Handbook of Comparative Interventions for Adult Disorders / Edition 2

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Overview

Handbook of Comparative Interventions for Adult Disorders Second Edition

A recognized leader in the field of psychology, this Second Edition looks at psychodynamic, behavioral, and pharmacological approaches to the most common psychiatric disorders, with a comparison of techniques, theoretical differences, treatment strategies, and case-handling procedures. Along with a comprehensive focus on DSM-IV and a new subsection on prescriptive treatment and managed care, the Second Edition offers the first comparative review of different approaches to specific mental disorders by leading scholars and represents the most current thinking in the field on disorders and treatment, including:
* Dynamic psychotherapy
* Behavior therapy
* Cognitive behavior therapy
* Social skills training
* Interpersonal psychotherapy
* Family network therapy
* Borderline personality disorder
* Obsessive-compulsive disorder
* Alcoholism
* Depression
* Posttraumatic stress disorder
* Panic and agoraphobia
* Anorexia and bulimia

This book contains no figures.

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Editorial Reviews

Doody's Review Service
Reviewer: Ozlem Dubauskas, MD (Rush University Medical Center)
Description: This is a book about different treatment approaches and their use and comparisons in psychiatric disorders.
Purpose: This book is meant to be a guide to treatment of certain disorders, with information about different treatment techniques and how to pproach patients with available treatment methods.
Audience: The audience is psychiatrists, psychiatry residents, psychologists, and social workers. The book is useful for any clinician who evaluates and follows up patients with psychiatric problems on an outpatient basis.
Features: The first part of the book is an introduction to major treatment approaches including dynamic, behavioral, cognitive, behavioral, and pharmacotherapy. Other parts include diagnostic issues (along with a comprehensive focus on DSM-IV) and treatments of chemical dependency, depression, anxiety disorders, and eating disorders, as well as borderline personality disorder. Each disorder is broken down into different chapters in which different treatment methods for the particular disorder are described. Combinations of treatment methods are discussed with comparisons. Treatments in relation to managed care are evaluated in great detail. Case illustrations and example dialogues between the therapist and the patient enhance the understanding of the material. Literature reviews of individual and combination treatment outcomes are very enlightening. Special populations are also discussed in great detail. Each chapter includes a summary and a list of resources including the web sites. This book is a great source of recent literature references. Tables and figures illustrate points and present data well. The language used is easy to understand. The index is very helpful.
Assessment: This is an excellent review of different treatment approaches to specific mental disorders. It represents a current way of thinking about treatment.
Ozlem Uyar
This is a book about different treatment approaches and their use and comparisons in psychiatric disorders. This book is meant to be a guide to treatment of certain disorders, with information about different treatment techniques and how to pproach patients with available treatment methods. The audience is psychiatrists, psychiatry residents, psychologists, and social workers. The book is useful for any clinician who evaluates and follows up patients with psychiatric problems on an outpatient basis. The first part of the book is an introduction to major treatment approaches including dynamic, behavioral, cognitive, behavioral, and pharmacotherapy. Other parts include diagnostic issues (along with a comprehensive focus on DSM-IV) and treatments of chemical dependency, depression, anxiety disorders, and eating disorders, as well as borderline personality disorder. Each disorder is broken down into different chapters in which different treatment methods for the particular disorder are described. Combinations of treatment methods are discussed with comparisons. Treatments in relation to managed care are evaluated in great detail. Case illustrations and example dialogues between the therapist and the patient enhance the understanding of the material. Literature reviews of individual and combination treatment outcomes are very enlightening. Special populations are also discussed in great detail. Each chapter includes a summary and a list of resources including the web sites. This book is a great source of recent literature references. Tables and figures illustrate points and present data well. The language used is easy to understand. The index is very helpful. This is an excellentreview of different treatment approaches to specific mental disorders. It represents a current way of thinking about treatment.

4 Stars! from Doody
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Product Details

  • ISBN-13: 9780471163428
  • Publisher: Wiley, John & Sons, Incorporated
  • Publication date: 8/4/1999
  • Edition description: REV
  • Edition number: 2
  • Pages: 720
  • Product dimensions: 7.00 (w) x 10.00 (h) x 1.63 (d)

Table of Contents

MAJOR STRATEGIES.

Dynamic Psychotherapy (S. Butler, et al.).

Behavior Therapy (G. Watson & A. Gross).

Cognitive Behavior Therapy (D. Haaga, et al.).

Pharmacotherapy (J. Meyer & G. Simpson).

DEPRESSION.

Dynamic Psychotherapy (J. Bemporad & R. Vasile).

Cognitive Behavior Therapy (A. Freeman & C. Oster).

Interpersonal Psychotherapy (H. Swartz).

Pharmacotherapy (M. Feinberg).

PANIC AND AGORAPHOBIA.

Psychoanalytic Approaches (D. Wolitsky & M. Eagle).

Cognitive Behavior Therapy (F. McGlynn & L. Bates).

Pharmacotherapy (E. Silberman).

SOCIAL PHOBIA.

Cognitive Behavior Therapy (C. Turk, et al.).

Social Skills Training (M. Franklin, et al.).

Pharmacotherapy (J. Kunovac & M. Stein.

OBSESSIVE-COMPULSIVE DISORDER.

Cognitive Behavior Therapy (E. Foa & M. Franklin).

Pharmacotherapy (M. O'Neill, et al.).

POSTTRAUMATIC STRESS DISORDER.

Dynamic Psychotherapy (M. Horowitz).

Behavior Therapy (T. Weaver, et al.).

ANOREXIA AND BULIMIA.

Dynamic Psychotherapy (R. Pyle).

Cognitive Behavior Therapy (L. Porzelius, et al.).

BORDERLINE PERSONALITY DISORDER.

Dynamic Psychotherapy (W. Pollack).

Behavior Therapy (K. Comtois, et al.).

Pharmacotherapy (R. Kavoussi & E. Coccaro).

ALCOHOLISM AND SUBSTANCE ABUSE.

Psychotherapy and Family Network Therapy (M. Galanter & R. Castañeda).

Alcoholism-Behavior Therapy (J. Kassel, et al.).

Pharmacotherapy (H. Moss).

Indexes.

