2
As it is said, the history of short-term dynamic therapy is long. From a historical and conceptual viewpoint, brief dynamic psychotherapies may be conveniently grouped into “generations” (Crits-Christoph, Barber, & Kurcias, 1991). As with all generations, customary ways of doing things are passed down, embraced, and become beloved or unquestioned traditions, and then are challenged and replaced by the “younger generation of whippersnappers.” I will delineate four such generations as a way of tracing the evolution in the thinking and practice of brief dynamic psychotherapy. The history of these four generations can also be described, as Fosha (1995) so ingeniously puts it, as “a story of progressive taboo breaking; [where] with each step, a different psychoanalytic taboo must be confronted and broken” (p. 297).1
Contemporary brief dynamic psychotherapy is anchored in the work of Freud. In fact, Bauer and Kobos (1987) unequivocally state that “[b]rief psychotherapy was born when Freud renounced hypnosis as an effective treatment technique” (p. 13). Several of Freud’s early treatments were short-term therapies. Bruno Walter, the famous conductor, wrote in his autobiography that he was treated successfully by Freud in 1906 for partial paralysis of his right arm in six sessions (Walter, 1940). Reportedly, Freud prescribed a vacation for Walter following which he was to return to his conducting (Sterba, 1951). When Walter protested fearing embarrassment should he not be able to conduct while on stage, Freud said he would accept complete responsibility! And in 1908 Freud purportedly cured the composer Gustav Mahler of impotency problems in a single-session therapy during a four-hour walk in a Viennese park (Flegenheimer, 1982; Jones, 1955)—giving new meaning to the colloquial expression, “It was a walk in the park!” Even training analyses were conducted in less than one year. During this time, Freud, the brief therapist, used suggestion, catharsis, and education to accomplish the chief goal of psychoanalysis—to make conscious what is unconscious (Freud, 1964b).
However, as Freud became less fond of these active interventions, he adopted a more passive stance, and the therapies became less focused. As a consequence, the therapies became longer. Psychoanalytic theory became more complex and elaborate, and the goals of analysis became more ambitious. These too increased treatment length. When Freud made the switch from catharsis to a growing reliance on free association, it was, as Davanloo (1986) noted, a “fateful step”:
Almost all attempts to reverse this trend and develop an effective technique of short-term psychotherapy have been based on taking back some of the control and putting more of the motive power [for the treatment] into the hands of the therapist. (p. 108)
Similarly, Malan (1980) observed the following:
It needs to be stated categorically that in the early part of this century Freud unwittingly took a wrong turn which led to disastrous consequences for the future of psychotherapy. This was to react to increasing resistance with increased passivity—eventually adopting the technique of free association on the part of the patient, and the role of “passive sounding board,” free-floating attention, and infinite patience on the part of the therapist. (p. 13)
By the time of his death, however, Freud was quite disillusioned with the effectiveness of these “interminable” analyses and concluded that it “was a lengthy business” (Freud, 1964a) with sometimes disappointing results.
Fosha (1995) credits psychoanalysis with breaking the taboo prohibiting everything but polite social discourse. Freud delved into the nether regions of the unconsciousness mind, exploring sexual and aggressive impulses and fantasies, and the world has not been the same since. Grotjahn (1966) put it quite poetically: “It might be said that Sigmund Freud disturbed the sleep of the world” (p. 47).
I would like to apply Fosha’s concept of taboo breaking to other brief therapy pioneers and practitioners.2 In this way, hopefully, it will become clear how these innovators were dedicated to (re)discovering and devising strategies and techniques that would more efficiently and effectively lessen their patients’ suffering, even if it meant going against prescribed, established psychoanalytic principles (“the pure gold of analysis”).
Sandor Ferenczi (1920/1950) challenged many psychoanalytic taboos. First and foremost, he criticized the passive therapist stance. A contemporary of Freud’s, he saw that “psychoanalysis as we employ it today, is a procedure whose most prominent characteristic is passivity” (p. 199). He believed that the technique of interpretation was not a powerful enough change agent and saw that the therapist had to be more direct. Not only did he encourage activities previously avoided by the patient, he also prohibited certain behaviors (e.g., rituals). Ferenczi compared his “active therapy” to using “obstetric forceps” (1920/1950, p. 208). In addition to believing in the need for more directness on the part of therapists, he also stressed frankness, empathy, and democracy in the patient-therapist relationship (Rachman, 1988), presaging many aspects of object relations, self-psychology, and social justice therapies.
