4
The Therapy Process
In this chapter, ways to formulate and intervene in time-limited dynamic psychotherapy (TLDP) are presented. In addition, I provide a detailed case to illustrate.
FORMULATION: THE CYCLICAL MALADAPTIVE PATTERN
One of the ways that distinguishes fourth generation brief dynamic therapists from their predecessors is their more explicit and structured way of formulating cases. For TLDP, this procedure is called the cyclical maladaptive pattern (CMP; Schacht, Binder, & Strupp, 1984). The CMP describes the cycles or patterns people get into with their attendant emotions that involve inflexible, self-perpetuating behaviors, self-defeating expectations, and negative self-appraisals and that lead to dysfunctional and maladaptive interactions with others (Butler & Binder, 1987; Butler, Strupp, & Binder, 1993).
The CMP provides an organizational framework that makes comprehensible a large mass of data and leads to fruitful hypotheses. In keeping with other modern brief dynamic psychotherapies, this way of formulating is not seen as an encapsulated version of “truth,” but rather as a plausible narrative, incorporating major components of a person’s current and historical interactive world. As Strupp and Binder (1984) framed it, it is a map of the territory—not the territory itself. A TLDP formulation should provide a blueprint for the entire therapy. It should describe the nature of the intrapersonal and interpersonal dynamics, lead to the delineation of goals, suggest how and when the client (and the therapist) may become emotionally dysregulated, guide particular interventions, enable the therapist to anticipate in and out of session reenactments, and provide a way to assess whether the therapy is on the right track—in terms of outcome at termination as well as in-session mini-outcomes. Thus, the CMP is integrally tied to the therapeutic process. By helping the therapist intervene in ways that are relevant for the goals for treatment, the therapy can be time-efficient and effective at the same time.
The timing of when to formulate a case is a dilemma for the brief therapist. If one does not formulate early enough, the therapy will be half over before one knows how to intervene. (Remember my experience in my internship with 3-month evaluations?) If one formulates too quickly, the therapist may proceed down a wrong or secondary path. In general, the more repetition one can see in a variety of emotional-relationship patterns, the more confident one can be in formulating early. It is, therefore, easier to formulate the presentation of individuals with limited and rigid styles. Their behavior is often so stereotypical that dysfunctional themes are more readily discernible in their narratives and interactions with others (including in-session transference–countertransference reenactments). Dysfunctional interactional patterns that are more subtle or that depend on a particular state or situation to emerge are more difficult to formulate (but, then again, are usually easier to treat). The best advice is to think of the CMP as a fluid, individualistic, working formulation that is meant to be refined throughout the therapy.
CMP Categories
The CMP comprises four categories around which a thematic narrative is developed. In my latest thinking, I see that the dysfunctional cycles are held together by and permeated with affect—that emotional processes make up the underlying fabric of the CMP and serve an organizing and directing function for the internalized working model. This is in keeping with the stance that “emotion is not just affect, but a dynamic network of thoughts, feelings, motives, expectations, and sensory and bodily experience” (Greenberg & Paivio, 1997, p. 3).
1. Acts of the Self.1 These include the thoughts, feelings, motives, perceptions, and behaviors of the client of an interpersonal nature. For example, “When I meet strangers, I believe they are out for their own self-interest” (thought). “I am afraid to go to the dance” (feeling). “I wish I were the life of the party” (motive). “It seemed she was on my side” (perception). “I start crying when I get angry with my husband” (behavior). Sometimes these acts are conscious as those above, and sometimes they are outside awareness. Of particular relevance are those emotions that are unknown, disowned, and/or distorted and their attendant attachment needs.
2. Expectations of Others’ Reactions. This category pertains to all the statements having to do with how the individual imagines others will react to him or her. “My boss will fire me if I make a mistake.” “If I go to the dance, no one will ask me to dance.” A large part of one’s expectations is made up of the emotional valence with which he or she holds that expectation. Often these expectations reveal the person’s deep-seated attachment fears of what is being avoided and why.
3. Acts of Others Toward the Self. This third grouping consists of the behaviors of other people, as observed (or assumed) and interpreted by the client. “When I made a mistake at work, my boss shunned me for the rest of the day.” “When I went to the dance, guys asked me to dance, but only because they felt sorry for me.” The perceived acts of others often give the rationale for the person’s actions and related affects.
4. Acts of the Self Toward the Self (Introject). In this section belong all of the client’s behaviors, feelings, or thoughts concerning oneself—when the self is the object.2 How do clients treat themselves? “When no one asked me to dance, I told myself it’s because I’m fat, ugly, and unlovable, and poured myself a drink.” Quite often the person’s introject revolves around acts of self-condemnation and feelings of inadequacy and downright worthlessness. The preceding example is one in which the individual was conscious of these feelings and could voice them. But so often people are unaware of the negative messages they are sending themselves. These messages, however, become obvious (“hidden in plain sight”) through, for example, the words clients use (e.g., “I should have . . .”), voice quality (e.g., mocking), posture (e.g., slumped), and visceral changes (e.g., upset stomach). Here, too, the therapist must be ever vigilant for subtle shifts in the person’s behavior that might lead to understanding the emotional underpinnings of that person’s introject.
When I am giving TLDP workshops, I like showing a New Yorker cartoon that captures the essence of the external–internal interplay of treatment by others and view of self (introject). The cartoon depicts a dog standing amid shreds of paper with a telltale bit of paper in his mouth looking at himself and the destruction he has caused in a mirror. The dog is saying to his reflection, “Bad dog!”
5. Therapist’s interactive countertransference. In addition to the four categories of the CMP as outlined originally by Strupp and Binder (1984), I have added a fifth category—the therapist’s interactive countertransference. What are your reactions to the client? What are you pulled to do or not do? What is happening in your gut, in your mind, in your heart? Especially with the “difficult” client who has a more rigid style, the therapist’s internal and external responses can provide important sources of information for understanding the person’s lifelong dysfunctional interactive pattern. One’s reactions to the client usually make sense given the client’s interpersonal pattern.3 Of course, each therapist has a unique personality that might contribute to the particular shading of the reaction that is elicited by the client, but the assumption from a TLDP perspective is that the therapist’s behavior is predominantly shaped by the client’s evoking patterns.4
Steps in Case Formulation
Table 4.1 presents the three major tasks involved in deriving a TLDP formulation: assessment, conceptualization, and treatment planning.
Subsumed under these tasks are 13 steps useful in formulating a case. These steps should not be thought of as separate procedures applied in a linear, rigid fashion, but rather as guidelines for the therapist to be used in a fluid manner (Levenson & Strupp, 1999).
Table 4.1
Steps in Time-Limited Dynamic Psychotherapy (TLDP) Formulation
Assessment
1. Lets the client tell his or her own story in his or her own words and manner.
2. Conducts and anchored history.
3. Attends to the emotional flavor of the story (including nonverbal signs).
4. Explores the emotional-interpersonal context related to symptoms or problems.
5. Uses the categories of the CMP to gather, organize, and probe for information.
Conceptualization
6. Listens for themes in the client’s transactional behaviors and concomitant emotions (in past and present relationships as well as with the therapist).
7. Is aware of his or her reciprocal behavioral and emotional reactions (countertransferential pushes and pulls).
8. Is vigilant for reenactments of dysfunction interactions in the therapeutic relationship.
9. Develops a CMP narrative (story) describing the client’s predominant dysfunctional emotional-interactive pattern.
Treatment planning
10. Uses the CMP to formulate what new experiences (intrapersonally and interpersonally) might lead to more adaptive relating (Goal 1).
11. Uses the CMP to formulate what new understandings (intrapersonally and interpersonally) might lead to more adaptive relating (Goals 2).