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First Chapter


Note: The Figures, References, and/or Tables mentioned in this sample chapter do not appear on the Web. PART ONE
MAJOR STRATEGIES
CHAPTER 1
Dynamic PsychotherapySTEPHEN F. BUTLER, KENNETH L. CRITCHFIELD, and HANS H. STRUPP

PSYCHOTHERAPY IS often described as a "treatment," and because medical terminology patient, therapist, diagnosis, etiology, etc. has traditionally been used, the analogy of a physician ministering to a relatively passive patient readily springs to mind. The roles assumed by patient and therapist in psychotherapy have only superficial resemblance to this medical model. Psychotherapy is more accurately defined as a collaborative endeavor, or a partnership, in which the patient is expected to play an active part almost from the beginning. This active role is essential if patients are to become more autonomous, more self-directing, and more responsible for their feelings, beliefs, and actions. To feel better about themselves, their relationships with others, and their behavior, patients must learn to make changes within themselves and in their environments that permit them to feel and act differently. The process of therapy is designed not to change patients but to help patients change themselves.
In this sense, psychotherapy is a learning process, and the role of the therapist is analogous to that of a teacher or mentor. Psychotherapy is based on the assumption that feelings, cognitions, attitudes, and behaviors are the product of a person's life experience; that is, they have been learned. If something has been learned, modification of the previous learning can occur. Where learning is impossible for example, in conditions attributable to genetic or biochemical factors, psychotherapy has little to offer directly, but even here psychotherapy can assist with coping. Similarly, if the disturbance is solely due to factors in the person's social milieu poverty, oppression, imprisonment, or if patients do not desire change on their own e. g., they are referred by a court or school system, psychotherapists encounter great difficulties. Thus, psychotherapy works best 1 if patients desire change of their own accord and are motivated to work toward it, 2 if the environment in which they live tolerates the possibility of change, and 3 if the inner obstacles to learning defenses and rigidities of character are not insurmountable.
No single definition of psychotherapy has found universal acceptance. Depending on the therapist's theoretical orientation and other factors, psychotherapy is seen by some as a psychosocial treatment, by others as a special form of education, and by still others as a means of promoting personality growth and self-actualization, to cite but a few divergent views. Most therapists agree, however, that psychotherapy involves both a human relationship and a set of techniques for bringing about personality and behavior change.
Historically, psychotherapy has roots in ancient medicine, religion, faith healing, and hypnotism. In the nineteenth century psychotherapy emerged as a prominent treatment for so-called nervous and mental diseases, and its practice became a medical art, restricted to psychiatrists. Around the middle of the twentieth century, other professions gained entry into the field, largely as a result of the growing demand for psychotherapy services. This broadened base of clinical and theoretical influence has led to modifications of the earlier disease-oriented treatment model. Today, the term psychotherapy is the generic term for psychological interventions that are designed to ameliorate emotional or behavioral problems of various kinds. Contemporary psychotherapy is characterized by a diversity of theoretical orientations e. g., psychodynamic, client-centered, rational-emotive, behavioral, cognitive-behavioral, Gestalt and treatment modalities individual, group, family, marital.
In broadest terms, psychotherapy is concerned with personality and behavior change. The patient who seeks help for a psychological problem desires change the patient wants to feel or act differently and the psychotherapist agrees to assist the patient in achieving this goal. The major issues in psychotherapy relate to 1 what is to be changed, and 2 how change can be brought about. The first requires definition of the problem for which the patient is seeking help depression, marital difficulties, shyness, nail biting, sexual dysfunctions, existential anxiety, etc.; the second pertains to the processes and techniques used to foster change support, ventilation of feelings, interpretations, systematic desensitization, assertiveness training, etc..
At this time, a considerable lack of consensus remains about how to define problems in therapy and how to foster change. Given the extraordinary complexity of the psychotherapy process, it is unlikely that any single currently existing perspective will emerge as clearly superior to the rest. Indeed, any ultimate theory of psychotherapy will certainly encompass the clinical wisdom embodied in all important perspectives. Although a mainly psychodynamic view is presented in this chapter, the attempt has been to eschew theoretical rhetoric in favor of discussing the fundamental elements of the therapeutic encounter, that is, the contributions of the patient, the therapist, and their relationship to the therapeutic encounter. In addition, conceptual and methodological concerns in the study of psychotherapy are examined; concerns that must be addressed if the field is to make appreciable scientific advances.

