by David G. Kingdon and Douglas Turkington; New York, Guilford Press, 2004, 219 pages, $37
Dr. Sullivan is chief of services for the seriously mentally ill at Saint Vincent's Catholic Medical Center, Westchester, New York, and assistant professor of psychiatry at New York Medical College, Valhalla.
It's hard to say how bad ideas, misinformed or misguided clinical saws, originate. One of the most enduring in psychiatry is the notion that talking to patients with schizophrenia about their symptoms or about their subjective experiences is potentially harmful. It is little wonder that so few medical students or psychiatric residents wish to specialize in work with patients who have seriously mental illness.
There have been studies and reviews, most famously the Patient Outcomes Research Team recommendations (1), which have directed our attention to the lack of efficacy (2), obvious paucity of controlled observation, and insufficiently documented putative harm associated with "uncovering therapies," by which is meant psychoanalytic therapy and its congeners. Kingdon and Turkington lament the effect these proscriptions have unintentionally had on creative engagement of persons suffering from disorders such as schizophrenia. They note that "many practitioners continue to believe that the content of psychotic symptoms should be ignored and that any psychological work … is liable to lead to increased distress and exacerbation of symptoms, as a result of having opened up disturbing areas."
Of course the problem with past, well-intentioned, and compassionate efforts by a legion of gifted therapists is that the therapeutic model, and the theory of mind supporting it, did not accurately reflect the nature of the disorder. It was not the effort to be empathic that was flawed but the various notions about how symptoms were produced or could be ameliorated. If you don't understand what you're treating, you will misdirect, misinform, and inevitably disappoint.
Kingdon and Turkington set out to provide clinicians with a treatment model that will make the uncertain knowable and that which is alienating comfortable. They successfully present a cogent, approachable, and flexible model for psychotherapeutic engagement of persons suffering from serious psychotic illness. This is not a "manualized" treatment, and the authors explain why that approach is not appropriate. A careful exposition of the nature of the illness processes, and the theory of cognitive-behavioral therapy and its particular adaptation to this setting, is explicated. There are many clinical examples, guidelines, forms to use, and even patient handouts that can be copied and distributed are included. The succinct review of the psychology of schizophrenia is particularly useful, such as the discussion of "externalizing bias" and the central role of stigmatization in symptom development.
The fourth chapter, on therapeutic engagement, and later chapters on work with delusions and hallucinations, are not only brilliantly executed but come as close as one can, in print, to detailed individual case supervision. Even experienced practitioners will find these presentations extremely helpful, because they reflect the careful thought of talented clinicians who have immersed themselves in their subject and achieved valuable insights.
I do have one brief quibble. As a heuristic device, Kingdon and Turkington use four clinical subgroups to differentiate "types" of schizophrenia. In the context of the book, these subgroups are useful and unify their presentation. I am not sure I can agree that the subgroups encompass the range of patients I see.
Reviewers will often say that the book they are reviewing belongs on everyone's shelf. I urge you to please buy and read this book. Our patients deserve our attention to these issues. Those of you who are talented clinicians but who avoid this population out of confusion or lack of confidence in your ability to help will, I assure you, find this book crucial. You will find yourself able to approach a person with schizophrenia with confidence, and it will change how you think about your work.
Lehman AF, Steinwachs DM: Translating research into practice: the Schizophrenia Patient Outcomes Research Team (PORT) treatment recommendations. Schizophrenia Bulletin 24:1-10, 1998
Gunderson JG: Effects of psychotherapy in schizophrenia: II. comparative outcome of two forms of treatment. Schizophrenia Bulletin 10:564-598, 1984