Zgryźliwość kojarzy mi się z radością, która źle skończyła.
PERSONALITY STYLES AND BRIEF PSYCHOTHERAPY
Mardi Horowitz. Charles Marmar Janice Krupnick. Nancy Wilner Nancy Kaltreider. Robert Wallerstein
Basic Books, Inc., Publishers
NEW YORK
Excerpts from
DSM-III
reprinted by permission from the American Psychiatric Association,
Diagnostic and Statistical Manual of Mental Disorders,
Third Edition, Washington, D.C., APA, 1980.
Excerpts from Peter E. Sifneos,
Short-Term Psychotherapy and Emotional Crisis
(Cambridge, Mass.: Harvard University Press, 1972). Reprinted
by Permission.
Excerpts from Habib Davanloo, ed.,
Short-Term Dynamic Therapy
(New York: Jason Aronson, 1980). Reprinted by permission.
Library of Congress Cataloging in Publication Data
Main entry under title:
Personality styles and brief psychotherapy.
Bibliography: p. 331
Includes index.
1. Psychotherapy, Brief. 2. Mental illness-Diagnosis. I. Horowitz, Mardi J.
RC480.55.P47 1984 616.89'14 83-45378
ISBN 0-465-05575-3
Copyright © 1984 by Basic Books, Inc.
Printed in the United States of America
Designed by Vincent Torre
10 9 8 7 6 5 4 3 2 1
CONTENTS
ACNOWLEDGMENTS
ix
INTRODUCTION
xi
1. The History of Brief Dynamic Psychotherapy
3
2. Our Approach to Brief Therapy: Focused on
Current Stressors
34
3. Configurational Analysis: An Approach to Case
Formulation and Review
51
4. The Hysterical Personality
68
5. The More Disturbed Hysterical Personality
6. The Compulsive Personality
7. The Narcissistic Personality
8. The Borderline Personality
9. Change in Brief Psychotherapy
REFERENCES
INDEX
-vii-
ACKNOWLEDGMENTS
We acknowledge with gratitude the cooperation of the patients involved in entering a clinical research setting; consenting to the videotaping and
scientific study of their psychotherapies; and their continued dedication to this effort to improve treatment by returning for evaluation sessions
up to several years after the termination of treatment.
Extensive help was provided by the support of a clinical research center grant from the National Institute of Mental Health. The Center for the
Study of Neuroses at the Langley Porter Psychiatric Institute was also supported by the Department of Psychiatry at the University of California,
San Francisco. This work would not have been possible without the therapists at this clinical research center who, like their patients, allowed their
work together to be recorded on videotape.
We are also grateful to the staff at the Center for the Study of Neuroses who helped greatly to bring the present work to its completion. Daniel
Weiss, Kathryn DeWitt, Phyllis Cameron, JoLynne McSweeney, Tony Leong, Matthew Holden, Roy Gesley, Geri Krasner, and John Starkweather
especially merit our thanks. The concluding work on this book was facilitated by a fellowship year provided for the first author by the Center for
Advanced Studies in the Behavioral Sciences at Stanford University under a grant from the John D. and Catherine T. MacArthur Foundation.
Mardi Horowitz
Charles Marmar
Janice Krupnick
Nancy Wilner
Nancy Kaltreider
Robert Wallerstein
-ix-
INTRODUCTION
MOST PSYCHOTHERAPIES today begin without any time limit. The therapies do not necessarily last for a long time: many patients recover from
their symptoms quickly and terminate, while others drop out before termination. Such discontinued therapies, however, are not specifically
construed as time-limited. "Brief therapy" implies a limitation of time that is set in advance. For many it also implies a relatively narrow focus—
that is, concentration on a particular set of problems or a particular area of functioning.
We began our own type of brief therapy at the Center for the Study of Neuroses at the Langley Porter Psychiatric Institute of the University of
California, San Francisco. At that center we developed a special research clinic for stress and anxiety with a focus on stress-response syndromes
— that is, problems brought about by distressing, fairly recent life events. We developed a time-limited dynamic psychotherapy for the
amelioration of such syndromes. Although we concentrated on the effects of the particular disturbing life event, we found that each patient's
personality characteristics were prominent in our formulations of the patient's problems and in the plans that we developed for the treatment
process.
Our patients were not unusual. Anyone who seeks psychotherapy is under stress, regardless of whether or not a recent serious life event has
brought about this state. And psychotherapy itself imposes a threat because the person anticipates exposure and confrontation with ideas and
feelings that have usually been warded off, but which nonetheless may have had intrusive consequences. In response to this threat, the patient
will display habitual coping styles, often of a defensive or resistive na
-xi-
ture. The more inflexible these styles, the more the therapist will have to recognize and deal with them in order to work on problem areas.
Despite centuries of effort, there has been no generally agreed-upon framework for the classification of personalities. Since dynamic
psychotherapy focuses on transferences and resistances to therapy as well as the way in which it progresses, classifying personalities according
to various relationship styles and defensive styles appears appropriate. The theory of psychological defense was originated by psychoanalysts,
and in that tradition an important dichotomy has grown up between the
hysterical
defenses of repression and denial, and the relatively more
obsessional
defenses of intellectualization, reversal of affects, isolation, and undoing. More recently,
sliding of meanings
and
disavowal
in the
narcissistic personality, as well as splitting in the borderline personality, have been emphasized. We use these prototypes as a way of organizing
the chapters in this book.
While the book does make use of these prototypes, it basically presents a method for approaching personality individually. Each chapter deals
with a prototype, but it also indicates individual features that may deviate from that prototype. Each chapter also follows a method,
configurational analysis
, that allows the clinician to examine his or her cases in a highly individualized way. Our aim is to show readers how to
identify salient personality patterns in their own patients in the context of a brief therapy approach. Configurational analysis may also, however,
be useful in descriptive explanation of long-term therapies or psychoanalyses.
