engage in a communicative process that has an explicit structure, for instance in relation to the timing of sessions and length of treatment. In each, the therapist pays serious attention to the patient’s presenting complaints and to wider aspects of the patient’s experience, especially in their social relations. Each form of psychotherapy is intended to help the patient reflect upon his or her experiences from new perspectives. In the course of therapy, it is expected that the process may tap potentially relevant feelings of which the patient has been unaware. As explicitly stated by advocates of several of the approaches, it is perfectly appropriate to begin with the “surface” of what transpires between patient and therapist—something to which all the therapies are alert—and by this route, to gain access to depths of a person’s emotional life.
Tese points of similarity are far from trivial. For many a patient, the experience of meeting a professional who devotes care and attention not just to the person’s illness, but more especially to his or her subjective experiences and struggles can be profoundly moving and significant. Beyond this, one needs to bear in mind the risk of oversimplifying and even distorting matters when any given psychotherapy is practiced in a variet y of ways, some of which blur seemingly clear boundaries among techniques.
On the other hand, one could take the view that the therapies described fall into groupings that are as different as (say) anxiolytic, antidepressant, and mild antipsychotic medications. Tey might be indicated for quite different conditions and/or patients, or perhaps appropriately delivered by different kinds of psychotherapist. Te developmental principles underlying each psy- chotherapeutic enterprise overlap and diverge, and in certain respects seem
to be as distinctive as the pharmacological principles underlying the effects of different psychotropic drugs. Here I focus on a single set of contrasts.
The therapeutic stance
At the heart of psychotherapy is the therapist’s stance. Among some psycho- therapists, it is taken for granted that the therapist should make efforts to establish a friendly but formal supportive and collaborative relationship. o be sure, an underlying therapeutic alliance is critical for the cooperative work that every kind of dynamic psychotherapy entails. Yet there do seem to be substantial and significant differences in how therapists conceive that alliance
should be strengthened, and how it operates. Not only the joint focus, but also how patient and therapist jointly work on that focus, are in contention.
Te initial phases of treatment illustrate divergences among psychothera- pies especially clearly. If the IP therapist works to instil hope and an expect- ation of change, or the CA therapist gives homework to further the task of mapping out precipitants and sequelae to symptoms, or the DI therapist
THEMES AND VARIATIONS IN BRIEF PSYCHODYNAMIC PSYCHOTHERAPY 32
assists the patient to think in terms o thoughts and eelings, explores new ways o dealing with problems and encourages reflection, or the ISDP ther- apist makes it abundantly clear he or she is on the patient’s side in the battle against untoward deences, or the therapist using the Conversational Model conveys openness and flexibility when embarking on a tentative mutual dia- logue, how could these kinds o patient-centered intervention be aulted? Surely the BP therapist, earnestly intent to address and oster the unold- ing o patient–therapist engagement, runs the risk that he or she will ail to cement an effective therapeutic collaboration, neglect the value o detailed history taking, deflect rom truly mutual engagement, and even undermine the personal authority and dignity o the patient.
But consider this. In commencing on psychotherapy in a particular way, a therapist is conveying a lot about his or her orientation to the patient’s difficul- ties, and to the respective roles that patient and therapist are expected to adopt in the treatment that ensues. Very ofen, patients are highly tuned to what a given therapist seems to be wishing to achieve, and soon discern what the thera- pist will receive with either approval or disapproval. Patients may respond to their perception o the therapist’s wishes or needs in various ways, o course: or instance, by enthusiastically pitching in, or by trying to please or placate the therapist, or by subtly undermining or passively resisting the therapist’s efforts. Tereore the question arises: in balance, is it best to assert or strongly imply the importance o a particular kind o therapeutic alliance between patient and therapist, and then press on unless or until obstructions to the treatment become apparent, or is it best to explore what the patient’s atti- tudes, expectations and reactions are now, even rom the beginning o treat- ment? Do assertive therapeutic strategies drive important emotional issues underground when these are in urgent need o attention, or do they recruit a patient’s motivation or the task in hand, and merely postpone the emergence o significant repeating patterns o relatedness?
