Abstract
This text is a welcome update given the escalating developments in the fields of neuroscience, and psychodynamic research and thinking. It is an extremely complex task to marry descriptive diagnosis based on DSM-IV criteria with psychodynamic diagnosis ‘based on an understanding of the patient and the illness’ (p.79). The former involves ‘assignment of a correct label’ (p.79) and is based on what is directly observable, while the latter is concerned with what, by definition, includes the patient's inner world, and is not so directly observable. In short, these are fundamentally different approaches to understanding, and this becomes obvious in the second and third sections of the text which deal with dynamic approaches to Axis 1 and Axis 11 Disorders. For example, in chapter 16, Cluster B Personality Disorders: Narcissistic, we find this label applies ‘equally well to patients with quite different clinical pictures’ (p.466). To those used to thinking along descriptive diagnostic lines (DSM-IV), it might seem that psychodynamic understanding has little coherence or consistence.
The preface to this third edition, states that it has been ‘rewritten, not [as was the second edition] in response to a nomenclature change [the publication of DSM-IV] but rather “to reflect changes in the science and art of psychodynamic psychiatry”. Further stated aims include – the ‘integration of neuroscience and psychodynamics’, the highlighting of theoretical trends and the implications of these for clinical practice, and the inclusion of research findings ‘to bolster the case for a psychodynamic approach’. All of these have been admirably achieved.
Section 1, on Basic Principles and Treatment Approaches in Dynamic Psychiatry is written in a clear and informative manner, carefully placing psychotherapy in context with many examples to aid understanding. Yet, on some occasions, the examples given are surprising. When categorizing the types of intervention under Advice and Praise, we read under Advice: ‘I think you should stop going out with that man immediately’, under Praise: ‘I am very pleased you were able to tell him you will not see him again’(p.98). Gabbard goes on to state that ‘the vast majority of psychotherapeutic processes contain all these interventions (including advice and praise) at some time during the course of treatment’ (p.98). This is certainly not my understanding, and both interventions seem to leave no room for the patient's autonomy. I cannot think of a situation in which they would be likely to be therapeutic.
In the introduction to chapter 2, Gabbard states ‘psychoanalytic theory is the foundation of dynamic psychiatry’ (p.27). I think it is worth adding it is the theory and the method (which inform each other) that provide this foundation. In chapter 4, he makes the point: ‘Historically, insight and understanding were always considered the ultimate goals of psychoanalysis and psychotherapy… In the last 40 years, however, there has been considerable acceptance of the notion that the therapeutic relationship itself is healing independently of its role as delivering insight. Loewald (1957/1980) noted that the process of change is “set in motion not simply by the technical skill of the analyst, but by the fact that the analyst makes himself available for the development of a new object relationship between the patient and the analyst’ (p.91).
A text such as this is highly relevant to alert psychiatrists to the danger of over-emphasizing either a biological or a psychodynamic (psychosocial) approach at the expense of the other. It is most suited to those who are in psychiatric training, and those who need convincing that a psychodynamic understanding is an integral part of the assessment and management. This third edition is an important reference for the latest in research findings, together with theoretical and clinical developments.