Practice Procedures (Book Review)

The How-To Book for Students of Psychoanalysis and Psychotherapy
Author:  Bach, Sheldon
Publisher: London: Karnac Books, 2011 
Reviewed By: Anthony F. Tasso, Summer 2012, 100 pp.

Manual of Panic Focused Psychodynamic Psychotherapy — Extended Range
Author:
  Busch, Fredric N., Milrod, Barbara L., Singer, Meriamne B., Aronson, Andrew C.
Publisher: New York, NY: Routledge Books, 2011 
Reviewed By: Anthony F. Tasso, Summer 2012, 230 pp.

Although academic disciplines ranging from the humanities to the neurosciences are readily stimulated by the depth and breadth of psychoanalysis and the ways in which psychoanalytic thinking captures the complexity of the human condition, the relationship between the clinical mental health field and psychoanalysis is strained, to say the least, and in many settings, psychodynamic treatments are no longer in primary use. Cognitive behaviorism and psychopharmacology now constitute the mainstream. Clinical trainees are increasingly non analytic in orientation and are even educated to vociferously denounce psychoanalysis. However, it is a striking fact that the professional rejection of psychoanalysis and acceptance of CBT contradicts what beginner practitioners look for in terms of their own therapy. There is a well-established record indicating that psychoanalytically oriented therapists demonstrate the strongest orientation loyalty when it comes to selecting their personal therapist, whereas practitioners of other theoretical persuasions are more perfidious and commonly see a personal therapist outside their chosen orientation (Norcross, Bike, & Evans, 2009). Regarding treatment for themselves, psychodynamic trainees have a confidence in their modality that is lacking for nonanalytic trainees regarding their chosen therapeutic approach.

In fact, psychodynamic training has been falling out of fashion for several reasons. An inhospitable academic climate for psychoanalytic thinking is clearly at play, in large part due to a vocal majority of psychoanalysts unwilling to embrace psychological science. The triumph of managed care, with its value on managing costs, valuing brevity over quality, also bears responsibility. However, it would be incorrect to blame the field's resistance to research and time limited treatments as accounting for the entire variance of psychoanalysis's receding status within the mental health field. Also central in swaying graduate students from embarking on psychodynamic clinical training is the daunting, oft-amorphous process of learning to practice psychoanalytic psychotherapies. Psychoanalytic primers and systematically organized technical and treatment texts have been few and far between. Scientifically grounded treatment manuals— the standard for many modalities—have been close to anathema within psychoanalysis, often derided as "watered down" and boilerplate. The unfortunate by-product of these "in house" (i.e., psychoanalytic field) beliefs is the creation of a wall that prevents many neophyte clinical trainees from becoming psychodynamic practitioners, while unfortunately buttressing the claims of psychoanalysis as the impossible profession.

Two recent books may help remedy this imbalance. Sheldon Bach's The How-To Book for Students of Psychoanalysis and Psychotherapy (Karnac, 2011), a bona fide step-by-step assistance for beginners, and Busch, Milrod, Singer, and Aronson's Manual of Panic Focused Psychodynamic Psychotherapy—Extended Range (Routledge, 2012), a scientifically based time-limited manual, represent separate but interrelated positions within psychoanalysis. In the former text, Bach leans on his extensive experience as a practitioner and educator to provide practical information primarily geared toward helping early career psychotherapists develop a successful psychotherapy practice. The latter text represents an empirically grounded, systematic, conceptual, and interventional approach thoroughly anchored in the analytic method to treat panic and anxiety. These two books have separate purposes but overlap in their excellence in educating, training, and treatment guidance.

In The How-To Book, Bach brings the reader a compact, user-friendly text that comprehensively yet pithily grounds the student or new professional in initiating a career as a psychotherapist. Bach begins by stating that this work is a consolidation of the accumulated wisdom of a 50-year professional career. He chronicles the process of developing and sustaining a successful psychotherapeutic practice by providing invaluable information on the "nuts and bolts" of commencing psychoanalytic patient work. He describes critical facets of becoming a therapist that often fly under the radar of explicit training or mentorship, such as the nuances of choosing a preferred analytic orientation and selecting one's personal analyst, to name just a few. Bach offers incredible insights with quick, several sentence examples.

