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HANDBOOK

OF

SHORT-TERM
PSYCHOTHERAPY
LEWIS R. WOLBERG, M.D.

C o p y rig h t 1980 Louis R Wolberg


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Contents
Preface, vii

1. M o d e l s of S h o r t - te r m T h e r a p y , 1
2. A R a tio n a le for D y n a m ic S h o r t - te r m T h e r a p y , 22
3. C r it e r i a of Selection, 30
4. A G e n e r a l O u tli n e of S h o r t - te r m T h e r a p y , 35
5. T h e Initial Inte rv ie w : A. C o m m o n Q u estio n s, 49
6. T h e In itial In terv ie w : B. C a s e H isto rie s , 61
7. C h o o sin g a n I m m e d ia te F o cus, 90
8. C h o o sin g a

D y n a m ic Focus: A. P r o b i n g into th e P a st, 101

9. C h o o sin g a

D y n a m ic Focus: B. S o m e C o m m o n D y n a m ic T h e m e s , 113

10. C h o o sin g a D y n a m ic Focus: C . P re s e n tin g I n t e rp re t a ti o n s , 125


11. T e c h n iq u e s in S h o r t - te r m T h e r a p y , 135
12. T h e U se of D r e a m s , 170
13. C a ta l y z in g th e T h e r a p e u t i c Process: T h e U se of H y p n o sis , 190
14. C ris is In te rv e n tio n , 208
15. M a k i n g a R e la x in g a n d E g o -B u ild in g T a p e , 223
16. H o m e w o r k A ssig n m e n ts, 235
17. T e r m i n a t i o n of S h o r t - te r m T h e r a p y , 243

R eferences, 25 0

Preface
In 1959, I ch aired a s e m in a r at th e P o s t
g r a d u a t e C e n te r for M e n t a l H e a l t h in N e w

d a te d a n asto n ish in g ly larg e p e rc e n ta g e of th e

Y ork C ity , d u r i n g w h ich a n u m b e r of p a r

re latively recently, h ow e v e r, th a t th e r e has


been a sw in g t o w a r d s h o r t- t e r m t h e r a p y as a

tic ip a n ts p resen ted m a te ria l d e ta ilin g th e ir


th o u g h ts a b o u t an d ex perien ces w ith s h o r t

id eas a n d o b se rv a tio n s of th is s em in ar. It is

p r i m a r y a n d p re f e rre d t r e a t m e n t r a t h e r t h a n

te r m th e r a p y . H e le n A vnet, D ir e c t o r of R e

as a n e x p ed ie n t. E ven n a tio n a l p sy ch o an aly tic

search,

In s u r a n c e C o m p a n y ,

o rg a n iz a tio n s , stro n g h o ld s of lo n g - te rm t r e a t

revealed the res u lts of a p ro ject th a t lasted tw o


a n d o n e -h a lf years, in w h ic h a p a n e l of 1,139

m e n t, have b e g u n to p re a c h its v irtu es and


h a v e o rg a n iz e d c o n ti n u in g - e d u c a tio n courses

psy chiatrists tre a te d p a tie n ts o n a s h o r t-t e rm


basis. O n te r m i n a ti o n , 7 0 p ercen t of the p a

on th e subject. A ho st of articles an d a n u m b e r
of in te re stin g books h ave a p p e a r e d , o u tlin in g

tien ts w ere r a t e d by th e p a n e l as im p ro v e d or
recovered. It w a s concluded th a t a large p o r

te c h n iq u e s th a t th e a u th o r s h av e found v a l u a

t i o n o f th e c o m m u n i t y s p s y c h i a t r i c n e e d s
could be m et by s h o r t-t e rm tre a tm e n ts . J u l e s

ble in th e ir a tt e m p t s to a b b re v ia te tr e a tm e n t.
In th e m a in , sim ilarities of concepts h ave e x

