email page print pageAll Topic Reviews
Maximizing Effectiveness in Dynamic Psychotherapy Self-Compassion in Psychotherapy101 Healing StoriesA Clinician's Guide to Legal Issues in PsychotherapyA Map of the MindA Primer for Beginning PsychotherapyACT With LoveActive Treatment of DepressionAffect Regulation, Mentalization, and the Development of SelfAlready FreeBad TherapyBecoming an Effective PsychotherapistBecoming MyselfBefore ForgivingBeing a Brain-Wise TherapistBetrayed as BoysBeyond Evidence-Based PsychotherapyBeyond MadnessBeyond PostmodernismBinge No MoreBiofeedback for the BrainBipolar DisorderBody PsychotherapyBoundaries and Boundary Violations in PsychoanalysisBrain Change TherapyBrain Science and Psychological DisordersBrain-Based Therapy with AdultsBrain-Based Therapy with Children and AdolescentsBrief Adolescent Therapy Homework PlannerBrief Child Therapy Homework PlannerBrief Therapy Homework PlannerBuffy the Vampire Slayer and PhilosophyBuilding on BionCare of the PsycheCase Studies in DepressionCaught in the NetChild and Adolescent Treatment for Social Work PracticeChoosing an Online TherapistChronic DepressionClinical Dilemmas in PsychotherapyClinical Handbook of Psychological DisordersClinical Intuition in PsychotherapyClinical Pearls of WisdomCo-Creating ChangeCognitive Therapy for Challenging ProblemsCompassionConfessions of a Former ChildConfidential RelationshipsConfidentiality and Mental HealthConfidingContemplative Psychotherapy EssentialsControlConversations About Psychology and Sexual OrientationCoping with BPDCouch FictionCounseling in GenderlandCounseling with Choice TheoryCouple SkillsCrazy for YouCreating a Life of Meaning and CompassionCreating HysteriaCritical Issues in PsychotherapyCrucial Choices, Crucial ChangesDeafness In MindDecoding the Ethics CodeDeconstructing PsychotherapyDeep Brain StimulationDemystifying TherapyDepression 101Depression in ContextDialogues on DifferenceDissociative ChildrenDo-It-Yourself Eye Movement Techniques for Emotional HealingDoing CBTE-TherapyEarly WarningEncountering the Sacred in PsychotherapyEnergy Psychology InteractiveErrant SelvesEssays on Philosophical CounselingEssentials of Wais-III AssessmentEthically Challenged ProfessionsEthics and Values in PsychotherapyEthics in Plain EnglishEthics in Psychotherapy and CounselingExistential PsychotherapyExpectationExploring the Self through PhotographyExpressing EmotionFacing Human SufferingFairbairn's Object Relations Theory in the Clinical SettingFamily TherapyFavorite Counseling and Therapy Homework AssignmentsFear of IntimacyFlourishingFolie a DeuxForms of Intersubjectivity in Infant Reasearch and Adult TreatmentFoundations of Ethical Practice, Research, and Teaching in PsychologyFreud and the Question of PseudoscienceFrom Morality to Mental HealthFundamentals of Psychoanalytic TechniqueGenes on the CouchGod & TherapyHalf Empty, Half FullHandbook of Clinical Psychopharmacology for TherapistsHandbook of Counseling and Psychotherapy with Lesbian, Gay, and Bisexual ClientsHandbook of Evidence-Based Therapies for Children and AdolescentsHealing the Heart and Mind with MindfulnessHeinz KohutHelping Children Cope With Disasters and TerrorismHigh RiskHistory of PsychotherapyHow and Why Are Some Therapists Better Than Others?How Clients Make Therapy WorkHow People ChangeHow Psychotherapists DevelopHow to Fail As a TherapistHow to Go to TherapyHypnosis for Inner Conflict ResolutionHypnosis for Smoking CessationI Never Promised You a Rose GardenIf Only I Had KnownIn Others' EyesIn SessionIn Therapy We TrustIn Treatment: Season 1Incorporating Spirituality in Counseling and PsychotherapyInside the SessionInside TherapyIs Long-Term Therapy Unethical?Issues in Philosophical CounselingIt's Not as Bad as It SeemsItís Your HourLearning ACTLearning from Our MistakesLearning Supportive PsychotherapyLetters to a Young TherapistLife CoachingLogotherapy and Existential AnalysisLove's ExecutionerMadness and