Chapter 8 – Brief Psychodynamic Psychotherapies




Abstract




Brief models of psychotherapy have been discussed for nearly a century but there is still considerable ambiguity about what exactly is meant by a brief therapy and what constitutes an effective brief intervention.





Chapter 8 Brief Psychodynamic Psychotherapies



Frank Margison


Brief models of psychotherapy have been discussed for nearly a century but there is still considerable ambiguity about what exactly is meant by a brief therapy and what constitutes an effective brief intervention.


The focus in this chapter is on the brief therapies that are drawn from a broad set of psychodynamic and relational approaches, and emphasising those with evidence of effectiveness. It will look in more detail at some examples of well-established models of psychotherapy which work from this stance such as Dynamic Interpersonal Therapy (DIT) [1] and Psychodynamic Interpersonal Therapy (PIT) [2]. Initially, some of the basic concepts involved in brief therapy will be explored.



How Do We Choose Which Therapy?


The plurality of methods available makes it difficult to decide what approach is best for an individual patient. There is very little evidence that demonstrates that a particular therapy is superior to any other for a particular condition. That position has barely changed since Luborsky and colleagues commented about the Dodo bird effect – ‘all have won and all shall have prizes’ – citing Alice in Wonderland [3]. This is perhaps not surprising as the sample size of a study having enough statistical power to differentiate between two therapies would be enormous. It is generally considered, however, that the lack of differences relates to ‘common therapeutic factors’ [4] which contribute a lot of the variance in comparison studies.



Common Therapeutic Factors


Different methods of psychotherapy and counselling are thought to share common factors that account for much of the effectiveness of a psychological treatment. The empirical evidence for common factors is strong and refers back to writers from half a century ago who tried to describe the key factors. Jerome Frank described these common themes [5, p. 350]:



Common to all psychotherapies are (a) an emotionally charged, confiding relationship; (b) a therapeutic rationale accepted by patient and therapist; (c) provision of new information by precept, example and self-discovery; (d) strengthening of the patient’s expectation of help; (e) providing the patient with success experiences; and (f) facilitation of emotional arousal.


There is more that unites different approaches to therapy than separates them. The Centre for Outcomes Research and Evaluation (CORE at University College London) has developed a competence framework that provides a map describing common features down to specific details of particular models across these psychological approaches [6, 7]. This has allowed similarities and differences for most models of therapy to be described in very practical ways, including generic and specific areas of competence in different models of therapy including brief dynamic/analytic models such as DIT.


The generic therapeutic competences for brief therapy include relatively non-specific skills and knowledge, such as




  • engaging the patient



  • assessing and managing risk of self-harm


The next level of competence covers basic psychodynamic skills which are pertinent to brief therapy such as




  • deriving a psychodynamic formulation



  • managing therapeutic frame and boundaries



  • maintaining an agreed focus


The next level covers skills specified in a psychoanalytic way of working with unconscious communication such as




  • helping the patient become aware of unexpressed or unconscious feelings



  • making psychodynamic interpretations



  • working with countertransference



  • recognizing and working with defences



  • working through the termination phase of therapy


There are also a set of overarching ‘generic meta-competences’ to support therapeutic flexibility concerning




  • use of clinical judgement and adapting interventions in the light of patient feedback



  • making use of the therapeutic relationship as a vehicle for change



  • maintaining an appropriate balance between interpretive and supportive work



  • applying the model flexibly and in context



  • identifying and using the most appropriate among the analytic/dynamic approaches


After all of these shared aspects for the psychodynamic therapies there can then be specified techniques that delineate a very specific model, such as the specific competences for DIT or PIT.



What Do We Mean by Brief?


There is a somewhat arbitrary definition of less than 25 sessions in the psychotherapy research literature constituting brief therapy [8, p. 666], so in practice up to around six months of weekly therapy.


