Therapeutic dialogues I

In this chapter the focus moves away from stories of patients who enter treatment, to the nature of interpersonal transactions within particular sessions of Brief Psychoanalytic Therapy. Patient–therapist transactions are represented through succinct segments of dialogue drawn from transcripts of audiotaped sessions. A running commentary is interpolated among these brief sequences of verbal exchange. Special attention is paid to features of the two therapists’ styles of intervention, as well as the nature of shifts in the patients’ communicative stance. All this material anchors aspects of technique in the details of what actually transpires in episodes of Brief Psychoanalytic Therapy.

A first case history

The purpose of this chapter is to introduce Brief Psychoanalytic Therapy through the case history of a woman who presented with fatigue and a variety of medical ailments. Descriptions are given of the initial assessment consultation and then the course of 16 sessions of Brief Psychoanalytic Therapy. The clinical material represented illustrates both the therapist’s orientation and style of intervention, and the patient’s step-by-step development in the direction of more open, trusting, and fulfilling attitudes toward other people and the possibilities of life. The nature as well as the influence of the therapist’s focus on the transference and countertransference receive special attention.

The psychoanalytic background

The aim of this chapter is to set out the psychoanalytic ideas and clinical principles on which Brief Psychoanalytic Therapy is founded. Topics include the centrality of intersubjective knowledge, the pivotal notion of transference, and the various ways in which a patient may affect a therapist’s emotional state. The clinical issues addressed range from varieties of communication and defence, contrasts between paranoid-schizoid and depressive position functioning, and the roles of countertransference and containment in the therapeutic endeavor. Overall, the chapter is concerned with the developmental potential of a therapeutic relationship in which the therapist is emotionally available and able to reflect upon the patterns of relatedness that a patient attempts to introduce into the therapeutic relationship, in part to avoid states of mind that are painful or conflictual.

The course of treatment

Two final cases are presented, this time with a view to tracing the course of treatment from initial assessment to completion of therapy, both descriptively and through brief verbatim exchanges between patient and therapist. The aim is to achieve depth of focus, and complement a picture of the unfolding of psychotherapy over time with snapshots of more detailed clinical material. It is in slow but meaningful progress, manifest both in the scope and integration of a patient’s states of mind and in the coherence and depth of patient–therapist communication, that some of the most persuasive evidence for the value of treatment emerges.

Is Brief Psychoanalytic Therapy distinctive? A research study

This chapter describes a formal study of therapeutic interventions in Brief Psychoanalytic Therapy (BPT). The aim of the study was to examine whether the therapeutic approach has distinctive qualities when compared with another relationship-oriented treatment, Interpersonal Therapy (IPT). The materials studied were transcripts from seven sessions of BPT and seven sessions of IPT, each involving different patients and different therapists. Separate therapists “blind” to treatment were asked to rate the transcripts for characteristics captured on a series of adherence scales, including BPT and IPT Adherence Scales. The results indicated very substantial differences between the treatments, with BPT more “interpretive” and IPT more “supportive” in nature.

The Treatment Manual

The Brief Psychoanalytic Therapy Treatment Manual is presented. This summarizes the rationale and principles of treatment—in part, distilling and organizing themes that had been introduced in Chapter 1—and then devotes attention to characterizing a particular style of attending to and interpreting the transference. In a final section of the chapter, the very beginning of the assessment consultation from Chapter 3 is revisited, in order to review how the therapeutic orientation and techniques described in the Manual can be identified in clinical material. In a manner that will be developed in subsequent chapters, therefore, principles are exemplified in clinical practice.

The place of Brief Psychoanalytic Therapy

The concluding chapter serves as an overview of the origins, challenges, limitations, and potential specialness of Brief Psychoanalytic Therapy. Here it is important to acknowledge, rather than gloss over, doubts and uncertainties that surround the approach. Should this be viewed as a discrete and distinctive 16-session treatment—which in some respects it is, especially in its narrow focus on working in the transference—or is it more a style of therapeutic engagement, one that could (for instance) constitute an element within a more eclectic approach? How far is the term “psychoanalytic” justified? In essence, Brief Psychoanalytic Therapy is an attempt to achieve a quality and depth of communication that promises to have special value in promoting a patient’s psychic integration and health.

The Adherence Manual

An Adherence Manual for Brief Psychoanalytic Therapy is presented. This Manual details how principles of treatment are embodied in the to and fro of patient–therapist verbal exchanges. There are 17 principles in the Manual, and for each of these principles, illustrative styles of intervention are presented. In addition, specific examples of therapist interventions are drawn from recordings of sessions. One function of the Adherence Manual is to allow for the assessment of the delivery of treatment, for research purposes (as described in a later chapter); another is to ground abstract technical guidelines in the down-to-earth minutiae of clinical practice.

Themes and variations in brief psychodynamic psychotherapy

This chapter surveys a range of relationship-orientated brief therapies: Interpersonal Therapy (IPT), Cognitive-Analytic Therapy (CAT), Dynamic Interpersonal Therapy (DIT), Intensive Short-Term Dynamic Psychotherapy (ISTDP), the Conversational Model (a version of which became known as Psychodynamic Interpersonal Therapy, or PIT), and Brief Psychoanalytic Therapy (BPT). Principles of treatment and mechanisms of change are considered, and for each approach, an excerpt of therapeutic dialogue provides vivid illustration. This establishes a basis for considering how far the treatments have features in common, and how far they are distinctive from one another. The chapter concludes by noting substantial evidence for the effectiveness of brief psychodynamic psychotherapies.

Therapeutic dialogues II

This chapter records a series of five extended vignettes that have been transcribed almost verbatim from transcripts of audiotaped sessions involving five different clinicians and their respective patients. The vignettes are considered in turn, and each of the 17 items of the Adherence Manual is seen to apply to the clinical material. This careful review of episodes of therapeutic dialogue strengthens the links already established among the Manual, the Adherence Manual, and the nitty gritty of verbal exchanges between patients and their therapists. It also extends the range of clinical material presented, introducing new patients and new therapists, each with their own style of emotional and intellectual conduct in the therapeutic encounter. Nevertheless, the different clinicians show remarkable consistency in therapeutic orientation.