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Theoretical foundations of behaviour therapy
BOOKREVIEWS
1218 JAY BELSKYand TERFSA pp. xvii + 440. S33.95.
NEZWORSKI: Clinical
Implicarions of Afrachmenl.
Lawrence Erlbaum, Hillsdale N.J. (1988).
The concept of attachment, as first applied to the development of an infant’s bonds with its parents, revolutionized thinking on the growth of social relationships and led to an immense body of empirical research. Ainsworth’s application of an individual differences approach as reflected in the A,BC (and more recently, also, D) classification of attachment relationships paid off richly and it is clear that this classification has an important predictive value. From the outset, attachment theorists were interested in clinical applications but their ideas were more taken up by developmental psychologists than by clinical researchers. This edited volume represents a bold attempt to survey the evidence on the antecedents and consequences of variations in patterns of attachment in order to draw inferences on clinical implications. It serves the purpose well, although there are a few surprising gaps (especially the lack of any detailed consideration of studies of institution-reared children), and anyone interested in early abnormalities of social development will find this book a most useful source of ideas and findings. However, more than anything else, this thoughtful set of essays by some of the leaders of the field underlines the very limited empirical basis for extrapolations on clinical applications of attachment. The exploration of disorders of attachment is likely to prove rewarding but the territory remains largely uncharted as yet. MICHAELRL’TTER
DAVIDM. ALLEN: Unvj?ng Individual and Family Therapies. Jossey-Bass,
San Francisco (1988). 371 pp. f27.95.
The author of this book is a psychiatrist in private practice in California. He is not the first, and certainly will not be the last, to believe that he has discovered “the major cause of all dysfunctional behavior”. Would that life were so simple. For what it has to say, the book is very long. The first 214 pages are devoted to expounding the theoretical basis of the theory which is described from p. 215 onwards. The author’s ideas are not particularly original. He openly acknowledges his indebtedness to the family therapist Murray Bowen whose preoccupation is with what he has called the differentiation of self from the family of origin. Ideally this involves the establishment of a distinct and separate identity which the author calls the patient’s true self. In order for this to happen the individual needs to experience some sense of consensual validation of his emerging self which Kohut has called mirroring. Sometimes this does not happen because he comes to sacrifice his own natural predisposition when the good of the family collective seems to demand it. This suppression of the real self for the good of the family the author calls the altruistic paradox. He maintains that this sacrifice is destructive not only to the individual but also, eventually to the family system. In place of his true self the individual presents to the world a false self or persona. Yalom’s term groundlessness is borrowed to describe the confusion this gives rise to. It is not until p. 215 that the author first reveals his distaste for family therapy. Thereafter it gradually becomes apparent that what he is advocating, and what the title of the book means, is a form of individual psychotherapy in which the therapist tries to encourage the patient to reveal his true self. The author stresses that, in this form of therapy, the development of a transference, which essentially he claims is a manifestation of the false self, is discouraged. The patient is instead encouraged, with the therapist’s support, to challenge and change the family homeostasis. It is argued that children and schizophrenics have not developed a self which is powerful enough to do this. The author makes the important point that there is no gain in helping to free the patient at the expense of causing serious disruption within the family and that it is necessary to try to understand why the family originally needed to coerce the patient to make the sacrifice. Whilst acknowledging that the process of differentiation of self is an important aspect of psychological development and an important consideration in any psychotherapeutic procedure, I would not agree that the presentation of a false self is the only manifestation of incomplete differentiation. Besides, it is not always easy to differentiate between the true and the false self. However, the author is on the right lines. What is required is more research in the area of differentiation. JOHN BIRTCH~TLL
HANSJ. EYSENCKand IRENEMARTIN: Theorerical Foundations of Behaoiour Therapy. Plenum Press, New York S55. ISBN 0-306-42634-X. I have become a little tired of reading and reviewing books on various therapies which present a totally misconstrued picture of behaviour therapy. Books, even those published this year, continue to describe a theoretical foundation based in the 1930s and which owe little to developments over the last 50 yr. Of course, to some extent the fault lies with behaviour therapists, many of whom rarely listen to each other, and present an apparently non-integrated and variegated mass of techniques having little in common. There are excellent texts on the theoretical basis of behaviour therapy, but none which clearly presents the differing perspectives in a coherent way. The editors of this text have achieved that task. There are faults. As always those who work primarily with adults fail to take adequate account of the contributions to behavioural theory emerging from clinical work with children. Developmental theories receive scant attention and the important practical as well as theoretical contributions from behavioural ecology or environmental design are missing. The social context is missing, consequently so are key issues of ethical and professional practice which arise from the theoretical model. The cause of this lapse may lie in the limitation of the text to traditional therapeutic areas. They bemoan the fact that psychiatrists and others see behaviour therapy as limited to simple neurotic conditions. Yet they essentially maintain a world view anchored in ‘behaviour therapy and the treatment of neuroses’. Behaviour therapy is much more than this. It is an approach to treatment in a wide variety of conditions and contexts. But even more importantly, its theoretical foundations provide powerful models for examining the individual and the context for change. Staying with neurosis limits the theoretical possibilities unnecessarily.