Most o the psychotherapeutic approaches I have listed in this chapter espouse a hefy dose o interrogation and instruction, especially at the begin- ning o treatment. In contrast, a therapist in the style o the Conversational Model or BP proceeds in a way designed to reveal, slowly but persistently, how a patient experiences the therapist’s stance and communication. In BP in particular, the ocus is on how a patient’s expectations and active shap- ing o engagement with the therapist constrain, ampliy, disclose, or disguise what is really happening in the therapeutic relationship.
It is not that the BP therapist is under instruction to avoid asking ques- tions about symptomatology or the patient’s history. However, i the transer- ence is likely to be obscured by direct enquiries, it makes sense to delay more
THE THERAPEUTIC STANCE 33
detailed questioning, insoar as this is indicated, until a point at which ques- tions might clariy the patterns o relationship that are emerging, and have a lesser impact in molding therapist–patient exchanges. Nor is the therapist disguising his or her own therapeutic attitude. It soon becomes maniest that the therapist is trying to understand the truth o what is happening in the ses- sion, on the patient’s behal.
Contrasts in therapeutic orientation crystallize in the matter o arriving at a shared ormulation. Tis figures prominently in the early part o treatment o many o the approaches considered above, and casts its spotlight or shadow, depending on one’s viewpoint, on what ollows. Te dominant view is that an agreed ormulation is a valuable distillation, whether o the problems (at the beginning o treatment) or insights gained (at the end), a reminder o what needs to be in ocus (at the beginning), and a bulwark against the vagaries o memory and the passing o time (at the end).
A BP therapist is inclined to think that the “ormulation” approach is oversimpliying and premature (and incidentally, although a eature o PI, I think I recall my ather expressing mixed eelings about ormulations, and I do not see it as a cardinal eature o the Conversational Model). More impor- tantly, and even at the end o treatment, the process o jointly ormulating may have untoward consequences. Formulation building establishes an intel- lectual rame in which patient and therapist have this objective something— the ormulation—to talk about . Even i this avoids the danger o leaving the patient “pinned and wriggling on the wall” (Eliot, 1969, p. 14, originally 1917), a narrative “it” has been created as a ocus o joint attention. Tis topic o mutual interest may allow or, perhaps even encourage, a patient to speak o him or hersel rom a distanced vantage point, at one remove rom his or her immediate experience—and specifically, at a remove rom his or her immedi- ate experience in relation to the therapist. Tere are costs attached i a patient is recruited into the role o co-therapist.
Meanwhile, we do not have to assume that a brie intervention either does or does not need an explicitly ormulated ocus. Attention tothat kind o ocus is just one way to keep a therapy on track. A ocus on the here-and-now transer- ence can do so, too. Very ofen, a relatively small number o issues repeatedly re-emerge in different ways in the transerence, and a therapist may be dogged in highlighting recurrent themes. Arguably, what is happening in the trans- erence is that which is most emotionally available and alive, and that which affords the most penetrating ocus or what needs to be addressed to promote change. So, too, we really do not know about the beneficial or constricting implications or a patient’s sel-experience and emotional perspective, when he or she carries away a written ormulation at the end o treatment.
THEMES AND VARIATIONS IN BRIEF PSYCHODYNAMIC PSYCHOTHERAPY 34
I want to return to the matter o respect or patients. Does BPT represent the return o the arrogant, dogmatic, and impervious stance o the all-knowing, though perhaps mythical, analytic therapist? Well, ew would disagree that it is respectul or any therapist to point out what is happening in the patient– therapist relation, when there is evidence or the happenings in question. It is a hallmark o BPT that there is usually a close temporal as well as mean- ingul relation between a therapist’s comments and the evidence or those comments in the patient–therapist interaction. I it is necessary or helpul, the BPT therapist can point to the basis on which observations are made. Whether the patient accepts or rejects the intervention, the therapist is com- mitted to reviewing and perhaps revising what he or she had thought and said. Note that respect here works on several levels at once: there is respect or the patient’s current mode o relatedness, respect or the truth o what is actually taking place at any given moment in the therapeutic relationship, and respect or the patient’s potential to apprehend, explore, and ultimately commit to what emerges as true. O course it is possible to construe this as the imposition o a therapist’s version o what is true, and readers will need to judge rom the detailed case material that is offered in subsequent chapters o
the book, whether this concern is justified.
