Treating Chronic and Severe Mental Disorders: Handbook of Empirically Supported Interventions
The premise of this book is that developments over the last decade in clinical psychology and evidence-based treatment models for severe mental disorders are not well known but should be. The development of effective psychological treatments, some in combination with psychopharmacological treatment, have demonstrated longer-term efficacy than other treatments or pharmacological treatment alone. The authors’ premise is supported by the research presented in well-organized chapters on the specifics of how to be practical in assessing and treating severe disorders. They focus on four clusters of psychopathology: schizophrenia, addictive disorders, severe mood disorders, and severe personality disorders. They emphasize, rightly so I believe, that psychological intervention is a powerful treatment.
In the first of the four sections, the authors review the research for psychological techniques for treating patients with schizophrenia. They cite negative findings for insight-oriented treatment with these patients and then proceed to discuss evidence-based treatment strategies: 1) cognitive behavior family and education intervention, 2) social skills training, 3) personal therapy, and 4) cognitive behavior therapy. Personal therapy is the newest of these treatments and proposes a combination of pharmacological treatment with the incremental acquisition of adaptive, self-regulating strategies. It is stressed as a collaborative treatment that is more interpersonal than interpretive.
The second section of the book is on the treatment of mood disorders. The authors describe three researched-based approaches: cognitive behavior, interpersonal, and family-focused treatment. The research indicating that cognitive behavior treatment is effective for depression is well established and now sanctioned by Division 12 of the American Psychological Association, but I remain ambivalent. On the one hand I see results with some patients, but I also see failures with other patients, who react to this form of therapy as a naive view of the world. The idea that depression is based on cognitive interpretation and that this interpretation can be modified can be experienced by the patient as a large empathic failure.
The third section focuses on treatment of substance abuse. The authors begin by stating that acceptance of one’s alcoholism or addiction is not the beginning of a readiness to change, as many people believe, but that ambivalence is the more common and understandable starting place for change. They then introduce motivational interviewing as a method to help patients work through their mixed feelings about giving up their addiction. In the second chapter in this section they report on a cognitive behavior therapy model for addiction that focuses on coping and social skills training. The focus is on the cognitive and environmental determinants that precede alcohol and drug use.
There is also a chapter on 12-step treatment that again focuses on facilitation, on getting a person into active and ongoing involvement in a 12-step program, which is often associated with recovery. Twelve-step facilitation is a time-limited program to get individuals engaged in 12-step treatment.
The fourth chapter in this section shows that the best efficacy evidence for outpatient alcohol treatment comes from approaches including spouses or significant others. The last chapter describes a community reinforcement approach plus vouchers. This treatment combines therapy with a voucher-based incentive program based on operant conditioning, learning theory, and behavioral pharmacology. Cocaine use is seen as a learned behavior that is maintained by the reinforcement effects of dopamine-enhancing effects of cocaine, combined with social and other reinforcement from a cocaine-using lifestyle.
The final section discusses psychological treatments for severe personality disorders. Two chapters discuss treatment of borderline personality disorder. It is hoped that the first, dialectical behavior therapy, will prove to be a cost-effective version of cognitive behavior therapy oriented to suicidal patients who have borderline disorder. The second of these chapters discusses multifamily group therapy for borderline disorder, which tries to ameliorate family factors that precipitate relapse into self-endangering borderline behavior. The chapter on antisocial behavior in adolescents describes multisystemic therapy as the most effective model of treatment for this population; this model is supported by decades of research.
Overall, I liked this book and believe the authors have done what they set out to do: set forth the research support for psychological treatment. I do have a couple of criticisms. One, the book is clearly a product, in part, of a managed care culture. There is an emphasis on a time-limited approach, clarifying goals, and descriptions of manuals with protocols for directing the step-by-step scientific treatment of therapy. There is little mention of a therapeutic relationship (most of these treatments start by telling patients that therapy will end soon) and clearly a bias toward looking at only a behaviorally oriented treatment. A chapter missing in this otherwise commendable volume would be on the treatment of chronic and severe mental disorders with psychoanalytic therapy and psychoanalysis with research citing Robert Levy, George Klumpner, and Glen Gabbard.
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