Psychodynamics, Training, and Outcome in Brief Psychotherapy

David Malan, Ferruccio Osimo

• Publisher: Butterworth-Heinemann
• Year: 2014
• Print ISBN: 9780750615457
• eBook ISBN: 9781483193854
• Topic: Medicine
• Subtopic: Clinical Medicine

Psychodynamics, Training, and Outcome in Brief Psychotherapy provides information pertinent to the fundamental aspects of dynamic psychotherapy. This book discusses the selection criteria, the principles of therapeutic methods, and the factors leading to therapeutic effects in psychotherapy. Organized into five parts encompassing 37 chapters, this book begins with an overview of the influence of research on clinical practice. This text then examines the evidences showing that most of the improvements were in fact due to therapy. Other chapters summarize the essential characteristics of the methods used with the patients in various case studies. This book discusses as well the concept of the triangle of conflict, which refers to one of the cornerstones of psychodynamic theory. The final chapter deals with the advantages of a psychotherapeutic clinic to certain kind of patients who can be greatly helped in a relatively short time. This book is a valuable resource for psychotherapists, psychiatrists, psychologists, and social workers.

1

Beginning at the end

Publisher Summary

This chapter discusses the features of a complete therapeutic result. For many patients their therapy is like a dream, which sinks into unconsciousness when the dreamer enters the waking state. The chapter presents a case where the patient remembered little other than silence from the first session but the therapist made many interventions and toward the end the patient reached a crucial piece of insight; during the silences she was thinking irrelevant thoughts to stop herself from thinking painful ones; but this device no longer worked and that was why she was depressed. It was in fact this moment of insight that brought on her tears, which began to come at that point in the session, and not afterward as she remembered. The rest of therapy also contained much interaction and was sometimes quite dramatic. One of the major aims of dynamic psychotherapy of any kind is to prevent the pathological mechanism from coming into action again and, thus, leading to similar difficulties.

The Nurse Mourning her Fiancé

Interviewer (FO, one of the present authors): Can you tell me how you feel now that you’re here for this follow-up interview?

Patient (now aged 39): I got out of the car and I felt very nervous. It reminded me of the first time I came. I remember sitting here, and then I was crying a lot while going home. When I first got the letter from Dr Malan asking me to come for follow-up, those days didn’t seem part of my life any more. It was as if they never happened.

Interviewer: Can you tell me what feelings you can recall from that first session 6 years ago?

Patient: It didn’t seem real somehow. It seems so different now for the last 3 of 4 years that it seems impossible I was in such a state.

Interviewer: Can you tell me what it is that’s different?

Patient: Well, I am quite happy now. I do get upset, but it’s not a lasting feeling. Then, I just didn’t feel anything.

Interviewer: So now you do feel something?

Patient: Yes … for instance, a few days ago when I heard of the soldiers killed in the Falklands, I was moved and cried. Six years ago, when I first came, I wouldn’t have cried. I would have been shut off. Last August, my stepmother was very ill, in hospital, and I did become very upset. But it seemed to be just normal upset, I was able to get over it. Crying made me feel better afterwards. And you can see the opposite feeling as well – in those days I didn’t laugh any more.

Interviewer: So now you are participating in both happy and sad events?

Patient: Yes, in everything somehow. I was just existing for 4 years. It seemed perfectly normal to me at the time. But, looking back … then, I couldn’t care less about anything, really.

Interviewer: Can you say at all how this change took place?

Patient: I can’t really pinpoint it to anything. Not that everything was better at once, but gradually things began to fall into place.

Interviewer: Can you say what things, and what you mean by ‘falling into place?’

Patient: I think, after I left here, I didn’t immediately feel I was better, but I feel now that I am. I don’t know how it happened. It is difficult to put into words. With my stepmother last year … it was pneumonia, and some friends were blaming somebody else for giving her the initial cold. I thought I was possibly the one, and I told my husband. I felt it was my fault. I was very upset, but we talked it over and then I was better. Before, I would have shut it inside without saying anything to anybody, and felt awful.

Interviewer: So you were able to talk it over with him?

Patient: Yes. It was a bit difficult to begin talking – I suppose I still have got the ability to shut things off, but I deliberately try not to.

Interviewer: Why is that?

Patient: Because it makes me feel better.

Interviewer: Why couldn’t you do it before?

Patient: Because I thought it would be too painful to do it.

Interviewer: What made you change your mind?

Patient: I don’t know. The first time when I was crying, it was the initial feeling of relief.

Interviewer: You didn’t cry at all before that first session?

Patient: Not for years.

Interviewer: What made you cry?

Patient: I suppose it made me feel something. I was worried about coming here. It was a relief when I saw I could get through the hour.

Interviewer: What were you afraid of before coming?

Patient: I was afraid she was going to ask me all those questions I was trying to forget about.

Interviewer: Can you try and say why you came back for the second session?

Patient: Well, I came back for more relief.

Interviewer: So there was a difference between the doctor you expected and the real one. Can you say what?

Patient: Yes, I suspect … She didn’t ask direct questions that I couldn’t avoid answering. So I suppose I felt … sort of safer, because she wasn’t threatening me directly….

Interviewer: Was she like that subsequently?

Patient: Yes, occasionally she asked things but not often. Most of the time I can’t really remember what happened. The first time I particularly remember, the rest of it I don’t remember anything really.

Interviewer: Now can you perhaps tell me about your engagement and your marriage? As I understand it, you didn’t think it possible ever again to become close to a man.

