High-yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide, includes DVD by Jesse H. Wright, Donna M. Sudak, Douglas Turkington, Michael E. Thase (American Psychiatric Publishing)
High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide breaks entirely new ground in explaining how to weave together the powerful tools of CBT with pharmacotherapy in sessions shorter than the traditional "50-minute hour." Written for psychiatrists, therapists, and other clinicians, the book details ways to enrich brief sessions with practical CBT interventions that work to relieve symptoms and promote wellness.
An engaging and instructive resource of video illustrations included with the book demonstrates how to successfully implement brief CBT sessions for some of the most common and important problems seen in clinical practice—depression, anxiety, psychotic symptoms, suicidality, sleep disturbances, substance abuse, and coping with physical health issues. Written by practicing clinicians with extensive experience in combining CBT and pharmacotherapy, this volume builds on the constructs and techniques described in the authors' earlier best-selling illustrated guides, Learning Cognitive-Behavior Therapy and Cognitive-Behavior Therapy for Severe Mental Illness.
A must-read for working clinicians as well as trainees, this book offers pragmatic solutions for the challenge of providing effective psychotherapy in brief treatment sessions.
Jesse H. Wright, M.D., Ph.D., is Professor and Vice Chair for Academic Affairs in the Department of Psychiatry and Behavioral Sciences and Director of the Depression Center at the University of Louisville, Kentucky.
Donna M. Sudak, M.D., is Professor of Psychiatry and Director of Psychotherapy Training at Drexel University College of Medicine in Philadelphia, Pennsylvania.
Douglas Turkington, M.D., is Professor of Psychosocial Psychiatry at the Institute of Neuroscience, Newcastle University, Royal Victoria Infirmary; and Consultant Liaison Psychiatrist with Northumberland, Tyne and Wear NHS Trust, St. Nicholas Hospital, Gosforth, Newcastle-upon-Tyne, United Kingdom.
Michael E. Thase, M.D., is Professor of Psychiatry and Director of the Mood and Anxiety Disorders Section at the University of Pennsylvania School of Medicine in Philadelphia, Pennsylvania.
In the courses and workshops we teach on cognitive-behavior therapy (CBT), we have been hearing an increasing chorus of requests to help practicing clinicians learn how to use key CBT methods along with psychopharmacology in brief sessions. These requests are pertinent 1) because most psychiatrists and other clinicians who use psychopharmacology in treatment of mental disorders are devoting large portions of their practice to sessions that are briefer than the traditional "50-minute hour" and 2) because medications, while invaluable, frequently do not provide full relief from the symptoms of mental illness. If clinicians want to offer more than symptom assessment and medication management in these sessions, how can they pragmatically apply CBT methods to enhance the treatment process?
As psychiatrists who have been trained in both pharmacotherapy and CBT, we have been using a combined approach in brief sessions for a number of years and have learned ways of infusing these sessions with the collaborative-empirical style of CBT. We have also been working on methods of efficiently using "high yield" techniques to target specific symptoms or problems and have drawn on these experiences to write this guide to combining CBT and pharmacotherapy in brief sessions. The methods described here are offered as suggestions or clinical tips, not as a scientifically proven treatment approach. Randomized controlled trials of CBT have focused heavily on implementation in 45-60 minute sessions. Research on CBT in brief sessions is clearly needed, but we believe that there has been enough clinical experience in using CBT in shorter sessions with medication to present guidelines for practitioners who want to use this approach.
The book begins with chapters that 1) describe basic principles for combining CBT with pharmacotherapy in brief sessions, 2) explain the comprehensive cognitive-behavioral-biological-sociocultural model for treatment, and 3) describe indications and applications of the brief session format. Because CBT is formulation driven, even in shorter sessions, a chapter is included on how to perform a succinct case conceptualization, construct a "mini-formulation," and plan treatment interventions. Also, an early chapter discusses ways of promoting effective therapeutic relationships when brief sessions are being used. The first four chapters cover the core methods of combined CBT and pharmacotherapy that provide a solid platform for implementation of the specific procedures described in subsequent chapters.
Portions of the book devoted to targeted applications of CBT cover topics that we have found to be especially important in treatment of a broad range of clinical conditions, including mood and anxiety disorders and psychoses. One of the most important chapters is on medication adherence. Application of CBT in brief sessions might be justified by this indication alone because of the very high rate of nonadherence to psycho-tropic medications and the strong evidence for effectiveness of CBT in improving adherence. We think that CBT offers very practical methods for adherence that are easily adapted for use in medication management.
Other chapters focus on some of the key elements of CBT that we have found to be particularly helpful in brief sessions. These include behavioral methods for depression and anxiety, cognitive restructuring techniques, and interventions to reduce hopelessness and suicidality. Behavioral methods such as activity scheduling, graded task assignments, exposure and response prevention, and breathing retraining can be explained in brief sessions, assigned for homework, and followed up at subsequent visits. Simple, targeted cognitive restructuring can be performed either to reverse maladaptive patterns of thinking in mood disorders or to assist with other therapy tasks such as improving adherence. CBT methods can also be very helpful in working with patients who have hopelessness and suicidal thinking. Although longer sessions or hospitalization may be needed when suicide risk is high, we describe how CBT may have a place in shorter sessions for patients who are hopeless and despairing.
Insomnia is another very useful application for CBT in brief sessions. CBT has been shown to be at least as effective as sleeping medication for insomnia and does not have problems with side effects, tolerance, or rebound insomnia. In Chapter 10, "CBT Methods for Insomnia," we outline the CBT approach to insomnia including education on sleep hygiene, restructuring of cognitions about sleep, use of relaxation and imagery strategies, sleep logs, and other valuable techniques.
Chapter 11, "Modifying Delusions," and Chapter 12, "Coping With Hallucinations," deal with specialized CBT interventions for patients with delusions or hallucinations. Often, briefer sessions are preferentially selected for patients with psychotic disorders because problems with attention span, concentration, or agitation may decrease the value of longer interventions. After establishing a collaborative therapeutic relationship, clinicians can help normalize symptoms, perform effective psychoeducation, modify delusional thinking, and teach methods for coping with hallucinations. CBT methods for adherence described earlier in the book are especially helpful for working with patients with psychotic disorders.
CBT is gaining increasing acceptance in the treatment of substance abuse and can be delivered in some instances in short sessions in combination with other approaches, such as pharmacotherapy and 12-step involvement. For example, the authors have had positive outcomes of treatment of individuals with alcohol addiction who were seen for brief CBT-oriented sessions on a weekly basis, in addition to attending AA meetings and taking naltrexone. In Chapter 13, "CBT for Substance Misuse and Abuse," we detail a variety of methods of efficient adaptation of CBT techniques in treatment of substance abuse.
We discuss CBT methods for helping with problems of habits or lifestyle in Chapter 14, "Lifestyle Change: Building Healthy Habits." These techniques include helping patients stick with exercise or diet programs or break patterns of procrastination. In Chapter 15, "CBT in Medical Patients," we explain how to integrate a CBT approach into long-term medication management and how to use CBT to build the patient's strengths in preventing symptom return.
The final chapter covers one of the most useful applications of CBT in brief sessions—relapse prevention. In our clinical practices, we see many patients with conditions that require indefinite maintenance therapy with medications such as lithium carbonate, atypical antipsychotics, anticonvulsants, or antidepressants. For these patients, acquiring CBT skills for managing stress and spotting early signs of potential relapse can be a very useful addition to the treatment program.
As in two earlier books, we use video illustrations to convey key concepts and methods. Readers of these earlier books have told us that video illustrations help bring CBT alive and provide useful models for how to implement therapy. The video illustrations are integrated with specific content in the book so that you will find them to be most effective if viewed in sequence at the time recommended in the text. The videos were produced with the kind assistance of colleagues who role-played patients with various psychiatric problems. We used a naturalistic style of filming that attempted to show interventions much as they would appear
in actual clinical practice. The videos were filmed in clinical offices at the University of Louisville in Kentucky and at Newcastle University in the United Kingdom with the help of video production departments from both of these institutions.
Case illustrations that appear in the videos or elsewhere in the text are either entirely fictitious or are amalgams of cases that we have treated in which identifiers have been removed or altered to protect confidentiality. We use the convention of writing about cases as if they have actually been treated by us in order to enhance the flow and appeal of the text. Instead of using the phrase he or she (or she or he), we alternate use of personal pronouns when not describing specific cases.
Throughout the book, we discuss various worksheets, forms, and resources that are useful tools for patients and clinicians to use in CBT. To aid our readers, we've collected these materials in Appendix 1, "Worksheets and Checklists," and Appendix 2, "CBT Resources for Patients and Families." We have included these appendixes online, available as free downloads and in larger format, on the American Psychiatric Publishing Web site:www.appi.org/pdf/62362. Permission is granted for readers to use these worksheets, handouts, and inventories in clinical practice. Please seek permission from the individual rights holder for any other use. See
Two additional appendixes are provided to aid your use of this book and learning CBT methods. As a handy reference, Appendix 3, "CBT Educational Resources for Clinicians," lists courses and workshops, certification, fellowship opportunities, and a resource for computer-assisted CBT training. Appendix 4, "DVD Guide," contains a list of videos discussed in the text.
In writing this book on brief sessions of CBT and medication, we do not intend to recommend or advocate for this approach over the more conventional modes of treatment delivery for CBT. In fact, we typically perform CBT in 50-minute sessions with a portion of our patients and also frequently arrange for other therapists to provide this form of treatment. The purpose of the book is to help psychiatrists and other clinicians who perform pharmacotherapy to adapt CBT for use in their brief sessions, and thus add a cognitive-behavioral therapeutic dimension to routine clinical management. In Chapter 2, "Indications and Formats for Brief CBT Sessions," we explain clinical situations in which brief sessions may be indicated either as the sole treatment method or as an adjunct to longer sessions with another therapist.
Our own clinical practices have been enriched by the practical yet compelling methods of CBT, and we hope that you will also find that CBT helps your patients get the most from the time spent in treatment sessions.
Psychodynamic Psychotherapy for Personality Disorders: A Clinical Handbook edited by John F. Clarkin, Ph.D., Peter Fonagy, Ph.D., and Glen O. Gabbard (American Psychiatric Publishing) This well-documented and articulate manual gathers in one place the psychodynamic psychotherapy thinking and research on each of the Axis II personality disorders. Psychodynamic Psychotherapy for Personality Disorders: A Clinical Handbook includes the work of 22 contributing writers in addition to the three primary authors, John F. Clarkin, Ph.D., Peter Fonagy, Ph.D., and Glen O. Gabbard, M.D. Each contributor has extensive clinical experience, and some also have research experience, with the assessment and treatment of specific personality disorders. The focus of the book is the psychodynamic conceptualization, assessment, and treatment of the personality disorders as currently described in the Diagnostic and Statistical Manual of Mental Disorders. The 16 chapters are divided into sections that address the definition of personality pathology, approaches to treatment, and research for future directions. The authors conclude that to the surprise of many new research and reviews indicate that psychodynamic treatments are effective for personality disorders, and their impact is as great as that of cognitive-behavioral treatments.
Excerpt: Clinicians recognize that symptoms reside within a person whose personality patterns are unique (Westen et al. 2006). All therapeutic interventions, including medication management, involve a complex relationship between a patient, of unique personality, and a clinician. This book is about the individual patient whose personality can be conceptualized as dysfunctional along a continuum from mildly to severely disturbed; its focus is on advances in assessment and treatment of the personality disorders from a psychodynamic orientation.
The prevalence of the personality disorders is high; in the general U.S. population, it ranges from 1.5% for the Cluster B disorders to 5.7% for the Cluster A disorders and 6.0% for the Cluster C disorders, with 9.1% for any personality disorder (Lenzenweger et al. 2007). A reexamination of psychodynamic treatments is timely. Recent empirical evidence indicates that patients with mixed personality disorder and those with severe personality disorders, such as borderline personality disorder, respond to psychodynamic treatments, as documented by Leichsenring in Chapter 15.
This handbook is intended for clinicians with a range of expertise who utilize a psychodynamic orientation in their assessment and/or treatment of patients with personality pathology. The chapters are organized to inform students of psychotherapy (psychology graduate students, psychiatric residents, psychoanalytic candidates) and experienced clinicians. Of special interest to students are the clear statement of intervention principles (Key Clinical Concepts) and the suggested readings section offered in each chapter. Experienced clinicians may find the update of object relations and attachment theory and research, neurocognitive science information, and differentiated chapters on the various personality disorders and constellations helpful in refining their work. The treatment chapters include both principles of intervention
and clinical illustrations. Although the chapters cover a particular disorder (e.g., borderline personality disorder) or one of the three clusters of disorders in Axis II, we do not overlook the extensive comorbidity on Axis II and the superiority of a dimensional view of personality pathology over a categorical one (see Chapter 1).
Part I is focused on the nature of personality pathology. The model of personality and personality pathology informs the clinician at every step in the assessment and treatment of patients, whether they be patients with major Axis I disorders with comorbid personality pathology or patients with major difficulties of personality. Caligor and Clarkin (Chapter 1) describe an object relations model of normal and disturbed personality functioning with its implications for a typology and an assessment of personality organization. From this orientation, the assessment of personality pathology for differential treatment planning must take into account not only the descriptive characteristics of the personality pattern, but also the severity of personality pathology in reference to key functions of the individual such as self and other representations, defensive functioning, modulation of affect, and moral functioning. In Chapter 2, Fonagy and colleagues present an attachment theory perspective on personality development and functioning. Attachment theory, with its related methods for empirical assessment of working models of self and others and related interpersonal behavior, has provided a powerful framework for understanding personality from a developmental perspective. Roth and Buchheim (Chapter 3) provide the reader with a current understanding of the neurobiology of personality functioning. They point out that personality disorders are the result of a combination of genetic polymorphisms, deficits in brain development, and adverse developmental experiences. They emphasize that many brain areas are sites of intense interaction between emotional and cognitive processes. Neurobiological data have accumulated particularly on borderline and antisocial personality disorders, revealing dysfunctions in brain networks and in neuronal metabolism. To complete this section, Shedler and Westen (Chapter 4) explore the divide between science and clinical practice in understanding personality disorder, a gap that is most evident in the assessment of personality pathology. Rather than use the semistructured interviews so popular in research, clinicians employ the clinical interview to examine the interpersonal world of the patient, including how the patient relates to the clinician. These authors provide both a method of diagnosis based on a clinical interview that is empirically sound and a description of personality disorder prototypes that is richer than that found on Axis II of DSM-IV-TR (American Psychiatric Association 2000).
The background of models of personality and its pathology comprises Part I. Part II contains chapters on the treatment of specific constellations of personality disorder. Each of the treatment chapters provides information on the relevant empirical research, patient phenomenology and psychodynamics, and treatment strategies and techniques, woven together with clinical illustrations and vignettes.