DemocracyMaking the Big LeapMan's Search for MeaningMetaphoria: Metaphor and Guided Metaphor for Psychotherapy and HealingMind GamesMindfulnessMindfulness and AcceptanceMindfulness-Based Cognitive Therapy for DepressionMindworks: An Introduction to NLPMockingbird YearsMoments of EngagementMomma and the Meaning of LifeMotivational Interviewing: Preparing People For ChangeMulticulturalism and the Therapeutic ProcessMultifamily Groups in the Treatment of Severe Psychiatric DisordersNarrative PracticeOn the CouchOne Nation Under TherapyOur Inner WorldOur Last Great IllusionOutsider ArtOutsider Art and Art TherapyOvercoming Destructive Beliefs, Feelings, and BehaviorsOverexposedPathways to SpiritualityPersonality and PsychotherapyPhilosophical CounselingPhilosophical Counselling and the UnconsciousPhilosophical Issues in Counseling and PsychotherapyPhilosophical PracticePhilosophy and PsychotherapyPhilosophy for Counselling and PsychotherapyPhilosophy PracticePhilosophy's Role in Counseling and PsychotherapyPillar of SaltPlan BPlato, Not Prozac!Polarities of ExperiencesPower GamesPractical Psychoanalysis for Therapists and PatientsPrinciples and Practice of Sex TherapyProcess-Based CBTPsychologists Defying the CrowdPsychology, Psychotherapy, Psychoanalysis, and the Politics of Human RelationshipsPsychosis in the FamilyPsychotherapyPsychotherapyPsychotherapy and ConfidentialityPsychotherapy As PraxisPsychotherapy East and WestPsychotherapy for Children and AdolescentsPsychotherapy for Personality DisordersPsychotherapy Is Worth ItPsychotherapy Isn't What You ThinkPsychotherapy with Adolescent Girls and Young WomenPsychotherapy with Children and AdolescentsPsychotherapy without the SelfPsychotherapy, American Culture, and Social PolicyRapid Cognitive TherapyRational Emotive Behavior TherapyRational Emotive Behavior TherapyRationality and the Pursuit of HappinessRebuilding Shattered LivesReclaiming Our ChildrenRecovery OptionsRelationalityRent Two Films and Let's Talk in the MorningSaving the Modern SoulScience and Pseudoscience in Clinical PsychologySecond-order Change in PsychotherapySelf-Compassion in PsychotherapySelf-Determination Theory in the ClinicSelf-Disclosure in Psychotherapy and RecoverySerious ShoppingSex, Therapy, and KidsSexual Orientation and Psychodynamic PsychotherapySigns of SafetySoul Murder RevisitedStaring at the SunStraight to JesusStrangers to OurselvesSubjective Experience and the Logic of the OtherTaking America Off DrugsTales of PsychotherapyTales of UnknowingTalk is Not EnoughTalking Cures and Placebo EffectsTelling SecretsThe Behavioral Medicine Treatment PlannerThe Body in PsychotherapyThe Brief Couples Therapy Homework Planner with DiskThe Case Formulation Approach to Cognitive-Behavior TherapyThe Challenge for Psychoanalysis and PsychotherapyThe Child and Adolescent Psychotherapy Treatment PlannerThe Clinical Child Documentation SourcebookThe Clinical Documentation SourcebookThe Complete Adult Psychotherapy Treatment PlannerThe Couch and the TreeThe Couples Psychotherapy Treatment PlannerThe Crucible of ExperienceThe Cure of SoulsThe Death of PsychotherapyThe Education of Mrs. BemisThe Ethical Treatment of DepressionThe Ethics of PsychoanalysisThe Gay and Lesbian Psychotherapy Treatment PlannerThe Gift of TherapyThe Great Psychotherapy Debate: The Evidence for What Makes Psychotherapy Work The Healing JourneyThe Heart & Soul of ChangeThe Heroic ClientThe Husbands and Wives ClubThe Love CureThe Making of a TherapistThe Mindful TherapistThe Mirror Crack'dThe Mummy at the Dining Room TableThe Neuroscience of PsychotherapyThe Neuroscience of Psychotherapy: Healing the Social BrainThe New Rational TherapyThe Older Adult Psychotherapy Treatment PlannerThe Other Side of DesireThe Pastoral Counseling Treatment PlannerThe Philosopher's Autobiography The Pornographer's GriefThe Portable CoachThe Portable Ethicist for Mental Health Professionals The Present Moment in Psychotherapy and Everyday LifeThe