12. Revises and refines the CMP throughout therapy.
13. For each of the foregoing steps, considers the influence of cultural factors.
Assessment
To derive a TLDP formulation, the therapist lets the client tell his or her own story (Step 1) in the initial sessions rather than relying on the traditional psychiatric interview to gather specific information about developmental history, educational background, and so forth. By listening to how the client tells his or her story (e.g., deferentially, cautiously, dramatically), what is included (e.g., lots of information about how he or she is in distress), and what is left out (e.g., no comment on other people), the therapist can learn much about the client’s interpersonal style. In responding to the client in these initial sessions, the therapist expands the client’s story by conducting an “anchored history” (Step 2) in which he or she starts with where the client is and then asks questions that are designed to help the client and therapist understand what led up to particular actions, feelings, and attributions. For example, when Mr. Johnson said he started drinking when his daughter didn’t visit, I inquired about other times when he felt ignored or abandoned.
In particular, the therapist attends to the emotional flavor of the client’s narrative (Step 3). Are there signs of emotional overstimulation (e.g., forgetting what one was talking about, holding the arms of the chair for dear life, uncontrolled laughter)? Are there signs of dampened emotionality (dry rendition of the “facts,” blank facial expression, stiff body position)? The emotions and feelings the person expresses during his or her story will often be bookmarks to those parts that are particularly relevant.
The therapist then explores the interpersonal-emotional context of the client’s symptoms or problems (Step 4). When did the problems begin? What else was going on in the client’s life at that time, especially of an interpersonal nature? In conjunction with this exploration into relational dynamics, the therapist begins to explore the intrapersonal dynamics. Where is the person’s pain? What parts of themselves have clients had to disown, tone down, or distort to make themselves acceptable to others?
The therapist uses the categories of the CMP to suggest areas where additional information is needed (Step 5). For example, does the therapist know a great deal about how other people have treated the client (acts of others), but almost nothing about how the client treats himself or herself (acts of self toward self)? I have found that actually writing down the information organized by the CMP categories can be helpful for tracking changes over time and developing the client’s interpersonal story. A schematic form for doing so is provided in Figure 4.1.
Conceptualization
For Step 6, the therapist listens for themes in the emerging material linking the four components together. By being sensitive to commonalities and redundancies in the client’s transactional and emotional patterns over person, time, and place, the therapist begins to discern a pattern.
Figure 4.1
Form for the Cyclical Maladaptive Pattern (CMP). From Time-Limited Dynamic Psychotherapy: A Guide to Clinical Practice (p. 50), by H. Levenson, 1995, New York, NY: Basic Books. Adapted with permission.
Throughout the sessions, the therapist should have a hovering awareness of how he or she feels during the session, especially when pushed or pulled (i.e., interactive countertransference) to respond in a certain way in keeping with the client’s expectation of others and/or acts of others (Step 7). These pulls are often experienced as visceral changes (e.g., therapist’s heart rate increases as client glowers), a change in attention (e.g., therapist begins thinking of how much time is left in the session), affective shifts (e.g., therapist feels like he or she is walking on eggshells), and vivid imagery (e.g., a puppy wagging his tail).
Such self-awareness is of critical importance in TLDP, and there is no easy way to get there. One’s own personal therapy, self-reflection, and good supervision/consultation have all been recommended in the psychotherapy literature (see Boswell & Castonguay, 2007). In addition, mindfulness exercises have been suggested as a way to help therapists recognize and appreciate the significance of their own experience. As observed by Safran and Muran (2000), “gradually, over time, this type of mindfulness work helps trainees to become more aware of subtle feelings, thoughts, and fantasies emerging on the edge of awareness when working with their patients, which can subsequently provide an important source of information about what is occurring in the relationship” (p. 210).
Finding out how others have treated the client can give the therapist a “head’s up” about likely ways he or she will be recruited into becoming an unsuspecting “accomplice” (Kiesler, 1982) in a dysfunctional relational dynamic (Step 8). This is not considered to be a “mistake” in TLDP, but rather a reenactment in the here-and-now of the sessions that could be helpful eventually in providing opportunities for experiential learning and cognitive understanding.
By using the four categories of the CMP, the therapist’s own reactions to the developing relationship with the client, and any reenactments in the session, the therapist discerns a narrative story that describes the client’s predominant dysfunctional emotional-interactive pattern emanating from attachment needs and strivings (Step 9). This narrative fits the following outline: The client behaves, feels, and thinks in certain ways regarding transactions with others and has come to expect others to behave in certain ways in response. These expectations are communicated to others primarily through nonverbal, emotional signals that trigger others to behave in ways the client unconsciously expects. The client then reads these complementary behaviors also through an emotional lens and these apperceptions affect the client’s self-appraisal and treatment of himself or herself, which further encourages the client to behave, feel, and think in certain ways, completing the cycle.
Treatment Planning
From the CMP formulation, the therapist then ascertains the two broad goals for treatment. The first goal involves determining the nature of the new experience (Step 10) for this particular client. The therapist discerns what he or she could say or do to help this person have (a) a set of new, relevant, intrapersonal-affective experiences and (b) a set of new, relevant, interpersonal experiences (with the therapist and/or with others) that would most likely subvert or interrupt the client’s maladaptive, vicious cycle. After determining the nature of these new experiences, the therapist can use the CMP formulation to determine the second broad goal for treatment—the new understanding (Step 11). The therapist figures out how he or she could help the person understand (a) the relevancy and meaning of one’s own emotions and (b) the role he or she plays in co-creating a dysfunctional pattern with significant others.
Step 12 in the formulation process involves the continuous refinement of the CMP throughout the therapy. In a brief therapy, the therapist cannot wait to have all the “facts” before formulating the case and intervening. As the therapy proceeds, new content and interactional data become available and are used to strengthen or alter the working formulation. Thus, the information gleaned from the CMP is invaluable: It guides the therapist in how to handle therapeutic situations to maximize clinical outcome and process—a necessity when time is of the essence.
With regard to formulating the case of Mr. Johnson, I could see by the end of the first session that Mr. Johnson was a very passive man, an adaptation he began to make as a child in order to deal with his father’s physical and emotional abuse. As an adult, he understandably feared that if he expressed any anger, others would reject or hurt him. Since rejection would be devastating for Mr. Johnson, he learned to be placating—swallowing his anger instead of expressing it. Others unfortunately took advantage of Mr. Johnson’s deferential attitude and experienced his sad-sack, passive style as off-putting, leading them to avoid and even reject him. This left Mr. Johnson’s feeling worthless and helpless, causing him to be more hopeless and passive, thereby perpetuating the cycle. My experiential goal for Mr. Johnson was to help him recognize his more empowering emotions (e.g., anger) and to help him take some active control over his life. My goal was also to help him understand his own role in fostering the very response he wished to avoid and how his own core feelings could be used to steer him in a more rewarding direction.
The final step (Step 13) involves taking into consideration cultural aspects involved in TLDP formulation. This cultural perspective is one that should permeate all the others. The therapist needs to be culturally sensitive within each of the formulation steps. The multicultural aspects are so important in formulating and intervening in TLDP that a separate section below is provided.
Multicultural Aspects
Because TLDP acknowledges that both therapist and client bring their own personal qualities, history, and values to the therapeutic encounter, it can be sensitive to all the factors that are involved in making up one’s worldview (e.g., internalized working models). For understanding the clients’ CMPs, consideration of gender, race, ethnicity, sexual orientation, socioeconomic status, age, disability status, and so on all potentially play a significant role. The TLDP therapist needs explicitly to consider the larger context in which any therapy takes place. For example, “it seems crucial to extend . . . [the notion] of transference to include the organizing principles and imagery crystallized out of the values, roles, beliefs, and history of the cultural environment” (LaRoche, 1999, p. 391, emphasis added). Thus, it is of paramount importance that the therapist be aware of and understand how cultural and worldview factors may be playing a role in the client’s lifelong patterns and in interpersonal difficulties, including those that might manifest between therapist and client.
From a relational point of view, the client’s interpersonal style inside and outside of the therapy office is an amalgamation of his or her unique adaptations within a sociocultural context. Given the impact of culture on one’s assumptive world, it would be expected that individuals from a similar background might manifest some analogous actions, thoughts, assumptions, and expectations, and invite back from people reactions based on these cultural, racial, personal, and demographic variables.5 For example, in our racist society, it is not uncommon that an African American child gets less positive academic attention from White teachers that in turn plays a role in lowering the child’s self-esteem and future academic performance. If a therapist does not consider these factors and the manner in which they foster certain cyclical dynamic patterns, important dimensions could be missed or misunderstood, thereby endangering the entire therapeutic process and outcome. Thus, the TLDP therapist must adopt the point of view that cultural parameters and interpersonal working models are inextricably linked.
