Abstract
This book is a powerful illustration of the extent and depth of development of cognitive–behaviour therapies in the last decade or so. The traditional applications of cognitive–behaviour therapy (CBT) to disorders such as depression and anxiety have advanced well beyond the modification of automatic thoughts and educative dialogue about cognitive distortions. Nor is content and technology of CBT the only domain that has expanded. As this book clearly demonstrates, cognitive therapies are being widely applied and researched in even the most difficult to treat of all disorders – the psychoses and the disorders of personality.
Edited by two internationally respected innovators, Carlo Perris (Sweden) and Patrick McGorry (Australia), the volume consists of 21 contributions from eight countries. Four chapters address both psychotic and personality disorders, and the remainder primarily focus on one disorder.
A few chapters are introductory, for example, the excellent first chapter by Davidson et al. which reviews both psychotherapy and cognitive therapy in schizophrenia in a way that is respectful and helpful to readers coming from either background. Pretzer's review of cognitive–behavioural treatments for personality disorders is a little repetitive, but usefully outlines different models and nicely clarifies the current level of research evidence about the efficacy of each. Some chapters, such as that by Perris on vulnerability and Vallis outlining a meta-theory for cognitive therapy, are significant theoretical presentations. Perris's vulnerability model provides a useful bridge between traditional vulnerability-stress models of psychosis and cognitive approaches to therapy. Vallis draws out the differences between five main cognitive therapy models in a matrix schema which he proposes as a framework for guiding choice of cognitive therapy according to the client's needs.
The majority of chapters focus on specific disorders typically presenting a cognitive model and then either describing the elements of treatment, or presenting a case example to illustrate its implementation. A fine example of this is the chapter by Fowler et al. that succinctly reviews research on reasoning and emotional processing biases to support the contention that delusions may be ‘understandable’. An outline of their treatment approach is illustrated by three case examples. Another is the chapter by Liotti and Intreccialagli suggesting a framework and therapeutic method for working with patients who are difficult to treat because of poor meta-cognitive capacity, that is, an inability to monitor and reflect upon thoughts and emotions.
The topic of assessment receives much less emphasis than does that of theory or practice, with only three chapters on this subject. Jackson provides a scholarly, but perhaps unnecessarily broad review of personality disorder diagnosis and assessment: a greater emphasis on assessment for therapy rather than diagnosis would better suit the theme of the book. Yusupoff and Haddock's practical approach to assessment of hallucinations and delusions is useful (but their therapy overview rather too brief) while the report by Perris et al. of a cross-national study on assessment of dysfunctional working models of self and others seems rather too preliminary. Nonetheless, these contributions on assessment probably reflect the early stage of development of assessment in these fields.
Program or service descriptions are the focus of a small number of contributions. The material on preventively orientated psychological interventions by McGorry et al. may be familiar to some Australian readers, but it is nonetheless an excellent illustration of how a service system can (and should) be developed with synergy between its structures and therapy components. By contrast, the Edwards and McGorry chapter outlining the Early Psychosis Prevention and Intervention Centre (EPPIC) program seems too general to warrant inclusion in a book on therapy. The service descriptions of coping therapy from Germany (Schaub) and remediation of information processing deficits from Switzerland (Hodel and Brenner) give a useful picture of those applications, but without novel material.
A feature of the book is the breadth of ‘cognitive’ models encompassed. Theoretical influences include personal construct theory, grief counselling, skills coping models and attachment theory in addition to more typically ‘rational’ cognitive therapy conceptualisations using schemas, beliefs and automatic thoughts. Purists may not feel so comfortable with a book on cognitive therapy in which clinical use of projective techniques is advocated (H Perris) and remediation of basic information processing deficits is welcomed as a ‘cognitive therapy’ (Editors' Foreword). However, for me, the editors' openness to a wide range of ideas is one of the book's major strengths. In this one volume the reader is presented with a range of ‘cognitive’ approaches that overlap enough to invite and stimulate connection and comparison between them. Particularly useful for English language readers are the Swedish and Italian contributions presented alongside the possibly more familiar authors (and ideas) from the UK, Australia and the USA.
The logic of drawing together presentations on both psychotic and personality disorders is only briefly addressed in the Foreword, and a more substantive development of this theme via a chapter may have further stimulated integrative thinking by readers. The rationale is couched in terms of the tendency of public mental health systems to focus on ‘serious mental illness’, which often includes those with severe personality disorders as well as people diagnosed with psychoses. However, some of the chapters suggest other pertinent commonalities, the most therapeutically important one being the centrality (or extent) of impairment of sense of self in both personality and psychotic disorders. The metatheoretical framework presented by Vallis is an example of the utility of such integrative thinking.
For readers skeptical of the outcomes of therapy for such difficult disorders, the book has references through its review chapters to key literature, including the few randomised, controlled trails (RTCs) that existed at the time of writing. Publication lag means that the recently published RCTs of CBT for psychosis from the London East Anglia group [1] and the Manchester group [2] are not referenced. The predominance of content on theory and practice, rather than research, simply illustrates the extent to which research lags behind thought and practice innovation. Given this natural limitation, the breadth and depth of contributions makes this a most stimulating and authoritative ‘handbook of theory and practice’. It should be an excellent resource for therapists and postgraduate students.