McCullough anad co-author Marvin Goldfried have produced a treatment manual for the Cognitive Behavioral Analysis System of Psychotherapy (CBASP), a new form of therapy for chronic depression. Many readers may be deterred by the description of it as a treatment manual and conclude that it is not of any further interest. Some authors have held that the trend toward manualized approaches to therapy is a bad thing for psychotherapy and leads to impoverished and perhaps hopelessly ineffective treatment.1 Those of us trained in cognitive behavioral models accept and value the movement. However, cognitive therapists might ask why we would need a new manual on treatment of depression. After all, didn't Beck2 set the standard for treatment manuals with the classic Cognitive Therapy of Depression? Furthermore, hasn't cognitive therapy demonstrated its efficacy in treatment of depression? This book speaks to these questions and makes it clear that is has an important place because it offers a new conceptualization that is testable and appears to be an effective method for treating patients with a frustrating, resistant, life-threatening condition. McCullough points out that neither standard cognitive therapy using Beck's model nor interpersonal therapy was specifically designed to deal with chronic depression. The book summarizes outcome data, which show an impressive response rate for CBASP especially when combined with antidepressant medication. The model of therapy is based on an etiological theory of chronic depression that is deceptively simple. McCullough first explains what led to development of the model he will work with throughout the book. He draws from Piaget and argues that the chronically depressed are functioning at a preoperational level of cognitive processing. This leads to patients not connecting their actions with the consequences in their lives. This disconnection is the fatal flaw in chronic depression, leading to the hopelessness and helplessness that characterize the disorder. According to McCullough, individuals with early-onset chronic depression have never reached a stage of formal operations, and those with late-onset chronic depression have lost the ability to think this way in interpersonal contexts. The goal of therapy in part, then, is to drag the patient to the point where he can function using formal operations and so understand the consequences of his own behavior. McCullough offers tools to facilitate this change and conceptualizes the learning that must take place in the language of operant conditioning. Motivation to change is elicited by skillful use of negative reinforcement. The principal technique of CBASP is the situation analysis, or SA. The book spells out in detail what is involved in conducting SAs and the rationale for each step. McCullough frequently points out mistakes of novice CBASP therapists and the traps that anyone trying to do this type of therapy will encounter. The most common one is doing the work for the patient. He simply enjoins us not to do it. The reader is given examples and specific questions to use in conducting the SA as well as a method to evaluate the patient's progress in learning to do these on his own. We are led to understand that only by therapists' shaping behavior and applying consequences, primarily in the form of negative reinforcement, will patients learn how their behavior affects their environment and begin to think in the formal operations mode. Only then will they realize they have the power to achieve their own desired outcomes in life and begin to relate to others in an empathetic way. Those of us who have cognitive-behavioral backgrounds do not focus on transference and will find McCullough's model and discussion clear and useful. My guess is readers with psychodynamic backgrounds will find his ideas disturbingly simplified. The therapy model does include the idea that learning from earlier relationships is played out in the therapy relationship. McCullough does suggest developing a hypothesis about how this will happen, based on data gathered in an early session. Unfortunately, he does not explain how to formulate the hypotheses. When transference hot spots do occur in session, the therapist uses the opportunity to teach the patient to discriminate between the different relationships. This is called an Interpersonal Discrimination Exercise or IDE. As in the SA, we are applying consequences to the patients' behavior in order to teach them how their behavior affects others and to lead them toward interacting with others in an empathetic formal operational manner. McCullough brings in a unique idea about use of the therapist's self in the therapy. He describes Kiesler's model of interpersonal interactions. Using this model and a measure of interactions, the Impact Message Inventory, McCullough describes how the typical chronically depressed patient will interact, and the pulls for the therapist to respond in certain ways. However, the response must not be the automatic one because that will lead to failure of the therapy. Instead, a disciplined use of self in the therapy, guided by an understanding of the psychopathology, is recommended. Let me end where I began: Do we need another treatment manual? McCullough reflects that the experience of treating the chronically depressed can be likened to pouring energy down a black hole. Since he has a new model and a method with which to approach this needy population, and the evidence seems to suggest it may work very well, I for one am encouraged and feeling less hopeless already. My answer is a resounding yes.
