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Book review for Jon Frew and Michael D. Spiegler Contemporary psychotherapies for a diverse world (first revised edition)

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Elizabeth Day, The Australian College of Applied Psychology

 

In this hefty textbook, running to over 600 pages after its first revision, Frew and Spiegler have managed to produce an excellent resource for students and practitioners curious about contemporary psychotherapy and counselling as they are practised in the USA.  Aimed at graduate students in North America, the text comprises elucidations of the histories, theories and practices of 11 new and renewed approaches within contemporary psychotherapy.

The approaches are listed according to the chronology of their historical development, respectively: psychoanalytic therapy, Adlerian therapy, existential therapy, person-centered therapy, gestalt therapy, behaviourism (which gets two chapters: ‘Traditional Behaviour Therapy’ and ‘Cognitive-behavioural Therapy’), reality therapy, feminist therapy, family therapy, and narrative therapy. 

This approach to organising the material provides a clear sense of the evolutions and revolutions in therapy in North America across the twentieth and twenty-first centuries.  But it is not without contention.  

The text’s structure

The text follows the current trend of additional “devices” desired by textbook publishers: key terms and resources for further study, evaluation of the method, blind spots, future developments.  Such devices can clutter the flow, though they can be of benefit to some learning styles. Here they are well implemented and function to provide thorough and easily accessible coverage of the selected approaches to psychotherapy. 

The most impressive feature of the text is, in my view, the “Author’s Journey” segment in each chapter. Here the writer-therapists locate themselves culturally and model the relevance of the contextual approach. This feature grounds the psychotherapeutic approach in a time and place, offers interesting detail and insight into some of the original thinkers and practitioners of the given approach, and exemplify for student readers the complex process of adopting a psychotherapeutic approach.  The use of this feature is also an implicit recognition of the role of the therapist in the effectiveness of therapy.

The theoretical foundations of each approach are well laid out. This brings depth to the discussions and may come as a relief to readers, considering the reductive professional discourse effected by the more narrow focus of recent years.  Chapter authors take a sanguine approach to these contextual changes and pressures, and include recent research evidence validating the given approach, its blind spots, and discussion on its capacity to adapt to diverse client cohorts, as well as future directions.

Stated aims of the text

There are two stated aims of the text: to introduce graduate students to theoretical approaches in psychotherapy via the “champions” of those approaches, rather than from a single author covering them all; and to prepare students to work in an informed way with an increasingly diverse cohort of clients.  Each is a commendable aim and generally very well executed, with some significant and overlapping exceptions.

The integration of diversity discourse and practice is modelled in the second chapter on ethics, which is written by a well chosen author with expertise in multicultural and feminist ethical perspectives. This signals upfront the text’s commitment to diversity and models well the integration of discourses of equity with applied practice.

A diversity orientation is evident throughout the text, particularly so in those psychotherapeutic approaches whose theoretical base includes feminist, literary, critical and/or social theory – such as feminist, narrative, and family therapy – than those without a more rigorous contextual basis – such as reality, behavioural, and cognitive-behavioural therapy. The authors of these latter chapters do, however, endeavour to make links to the needs of an increasingly diverse client base of therapy in the USA. 

A jarring note is sounded between the editors stating how they chose writers at “the top of their game” (p. ix) and the breakdown of nationality and gender of the writers. People at the top of the game would have to include international theorists and practitioners – such as van Deurzen, or Spinelli perhaps, for Existential therapy; and the field would be hotly contested internationally for those at the top of their game in psychoanalysis. It was a smart choice, though, to invite an antipodean writer (Kathie Crocket from New Zealand) on Narrative therapy, to reference its origins in Australia and New Zealand.  While no single text can be asked to do all things, nevertheless a next step could be to include chapters from international theorists, researchers and practitioners, to stimulate a truly global dialogue in the field. 

In a profession whose practitioners are still predominantly women, people at the top of the game would have to include a high proportion of women and yet the gender breakdown of writers in the text is a strikingly disproportionate 2:1 men to women.  This begs the question beyond the editors of this book, who clearly lean toward contextual and inclusive practices, regarding the content and other choices made through the text. The relevant question for the profession in relation to people at the top of their game is: who is leading the development of research and practice modalities, and why?  How does the field ensure a better proportional representation at all levels given the higher proportion of women in its workforce and among the client base of psychotherapy? 

Although the text does not raise this question directly, some clues emerge in what we learn of the evolution of the approaches it covers, and the context for their development. We learn that in twentieth-century North America psychoanalysis and Adlerian therapy were the only or predominant approaches to psychotherapy until the post war (WWII) era. The 1950s saw the emergence of Rogers’ person-centered counselling, the Perls’s gestalt therapy, behavioural therapy and existential therapy.  Reality therapy and cognitive-behavioural therapies appeared in the 1960s but it was not until the rise of critical theory and postmodernity that feminist, family and narrative approaches developed (in the 1970s and 1980s), and led the way toward more contextual and inclusive practices.  

