A Study of Brief Psychotherapy

D. H. Malan, D. H. Malan

• Verlag: Routledge
• Jahr: 2013
• ISBN:
  9781136441608
• Auflage: 1
• Thema: Medizin
• Thema: Gesundheitsversorgung

Tavistock Press was established as a co-operative venture between the Tavistock Institute and Routledge & Kegan Paul (RKP) in the 1950s to produce a series of major contributions across the social sciences.
This volume is part of a 2001 reissue of a selection of those important works which have since gone out of print, or are difficult to locate. Published by Routledge, 112 volumes in total are being brought together under the name The International Behavioural and Social Sciences Library: Classics from the Tavistock Press.
Reproduced here in facsimile, this volume was originally published in 1963 and is available individually. The collection is also available in a number of themed mini-sets of between 5 and 13 volumes, or as a complete collection.

Part I
Historical and Theoretical Survey

Chapter 1
Introductory

In spite of the immense advances of the present century in the understanding and treatment of neurotic illness, many problems remain that are both pressing and largely unsolved. The present work approaches two of these: first, that of reducing the length of psychotherapy; and second, that of basing generalizations about psychotherapy on evidence that is publishable and also contains the minimum of unsupported inference. The value of any contribution, however small, to these two problems needs little emphasis.

The book consists of a study of the clmical work carried out by a team of psycho-analysts, of which the author was a member, under the leadership of Dr. Michael Balint. The work was originated by Balint and arose from his recognition that however favourably 'long-term' psychotherapy—and particularly psychoanalysis—may influence the lives of selected individuals, in comparison with the amount of neurotic unhappiness in the world its contribution can never be anything but negligible. He has therefore turned in the last few years to investigating how the experience of a lifetime of psycho-analysis may contribute towards therapeutic aims which are more limited but of wider application. His book, The Doctor, his Patient and the Illness (1957), was the result of applying this idea to psychotherapy in general practice. There the therapeutic work is relatively superficial and is carried out by general practitioners with relatively little training. The present research is complementary to this. The aim has been to investigate brief psychotherapy carried out, on a much 'deeper' and more intense level, by therapists with a fairly complete knowledge and experience of the technique of psycho-analysis. Although such work has of course been done before, it has led to no systematic body of knowledge and to little that is generally agreed; so that no apology is needed for a wish to approach the subject once more with an open mind and from the very beginning.

All members of the team have contributed to the thinking set out here, and particularly to the formulation of hypotheses. My own contribution has been the testing of these hypotheses, and the search for new ones, in the data provided by those cases—about twenty—treated in the first two years of the work. It is necessary to state that I do not necessarily speak for the team as a whole. The methods used are entirely my own responsibility; and the conclusions reached are not necessarily acceptable to the other members—though deriving much from them, and I hope representing a systematic exploration in the directions in which their own thought has been leading.

The undertaking of this work has led to the second of the two main problems, that of handling data on psychotherapy in such a way that hypotheses or conclusions are based on something more than 'clinical impression', and of presenting the evidence in such a way that it can be judged, to some extent at least, by an independent observer. This second, 'methodological' problem has seemed in the past hardly less intractable than the purely therapeutic problem. The literature on psychotherapy shows the usual divergence between 'subjective' methods, which depend on apparently unverifiable inference, and methods which, the more 'objective' they are, the more clinically meaningless they become. Yet, growing experience has led me—and an increasing number of other authors—ever more certainly to the conclusion that this divergence is at least partly artificial, and is maintained by emotional problems rooted in the traditions of psycho-analysis and experimental psychology. Much effort has therefore been given to reducing the divergence by trying to treat clinical judgements in exactly as rigorous a manner as is appropriate, no more and no less.

The attempt to apply rigorous methods meets very serious difficulties caused by the main orientation of the work and the conditions in which it was undertaken. The orientation was essentially clinical and exploratory, and all members of the team were motivated more by clinical enthusiasm than by any desire to subject themselves to the discipline necessary for the thorough testing of scientific hypotheses. Moreover, since there was no financial support, all therapists and secretaries had to work in such time as could be spared from heavy routine commitments. This research, therefore, suffers from serious defects: clinical records dictated from memory, and retrospective judgements only partially checked by independent observers. For this reason the main emphasis must be essentially clinical; but particular attention is given to the publication of the evidence on which judgements are based, to the presence or absence of 'controls', to the need to explore fallacies, and to the possibility of obtaining a given result by chance alone. In addition, more 'objective' methods are explored in an attempt to reduce—though far from eliminate—the subjective and unverifiable element in the evidence presented.

It is shown that, in spite of the deficiencies in the material, the clinical and the more 'obejctive' approaches often point in the same direction. In the hands of a single observer, this must obviously be treated with reserve. Nevertheless, the final result is a series of hypotheses which—though each alone is derived from inconclusive evidence—support each other by making sense as a whole, and are in turn supported by principles established independently, namely those by now well accepted for psycho-analysis itself. This kind of convergence of evidence is often all that is possible in scientific problems of many different kinds. I should like to refer the reader especially to a critical discussion of the status of the evidence (pages 268-72). And finally, there emerge certain incontrovertible facts which—though indeed reported in the literature before—have never been widely accepted, and which could be of considerable practical value in the future.

There follows a long exposition of the background to this work, all of which is necessary if the problems involved in brief psychotherapy are to be fully understood, and if the present position reached is to be seen clearly in its historical setting.

