Psychotherapy

Work, Love, Play, Self Repair in the Psychoanalytic Dialogue

Work, Love, Play, Self Repair in the Psychoanalytic Dialogue

Joel Shor

New York, NY: Brunner/Mazel Publishers Inc., 212 pp., 1992

Dr. Shor has written a thought-provoking account of his humanistic approach to psychoanalytic therapy. Central to his method is a model of therapy aimed at providing a safe space, a playground which leaves the patient in charge of the pace and direction of treatment and facilitates the emergence of his or her innate potential for self-repair. The hypothesis underlying his view is that the individual’s desire to regain the lost illusions of “primary narcissism” (Freud) and “primary love” (Balint) of early infancy sets in motion powerful reparative wishes aimed at the self and the object. The therapeutic setting allows these wishes to be reactivated through “benign regressions,” allowing for the restructuring of the patient’s narcissism and object relationships. The author takes the controversial position that the benign authoritarianism of the classical tradition introduces iatrogenic treatment complications, impeding the creation of a playful, open-ended and generative dialogue between the patient and the analyst. Shor favors a responsive and unobtrusive analytic stance and eschews practices which he believes place the analyst in an authority position or interfere with the patient’s spontaneity: use of diagnostic categories, resistance analysis, introduction of the “basic rule,” emphasis on dream interpretation, etc.

Work, Love, Play is a mosaic of the author’s ideas, technical recommendations, unpublished writings, which are interwoven with a personal narrative that documents Shor’s association with influential mentors, the ideas gleaned from them, and the disillusion caused by the rift with them when he pursued uncongenial views. The author is a scholar and clinician who began his analytic training in the 40s with E. Kris and T. Reik and whose concerns drew him away from ego psychology and towards the work of Balint and Winnicott.

The book’s varied form makes reading difficult at times. The clinician may be most interested in the chapters which present a detailed account of his approach based on negotiation and dialogue. Dr. Shor’s attunement to the intersubjective and affective aspects of therapy shows through in these pages. This controversial book will be of interest to students of psychotherapy and psychoanalysis and to historians of psychoanalysis. My impression is that the author stretches his points too far. Examples are such statements as “the expression of transferences is thus in part a test of the therapeutic relationship,” and “the resisting patient…is demonstrating a healthy opposition to impositions.” While many clinicians recognize that certain groups of patients (narcissistic and borderline patients) display other than neurotic-type transferences, it remains that Freud based the specificity of psychoanalysis (what distinguishes it from other forms of psychotherapy) on the “facts of transference and resistance” (Freud 1914). Shor’s statements appear to reduce Freud’s “basic facts” to the status of artefacts.

Adaptation to Loss Through Short-Term Group Psychotherapy

Adaptation to Loss Through Short-Term Group Psychotherapy

William E. Piper, Mary McCallum, Hassan F. Azini

New York, NY: The Guilford Press, 219 pp, 1992

Adaptation to Loss is extremely useful at several levels, some of which are not outwardly evident from the title, and that is perhaps the book’s only significant shortcoming.

First and foremost, this book is a guide to treating pathological reactions to loss, either through death or divorce, among adults, using short term psychodynamic group psychotherapy. In that alone, the book succeeds. The direct clinical material is extremely helpful and is built on a careful and well-explained theoretical base. The authors’ summary of psychoanalytic theories of pathological grief is broadly applicable.

The greatest strength of the book, and the quality that sets it apart from most books that describe a psychotherapeutic approach to a problem, is the incorporation of the authors’ research findings. All three are well-known for their meticulous and valuable research into the process and outcome of psychotherapy. Adaptation to Loss describes an exemplary model of research and clinical integration, beginning with the theoretical base described above, progressing to the issue of selecting individuals likely to benefit (prescribing the therapy), followed by a description of the clinical work, and finally providing evidence of positive outcome for their approach. The evidence on outcome is in turn knit together with some interesting findings on the process of psychotherapy, and all are frankly discussed in terms of future directions as well as the authors’ understanding of the limitations of their project.

