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Richard P. Fox

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PSYCHOTHERAPY
Psychodynamic Therapy: A Guide to Evidence-Based Practice. By
Richard F. Summers and Jacques P. Barber. New York: Guilford Press,
2010, xii + 356 pp., $40.00.
Psychodynamic Techniques: Working with Emotion in the Therapeutic
Relationship. By Karen J. Maroda. New York: Guilford Press, 2010,
xii + 274 pp., $35.00.
Change in Psychotherapy: A Unifying Paradigm. By The Boston Change
Process Study Group. New York: W. W. Norton, 2010, xx + 236
pp., $35.00.
Psychotherapy Is Worth It: A Comprehensive Review of Its CostEffectiveness. By The Committee on Psychotherapy. Edited by Susan
G. Lazar. Washington, DC: American Psychiatric Publishing, 2010, viii
+ 352 pp., $60.00 paperback.

nitially psychoanalytic theory and technique informed and helped

shape that of psychotherapy. In Freuds words, analysis was the pure
gold that was blended with suggestion to create the bronze (later
reduced to baser metals) of psychotherapy.
With the progression of analytic thought from a one-person to a twoperson psychology and the innovations of object relations theory, self
psychology, and the intersubjective and relational points of view, the
connection between the two practices has become a two-way street in
which each stands to benefit from the other.
These four books, standing at the interface between psychoanalysis
and psychotherapy, demonstrate to analysts and therapists alike what they
stand to gain from careful consideration of the data provided by thoughtful study of psychodynamic or psychoanalytic psychotherapy. For the
analyst they provide a fresh perspective on the interaction and therapeutic
process in the analytic situation.
The books reviewed here provide an impressive demonstration of the
vitality and significance of recent work in the fields of psychodynamic
psychotherapy. The first two titles offer introductions to clinical psychotherapy for beginning and seasoned practitioners alike. The third book

DOI: 10.1177/0003065111409035

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presents a provocative new perspective on therapeutic process and change.

The final volume offers an encyclopedic survey of research on the efficacy and cost-effectiveness of psychotherapy. Together the books highlight for the psychoanalytic reader the relevance of psychotherapy studies
for our core discipline.
DYNAMIC PSYCHOTHERAPY: A GUIDE
TO EVIDENCE-BASED PRACTICE

Richard F. Summers and Jacques P. Barber from the Department of

Psychiatry of the University of Pennsylvania School of Medicine introduce a closely reasoned, exhaustively elaborated application of psychoanalysis to psychodynamic psychotherapy. They detail a comprehensive
description of pragmatic psychodynamic psychotherapy (PPP) that
will serve as a resource for practicing, teaching, and investigating psychotherapy. For the newcomer they offer a comprehensive framework for
approaching the patient in actual clinical practice. For seasoned practitioners it offers a refocused perspective on ongoing therapeutic work. For
the teacher the text provides an excellent outline for focusing on the
clinical situation. For the researcher it offers a framework that lends itself
to use as a research manual.
The authors, who teach in a medical setting, use a primary care
model to address the patients problem. They consider the presenting
problem as a manifestation of a lifelong condition, not unlike any chronic
condition. Intervention is not a scientific quest for the source but rather
a therapeutic effort to diagnose the problem and demonstrate it to the
patient. The therapist works to help the patient recognize its impact on
his life and suggests how he might make changes to improve his situation. The therapist works to rally the patients strengths and foster his
adaptation with the goal of reducing the conditions impact on his life.
The PPP therapist works within a conceptual framework of six core
psychodynamic problems: depression, obsessionality, abandonment, low
self-esteem, panic anxiety, and trauma. For each of these core problems
the authors provide a comprehensive description of the problem, the psychoanalytic theory it encompasses (ego psychology, object relations, or
self psychology), the goals of treatment, the character strengths affected,
and the manifestations and underlying dynamics of the problem. They
then describe the kinds of issues the patient struggles with and the characteristic resistances he presents, including therapeutic alliance issues
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and typical transferences and countertransferences. Clinical examples are