Psychotherapy, counselling and psychology: some confusion

The other contention I have with the text is that it conflates counselling and psychotherapy as though their different histories, training requirements and philosophical foundations are of no consequence: “despite any definitional differences, the theories underlying psychotherapy and counselling are the same” (p. 4).  This elision of difference seems unnecessary, and can not sufficiently account for the significant differences between long-term therapeutic process in some of the psychodynamic approaches, gestalt and similar therapies on one hand, and the skills oriented and problem focussed short-term solutions of cognitive-behavioural, reality therapy and similar therapies.  

Neither is there any discussion in the text of the different histories and orientations of psychology and psychotherapy.  There are indeed significant differences – perhaps fewer in the USA than in Australia – and it is curious that these are either not addressed or not seen. 

Evidently there has been a swing away from the sometimes bitter emphasis on differences between orientations, toward a confluence that denies important differences. Perhaps this is a sign that psychotherapy, counselling and psychology, and disciplines that inform them, are still wending their way toward differentiation.  In the interim, however, the result can lead to confusion.

An example of this is the choice of approaches for inclusion in the text.  Out of what the editors approximate are 400 therapeutic orientations, modalities or approaches, they had to distil 11.  Of those 11 two are almost invisible in the Australian context – Adlerian and Reality Therapies – and another two are given over to behavioural therapies that really represent techniques rather than stand alone modalities or schools of thought.

The inclusion of Adlerian therapy indicates a cultural difference between the USA and Australia where Adlerian therapy does not figure amongst the 25+ modalities under the PACFA banner.  Adler developed a theory that acknowledges the effects of “social class, racism, and gender on the behaviour of individuals” (p. 124).  Its apparent emphasis on “prevention and education, multiculturalism, and social justice” (p. xi) made me curious to learn more about it and to wonder what happened to it in the Australian context.  

At a glance its individualistic bent may shape it more to the late capitalist context of North America.  Its origins in psychology may also have influenced its relative invisibility within the psychotherapy and counselling profession, apparently more differentiated from psychology in Australia than in North America and elsewhere.  In addition, Carlson and Englar-Carlson describe Adlerian therapy as operating like a closed community. This is a risk for any school of therapy that shores up its approach through exclusive conferences, events and publications at the risk of falling away from a broader professional dialogue. 

Reality therapy also struck me as an odd inclusion. An extension of cognitive-behavioural therapy, it developed out of psychiatry.  Again, it was formed on a thin base, and was in fact a methodology used to manage clients in a psychiatric ward of a hospital and a correctional institution for delinquent girls (p. 340).  In response to criticism that it lacked a theoretical base Glasser retrospectively created one.  The distinction between such an approach and the more theoretically intricate and evolved approaches is worthy of greater attention in a textbook such as this.

Notes on chapters

Existential therapy is accorded its due place as an important development in post-war North America. The author, Vontress, is a credentialed American practitioner of the approach.  He covers the core principles of the approach and a history pertinent to its development in North America. However the relative absence of a European perspective, which has been so important it its development in most countries, was surprising. Van Deurzen was barely there, Spinelli not at all.  Moreover the client therapist relationship is described in this way: “the counselor (subject) helps the client (object) to understand the human condition” (p. 161).  This was startling, reading as I am from an Australian context more influenced by the European schools of existential philosophy and therapy and by the intersubjective implications of phenomenology, which posit a more mutual relationship and enquiry.  Clearly the existential approach has developed in a different direction, under the combined influence of Carl Rogers and Rollo May.  

It was encouraging to note in the chapter on person-centered therapy the adaptation of the approach to include the common factors research findings, with the chapter’s author, Cain, advocating client-informed and client-directed therapy as optimal forms of this approach (p. 207). Cain notes that current trends in the US are toward cognitive-behavioural therapy but that graduate students, there as here, typically prefer person-centered and other humanistic psychotherapy modalities.  Despite the pressure for short-term treatments, the author argues that person-centered therapy continues to remain relevant, evident both in the exponentially proliferating number of publications in the field, and the permeation across diverse schools of practice of Rogers’ main principles of the therapeutic stance: empathy, congruence and unconditional positive regard. 

The chapter on gestalt therapy tracks the philosophical strengths that made the approach fresh after the hyper interpretive and directive forms of psychodynamic approaches in the early twentieth century. Developed in reaction against ‘fascism and orthodox psychoanalysis” (p 221), and making a shift from drive theory toward relational practice, Gestalt was “conceptualized as a radical revision of psychoanalysis” (p 222).

It was interesting to read Frew’s own formation as a getsalt therapist: from his initial prejudice about it as a confrontational approach that dealt mainly with empty chairs and was clearly not for him, to his experience with a skilled gestalt therapist at a workshop. He discovered in practice that it is not “an adjustment therapy” but a powerfully transformative practice, using the phenomenological method of inquiry in a dialogic process that truly belongs to the client. Frew notes the evolution of gestalt into a “culturally sensitive and diversity friendly orientation” (p. 250), from the notoriously confrontational style of Perls, to the subtle focus on awareness, presence, a client’s environment and interpersonal ecology.

