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The Psychotherapy of HopeReview - The Psychotherapy of Hope
The Legacy of Persuasion and Healing
by Renato Alarcon and Julia Frank (Editors)
Johns Hopkins University Press, 2011
Review by E. James Lieberman
Oct 2nd 2012 (Volume 16, Issue 40)

Psychiatrist Jerome Frank (1909-2005) taught for fifty years at Johns Hopkins University, where Adolph Meyer and John Whitehorn melded service and research, science and humanity. When Frank’s Persuasion and Healing appeared in 1961, psychoanalysis dominated psychiatric practice and training. The book encouraged residents like me to emulate clinicians whose interviews went well and whose patients felt better, rather than teachers prone to cite chapter and verse of Freudian theory. Despite two subsequent editions of P&H (1973 and 1991, the latter co-authored by Jerome’s daughter, Julia Frank) many therapists today still champion one school over another, ignoring Frank’s central theme: interventions work when provider and patient believe in them.

The placebo effect makes the rivalry of therapeutic schools seem a tempest in a teapot: “until this century most medications prescribed by physicians were pharmacologically inert, if not actually harmful. ... Placebos exert their effects primarily through symbolization of the physician’s healing powers. The expectations conveyed by the physician in prescribing medication can be sufficiently powerful to reverse the pharmacological action of some drugs.” (P&H, ed. 3, 1991,  p. 134). When technique promotes belief and hope, one theory is as good as another.

 In The Psychotherapy of Hope, editors Renato Alarcon, Julia Frank and 18 other clinicians and researchers assess and go forward with Jerome Frank’s pioneering.  A fine introduction by the late Leon Eisenberg precedes  15 chapters, of which six deal with basic principles of psychotherapy, nine with current practices. The chapters are sound, clear, and apply to all health professions, not just psychotherapists. The editors establish “a process of aligning a general, empirically and culturally grounded theory of psychotherapy with the changing environment of practice and scientific investigation.” (xvii)

 Bruce Wampold and Joel Weinberger lead off with “Critical Thinking in the Design of Psychotherapy Research;” Glen Triesman and Paul McHugh (chair of  JHU psychiatry) present “Life Story as the Focus of Psychotherapy: The Johns Hopkins Conceptual and Didactic Perspectives.”  An illustrated review of relevant neuroscience by G. Viamontes and B. Beitman is a gift to all non-specialists in that bustling arena. Such diverse scholarship counters the tendency to overspecialize in training, practice, and research. The notion of “common factors in psychotherapy” requires integrating neurobiology and evolution in a Frankian framework that includes rhetoric and hermeneutics along with science, a challenge to the Diagnostic and Statistical Manual (DSM) that preoccupies the American Psychiatric Association, and is rightly challenged here.

Evolutionary Biology and Cultural Concepts, respectively, are fine chapters by the editors (and Mark Williams, for the latter). “Deconstructing Demoralization” by John de Figueiredo, reviews research on Frank’s central concept. Demoralization is marked by “subjective incompetence,” pervasive self doubt, independent of the severity of a medical condition or diagnosis. Whatever the physical condition or traumatic event, further complications coincide with terms like “uncertain,” “indecisive” and “trapped” along with low self-esteem.

David Clarke’s chapter on psychotherapy with medical patients is a beacon for psychiatry, which needs strong links to the rest of medicine. Clarke joins the DSM critics; he found, with quantitative methods, three significant subtypes of depression:  grief; anhedonic depression (no interest or pleasure); and, most common, demoralization--helplessness and hopelessness with some capacity for pleasure in the moment. A fourth group is Post-traumatic Distress. Because demoralization is associated with relapse in cancer patients, he wants to know what contributes to morale and what accounts for resilience. Hopelessness must be addressed early with psychotherapy, as drugs don’t help. (Antidepressants help with melancholia, not with demoralization.  Psychotherapy does little for severe anhedonia.) For the terminally ill, whose demoralization can be contagious, Clarke alludes to brief bedside therapy and group therapy, discussed in other chapters of this wide-ranging compilation.

“Acknowledging that one’s assumptions help create one’s difficulties can, paradoxically, be uplifting.” So say James Griffith and Anjali DSouza, writing about psychotherapy (Ch. 8). They say that “compassionate witnessing” activates hope. “Catching glimpses of hope within stories of loss, trauma and violence is vital.” The paucity of  bedside psychotherapy is due to inadequate time and funds, and consultation-liaison psychiatry fails to realize its possibilities.     Subsequent chapters take up psychotherapy with children, group therapy, cultural dynamics and religion.  As one who opposes direct-to-consumer ads for prescription drugs (legal only in the U.S. and New Zealand), I was struck by, “Taking an advertised pill may elicit a a placebo response” in patients who watch American television. (p. 295) Of course! New drugs under patent are very profitable, though often no better--and more risky--than well-established generics.  In those ads, “Ask your doctor” means non-psychiatrists, who lack the knowledge, time, and inclination to educate the patient. There is no industrial-strength lobby for psychotherapy, which has yielded its dominance to psychopharmacology in psychiatric training and practice. But those expensive pills depend on the placebo effect for at least half their benefit.

The original Persuasion and Healing gave more attention to family therapy than the present volume, and deserves more emphasis here. In my experience, adjunctive couples and family therapy is highly relevant to morale for the identified patient and close relatives. Another quibble: find another way to say “classificatory” and “representativeness.”

The Psychotherapy of Hope is more than a tribute to Jerome Frank. It is a work of utmost currency and a historical landmark, upholding the art and science of psychotherapy in a way that challenges readers--especially adepts of particular schools--to practice, study and teach a few overarching principles.

 

© 2012 E. James Lieberman

 

E. James Lieberman, M.D., Clinical Professor of Psychiatry, Emeritus, George Washington University School of Medicine


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