used to demonstrate each of the six core psychodynamic problems, how
they present in treatment, and the course of the clinical work.
Summers and Barber present a number of valuable clinical observations. For example, they suggest that psychoanalysis would benefit from
a theory-ectomy. Their eclectic approach allows them to draw on different analytic theories and on techniques from other approaches, notably
cognitive behavioral therapy. They highlight working with a patients
strengths and encouraging the development of new skills and coping
mechanisms. In the process, patients develop new emotional perspectives
and behavioral responses.
The chapter on change is especially illuminating. Traditionally, as
the authors point out, analysis has viewed insight as the silver bullet
that of itself facilitates change. The other volumes under discussion will
have more to say on this subject, but Summers and Barber take a detailed
look at aspects of change that we analysts subsume under the catchall
phrase working through. What are the mechanisms of change and how do
we facilitate it? Beyond insight, what is needed to effect change in the
patients life? What changes in the patient? How does the therapist mobilize strengths and promote more adaptive behaviors? Psychotherapy
presents a fertile field for exploration of such questions.
The authors focus on the patients personal narrative and how treatment
may help the patient modify it. Another of their insights is the observation
that therapy helps the patient develop empathy for himself as a child. The
patient can modify his narrative by telling it to a new and objective listener.
I have noted that the authors cite three analytic theories in identifying
their six core dynamic problems: ego psychology, object relations theory, and
self psychology. Conspicuous by their absence are the more recent intersubjective and relational points of view. I also find the authors presentation
one-sided in placing the therapist somewhat outside the process. Instead the
therapist is pictured as the objective diagnostician, a coachlike therapeutic
agent. Less emphasis is placed on the therapist as a coparticipant in a twoperson field. The Maroda and BCPSG books will elaborate on this theme.
Another concern with this approach is that it leaves little room for
the free-floating attention of the therapist, who instead enters the session with a preconceived formulation and agenda. Rather than serve as a
resonating coparticipant, the PPP therapist approaches the patient like a
coach who knows how the game is played. As analysts we might find
ourselves hamstrung by such an approach. This said, there is much value
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in bringing a clear focus to therapeutic work; still, flexibility is necessary

to shift the focus when the situation demands.
PSYCHODYNAMIC TECHNIQUES: WORKING WITH
EMOTION IN THE THERAPEUTIC RELATIONSHIP

Karen J. Maroda is Assistant Clinical Professor of Psychiatry at the

Medical College of Wisconsin and in private practice in Milwaukee. Her
book, Psychodynamic Technique, is a perfect counterpoint to the Summers
and Barber and provides a segue to the Boston Change Process Study
Groups volume on the therapeutic process.
In contrast to Summers and Barbers emphasis on a cognitive approach,
Marodas study is rooted in an interactive and intersubjective point of
view. As her subtitle makes clear, her focus is on working with emotion in
the therapeutic relationship. Her central thesis is that therapeutic communication centers on affect and attachment. Treatment requires emotional
engagement and mutual influence. Both the patient and the therapist contribute to this development in a bipersonal field. The BCPSG volume will
add to understanding how this approach effects therapeutic change.
The therapeutic relationship is asymmetric and is built on more than
empathy. In addition to being a good match, the therapist must foster the
patients comfort in talking about himself and in experiencing emotion
within the sessions. Highlighting the importance of this opening phase,
Maroda reports that half of all patients drop out by the third session; she
offers helpful suggestions for the novice therapist working with the new
patient. At the other end of the process, 60 percent of patients report after a
successful treatment that they feel they stayed too long. Apparently therapists as well as patients have their problems ending such a relationship.
In the evolution of the relationship, both partners bring a core identity
and established ways of being in relation to another. Maroda feels that
patient and therapist repeat the past and that it is important that client and
therapist come to know each other unconsciously. Influence is a mutual
process based in the emotional field needed to create such a collaborative
relationship. The therapist needs be aware of his contribution to this process.
Maroda notes that the term regression has fallen into disuse and is in
need of redefinition. She suggests that regression is a process of letting
down defenses and allowing the self to be vulnerable and open to new
emotional experience. Significantly, Summers and Barber do not discuss
regression at all.
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Maroda lists a number of features that alert the beginning therapist