We begin with a review of brief therapy as it has been conducted by others. Imbedded in that review is a controversy about what aims are
appropriate when time is to be limited. At one extreme there are clinicians who claim that it is possible to resolve all neurotic character
difficulties. At the other extreme are those who feel that only relatively acute symptoms, such as those following a distressing life event, can be
worked through in a short time. Our position lies somewhere between these extremes, and is described in chapter 2.
Depending on the aims of brief therapy, different idealized criteria are used for the selection of patients. The more a patient meets these criteria,
the more likely it is that the therapy will proceed smoothly with positive consequences. Of course, people who do not meet these criteria may
nonetheless seek out brief therapy. Such people may certainly benefit, although perhaps not to the same degree as ideal candidates. In some
instances, for example, a brief therapy is the only kind that a patient will accept. Such patients may also resist engaging in an open-ended
agreement because they fear that they will become excessively dependent on
-xii-
the therapist without changing for the better. Many patients are less than ideal because of their personality traits. Understanding these
personality patterns is important if the therapist is to provide the patient with the best chance for therapeutic success.
In the description of our own approach in chapter 2, we emphasize our aim at symptom reduction, but in a context of work that might allow a
patient to learn new coping strategies, to modify enduring attitudes, and to improve habitual strategies for relating to others. We examine each
prototype both in terms of symptom reduction and in terms of the patient's progress in a broader sense.
In chapter 3 we present configurational analysis, our method of descriptive explanation. We use this method in chapters 4 through 8 as a way of
organizing observations and illustrating different personality styles. The beginning section of each of these chapters considers the presenting
picture, and provides a discussion of the reasons behind symptom formation. The next section of the chapter deals at length with the therapy
process. Finally, we describe the outcome of each case. These outcomes were assessed through systematic interviews conducted several months
after the conclusion of the therapies.
The representative cases described in chapters 4 through 8 are based on our clinical records. In many ways, however, these are composite cases.
In order to disguise identity, or to illustrate a given dynamic more sharply, material from a given patient has been changed, deleted, or
substituted by material from another patient drawn from the same typology. However, quantitative data, as contained in the Patterns of
Individual Change and other rating-scale data reported in the outcome sections of each chapter, is not composited; it is the data obtained from a
specific representative case. In changing a patient's individual characteristics, we have paid attention to preserving dynamic implications.
The final chapter considers the change processes in brief therapy, raising for discussion the question of what changes are possible when time is
limited.
-xiii-
1
THE HISTORY OF
BRIEF DYNAMIC
PSYC HOT H E RAPY
ALTHOUGH the history of psychoanalysis has been characterized by a trend toward increasing length of treatment, there have been occasional
counter efforts. Those of Ferenczi stand out; for a time he advocated "active therapy" as an effort to shorten the length of therapy. In a paper
written in 1920, he presented the theoretical rationale for his approach, citing Freud's observation (1919) that in the treatment of phobic and
obsessional anxiety it was often necessary to suggest firmly that the patient confront a phobic situation as a necessary adjunct to the analysis of
the unconscious reasons for symptom formation, and to encourage such efforts once they were made. Ferenczi (cited in Marmor 1979) believed
that the ideal of a neutral and unobtrusive analyst was unattainable, because each time the analyst interpreted patient material, the flow of the
patient's "free" associations was interrupted to some degree, stimulating a new train of thought that otherwise would not have occurred in that
exact form or at that exact moment. In this sense, Ferenczi argued that all therapeutic techniques were suggestive to some degree ; his
explicitly active technique differed only in degree and timing.
Despite this rationale, it was clear that Ferenczi advocated a controversial shift toward directive therapy. He prohibited such tension-reducing
-3-
activities as masturbation, in an effort to increase the expression of warded-off themes. He advocated restorative care for especially impaired
patients who had suffered childhood losses and trauma. This rationale covered such activities as hugging and kissing, and motivated Freud to
respond with the now famous "God the Father" letter (Jones 1957) in which he remonstrated with Ferenczi on the dangers of clouding the
boundaries between therapeutic and social relationships.
Ferenczi's views on a technique that was brief, more active, and more focused in the present brought him into collaboration with Otto Rank,
whose theoretical position was evolving in a similar direction. The result was their publication of
The Development of Psychoanalysis
(1925), a
book that criticized some aspects of psychoanalysis and advocated brief dynamic psychotherapy. Some of Ferenczi and Rank's concepts are still
used in contemporary therapy; others have been left behind. Rank's work on birth trauma (1924) also led him into confrontation with the
prevailing psychoanalytic view of the primacy of oedipal problems. As his thinking evolved, he modified his view that the physical separation of
mother and child at the moment of birth was crucial for adaptation, advocating that the later emotional emancipation of the child from the
mother was more germane. In so doing, he laid the foundation for the work on attachment, bonding, separation, and individuation by Spitz,
Bowlby, Mahler, and others, who were important contributors to recognition of the powerful role of pre-oedipal factors in human development.
