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Book Forum: Psychotherapy   |    
Cognitive Psychotherapy of Psychotic and Personality Disorders: Handbook of Theory and Practice
JOHN C. MARKOWITZ, M.D.
Am J Psychiatry 2000;157:479-479. doi:10.1176/appi.ajp.157.3.479
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edited by Carlo Perris, and Patrick D. McGorry. New York, John Wiley & Sons, 1999, 444 pp., $131.95.

Can psychotherapy treat psychosis? We were all taught that it cannot, that therapists are foolhardy to challenge delusions, that psychodynamic theory might help therapists to understand patients but provides no symptom relief, and that supportive psychotherapy—a historically pejorative term—is what remains for therapists to deliver while providing pharmacotherapy to psychotic patients. This view has shifted slightly in recent years with Liberman’s development of skills training (1), which seems like adjunctive, supportive remediation rather than a psychotherapeutic confrontation of symptoms.

Now cognitive behavior therapists are daring to approach psychosis again, using the familiar tools of "collaborative empiricism" (p. 9), such as Socratic questioning and behavioral testing. The therapist becomes the patient’s ally in working on a graded hierarchy of tasks, beginning with the least firmly held beliefs. Hallucinations and delusions are explored in depth, and both their negative and positive effects on the patient are noted. A "verbal challenge" raises doubt about the evidence for delusional beliefs and offers alternative explanations. "Behavioral experiments"/"planned reality testing" evaluate evidence. These interventions, targeting both the form and content of delusional cognitions, are not magic. They work adjunctively with pharmacotherapy, affect positive but not negative symptoms, and their efficacy lacks definitive proof in replicated, randomized controlled trials. Evidence for utility is mounting, however, and it is impressive that cognitive behavior therapy psychotherapists accept the challenge of such difficult symptoms.

The book also discusses the use of cognitive behavior therapy for personality disorders, a less controversial but still daunting psychotherapeutic challenge. Given this willingness to brave two difficult areas for psychotherapy—one traditionally avoided, the other claimed but rarely researched—the book might have been subtitled "in the face of conventional wisdom"! In parallel process, the authors induce the skeptical reader to reexamine his or her own cognitions about the untreatability of psychotic disorders.

In addressing personality disorders, the cognitive terminology often sounds like a relabeling of psychodynamic techniques—emphasis on "developmental reconstruction" (p. 52), for example. Some authors concede the absence of data on the schemata on which personality disorders work focuses. It is surprising to find little mention of Linehan and her cognitive variant, dialectical behavioral therapy.

Given the limited empirical data and the length of the book, it is not surprising that the balance of theory and practice noted in the subtitle tilts to the former. The chapter authors assume the reader’s knowledge of cognitive therapy and theory—and even cognitive training for information processing—using terminology with little explanation and no glossary. More research data and practical technique would have been preferable. Case examples are helpful when provided. This book is not a manual on applying cognitive behavior therapy to the targeted syndromes but does offer assessment and treatment approaches, including various homegrown inpatient and outpatient clinical models.

This edited volume draws on experts from several countries. More authors hail from Europe and Australia than from North America, reflecting the geography of research on cognitive behavior therapy for psychosis and personality disorders. The book inadvertently reveals the diffusion of cognitive therapy over time. Several cognitive behavior therapy variants now exist, and the authors, countries aside, seem not always to be speaking the same language. Some approaches, although they have a cognitive core, are quite eclectic. Many authors take an actively antinosological stance, addressing psychotic symptoms and personality disorders in dimensional rather than targeted diagnostic terms. Accordingly, they rarely distinguish between first-break and chronically ill patients or between affective and schizophrenic spectrum psychoses. Although it is not the first book to describe cognitive behavior therapy for psychosis (e.g., references 2 and 3) or personality disorders, this volume does provide reasonably current coverage and useful references.

Although handsome with a large, legible font, the book is marred by typographical errors that are inexcusable in the era of the spellchecker. It provides a helpful introduction to the taming of the wild frontiers of contemporary psychotherapy.

Liberman RP: Psychiatric Rehabilitation of Chronic Mental Patients. Washington, DC, American Psychiatric Press, 1988
 
Kingdon DG, Turkington D: Cognitive-Behavioural Therapy of Schizophrenia. Hove, UK, Lawrence Erlbaum Associates, 1994
 
Chadwick P, Birchwood M, Trower P: Cognitive Therapy for Delusions, Voices and Paranoia. London, John Wiley & Sons, 1996
 
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References

Liberman RP: Psychiatric Rehabilitation of Chronic Mental Patients. Washington, DC, American Psychiatric Press, 1988
 
Kingdon DG, Turkington D: Cognitive-Behavioural Therapy of Schizophrenia. Hove, UK, Lawrence Erlbaum Associates, 1994
 
Chadwick P, Birchwood M, Trower P: Cognitive Therapy for Delusions, Voices and Paranoia. London, John Wiley & Sons, 1996
 
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