Let me be blunt. I coness that as a patient, I would find it uncomortable or a therapist to suggest we “work together” on my problems in the ways proposed by some orms o psychotherapy. I would eel both restricted by and resentul about the presumption that we could or should arrive at an explicit ormulation o my difficulties. I would question how ar seeming egalitari- anism was disguising subtle condescension; I would be uneasy that the vital complementarity in our positions—therapist as therapist, mysel as patient— was being denied; and I would wonder what had happened to convert “mysel” into a topic that could be condensed into a brie narrative. Toward the con- clusion o treatment, I would preer to work on the meaning o the ending, shake hands, and leave to assume my own lie. I would be glad to take with me whatever o the therapy and therapist I ound valuable, and not have to pocket a ormulation. I am told other patients eel differently, something I need to acknowledge and understand.
Overall, the critical question is this: What kind o stance is optimal or iden- tiying and/or addressing the truth o a patient’s emotional difficulties? If the task o identiying here-and-now instances o the person’s problematic and ofen highly conflictual relatedness patterns and deences in the transerence is so important—and by no means all the therapeutic approaches I have out- lined deem this so central a matter—then how is one to proceed? If a principal goal is to achieve depth, coherence, and directness o interpersonal contact
EFFECTIVENESS 35
between therapist and patient—a goal that the Conversational Model and BP consider critical or the kind o insight that brings proound change—
then what are the most appropriate means to accomplish this?
Now I shall say just a little about the evidence that short-term psycho- dynamic treatments can be effective.
Effectiveness
I propose to deal swifly with the question o evidence or effectiveness o short-term psychodynamic psychotherapy. One reason is that, given the het- erogeneity among treatments and therapists involved in the studies, it is not clear how much bearing the results might have on the question o whether BP is effective. Nevertheless, it is worth making a single point, rather firmly, or the reason that critics (ofen rivals) o psychodynamic orms o psychotherapy disseminate the view that there is little evidence in avor o such approaches. Meta-analyses o relevant research, including randomized controlled trials, suggest otherwise (e.g., Abbass et al. 2014; Leichsenring, Rabung, and Leibing 2004; Leichsenring 2005; Gerber et al. 2011).
For the present purposes, it may be helpul to provide just two examples o specific studies. Te first concerns Psychodynamic Interpersonal Terapy, which as I have described, derives rom the Conversational Model o R.F. Hobson. Te study was conducted by Guthrie and her colleagues (1999), and concerned high utilizers o psychiatric services and, more specifically, patients with neurotic conditions who did not respond to psychiatric treatment. Tis was a randomized controlled trial o Psychodynamic Interpersonal Terapy plus treatment as usual, in relation to treatment as usual alone. Te treat- ment was manualized, and adherence to the approach was evaluated. Patients were assessed on entry, at end o the eight-week trial, and at ollow-up six months later. Te findings were that improvements at six-month ollow-up were greater or psychodynamic psychotherapy than treatment as usual in measures o psychological distress and social unctioning. Although there had been similar service utilization during treatment, over the six-month ollow-up, patients who had received psychodynamic psychotherapy had ewer days as in-patients and ewer GP consultations and contacts with the practice nurse, received less medication and less inormal care rom relatives. Te extra cost o treatment was recouped within six months through reduc- tions in health care use.
Te second example is a study by Milrod et al. (2007), and was a rand- omized controlled trial o psychoanalytic psychotherapy compared with relaxation training or panic disorder among patients, some o whom were also depressed. reatments were given twice weekly or 12 weeks. Patients in
THEMES AND VARIATIONS IN BRIEF PSYCHODYNAMIC PSYCHOTHERAPY 36
psychodynamic treatment had significantly more reduction of panic symp- toms, and greater improvement in psychosocial functioning.
Te upshot of these and other studies summarized in the meta- analyses cited above is that thereis evidence for the potential benefit of brief psychody-
namic therapies for a range of patients. As I have said, this does not mean that BP is effective, or rather, that it is effective for certain patients, as delivered by skilled therapists. In style and brief format, however, BP seems broadly in line with other approaches for which there is formal evidence of value. Whether it may be more or less effective, or (as I would prefer to think of this) of greater or lesser value in promoting certain kinds of developmental, clini- cally relevant change, is simply not known.
It is time to offer a more vivid portrayal of Brief Psychoanalytic Terapy, through extended clinical vignettes.