Book Review
Psychotherapy 
Your Inner World:
A Guide to Psychodynamics and Psychotherapy Scott R Ahles. Baltimore (MD): The Johns Hopkins University Press: 2004. 335 p. US$24.95
Reviewer
rating*: Fair
Review by: V Lantos, MD
Ottawa, Ontario
As students of psychology and psychiatry are painfully aware, the bewildering array of theories concerning development and its vicissitudes is confusing for the beginner and remains a challenge for the teacher. In this book, Dr Ahles sets out to create a systematic method that integrates these theories and teaches dynamic formulation in a didactic manner.
The book is divided into 3 main sections. Part 1, “Model of Psychodynamics,” explains the basic psychodynamic concepts—id and ego psychology, defenses, object-relations theory, and self-psychology—as well as attachment and affect theories. The author presents complex concepts clearly and simply, and the use of pictorial representation enhances the whole.
Psychopathology is introduced as the logical consequence of different degrees and levels of failure in the separation– individuation process. I would have liked more acknowledgement of the fact that the psychodynamic model has severe limitations in explaining psychosis. His object relations model provides an excellent clinical perspective on borderline pathology, but there is little mention of the related neurobiology of secure attachments contrasted with orbitofrontal–amygdala dysfunction in rage states.
In the same vein, while discussing development, he gives little credit to the enormous impact of early caregiving on the size, structure, and agility of the brain itself and far too much to constitutional and genetic factors. Indulgent detail is of course beyond the scope of this book, yet these aspects are vitally relevant.
The second part deals with development in more detail: What are the building blocks of a healthy sense of self? How do patterns of relating form and evolve along one’s lifespan? What kind of interference will lead to the pathology of the self and to the most common patterns of attachment failures?
Using the previously established psychodynamic concepts, the author demonstrates how to visualize the inner representational world of the illustrated clinical examples, thus laying the foundation for psychodynamic formulation. This is a difficult task to teach. One has the impression that the demands of didactic necessity—of keeping it all simple—prevail; the resulting discussion is unfortunately somewhat mechanical, repetitious, and sketchy.
The third and final section, “Psychotherapy,” begins with the method of history- taking to arrive at a descriptive (that is, DSM-IV) and psychodynamic diagnosis. It is followed by a pragmatic list of treatment options and techniques. The goal is symptomatic improvement (according to the DSM-IV) or, often, personal growth, as in most psychotherapies. We learn about the necessary ingredients of general and specific interventions in psychotherapy; then, through a series of case histories, Dr Ahles demonstrates how to implement those formulations and techniques in the hope of repairing pathological attachment patterns and their manifestations in the present.
The author emphasizes that this guide does not attempt to offer an exhausting discussion of its subject: it is clearly meant as an introductory reference. However, its generous use of professional jargon and formal correctness notwithstanding, it left me somewhat disappointed. There are several reasons for this: it is lax in its use of values and their relevance to the process; vital issues have been omitted (for example, patient candidacy, therapist quality, and the issue of “fit” between them); and the clinical summaries are dry and schematic (with fairytale resolutions). Most of all, I regret that it fails to convey a sense of the art of therapy and the magic that can take place between 2 human beings—the patient and the therapist—when they embark on this journey.
*Reviewer
Rating Scale/ Échelle d’évaluation du réviseur
Excellent / Excellent
Very Good / Très bon
Good / Bon
Fair / Passable
Not recommended / Pas recommandé
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