The DSM-IV-TR Axis II Cluster A personality disorders (schizoid, schizotypal, and paranoid personality disorders) and their treatment are described by Williams (Chapter 5). The therapist is faced with many challenges in patients with these treatment-resistant disorders, especially transference difficulties, which may only be hinted at by the patient. The pathology of these personality disorders demands that the therapist give special attention to building a trusting therapeutic relationship with patience, persistence, and careful attention to the interaction.
Probably the most extensive research, both phenomenological and therapeutic, has been done with the Cluster B personality disorders. Bateman and Fonagy (Chapter 6) describe a treatment for borderline patients that is focused on improving the ability of the patient to understand self and others in terms of thoughts, emotions, and motivation: that is, mentalization skills. This treatment has been shown to significantly reduce symptoms in day hospital and outpatient treatment settings. In addition, the follow-up data indicate that patients who have been treated with mentalization-based therapy maintain their treatment gains, and this result is hypothesized to be related to their increased mentalizing capacities in understanding self and others. Yeomans and Diamond (Chapter 7) describe an alternative psychodynamic treatment for borderline patients called transference-focused psychotherapy (TFP). This intense individual treatment for borderline patients targets the patient's representations of self and others as they are demonstrated in the interaction with the therapist. TFP has been shown to significantly reduce symptoms and to compare favorably with a special supportive treatment and with dialectical behavior therapy. In addition, TFP has been shown to significantly increase reflective functioning, a measure of the ability to conceptually describe self and others with depth of understanding. In Chapter 8, Gabbard raises the central question of current psychotherapy research: If treatments work (i.e., reduce symptoms), how do they work? What are the mechanisms of change? He argues that the clinical and research approaches to the mechanisms of change all have limitations, but that it is quite likely that multiple mechanisms of change are operative. This focus on multiple mechanisms of change is demonstrated in all the treatment chapters in this volume.
In Chapter 9, Kernberg views narcissism as a pathological regulation of self-esteem and self-regard. He explores the complex relationship between self-esteem, moods, and the vicissitudes of internalized object relations. Normal narcissism, infantile narcissism, and pathological narcissism are distinguished, and treatments for different levels of pathological narcissism are examined. In particular, Kohut's self psychology, Rosenfeld's Kleinian approach, and Kernberg's object relations approach are described and contrasted. Horowitz and Lerner (Chapter 10) use an understanding of states of mind and configural analysis to formulate treatment for patients with histrionic personality disorder—that is, individuals with undermodulated states of intense negativity that lead to emotionally impulsive relationship behaviors. Three treatment phases are described: reduction of crises and increase in stability, increasing connections to others, and finally increased self-coherence and improvement of intimacy with others. Meloy and Yakeley (Chapter 11) view antisocial personality disorder from an attachment theory perspective with an emphasis on the dimensionality of the pathology. Whereas specific cognitive-behavioral techniques have been emphasized in the literature, the importance of deficits in internal experiences of these patients leads to the consideration of dynamic approaches to increasing self-reflection and mentalization for a subset of these patients. Svartberg and McCullough (Chapter 12) utilize their empirical work with Cluster C patients (avoidant, dependent, obsessive-compulsive) to describe a treatment that integrates cognitive-behavioral and psycho-dynamic techniques to assist patients in the management of affect.
The setting of treatment for patients with personality disorders is usually an outpatient one. However, when functioning is compromised and symptoms are severe, inpatient and day hospital settings offer a unique opportunity to treat patients with severe personality disorders. With their extensive clinical and research experience with these treatment settings, Piper and Steinberg (Chapter 13) address the need for day hospital and inpatient treatment for selected patients. Despite advances in the treatment of many of the personality disorders, there are patient characteristics with diagnostic and nondiagnostic features that define the limits of treatability. Stone (Chapter 14) describes these specific factors based on the literature and his own clinical experience.
Part III includes a summary of the existing treatment outcome research and a glimpse of the diagnostic procedures in the near future. The introduction of Axis II in DSM-III (American Psychiatric Association 1980) provided a reliable diagnostic framework that led to many empirical studies on the pathology and treatment of individuals with personality disorders. The growing empirical investigation of psycho- dynamic treatments for personality pathology is summarized in Chapter 15 by Leichsenring. This research puts dynamic treatments for patients with personality disorders on a firm footing in the current environment of empirically supported treatments.
Empirical research generated since 1980 on the phenomenology of the personality disorders has produced new information that will be utilized in an improved description of personality pathology in the forthcoming DSM-5. Oldham, a member of the committee on Axis II for DSM-5, describes (in Chapter 16) the current thinking of the committee concerning the diagnosis of personality pathology.
The interested reader must legitimately ask: What is it about the treatments in this book that makes them psychodynamic? What are the defining features of psychodynamic treatments across disorders, and, more specifically, psychodynamic treatments for the patients with personality disorders? The latter question is especially relevant in this era of manualized treatments with specified treatment strategies and techniques that provide a much more refined description of the treatment in question than some vague and abstract label of psychodynamic, cognitive-behavioral, or emotion-focused therapy.
The question of what is psychodynamic treatment for the patients with personality disorders can be answered at two levels. First of all, one can consider the definition of psychodynamic treatments and their defining characteristics in contrast to other treatments such as those with a cognitive-behavioral orientation. Second, one can examine the treatments described in this book that claim to be psychodynamic and generalize to commonalities across the treatments. Taking the latter approach, we can readily see that, at a general level, psychodynamic treatments have a number of characteristics in common. There is great attention to the current active relationship between patient and therapist. The psychodynamic therapist uses many sources of information to understand her patient's relationship style, including an observation of the patient's behavior, his conscious understanding of his own interactive style, and his descriptions of relationships, as well as the therapist's own cognitive-emotional reaction to how the patient is relating to her. In trying to understand this relationship in the present, the psychodynamic therapist has a model of the mind that goes beyond the overt behavior and the conscious cognitive statements of the patient to a level of motivation and mental life that is out of the awareness of the patient. The therapist is very interested in the meanings that the patient attributes to his own thoughts, affective states, and actions, as well as his understanding of internal and external experiences. The therapist is interested in understanding the way a patient's experience and actions
can be understood by hypothesizing about past experience (the influence of the patient's past upon present attitudes and behavior) and is on the alert for signs of transference—that is, patterns of relating to the therapist in the present that may indicate persistence of or reactions against significant relationship patterns in the past.
How are these psychoanalytic models characterized in relation to patients with personality disorders? Patients with personality disorders are those individuals who, by definition, have difficulties in relating to others to such a degree that it interferes with major areas of adjustment in life such as work, profession, social life, and intimate relations. Therapists who consider themselves psychodynamic are most alert to how the patient structures the present relationship in the initial sessions. This attention to the patient's current interactive style is simultaneously both diagnostic and relevant to the therapist reactions that might be crucial to whether the treatment continues or the patient prematurely ends the relationship. While the dynamic therapist is alert to symptoms that may plague the patient with a personality disorder (e.g., depression, anxiety), the major focus is on the anomalies and distortions, conflicts and deficits in relating to others (including, but not exclusive to, the therapist) that may have a central role in the symptomatic state of the patient.
Dynamic therapists working with personality-disordered patients utilize models of personality pathology (Chapters 1 and 2) that emphasize developmental distortions and anomalies in cognitive and affective processes in the understanding of self and others. It is these poorly articulated, underdeveloped, or distorted internalized representations that are the object of assessment and change. The need to arrive at a diagnosis of the personality pathology, both prototypically (Shedler and Westen, Chapter 4) and dimensionally (Chapter 1) is followed by a shaping of the dynamic treatment to the differential characteristics of the patient.
A careful examination of the psychodynamic treatments for the various personality disorder diagnoses in this book suggests that contemporary psychodynamic researchers and clinicians experience the need to vary the treatment to the specifics of the personality pathology. There is no suggestion in this book that one psychodynamic treatment fits all personality pathology (although this has been frequently assumed to be the case in the past). One could argue that any treatment, whether psychodynamic or cognitive-behavioral, must go beyond the general treatment for a patient with a specific personality disorder to the tailoring of the treatment for the specific patient, who has a personality disorder that is not adequately captured by the category of pathology because it is modified by the patient's strengths and particular social context. In this regard, the various chapters in this book provide psychodynamic templates for approaching patients with prominent (but not exclusive) personality features that match a particular category. These templates can be adapted to the specifics of the individual patient with his or her unique combination of pathology and strengths being played out in a particular environment that the patient helped construct. In contrast to the stereotype of dynamic treatment as focused on the patient's past, the treatments for personality disorders described here focus primarily on the present.
There is a marked overlap between modern dynamic treatments and cognitive-behavioral treatments for patients with personality disorder. This is an indication of historical shifts in both orientations and also of the common constraints that personality disorder places on the therapeutic relationship. The so-called common factors of structure, support, empathic relationship, and therapeutic alliance are active in most treatments. In addition to the common strategies and techniques, some psychodynamic treatments (see, e.g., Chapter 12) describe an explicit combination of what are called psychodynamic and cognitive-behavioral techniques. In general, in putting together this book we have noted a marked convergence of therapeutic approaches and many indications that the era of a strict and clear demarcation between psychodynamic and other treatments may be over. One sees the inclusion of cognitive-behavioral techniques in dynamic treatments, and conversely one sees cognitive-behavioral writers putting more emphasis on the therapeutic relationship and the patient's resistance (see Leahy 2001).
We, the editors of this volume, have enjoyed the collegial support of our accomplished authors. It was only with their enthusiastic response that we could bring together current psychodynamic thinking on the models, assessment, and treatment of patients with personality disorders.
Systems of Psychotherapy: A Transtheoretical Analysisby James O. Prochaska, John C. Norcross John C. Norcross (Brooks Cole) Systematic and balanced, this comprehensive text uses a wealth of clinical case illustrations to help readers understand a wide variety of psychotherapies including psychoanalytic, psychodynamic, existential, person-centered, experiential, interpersonal, exposure, behavioral, cognitive, systemic, multicultural, and integrative. The Seventh Edition thoroughly analyzes 15 leading systems of psychotherapy and briefly surveys another 30, thus providing a broader scope than is available in most textbooks. Prochaska and Norcross explore each system's theory of personality, theory of psychopathology, and resulting therapeutic process and relationship. By doing so, they demonstrate how much psychotherapy systems agree on the processes producing change, while showing how they disagree on the content that needs to be changed. To bring these similarities and differences to life, the authors also present the limitations, practicalities, and outcome research of each system of psychotherapy.
The book provides a systematic, comprehensive, and balanced survey of the leading systems of psychotherapy. It is designed, however, to be more than just a survey, as we strive toward a synthesis both within each psychotherapy system and across the various systems. Within a particular system of therapy, this book follows the integrative steps that flow from the system's theory of personality to its theory of psychopathology and culminates in its therapeutic process and therapy relationship. Across the various systems of therapy, our book offers an integrative framework that highlights the many similarities of therapy systems without blurring their essential differences. The comparative analysis clearly demonstrates how much psychotherapy systems agree on the processes producing change while disagreeing on the content that needs to be changed.
Systems of Psychotherapy: A Transtheoretical Analysis is intended, primarily, for advanced undergraduate and graduate students enrolled in introductory courses in psychotherapy and counseling. This course is commonly titled Systems of Psychotherapy, Theories of Counseling, Psychological Interventions, or Introduction to Counseling and is offered to psychology, counseling, social work, psychiatry, nursing, human relations, and other students. Our volume is intended, secondarily, for psychotherapists of all professions and persuasions seeking a comparative overview of the burgeoning field of psychotherapy. We have been immensely gratified by the letters and comments from readers who have used this text in preparing for comprehensive exams, licensure tests, and board certification as well as from those who have found it instrumental in acquiring a more integrative perspective on clinical work.
The contents and goals of this seventh edition embody our objectives as psychotherapy practitioners, teachers, researchers, and theorists. As practitioners, we appreciate the vitality and meaning of different clinical approaches. We attempt to communicate the excitement and depth of understanding of these psychotherapy systems. Accordingly, we avoid simple descriptions of the systems as detached observers in favor of immersing ourselves in each system as advocates.
As practitioners, we are convinced that any treatise on such a vital field as psychotherapy must come alive to do the subject matter justice. To this end, we have included a wealth of case illustrations drawn from our combined 65 years of clinical practice. (When one of us is speaking from our own experience, we will identify ourselves by our initials—JOP for James 0. Prochaska and JCN for John C. Norcross.) We demonstrate how the same complicated psychotherapy case—Mrs. C—is formulated and treated by each system of psychotherapy. This and all of the case examples counterbalance the theoretical considerations; in this way, theories become pragmatic and consequential—relevant to what transpires in the therapeutic hour. The details of individual clients have been altered, of course, to preserve their anonymity.
As psychotherapy teachers, we recognize the complexity and diversity of the leading theories of psychotherapy. This book endeavors to present the essential concepts clearly and concisely but without resorting to oversimplification. Our students occasionally complain that theorists seem to have a knack for making things more complicated than they really are. We hope that as readers move through these pages they gain a deeper appreciation for the complexity of the human condition or, at least, the complexity of the minds of those attempting to articulate the human condition.
Our decades of teaching and supervising psychotherapy have also taught us that students desire an overarching structure to guide the acquisition, analysis, and comparison of information. Unlike edited psychotherapy texts with varying writing styles and chapter content, we use a consistent structure and voice throughout the book. Instead of illustrating one approach with Ms. Apple and another approach with Mr. Orange, we systematically present a detailed treatment of Mrs. C for each and every approach.
As psychotherapy researchers, the empirical evidence has taught us that psychotherapy has enormous potential for impacting patients in a positive (and occasionally a negative) manner. In this view, therapy is more analogous to penicillin than to aspirin. With psychotherapy expected to produce strong rather than weak effects, we should be able to demonstrate the effectiveness of psychotherapy even in the face of error caused by measurement and methodological problems. We thus include a summary of controlled outcome studies and meta-analytic reviews that have evaluated the effectiveness of each therapy system.
Research and practice have further taught us that each psychotherapy system has its respective limitations and contraindications. For this reason, we offer cogent criticisms of each approach from the vantage points of cognitive-behavioral, psychoanalytic, humanistic, cultural, and integrative perspectives. The net effect is a balanced coverage combining sympathetic presentation and critical analysis.
As psychotherapy theorists, we do not endorse the endless proliferation of psychotherapy systems, each purportedly unique and superior despite the absence of research evidence. What our amorphous discipline does need is a concerted effort to pull together the essentials operating in effective therapies and to discard those features unrelated to effective practice. From our comparative analysis of the major systems of therapy, we hope to move toward a higher integration that will yield a transtheoretical approach to psychotherapy.
And from comparative analysis and research, we hope to contribute to an inclusive, evidence-based psychotherapy in which treatment methods and therapy relationships—derived from these major systems of therapy—will be tailored to the needs of the individual client. In this way, we believe, the effectiveness and applicability of psychotherapy will be permanently enhanced.
