professionals

today may be the ones we spend our retirement

living in tomorrow. The authors suggest that change

from within organizations is well meaning but not

nearly enough. It is not therapy or magic that is

needed, but money and resources. For this to occur

the needs of the elderly require a boost up the pri-

orities on the political agenda if truly individualized

person-centred care is to be realized and delivered.

Conclusion

After reviewing the book, despite our reservations,

we are still of the opinion that this is an important

text which will be practically useful to all those

engaged in dementia care from students to qualified

nursing staff. We strongly recommend it as a source

book for dementia care teams.

References

Bowlby J. (1988) A Secure Base: Clinical Applications ofAttachment Theory. Routledge, London.

Kitwood T. (1997) Dementia Reconsidered: The PersonComes First. Open University Press, Buckingham.

Miller J. (1988) Life File, BBC Television (Midlands),

Audio Transcript.

GRACE SANSOM1 & MIC RAFFERTY2

1Senior Nurse for Quality & Development forSwansea NHS Trust

2Programme Manager for Clinical DevelopmentsSchool of Health Science

University of WalesSwansea

UK

Treating Complex Cases: the CognitiveBehavioural Therapy Approach

N. Tarrier, A. Wells & G. Haddock (eds)John Wiley & Sons, London1999 ISBN: 0-471-97839-6 (Pbk)

This book is edited by three clinical psychologists,

two of whom (Tarrier and Haddock) have been

associated with the Thorn Programme at the

University of Manchester. The editors have

managed to bring together some of the leading

experts in cognitive behaviour therapy from around

the world and the 17 chapters cover the spectrum

from social phobia and agoraphobia to issues in

treating rape and sexual assault and the manage-

ment of parasuicide.

As the editors point out, the practice and

application of cognitive therapy has expanded

enormously over the past decade or so and the core

categories of phobia and obsession, once targeted

by nurse therapists, have grown to include not only

depression and general anxiety, but a wide range

of other clinical problems and the phenomena of

aggression and violence and sexual assault. The

editors have specifically targeted the management

of complex cases which, in their own words, do not

Book reviews

374 © 2001 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 8, 373–378

fit comfortably into simple case conceptualizations

or diagnostic categories. They have attempted, with

varying success in the chapters, to examine the

management of comorbidity, unremitting chronic-

ity and the admixture of social problems and

psychosis which bedevil simple mental health

interventions.

From the point of view of the clinician, the

chapters provide a great deal of very practical

information which will certainly assist with the

management of complex cases. All of the chapters

without exception, are well written and authorita-

tive, but I found several which stood out. Kevin

Howells provides the chapter on anger, aggression

and violence and highlights that this is a neglected

area within therapy research. His overview of

topics which should be assessed, is invaluable. Gary

Sidley wrote the chapter on parasuicide and pro-

vided both an authoritative overview of the litera-

ture and two very useful case studies. As might

be expected, Haddock and Tarrier contributed an

excellent chapter on the assessment and formula-

tion processes in the treatment of psychosis. I shall

certainly ensure that the students on our psycho-

social interventions programmes read and digest

this most valuable contribution. Finally, I must pay

tribute to Paul Gilbert, whose chapter on shame

and humiliation provided me with a new perspec-

tive on these issues which underpin many types of

psychological difficulties. Gilbert writes, not only

as a very respected academic figure in cognitive

therapy, but also as a clinician with enormous

insight into some of the underlying processes one

sees in therapist/patient relationships.

I really have two areas of concern about this text.

The first concerns the contribution of behavioural

techniques. In my view, the book underplays the

significance of behavioural procedures. I am

of the firm opinion that some of the chapters

go beyond the evidence base, to be in my view,

overly optimistic about the efficacy of the cognitive

approaches. In some ways, I believe cognitive

therapy has become one of the new religions with

cult followers who have ceased to be objective. One

needs to remind one’s self that although the evi-

dence base for cognitive behaviour therapy in psy-

chosis is promising, the Cochrane review published

in 1998, contained only four randomized trials.