THE PATIENT: GENERAL CONSIDERATIONS

Perhaps the single most important characteristic of individuals who decide to consult a psychotherapist is that they are troubled. At times, they may be unaware of the cause of their suffering and unhappiness; more often, they have identified a set of circumstances they view as accounting for their disturbance. Typically, either they are dissatisfied with their lives and complain of troublesome feelings anxiety, depression, etc. or they see difficulties with some aspect of their behavior phobia, impulsiveness, etc.. Often, they have tried various means of combating their difficulties, without notable success. Not uncommonly, patients have previously consulted medical specialists who refer them to a psychotherapist because the physician senses either the involvement of emotional factors or the futility of other treatment approaches.
However the patient comes to therapy, the therapist is confronted with a unique set of problems and, most important, a unique individual. Not only do prospective patients differ in the kinds of problems for which they seek help, but also they show great variations in 1 the degree of subjective distress they experience, 2 the urgency with which they desire relief, and 3 the eagerness with which they accept help once it is offered. A great deal of research has focused on the issue of what kinds of patients benefit most from psychotherapy Garfield, 1994. For the most part, this research has not led to any clear-cut or simple results. People from all races, socioeconomic statuses, genders, and ages can benefit from therapy. These results underscore the importance of understanding the unique perspective of an individual patient in therapy, as opposed to their more general characteristics.
Further, prospective patients differ in their expectations of what a helping professional might do to bring about relief. Virtually everyone has retained from childhood the hope of magical solutions to problems— a wish that tends to become intensified when a person experiences anxiety and distress. A magical solution involves the patient's wish to be relieved of distress simply by submitting to a powerful figure in this case the therapist. For the uninitiated, such wishes contribute to unrealistically high expectations of what psychotherapy can do. Alternatively, people whose experience with authority figures in the past has been profoundly disappointing may enter therapy with unrealistically low expectations. Such expectations occur not only among uneducated or unsophisticated patients, but also among those with broad educational and cultural backgrounds. At any rate, these expectations may have considerable bearing on a given patient's approach to psychotherapy and the evolving relationship with the therapist. A patient's unique understanding of therapy, as well as his or her transferential reactions toward therapy that is, expectations based in parent-child and other important past relationships that are transferred to the therapy relationship can be useful information that the therapist may use to determine the course of therapy.
As stated, patients typically want to feel better, to act differently, to stop some pattern of behavior, or to shed inhibitions that prevent them from engaging in behavior considered to be desirable. In most instances, patients tend to complain of a lack of will power and of feeling helpless. At the same time, they tend to blame their difficulties on other persons in their lives, referring to themselves explicitly or implicitly as victims. Whatever the nature of the complaint, the patient generally measures the outcome of therapy by improvements in feelings and behavior.
From the therapist's standpoint, the change desired by the patient is sometimes not possible, or at least not in the manner the patient desires. In many cases, although patients ostensibly desire change of a certain kind, they are unwittingly committed to maintenance of the status quo and actively oppose any change. For example, patients may express a wish to become more assertive, but it becomes apparent on exploration that they are actually searching for a human relationship that allows them to be passive and dependent.
The task of therapy involves helping the patient identify and overcome the self-imposed obstacles to change. Such obstacles are present from the beginning of a therapy, so that the patient's problem is often not what it initially appears to be. Clues about the deeper nature of a patient's problems may be evident in patterns of affect, cognition, or behavior that the patient experiences. A patient's wishes, fears, and expectations of others may also provide important information for a therapist. Still more clues may be found in the patient's relationships ranging from early experiences with caregivers, to current relationships, and even to the ongoing therapeutic relationship. Redefinitions of the problem and the goals of therapy may be indicated. As therapy proceeds, the patient and therapist 1 must work toward a mutual understanding of the problems and goals and 2 must neutralize the obstacles in order to develop a collaborative and constructive alliance. This is delicate and important work, and the achievement of this alliance alone often heralds increases in the patient's self-esteem and self-worth. Indeed, one of the most consistent findings in psychotherapy research is that the formation and maintenance of a good therapeutic relationship, from early in therapy, predicts better patient outcome Henry, Strupp, Schacht, & Gaston, 1994; Orlinsky, Grawe, & Parks, 1994.

THE THERAPIST: GENERAL CONSIDERATIONS

The therapist attempts to be helpful to the patient or client. However, as a result of disagreements over both the purpose of psychotherapy and the way in which therapeutic change is to be brought about, there is little consensus concerning the precise role and function of the therapist even among primarily psychodynamic therapists. Some therapists view their primary task as providing patients with insight into their emotional conflicts; others seek to bring about a reorganization of the patient's cognitions and beliefs; still others work more directly toward behavioral change in the hope that successful experiences in one area will help patients gain greater self-confidence, which in turn may enable them to tackle other problems in living.
Most professionals agree that the therapist must acquire special skills, but for the aforementioned reasons, there is less agreement on the nature of these skills or on how to perfect them. Consequently, training programs for psychotherapists differ markedly in content, breadth, and duration Strupp, Butler, & Rosser, 1988. It has even been asserted that naturally helpful persons indigenous helpers, nonprofessionals, and paraprofessionals may be as helpful as professionally trained therapists, thus calling into question the necessity for training in special skills or techniques.
Whatever the therapist's background or level of training, the therapist must necessarily form some notions or hypotheses about the patient's problem or difficulty, and decide what needs to be done to bring about an improvement in the patient's condition. Thus, therapists must become diagnosticians as they engage patients in activities they consider therapeutic. Both of these activities usually entail verbal and nonverbal communications, occurring in the context of a relationship that develops between patient and therapist.
In this therapeutic relationship, the patient expresses fears, hopes, and expectations, and views the therapist as a person who can provide relief from suffering. Some of the patient's expectations are realistic, but others, as already noted, are distorted, tinged with the hope of magic solutions.
Almost by definition, patients view themselves as persons in need of outside help. This places them, à priori, into a dependent position vis-à-vis the therapist. Thus, patients unwittingly tend to relate to the therapist as helpless children relate to a powerful parent transference, thereby turning the therapeutic relationship into a quasi-parent-child relationship. Psychodynamic therapists, who essentially define the therapist as a specialist in detecting and resolving transferences, find this particularly interesting. Although there is no single agreed-upon definition of "transference," many psychodynamic therapists include in the definition any maladaptive interpersonal behavior patterns, usually learned in early important relationships, that create difficulties in the patient's current relationships and that also occur in the therapeutic relationship Anchin & Kiesler, 1982; Butler & Binder, 1987; Gill, 1982; Henry et al., 1994; Strupp & Binder, 1984. Although some may object to the term transference as being too exclusively psychoanalytic a term, there is increasing recognition of the importance of the therapeutic relationship and the prior relational learning that may affect it by nonpsychodynamic theorists e. g., behavior therapists: Wilson & Evans, 1977; cognitive therapists: Mahoney & Gabriel, 1987; Safran & Segal, 1990.
In the course of therapy, the therapist necessarily engages in a relationship with the patient and brings his or her personal influence to bear upon that relationship in order to bring about change. Of course, both the patient's and therapist's personalities determine the character and quality of their interaction, but it is the therapist who mainly defines the framework of the relationship and determines to a large extent how the relationship shall be used to achieve particular therapeutic ends. There is still a lively debate about the degree to which the therapist determines the outcome of therapy primarily by personal qualities or the degree to which the outcome is a function of the techniques employed by the therapist. It is likely that both sets of variables are interdependent and contribute significantly to the resulting therapeutic process and outcome Butler & Strupp, 1986. Thus, whatever the role of technique, it is clear that the personal qualities of the therapist and their interaction with the patient's characteristics, expectations, and transference must be important factors in the equation Beutler, Crago, & Arizmendi, 1986; Beutler, Machado, & Neufeldt, 1994; Parloff, Waskow, & Wolfe, 1978.
Finally, it is important to examine how the professional therapist differs from other helpful persons. Above all, the therapist creates a professional rather than a personal relationship with the patient. Although the patient may be lonely and in need of a friend, the therapist does not view the therapeutic task as fulfilling this need. Instead, the goal is to facilitate patients' interpersonal relationships with others and to help them cope more adaptively and effectively on their own. Consequently, the therapist seeks to avoid personal involvement with the patient, a stance frequently contrary to the patient's wishes.
This relative detachment allows the therapist to be more objective about the patient's difficulties. More important, the professional nature of this relationship determined by time restrictions and the presence of a fee enables the patient to communicate more freely by minimizing the potential for social consequences, such as shame, fear, anger, and retaliation from others. Thus, the therapeutic context makes possible the overt expression of hidden thoughts, fantasies, wishes, and so forth. As patients learn to trust the therapist and the safety of the therapeutic situation, the experience of acceptance and understanding contributes to greater self-acceptance and diminishes the patient's sense of isolation or aloneness. Armed with enhanced confidence, patients can often begin to tackle other troublesome problems in life.
Ideally, the professional therapist's interpersonal stance is one of collaboration, acceptance, respect, understanding, helpfulness, and warmth. This stance must be combined with deliberate efforts not to criticize, to pass judgment, to react emotionally to provocations, or to play an unwitting role in the harmful reenactment of transference scenarios. This deliberate effort is necessary because some patients expect to be criticized or harmed by people in positions of power or authority perhaps mirroring experiences in other relationships, and they are particularly sensitive to the subtle implications of the words and actions of the therapist. If the therapist reenacts the role of a significant person in the past, such as critical, self-absorbed mother, then the therapist is at a disadvantage to help bring about change. In such instances, the therapist serves to reinforce relational problems. Indeed, unskillful use of a primary strategy for change in psychodynamic therapy, namely, the transference interpretation, may take on a pejorative quality. Research suggests that when this occurs, thetherapistt is cast in a hostile, dominant role that is harmful to the patient Henry et al., 1994. When the therapist can maintain a collaborative and helpful stance in relation to the patient, particularly when the patient expects hostility and condemnation, this experience itself may contribute to positive changes in the patient. How to create such a relationship and to turn it to maximal therapeutic advantage is the challenge facing the psychodynamic therapist.