In the subtitle the authors refer to their book as a “guide.” Later in the text they describe it as a manual. Manuals on how to do psychotherapy have always somewhat put me off, since I have always experienced psychotherapy (whether in the role of patient or therapist) as a most unpredictable and hard-to-formulate enterprise. The authors, to their credit, are sensitive to this matter and address it immediately. They say they do not want to produce a “cookbook” that would mechanize the therapy process but rather wish to “strike a balance” between, on the one hand, treating new cases as unique and, on the other hand, refining existing theory and technique by relating it to the new situation. They have succeeded admirably in striking that balance, and in the process have produced a very rich book (or, if you will, manual) that I would recommend to clinicians from all schools of psychotherapy. Their central focus is, as the title indicates, on the therapeutic alliance, and more specifically on how clinicians can resolve ruptures in that alliance. Another way to say this is that the authors are describing and discussing various ideas and techniques for resolving the inevitable and often highly distressing transference–countertransference binds that occur in psychotherapy. They particularly emphasize the importance of therapists' focusing on their own contributions to the binds and, further, exploring and negotiating difficult moments in the relationship directly with the patients—something the authors refer to as “collaborative inquiry.” There are a number of wonderful and clearly written chapters in this book. The first one presents a historical review of the notion of the therapeutic alliance and then reconceptualizes it from a relational perspective, which asserts that a central change mechanism in psychotherapy is the negotiation and resolution of ruptures in the alliance. The authors then offer a very useful taxonomy of interventions for addressing ruptures, accompanied by helpful vignettes illustrating their ideas. The second chapter is a review and summary of the ideas of leading relational thinkers. Readers interested in learning about these ideas and the issues under development by this school of psychotherapy, as well as its historical origins, will be especially pleased by this chapter. The next chapter tackles the omnipresent problems of resistance of therapeutic impasses. The authors distinguish between intrapsychic, characterological, and relational views of resistance, demonstrating familiarity with thinkers from all schools of psychotherapy on this topic. In keeping with their central theme, they stress the importance of therapists' understanding their own contributions to enactments and impasses by paying vigorous attention to their feelings and countertransference experience. Following the discussion of ruptures and impasses is a chapter on “therapeutic metacommunication.” This term refers to procedures designed to help therapists disembed from relational cycles that are being enacted by focusing on the transactions and implicit communications taking place between therapist and patient. The goal of metacommunicating is to articulate the therapist's implicit sense of the interaction in order to initiate an explicit exploration of what is being unconsciously enacted. The authors provide a succinct and specific set of principles (e.g., “emphasize awareness rather than change,” “explore patient's experience of interventions”) to keep in mind as one uses this kind of communication when conducting therapy. The most original chapter in the book describes a stage-process model for resolving alliance ruptures. Stage-process models of psychotherapy are designed to help therapists recognize stages that are likely to recur in therapy and thus provide facilitating interventions. The authors list two basic rupture subtypes: withdrawal and confrontation. Patients vary in their use of these coping strategies but are likely to present a predominance of one type of rupture over another. The authors indicate that it is important to be sensitive to the specific qualities of a rupture and its stage in order to help clarify patient tasks and provide appropriate interventions. They acknowledge that models like this are oversimplifications of the processes they are striving to capture. However, the notions presented and the clinical illustrations are first rate and well worth consideration by clinicians looking for new ways to think about ruptures in the therapeutic process. The authors have also dedicated a chapter to explaining and demonstrating the application of their ideas to a short-term therapy process they call Brief Relational Therapy. The discussion is clear and sophisticated, but they do not adequately address what I see as the complex matter of differential diagnosis and short-term therapy. People recovering from trauma and certain kinds of depression often profit from short-term treatment. However, the picture is complex. For instance, Ablon and Jones1 in their analysis of the NIMH-sponsored Treatment of Depression Collaborative Research Program found that positive outcome in brief therapy correlated with pre-treatment patient characteristics of being accepting, compliant, and agreeable. Patients with personality disorders, on the other hand, are known to be difficult and often require intensive and long-term therapy. I would recommend that these authors apply their impressive research, writing, and clinical skills to addressing more fully the issue of differential diagnosis and the relational approach to treating the more formidable psychiatric disorders. The authors believe that the training of therapists is most critical and consequently devote an entire chapter to the topic. They stress the importance of training therapists to deal specifically with negative processes and therapeutic impasses. They also emphasize the experiential side of training over the conceptual and the value of self-exploration as a primary vehicle for learning. The ideas presented in this chapter are very creative and stimulating, and I would strongly recommend it to all training programs and institutes. In fact, I would recommend this book to all clinicians. It should be especially useful for beginning therapists, and experienced clinicians should also find it valuable because it provides such a clear, comprehensive discussion of the relational approach to psychotherapy.
