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On Apologyby Aaron Lazare. New York, Oxford University Press, 2004, 320 pp.,
$24.00.

Article  in  American Journal of Psychiatry · April 2007

DOI: 10.1176/ajp.2007.164.4.685

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 Book Forum
On Apology, by Aaron Lazare. New York, Oxford University
Press, 2004, 320 pp., $24.00.
What a pleasure to read a book by a prominent psychiatrist
that bubbles with wisdom. Aaron Lazare, M.D., Chancellor
and Dean and Professor of Psychiatry at the University of
Massachusetts Medical School, previously gifted the field
with seminal research on the “negotiated encounter” be-
tween clinicians and patients. In part as an extension of that
work—in this erudite, edifying and deeply satisfying vol-
ume—he now focuses on processes of apology as key transac-
tions in human affairs. Beginning with the observation that
articles about apologies in popular media have more than
doubled in the past decade, he identifies several contempo-
rary factors contributing to this increase. One such factor be-
ing that apologies are necessary as the world flattens to help
diverse individuals and groups get along if they are to work to-
gether successfully. And thanks to the ubiquity of media, vir-
tually every cell phone is now a video camera, so that poten-
tially embarrassing and offending acts that were previously
private have suddenly become public. Perhaps there is now
more out and about to apologize for.
In select subcultures, cultures, and alpha-male-dominated
social classes, the idea of having to apologize has sometimes
been abhorrent, indeed shamefully dishonorable, leading cer-
tain prominent historical figures to publicly condemn the idea
of apologizing, regardless of the offense. But times are chang-
ing. Now, given the groundswell in acts of apology and advo-
cates for apologizing in certain prominent and very public
subgroups, we may be witnessing a deep shift in cultural val-
ues and behavioral norms. Lazare’s take is that the art of apol-
ogy, always important in human conduct, is likely to become
even more important to assure future social harmony among
individuals, groups, nations, and transnational aggregations.
Having established this premise, Lazare formulates his anal-
yses based on more than 1,000 acts of apology, from episodes
in his personal and family life, clinical practice, and demanding
administrative positions in complex organizations to publicly
documented apologies in today’s media and historical and reli-
gious sources. He is both a scholar and a skilled practitioner.
First, he carefully deconstructs virtually every aspect of these
transactions—linguistic, developmental, intrapsychic, inter-
personal, cultural, political, historical, philosophical, and reli-
gious. From these inquiries, he then fashions concise, largely
Am J Psychiatry 164:4, April 2007
face-valid, testable, theoretical models as well as field-tested
techniques for offering apologies and for mediating apologies
between offending and offended parties. Woven throughout
the book are valuable pointers on what constitutes genuine
and effective apologies and how this may be achieved.
The book focuses on what you might call “the offended-of-
fender relationship”: those intersubjective fields encompass-
ing key intrapsychic and interpersonal events that can con-
sume victims with humiliation, shame, guilt, and rage, and
sometimes perpetrators with humility, remorse, repentance,
and redemption. In the best possible humanistic scenarios,
these transactions can lead to genuine forgiveness. Within
this broad interactive space, numerous types of offenses ex-
ist—from thoughtless blunders to intentional violations, per-
sonal versus impersonal affronts, single acts versus ongoing
offenses, those causing trivial damages and slights versus un-
forgivable offenses such as intentional genocides.
Offended parties vary in sensitivity from self-blaming victims
to prickly grudge-seekers and grudge-holders. Similarly, offend-
ers and their apologies vary in important ways—from sincere,
heart-wrenching remorseful confessors to half-hearted, co-
erced, apologists; from private face-to-face acts of truly hum-
bling apologies to staged, indirect acts that reek of insincerity
(such as having an excuse-laden letter read to a news-confer-
ence by a spokesperson). And there are “apologias” that serve
more to justify offensive actions than to apologize for them.
Apologies may occur immediately or delayed in time, contribut-
ing to personal rituals of restoration as through steps 8 and 9 of
12-step programs or through national rituals of reconciliation as
in the post-Apartheid public political rituals in South Africa.
On the “offended” side of the equation, Lazare identifies
seven needs that offended persons and groups hope to satisfy
through apology to varying degrees. These include needs for
restoration of dignity, acknowledgment that the offender actu-
ally shares important core values held by the offended party
(such as respect for treating individuals with dignity), truthful
explanations as to why the offense was perpetrated, assurances
of future safety, exculpation from blame (i.e., assuring that the
offense was not somehow the offended party’s fault in the first
place), revenge and/or restitutive justice, and reparations.
On the “offender” side, motivations to apologize stem from
intrapsychic needs to alleviate guilt and shame in order to re-
store an inner sense of peace and/or from externally moti-
ajp.psychiatryonline.org 685
 BOOK FORUM
vated adaptive needs, such as the cost of doing business to
meet social expectations in order to move on, to preserve so-
cial harmony. Lazare’s insightful analyses of failed and uncon-
summated apologies show how these misguided stumbles
may leave the offended party feeling even more offended,
hopeless, and further enraged. In essence, this section offers a
helpful guide of what not to say and what not to do. He also
discusses why certain individuals and groups are unwilling
and/or unable to apologize.
Although this book transcends psychiatry per se, implicit
are hosts of clinically relevant questions that beg further
study. What accounts for the fact that males seemingly have a
