The evaluation is particularly important in brief individual psychodynamic psychotherapy because of the need for rapid and accurate assessment. In contrast to longer term treatments, brief individual psychodynamic psychotherapy does not offer the luxury of time to re-evaluate and correct mistakes. Although at times we think of psychotherapy as beginning as soon as the doctor sees the patient, this is a hyperbole, used to underscore the importance of interpersonal and transferential elements in the initial meeting with the patient. In fact, it is extremely important, particularly in brief individual psychodynamic psychotherapy, to distinguish the diagnostic interviews from the ongoing treatment.
The interventions and technical procedures performed during the evaluation phase, usually one to four sessions, are substantially different from the technical aspects of brief individual psychodynamic psychotherapy itself. The evaluation phase includes the diagnosis, consideration of the interaction among the patient’s ego strength, physical health, and selection variables, and the treatment recommendation, including considering the option that no treatment is indicated.

As in all medical treatments, brief individual psychodynamic psychotherapy is given to patients rather than to diseases. The ability to participate in brief individual psychodynamic psychotherapy process requires the patient to be able to access his or her fantasy life in an active and experiencing manner (i.e. psychologically minded) and, importantly, is able to get up and leave this process behind at the end of a session and not be lost in reverie or uncontrolled fantasies or fears. Note that this does not mean the patient requires a ‘high IQ’. In fact, a high IQ, when accompanied with rigidity, intellectualization, and rumination, as is often seen, can be a contraindication to a brief psychodynamic treatment since these defences can be quite formidable. The availability of interpersonal support in the patient’s real environment and the patient’s ability to experience and simultaneously observe highly charged affective states are necessary to a successful treatment. Individuals who are in an emergent crisis (e.g. imminently suicidal, psychotic, recent major life trauma) and therefore are very concerned and focused on the real events in their life cannot enter into a brief psychodynamic psychotherapy without first having a period of supportive treatment. A true life crisis does not allow the patient the opportunity to explore fantasies.

Negotiation with the patient is an important part of reaching a treatment decision in brief individual psychodynamic psychotherapy. The patient must rapidly feel a part of the treatment and committed to the process. The process of setting a time limit at the beginning of the treatment can be an important element in decreasing the dropout rate from this form of treatment,⁽⁷⁾ particularly with the patient who is concerned about dependency, ‘becoming addicted’ to the therapist, or who needs to maintain a substantial sense of control. What is dealt with in treatment can only be what the patient is able to bring into focus, what the patient can tolerate talking about, and what he or she can tolerate the therapist talking about.⁽⁸⁾ Although this is not different than other psychodynamic treatments, the limited time of brief individual psychodynamic psychotherapy means that there is limited ability to interpret multiple defences that might open new areas of exploration.

The rapid establishment of the therapeutic alliance is critical to brief individual psychodynamic psychotherapy.⁽⁹⁾ Identifying the patient’s initial anxieties related to beginning therapy is an important technique in the early sessions of brief individual psychodynamic psychotherapy in order to assure the alliance and to establish the conditions under which the patient can favourably hear and respond to the interpretations that the therapist will later give. As the therapy unfolds, the therapist operates on the hypothesis that each session is related to the previous one. The therapist strives in each session to identify the continuity of meaning related to the treatment focus that is present but hidden.⁽¹⁰⁾ This continuity is driven by the ‘experience bias’ of the patient, and his or her tendency to experience the world in a certain way due to unique developmental experiences that have moulded his or her perception, interpersonal beliefs, and expectations.⁽¹¹⁾

Brief individual psychodynamic psychotherapy is more focused, and more ‘here and now’ oriented with fewer attempts to reconstruct the developmental origins of conflicts than the extensive reworking of personality undertaken in longer term psychotherapies. Through the exploration of the patient’s metaphors and symbols, both defensive patterns and disturbances in present interpersonal relations are identified in the treatment setting as well as in the patient’s life. The importance of being able to hear what the patient has to say and to understand its meaning remains central as in other psychoanalytically oriented treatments.

Free association and inquiry: Free association is part of the technique of brief individual psychodynamic psychotherapy. But what constitutes free association—as in all dynamic therapies— requires thoughtful consideration. In its most basic form, and particularly highlighted in brief individual psychodynamic psychotherapy, free association means that the patient is free to choose what they wish to talk about. This rather direct definition emphasizes that free association is always relative. In addition, in brief dynamic psychotherapy, the patient is always somewhat more task focused that in open-ended treatments or psychoanalysis and this focus should not be discouraged by the therapist. Rather it is the therapist’s task to hear the themes in the patient’s concerns. The therapist asks questions, directs the patient’s attention, and uses benign neglect, i.e. avoids some areas of conflict that cannot be dealt with at this time or in a short period of time. The therapist identifies those spots at which free association breaks down (the presence of a defence) or at which the narrative is carrying a single emotional story out of the patient’s awareness. As in all dynamic treatments, often when the patient is able to talk freely and with a coherent narrative about their conflicts, the work of the treatment is completed.