But taking into account the client’s culture is only one of four perspectives relevant to obtaining a culturally sensitive TLDP formulation. Another perspective involves the therapists’ taking into consideration how their working models have been influenced by their own culture in which they were raised, live, and/or use as a reference group. Does the therapist understand the cultural lens through which he or she sees the world?
The third perspective focuses on how the entire therapeutic endeavor has its own culture with proscribed roles, expectations, beliefs, and institutions.6 For example, in our society, there is an inherent power differential between the therapist and the client. The last perspective concerns how all of these might interact. How might the worldview of the client and that of the therapist dynamically relate within the frame of a therapy?
INTERVENTION STRATEGIES
Implementation of TLDP does not rely on a set of techniques. Rather, interventions in TLDP are seen as therapeutic strategies that are inextricably embedded in an interpersonal relationship. Therefore, all TLDP interventions are considered to be relational acts (Norcross, 2002)—even those that seem rather concrete and straightforward like assigning homework. As Butler and Strupp (1986) concluded, interventions “cannot be reduced to a set of disembodied techniques because techniques gain their meaning and, in turn, their effectiveness from the particular interaction of the individuals involved” (p. 33).
In theory, any intervention that could facilitate the goals of new experiencing and new understanding can be used in TLDP. In my work with clients, I feel free to use whatever strategies are within my therapeutic armamentarium. In addition to traditional psychodynamic interventions (e.g., clarification, confrontation, interpretation), I have used the gestalt empty-chair technique, somatic focusing, mindful meditation, metaphor/storytelling, behavioral rehearsal, psychoeducation, reframing, suggestion, and homework, to name a few. Given the brevity of the work, clients become accustomed to brief therapists using a variety of pragmatically designed strategies. Furthermore, as the interventions are all designed to promote the same major goals, they have a common, coherent theme. Phenomenologically, they make sense.7 Also, as stated in the introductory chapter, in brief therapies, therapists are more directive, active, and pragmatic (Levenson, Butler, Powers, & Beitman, 2002). They are more willing and (one hopes) more able to incorporate a variety of potentially useful strategies in a practically helpful way.
Before getting into some of the categories of TLDP interventions, let me make a general comment about when and how to intervene. In brief dynamic therapy, therapists must become comfortable with intervening before they have sufficient information. Often putting forth statements as tentative (“I may have this wrong, but . . .”) and seeking feedback from clients (“Do I have that right?”), builds a sense of collaboration and dissuades clients from believing their therapists are reading their minds and making veridical pronouncements. Interventions do not need to be “correct” in an absolute sense. They can be thought of as invitations to see and feel things in a different way and from a different perspective. Staying close to what is observable and asking for as much detail as possible promotes reflection on the part of the client rather than submissive acceptance (or outright refutation) of what the therapist is saying. (“When I commented on your lateness, I noticed you began looking at the floor and started to talk in a soft voice about how you never get it right. Could we replay this in slow motion—from my comment to your self-condemnation—to see what just happened here between us?”)
In my attempt to assimilate attachment theory and emotion-focused experiential approaches into interpersonal therapy, I have taken previously identified TLDP strategies from the Vanderbilt Therapeutic Strategies Scale (VTSS; Butler & the Center, 1986)8 and modified them to be more attachment- and affect-based.9 These 25 strategies are grouped into seven categories described subsequently. (See Table 4.2 for a listing of these items.)
Maintaining the Therapeutic Relationship
In TLDP, as with most clinical approaches, managing the therapeutic relationship is a critical competency (Binder, 2004). To strengthen the therapeutic alliance, the TLDP therapist engages clients from a respectful and nonjudgmental stance, validates their feelings and perceptions, and invites their collaboration in the process (Strategy 1).
Table 4.2
Time-Limited Dynamic Psychotherapy (TLDP) Therapist Strategies
Maintaining the therapeutic relationship
1. Responds to the client conveying a respectful, collaborative, empathic, validating, nonjudgmental stance. (VTSS 4,5)*
2. Shows evidence of listening receptively. (VTSS 10)
3. Recognizes the client’s strengths and conveys this to the client.
4. Addresses obstacles (e.g., silences, coming late, avoidance of meaningful topics) and opportunities (e.g., inquisitiveness, assertiveness, willingness to be vulnerable) that might influence the therapeutic process. (VTSS 20)
Accessing and processing emotion
5. Helps the client stay emotionally regulated.
6. Encourages the client to experience and express affect in the session. (VTSS 1)
7. Facilitates the client’s awareness of emotions, and uses various strategies to help deepen his or her emotional experience.
8. Helps the client label emotional experience and recognize its goal-directed significance.
9. Helps the client access, experience, and deepen attachment-related feelings and/or primary emotions specifically related to the CMP.
Empathic exploration
10. Uses open-ended questions. (VTSS 12)
11. Inquires into the personal or unique meanings of the client’s words. (VTSS 7)
12. Responds to the client’s statements or descriptions by seeking concrete detail. (VTSS 8)
Focused inquiry
13. Throughout the therapy, maintains a focused line of inquiry. (VTSS 6)
Relationship focus
14. Facilitates the client’s expression and exploration of feelings, thoughts, and beliefs in relation to significant others (including the therapist or the therapeutic relationship). (VTSS 2, 3, 14)
15. Encourages the client to discuss how the therapist might feel or think about the client. (VTSS 15)
16. Discloses one’s own reactions to some aspect of the client’s behavior in general and to the client’s CMP in particular. (VTSS 16)
17. Metacommunicates about the interpersonal process that is evolving between therapist and client. (VTSS 11, 13, 19)
Cyclical patterns
18. Asks about the client’s introject. (VTSS 18)
19. Helps the client link his or her emotions and personal meanings to a recurrent pattern of interpersonal behavior.
20. Deepens the client’s emotional and conceptual understanding of how the CMP has affected one’s intrapersonal and interpersonal functioning.
21. Links the need for disowning primary emotions to the client’s early experiences with caregivers.
22. Helps the client incorporate his or her more adaptive (healthier) feelings, thoughts, and behaviors into a new narrative.
Promoting change directly
23. Provides opportunities for the client to have new experiences of himself or herself in interaction with the therapist and to have new relational experiences in interaction with the therapist in accord with the goals for treatment.
24. Gives process directives in session and outside of session (e.g., homework) to help the client take steps toward new emotional and/or interpersonal experiences and understandings.
Time-limited aspects of therapy
25. Discusses the time-limited nature of the therapy in light of the client’s CMP and new adaptive narrative. (VTSS 21)
Note. Numbers in parentheses refer to the item number from the original Vanderbilt Therapeutic Strategies Scale (VTSS), reprinted with permission of S. F. Butler. In some cases, content from an original item has been combined with that from another item(s) and/or has been altered to include more of an emotional or attachment focus.
It is critical in this relationally based approach that the therapist shows evidence of listening receptively to what the client is saying. This receptivity may be communicated by body position, facial expression, and head nodding (Strategy 2). Many of these are culturally determined. In a brief therapy in general and in TLDP in particular, it is critical to assess, use, and comment on the strengths of the client to foster change (Strategy 3). Often clients are the last to know about their own capacities. No one has ever commented on them, elicited them, admired them; therefore, clients are often blind to their own cognitive, emotional, and relational resources. Highlighting their internal and external resources can often build a strong positive alliance.
In Strategy 4, the therapist addresses “obstacles” (e.g., coming late) and “opportunities” (e.g., willingness to be vulnerable) that might influence the therapeutic process. In psychoanalytically oriented therapies, “covert or overt opposition to the therapist, the counseling process, or the therapist’s agenda” (Bischoff & Tracey, 1995, p. 488) has been called resistance. Resistance from the perspective of TLDP, on the other hand, is viewed within the interpersonal sphere—as one of a number of transactions between therapist and client (Levenson, 1995). The assumption is that clients are doing what they believe is necessary to maintain their personal integrity, ingrained perceptions of themselves, and interpersonal connectedness. Resistance in this light reflects the clients’ attempts to do the best they can given how they construe the world. For example, a client might miss a session following the session when she has cried in the hour because she is so worried that the therapist will perceive her as too needy.