Interpersonal psychotherapy (IPT) has demonstrated efficacy in protecting against a recurrence of major depression in elderly subjects when used alone on a monthly basis and when combined with antidepressant medication. The authors summarize their experience using IPT over the past 10 years and discuss a variety of treatment correlates. In addition, preliminary results using IPT combined with paroxetine in depressed elders reveals no difference in remission rates between cognitively intact and cognitively impaired depressed elders.
The authors introduce and define ethnocultural allodynia as an abnormally increased sensitivity to relatively innocuous or neutral stimuli resulting from previous exposure to painful culturally based situations. Ethnocultural, gender-specific, and cognitive-behavioral techniques are used in clinical vignettes to illustrate the pervasive ethnic, racial, and gender effects of ethnocultural allodynia in the lives of people of color. Therapy components for the treatment of ethnocultural allodynia are described, including psychoeducation regarding racism and its sequelae, racial socialization, inoculation, and racial stress management.
This study examined psychotherapists' experiences in conducting treatment with fellow mental health professionals. 349 psychologists (35% response) rated the extent to which their therapeutic approach with psychotherapists differed from their approach with laypersons of comparable intelligence, socioeconomic status, and diagnosis. Respondents also provided recommendations for conducting effective treatment with this elite clientele. Psychologists indicated that their practices with fellow psychotherapists were in most respects similar to those used with laypersons; 55 of the 78 items were rated of equivalent frequency. Practitioners' self-characterization as "a therapists' therapist" was related to the manner in which they treated mental health professionals. Broadly speaking, two types of advice were offered: to cultivate a warm and collaborative therapeutic relationship and to maintain proper boundaries. Recommendations for clinical work and future research on psychotherapists' psychotherapy are advanced.
This is a complete report of an open trial of manualized psychodynamic psychotherapy for treatment of panic disorder, Panic-Focused Psychodynamic Psychotherapy (PFPP). Twenty-one patients with PD were entered into a trial of twice-weekly, 24-session treatment. Sixteen of 21 experienced remission of panic and agoraphobia. Treatment completers with depression also experienced remission of depression. Improvements in symptoms and in quality of life were substantial and consistent across all measured areas. Symptomatic gains were maintained over 6 months. This report was prepared specifically to describe 6-month follow-up on these patients. Psychodynamic psychotherapy appears to be a promising nonpharmacological treatment for panic disorder.