M a s s e r m a n detailed the h isto ric a l-c o m p a ra tiv e

ceeded differences. N ev erth eless, a g re a t n u m


b er of q u e stio n s r e m a in u n a n s w e r e d , an d it is

G ro up

H e a lth

an d e x p e rim e n ta l roots of s h o r t- t e r m th e r a p y ,
tra c in g its o rig in s in th e past. S a n d o r R ad o

p hilo so p h ies, goals, selection p ro c e d u r e s a n d

th e p u r p o s e of th e p re s e n t v o lu m e to c o n tr ib u te
to th e re s o lu tio n of som e of these.

p resen ted m a t e r i a l on m o tiv a tio n a l factors th a t


could prov id e guid elines for tech n iq u e s in
s h o r t-te rm th e r a p y . P a u l H o c h differentiated

O n e of th e m ost critical q u e stio n s is re lated

th e charac teristic s of s h o r t-t e rm versus lo n g


te r m th e r a p y . F r a n z A le x a n d e r d ealt w ith p s y

to th e valu e of d y n a m ic a p p r o a c h e s in s h o r t
te r m th e r a p y . M o s t im p o r t a n tl y , can w e e m p i
rically p ro ve th e effectiveness of a d y n a m ic a lly
based s h o r t- t e r m th e r a p y ? C o n tro lle d e x p e r i
m e n ts h av e been few, a n d even in th ese the dif

cho analytic c o n tr ib u tio n s to s h o r t- t e r m th e r a p y


in facilitating a corrective e m o tio n al e x p e r i
ence. L o t h a r K alin o w sk y lectu re d on th e use of

ficulties th a t s h a d o w o u tc o m e stu dies te n d to

s o m a ti c t r e a t m e n t s

th erap y .

o b scu re results. Yet w ith all o u r skepticism

A le x a n d e r W o lf d ealt w ith s h o r t-t e rm g r o u p

a b o u t q u a n tify in g brief clinical o p e ra t io n s suf

p sy ch o th erap y . M o lly H a r r o w e r described a

ficiently to satisfy th e c rite r ia of objectivity,


validity, a n d relia bility so essential in scientific
studies, d is c rim in a t in g e x p e rie n c e estab lish es
b eyo nd r e a s o n a b le d o u b t th e usefulness of a
d y n a m ic o rie n ta t io n in a n y form of s h o r t-te rm
p sy c h o th e ra p y . T h i s a p p lie s w h e t h e r w e a re
h e lp in g a p e rs o n recognize a n d th e n to com e to

in s h o r t - t e r m

research p roject related to o u tco m e of lo n g


te r m a n d s h o r t-t e rm t h e r a p y . A rle n e W o lb e r g
discussed the in c o r p o ra tio n of ca se -w o rk p ro c e
d u re s in a s h o r t-t e rm p r o g r a m . I gave tw o lec
tu res, o ne on g en era l aspects of te c h n iq u e an d
the o th e r on the e m p lo y m e n t of h y p n o sis as a n
ad ju n ct in s h o r t-te rm t h e r a p y . T h e s e m in a r
w a s pu b lish ed later by G r u n e & S tr a tt o n
u n d e r th e title S h o rt-term P sych o th era p y.
It is in terestin g in review in g th e c u rr e n t
lite r a tu re th a t in d e p e n d e n t studies hav e v a li

vii

te r m s w ith his p ast, as in insig ht th e r a p y , or


e lim in a tin g effects of th e p a st t h r o u g h r e i n
fo rcem ent of a d a p ti v e be hav iors, as in b eh av io r
th e r a p y , o r sq u e e z in g the p a st o ut of m uscles
a n d tissues as in th e n e w body th e r a p i e s , or

viii

HANDBO OK OF SHORT-TERM PSYCHOTHERAPY

g a in in g a perspective on in n e r e m o tio n a l ef
fects of the p a s t th r o u g h sensory a w a re n e s s

