Short-Term Psychodynamic Psychotherapy

An Analysis of the Key Principles

Penny Rawson

• Publisher: Routledge
• Year: 2019
• Print ISBN: 9780367105280
• eBook ISBN: 9780429919176
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

In this book, the author succeeds in showing short-term psychodynamic psychotherapy to be an authentic and accepted method of therapy. She roots the concept in tradition and also introduces the reader to the relevant contemporary literature. In examining several cases in detail she draws out the key principles involved to present these in a clear and concise manner and demonstrates aspects of the method in practice. This book is both an excellent introduction and in depth exposition so it is highly relevant to the experienced practitioner or student. It will appeal to people both lay and professional who have an interest in an approach to therapy that is condensed but not diluted.'This book concentrates on short term psychodynamic psychotherapy. It aims to discover and analyse the key principles involved. It also aims to enrich the understanding of an approach to therapy that is already of benefit to many in our community, but that could reach very many others if it were better known and understood.'- From the Introduction.

Chapter One

Why this book? A personal and contextual perspective

What is focal and short term psychotherapy? This is a question that I am frequently asked by professional counsellors, therapists and lay people and this is what inspired me to write this book.

I am asked the question because it is an approach that I practise and believe in. It is an approach that I teach and write about and have appeared on TV to talk about in Carlton TV’s programme “What Therapy” —November 1990 and again in March 1995.

“So, what is it?” I know that the approach I have come to practise is called focal and short-term psychotherapy—but how to explain it to other professionals. How do they not know of its existence? Very many people are practising a brief approach—but often due to external pressures. These are often caused by economic factors. GPs may restrict their counsellors to six sessions per client, and colleges and employee assistance schemes often restrict therapists to six or eight sessions or less. The Tavistock Clinic has an Adolescent Unit where sessions are restricted to four. All of these do so for economic reasons, i.e. scarcity of counsellors/therapists in relation to the client demand.

Many counsellors/psychotherapists working in such situations, who practise a brief approach by compulsion, believe that they are doing a disservice to their clients. I reflect on a conference on brief therapy I attended in November 1988, where some 40 counsellors/therapists attended and only my colleague and myself appeared to have prior knowledge of the method and to be practising it by choice rather than by constraint.

At a recent training course I ran for counsellors in GP practices I encountered a sense of guilt in the participants who believed that clients were being given “short shrift” by the brief approach. There was also a general ignorance as to the historical place of focal therapy in the development of psychotherapy or its inherent features. Many were practising elements of the approach unknowingly and reluctantly and thereby were, potentially, also undermining its efficacy. The fact that the FHSA (Family Health Service Association) funded the course I ran recently no doubt reflects an economic factor—and a hope that more clients would be helped to move on quickly and therefore more cheaply.

The feedback at the end of the course included the following comments.

“The course gave short-term work much more validity and helped me to focus much more on it specifically”.

“Helpful towards working more flexibly”.

“Especially helpful in helping me to shift with the focus in six sessions”.

“Made me think hard about short-term work as a treatment of choice”.

A treatment of choice

I wish to stress that my choice of and interest in this method is a choice—it is not due to economic or social constraints. I choose the approach since I believe that very many people can be helped to resolve the issues that are causing them pain or difficulty in a shorter time, when facilitated by a therapist skilled in the focal and short-term approach. I see it as a treatment of choice, as shown in the following extract from an article (Rawson, 1992) wrote to refute John Rowan’s statement about short changing clients.

“FOCAL AND SHORT-TERM THERAPY—A TREATMENT OF CHOICE”

I read, with interest, Stephen Palmer’s interview of Professor Windy Dryden with reference to brief short-term psychotherapy (February 1992). Professor Dryden quotes John Rowan as saying:

“We are short-changing individuals who come for counselling if we don’t encourage them to see that counselling is an opportunity for them to reflect on themselves in the context of their entire life. We can’t do that,” says John, “if we are only offering brief psychotherapy.”

I would like to ask who’s short-changing whom?

I believe the principles of brief and focal psychotherapy make it clear that we are not short-changing clients by offering them this type of counselling/therapy. Brief and focal therapy is a treatment of choice—not simply a method to use because financial or resource restraints so dictate as Professor Dryden implies.

