Early Detection and Cognitive Therapy for People at High Risk of Developing Psychosis: A Treatment Approach
PAUL FRENCH & ANTHONY P. MORRISON
Chichester: John Wiley & Sons Ltd, 2004
ISBN 0 470 86315 3, 146 pp. Price: $52.95
The identification of young people at high risk of developing a psychotic illness is an interesting and expanding area. Research is helping clinicians to identify psychosis-prone individuals through the development of scales sensitive to the high-risk group. Psychological treatments that adopt a symptom-approach to the treatment of people meeting high risk for psychosis criteria are being advocated by many researchers and clinicians. The treatment approach described in this book is cognitive therapy (CT), and specific strategies the authors have developed for working with the high risk for psychosis group are examined in detail. In their book, French & Morrison discuss the theoretical basis for utilizing CT in the high-risk group and offer practical examples using case studies to elicit the effectiveness of this treatment approach among this population.
The book is divided into three parts, with an Appendices section at the end. Part I is broken up into three easy-to-read chapters, focusing on the early psychosis literature. First, it explores the rationale for early recognition and detection of psychosis, highlighting the importance of a preventative framework. Secondly, it explores assessment and prevention strategies for identifying individuals at high risk of developing psychosis by specifically reviewing four reputable international research groups in the early psychosis field: the Australian Group (PACE approach), the German Group (Huber and others), the American Group (McGlashan and colleagues) and the EDDIE approach (England). The final chapter in this section considers different types of preventative strategy and makes recommendations about which type is beneficial in this group.
Part II of the book consists of another three clinician-friendly chapters and discusses the rationale for, and application of, CT with a high-risk group. The techniques discussed in this section focus on an individual treatment delivery approach, rather than a group therapy approach. The first chapter reviews the basic tenets of CT as developed by Beck, and argues for the use of CT with the high-risk population. According to Beck, CT should describe the onset and maintenance of the disorder being treated, be formulation-driven, be a structured process, be based on shared problems and goals, be educational, use guided discovery as the tool for change, involve homework tasks and be time-limited. A crucial technique when working with young people is engagement, and Chapter 5 emphasizes the importance of, and difficulties with, this issue. The principles of engagement are explored in detail and are elicited via a case example. The final chapter of this section examines Morrison's cognitive theory of the development of psychosis, including a client-friendly version of the model. The authors also provide a number of useful anchor questions that can be used to assess the cognitive components described in this model. For those working in the drug and alcohol field, Chapter 6 acknowledges the importance of collecting information on levels of substance use; however, it does not explore this area in detail.
In Part III, the authors focus on specific strategies for change. The book dedicates eight chapters to this section, and clinicians working therapeutically with high-risk clients will find this section particularly helpful. The first chapter asks the question ‘Why should we normalise psychotic symptoms?’ and demonstrates, via two case examples, how the strategy of normalizing can be used with high-risk clients. Chapters 8, 9 and 10 explore other CT techniques, including generating and evaluating alternative explanations, safety behaviours and metacognitive beliefs by drawing and applying the works of David Clark, Paul Salkovskis, Adrian Wells and colleagues to the high-risk population. The section continues with Chapter 11 focusing on modifying core beliefs using the ‘downward arrow’ technique and other strategies. The following chapters discuss social isolation and relapse prevention. Finally, the authors summarize their work and consider future directions. An Appendices section is also included, with useful client handouts and worksheets. The ‘client-treatment rationale’ monologues in this section are particularly helpful, as they can be used as a guide for explaining the high-risk criteria groups, discussed earlier in the book, to clients and their families. It is also a useful reference when explaining the rationale for CT.
If you are a clinician wishing to use CT with people at high risk of developing psychosis, the detailed strategies and case examples in this book will help to inform your work. Indeed, these two aspects are the core strengths of this book. If this is the case, I would recommend you refer directly to Parts II and III, which draw on case studies and expand on cognitive strategies that can be used with this group. If, however, you are more interested in reviewing current assessment scales used to assess individuals who may be at high risk of developing psychosis, then you will find Part I particularly useful. Researchers who may be interested in conducting trials with the high-risk group will also find this section useful, as the authors discuss the particular strategies they used to recruit people into their research trials. Other useful references relevant to research trials are also detailed.
In summary, this book provides an interesting and comprehensive cognitive model for working with the high-risk group and offers a practical guide for clinicians working in the early psychosis setting. Many of the CT techniques discussed in this book will be familiar to clinicians who use this model in their clinical practice; however, French & Morrison apply the techniques successfully to people at high risk of developing psychosis. It is an invaluable text for clinicians new to the area of detection and treatment of early psychosis because of its practical nature, and for those who have been involved in the early psychosis field for a number of years it offers a useful summary of research findings and current assessment scales from a number of reputable early psychosis research groups. This book is an essential resource for anyone working in the early psychosis setting who either uses, or wishes to use, CT in their clinical practice.
