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by Alex N. Sabo and Leston Havens (editors)
Harvard University Press, 2000
Review by Alex Howard on Jun 30th 2001

The Real World Guide to Psychotherapy PracticeAs the title suggests, this series of essays seeks to provide up to date information concerning psychotherapy as it is currently practised 'in the real world'. It is organised into three sections and twelve chapters.

Part I, 'The Relationship in Clinical Work', provides two excellent chapters on the central importance of forming effective relationships.

Part II, 'How the Work Gets Done', is written by therapists involved with people stressed by poverty, with violent men, in emergency situations, treating psychoses, with borderline patients and in 'desperate situations'.

Part III, 'Rethinking Psychotherapy' offers four, more theoretical, formulations.

All the writers, whether reporting on their practice, or writing in more theoretical terms, draw first and foremost from their very substantial experience of working with clients in diverse, and often difficult, circumstances. Here are the veterans who have 'been there', 'done that', and have the scars, humility and humanity to prove it. They provide a description of their practice more than a tour of the literature.

Many have chosen contexts where talking treatments are most difficult to apply; where trauma, culture, circumstance, physiology are all significant barriers and challenges to any psychotherapy.

In such tough circumstances, therapy, therapists and clients are all pushed to their limits. Traditional boundaries and the fifty-minute hour are, inevitably, shaken, stretched, and sometimes shattered, when working 'in desperate situations'.

I found the chapters in part II, of particular interest and value. Here were practitioners from the hottest hotspots of the 'front line'. I was at times moved by their commitment, and willingness to learn, adapt and take risks. The scale of the difficulties many of their clients face is overwhelming. What can one person to do in a fifty-minute hour to overcome intractable, poverty-infested, vicious and dangerous circumstances? Clients themselves will often despair and their despair is contagious.

Whoever the client, these writers place an effective relationship at the centre of the healing process. Leston Havens observes that Nothing destroys the development of an effective relationship more rapidly than the diagnostic, pathological ideas we communicate to patients. Yet he accepts that there is no way to prevent therapists from developing ideas that the patient is sick or wrong, despite the chilling effects these ideas have on relationships.

All the writers complain about the growth of managed care. Relationships are so central, yet time and funds are limited, and managers are concerned with inputs, outputs and evidence. Attention must be paid, but who has the remit, is it cost effective, and is it covered within the care plan contract?

The chapters in part III are more of a mixed bag and, perhaps inevitably, cover less ground than is first implied. 'Dialectical Behavior Therapy' (DBT) is a particular, though interesting approach. I groaned a little at having to confront yet another BT acronym. Brief therapy is brief, but after that a summation in one chapter seems an impossible task. The writer focuses on his own particular, and interesting enough, theorising about this work. Is 'The Field of Brief Psychotherapy' a field at all, or just a small helping of psychotherapy? 'Small' is the standard ration in the managed care environment and so it may be said that virtually all psychotherapy is now brief psychotherapy.

The chapter on Chronically Traumatized People suggests that success here requires raw heroism among other qualities. This is my own observation; the writer is herself too modest to say so.

A psychoanalyst writes the final chapter on the relevance of Psychoanalysis. Are all psychoanalysts themselves too traumatised by the blows to their profession in the last twenty years to be able to provide a perspective on the experience? Here is a worthy though, I believe, doomed effort that does not engage with the scale of the critique that psychoanalysis has received from those outside Psychoanalytic Institutes.

This book delivers admirably on its claim to provide a 'real world' account promised in the title. It might have been safer, though, to stay with, and add more of, the vivid descriptions of, and lessons from, practice. The attempt to tackle a theoretical overview as well in just one title may have been over-ambitious.

The last word, in the world we now inhabit, belongs to the health care manager. They are not evident in this book. What would be their comment? Here's my suggestion: Wonderful prose, admirably committed human beings and moving stories. But what are the outcomes? Where is the evidence? Is your brand of psychotherapy (please describe on the attached form) the most cost effective?

© Alex Howard 2001

Alex Howard was a tutor in philosophy, counseling and psychotherapy for over twenty years before being drawn into the management of adult education. He has written five books, and many articles, about psychotherapy addressed to the lay reader as well as to the practitioner. His most recent, Philosophy for Counselling and Psychotherapy: Pythagoras to Postmodernism (2000) is published by Palgrave. In May 2001 he extended to an online practice of philosophical counseling and consultancy.