Innovations appear and vanish with bewildering rapidity on the psychotherapeutic scene. One year's treatment fad—say, neurolinguistic programming—fades into oblivion in just a few years. The volatile nature of the psychotherapy discipline requires regular updates in order for practitioners and students to stay abreast of contemporary developments.
The evolution of this book closely reflects the changing landscape of psychotherapy. The first edition in 1979 was relatively brief and only hinted at the possibility of sophisticated psychotherapy integration. The second edition added sections on object relations, cognitive, and systems therapies. The third edition brought new chapters on gender-sensitive therapies and integrative therapies, new sections on interpersonal therapies and short-term psychodynamic therapies, and John Norcross as a coauthor. The fourth edition featured a new chapter on constructivist therapies and the addition of material on motivational interviewing, EMDR, and psychotherapy for men. The fifth edition brought a chapter on the future of psychotherapy to close the book and more material on the experiential therapies and on interpersonal psychotherapy (IPT). The sixth edition provided a separate chapter on multicultural therapies (formerly combined with gender-sensitive therapies) as well as a new section on common factors in the integrative therapies chapter.
This seventh edition, in turn, brings a host of changes that reflect recent trends in the field. Among these are:
With these additions, the text now thoroughly analyses 16 leading systems of psychotherapy and briefly surveys another 30, thus affording a broader scope than is available in most textbooks. Guiding all these modifications, however, has been the unwavering goal of our book: to provide a comprehensive, rigorous, and balanced survey of the major theories of psychotherapy. Expanding the breadth of Systems of Psychotherapy has been accomplished only within the context of a comparative analysis that seeks to explicate both the fundamental similarities and the useful differences among the therapy schools.
The 30-plus years since the first edition of this book have repeatedly taught us to keep our eye on the ball: student learning. On the basis of feedback from readers and our students, we have introduced aids to enhance student learning. These include:
Long-term Psychodynamic Psychotherapy: A Basic Text by Glen O. Gabbard (American Psychiatric Publishing) instructs in both the core principles of this fundamental treatment modality and its practice in real-world treatment settings. This second edition expands on the theoretical, technical, and clinical issues addressed in the popular first edition. Since the first edition appeared in 2004, rigorous research revealed in major psychiatric and psychological journals has further confirmed the efficacy of psychodynamic psychotherapy and how it can improve the lives of patients over time. Those findings make a thorough understanding of key concepts, assessment, indications, formulation, interventions, and the goals of therapy crucial for emerging psychotherapy professionals. An innovative feature of the new edition is a companion DVD in which the author brings the text to life, giving psychiatric residents and other mental health professionals an invaluable glimpse of a senior clinician at work. The DVD illustrates key clinical problems encountered in psychiatry, psychology, or social work and proven solutions gathered over many years of actual clinical experience.
The addition of findings from cognitive neuroscience studies of unconscious mental functioning, psychodynamic psychotherapy efficacy studies and the updated section on evaluating core competencies bring the reader up to date with advances in the field. This revision of Dr. Gabbard's introductory "course" in psychodynamic psychotherapy is a gift to all students of this complex yet essential form of treatment. An already outstanding volume is much improved by thoughtful additions to the text and accompanying videos that bring the words alive. It is like have one of the great clinician/educators of our time in the room, steadily opening doors to understanding.
Long-term psychodynamic psychotherapy can be defined as a treatment that focuses on thoughtfully timed interpretation of transference and resistance and a sensitive appreciation of how the therapist contributes to the interaction with the patient. For purposes of this text, the definition of long term is a duration greater than 24 sessions or 6 months. A set of basic theoretical models are also fundamental to dynamic therapy. These include ego psychology, object-relations theory, self psychology, and attachment theory. In addition to these theoretical models, a psychodynamic therapist is guided by a set of key concepts: 1) much of mental life is unconscious; 2) childhood experiences in concert with genetic factors shape the adult; 3) the patient's transference to the therapist is a primary source of understanding; 4) the therapist's countertransference provides valuable understanding about what the patient induces in others; 5) the patient's resistance to the therapy process is a major focus of the therapy; 6) symptoms and behaviors serve multiple functions and are determined by complex and often unconscious forces; and 7) a psychodynamic therapist assists the patient in achieving a sense of authenticity and uniqueness. A research base in long-term psychodynamic psychotherapy has been slow to develop, but the findings of existing studies are encouraging.
Psychotherapy Is Worth It: A Comprehensive Review of Its Cost-effectiveness by Susan G. Lazar (American Psychiatric Publishing) is a multi-authored systematic review of the medical literature from 1984 to 2007 relevant to the cost-effectiveness of all kinds of psychotherapy. It also reviews the stigma associated with psychiatric illness and its true cost to society. Mental illness is the leading cause of disability around the globe, according to the World Health Organization, and nearly half of the population will suffer from at least one psychiatric disorder in their lifetime. This book examines attitudes undermining the provision of psychiatric care including psychotherapy and the resulting lack of treatment leading to increased morbidity and mortality. The studies reviewed demonstrate that appropriate psychotherapeutic treatment contributes to better outcomes overall. Psychotherapy Is Worth It: A Comprehensive Review of Its Cost-Effectiveness concludes that psychotherapy works for many conditions, is cost-effective, can at times provide significant cost-offset in other medical and hospital expenses, and is not abused by those persons not truly in need.
In this much-needed, compelling, and well-researched volume, Dr. Lazar and The GAP Committee On Psychotherapy bring to light, in very accessible language, what psychotherapists witness first-hand and what the public-at-large, including policy-makers, needs to know about mental health and its startling connection to economics. Armed with scientific data about the efficacy of and necessity for psychotherapy, the authors underscore the ameliorative effects and, crucial in today's economic climate, the cost-effectiveness of engaging in psychotherapy in response to wide-ranging physical and emotional problems. This book is a must-read for anyone interested in reducing human suffering and the enormous fiscal toll that it perpetuates. --William J. Coburn, Ph.D., Psy.D., Editor-in-Chief, International Journal of Psychoanalytic Self Psychology
Psychotherapy As a Human Science by Daniel Burston and Roger A. Frie (Duquesne University Press) "An excellent brief philosophical background. I feel this book should be read by every psychotherapist in the field."—Maurice Friedman, author of The Worlds of Existentialism
A masterful survey, Psychotherapy as a Human Science provides a critical and clinical introduction to the core themes and influential thinkers that helped to shape contemporary human science approaches to psychotherapy.
Following in the continental tradition of a broad phenomenological orientation, Burston and Frie consider psychotherapies issues in light of the greater 20th centuries approach to meaning. The volume addresses issues not often addressed in psychotherapeutic framework that invites psychotherapists to become more engaged in self reflective practice than is the norm in objectified bureaucratized insurance driven psychotherapeutic practice.
Burston and Frie present an excellent and concise journey through the historical background that informs the development of psychotherapy, and then proceed to deal with many of the important facets of modem psychology and psychiatry from Dilthey and Husserl to the postmodern. Perennial issues in philosophy—the nature and scope of self-knowledge and self-deception, the roots of inner and interpersonal conflicts, the nature of love and reason, the relationship between reason and faith and imagination—take on new depth and meaning in light of nineteenth and twentieth century concepts of the unconscious, alienation, authenticity, alterity and the like. Burston and Frie not only demonstrate that European philosophers laid the foundations for the way many contemporary clinicians think and practice today but provide a theoretical orientation that is too often missing in today's medicalized practice environment.
Excerpt: This book invites readers to delve deeply into the history and theory of existentialism, phenomenology, psychoanalysis, depth psychology and humanistic psychology. The authors both explore the implications of these approaches for clinical practice and assert the significance of theory for clinical endeavors, encouraging mental health professionals, students and theorists to widen the scope of psychotherapy practice and training.
This book is the culmination of many years of research, reflection, and spirited, scholarly communication about psychotherapy as a human science. We began this process with the aim of filling a gap in the current literature on psychotherapy. Much is written today about advances in neuroscience, empirically validated treatments, and quantitative methods for the practice of psychotherapy. Yet scant attention is paid to the role that history, philosophy, and our implicit theoretical assumptions play in the assessment and treatment of human behavior. Our emphasis on psychotherapy as a human science does not mean we have overlooked the significance of neuroscientific studies, or deny the fact that empirically validated treatments have improved the reduction of specific symptoms in some disorders. Rather, our view is that unless psychotherapy as a whole is understood from the perspective of history and philosophy, the contemporary focus on manualized treatments and quantitative research results in a one-sided view of human psychology. Our chief objective, therefore, is to challenge the implicit theoretical assumptions we hold by demonstrating the extensive links that exist between psychotherapeutic and philosophic approaches to human experience, with special emphasis on the enduring importance of the existential-phenomenological tradition.
The scale of issues we attempt to incorporate is broad. At the same time, there are important trends in the contemporary literature on psychotherapy to which we have not been able to give our full attention. These include, for example, the discussion of gender, race, and post-colonialism; attachment studies; and neuroscientific research. All are relevant to understanding clinical theory and practice, but are not
covered extensively here. The limited discussion of a particular theme or approach should not be interpreted as evidence that we view one perspective as more or less relevant than another. Our choice of what to include — and what to exclude — has been shaped by our desire to provide readers with an in-depth historical analysis of the issues at hand, as well as by restrictions of space and length. Wherever possible we have sought to provide specific references to important contemporary themes and texts that we have been unable sufficiently to expand and elaborate ourselves.
Training in the mental health professions is increasingly driven by political and economic forces and has become very technical in focus. Insurance companies demand that psychotherapy be objectifiable, and as a result, manualized treatment protocols are now widespread. Because of this growing reliance on a natural science approach, the fact that psychotherapy rests on a set of implicit, philosophical assumptions about human experience is largely overlooked. Yet these philosophical assumptions often determine not only the objectives of psychotherapy, but also the actual framework in which it is practiced.
We have written this book in an attempt to move beyond the narrow technical concerns of much current psychotherapy. Our aim is to elaborate psychotherapy from a human science perspective in order to help professionals, students, and interested readers appreciate the importance of theory for clinical endeavors and thus to enlarge the scope of psychotherapy training and practice. Psychotherapy cannot be studied in a strictly empirical manner without also considering the history of philosophy, the challenges of ethics, and the vagaries of politics.
Our journey will take us on an exploration of an intellectual tradition that freely combines insights from philosophers, psychiatrists, and psychologists. The interplay between philosophy and psychotherapy, and its long history in Western thought, is especially relevant to our undertaking. The juxtaposition of philosophy and psychotherapy may seem unusual to those who are unaccustomed to making this connection. In fact, we will demonstrate that philosophers have much to teach therapists. In our view, philosophy is inherent to the very practice of psychotherapy.
For many psychotherapists, the greatest impediment to the introduction of philosophy into clinical discourse is the issue of how data are accumulated, interpreted, and assessed. Many clinicians have a stereotyped conception of the philosopher as an isolated scholar who reflects only on his or her own experience in a process of introspection. This view overlooks precisely what postmodernism has taught us: the generation of ideas is always dependent upon difference and otherness. Only by engaging with what is other than ourselves is it possible to open up new ways of thinking. And, as we shall see, many of the philosophers considered in this book are directly concerned with the practical application of their ideas, whether through teaching and research or the actual practice of psychology.
A dialogue with philosophy is not merely useful, but also vitally necessary for the grounding of theory, practice, and research in psychotherapy from a human science perspective. But what is a "human science perspective"? Prior to 1874, when Wilhelm Wundt founded the first psychological laboratory in Leipzig, psychology was traditionally linked with philosophy and focused not only on human behavior, but also on the nature of the mind or soul. Psychologists who broke with that tradition and embraced experimentalism and the natural science approach were often German or German-speaking and sought to distinguish their orientation from that of their predecessors and counterparts in philosophy and the humanities. So in the German language a distinction is often made between the natural sciences (Naturwissenschaften) and the human sciences (Geisteswissenschaften).
In the broadest sense, "natural" science seeks to study and elucidate the behavior of entities and processes that exist in nature. These are generally void of intention; that is to say, they are not endowed with experience or intentionality. Conversely, human behavior is almost always a function of an individual's experience of and intentions toward the world — a world that is constituted by and for the individual interms of culturally and historically embedded meanings and symbols, as well as his or her own idiosyncratic choices and decisions. Unfortunately, since the rise of experimental psychology more than a century ago, many branches of psychology and psychiatry methodically seek to bracket or nullify any careful consideration of human subjectivity and intentions — the very things that render human behavior intelligible in ordinary circumstances. Under the pretext that human behavior can be explained or interpreted without reference to the subject's experience and intentions, psychology, and psychiatry tend to reify or "objectify" the individual (Laing 1960).
For most of the twentieth century, academic psychology sought to elucidate the structures, processes, and functional interrelationships that suffused the mind and mental faculties or functions like intelligence, perception, memory, language acquisition, and the like. In order to achieve this objective, it generated empirical generalizations regarding the behavior of the organism under rigorously controlled laboratory conditions or in carefully designed longitudinal studies, in surveys, questionnaires, and so on. Moreover, it prided itself on being able to express or translate its findings into measurable mathematical formulas. The problem is that, on reflection, the "laws" arrived at in this way are merely empirical generalizations that apply to everyone at once, and to no one in particular. They are quite useful for understanding overarching trends in human behavior, but in the end they refer to a disembodied, ahistorical entity — a "generalized other."
The objectification of human behavior in academic psychology poses a number of challenges for psychotherapy. From a clinical point of view, one can be thoroughly versed in these laws of behavior, yet remain utterly incapable of developing a rapport with another human being or of understanding the nuances of clinical interaction when problems arise. For clinical purposes, these data just will not do. We require an approach that addresses what is distinctive about human behavior, applied judiciously to real flesh-and-blood human beings.
In light of these reflections, it should be clear by now that the various philosophical traditions we draw on are not distinct or discrete bodies of thought. On the contrary, they are often densely intertwined. Moreover, thinkers and therapists often situate themselves (or are situated by others) in more than one school of thought at once. This fact prompts a great deal of philosophical discussion, which precedes or accompanies our reflections on the theory and practice of psychotherapy throughout this book. The practical, clinical application of the ideas that make up the human science perspective in psychotherapy will be addressed in the concluding "Clinical Postscript."
The first chapters, which span the interval from Descartes to Dilthey, say little about psychotherapy as such. Instead, they survey a wealth of reasoned reflection on issues such as reason, faith, and emotion, the nature of love and work, the sources of human conflict and aggression, conscious and unconscious mental processes, authenticity and inauthenticity, and the scope and impact of self-deception in individual and group psychology.
Those with a clinical focus may balk at this lengthy preamble, for fear of losing their way in the dense thicket of ideas, or losing sight of the common ground that unites the therapists of today with philosophers of the past. To keep these common concerns clearly in view, we employ a series of binary classifications that enables us to make instructive comparisons between theorists in these different (but closely linked) fields of endeavor.