Indeed, I think it is worth adding that a recent 5-

year follow-up of a randomized trial of cognitive

therapy in acute psychosis (Drury et al. 2000)

demonstrated that there was no overall long-term

benefit for cognitive therapy in a cohort of patients

with schizophrenia followed-up for 5 years. The

authors did report that a subgroup analysis found

some benefit in patients who had no relapse or only

one relapse over the follow-up period. However,

this was a post hoc analysis and I certainly had the

feeling when I read this paper that the authors were

desperately trying to retrieve something positive.

With regard to the neglected area of behavioural

interventions per se, I think that the book overall

failed to convey that it is quite difficult to separate

out the effects of behavioural interventions from the

cognitive therapy additions. In two areas at least,

i.e. obsessive compulsive disorder and severe ago-

raphobic avoidance, I believe there is, as yet, no real

evidence to suggest that cognitive therapy adds to

the efficacy of comprehensive behavioural manage-

ment. Some of the cognitive approaches described

in the book clearly have promise, but no real data

to attest to efficacy. My second and perhaps most

important point concerns an area that I have

covered in other reviews and articles, i.e. the capac-

ity of trained cognitive behaviour therapists to

deliver treatment. At the present time, there are

a few hundred, or at most a thousand or so in-

dividuals who have received higher level cognitive

behaviour therapy training. At the same time,

there are literally millions of people in the United

Kingdom who have disorders known to be respon-

sive to such approaches. With the best will in the

world, we can only target small numbers of patients

and we need to consider where we place our finite

resources. Jan Scott’s excellent chapter on cognitive

therapy for people with chronic depressive dis-

orders, I think spells out the difficulty. She describes

a case example ‘Edith’ and her 28 treatment ses-

sions with continuing follow-up, which included

four booster sessions per year over a 3-year period.

How many patients with depression will be able

to access such treatment? Furthermore, should we

be giving precious cognitive behaviour therapy

resources to populations which have very high rates

of spontaneous remission, such as anxiety and

depression or should we be confining our activities

to populations where spontaneous remission is rare

and where evidence for efficacy is very strong.

In conclusion, this book is a worthwhile read and

all experienced cognitive behavioural practitioners

will benefit from some, if not all, of the chapters.

Nevertheless, as my comments above suggest, the

purchaser of this book should also obtain the

proverbial pinch of salt!

© 2001 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 8, 373–378 375

Book reviews

Reference

Drury V., Birchwood M. & Cochrane R. (2000) Cogni-

tive therapy and recovery from acute psychosis: a con-

trolled trial 3. Five year follow-up. British Journal ofPsychiatry 177, 8–14.

KEVIN GOURNAYInstitute of Psychiatry

De Crespigny ParkDenmark Hill

London SE5 8AF

UK

Forensic Nursing and MultidisciplinaryCare of the Mentally DisorderedOffender

David Robinson and Alyson KettlesJessica Kingsley Publishers, London, Philadelphia2000ISBN: 1–85302–754–5

Given the nature of the limited availability in liter-

ature review with regard to forensic nursing, this

book is unique in attempting to examine the role

of the professional forensic nurse and explore

the multi-professional boundaries within mental

health. Its contents provide an insight into the

cross-cultural thinking and the complexities and

conflict of the forensic nurse. It attempts to define

this complex role within mainstream psychiatric

nursing and puts forward strong arguments that

forensic nurses require different and advanced

nursing skills. There is a national and international

flavour to the book and it would therefore be of

value to nurses, psychologists, psychiatrists and

health care practitioners, and also prison nurses,

the police, and probationists.

Chapter 1 examines the definition of forensic

nursing, and questions whether forensic nursing is

nursing at all. It also examined the relationship

between health professionals and the criminal

justice system. Chapter 2 is of particular impor-

tance to nurses working within the field of forensic

nursing. The authors query the role of the for-

ensic nurse and ask whether such a person as a

forensic nurse exists. The current thinking by con-

temporary nurses is that forensic nursing is still

viewed as an elitist subspecialism of mental health

nursing. Mike Collins, from the Rampton Hospital

Authority, provides an insight into the detailed

practice and policies in caring for the mentally dis-

ordered offenders. He highlights the lack of pre-reg-

istration education in preparing nurses to work in

the field of forensic nursing. He strongly advises the

inclusion of clinical competencies within mental

health nursing curriculum.