Otto Rank (1929/1936), a colleague of Ferenczi’s, broke two important psychoanalytic taboos. The first was by setting time limits on treatment, initially stemming from his concept of the birth trauma. If pathology were not solely due to insufficient resolution of the Oedipal conflict, but also to earlier developmental issues of separation and individuation, then setting time limits could help patients deal with their separation anxieties. The second major brief therapy influence was Rank’s assessment of the patient’s motivation to change—his concept of will. Resistance was no longer seen as something negative to be overcome by interpretation, but rather in a positive light, as a strength of the individual. As Rank’s biographer, Jessie Taft (1958) wrote, “the ‘will’ focus liberated Rank finally from his Freudian past, from the biological developmental details of family history as the core of analytic procedure and from the old psychoanalytic terminology” (p. 145). Because his contributions have formed the backbone of many modern approaches, Marmor (1979) suggested that Rank “may well be the most important historical forerunner of the brief dynamic psychotherapy movement” (p. 150).
In 1925, Ferenczi and Rank published The Development of Psychoanalysis, in which they advocated time limits, a focus for the treatment, an active stance for the therapist, and the importance of the patient’s emotional experience. Even by today’s standards, these authors’ contributions to brief dynamic psychotherapy remain innovative and central to current dynamic approaches. If we look at Ferenczi and Rank (1925) in terms of psychoanalytic prohibitions, they were bulls in the virtual china shop of taboos. No longer was there an interminable therapy with an emotionally distant therapist. Gone too was the taboo on self-disclosure and authenticity. Needless to say, their views were not greeted warmly by Freud and the established analytic circle, who saw them as threats to the traditional therapeutic stance. This strong negative reaction stultified the previously promising trajectory of brief therapy for many years.
Several years after Freud’s death in 1939, another serious challenge to classical psychoanalysis occurred. In their seminal book Psychoanalytic Therapy: Principles and Applications, Alexander and French (1946) questioned the presumed relationship between therapeutic outcome and length of therapy. Their suggestions are so specific, and the eventual impact of their book so great, that I consider it to be the first brief therapy manual. Alexander and French challenged the prevailing assumption that it was critical for the analyst to expose repressed memories through interpretation. They felt that psychotherapists should provide their patients with a corrective emotional experience. In commenting on a specific case, they concluded the following:
The patient had to experience a new father-son relationship before he could release the old one. This cannot be done as an intellectual exercise; it has to be lived through, i.e., felt, by the patient and thus become an integral part of his emotional life. Only then can he change his attitudes. (Alexander & French, 1946, p. 63)
In addition, Alexander and French advocated therapist flexibility and adjusting the length and frequency of sessions. These maneuvers were intended to prevent the patient’s passive dependency and decompensation into acting out strong infantile feelings and conflicts toward the analyst (i.e., transference neurosis). These ideas were met with intense controversy within the psychoanalytic establishment, and as with Rank and Ferenczi, Alexander and French’s contributions were ignored for many years. The taboos Alexander and French broke were multifold. As a result, several major, modern therapeutic models can be traced to their ideas of providing a corrective emotional experience and flexibility in therapeutic strategies and treatment length. Grotjahn (1966) extended his observation that if Freud disturbed the sleep of the world, then “Franz Alexander disturbed the sleep of the psychiatrists and psychoanalysts” (p. 390)!
In this phase, roughly from 1960 to 1980, brief dynamic therapy began to emerge as a legitimate therapeutic method in its own right. David Malan of the Tavistock Clinic in London, Habib Davanloo of Montreal General Hospital in Canada, Peter Sifneos of Massachusetts General Hospital in Boston, and James Mann of Boston University School of Medicine are seen as the main representatives of this second generation. As Messer and Warren (1995) pointed out, the aim of the members of this generation was to use psychoanalytic techniques such as interpretation and clarification in ways that would shorten the therapies.