BOOK REVIEWS
1219
Most readers of the book, will say I protest too much. the contributors are well aware of the limits and problems caused by the ‘pathological metaphors’, and they are right. I do. But I think the book needed 23 not 21 chapters to adequately address this imbalance. The 21 chapters cover theoretical principles of behaviour therapy and behaviour modification, conditioning theory. cognitive theory, the description and organisation of behaviour and the biological basis of personality and behaviour. There is also a concluding discussion of the requirements for theoretical foundations. It is difficult to separate out the chapters for consideration since they are so varied. detailed and often provocative. I read them all with great interest although not necessarily agreement. A number introduced material which was new to me and some which seemed very tired. A number of key issues are raised in this book. It is contended that behaviour therapy has continuously questioned its own theoretical foundations and their relationship to clinical practice. To some extent the diversity of approaches represented provides support for that position. The fragmentation of theory is a strength. One suspects that there has been too little questioning and too great a claim for the scientific purity of our endeavours. It is argued that behaviour therapists have led the way in championing a move from psychiatric classifications. Yet the reference lists for the chapters provide a glimpse into the straitjacket of classification which still holds behaviour therapists in check. The hybrid models of behaviour change which now represent modern behaviour therapy are carefully explored. Do the majority of clients who experience therapy really see the benefit of that creativity? Much of the criticism from outside suggests that very little has changed since the 1970s. The gap between what we claim and what we do remains large. One solution would be to abandon theory and aim for a pragmatic ‘suck it and see’ approach to intervention. It is argued here that this would be a mistake. A powerful case for retaining the sense of theoretical search in clinical practice is made by several of the contributors. The role of cognitions can no longer be ignored. The integration of theory in this field is given extended coverage. Some behaviour is better understood in SR terms, other behaviour is not. The apparent simplicity in this idea is illusionary. Understanding the place of verbalisations is highly complex. Some of the simplistic models of cognitive therapy, widely practised do an injustice to their role. It is paradoxical that behaviour therapists evidence more respect for the complexity of cognitions than do some of those who champion them. Modern behaviour therapy covers a broad spectrum of approaches. Integration is going to be difficult. If those who represent differing traditions begin to listen to each other progress will be made. This book is the ideal starting point for that dialogue. Everybody should read it. even though it is two chapters too short. DAVID A. LANE
1218 JAY BELSKYand TERFSA pp. xvii + 440. S33.95.
NEZWORSKI: Clinical
Implicarions of Afrachmenl.
Lawrence Erlbaum, Hillsdale N.J. (1988).
The concept of attachment, as first applied to the development of an infant’s bonds with its parents, revolutionized thinking on the growth of social relationships and led to an immense body of empirical research. Ainsworth’s application of an individual differences approach as reflected in the A,BC (and more recently, also, D) classification of attachment relationships paid off richly and it is clear that this classification has an important predictive value. From the outset, attachment theorists were interested in clinical applications but their ideas were more taken up by developmental psychologists than by clinical researchers. This edited volume represents a bold attempt to survey the evidence on the antecedents and consequences of variations in patterns of attachment in order to draw inferences on clinical implications. It serves the purpose well, although there are a few surprising gaps (especially the lack of any detailed consideration of studies of institution-reared children), and anyone interested in early abnormalities of social development will find this book a most useful source of ideas and findings. However, more than anything else, this thoughtful set of essays by some of the leaders of the field underlines the very limited empirical basis for extrapolations on clinical applications of attachment. The exploration of disorders of attachment is likely to prove rewarding but the territory remains largely uncharted as yet. MICHAELRL’TTER
DAVIDM. ALLEN: Unvj?ng Individual and Family Therapies. Jossey-Bass,
San Francisco (1988). 371 pp. f27.95.
