Book Review
Psychotherapy 
Key Competencies in Brief Dynamic Psychotherapy: Clinical Practice Beyond the Manual Jeffrey L Binder. New York (NY): The Guilford Press; 2004. 290 p. US$35.00.
Reviewer
rating*: Excellent
Review by: John G O’Kelly, MB, MRCPsych, FRCPC
Edmonton, Alberta
In the present climate of managed care and 15-minute evaluations, where psychiatric practice is often reduced to a series of pharmacologic interventions, any new book addressing issues in psychotherapy training and practice is welcome. This is particularly true when the author has
Dr Binder’s well-established track record.
The book’s subtitle, Clinical Practice Beyond the Manual, gives a clue as to the content of this intriguing and innovative book. Dr Binder quickly sets its tone by making the point that skilled psychotherapists often practise good therapy despite, rather than because of, their training. He observes that, in the interest of neutrality, the beginning therapist’s already developed interpersonal skills are “parked at the door” and may not emerge, to be integrated into the therapeutic approach, until much later—if at all. Revisiting the use of manuals, he cogently reminds us that they were originally designed for research. Even in that setting, the most successful therapists did not slavishly adhere to them. They were able to improvise successfully within the constraints of the approach, where clinically warranted. Binder states that this ability to improvise is the hallmark of an expert therapist. It is no different from the way in which any other master craftsperson operates, be he or she a professional athlete or a jazz musician. Thus psychotherapy training should not churn out manual-trained automatons but should constantly strive to find an optimal blend of formal instruction for therapists that allows them to fully employ their positive personal attributes.
From the outset, Dr Binder states that his approach is broadly psychodynamic and interpersonal, borrowing from cognitive-behavioural approaches. In Chapter 2, he uses cognitive-behavioural approaches to introduce the reader to a set of skills designed to teach the neophyte therapist how to self-monitor and alter interventions “in the heat of the battle,” as it were. As with the professional athlete or musician, this can be a tangible strategy to temper performance anxiety. In the context of therapy, this anxiety can be greatly intensified by countertransference. Because he comes from an interpersonal and, it seems, object-relations perspective, Dr Binder does not see a treatment impasse as exclusively arising from patient resistance. Rather, he sees it as a function of transference–countertransference enactments and devotes most of Chapter 5 to examining this important aspect of practice.
In the opening chapters of the book, Dr Binder lays out the psychotherapist’s core competencies, and in successive chapters, he masterfully develops and expands on each. In so doing, he quotes extensively from the psychotherapy literature—with suitable Canadian content! His use of clinical examples, including exact dialogue, is particularly apt. He often returns to the same vignette in subsequent chapters to illustrate a different point, thus sparing the reader the effort of learning a new case example. Along the way, he challenges several sacred cows of dynamic therapy. These include whether here-and-now transference issues are always the most important consideration. He argues that, given the time constraints of brief psychotherapy, it might be better to focus more on the vicissitudes of current relationships. For similar reasons, he argues that termination is not always a major issue for some patients. Further, he is not above offering some feedback to patients regarding progress, nor is he above making some self-disclosures, particularly toward the end of therapy. An example of the latter might be a statement that the therapist would miss the weekly therapeutic meeting (assuming it’s true).
Toward the end of this book, the momentum abates. The chapter on termination seems surprisingly sketchy. It is much shorter than the other chapters, despite the fact that the author enlisted a cowriter, doctoral student Karishma K Patel, who presumably works with him. This may reflect Dr Binder’s current views on termination, as mentioned above. It also seems to reflect the vagaries of psychotherapy practice trammelled by managed care. In that setting, it is often necessary to have planned interruptions to therapy that are not based on any clinical rationale. This “stop-and-go” approach dilutes the clinical importance of termination. Thankfully, this is not as yet so relevant to a Canadian audience.
The final chapter on training, which includes a section on supervision, highlights the scarcity of meaningful research on these related topics. The author’s own research, dating from the Vanderbilt 2 Study (1), highlighted the shortcomings of manual-guided training in terms of subsequent therapist performance. Even the time-honoured practice of combining personal analysis, didactic course work, and clinical supervision has not been scrutinized in any meaningful, systematic manner. Binder again presents several thought-provoking suggestions to improve this particularly neglected, yet extremely important, area. One is left with the impression that this could be a topic for a sequel.
I found a few typographic errors. On page 1, the word “acknowledged” appears instead of “acknowledgement.” On page 245, “you’re” appears instead as “your.” In a segment on page 249, the word “can” appears twice, which renders the paragraph difficult to understand.
The book is, notwithstanding, well written and thought-provoking. It should appeal to all psychotherapists, regardless of their orientation and experience level. It is a good buy at the price.
Reference
1. Strupp HH. 1993. The Vanderbilt Psychotherapy Studies: Synopsis Journal of Consulting and Clinical Psychology 1993;61:431–33.
*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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