A Guide to Treatments That Work

A Guide to Treatments That Work

Peter E. Nathan and Jack M. Gorman, editors

New York, Oxford: Oxford University Press; 1998 . 594 pp. with index

ISBN 0-19-510227-4 (cloth)

This kind of book has to be written from time to time in any area of knowledge, in an attempt to establish benchmarks. In this case the aim is to highlight current “state of the art” aspects of the treatment of psychiatric disorders. It is a brave effort, tightly edited and with a large number of eminent and expert authors who are, in general, balanced and incisive in their viewpoints. They consist of a judicious mix of MD psychiatrists and PhD clinical psychologists, and there is a refreshing lack of inter-profession infighting in their writings.

The editors have insisted that the contributors’ approach should be evidence-based, and they have clearly delineated the relative degrees of investigative rigour present in the many studies under review. In their introduction, they say that, to be reputable, treatment studies must show that patients got “better” (acknowledging the difficulties in defining and measuring that concept). They also say that treatment simply as an exercise in promoting self-awareness is a more appropriate approach for religion than for a science-based medical specialty. Now there’s a brisk, no-nonsense send-off, so why is the last word (”Afterword — a plea”) given to a writer who makes a pitch for the supremely intuitive psychoanalytically based forms of psychotherapy? And why is that writer advocating impracticable methods of research that have never been effective in giving them a verifiable basis in the past? I can only assume that this is a manifestation of that aspect of the American psychiatric Zeitgeist that has never quite lost its awe of psychoanalysis even when knocking it, and which has to indulge in little propitiatory rituals to allay some possible ”Furor Sigmundicus.” That said, it should be emphasized that the psychological contributors adhere mostly to reviews of behavioural and cognitive therapies, with a strong emphasis on psychosocial intervention, and take a very objective view of what constitutes psychotherapy and how its outcomes may be assessed.

This is a solid tome, with 28 dense, closely-argued chapters on 18 wide-ranging areas of psychiatric disorder, mostly grouped in complementary pairs of presentations reviewing pharmacologic and psychosocial approaches. Despite this diversity and apparent depth, however, there is an introductory section entitled “Summary of treatments that work,” which occupies only 13 pages. It seems extraordinarily sad that in 1998 all our verifiable knowledge of psychiatric treatment can seemingly be encapsulated in 13 pages of text (reading time approximately 30 minutes).

But to some extent this brevity is misleading, since we are considering a highly-selected filtrate of the best-attested results available. The editors have been further selective in appearing to concentrate on disorders that seem more treatable than others, and there is a sense that some of the choice is influenced by what the psychology contributors consider “sexy” these days. The result is a number of notable omissions, including, for example, delusional disorder, schizoaffective disorder and dysthymic disorder.

Although the book is entitled A Guide to Treatments that Work, relatively little attention is given to the question, Work on what? The authors have meticulously culled their literatures, and most of the references are impressively recent. Nevertheless, we have to be aware how crude our nosologic system remains and what a moving target it is. DSM and ICD have become very intent on narrowing their diagnostic criteria to exclude false-positive findings. A result of this is an over-refinement of case identification in formal investigations and the provision of a number of residual diagnostic categories to which “atypical” cases may be consigned. The latter are so heterogeneous that they virtually deny investigation. Also, small but significant differences in diagnostic criteria between DSM and ICD, or between successive editions of these authorities, are sometimes enough to make superficially similar treatment studies incompatible with each other. So, when the editors use refinement of technique in the measurement of quality of treatment studies as their major criterion of credibility they narrow the scope of their work very considerably. They may be, in effect, investigating Jello with techniques appropriate to the testing of properties of high-tensile titanium. This feeling, in my mind at least, is accentuated when so many dramatic results are reported for behavioural cognitive treatment methods. I know how effective they can be, but when I read of their apparent success as primary intervention in what are reputed to be severe psychotic disorders, I just know that we are not talking about the unselected cases the front-line psychiatrist meets in everyday practice.

I do not intend to belittle this book because I think it serves a very useful purpose in hammering home the need for much more science in our clinical and research activities. The editors are at pains to point out that it is neither a comprehensive textbook nor a therapeutic vade mecum. But read uncritically, it could give an unbalanced message. Like it or not, “state-of-the-art” treatment in psychiatry still has a great deal of art in it, and the more difficult the patient, the greater is the need for that very art.

If we regard this book as a starting point from which we can move on and begin to validate the much bigger, much messier and much more demanding world of non-academic psychiatry, then we need not be discouraged by these mere 13 pages of summary. It is good to see a psychiatric work aim high, and it is a trenchant reminder of how far we have to go in psychiatry before we can be regarded as a scientifically-based discipline. I would suggest that every psychiatric library have a copy of this text.