PSYCHOTHERAPY AND RESEARCH

Psychotherapy has always been a very practical undertaking, growing out of the clinician's desire to help a suffering human being in the most effective, economical, efficient, and humane way. The clinician's first question has always been Does a treatment help? Recognizing the importance of understanding why a treatment works, therapists have devised theories of psychotherapy. Of course, a treatment or a set of therapeutic procedures may work when the theory is wrong; or the theory may be reasonable, but the techniques inefficient or ineffective. The point to be made is that individual practitioners have no sure way of answering these questions because they must necessarily rely on the clinical method, that is, naturalistic observation of a few cases— their own. Furthermore, the history of science amply demonstrates that humanity's capacity for self-deception is so great that misconceptions e. g., the geocentric view of the universe may persist for centuries.
As modern psychotherapy gained momentum and its practitioners grew in number, questions were raised about the quality of the outcome, the nature of the problems to which psychotherapy might be applied, the relative effectiveness of different techniques, the adequacy of the underlying theoretical formulations, the training and qualification of therapists, the possibility of harmful effects, and many other issues. From its slow beginnings in the 1940s, research in psychotherapy has grown impressively in size and quality. It is a product of contemporary behavioral science, and as such, it exemplifies the application of modern scientific methodology to the solution of important clinical and theoretical problems. We now take a closer look at some of these problems.

THE PROBLEM OF THERAPY OUTCOME

The single most important problem, overshadowing all others and placing them in perspective, is the issue of psychotherapeutic effectiveness. The question has usually been, Is psychotherapy effective? Research efforts to address this question have been voluminous and sustained. In the years since Eysenck 1952 charged that psychotherapy produces no greater changes in emotionally disturbed individuals than naturally occurring life experiences, researchers and clinicians alike have felt compelled to answer the challenge.
Analyzing and synthesizing the data from 25 years of research on the efficacy of psychotherapy, Luborsky, Singer, and Luborsky 1975 concluded that most forms of psychotherapy produce changes in a substantial proportion of patients. These changes are often, but not always, greater than those achieved by control patients who did not receive therapy. Most contemporary reviews e. g., Lambert & Bergin, 1994; Lambert, Shapiro, & Bergin, 1986 have reached similar conclusions. In a now-classic analysis, which summarizes our current understanding of the question, Is psychotherapy effective? M. Smith, Glass, and Miller 1980 demonstrated that across all types of therapy, patients, therapists, and outcome criteria, the average patient shows more improvement than 75 percent of untreated individuals. The preponderance of the evidence, it has become clear, does not support Eysenck's pessimistic conclusion. Overall, nearly every type of psychotherapy that has been subjected to analysis, including a number of purely psychodynamic therapies, has been shown to be more effective than no therapy at all. However, no single type of therapy or set of techniques has proven uniquely superior Lambert & Bergin, 1994.
One difficulty encountered in investigations of differential efficacy of competing types of therapy is how to define outcome. When considering psychotherapy outcome, researchers and therapists alike have difficulty adequately conceptualizing and defining the notion of outcome. This lack of clarity is problematic for both psychotherapy researchers and for those charged with policy decisions regarding psychotherapy Strupp, 1986. For example, insurance companies and government agencies increasingly are demanding accountability for treatments they are asked to reimburse.
The problem of defining psychotherapy outcome touches on many facets of human life, and conceptions of mental health and illness cannot be considered apart from the problems of philosophy, ethics, religion, and public policy. Inescapably, we deal with human existence and the person's place in the world, and ultimately, any adequate conception of outcome must confront questions of value Strupp & Hadley, 1977. Someone must make a judgment about whether a person's concern with duty is a virtue or a symptom of compulsiveness; whether in one case we accept a patient's judgment that he or she feels better, whereas in another we set it aside, calling it "flight into health," "reaction formation," "delusional," and so forth. These decisions can only be made by reference to the values society assigns to feelings, attitudes, and actions. These values are inherent in conceptions of mental health and illness as well as in clinical judgments based on one of these models.
Freud 1916 already saw the outcome issue as a practical one, and this may well be the best way to treat it. When all is said and done, there may be common sense agreement on what constitutes a mentally healthy, non-neurotic person. Knight 1941 postulated three major rubrics for considering therapeutic change, which still seem eminently reasonable: 1 disappearance of presenting symptoms; 2 real improvement in mental functioning; and 3 improved adjustment to reality.
Most therapists and researchers, although they may disagree on criteria and operations for assessing these changes, would concur that therapeutic success should be demonstrable in the person's 1 feeling state well-being, 2 social functioning performance, and 3 personality organization structure. The first is clearly the individual's subjective perspective; the second is that of society, including prevailing standards of conduct and "normalcy"; the third is the perspective of mental health professionals, whose technical concepts e. g., ego strength, impulse control partake of information and standards derived from the preceding sources but are ostensibly scientific, objective, and value free.
As Strupp and Hadley 1977 have shown, few therapists or researchers have taken seriously implications of this complex view of outcome. Therapists continue to assess treatment outcomes on the basis of global clinical impressions, whereas researchers persist in the assumption that quantitative indexes can be interpreted as if they were thermometer readings. In reality, values influence and suffuse every judgment of outcome.
Such outcome issues call into doubt the utility of the traditional, global question, Is psychotherapy effective? It has become increasingly apparent that psychotherapy is not a unitary process, nor is it applied to a unitary problem Kiesler, 1966. Furthermore, therapists cannot be regarded as interchangeable units that deliver a standard treatment in uniform quantity or quality see Beutler et al., 1994; Parloff et al., 1978. Patients, too, cannot be considered a uniform variable. Instead, they respond differentially to various forms of therapeutic influence, depending on the complex interplay of personality, education, intelligence, nature of emotional difficulties, motivation, and other variables Garfield, 1994. Finally, technique variables are thoroughly intertwined with the person of the therapist and cannot be considered in isolation Butler & Strupp, 1986; Orlinsky, Grawe, & Parks, 1994; Orlinsky & Howard, 1986.
Accordingly, the problem of therapeutic outcomes must be reformulated as a standard scientific question: What specific therapeutic activities of specific therapists produce specific changes in specific patients under specific conditions? This question implies the scientific imperative of improving descriptions and understanding of therapists' in-session actions, other therapist variables, patient variables, and the ways in which these interact. In essence, psychotherapy researchers need to be asking still deeper questions about the nature of psychotherapy such as, How does psychotherapy work? for whom? and under what conditions. Progress along these lines, coupled with greater conceptual precision regarding outcome itself, will be essential if we are to address successfully questions regarding the relationship between therapist actions and patient outcomes. A number of researchers have recently turned to these issues utilizing new methodologies that focus on the process of therapy, the interaction of patient characteristics and approaches to treatment, and factors thought to be common to all therapies Beutler, 1991; Bryk & Raudenbush, 1991; Rogosa, 1991; Shoham-Salomon & Hannah, 1991; Shoham & Rohrbaugh, 1995; B. Smith & Sechrest, 1991.

