Abstract
Reading this little book is quite a disturbing experience. The reason for this is implied in its title, which clearly suggests that the ‘principles and techniques’ of psychotherapy have changed significantly as a result of the change in the manner of funding in America. A similar book written about surgery or internal medicine would cause an uproar of protest. Aspects of management such as length of hospitalisation or day surgery clinics may change, but if surgical ‘principles and techniques’ were to be significantly compromised, there would be great concern about standards of patient care and safety.
This is the second edition of the book, which is part of the American Psychiatric Press Concise Guides series, and in the introduction (by the series editor, Robert E. Hales), the book is described as having been ‘thoroughly updated to include frequent references to psychotherapy in today's era of managed care'. These references, however, are not clearly delineated or made explicit; rather, it seems that the whole book has been written in a defensive, over-inclusive and pseudo-scientific manner which appears to indicate a profound change in approach and attitude to the topic of psychodynamic psychotherapy. The book reflects rather than discusses these changes. Unfortunately, I have not read the first edition. It would be very interesting to compare the two books in this regard. In keeping with the tradition of the series, the book is aimed at practitioners (psychiatrists and psychiatry residents), is small (‘designed to fit into lab coat pockets’) and is meant to provide a brief review of the subject, with tables and summaries, as well as a glossary of terms for ready reference. A more appropriate feature is the frequent use of clinical anecdotes and brief case histories, which saves some of the chapters from sounding like a cookbook, or a do-it-yourself home repair manual.
The first chapter is entitled ‘Why psychotherapy?’ and seems to be aimed at an unsophisticated, relatively ignorant and somewhat hostile (or at least reluctant) audience. Statistics abound, and the results of research are quoted freely, but superficially (e.g. ‘a revaluation of a classic study by Eysenck indicates that psychotherapy accomplishes in 15 sessions what spontaneous remission takes 2 years to do’). In six small pages, the high prevalence and cost of psychiatric illness is established, and the (positive only) results of a large array of outcome research studies are presented. The chapter is summarised in a table which asserts that psychotherapy's benefits include that it is effective, is ‘part of the medical armamentarium available for treatment of a range of disorders’, targets behavioural and interpersonal symptoms, is useful in conjunction with psychopharmacological treatment, is ‘treatment of choice’ in some psychiatric disorders, and decreases overall cost of hospitalisation. I have no problem with any of these assertions. My objection is to the defensive, proselytising tone of the text, which would seem more appropriate in the board room or at a political meeting, rather than as part of a serious overview of a treatment modality aimed at practitioners. As an opening chapter, it seems to be aimed at either convincing the reader of the value of continuing or at providing the reader with a handy list of succinct arguments and statistics with which to defend psychotherapy.
The following four chapters are devoted to a delineation of basic principles and patient evaluation. Here, the problems of over-inclusiveness and simplification are at their most obvious and annoying, since the topics covered are so large and diverse, and the language used is very basic, avoiding definitions of jargon or using only very limited descriptions. The ‘four psychologies’: drive theory, ego psychology, self psychology and object relations theory are described, and several tables summarise and compare them. The ‘beginning therapist’ is exhorted to try to understand the patient from all these points of view, as well as to take a full clinical and developmental history, using the technique of ‘psychodynamic listening’ which is well illustrated through the use of clinical vignettes. The naive reader would, I think, be totally overwhelmed by all of this, or worse still, be encouraged to idealise practising psychotherapists, and the more experienced and knowledgable reader would object to many aspects of the attempt to simplify and amalgamate the ‘four psychologies’.
Having emphasised an eclectic approach to assessment, the book now proceeds to describe therapy itself in a traditional analytic style. Chapters on beginning treatment, resistance and defence, transference, countertransference, dreams and termination are followed by an interesting chapter on ‘Practical problems and their management’, which includes two paragraphs headed ‘Medical insurance and managed care’ which discuss issues involved in dealing with the case manager, providing case reviews and reports, and dealing with a manager's refusal to continue funding. It ends with this sentence: ‘The focus of the therapy may well become understanding the patient's conflicts as they are evidenced in dealing with the process of appropriately protecting oneself and seeking resolution of insurer or managed-care disagreements'. It seems that the triadic nature of American psychotherapy has become very well accepted. The material in this small section could have been expanded to constitute almost the whole book, in my opinion.
The last few chapters deal with brief psychotherapy, therapy of borderline and severe personality disorder, and supportive psychotherapy. Again, important and illuminating clinical insights and vignettes are let down by the inconsistencies, confusions and inaccuracies brought about by so much simplification and condensation of material.
This book might appeal to the trainee or general psychiatrist who is curious about contemporary psychotherapy practice in America. However, I think reading it would be confusing for ‘the beginning therapist’, and disturbing for the more experienced Australian clinician, in view of the common perception that the American experience is an indication of our future. If the book's size and simplicity of style tempt you to regard it as suitable for bedside reading, be warned: the other side of your brain might give you nightmares!