At the outset of this book, Robert Langs argues convincingly that psychotherapy is unlikely to survive as a distinct discipline without the “development of formal science of its own.” He tells us that to turn away from the rigors of theory-building and the testing of assumptions that guide practice is worse than an indulgence. From here he then sets out to describe to us the quest he has undertaken over the course of his long and fruitful career to bring science to bear on psychotherapy. The style of the book is an engaging mixture of personal narratives about his triumphs and disappointments and more formal academic writing about Langs' theories and his understanding of the key questions science has yet to address. The tone is impassioned and the work as a whole seems to be an effort to awaken a field that the author perceives as slumbering. To both describe his own adventures and discuss the issues of the field, Langs has divided this book into four parts. In the first he introduces basic issues and talks about why our field is ambivalent about scientific inquiry. Here Langs perceives an emotional rather than an abstract issue. In a manner that rings true, he writes: “the universal dread.…of a confrontation with the most awful aspects of one's relationships, self, life experience, inner impulses and particularly, inevitable demise carries over to a dread of science.” In the second section, Langs presents a model of the aspects of the mind that are addressed by psychotherapy, those aspects or systems that make meaning of emotionally charged information. His presentation is dense and detailed. He offers lists of numbered postulates. He describes the division of the emotional processing mind into conscious and unconscious domains and uses names such as the “perception-analyzing receiving system” and “output control center” to distinguish individual components of these domains. In the third and most engaging section, Langs takes us into his confidence and describes his personal tribulations as a little more than a decade ago he attempted to code a series of psychotherapy transcripts and then subject the data to mathematical modeling. For example, Langs tells us how he found in one series of studies that the amount of time clients spent narrating versus intellectualizing increased as the therapist was quiet but actively lending energy to the interaction. Here Langs explains that he believes he was measuring mental energy, and he evolves a number of laws about human communication. While I suggest that there are many alternative explanations of this finding, including ones that draw from a less synthetic and mechanistic view of the mind,1,2 these findings and Langs' thoughts are nonetheless exciting and provocative. They draw the reader into arguing both with Langs and with themselves about the basic processes that go on between therapists and clients. Thus here more strongly than in any other section of the book, the case is made in vivo for how science can revitalize our thinking about psychotherapy. In the last section, Langs speculates about how the forces of evolution may have shaped the human mind into the structures he has observed. Here he grapples with the issue of why people act in so many absurdly self-destructive ways. Why do we have important knowledge that is so difficult to access (knowledge Langs calls unconscious)? Then, at the close, Langs returns briefly to try to put psychotherapy into the context of the mind as evolving entity. This book is ultimately a collection of closely related assertions about the nature of human consciousness and psychotherapy. The directness of Langs' assertions is both the strength and the weakness of the work. His points are clearly made. There is no guessing about his postulates or conclusions. Some of his points, though, seem unlikely to stand the test of time. For example, he asserts that “the human brain is a Darwin machine” and that there is an unwavering biological basis of the denial of death. This may be unconvincing to many readers familiar with literature on the social construction of narrative.3 Some of his thoughts about the philosophy of science are also perhaps limited by their reliance on the early 20th century positivist view. Nevertheless, this is how science moves forward. Langs is courageous enough to tell us what he thinks, and we can consequently accept or reject what he purports, thereby advancing our field. Langs writes: “It is my fervent hope that this book has aroused a restless interest and need for science.” For myself, it was the case that Langs' work helped to revitalize and spur on just such a process.
The author addressed the question of consistency in psychotherapists' countertransference feelings. Research findings have indicated that the therapist's own personal feeling style may be more important than the patient's impact on the therapist's feelings. In this study, the feelings of 9 psychotherapists toward 28 patients were followed by using checklist self-report after each session during moderately long psychotherapies. ANOVAs and discriminant analyses showed that the therapists were very consistent in their feeling style over different patients and over time. The consistency in feelings toward the individual patients was smaller. Deviations from consistency are analyzed, and their importance for the understanding of different aspects of the countertransference is discussed. It is suggested that a meaningful use of the countertransference concept ought to be based on systematic identifications of recurrent and deviant patterns in the therapist's reactions.