Defence and transference: Brief individual psychodynamic psychotherapy emphasizes understanding (a) the mechanisms of defence used by the patient to decrease anxiety and other uncomfortable feelings associated with areas of conflict which are out of awareness, and (b) the characteristic transference relationships which distort the patients response to their adult world. Typically these two areas, defence and transference, create the world of meaning and expectations in which the patient lives. The techniques of the brief psychodynamic psychotherapy are directed towards clarifying these areas and presenting them to the patient to increase understanding and in this manner change symptoms and behaviour. Often only one defence is concentrated on in a given brief treatment. As the defence is clarified, the transference relationship may become evident. The developmental narrative of how the patient came to see the world in the way he or she does, provides the ‘glue’ through which the patient can integrate this knowledge into their life experience and behaviours, and recall it for practice and future use.

The brief individual psychodynamic psychotherapy therapist, similar to longer term psychodynamic work, must both enhance the patient’s observing capacity in order that the transference can be observed by the patient and therapist, and create the therapeutic situation in which the patient can hear the therapist’s interpretations in a useful manner. Dreams, as well as slips of the tongue and symptoms, can provide an avenue to the understanding of unconscious conflict which can be taught and explored with the
patient. The therapist strives to interpret both the triangle of anxiety (wish-defence-anxiety) and the triangle of insight (transference figure in the present—the therapist/patient interaction— transference figure from the past).

Frequently, when the transference is most evident, other elements of the past are simultaneously experienced in the patient’s life. In brief individual psychodynamic psychotherapy these can be particularly important to the patient’s understanding the feeling elements of the transference in a mutative manner since the depth and intensity of the transference is much less and much briefer than in long-term work. In contrast, however, the presence of a recent precipitant to the patient’s problems, as is usually the case in brief psychodynamic psychotherapy, can considerably intensify transference responses and be a central element in developing the psychodynamic understanding for the patient. The transference experience—the transference, the life experiences being relived, and particularly the precipitant—provide the web of meaning that is the focus of interpretation and the mutative force in brief individual psychodynamic psychotherapy.

Often the transference in brief individual psychodynamic psychotherapy is paternal or maternal, but it has also been noted that, perhaps due to the time-limited nature of the work, sibling and transference figures from adolescence may more often be recalled in brief individual psychodynamic psychotherapy. The transference is rarely as deep as that seen in long-term treatment. It requires a skilled eye to note and bring the transference to the attention of the patient in a manner that is neither intrusive nor offensive.⁽¹²⁾ Interpretations usually occur over several sessions, in the middle or later third of the treatment, during which past, present, and transference experiences are linked together. In the context of the affective arousal associated with this transference experience and the simultaneous understanding of the experience, behavioural change occurs and the patient’s ability to perceive previously hidden feelings and relationships as well as his or her view of the future and the past can change.

Countertransference: Countertransference is also an important element in brief individual psychodynamic psychotherapy as in other psychodynamic treatments.⁽¹³⁾ Analysis of countertransference reactions can allow the therapist to recognize subtle aspects of the transference relationship and to understand the patient’s experience better. Because of the more active stance, the brief psychodynamic psychotherapist can be particularly prone to countertransferences that show up as over-involvement or aggression. In addition, the brief time available for treatment can make recovery from countertransference errors quite difficult.

Medication is frequently used in conjunction with brief psychodynamic psychotherapy. This can complicate the treatment and its progress as well as aid in symptom recovery. The therapist must explore the meaning of the medication and its role in the patient’s view of himself or herself and interpersonal strengths and vulnerabilities. At times, brief individual psychodynamic psychotherapy can also serve as an alternative to medication treatment for less severe symptoms or when medication is contraindicated. Medication may have also begun during the initial brief psychodynamic psychotherapy and then continued after the psychotherapy has formally stopped and the patient is followed with less frequent meetings to monitor medication. This sequence has many advantages including resolving present stressors and precipitants, encouraging medication compliance, and ongoing medical follow-up after therapy either in maintenance or intermittent frequency. Another course of brief dynamic therapy may be indicated at a later date if the response to combined treatment is ineffective or if new problems appear. Greater education of clinicians and research on this combined and sequential treatment is needed.