Rank's concern with separation led to an emphasis on time-limited treatment and an early focus on the meanings of separation that are currently
reiterated in the work of Mann (1973; Mann and Goldman 1982). Finally, Rank's writings on "will therapy" (1947) are seen by Marmor, in his
review of historical trends in psychotherapy (1979), as seminal for later selection criteria for brief psychotherapy:
If we substitute the more modem term "motivation" for the word "will," we find that Rank was saying something that has been emphasized by all
modem theorists about short-term dynamic psychotherapy, namely, the overwhelming importance of the patient's having a strong motivation to
change, if a favorable therapeutic outcome is to be achieved by this technique. In this connection, it is noteworthy that four of the seven criteria
for motivation to change that Sifneos (1972) utilizes for selecting [people] for brief dynamic psychotherapy employ the concept of "willingness,"
i.e., willingness to actively participate in the treatment situation, willingness to understand oneself, willingness to change, and willingness to
make reasonable sacrifice in terms of time and fees. What is willingness in this context but the ability to mobilize one's will towards the particular
objectives ? (Marmor 1979, p. 6)
-4-
Alexander and French (1946) followed Ferenczi and Rank as important figures in the historical evolution of brief dynamic psychotherapy. They
experimented with methods for accomplishing a time-limited psychoanalysis. Their report on the findings of the research project of the Chicago
Institute of Psychoanalysis is best known for the concept of the "corrective emotional experience" as a curative agent in psychotherapy. This is
defined in the glossary of the third edition of the
Comprehensive Textbook of Psychiatry
(Kaplan, Freedman, and Sadock 1980) as "reexposure
under favorable circumstances to an emotional situation that the patient could not handle in the past." In the approach advocated by Alexander
and French, the therapist temporarily assumes a particular role to "generate the experience and facilitate reality testing." If, for example, a
person has been traumatized by repeated exposure to a hostile, abusive world, the therapist might adopt a warm, compassionate, empathic role
to provide a compensatory or "corrective" experience. At the time it was proposed, this approach aroused major criticism and was rejected by
the majority of psychoanalytically oriented theorists.
Use of the "corrective emotional experience" carries therapeutic risks as well. The kindly therapist may play into the patient's unfulfilled wish to
establish a relationship patterned on the model of a loving parent caring for an adorable child. This role relationship model may facilitate
remission of symptoms, but at the same time it may conceal a neglectful parent, abused child view of the relationship by encouraging an
idealized transference. The result may be an increase in the repression, or splitting off from consciousness, of this relationship potential,
rendering work on an important interpersonal pattern less accessible in subsequent therapy (Gill 1954). Such negative role representations might
easily be reactivated later in the face of the unpredictable and not necessarily "corrective" vicissitudes of everyday life.
An alternative approach, directly counter to Alexander's prescription, is sometimes advocated by brief therapists in the treatment of patients with
a history of parental abuse. The therapist adopts a provocatively critical role, in an effort to mobilize negative transference and permit earlier
working through. This approach is anxiety-provoking, may intensify symptoms, and may undermine the therapeutic alliance.
Unfortunately, because of the time constraints of brief active therapies, both of these approaches carry risks: either manipulative
retraumatization or defensive idealization may occur. In contrast, the meticulously neutral stance of the long-term therapist permits a natural
emergence and working through of both idealizing and denigrating transferences. These
-5-
are more difficult for the patient to disavow precisely because they have not been directly provoked by the therapist.
In presenting their ideas, Alexander and French (1946) challenged the prevailing assumptions that length and depth of therapy were positively
correlated, that the stability of the outcome was a function of the duration of treatment, and that the regressions observed in long-term therapy
were necessary for the resolution of the patient's psychopathology. They advocated countering regression by shortening the treatment, seeing
patients at less frequent and sometimes irregular intervals, and remaining focused on the present rather than fostering a reconstruction of
childhood trauma. They believed that the value of formulations concerning the generation of conflicts was not to resurrect the past, but rather to
guide the therapist in providing the optimal corrective experience in the present.
The corrective emotional experience approach can be seen as an effort to accelerate the time course of a relatively complete psychoanalysis,
rather than an attempt to evolve specific techniques for brief and problem-focused dynamic psychotherapy. By comparison, the contemporary
approaches to brief therapy are more restricted in scope, with a single focus (or at most several dynamically related foci) chosen at the exclusion
of other possible issues. The theoretical contributions of French (1958, 1970) are relevant in this regard. He introduced the term "focal conflict"
to refer to a situation where a wish or impulse, in conflict with a person's enduring values and expectations, leads to a defensive compromise.
Since confrontation with all three features—wish, threat, defensive compromise—might help a patient to arrive at more adaptive positions, this
model has been referred to as one of several "triangles of insight."
Formulation of the focal conflict in therapy serves to guide interpretive work around an organizing theme, a strategy independently advanced by
Balint, Ornstein, and Balint in their influential work
Focal Psychotherapy
(1972). In this intensive, single case study of a brief psychotherapeutic
treatment, they explicate the technique of restricting brief psychotherapy to a particular sector of the personality.
Malan (1963) summarized additional departures from techniques that were originally advocated by Ferenczi. These include a time limit set at the
outset of treatment, requests for the patient to fantasize about a specific theme (forced fantasies), and the playing of a specific role in relation to
the patient in order to facilitate the emergence of transference reactions. The technique of "seeding," or manipulating, the transference has the
apparent advantage of accelerating its development and the possible disadvantage of traumatizing the patient, causing him to feel manipulated
or to disavow his own contribution (Gill 1954).
-6-
The following overview of the proliferation of theoretical and technical reports on brief dynamic psychotherapies over the past twenty years draws
on several excellent reviews, particularly those of Malan (1976); Burke, White, and Havens (1979); Marmor (1979); Davanloo (1979, 1980); and
Budman (1981).
Intensive Brief Psychotherapy: The Contributions of
David Malan and the British School
The British contribution to the theory, practice, and evaluation of brief dynamic psychotherapy is central to contemporary developments. Such
work began with the pioneering work of Balint, Ornstein, and Balint on focal psychotherapy (1972) and evolved through the seminal clinical and
research contributions of David Malan. A distillation of the British efforts is found in Malan's book (1976a) on research and clinical practice.
Malan's book is a noteworthy exception to the statement that psychotherapy research and psychotherapy practice run a parallel but never
intersecting course (Wallerstein 1976; Parloff 1982).
The history of the British effort began with Balint's workshop, an alliance of the experienced psychoanalytic psychotherapists working at the
Tavistock Clinic and those at the Cassel Hospital, with an initial emphasis on clinical rather than empirical evaluation. As Malan, a participant in
the workshop, described this effort, "Judgments, when made, were by consensus of opinion, or in Balint's words, knocking our heads together
until something comes out of it, which has its own advantages, like trial by 'jury' " (1963, p. 40). Malan developed and applied methods for
assessing process and outcome variables to a sample of cases from the workshop. He later replicated and extended this effort in his own project
at the Tavistock Brief Therapy Unit.
