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Letter to the Editor   |    
Changing Character: Short-Term Anxiety-Regulating Psychotherapy for Restructuring Defenses, Affects, and Attachment
David Brizer, M.D.
Psychiatric Services 1998; doi:
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by Leigh McCullough Vaillant, Ph.D.; New York City, BasicBooks, 1997, 510 pages, $35

text A A A

There is a peculiar genre in literary fiction that, starting from assumption A, launches into a cosmology of names, dates, events, and narrative that through iteration, reiteration, and reification ultimately takes on the appearance of reality. Borges remains the undisputed master of this turf, although it could be argued that the Bible and other canonical texts paved the way for and remain the most powerful and influential of these exercises.

Reading Dr. Vaillant's densely informative, citation-rich treatise on a type of brief therapy practiced in several centers provokes a similar feeling—of watching a highly creative magician creating a world in a jar. It isn't until we arrive at page 422 that a brief overview of research antedating and presumably validating this particular approach is touched on. Before we get there, however, we are feted royally with a banquet of highly articulate descriptions of method, theory, and clinical practice. Like Borges, the author attempts to validate her text with frequent bottom-of-the-page citations that make reference to conversations with and statements by co-locutors, co-referents, and, one might even snidely suppose, co-religionists.

The book should start with the data. That approach would give the reader a chance to decide whether the ensuing journey is worth the time. On the other hand, those who are already convinced that brief therapy is the way to go will find a wealth of observations, techniques, and ultimately humane reflections that will undoubtedly enhance their own clinical expertise. Clearly, Dr. Vaillant is dedicated to her work and her patients. The book represents a mammoth scholarly effort, complemented by an attention to detail and sensitivity to patients' needs that go a long way toward remedying the circular hypothesis problem alluded to above.

The book begins with a concise and informative overview of brief therapies in general, followed by a chapter on functional assessment of patients. The subsequent discussions of conflict resolution, defense recognition and relinquishing, and affect expression are richly complemented with case examples. The relatively spare treatment of outcome data is followed by a final section on directions for future work. Although mention is made from time to time of the possible incursions of managed care into clinical practice, insufficient discussion is devoted to alternative and possibly even briefer approaches. (Are you listening to Prozac, Dr. Vaillant?)

After one finishes the book, the following is clear: the author has a powerful intellect and is motivated by a sincere desire to reduce the suffering of others in the best way she knows how. She has drawn a map of a territory staked out by a group of clinicians and researchers that deserves further and deeper exploration. One would have no problem sending one's mother to her or her coworkers for treatment. However, I would not necessarily recommend this book as reading for the beginning student of psychotherapy. It is a variably eloquent addition to some of the increasingly sophisticated work that is appearing, and that needs to continue to appear, on short-term psychotherapy.

Dr. Brizer is director of the department of behavioral health at Lutheran Medical Center in Brooklyn, New York.




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