Malan’s approach was initially called focal therapy; later it was referred to as intensive brief psychotherapy, the first major approach to my knowledge to use the word “brief” (usually taking 20–40 sessions). Malan (1976) believed that “far reaching changes could be brought about in relatively severe and chronic illnesses by a technique of active interpretation containing all the essential elements of full scale analysis” (p. 20). Like Ferenczi before him, Malan thought that the analyst’s passivity was chiefly responsible for the lengthy analyses and that one way to combat this passivity was to find a focus for the therapy. Malan concentrated on identification of a “focal problem”—a nuclear (childhood) conflict that was manifested in some form in the current presenting problem. He would frame the focal problem in terms of patients’ characteristic defense-anxiety-impulse configurations—that is, the characteristic defensive behaviors patients employed to protect themselves from experiencing anxiety-provoking impulses or feelings. Malan referred to this configuration as the triangle of conflict and used interpretations to articulate the connections between and among the three components. For example, the therapist might observe that a patient becomes very intellectual whenever she feels anger.
Malan would also draw patients’ attention to how they used the same defensive strategies developed in childhood in sessions with the therapist (transference) and with others in their lives. Interpretations connecting emotionally charged interactions with past significant others, present significant others, and one’s therapist form what has been called the triangle of person or triangle of insight (Menninger, 1958). For example, the therapist might point out that a patient’s intellectualizing in session seems characteristic of how she handled anxiety as a child. Even though Malan was writing a half-century ago, his description of the need to maintain a focus sounds like a current text for those wanting to learn how to practice brief therapy. “The therapist refuses to be diverted by material irrelevant to the focus, however tempting this may be” (Malan, 1963, p. 210).
In terms of taboo breaking, Malan broke the psychoanalytic taboo on activity and directiveness (Fosha, 1995). He also specifically broke the taboo on limiting the inquiry of the analyst. Here we see explicit permission for the therapist to selectively neglect certain aspects of the clinical material, as fascinating as they might be, if they are not germane to the focus.
Davanloo developed the intensive short-term dynamic psychotherapy (ISTDP) approach in the 1960s. ISTDP was designed to break through the patient’s defensive barrier using active, confrontive techniques in addition to interpretation (Neborsky, 2006). Davanloo challenged not only formal defenses (e.g., projection, rationalization), but also the more tactical, verbal, and nonverbal defenses. For example, he would attack the patient’s vagueness, tentativeness, looking away, evasiveness, sighing, rumination, and weepiness. Here instead of interpretation, there was head-on confrontation. Insight into one’s defensive posture was not the goal, but rather eradication of defenses so that the patient could release a full range of repressed thoughts, memories, and feelings. “You don’t limit yourself to squinting through a peephole when you can walk in through the front door” (Davanloo, as quoted in Fosha, 1995). Davanloo (1978) has a reputation for being “the relentless healer.” It is not surprising that he originally was in training to become a surgeon.
Davanloo violated many psychoanalytic prohibitions. He broke particularly sacred taboos requiring neutrality, abstinence, and being “nice” to the patient (Fosha, 1995). He also broke the taboo on keeping what went on in therapy private. He video-recorded ISTDP sessions and scrutinized them to learn what was helpful and what was not.
Sifneos (1979/1987), in his short-term anxiety-provoking psychotherapy (STAPP), specified selection and exclusion criteria, used heightened focal inquiry, and actively interpreted and confronted defenses. STAPP concentrates on brief dynamic therapy with relatively high-functioning patients experiencing conflicts associated with Oedipal issues. No number of sessions is agreed on at the outset, but a length between 10 and 20 sessions is determined as the therapy proceeds. Sifneos assumes a role that is part therapist and part teacher; he is “like a schoolmaster seeing through the excuses and alibis of his recalcitrant pupils” (Burke, White, & Havens, 1979, p. 178). For example, a STAPP therapist, after hearing “I don’t know” from the patient in response to a question about the patient’s emotional ties to her father, says, “Oh, come on, of course you know! Just tell me!” (Nielsen & Barth, 1991, p. 66).