I have been spurred to write this in the hope that many potential clients may benefit as more counsellors become aware of the value of the focal and brief approach.

In my experience a large number of individuals approach counselling/therapy with the assumption, encouraged by popular opinion and their therapist that their problem will take a very long time to resolve. This may be the case if, for example, their presenting “depression” has been with them for several years. Some will have been receiving medication for many years and will anyway be sceptical as to whether a counsellor can help. It is my contention and experience that very many people can be helped significantly in less than 10 sessions. Many in as few as 2–6. By significantly, I mean reach a point:

1. Where they understand the roots of their depression often from a traumatic experience in childhood;
2. Where they have discharged the emotions relating to that; and
3. Are in a position to say: “I feel I can cope with my life now—I’ll know how to deal with similar events if they occur.”

I believe the majority of people approach counselling/therapy because they are “unhappy”. There is usually something they wish to change and they hope to feel better. Many more people would approach counselling/therapy if they had confidence that they could be helped in a few (2–10) sessions. These they could afford—whereas the idea of ongoing therapy for six months or years may prevent them even considering therapy. Many more could be helped in this way if they were aware of the focal and short-term method.” (1992, p. 106).

My professional background

I learned the brief approach at the Dympna Centre under the tutelage of Louis Marteau. The Centre specialized in therapy for members of religious orders and clergy. The therapists, who trained and worked there, were truly ecumenical and came from all branches of the Judeo–Christian tradition.

The training approach was one of applied practice under intense supervision, with videoed role plays and intensive teaching. I attended these 2½-hour sessions weekly from 1975–1984.

In parallel with my experience at the Dympna Centre, I undertook full-time training at the Westminster Pastoral Centre (WPF) in Westminster and then Kensington. There the long-term analytic approach was advocated within a Jungian framework.

The Dympna Centre model was an eight-session focused model with the option for further eight-session contracts if required. Louis Marteau would describe the approach taught as “psychodynamic using the newer therapies”.

It was this process of parallel training, in long- (WPF) and short-term (Dympna Centre), that aroused my curiosity about the more brief method. The clients I saw in both settings seemed similar, in one setting they completed seemingly successfully in eight sessions, in the other 1 year or more was not unusual. Indeed, as part of the training we were required to see clients for 40 sessions at least or we were not permitted to go on to the next stage of training. Is this an ethical requirement? I now feel in a stronger position to quote the BAC Code of Ethics to refute such a requirement. Surely this puts the needs of the student or therapist before the needs of the client? Equally, in looking at the brief approach and whilst I wholly support the brief method, I do so within the framework of what the client needs. I therefore staunchly support the concept of flexibility with regard to the length of counselling contracts. This is to be judged in relation to client need.

The Dympna training was more in the style of an apprenticeship than a formal academic course. I learned there the foundations of my practice in therapy, although I gained no paper qualifications from the Dympna Centre. There I learned something more valuable—a very special quality of “care” and respect for the individual that underpinned the whole philosophy of the Centre. I gained the necessary pieces of paper and valuable breadth to my training at the Richmond Fellowship and the Westminster Pastoral Foundation.

Economic factors

I earlier referred to pressure for brevity in the interest of economy. Other aspects of the economics of brief therapy is the effect on the therapist and on the client.

For therapists working in private practice the constant turnover of clients may seem daunting. To acquire an ongoing case load of several clients over months or years is a more secure source of income than seeing many people for a few sessions. I believe all therapists must keep the focus of client need to the fore in making judgments about the duration of therapy. In this way they can be sure of an ethical approach.

Since there is such widespread ignorance about the method of short-term focal therapy despite its history going back to Freud and being progressively developed by his later colleagues, could the economic angle be significant here? One aspect of focal therapy’s history is the aspect of rediscovery. Could it be that it is convenient to lose it from an economic viewpoint?

I believe it is not insignificant that Louis Marteau at the Dympna Centre is a priest and therefore not primarily earning a living from his work in establishing and directing the Dympna Centre. Could this have freed him to be open to the brief approach? A sentiment that rings in my ears from the years of training there is helping the client through and out of their pain as quickly as possible! This reflects a different sort of economy.

