Brief individual psychodynamic psychotherapy

Amy M. Ursano

Robert J. Ursano

Introduction

Interest in brief dynamic psychotherapy has flourished in recent years. The psychodynamic psychotherapies, including brief psychodynamic psychotherapy, aim to change behaviour through new understanding and the recognition of maladaptive patterns of behaviour enacted since childhood but not previously observed. Through this process, perceptions, expectations, beliefs, and, therefore, behaviours and feelings are altered.⁽¹⁾

Historically, ‘brief psychotherapy’ and ‘long-term psychotherapy’ were used synonymously with ‘supportive’ and ‘explorative’ psychotherapy, respectively. However, brief and long-term describe only the duration rather than the technique, focus, or goal of treatment.⁽²⁾ The time limits of brief dynamic psychotherapy give it a unique character and distinguish it from long-term psychotherapy and psychoanalysis. Because of its limited goals, the brief dynamic psychotherapist must confront his or her ambitiousness and perfectionism as well as any exaggerated ideal of personality structure and function.

Psychotherapy in general, and brief individual psychodynamic psychotherapy in particular, is perhaps the most elegant form of micro-neurosurgery. Psychotherapy strives to alter behaviour (i.e. cognitions, affects, and actions) with verbal interchange— fundamentally to change neurone A that used to connect to neurone B so it will now connect to neurone C. Although the therapist in the individual psychodynamically derived psychotherapies does not ‘require’ behavioural change, the end result of the therapist’s technical expertise is to achieve behavioural change, including changes in well-being, physical health, social supports, and societal productivity as well as symptomatic relief. As in all of medicine, both non-specific and specific curative factors affect the outcome of this work. The non-specific curative factors—abreaction, the provision of new information, and maximizing success experiences—are present in all forms of medical treatment including brief psychotherapy. Brief individual dynamic psychotherapy also has specific technical interventions and procedures above and beyond the non-specific curative factors. As in other medical therapies, there are contraindications and dangers in the use of this treatment.

Background

Evolving from psychoanalysis in the mid-twentieth century, brief individual psychodynamic psychotherapy, like other psychodynamic treatments, is based on the principle that meanings and past experience play an important role in behaviour and illness. Although psychoanalysis is now a lengthy procedure usually requiring a number of years to complete, the early psychoanalytic literature, including Freud’s first cases, contain histories of successful short analyses. During the first 30 years of psychoanalysis, it was unusual for treatments to extend beyond 1 year.⁽³⁾ Ferenczi was the first analyst to advocate shortening psychoanalysis. He advocated ‘active therapy’ a more directive, focused, and briefer treatment. Rank was the first one to explicitly to set a time limit on treatment. Ferenczi and Rank⁽⁴⁾ articulated the advantages of brief dynamic psychotherapy.

Following the Second World War, the interest in psychoanalysis resulted in greater demand for psychotherapy and increased pressure to develop briefer treatments. In the mid-1940s, Alexander and French advocated shortening treatment by decreasing the frequency of sessions in order to minimize regression. They proposed to focus treatment on the present rather than the past, using historical conflicts to inform the therapist in providing the best corrective emotional experience for the patient in the present.

The community-based mental health treatment movement, the increasing cost of mental health care, and the rise of managed care in the United States; have stimulated efforts to find briefer forms of psychotherapy. Contemporary brief individual psychodynamic psychotherapy is heavily influenced by the British School’s development of brief focal psychotherapy. Balint sponsored a workshop of experienced psychoanalytic psychotherapists, which focused on clinical evaluation and attempted to understand which patients might be suitable for briefer treatment. After Balint’s death, Malan carried on the work of the group. At the Tavistock clinic, Malan developed and applied the principles of psychodynamic treatment to brief treatment, delineating methods for evaluating process and outcome variables. He emphasized the importance of therapeutic planning and the identification of a focal conflict.

Concurrently, Sifneos, at the Massachusetts General Hospital, was studying brief psychotherapy.⁽⁵^,⁶⁾ Sifneos developed ‘short-term anxiety-provoking psychotherapy’ as a technique and theory with strict inclusion and exclusion criteria for choosing patients. Davanloo broadened the focus of the brief psychodynamic psychotherapies to include more than one conflict. He also expanded the inclusion criteria to individuals with character pathology and chronic phobic and obsessional neuroses, and advocated actively confronting resistances. Mann’s time-limited psychotherapy identified a central issue related to the meaning of time, as the focus of the treatment. Mann related this to the patient’s difficulties in confronting loss and separation and the reality of time and death.