In summary, the book works as a useful and thorough guide to a clinical approach to an important problem, as a discussion of pathological grief in general, and uniquely, as a model of clinical and research integration. For the latter reason alone, it is a useful book for any readers interested in psychotherapy, regardless of their approach.

A DSM III-R Case Book of Treatment Selection

A DSM III-R Case Book of Treatment Selection

Samuel Perry, Alan Francis, John Clarkin

New York, NY: Brunner/ Mazel Publishers, 416 pp., 1990

In the introduction to this book John Talbot states “as the science of psychiatry progresses at such a rapid pace it is apparent that its art must advance just as quickly. With every development, the selection of the most perfect treatment becomes more complex but also more critical.”

Talbot goes on to state “too often patients receive the treatment known best to, or practised primarily by the first person they consult, rather then that from which they might best benefit.” These ideas resonate very much with the concerns of many academic psychiatrists in North America.

The authors of this book have attempted to offer some guidelines for appropriate and yet critical treatment selection. They have written a fine introductory chapter in which they describe how treatment needs to be planned, they also indicate their biases. Some of these biases are that treatment decisions are not based on disgnosis alone, but in order for patients to receive the best and most effective treatment their past history, life style, current situation and interaction with the therapist must be considered in order to provide properly individually tailored treatment.

They indicate that there are somewhere between 130-200 treatments available in psychiatry, and that perhaps psychiatrists can be categorized in three groups: specialists, eclectics and sceptics who believe that non-specific factors are most important. The authors examine the setting, format, time, approach, and the question of somatic treatments or no treatment as entering into all treatment decisions.

They state that the process of treatment selection is truly a matter that academic psychiatrists must examine more carefully. For instance people can decide on a medical model entirely. The authors state this is too simple. They state that diagnosis has been shown to have only slight correlation with treatment selection and outcome and give a reference in the Archives of General Psychiatry to back up this statement.

A preferable method of selecting treatments is to consider other aspects of the patient in addition to treatment. One must train our students and all mental health professionals to consider the presenting problem, character traits, premorbid personality, motivation, psychological-mindedness, socio-economic status, family situations and ego strength. The authors point out that patients have expectations of treatment and that this influences outcome. This finding has been shown in many trials particularly in the area of depression.

And finally as we might expect, the cases which are outlined in all DSM III-R categories are rich and exciting to read. Furthermore, cases under mood disorders, anxiety disorders and adjustment disorders provide the most provocative and interesting discussions as to why various forms of psychotherapy or pharmacotherapy or a combination of these modalities have been chosen. It has always been my view that these are the most exciting areas in psychiatry because they lead to bias in treatment selection and should, in sophisticated academic centers, lead to an opportunity to further our knowledge by enlightened and constructive intellectual debate.

The Art of Psychotherapy

The Art of Psychotherapy, Second Edition

Anthony Storr

New York, NY: Routledge, 208 pp, 1990

In the first edition of The Art of Psychotherapy, published in 1980, the renowned psychiatrist, psychotherapist and author Dr. Anthony Storr tackled the monumental task of writing a truly introductory book about dynamic psychotherapy that is both accessible and understandable. He succeeded at that task admirably and ten years later has published a second edition which is just as effective an introduction. The second edition has an updated section on the obsessional patient and an added chapter outlining some of the ideas that he explored in Solitude, published in 1988. As always, Dr. Storr’s writing is readable, easy to understand and thoughtful.

Most writing in the field of dynamic psychotherapy can be inaccessible to those struggling to come to grips with the field because of language and terminology that is highly technical and often largely theory-bound. Although this type of writing allows for precision, it can also frustrate the new psychotherapist, who is already facing the anxiety of learning a very new and different way of working with patients.

Dr. Storr is able, in his book, to strip away almost all the theory-bound concepts and terminology that create confusion and still preserve the core ideas that underlie the work and art of dynamic psychotherapy. His ideas are clearly formulated and presented, divorced as much as possible from theory without losing their strength.