Thus, when TLDP therapists feel as if they have hit a wall of resistance from the client, they can stand back, appreciate the attachment-based significance of the wall, and invite the client to look at possible “good” reasons to have the wall. Such an approach often avoids power plays with hostile clients and helps to promote empathy and collaboration.
Accessing and Processing Emotion
No matter what else the therapist may do in the therapy, he or she is trying to relate to clients in the here-and-now of the therapeutic relationship from a deeply empathic place, helping to keep clients in an emotionally receptive “working space” through what has been called dyadic regulation (e.g., Tronick, 1989). Such transactions are hypothesized to be beneficial in and of themselves in that they permit emotional processing and the modulation of goal-directed behaviors and adaptive strategies. However, as pointed out by Binder (2004) and others (e.g., Anderson, Crowley, Patterson, & Heckman, 2012; Henry et al., 1993b), helping clients stay emotionally regulated (Strategy 5) is easier said than done when one is interacting with powerful interpersonal dynamics that dysregulate the therapist’s own emotional state. Thus, this strategy is more of a desired optimum therapeutic stance that will usually be manifested through several other specific interventions.
For Strategy 6, the therapist actively encourages clients to experience and express affect in the session. Activating the emotional fabric of the person’s CMP is critical in changing it. As emotion focused therapist, Les Greenberg, is fond of saying, “You must arrive at a place before you can leave it.” From experiential theory, research, and practice, we know that emotional arousal and expression are necessary precursors of change (e.g., Fisher et al., 2016; Greenberg, 2012; Johnson, 2004). Similarly, the therapist helps clients become aware of emotions on the edge of awareness and helps them deepen their emotional experience (Strategy 7). However, mere ventilation of emotions is not enough, and the therapist must help clients label their emotional experience and tune into its goal-directed significance (Strategy 8). In particular, the TLDP therapist is invested in focusing on the client’s accessing, experiencing, and deepening any attachment-related feelings specifically related to the person’s CMP (Strategy 9).
Empathic Exploration
Open-ended questions (Strategy 10) and inquiring into the personal meanings of the clients’ words (Strategy 11) as well as asking for concrete details (Strategy 12) all help the therapist understand the client’s world from the inside out. It is not unusual when I am listening to the client talk in a global fashion about a disturbing (or rewarding) interaction with another person (“She just really ticked me off!”) to ask them to slow the action down so that I can understand the details of the situation—both in terms of external transactions and internal, visceral responses. Often clients are quite surprised to see all the steps (e.g., attributions of self and other) that have led them to their reaction that often feels as if it “just happens.”10
Focused Inquiry
Throughout the therapy, the TLDP therapist attempts to maintain a circumscribed line of inquiry and stays on the focus unless there are dramatic indications to the contrary (Strategy 13). Such a focusing, however, should not be done in a dogmatic or controlling manner. Binder (2004) defined problem formulation and focusing to be one of the five competencies in conducting good interpersonal-psychodynamic therapy. And as pointed out in Chapter 1, maintaining a focus is the most commonly mentioned feature defining brief dynamic therapy. The TLDP therapist uses the emotional-interpersonal goals derived from the formulation to keep the therapy on track. Such focusing is critical in a brief therapy that demands making the best use of time.
Relationship Focus
The TLDP therapist encourages clients to talk about their relationships with others (including with the therapist). Focusing on relevant thoughts, feelings, and beliefs associated with such transactions is of paramount importance (Strategy 14). Much of the therapeutic work will focus on the clients’ relationships outside of the sessions (unless a negative process emanating from within the sessions needs to be addressed directly). Similarly, the therapist helps clients explore their perceptions of how the therapist might be acting, feeling, or thinking about them (Strategy 15). In this way, the therapeutic relationship is examined as a here-and-now microcosm of what might happen with others.
In a reciprocal fashion, it can often be helpful for therapists to self-disclose their countertransference in response to clients’ specific behaviors (Strategy 16). Of course the therapist is always self-disclosing inadvertently through gestures, voice quality, facial expression, and so forth. Self-disclosure is “not an option; it is an inevitability” (Aron, 1991, p. 40). But here I am talking about the therapist’s self-involving disclosures—statements in the present tense that describe the therapist’s reactions to some aspect of the client’s CMP (Kasper, Hill, & Kivlighan, 2008). In this way the therapist can open up other possibilities in the clients’ perceptions of others and help clients appreciate their impact on others. In TLDP therapists need to become comfortable with comprehending their own internal processes and then deciding when, where, and how to share these with clients. TLDP advocates limited self-disclosure specifically designed to give clients more information about the dynamics involved in relating to others.
In particular, the therapist focuses on his or her reactions to the client that are particularly relevant for the client’s CMP. It should be noted that the therapist’s sharing such reactions is not only helpful for bringing into awareness negative aspects when there are reenactments, but also for recognizing when there are positive shifts in the quality of the interaction. For example, after Mr. Johnson got irritated with me in Session 6, I shared that I felt more engaged with him than when he was more placating.
Related to self-disclosing strategies is metacommunication (Strategy 17). From an interpersonalist position (Kiesler, 1996), metacommunication involves discussing and processing what occurs in the here-and-now client–therapist relationship that involves both therapist and client. For example, “It seems, Mr. Johnson, as you get quieter and quieter, I become more and more directive. I am not sure what is happening here, but can we take a look at what this feels like for both of us?” Muran’s (2001) expansion of the definition of metacommunication to include intrapersonal aspects (i.e., communication with parts of the self) is also useful. From an attachment point of view, metacommunication can be pivotal in providing corrective emotional experiences, shifts in self-awareness, and richer narratives of the self in relation to self and others.
While much of the therapy is devoted to examining the clients’ relational lives outside the therapy (especially for those with more flexible working models), the therapist’s observations about manifestations of the CMP (not necessarily full-blown reenactments) in the sessions provides an in vivo understanding of the client’s behaviors and stimulus value. By ascertaining how an interpersonal pattern has emerged in the therapeutic relationship, the client has, perhaps for the first time, the opportunity to examine the nature of such behaviors in a relatively safe environment.
I want to make a comment here about the use of transference interpretations, because they have been a standard intervention strategy for psychodynamic therapists in both short- and long-term therapies (although intersubjective, two-person approaches like TLDP shy away from using them). When therapists are “analyzing the transference,” they are linking emotionally charged interactions with past significant others (usually parents) with what is happening in present transactions between therapist and client, rather than making observations about the ongoing therapeutic process. For example, if I would have explained to Mr. Johnson that “you want me to nurture and take care of you in ways you didn’t get from your parents,” this would be an example of a transference interpretation.
Hill and colleagues (Kasper et al., 2008) differentiated between immediacy (her term for metacommunication) and transference interpretations in a similar manner:
Immediacy seeks to promote the here-and-now awareness of problematic interpersonal patterns and to create a corrective emotional experience by establishing new interpersonal patterns. By contrast, transference interpretations seek to promote the client’s awareness of the existence and insight into the origin of displaced interactional patterns by providing an explanation or reason for the behaviors. (emphasis added, Kasper et al., 2008, p. 282)
I very much like quoting Strupp’s admonition that the supply of transference interpretations far exceeds the demand. A few go a long way. In part I have placed a major focus in TLDP on experiential learning and empathic attunement because of the deleterious effect repeated transference interpretations can have on psychotherapeutic process and outcome. Clients often experience such interventions as blaming and/or belittling (e.g., Henry et al., 1993a).
Exploration of Maladaptive Cyclical Patterns
In Strategy 18, the therapist helps clients explore their introjects (how they feel about and treat themselves) and how these relate to their interpersonal patterns (CMPs). Inquiring about how one feels about oneself during certain interpersonal behaviors (especially those that are attachment-related) links one’s sense of self with transactions with others. As I say to Ann in the clinical case to follow, “How do you feel about yourself when you cry yourself to sleep, making sure that your boyfriend does not hear you?”
