Object Relations Individual Therapy. Jill Savege Scharff, David E Scharff.
North Vale (NJ): Jason Aronson; 1998. 640 p. US$75.00.
Paul Ian Steinberg, MD, FRCPC
This very comprehensive text is divided into 2 parts. The first 10 chapters
deal with object relations theory (ORT) and the next 16 with object relations
therapy. Chapters 1 and 2 introduce the reader to ORT in an engaging way,
using case vignettes and a “clinical guided tour” in which the subjects
of chapters that follow are described. Some of the Scharffs’ terminology
is distractingly corny, for example the “here-and-if-and-when” transference.
Chapters 3 to 6 describe fundamentals of ORT according to different schools.
The description of the origins of object relations therapy, with the Scharffs’
particular focus on Fairbairn’s model of the mind, is the best organized
and most comprehensive description of ORT that this reader has found. The
diagrams provided complement the excellent and concise summaries of Fairbairn’s,
Klein’s, and Winnicott’s work. This dense chapter may be a challenge to
integrate for readers naive to psychoanalytic theory. The chapter on Freud’s
contributions includes a thoughtful description of 19th century influences
on Freud’s thinking. Subsequent chapters describe the transition from drive/structural
theories to American relational models and British ORT.
The chapter on the clinical relevance of research effectively shows empirical
support for ORT and attachment theory. Chapters 7 to 10 describe advances
in ORT. The Scharffs’ use of chaos theory and fractals is original and
intriguing; it remains a question to what extent these theories add to
our understanding. Applying fractal geometry to ORT appeared at times somewhat
forced to this writer. Applying chaos theory to child therapy was effective,
but the information was too limited to draw conclusions about the utility
of chaos theory in this treatment.
The second part of this text opens with 3 chapters on technique, beginning
with a rather original discussion of “the geography of transference and
countertransference.” The Scharffs organize this material in a useful way,
although one feels at times that the tables and figures are more complicated
than necessary. A chapter on the structure and process of therapy covers
many practical aspects of treatment, showing the psychological basis for
decisions about technique. A chapter on the theory and technique of assessment
is similarly complete and useful.
Section 5, on assessment, describes the extended assessment of a woman,
her husband, and the couple. The Scharffs recognize the influence of the
relationship of parents with each other and of social and cultural factors
and how the family copes with them as important factors influencing individual
development, which is not always appreciated by psychodynamic authors.
The Scharffs’ practical and flexible approach regarding the format of treatment,
brief versus long-term, considering the patient’s both concrete and psychological
limitations and applying ORT consistently in individual and couples therapy,
is admirable. A section on brief therapy discusses ORT of serial brief
therapy after long-term therapy and brief therapy instead of long-term
therapy. The section on intensive therapy contains chapters on the opening
phase, midphase, late midphase, pretermination, and termination. The advantage
of such a lengthy description of therapy is that one has a very good idea
of how the Scharffs apply their theoretical approach practically. The drawback
of course is that one must be committed to reading this lengthy description
of treatment, as is true for reading the book itself, more than 600 pages
long. It is work to do so, but rewarding. The book finishes with a condensed
narrative of a complete analysis and a chapter describing a fractal of
an analysis using 5 dreams.
This book very well fulfills the purpose for which it was written. The
authors are obviously very competent on the subject, both having international
reputations as teachers and therapists. The subject is of great topical
interest. The book is written clearly, although one cannot say it is written
briefly. The volume is attractive in layout and generally free of production
errors. This text is highly recommended to both experienced and less experienced
therapists who wish to understand ORT and its therapeutic applications.
Given the length of the book, it may be more easily read piecemeal than
continuously, but the consistently high quality of the writing more than
adequately rewards persistence.
In spite of the above minor criticisms, I found the Scharffs’ text to be
an excellent description of the basis for their work, loaded with helpful
clinical examples. The Scharffs describe therapeutic sessions in enough
detail that the reader usually understands the basis for the interventions
they make. Compared with other texts dealing with ORT (1,2) reviewed in
this Journal, this is a much more ambitious and successful approach to
ORT and may be considered a comprehensive textbook thereof.
Cashdan S. Object relations therapy: using the relationship. New York:
WW Norton; 1988.
Horner A. Psychoanalytic object relations theory. Northvale (NJ): Jason
Addiction Treatment: Avoiding Pitfalls –
A Case Approach. Committee on
Alcoholism and Addictions, Group for the Advancement of Psychiatry Report
No 142. Washington (DC): American Psychiatric Press; 1998. 242 p. US$38.00.