ASSESSMENT OF SUITABILITY
Malan considers the initial evaluation and selection process to be critical. The evaluation begins with a psychiatric history, in order to exclude
individuals with more serious psychopathology such as mania, depression, schizophreniform psychoses, as well as those who have made serious
suicide attempts, had extensive early trauma, or have entangled marital and family problems. Next comes a psychodynamic history, which
stresses the quality of interpersonal relations and recurrent conflict pat
-7-
terns. How emotionally open the patient is able to be with the interviewer, and how he responds to early interpretations of derivative aspects of
the core neurotic conflict, are indicative of how well the therapy process might proceed.
Like others in the field (Sifneos 1972, 1979; Davanloo 1980), Malan assesses patient's initial motivation for psychotherapy and focality of
complaint. He explains the purpose of this:
At the end of the psychiatric interview, therefore, it should be possible to make a full psychodynamic diagnosis, and to see whether there seems
to be some circumscribed aspect of pathology that can be made into a focus, and hence, whether there appears to be a possible therapeutic
plan. These are all aspects of the therapist's role, and thus represent only half of the information that has been provided. It should also be
possible to answer many questions to do with the patient's role: to forecast likely events if he undergoes uncovering psychotherapy, and to
assess his capacity for insight, ability to respond to interpretation, strength to face anxiety provoking material, potential for growth, and
motivation to carry him through the stresses of therapy (Malan 1976, p. 254).
Malan recommends fixing the time limit from the outset, and prefers a termination date rather than an exact number of sessions. He does report
in one of his studies a median length of eighteen sessions for experienced therapists, and a standard limit of thirty sessions for trainees. This is
essentially in agreement with Mann (1973, 1980) and differs from the practices of Sifneos (1972) and Davanloo (1980), who set the termination
date during mid or late treatment rather than before it begins.
TECHNIQUES OF TREATMENT
Malan (1976) has provided a sequence that might unfold in a prototypical case. He refers to two triangles. One of them has already been
mentioned. It consists of the aim, the moral injunction or social threat that makes the aim dangerous, and the defense used to reduce anxiety.
Conflict is usually regarded as the play of forces, ideas, feelings, or plans between these impulsive and defensive aims.
The second "triangle of insight," which Menninger (1958) described particularly well, conceptualizes a recurring maladaptive relationship pattern
found in three contexts. One of these consists of projections and introjections about the relationship with the therapist (transference). The
second is recently terminated or current relationships outside of therapy as described within it. The third context is past real or imagined
transactions with parental figures, siblings, and other primary figures.
Malan emphasizes the importance of interpretations that link these relationship patterns in order to establish insight into the patient's con
-8-
stant, recurrent, conflictual, and maladaptive schemata—that is, the internalized relationship pattern. He especially emphasizes interpretations
that show the recursiveness of patterns within the transference and those with parental-type figures. He calls the links between patterns of
relationship projected into the therapy situation and equivalent patterns with primal past figures the T/P link—that is, the transference-parent
link. The skill of a brief therapist is determined in part by the capacity to identify such dynamics quickly but accurately, and to pace the sequence
of interpretations about them at the appropriate "depth" or tolerable dosage for a given patient. Malan noted:
1. The impulse-defense triad should be interpreted before the triangle of insight, i.e., the components of the conflict should be clarified in
one area before the link is made to another.
2. As far as the individual components of the impulse-defense triad are concemed, the defense should usually be interpreted first, and the
anxiety should be interpreted with the impulse. One of the main aims of therapy, however, is to reach the impulse.
3. When this triad has been clarified in one area then the link should be made to another.
4. There is no general rule as to the sequencing with which the triangle of insights should be interpreted. This depends largely on the
rapidity with which the transference develops, which is not under the therapist's control. However, as soon as the transference does
develop, it should be clarified in terms of the three components of the impulse-defense triad, and the ultimate aim of therapy is to make
the link with the past (the T/P link) many times and in as meaningful a way as possible.
5. Finally, all of the above principles converge towards suggesting that of all the different types of interpretations that it is possible to make,
it is the impulse component of the T/P link that is the most important (Malan 1976, pp. 261-62).
THE TERMINATION PHASE
The patient's reactions to termination are guided by the nature of the core conflict, and, in a prototypical case, the major therapist-parent linking
interpretations are repeated in the course of understanding these reactions. Termination is also seen as having an organizing effect that
counteracts the dangers of diffusion of focus.
-9-
Short-Term Anxiety-Provoking Psychotherapy:
The Work of Peter Sifneos
At the time that David Malan was articulating the theory and technique of brief psychodynamic psychotherapy at the Tavistock Clinic in London,
Peter Sifneos was reaching similar conclusions at the Massachusetts General Hospital in Boston.Along with Malan, Sifneos departed radically from
a tradition of short
‐
term supportive (anxiety-suppressive) psychotherapy by using confrontational interpretations that were usually reserved for
psychoanalytic psychotherapy or psychoanalysis. His approach, too, is aimed at effecting enduring characterological changes through resolution
of a core neurotic conflict.Sifneos' procedure emphasizes stringent inclusion and exclusion criteria, determined through screening interviews.
Patients need to be able to engage rapidly; to tolerate the anxiety provoked by early and repeated interpretations of defenses, transference, and
impulses; and to take an active part in working through in the brief time frame. Patients who display the following characteristics are thought to
be most appropriate (Sifneos 1972):
1. Above-average intelligence (reflected in a capacity for new learning).
2. A history of at least one meaningful relationship during the patient's lifetime (implying shared intimacy, trust, and emotional
involvement).