search of p a tie n ts w h o h a d been tre a te d in a

techn iq ues, o r co rrec ting h a b itu a l p a st m odes

c o m p a r is o n stu d y w ith tw o fo rm s of b rief psy


c h o th e r a p y (b e h av io r t h e r a p y a n d p sy c h o a n a -

of th in k in g , as in cognitive t h e r a p y . In d eed , a

l y t ic a l ly o r i e n t e d p s y c h o t h e r a p y ) a n d w h o

d y n a m ic a p p r o a c h , in m y o p in io n , is th e best

w e re d is c h a rg e d as im p ro v e d , P a tte rs o n , et al
(1977) found th a t on e y e a r after te r m i n a ti o n ,

design to follow in all form s of p s y c h o th e ra p y ,


h ow ev er b rief th ey m a y be, a n d w h ile it m ay

fully 60 p e rc e n t h a d so u g h t o u t a n d o b ta in e d

not hav e a n im m e d ia te d r a m a ti c influence on

f u r th e r tr e a tm e n t. T h e s e figures a re p ro b a b l y

the p e rs o n a lity stru c tu re , it can catalyze such


c h ang es ev entu ally th r o u g h its c o n tin u in g in

low b ecau se m a n y d is ch arg ed p a tie n ts w h o do

fluence on cognition.

n ot seek fo rm al t h e r a p y u tilize o th e r form s of


h e lp o r self-help to redu ce th e i r tension a n d

In this v o lu m e I h ave a tt e m p t e d to b rin g

b etter th e i r a d ju s tm e n t. Life, after satisfactory

to g eth er co m m o n elem ents in th e chief m odels


of s h o r t-te rm th e r a p y c u rr e n tly in use a n d to

p s y c h o t h e r a p e u t i c t r e a t m e n t , c o n t i n u e s to
p re s e n t a n ev er en d in g series of c hallenges th a t

evolve p rinc iple s th a t can be em p lo yed by in d i

can ta x co p in g capacities of even c u r e d p a

vidual th e r a p ists,

retical biases a n d styles of o p e ra tio n . H o w a


d y n a m ic view p o in t m ay p ractically be in

tients. T h i s is n o t a lto g e th e r bad , for in m e e t


ing th ese cha llen g es th e in d iv idu al h a s a n o p
p o r t u n i t y of s tre n g th e n in g a d a p tiv e p a tt e r n s ,

trodu ced in an y form of p s y c h o th e ra p y is one


of m y goals. T h e s h o r t-t e rm m e th o d th a t I will

of a p r i o r v accination . S h o r t - te r m p s y c h o t h e r

irrespective of th e ir th e o

describe is no t p res e n te d w ith illusion t h a t it is


flawless, infallible, o r u n iv ersally ap plicab le.

m u c h like a boo ster shot can e n h a n c e th e effect


ap y offers th e p a ti e n t a m e a n s by w h ic h o n e s
f u tu re m a y be reg u la te d , p ro v id ed th e th e r a p is t

N o r m a y it p ro ve e q u a lly helpful to all t h e r a

p re p a r e s th e p a ti e n t for a n tic ip a te d events an d

pists o r cu rativ e in every case. It is, n e v e rth e

con tin gen cies a n d te aches a w a y of d e a lin g

less, in m y o p in io n , (and in th e j u d g m e n t of
th e r a p ists w h o have u tilized th e m eth o d ), an
easily learn ed a n d effective te c h n iq u e servicea

w ith these, sh o u ld th ey a p p e a r .
As a h a n d b o o k , th is v o lu m e prov ides a n o u t

ble for the g re a t m a jo rity of p a tie n ts seen in


clinics a n d p riv a te practice. T h e m eth o d also
tak es into co n sid eratio n th e fact th a t th e r e will
be p a tie n ts w h o a re n ot good subjects for
s h o r t-te rm

t r e a tm e n t a n d

line of process in s h o r t- t e r m th e r a p y . S h o u ld
ex tensive d etails of te c h n iq u e be sou gh t, th ey
m a y be found elsew h ere, in clu d in g th e th ird
ed itio n of m y b oo k T h e T ech n iq u e o f P s y
ch o th era p y. It is r e c o m m e n d e d th a t th e re a d e r

