Abstract
As a trainee psychiatrist, I invested in the first edition of this book in the early 1990s. At the time I felt it filled an important niche in providing a psychodynamic perspective that complemented the descriptive psychiatry upon which general psychiatric training is based. The latest edition of this book is considerably expanded in scope and achieves a skilful integration of psychodynamic perspectives with neuroscience, biological and other psychological approaches, all within the descriptive framework of DSM-IV-TR. It includes a wealth of clinical illustrations which serve the important function of enlivening the understanding of descriptive categories and conveying the importance of working empathically with the individuality that each patient brings to the clinical setting.
Throughout the book, Gabbard emphasizes integration of treatment approaches. He embraces the current zeitgeist of evidence-based medicine (EBM) and is modest in his claims for psychodynamic therapies, highlighting when not to pursue expressive forms of psychotherapy as well as illustrating the many ways in which such therapy can enrich or add something beyond other forms of treatment. Considerable space is devoted to a psychodynamic understanding of pharmacotherapy and the need to integrate both forms of treatment rather than see them as competing options. Although replete with individual clinical illustrations, Gabbard chooses to give priority to controlled trials, especially randomized controlled trials, when citing evidence for outcomes, unless no such evidence is available. This may have led to a tendency to omit some significant studies, although it keeps the book in the mainstream in relation current demands for ‘scientific accountability’.
The first section covers ‘Basic Principles and Treatment Approaches’ and gives useful historical and theoretical perspectives on psychoanalytic principles for individual therapies as well as group, family, hospital and pharmacological approaches. The theoretical schools that Gabbard covers are classical psychoanalysis and ego psychology, the object relations school, self-psychology and attachment-based therapies. In the spirit of eclecticism, Gabbard argues that some approaches may be better suited to some patients and disorders while other technical styles may be adopted ‘as needed’ for different patients and situations. This process of adaptation of approach and style to fit the patient is conceptualized using the spectrum of ‘expressive’ to ‘supportive’ interventions. This section includes discussion of dynamic diagnosis and a brief and accessible account of psychological mechanisms of defence which will be appreciated by trainees.
The second section deals with axis I disorders and will provide readers with a variety of analytic insights into these conditions, often lacking in standard psychiatric textbooks. This includes discussion of the value of psychodynamic work in areas where it is not commonly considered such as schizophrenia and dementia. The importance of understanding and working with countertransference is highlighted throughout the book and properly seen as essential to all psychiatric training. With all conditions the interplay of genetic, biological and environmental factors are considered as well as common psychodynamic formulations and the relative values of different interventions. Case illustration allows a rational appraisal of the role of longer term psychotherapies in a way that has become unusual in general psychiatry texts.
The final part of the book covers axis II disorders, the area of theory and treatment usually seen as most central for psychodynamic approaches. The ‘mentalization’ approach of Fonagy and Bateman is well covered as are the debates between Kernberg and Kohut in relation to theory and treatment of Borderline and Narcissistic Personality Disorders. Pitfalls of treatment are addressed, for instance, in relation to attempts to manage antisocial patients with individual psychotherapy or in general psychiatry settings. There is a lucid section on erotic transference and throughout Gabbard cogently discusses countertransference and boundary issues that are commonly encountered.
This book is probably largely intended for psychiatry trainees, although it is a useful resource for any psychiatrist with an interest in psychodynamic psychiatry. It can be used as a reference book but is also eminently readable and many will find it profitable to read cover-tocover. In somewhat unquestioningly following the DSM and EBM formats, Gabbard could be seen as failing to explore philosophical critiques of these methods. However, that is not the intention of the book. It succeeds admirably in its own terms of providing a broad account of psychodynamic psychiatry that meshes with the contemporary structure of general psychiatric theory and training.
There is a tendency to quote mainly from North American and English research and perhaps a lack of acknowledgement of contributions from other parts of the world, although the breadth of Gabbard's scholarship remains impressive. Discussions of the work of researchers such as Kandel and Edelman, as well as the recent discovery of ‘mirror neurons’ show some of the ways in which our understanding of dynamic psychological processes is being enhanced and supported by modern neuroscience.
Practitioners who have devoted themselves to specific psychological approaches may find Gabbard's appeal to eclecticism something of an impossible ideal. Perhaps, it is best interpreted as highlighting the need for flexibility and thoughtfulness no matter what one's theoretical orientation might be. I would recommend this book to anyone interested in the interface between psychiatry and the psychotherapies. For trainees, in particular, it provides an integrative appreciation of psychodynamic psychiatry in an accessible style that does not assume a lot of prior knowledge.