3. The ability to interact well with the evaluator (reflected in flexibility in style and access to emotion).
4. A circumscribed chief complaint.
5. Motivation for change. (This is a multifaceted concept involving the ability to recognize that symptoms are psychological in origin; the
zanotowane.pl doc.pisz.pl pdf.pisz.pl hannaeva.xlx.pl
Mardi Horowitz. Charles Marmar Janice Krupnick. Nancy Wilner Nancy Kaltreider. Robert Wallerstein
Basic Books, Inc., Publishers
NEW YORK
Excerpts from
DSM-III
reprinted by permission from the American Psychiatric Association,
Diagnostic and Statistical Manual of Mental Disorders,
Third Edition, Washington, D.C., APA, 1980.
Excerpts from Peter E. Sifneos,
Short-Term Psychotherapy and Emotional Crisis
(Cambridge, Mass.: Harvard University Press, 1972). Reprinted
by Permission.
Excerpts from Habib Davanloo, ed.,
Short-Term Dynamic Therapy
(New York: Jason Aronson, 1980). Reprinted by permission.
Library of Congress Cataloging in Publication Data
Main entry under title:
Personality styles and brief psychotherapy.
Bibliography: p. 331
Includes index.
1. Psychotherapy, Brief. 2. Mental illness-Diagnosis. I. Horowitz, Mardi J.
RC480.55.P47 1984 616.89'14 83-45378
ISBN 0-465-05575-3
Copyright © 1984 by Basic Books, Inc.
Printed in the United States of America
Designed by Vincent Torre
10 9 8 7 6 5 4 3 2 1
CONTENTS
ACNOWLEDGMENTS
ix
INTRODUCTION
xi
1. The History of Brief Dynamic Psychotherapy
3
2. Our Approach to Brief Therapy: Focused on
Current Stressors
34
3. Configurational Analysis: An Approach to Case
Formulation and Review
51
4. The Hysterical Personality
68
5. The More Disturbed Hysterical Personality
6. The Compulsive Personality
7. The Narcissistic Personality
8. The Borderline Personality
9. Change in Brief Psychotherapy
REFERENCES
INDEX
-vii-
ACKNOWLEDGMENTS
We acknowledge with gratitude the cooperation of the patients involved in entering a clinical research setting; consenting to the videotaping and
scientific study of their psychotherapies; and their continued dedication to this effort to improve treatment by returning for evaluation sessions
up to several years after the termination of treatment.
Extensive help was provided by the support of a clinical research center grant from the National Institute of Mental Health. The Center for the
Study of Neuroses at the Langley Porter Psychiatric Institute was also supported by the Department of Psychiatry at the University of California,
San Francisco. This work would not have been possible without the therapists at this clinical research center who, like their patients, allowed their
work together to be recorded on videotape.
We are also grateful to the staff at the Center for the Study of Neuroses who helped greatly to bring the present work to its completion. Daniel
Weiss, Kathryn DeWitt, Phyllis Cameron, JoLynne McSweeney, Tony Leong, Matthew Holden, Roy Gesley, Geri Krasner, and John Starkweather
especially merit our thanks. The concluding work on this book was facilitated by a fellowship year provided for the first author by the Center for
Advanced Studies in the Behavioral Sciences at Stanford University under a grant from the John D. and Catherine T. MacArthur Foundation.
Mardi Horowitz
Charles Marmar
Janice Krupnick
Nancy Wilner
Nancy Kaltreider
Robert Wallerstein
-ix-
INTRODUCTION
MOST PSYCHOTHERAPIES today begin without any time limit. The therapies do not necessarily last for a long time: many patients recover from
their symptoms quickly and terminate, while others drop out before termination. Such discontinued therapies, however, are not specifically
construed as time-limited. "Brief therapy" implies a limitation of time that is set in advance. For many it also implies a relatively narrow focus—
that is, concentration on a particular set of problems or a particular area of functioning.
We began our own type of brief therapy at the Center for the Study of Neuroses at the Langley Porter Psychiatric Institute of the University of
California, San Francisco. At that center we developed a special research clinic for stress and anxiety with a focus on stress-response syndromes
— that is, problems brought about by distressing, fairly recent life events. We developed a time-limited dynamic psychotherapy for the
amelioration of such syndromes. Although we concentrated on the effects of the particular disturbing life event, we found that each patient's
personality characteristics were prominent in our formulations of the patient's problems and in the plans that we developed for the treatment
process.
Our patients were not unusual. Anyone who seeks psychotherapy is under stress, regardless of whether or not a recent serious life event has
brought about this state. And psychotherapy itself imposes a threat because the person anticipates exposure and confrontation with ideas and
feelings that have usually been warded off, but which nonetheless may have had intrusive consequences. In response to this threat, the patient
will display habitual coping styles, often of a defensive or resistive na
-xi-
ture. The more inflexible these styles, the more the therapist will have to recognize and deal with them in order to work on problem areas.
Despite centuries of effort, there has been no generally agreed-upon framework for the classification of personalities. Since dynamic
psychotherapy focuses on transferences and resistances to therapy as well as the way in which it progresses, classifying personalities according
to various relationship styles and defensive styles appears appropriate. The theory of psychological defense was originated by psychoanalysts,
and in that tradition an important dichotomy has grown up between the
hysterical
defenses of repression and denial, and the relatively more
obsessional
defenses of intellectualization, reversal of affects, isolation, and undoing. More recently,
sliding of meanings
and
disavowal
in the
narcissistic personality, as well as splitting in the borderline personality, have been emphasized. We use these prototypes as a way of organizing
the chapters in this book.
While the book does make use of these prototypes, it basically presents a method for approaching personality individually. Each chapter deals
with a prototype, but it also indicates individual features that may deviate from that prototype. Each chapter also follows a method,
configurational analysis
, that allows the clinician to examine his or her cases in a highly individualized way. Our aim is to show readers how to
identify salient personality patterns in their own patients in the context of a brief therapy approach. Configurational analysis may also, however,
be useful in descriptive explanation of long-term therapies or psychoanalyses.