The therapist then helps clients put all of the aforementioned emotional-interpersonal information of self and others into describing a cyclical pattern (Strategy 19). For example:
So when you feel so alone and depressed and expect no one will be there for you, you make sure that you present yourself as “together,” “cool,” and not “needy.” Is that right? The problem is that others get the message that you don’t want their attention, and so they leave you alone. Yes? You see people aren’t there for you, and you then tell yourself that no one would want to be with someone so needy, and this makes you feel more depressed, and the whole cycle begins again. Do I have that right?
It is very important at this stage that the therapist be as specific as possible and slowly review each component of the pattern, checking it out with clients at each linking, soliciting their elaboration and emotional confirmation.
Once the pattern has been recognized, the therapist refers to the CMP throughout the therapy and, at each link, helps the client access, experience, and deepen the attachment-related feelings (Strategy 20). The therapist focuses on previously warded-off, unacknowledged, disowned, or disavowed attachment-related feelings and/or primary emotions specifically relevant to the CMP. The therapist confronts blocks in experiencing by using experiential techniques such as arousal, heightening, and empathic conjecture (Johnson, 2004). In this way, the client comes to understand the deeper, attachment-based needs that drive the maladaptive cycle and begins to appreciate how this working model has colored his or her worldview. When appropriate, the therapist then links the need for disowning these primary emotions to the clients’ early experiences (Strategy 21). The clients come to understand how they perceived these basic core emotions as undesirable by caregivers; therefore, these emotions were suppressed and finally disowned so that early attachments would not be threatened. The therapist can help depathologize the client’s current behavior and symptoms by explaining how they were a way to survive emotionally as a child, but now they serve no useful purpose and may even be alienating.
Over time, the therapist helps the client incorporate more core feelings (Fosha, 2000) and more adaptive thoughts and behaviors into a new coherent narrative that opens up an expanded sense of self and a wider repertoire of actions, leading to greater intrapersonal and interpersonal health (Strategy 22). Going back to our example of Mr. Johnson, by the end of therapy, he was able to talk about how he had to squelch his angry feelings as a child to avoid being beaten by his alcoholic father—a very different narrative than when he entered therapy and shamefully saw himself as weak. In his last session, Mr. Johnson said he now felt entitled to be angry—“honest anger.”
Promoting Change Directly
One of the most important TLDP treatment strategies is providing opportunities for clients to have new experiences in session that are designed to help undermine their CMPs (Strategy 23). Therapists should seize opportunities to expand or deepen experiences that disconfirm clients’ intrapersonal and interpersonal schemata. The therapist makes clear and repeated efforts to promote such experiential learning (e.g., facilitating new behaviors that the client sees as “risky”). With sufficient quality and/or quantity of these experiences, clients can foster healthier internalized working models of relationships. In this way TLDP promotes change by altering the basic infrastructure of the client’s transactional world, which then reverberates to influence the concept of self.
Going back to our case of Mr. Johnson, at one point in the sixth session, he was complaining that he could not think and participate in the therapy because he had not eaten breakfast. When I asked him what he wanted to do, he was confused by my question. Of course he would finish the session! Upon further inquiry, I learned that he thought I would be angry if he left the session early to get something to eat, and he would want to avoid my anger at all costs. When I simply stated back to him that it seemed he was choosing to remain in the session and be uncomfortable hoping not to displease me, he said he would go get some food if I thought it were a good idea. I expressed my curiosity about his leaving the decision up to me by stating in a puzzled tone, “If I thought it was a good idea?”
A short while later, Mr. Johnson said he felt better and would finish the session. However, in the next session a similar dynamic (but with different content) arose, and that time, Mr. Johnson announced that he wanted to leave the session early to attend to his personal needs (i.e., take a stool softener so he would not be constipated later that evening when his children came to visit). Rather than interpreting what I thought was going on at an unconscious level, I simply told Mr. Johnson I would look forward to seeing him at our usual time next week. Mr. Johnson’s stating his own needs over what he imagined were my wishes (that he should stay in the session no matter what) had been a big risk for him because, as I learned later, he thought I was going to throw him out of therapy if he were not “compliant.” Being aware that he was directly verbalizing his own needs (for once in his life), taking a chance that I would disapprove and might even retaliate, and then finding out that his assertiveness did not jeopardize our relationship was a major new intrapersonal and interpersonal experience for Mr. Johnson.
However, I do not want to give the impression that in TLDP the therapist tries to create that one new experience that totally realigns the client’s affective and cognitive world. Rather, new experiences should be encountered throughout the therapy—sometimes as almost imperceptible nuances embedded in the relationship context. In our long-term follow-up study of clients who have received TLDP (Bein et al., 1994), many clients described that one of the biggest benefits they got from therapy was having the opportunity to be more in touch with their emotions as they related in new and healthier ways to their therapists.
Unlike many long-term psychodynamic models, in TLDP the therapist may give directives to help clients foster their growth outside of the session (Strategy 24). Giving homework, for example, is very compatible with the TLDP approach. However, before making any such assignments, the TLDP therapist must carefully weigh the implications of such directives to make sure they are not a subtle reenactment of the client’s dysfunctional pattern. For example, asking Mr. Johnson to take assertiveness training classes may sound like a good idea on the surface. But if it is something he does because he feels he must do whatever I say in order to stay in my good graces, the homework assignment just serves to feed his attachment fears and compliant security operations—ultimately making sure he has yet another dysfunctional interpersonal interaction.
Time-Limited Aspects
Strategy 25 involves the therapist’s introducing and discussing the time-limited or brief nature of the therapy. The brief therapist does not do this just at the end of the treatment. At the beginning of the work and periodically throughout, the TLDP therapist comments on the limits on the time and/or scope of the work. TLDP, however, is not one of those models (like that of Mann, 1973, introduced in Chapter 2) that emphasizes the finiteness of time in order to precipitate change. Rather, it is thought of as the backdrop against which dysfunctional patterns take center stage. As termination approaches, one can expect to see the client’s anxiety about loss handled in ways characteristic for that particular person given his or her CMP. Painful emotions associated with previous losses can be evoked. However, the TLDP therapist does not stray from the overarching goals of the treatment.
Given the TLDP systems framework, when one person (the client) changes, other people’s responses are affected, usually reinforcing the client’s positive changes. As previously mentioned, I think of the therapeutic work continuing after the sessions have ended. For example, with Mr. Johnson, where there used to be a vicious dysfunctional cycle, now there was more of a victorious cycle filled with energy and joy. As a consequence of his feeling more powerful in the world, he began socializing more. He experienced himself as more alive and involved in life; his self-pity and depressive thinking were dramatically decreased. Now that he was a happier person, his adult children enjoyed being around him more, which only served to quiet his fears of abandonment and reinforce his sense of connectedness.
How does the therapist make a good decision about knowing when a client is “ready” to end?11 In brief therapy, we are clearly not looking for therapeutic perfectionism. All of the loose ends are not tied together. However, because brief therapy often ends while the client usually is in the midst of changing, I have six sets of questions to help guide beginning brief therapists in making termination decisions as the therapy is proceeding.12
- Has the client evidenced interactional changes with significant others in his or her life? Are these transactions more rewarding?
- Does the client evidence more emotional fluidity within himself or herself? Does the client report a fuller experience of self?
- Has the client had a new experience (or a series of new experiences) of himself or herself and the therapist within the therapy?
- Has there been a change in the level on which the therapist and client are relating (usually from parent-child to adult-adult)?
- Has the therapist’s countertransferential reaction to the client shifted (usually from negative to positive)?
- Does the client manifest some understanding about his or her dynamics and the role he or she needed to play to maintain them?
If the answer to most of these questions is no, then I do not consider that the client has had an adequate course of TLDP. The therapist should consider why this has been the case and weigh the possible benefits of using another therapeutic model, another course of TLDP, a different therapist, nonpsychological interventions, and so forth.
Case Example
I wish to discuss the case of Ann, the young woman who was kind enough to allow me to work with her in therapy for six sessions that were videotaped for the American Psychological Association’s series Psychotherapy in Six Sessions.13 Ann is a 25-year-old, attractive, thin, single, White woman with short curly hair. She enters the first session all bubbly and smiling.