James Mann (1973) is credited with modifying basic psychoanalytic philosophy and techniques by focusing specifically on difficulties dealing with separation and loss (Levenson, Butler, & Bein, 2002), lending a decidedly existential tone. Viewing a sense of timelessness as part of a person’s unconscious, Mann designed a time-limited structure for the therapy consisting of 12 sessions—no more, no less. Theoretically, this structure with a precise ending date was designed to help the patient face unconscious wishes for “eternal time,” and thereby master separation anxiety in the context of an empathic therapeutic relationship. More dramatically than his brief therapy peers, Mann definitively broke the taboo challenging the concept of the ever-present therapist—a therapist who “will be here as long as you need me.”
Clearly contemporary brief therapists owe a debt of gratitude to these second-generation pioneers. But although Malan, Davanloo, Sifneos, and Mann challenged some basic tenets of psychoanalytic theory and practice, they all (to varying degrees) still adhered to the Freudian, intrapsychic (one-person), drive/structural model (Messer & Warren, 1995). From this perspective, sexual and aggressive impulses are viewed as basic drives within the individual, seeking an outlet, with the ego mediating between their push for unbounded expression and internalized societal constraints.
The approaches of the second generation furthered the practice of brief dynamic psychotherapy, but empirical support for such theories was sparse. Selection criteria and interventions were formulated primarily by ideology, clinical judgment, and theoretical inference, rather than being guided by systematic application of research findings (Perry et al., 1983). The third generation of brief therapies, beginning in the mid-1980s, did much to provide empirical support for the efficacy of brief dynamic therapy as well as to elucidate its active therapeutic ingredients. Furthermore, the third-generation therapies heralded a move away from intrapsychic (one-person) models of theory and practice to more interpersonal (two-person) ones. In fact, Messer and Warren (1995) referred to the therapies of this generation as examples of “relational models,” because they emphasize the fundamental importance of relationships with others in understanding psychological health and pathology. Representatives of this wave are time-limited dynamic psychotherapy (TLDP), developed by Hans Strupp and Jeffrey Binder (1984) at Vanderbilt University; supportive–expressive psychotherapy, formulated by Lester Luborsky (1984) at the University of Pennsylvania; and control mastery theory, created by Joseph Weiss and Harold Sampson (1986) at Mount Zion Hospital in San Francisco.
The original version of TLDP will be briefly reviewed as both an example of a third-generation model and as the foundation for examining it in greater depth throughout this book. The background for TLDP comes from a program of empirical research begun in the early 1950s. Strupp (1955a, 1955b, 1955c, 1960) found that therapists’ interventions reflected their personal (positive or negative) attitude toward clients. His later work (Strupp, 1980) revealed that clients who were hostile, negativistic, inflexible, mistrusting, or otherwise highly resistant uniformly had poor outcomes. Strupp reasoned that these difficult clients had characterological styles that made it very hard for them to negotiate good working relationships with their therapists. In such cases, the therapists’ skill in managing the interpersonal therapeutic climate was severely taxed, and the therapists became trapped into reacting with negativity, hostility, confusion, and disrespect (Anderson, Knobloch-Fedders, Stiles, Ordoñez, & Heckman, 2012; Anderson & Strupp, 2015). Because the therapies were brief, this inability to form a therapeutic alliance quickly had deleterious effects on the entire therapy. These negative effects led Strupp and colleagues to develop TLDP as a method that could help treating professionals maintain their own equilibrium and foster empathy when working with difficult clients. Personality development and functioning were viewed from an interpersonal and object relations perspective. The major objective of TLDP as originally conceived was to examine recurrent, maladaptive themes as evident in the client’s interactions with others and with his or her therapist.3
Consistent focus was directed to the client’s manner of construing and relating to the therapist both as a significant person in the present and as the personification of past relationships (i.e., transference). “The TLDP therapist anticipates that (a) troublesome patterns of interpersonal behavior will presently be activated in the patient-therapist relationship; and (b) when an appropriate affective context exists, their hitherto unrecognized meaning can be identified and recast (interpreted)” (Strupp & Binder, 1984, pp. 136–137). The rationale for this approach stemmed from the view that regardless of the severity of psychopathology, interpersonal relations are the arena in which intrapsychic conflict is expressed. A manual for the practice of TLDP, Psychotherapy in a New Key (Strupp & Binder, 1984), was published, designed to make the model easier to learn and to standardize the application of TLDP technique.