N el-Guebaly, MD
This book, conceptualized by a committee of some 15 psychiatrists, leaders
in American addiction psychiatry, focuses on clinical problems commonly
encountered in the field. These problems are introduced and highlighted
through the use of an array of case vignettes. This approach will be of
particular appeal to the clinician who can readily identify with the challenges
The book comprises 3 main sections. The first portion highlights the initial
interview process and outlines the various phases of recovery. Twenty vignettes,
each approximately 1 paragraph long, deftly exemplify the importance of
routine screening for the use of alcohol and other drugs followed by an
appropriate history leading to a diagnosis. Clinicians will appreciate
the pitfalls resulting in over- and underdiagnosing addictive disorders
as well as the associated comorbidities. Reaching a diagnosis results in
the need to plan a comprehensive treatment and rehabilitation program.
The next 14 vignettes capture the 3 phases of recovery; namely safety,
stability, and functionality within sobriety. The psychiatrist will recognize
the challenges often presented by psychiatric comorbidities underlying
the so-called “dry drunks” and “white-knuckled recoveries.”
This reviewer particularly enjoyed the second portion devoted to biopsychosocial
management. Fourteen vignettes highlight challenges associated with somatic
therapies—from the sensitivity to disulfiram, the vulnerability of the
cocaine user to extrapyramidal side effects, the benefits and limitations
of benzodiazepines, to the drug–drug interactions associated with opiate
Amid the various psychotherapeutic approaches, 6 vignettes highlight the
importance of a proper needs-assessment process as well as of enhancing
the motivation to change. Treating the addicted patient is “not psychodynamic
psychotherapy as usual.” Active interventions involving the patient’s family
and friends as well as a working knowledge of the 12-Step Recovery Process
are among the additional tools required by the therapist for a successful
outcome. A sensitivity to transference and countertransference issues is
essential in the management of addiction, a chronic illness with a propensity
for relapses. An entire chapter including 16 vignettes is devoted to the
doctor–patient relationship and is a trove of clinical dos and don’ts.
The social aspects of management are highlighted by the network therapy
approach, in which a significant aspect of treatment is introducing people
close to the patient into the therapy sessions. Network members can, for
example, help reestablish therapeutic contact when the patient relapses.
Nineteen vignettes illustrate the main tenets of the therapy as well as
the sensitivities inherent in a coordinated approach between professional
input and self-help groups.
The last portion of the book is devoted to special needs, of women as well
as of an array of special populations. Treatment programs having traditionally
evolved around the needs of men; a chapter on some mistaken notions surrounding
addicted women with suggestions for gender-specific measures is welcome
at this point. A dozen vignettes examine the clinical impact of stereotypes
as well as the challenges resulting from a history of physical or sexual
abuse, pregnancy, and the demands of spousal and maternal roles. A smattering
of 44 vignettes completes the clinical portion of this book by highlighting
the need for an individualized approach to management. Age, ethnicity,
levels of disability, and financial status all receive mention. This chapter’s
scope is somewhat ambitious. Of particular interest will be the section
referring to the special challenges presented by addicted health care providers.
Overall, the book is enjoyable and was a pleasure to review. Appreciating
the book requires some knowledge of the care delivery system in the United
States as well as some sophistication in psychiatry. This book is an excellent
clinical guide for psychiatrist clinicians, psychiatric residents, and
other senior clinicians in the mental health field. It may not be as accessible
to, for example, family physicians. In a future edition, a section on behavioural
addictions like pathological gambling would be welcomed. The book is indeed
a valued addition to the current literature, as it further outlines the
standards required in dealing with this challenging population. As physicians
worldwide are rediscovering addiction as a major public health problem,
the clinical illustrations of the various ways patients present are noteworthy.
The layout is attractive and free from production errors.
Cognitive Vulnerability to Depression. Rick E Ingram, Jeanne Miranda, Zindel
V Segal. New York: Guilford Press; 1998. 330 p. US$36.95.
Llewellyn Joseph, MD, FRCPC
North York, Toronto
Cognitive therapy (CT) for depression has been traced back to Aaron Beck,
who developed the approach from the observation that depressed patients
displayed a characteristic negative pattern of thinking or cognition about
the self, the world, and the future. These negative cognitions are activated
by latent dysfunctional beliefs about the meaning of certain types of experiences,
a personality type that places high subjective value on such experiences,
and the occurrence of the appropriate stressors (1). This applies only
to reactive, nonendogenous depressions.
Despite the demonstrated effectiveness of CT in treating many forms of
depression, there is no satisfactory cognitive theory of depression nor
adequate clarification of the salient factors responsible for the effectiveness
of CT (1, p 511–3).