Unfortunately, like all heuristic schemata, the labels we use to classify thinkers across disciplinary boundaries may promote an oversimplification of very complex perspectives on the human condition. We are well aware of these dangers. Nevertheless, for the sake of drawing comparisons and of making instructive contrasts, we found it very helpful to discriminate between religious and irreligious thinkers, between rationalist and irrationalist thinkers, utopian and anti-utopian thinkers, and between moderns and postmoderns.
Because religion plays a central role in the work of many of the thinkers we examine, we begin with the contrast between religious and irreligious thinkers. Though not common in the American vernacular any longer, we deliberately chose the term "irreligious" to indicate that more than simple atheism is at issue here. Taken at face value, the word "atheism" simply betokens an absence of faith, which could easily be the expression of an indifferent or merely skeptical attitude toward the existence of God. The thinkers we deem to be "irreligious" were not merely indifferent or skeptical. On the contrary, they were atheists who rejected supernaturalism and the otherworldliness of traditional piety in principle. They thought of belief in God as an illusion, or as an ideological instrument wielded for the benefit of one group of people at the expense of another. Alternatively, they saw belief in God as a measure of our psychological immaturity, our inability to face up to the challenges of existence, and take responsibility for our own lives. Despite deep differences on other matters, there is a striking convergence on this point among the works of Feuerbach, Marx, Nietzsche, Freud, Alexandre Kojève, and Sartre.
Alternatively, among thinkers who cherish religious convictions, there is a startling diversity of perspectives, ranging from Pascal's "deus absconditus" to Hegel's "Absolute Spirit," Kierkegaard's "Single One," and Buber's "eternal Thou." Though we discuss broad trends, we cannot do justice to all the complex theological differences that exist among these thinkers. But we are aware of them and mindful of the fact that from Descartes to Dilthey, theological and philosophicalperspectives on human behavior are deeply intertwined. Indeed, though often dismissed as "unscientific" by clinicians who embrace a naturalistic perspective, theological issues are still pressing concerns for thinkers like Max Scheler and Martin Buber, and several therapists in our survey, including C. G. Jung, Erich Fromm, and R. D. Laing.
The distinction between religious and irreligious thinkers, though critical, provides only one way to map, explore and interpret a person's thought. Other dimensions are equally important, and equally revealing, albeit in different ways. Let us examine the distinction between rationalism and irrationalism.
Rationalism is characterized by its emphasis on the primacy of reason. Though it has roots in Greek philosophy and medieval scholasticism, modern rationalism really begins with Descartes (Levi 1974). Rationalists argue that reason alone provides us with a reliable guide to the truth — or "the Truth," as the case may be. By contrast with reason, say rationalists, faith, will, instinct, imagination, and passion are apt to mislead or cloud our judgment. Therefore, reason (or "the intellect") ought to inform, constrain, or, wherever possible, dominate all other aspects of human existence — especially passion, which is closely bound up with the body and its appetites.
In contrast to the primacy of reason espoused by rationalist thinkers, irrationalists contend that the human intellect is an inherently limited and imperfect instrument that operates in unconscious subjection to the person's will and the imagination. Or, as David Hume says, "the intellect is the slave of the passions." Another common theme among irrationalist philosophers is that there are other, equally valid ways of apprehending the truth that rationalism habitually disqualifies, such as faith, love, will, imagination, and so on. The classic statement of this idea is Pascal's maxim that "The heart has its reasons, of which reason is ignorant." Closely related to this kind of irrationalism is a view of human subjectivity shared by Dilthey, Buber, Marcel, Binswanger, Laing, and Levinas, which is beautifully summed up in Dilthey's favorite Latin saying: individuum est ineffabile. In other words, the core or heart of the human personality is always an ineffable mystery that cannot be adequately captured and expressed in language, or even comprehended by the intellect alone. On the contrary, a deep understanding of the other person requires that we address and encounter him or her with our entire being. As we shall see, this is an ethical as well as an epistemological imperative.
While rationalism and irrationalism clash incessantly in the history of philosophy, their disagreements are not purely theoretical. Leaving psychotherapy aside for the moment, they have profound ramifications for the study of politics and history. By and large, rationalists espouse a vision of the good life based on the belief that social relations are —or should be — regulated by contract, consent and rational deliberation. Indeed, for rationalists, these modes of relationship constitute the essential forms of social life, absent which a descent into barbarism is supposedly only a matter of time.
By contrast, irrationalists dismiss contract, consent, and rational deliberation as relatively recent and superficial accretions in the history of culture, and they emphasize the power of specifically nonrational processes that presumably promote solidarity and social cohesion, or their opposite, fragmentation, and conflict (Avineri 1974). Irrationalists regard the rationalist emphasis on the primacy of reason as being ignorant of the paradoxes and mysteries of the human soul. Rationalists, in turn, mistrust irrationalist politics, calling attention to their tendency to align themselves with extreme reactionary or revolutionary movements. And rightly so. If you survey major social movements in the nineteenth and twentieth centuries, you will find that fascism and anarchism both draw deeply on irrationalist ideologies of one sort or another.
Nevertheless, if you analyze the less virulent varieties of irrationalism, many of the arguments adduced against the hegemony of reason are cogent and humane. Indeed, as we shall see shortly, a "moderate" irrationalism, like Pascal's, for example, looks positively balanced in comparison with Descartes's sweeping rationalist assertions. Therefore, we maintain that not all "irrationalisms" are equivalent in terms of content, cogency, or overall merit, and that some versions of "irrationalism" are philosophically defensible. So we are not going to use the "irrationalist" label in a sweeping, indiscriminate fashion. And because so
many thinkers in our survey have been labeled as irrationalists at one point or another, we hasten to point out that there are also strong strains of rationalism embedded in the human science perspective in the work of Hegel, Husserl, Jaspers, Sartre, and Fromm. Though convenient for polemical purposes, it is actually quite misleading to represent the human science perspective as a specifically irrationalist one. The tension between rationalism and irrationalism runs right through it, as it does through all modern, and to a lesser extent, postmodern philosophy.
Beyond what we have said to this point, it is difficult to generalize about rationalism and irrationalism because this way of describing and apprehending a particular theoretical perspective cuts across the other relevant dimensions. Thus, irrationalism cuts across the traditional distinction between left- and right-wing ideologies. But it also complicates the distinction between religious and irreligious thinkers. This comes as a surprise to many people because, in the Enlightenment and post-Enlightenment context, when faith was often justified on the basis of "feeling," rationalism was often associated or simply equated with atheism. Nevertheless, Descartes was both a rationalist and a religious thinker, while Pascal, who was more devout, viewed Descartes's professions of faith as deluded or insincere. Leap two centuries ahead and you will find a similar drama played out between Hegel and Kierkegaard. Though no Cartesian, Hegel was a rationalist of sorts, while Kierkegaard was an irrationalist like Pascal, who doubted the sincerity of his bête noire's religious convictions.
Contrary to popular misconception, then, rationalism and irrationalism are perspectives or styles of thought that are actively at play within the theologico-philosophical perspective, as well as between religious and irreligious thinkers. And these reflections bring us to the inimitable Friedrich Nietzsche, who was both irreligious and an irrationalist at the same time. In this, no doubt, he was an original, and possibly the first of his kind. Indeed, Nietzsche was the only major thinker in the late nineteenth century who forcefully combined these two attributes, becoming the progenitor for the "postmodern" turn in philosophy.
Another issue we employ here that cuts across centuries, disciplines, and the other classificatory schemata is the role assigned to conflict and sociability in human existence. Beginning with Pascal, one school of thought, which we call "anti-utopian," says that human beings are constituted such that we are often at variance with one another, and indeed, with ourselves, and therefore destined to suffer from intractable inner and interpersonal conflict. From this point of view, peace and harmony, personal or interpersonal, are actually somewhat ephemeral goals because the roots of conflict and aggression are built into the human condition and no amount of inner transformation or social reform can alter this basic fact of life. This emphasis on the ubiquity of conflict characterizes theorists as diverse as Pascal, Nietzsche, Freud, Sartre, and Lacan. At the other extreme are theorists who stress human solidarity and sociability and our potential to mitigate or transcend inner and interpersonal conflict.
These divergent ways of framing the role of conflict and sociability in human affairs play an important role in how we manage and interpret (inner and interpersonal) conflict, and what we hope to achieve through clinical interventions. In psychoanalysis, for example, Freud's pessimism about human nature affected his austere approach to therapeutic interaction, while Binswanger's optimism led to a dialogical perspective on theory and practice. In fact, Freud told patients that the only thing the analytic process held in store for them was the prospect of exchanging their "neurotic misery" for "everyday unhappiness." Conversely, many post-Freudian analysts suggest that analytic therapy, if properly conducted, should yield robust improvements in the patient's interpersonal relationships.
Moreover, attitudes on this point — the presence and persistence of conflict — are often closely correlated with a theorist's views on love. Freud, Sartre, and Lacan subscribe to the view that love is blind, and they see love as an involuntary passion, or even an affliction. Others, like Scheler, Buber, Binswanger, and Fromm, claim that love bestows deeper insight into the beloved than is possible in any other way. Similarly, Freud, Sartre, and Lacan see love as a mode of relatedness to others that springs from a need for gratification, and they interpret attachment and desire as a response to that need. In other words, they see love as a creature of scarcity, driven to compensate for an experiencedabsence in the individual's existence. By contrast, Scheler, Buber, Binswanger, and Fromm see love as a mode of relatedness rooted in abundant strength, and in the presence, the particularity, and the immediacy of the other apprehended in a fully human way.Finally, we return to the distinction between modernism and postmodernism. In some ways, this should be the least troublesome classification. After all, with the well-known exception of Nietzsche, a distant progenitor, it is often assumed that postmodernism only becomes truly relevant after its inception in the political and social upheavals of 1968. In truth, however, many of the ideas implicit in postmodernism — the emphasis on perspectivity, the deconstruction of the isolated Cartesian subject, and recognition of our fundamental embeddedness in contexts beyond our awareness and control — were already introduced much earlier by the thinkers we will examine. The tension between modern and postmodern perspectives, which was supposed to have begun in the late twentieth century, already had shown up in the twenties, thirties and forties, demonstrating that modernism is a far more complex and ambiguous entity than its postmodern critics would have us believe. The tension between modernism and postmodernism will provide a means to understand the excesses of rationalism and irrationalism and will be a focus of the chapters ahead.
Introduction to Clinical Psychology (6th Edition) by Michael T. Nietzel, Douglas A. Bernstein, Richard Milich, Geoff Kramer (Prentice Hall) In the five previous editions of this book, we tried to accomplish three goals. First, we wanted a book that, while appropriate for graduate students, was written especially with sophisticated undergraduates in mind. Many undergraduate psychology majors express an interest in clinical psychology without having a clear understanding of what the field involves and requires. An even larger number of nonmajors also wish to know more about clinical psychology. We felt that both groups of undergraduates would benefit from a thorough survey of the field which does not go into all the details typically found in "graduate study only" texts.
Second, we wanted to present a scholarly portrayal of the history of clinical psychology, its scope, functions, and future that reviewed a full range of theoretical perspectives. For this reason, we have not allowed our preference for cognitive‑behavioral theories to limit our presentation. Instead, we present psychodynamic, phenomenological/experiential, interpersonal, and biological perspectives as well, and we have sought to do so in as neutral a manner as possible. We do champion the empirical research tradition of clinical psychology throughout the book because we believe it is a necessary and useful perspective for all clinicians to follow, regardless of their theoretical orientation.
Third, we wanted our book to be interesting and enjoyable to read. Because we like being clinical psychologists and because we enjoy teaching courses in the field, we tried to create a book that communicates our enthusiasm for its content.
Our goals for this sixth edition remain the same. However, in addition to the comprehensive updating of the content of all chapters, we have introduced some new material and reorganized our coverage of existing material somewhat. For example, we have expanded the coverage of clinical interventions to four chapters by adding a new chapter on alternative modes of intervention: group therapy, couples therapy, family therapy, psychosocial rehabilitation, prevention, community psychology, and self‑help. We have also combined the presentation of interviewing and observation into one chapter to reflect the complementary nature of these activities. In our updating of the major theoretical orientations and psychotherapeutic approaches, we have added new information on the movement toward theoretical integration and eclecticism. Sociocultural diversity affects psychological assessment, psychotherapy, and clinical research, so we have included new information on this topic throughout the book. Since our last edition, numerous changes have occurred in the health care delivery system, both in the United States and in other countries. Accordingly, we have addressed how managed care has continued to influence research and practice in clinical psychology since our last edition. Rapid changes have also occurred in psychotherapy research, so we have expanded our presentation of empirically supported treatments and of research on nonspecific treatment factors (i.e., therapist, client, and therapeutic relationship variables). Finally, we have expanded our discussions of the growing employment arenas for clinical psychologists in the fields of neuropsychology, health psychology, clinical child psychology, and forensic psychology.
Playing Hard at Life: A Relational Approach to Treating Multiply
Traumatized Adolescents by Etty Cohen (Analytic
Press, Inc., Publishers, Lawrence Earlbaum Associates) brings
contemporary relational thinking to bear on the psychodynamic
treatment of a notably difficult group of young patients: multiply
traumatized adolescents, whose understandable hostility, resistance,
even obstructiveness, render them poor candidates for treatment of
any kind. Working with
The strength of
Playing Hard at Life is Cohens detailed and moving
case-histories of hands-on encounters with her adolescent patients,
seen both individually and in group. Cohen makes plain that, with
young people so horrendously traumatized, treatment assumes a
necessarily improvisational character. And yet, she argues, even in
the type of pragmatic encounters dictated by massive and repeated
trauma, contemporary relational theory provides a compass with which
to navigate the rocky shoals of clinical work. Whether juxtaposing
issues of disclosure with adolescents love of secrets; drawing on
the relational literature on enactment to comprehend more humanly
the massive acting out of her patients: or invoking Ferenczis
distinction between tenderness and passion to chart the course of
her groups transference engagement of her, she is persuasive. She is
also persuasive in showing how a relational approach enables
productive therapy with this treatment-resistant population, and
adolescent therapists of all persuasions will find something new and
exciting in her synthesis of relational and classic psychoanalytic
writings on adolescence. Cohen is a faculty member and supervisor in
the Child and Adolescent Psychoanalytic Training Program, a training
and supervising analyst at The American Institute for Psychoanalysis
of The Karen Homey Psychoanalytic Center, and an adjunct professor
at the NYU Ehrenkranz School of Social Work.
This is a book about bravery, the bravery of the young people
courageous enough to face histories of multiple trauma and the
bravery of the author courageous enough to work with young people
who have survived
Motivational Interviewing, Second Edition by William R.