to the emergence of regression. The process is attachment-based and
unconscious. She cautions against the perils of nontherapeutic regression.
This section is sprinkled with helpful clinical vignettes that demonstrate
techniques the therapist can use to manage the regressive process and
keep it within manageable limits. Maintaining the therapeutic frame is
essential in dealing with the regressed patient and in recognizing the emergence of nontherapeutic regression.
Maroda agrees with Summers and Barbers caution that insight is in
itself not enough. She states her premise more forcefully: what is truly
therapeutic has more to do with the emotional experience between therapist and patient than with the correctness of interpretations and intellectual
understanding. In her chapter on tracking interventions she recommends
an active, ongoing interaction with the patient.
Her comments on self-disclosure serve to introduce the topic of the
person of the therapist as it is revealed by the therapists authenticity.
Self-disclosure may be effected through spontaneity, intuition, emotion,
facial expression, advice, answering questions, and so forth. Maroda notes
that self-disclosure has gone from being forbidden to being embraced as
a vital ingredient of a strong therapeutic relationship. In considering the
therapeutic action of self-disclosure, she proposes three basic, interwoven
aspects of human development that contribute to its impact: (1) affect
management, (2) reinforcing individual identity, and (3) separationindividuation. She emphasizes that self-disclosure includes real emotion
and that the therapist should be comfortable with making such an exposure. She discusses and gives examples of dealing with anger, sadness,
erotic feelings, and joy. It is particularly important that the therapist stay
in the realm of feeling to complete what she calls the cycle of affective
communication. The experienced therapist, she notes, is more likely to
act comfortably out of his unconscious than is the novice.
Summers and Barber do not include a discussion of borderline personality disorder, on the grounds it is more a pejorative label than a diagnostic assessment. Maroda takes up the topic of the borderline patient as
a means to discuss management of emotion, both that of the patient and
that of the therapist. She emphasizes the value of new experience in creating different patterns for managing emotion. This is in the service of
empowering the patient and offsetting his feeling of helplessness. Drawing
on the research on mother-infant interaction, she notes that everything
that becomes intrapsychic was once interpersonal.
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In conclusion, Maroda adds the caveat that providing guidelines and

examples can aid the therapists growth and development, but that ultimately on the job training is essential: therapeutic expertise must be
learned in the relationship with the patient.
CHANGE IN PSYCHOTHERAPY: A UNIFYING PARADIGM

In the 1970s a small group of psychoanalysts and developmentalists conducted pioneering infant-mother observations and reported early results
at odds with aspects of existing psychoanalytic developmental theory.
In 1994, when Daniel N. Stern and Nadia Bruschweiler-Stern moved
to Boston, a group formed that has come to be known as the Boston Change
Process Study Group (BCPSG). In addition to the Sterns, BCPSG includes
Karlen Lyons-Ruth, Alexander C. Morgan, Jeremy P. Nahum, and Louis W.
Sander. Alexandra M. Harrison and Edward Z. Tronick were members of
the group until 2002.
This BCPSG attempted to adapt methods developed in their infant
research to study the change process in the psychotherapeutic relationship. This current volume presents a collection of their papers describing
their findings and conclusions to the present time. It presents what they
hope will be a unifying paradigm to explain how the therapeutic relationship produces change beyond the realm of interpretation and verbal
insight. The theory they propose lends support and clarification to some
of the observations in Marodas book.
The BCPSG book presents a formidable challenge to the reader unfamiliar with the groups previous work and the idiosyncratic vocabulary developed to describe their observations. The book, a collection of previously
published papers, each written by a different author, reads as if written by a
committee. It would have benefited from a dual editorship, one editor from
the group and the other unfamiliar with its methodology and vocabulary.
At the time the Boston Change group was applying its new research
methods to the investigation of the psychoanalytic process, there was
growing interest in two-person psychology, intersubjectivity in interactive exchange, and the importance of implicit communication.
The book summarizes their work over the past two decades in applying their methods to the study of the change processes in psychoanalysis
and psychotherapy. It offers a unique perspective on the psychotherapeutic
process, expands our view of our clinical work, and heightens our appreciation of the subtle processes operative in the psychotherapeutic dyad.
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In approaching therapeutic interaction and its components, the Boston