We begin with a review of brief therapy as it has been conducted by others. Imbedded in that review is a controversy about what aims are
appropriate when time is to be limited. At one extreme there are clinicians who claim that it is possible to resolve all neurotic character
difficulties. At the other extreme are those who feel that only relatively acute symptoms, such as those following a distressing life event, can be
worked through in a short time. Our position lies somewhere between these extremes, and is described in chapter 2.
Depending on the aims of brief therapy, different idealized criteria are used for the selection of patients. The more a patient meets these criteria,
the more likely it is that the therapy will proceed smoothly with positive consequences. Of course, people who do not meet these criteria may
nonetheless seek out brief therapy. Such people may certainly benefit, although perhaps not to the same degree as ideal candidates. In some
instances, for example, a brief therapy is the only kind that a patient will accept. Such patients may also resist engaging in an open-ended
agreement because they fear that they will become excessively dependent on
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the therapist without changing for the better. Many patients are less than ideal because of their personality traits. Understanding these
personality patterns is important if the therapist is to provide the patient with the best chance for therapeutic success.
In the description of our own approach in chapter 2, we emphasize our aim at symptom reduction, but in a context of work that might allow a
patient to learn new coping strategies, to modify enduring attitudes, and to improve habitual strategies for relating to others. We examine each
prototype both in terms of symptom reduction and in terms of the patient's progress in a broader sense.
In chapter 3 we present configurational analysis, our method of descriptive explanation. We use this method in chapters 4 through 8 as a way of
organizing observations and illustrating different personality styles. The beginning section of each of these chapters considers the presenting
picture, and provides a discussion of the reasons behind symptom formation. The next section of the chapter deals at length with the therapy
process. Finally, we describe the outcome of each case. These outcomes were assessed through systematic interviews conducted several months
after the conclusion of the therapies.
The representative cases described in chapters 4 through 8 are based on our clinical records. In many ways, however, these are composite cases.
In order to disguise identity, or to illustrate a given dynamic more sharply, material from a given patient has been changed, deleted, or
substituted by material from another patient drawn from the same typology. However, quantitative data, as contained in the Patterns of
Individual Change and other rating-scale data reported in the outcome sections of each chapter, is not composited; it is the data obtained from a
specific representative case. In changing a patient's individual characteristics, we have paid attention to preserving dynamic implications.
The final chapter considers the change processes in brief therapy, raising for discussion the question of what changes are possible when time is
limited.
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1
THE HISTORY OF
BRIEF DYNAMIC
PSYC HOT H E RAPY
ALTHOUGH the history of psychoanalysis has been characterized by a trend toward increasing length of treatment, there have been occasional
counter efforts. Those of Ferenczi stand out; for a time he advocated "active therapy" as an effort to shorten the length of therapy. In a paper
written in 1920, he presented the theoretical rationale for his approach, citing Freud's observation (1919) that in the treatment of phobic and
obsessional anxiety it was often necessary to suggest firmly that the patient confront a phobic situation as a necessary adjunct to the analysis of
the unconscious reasons for symptom formation, and to encourage such efforts once they were made. Ferenczi (cited in Marmor 1979) believed
that the ideal of a neutral and unobtrusive analyst was unattainable, because each time the analyst interpreted patient material, the flow of the
patient's "free" associations was interrupted to some degree, stimulating a new train of thought that otherwise would not have occurred in that
exact form or at that exact moment. In this sense, Ferenczi argued that all therapeutic techniques were suggestive to some degree ; his
explicitly active technique differed only in degree and timing.
Despite this rationale, it was clear that Ferenczi advocated a controversial shift toward directive therapy. He prohibited such tension-reducing
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activities as masturbation, in an effort to increase the expression of warded-off themes. He advocated restorative care for especially impaired
patients who had suffered childhood losses and trauma. This rationale covered such activities as hugging and kissing, and motivated Freud to
respond with the now famous "God the Father" letter (Jones 1957) in which he remonstrated with Ferenczi on the dangers of clouding the
boundaries between therapeutic and social relationships.
Ferenczi's views on a technique that was brief, more active, and more focused in the present brought him into collaboration with Otto Rank,
whose theoretical position was evolving in a similar direction. The result was their publication of
The Development of Psychoanalysis
(1925), a
book that criticized some aspects of psychoanalysis and advocated brief dynamic psychotherapy. Some of Ferenczi and Rank's concepts are still
used in contemporary therapy; others have been left behind. Rank's work on birth trauma (1924) also led him into confrontation with the
prevailing psychoanalytic view of the primacy of oedipal problems. As his thinking evolved, he modified his view that the physical separation of
mother and child at the moment of birth was crucial for adaptation, advocating that the later emotional emancipation of the child from the
mother was more germane. In so doing, he laid the foundation for the work on attachment, bonding, separation, and individuation by Spitz,
Bowlby, Mahler, and others, who were important contributors to recognition of the powerful role of pre-oedipal factors in human development.