Miller, Stephen Rollnick (Guilford Press)
Motivational interviewing (MI) is an effective evidence‑based
approach to overcoming the ambivalence that keeps many people from
making desired changes in their lives, even after seeking or being
referred to professional treatment. Countless clinicians have used
MI since the initial publication of this important book‑and theory
and methods have evolved apace. Extensively rewritten, this revised
and expanded second edition applies MI to the challenges of change
within and beyond the addictions field, with updates from what has
been learned in the last decade. The volume incorporates emerging
knowledge on the process of behavior change, a growing body of
outcome research, and discussions of novel applications. It is
essential reading for anyone wishing to help clients get "unstuck"
and free up their own resources for change.
The book first reviews the conceptual and research background
supporting MI. The concept of ambivalence is examined and the
critical conditions necessary for change are delineated. Elucidating
the guiding principles of MI, the authors then provide a practical
description of the approach. Outlined are specific strategies for
building motivation and strengthening commitment to change, with
attention given to avoiding first‑session pitfalls, responding to
resistance, enhancing the client's confidence, and recognizing
readiness to change. Case examples illuminate key points and
demonstrate the efficacy of the approach in action. Subsequent
chapters address the process of learning MI‑including personal
reflections from the authors‑and explore implications for clinical
training. The volume's final section brings together an array of
leading MI practitioners to present their work in diverse settings.
Topics covered in 11 all‑new chapters include MI and the
stages‑of‑change model; applications in medical, public health, and
criminal justice contexts; and the use of the approach with groups,
couples, and adolescents.
This accessible work will be relevant to professionals and
students in a broad range of fields, including psychology,
psychiatry, social work, addictions treatment, general medical care,
health promotion, and corrections. It will serve as a core text for
graduate‑level counseling and psychotherapy courses, as well as MI
Philosophy and Psychotherapy: Razing the Troubles of the Brain by Edward Erwin (Perspectives on Psychotherapy: Sage) Clearly written and accessible, this pioneering book analyses the interface between philosophy and psychotherapy. It is the first authoritative work to apply rigorous philosophical discipline to therapeutic claims and counter claims.
Edward Erwin discusses some of the key philosophical issues that have a particular relevance to psychotherapeutic theory ‑ autonomy and free choice, the nature of the self, epistemology, and values and morals ‑ as well as examining specific interdisciplinary issues that cut across the boundaries between philosophy and psychotherapy. Finally, he looks at the `crisis' in psychotherapy today, offering a valuable philosophical insight into the debate about the proliferation and efficacy of therapeutic approaches.
Challenging and incisive, Philosophy and Psychotherapy will encourage all psychotherapists, counsellors and applied psychologists to examine their practice and clarify their thinking. It is a major contribution to the critical analysis of one of the most influential systems of thought and practice of our time.
Author introduction: When Joseph Breuer used his "talking cure" in treating Anna 0 in the late nineteenth century, there were few alternative psychological therapies available. Today, in contrast, there are more than 400 distinct types of psychotherapy. Some closely resemble the original talking cure, at least as it was transformed by Sigmund Freud, but many are quite different. Consequently, the term "psychotherapy" has come to denote virtually any kind of psychological treatment.
As the list of therapies has expanded, the number of types of professionals dispensing psychotherapy has also increased. Practitioners now include psychiatrists, social workers, clinical psychologists, members of the clergy, psychiatric nurses, and counselors, working in hospitals, prisons, corporations, schools, outpatient clinics, private offces, and many other settings in numerous countries around the world. This book is addressed to these professionals and to anyone who has an interest in psychotherapy.
It is also addressed to my fellow philosophers, who, until recently, have written comparatively little about the field. Although some (most notably, Adolf Grunbaum, 1984, 1993) have written about the theories of Sigmund Freud, most philosophers of psychology have focussed in recent decades on cognitive science. It is not surprising that philosophers are attracted to cognitive science given its close connections to logic and philosophy of mind, but the time is right for more philosophers to pay attention to psychotherapy, and some in fact are now doing so ‑ see, for example, the papers in Graham and Stephens (1994), the new journal Philosophy, Psychiatry & Psychology, and recent philosophic works on multiple personality. Psychotherapy, after all, is a huge field (in the United States, clinical psychology, for example, includes more psychologists than all other areas of psychology combined), and it is rich in theory and in issues that ought to be of interest to philosophers. For example, philosophers have written a great deal about the nature of the self, but there is a parallel literature that discusses numerous psychotherapeutic theories of the self, as well as related clinical phenomena.
To take another example, meta‑analysis has produced a revolutionary change in the way outcome literature is now evaluated. The use of metaanalysis, however, has engendered significant epistemological discussions that philosophers of science can both learn from and contribute to. Other psychotherapeutic examples of philosophic interest include: questions about basic criteria for evaluating psychotherapeutic goals and outcomes, the postmodemist epistemology that is becoming increasingly influential in the field of psychotherapy, the new behaviorism, the proper epistemological standards for evaluating clinical work, and various philosophic issues raised in the cognitive‑behavior therapy literature.
If psychotherapy should be of interest to philosophers, what about the reverse question? Why should psychotherapists take a professional interest in philosophy? One can, quite obviously, do psychotherapy without paying much attention to philosophic questions. Yet, at least occasionally, it is useful for psychotherapists to reflect on the field as a whole, or to think through particular questions that are basic to the enterprise. Is the field developing in the right direction? Is progress being made? What are the proper standards for evaluating psychotherapies and therapeutic theories? Many psychotherapy theories talk about the self. What sort of thing is this supposed to be? Are the goals of psychotherapists jointly realizable? For example, is it possible to provide genuine autonomy for the client and yet develop a science of psychotherapy?
There are many different ways to deal with such questions. One could examine the works of particular philosophers, such as Wittgenstein, Sartre, Foucault, or Nietzsche, and see what implications their work has for psychotherapy, or try to determine whether the contributions of psychotherapists bear on the work of the philosophers. Another approach would be to concentrate on a single topic of joint interest to psychotherapists and philosophers, such as multiple personality disorder (now commonly referred to as dissociative identity disorder) or various forms of irrationality. This book adopts neither approach. It is not about the work of any one philosopher, nor is it about any single issue. It is, rather, about many different issues concerning autonomy, value, the self, epistemic justification, and other philosophic matters relevant to psychotherapy.
Except for the applied ethics questions discussed in Chapter 2, the issues of Part I are examples of "pure philosophy." Part II discusses issues in applied philosophy as they arise within some of the main paradigms of psychotherapy. Empirical issues here are interwoven with various evaluative, conceptual, and epistemological questions.
In discussing issues associated with the main paradigms, I have not aimed for completeness. In particular, I do not discuss a "humanistic paradigm" partly because I doubt that there is such a single coherent paradigm (Carl Rogers' views, however, are briefly discussed in Chapter 3).
1 have also included descriptions of various theories and therapies. In some cases, these accounts are very brief, too brief to be of interest to the specialist. I have included them partly because even a superficial statement of certain theories of psychotherapy helps to ground the philosophic discussion, and partly because the field is so fragmented that people working
in one area often complain that their work is unknown to those working in separate areas.
As the reader has no doubt noticed, the subtitle of the book is borrowed from Macbeth; it reflects neither a commitment to nor a rejection of philosophic materialism.
Contents: Preface Part I Foundational Questions 1
Autonomy, Free Choice, and the Possibility of a Psychotherapeutic
Science 2 Values and Morals 3 The Self in Psychotherapy 4
Postmodernist Clinical Epistemology: a Critique Part II
Psychotherapeutic Paradigms 5 Behavior Modification and the New
Behaviorism 6 Cognitive Therapy and Behavior Therapy 7
Psychoanalysis and the Psychodynamic Therapies
Epilogue 8 The Crisis in Psychotherapy References Name Index Subject Index
Crucial Choices, Crucial Changes - The Resurrection of Psychotherapy by Stefan De Schill (The Search for the Future, V.3: Prometheus Press) Now with Psychotherapy needing to reinvent itself in order to meet the cost requirements of HMOs, Short-term therapy is becoming a norm though the older theoretical long-term perspectives still dominates training. Crucial Choices, Crucial Changes attempts to address the necessity not only of these changes but also of ways to evaluate various therapeutic protocols. Based on more than 45 years of research at the American Mental Health Foundation (AMHF), this intensive examination of psychotherapy and psychoanalysis points out the important shortcomings in the profession and concludes that there has been a marked decline in the last decades caused by the ever‑increasing use of superficial, facile treatment methods. Nonetheless, AMHF research has resulted in invaluable findings, which separate valid approaches from unsustained theorizing and pseudoscientific pretense. The solutions proposed will lead to the transformation of psychotherapy and psychoanalysis into truly viable crafts.
This work has already received widespread critical acclaim:
"Crucial Choices, Crucial Changes: The Resurrection of Psychotherapy is one of the most challenging works to appear in decades. It is of paramount importance to the future of psychotherapy. This work examines basic problems of psychoanalysis, psychotherapy, and mental health with three major considerations foremost: the extent to which the welfare of the patient is considered, the examination of present‑day quality of professional work, and the steps that are necessary to bring about decisive improvements in psychotherapeutic effectiveness and teaching." ‑ Psychotherapies (Geneva)
"What a welcome breath of fresh air Dr. de Schill's book is. Dr. de Schill's main work stands as a much‑needed expert correction to the mountain of highly speculative and unanchored theory‑building in the field of psychoanalysis and psychotherapy. On the basis of numerous cogent examples, he demonstrates the need for an expert clinical approach as the indispensable tool for understanding the unique psychological make‑up of the individual. This stands in marked contrast to the facile practice of generalizing broad `theory' to every patient, regardless of his/her individuality in structure and dynamics. I do not know of any analyst more capable of understanding and formulating very complex concepts in a clear and cogent manner. I believe the book will have a major impact where improvement is most needed: (1) in patient care, and (2) in the training of psychotherapists. Dr. de Schill's incisive wit, exceptional clinical acumen, and direct critical evaluation of a large number of renowned writers in our field make the book a most readable and instructive contribution." ‑ Professor Fabian X. Schupper, Vice President of the Institute for the Advancement of Mental Health (Geneva)
"I consider the volume Crucial Choices, Crucial Changes: The Resurrection of Psychotherapy to be a most fascinating, insightful and challenging work.... The incisive changes and reforms worked out by Dr. Stefan de Schill attest to an unusual perceptiveness of the essence and needs of psychotherapy. A dozen years of studies in universities, hospitals, and institutes will not provide even a small percentage of the expert psychotherapeutic knowledge to be found in this volume. The remedies it proposes are indispensable if psychotherapy and psychoanalysis are to be rescued from their long decline and put on the path leading to their unfulfilled potential." Prof. Toni Graf‑Baumann, former director of clinical medicine, Springer Verlag
"This is probably one of the most intelligent and insightful books to appear in psychotherapy and psychoanalysis. It is based on intensive long‑term studies at the American Mental Health Foundation. Undertaken with a constructive intent, Crucial Choices, Crucial Changes: The Resurrection of Psychotherapy is an extremely careful and expert analysis of the problems and shortcomings besetting psychotherapy and psychoanalysis. A major part of the work provides the most knowledgeable description of new and creative measures that are indispensable to the practice of psychotherapy and psychoanalysis." Professor Andre' Haynal, Chairman of the Department of Psychiatry of the University of Geneva
Stefan de Schill is director of research, since 1948, of the
American Mental Health Foundation, New York City.
THERAPY SOURCEBOOK by Francine M. Roberts, PSY.D., R.N. ($28.00, hardcover, 256 pages, Lowell House, ISBN: 1565657934 )
Modern life often presents challenges, conflicts, and disappointments that many people are ill-equipped to deal with by themselves. Anxiety, fear, depression, and relationship concerns often motivate people to seek the help of a professional. For those who have considered or are considering therapy as a means of healing or personal growth, THE THERAPY SOURCEBOOK is a complete guide to understanding the broad range of information about mental health treatments, techniques, and options.
Mental well-being is a highly subjective and personal experience, not necessarily a state of being "normal" but of being well adjusted and self accepting. THE THERAPY SOURCEBOOK defines good mental health attitudes, psychological distress, and the kinds of issues that often prompt people to seek treatment, including anxiety disorders, depression, addiction, relationships, and personality disorders.
Recognizing a need for help is a valid, healthy response to a psychological problem. But knowing how or where to get help can be challenging. Finding the right therapist involves matching the individual with the appropriate treatment. THE THERAPY SOURCEBOOK offers cogent advice on how to find the right therapist; how to establish treatment goals; and how to get the most out of therapy sessions.
Francine Roberts, a licensed psychotherapist, explains the different treatment approaches to therapy, including behavioral, cognitive, psychodynamic, and biological. Depending on the individual and his or her conflict, each approach uses varying aims, goals, and processes for resolving issues. Also included is information on the growing use of pharmacotherapy and common medications used to treat mood disorders and anxiety.
Other forms of therapy may sometimes be more appropriate to a specific situation. Self-help therapies, twelve step programs, and adjunct therapies can be effective means of enhancing treatment. Finally, the human experience offers its own natural therapeutic effects. Life events and relationships can have healing and learning opportunities either alone or in conjunction with therapy.
Seeking professional help is not a weakness but a sign of emotional strength. And while therapy is not a panacea, it does offer new ways of thinking and new techniques for changing unhealthy thinking patterns and behaviors. Therapy can complement existing coping mechanisms and provide much needed support for meeting personal challenges. THE THERAPY SOURCEBOOK can be a road map for a journey of positive change and personal growth.
FRANCINE M. ROBERTS, M.D., R.N. is a licensed psychologist, registered nurse, and assistant professor at Thomas Jefferson University. She has more than twelve years’ clinical health care experience in inpatient, private practice and community service.
THE EXPRESSION OF THE EMOTIONS IN MAN AND ANIMALS by Charler darwin, Definitive Edition Introduction, Afterword and Commentaries by Paul Ekman ($30.00, Oxford University Press 0195112717)
The appearance of this new edition of Darwin’s extraordinary book is a major event in the human sciences. Everyone interested in emotion --and who isn’t?-- should be grateful to Ekman for this book.
Why do we (humans) like to nuzzle, nibble, and bite those we feel affection towards? Why do we blush when we are embarrassed? Are animals capable of emotion? Is a dog’s wagging tail, or a cat’s purr, an emotional signal? And if so, can animals anticipate their emotions? These and many other controversial questions about the emotional lives of people and animals are addressed in THE EXPRESSION OF THE EMOTIONS IN MAN AND ANIMALS, Definitive Third Edition with an introduction, afterword, and commentaries by Paul Ekman.
In Darwin’s day, every educated person knew of his work and his revolutionary theories about the expression of emotions. Today however, scientists and laymen alike know of Darwin and his theory of evolution, but few are aware of his controversial work on the expression of emotion. How did this best-selling book, by one of the world’s most famous scientists and authors, become virtually forgotten for the last 90 years?