PATIENT VARIABLES AND THE PROBLEMS OF DIAGNOSIS

Although it may not always be recognized, therapy outcomes depend to a significant extent on patient characteristics. When a therapist encounters a new patient, the first task is to define the nature of the problem in need of treatment or amelioration. As previously mentioned, therapists must be diagnosticians who attempt to identify a problem in order to take appropriate therapeutic steps. This requires not only an understanding of the diagnostic categories into which many patients fit, but also an appreciation of the vast array of individual differences among patients, which may affect therapy. Deceptively simple, this problem is exceedingly fateful in its implications for therapy and research.
To illustrate, many therapists and researchers have come to realize that a phobia, a depression, or an anxiety state in one patient is not identical to a seemingly comparable problem in another. Accordingly, it may be hazardous to categorize or type patients on the basis of the presenting difficulty alone. Traditional diagnostic categories e. g., Diagnostic and Statistical Manual, 4th ed., American Psychiatric Association [APA], 1994 DSM-IV, although helpful, are limited in their utility for psychotherapeutic practice and research. Other systems of classification e. g., in terms of maladaptive interpersonal patterns, defensive styles, or ego functions, although sometimes useful, have shortcomings of their own.
The plain fact, long recognized by clinicians, is that patients differ on a host of dimensions, from intelligence, education, socioeconomic status, and age to such variables as psychological-mindedness, motivation for psychotherapy, organization of defenses, and rigidity of character. The latter grouping of patient qualities is part of a relatively stable constellation of person characteristics usually thought of as "personality." In a very real sense, the psychotherapist confronts not so much a diagnosed illness, but complex, organized patient qualities or personality characteristics that help or hinder the therapeutic process.
Human personality is organized, and personality organization often forms an integral part of the therapeutic problem. For example, phobic patients tend to be generally shy, dependent, and anxious in many situations Andrews, 1966. Genetic, social, temperamental, and environmental factors of various kinds all influence the patient's current disturbance. From the psychodynamic perspective, the patient's life history, particularly interpersonal relationships in early childhood, may be crucially important for understanding and treating the current problem. This reflects the recognition that the current problem must be understood in the context of this person's life Butler & Strupp, 1986 and of the unique constellation of variables that constitute this person's personality. The interest of clinicians in the Personality Disorders Axis II of the DSM-IV corresponds to an increasing awareness of this issue cf. Frances, 1986.
The study of patient characteristics in relation to therapeutic change has for the most part focused on one basic issue: How do patient variables influence the course of psychotherapy? One ultimate goal is to answer the question, Which patient characteristics and problems are most amenable to which techniques conducted by which type of therapist in what kind of setting? Thus, rather than identifying patient characteristics associated with success across a broad band of different types of therapies, it is more important either to devise reasonably specific therapies that will benefit particular kinds of patients or to identify processes common to all therapies that may interact with patient characteristics Gaston & Gagnon, 1996; Goldfried & Wolfe, 1996; Henry, 1996; Lambert & Lambert, 1997.