Other writers, in attempting introductions to this field, have used the approach of sticking to one theoretical model in an attempt to simplify the issues. However, this can create dogmatism as a defence against the anxiety of not knowing “the answers.” Storr’s approach instead is to introduce the core ideas and introduce the idea that there is uncertainty in any attempt to understand people, encouraging an openness to question that parallels the therapeutic stance in psychotherapy. Indeed, in this book he attacks the rigid adherence to one psychotherapeutic school several times, a practice he predicted would fade even in his first edition, which was written over ten years ago.

Unfortunately, the one weakness of the book as an introductory text is closely if not inextricably bound to its very strength. His avoidance of technical terminology, particularly as it pertains to diagnostic systems in vogue, will create some barriers in the task of introducing psychotherapy to people who are new to the field. With no attempt to integrate the ideas expressed in the DSM or ICD diagnostic systems, which new therapists will already know, the book may reinforce the apparent artificial dichotomy between these areas of psychotherapy and biological psychiatry. It can be useful to move away from these diagnostic systems at times in psychotherapy to enhance the understanding of individuals, but may also create resistance and misunderstanding in some readers new to this area. In part because of this lack of integration, references to the pharma-cotherapy of depressed patients infer that such treatment is generally incomplete and may be harmful in the long run, not allowing for complete resolution of the underlying depressive ideas. This may create unnecessary resistance to his other ideas and may reinforce the apparent dichotomy between biological and dynamic psychiatry.

This book is nonetheless excellent and one of the best books to introduce mental health professionals to the field of dynamic psychotherapy. It could well form the core of an introductory text in this area. Its tendency to avoid overreliance on theory, and Dr. Storr’s brilliant distillation of the core concepts of psychotherapy are quite unmatched now as they were unique ten years ago.

Understanding and Treating Mental Illness

Understanding and Treating Mental Illness

John M. Cleghorn, M.D., Betty Lou Lee

Toronto: Hogrefe & Huber Publishers, 237 pp., 1991

This book emerges from the work of the Scientific Council of the Canadian Psychiatric Association, chaired by Dr. John Cleghorn, who with Betty Lou Lee has edited this excellent book.

The book is sub-titled “Understanding and Treating Mental Illness”; it is written to give an understanding of mental illness to those suffering from mental illness and for those interested members of the general public. It will be of particular value to the families of people who are unfortunate enough to have a member who is mentally ill.

Although, the book is a product of a committee, it has been superbly edited; it is very readable, indeed, I found it a pleasure to read.

It reviews all the major categories of mental illness, including chapters on personality disorders, addictions, Aids, sexual abuse, etc. After general discussion of each disorder it looks at causes, various treatment approaches, recent research where applicable, and ends with references to further information sources, including addresses of organizations associated with a specific condition.

This book should be read by all people involved with mental illness, and mental health in its broadest sense. It should be available in all hospitals, clinics and libraries.

I thoroughly enjoyed reading it, found it easy to read and sincerely hope that it will receive wide distribution. A book of this nature, which explains the strengths and limits of modern psychiatry, has long been needed.

Swimming Upstream: Teaching and Learning Psychotherapy in a Biological Era

Swimming Upstream: Teaching and Learning Psychotherapy in a Biological Era

Jerry M. Lewis

New York: Brunner/Mazel Publishers, 168 pp, 1991

This book is both a review and an update of the author’s seminal contributions to the psychotherapy education of psychiatrists. The title emphatically reflects what many of us who are committed to a certain vision of psychiatry feel as we attempt to educate the next generation of psychiatrists.

The literary style of Jerry Lewis is a marvelous combination of simple and direct language with highly self-revelatory content. His writing is at once very personal and very dignified. Compelling examples from his own experiences provide exquisite demonstrations of the method he proposes. Reading Lewis is more like listening to and being with a wise and close friend than just reading.

The book describes the seminar at the core of Lewis’ structured approach to psychotherapy education. Each chapter takes the reader through the content of the seminar with a clear outline of topic areas and elegantly simple concepts within each topic area.