Paul Ekman, Professor of Psychology at the University of California, San Francisco, answers this intriguing question and many others with respect to Darwin and his work on the expression of emotion in this new, definitive edition of THE EXPRESSION OF THE EMOTIONS. Ekman, himself an expert on emotional response who some have called "a human lie detector," discusses the reception of the book at the time of its publication and later, describes Darwin’s unpublished replies to his critics, considers the impact of Darwin’s ideas on current research, and provides commentaries that use today’s scientific knowledge to elaborate, support, and occasionally challenge Darwin’s insights.
For this edition, Ekman has returned to Darwin’s original notes in order, for the first time, to produce a corrected authoritative text, illustrated by the original drawings and photographs positioned exactly where Darwin intended. Also included are several illustrations Darwin discussed, but which never appeared in previous editions. In this definitive edition, today’s reader will rediscover Darwin’s gifts as a writer and insightful scientist that make THE EXPRESSION OF THE EMOTIONS as fresh, accessible, and direct as today’s finest popular science writing.
About the Editor: Paul Ekman is Professor of Psychology at the University of California at San Francisco. He is the editor of Darwin and Facial Expression (Academic Press) and The Nature of Emotions (Oxford) and the author of Telling Lies: Clues to Deceit in the Marketplace, Politics and Marriage. Ekman is recognized as the expert on facial expression and emotion and has been reviewed, profiled, interviewed by numerous newspapers, magazines and television programs, including The New York Times, Time, Cosmopolitan, Reader’s Digest, Glamour, Mademoiselle, Good Morning America, Dateline The New York Times, Time, Cosmopolitan, Reader’s Digest, Glamour, Mademoiselle, Good Morning America, Dateline NBC, The Oprah Winfrey Show, and CBS News News. In 1994, Ekman received the highest honor awarded by the American Psychological Association for contribution to basic knowledge, the Distinguished Scientific Contribution Award.
How much are our character, intelligence, and lifestyle a result of our genes? In this compelling book, award winning journalist Lawrence Wright reveals how twins are helping to unravel these and other mysteries of human identity.
Recent studies of twins have shaken the field of psychology to its foundations, revolutionizing our understanding of our own personalities. Because identical twins separated at birth share all the same genes, yet live separate lives, they offer a unique opportunity to test theories about the roles played by nature and nurture in shaping who we are.
With its genesis in the author’s acclaimed New Yorker magazine article,TWINS directly challenges many long held beliefs. For instance, a series of groundbreaking studies of twins has shown that our genes play a much stronger role in shaping our identities than previously thought. Today, scientists can actually estimate what proportion of our intelligence, our personality, and our behavior is determined by inherited tendencies. Even our political orientation and our religious commitment, it turns out, are largely, governed by our genes. Twins is filled with astounding stories of identical twins who have lived entirely separate lives but have an incredible amount in common: their hobbies, their mannerisms, their taste in music, food, and clothes, their experiences in marriage and divorce, their careers, their sexuality, even the names they’ve given their children.
Perhaps even more surprising is the discovery that our family life has startlingly little effect on the type of person we become. The nongenetic factors that have the greatest impact on shaping our lives are not the way our parents raise us, or the kind of family in which we grow up, but our experiences outside our families.
Introducing the latest findings in this heated area of research, Lawrence Wright presents a lively narrative that is at once engaging, provocative, and told with remarkable clarity. The ongoing and often volatile debate of nature vs. nurture has intrigued mankind for centuries. With Twins, Lawrence Wright provides a bold addition to current thinking, and a must read for all those fascinated by the deepest mysteries of human nature and identity.
LAWRENCE WRIGHT is a staff writer for the New Yorker. His work has also appeared in Rolling Stone, the New York Times Magazine, and Texas Monthly. He is the author of three previous books, including Saints and Sinners, and the critically acclaimed Remembering Satan, for which he received the National Magazine Award for reporting in 1993.Kernberg On Love
Kernberg, the internationally renowned psychoanalytic theorist and clinician, examines in this volume the success and failure of sexual love in couples, from adolescence to old age. Dr. Kernberg considers both so-called normal and pathological relationships, including the role of narcissism, masochism, and aggression in each. The result is a book that expands the boundaries of our current understanding of love relationships
Kernberg’s is arguably the richest psychoanalytic text on ‘love’ (in whatever way we may choose to define this most abused of words) since Freud’s Three Essays on the Theory of Sexuality. This extremely wide-ranging book, spanning from a biological perspective to the sociocultural a personal as well as professional adventure to read that offers a creative, stimulating reflection on the intricacy of human sexual relations throughout the life cycle.
Years ago, when my writings about patients presenting borderline personality organization were stressing the importance of aggression in their psychodynamics, a colleague and good friend said to me, half jokingly: "Why don’t you write about love? Everybody has the impression that you are concerned only with aggression!" I promised him I would do so when some of the puzzling questions in this area had become clearer to me. This book is the result, although I must admit that I have by no means found the answers to all those questions. Nevertheless, I believe I have come far enough in my thinking to share those answers I have found. I hope others will take the opportunity to illuminate what is still obscure.
Over the centuries the subject of love has received a great deal of attention from poets and philosophers. In more recent times it has been scrutinized by sociologists and psychologists. But surprisingly little about love can be found in the psychoanalytic literature.
Again and again, in my attempts to study the nature of love, the relation of the erotic to sexuality became inescapable. I discovered that, in contrast to the abundance of studies on the sexual response from a biological perspective, little had been written about it as a subjective experience. As I explored this subjective aspect with patients, I soon found myself dealing with unconscious fantasies and their roots in infantile sexuality, in short, back to Freud. Clinically I also found that it was through mutual projective identification that couples reenacted past "scenarios" (unconscious experiences and fantasies) in their relationships and that fantasized and real mutual "persecution" derived from the projection of the infantile superego as well as the establishment of a joint ego ideal-powerfully influenced a couple’s life.
I noticed that it was almost impossible to predict the destiny of a love relation or marriage on the basis of a patient’s particular psychopathology. Sometimes different types and degrees of psychopathology in the partners seem to result in a comfortable match; at other times the differences seem to be the source of incompatibility. The questions "What keeps couples together? What destroys their relationship?" haunted me and were the impetus for my studying the underlying dynamics of couples in intimate relationships.
My sources of data are the treatment of patients by psychoanalysis and psychoanalytic psychotherapy, the evaluation and treatment of couples suffering from marital conflict, and particularly the long-term follow-up study of couples through the window of the psychoanalysis and psychoanalytic psychotherapy of individual patients.
It did not take me long to discover that it was just as impossible to study the vicissitudes of love without the vicissitudes of aggression in the relationship of the couple as in the individual. Aggressive aspects of the couple’s erotic relationship emerged as important in all intimate sexual relations, an area in which the pioneering work of Robert J. Stoller has provided significant clarification. But I found the aggressive components of the universal ambivalence of intimate object relations equally important, as well as the aggressive components of superego pressures unleashed in the couple’s intimate life. A psychoanalytic object relations theory facilitated the study of the dynamics linking intrapsychic conflicts and interpersonal relations, the mutual influences of the couple and its surrounding social group, and the interplay of love and aggression in all these fields.
So, despite the best of intentions, the incontrovertible evidence forces me to focus sharply on aggression in this treatise on love. But, by the same token, the acknowledgment of the complex ways in which love and aggression merge and interact in the couple’s life also highlights the mechanisms by which love can integrate and neutralize aggression and, under many circumstances, triumph over it.
1. The Sexual Experience
2. Sexual Excitement and Erotic Desire
3. Mature Sexual Love
4. Love, Oedipus, and the Couple
6. Aggression, Love, and the Couple
7. Superego Functions
8. Love in the Analytic Setting
9. Masochistic Pathology
11. Latency, Group Dynamics, and Conventionality
12. The Couple and the Group
Otto F. Kernberg, M.D., is a training and supervising analyst at the Columbia University Center for Psychoanalytic Training and Research, professor of psychiatry at Cornell University Medical College, and director of the Institute for Personality Disorders at the New York Hospital Cornell Medical Center, Westchester Division. He is the author or co-author of many books, including: Internal World and External Reality Object Relations Theory Applied (Jason Aronson) and Ideology, Conflict, and Leadership in Groups and Organizations (Yale)Transpersonal Psychology as a Clinical Guide
PSYCHOTHERAPY AND SPIRIT: Theory and Practice in Transpersonal Psychotherapy by Brant Cortright ($17.95, paper, $54.50, hardcover, 257 pages, references, index;SUNY, State University of New York, 0-7914-3466-4)
PSYCHOTHERAPY AND SPIRIT by Brant Cortright, Director of the Integral Counseling Psychology Program at the California Institute of Integral Studies, brings together in one volume essays highlighting the major developments in the field of transpersonal psychotherapy. They together articulate a unifying theoretical framework and explore the centrality of consciousness for both theory and practice in this discipline. The essays review the major transpersonal models of psychotherapy, including Wilber, Jung, Washburn, Grof, Ali, and existential, psychoanalytic, and body centered approaches, and assess the strengths and limitations of each. The book also examines the key clinical issues in the field. It concludes by synthesizing some of the overarching principles of transpersonal psychotherapy as they apply to actual clinical work. The volume makes a good intermediate introduction to the field.A Basic Reference to Psychodrama : Group Psychotherapy as Experimental Theater by Eva Roine ($29.95, paperback, Jessica Kingsley Publications, 1853024945)
This comprehensive work is grounded on the author’s broad knowledge and experience of psychology, the theater and psychodrama. It includes discussion of the theory behind psychodrama as well as the methods used in its practice. Roine writes of technical concepts in a comprehensible and accessible style, giving examples from her work in America and Norway. As well as examining the specific field of psychodrama, she relates the topic to the history and practice of the theater, providing new angles and insights. The volume is one of the most intensive overviews of psychodrama now available. It is recommended not only as introduction but as basic reference to basic practices and theory.
Expressive therapies including psychodrama are becoming steadily more influential and this book has already played a part in that development. It addresses the needs of professionals, students and teachers directly involved in psychodrama and will also be of interest to professionals in other fields.
Eva Roine trained as an actress in London. After four years of acting she became a journalist writing chiefly about the theater. Her clinical work is extensive as is her teaching. She conducted a three year psychodrama program in Krakow, and has worked extensively in Germany and the Nordic countries. a Director of the Norwegian Psychodrama Institute.Hurricane As Archetype
DIVINE TEMPEST: The Hurricane as a Psychic Phenomenon by David E. Schoen ($15.00, sewn paper, 128 pages, 15 illustrations, glossary, bibliography, index; Inner City Books; 0-919123-79-1)
The human response to hurricanes spans a continuum from fascination to terror. Though we recognize the need to protect ourselves from the physical dangers of the great storm, we are yet drawn to witness its awesome power.
The thesis of DIVINE TEMPEST is that the hurricane is a universal symbol of the Self (in a Jungian sense) in its most primordial form. Schoen explores the world views of both aboriginal and modern cultures to paint a vivid picture of how humankind has related to this cataclysm of nature, inwardly and outwardly, for millennia.
Visual imagery, meteorological and historical data, mythological amplification, modern dream material, synchronistic andESP phenomena, and firsthand experience are the substance of this whirlwind text, interwoven into a comprehensive psychological theory about the significance of hurricanes and other great storms.
David E. Schoen, M.S.S.W., has a Diploma in Analytical Psychology from the InterRegional Society of Jungian Analysts, and a Masters degree in clinical social work from the University of Texas in Austin. He is an advisor to the C.G. Jung Society of New Orleans, and has a private practice in Covington. Louisiana.
Hurricanes, a Psychological Approach
I was born and raised in south Louisiana, never very far from the great Gulf of Mexico, hence hurricanes have always been a part of my life geographically and psychologically.
My earliest memory of a hurricane was in the 1950s when I was four or five years of age. I remember flood waters three feet high everywhere around my house in New Orleans. It was exciting and novel: cars parked on neutral grounds, boats floating by the front door, my whole neighborhood a giant swimming pool. Hurricane Betsy in 1965 touched me in a different way. I walked through National Guard tents with hundreds of homeless frightened families huddled together around Army cots, with only meager possessions hastily salvaged from the devastating storm. I saw the mark of floodwaters to the ceiling, almost engulfing the house of a classmate.
In 1969, I walked where the awesome power of Hurricane Camille had taken out complete highways in Bay St. Louis, Mississippi, and swept away whole buildings, leaving nothing but the foundations and concrete slabs. I played touch football once in the eye of a smaller storm during my college days in Lafayette, Louisiana. I’ve witnessed towering pine trees (with roots half a mile deep), sway and snap like twigs before the mighty hurricane. I’ve weathered Hurricanes Juan and Andrew and dozens of others through the years. I dream of hurricanes, too.
For me and for most people living along the Gulf Coast the hurricane has always been an integral part of our experience, our lore, our culture, our collective psyche. Hurricanes are mysterious, dangerous, fascinating, exciting, frightening, unpredictable, awesome, powerful, special, fun, deathly destructive and uncontrollable. They are interwoven in the fabric and texture of our way of life and our way of looking at life. Let the good times roll, for tomorrow may not come. They fall into a special category of our culture, like Mardi Gras, jazz funerals and the rare snowstorm. We live with the hurricane and it lives within us. Hurricanes move us literally and figuratively, inwardly and outwardly. The hurricane season is paradoxically both feared and anticipated with edgy delight.
The experience of the hurricane is imprinted deeply in me, and its gale force winds have never ceased to whirl powerfully through my veins. This is why I was moved on a personal level to write about hurricanes; they are so close to my spirit and to my soul.
From my own experience, I then formulated objective, theoretical questions: What does the hurricane represent in the psyches of human beings? What does the image of the hurricane signify in history, literature and myth? What does it mean in dreams, fantasies, imagination? How does the image of the hurricane act upon the human psyche, and how does the human psyche act upon and modify the image of the hurricane for its own purposes? How can the hurricane be viewed psychologically, and from a Jungian perspective?
It is to these overarching questions that this book is addressed. I am more concerned with the overview, the big picture of the hurricane, than with attempting to track down every possible allusion and detail associated with it.
My hypothesis is that the hurricane is a universal symbol reflecting an archetypal image of the Self in perhaps its most primordial form. It echoes deeply within the psyches of both aboriginal and mode peoples, whose attempts to deal with it inwardly and outwardly, have both similarities and differences based on the assumptions and world views of each.Cognative Affect
KNOWING FEELING: Affect, Script, and Psychotherapy edited by Donald L. Nathanson ($45.00, hardcover, 425 pages, references, index; Norton: 0-393-7270214-6)
KNOWING FEELING is about knowing feeling in all its aspects—and the difference that makes in psychotherapy. It is the first book to present specific therapeutic techniques and ways of looking at the human condition based on the Tomkins-Nathanson theory of emotion.