Session 1
There is much to accomplish in a first session of a brief dynamic therapy. The therapist sets the time frame (for each individual session length and for the length of the therapy in total); assesses the client’s appropriateness for a brief dynamic approach; attempts to establish safety and collaboration with the client fostering a therapeutic alliance; listens for relational themes in the content and process of what the client is presenting so that a rudimentary, initial focus may be discerned; becomes aware of how he or she is feeling and interacting with the client; and begins delineating the goals for the work. In addition, the client’s responses to initial interventions in the first session give an indication of the pacing of the therapy. Hence, the first session is critical—brief therapists must formulate and intervene knowing the time is limited; they are motivated to make every session count. The first session captures the essence of a brief therapy; one must proceed on relatively little information and be willing to “lead the client one step behind.”14
After introducing myself to Ann, I tell her that we will be able to “meet for 45 minutes today and then if I can be of help, we can meet another five times,” over the next 3 months, to which she replies enthusiastically, “Oh, great!” I note that she appears cheerfully accommodating to what is a strange setting for such an intimate discussion, because we are being videotaped on a sound stage with bright lights and three cameras pointed at us. She tells me her reason for wanting therapy at this time is that she has been thinking about being in therapy “for years,” and “was excited to see how this all works.” While she briefly alludes to being “stressed” (i.e., working full time, going to school, and in a long-distance relationship), I am wondering where her pain is—what would motivate her to do an intensive piece of therapeutic work at this time. I sense her “excitement” has an anxious undertone. Of course, there is much in the present fish-bowl setting to cause us both to be anxious. Nonetheless, there is something in her eagerness to please that feels more part of her characteristic style. Given that only 2 minutes have passed, this may seem like a lot of conjecturing for a therapist to do; yet this is this part of how one starts conceptualizing in a brief dynamic model.
Because I am not sure what Ann is hoping to get out of any work we might do together, I simply ask her, “Is there something in particular . . . that concerns you?” Again, this straightforward sentence exemplifies the transparency and directness that often is a part of brief therapy. When she replies, “just the stress level” and her “anxiety,” I ask for specifics. For example, how does she experience the anxiety in her body? Having the client focus on her somatic sense of self will enable the therapist to assess the client’s level of emotional awareness. In addition, it lays the groundwork for facilitating the client’s understanding of how emotions are significant for change.
Ann is able to tell me that when she is anxious, she feels her heart and thoughts “racing.” This is a good prognostic sign in that she has some awareness of what she is experiencing physically and mentally.15 Ann also comments that she does not get a good night’s sleep and that her boyfriend’s alarm clock is “not dependable.” This is a curious statement. Why wouldn’t an alarm clock be dependable, and if it were truly not reliable, why wouldn’t one buy one that is? The thought crosses my mind that perhaps it is her boyfriend that is not dependable. I am not attached to this thought, but I am intrigued by associations, metaphors, and images that the client or I might have—all aspects that do not depend on explicit, linguistically mediated ideas.
I am keenly aware of my own thoughts and feelings as I interact with Ann. My interactive countertransference as I step into a relationship with the client informs me of what others might experience relating to her and also gives me a window into what he or she might be experiencing. At the outset, I am relieved that Ann seems to be “nice” and “cooperative,” but also suspect that there is more here than meets the eye.16
I also take note of the mismatch between the content of what Ann is saying and her presentational style. She is smiling broadly and nodding enthusiastically. If one were watching the video of this session without the volume, there would be little indication of the negative things she is relating. The disparity between the way she is talking (cheerfully) and what she is talking about (being tired, stressed, and overwhelmed) is another clue as to where we might need to go therapeutically. I think to myself, where and when did she learn to keep private how much she is hurting inside? Attachment theory suggests to me possible reasons why she may have needed to hide her pain (from others and possibly from herself)—perhaps it was not accepted by her caregivers or significant others in her life and, therefore, needed to be suppressed and/or disowned.
I am conscious of being intrigued and feel some hope that Ann and I could do a meaningful piece of work—even in six sessions. Specifically, I am encouraged because she is answering my queries, demonstrating trust in me and in the process, and sharing in a revealing manner what is going on at a visceral level. I feel engaged, pulled in emotionally by her style, and start to discern a pattern in the content of what she is saying and the process of how she is saying it.
I proceed to check out whether the “stress” she is experiencing is acute or more long lasting. Her reply (“That’s been my life ever since I can remember”) resonates with my sense. I then turn to gauging her resourcefulness and ask her how she has tried to deal with her anxiety in the past. This might not only give me an idea as to her strengths, but also an indication of what might not be helpful. Ann tells me about an area of pride—that she has changed her eating patterns to become healthier (“Now I crave better foods”). I am delighted to hear this, not only because it connotes that she is motivated for self-care and changing long-existing behaviors, but also that it provides us with a metaphor for how she might want to “nourish” other parts of herself. I reframe this back to her as, “It sounds like feeling strong in your own skin is very important to you now,” creating a bridge from the physiological realm to the psychological. A little while later, Ann confirms, “It is important for me to be an overall strong person and independent person in all aspects.” I am aware that I do not experience her as an independent person—rather, I have a sense based on her presentation thus far that she would go a long way to please me (and others). I entertain the idea that she is conveying a wish—a self as she would like to be. I have gone into some detail describing what are only minutes of a first session to illustrate that from a TLDP therapist’s point of view, formulation is already under way.
I begin to do an anchored history, following what Ann was saying, asking for more detail, expanding it forward and backward in time. In this way, I get a trajectory, context, and thickening of her life’s story. For example, when she talks about her family, I ask her if there is anything about her childhood she would have liked to have been different, and I hear that she wished she had had friends. As I explore this missing aspect of her youth, I find out that she was terribly hurt by a childhood chum (a past significant other) who pushed her away. In session, I conjecture (in a way designed to heighten any underlying emotion) that perhaps she made a vow to herself that she was not going to let herself get hurt like that ever again.17 Ann confirms this (“Because I wasn’t getting my needs met; she wasn’t reciprocating. I have a hard time with that”) and elaborates that “I feel like I am always the one giving . . . and sometimes I don’t feel like I am getting anything back.”
I then take what seems to be coalescing into a recognizable relational theme and ask if it manifests with her boyfriend (a present significant other), to which she empathically replies, “Absolutely!” With this her voice trembles, and I simply ask her in a soft, slow-paced voice pointing at my own chest, “What is going on inside with you right now?” She is no longer the bubbly, effervescent ingenue. She says she is frustrated and apologizes—both the feeling and the behavior are noteworthy. Women in our society often experience frustration when they are angry because it is socially frowned on for women to be aggressive; therefore, I wonder if her frustration comes from censored, suppressed, or disowned angry feelings. In addition, she is apologizing to me as though expressing her frustration would be unacceptable.
Following this, I link her behavior (acts of self) to her experience of her boyfriend (acts of others) in the first person. “Why isn’t he going out of his way for me? I go out of my way for him! Why isn’t he giving when it is not convenient?” Ann sobs when I say this. When she exclaims “I give and I give and I want something back!” through her tears, I feel the power, truth, and integrity (congruence between what she is saying and how she is saying it) of what she is sharing with me. I am getting the sense that this claiming of what she wants is the beginning of some new experiential learning for her.
A little while later, I lead Ann in an exploration of how she acts with her boyfriend and learn (not surprisingly) that she does not let him know how much she is hurt by his self-centered behavior. She volunteers that she is “scared” to let him know—“afraid he will leave. I will say my needs and he will leave” (expectations of others’ behaviors). Here we have a possible root of her attachment fear—that if she expresses fully who she is, she will be rejected. This leads me to ask about the fourth component of the CMP (acts of the self toward the self)—“It sounds like somehow you don’t believe that you would be enough; that he really just loves the you that is giving, giving, giving.” And she confirms, “Yes, I have to keep giving to make sure I am enough for him. I absolutely feel that way.”