Initially brief and time-limited were seen as broadly synonymous as they were being contrasted with the mainstream psychoanalytic practice of an open-ended therapy, usually occurring several times a week, whereas brief psychodynamic therapies were typically weekly and over a much shorter period. Gradually the concept was refined through a multitude of research studies defining brief interventions as anything from 2 sessions [9] to around 24 sessions, with most clustering around 8, or 16 sessions [10].


Built into the concept of all brief therapies were gradually assimilated ideas that




  1. (a) there is an inherent structure (even if only beginning, middle phase and ending phase)



  2. (b) the intervention can be compared and contrasted with other therapies (usually through a treatment manual and fidelity measure)



  3. (c) there should be some agreement about the desired result of the therapy (ultimately leading to ways of assessing outcome and setting agreed goals)



  4. (d) the therapist is active, meaning that the therapist provides structure, intervenes more often than is common in psychoanalytic practice and often co-constructs meaning as part of the therapy



  5. (e) there is a focus on maintaining and if necessary repairing a secure, positive therapeutic alliance



History of Brief Psychodynamic Approaches


The main purpose of Short-Term Dynamic Psychotherapy (STDP) was described by Michael Hobbs, previously consultant psychiatrist and psychotherapist in Oxford [11, p. 115], as



… to engage the patient in active examination of his difficulties, including how these impact on the therapeutic relationship, and thereby to liberate adaptive capacities and develop mental potential.


This idea is based on the assumption that individuals are blocked in their psychological development and that by gaining greater understanding of the origins and current manifestations of difficulties they can become freer to develop their potential.



The Therapy Is Time-Limited and Focusses on Ending


James Mann, a former professor of psychiatry in Boston and psychoanalyst [12], developed the idea that limiting the length of a therapy, usually 10 sessions in his model, was not just a practical aid to efficiency, but allowed a sharp focus on core anxieties about loss and separation. Mann’s Time-Limited Therapy became a popular approach in its own right, but its lasting legacy was on having an agreed ending date at the outset and constantly keeping issues of ending in mind as a practical way of focussing on themes of loss. These principles have been incorporated into most forms of brief psychodynamic therapy.



The Therapist Is Active


A common feature of early brief psychodynamic models was in the therapist being active. This means that the therapist may be more directive about the structure and works with the client in understanding meaning, rather than commenting as if from outside. Typically, the therapist will say more and be more ‘transparent’ about his or her own thoughts and responses.


The disadvantage of greater therapist activity from a psychoanalytic perspective is that the therapist can become intrusive and foreclose options for the patient to imagine the therapist having qualities belonging to key figures from the past. Initially, this was seen as a ‘trade-off’ with brief psychodynamic approaches in effect being ‘weaker’ versions of psychoanalysis. There was criticism of these newer active methods for ‘gratifying’ the patient and losing valuable information by not holding to an ‘abstinent’ approach.


The current view is that psychoanalysis and brief psychodynamic psychotherapy are within the same broad family, but are essentially different in their methods and aims. STDPs have now evolved to the point that they can stand alone as distinct therapies in their own right, rather than diluted forms of psychoanalysis.


So, for example, in short-term psychodynamic therapies the therapist is less likely to leave long silences. There is likely to be greater collaborative effort in finding shared meaning, and the therapist is more likely to bring in to the conversation more information based on his or her own reactions.


These features are not absolute and different models and different therapists will fall on a spectrum of how comfortable they feel about being active. In some therapies, for example PIT, an active conversation between therapist and patient is seen as central to therapeutic change. This collaborative approach is also seen as central in other approaches to therapy (see Chapter 10 on cognitive analytic therapy), whereas some models expect the therapist to be less active and rely more on interpretation rather than jointly co-constructing meaning.