Once grasped, Tomkins’s affect theory illuminates both the small moments when shame takes over and the large patterns of human emotional interaction. As the contributors demonstrate in these wide-ranging essays, it provides new ways to understand intimacy, human sexuality, and the relationship between infants and their caregivers. It changes the way one assesses a client, forms a diagnostic alliance, or does research on shame and guilt.
In clinical chapters, readers will find that understanding the basic affects-interest-excitement, enjoyment-joy, surprise-startle, fear terror, distress-anguish, anger-rage, dismal, disgust, and shame-humiliation-gives direction and richness to the practice of marital therapy, cognitive therapy, psychopharmacology, art therapy, psychoanalysis, and Jungian depth therapy. It can be applied to the treatment of trauma following abuse or war, in dramatic role-playing for suchPTSD patients, in the remediation of young criminals, and even in the theater.
This is an ambitious and wide-ranging work. Nathanson’s thought-provoking chapter introductions provide continuity and bridges. Readers open to new possibilities are likely to find that their ways of practicing therapy and of being in the world are profoundly changed by what they learn here.
DONALD L. NATHANSON, M.D., is Senior Attending Psychiatrist at the Institute of Pennsylvania Hospital, Clinical Professor of Psychiatry and Human Behavior at the Jefferson Medical College, and founding Executive Director of the Silvan S. Tomkins Institute, Philadelphia. He is the author of Shame and Pride: Affect, Sex, and the Birth of the Self, and the editor of The Many Faces of Shame.
Dreams in Psychotherapy
The past few years have witnessed rapid evolution in the clinical application of the affect theory introduced by Silvan Tomkins. The steady growth of the international network of study groups chartered by the Philadelphia-based Tomkins Institute has been accompanied by increasingly frequent public presentations by clinicians who have found these theories useful in their practice of psychotherapy. The present text is a group of essays by clinicians and researchers from a wide spectrum of disciplines, each of whom has found that using Tomkins’s concepts as the theoretical base for clinical work has made it easier and more effective. It offers links to classical psychoanalysis and Jungian psychology, diagnostic evaluation, psychometrics, cognitive theory and cognitive behavioral therapy, image-oriented psychotherapy, psychopharmacology, couples therapy, sexual counseling, the theater, the evaluation and treatment of massive psychic trauma, and a new sociopolitical system for the management of juvenile offenders.
That so much attention has been paid to a theory, indeed to a rigorous, complex, and demanding theoretical system, is in itself remarkable, for all of us feel most comfortable with what we learned during our training and saw validated by articles in journals edited by peers who were similarly committed to that early training. Yet we have become uncomfortable as we survey our therapeutic failures, curious about research into brain mechanisms that disconfirm traditional theory but offer no clear model of the mind, and perturbed by the steady increase in anecdotal reports of therapeutic success involving techniques that seem foreign to our very nature…
Take, for instance, the work that Jeanette Wright presents in her chapter on "Image-Oriented Psychotherapy." Trained as an art therapist and steeped in Freudian drive theory, Wright became fascinated by the faces drawn by her patients. With the permission of an artistically gifted woman who bore the diagnostic label of dissociative identity disorder, and whose concept of self seemed split into several distinct alternate personalities, Wright traveled from Iowa to show me a sheaf of her drawings. Not only could we see that these highly evocative pictures represented scenes characterized by intense affective experience, but we could with ease recognize each of the innate affects on the faces of the characters she depicted, even though the artist had no prior knowledge of affect theory. Wright has developed a novel therapeutic technique through which she encourages her clients to use drawings as a way of learning more about their affects, about the consistent and replicable systems through which they have learned to manage these affects, and about the historical sequences that produced these painful scripts, all while teaching new methods of affect modulation. In an era characterized by intense sociopolitical attention to the loss of natural resources and the scarcity of unspoiled territory, Wright’s work reminds us that what we ignore as banal and ugly may be the doorway to the new and exciting. This is breakthrough work because it uses information that has always been available in the artistic productions of people in therapy and recognizes that the graphic depiction of facial affect display is all the more important in those whose affective experience has been so intense and painful as to foster dissociative defenses that interfere with awareness.
It was at the suggestion of a student that David Cook, now emeritus professor of counseling psychology at the University of Wisconsin in Stout, began to develop the Internalized Shame Scale (ISS). Previous shame scales had been based on lists of adjectives used by college students, perhaps the best studied cohort in the world of academic psychology. Cook went in the opposite direction, picking statements about shame experience culled from the work of such clinicians as Gershen Kaufman, whose 1980 book Shame: The Power of Caring was one of the first to introduce affect theory in the context of psychotherapy, and psychoanalyst Leon Wurmser, whose 1981 book The Mask of Shame was perhaps the most evocative ever written on what had until then been known as "the ignored emotion." Cook went on to revise and adjust his test in terms of the emerging work on affect theory and to determine the importance to clinical practice of this complex group of scripts. His chapter not only describes the science and logic behind the ISS, but is also a chronicle of his own journey from academic cognitive theory toward affect theory. In a later chapter, psychologist Shelley Milestone, also trained as a cognitive-behavioral therapist, offers a concise outline of her clearly stated and easily learned recommendations for the incorporation of affect theory into classical cognitive therapy.
Vernon C. Kelly, Jr., Training Director of the Tomkins Institute, has a career-long interest in the treatment of couples. Working with Tomkins in the months before the latter’s death in 1991, Kelly produced an entirely novel definition of intimacy. In the intervening years, he has developed a new system of couples therapy based on these concepts. Briefly stated, it takes note of Tomkins’s recognition that all humans are "wired" to enjoy the positive affects and dislike the negative affects. The basic "blueprint" of human psychological function requires that we try to increase positive affect, decrease negative affect, express all affect so these two goals may be accomplished, and develop scripts that foster these three goals. Kelly was the first to recognize that intimacy requires a private interpersonal relationship within which two people seek to mutualize positive affect so that it may be increased as a function of the relationship, to mutualize negative affect so that it may be down regulated, and to develop relationship-specific techniques for the expression of all affect so that it may be managed in the way best for the couple. Treatment, as he explains in this seminal chapter, requires far less attention to the content of quarrels and battles than to the affects that make these issues salient.
As a researcher and teacher for the Post Traumatic Stress Disorder unit of the Philadelphia Veterans Administration Hospital, Andrew M. Stone has found it useful to reevaluate our concepts of trauma in terms of innate affect mechanisms. His first contribution outlines a method of assessment that offers a bridge between the biological and the biographical factors operating in these devastating clinical conditions. My longtime colleague and collaborator, Dr. Stone was the first to suggest that we gather into one volume the growing collection of studies on the clinical applications of affect theory under the title KNOWING FEELING.
Both Dr. Stone and Norfolk-based clinical psychologist Anthony Hite have become intrigued by the changes in the process of diagnosis made possible by an understanding of affect theory and script theory. Each offers a chapter that describes how to approach a new patient or to revise your way of dealing with a patient whose treatment has gotten stuck for lack of understanding of emotional issues—two contributions that differ dramatically in their focus and style.
A new theory should be capable of integration with the old so that the wisdom acquired by previous generations of clinicians is neither ignored nor lost in the excitement provided by novelty. It was Michael Franz Basch, one of the best known and loved psychoanalytic writers, who first introduced Tomkins and his affect theory to the culture of psychodynamic psychotherapy and psychoanalysis. Here he reminds us that all of the defense mechanisms outlined by Freud are actually affect management scripts. Basch places affect at the center of all considerations of the mental mechanisms. Louis Stewart is a Jungian psychologist who points out that each of the archetypes defined by Jung may be viewed as a specific pattern of affect modulation. Moving easily between the concepts of Jung and those of Tomkins, Stewart asks us to think of myth, personality types, and psychic structure in terms of his own highly personal understanding of innate affect. And, just as it is important to build bridges between these classical systems for the understanding of human function and the new system offered by affect and script theory, our clinical work must be linked firmly to the research of psychologists who study infant and child behavior. Drs. Julie Faude, Wayne Jones, and Michele Robins have collaborated on a scholarly review of work that demonstrates both the innateness of affect and its importance in the establishment of a clinically relevant developmental theory.
Two of the authors are known for the intensity and duration of their work with Tomkins. Like most of us clinicians, I learned of affect theory through the work of Basch and, like so many others who saw in affect theory a way toward new clarity, wrote Tomkins asking for the privilege of a personal conversation. It was my great good fortune to work closely with him during the last decade of his life as I struggled to unlearn the theories of my training and adapt to both a system and a teacher at times clear and simple and at other times maddeningly obscure. Educated first as a research biologist, next as a physician and endocrinologist, and only much later in psychiatry, I kept trying to place the affect system in the body, hoping to establish it within the emerging fields of neuroendocrinology and psychopharmacology. In a series of papers and books, I have focused on the basic biological mechanisms involved in shame affect while trying to clarify the scripts through which it is incorporated into the range of experience from everyday life to severe psychopathology. This work is summarized as the opening chapter of Knowing Feeling. In a later chapter written with the invaluable assistance of psychopharmacologist and longtime colleague James Pfrommer, I suggest a way of understanding the interface between innate affect and the mechanisms of action postulated for some of the best known psychoactive drugs.
Exactly contemporaneous with my relationship with Tomkins was that of Donald Mosher, whose research into the emotionality associated with sexual behavior and experience had led him to affect theory. It was a peculiarity of Silvan Tomkins, possibly born of a professor’s need to keep separate the research being done by his students, that neither of us knew anything about the other until Tomkins’s death in 1991. Mosher’s work on sexual scripts is the most sophisticated adaptation of script theory to date—often as complex as that of our mentor while at all times firmly linked to the world of psychotherapy. Here he summarizes what is to appear in his long-anticipated book on sexuality, offering what may be regarded as a glossary for the text of sexual scripts.
Using the emotionality of theatrical performance as their model, Miller James and David Read Johnson outline their novel and sophisticated treatment for posttraumatic stress disorder. Writing from the Veteran Administration’s National Center for PTSD, they describe the "relationship lab" within which they use the teachings of leading drama theorists to enhance safer and more meaningful expression of emotion in this cohort. A contrasting view of the drama is presented by its originator, Bruce Shapiro, whose theory of iconicity has now been brought into conformance with our current understanding of human emotion. Shapiro sketches his revolutionary theory for the nature of dramatic performance, remarks on the significance of the theater for emotional health, and suggests the formation of an entirely new method of drama therapy that may be capable of producing deeper levels of change than those in use at this time.
Finally, just as Kelly insists that an understanding of intimacy must be informed by our affect-based theory of the person, the Australian political scientist and criminologist David B. Moore makes us realize that our understanding of society must be assisted by all valid theories of the personality. One of the leaders in the international movement to change the criminal justice system, Moore combines a willingness to read voluminously in any area of scholarship that might impinge on his topic with an unmatched ability to create working relationships among thinkers in disparate fields. When the town of Wagga Wagga, New South Wales, decided to implement the juvenile justice program suggested by John Braithwaite in his 1989 book Crime, Shame and Reintegration, Moore read the world literature on shame and became convinced that affect theory offered the best way of explaining the social phenomena being investigated by his group. His chapter offers a concise summary of modern criminology, describes the operation of the Wagga Wagga model of family group conferencing, and demonstrates how the conferencing system heals a community that has been wounded by crime. The same patterns of affect modulation that produce intimacy in private interpersonal relationships are necessary to create the sociality that forms the sense of community.
The day is long gone when any one therapist or one school of therapy can promise either explanation or cure for the woes of all. Neither affect theory nor script theory is a form of therapy, even though these concepts fit well into any system of treatment. All of us understand that a mood that persists despite sensible attention to its scripts may actually be due to abnormality of neurotransmitter function, just as the patient whose condition fails to improve no matter what medication is used may (for example) need attention to an interpersonal source of affect better handled in couple therapy. Therapeutic systems that depend on laboratory tests or the verbal productions of patients may be enlivened by attention to drawings. Psychodrama offers an opportunity to try out other ways of being—other patterns of affect modulation—just as hypnosis may allow access to parts of the personality held hostage by mental mechanisms earlier brought into use to manage affective overload. Cognitive therapy works better than psychodynamic insight or uncovering therapy in that fraction of the population for whom a highly structured therapeutic environment is needed to act as scaffold when the individual has little experience of affect modulation. Psychological tests may be used not just for diagnosis but to provoke skeins of associations that may be useful in therapy. A method of treatment based on preexisting sets of symbols, like Jungian psychology, may be used as a grid to anchor the individual who is otherwise skittish about depth psychology.
The history of our evolution as thinking beings changes greatly when one takes into account Tomkins’s view of affect. A race of computers unable to assign salience, unable to determine which voice in the Babel of data required the most advanced form of attention, is unlikely to have been able to adjust to the ever-changing demands placed on it by the ability to move away from its roots and into new territory and new problems. We were not assigned the species name homo sentiens, the sentient or thinking human, but homo sapiens, the organism that lives according to innate abilities denoted by the Latin verb sapere, to savor or know, to be sensible or wise. This is a book about what makes us truly human, truly sapient. It is about knowing feeling in all of its aspects.
Good treatment is flexible, tailored to the needs of the individual or the cluster that has sought assistance, and capable of alteration on demand. It is our belief that the new attitudes toward human emotion described in these pages may alert the clinician to a wider variety of treatment options and illuminate ever-changing systems of therapy.
DREAMS AS A TOOL IN PSYCHODYNAMIC PSYCHOTHERAPY: Traveling the Royal Road to the Unconscious by Vincenzo Conigliaro, M.D. ($62.50, hardcover, International Universities Press 0823614395)
Dreams are such a fascinating, powerful, and central aspect of the psychoanalytic process that anyone who provides us with a comprehensive, creative and original work on dreams, dream theory, and the art of dream interpretation is well deserving of note. This study also sheds light upon neglected aspects of these fields. This scholarly and literate book, by a master teacher and clinician, explicates Freudian theory relevant to dream theory and formation in a manner which is both respectful of the novice to the field and holds the interest of the experienced clinician. However, the most valuable sections of the book are those in which Conigliaro demonstrates with a unique clinical and aesthetic sensibility his understanding and interpretation of the dream in the session. In a major portion of this work, Dr. Conigliaro elaborates on Freud’s concepts of dreams by sharing with us his own free associations and subjective interpretations of a wide variety of illustrative dreams those inner ruminations that he regularly uses as working hypotheses when treating patients. His extensive, elegant clinical illustrations focus on the analyst’s internal processes as well as the patient’s, and are a model for describing analytic work.
"As a researcher in the field of sleep and dreams, I am particularly glad to see the careful discussion of the current scientific studies in this field as they may be used to shed light on dream theory. This admirable synthesis of Freudian dream theory and up-to-date laboratory research will be of much use to the clinician. I recommend Dr. Conigliaro’s book to any serious psychotherapist who wants to expand his or her psychodynantic perspective and clinical skills by thoroughly mastering the art of modern dream interpretation." — Patricia Carrington, Ph.D.
