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Book Forum: Psychotherapy   |    
The Integrative Power of Cognitive Therapy
Am J Psychiatry 1999;156:963-964.
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New York, N.Y.

by Brad A. Alford, and Aaron T. Beck. New York, Guilford Publications, 1997, 197 pp., $25.00; $16.95 (paper, published 1998).

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Aaron Beck, paterfamilias of cognitive therapy, has written extensively as his research and clinical offspring have grown: books on depression, anxiety disorders, personality disorders, and more. He can take just pride in this family. Practicality and clinical empiricism rank among the great attractions of cognitive therapy, but Beck has also long been interested in the theory behind these pragmatic advances. The first author of this volume, Brad Alford, seems more concerned with abstract cognitive theory than with clinical empiricism, but the book may be read in part as a genogram of cognitive therapy, summarizing and integrating Beck’s widespread accomplishments to date.

The authors propose that cognitive theory has a universality that could provide the basis for psychotherapy integration. Cognition, they point out, subsumes all psychotherapeutic communication. Psychotherapy integration is a topic of circumscribed interest, and some of the authors’ arguments sound syllogistic and abstract, but several are important. The emphasis on coherence in a psychotherapeutic system and its presentation to patients is clinically undeniable. Nonetheless, a tension exists in the book between theory and therapeutic practice. The Integrative Power of Cognitive Theory might have been a fairer title.

The two opening chapters, "Theory" and "Metatheory," are thoughtful, clearly written, and review cognitive therapy principles. "Metatheory" contains a small treatise on "the nature of theory" and develops a syllogism to demonstrate the utility of cognitive theory for psychotherapy integration. If occasionally tendentious, the argument is informed and informative. Still, the idea of a universal theory runs counter to clinical trends toward differential therapeutics and a diversity of treatments rather than a Procrustean approach: the search for a single formula contrasts with pragmatic clinical relativism.

Chapter 3, "Cognitive Mediation of Consequences," builds on Dr. Alford’s 1984 doctoral dissertation and explores conflicts between short-term and long-term goals. There is an unfortunate suggestion that these conflicts are "psychopathogenic for a wide range of conditions seen in clinical psychological practice" (p. 70). "Psychopathogenic" denotes an etiological explanation of cognitive processes that has not been demonstrated: we do not know whether cognitive phenomena are cause, effect, or epiphenomena of clinical syndromes. Theory here appears to supersede, and perhaps to misguide, clinical empiricism.

The second section of the book discusses psychotherapy integration. One chapter neatly reviews the controversies and ideologies of this area, conceding that integration is a theoretical goal rather than an accomplished fact. The integrationists themselves are divided. The authors usefully distinguish among technical eclecticism, theoretical integration, and a common-factors approach to integration. The next chapter makes a spirited effort to present cognitive therapy as the basis for psychotherapy integration. It remains unclear why any single universal approach is desirable.

The volume culminates in two chapters on the application of cognitive therapy to clinical disorders. The chapter on panic disorder maintains the emphasis on theory, discussing how cognitive theory accords with and adds to behavioral theory. Since few therapists now practice behavior therapy without a cognitive component, this appears to be a convincing attempt to accommodate theory to clinical developments.

The final chapter, "Schizophrenia and Other Psychotic Disorders," is an exciting discussion of a relatively new clinical frontier for cognitive therapy. Many clinicians, having been taught that "you can’t talk a delusional patient out of his belief," may find it counterintuitive that a talking therapy can help psychotic patients. Cognitive therapy can help such patients, but the authors might have designated cognitive therapy more modestly as adjunctive to pharmacotherapy, rather than vice versa (p. 139). Cognitive therapy for psychosis attempts to address distortions of cognitive process as well as cognitive content. It requires a strong therapeutic alliance, building meta-cognitive awareness while protecting patient self-esteem, and seeks to test delusional beliefs collaboratively rather than challenge them directly.

The authors conclude that cognitive therapy theory and practice are congruent and that the theory is "internally consistent, parsimonious, testable,…broad in its scope of application," and empirically supported (p. 165).

Although Dr. Beck is a psychiatrist, for several reasons cognitive therapy has become principally the domain of psychologists. Unfortunately few psychiatrists practice this potent treatment. Focusing as it does on theory more than on practice, this book may not provide the ideal introduction for psychiatrists who wish to learn cognitive therapy, but it does provide an overview of this still evolving and critically important treatment modality.




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