Inner Representations of Key Figures or Relationships


All psychodynamic therapies have in common ways in which key figures from the past continue to shape perceptions in the present, through unconscious psychological processes. Some approaches to therapy are based on psychoanalytic theory. For example, Brief Psychoanalytic Therapy developed by R Peter Hobson, a British psychoanalyst, psychiatrist and researcher in developmental psychology [13], works with a revised and updated model of transference and countertransference drawing on Object Relations theory based on the work of Melanie Klein and her followers.


Another powerful way of understanding these inner representations is from Attachment Theory. This theoretical approach began with John Bowlby [14] (see Chapter 1) but has become an underpinning concept for many psychodynamic and relational therapies and has developed its own specific school of therapy. Holmes and Slade [15] describe an Attachment-based psychotherapy based on the work of John Bowlby and colleagues reiterating the key emphasis on modifying internalised models of attachment figures.


Another influential approach came from Lester Luborsky, a prominent US researcher into psychotherapy effectiveness [16], who described the Core Conflictual Relationship Theme (CCRT). This approach is characterised by three components: a wished-for state, a typical response from the Other and a response of the Self.


This has been developed into a full coding system for relationship themes in his symptom-context method [17], and an example is given below.



Wish: I wish to be loved and positively responded to and to avoid the recurrent experiences of rejection.


Response from Other: Rejects and dominates me


Response from Self: I am self-critical, self-destructive, helpless, and sometimes oppositional (for example by cancelling the session to get back at my therapist)


Luborsky [17, p. 9]

Other psychotherapy researchers developed similar models of repetitive conflicts in relationships as the core of the work in brief therapies. Hans Strupp, another prominent US psychotherapy researcher, and colleagues developed Time-Limited Dynamic Psychotherapy (TLDP). The patterns are called Cyclical Maladaptive Patterns (CMPs) [18]. The key themes are similar to those in the CCRT in including




  • Acts of the Self



  • Expectations of the reactions of others and



  • Acts of others towards the self with an additional category of



  • Acts of the self towards the self


The additional category is helpful in unpicking the damaging internal relationships with overwhelming self-criticism that is difficult to access without understanding the self-to-self aspects of object relations. Self-to-self relationships are often experienced as part of an inner dialogue – usually critical in nature, for example, ‘I despise myself’. They are often hard to access because both aspects (‘I and me’) are experienced as part of the self.


At around the same time, in the United Kingdom, there was a similar growing emphasis on researchable, succinct models to understand repeated patterns in relating. Anthony Ryle (as described in Chapter 10) was developing a model of internalised Reciprocal Role Procedures as the templates of similar ways of habitually relating to the self and to others.


Robert Hobson [19, pp. 169–73] in his Conversational Model (later described as Psychodynamic Interpersonal Therapy (PIT)) described ‘Explanatory Hypotheses’ to summarise these interpersonal conflicts that led to recurrent symptoms and relationship difficulties. In this model, the word hypothesis was used to emphasise the tentative, collaborative co-construction of the meaning of a symptom [2, pp. 167–8].


David Malan, a British psychoanalytic psychotherapist, made a major contribution to the development of brief dynamic psychotherapy in his seminal text Brief Dynamic Psychotherapy [20]. He provided an integrative summary described as the overlapping Triangles of Person and of Conflict. This highly influential model involved a pattern of a feeling or impulse leading to anxiety, and in turn to psychological defences that block the person’s development. The same triangle of conflict can be traced in relationships (especially parents) in the past; others in the outside present; and in the (transference) relationship with the therapist [20, p. 80]. These triangles are still widely used in drawing up a psychodynamic formulation to help maintain the therapeutic focus.