The behavioural techniques did not really warrant two chapters in a book of so few modalities aiming to represent the range practised today. In “Behavior therapy II: Cognitive-behavioral therapy” some of the examples are thin and grating; overly rationalised at the expense of emotional nuance.  Clients here, for example, do not connect more broadly with their context to discern where support lies, they “collect data that refute their false assumptions” (p. 316).  See especially the discussion with the lesbian client about her parents’ homophobic responses to her (pp. 306-07) that borders on cultural disregard. 

The chapter’s author, Spiegler, acknowledges among its blind spots its external and narrow focus (p. 328); and I would add its lack of philosophical depth.  It comes across less as a school of thought and practice than a set of techniques that might suit clients with an external locus of control and a shot term goal of behavioural change. Notwithstanding the common factors research and the profession’s consensus regarding the centrality of the therapeutic relationship, in this approach that relationship is subordinated to the therapeutic technique; and, in this chapter, likened to the role of anaesthesia in surgery: “the crucial factor in the success of the surgery is the surgical procedure itself, not the anesthesia” (p. 323).  So firmly set into a medical model – not only by the surgical analogy – this approach seems more suited to a psychology textbook rather than one on counselling and psychotherapy; at least as they are practised in Australia.  As Spiegler concedes, “people are more than the sum of their behaviours” (p. 328.) 

The ABCs of behavioural therapy and the A to Gs of toxic behaviour in reality therapy leave the impression of intellectual superficiality.  These approaches can come across as bossy and impatient with assumptions such as “behaviours are choices”, and the corollary that all one has to do is just make better choices. The chapters’ author, Wubbolding acknowledges this as a limitation (p. 367). Nevertheless within their limitations, there is evidence of their effectiveness for some presenting problems, though not for the enduring conditions that depth psychotherapy and counselling can address.

The inclusion of feminist therapy, as an important development toward diversity and theoretical sophistication, again instantiates the stated aim of the text regarding the preparation of students for working in an informed way with an increasing diversity of clients.  It was illuminating to hear the context in which the author, Remer, emerged as a feminist therapist, including the discouragement from peers to identify herself as such (pp. 381-2). She does not mention the fairly prominent work in feminist intersectionality but implicitly notes the importance of expanding the therapeutic approach from beyond a White heterosexual discourse, and discusses some of the ground already covered in that regard. Certainly recourse to contemporary feminist theory provides ample referencing for that integrative work, though her list of further reading is constrained – with a couple of exceptions – more to psychology texts.

Discussion in the chapter on family therapy recognised a global context for the practice and the important contributions from diverse contexts, not simply as add-ons: “Some of the most exciting work in the field is now coming from emerging nations in Eastern Europe from the changing societies in South America, and from areas only recently discovering family therapy, such as Asia” (Trepper, 2005, cited by Rigazio-DGilio & McDowell, in Frew p 450). The chapter also considered how family therapy is applied in a diversity of contexts in the USA, including with First Nations Peoples, African Americans, Latinos as well as lesbian and gay families, and military families.

Fully at the postmodern end of the text, the chapter on narrative therapy touched on its Foucauldian inspired, post-structurally informed contemporary discourse of subjectivity, power and change. It prompted me to think that this theoretical grounding should be included as a basic introduction to all counselling and psychotherapy courses as a touchstone for the capacity of any therapeutic approach to understand how power functions through language, and to open to diversity with commitment and competence.  

Concluding comments

In a solid text such as this with its ambitions to represent the main psychotherapeutic approaches, by experts in these approaches, there will inevitably be gaps and exclusions, such are the inevitable politics of editorial choice. Indigenous models of therapy were not evident, nor expressive arts therapies. On the other hand the often excluded but important feminist approach was well represented, along with the clearly non-American approach of narrative therapy.  Frew and Spiegler have otherwise managed this challenge with deft formal organisation of the material and an editorial touch that brings consistency and clarity. 

In the interests of the profession I think it better to identify modalities and techniques as separate elements of therapy, rather than conflate them. There is a vast difference between psychoanalysis, existential, gestalt and similar therapies on one hand, and the instrumentalist techniques of cognitive, behavioural, and reality therapy, on the other.  Such an approach may help to structure a textbook according to the relative disciplinary weight and depth of the different approaches, and help students to discern the differences between a school of thought, an orientation and a technique.

In terms of a global outlook, it would have been more effective were there more of an international engagement in this text. Resources for further study in each chapter generally linked to international journals and groups, which is a good start. Moreover it is the responsibility of all of us in the profession through the activities of publication in international journals and presentations at international conferences to expand the dialogue beyond the confines of our own practice context. Clearly this text was aimed at North American students, and evidently many psychotherapeutic approaches are developing with different emphases in the USA than here. That is definitely worth an international dialogue.



Title: Contemporary psychotherapies for a diverse world (first revised edition)
Jon Frew and Michael D. Spiegler (Eds).
New York and London: Routledge, Taylor & Francis. 2013.

 

 

 


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