on 6 December 2000
With four editors and a dozen contributors in all, this book represents a collection of points of view. The unifying element seems to be that all the contributors are experienced clinical practitioners of behaviour therapy who are in the midst of coming to terms with the encroach of cognitive approaches on their established models of practice. So if you read this book hoping to gain insight into behavioural therapies and into the place of psychological therapy in a clinical psychiatric setting, you will be well pleased with its wide scope and practicality. But if you are hoping to understand how cognitive behaviour therapy (CBT) applies in this setting, you are likely to be either disappointed or misled -- disappointed if you already understand CBT, misled if you are reading this book to find out about it.
The writing style is clear and direct throughout. This book concentrates on what really happens and explains with examples. It refers you to other sources for details of the underlying theory. At the same time the style is curiously distant, like an old-fashioned textbook. If you are familiar with the philosophy of CBT, with the idea of people being in charge of their own selves, then these authors read like passive victims of their own profession. For example, Melanie Fennell writing on depression tells us that, "The [initial] interview, which normally takes 1 - 1½ hours, comes after diagnostic assessment and evaluation of suitability for treatment as outlined above" (p176) as if she has no choice in the matter. It would have been much more interesting to understand Melanie's reasons for working in this way rather than some other way, but that is not this book's style.
On the cognitive aspects of therapy the book makes a promising start. Chapter 1, "Development and principles", outlines the progress of ideas starting, a little surprisingly, from Charles Darwin, through to A.T. Beck's work on negative automatic thoughts and the cognitive triad. In the remainder of the book, though, these newer ideas rarely resurface. A telling passage in Chapter 2, "Cognitive-behavioural assessment", explains how the widely-used Antecedents -- Behaviours and beliefs -- Consequences model can be applied to a patient's smoking habit. It explains the antecedent and the behaviour, then leaps to the consequence without mentioning the belief element, the cognitive part.
The chapter that comes closest to incorporating cognitive ideas is Chapter 6, "Depression". Even here, while cognition plays a part in the therapist's assessment and evaluation of the patient, it is missing from the suggested treatment schemes, which are purely behavioural. A colleague once described to me patients of hers who had inappropriately received purely behavioural therapy in the past as "not cured, but going through the motions of what a cured person could do." So for me this lack is the book's most disappointing feature.
The structure of the book has its problems, too. Though the chapters at the start and end are generally applicable, all the rest are based on categories of diagnosis. Starting each chapter with a diagnosis and going on to read about the initial assessment has an odd feel to it, because of course a wise therapist commences an assessment with an open mind, prepared to revise any prior diagnosis. Also, while the book is wide-ranging in the scope of diagnoses covered, it is by no means comprehensive. For example, if you want to dip into it for a few hints before tackling your first case of post-traumatic stress disorder, you will not find that, or even stress, in the index. You might feel you were close enough with Chapter 3, "Anxiety states", but it's hard to be sure.
The clinical setting, too, is incompletely covered. Even though Chapter 7, "Somatic Problems", warns, "Careful co-ordination with all other professionals involved is the key...", neither it nor any other chapter tells you how to achieve this coordination. The authors must surely have valuable views on referrals, on reporting back to referring clinicians, on standard diagnostic classifications like DSM-IV, on the effects of prior therapies, and so forth, but they are not giving anything away on these topics.
To summarize, this book is packed with clear information on a wide range of psychiatric conditions. Subtitled "A Practical Guide", it appears to be practical, authoritative and comprehensive. But in various ways it is not. Most significantly of these, it fails to integrate cognition to the extent that you would expect from the title, so that if you were to rely on it in the treatment of your patients you would be discouraged from offering them some of the most effective therapeutic interventions around.