Rank's concern with separation led to an emphasis on time-limited treatment and an early focus on the meanings of separation that are currently
reiterated in the work of Mann (1973; Mann and Goldman 1982). Finally, Rank's writings on "will therapy" (1947) are seen by Marmor, in his
review of historical trends in psychotherapy (1979), as seminal for later selection criteria for brief psychotherapy:
If we substitute the more modem term "motivation" for the word "will," we find that Rank was saying something that has been emphasized by all
modem theorists about short-term dynamic psychotherapy, namely, the overwhelming importance of the patient's having a strong motivation to
change, if a favorable therapeutic outcome is to be achieved by this technique. In this connection, it is noteworthy that four of the seven criteria
for motivation to change that Sifneos (1972) utilizes for selecting [people] for brief dynamic psychotherapy employ the concept of "willingness,"
i.e., willingness to actively participate in the treatment situation, willingness to understand oneself, willingness to change, and willingness to
make reasonable sacrifice in terms of time and fees. What is willingness in this context but the ability to mobilize one's will towards the particular
objectives ? (Marmor 1979, p. 6)
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Alexander and French (1946) followed Ferenczi and Rank as important figures in the historical evolution of brief dynamic psychotherapy. They
experimented with methods for accomplishing a time-limited psychoanalysis. Their report on the findings of the research project of the Chicago
Institute of Psychoanalysis is best known for the concept of the "corrective emotional experience" as a curative agent in psychotherapy. This is
defined in the glossary of the third edition of the
Comprehensive Textbook of Psychiatry
(Kaplan, Freedman, and Sadock 1980) as "reexposure
under favorable circumstances to an emotional situation that the patient could not handle in the past." In the approach advocated by Alexander
and French, the therapist temporarily assumes a particular role to "generate the experience and facilitate reality testing." If, for example, a
person has been traumatized by repeated exposure to a hostile, abusive world, the therapist might adopt a warm, compassionate, empathic role
to provide a compensatory or "corrective" experience. At the time it was proposed, this approach aroused major criticism and was rejected by
the majority of psychoanalytically oriented theorists.
Use of the "corrective emotional experience" carries therapeutic risks as well. The kindly therapist may play into the patient's unfulfilled wish to
establish a relationship patterned on the model of a loving parent caring for an adorable child. This role relationship model may facilitate
remission of symptoms, but at the same time it may conceal a neglectful parent, abused child view of the relationship by encouraging an
idealized transference. The result may be an increase in the repression, or splitting off from consciousness, of this relationship potential,
rendering work on an important interpersonal pattern less accessible in subsequent therapy (Gill 1954). Such negative role representations might
easily be reactivated later in the face of the unpredictable and not necessarily "corrective" vicissitudes of everyday life.
An alternative approach, directly counter to Alexander's prescription, is sometimes advocated by brief therapists in the treatment of patients with
a history of parental abuse. The therapist adopts a provocatively critical role, in an effort to mobilize negative transference and permit earlier
working through. This approach is anxiety-provoking, may intensify symptoms, and may undermine the therapeutic alliance.
Unfortunately, because of the time constraints of brief active therapies, both of these approaches carry risks: either manipulative
retraumatization or defensive idealization may occur. In contrast, the meticulously neutral stance of the long-term therapist permits a natural
emergence and working through of both idealizing and denigrating transferences. These
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are more difficult for the patient to disavow precisely because they have not been directly provoked by the therapist.
In presenting their ideas, Alexander and French (1946) challenged the prevailing assumptions that length and depth of therapy were positively
correlated, that the stability of the outcome was a function of the duration of treatment, and that the regressions observed in long-term therapy
were necessary for the resolution of the patient's psychopathology. They advocated countering regression by shortening the treatment, seeing
patients at less frequent and sometimes irregular intervals, and remaining focused on the present rather than fostering a reconstruction of
childhood trauma. They believed that the value of formulations concerning the generation of conflicts was not to resurrect the past, but rather to
guide the therapist in providing the optimal corrective experience in the present.
The corrective emotional experience approach can be seen as an effort to accelerate the time course of a relatively complete psychoanalysis,
rather than an attempt to evolve specific techniques for brief and problem-focused dynamic psychotherapy. By comparison, the contemporary
approaches to brief therapy are more restricted in scope, with a single focus (or at most several dynamically related foci) chosen at the exclusion
of other possible issues. The theoretical contributions of French (1958, 1970) are relevant in this regard. He introduced the term "focal conflict"
to refer to a situation where a wish or impulse, in conflict with a person's enduring values and expectations, leads to a defensive compromise.
Since confrontation with all three features—wish, threat, defensive compromise—might help a patient to arrive at more adaptive positions, this
model has been referred to as one of several "triangles of insight."
Formulation of the focal conflict in therapy serves to guide interpretive work around an organizing theme, a strategy independently advanced by
Balint, Ornstein, and Balint in their influential work
Focal Psychotherapy
(1972). In this intensive, single case study of a brief psychotherapeutic
treatment, they explicate the technique of restricting brief psychotherapy to a particular sector of the personality.
Malan (1963) summarized additional departures from techniques that were originally advocated by Ferenczi. These include a time limit set at the
outset of treatment, requests for the patient to fantasize about a specific theme (forced fantasies), and the playing of a specific role in relation to
the patient in order to facilitate the emergence of transference reactions. The technique of "seeding," or manipulating, the transference has the
apparent advantage of accelerating its development and the possible disadvantage of traumatizing the patient, causing him to feel manipulated
or to disavow his own contribution (Gill 1954).
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The following overview of the proliferation of theoretical and technical reports on brief dynamic psychotherapies over the past twenty years draws
on several excellent reviews, particularly those of Malan (1976); Burke, White, and Havens (1979); Marmor (1979); Davanloo (1979, 1980); and
Budman (1981).
Intensive Brief Psychotherapy: The Contributions of
David Malan and the British School
The British contribution to the theory, practice, and evaluation of brief dynamic psychotherapy is central to contemporary developments. Such
work began with the pioneering work of Balint, Ornstein, and Balint on focal psychotherapy (1972) and evolved through the seminal clinical and
research contributions of David Malan. A distillation of the British efforts is found in Malan's book (1976a) on research and clinical practice.
Malan's book is a noteworthy exception to the statement that psychotherapy research and psychotherapy practice run a parallel but never
intersecting course (Wallerstein 1976; Parloff 1982).
The history of the British effort began with Balint's workshop, an alliance of the experienced psychoanalytic psychotherapists working at the
Tavistock Clinic and those at the Cassel Hospital, with an initial emphasis on clinical rather than empirical evaluation. As Malan, a participant in
the workshop, described this effort, "Judgments, when made, were by consensus of opinion, or in Balint's words, knocking our heads together
until something comes out of it, which has its own advantages, like trial by 'jury' " (1963, p. 40). Malan developed and applied methods for
assessing process and outcome variables to a sample of cases from the workshop. He later replicated and extended this effort in his own project
at the Tavistock Brief Therapy Unit.
