This book aims to provide a practical guide for clinicians offering brief therapy. Balanced and authoritative chapters by the three editors cover brief therapy in general, including overview topics such as common therapeutic factors, selection of patients for brief therapy, and the therapist's stance in brief work. Alongside this, leading clinicians from various major schools of therapy explain how they conduct their work, with a slant to working in roughly 20 sessions or less. There are web-links to extended video clips to see the therapists in action.
I like the main editors' standpoint; they are open to what different therapeutic approaches have to offer and take a ‘what works for whom’ perspective. Reading the main editors' chapters brought to my mind a scene from the Woody Allen film, Annie Hall. Allen's character is waiting in a cinema queue, about to ‘have a stroke’ with rage in connection to the man behind him who is ‘pontificating’ about an arcane academic point. Allen disagrees with the man in the queue and you think the situation will reach impasse until a surreal turn of genius: Allen, with a casualness that betrays his glee, produces the leading academic from the field in question from behind a poster (‘I happen to have the Professor here…’). Playing out a fantasy of wish-fulfilment, the professor calmly pronounces his views as being in line with Allen's and resolves the situation once and for all.
Similarly, I found myself day-dreaming about bringing in Professors Dewan, Steenbarger and Greenberg to coolly and persuasively settle the matter in meetings when us therapists split along the fault-lines and descend into conflict about whose therapy approach is ‘the best’… to the detriment of our patients who we have unwittingly forgotten. These professors would say to us that that some therapies ‘focus more on the present, whereas others focus on the past and present. Some emphasize interactions with the therapist as a primary locus of change efforts; others place greater weight on out-of-session experiences’. Dewan would assert that working out what therapeutic approach (or combinations of approaches) best suits each patient is a better fit with research evidence than ‘unwavering allegiance to single-therapy systems’. And that would settle the matter!
Back to reality… Dewan builds on this inclusive approach by explaining that some patients may benefit from different kinds of therapy at different points in their journey. For me, this reflects the real world, where many patients have undertaken therapies previously and are still seeking something else. Dewan's chapter on combining therapy with medication is also highly recommended: alive to the psychological meaning and impact of medication while providing pragmatic guidance for therapists and prescribers.
In terms of specific chapters, the mentalization chapter by Bateman & Fonagy articulates a subtle argument that has potentially wide ramifications. They argue that change occurs between sessions as ‘a consequence of changed attitudes to learning engendered by the therapy’. Echoing Bion and Winnicott, they contend that the crux of the matter is the clinician's ‘careful focussing on the patient's internal experience’, which in turn can provide an experience for the patient ‘of another human being having [their] mind in mind’. Referring predominantly to patients who have so far lacked sufficient experiences of really feeling held in mind, Bateman & Fonagy describe that through this sort of interactive process a patient may gradually become more open to trusting what the therapist has to offer. They hypothesise that this ‘epistemic trust’ towards the clinician can open up a channel for trusting others more generally and so create the potential to ‘take in’ good things from others and develop more positive relationships. I think this process is highly relevant not only to formal therapy delivered by psychological therapists, but to encounters in psychiatry more generally in out-patient clinics and on the wards, and beyond this to wider areas such as housing, the voluntary sector and education.
I found the dialectical-behavioural therapy chapter by Wilks & Linehan very engaging. Linehan comes across as a clinician unafraid to get ‘stuck in’, taking being patient-centred right to the edge of what is bearable (and sensible?) for the clinician. How often do you see this in a research proposal: ‘To conduct a clinical trial applying behavior therapy, Linehan called area hospitals and asked them to send her the most severe, highly suicidal, and difficult to treat patients’. Despite this audaciousness, the narrative that follows is not overconfident but conveys close listening and humility as they reflect on lessons learnt from this trial and how these led to the development of Linehan's therapeutic approach. Namely, how patients with a diagnosis of borderline personality disorder experienced a behavioural problem-solving approach as invalidating, as they inferred they were the problem that needed to change and so ‘lashed out at the therapist’ or dropped out altogether. This led to Linehan realising the need for a dialectic between acceptance and change.
Regardless of whether one is a dialectical-behavioural therapist, I recommend watching the video of Linehan in action to observe her style of working with a patient with emotional and relationship difficulties. Linehan is validating about her patient's feelings yet also ‘challenging’ and non-collusive about the patient's ways of seeing and doing. Linehan strikes a balance in her level of closeness to the patient by being warm and empathic to help engagement, yet also matter-of-fact and straightforward enough to keep the emotional tone from rising too high.
I felt one important aspect was missing from this book. This was a detailed account of the interpersonal pressures that arise that may lead clinicians from all schools to inadvertently act in ways that are unhelpful to the therapy. We may know about the value of common therapeutic factors such as empathy, close listening, and support – but sustaining these in relation to someone who rejects or attacks offered care is another matter. Herein is the role of reflective practice and processing the interpersonal dynamics of clinical work, alongside the more technical aspects of therapy that are the heartland of this book.
There are a few places in this book that might raise antibodies for some readers. On occasion some contributors perhaps overdo their certainty about expected benefits and what they see as positive attributes of their preferred way of working. For example, Edna Foa states that, ‘…clinicians initiate a course of [manualised] CBT knowing not only how the treatment as a whole will progress but also what each treatment session should entail’. But how might the patient feel about that, I grumbled to myself? Additionally, in chapters about particular schools of therapy, I felt in one or two places that the interpretations of the evidence-base were somewhat partisan, triggering again my Woody Allen fantasy of producing the three editors to recount their balanced analysis.
I expect this book is best suited to therapists mid-way through their training who are seeking fairly detailed accounts of various therapeutic approaches. More experienced therapists and general clinicians are likely to enjoy the overview chapters and to dip into the other sections, rather than read the book cover to cover.
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