An example Malan uses to demonstrate this triangle concerns a young man who has a repetitive pattern of backing off and being unable to feel as his relationships with women develop. The inability to feel is suggested as a defence, against the anxiety of something happening if he becomes more deeply involved. The deeper, hidden feeling is of overwhelming loss and grief. Initially this triangle is explored about his current relationship outside (other relationship), but then further links are made to the same triangle in relation to his mother’s death (past or parental relationship). After a period of resistance to change, a breakthrough occurs when the patient is made aware of a similar constellation in relation to the therapist (transference relationship). The triangles act as a form of scaffolding to help the therapist build up links, eventually allowing change to occur [20, pp. 80–91]. What is most striking about reading Malan’s example is the gradual, patient piecing together of links until the whole rich picture emerges. This is similar to Hobson’s Conversational model which also gradually builds up hypotheses of increasing depth [19, pp. 197–8].


More recently, in Dynamic Interpersonal Therapy (DIT) the underlying pattern is described as an Interpersonal Affective Focus (IPAF) [1, p. 106].


This approach takes the same basic elements but describes them in terms that Otto Kernberg, a psychoanalyst and professor of psychiatry [21], had developed. The IPAF dimensions are described as:




  • Self Representation (e.g. a demanding infant: ‘I always ask for too much’)



  • An Object representation (e.g. a rejecting mother: ‘No-one is there for me when I need them’)



  • An affect linking the two themes (e.g. terror: ‘The worst moments are when I feel in pain and there is no-one to turn to.’)



  • The defensive function of this configuration (e.g. avoidance of own aggression – by maintaining the other in one’s mind as ‘always rejecting’ the patient can remain in the victim position and avoid reflecting on his own tendency to reject.)



Focus


A common theme across the brief psychodynamic and relational therapies is an emphasis on Focus. The focus may be a restatement of a formulation as described using the methods described above, but expressed in practical ways and often linked to defined goals. Most brief therapies have an initial period of a few sessions agreeing such a focus.


It now seems obvious to focus the time available on some agreed aspects of the person’s difficulties, but this was a contentious matter, and only after there was a clear consensus in the research literature did it become incorporated in routine practice:



The major technical error related to negative outcomes in brief therapy is the failure of the therapist to structure or focus the sessions [22].



Setting Goals


How the therapist helps the patient to define their goals will determine how they work together. A goal may be very specific but limited in its depth of understanding. For example, an agreed goal may be to show reliable and clinically significant change on an agreed measure, say of depression. Reliable means that the change is more than measurement error, and clinically significant means that the person shifts from a score characteristic of an unwell population to the score typical of the general population – shown practically as falling below a threshold score [23].


This way of setting goals is helpful in making sure a therapy stays ‘on track’ and in giving feedback on progress, but the goal is likely to lack any personal meaning. Some goals may be common and shared by most people, but more specific than a score on an outcome measure (e.g. feeling able to enjoy social events with friends), or something very specific and personal like being able to cry at the anniversary of the death of a child without feeling cut off and empty [24].



Length and Structure


Most brief therapies have an inherent structure embedded within an agreed length of therapy. DIT [1], for example, has 16 sessions as its standard length defining what they call a ‘Trajectory of Therapy’, with an Initial Phase of Sessions 1–4 aimed at engagement, and identifying the focus. The Middle Phase of Sessions 5–12 is where the main intervention occurs using a variety of techniques including interpretation, focussing on affect, and mentalising interventions alongside more general interventions such as clarification. The final phase covers sessions 13–16 focussing on ending and paying full attention to loss. As with many brief therapies the ending is consolidated with a letter from the therapist to patient.


PIT [2, pp. 20–2] does not have a standard length but agrees a length as determined by the type of focus. At one extreme there has been a study of two-session therapy with one follow-up session [9] which showed that a skilled therapist can achieve substantial change after a very brief intervention in patients with mild depression. At the other extreme in Australian studies with patients with borderline disorders a therapy of one to two years has been evaluated [25]. However, the commonest lengths have been 8- and 16-session therapies with better results overall for the longer version in more severe depression, but no difference by length in less severe depression [2, p. 20; 26].

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Jun 6, 2021 | Posted by in PSYCHOLOGY | Comments Off on Chapter 8 – Brief Psychodynamic Psychotherapies
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