Bach also explicates more advanced aspects of the process of psychoanalysis and psychoanalytic psychotherapies. For example, he addresses the importance of the initial interview. Although the significance of the initial consult is nothing new to psychoanalysts, Bach carefully highlights what he sees as indispensable first-session tasks: forming a thorough understanding of previous treatment experiences and initiating a working alliance— both of which are paramount to determining diagnostic classifications or collecting demographic and mental status data. The author also examines the imperativeness of exploring patients' fluctuating experiences of self and others. In The How-To Book, Bach also devotes three chapters to exploring transference phenomena by providing the phenomenological aspects of such clinical experiences from the perspective of both the analyst and the analysand—with several disparate clinical and supervisory vignettes. Bach delineates primitive or narcissistic transferences and their corresponding part-object experiences from neurotic transferences and their whole-object transferences. Furthermore, he spends a considerable portion of this section discussing sadomasochistic transferences— something rarely seen in primers. The author expands Freud's theorizing on the universality of the beating fantasy by underscoring sadomasochistic attachments through incorporating rapprochement stage experiences of repeated unpleasant or dismissive parent-child interactions as the template for this method of relating to others. Bach illuminates how this is experienced in the transference, explores some regularly evoked countertransference reactions, and provides cogent technical tips on managing such phenomena. Beginning therapists will undoubtedly appreciate Bach's lucid descriptions of the breadth of transferential themes. Experienced therapists are sure to value his ability to spell out the intricacies of such pervasive clinical experiences.

Bach also investigates topics that are often uncomfortable for the fledging, as well as seasoned, clinician. First, he discusses the somewhat taboo topic of getting paid for being a psychotherapist, in particular the concept of charging for missed sessions and its relation to one's self-worth as a clinician. He additionally addresses the delicate, mutually interactive relationship between the patient's and therapist's self-esteem and need for recognition. Bach carefully describes how clinicians need to be mindful of the subtle ways in which patients' and clinicians' narcissistic fragility can impinge upon (and possibly spoil) the analysis.

The How-To Book does not neglect day-today topics that often are peripheral in formal clinical training, such as the sensitive process of referring out a patient without intimating abandonment or untreatability, determining when to seek psychopharmacological adjunctive assistance, the management of vacations and the attendant experiences of abandonment, and helpful tips for therapist self-care. These topics only scratch the surface of the dense practical advice available here. Bach covers more user-friendly information in an economical 86 pages than typically seen in textbooks twice as long, or longer.

Busch, Milrod, Singer, and Aronson's Manual of Panic Focused Psychodynamic Psychotherapy—Extended Range is a scientifically grounded text on the programmatic analytic treatment of panic and anxiety disorders. In an extension of their earlier work (Milrod, Busch, Cooper, & Shapiro, 1997), the authors open by reporting on their carefully controlled, comprehensive training and extensive body of research examining panic-focused psychodynamic psychotherapy (PFPP) with panic disorders, and they further report on the developing scientific support for PFPP with different anxiety-based conditions as well as Cluster C personality disorders. The authors make a strong case for the need for systematic non pharmacological treatment of anxiety, given the oft-precluding adverse effects of medications that many patients experience. Busch and colleagues also report on empirical evidence shedding light on the limits of CBT's effectiveness in treating panic anxieties, disabusing the popular sentiments of its panacea reputation. They explain the historical chasm between analytic scholars championing psychological science and those within the analytic community averse to integrating research within psychoanalysis. The authors argue how embracing treatment manuals would better allow psychoanalytic researchers to examine what works and what does not.