group postulates two realms of relational knowing. The first is the semantic,
which is represented in language. This is the realm of interpretation, a
familiar element in the analytic and therapeutic process. Summers and
Barber provide an excellent introduction to this semantic dimension.
The second is the sphere of what the Boston group calls implicit relational knowing, the something more than interpretation. Both therapist
and patient bring to the therapeutic encounter personal implicit relational
knowledge based on their individual relational experience. Implicit relational knowledge was an essential element in the groups psychology of
preverbal infants. It is registered in representations of interpersonal events
in nonsymbolic form and is the individuals unique configuration of adaptive strategies developed over time in subsequent interpersonal experience.
My understanding is that this knowing reflects the transference and
countertransference in the broadest sense of those terms.
Implicit relational knowing is a form of procedural knowledge. The
oft-repeated example of procedural knowledge is that of knowing how to
ride a bicycle. Procedural knowledge is not usually conscious, but it is
not repressed. Procedural knowledge is learned, often by trial and error.
The Boston Change group approaches their observations of the therapeutic process at what they call the local level. The group focuses on
the microprocess in the therapeutic interaction as the pair interact with
each other on a moment-to-moment basis. They observe the couple feeling their way along, correcting, repairing, repeating in an improvisational
way, working to sustain the ongoing nature of the interaction. In therapy
these improvisations remain for the most part within the boundaries set
by therapeutic technique.
Destabilization is a necessary step in moving the system out of its
habitual ways of moving along. This moving along process occurs in small,
less charged moments, as well as in the highly charged now moments and
moments of meeting to be described below. This interactive process does
not proceed in a predictable way but is subject to stops and starts, missteps and misunderstandings, misdirections and corrections. In other
words, the process is sloppy, a word the group add to their lexicon, highlighting its importance.
Sloppiness, according to the BCPSG, is an inherent property of the
two-person intersubjective dialogue. At the local level, the authors find
that this process, though not immediately comprehensible, leads to fittedness, a more coherent way of being together. Sloppiness is a necessary
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ingredient in the recognition process as the couple strives for fittedness

and co-creativity. The group see this sloppiness not as representing errors
or mishaps in the dialogue but as generating potentially creative elements. They postulate that such fittedness states are co-created out of the
ongoing communication process of trial and error in the dyad, a kind of
two-person, jazzlike improvisation. The authors propose that sloppiness
is to two-person psychology what free association is to one-person psychology, a background out of which creativity and change emerge.
Implicit relational knowing is acquired by an ongoing lived experience of trial and error within a relationship, a process the group calls
moving along. Implicit relational knowing is not static but can be modified by new relational experience and hence becomes the vehicle through
which noninterpretive therapeutic change may occur. The BCPSG has
studied this process and describes how it operates within the psychotherapeutic relationship. From a clinical perspective, Karen Maroda speaks to
this dimension with excellent clinical descriptions.
The Boston Change group approaches this at the local level by
examining the microprocess in the therapeutic interaction as the pair interacts on a moment-to-moment basis. This moving along process goes from
present moment to present moment (its time units), developing ongoing,
evolving schemes for being with another. Moving along is directed
toward the shared intersubjective goal of relating to one another. Moving
along does not necessarily recognize the others specific goals, desires,
and aims. Instead it seeks to establish and maintain fittedness in relationship with another.
As the moving along progresses, a sudden shift may occur that disrupts this habitual mode of relating. This unexpected shift, what the
BCPSG calls a hot moment, jumps out of the expected pattern of the interaction and threatens the stability of the ongoing state. To add to the confusion, the authors also label such a shift a now moment, observing that such
moments beg for a response. An example they cite is a moment when the
patient suddenly sits up on the couch, looks at the analyst, and asks, Do
you love me? A less dramatic moment might be when the patient, while
continuing to describe an encounter, momentarily looks at the clock.
The now moment is a special kind of present (or hot) moment that
gets lit up subjectively and affectively. Now moments are not familiar
and represent breaches in the established proceedings. Now moments
destabilize the process, are often accompanied by anxiety, and demand
intensified attention. They are novel compared to the usual way of doing
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things and require a correspondingly unique response. They compel the