w h o will r e q u i r e

if no t a lr e a d y a c q u a i n te d w ith som e tech n iq u e s

o th e r form s of help. U n d e r these c ir c u m


stances, the m e th o d will fun ction as a useful
in itial d iag n ostic p ro c e d u re , e n a b lin g th e t h e r a
pist to select m od alities th a t will serve th e p a

o th e r th a n ind iv idu al p s y c h o th e ra p y e x p e r i
m e n t w ith these to see w h e t h e r they accord

tien t best.
T h e m e th o d also co n ta in s a m ean s of p r o
v id i n g c o n t i n u i n g t h e r a p y for th e p a t i e n t
th r o u g h assigned h o m e w o r k an d th e use of a
casette tape, th e m a k i n g of w h ich will be
described in detail. It h a s a lw a y s confoun ded
me th a t so m a n y th e r a p is ts a ssu m e th a t w h e n
th e last form al t r e a tm e n t session h a s en ded ,
th e p a tie n t can sally fo rth like the fabled
p rin c e a n d princess to live h a p p il y ever after.
T h e facts on the follow -up a r e a g rim d en ial of
this fantasy. F o r e x am p le , in follo w -up r e

w ith o n e s in d iv id u al styles of w o rk in g . In m y
o p in io n , a t h e r a p i s t s usefulness is especially
en h a n c e d by k n o w le d g e of g r o u p th e r a p y (see
T h e T ech n iq u e o f P sy ch o th era p y, 3 rd ed, pp.
7 0 2 - 7 2 9 ) , f a m il y t h e r a p y ( p p . 7 2 9 - 7 3 3 ) ,
m a r it a l (couple) th e r a p y (pp . 7 3 3 - 7 4 0 ) , be
h a v io r t h e r a p y (p p. 6 8 5 - 7 0 1 ) , re la x a tio n p r o
ced ures (pp. 7 6 1 - 7 6 6 ) , a n d so m a tic th e r a p y
(pp. 7 6 7 - 7 8 9 ) . O t h e r te c h n iq u e s m a y p e r i
odically be useful such as h y p n o sis (pp. 791
8 09 ), sex t h e r a p y (pp. 8 0 9 - 8 1 7 ) , a n d biblio th e r a p y (pp. 8 1 7 - 8 3 3 ) . It goes w ith o u t say
in g th a t k n o w le d g e of th e th e r a p e u ti c process
from th e in itial interv iew to te r m i n a ti o n (pp.

PREFACE

ix

3 5 3 - 6 8 4 ; 7 4 3 - 7 5 8 ) an d especially in te rv ie w

W h a t e v e r g a in s m a y accrue from a n y evolving

ing tech niqu es (pp. 3 6 0 - 3 8 2 ) a re in d ispen si-

insights a re n e u tr a liz e d by th e crip p lin g influ

ble.

ence of th e p ro lo n g e d sh elte re d relatio n sh ip .

A final w o rd of cau tio n m a y be indicated.


O n e should not a ssu m e th a t it is alw a y s po ssi
ble to d up lica te or s u r p a s s w ith s h o r t- t e r m a p
pro ach es w h a t can be d o n e w ith a p p ro p r ia te ly
selected p a tie n ts th r o u g h lo n g e r -te rm t r e a t

P la y in g a w a iti n g g a m e in th e h o p e th a t tim e
will even tually dislodge a neu ro sis too fre
q u e n tl y resu lts in p a tie n t p a ra ly sis an d t h e r a
pist fru str a tio n .

m en t. B ut, for the g re a t m a jo rity of pe op le

S u ch disc on certing p h e n o m e n a give im p e tu s


to o u r efforts to s h o rte n th e t h e r a p e u ti c process

seeking help for em o tio n al p ro b le m s, th e tim e

w ith o u t d e v italizin g its effect. T h i s is n ot to

elem ent is no t th e most im p o r t a n t v a ria b le in

d e p reciate e conom ic a n d o th e r practic al r e a

p sy ch oth era py .