About the Author
Vincenzo Conigliaro, M.D., is Associate Professor of Behavioral Sciences at Fordham University Graduate School of Social Services, and Dean and Medical Director of the Training Institute for Mental Health in New York. Author of more than 25 articles and several book chapters, Dr. Conigliaro has a private practice in psychiatry and psychoanalysis in New York.Catching Affect Experimentally EYE: Emotional Influences in Perception and Attention edited by Paula M. Niedenthal and Shinobu Kitayarna ($58.00, hardcover, Academic Press 0124105602)
This book consists of 13 chapters by experimental psychologists, that together suggest an emerging theme in the current psychological thinking on two issues: (1) the emotion cognition interface, the question of how emotion interacts with other mental processes such as perception and cognition; and (2) nonconscious processing, the question of how and when mental processes proceed without the awareness of the individual (i.e., occur automatically) or are initiated by events of which the individual is not aware (i.e., by implicitly or subliminally perceived information).
The authors of this volume share an interest in emotional influences in perception and attention. Their ideas about where the emotion comes from, the types of feelings they are interested in, and the processes of perception and attention that they believe are affected vary, however. In order to provide something of a common language some attempt is made to define key terms such as emotion, motivation, affect, and mood, and to associate the definitions with different authors.
They see emotion as a set of adaptive functions of acting or responding to stimuli, that are both prewired or "prepared" by biological evolution and yet at the same time, shaped, elaborated, and finely "configured" by learning especially by social and cultural learning. Emotion, then, is seen as a psychological processing structure of action readiness with which to perceive, attend, and respond to biologically, personally, and/or culturally significant stimuli. Emotion consists of myriad component processes organized into some fuzzy sets according to the functional relationship between the organism or the self and its biological or cultural environment. Some components involve cognitive and lexical processing as suggested by recent cognitive appraisal theorists of emotion; other components involve autonomic, efferent, and somatic activations. Clearly, many of these components are interconnected, Recent advances in neuroscience indicate that the brain substrates involved in the processing of emotion are highly integrated with those that participate in memory, learning, and other cognitive processes.
Above and beyond this general definition of emotion, researchers vary considerably in emphasis, and some of them use different, albeit related, terms for it accordingly. Depending on their major emphases, the contributions to this volume can be divided into the following four groups. Although in actuality the groups overlap in some obvious ways, the divisions are offered here as a heuristic frame with which to understand the scope of the current volume.
1. Emotion as a biological function of adaptation. Consistent with a definition of emotion offered by Davidson and Cacioppo, as a self-organizing, integrative state that is coherent across several response systems," Hansen and Hansen emphasize the biologically hardwired processes of emotion and its information processing structure. Adopting a similar biological view of emotion, Derryberry and Ticker highlight the goal oriented function of emotion, for which they use the notion of motivation. They use the term, emotion, somewhat narrowly to refer to a subjective concomitant of the motivation so defined.
2. Emotion as evaluation. Some other contributors to this volume are more psychological in their approach to emotion. Thus, Pratto and Klinger and Greenwald study the evaluative informational function of emotion. Many would agree that this is the central element of emotion, captured by a number of classic dimensions of "good-bad," "approach avoidance," "liked-is-like," and the like. But because evaluation is just one of many components of emotion just noted, Kitayama and Howard use the term affect to narrowly refer to the evaluative dimension of emotion and distinguish it from emotion itself. Affect so defined is also central in social attitudes, as made evident by Fazio et al. in their chapter on an emotional basis of attitude.
3. Emotion as categorical states. When emotional states are fairly enduring and have no specific objects to which the emotion is directed, they are called moods. By contrast, there appear to be a small number of primary emotions that are acute, structurally distinct, and have specific eliciting conditions. Consistent with researchers who study conceptual emotion knowledge and brain substrates of emotion, Niedenthal et al. argue that these categorical states, such as joy, sadness, and fear, have unique information processing effects, organizing memory in a more categorical way. A paper written at the turn of this century by a French physician, Israel Waynbaum, which is included here with an introduction by Robert Zajonc, seem to share this view of emotion.
4. Emotion as activation. Finally another important aspect of emotion is its energizing or amplifying capacity or what has traditionally been called arousal. The emphasis on arousal is evident in a number of influential papers in the history of psychology of emotion including Schachter. It is reflected in the notion of amplification described by Kitayama and Howard. In a related vein, Egeth discusses both promises and problems of this notion in his review of the literature on the effects of arousal in eyewitness testimony. Finally, Derryberry differentiate this unidimensional, admittedly oversimplified notion of arousal into two qualitatively distinct kinds of arousal, called phasic arousal and tonic activation.
Perception and Attention
The present volume is organized into two sections, the first on emotion and perception, the second on emotion and attention. Perception and attention are not strictly separate. They are indeed highly overlapping. The specific effects, experimental tasks, and cognitive mechanisms implicated differ systematically.
Perception is the transformation of sensations caused by an impinging stimulus into an internal representation of that stimulus. There are many component processes that mediate the transformation. And attention mediates perception when it is aligned with the mental pathway corresponding to the perceived event. However, the perceptual phenomena described in chapters in the first section are largely ones in which the mechanism of attention does not, or, in some case, does not exclusively, play a role.
Some chapters are concerned with affect in nonconscious perception. In work of this sort, the issue is whether implicit or explicit measures of affect indicate that the emotional meaning of a stimulus is extracted prior to the conscious detection or recognition of the stimulus. Other work addresses the idea that emotions have automatic effects in early perceptual processes that cause individuals to perceive certain events more efficiently than other events.
One mechanism implicated in much of this work is that of spreading activation. Spreading activation involves the automatic transfer of excitation between interconnected elements of the cognitive processing system. In such models, for example, preliminary nonconscious processing of the visual (or auditory) held primes corresponding perceptual pathways, thereby making some representations more likely than others to organize perception or bias responses. internal sources of activation include emotional state and. relatedly, arousal. Kitayama and Howard suggest, for example, that emotional arousal can amplify activation of perceptual pathways that have been previously excited.
The tasks that allow the researcher to measure the efficiency or ease with which a perceiver can detect a stimulus are most often used in the examination of automatic activation in perception. In theory the tasks involve measurement of the facilitation in the ease of perception of a primed, compared to a nonprimed, stimulus. In practice, of course, subjects communicate perceptibility with a motor response. Consequently, a problem with such tasks is that it is difficult to separate the facilitation of a perceptual response from that of a motor response.
Attention is held to be a limited capacity mechanism that mediates conscious awareness of internal and external events. Events that are the focus of attention receive the benefit of conscious processing. Processing "costs" accrue when attention has been allocated to certain events but processing of different events is required for some task. One of the classic paradigms for studying the allocation of visual and auditory attention is the Stroop task in which interference with conscious attention by automatic processes such as access to the semantic meaning of words can be observed. Several of the authors of the chapters contained in this volume have used the Stroop task to examine the effects of negative and positive information on the allocation of visual attention.
This work attempts to offer a series of operationalized approaches to the discrimination of attention and perception as affected by emotional arousal.
RECLAIMING HERSTORY: Ericksonian Solution-Focused Therapy for Sexual Abuse by Cheryl Bell Gadshy and Anne Siegenberg ($33.95, hardcover, 272 pages, Brunner/Mazel, ISBN: 0876307772)
Women who have survived sexual abuse are among the most traumatized individuals who seek therapy. Assisting such clients to reframe and transcend their abusive pasts requires enormous sensitivity and therapeutic skill.
RECLAIMING HERSTORY offers help to therapists to hone their craft with its solution-focused, Ericksonian approach and highly refined techniques for working with this population. The approach the authors present has evolved through work with hundreds of sexual abuse survivors. The authors have found their techniques to be remarkably effective in helping clients to regain a sense of freedom and empowerment in their lives.
The authors view the healing process as a collaborative partnership in which the therapist co-creates with the client a positive context for healing. This process is comprised of four distinct stages through which every client must pass in order to achieve their own unique potential. The book clearly describes the primary symptoms and features of each of these four stages:
It also presents, for each stage, a series of detailed metaphorical stories, exercises, and rituals designed to assist a client who is traversing a particular stage. Numerous suggestions, lists, questions, and vivid case studies help the therapist to identify and assess the individual needs of a particular client and then pinpoint those tools that will best facilitate the healing process at a given stage.
Recognizing the severe toll that work with sexually abused clients can take on the therapist, RECLAIMING HERSTORY also provides strategies for self care that can be used during various stages of therapeutic practice. The volume also provides a timely and important discussion of the controversial "false memory backlash" and its impact on the survivor and implications for the therapist.
Cheryl Bell Gadshy, M.A., M.F.C.C., is Coordinator, Sexual Assault Resolution Program, Family Services of the North Shore, North Vancouver. B.C., Canada. She also has a private practice specializing in childhood trauma and hypnotherapy.
Anne Siegenberg, M.S.W., R.S.W., is Family Therapist at the Jewish Family Service Agency, and Group Facilitator with survivors of sexual abuse at Family Services.
ON PLAYING A POOR HAND WELL: Insights from the Lives of Those Who have Overcome Childhood Risks and Adversities by Mark Katz ($29.00, hardcover, 187 pages, references, index; Norton; 0-393-7270232-4)
Robert Louis Stevenson said, "Life is not so much a matter of holding good cards, but sometimes of playing a poor hand well." Many adults who now enjoy happy and productive lives grew up under emotionally and environmentally difficult conditions that were beyond their control. As children they were clearly at risk of developing serious problems later in life. Yet they never did. Why not? What was the secret of their strength, their resilience? How did they turn their lives around?
Others who were exposed to similar adverse childhood conditions were less fortunate and continued to struggle with serious difficulties into their adult years. Yet many eventually successfully turned their lives around. How did they do it? What were the turning points in their lives?
ON PLAYING A POOR HAND WELL sets out to answer these questions. The book begins with insights into childhood risks and adversities—enduring and inescapable stressful experiences, such as growing up under violent, dangerous, or abusive conditions, or experiencing years of school failure as a result of serious learning disabilities or attention problems. The author then explores the latest research into life’s trajectories and culls the lessons we must learn in order to provide avenues through which turning point experiences and second-chance opportunities can occur—to change the odds, so to speak, for individuals who were dealt a poor hand.
ON PLAYING A POOR HAND WELL focuses on how people overcome different adversities— not simply on the effects these stresses had on their lives. This book will enable disadvantaged individuals and their families to validate the pain they’ve endured and to celebrate their resilience.
It is written as much for clients as for therapists and moves toward basic self acceptance.
MARK KATZ, Ph.D., is the director of Learning Development Services in San Diego and supervising psychologist at San Diego Center for Children. He is also the educational consultant to the Casey Family Program and a consultant to the San Diego Unified School District’s PARD (Partners for Attention Related Disorders) Project.
Other practical titles that address the treatment of abuse:
TRUE AND FALSE ALLEGATIONS OF CHILD SEXUAL ABUSE: Assessment and Case Management edited by Tara Ney, Ph.D. is the first volume to address, through the expertise of a diverse group of scholars and practitioners, current research and the clinical, legal and ethical issues that arise in sexual abuse cases.
ENDING THE CYCLE OF ABUSE: The Stories of Women Abused as Children and the Group Therapy Techniques that Helped Them Heal by Philip G. Ney, M.D., F.R.C.P. and Anna Peters is an accessible tool for both therapist and abuse victims in the group endeavor.
OPENING THE DOOR: A Treatment Model for Therapy with Male Survivors of Sexual Abuse by Adrienne Crowder, M.S.W. is written in clear, concise language, and features a four-phase treatment model that presents in detail the therapeutic tasks necessary for each phase.
CHILDREN SPEAK FOR THEMSELVES: Using the Kempe Interactional Assessment to Evaluate Allegations of Parent-Child Sexual Abuse by Clare HaynesSeman, Ph.D. and David Baumgarten, J.D. This pioneering volume describes the Kempe Interactional Assessmentfor Parent-Child Sexual Abuse, which facilitates the emergence of reliable data without the pressure of directly questioning the child.
FOCUSED PSYCHOTHERAPY: A Casebook of Brief, Intermittent Psychotherapy Throughout the Life Cycle by Nick Cummings with Mike Sayama ($34.95, hardcover, Brunner/Mazel 0876307896)
Confronted with the harsh financial realities of managed care, many psychotherapists fear they will be unable to provide their clients with appropriate treatment regimens that will stay within the boundaries determined by the increasing presence of Health Maintenance Organizations (HMOs) and other forms of managed care.
FOCUSED PSYCHOTHERAPY offers practitioners an approach to psychotherapeutic treatment that is financially viable and has sufficient clinical depth to assure genuine psychological growth. This highly practical model of "brief, intermittent therapy throughout the life cycle," a method that originated at the Kaiser Permanente HMO in Northern California under the direction of senior author Nick Cummings, is based on the developmental model of Erik Erikson, the Strategic Therapy of Milton Erickson, and 30 years of empirical outcomes research in which helping the patient in the most effective and efficient ways were the primary criteria.
The book describes a general theoretical and practical approach to focused psychotherapy, including the metapsychological assumptions of this type of therapy, techniques to utilize resistance in the service of healing and growth, and a way of structuring treatment episodes. The volume goes on to present, with numerous clinical case examples, the application of this approach to various diagnostic categories. Various chapters examine diagnostic schema that differentiates between patients who suffer, and those who cause others to suffer, as well as between patients who can be helped through insight and those who cannot. These diagnostic criteria are consistent with the categories of DSM IV, but are grouped according to psychodynamics and treatment implications rather than according to symptomatology homework assignments to both continue the process of change between sessions and convince patients that they are truly partners in their own treatment.
Finally, the book explores the incidence of suicide among borderline personalities, hysterics, paranoid schizophrenics, adolescents, the elderly and others.
FOCUSED PSYCHOTHERAPY will be essential for all psychotherapists striving to maintain the most efficient and, more important, the most effective treatment methods while working in our continually changing health care environment.
Nick Cummings, Ph.D., Sc.D., is President, of the Foundation for Behavioral Health, former President of the American Psychological Association, and founder of the California School of Professional Psychology. He is the founding CEO of American Biodyne, now MedCo Behavioral Care Systems. Dr. Cummings also launched the National Council of Schools of Professional Psychology, as well as the American Managed Behavioral Care Association, and he is founder of the National Academies of Practice in Washington, D.C. Dr. Cummings wrote and implemented the first comprehensive psychotherapy insurance benefit at Kaiser Permanente HMO in the 1950s. He is the author of over 300 scientific articles, book chapters, and books.
Mike Sayama has also written SAMADHI: Self Development in Zen,
Swordsmanship, and Psychotherapy (SUNY Series in Transpersonal
and Humanistic Psychology, hardcover, Paperback). This title integrates martial arts training with traditional spiritual disciplines as analogous to some goals in transpersonal psychotherapy.
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