ASSESSMENT OF SUITABILITY
Malan considers the initial evaluation and selection process to be critical. The evaluation begins with a psychiatric history, in order to exclude
individuals with more serious psychopathology such as mania, depression, schizophreniform psychoses, as well as those who have made serious
suicide attempts, had extensive early trauma, or have entangled marital and family problems. Next comes a psychodynamic history, which
stresses the quality of interpersonal relations and recurrent conflict pat
-7-
terns. How emotionally open the patient is able to be with the interviewer, and how he responds to early interpretations of derivative aspects of
the core neurotic conflict, are indicative of how well the therapy process might proceed.
Like others in the field (Sifneos 1972, 1979; Davanloo 1980), Malan assesses patient's initial motivation for psychotherapy and focality of
complaint. He explains the purpose of this:
At the end of the psychiatric interview, therefore, it should be possible to make a full psychodynamic diagnosis, and to see whether there seems
to be some circumscribed aspect of pathology that can be made into a focus, and hence, whether there appears to be a possible therapeutic
plan. These are all aspects of the therapist's role, and thus represent only half of the information that has been provided. It should also be
possible to answer many questions to do with the patient's role: to forecast likely events if he undergoes uncovering psychotherapy, and to
assess his capacity for insight, ability to respond to interpretation, strength to face anxiety provoking material, potential for growth, and
motivation to carry him through the stresses of therapy (Malan 1976, p. 254).
Malan recommends fixing the time limit from the outset, and prefers a termination date rather than an exact number of sessions. He does report
in one of his studies a median length of eighteen sessions for experienced therapists, and a standard limit of thirty sessions for trainees. This is
essentially in agreement with Mann (1973, 1980) and differs from the practices of Sifneos (1972) and Davanloo (1980), who set the termination
date during mid or late treatment rather than before it begins.
TECHNIQUES OF TREATMENT
Malan (1976) has provided a sequence that might unfold in a prototypical case. He refers to two triangles. One of them has already been
mentioned. It consists of the aim, the moral injunction or social threat that makes the aim dangerous, and the defense used to reduce anxiety.
Conflict is usually regarded as the play of forces, ideas, feelings, or plans between these impulsive and defensive aims.
The second "triangle of insight," which Menninger (1958) described particularly well, conceptualizes a recurring maladaptive relationship pattern
found in three contexts. One of these consists of projections and introjections about the relationship with the therapist (transference). The
second is recently terminated or current relationships outside of therapy as described within it. The third context is past real or imagined
transactions with parental figures, siblings, and other primary figures.
Malan emphasizes the importance of interpretations that link these relationship patterns in order to establish insight into the patient's con
-8-
stant, recurrent, conflictual, and maladaptive schemata—that is, the internalized relationship pattern. He especially emphasizes interpretations
that show the recursiveness of patterns within the transference and those with parental-type figures. He calls the links between patterns of
relationship projected into the therapy situation and equivalent patterns with primal past figures the T/P link—that is, the transference-parent
link. The skill of a brief therapist is determined in part by the capacity to identify such dynamics quickly but accurately, and to pace the sequence
of interpretations about them at the appropriate "depth" or tolerable dosage for a given patient. Malan noted:
1. The impulse-defense triad should be interpreted before the triangle of insight, i.e., the components of the conflict should be clarified in
one area before the link is made to another.
2. As far as the individual components of the impulse-defense triad are concemed, the defense should usually be interpreted first, and the
anxiety should be interpreted with the impulse. One of the main aims of therapy, however, is to reach the impulse.
3. When this triad has been clarified in one area then the link should be made to another.
4. There is no general rule as to the sequencing with which the triangle of insights should be interpreted. This depends largely on the
rapidity with which the transference develops, which is not under the therapist's control. However, as soon as the transference does
develop, it should be clarified in terms of the three components of the impulse-defense triad, and the ultimate aim of therapy is to make
the link with the past (the T/P link) many times and in as meaningful a way as possible.
5. Finally, all of the above principles converge towards suggesting that of all the different types of interpretations that it is possible to make,
it is the impulse component of the T/P link that is the most important (Malan 1976, pp. 261-62).
THE TERMINATION PHASE
The patient's reactions to termination are guided by the nature of the core conflict, and, in a prototypical case, the major therapist-parent linking
interpretations are repeated in the course of understanding these reactions. Termination is also seen as having an organizing effect that
counteracts the dangers of diffusion of focus.
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Short-Term Anxiety-Provoking Psychotherapy:
The Work of Peter Sifneos
At the time that David Malan was articulating the theory and technique of brief psychodynamic psychotherapy at the Tavistock Clinic in London,
Peter Sifneos was reaching similar conclusions at the Massachusetts General Hospital in Boston.Along with Malan, Sifneos departed radically from
a tradition of short
‐
term supportive (anxiety-suppressive) psychotherapy by using confrontational interpretations that were usually reserved for
psychoanalytic psychotherapy or psychoanalysis. His approach, too, is aimed at effecting enduring characterological changes through resolution
of a core neurotic conflict.Sifneos' procedure emphasizes stringent inclusion and exclusion criteria, determined through screening interviews.
Patients need to be able to engage rapidly; to tolerate the anxiety provoked by early and repeated interpretations of defenses, transference, and
impulses; and to take an active part in working through in the brief time frame. Patients who display the following characteristics are thought to
be most appropriate (Sifneos 1972):
1. Above-average intelligence (reflected in a capacity for new learning).
2. A history of at least one meaningful relationship during the patient's lifetime (implying shared intimacy, trust, and emotional
involvement).
3. The ability to interact well with the evaluator (reflected in flexibility in style and access to emotion).
4. A circumscribed chief complaint.
5. Motivation for change. (This is a multifaceted concept involving the ability to recognize that symptoms are psychological in origin; the