is too fr e q u e n tly co n

sons for a b b re v ia tin g s h o r t- t e r m t h e r a p y . B ut

sidered a m agical device th a t acts like a d e

a p a r t from cost effectiveness a n d th e need to

tergen t, w a s h in g a w a y a c c u m u la te d n e u ro tic
residues. It is assu m ed tr a d itio n a lly t h a t the

m in is te r to th e g ro w in g m u ltitu d e s of p eop le
w h o seek help , d y n a m ic s h o r t- t e r m t r e a tm e n t

longer a p a tie n t r e m a in s in p s y c h o th e ra p y , the


g re a te r the benefits h e will derive fro m it.
C o m m o n practice, how ever, convinces t h a t this

is ju stified o nly if it can p ro v e itself to be a


tr u ly useful m e a n s of d e a lin g w ith em o tio n al

T im e

is t r u e only u p to a certain p oint. Beyond such


a p oin t, resistances pile u p in a d is tu rb i n g
n u m b e r of p atie n ts , gain s a r e n e u tr a liz e d , a n d
a setback ensues. P e e rin g into the causes of
these m isfortunes, w e observe in th e r a p y th a t
goes on for too p ro tra c te d a period an e m e r g
ing sense of helplessness th a t m a y be concealed
by vario u s reactio n fo rm atio n s. T h e c onse
q u en ce is a sab otage of p ro g re ss a n d u ltim a te ly
an ex ac erb atio n of sy m p to m s. T h e th e r a p is t
th e n becomes for th e p a tie n t a crutch ; w ith o u t

p ro b le m s in th e vast m a jo rity of cases. In m y


o p in io n , this p ro o f has n o w been established.
A c k n o w le d g m e n t is m a d e to th e P o s t g r a d u
ate C e n t e r for M e n t a l H e a l t h , u n d e r w ho se
auspices this book w a s w r it te n , an d to its Staff
for th e s tim u la tio n th ey in spire d. T h a n k s a re
d u e to G r u n e & S tr a tt o n , th e p u b lish e rs of m y
books S h o rt-te rm P sy c h o th e ra p y a n d T he D y
n am ics o f P e rso n a lity (w ith J o h n K ild ah l) for
p e rm iss io n to utilize som e m a te ria l from these
v o lu m es in C h a p t e r s 7, 8, 9 a n d 16. C r e d it is
also d u e to m y secretary, A n n K o c h a n sk e , for

w h o m in d e p e n d e n t steps a r e avoided. T h i s is

h e r effective h e lp w ith th e physical p r e p a r a t i o n

p a rtic u la rly the case in sicker p a tie n ts w hose

of th e book a n d th e checking of references.

d ep end ency needs a re h a ll m a r k s of th e i r basic


pe rson ality stru c tu re , o r w h o have, b ecau se of
persisten t a nx iety , lost th e ir sense of m a s te ry

N e w Y ork, N e w Y o rk

an d d istru st th e ir o w n c apacities to function.

N o v e m b e r 1, 1979

L e w is R. W o lb e r g , M . D .

CHAPTER 1

Models of Short-term Therapy


B rief tr e a tm e n t is no n e w c o m e r on the
p s y c h o th e ra p e u tic scene. C h ro n ic le d in p r i m i

th e b eg in n in g of the tw e n tie th c e n tu r y m e th o d s
of t r e a tm e n t w e re sh o rt te r m ; even th e orig in a l
F r e u d i a n te c h n iq u e s w e re im p le m e n te d over a

tive archives of earliest rec orded h isto ry , p a r


ti cularly in E g y p t a n d G reece, a r e acc o u n ts of

p erio d of a few m o n th s. G r a d u a l l y p s y c h o a n a
lytic m eth o d s stretch e d o ut in tim e, a n d the

w h a t we m a y consider species of s h o r t-te rm


p sy c h o th erap y .

