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Book Review   |    
The Talking Cure: The Science Behind Psychotherapy • Psychotherapy With "Impossible" Cases: The Efficient Treatment of Therapy Veterans • Psychological Mindedness: A Contemporary Understanding
Nancy Glimm, M.S.W., C.S.W.
Psychiatric Services 1998; doi:
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by Susan C. Vaughan, M.D.; New York City, G. P. Putnam's Sons, 1997, 208 pages, $24.95 • by Barry L. Duncan, Psy.D., Mark A. Hubble, Ph.D., and Scott D. Miller, Ph.D.; New York City, W. W. Norton & Company, 1997, 222 pages, $35 • edited by Mary McCallum, Ph.D., and William E. Piper, Ph.D.; Mahwah, New Jersey, Lawrence Erlbaum Associates, 1997, 276 pages, $39.95

Three recent books have different contributions to make to mental health professionals who practice psychotherapy. In the first, psychiatrist and psychoanalyst Susan Vaughan very readably draws on neuroscience and other disciplines to address the question of how psychotherapy affects the brain. Next, three experienced therapists and supervisors offer a specific approach to dealing with "impossible" cases—patients who have not responded to therapy. The third book, edited by two research psychologists, examines psychological mindedness from a research perspective.

Dr. Susan Vaughan's engaging new book, The Talking Cure: The Science Behind Psychotherapy, demonstrates her knowledge and mastery of varied subjects including neuroscience, psychotherapy research, developmental psychology, and psychoanalysis. She provides the reader with an overview of the state-of-the-art research integrating the neuroscientific basis of dream theory, intelligence, memory, cognition, and infant development.

Dr. Vaughan is a National Institute of Mental Health fellow at the New York State Psychiatric Institute and a senior candidate at the Columbia Center for Psychoanalytic Training and Research in New York City. She has applied current quantitative science to the theory of psychotherapeutic practice. She is a gifted writer, which makes this intriguing book accessible and the concepts easy to grasp.

The author states that she wrote the book for her patients because they deserve to know as much as she does about how psychotherapy works. Dr. Vaughan believes the modality works because it produces enduring change on a neuronal level, a view she proceeds to illustrate chapter by chapter. This process coincidentally reinforces the enduring nature of the patient-therapist relationship. The book takes us on a scientific journey that reconfirms the ultimate humanness of psychotherapy and psychoanalysis.

In her first chapter, "Putting the Neuron Back in Neurosis," the author applies current dream theory, neurology, and psychotherapy research to elucidate her ideas. Freud's genius is acknowledged, as is his training as a neurologist and biologist of the soul and his prescient view of psychotherapy. What would he make of the science now available to Dr. Vaughan? She refers to her work with patients as "carefully and systematically examining, challenging, and rewiring the story synthesizer [the patient's] cortex contains."

The author next moves to artificial intelligence and memory research, with a dash of Heinz Kohut. She uses the sea slug to teach about the "psychotherapy of the single synapse," and she draws on learning theory, habituation, and neurochemistry. An examination of long-term memory, Pavlov, and the associations of a patient named Ted is next. Dr. Vaughan reviews and applies the work of infant observer Daniel Stern, using examples from his work as prototypes for the development of self and other. She addresses the affective component in development and its neural basis.

Dr. Vaughan also takes care to address the issue of medication and the impact the psychotherapeutic relationship has on brain chemistry. She examines the complicated interplay between "early life relationships, positive and negative affects, and the regulation of emotions and self-esteem" and then explains how she thinks medications fit into that picture.

The final chapter presents a psychoanalytic case in which much synthesis, integration, and progress takes place, both for the patient and for the author's theory. Dr. Vaughan playfully ends the book with an analysis of one of her own dreams. The reader is left with the feeling that psychotherapy can change brain chemistry in ways that are positive and with lasting results.

The Talking Cure makes an important contribution to the psychotherapy community as well as to patients who wish to explore intellectually why they are feeling better. Dr. Vaughan puts hard science into the psychotherapy treatment process. Her book certainly challenges blanket applications of models of brief treatment. She also directly addresses the use of medication without conjoint psychotherapy and the potential for relapse it carries.

This book provides a rich overview of current brain research, and it is written in a popular manner for both the lay and the professional community. The author's approach to the complex material is sometimes glib, which can be forgiven if the reader remains focused on the content and scope of what is covered. Psychotherapy patients will find the author's integration of this remarkable subject matter to be accessible. Therapists in all mental health disciplines will benefit from Dr. Vaughan's integration and application as well. The Talking Cure: How Psychotherapy Works demonstrates mastery of complex, fascinating material.

Psychotherapy With "Impossible" Cases: The Efficient Treatment of Therapy Veterans accomplishes several important services. Authors Barry Duncan, Psy.D., Mark Hubble, Ph.D., and Scott Miller, Ph.D., are experienced therapists, teachers, and supervisors who became curious about how a client becomes "impossible," and how such a situation can be overcome.

They were no longer satisfied, they say, with answers that "blamed the client or criticized the therapist" and embarked on a five-year course of working with or consulting on impossible cases. From it and from previous work with treatment failures, they concluded that success can occur with impossible patients "when therapy is accommodated to the client's frame of reference and the client's theory of change is honored." They humbly and elegantly report their findings, including explicit accounts of how to approach clients who have not responded to or have had negative experiences in therapy. They consider this book a companion to their Escape From Babel, in which they conceptualize a psychotherapy that maximizes known curative factors (1).

