A Handbook of Short-Term Psychodynamic Psychotherapy

Penny Rawson

• Publisher: Routledge
• Year: 2019
• ISBN:
  9780429910326
• Edition: 1
• Topic: Psicologia
• Subtopic: Storia e teoria della psicologia

Short-term psychotherapy has become more and more popular in recent years and there is an increasing need for therapists to be able to offer help without entering into many years of therapy. This practical volume is an introductory text and a quick reference guide to short-term therapy, by an experienced therapist and teacher of psychodynamic short-term therapy. It is based on lectures given on the topic to experienced therapists wanting to familiarise themselves with short-term therapy. In a clear and concise manner, the author explores the basics of this approach and moves on to discuss such topics as the importance of the first session; the timescale of the therapy, the different techniques; and ending of analysis. Full of useful tables and bullet points, this volume is an indispensable guide to short-term psychodynamic therapy for experienced therapists as well as laypeople who are interested in learning more about this method of therapy.

Chapter One

What is Brief Psychodynamic Psychotherapy? An Overview

What is the approach? What do we understand by brief psychotherapy?

Well, first, what do we mean by short? By short I mean four to six sessions. However, this is flexible. If the client needs more then that will be what they will get. The aim is to complete the work in the shortest time possible so that the client is back on track again quickly. This therapy is not brief because of financial restraints nor because of pressure of numbers. Brief therapy is short because we hope to achieve what is required quickly. This is so that clients are able to get on with their lives without the burden that has brought them to therapy continuing to weigh them down. My research (Rawson, 2002), examining many studies, showed four to six sessions as the mean. This was with counsellors of all orientations and with clients and counsellors who had not intended to work in a brief way at all.

Colleges across the country also find that four sessions is average over the year. That means that some clients will be seen only once, while others might be seen as much as twenty times. Each contract will be made on an individual basis according to need. The contract is flexible.

To sum up, each client will be given what is needed.

Joint approach

The decision about how long will be made in conjunction with the client. One of the aspects of this approach is that it is a joint affair. This applies not just to the time scale but also to the focal issue. That is, to the main topic that is to be explored by the client. This joint approach encourages the client to work on their issues, to think about themselves and ultimately to become their own therapist. The therapist is simply facilitating their journey and being alongside them as they travel. The therapist will use all the skills at their disposal to help the client in their exploration. This includes helping the client to make connections with past and often buried issues. The baggage that remains, when problems have not been dealt with, can weigh heavily. Often, by working with the client on the past issue, they are enabled to move on more freely. One of the images I use with clients to explain this is that of a splinter.

Splinter image

If you have a splinter in your finger, you can mostly get on with things and ignore the splinter. But as you go along, if you press on the spot where the splinter is it hurts, and you cannot fully use that finger. Therapy helps to remove the emotional splinter. When we remove a real splinter we have to open up the wound and it bleeds and hurts, but then the splinter can be removed and we can immediately use the finger fully once again. It may take a little while to heal completely and sometimes a scar may remain, but essentially it is now all right. Similarly, it can be painful to explore emotional wounds. However, once they are brought out into the open and looked at they can be put into perspective. When they are accepted and ‘emoted’, then the burden can be put down and the client can be free to move on. By emoted, I mean that the emotions surrounding the issue and the emotional wound are allowed to ‘be’ and are acknowledged and expressed, perhaps with tears, or anger, or sadness. It is important to let the emotions out. Again, an image is useful here, this time that of a pressure cooker.

Pressure cooker image

The pressure cooker has a safety valve. It steams away. If the valve is blocked the pressure in the cooker can build up, and eventually there could be an explosion. Psychologically, the same thing can happen. If we hold on to or bury our feelings – anger or grief, for example – they can build up and keep slipping out in inappropriate circumstances. This can cause relationship difficulties in the home or at work. Sometimes emotions are buried for years and then something triggers them or there is such a build-up that, as in the pressure cooker image, the feelings can no longer be contained and there is some sort of crisis. This may take the form of an angry explosion, or perhaps a complete breakdown, where the person can no longer bear to carry on or no longer can bear their burden of responsibility. One may see a competent person suddenly totally unable to make decisions or carry out their job effectively. In others, the repressed emotions come out in the body through various illnesses. We see a definite correlation. for example. between ill health and the stress that befalls us at the time of a bereavement. If someone has too many stresses and too little support at the time of bereavement, ill health can ensue. McGannon (1996) gives some examples of the incidence of this. The scores that he refers to are in relation to the Holmes–Rahe scale that he also quotes (see quick reference notes at the end of the chapter). This scale is often quoted and is seen in both popular magazines and serious psychology books. It helps people to see how much change they are contending with in their lives, often as a result of a bereavement. It shows the devastating effect too much change all at once can have. We need, of course, to remember that some stress is good for us. Too little and we become bored, and that in itself is a stress, but this type of stress often spurs us to activity and out of our boredom. So to return to McGannon, he said:

For those whose changes came too fast or too severe[ly], such as the group who scored more than 300, the chance of developing an illness in the near future (within a three month period) was about 80%, 51% in those who scored between 150 and 299, and 37% in those who scored less than 150. The severity of the illness corresponded to the score. Those diseases like heart diseases, ulcer disease, diabetes, alcoholism, cancers, depression, suicide, and certain infections, to less life-threatening annoyances, such as the common cold and indigestion. [McGannon, 1996, p. 188]

Being aware of the effect of stress, whether caused by a bereavement or some other change or loss, is only the beginning. One cannot rest there. It is the task of the individual, with or without the help of the therapist, to work out ways of alleviating the stress. Where this is not possible, it is necessary to build in better supports to help the person, as they slowly adapt to the new situation. The therapist can help by giving the support of a listening ear or by helping to unhitch past emotional baggage that has got caught up with the present situation. One might be unable to do anything to change the present trauma, but if one can release some of the weight of unfinished business from the past, the present situation might become more manageable. The therapist can sometimes enable the client to see their situation from a different perspective and so make the burden lighter. Simply allowing the client time and space, in a safe environment, to think over their situation and to make sense of what is going on, can also be helpful. In the process, if they are able to see new ways forward or new ways of approaching difficult situations, this too, can be good.

Psychodynamic

We call this approach, where the past issues are retrieved and explored, psychodynamic. Brief psychodynamic psychotherapy recognizes the effects of the unconscious and past events on the present situation. We do not just stay in the past. We are, as Louis Marteau (1986) says, ‘reaching through the initial focus into the past ‘to the very roots’, but having dealt with the past we need to return to the present to go on, armed with what we have learned from the our past experiences. So we seek the emotional splinter – the focal issue.

Names of brief therapy.

There are many names for this brief approach, some twenty-five or so. These are listed in Rawson, 2002. One is ‘Focal Therapy’, a term coined by Balint, one of the key proponents of this method. One can understand why it is called this, since maintaining and keeping the focus in the approach is one of the factors that shortens the therapy. I shall return to this at a later point.

Who is brief psychodynamic therapy for?

This type of therapy is not for everyone. The same actually could be said of any therapy. I believe that we should aim to use the brief approach with everyone and only if it becomes apparent that it is not possible should we engage in longer therapy. This is entirely consistent with an earlier statement that I made that ‘therapy should be as long as is necessary’.

Suitability of clients for brief therapy

There are certain conditions that need to be met for the brief therapy to be realistically possible. First, the clients need to be able to establish a reasonable rapport with the therapist. Sifneos, one of the early proponents of brief psychodynamic psychotherapy, would expect the clients to have at least one meaningful relationship in their life to date.

Second, the clients need to have a degree of insight and to be prepared to explore the possibility that the problem may have its roots in the past.

Third, they need to agree to the contract and to the area that the sessions are to focus on. As Sifneos states: ‘Psychotherapy is always presented to the patient as a joint venture for the therapist and himself ... If an area of conflict can be agreed upon, treatment will be undertaken’ (Sifneos, 1968b, from Malan, 1971, p. 23).

Malan also quotes Balint as saying, ‘The patient’s and therapist’s aim must be the same’ (ibid.). This is such an important and obvious statement but is not always heeded. One recalls stories, apocryphal I hope, of clients who leave the college counsellor’s office wondering why they have been so closely questioned about some issue in their past when, in fact, all they wanted to do was obtain a bus pass!

Can compulsory therapy work?

This need for agreement makes me wonder at times as to the wisdom and effectiveness of court orders that compel people to go for counselling before some desired outcome is permitted, e.g., the custody of a child. The British Association of Counselling and Psychotherapy’s definition of counselling refers to it being a ‘freely entered into activity’. College senior staff, not infrequently, refer students as part of a disciplinary procedure; again the compulsion element militates against successful action. Can counsellors take on such a client? I would suggest that, if in the first session it is clear that the client is ONLY there through compulsion, it would be questionable to continue. If that is but one of their reasons, and they can be helped to see the intrinsic value of the sessions and, having become aware of this, choose to stay, that is another matter.

Circumscribed focal issue

There needs also to be an identifiable issue that the client wishes to explore. A ‘circumscribed’ focal issue, as Sifneos would express it. This means that the client and therapist can identify a specific emotional area about which the client is concerned, and on which they wish to work. Very often the client will come for therapy in some kind of emotional crisis triggered by a present event or situation. While it can be helpful to see the client in the throes of such a crisis, this type of therapy is not a therapy that deals only with crises. It aims to get to the very roots of a problem and thus help the client deal with the deeper issues, often stemming from the past. Otherwise these keep rearing their heads ...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• Dedication
• ACKNOWLEDGEMENTS
• ABOUT THE AUTHOR
• INTRODUCTION
• AIMS OF THE BOOK
• CHAPTER ONE
• CHAPTER TWO
• CHAPTER THREE
• CHAPTER FOUR
• CHAPTER FIVE
• CHAPTER SIX
• CHAPTER SEVEN
• CHAPTER EIGHT
• CHAPTER NINE
• CHAPTER TEN
• CHAPTER ELEVEN
• REFERENCES AND BIBLOGRAPHY