therapist to make a choice and take some kind of action. The therapist
must respond in some way when the patient directs a straightforward
challenge, as in the first example; in the second, the therapist may choose
to redirect the patients attention to the glance at the clock or allow him
to continue his ongoing story.
In either case, the now moment may mark the breakthrough of a
transference-countertransference element. We are familiar with the interpretive response to such an episode. The BCPSG draws attention to the
emotional response. Both Maroda and the Boston group highlight the
need for an authentic response from the therapist, though the exact
definition of authentic remains vague.
Authentic seems to represent a more personal, individual reaction,
not just a technical one. An authentic response may include affect or another
form of self-disclosure, as elaborated by Maroda. It is not predictable and
may reveal surprise. The now moment may spring from the patients implicit
relational knowing; the response likewise may spring from the therapists.
When the now moment elicits an authentic response it results in a moment
of meeting that momentarily disrupts the sequence of mutual regulation and
reflects a unique interaction between the two participants.
In their developmental research, the authors observed an open space
in the infant-parent interactive process immediately following such a
moment of meeting. They observed a similar pause in the psychotherapeutic interaction following such a moment. The group suggest that the
participants assimilate the effect of the moment of meeting and go on to
find a new equilibrium in the now altered intersubjective state. The partners then take up a new moving along process.
Other fates are possible for such now moments when a potential
moment of meeting fails to occur. The now moment may simply be
missed and with it an opportunity lost; but the authors add that a similar
opening may reappear down the way and may be taken up at that point.
This is not unlike the fate of a missed opportunity to make an interpretation; the therapist often gets another opportunity. However, the authors
caution that if the occasion is not repaired at some point, part of the intersubjective terrain gets closed off and the therapeutic relationship may be
threatened. The authors suggest that fortunately several opportunities to
respond usually recur. When they do, a new moment of meeting may
follow. Sometimes the now moment may remain open for a period of
time, allowing for a delayed moment of meeting.
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This moment-of-meeting model of therapeutic action reminds me of

the old notion of corrective emotional experience, not as a contrived
intervention but as an authentic and unexpected response. This shared
moment is an important dimension paralleling insight as a critical factor
in therapeutic change. The interesting possibility is that such experiences
need not be single, dramatic moments like a flash of insight, but rather
can be the product of ongoing and repetitive corrections through a series
of small moments of meeting.
A significant problem in this part of the presentation is the absence of
clinical vignettes to clarify what is described in research terms. I found the
BCPSG formulation of the interactive process useful in understanding my
patients and will summarize a case from my practice where I found their
model very helpful in conceptualizing the therapeutic process.
The patient, in his early fifties, consulted with me a few years after
having terminated a long-term therapy with a psychoanalyst. In spite of
years in search for the key to unlock the consequences of his childhood
in a dysfunctional family, he still complained of chronic self-criticism
and a lack of confidence. One day, after months of our work on details of
his everyday life, he observed that he was being less critical of himself
and was no longer undoing his successes and spoiling his good times. We
were both pleased by what had happened but were unsure about how it
had come about after so many years of treatment.
In a later session the patient volunteered that I had allowed him to be
angry and critical and to harbor mean feelings toward others. He added
that his previous therapist had always curtailed his anger and blocked
such criticism.
As I apply some of what I have taken away from my reading of he
BCPSG book, I find a model that offers a helpful way of thinking about
therapeutic process. Over months of treatment my patient and I must
have encountered many hot or now moments as he voiced anger or
criticism. Apparently I responded in a way that allowed and even encouraged him to continue complaining or criticizing. This kind of interaction
resulted in many silent moments of meeting. These shared moments led
us to new ways of moving along and provided him an altered implicit
relational knowing. The fact that weeks later he could self-correct his
own self-critical moments attests to its becoming a more reliable internalization. The interpersonal became the intrapsychic.
In the concluding chapters of the book the authors move to a consideration of what constitutes meaning and attempt to formulate how it
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is constructed. I find this section to be speculation that does not add