Problem of EvilThe Problem with Cognitive Behavioural TherapyThe Psychodynamics of Gender and Gender RoleThe Psychotherapy Documentation PrimerThe Psychotherapy Documentation PrimerThe Psychotherapy of HopeThe Real World Guide to Psychotherapy PracticeThe Schopenhauer CureThe Sex Lives of TeenagersThe Talking CureThe Therapeutic "Aha!"The Therapist's Guide to PsychopharmacologyThe Therapist's Guide to Psychopharmacology, Revised EditionThe Therapist's Ultimate Solution BookThe Trauma of Everyday LifeThe Trouble with IllnessThe UnsayableThe Way of the JournalTheory and Practice of Brief TherapyTherapy with ChildrenTherapy's DelusionsTheraScribe 3.0 for WindowsTheraScribe 4.0Thinking about ThinkingThinking for CliniciansThinking for CliniciansThoughts Without a ThinkerThriveToward a Psychology of AwakeningTracking Mental Health OutcomesTrauma, Truth and ReconciliationTreating Attachment DisordersTreatment for Chronic DepressionTreatment Plans and Interventions for Depression and Anxiety DisordersUnderstanding Child MolestersUnspeakable Truths and Happy EndingsWhat the Buddha FeltWhat Works for Whom?What Works for Whom? Second EditionWhen the Body SpeaksWhispers from the EastWise TherapyWittgenstein and PsychotherapyWorking MindsWoulda, Coulda, ShouldaWriting About PatientsYoga Skills for Therapists:Yoga Therapy
The authors, a mix of psychiatrists and therapists, begin early on to point out the iniquitous state of mental health care despite massive spend over the last 100 years. They mention the usual problems including some that are less well know. For instance, most people on medication for behavioral conditions never finish their treatment, and indeed, most don't even fill the second script for antidepressants. They certainly do mention the dismal findings of STAR-D(epression) study: just over 30% of patients get better on one drug, two thirds will require up to four changes. CATIE, which they also mention, finds that about three quarters of patients with Schizophrenia will fare poorly on their medication. The authors appear to believe that a collaborative effort will improve this.
They would not have had the opportunity by 2006 to view the recent findings on data gleaned from FDA material, that most drugs don't beat placebo in depression, and when they do, it's in those groups where the placebo response is most muted.
One-size fits all treatments don't seem to guarantee success. Most care is in the hands of often poorly-tooled PCP's as is the case with disability pronouncements. The annual cost to the USA is a $2.2 trillion spend with little outcome worthy of pride, about equal to the total GDP of China, and set to double within a few years. Americans pay up to 70% of some scripts, and despite not having universal healthcare for free, the USA pays up about $8000 per year per citizen in medical care, whereas countries like the UK and Australia, which do have universal free healthcare, pay about $2500 per head.
It's a dismal scenario overall, and in behavioral health, it's even worse. The reality is that when a drug company produces a behavioral management compound for approval, about half don't make it. Of those that do, placebo is the most active ingredient. Alternative treatment clinics are growing in size and influence. We don't have any cures for these things, despite the clarity of the growing cost to the US economy in people and money terms, per year. It's billions.
This is what the book offers in 2006:
Firstly, it acknowledges that the clinicians involved may not actually have any real understanding of the brain or its constituent parts, and just 11 pages are devoted to this subject, but includes the entire nervous system in tightly written text. Five pages are devoted to how psychotropic drugs work, citing pharmacodynamics and pharmacokinetics along the way. Not since Bill Bryson has anyone crammed so much into everything you need to know texts, and obviously they have been extremely selective.