THE PROBLEM OF TECHNIQUE

Techniques are, of course, the core and raison d'être of modern psychotherapy and, as previously noted, are usually anchored in a theory of psychopathology or maladaptive learning. Psychoanalysis has stressed the interpretation of resistances and transference phenomena as the principal curative factors, contrasting these operations with the suggestions of early hypnotists. Behavior therapy, to cite another example, has developed its own armamentarium of techniques, such as systematic desensitization, modeling, aversive and operant conditioning, cognitive restructuring, and training in self-regulation and self-control. In general, the proponents of all systems of psychotherapy credit their successes to more or less specific operations, which are usually claimed to be uniquely effective. A corollary of this proposition is that a therapist is a professional who must receive systematic training in the application of the recommended techniques.
Only in the past decade or so have psychotherapy researchers turned to an examination of psychodynamic techniques and their relation to outcome. One technique in particular that has received attention is that of transference interpretation. In a recent review of the literature, Henry and colleagues 1994 concluded that although transference interpretations may indeed be beneficial, they also present unique risks to therapy, which may take a good deal of therapist skill and tact to handle. In particular, they noted that, consistent with the views of mainstream psychoanalytic thinkers, more interpretations are not necessarily better, and in some cases, too many or ill-considered interpretations may even damage the therapeutic alliance. Henry and colleagues also noted that therapists do not always deliver accurate transference interpretations, and some interpretations may be less accurate than had been previously assumed. One consequence of poorly timed or inaccurate interpretations is that the patient's level of defensiveness may rise, resulting in less openness to the therapy process and damage to the relationship overall.
As we have already mentioned, psychotherapy researchers have found little evidence that one approach to therapy or set of techniques is clearly superior to another, even under reasonably controlled conditions Lambert et al., 1994; Luborsky et al., 1975; Sloane et al., 1975. The commonly accepted finding that approximately two-thirds of neurotic patients who enter outpatient psychotherapy of whatever description show noticeable improvement Garfield, 1994; Lambert et al., 1994 likewise reinforces a skeptical attitude concerning the unique effectiveness of particular techniques. Finally, it often turns out that initial claims for a new technique cannot be sustained when the accumulating evidence is critically examined. For example, initial claims regarding the efficacy of systematic desensitization in the treatment of phobias appear not to have held up to long-term scrutiny Marks, 1978.
An alternative hypothesis that has been advanced to account for the "no differences" finding asserts that psychotherapeutic change is predominantly a function of factors common to all therapeutic approaches e. g., Frank, 1981. These factors are brought to bear on the human relationship between the patient and the healer. One version of this hypothesis holds that individuals, defined by themselves or others as patients, suffer from demoralization and a sense of hopelessness. Consequently, any benign human influence is likely to boost their morale, which in turn is registered as improvement. Primary ingredients of these factors, common to most forms of psychotherapy, include understanding, respect, interest, encouragement, acceptance, forgiveness, in short, the kinds of human qualities that since time immemorial have been considered effective in buoying the human spirit.
Frank identifies another important common factor in all psychotherapies, that is, their tendency to operate in terms of a conceptual scheme and associated procedures that are thought to be beneficial. Although the contents of the schemes and the procedures differ among therapies, they have common morale-building functions. They combat the patient's demoralization by providing an explanation, acceptable to both patient and therapist, for the patient's hitherto inexplicable feelings and behavior. This process serves to remove the mystery from the patient's suffering and eventually to supplant it with hope.
Frank's formulation implies that training in and enthusiasm for a special theory and method may increase the effectiveness of therapists, in contrast to nonprofessional helpers who may lack belief in a coherent system or rationale. This hypothesis also underscores the continuity between faith healers, shamans, and modern psychotherapists. The latter may operate on the basis of sophisticated scientific theories by contemporary standards, but the function of these theories may intrinsically be no different from the most primitive rationale undergirding a faith healer's efforts. In both, techniques of whatever description are inseparable from the therapist's belief system, which in successful therapy is accepted and integrated by the patient. Of course, some patients more than others may be receptive to, and thus likely to benefit from, the therapist's manipulations.
Rogers 1956, from a different perspective, regarded a set of "facilitative conditions" i. e., accurate empathy, genuineness, and unconditional positive regard as necessary and sufficient conditions for beneficial therapeutic change. Thus, both Rogers and Frank de-de-emphasizehe effectiveness of therapeutic techniques per se and elevate relationship factors to a position of preeminence. From this perspective, management of the interpersonal relationship between patient and therapist may be considered a special technique in and of itself. It has been asserted that the relationship between patient and therapist not only facilitates the techniques specific to a given therapy, and that it provides a sense of hope and a rationale, but that it is also healing in another direct sense. By engaging in a relationship with a therapist, a patient is able to internalize and incorporate introject the relationship with the therapist so as to replace earlier maladaptive introjections Henry & Strupp, 1994. It is in this sense that psychotherapy has been referred to as a "reconstructive" process Benjamin, 1993. Early attempts to empirically establish the mechanism s by which the relationship may be linked to patient change have yielded positive results Harrist, Quintana, Strupp, & Henry, 1994; Henry, Schacht, & Strupp, 1990; Quintana & Meara, 1990.
It is clear that the problem of technique has important ramifications for research and practice. For example, if further evidence can be adduced that techniques contribute less to good therapy outcomes than has been claimed, greater effort might be expended in selecting and training therapists who are able to provide the aforementioned common factors, and who are more sensitive and responsive to the relational processes that are a part of nearly every kind of therapy. We also need far more information about the kinds of therapeutic services that may be performed safely by individuals with relatively little formal training paraprofessionals, as well as the limits set by their lack of comprehensive training. Furthermore, there may be patients for whom the establishment of any sort of positively toned relationship may be extremely difficult e. g., personality-disordered patients, and whose treatment should be relegated to professionals specially trained in techniques designed to help create and maintain a therapeutic relationship with such patients. Nevertheless, there may be definite limitations to what techniques, per se, can accomplish Frank, 1974. Limits may be set by patient characteristics and therapist qualities, which may include the therapist's level of training.