In the current book the authors describe how psychotherapy cases become clinically "impossible." The client who has received multiple treatments often is labeled problematic, or a therapy veteran. The authors reflect on the training of therapists as fundamentally a theory-driven educational process, which they believe can lead to "theory countertransference" when the therapist confronts a challenging case. The therapist pursues agendas that fit the therapist's own theoretical premises but that can violate the client's sensibilities and beliefs. This process can lead to doing more of the same and to a treatment that does not work. The authors present a method "for redirecting therapy from confirming theory-driven objective truths to discovering subjective truths that promote the possibility for change by the client."

They make other important points about clients' motivation. Clearly, treatment can become impossible when the client's motivation is misunderstood or neglected. Even the most experienced therapist can easily overlook what the client wants to accomplish while focused on what the therapist believes might be best. We are reminded of the work of Carl Rogers and his empathic and client-centered approach. The authors also stress the critical importance of therapist-client collaboration.

Drs. Duncan, Hubble, and Miller summarize their approach by stressing that the therapy veteran's frame of reference should guide the therapist's actions. They trust that "within each client is a theory of change waiting for discovery, a framework for intervention to be unfolded and intentionality accommodated for a successful outcome." Each client holds the potential for his or her own creative cure, and the potential for new theory and interventions for the therapist.

The authors illustrate their beliefs with chapters on clinical methods, including exploring the client's own theory of change and accommodating therapy to the client's frame of reference. They provide rich clinical examples of their work with individuals carrying some of the most difficult diagnoses—dissociative identity disorder, delusional disorder, borderline personality disorder, alcoholism, and manic-depressive illness. These examples are down to earth and highly respectful of the clients, exploring, discovering, and validating their world.

In this section…

Therapy and therapists are what many of the books in this month's section cover—including the science behind psychotherapy, treatment of "impossible" cases, and supervision. At least two of the books challenge professional codes of ethics, but the authors' views are ultimately rejected by the reviewers. Also in the ethics area is a review of a decision-making guide for health professionals on assisted suicide. Books on transcultural psychiatry, mental health library services, traumatic events, and the other topics round out the section.

Some therapists will have difficulty with the treatment outcomes in which insight or appropriate states of conventional mental health are not achieved. Yet in each clinical example, the client reports a satisfactory outcome.

Psychotherapy With "Impossible" Cases is a reminder of the basic wisdoms of treatment: empathic listening, collaborating, empowering, and allowing the client to discover the cure. The authors use a team approach in working with these cases, and they remind fellow clinicians that collaboration with colleagues about therapeutic impasses can be liberating.

This book would benefit the experienced psychotherapist, whether a psychiatrist, social worker, or psychologist. It could be used as a teaching tool for students because of its practical and time-honored messages. The authors have made a valuable contribution to the therapy community, to help us remember to see and hear the real communication within the most dire clinical situation or diagnosis.

Psychological Mindedness, by Mary McCallum, Ph.D., and William E. Piper, Ph.D., is a book of inquiry. A creatively developed volume of essays, it explores the concept of psychological mindedness from the research psychologist's perspective. The reader is offered a masterful composite of information that illustrates the range of thinking in the literature today.

The editors, who are affiliated with the University of Alberta department of psychiatry, are senior research psychologists who have published widely. In 1977 Dr. Piper began to investigate psychological mindedness as a variable therapists use to rate psychotherapy patients, and in 1981 Dr. McCallum began looking for a more refined measure for psychological mindedness. Research collaborations between the two eventually led to this current volume of essays. Leading North American researchers on psychological mindedness were invited to contribute, with the editors' suggesting a common outline for the chapters.

The editors' stated purpose in compiling this volume is to increase mental health practitioners' understanding of the concept of psychological mindedness in assessment and treatment. Their secondary purpose is to address psychological mindedness in interpersonal contexts outside of mental health, including motivational, developmental, creative, and cognitive research.

Part 1 reviews questionnaire measures of psychological mindedness; alternative methods of assessing this variable, including Piper and McCallum's own measure; and assessment of psychological mindedness in children. Part 2 describes related concepts the editors discovered during their literature searches. The concept of alexithymia, considered the opposite of psychological mindedness, is reviewed, as are personal and private self-consciousness, personal intelligence, "reading between the lines," and social perspective taking among children. Part 3 contains two chapters, one of which describes the psychological mindedness of psychotherapists. In the final chapter the editors review and integrate the material presented.

Psychological Mindedness makes a clarifying contribution to the literature. The book is carefully conceived and organized; intellectual freedom is evident, and ideas unfold without bias. Positive and negative findings are reported with clarity and fairness. The chapters highlight the problems in psychological and psychotherapy research, the limitations of language in describing mental states, and the difficulty in pinpointing the variables in treatment that contribute to positive or negative outcome.

As appropriate, Psychological Mindedness raises more questions than it answers, and does so in a straightforward manner. It may be of most interest, as the editors note, to therapists with a psychodynamic orientation. However, psychotherapists interested in expanding their understanding of the construct of psychological mindedness should be able to draw useful ideas from it.

Ms. Glimm is a psychiatric social worker with the child and adolescent team at the Bronx Mental Health Center of the Health Insurance Plan of New York.

Miller SD, Duncan BL, Hubble MA: Escape From Babel: Toward a Unifying Language for Psychotherapy Practice. New York, Norton, 1996


Miller SD, Duncan BL, Hubble MA: Escape From Babel: Toward a Unifying Language for Psychotherapy Practice. New York, Norton, 1996

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