My own view is that, in fact, the brief therapist’s clients would not be in short supply if they but knew about this method. From the client’s perspective, the fewer sessions required to move them on is surely economically a good option. If a therapist can offer help to the required end in a limited number of sessions, many clients would choose this over and against a more open-ended contract. A brief contract can be budgeted for and managed. The ongoing open-ended one may mean some clients never start because they simply cannot afford it.

I am not alone in making such observations with regard to the economics. Wolberg (1965) makes the challenge strongly.

Early on in my career I decided that I would never wish to earn my living solely by private practice. I would always prefer to finance this practice from other sources, so that such economic factors would not be allowed to intrude on any client decisions. In practice I have been fortunate in being mostly in paid employment where I have been paid regardless of client numbers. I believe this may have been significant in freeing me to develop the brief approach in my work.

A refinement of the methods

I referred earlier to the eight-session model I was taught at the Dympna Centre. Over the 12 years I was practising full-time as a Senior College Counsellor at Thames Valley University (formerly Ealing College of Higher Education) I became much more flexible in my approach and counselling/therapy contracts became on average much more brief, often being one or two sessions and the mean being around four to six.

Over the years I have also become more flexible in the application of skills and techniques borrowed from traditions other than the psychodynamic in which my earlier training was rooted. I believe that I now have an integrated approach to client work fusing many different strands together. Whilst I believe this to be helpful to the client, it is less easy to unravel in order to clarify what the key principles are.

Assumptions

Before moving on to set the parameters of the study and to define terms which begins the work of the exploration and takes place in the next chapter, I have outlined below some of the assumptions which I bring to the work and which colour the practice from which the case studies are drawn.

An assumption that is made in this therapy practice is that most human beings can develop and function well in all areas of their lives without requiring a therapeutic intervention to achieve this. It is only when this normal development becomes blocked that the therapist is required. For example, bereavement is something that most people have to cope with in the course of their lives. The majority are able to come to terms with their loss without having recourse to a therapist. If however the grieving process is more than normally debilitating, or is still in process several years after the loss, then it would indicate that there is a need for professional help.

This basic assumption that people can “cope alone” enables the short-term and focal therapist to “focus” on the issue that needs to be addressed with the client and then to allow the client to “cope alone”. The expectation is that there is a problem to be tackled, dealt with and the therapeutic alliance ended at that point. The intention is that the therapist will help the client towards a new understanding and to change. The client then is expected to continue the development subsequent to change in his/her life. The changed behaviour will produce changed consequences which in themselves will reinforce the new insights and behaviour. This does not necessarily require a therapist’s intervention or support. This assumption does not intend to imply a superficial or present-day problem oriented approach. It assumes a psychodynamic approach which is referred to in the next chapter under definitions.

Another assumption made in the therapist’s practice is that people are mind, body and spirit. Therefore every aspect of the individual’s response to life and its stresses are considered important. This includes spiritual aspirations and beliefs.

The client has to be able to form a relationship, at least with the therapist for any success to occur in the therapy. If no rapport can be established no therapeutic alliance can take place and this would be a counter indicator for this type of therapy.

In focal therapy client motivation is a crucial and critical factor. This needs to be established in the initial or intake session. There is often resistance to therapy since change is usually a painful process....

Table of contents

• Cover
• Half Title
• Title
• Copyright
• TABLE OF CONTENTS
• INDEX OF APPENDIX AND TABLES
• INDEX OF ILLUSTRATIONS
• Acknowledgements
• About the author
• Dedication
• Introduction
• CHAPTER ONE Why this book? A personal and contextual perspective
• CHAPTER TWO Setting the parameters
• CHAPTER THREE Theoretical framework and methodology
• CHAPTER FOUR Findings from the initial cycles of analysis
• CHAPTER FIVE
• CHAPTER SEVEN The analysis within the wider context of the latest thinking in the field
• CHAPTER EIGHT Inconsistency in the “universal characteristics” seen in the literature
• CHAPTER NINE Concluding chapter: Brief psychodynamic psychotherapy: A contextual framework and key principles
• APPENDIX
• BIBLIOGRAPHY