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The Psychotherapy of Hope: The Legacy of Persuasion and Healing

edited by Renato D. Alarcón,, M.D., and Julia B. Frank, M.D. Baltimore, Johns Hopkins University Press, 2011, 368 pp., $55.00.

Reviewed by Thomas N. Wise, M.D.
Am J Psychiatry 2012;169:871-872. doi:10.1176/appi.ajp.2012.12040486
View Author and Article Information
Falls Church, Va.

Dr. Wise is affiliated with Fairfax Hospital, Falls Church, Va.

The author reports no financial relationships with commercial interests.

Book review accepted for publication April 2012.

Accepted April , 2012.

Jerome Frank was a towering figure in American psychiatry. Sadly, I doubt if his work is well-known by many in our profession. This carefully edited volume should fill that knowledge gap. The book is not a Festschrift, but a primer on common elements in psychotherapy, with a focus on the concept of demoralization. Its two editors have done a masterful job of carefully integrating the chapters in a sequential manner so that the book is a joy to read but also so that each chapter can stand alone.

Frank's genius was his ability to ask important questions about the theory-bound psychodynamic psychotherapy of mid-twentieth century America, which was dominated by psychoanalytic schools of thought. He concluded that the role of the socially sanctioned healer, whether a psychoanalyst or culturally based practitioner, was to instill hope in the demoralized patient. It was this phenomenon, rather than the specific theory, that fostered the treatment alliance and fueled the trajectory toward a positive therapeutic model. It must be noted at the outset that his research was focused on nonpsychotic ambulatory patients but also contained elements that were helpful to other clinical populations and their families.

The book is divided into two parts. The first section reviews the basic principles common to all psychotherapies, and the second focuses on clinical issues regarding a variety of therapies and clinical populations. The book opens with a discussion of the genius of Frank and provides a review of his systematic research of the therapeutic elements of psychotherapy. By developing such testable hypotheses via empirically based outcomes, Frank documented that a demoralized individual is able to restore a sense of hope and mastery via various psychotherapies. This denotes the development of self-efficacy, which is defined as an individual's belief that he or she can accomplish a given task. Role induction was an essential technique for successful outcomes. Role induction is educating the patient about what to expect from the therapy and how it might work. This process may enhance placebo responses in many therapies and has currently reemerged as a controversial topic (1). Chapters on the biological substrates of therapy and evolutionary biology offer current neuroscience data on psychotherapy. Demoralization is the central element in Frank's work. de Figueiredo's essay on deconstructing demoralization defines and expands the role of this psychological state that may include hopelessness, helplessness, and a sense of subjective incompetence. Drs. Slavney and McHugh (2) placed Frank's work within the life story perspective of psychiatry and described how demoralization fits into the personal narrative that patients offer the therapist.

The role of hope in various forms of practices in psychotherapy is reviewed in the second part of the book. Dr. Clarke presents a chapter on depression, demoralization, and psychotherapy in the medically ill. He conceptualizes demoralization as a construct that is an independent dimension in depressed individuals. Demoralization is similar to but has unique qualities distinct from a major mood episode and is also different from grief. It may be best categorized as a subtype of depression, which is rarely a stand-alone phenomenon. The chapter on psychotherapeutic communication in the medical setting is discussed by Dr. Freeman and should be essential reading for all consultation-liaison psychiatrists. Both of these chapters should be essential reading for psychosomatic specialists.

Next, Drs. Griffith and D'Souza review the development of self-efficacy in clinical work as a product of “agency thinking,” wherein an individual's perceptions evolve into the belief that he or she can act effectively, and the development of “pathway thinking,” which is a road map of how to reach such coping mechanisms and relief from current stressors.

One of the gems of this book is the chapter on psychodynamic psychotherapy, by Drs. Wells and Frank. The subtitle, “From Psychoanalytic Arrogance to Evidence-Based Modesty,” summarizes the evolution of theory-bound psychoanalysis as a contemporary form of psychotherapy. Other chapters expand on behavioral therapies, group therapy, and cultural psychotherapies. The book concludes with a discussion by Dr. Griffith on religion and spirituality. He elegantly reminds us that many individuals have increasingly turned to religion but can easily become demoralized when adversity strikes, and he reviews management strategies for such demoralized individuals bereft of a previously held spiritual orientation. The discussion of cultural elements by Dr. Alarcón is also important in the multiethnic fabric of contemporary America.

This volume should be required reading not only for all psychiatric residents, but also seasoned psychotherapists, as it should lead to a more tempered advocacy of specific forms of therapy and allow better understanding of the common therapeutic elements in this essential psychiatric intervention.

Kirsch  I:  The use of placebos in clinical trials and clinical practice.  Can J Psychiatry 2011; 56:191–192
[PubMed]
 
McHugh  PR;  Slavney  PR:  The Perspectives of Psychiatry , 2nd ed.  Baltimore,  Johns Hopkins University Press, 1998
 
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References

Kirsch  I:  The use of placebos in clinical trials and clinical practice.  Can J Psychiatry 2011; 56:191–192
[PubMed]
 
McHugh  PR;  Slavney  PR:  The Perspectives of Psychiatry , 2nd ed.  Baltimore,  Johns Hopkins University Press, 1998
 
References Container
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