In

these

a n c ie n t

d o c u m e n ts

n u m b e r of w eek ly sessions increased as efforts


w e re directed at the task of resolving resistance

th e r e a re tra n sc rib e d e la b o r a te ritu a ls to heal


th e afflicted, to solace tr o u b le d souls, a n d to

to u n co nscio us conflict. A few c o n te m p o ra r ie s


of F r e u d , n o ta b ly A d ler, F e ren cz i, Stekel, an d

assuage a n g u is h an d distress. A m o n g such in


terv entio ns a re tr a n q u il iz i n g n o s tru m s , bodily

R a n k , tried h ero ically to s h o r te n th e p r o


tra cted tim e of psy ch o a n a ly sis, b ut th e i r m e t h

m a n ip u la tio n s , tr a n c e in can ta tio n s, persu a siv e


suggestions, a n d even r u d i m e n t s of rein fo rce

ods w e re re p u d i a te d by th e official a n a ly tic es


ta b lis h m e n t. S om e R a n k i a n a n d S teke lian stra-

m e n t th e r a p y , em o tio n al c ath a rsis, a n d i n t e r


p re ta tio n of fantasies a n d d re a m s . E la b o r a tio n s
of these th e r a p ie s c o n tin u e to th is d a y d r a p e d

te gem s survived, nevertheless, a n d h ave been


a d a p te d to fit in w ith p re s e n t-d a y styles a n d
c o n te m p o r a r y ideologies.

in th e soph istication of m o d e r n theories. U p to

Psychoanalytic Modifications in
Brief Dynamic Therapy
It w a s F r a n z A le x a n d e r in 1946 w h o most
strikin gly challeng ed th e validity of p ro lo n g ed

prior

to t e r m i n a t i o n ,

strateg ic

p l a y i n g of

stu d ie d roles, a n d co m b ined use of p s y c h o t h e r


a p y w ith d r u g a n d o th e r tr e a tm e n ts . A t th e

tim e as a necessary c o m p o n e n t of t r e a tm e n t
m eth o d s directed at rec on structive goals. R e a c

tim e th e ir e x p e ri m e n t s w e re considered as d a r
ing a n d innovative. P a r t ic u l a r ly re g a r d e d as
a b e r r a n t w e re th e e m p h a s is o n p ro b le m solv
ing a n d th e c o n sid e ratio n of t h e r a p y as a c o r

tion to A l e x a n d e r s u n o rt h o d o x y w a s at first
h a rs h , a n d a lth o u g h h e w a s accused of a b a n
d o n in g the psy c h o an aly tic sh ip, it is to his
credit th a t he resisted re c a n tin g his convictions.

rective em o tio n a l e x p erien ce th a t functioned to


b r e a k u p old reactio n p a tt e rn s . In some

A lo ng w ith F re n c h he p u b lish ed a p io n e e r
w o rk on b rief th e r a p y (A le x a n d e r & F r e n c h ,
1946) th a t q u estio n ed m a n y of th e a s s u m p tio n s
of lo n g -term classical p sy choanalysis.
In th eir v olu m e the a u th o r s describe e x p e r i

ca se s , th ey w ro te , th e d ev elo p m e n t of a fullfledged tr a n sferen ce n eu ro s is m a y be d e sir


able; in o th e rs it sho uld p e r h a p s be avoided
a l t o g e t h e r . In s o m e it is i m p e r a t i v e t h a t

m e n tin g w ith v a ry in g th e fre qu enc y of in t e r


views, the a lte rn a tiv e use of th e c h a ir a n d
couch, d e lib erate in te rr u p t io n s of t r e a tm e n t

e m o tio n a l d is c h a rg e a n d insight ta k e place


g ra d u a lly ; in o th e rs, w ith p a ti e n ts w h o se ego
stre n g th is g re a t e r , in terview s w ith g re a t e m o