Chapter 2
Historical Approach

The History of Psycho-Analysis

The evolution of psycho-analysis may be regarded as an 'ecological' process involving the interaction of patients of a particular kind and therapists of a particular outlook, within the environment of Western civilization. When any such process begins, there will usually be seen a tendency towards change in some definite direction, leading eventually to a state of equilibrium. With psycho-analysis the most easily identified tendency, manifested repeatedly as each new advance was made, has been towards an increase in the length of therapy. Thus anyone who tries to develop a technique of brief psychotherapy is trying to reverse an evolutionary process impelled by powerful forces, and it is as well that he should first identify these forces, and specifically try to oppose them.

The history of psycho-analysis, regarded from this point of view, may be summarized as follows (see Breuer and Freud, 1895; Freud, 1896, 1904, and 1914). The original observation, made by Breuer, was that hysterical symptoms could be relieved by making the patient re-live, under hypnosis, painful memories and feelings that had been forgotten ('repressed'). Freud, finding that not all patients could be hypnotized, replaced this method by suggesting forcefully to the patient in the waking state that there were things that she had forgotten and could remember. He now found, however, that suggestion was often insufficient to overcome a marked resistance put up by the patient against recovering these memories. He was able to by-pass this difficulty when he found that, if he simply asked the patient to say what came into her mind in connection with her symptoms, the memories returned in a disguised and symbolized form; and that when he learned how to translate the disguise the memories returned undisguised. With more experience he began to realize that whatever came into the patient's mind (not necessarily in connection with her symptoms) had a bearing on the memories or on the resistance against them; and he concentrated on the latter, finding that when the resistances were pointed out the memories could be recovered without any forcing. In this sequence, from hypnosis through suggestion to 'free association', the tendency for the therapist to become increasingly passive is clearly to be observed.

During this time a quite unexpected phenomenon had appeared, namely that patients inevitably began to have intense feelings (transference) about the therapist. This was already present in the first case treated by Breuer ('Anna O.'; see Jones, 1953, p. 246) and was the cause of Breuer's abandoning this work altogether. Freud found that, if he interpreted to the patient that these feelings were really not about the therapist at all, but were transferred onto him from some important person in the patient's childhood, then they could be handled without jeopardizing the therapy and could finally be resolved.

Yet there was always present the tendency for each new technique, initially successful, to become less and less reliable. Whereas early patients seemed to be cured through the recovery of comparatively recent memories and the interpretation of the related transference feelings, later patients tended to relapse again and could be cured only by uncovering further memories and transference feelings belonging to increasingly early childhood. Analyses were prolonged by two further phenomena: the fact that a single symptom was usually found to have its roots in many quite separate memories and feelings, each of which had to be uncovered before the symptom could be relieved (over-determination); and the fact that each root often had to be uncovered many times in different contexts, and not once for all, before relief was permanent (necessity for working through).

It became recognized that early relief of symptoms was often simply due to the satisfaction of the patient's need for love provided by the analytical situation ('transference cure'); and that the relapse that frequently occurred at threat of termination could be reversed only by interpreting the patient's anger (negative transference) at being abandoned, and relating this to its true source in childhood. Meanwhile the importance of transference has steadily increased. The following is now a standard pattern for an analysis: there is an initial period in which both transference and non-transference interpretations seem to be effective and everything seems to be going well (the 'analytic honeymoon'); there is then a period of resistance in which insight is often lost and interpretations which were previously effective become useless; and finally there develops a state known as the transference neurosis in which the patient's whole neurosis is expressed in his relation to the therapist, on whom he often becomes extremely dependent. Now, to a large extent, only transference interpretations are of any value; and only after this transference has been interpreted again and again, and related to its true source in childhood, can the situation be resolved.

In the meantime emphasis has gradually shifted. The transference has come to be regarded not as a necessary evil, but as the main therapeutic tool—thus transference is welcomed, and especially negative transference, since the patient's unconscious hatred is felt to be a powerful source of neurosis; memories, especially those concerned with sexual traumata, are regarded as of less importance, and emphasis is now laid on the repetition of neurotic childhood patterns in the relation to the therapist, and the gradual acquisition of insight into these; and finally it is held that one of the most important factors is not so much the insight itself, as the actual experience of a new kind of relationship with the therapist, through which these neurotic patterns can be corrected (see Ferenczi and Rank, 1925, p. 59; Alexander and French, 1946, p. 22; Alexander, 1957, p. 71).

Factors leading to longer analyses ('lengthening factors') may be summarized thus:

1. Resistance,
2. Over-determination,
3. Necessity for working through,
4. Roots of neurosis in early childhood,
5. Transference,
6. Dependence,
7. Negative transference connected with termination,
8. The transference neurosis.

At the same time, the ecological view of the history of psychoanalysis makes clear that the list of lengthening factors given above shows only part of the picture, for it contains only those factors to be found in the patient. It is clear that some of the tendency towards long analyses may well be due to factors in the analyst, of which we may list the following:

• 9. A tendency towards passivity and the willingness to follow where the patient leads,
• 10. The 'sense of timelessness' (Stone, 1951) conveyed to the patient,

• 11. Therapeutic perfectionism,
• 12. The increasing preoccupation with ever deeper and earlier experiences.

The result of all these factors has been that, whereas early analyses tended to last a few months, nowadays an analysis that lasts twice as many years is nothing remarkable.

It is clear that a rationally based technique of brief psychotherapy must be based on a conscious opposition to one or more of these factors, particularly those in the therapist. Moreover, s...