Former residents rated their videotaped psychotherapy supervision sessions on how helpful their supervisors were as teachers during the session. Residents' and experts' ratings of the same videotape were compared and found to have no significant correlation. However, male residents were less critical than either female residents or experts. Former residents were also interviewed. Supervisors were rated as excellent when they were accepting and also when they provided guidance about highly charged clinical dilemmas. Discussion of the impact of the residents' personal experiences on the clinical encounter was also rated high and is best understood from an adult developmental perspective. The findings reveal the lasting value of sympathetic supervisors acknowledging personal concerns and are likely mirrored in all clinical settings.
The authors report on the development of a manual for treating adolescents with anorexia nervosa modeled on a family-based intervention originating at the Maudsley Hospital in London. The manual provides the first detailed account of a clinical approach shown to be consistently efficacious in randomized clinical trials for this disorder. Manualized family therapy appears to be acceptable to therapists, patients, and families. Preliminary outcomes are comparable to what would be expected in clinically supervised sessions. These results suggest that through the use of this manual a valuable treatment approach can now be tested more broadly in controlled and uncontrolled settings.
This volume gives to psychotherapy what a basic life support manual gives to the first responder: an easy way to conceptualize patients' problems and start immediate treatment. Dr. Goldstein is well qualified to provide such a manual. He is on the faculty of the Baltimore-Washington Institute for Psychoanalysis, where he is director of their Adult Psychotherapy Training Program. He is also a Clinical Professor of Psychiatry at the Georgetown University Medical Center and currently practices psychotherapy and psychoanalysis. He is extensively published and has taught many the art of psychotherapy. This book is the second edition and differs from the first in the addition of a chapter describing newer schools of psychotherapy. The update allows the novice to understand how the approach illustrated fits within the context of the contemporary schools. The concise, easy-to-follow format uses a question-and-answer style. The most pertinent concepts and terms used are described in an appendix on ego functions. The layout is all business. The author wastes no words in explaining the basic questions of psychotherapy, and he covers more topics and in greater depth than one would have thought possible in a book of this size. Fourteen chapters flow from beginning to end along the line of questions most therapists should have before seeing their first patient. His first chapters are the equivalent of “Airway, Breathing and Circulation” for psychotherapy. This section gives the main elements of what needs to be done immediately to size up the debilities of patients and quickly categorize them by ego strength assessment into a normal-neurotic, narcissistic, borderline, or psychotic organization. In these early chapters Goldstein gives a description of the varied backgrounds of patients and therapists and raises questions of the motivations of both for entering therapy. His directness in addressing some therapists' motivations for entering the field is unexpected but well employed. In light of this initial triage, he then discusses the basic life support measures—the spectrum of psychotherapy from analytic to supportive—using the degree of interpreted transference and insight as a measure of differentiation. Cognitive therapy is also given attention as an alternative treatment. The next four chapters cover issues to be pondered before meeting the patient. The degree of therapist's expressed emotion, office arrangement, initial phone contact, and the contract with the patient are all discussed, leading to a more in-depth question-and-answer coverage of therapeutic alliance and the role of transference. Following a brief lesson on basic strategies, Goldstein leads the students through several techniques of psychotherapeutic intervention. Along the way he gives the beginning therapist a candid look at some of his early follies and difficult patients. Recounting confrontations with racism, sexism, and attacks of incompetence, he demonstrates his personal trials without resorting to long narratives. At times his short descriptions create such a vivid picture that chuckles and outright laughter are unavoidable. The examples capture the worst fears of beginning therapists and make it clear that the feared situations, if encountered, can be overcome and dealt with therapeutically. A brief chapter on termination is included for the sake of completeness. It is only three pages—long enough to stress its importance but meant for nothing more. Finally, contemporary strategies, from the Relational School to Self Psychology, are discussed. The novice will find the appendix on ego functions very helpful. In the question-and-answer format, there is never time to get bored with one topic. This book, though, in no way resembles a mere series of bullet statements. The author writes engagingly, with seriousness as well as humor; throughout, his voice is both wise and concise. The beginning therapist reading this book will have the tools illustrated for making the four basic diagnostic groupings—and thus will be already far ahead of therapists with more experience who may suffer from lack of direction. For those already in the field who may be having trouble making quick and accurate conceptualizations, this book is also helpful. The framework set forth provides a way to organize further readings on various topics in psychotherapy, making a complex and growing field more manageable. Any new or inexperienced therapist will come away feeling more secure in his or her ability to conduct therapy and will be better able to do so. This is a three-evening book that conveys the practical information often not gathered through a month of introductory lectures.