Readers would find Chapter 5, on the role of the

forensic nurses in the community, of great value.

Phil Woods, from the University of Manchester,

makes a brave attempt to unlock the conflicting role

of the forensic nurses working within a community

multidisciplinary setting. Chapters 6 and 7 offer

valuable information from a psychiatrist’s perspec-

tive on the contribution of forensic nurses in caring

for the mentally disordered offenders.

Social workers working in the field of forensic

medicine would find Chapter 8 of interest. It high-

lights some of the administrative wrangle between

local authorities, and also the value that inter-

professional education could have in providing a

collaborative approach to caring for the mentally

disordered offenders.

John Swinton, from the University of Aberdeen,

provides a spiritual perspective on forensic nursing.

He provides convincing evidence towards the thera-

peutic benefits of spirituality for mental health. He

advocates the inclusion of spirituality within the

theory and practice of forensic nursing. Swinton

and Boyd provide an insight into the complexities

of ethical practices within forensic nursing

(Chapter 10).

The role of the forensic nurse in clinical supervi-

sion is discussed in Chapter 11. Mary Addo claims

there is no finer model of clinical supervision, but

states that it is possible to move between different

modes at any one time. Heron’s Six-Category

Intervention Analysis is advocated. Gournay and

Carsom, from the Institute of Psychiatry, examine

stress in the forensic environment. The Special Hos-

pital’s Nursing Staff Stress Survey, undertaken by

the two authors, provides a better understanding of

stress in forensic nurses.

Chapters 13–18 are of special interest to nurses

who wish to develop a better understanding of

cross-cultural thinking within the realm of forensic

nursing. The role of forensic nurses in countries

such as Netherlands, Australia, Canada, USA,

Norway and Germany are examined in great depth.

It highlights many dilemmas and challenges facing

Book reviews

376 © 2001 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 8, 373–378

nurses in these countries. The key question remains

– there is no clear definition of forensic nurses.

Many questions have yet to be answered regarding

what all forensic nurses should know. The debate

between forensic psychiatric nursing as a speciality

area of nursing vs. general mental health nursing

continues. There appears to be a cry for a national

policy involving a statement of principles and goals

with regard to the role of forensic nurses.

Using empirical data, the contributors within the

book have provided a strong platform in promot-

ing a better understanding of Forensic Nursing,

both nationally and internationally. The issues

of training and multi-professional collaboration

remains central to the care for the mentally disor-

dered offenders. This book is highly recommended

to all health care practitioners involved in the field

of forensic medicine.

DAVE GUKHOOLAssistant Director, Mental Health

School of Nursing and Midwifery StudiesUniversity of Wales College of Medicine

Caerleon Education CentreGrounds of St Cadoc’s Hospital

CaerleonNewport

NP18 3XRUK

Spirituality, Healing and Medicine.Return to the Silence

David AldridgeJessica Kingsley, London, Philadelphia2000, 240 pages, £14.95ISBN: 1-85302-554-2

This book is the third of three related titles, the first

of which is about music therapy in the art of

medicine, the second concerning suicide. This third

book can be described as a synthesis. It is an exis-

tential account of what it is to perform health, how

that performed health is dependent upon a variety

of negotiated meanings and how these meanings are

transcended. In this book the author challenges the

reader to engage in talking about spirituality in a

culture of health care delivery. David Aldridge

presents the first unified approach to the subject.

The literature is evaluated across the disciplines

to ascertain just how effective and influential

spiritual healing may be on the patients’ physical

and psychological well-being.

The second chapter offers a series of explanations

regarding spirituality. Seeing it as being of the indi-

vidual, ineffable and implicit. The third chapter

offers a series of definitions on religion. Seeing it as

being about the social, spoken and explicit. The

overlap between religion and spirituality is then

explored.

Chapter four takes its material from incidents in

everyday life and is entitled ‘Lifestyle, charismatic

ideology and a praxis aesthetic’. The incidents indi-

cate the difficulties that we face when we talk about

health and the practices that are used to main-

tain and promote such health. This chapter also

explores various definitions of health and the

definers of health.

The next chapter is concerned with the body and

how the pursuit of pleasure can become an activity

that is far from pleasurable and uses the example

of alcohol-related disorders as a major health care

problem throughout the rest of the chapter.