Part I of Manual of Panic Focused Psychodynamic Psychotherapy consists of a concise description of basic analytic principles, where Busch and colleagues distinguish between intrapsychic concepts (e.g., the unconscious, defenses, self and other representations) and clinical manifestations (e.g., resistance, transference, countertransference). The authors highlight the developmental underpinnings of panic and anxiety, and later emphasize the value of a comprehensive psychoanalytic case formulation by describing the ways in which a thorough, psychodynamically anchored conceptualization illuminates the patient's character structure, meaning of symptoms, attachments, and representations of self and others—all of which allow for the tailoring of patient-specific treatment, even within a structured therapy protocol. Part I provides the necessary backdrop for a psychoanalytic conceptualization and intervention of anxiety, and the authors provide numerous clinical examples for these concepts. Such vignettes pepper the entire book, truly making this manualized text clinically rich.

Part II begins with an overview of PFPP, a 24-session, twice-weekly, psychodynamic treatment approach. Busch and colleagues underscore key concepts of PFPP, and psychoanalytic therapies at large, that distinguish analytic treatments from most other modalities of psychotherapy: the patient (rather than therapist) guides the treatment, the therapist carefully tracks the patient's associations and affects, and the therapist suspends advice giving. The authors also explain the treatment foci of PFPP, including the initial evaluation (e.g., exploration of circumstances, meaning, and experience of anxiety), treatment proper (e.g., intervention of intrapsychic and interpersonal conflicts), and termination (e.g., re-experiencing of central themes within the transference) phases. They undergird the versatility of PFPP in treating the idiography of a patient, even within its time-limited, semistructured approach.

In this middle section of Manual of Panic Focused Psychodynamic Psychotherapy, Busch and colleagues further delve into the nuances of panic and anxiety. The authors describe PFPP's incorporation of dreamwork, interpretative processes, and working within the transference. They also discuss key factors in the commencing of PFPP, including mindfulness of often-severe experiences of humiliation and shame about panic and anxiety in addition to the core conflicts with such patients, such as separation and autonomy, struggles with anger and guilt, and the role of sadomasochistic and sexual impulses. The authors also examine common defense mechanisms seen in panic and anxiety conditions (e.g., reaction formation, undoing) as well as the propensity for somatization. They close Part II by comprehensively describing the working through and termination phases. Here, the authors beautifully tie these and other concepts directly to panic and anxieties without straying to a metatheoretical discussion, thus making it a true practice technique book.

In Part III—the final section—Busch and colleagues demonstrate the "extended range" of this current edition of Manual of Panic Focused Psychodynamic Psychotherapy by moving the application beyond panic disorders to the broad domain of anxiety. They offer a chapter each to the application of PFPP to agoraphobia (and other phobias), social anxiety, generalized anxiety, posttraumatic stress disorder (coauthored by Marie Rudden), as well as PFPP vis-à-vis dependent, avoidant, and obsessive-compulsive personalities. Busch and company underscore phobic patients' struggles with dependency, independence, and aggressiveness, in addition to the magical, aggrandized fantasies that certain inanimate objects or places are dangerous while others are safe. They also identify perhaps the most striking contrast between PFPP and CBT approaches to the treatment of phobias: PFPP's de-emphasis of direct exposure to the feared stimulus because of its likelihood of colluding with dependency. They also examine socially anxious persons, with their confl icts around exhibitionism and fantasies of ostentatious displays of power and grandiosity, and report on clinical and empirical data suggesting that such persons commonly recollect their parents as fear-inducing and uncaring, findings that link to the childhood behavioral inhibitory tendencies regularly seen in early development of social anxiety. With such patients, PFPP aims to address the core feelings of inadequacy and conflicts between inferiority and the desire to display one's self. The authors describe generalized anxiety as a hypervigilance in defending against the emergence of unacceptable feelings and fantasies along with fears of losing a relationship, avoidance of negative affect, and the inchoate ability to identify emotions, which are the circumscribed PFPP treatment foci. Busch and colleagues examine PTSD with its dissociative tendencies, rage, identifi cation with the aggressor (and subsequent self-punishment), and sense of terror. The authors identify the therapeutic need to address the experiences of the trauma and terror that begot dissociation, conflict, and guilt. Also, they demonstrate some of the early promising data suggesting PFPP can assist with dependent, avoidant, and obsessive-compulsive personality styles by intervening on their conflicts around aggression, independence, and assertiveness. Numerous pertinent clinical vignettes accompany each of these condition-specific chapters.

