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Change in Psychotherapy: A Unifying Paradigm
Reviewed by Mardi J. Horowitz, M.D.
Am J Psychiatry 2010;167:1280-1280. doi:10.1176/appi.ajp.2010.10060873
View Author and Article Information
San Francisco, Calif.

Book review accepted for publication June 2010

The author reports no financial relationships with commercial interests.

Accepted June , 2010.

Copyright © American Psychiatric Association

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The Boston Change Process Study Group integrate their journal publications and presentations over the last 15 years into this well-written book. They give their answers to a fundamental question: How does a patient change for the better in intensive, deep, and exploratory psychotherapy? The focal point of their answers is on learning from new interpersonal experience in the treatment. They changed theory on this topic of the relationship evolving between the patient and clinician from prior theory that they had been taught. What was that earlier psychoanalytic theory?

Psychoanalytic theory has always been pluralistic, but in the United States there was a prevalent institutional view called ego psychology. Ego psychology, including a focus on defensive operations working as unconscious controls of emotional dangers, prevailed in the last third of the 20th century. Technical advice focused on romantic drama-conflicts, as in Oedipal configurations. Neurotic patients were regarded as "most analyzable," that is, most likely to change unconscious structures of motivation and meaning. Such change was seen as enabled by insight and achieved with the help of the clinician's interpretations. By modification of unconscious defensive mechanisms, what was relatively unknown could be jointly examined.

A key additional ingredient in the earlier theory was intensification of transference in the here and now of therapy. A growing therapeutic alliance led to the resolution of transference expectations in favor of understanding what was really going on. The analyst was trained to become an expert at letting this unfold and then making correct interpretations.

How do the authors change this earlier theory? The big changes stem from advanced developmental theory focusing on attachment to maternal-type figures. The therapist trains himself and his patient to listen to the cocreating nature of the therapy dyad. Both parties then experience new relationship possibilities and can perhaps verbalize derivatives of prerepresentational infantile views. Both parties learn from an ever closer empathy and learn a new kind of mutual connection.

The authors have the earlier theory in their bones. They do not advance in an either-or model. What they do add is more theory about the nature of unconscious fantasy and disturbances in personality. They present enough illustrations to anchor their theory of change to observations of what there was to be changed.

The authors do not reference the large body of psychotherapy research on change processes. They do clarify a consensus that they achieved within a group. Here is a taste of their unifying paradigm. In concentrated work on frank disclosure and a growing and emergent alliance, both clinician and patient learn how to increase their mutual trust and, what the authors call, a kind of mutual "vitalization."

The authors view the end results of such invigoration as more coherence in the patient's self-conceptualization. The outcome for a patient is that he becomes more capable of having mutually satisfying experiences outside of therapy.

This is a profound, concise book from experienced analysts and outstanding child developmental researchers. It does not attempt to unify psychotherapies and may not be of interest to psychiatrists who are more oriented to cognitive and behavioral techniques. I recommend the book highly for psychoanalytically-oriented clinicians who know the historical background theory and teach mechanisms of change in exploratory psychotherapy and psychoanalysis.

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