notably to the gtoups detailed formulation of the interactive therapeutic process. I will leave this section to those who wish to pursue the
topic more fully.
In summary, in the BCPSG framework there are two realms of knowing in the therapeutic interaction. An interpretation alters the patients
explicit knowledge. A moment of meeting alters the patients implicit
relational knowing. These two domains may operate separately or together.
The analytic process involves working at both the affective and cognitive levels to deactivate old, more negative processes and meanings
while simultaneously constructing more flexible and coherent ways of
being together.
In the BCPSG model, the past experiences of both participants influence their interactions as expressions of transference and countertransference. The authors feel that the center of gravity lies in the process of
interaction between the two parties, not in the individual past of either.
My patient came away from his first treatment with many canned insights
that failed to free him from his past. He required new experiences to
modify his implicit relational knowledge.
The psychotherapists openness to sloppiness and the need to join the
patient through dialogue and negotiation are necessary for shared direction and ultimately for successful treatment.
We might conclude that transference and countertransference are
products of both the repressed unconscious and implicit relational knowing. In the light of these findings, perhaps it is time to revisit and rethink
the much-maligned corrective emotional experience.
PSYCHOTHERAPY IS WORTH IT: A COMPREHENSIVE
REVIEW OF ITS COST-EFFECTIVENESS.

Susan G. Lazar has edited this valuable survey of the cost-effectiveness of

psychotherapy sponsored by the Committee on Psychotherapy for the Group
for the Advancement of Psychiatry. Her colleagues for the project include
William H. Sledge, Gerald Adler, Jules Bemporad, Joel Gold, James
Hutchinson, William Offenkranz, Lawrence H. Rockland, Allan Rosenblatt,
and Robert J. Waldinger. Five of the contributors are psychoanalysts.
Although this book too is written by a committee, it benefits from
thoughtful editing and planning. Lazar suggests it be used as an encyclopedia, a source book, not a textbook. In an epilogue she states that the
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book is meant for policy makers in public and private settings, as well as
for clinicians, teachers, and others interested in psychotherapy.
Lazar recognizes the large body of researchthe relevant medical,
psychiatric, and psychological literature from 1984 to 2007showing
there is no question that psychotherapy is effective. This volume was
designed to survey whether it is also cost-effective.
Cost-effectiveness refers to value returned per dollar spent. To consider the cost-effectiveness of a treatment for a population it is necessary
to include the frequency of the disorder, the cost of leaving a condition
untreated, and the cost of the treatment itself. In addition, any measure of
cost-effectiveness must take into account patients improved work function, decreased hospitalization, and reductions in other medical expenses.
The first chapter, by Lazar, Sledge, and Adler, provides an overview of
the epidemiology of mental illness. It is estimated that fully 50 percent of the
U.S. population will suffer some form of mental illness over the life span,
and that at any given time 30 percent have a diagnosable psychiatric disorder.
The chapter details the frequency of mental illness and highlights factors that
limit the frequency and effectiveness of psychotherapy in a general population. Denial, ignorance, prejudice, and limited insurance coverage (or none)
all play a part in reducing the availability of psychotherapy. This study
emphasizes the public health cost of this policy of neglect.
Nine chapters are dedicated to individual mental health conditions, each
written by one or two authors. They involve different approaches to surveying the cost-effectiveness of psychotherapy. Helpful charts at the end of
each chapter list and summarize the many studies relevant to the illness.
Unlike medical conditions for which interventions can be easily
defined and counted, psychotherapies lack a comprehensive definition.
As a result, psychotherapy is a generic term and, for a given diagnostic
entity, may include various forms of intervention. For example, family
interventions and social skills training in schizophrenia are included in
the study. Rockland, in summarizing the psychotherapeutic and psychosocial interventions in schizophrenia, concludes that any approach that
reduces relapses is cost-effective.
Waldinger reviews treatments for patients diagnosed with borderline
personality disorder and concludes that group and individual psychotherapy reduce the use of inpatient and outpatient services and decrease
the incidence of absenteeism at work and of self-destructive episodes.
Lazar and Offenkrantz review the cost-effectiveness of treatment for
posttraumatic stress disorder. In the absence of adequate studies of this
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costly illness, they suggest that multiple psychotherapeutic approaches