For psychiatric educators who have found his approach useful and have modified it to fit their circumstances, this book is a pragmatic “state-of-the-process” message. We have neglected a component of values in our psychotherapy curriculum, and this book provides ideas on including relationship structure and family and marital function. For those who learned psychotherapy without the benefit of Lewis’ perspective, this book will be an exciting introduction to a new and better approach to psychotherapy education. For residents in psychiatry or other developing psychotherapists, this book offers a vision of collaborative possibilities in both the practice and learning of psychotherapy. An added bonus for all of us is the sense of being with one of the really great teachers in our field.

Behavior and Medicine

Behavior and Medicine

Danny Wedding, St. Louis

Mosby Year Book, 522 pp, 185 Illustrations, 1990

This book is aimed at the first year medical student and teaching of the social and behavioral sciences and their relevance for the practice of medicine.

There are five major sections. The first section, “Human Development”, reviews the life span and provides medically relevant information about each life stage. “Love and Work” is the title of the second section, covering human sexuality, sexual dysfunction, family relationships, work adjustment and mental health in medicine. The third section is entitled “Assessing Patients” and examines clinical interviewing, physician/patient relationships, the mental status examination, personality assessment and psychodynamic formulations of human behavior. The fourth section: “Behavioral Medicine” looks at stress and stress management, addictions, chronic benign pain, placebo response, cardiovascular risk and health behavior, and Aids. The final section: “Behavioral Science Foundations” looks at brain and behavior, neurochemistry, sleep and sleep disturbances, Sociology and Anthropology in relationship to medicine and Medical Economics. I found the book very readable; it is multi-authored by many M.D.’s and P.h.D’s, and is concise in its coverage of the topics mentioned above.

Each chapter has several study questions, and a very complete list of appropriate references.

The book is very well illustrated with a wide range of classic works of art, indeed the book is almost a short course in art, painting, lithography etc, the 185 illustrations coming from the classics of the art world, and selected very appropriately for the particular behavioral topic under discussion.

I think it is a excellent book, and will find its place in first year medical school programs in behavioral medicine. It will also be of great value to other professionals working in the health and medical fields. It purposely avoids any depth of psychopathology, as the editor points out that a good basic knowledge of behavior and its relationship to medicine is essential before the students get into more grossly abnormal behavior.

The Hypnotic Brain: Hypnotherapy and Social Communication

The Hypnotic Brain: Hypnotherapy and Social Communication

Peter Brown

New Haven, CT: Yale University Press, 322 pp., 1991

Those with a more serious interest in hypnosis will enjoy this book not only in the first reading, but as a future reference volume. Dr. Peter Brown, a psychiatrist from Toronto, has presented an extensively referenced work with the intention of reviewing”. . . our changing understanding of hypnosis and its clinical use in hypnotherapy in the light of our new knowledge of human behavior and brain function.” Appreciating that hypnosis is a special inherent state of communication of the human mind which has evolved from our pre-verbal ancestors, he begins with an anthropological review of the theories of non-verbal face-to-face communication skills and progresses from prehistoric times to the twentieth century’s renown hypnotherapist, Milton Erikson.

Erikson was master not only of non-verbal hypnotic communication but also of the use of the metaphor in hypnotherapeutic communication. Between the above mentioned wide time span, Brown also makes literary stops with Darwin, Freud, Janet, and then moves to modern day researchers of the psychoneurophysiological aspect of hypnotic/trance communication.

A brief book review cannot do justice to the many stops in Dr. Brown’s communication journey. He studies concepts of hypnosis from such areas as ultradian cycles, cerebral hemispheric inter-relationships, cortical and subcortical pathways in the process of trance production, neurophysiological changes in the application of clinical hypnosis, the relationship to multiple personality and post traumatic stress disorder, and many others.

Readers will probably also be impressed by the wide array of present day authors which are cited along with their contributions which are leading us to a better scientific understanding of the trance state and its application to clinical hypnotherapeutic communication. At times the material is complicated, leading to ‘heavy’ reading, but those who wish to learn the phenomena of trance and trance communication will find this reading a worthwhile endeavor. Hypnosis unlocks a door to the trance state: the hypnotic brain. It behooves us to learn the lessons it can teach about interpersonal communication which is a major part of what this book is all about.