The efficacy of CT in preventing relapse in depression is being increasingly
demonstrated, and the idea that dysfunctional beliefs are latent in the
healthy state but may be activated by appropriate stress in the appropriate
personality provides at least partial explanation for the relapse of depression
and for the benefit of CT (1, p 516–9).
This book attempts to explain “how cognition might predispose individuals
to depression” and, in so doing, contributes to the theoretical foundation
for the usefulness of CT in depression and particularly in the prevention
of relapse. The 3 coauthors have individually made significant contributions
to the literature on cognitive therapy, to cognitive theory of depression,
and to cognitive theory generally.
The central thesis of this book is that cognition significantly contributes
to the individual’s vulnerability to depression, both by virtue of early
experiences that affect one’s cognitive system and by stressful life events
that activate this depressogenic cognitive system, which in turn activates
a depressive-affective system. Alternatively, a bottom-up process may occur,
in which a depressive-affective system activates depressive cognition,
which leads to a negative perception of reality and an increase in stress,
starting the previous depressogenic cycle. In developing their thesis,
the authors quite logically make the case that vulnerability, which is
accepted as an attribute intrinsic to the individual, is not just biological
but does have a cognitive element and, further, that it “is not necessarily
permanent or unalterable” (p 79). They also limit the definition of depression
to a psychologically mediated process leading to psychosocial distress
and functional impairment, and they make the case for vulnerability to
include susceptibility to recurrence as well as to initial episodes of
depression. Bipolar depression and other biologically medicated depression
are excluded. The dimensional approach is also taken, in which depression
is seen as an extension of normal sadness.
The book is very logically organized in 10 chapters that progressively
move from the more peripheral but very relevant foundation issues to the
central integrative discussion and conclusion. The first chapter, “The
Cognitive Approach to Psychopathology,” is a most useful systematic review
of the various cognitive models of psychopathology, which often employ
different constructs and terminology. This chapter provides an organizational
foundation for anyone trying to understand the literature on cognitive
therapy with its various viewpoints and languages. A metaconstruct is presented
for organizing the various major existing constructs. The cognitive system
is seen as having the following properties: structure, how information
is stored and organized; propositions, content of the system; operations,
processes characteristic of the system; and products, output of the system.
Different cognitive models of psychopathology tend to focus on one particular
property of the cognitive system as being dysfunctional in a particular
pathological disorder. In this study of depression, the authors stick to
a paradigm in which depression is seen as a disorder of cognitive processing.
The depressogenic cognitive system is conceived as comprising 4 elements:
1) Structural (schemas): these “basic cognitive vulnerability structures
have been established through . . . problematic-attachment-related learning.”
2) Propositions (content): these include memories and dominant themes that
are activated by certain depressogenic experiences. 3) Operations (processes):
by which life events are cognitively appraised in terms of their personal
and interpersonal meaningfulness and therefore leading to the activation
of a depressive core. 4) Products: including the cognitions and thoughts
that result from the interaction of the above elements; that is, attributions
Subsequent chapters, “An Overview of Depression,” “Cognitive Theories of
Depression,” “Vulnerability Approaches to Psychopathology,” and “Conceptual
Issues in the Study of Vulnerability,” precede 3 chapters that look at
methodological strategies in the study of both “proximal” and “distal”
vulnerability and examine cognitive theory and data on both. The final
chapter, “Proximal and Distal Perspectives: An Integrative Approach to
Cognitive Vulnerability to Depression,” unifies all aspects.
This approach of discussing all background facts and ideas relevant and
requisite to the central thesis provides a good foundation for understanding
the arguments and flows logically.
Chapter 5, “Conceptual Issues,” very critically examines such concepts
as “what is disease versus disorder or syndrome?” and the implications
of defining dysfunctional states categorically versus dimensionally. This
detailed dialectical examination is applied to the discussion of depression.
Some very insightful side points are made in the course of this discussion;
for example, “Reliance on a categorical, medical model-based construct
with . . . diagnostic criteria has . . . led to a reification of depression
that is by developing ‘objective’ formal diagnostic criteria . . . researchers
have tended to remove the idea from the realm of a psychological construct
and have given it a separate reality in its own right” (p 102–3).
Overall, the book is very well-written and carefully and logically thought-out,
with a very extensive scholarly discussion. The discussion is well supported
by the large body of relevant literature reviewed. There is enough recapitulation
and overlap at the beginning of each chapter to take a nonexpert reader
This book would be of interest and value to people who are interested in
depression and in cognitive theory and therapy.
The only disappointment is that only very little was said about the treatment
implications, which is of most interest to the clinician. One hopes that
another book of similar thoroughness oriented to clinical implications
is in the works.
Paykel ES, editor. Handbook of affective disorders. 2nd ed. New York: Guilford