Sandra Bucci
Psychologist
Psychiatric Assistance Service
Hunter New England Area Health Service
43 Brunker Road
Adamstown
NSW 2289
Australia
Cognitive Therapy of Personality Disorders, 2nd edition
A. T. BECK, A. FREEMAN, D. D. DAVIS, et al.
Leichardt, New South Wales: Guilford Press, 2004
ISBN 1 57230 856 7, 412 pp. Price: $54.00
Any book produced by Beck and his associates is usually clear, innovative, well-researched and worthy of our attention. This volume is no exception. In the 14 years that have elapsed since the first edition of this book, cognitive therapy has grown and developed in a most impressive way and has become one of the leading models of psychotherapy used in daily clinical practice. Accumulating evidence has demonstrated the efficacy of this approach for a wide range of clinical disorders. In this second edition, the authors have built on their growing skill and sophistication as therapists to explore and develop the potential of this approach with a group of clients who were until fairly recently thought of as untreatable. The original text has been extensively rewritten and updated. There are several new authors, more new evidence from outcome studies, more on clinical assessment and more on the role of emotions and the therapy relationship.
The book is divided into two sections. Part 1 offers a broad overview of historical, theoretical and clinical aspects. The first thing that strikes one reading through these chapters is the limited evidence base for the effectiveness of cognitive therapy for this group of disorders. The majority of studies that do exist are uncontrolled clinical reports that support the use of cognitive therapy with this group of disorders. There are far fewer controlled outcome studies. The authors acknowledge this but point to the increasing momentum of work in this area and, in general, the positive results that are being achieved. In particular, formal outcome studies have focused on three personality disorder types and these are borderline, antisocial and avoidant personality disorders. The studies in each of these areas have produced modest but favourable results.
The research on borderline personality disorder is perhaps at a more advanced stage than the work on the other disorders. It is based on the work of Linehan and her colleagues using dialectical behaviour therapy. This was designed originally for the treatment of chronically suicidal patients. In general, this approach has demonstrated a reduced ‘drop-out rate’, less self-injurious behaviour and better interpersonal and social adjustment than subjects receiving ‘treatment as usual’ but only modest improvement on depression and other symptomatology. These findings are encouraging though, since this unstable group is particularly difficult to work with.
The chapter on ‘General principles and specialized techniques’ will be particularly helpful to students learning about personality disorders or to clinicians who are encountering this group for the first time. The authors include discussions on conceptualizing a case, identifying schemas, specifying goals and some aspects of the therapist–client relationship, all of which are crucial to the success of therapy with this group. The final chapter in Part 1 is perhaps one of the most clinically relevant in the book. This chapter is a detailed look at all aspects of the therapeutic relationship when working with personality-disordered clients and highlights many pitfalls and difficulties of working with this group. It also includes a discussion of why patients often do not collaborate in therapy and suggests ways of understanding this and tackling it effectively.
Part 2 of the book devotes a chapter to each of the specific personality disorder types. These sections provide an historical context for the relevant personality type, an approach to conceptualizing the case, advice on devising an effective treatment approach, specific interventions and much helpful dialogue illustrating clinical scenarios. Perhaps the best-developed chapter here is that on borderline personality disorder, reflecting the size of the literature in this area. The discussion on the contribution of an abusive background to the development of borderline features was particularly relevant and up to date.
The chapter on antisocial personality disorder is realistic and acknowledges the difficulties of working with this group and the claims made for the effectiveness of the therapy are modest. Interestingly the authors decided to include a discussion of passive–aggressive personality disorder even though it has been removed from the Diagnostic and Statistical Manual version IV (DSM-IV-TR) list of personality disorders. They suggest that their justification for doing this is that their research supports a unique set of dysfunctional beliefs underlying this disorder. Despite there being limited evidence underpinning the cognitive treatment of some of these disorders, each of these chapters is practical and provides a constructive illustration of how to tailor therapeutic interventions to meet individual patient's needs.
In summary, this book is a clearly written, up-to-date, innovative and humane account of personality disorders in all their diversity. Most clinicians will acknowledge how difficult it is to work effectively with this group of patients. However, Beck and his colleagues provide in this volume a theoretical framework and practical set of clinical tools to make the task a little easier. It should be essential reading for all clinicians as it sums up the state of the field and is also full of insightful and practical advice.
Leslie R. Pollock
Clinical Director
Centre for Psychotherapy
Hunter New England Area Health Service
James Fletcher Hospital
PO Box 833
Newcastle
NSW 2300
Australia