THE PERSON OF THE THERAPIST

As previously suggested, psychotherapy prominently involves the interaction of two or more people, and the therapeutic influence is by no means restricted to the formal techniques a therapist may use. The patient, like the therapist, reacts to the other as a total person; hence, both researchers and clinicians must become centrally concerned with the therapist as a human being. What has been said about enormous individual differences among patients applies, of course, with equal force to therapists. Indeed, it is difficult to fathom how, in early psychoanalysis, as well as in the later research studies, therapists could ever have been treated as interchangeable units, presumably equal in skill and personal influence Kiesler, 1966. Therapists, like patients, obviously differ in as many dimensions as one cares to mention: age, gender, cultural background, ethnic factors, level of professional experience, psychological sophistication, maturity, empathy, tact, social values, to name but a few. Any or all of these may have a significant bearing on the therapist's theoretical orientation, the therapist's techniques, and the manner in which the therapist interacts with and influences a given patient.
When considering the unique effects of each therapist as an individual, many therapist qualities elude definition. This elusiveness has posed serious obstacles to research in this area, although it is possible to specify human qualities a good therapist should possess Holt & Luborsky, 1958, as well as those that may be harmful to patients Bergin, 1966; Strupp, Hadley, & Gomes-Schwartz, 1977. Research and practical interest in identifying and describing qualities of therapists that may be detrimental to patients is reminiscent of the ancient medical principle, Above all, do no harm. Clearly it is as important to know what a therapist should not do as it is to specify what the therapist should do.
Among the therapist variables that have been subjected to quantitative research are the therapist's personal adjustment and well-being; the facilitative conditions already mentioned warmth, empathy, genuineness, etc.; the therapist's cognitive style; the therapist's level of professional experience; the therapist's professional status professionals versus nonprofessionals or para-professionals; gender; age; socioeconomic status; ethnicity; and the therapist's social and cultural values. Effects of personality conflicts, needs, and attitudes of the therapist toward the patient have also been investigated in a variety of studies Beutler et al., 1994; Orlinsky & Howard, 1986; Parloff et al., 1978. Of all the therapist variables that have been studied, one of the few relatively robust findings has been that the therapist's level of emotional well-being, impacts patient outcome. Beutler and colleagues summarize by stating:

While one can currently conclude only that therapist mental health may be an important but not necessary condition for improvement in high-functioning clients, the possibility that emotional problems on the part of the therapist may negatively affect even relatively well-functioning clients should be given considerably more attention. p. 238

Furthermore, patient personality characteristics demonstrably influence the therapist's effectiveness, which suggests that patients should be selected more carefully to match the therapist's capabilities, or perhaps therapists should be more specifically trained to deal with different personalities. Although therapists appear to be differentially effective with particular patients Strupp, 1980a, 1980b, 1980c, 1980d, it has proven difficult to isolate salient dimensions of the therapist's personality and to measure the impact of those dimensions. Indeed, it is becoming increasingly clear that variables of individual therapists, except perhaps for glaring defects in the therapist's personality, are not likely to provide the answers sought by researchers and clinicians. Instead, a combination of therapist attributes appears to form an integrated gestalt, to which the patient responds positively, negatively, or neutrally, other things being equal.
Clinical wisdom suggests that the effective therapist must be able to instill trust, confidence, hope, and conviction in the patient's personal strength and resilience. To have a therapeutic impact on the patient, the therapist's personality must have distinctive stimulus value or salience; therapists can never be impersonal technicians, nor can they apply therapeutic techniques in a vacuum. At times, therapists must be capable of encouraging patients to explore a particular feeling, belief, attitude, and so on; at other times, they must wait patiently for the patient to find his or her own solutions. They must be able to distinguish between the patient's neurotic and nonneurotic needs, and they must avoid getting entangled in the patient's neurotic maneuvers. Above all, they must make a careful assessment of how much help is needed, what kind of help is needed, and what obstacles prevent the patient from reaching a constructive solution.

THE THERAPEUTIC ALLIANCE

Psychoanalytic theorists e. g., Greenson, 1967; Langs, 1973; Menninger & Holtzman, 1973 have identified the relationship between patient and therapist as a major therapeutic force. As Freud developed the technique of psychoanalytic therapy, he recognized that the patient must become an active partner who collaborates with the therapist in his or her own cure. Traditionally, psychoanalysts have postulated an "observing ego" cf. Strupp & Binder, 1984, p. 39, which represents the reasonable and rational part of the patient's personality and is capable of forming an alliance with the therapist's efforts to analyze the irrational transferential aspects of the patient's personality. This alliance is the foundation for the necessary collaboration between therapist and patient that permits the analysis to proceed.
To the extent that factors within the patient or the therapist interfere with the establishment of a productive therapeutic alliance, therapeutic progress will be retarded or even vitiated. Premature termination or intractable dependency on the therapist are instances of such failures. It is also well known that patients who have relatively intact and strong egos have a better chance of succeeding in analytic therapy Horwitz, 1974; Kernberg, 1976, and perhaps in other forms of therapy as well.
Research into the nature of the alliance, as well as its relation to outcome, has greatly increased over the past fifteen to twenty years in response to the work of Bordin 1974, 1979, who reframed the traditionally psychodynamic concept of the alliance as a factor common to all types of therapy. Although there is no precise consensual definition of the alliance, theorists have addressed such questions as, How does the alliance develop? How is it best conceptualized? What is its structure? What are the relative contributions of patient and therapist? and How does the alliance impact outcome? Henry et al., 1994. Although these questions still remain largely unanswered, researchers agree that the alliance consists of aspects of the relationship between patient and therapist, such as their ability to collaborate on goals and tasks, their emotional bond, and their interpersonal behavior Bordin, 1979; Henry & Strupp, 1994; Orlinsky & Howard, 1986. Despite differing definitions and measures of the alliance, researchers have observed a consistent moderate relationship between measures of the therapeutic alliance and measures of outcome Horvath & Symonds, 1991. The link between alliance and outcome indicates that a better therapeutic alliance early in therapy predicts a better therapeutic outcome. This alliance  outcome relationship has been observed in a wide variety of therapeutic settings, patient populations, measures of outcome, and types of therapy Henry et al., 1994.
Horvath and Symonds 1991, in a meta-analysis of alliance research, found that the predictive validity of the alliance differs depending on the perspective of the rater. Alliance ratings made by patients and independent observers are more highly predictive of outcome than ratings made by therapists. In discussing this finding, Henry and colleagues 1994, have raised the possibility that therapists may have a blind spot p. 487 when it comes to judging the quality or strength of the alliance and that therapists may benefit from more training in the understanding, recognition, and enhancement of relational processes common to all types of therapy. If therapists are more aware of the ongoing relational process, they may be able to responsively adjust their own contributions to the therapeutic alliance according to the needs of patients.
Although it superficially resembles any good human relationship of the kind discussed elsewhere in this chapter, the therapeutic alliance provides a unique starting point for the patient's growing identification with the therapist, a point stressed by the proponents of object relations theory Fairbairn, 1952; Guntrip, 1971; Kernberg, 1976; Winnicott, 1965, who spearheaded advances in psychoanalytic theory. According to these authors, internalization of the therapist as a good object is crucial for significant psychotherapeutic change. Because internalization of bad objects has made the patient "ill," therapy succeeds to the extent that the therapist can be internalized as a good object. However, because patients tend to remain loyal to the early objects of childhood, defending them against modification, therapy inevitably becomes a struggle. From this perspective, patients' amenability to therapy i. e., their ability to form a therapeutic alliance is importantly influenced by their early relations with others. Consistent with these ideas, early work focused on a patient's contribution to the alliance points to the importance of a patient's pretherapy interpersonal functioning e. g., Gaston, 1991; Kiesler & Watkins, 1989; Kokotovic & Tracey, 1990; Marmar, Weiss, & Gaston, 1989; Moras & Strupp, 1982; Wallner, Muran, Segal, & Schumann, 1992, quality of object-relations e. g., Piper et al., 1991; Piper & McCallum, 1997, and the nature of their relationships with early caregivers e. g., Christenson, 1991; Mallinckrodt, 1991.