In recent years, brief psychotherapy has become increasingly research based. Strupp, Luborsky, and Horowitz have all introduced manualized focused psychodynamic treatments which substantially contribute to our research understanding of this treatment modality.

Brief dynamic psychotherapy technique

(a) Evaluation and setting

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.

(b) Technique

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.

Comparison of the brief psychodynamic psychotherapies

The work of Malan, Sifneos, Mann, and Davanloo shows substantial overlap in each author’s goals, selection criteria, technique, and duration of treatment.⁽¹⁴⁾ The goals of all of these models of brief psychotherapy include facilitating health-seeking behaviours and mitigating obstacles to normal growth. From this perspective, brief psychotherapy focuses on the patient’s continuous development throughout adult life and the context-dependent appearance of conflict, depending on environment, interpersonal relationships, biological health, and developmental stage. This picture of brief psychotherapy supports modest goals that require the therapist to refrain from perfectionism. Malan, Sifneos, Mann, and Davanloo also seem to agree with Stierlin’s⁽¹⁵⁾ contrast between brief psychotherapy’s use of the ‘propitious moment’ and long-term treatment’s use of ‘a shared past’ between therapist and patient. Both the propitious moment and the shared past carry psychotherapeutic advantages and disadvantages, emphasizing certain technical possibilities and limiting others.

Selection criteria: Many of the selection criteria emphasized by Malan, Sifneos, Mann, and Davanloo are common to all kinds of psychodynamic psychotherapy. However, unique selection criteria are required due to the brief duration of treatment. Patients in brief psychodynamic psychotherapy must be able to engage quickly with the therapist, terminate in a short period of time, and be able to carry on much of the working through and generalizing of the treatment effects on their own.

The necessity for greater independent action by the patient requires that the patient have high levels of ego strength, motivation, and responsiveness to interpretation. Sifneos’s rather unique emphasis on intelligence as a criterion may be related to his anxiety-provoking interpretations, which require a broader educational context in order to be understood. The importance of the rapid establishment of the therapeutic alliance underlies a substantial number of the selection and exclusion criteria.

Focus of brief psychotherapy: All authors mention the central importance of the focus in brief psychotherapy, and therefore the evaluation sessions to determine this focus. Mann formulates the focus to the patient in terms of the patient’s fears and pain. However, he would probably agree with Malan, Davanloo, and Sifneos in the importance of constructing the psychodynamic focus at a deeper level in one’s own understanding of the work being done. Maintaining the focus is the primary task of the therapist. This enables the therapist to deal with complicated personality structures in a brief period of time. Resistance is limited through benign neglect of potentially troublesome but non-focal areas of the personality. The elaboration of techniques for establishing and maintaining the focus of treatment is critical to all brief individual psychodynamic psychotherapies.

Transference: The manner and rapidity in which transference is dealt with vary considerably among proponents of brief individual psychodynamic psychotherapy. Malan takes a more typical psychoanalytic approach of waiting for transference to become resistance before it is interpreted. Sifneos, in his emphasis on the Oedipal relationship, is more aggressive in handling the deep conflictual areas of transference material. Davanloo is confrontational in developing a transference experience. This confrontational style may at times confuse the patient’s experience of the real and the transferential therapist. However, Davanloo often treats severe obsessional disorders. In these cases, the need to increase the patient’s affective awareness is high. These may be the patients in which this particular technique is most useful. Aggressive, competitive, and hostile feelings, which might otherwise remain firmly defended, may thus become available to these patients.