Sperling and colleagues have written a pragmatic, concise, thorough manual for the psychodynamic clinician who is entering upon work with managed care organizations. Remaining neutral as to the advisability of engaging with managed care, the authors describe how, within constraints, it is possible to do some meaningful work. The book can be read in its entirety or sampled for relevant chapters. Illustrative case vignettes are scattered throughout. The first of eight chapters explores some of the implications of making the change to a treatment triad. A case vignette has the therapist taken off the panel of a company that had proven impossible to work with in good faith. An overview of treatment and ethical dilemmas follows. Such dilemmas are explored throughout the work, but there is perhaps too little examination of the pitfalls awaiting the unwary clinician who attempts to accommodate the demands of managed care. The second chapter summarizes the history, structure, and agenda of managed care as these are reflected in interactions with therapists. The following chapter clarifies insurers' conception of medical necessity, describing the emphasis on functional impairment and the lack of appreciation for psychodynamic considerations on the part of care reviewers. A graph dividing possible cases into quadrants with orthogonal dimensions of functional and intrapsychic impairments illustrates the points at which managed care may be approached for support with realistic expectation of success. Perhaps best fulfilling the intention announced in the title are the chapters “Transforming Psychodynamic Concepts into a Managed Care (Functional) Language” and “Documenting Psychodynamic Treatment in a Managed Care Format.” These constitute a detailed guide to the formulation of treatment plans in the concise, “atheoretical,” functional language likely to win approval of managed care. The authors provide examples of treatment plans in which elaborate dynamic formulations are condensed into a format that gives managed care the “just sufficient information.” There follows a thoughtful consideration of what can and cannot be accomplished within the temporal constraints of short-term treatment. A chapter on the use of outcome studies provides a good overview of the many scales that might be used to demonstrate both improvement and the need for continuing work in therapy. The limitations and ease of administering each instrument are summarized. Unfortunately, the authors do not discuss whether, in their experience, using these scales helps secure support for treatment. The final chapter revisits the central concepts in a “frequently asked questions” format, describes current developments in managed care, and predicts likely aspects of its evolution. The reference section includes an annotated bibliography, an appendix with sources of rating instruments, and a glossary. Though somewhat dry and redundant, the Strategic Guide admirably fulfills its stated task. Readers will find lucid, practical guidance in the difficult task of succeeding as effective and ethical psychodynamic clinicians in the brave new world of managed mental health care. As the authors of this book acknowledge, the experienced clinician looking for a more general guide to coping with managed care or getting on provider panels should look elsewhere. In-depth consideration of the impact of managed care on the psyche and culture of clinicians is also relegated by default to other works. Its strength is greatest for the therapist with a psychodynamic practice and limited experience working with managed care who is contemplating entering the fray; and for such it is highly recommended. it may also be of value to the new therapist of any theoretical background who is learning to deal with managed care.