Beyond Dieting Psychoeducational Interventions for Chronically Obese Women: A Non-Dieting Approach

Beyond Dieting Psychoeducational Interventions for Chronically Obese Women: A Non-Dieting Approach

Donna Ciliska

New York: Brunner/ Mazel Eating Disorders Monograph Series, 1990

This book is the fifth in a series edited by Paul Garfmkle, M.D. and David Garner, Ph.D. As aptly acknowledged by the author, the initial ideas for the “Beyond Dieting” program came from Dr. Garner and from Janet Polivy who, with co-author P. Herman, wrote a book called “Breaking the Diet Habit” in 1983.

I feel this book is timely. The public is beginning to lose faith (finally) in the “Ultra Slim-Fast” approach to obesity and as the author mentions: “This (evidence) suggests that frequent dieting makes subsequent weight loss and maintenance more difficult — that dieting contributes to weight gain and obesity” (page 42).

After presenting a good literature review on dieting, obesity and self-esteem, the author explains the 12-week psychoeducational group therapy program. This program was initially part of a study (described in chapter 4) designed to compare an educational 1 hour/week, 12 week lecture series on dieting, obesity and self-esteem with a more “experiential”, 2 hour/week, 12 week psycho-educational group therapy approach. The methodological shortcomings of the study are well described (page 121) and make the results quite tenuous, and probably not scientifically valid. Nevertheless, there were significant improvements in self-esteem and body dissatisfaction measures with the “Beyond Dieting” program. As suggested by the author, this program still needs to be compared scientifically with the traditional dieting approach. Until this more definitive study gets done, I feel the merit of this book is in promoting a sensible approach to obesity and weight loss which hopefully will help curb our culture’s excessive preoccupation with thinness, a well-known factor in the increasing incidence of eating disorders.

I would recommend the program, as outlined in chapter 3 of this book, to all helping professions involved in treating chronic obesity (some men might also benefit). It is time we worked with dieticians to develop similar psychoeducational groups — surely we can offer patients a better alternative than the latest seductive weight loss gimmick on television.

Nutritional Influences on Mental Illness: A Source Book of Clinical Research

Nutritional Influences on Mental Illness: A Source Book of Clinical Research

Melvyn R. Werback

Third Line Press, Inc., 360 pp., 1991

Publication of this book is timely as nutritional science is emerging as an essential component of the practice of medicine. The book is a sequel to “Nutritional Influences on Illness” by the same author. In “Nutritional Influences on Mental Illness” the focus is narrowed to psychiatric illness.

The book is aptly described as a “source book for clinical research”. Part I of the book is composed of a thorough review of the literature on the relationship of nutritional abnormality to psychiatric illnesses such as depression, anxiety, schizophrenia, learning disabilities, premenstrual syndrome and so on. Additional chapters address the influence of nutritional abnormality on symptoms such as fatigue, insomnia and aggressive behavior. Most chapters begin with a brief overview on the subject under study followed by a compilation of relevant publications on the topic, fully referenced for any one who wishes to undertake his own further study in the specific area. The presentation is extremely well organized and thorough. However, the author seldom offers his own critical appraisal of the mass of volume he has reviewed.

Part II of the book consists of six practical appendices such as “Common Nutritional Deficiencies,” “Dangers of Nutritional Supplementation” and “Guidelines to Nutritional Supplementation”. Once again, this is largely a compilation of previously published work in this area presented in an organized and easily readable way. The scope is wide, looking at everything from proteins and carbohydrates to vitamins and minerals.

Overall, the author has succeeded in his objective to bring together the plethora of literature on the relationship of nutrition to cognition, emotion and behavior. However, the author leaves it up to the reader to arrive at his own final conclusions and derive from it any therapeutic value. In this respect the book does not represent original work. As a source for clinical research, this book will serve to avoid the tedious task of a literature search. I would recommend it for institutional libraries and for health care workers with a special interest in nutrition.