We are not quite 30 minutes into the session, and I am helping her piece together the links between her dysfunctional behaviors, self-defeating expectations, the way she is responded to, and her negative self-appraisals (i.e., the four components of the CMP). Interpersonal theory helps me trace the transactional patterns; attachment theory provides me an understanding of her longing for relational felt security and safety; and emotionally focused, experiential theory keeps me attuned to the expression and understanding of her primary emotions that will be the fulcrum of substantial and long-lasting change.
While my skills of observation and recognition have been honed over 40 years of doing clinical work, neophyte brief therapists can use the same five categories of the CMP and the same three theoretical foci that I am using. These provide a structure by which to make sense of the flood of information and to direct the therapist’s attention.
The redundancy of Ann’s interpersonal behaviors that occur across people, place, and time form the rudimentary CMP that I convey to Ann by the end of the first session. “You’re up against a pattern that you have established over your life to be okay. But now it’s not okay—that way of operating in the world—that giving, giving is not okay right now. You want something more. Uh oh, if I dare ask for something more, what’s going to happen? So this an important time for you.”
In this summation, I am doing a number of important things consistent with the TLDP model. I am naming that this is a pattern—helping her to see things within a different narrative—a narrative that has form, internal logic, and hope. In addition, by focusing on a patterned cycle, I am externalizing the problem—the problem is this pattern, not Ann herself. Furthermore, in keeping with the nonpathologizing stance of TLDP, I am validating that Ann has good reasons to have co-created this pattern in her life, because it helped her feel “okay.” I am also supporting the idea that this pattern of giving and giving is not working for her now, and that she wants something more. This statement takes us from a focus on understanding what keeps her stuck (the pattern that is causing her pain) to the idea that she wants something to shift. Finally, I am also underscoring that such change is scary and not to be taken lightly, while acknowledging that it is important.
Before leaving this discussion of the first session, I want to make two last points. First, while I feel rather confident about discerning an emerging pattern, I am holding all of it lightly, ready to change any and all of this rudimentary formulation depending upon what I hear, see, or sense next. Second, the goals for this therapy are process- and not content-based. For a successful treatment, it is not necessary for Ann to break up with her boyfriend. Rather what is important is that she is encouraged to have new experiences and new understandings designed to help free her from rigidly adhering to her emotional and behavioral dysfunctional patterns.
Specifically, given her pattern of pleasing others at the cost of suppressing her own emotional truth, my tentative plan is to focus interventions on helping Ann experience herself as more worthwhile (introject) and more entitled to speak her mind, heart, and gut in an assertive manner (acts of the self). In addition, I would like for her to experience me as interested in her because she is worthwhile and not because I need her to take care of me (acts of others). According to the TLDP model, these experiential goals address her intrapersonal and interpersonal life. By the end of the therapy, I would also want her to have an understanding of how suppressing her own feelings gives her a diminished sense of self (introject), and behaving in unauthentic ways (acts of self) only serves to invite the very response she so fears (acts of others) while depriving her of her own emotional compass.
A brief therapist is always aware of the time-limited aspects of the therapy and conveys this to clients at various junctures. At the end of the first session, I tell Ann that we have five more sessions if she would like to continue working with me. Ann enthusiastically and wholeheartedly says, “I’d love to!” I am very aware here and throughout the session that it would be in keeping with Ann’s style for her to attempt to please me. I remind myself that as the therapy goes forward I will need to stay alert to times when I am hooked into reenacting a dysfunctional dynamic with her—pulled to behave in certain ways by her pleasant, pleasing stance.
I close the session by telling Ann that “I think you’ve been very forthcoming and really told your story in a way that I am already getting a feel for what you are wrestling with. It sounds like it was a courageous act to come in.” In this way, I am supporting Ann’s strengths in confronting these emotional demons that have plagued her for so long. In doing TLDP, it is critical to convey to clients and to frame for them that doing a focused, intensive piece of work takes emotional energy and fortitude and that the therapist realizes and respects this.
I think quite a bit has been accomplished in this first session. Ann appears to be a good candidate for TLDP, meeting all five selection criteria (see Chapter 2). We seem to have the beginnings of a good alliance. I am already getting a sense of Ann’s dysfunctional interpersonal pattern and have some ideas about the goals for the therapy. I also have a hypothesis about how her dysfunctional pattern might manifest itself in the session (transference–countertransference reenactments) with her trying to be the “good patient.”
Session 2
In the second session, I let Ann set the agenda, but I am mindful of my working formulation and am already listening to her through this filter. The topics evolve from stress in school to her describing herself as the “clingy girlfriend.” At this point I share how from a cultural perspective girls in our society are given the message that their needs are not that important. She speaks about how she tries to model for her boyfriend that giving is good, but I gently confront her when I say, “Well, modeling is one way of showing someone, but then there is something that is keeping you from really letting him know what is really going on with you.”
A bit later, I open up the area of attachment fears by saying, “Somewhere you learned over the years, and I know society plays a role, but somewhere you learned you need to keep giving and giving and keep your fingers crossed that the other person is going to come around.” With this empathic conjecture, Ann begins to tell the story of how her mother drank heavily while she was growing up.18
Ann’s face contorts and she sobs as she tells me,
I have been wanting her to quit for years. Because there would be times she would come home and pass out, and I would sit on the floor next to her—to make sure she is breathing. I was afraid she would throw up and die.
I am very moved as she describes this, and I get an image of a small child crouched on the floor, feeling incredibly terrified and totally responsible for keeping her mother alive. I reply softly, “It doesn’t get any bigger than that for a child—wondering if a parent is going to die on them.”
Because of her reluctance to tell her boyfriend of her pain, I ask if she ever told her mother about what she was going through emotionally as a child. Not surprisingly, Ann responds, “No.” As the session comes to an end, I frame for her a different story than she has been telling herself all these years. I let her know that she is
wrestling with trying to do it differently—to honor yourself and your feelings. But it is difficult. The fears, the fears I can better understand now—the fears from when you were a little girl—fears about will there be anyone here to take care of me. . . . I can see where you would put your needs way down because those were very big stakes. Who wants their mother to die on them? . . . I can see where you learned those lessons very young.
By the time the session ends, Ann has the idea that she is dealing with an “old, old pattern” that gets rewoven in her present life. Now the enemy is not herself and her inadequacies, but rather that she learned a way of being that made sense at the time, but now does not serve her well. Of course during all of this exploration, I am mindful of being very present with her and empathic with her pain, providing the beginnings of a corrective emotional experience.
Session 3
In the third session, Ann comes in with her leg in a brace; she had had a knee replacement 2 days ago. When I acknowledged that such surgery can be pretty painful (coincidentally, I had had the same surgery on the same knee the previous year), she says, “It’s better that it hurts now and we’ll fix it, or it will hurt forever.” I wonder to myself if this statement also applies to her goals for therapy, so I say, “Sometimes it is hard to go through the acute pain and know in your mind it’s going to get better,” again speaking to her on two levels—the physical (her surgery) and the psychological (her therapy).
I ask her if there is anything on her mind she was hoping to work on in this session. On one level, this is a focusing intervention, and on another I am trying to give her another new experience (i.e., this is her time to use as she sees fit). She starts talking about how she fears that now that she cannot exercise (due to her recuperation), she might regain some weight she had worked so hard to lose.
Later when watching the videotape of this session, I could see that if she were more assertive, she might have confronted me at this point to let me know that I was not addressing her fear of gaining weight. Was Ann subverting her own needs in order to meet mine? If I would have been aware of this possible reenactment in the session, I might have processed (metacommunicated about) it with her in real time by saying something like, “I notice that I have taken our discussion away from your stated concerns; I wonder how that happened” (interpersonal focus). Or “I notice that I have taken our discussion away from your stated concerns; I’m wondering how you’re feeling about that” (intrapersonal focus). Or “I realized I was worried about your health” (self-disclosure).
By the middle of the third session, I have heard segments of Ann’s pattern several times, which encourages me to link these emotions and personal meanings into a CMP and proposed it to her as relevant to her most important current relationship.
Everything is planned to keep from getting hurt. To be how he would like you to be, so then he will be there. He won’t leave you. Because if you were who you are, the fear is that he would leave. You really believe that, yes?