reduce pain and disability and indicate their cost-effectiveness.
Anxiety disorders account for 31 percent of all mental health costs.
Rosenblatt suggests that psychotherapy (alone or in combination with
pharmacotherapy) is likely cost-effective. Many of these patients see
only a primary care physician, with medication often substituted for psychotherapy. In significant numbers, patients receive no treatment at all.
Rosenblatt concludes that underdiagnosis and undertreatment are a significant problem.
In examining the cost-effectiveness of psychotherapy in the treatment of depression, Lazar concludes that once again lack of recognition
and inadequate treatment rather than direct treatment costs have resulted
in the enormous costliness of depression.
In a chapter on psychotherapy and psychosocial interventions in the
treatment of substance abuse, Sledge and Hutchinson note the difficulties
in achieving abstinence. Brief interventions by medical professionals can
improve success rates, and more intensive treatments involving multiple
modalities can be effective.
Sledge and Gold surveyed psychotherapy for the medically ill and
report that treating the psychological as well as the medical illness is both
more effective and financially sound.
Bemporad notes that cost-effectiveness studies for psychotherapy for
children and adolescents are not generally available, but efficacy studies
have demonstrated their effectiveness for these younger patients. The
implications for public policy are discussed.
In the final chapter, Rosenblatt examines the place for more extended
and intense psychotherapy, not for specific diagnoses but as a recognized
form of treatment. This type of treatment is not usually covered by insurance. Rosenblatt cites a number of studies demonstrating the efficacy of
intensive psychotherapy in a number of conditions, but again studies of
its cost-effectiveness are quite limited.
In summary, the scope of these surveys is impressive. Literally hundreds of psychotherapy studies are enumerated, tabulated, and referenced.
In an epilogue, Sledge, Lazar, and Waldinger stress that psychotherapy,
more than other recognized treatments, has been required to demonstrate
its usefulness in cost terms. As is demonstrated in this comprehensive
survey, the preponderance of the literature reviewed attests in a general
but convincing way the cost-effectiveness of psychotherapy for the conditions examined.
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The case has been made. Psychotherapy is a cost-effective method

of treatment. The sad fact is that ignorance and misguided frugality
have increased the suffering of individuals and burdened society with
added costs.
CONCLUDING COMMENTS

Has the BCPSG succeeded in its search for a potentially unifying paradigm that will provide a common ground for understanding and discussing the therapeutic action of psychotherapy? My preliminary opinion is a
hopeful yes.
Psychoanalysis has suffered from competing theories that have tended
to divide rather than unify its practice and its practitioners. As the heir
apparent to psychoanalysis, psychodynamic psychotherapy allows therapists to move beyond theoretical conflicts and allegiance to one school or
another. As is apparent from these four volumes, modern psychotherapy
has fostered flexibility, creativity, and innovation.
Summers and Barbers pragmatic psychodynamic psychotherapy
affords the therapist theoretical models with which to address different
psychodynamic problems and to help the patient develop new adaptive
skills. Maroda places her emphasis on the therapists participation in the
emotional interaction of therapy and assigns a place for the therapists
self-disclosure in the healing process.
These two contributions present what could be seen as competing
models for therapeutic action, one focusing on understanding, the other
on emotional experience in the treatment. The Boston group offer a twosided model that encompasses both insight and relational development.
Within a given therapy, one or the other dimension may take center stage
at a given point, and both patient and therapist will likely determine the
direction taken.
In this spirit of mutuality, psychoanalysis and psychotherapy may be
seen as points on a continuum, not as competing practices in a hierarchical
configuration. These contributions suggest that Freuds pure gold has
been multiplied, not diluted.
226 Monarch Bay Drive
Dana Point, CA 92629
E-mail: rpfoxmd@aol.com

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