Richard E. Summers and Jacques P. Barber. (2010) New York: Guilford. Xii + 355 pp. $40.00.
This guide to psychotherapy and to some of the evidence supporting psychodynamic psychotherapy is an enjoyable and stimulating read. The authors, a psychiatrist and a psychologist/psychotherapy researcher, favor a pragmatic psychodynamic psychotherapy, and the overall flavor of the book is definitely pragmatic. They show an openness to other “brands” of psychotherapy and try to offer guidelines for tailoring psychotherapy to the patient's strengths, limitations, cognitive and emotional style and circumstances. Therefore, one feels that the authors are grounded in the real world and not stuck in the confines of an Randomized controlled trials (RCT) or in a propaganda war.
The book is divided into 5 parts, describing context, opening phase, middle phase, combining treatments, and ending. In the first part, they describe dynamic psychotherapy and the changes in technique over the years. Influenced by factors such as the convergence of the concepts of fantasy, schema and pathogenic thoughts, and the acknowledgment of the reality of trauma and real aspects of the patient/therapist relationship, there is a greater emphasis on schemas resulting from traumatic experiences and a less hierarchical treatment relationship. Several other changes and their influences are discussed. This leads into their new model, “Pragmatic Psychodynamic Psychotherapy (PPP),” which is based on a developmental and conflict model of mental life and involves clearly defined psychodynamic diagnosis and formulation, a focus on education and transparency, integration with other synergistic treatment modalities, and an active, engaged therapeutic stance. The reader might say, “Just what we need – another brand of psychotherapy,” but this modernization and integration of useful developments does have an appeal to open-minded therapists. Drive, affect, cognition, and behavior are given equal importance and are seen as parallel processes.
In a chapter on the other psychotherapies, the authors construct useful tables to identify the relative emphasis that different therapies place on cognition versus emotion, experience versus technique, and the role of narrative.
The section on the opening phase first focuses on the therapeutic alliance and its 3 components—goal, task, and bond, as described by Bordin. The authors stress the usefulness of thinking about these components of the alliance by giving clinical examples of one of these components being problematic. Being able to pinpoint which component is weak helps the therapist address the issue and improve the alliance. This section is more useful for beginning therapists than those with experience and ongoing training and education. The same applies to their explanations of the distinctions among therapeutic alliance, transference, and real relationship—consistent with a useful primer.
In the sections on core psychodynamic problems, the authors describe 6 problems—depression, obsessionality, fear of abandonment, low self-esteem, panic anxiety, and trauma—that are indications for psychodynamic psychotherapy. For each of these problems, they indicate associated key conflicts, predominant psychodynamic model used for formulation, typical core conflict relationship theme, DSM-IV diagnosis, psychodynamic treatment goals, character strengths affected, and therapeutic alliance issues. This exercise brings together the many frameworks that dynamic clinicians use in the everyday life but are often stripped away by adhering to the DSM-IV's theoretical structure. Their more embracing frameworks provide an organized template to capture many useful concepts. In addition, they examine the typical resistances, technique issues, transferences, and countertransferences associated with each psychodynamic problem.
It is also in these chapters that the authors discuss the evidence base for the use of psychodynamic psychotherapy for each specific problem. Much of the evidence indicates that it is as good as but not better than CBT and there is more evidence for CBT. However, there are some patients who yearn to understand their current problems in the context of their past experiences and who find CBT unsatisfying. On the other hand, some patients prefer the more cognitive, problem-solving style of CBT and do not relate to the psychodynamic orientation. Ultimately, this style may be the deciding factor in how patients are triaged. The strength of Pragmatic Psychodynamic Psychotherapy is that it allows a greater emphasis on cognition, emotion, or behavior, depending on the patient.
The chapter on psychodynamic formulation provides a guide for developing this working model for understanding the effect of biology, temperament, early and ongoing experiences on a patient's symptoms and problems. This guide is excellent for beginners and suggests a useful structure to allow a comprehensive but evolving understanding of the patient and the likely transferences and countertransferences that might emerge in the treatment. The chapter on defining a focus and goals is also useful, but more so for beginners. The middle phase chapters on building a personal narrative, mechanisms of change, and moments in psychotherapy are also useful for beginners.
In line with their efforts to be pragmatic and discuss psychotherapy in the real world, the authors have included chapters on the combination of pharmacotherapy and psychotherapy and on a family systems perspective. The advantages and disadvantages of having one therapist versus 2 therapists doing the pharmacotherapy and psychotherapy are outlined and they acknowledge those who have written on this topic before them. The family systems perspective is also useful and brings a framework to understand the effects of individual therapy on the family and the family's effect on the individual.
Finally, the chapter on termination is welcome. This is a topic covered by most time-limited therapy books but is often given short shrift in more comprehensive books. The practical, reality-based tone and the options offered are useful to the beginning therapist. Overall, this is a well-organized guide for a beginning therapist. It lacks in-depth case examples that really engage the reader, as they opt instead to give many brief examples to illustrate specific points. A seasoned therapist might find this book somewhat superficial and not emotionally engaging. Someone looking for a critical appraisal of the evidence for psychodynamic psychotherapy would have to go to the references and read the original studies because the empirical studies are not really analyzed. However, a beginning therapist would find much in this book that is useful. It synthesizes many approaches and its flexibility is a counterbalance against rigidly idealizing any one approach. Its comprehensive format makes it a valuable teaching tool.
Michael Bond, MD, FRCP(c), FAPA
Professor of Psychiatry
McGill University and Psychiatrist-in-Chief
Jewish General Hospital
Montreal, Quebec, Canada