Here I state her abandonment fear, simply and boldly, and I can tell from her emotional response—her eyes welling up and breaking into sobs—that she grasps the essence of what I am saying. Through her tears she describes a vivid and poignant image—“Like you reach out and no one is there.”
As we near the midway point in our work together (end of third session), I propose that she “experiment” coming forward with someone in her life who is “safe enough.” We collaborate on a homework assignment of her letting a new girlfriend know a bit more about her—for her to actually take up space instead of just being the accommodating listener. When one is working briefly and needing to make every session count, having the client take interpersonal risks outside of the session is an excellent way of speeding the process in a real and relevant way.
For the remaining three sessions we continue working on the same CMP that gets further elaborated and refined. My goals remain an overriding focus, and I find no reason in what she says to change them.
Sessions 4 and 5
In the fourth session, Ann relates how she felt the homework was a “success.” She was able to talk to her girlfriend “mostly about me,” and she is “really excited” that it went well. I reflect back, “So you took a risk and what you feared would happen didn’t happen.”
In the fifth session, I remind her that it is our “next to last session.” I introduce an examination of ways in which she felt her customary patterns may have emerged in our relationship. Ann talks about initially feeling pulled to “do a good job” in the sessions “to make your job a little easier.” However, now just a few sessions later, we both agree that “it’s definitely changed.” Ann exclaims that “it feels great, because I’m not overanalyzing anything, really! When I go home, I analyze it, but not in the moment.” In this penultimate session, Ann talks about how she has started journaling (on her own) about the “pros and cons” of her with and without her “walls”—her being the “fake person” versus her being “intimately close” by “just being myself, not having to pretend to be someone else.” Such self-reflection and learning between sessions are essential facets of a brief dynamic treatment.
Session 6
In our last session, Ann talks about how in the preceding week she took “a little baby step” toward asserting her needs with her boyfriend. “I wanted him to understand that [his behavior] hurt me.” Her feared outcome of being abandoned did not occur. In fact, “he held me [and] tried to make me feel better. Which is nice, because I don’t usually say anything. . . . He didn’t run away. I noticed that.” Although such a specific action was never a concrete goal of this TLDP, it is a dramatic manifestation of how far she has come in opening up options for herself to have more positive interpersonal outcomes. “I always wanted to have a connection with people, but I was afraid to do that . . . and with [my boyfriend] to be able to do that in six sessions was just unheard of. I never would have done that . . . but instead I have done a 180 and I like it!”
Of course, in this last session we need to say our good-byes. It has been a meaningful, interactive experience between us—not just as client and therapist, but also as two individuals who held each other in each other’s mind and who risked being emotionally present. With a couple of minutes left in the session, Ann says our time together “has gone by really fast. If anyone, even like future therapists, I definitely recommend getting your own therapy. . . . I would love to continue on the outside with another therapist.”
Although this was a truncated brief therapy done for demonstration training purposes, in many respects Ann meets the TLDP criteria for termination (discussed in the previous section). She has evidenced more rewarding transactions with others, has had a fuller emotional experience of herself, has had a new interpersonal experience with the therapist, was relating in a more resilient fashion, and has an understanding about the reasons her role relationships with others took a particular form. In addition, my countertransference reaction to her has shifted. I truly felt what I told her at the close of our last session: “It has been a very rich experience for me, and I think you are one courageous lady.”
1Strupp and Binder (1984) emphasized action (i.e., “acts”) in each of the four components of the CMP because they wanted to move away from formulations using static traits (e.g., introverted, grandiose) or theoretical abstractions (e.g., repressed orality). Furthermore, they felt the therapist’s empathy might be more easily evoked by an action’s concreteness, because he or she might recall having acted in a similar manner. This emphasis on “acts” is consistent with an emotional focus where one of the functions of emotions is to elicit action tendencies.
2Over 100 years ago, the sociologist Cooley (1902) termed these reflected self-appraisals “the looking glass self.”
3Ivy (2006) writing on the characteristics of a good formulation, uses my (Levenson, 1995) version of the CMP as a case example. He opines that the steps in the formulation process are spelled out and that the theoretical model is straightforward and jargon-free. He particularly notes that “its inclusion of the therapist’s emotional responsiveness to the patient as a source of formulation information” (p. 325) distinguishes it from earlier psychodynamic formulation models that assume a detached and neutral therapist.
4This is not to say that there are not times when the therapist’s own personality and/or idiosyncratic issues interfere with the therapy. This has been called classic countertransference (Gelso, 2004). In these cases consultation, supervision, and/or one’s own therapy are necessary to limit any untoward impact on the therapy. On the other hand, interactive countertransference is thought of as a more universal reaction to the client’s style and very useful in understanding the client’s dynamics.
5Of course clients will vary to the degree to which they identify with or adhere to their particular culture’s mores and expectations, and to the degree to which they are acculturated into another (usually dominant) culture.
6For a thoughtful (and thought-provoking) view of this perspective, the reader is referred to Jerome Frank’s 1961 classic book on Persuasion and Healing, now in its third edition (Frank & Frank, 1991).
7However, it is essential for the therapist to appreciate how the meaning and impact of any intervention shift when it is taken out of its original “home base” theory and incorporated into another model (Messer, 1992).
8The VTSS was designed by members of the Center for Psychotherapy Research Team at Vanderbilt University as a measure of adherence to TLDP modes of intervention. It comprises 12 items concerning general psychodynamic interviewing style and 10 items focused on strategies specific to TLDP. Research indicates that the VTSS is able to reflect changes in therapists’ behaviors following training in TLDP (Butler & Strupp, 1988; Henry et al., 1993b). For a copy of the VTSS with scoring instructions, see Appendix A in Levenson (1995).
9Although most of the interventions reflected in these items have strong empirical support from both experiential (e.g., Elliott, 2001) and interpersonal fields (e.g., Kiesler, 1996), this modified view of TLDP combining both approaches has not yet been explored in clinical trials. Hopefully, the clinical and theoretical model put forth here can serve as a guide for future empirical investigation.
10It is quite ironic that often my feedback to trainees learning to work briefly is to “slow down” the process.
11I have found that having an explicit ending date (rather than a fixed number of sessions or a brief therapy defined by a limited focus) works best for training. With a fixed date, therapists-in-training are forced to confront their “resistances” to working briefly (Hoyt, 1985)—for example, fears of being seen as withholding, the need to be needed, and overconcern for “successful” termination. Also when I do group supervision with a specific termination date, all the trainees are roughly on the same page—beginning and ending together. Without such a structure, I have found that beginning brief therapists often find “good reasons” for extending the length of the therapy.
12Unfortunately, in today’s managed care environment, the decision of when to end therapy is often not made collaboratively between therapist and client. Instead it may be a decision made by an administrative person or limited by one’s insurance coverage to a specified number of sessions for specific diagnoses. See Levenson and Burg (2000) for a discussion of the effect of these economic influences on professional training and patient care.
13All six sessions of my therapy with this client are available on DVD through the American Psychological Association (APA) Publications Department, Phone: (202) 336-5510; E-mail: order@apa.org; Internet: www.apa.org/books. These six sessions were not set up to be a complete brief dynamic therapy; the six-session format was specified by APA as part of its clinical demonstration series. Nonetheless, I think the work effectively illustrates many of the concepts and interventions of a modern brief dynamic therapy. For this book, several identifying aspects of the case have been altered.
14I particularly like this phrase of Milton Erickson’s because it so nicely phrases the paradox of a brief therapy; the therapist must be willing to give direction to the client, but also must follow the client’s leads.
15With clients who are not aware of what is going on in their bodies, the therapist needs to start there. Gendlin’s focusing work or Greenberg’s experiential processing approach is helpful in this regard. Also see Levenson (1995) for a discussion of alexithymia and brief therapy.
16Book’s (1998) conceptualization of a unique form of countertransference is applicable here. He speaks of in press countertransference as a therapist’s wish for a case to be a successful demonstration of a particular psychotherapy method so that it can be used as a case illustration in a book.
17My phrasing (i.e., “I have made a vow of never, never again will I be put in this position”) has been influenced by an intervention used by Johnson (2004).
18This is another technique used in experiential-process therapy.