Our Inner World: A Guide to Psychodynamics and Psychotherapy. S. R. Ahles Baltimore: The Johns Hopkins University Press, 2004, £18.00, pb, 335 pp. ISBN: 0-8018-7936-5

This book presents a selection of psychodynamic and developmental theories and a perspective on brief psychotherapy (10-25 sessions) that is discussed in terms of these theories. Detailed clinical material is used to illustrate the approach. It is a considerable achievement to have covered so much ground and brought so many strands of thinking together, but the result is far from satisfying. To my mind, this is for three main reasons.

Firstly, rather mechanistic, impersonal, language is used to describe and explain highly personal phenomena. This follows from the way in which Ahles regards Freudian structural theory and ego psychology as offering essential descriptive and explanatory concepts. Thus in one of the numerous clinical illustrations he writes, ‘Because of the tenuous affective balance within the ego and the tendency for it to be further imbalanced by superego and id forces, Roberta was quite dependent on external sources of positive affect to keep it in balance’ (p.175). Such a description of the internal world appears to conflate physical and psychological modes of explanation. In my view, the numerous diagrams that resemble illustrations of electrical circuitry exacerbate this problem.

Secondly, the linking of a large number of theoretical ideas continually begs the question of what constitutes the bottom line in his psychodynamic perspective. The clinical examples suggest that he regards modifying attachment patterns and ‘affective balance’ within the ego (largely through the expression of empathy and the provision of explanation) as the essence of psychodynamic work. This perspective is not presented in a critical way.

Thirdly, and to my mind most importantly, there is no discussion of the significance of understanding the ‘inner world of the primary process’. Thus, there is only scant reference to psychotic modes of being and relating, and then only as a level of separation-individuation. This serious deficiency is reflected in the relative neglect of the transference and the promotion of explanation over interpretation. Relatedly, none of the clinical examples are of patients with psychotic disorders.

Despite the troubling language and diagrams, the author has usefully summarised a range of psychodynamic ideas and produced an approach to psychotherapy that reads as if it would enjoy a high degree of acceptability among relatively high-functioning patients. However, the sidelining of the transference and the absence of any psychotherapeutic approach to psychosis significantly limits its value as a general psychodynamic text for trainees in psychiatry or psychotherapy.