Countertransference: The role of countertransference in brief psychotherapy is as complicated as it is in long-term treatment. Countertransference issues related to the aggressive techniques used by Sifneos and Davanloo have been observed. Countertransference experiences related to termination and loss can also be prominent.⁽¹⁶⁾ The goal-directed techniques of brief psychotherapy limit the development of regressive countertransference responses.⁽¹³⁾

Duration of treatment: There is remarkable agreement on the duration of brief psychotherapy. Although the duration ranges from 5 to 40 sessions, authors generally favour 10 to 20 sessions. The duration of treatment is critically related to maintaining the focus within the brief psychotherapy. Shlien et al.⁽¹⁷⁾ have found in Rogerian therapy, a correlation between the number of sessions and recovery. In general, they report an increasingly successful outcome (measured by the patient’s self-concept) up to about 20 sessions. Howard et al.⁽¹⁸⁾ using a meta-analytical technique, found 75 per cent of patients showing some improvement by 26 sessions. However, this study includes a wide range of types of treatment. When treatment extends beyond 20 sessions, the therapist frequently may find himself or herself enmeshed in a broad character analysis without a focal conflict. Change after 20 sessions may be quite slow. Clinical experience generally supports the idea that brief individual psychodynamic psychotherapy should be between 10 and 20 sessions although more complicated cases will require greater length of treatment. Often extending treatment beyond 20 sessions is recognition that treatment will be beyond 40 or 50 sessions.

Brief psychodynamic psychotherapy for depression, narcissistic disturbances, panic disorder, substance abuse, and post-traumatic stress disorder have been described.⁽¹⁴^,¹⁹⁾ Horowitz et al.⁽²⁰⁾ have described brief psychotherapy focused on the stress responses evidenced by various personality styles. He emphasizes that this psychotherapy is directed towards dealing with the process of the stress response and not character change. However, his outcomes indicate that selected character changes are possible in some areas. The distinction between recovery from a disruption in homoeostatic balance, reconstitution of self-esteem and self-concept, and changes in character structure require further exploration.

Critical points: The identification of critical points during brief psychotherapy, when the ‘danger’ of becoming a long-term treatment is most acute, clarifies the technical handling of brief psychodynamic psychotherapy. At these points, the therapist often notes an increasing vagueness of the goals of the treatment, decreased activity by the therapist, and the emergence of the transference as the central element. These variables indicate the potential of a short-term psychotherapy becoming a long-term treatment. The fourth to sixth hour of weekly 12-session therapy is often a point at which incipient or potential regression may suddenly appear. The patient at this time is testing the boundaries of the treatment. Action by the therapist is required if a brief psychotherapy is to remain exactly that—brief. The study of technical interventions, which occur at these critical moments, will further elucidate the technical handling of limited regression in brief psychodynamic psychotherapy.

Malan and the Tavistock group: focal psychotherapy: Developed from the workshops of Balint and Malan, focal psychotherapy is an example of applied psychoanalysis.⁽²¹⁾ Malan has carried on Balint’s earlier work.⁽²²^,²³⁾ Previous attempts to develop brief forms of psychoanalytic psychotherapy primarily involved the use of ‘activity’ which was frequently equated with manipulation. On the contrary, Malan emphasized the importance of choosing and maintaining a narrow focal area to be dealt with in a brief period of time. He stresses the importance of finding the appropriate focus in the patient’s story and consistently interpreting the focal problem area.⁽²³⁾ Through selective attention and neglect, the therapist maintains the focus and completes a brief psychotherapy. The importance of determining the focus underscores the value of the diagnostic process, including the psychodynamic assessment of the patient prior to the initiation of psychotherapy.⁽²⁴⁾

Malan identifies the following factors as leading to the lengthening of treatment: resistance, overdetermination, a need for working through the roots of conflict in early childhood, transference, dependence, negative transference connected with termination, and the transference neurosis. In addition, some therapist characteristics may lengthen treatment. These include a tendency towards passivity, a sense of timelessness conveyed to the patient, therapeutic perfectionism, and a preoccupation with deeper earlier experiences. All of these factors must be dealt with in order to maintain a brief therapy. For Malan, identifying a focal conflict acceptable to the patient is critical to a successful outcome (Table 6.3.4.1). In addition, the patient must have the capacity to think in feeling terms, demonstrate a high motivation, and exhibit a good response to trial interpretations made during the evaluation phase. Patients who have had serious suicidal attempts, drug addiction, long-term hospital stays, more than one course of electroconvulsive therapy, chronic alcoholism, incapacitating severe chronic obsessional symptoms, severe chronic phobic symptoms, or gross destructive or self-destructive acting-out are excluded from treatment. The patient is also excluded from focal psychotherapy if the therapist anticipates any of the items in Table 6.3.4.2.

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