Moving on to Mood disorders, and thus following the DSM idea of nosological categories is an obvious approach, but given recent critiques of that entire categorical system, such as by Steve Hyman, past President of the NIMH, it leads down a path they do not entirely deal with. Namely this: if these categories are too categorical, in other words, ignorant of the continuum of disorders, then drug discovery based on these categories is likely to be handicapped. This has happened. For instance, removing the category of anxiety disorder from mood disorders has not resulted in a single new drug for the treatment of anxiety that is not already a treatment for depression; similarly, most antipsychotics and anticonvulsants have properties across the spectrum of DSM categories as well.
So sadly, I do not believe that an understanding of brain or disorders categories in itself adds a thing to the treatment of behavioral disorders if we continue to replicate the baseline problem of how we define the targets of pharmacology. The modern issue of personalized medicine is not addressed her, although it is hinted at from time to time in the book. The issue of an integrated approach is not much addressed in that context, there is a two page summary table though; markers and biomarkers are not mentioned at all, nor is critical path analysis. This is a burden for a book written sometime in 2004-2005 or so to be published in 2006. There is some elaboration of these and other issues in the latter appendices of the book, but the future is now for this book. Not crippling, but limiting. The Pharma world is rapidly changing, so is the idea of biomarkers, which is apparently not limited to genes anymore, but to any brain marker of who will respond to what treatment.
Hence, as they discuss, the decision to give a drug is always a work in process with the risk of being wrong, and prescribing is trialing the drug, in that patient. The right drug, for the right patient, at the right time, is not clearly delineated on an identified target, as they acknowledge tacitly. They may not be looking at a depression when it turns out to rapidly cycle when given a stimulating antidepressant.
The collaborative approach is on the face of it a better approach than the single clinician with a single patient model. They acknowledge that some will have to give up cherished beliefs, or skills, and learn new ones, and a shift in attitude. In general they say, the therapist relinquishes the role of expert on the mental health and emotions of a shared patient, and instead embraces a more holistic view of the medical and mental health of the patient. In other words, if you want to work with medical practitioners including psychiatrists, you have to adapt to them, give up some protected information, understand that psychiatrists have less focus on the patient's story and life history, or what Miller has described as a failure to engage with patient suffering owing to a focus on evidence based medicine. Respect for the hierarchy and respect for perspective are the key features in dealing with this latter group (page 243).
Collaboration with the family is another issue of course. The authors are surprised at how seldom family are asked to provide collateral, and in terms of the family therapy movement of the 50's, engage with systems theory to elaborate on that relationship.
I think that two years ago, this book was really most helpful, and today, it still is a good primer for those it sets out to target. It focuses nicely, is tightly written, but I am not sure if it doesn't pretend to be more than it is at this stage in 2008. This is now a vast and complex field, and dumbing it down is very useful, although detail is often an interesting way to dumb things down. The arguments today in Pharma, Personalized Medicine, Genomic and other biomarkers, integrated and integrative approaches, the value of the new studies such as iSPOT-D which is a neuromarkers and placebo version of STAR-D, all are turning the field over on its head.
What the authors need is to hurry a second version to press, two years or more is a long long time in this field.
Are the sentiments timeless? I think the book represents, but does not present, an indictment of the way behavioral health is practiced. The mere fact of the absence of collaboration, and family centered and client centered approaches, and the fact that the science of psychopharmacology and the way drugs are discovered is so poor when compared to other fields of medicine, makes it hard to read these things without becoming angry. Recent works querying the DSM categorical approach, the value of the depression diagnosis instead of melancholia, the valueless application of evidence in ignorance of human engagement, all of these things illuminate that if you do become ill, the system to preserve and enhance you is not yet there. Any approach which combines a team with a family and neuroscience is to be applauded, and regularly updated.
© 2008 Roy Sugarman
Roy Sugarman PhD, Brain Resource Limited
Comment on this review