Since the first edition in 1984, this textbook has stood as one of the foremost in the field. It is the only non-edited one on psychodynamic group psychotherapy. Certainly, Yalom's textbook1 is more popular, but his is a here-and-now approach, which eschews the value of genetic insight and group dynamics and minimizes the importance of transference. These authors recognize that the group is a multidimensional system in which events at one level affect another. Therefore, the group therapist needs to pay attention simultaneously to what is happening with the individual, among members, and with the group-as-an-entity; how genetic material, current life events, and the group's history affect the process; and the relationship of affect to content and process—all the while intervening at a level that is near to experience and also facilitates the group's development. For this reason in 1995, when reviewing the second edition (published in 1993) in these pages, this reviewer stated that “this volume remains a textbook nonpareil,” and that “it is the best one for introducing the clinician to the practice of group psychotherapy” and should be used “as an aid for teaching junior colleagues.” Does that advice still hold? The answer is yes, but with one proviso, to be noted below. This edition appears eight years after the second and has been expanded by 40%. What has transpired during that period of time to warrant a new edition? Three areas of change come to mind. First, there have been refinements in theory and the infusion of intersubjectivity, an offshoot of self psychology. Second, there continue to be advances in psychopharmacology. Third, managed care has become entrenched. Has this third edition addressed those changes? The answer is, yes, as well as can be expected. The text addresses the advances in theory in a comprehensive way. In fact, at times the text is so rich in theory that clinicians who know little theory may get lost in its pages. The foregoing will indicate for whom this text is best suited. It is ideal for the clinician who is well grounded in the theory and technique of individual psychodynamic psychotherapy and wants to learn group psychotherapy. It is perfect for the group psychotherapist who wants to learn psychodynamic group psychotherapy. The novice may have some difficulty with those sections steeped in cutting-edge theory. But that allows the student to reread the text and glean its richness as he or she matures professionally. Like the second edition, the present text adequately addresses the use of medication. There is a small section on combining group psychotherapy with pharmacotherapy. But the current preference by so many for medication as a “quick fix” over the use of psychotherapy cannot be adequately discussed in such a volume. The text refers to the challenges, or perhaps the problems, caused by managed care. These are addressed throughout. There is no chapter on how to manage managed care, or, more simply, how to beat the system. However, a section from the second edition on Time-Limited Psychodynamic Therapy has been expanded into a full chapter. The third edition is both a revision and an expansion of the second. The former chapter on Group Composition has been revised and reconceptualized as A Systems Approach to Forming a Group. The new title speaks to its reformulation. A series of chapters in the second edition on Special Technical Considerations has been given new identity, and thereby greater focus. The one on Expressions of Affect has been enriched so that the reader can appreciate that the authors conceive of affect as the underpinning of group process. Throughout the text, clinical examples are added and theory expanded and updated. A new chapter is included that consists of an extended clinical example with running commentaries by both authors. Through that chapter, the reader can come to appreciate how a clinician conceives of the group's process and how he or she works with the group. More important, the reader can see how two experienced clinicians can approach the same clinical situation differently. The second chapter is about the history of group psychotherapy. The authors do a nice job of acquainting the reader with some of the seminal contributions. However, the work of Foulkes is presented on an equal footing with the work of others. Foulkes's “group analysis” is the dominant psychodynamic approach outside the United States and Canada. More attention should have been paid to his unique way of viewing the group as an organic entity and to his insistence that the therapist take a less intrusive role, so as to become the group's conductor (as in music) rather than its director. In one respect, the authors are closer to group analysis than they acknowledge. They do an excellent job of reminding the reader that the group is not merely a dynamic entity of its own, but functions within a sociocultural context that influences its processes. An early chapter on Therapeutic Factors is extremely rich in theory. However, the level of sophistication is so high that it might leave some novices behind. In contrast, a later chapter on The Difficult Patient explains theory in a very clear way and makes it clinically relevant. Well-grounded clinicians will not have difficulty with any of this. They can use the volume to learn about the pragmatics of group psychotherapy, its conceptual underpinnings, and its complexities. Clinical novices should be advised to skip that earlier chapter and not be discouraged if some of the theory is beyond their level of understanding. This volume can be read over and over by the beginner, who will learn more from it each time, will come to appreciate its sophistication, and will find fresh insight in its pages. In short, the authors have taken the previous edition and raised its level of excellence so that now reading the volume has become a comprehensive learning experience.