harder time than females in apologizing? What temperamen-
tal and developmental factors related to pride, narcissism, ri-
gidity, sociopathy, and so forth contribute to the maladaptive
impairments of the prone-to-offend personality, the easily-
offended personality, and the incapable-of-apologizing per-
sonality? Given how important apology is in clinical situa-
tions, dispute resolutions, and legal transactions, should clin-
ical training in many human-service fields mandate core
competencies in how to apologize, in teaching others how to
apologize, and in mediating apologies? (Indeed, Lazare pro-
poses that an apology-oriented curriculum might benefit
“ethics” and “communications” education in high schools,
colleges, and religious schools.)
At the same time, you can’t read this book without reflect-
ing on numerous apologies waiting out there to be delivered,
from those involving your own interactions with family,
friends, patients, and colleagues to those involving larger hu-
man aggregations, up to and including nations and transna-
tional ethnic and religious groups. Lazare’s analyses bring
welcome clarity to offenses that constantly occur at each of
these interacting levels. He adds considerably to our under-
standing of what might be done and difficulties likely to be
encountered in efforts to resolve long-standing offenses rang-
ing from minor humiliations to truly horrendous ongoing
policies and activities.
A must read for clinicians of all stripes, the book will also
stimulate, provoke, and possibly change ways of doing busi-
ness for a much wider audience, virtually anyone engaged in
reciprocal relationships. When you read it, I have no doubt
that you’ll think of family members, friends, colleagues, and
public figures to whom you’d like to send gift copies, with cer-
tain sections underlined.
JOEL YAGER, M.D.
Albuquerque, N.M.
Individuals, Families, and the New Era of Genetics:
Biopsychosocial Perspectives, e d i t e d b y S u z a n n e M .
Miller, Ph.D., Susan H. McDaniel, Ph.D., John S. Rolland, M.D.,
and Suzanne L. Feetham, Ph.D., R.N., F.A.A.N. New York, W.W.
Norton & Co., 2006, 520 pp., $49.95.
One could describe the stage of biomedical progress that is
currently upon us as a genomic revolution: we have recently
completed the Human Genome Project; we are witnessing the
acceleration of the International HapMap project devoted to
elucidating common variations in the human genome; and
we are entering an exponential phase in our understanding of
the relationship between these genomic patterns and human
disease, disease susceptibility, and therapy. And there is no
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end in sight. This opens up extraordinary possibilities for pro-
tecting and restoring health, possibilities that were unimagin-
able even a few years ago.
This is heady stuff, but before we are swept away on a wave
of optimism, we should acknowledge that even as the pace of
progress in genomics accelerates, so also accelerates the gap
between our understanding of the genetic basis of disease
and our ability to use this understanding to actually improve
health. Genetic information as it is emerging has a different
structure than what we are used to. It is probabilistic, multi-
factorial, interactive, and has a long time axis. It is ramified. It
is complicated. Already we know how to use only a little of
what we know, and this problem is getting worse. Clinicians
are hard pressed to explain genetic information simply but
accurately. Patients sometimes respond in surprising and
counterintuitive ways. Families hardly know how to cope with
news that will fundamentally alter their lives 50 years hence
or that may (or may not) drastically affect them tomorrow.
Employers and insurers and law enforcement officials argue
for access to information that will help them do their work
better, over the objections of those whose privacy is thereby
violated. Thus, the genetic revolution contains within it both
the seeds of hope for dramatic improvements in health and a
growing sense of dread at the waves of unmanageable infor-
mation that complicate our lives and bring unexpected con-
sequences. As genetic information rapidly accumulates, one
can sense a growing hunger in the health care community for
an organizing framework that can tame this material, render-
ing it more useful and less dangerous.
This is psychiatry’s business for at least three reasons. First,
psychiatric disorders are proving to have as conspicuous a ge-
netic component as all other diseases, and psychiatry is thus
joined with all of medicine in having to come to terms with
this new reality. Second, psychiatry and the other mental
health professions have something uniquely valuable to offer
people who are coping with massive, overwhelming life
events, such as genetic news sometimes is. (Psychiatry has
something valuable to offer to the problems of genetic coun-
seling, even when the problems are not massive and over-
whelming.) Third, three decades of work undertaken within
the field of medical family therapy has led to the development
of theoretical models and clinical approaches that can be
adapted to even the most difficult and elusive problems in
medical genetics. Thus, this hoped-for organizing framework
could emerge from the world of mental health care.
Individuals, Families, and the New Era of Genetics: Biopsycho-
social Perspectives comes to us from four co-editors who work in
the worlds of psychiatry, medical family therapy, family medi-
cine, genetic counseling, and nursing. This book serves up just
about exactly what we need in order to deal with the flood of ge-
netic information pouring over the transom. More than any-
thing else it gives clinicians, educators, and researchers a way to
think about genetic information as it applies to people’s lives
and patients’ health. It succeeds beyond expectations.
This book takes on three tasks: it offers a theoretical struc-
ture into which clinicians can fit the issues that arise when
counseling individuals and families dealing with genetic
problems; it reviews and interprets the genetic dimension of
nine specific medical conditions; and it takes us through the
ethical, legal, policy, and professional issues associated with
genetic considerations.
Am J Psychiatry 164:4, April 2007