Patient: I thought I must try and let myself get really involved. I had boy-friends but I would never get really close to them. There was a long time when I couldn’t allow myself to think what it had been like with my fiancé. Then I started thinking about what happened before his death. I remember I was talking to a girl-friend, and saying I wish there was someone I really cared about – a two-way relationship, security. It wasn’t enough just to go out with different men. I felt I had missed out. There had been a time when I started relying on a man and I provoked great rows. I did it on purpose so that it would come to an end.

Interviewer: Why didn’t you do the same with your future husband?

Patient: I felt too strongly that the relation with him was worth risking.

Interviewer: Do you sometimes get angry?

Patient: Yeah!

Interviewer: Can you give me an example?

Patient: With my husband sometimes. It doesn’t last long. I feel more irritated than angry.

Interviewer: What about with other people?

Patient: The other day, when the pupils went out for an excursion, two boys had been to a pub and came back to the school a bit drunk and caused a disturbance [the patient is a qualified nurse who works as matron in a mixed boarding school]. I was furious, I shouted at them, I really did shout and tried to make them feel as awkward as possible.

Interviewer: Were you successful?

Patient: Yes, with one of them anyhow.

These extracts from the follow-up of a 31-session therapy, 5½ years since termination, illustrate many features which will form important themes in the pages to follow.

The first issue is concerned with the validity of dynamic psychotherapy. Perhaps we may start by saying that the patient should really be called ‘the Nurse who couldn’t mourn her Fiancé’, because the point of her story is that after her fiancé’s sudden death in an accident 4 years before she came to us, she had not only been unable to cry, but had virtually lost the power to feel anything. The process of putting her in touch with her feelings began in the very first session. This is powerful evidence that her recovery was really due to her therapy, and that therefore it is justifiable to speak of ‘therapeutic results’ rather than the non-committal ‘changes that were found at follow-up’ – for it is very difficult to maintain that a disturbance lasting for several years should ‘just happen’ to begin to remit spontaneously within 1 hour of starting treatment.

The evidence for one of the important therapeutic factors is also highly suggestive. Surely it is clear that the patient’s ability to cry, after the lapse of as many as 4 years, could not possibly have been caused by nothing more than the relief of managing to survive the session, and that the therapist must have done much more than simply refrain from asking awkward questions; for the patient really implied that she found in her therapist a ‘holding’ atmosphere in which she felt that she now dared to face her pain. It was certainly the therapist’s aim to create this atmosphere. Her account of the session included not only many sympathetic interventions but also the following: ‘At one point I was thinking that very often the only way to help people in grief is to sit silently by their side’ – an example of the sensitivity and maturity possessed by many of these trainee therapists, which will be illustrated repeatedly in the following pages.

This story also illustrates the features of a complete therapeutic result. Although of course the evidence is much more extensive than in these brief extracts, much of it can be found there: in addition to the lifting of depression, the patient’s new-found ability to experience appropriate feelings within the situation that caused them, the relief that followed, the entirely changed attitude to feelings of all kinds, the abandonment of the determination never again to become involved with a man, the closeness that she achieved with her husband, the clear evidence that this relation is not idealised, and the ability to feel anger and to assert herself. Therapeutic results possessing such completeness are rare in any form of therapy, but we can state unequivocally that they do occur.

Also illustrated is the fact that for many patients their therapy is like a dream, which sinks into unconsciousness when the dreamer enters the waking state. This patient remembered little other than silence from the first session (and indeed there was much silence), but in fact – as mentioned above – the therapist made many i...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• What this book is about
• Acknowledgments
• Chapter 1: Beginning at the end
• Chapter 2: The present study: background, aims, methods
• Chapter 3: Measuring outcome
• Chapter 4: Overview of the present study and its results
• Chapter 5: The therapists
• Chapter 6: Therapeutic technique and the two therapeutic triangles
• Chapter 7: The conservative and radical techniques: two patients with favourable outcome
• Chapter 8: Two further patients with favourable outcome
• Chapter 9: Two male patients with Oedipal problems
• Chapter 10: A woman patient with Oedipal problems
• Chapter 11: The seven ‘best’ cases, discussion
• Chapter 12: False solutions: I General II Two patients with relatively adaptive false solutions
• Chapter 13: False solutions: III Three patients with less adaptive false solutions: IV General discussion
• Chapter 14: Two women patients who showed limited improvements
• Chapter 15: Patients who showed minimal improvements
• Chapter 16: Patients who showed no improvement
• Chapter 17: Discussion of the five patients who showed minimal or no improvement
• Chapter 18: Patients who were worse: I Three patients who were wrongly diagnosed at initial assessment
• Chapter 19: Patients who were worse: II A patient who ought to have given a favourable outcome
• Chapter 20: A calculated risk ending in catastrophe
• Chapter 21: The five patients who were worse: discussion
• Chapter 22: Types of change: general
• Chapter 23: Emotional freeing
• Chapter 24: Resolution of maladaptive behaviour patterns
• Chapter 25: The ability to ‘be oneself’
• Chapter 26: Symptoms
• Chapter 27: Relations with the opposite sex: I Clinical material
• Chapter 28: Relations with the opposite sex: II Problems of commitment
• Chapter 29: Problems of aggression and self-assertion: I General
• Chapter 30: Problems of aggression and self-assertion: II Clinical material
• Chapter 31: Problems of aggression and self-assertion: III Discussion
• Chapter 32: Therapeutic effects during therapy
• Chapter 33: Can the improvements be attributed to therapy?
• Chapter 34: Selection criteria
• Chapter 35: Further research results
• Chapter 36: The practical and theoretical value of the work: I For trainees, supervisors, and psychotherapists in general
• Chapter 37: The practical value of the work: II For psychotherapeutic clinics III For patients
• References
• Index