This preliminary study examined how patients' defense mechanisms and psychotherapists' techniques influence early alliance formation. The authors assessed the relationships among defense mechanisms, therapist interventions, and the development of alliance in a sample of 12 patients undergoing Brief Psychodynamic Investigation (4 sessions). Alliance development occurred rapidly and was clearly established by the third session. Neither defensive functioning nor supportive or exploratory interventions alone differentiated early alliance development. However, the degree of adjustment of therapists' interventions to patients' level of defensive functioning discriminated a low alliance from both improving and high alliances. The adjustment of therapeutic interventions to patients' level of defensive functioning is a promising predictor of alliance development and should be examined further, alongside other predictors of outcome.
The Ways of Responding (WOR) was developed to assess change in compensatory or metacognitive skills taught by cognitive therapists. Thus, one would expect WOR scores to change during cognitive therapy (CT) and to be associated with change in depression level. Twenty-seven patients with a DSM-III-R diagnosis of major depression who had received CT filled out the WOR and other measures of cognition. After 12 weeks of CT, the patients exhibited change in the WOR, the Attributional Style Questionnaire, the Dysfunctional Attitude Scale, and the Self-Control Scale. Furthermore, there were indications that change in depression was associated with changes in these measures of cognition, including the WOR. The WOR appears to be a sensitive measure of change during CT that covaries with change in depression. It remains to be tested whether change on the WOR is specific to CT.
The predictive validity of instruments commonly used to measure the therapeutic alliance was evaluated, using 46 sessions drawn from a clinical trial comparing manual-guided therapies for substance use. The California Psychotherapy Alliance Scale, Penn Helping Alliance Rating Scale, Vanderbilt Therapeutic Alliance Scale, and Working Alliance Inventory (Observer, Therapist, and Client versions) were rated for participants receiving either cognitive-behavioral therapy or twelve-step facilitation. All observer-rated instruments were significantly correlated with outcome; however, therapist-rated and client-rated instruments did not predict outcome. Findings suggest that the different observer-rated instruments are minimally different with respect to predictive validity, whereas patient- and therapist-rated measures may have a weaker relationship to outcome when highly objective outcome measures are used.
Studies of the therapeutic alliance in cognitive-behavioral therapy (CBT) have varied in their results, necessitating a deeper understanding of this construct. Through an exploratory factor analysis of the alliance in CBT, as measured by the Working Alliance Inventory (shortened, observer-rated version), the authors found a two-factor structure of alliance that challenges the commonly accepted one general factor of alliance. The results suggest that the relationship between therapist and client (Relationship) may be largely independent of the client's agreement with and confidence in the therapist and CBT (Agreement/ Confidence), necessitating independent measures of these two factors, not one measure of a general alliance factor.
A case study of a time-limited interpersonal psychotherapy group (IPT-G) is presented to illustrate the use of interpersonal therapy (IPT) to treat patients with major depression in a group psychotherapy format. The use of individual outcome measures as a helpful adjunct to clinical psychotherapeutic practice is demonstrated. Because IPT-G has only a few exclusion criteria (active suicidality and significant borderline personality features), it can be used in a broad range of clinical settings. This clinical example demonstrates IPT-G to be a useful modality for addressing a common and difficult patient population.
Patients with dysthymia have been shown to respond to treatment with antidepressant medications, and to some degree to psychotherapy. Even patients successfully treated with medication often have residual symptoms and impaired psychosocial functioning. The authors describe a prospective randomized 36-week study of dysthymic patients, comparing continued treatment with antidepressant medication (fluoxetine) alone and medication with the addition of group therapy treatment. After an 8-week trial of fluoxetine, medication-responsive subjects were randomly assigned to receive either continued medication only or medication plus 16 sessions of manualized group psychotherapy. Results provide preliminary evidence that group therapy may provide additional benefit to medication-responding dysthymic patients, particularly in interpersonal and psychosocial functioning.