Five major selection criteria are used in determining a client’s appropriateness for TLDP:
While these selection criteria are broad based, TLDP would not be appropriate for those whose reality processing is impaired (for example, due to a psychotic thought process, neurological difficulties, or substance abuse) or who present ongoing management issues (e.g., chronic suicidal behavior).
TLDP broke two major psychoanalytic taboos. First was the recognition that the therapist is another living, breathing, interactive person who at times will get pushed and pulled by the client’s style of relating, thus recreating with the client the dysfunctional dynamic for which the client is seeking help (i.e., transference-countertransference reenactments). For Freud and his followers, countertransference had been thought of as a “hindrance to therapy, something to be done away with” (Gelso, 2004, p. 231). It was seen as a manifestation of the therapist’s own unconscious, unresolved conflicts that needed to be dealt with in the therapist’s own therapy and consultation.
From the TLDP point of view, however, countertransference could be seen as a form of interpersonal empathy, “in which the therapist, for a time and to a limited degree, is recruited into enacting roles assigned to him or her by the patient’s preconceived neurotic scenarios” (Strupp & Binder, 1984, p. 149). By finding a way to recognize and to talk directly about these reenactments (metacommunicating), the therapist could help clients have an understanding of their own patterns and their impact. Here we see that the therapist’s countertransference can be used to further therapeutic gains rather than being viewed as only detrimental.
This challenged the position of the analyst as someone who is above the fray—an uninvolved, Sherlock Holmes type of detective who is interested in cleverly unearthing the truth without getting his hands dirty. With TLDP, the therapist gets dirty—because he or she is (for a time) in the rut with the client, with both of them relying on one another to find a way out.
Second, TLDP broke with psychoanalysis by rejecting as a major therapeutic goal reconstructions of the past or the recall of repressed memories. “From [the TLDP] viewpoint it is not required to reconstruct the patient’s history but only to assume that current emotional disturbances and interpersonal difficulties are a product of that history” (Strupp & Binder, 1984, p. 25). Thus, one can view TLDP as breaking several, major psychoanalytic taboos.
Contemporary brief dynamic approaches comprising the fourth generation are characterized by three main features. First, they assimilate concepts and/or techniques from a variety of sources external to psychoanalysis (e.g., cognitive behavior therapy, child development, neuroscience) into the more traditional perspectives and strategies, making them more integrative. Second, they emphasize in-session experiential factors as critical components of the therapeutic process. Third, they are also influenced in the direction of pragmatism and efficiency by powerful economic and sociopolitical forces (Levenson & Burg, 2000).
Examples of brief psychodynamic-integrative approaches are McCullough and colleagues’ (2003) short-term anxiety-regulating psychotherapy, which applies principles of learning theory while creating opportunities for intense in-session affective experience; Safran and Muran’s (2000) brief relational therapy, which is designed to help therapists recognize and resolve problems in the therapeutic alliance; Fosha’s (2000) accelerated experiential dynamic therapy (AEDP), which uses explicit empathy and radical therapeutic engagement to promote the clients’ own healing affects; and an integrative, attachment-based, experiential version of TLDP.
In 1995, I wrote Time-Limited Dynamic Psychotherapy: A Guide for Clinical Practice (Levenson, 1995). As the title indicates, that book was designed to translate TLDP principles and strategies into pragmatically useful ways of thinking and intervening for the practitioner. The text contains many examples of how to use TLDP concepts and interventions by providing moment-to-moment, nitty-gritty details of client–therapist interactions in real clinical situations. In that book, I made a substantial shift from that presented in Strupp and Binder’s original 1984 conception of TLDP in that I placed a major emphasis on change through experiential learning as opposed to insight.