In the chapter that follows, the author looks at

the area of prayer and healing. There is an explo-

ration of the forms of prayer and their content,

definitions of prayer, spiritual healing research in

the medical setting, prayer in medicine.

The last chapter is entitled ‘Pluralism and treat-

ment, healing initiatives and authority’. As the

words used for describing differing forms of healing

are based on varying traditions and have differing

meanings, this chapter looks at healing today and

explores the differences between health practi-

tioners, modern spiritual healers and traditional

shamans.

This book lacks a concrete conclusion and is

quite difficult to read for the lay person who merely

has an interest in the subject. A wide range of dis-

ciplines is covered, including medicine, anthropol-

ogy, psychology and sociology. I would recommend

that this book be suitable for those with a special-

ist interest whose work cuts across these disciplines.

DEBORAH EDWARDSUniversity of Wales College of Medicine

School of Nursing and Midwifery StudiesHeath Park

CardiffCF14 4XN

UK

© 2001 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 8, 373–378 377

Book reviews

Childhood Disorders (ClinicalPsychology: a Modular Course)

P. C. KendallPsychology Press, Hove2000, 229 pages, £11.95ISBN: 0-86377-609-4

This textbook forms part of a series of volumes

entitled Clinical Psychology: a Modular Course.Although it is stated in the book that it aims to

provide an accessible introduction to the field for

both students and professionals, it is not clear

precisely which professional groups are the target

audience.

The introductory chapter deals with models of

childhood mental ill health, although this is fairly

superficial. An exploration of the whole range of

mental health problems of childhood is then offered

in successive chapters. Information is offered on the

causes, presentation and treatment of the various

forms of mental health problems in childhood.

Little vignettes are used to introduce applied

aspects of theoretical ideas by presenting scenarios

of children with a range of mental health issues.

This helps to make the material feel more immedi-

ate and human. These case studies are a good way

of illustrating the global effects of mental health

problems in childhood not only for the child but

also for the wider family and community. The

potentially pervasive effects of mental health

problems on the child’s life and experience of life

are clearly shown.

Treatment modalities tend to be under-

emphasized, details on management tend to be

sketchy. However, this book does provide a useful

overview and discussion of a range of research in

this field. The style of writing is clear and fluent

and the text has a comprehensive index.

Overall, this text will probably be of interest to

the nonspecialist child or mental health care

worker. However, I would imagine that the spe-

cialist child and adolescent mental health care

worker will seek more detailed information and

discussion than is to be found in this book.

JIM RICHARDSONUniversity of Glamorgan

GlamorganUK

Researching Children’s Perspectives

A. Lewis & G. LindsayOpen University Press, Buckingham2000, 239 pages, £16.99ISBN: 0-335-20279-9

This edited volume has been written by a wide

range of contributors, although the majority are

teachers or experts in education. The Editors note

that they have attempted to produce a multidisci-

plinary approach to the investigation of children’s

perceptions and experiences. This would obviously

mirror current thinking on best practice in those

services aimed at children and their families.

The book is broadly divided into three sections:

theoretical and conceptual issues, practical applica-

tions and an overview. Within these sections a rich

diversity of topics is examined and discussed.

The emphasis throughout this book is placed on

new and innovative approaches to the complex and

challenging field of researching with children. There

is a clear acknowledgement of the specific issues

in relation to researching the lives of children of

differing ages, backgrounds, characteristics and

needs.

It is pleasing to note that a particular focus is

placed on the rights of children as a core and crucial

factor in researching children’s perspectives. An

interesting discussion of the legal and ethical

requirements of working as a researcher with

children is presented.

The text is well referenced and contains a useful

concise index. A range of appendices offers rele-

vant, interesting materials such as issues to consider

when interviewing young people with moderate

learning difficulties.

This is an absorbing and stimulating text. It

offers insights which may be useful in leading all

those who work with children and their families

to reappraise aspects of their practice. Although

intended as a multidisciplinary venture, a health

care perspective is missing. This does not neces-

sarily detract from this book, but rather indicates

an area for future development.

JIM RICHARDSONUniversity of Glamorgan

GlamorganUK

Book reviews

378 © 2001 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 8, 373–378