The therapist using an integrative time-limited approach first conducts several initial interviews to clarify what Ms. B is seeking from therapy and to collect details about her history with which to formulate the central issue, which includes time, affects, and her negative self-image, and which is stated as follows: "You are a competent, capable, hard-working woman whom others have always been able to depend upon. However, you now feel and have always felt unimportant and
unworthy." Next, the therapist gauges Ms. B's reaction to the statement, which, in keeping with her compliant attitude, is to agree with the statement although she says she is surprised and doesn't know why she feels this way because her life is good and she has been blessed. The therapist then asks Ms. B to agree to a 12-session treatment schedule, informs her of the date and duration of each session, including the date of the final session, and asks for her response. Ms. B says that she's worried she won't know what to talk about because she doesn't think she has any real problems compared to other people's suffering.
In the first two sessions, a positive transference develops as the therapist encourages Ms. B to talk about the increased demands on her time at work, in caring for her parents, and in helping her sons, and as the therapist empathizes with her feelings of chronic fatigue and ill health. Ms. B reports that she looks forward to sessions, and by the third or fourth session she starts to feel better and do more for herself, while the therapist maintains a steady focus on the central issue—Ms. B's tendency to sacrifice her own needs to the needs of others, which maintains their dependency and prevents her from experiencing separation and loss through normal
developmental phases. During this phase of treatment, the therapist learns a great deal more about the roots of Ms. B's problem in not being allowed to separate and individuate in her original family while growing up. She also begins to talk about her secret fantasy of quitting her job and becoming a travel agent. As the therapist continues to return her attention to the central issue by interrupting Ms. B's fantasies and suggesting they work on the problem at hand, her initial
enthusiasm changes to irritation. Now in the middle of the treatment, she experiences the therapist in terms of earlier ambivalence toward her parents, who did not attend to her needs but rather demanded that she be "good" while they focused on her sister, who got the lion's share of their attention while Ms. B was pushed to the sidelines, where she enviously watched her sister's
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adventures and exploits.
A negatively toned transference develops, and Ms. B begins to resist the treatment. Characteristic defenses such as reaction formation, somatization, and isolation of affect reappear along with denial of the seriousness of her situation, couched in a religious idiom. In the last set of sessions, Ms. B cancels one because of a vague somatic complaint. When the therapist queries her
awareness of the impending end of treatment, she denies remembering that a date for termination was scheduled at the outset and becomes uncharacteristically irritable, complaining that there is not enough time left to solve her problems. She begins to talk about being angry with her boss, who has shifted a number of onerous responsibilities to her job description without taking time to teach her new skills or give her direction. The therapist interprets her anger at her boss and at her parents for expecting too much and not helping her more. The therapist observes that this pattern is being repeated at work, where "being good" has resulted in more work for the same pay without adequate support and guidance.
By now it is obvious that Ms. B's problems stem from her inability to say no to the unreasonable demands of others, especially her parents—who have an extensive social network and sufficient financial resources not to have to rely on her exclusively—and her sons—who are well educated and able-bodied. This situation has alienated her husband, who has retreated into online computer games and perusing eBay. The therapist makes interpretations directed to Ms. B's negative
self-image, which has developed over years of subordinating her needs to the needs of others while never being recognized or rewarded for her self-sacrifice and hard work.
The termination phase in time-limited psychotherapy typically involves strong affects. In the next-to-last session, Ms. B questions her faith and rails at God as she unconsciously experiences the therapist as abandoning her. In the last session, Ms. B is more sad than angry and has positive feelings about what she has learned in therapy as she separates from the therapist.
During a 6-month follow-up interview, the interviewer discovers that after an initial period of disorganization and emotional upset, Ms. B did make significant changes in her life in terms of being able to set boundaries with her parents and sons, which freed up time to take a
long-postponed vacation with her husband. With his support and encouragement, she asked for a raise and got it, which enhanced her self-esteem. Although she still attends church on Sundays, she continues to question her faith and its demands for unquestioning obedience to authority. As she begins to assert herself, Ms. B's somatic complaints, depression, and fatigue subside and she has more energy and enthusiasm for life.
CONCLUSION
The development of brief dynamic psychotherapy has followed a path similar to that of long-term psychodynamic therapy, with drive/structural models adhering to classic psychoanalysis,
relational models adhering to the British object relations theory, and integrative models being connected to contemporary psychodynamic theories. Although these approaches have distinctly different flavors, all of them a) pay attention to the therapeutic relationship, b) have an active therapeutic stance, c) emphasize the development of a clear but narrow focus for treatment, d) have restrictive patient inclusion criteria, and e) limit the length of therapy and/or number of sessions.
Recent reviews of randomized controlled studies (Abbass et al. 2006; Leichsenring et al. 2006) demonstrate the value of brief dynamic psychotherapy across a wide range of mental disorders, with improvements maintained for up to 4 years. New methodologically strong studies are also being presented on the use of BPP in areas previously unreported, such as treating panic disorder (Milrod et al. 2007). This is a positive trend given that not all patients respond to other brief therapies such as cognitive-behavioral therapy, interpersonal psychotherapy, or the experiential therapies. We also need to study whether BPP can be integrated synergistically with these therapies and/or with medications to obtain more robust results. Clearly, BPP has emerged from the shadow of the better-studied cognitive-behavioral and interpersonal therapies. The decision as
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to which approach to select for a specific patient should be based on the empirical literature rather than personal preference. This literature is emerging at a rapid pace and will no doubt support exciting opportunities for both trainees and patients.
KEY POINTS
There are various models of brief psychodynamic psychotherapy (BPP).
Models of BPP differ according to many variables, such as the therapist's involvement as participant versus observer.
Most therapies consist of fewer than 24 sessions and last less than 6 months.
Techniques used in long-term dynamic therapy are also used in brief dynamic therapy.
Attention is given to rapid formation of a therapeutic alliance.
Drive/structural models adhere to Freud's classic psychoanalytic theory.
Relational models focus on object relations principles.
Integrative models attend to both classic and object relations principles.
Brief therapies can be useful for many patients with a variety of psychiatric problems.
Randomized controlled trials have demonstrated the efficacy of BPP.
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SUGGESTED READINGS
Dewan M, Steenbarger B, Greenberg R (eds): The Art and Science of Brief Psychotherapies: A Practitioner's Guide. Washington, DC, American Psychiatric Publishing, 2004
Messer SB, Warren CS: Models of Brief Psychodynamic Therapy: A Comparative Approach. New York, Guilford, 1995
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