I viewed this experiential learning as the first goal of TLDP; it highlighted the importance of affective-action components of change rather than those that come from cognitive shifts through insight. My view of such experiential learning at the time focused chiefly on modifying the interaction between client and others (initially often the therapist) so that the client had the opportunity to experience trying out new behaviors in the context of a safe enough therapeutic relationship. Could the person have a new experience in the present that would disconfirm his or her expectations of negative responses from others? If one could step forward to engage differently and be responded to differently (i.e., more positively), the anxiety that came with that interpersonal risk gets lessened or alleviated and one becomes encouraged to take other risks, thereby shifting one’s entire interpersonal pattern over time. This disconfirmation of the feared expectation follows learning theory principles embedded within a system of complementary interpersonal transactions and results in powerful learning reminiscent of that achieved through exposure treatment.
Imagine that a person who has been competitive and dominant his whole life takes a risk to be more vulnerable and dependent in the therapy and experiences a sense of relief when his therapist does not take advantage of him. With enough repetitions over time and with other people, he is encouraged to be increasingly more collaborative with others; eventually his off-putting dominant style softens, inviting others to be more connected to him.
Since writing my 1995 text, my belief about the central role of experiential learning has only been strengthened and broadened. During that time, the field of affective neuroscience has burgeoned (Schore, 2009), and the role of emotion has moved to center stage (Fisher et al., 2016; Greenberg, 2012; Thoma & McKay, 2015). We are learning more about how we are hard-wired to maintain interpersonal connectedness and how much of what makes us feel safe in the world is communicated in subtle but powerful moments when we sense someone is affectively attuned to us (Cosolino, 2006). The TLDP model set forth in this book highlights the need for affective attunement and evocative empathy along with promoting new interpersonal experiences (and new understandings) to foster healthier interpersonal and intrapersonal functioning.
TLDP has many attractive features. It does not emphasize pathology but rather sees that the client is doing the best he or she can. It has broad selection criteria so many challenging clients are accepted for treatment. As it addresses fundamental shifts intrapsychically and interpersonally, psychodynamically trained therapists can use it without giving up their allegiance to “depth-work.” In addition, it is one of the few short-term approaches that has studied how therapists learn a specific brief model of therapy (Henry et al., 1993a, 1993b). TLDP is rather jargon-free and avoids inferential concepts with unclear referents. Although the approach is clearly psychodynamic in origin, it does not view the individual as needing to work through childhood conflicts in therapy. Rather the client’s problems are seen as being maintained in the present through a dynamic system of maladaptive behaviors and self-defeating interpersonal expectations that “invite” the very response from others most feared by the client.
Fourth-generation brief dynamic models clearly broke the taboo of theoretical and strategic purity—they have become the mutts of the psychodynamic kennel. They do not look as elegant and refined as the purebreds. They have so welcomed ideas, strategies, and therapeutic stances from other models to jump the fence that it sometimes becomes quite difficult to clearly discern their “psychodynamic” lineage. However, what they give up in uniformity and grace, they more than make up for in their robustness and hardiness (and “heartiness” as well). They seem vital and flexible, able to adapt to the needs of their various owners at various times. They are also friendly and inviting—even welcoming positive experience over painful lessons (Fosha, 2000). It certainly is not your grandfather’s brief dynamic psychotherapy. However, at the base of these current brief psychotherapies, one can still make out the traditional importance placed on the role of conflict, unconscious processes, transference, countertransference, and the regulation of anxiety common to all psychodynamic models. In the ensuing chapters, my integrative version of time-limited dynamic psychotherapy is examined in depth to elucidate the theory, formulation, process, and application of a current fourth-generation model of brief dynamic psychotherapy.
1For further information on the early history of brief dynamic psychotherapy, the reader is referred to overviews by Marmor (1979), Messer and Warren (1995), Crits-Christoph, Barber, and Kurcias (1991), and Bauer and Kobos (1987) as well as to the original works.
2I thank Diana Fosha for her permission to use her concept of taboo in this way (personal communication, December 5, 2008).
3The reader will note that (except for quotations and historical background material) I begin to use the word client here in the text instead of patient. This change connotes a shift in psychotherapy in general from a medical model (of passive patient acted upon by The Doctor) to a more relational model in which therapy consists of two people (albeit one of whom is in more emotional pain and one of whom has expertise) who are trying to forge a healing relationship.