The author of this book is a psychiatrist in private practice in California. He is not the first, and certainly will not be the last, to believe that he has discovered “the major cause of all dysfunctional behavior”. Would that life were so simple. For what it has to say, the book is very long. The first 214 pages are devoted to expounding the theoretical basis of the theory which is described from p. 215 onwards. The author’s ideas are not particularly original. He openly acknowledges his indebtedness to the family therapist Murray Bowen whose preoccupation is with what he has called the differentiation of self from the family of origin. Ideally this involves the establishment of a distinct and separate identity which the author calls the patient’s true self. In order for this to happen the individual needs to experience some sense of consensual validation of his emerging self which Kohut has called mirroring. Sometimes this does not happen because he comes to sacrifice his own natural predisposition when the good of the family collective seems to demand it. This suppression of the real self for the good of the family the author calls the altruistic paradox. He maintains that this sacrifice is destructive not only to the individual but also, eventually to the family system. In place of his true self the individual presents to the world a false self or persona. Yalom’s term groundlessness is borrowed to describe the confusion this gives rise to. It is not until p. 215 that the author first reveals his distaste for family therapy. Thereafter it gradually becomes apparent that what he is advocating, and what the title of the book means, is a form of individual psychotherapy in which the therapist tries to encourage the patient to reveal his true self. The author stresses that, in this form of therapy, the development of a transference, which essentially he claims is a manifestation of the false self, is discouraged. The patient is instead encouraged, with the therapist’s support, to challenge and change the family homeostasis. It is argued that children and schizophrenics have not developed a self which is powerful enough to do this. The author makes the important point that there is no gain in helping to free the patient at the expense of causing serious disruption within the family and that it is necessary to try to understand why the family originally needed to coerce the patient to make the sacrifice. Whilst acknowledging that the process of differentiation of self is an important aspect of psychological development and an important consideration in any psychotherapeutic procedure, I would not agree that the presentation of a false self is the only manifestation of incomplete differentiation. Besides, it is not always easy to differentiate between the true and the false self. However, the author is on the right lines. What is required is more research in the area of differentiation. JOHN BIRTCH~TLL
HANSJ. EYSENCKand IRENEMARTIN: Theorerical Foundations of Behaoiour Therapy. Plenum Press, New York S55. ISBN 0-306-42634-X. I have become a little tired of reading and reviewing books on various therapies which present a totally misconstrued picture of behaviour therapy. Books, even those published this year, continue to describe a theoretical foundation based in the 1930s and which owe little to developments over the last 50 yr. Of course, to some extent the fault lies with behaviour therapists, many of whom rarely listen to each other, and present an apparently non-integrated and variegated mass of techniques having little in common. There are excellent texts on the theoretical basis of behaviour therapy, but none which clearly presents the differing perspectives in a coherent way. The editors of this text have achieved that task. There are faults. As always those who work primarily with adults fail to take adequate account of the contributions to behavioural theory emerging from clinical work with children. Developmental theories receive scant attention and the important practical as well as theoretical contributions from behavioural ecology or environmental design are missing. The social context is missing, consequently so are key issues of ethical and professional practice which arise from the theoretical model. The cause of this lapse may lie in the limitation of the text to traditional therapeutic areas. They bemoan the fact that psychiatrists and others see behaviour therapy as limited to simple neurotic conditions. Yet they essentially maintain a world view anchored in ‘behaviour therapy and the treatment of neuroses’. Behaviour therapy is much more than this. It is an approach to treatment in a wide variety of conditions and contexts. But even more importantly, its theoretical foundations provide powerful models for examining the individual and the context for change. Staying with neurosis limits the theoretical possibilities unnecessarily.
BOOK REVIEWS
1219
Most readers of the book, will say I protest too much. the contributors are well aware of the limits and problems caused by the ‘pathological metaphors’, and they are right. I do. But I think the book needed 23 not 21 chapters to adequately address this imbalance. The 21 chapters cover theoretical principles of behaviour therapy and behaviour modification, conditioning theory. cognitive theory, the description and organisation of behaviour and the biological basis of personality and behaviour. There is also a concluding discussion of the requirements for theoretical foundations. It is difficult to separate out the chapters for consideration since they are so varied. detailed and often provocative. I read them all with great interest although not necessarily agreement. A number introduced material which was new to me and some which seemed very tired. A number of key issues are raised in this book. It is contended that behaviour therapy has continuously questioned its own theoretical foundations and their relationship to clinical practice. To some extent the diversity of approaches represented provides support for that position. The fragmentation of theory is a strength. One suspects that there has been too little questioning and too great a claim for the scientific purity of our endeavours. It is argued that behaviour therapists have led the way in championing a move from psychiatric classifications. Yet the reference lists for the chapters provide a glimpse into the straitjacket of classification which still holds behaviour therapists in check. The hybrid models of behaviour change which now represent modern behaviour therapy are carefully explored. Do the majority of clients who experience therapy really see the benefit of that creativity? Much of the criticism from outside suggests that very little has changed since the 1970s. The gap between what we claim and what we do remains large. One solution would be to abandon theory and aim for a pragmatic ‘suck it and see’ approach to intervention. It is argued here that this would be a mistake. A powerful case for retaining the sense of theoretical search in clinical practice is made by several of the contributors. The role of cognitions can no longer be ignored. The integration of theory in this field is given extended coverage. Some behaviour is better understood in SR terms, other behaviour is not. The apparent simplicity in this idea is illusionary. Understanding the place of verbalisations is highly complex. Some of the simplistic models of cognitive therapy, widely practised do an injustice to their role. It is paradoxical that behaviour therapists evidence more respect for the complexity of cognitions than do some of those who champion them. Modern behaviour therapy covers a broad spectrum of approaches. Integration is going to be difficult. If those who represent differing traditions begin to listen to each other progress will be made. This book is the ideal starting point for that dialogue. Everybody should read it. even though it is two chapters too short. DAVID A. LANE