CODA: THE FUTURE OF PSYCHODYNAMIC PSYCHOTHERAPY?

In the previous edition of this volume, which was written at the end of the 1980s, we concluded with speculation on the great potential that might arise from intensive integration of psychotherapy research and practice. We envisioned a close collaboration of clinicians and researchers geared specifically toward greater understanding of which therapist actions are most effective with which patients in a way that could be readily integrated into the clinical situation. The tone of these conclusions was optimistic and forward looking, building on principles of dynamic psychotherapy, but inclusive of other perspectives as well. The ultimate goal of this systematic process of exploration was to understand what the clinician could do when facing the complex patient presentations that occur daily in the clinician's office.
However, just as the first edition of this volume was published, a profound change began to take place in the practice of psychotherapy. Economic and political changes in the early 1990s resulted in the proliferation of managed care entities, which began a process of defining both mental illness and psychotherapy, based on economic and political realities rather than scientific and clinical ones. The initial salvo of these powerful institutions was to adopt completely a medical model of "mental illness" based on symptom presentation, and to limit the role of psychotherapy to the amelioration of the acute version of these symptoms. That is, if someone presents with a phobia, for instance, the clinician is expected to focus on the presenting complaint— the phobia. The clinician is discouraged by case reviewers and extreme time limitations from working with the patient on how these phobic symptoms mesh with other, maladaptive aspects of his or her personality. Removal of the symptom from the patient's personality, as should be apparent from this chapter, is antithetical to a psychodynamic approach.
Consider an example from one of our caseloads. A young mother presented with a phobia of driving on interstate highways. Although one might approach a simple phobia with systematic desensitization, for instance, this woman was incapable of "imagining" with the therapist, of attempting progressive relaxation, or of even closing her eyes in the therapist's office. Exploration revealed that the main effect of the phobia on her was her difficulty visiting her invalid father a few hours drive away in an adjoining state. Further exploration revealed that she was extremely focused on maintaining interpersonal control in virtually any situation. This caused difficulty with her husband, neighbors, children, and her father who shared the controlling tendencies, and was evident in her refusal to consider a psychopharmacological evaluation. Thus, clearly the phobic symptoms were nested within a personality that demanded interpersonal control, even when it meant being out of control of which highways she could travel. This formulation does not insist that only a psychodynamic therapy could help this woman. Rather, the point is that divorcing the symptom presentation from the personality, as the managed care organizations would have the clinician do, is not consistent with clinical reality.
A recent APA Monitor front page article addressed the use of psychotherapy research by the managed care industry as justification for limiting benefits to very brief and inexpensive treatments Sleek, 1997. This article pointed out how some benefit limits have been justified by insurance companies on the basis of selecting controlled research that showed symptom improvement to be achieved in very brief periods of time such as six sessions. This ignores the fact that such research typically restricts patients to having only one problem, and specifically excludes those who present with active suicidal threat, have comorbid substance abuse problems, or present with other serious complicating factors that are commonly seen in clinical settings. The managed care companies also have ignored research concluding that improvements in psychotherapy tend to accrue with longer treatments e. g., Kopta, Howard, Lowry, & Beutler, 1994. Finally, the difficulties of measuring outcomes in psychotherapy continue to plague researchers and clinicians alike. Indeed, one problem in psychotherapy research is that patients tend to feel better about the decision to enter psychotherapy, so that it is common for patients to report feeling more in control, less frightened, and more optimistic. Such "improvement" often registers on standard symptom measures as improvement, even before the person meets with the therapist. Difficulties such as these conspire against simple, straightforward research designs and methods to demonstrate the effectiveness of psychotherapy.
What does the future hold for dynamic psychotherapy and psychotherapy in general? There are attempts by dynamic authors to tailor dynamic theory and therapy to demands of the medical model by highlighting that several models of brief dynamic therapy are directed toward particular symptom presentations e. g., Crits-Christoph & Barber, 1991; Levenson, Butler, & Beitman, 1997. Such approaches to the problem rest on the assumption that for dynamic psychotherapy to remain a viable force in the future, researchers and theorists will have to achieve greater precision about what the therapist is doing, with whom, and why.
Another approach to the dilemma facing psychotherapy is reflected in efforts to move psychotherapy research away from tightly controlled clinical trials efficacy research in rarefied, usually academic settings and toward examination of the treatment's effectiveness in traditional clinical settings. This approach is being advanced by the National Institute on Mental Health NIMH and APA Sleek, 1997. There is an emphasis on improving the research so that the case for extended treatments can be made when such treatments are indicated. Perhaps in this way, it will be possible to re-include personality as central to the treatment of our patients.
As discussed earlier, psychotherapy research emerged in response to charges from Eysenck 1952 that psychotherapy was no better at achieving changes in emotionally disturbed individuals than naturally occurring life experiences. Thirty years later, psychotherapy and psychotherapy research face another, ill-considered challenge. Once again, the field will need to respond with creativity and diligence to those who would criticize it. One hopes that the resulting advances in knowledge will take the theory and practice of psychotherapy well into the next century.

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