The Little Psychotherapy Book. Object Relations in PracticeRichard Balon, MD
Wayne State University, Detroit, MI, USA
By Allan G. Frankland. New York, NY: Oxford University Press; 2010; ISBN 978-0-19-539081-0; pp 187; $29.95 (paperback)
Learning the art and practice of psychotherapy is complicated and challenging. Most clinicians learned to practice psychotherapy through supervision in training programs, a process that frequently is hit or miss. Some supervisors are good in discussing the theoretical underpinnings and their own understanding of Freud, Jung, and others, but do not provide much practical advice on how to “run” a session. Others are practical, yet, for various reasons, do not clearly explain the basics such as defense mechanisms and how to deal with them. In all fairness, there are few who are providing both, but not many. Therefore, it is customary to supplement the lack of one or the other with a hopefully good text trainees can use.
There are many good books and articles discussing the theoretical underpinnings of various psychotherapies. There are not many good texts focused on explaining and presenting practical issues, such as opening a session or dealing with boundary infractions or termination, in a simple and easy-to-understand way that one can easily incorporate into his/her practice. One such text is the book by Bender and Messner.1 Seldom do we find a book that attempts and succeeds in combining both, explaining the theoretical underpinnings and providing good practical advice on how to apply this in everyday practice in a clear and simple manner.
Dr. Allan G. Frankland, a practicing psychiatrist and psychotherapist from Vancouver, British Columbia, Canada, put together this small book to help novices to “learn the basic nuts and bolts on how to perform psycho-dynamic psychotherapy from an object relations perspective” (p 3). He explains that, “object relations is one of the four main theoretical models of psychodynamic psychotherapy” (p 6) (the other 3 being self psychology, ego psychology, and attachment theory) and that “object relations focuses on inaccuracies in the individual’s mental representations (ie, ways of perceiving and understanding) of self and others and the impact of these on the person’s relationships” (p 178). He further expounds that “as object relations therapists, we use our experience of the therapeutic relationship in the here and now to guide and refine our understanding of the difficulties the patient has in relating to her/himself and others” (p 10), and that one of the main features of objects relations therapy is its emphasis on understanding and addressing pathology within the patient’s style of relating (p 13). He warns that this style of therapy can be emotionally charged for the patient and therapist (p 10).
The book is divided into 26 brief chapters, with references, glossary, and a suggested reading list. The titles of the chapters usually are informative enough to illustrate what they cover: 1. So what is object relations anyway; 2. The big picture (mine: of goals and benefits of object relations therapy); 3. Assessment and formulation; 4. Patient selection: Susan’s case; 5. The treatment contract; 6. The value of rules and boundaries; 7. Beginning the first session; 8. The four levels of meaning (in relationships—concrete, others, self, and therapist); 9. Tools of trade; 10. Projective identification; 11. Anxiety and the paranoid-schizoid position; 12. Silence and boredom in therapy; 13. Neediness in therapy; 14. Addressing possible decompensation; 15. Structure and how to use it therapeutically; 16. Verbal attacks on the therapist; 17. Sadness in therapy; 18. Erotic transference and countertransference; 19. Advice in therapy; 20. Self-disclosure; 21. Gifts in therapy; 22. Putting it all together, a sample session; 23. What is progress in therapy?; 24. Termination and other therapy endings; 25. Object relations concept and cognitive therapies; and 26. Objects relations concepts in general follow-up. The chapters are succinct, accompanied with explanatory footnotes and use a clinical example of a fictitious patient named Susan.
Dr. Frankland emphasizes that one of the particular strengths of object relations therapy lies in helping patients develop a more balanced view of self and others that reflects the simultaneous existence of good and bad qualities (p 14). He proposes a H.O.R.S.E. interviewing approach—Hear, Observe, React, Synthesize, and Execute. He presents a host of practical and concrete advice. For instance, he suggests telling the patient that the session will last 50 minutes and that one should avoid saying “around 50 minutes” or “just under an hour” (p 35). The statement of “50 minutes” and nothing else conveys several messages to the patient—that the therapy will be structured and organized by the therapist and the therapist is in full control. It is also a bit reassuring for the patient. He discusses the pros and cons of chitchat at the beginning of the first session. The text includes discussion of various defense mechanisms and their explanation, all in a clinical context. The discussion of the decompensation includes warning that a poor fit of patient and psychotherapy modality can lead to decompensation and if there is a poor fit, it is preferable to switch to a more appropriate treatment modality (including medication) or to transfer the patient to someone else. The chapters on dealing with verbal attacks, erotic transference, countertransference, gifts, and providing advice are filled with useful practical tips. The author also suggests that object relations therapy could be integrated with cognitive therapies. I also liked that the author does not use the politically correct term “client” and sticks to the good old “patient.”
The text explains everything, not leaving anything out and not taking the reader for granted, assuming that he/she knows anything specific. However, the author recognizes that this book will be a starting point for many and he warns that this text is not intended to be an in-depth discussion of object relations history, theory, or terminology (p 4). As he says, “there is a wise saying in the martial arts tradition, the best way to teach someone nothing is to teach him everything. I believe this to be true particularly when trying to help someone develop a challenging new skill” (p 4).
At the beginning of this book Dr. Frankland outlined his goals: to promote understanding of object relationships while keeping complicated theory and terminology to a minimum, to provide useful examples of the most clinical situations, and to be concise. I like brief texts that are to the point and this is clearly one of them. This little book will be useful for clinicians trying to learn the tools of the psychotherapy trade (especially object relations) together with some basic understanding of the theoretical underpinnings. I would suggest that psychotherapy novices use it together with the previously mentioned book by Bender and Messner.1 Nevertheless, I do not think that only novices will find this book useful. Many experienced clinicians not familiar with the practice of object relations will find it quite useful as a guide for dealing with patients having serious interpersonal/ relationship difficulties, such as the proverbial borderline personality disorder patients.
- Bender S, Messner E.. Becoming a therapist: what do I say and why. New York, NY: The Guilford Press; 2003.
Annals of Clinical Psychiatry ©2011 Quadrant HealthCom Inc.