The How-To Book and Manual of Panic Focused Psychodynamic Psychotherapy represent significant, mutually beneficial developments within psychoanalysis. Bach's book consolidates much of what goes into building a successful psychoanalytic psychotherapy practice. It will give students a sense of being professionally grounded, and it allows experienced clinicians to reflect on their way of thinking about patient work as well as to incorporate helpful steps from master clinicians and educators. Busch, Milrod, Singer, and Aronson's manual provides scientifically and technically grounded procedural information on conceptualizing and treating patients broadly falling within the realm of anxiety.

Each book provides the rich content of systematic analytic procedural information, and, in the case of Busch, Milrod, Singer, and Aronson's text, a solid scientifi c foundation. This allows for true development and expansion of the ways in which psychoanalytic treatments are practiced, thus making for good pedagogy and a template for further programmatic research—concepts that are sorely missing in psychoanalysis. Unfortunately, many analysts have overtly or covertly deemed such structure as pedestrian, nomothetic, and superfi cial. This is quite surprising, given that both time-limited and technical books have enjoyed both historical and contemporary success (e.g., Davenloo, 1980; Glover, 1968; Greenson, 1967; Luborsky, 1984; Malan, 2001; Mann, 1973; McWilliams, 2004; Sifneos, 1992). The How-To Book and Manual of Panic Focused Psychodynamic Psychotherapy soundly disabuse any notions of oversimplifi cation. What is regrettably true from such a misguided mind-set is that this belief has done more to fuel the antianalytic sentiments in academic and managed care circles than anything specific to CBT or pharmacological treatment proper, meaning that a significant portion of the ammunition used to criticize psychoanalysis is controllable. These two texts laudably assert such control.

The Manual of Panic Focused Psychodynamic Psychotherapy and The How-To Book are far from cookie-cutter or simplistic. Each text provides neophytes and experienced clinicians a solid base on which to conceptualize their practice, and Busch and colleagues' text also specifically provides rich conceptual and procedural information on the systematic, time-limited analytic treatment of panic and anxiety. This is the rich, user-friendly content of each book. The process of each is far greater, with the proactive inclusion of clearly delineated procedural processes within the psychoanalytic field, resulting in uncomplicated, jargon free reads. This allows for measuring the mechanisms of change and the outcomes of analytic interventions, thus enhancing the research ability of psychodynamic therapies, a crucial process for psychoanalytic theories and treatments to be viable in the clinical field and acceptable within a managed care environment.

References

Davenloo, H. (1980). Short-term dynamic psychotherapy. New York: Jason Aronson.

Glover, E. (1968). The technique of psychoanalysis. Madison, CT: International Universities Press.

Greenson, R. R. (1967). The technique and practice of psychoanalysis (vol. 1). Madison, CT: International Universities Press.

Luborsky, L. (1984). Principles of psychoanalytic psychotherapy: Manual for supportive-expressive treatment. New York: Basic Books.

Malan, D. H. (2001). Individual psychotherapy and the science of psychodynamics (2nd ed.). New York, NY: Arnold Publishers.

Mann, J. (1973). Time-limited psychotherapy. Cambridge, MA: Harvard University Press.

McWilliams, N. (2004). Psychoanalytic psychotherapy: A practitioner's guide. New York, NY: Guilford Press.

Milrod, B., Busch, F., Cooper, A. M., & Shapiro, T. (1997). Manual of panic-focused psychodynamic psychotherapy. Washington, DC: American Psychiatric Press.

Norcross. J. C., Bike, D. H., & Evans, K. L. (2009). The therapist's therapist: A replication and extension 20 years later. Psychotherapy: Theory, Research and Practice, 46, 32–41.

Sifneos, P. E. (1992). Short-term anxiety provoking psychotherapy: A treatment manual. New York, NY: Basic Books.

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