Abstract
The foreword by Andrew Powell states: This book brings to a wider audience papers that were presented at the first joint conference of the Association of University Teachers of Psychiatry and the Psychotherapy Section of the Royal College of Psychiatrists at the University of York in 1994′. The papers are divided into four sections: Part I—Psychodynamic and psychoanalytic approaches to psychosis; Part II—Behavioural and cognitive approaches to psychosis; Part III—Systemic and family therapies; and, Part IV—Integrative approaches to psychosis. There is also a brief introductory chapter, a similarly brief afterword, and notes introducing each section, by the editors Mace and Margison.
As the authors of the papers themselves each have different theoretical approaches, special interests, and writing styles, the material is inevitably uneven both within each of the four sections, and within the book as a whole. Readers are likely to experience very different responses from one paper to the next. For example, within the psychodynamic section, I found the word play and cleverness of Murray Cox's chapter, The great feast of languages: passwords to the psychotic's inner world', forced and irritating. There seemed a risk of this paper alienating readers from its important message: that listening attentively to the communications of psychotic patients may allow the intuition of latent meanings. In contrast, the following paper by David Taylor seemed particularly good. Taylor lucidly outlines the psychoanalytic understanding of the psychotic aspects of the personality as elaborated by Bion in particular, and uses detail from a clinical case in order to give life to theoretical points.
The transition to the cognitive-behavioural section seemed in some respects uneasy. For the clinician interested in gaining understanding of the inner world of the psychotic patient, the empiricism of the cognitive-behavioural approach may seem a restriction, and sometimes antithetical to the belief that the development of depth of relationship is a critical factor in psychotherapy. Some of these papers quoted large numbers of studies without any attempt to inform the reader of the methodology involved or to provide any critique of its adequacy. This verges on meaninglessness. At the same time, there clearly is evidence for the benefit of certain cognitive-behavioural approaches.
The editors suggest that the systemic approach explicated in the third section is something distinct from the wider application of a psychoanalytic method to the understanding of interpersonal and group processes. They state, for example, ‘Analysis of the power relations inherent in psychiatric care is intrinsic to a systemic approach’, as though this is distinctive and different. It seems an artificial discrimination, as their use of the word ‘analysis’ in this sentence perhaps suggests. The first two chapters in this section, by Chris Evans and Roger Kennedy, respectively, deal with the utilisation of psychoanalytic understandings in facilitating therapeutic processes in group situations, and in so doing rather undermine the distinction that the editors offer.
The final section is entitled ‘Integrative approaches to psychosis’. The integration discussed essentially attempts to integrate different elements of various treatment approaches to produce something hopefully more integrated and therefore more effective. Such strategies are valuable in attempting to provide optimal treatment; however, the editors do not draw a clear distinction between such pragmatic attempts at integration, and whether or not this is underpinned by an integrated theoretical understanding. This section contains a paper by Glenn Roberts entitled ‘Meaning and madness. A narrative approach to psychopathology and treatment’, which seems likely to be of value to the psychiatrist interested in practical approaches to the pursuit of meaning with psychotic patients.
This book contains much that is valuable but resembles the psychotic mind in that the papers exist as fragments that are insufficiently integrated. The lack of a systematic critique of the relationships between different theoretical perspectives and treatment strategies is, I think, a considerable limitation. Real theoretical incompatibilities are not identified for what they are, while at the same time no sustained effort is made to identify inconsistencies which may be more apparent than real, and to suggest possible overarching theoretical formulations which might allow for greater understanding. In particular, the editors could have considered whether or not the cognitive-behavioural intervention strategies discussed are compatible with current psychodynamic understandings of psychosis. As an example, the cognitive-behavioural approach of working with a patient to explore rationally the plausibility of a delusional conviction, seems to have common ground with the psychodynamic concept of attempting to enter into alliance with the non-psychotic part of the patient's mind in order to counteract psychotic processes.
The unevenness and variety of perspectives offered in this book is perhaps an inevitable consequence of it being a compilation of papers. Nevertheless, some further editorial work might have created a little more unity out of diversity. For the psychiatrist interested in developing deeper psychological understanding of psychosis in order that such understanding might inform treatment, I would suggest Unimaginable Storms: A Search for Meaning in Psychosis [1] as a better starting place.