Review of Barbara Lichner Ingram – “Clinical Case Formulations: Matching the Integrative Treatment Plan to the Client”

This is a dreadful book. Prof. Ingram does not believe in any of the therapeutic techniques or modalities that have been developed as psychology has evolved as a discipline. Rather she has created her own version of psychotherapy with its own approach, orientation and jargon. There are plenty of reasons to be skeptical of any taxonomy that purports to invent a new way of looking at the world. For one these initiatives have poor fit with actual clinical practice and more typically reflect the idiosyncratic personality of their originator.  As expressed in a different context by Martha Nussbaum in her book Upheavals of Thought – The Intelligence of the Emotions (2001), Ingram is guilty of “excessive rigidity and definitional dogmatism.  The first responsibility of any good account is to the phenomena, and classifications that make boundaries seem unrealistically sharp or rigid are to that extent suspect” (p. 133).

This tendency is particularly egregious when it ignores the entire history of psychotherapy, replacing it with a proprietary alternative schematic. A reader of this book, for example, will learn nothing about therapeutic techniques invented or refined by Freud; Jung; Adler; Ellis; Beck; Perls; Yalom; or anybody else for that matter. Prof. Ingram’s pedantic style of case summary and evaluation is unique to her and not followed by any real-life psychology clinic. There are 28 “core clinical hypotheses.” There are 33 “standards for evaluating case formulations.” From an operational standpoint how to apply them is obtuse, much less justified. What’s clear is Prof. Ingram’s peculiar fixation on matters of form. There are various rules specifying that at some points phrases must be used, at some points complete sentences, sometimes words have to be in bold, sometimes in parentheses, etc. None of this has any theoretical or practical usefulness.

Prof. Ingram’s approach is worrisome for two additional reasons.

The first is her attempt to manualize or “medicalize” psychotherapy. In a way what Prof. Ingram is trying to accomplish is to offer a psychotherapy version of the DSM. Even though it too is formulaic (with respect to psychopathology) at least it has the advantage of being widely used and accepted. An attempt to devise a DSM-like approach for psychotherapy however is conceptually flawed as any introductory class in philosophical psychology will tell you (see, e.g., John Searle’s critique of this approach in “The Rediscovery of the Mind” and “Mind – A Brief Introduction”). Prof. Ingram offers a certain way of parsing out a complex and irreducible set of social-scientific phenomena. The already-dubious validity of this approach vanishes when it’s presented as authoritative and the only possible way to consider them. There always will be explanatory gaps, cul-de-sacs, unexplained phenomena and lacunae that do not fit themselves neatly within pre-designated categories.

Illustrative is Prof. Ingram’s tortured explanation of Carl Roger’s concept of empathy, which simply is wrong. She is however oblivious to her error because she is so embedded in the straight-jacket imposed by her cook-book approach. Prof. Ingram’s other theoretical discussions are blithely impervious to developments in psychotherapy since circa 1970. For example the words “neurophysiology” and “neurochemistry” do not appear once in her book, nor is there any discussion of how to reconcile one of her psychotherapy diagnoses with its possible DSM counterpart. This should not be too much of a stretch for Prof. Ingram. Louis Cozolino just published the second edition of his book The Neuroscience of Psychotherapy – Healing the Social Brain, which deals with these topics in detail.  Prof. Ingram and Prof. Cozolino both teach at the Pepperdine Graduate School of Education and Psychology in Los Angeles.

The second is the “new-ageization” of psychotherapy. Prof. Ingram has what best might be described as a “mother hen” approach to counseling, hovering over her clients like a helicopter with a palette of core clinical hypotheses and standards for evaluating case formulations. She encourages the therapist to adopt a procession of different diagnoses, based primarily on client reports, none of which have much to do with sound clinical judgment. This approach is rigid and inflexible. It runs the risk of premature case conceptualization. Rather than remaining open to the client’s concerns the therapist’s primary orientation becomes accumulating data to justify that hypothesis, like so much loose baggage. Prof. Ingram invites readers not to become therapists, but rather simply to act like them by conducting a series of play-acting experiments. This has grave potential for client damage. Exacerbating the problem Prof. Ingram makes clear she expects her clients to achieve genuine personal benefit from this experience. One exercise requires the client to describe to the therapist the personal benefit the client has achieved as a result of the therapist’s intervention and to “say good things” about the therapist. This kind of  “kumbaya” approach makes unwarranted assumptions about the value of Prof. Ingram’s methodology.

In conclusion if you are interested in theoretical and practical approaches to psychotherapy I urge you to consider some other text.  If your professor is considering adopting this text for use in class, please do your level best to persuade him/her to choose something else.