HANDBO OK OF SHORT-TERM PSYCHOTHERAPY

tional tension m a y be not only h a rm le s s but

ti m e devoted to t r e a tm e n t w ith o u t d estro y in g

highly desirable. All this d ep en d s u p o n the

its

e ffe c tiv e n e ss

needs of the p a tie n t in a p a r t i c u l a r p h a s e of the

th e

o b serv a tio n s of A le x a n d e r

th e ra p e u tic p r o c e d u r e . T h e m odifications
suggested w e re form s of p sy ch oan aly sis based

M o r e o v e r, restrictio n of p a y m e n t s to a des
ig nated n u m b e r of sessions by in s u ra n c e c o m

on d y n a m ic p rin cip le s th a t a tt e m p t to secure a

p a n ie s h as forced even th o s e th e r a p is ts w h o by

m o re h a rm o n io u s e n v ir o n m e n ta l a d ju s tm e n t
w ith en h a n c ed d ev elo pm ent of o n e s capacities.
F r e q u e n t interview s over a lo n g - te rm p e
riod, th ey insisted, h a d a regressive conse
quence

o ften

gratify in g

th e

p a t i e n t s d e

has

rek in d led

interest
and

in

F re n c h .

t r a in i n g a n d conviction a r e dedicated to lo n g
te r m t h e r a p y to m odify th e i r tactics a n d to
b ri n g tr e a tm e n t to a h a lt w ith i n th e confines of
the alloted re i m b u r s e m e n t term . E con om ics
h a s th u s h a d a corrosive effect on ideology,

p end ency needs. T h e in itial soo th ing effect of

w h ich is p ro b a b l y all to the good in a field

th e prolo ng ed ou tlo o k g ra d u a l ly becomes c o r


ru ptiv e, a n d th e th e r a p is t, faced w ith th e task

w h e re bias a n d o p in io n h a v e frozen p ro fes


sionals to p o s tu la te s th a t could n ever h av e been

of driv ing the p a ti e n t from his co m fo rta b le in

o th e rw ise th a w e d o u t a n d revised.

fantile position, realizes a n e w h o w difficult it


is to force a n y o n e to give u p a c q u ir e d r i g h ts .

T h e w o r k of A le x a n d e r a n d F r e n c h p r o
vided th e fo u n d a tio n for o th e r dev elop in g sys

It w a s a fallacy, th ey con tend ed, to a ss u m e


th a t a n a n a ly sis o rien ted a r o u n d regressive

te m s of d y n a m i c s h o r t - t e r m t h e r a p y a n d
in s p ire d a n u m b e r of a n a ly s ts w h o th o u g h

m a te ria l w a s m o re th o r o u g h t h a n on e focused
on t h e i m m e d i a t e life co nflict. I n d e e d ,

loyal to the te ac h in g s of F r e u d refused to c o n


sider th e m as divine rev elatio n s ( M a r m o r ,

regressive m a te ria l w a s u su a lly a sign of n e u

1979).

rotic w i t h d r a w a l from a difficult life situ atio n .

concepts, th ey vouchsafed th e validity o f th e

It w a s the d u ty of th e th e r a p is t to d ivert this


re tre a t to w a r d n ew a tt e m p t s to solve p ro b le m s

d y n a m ic design. A m o n g th e best k n o w n of c o n

from w h ich the p a tie n t h a d fled in th e past.


A n o th e r d isa d v a n ta g e of too fr eq u e n t sessions

th e r a p y a r e th e w ritin g s of M a l a n , Sifneos,
and M ann.

w a s th a t tra n sferen ce w a s not allo w ed to a c c u


m u la te , being d ra i n e d off in sm all q u a n ti ti e s at

I n t h e s t u d y by M a l a n (1 9 6 3 ) a t th e
T a v i s t o c k C l i n i c in L o n d o n , t h e p a t i e n t s

each session, th u s lessening th e em o tio n al p a r

tre a te d w e re th ose w h o w e r e ab le to exp lo re


th e ir feelings a n d w h o gave the im p ressio n

ticipatio n. T h e y advised m a n i p u la t io n o f the


freq uency of sessions to intensify em o tio n al
reactions. A focus on th e p re s e n t he lped redu ce
th e evolvem ent of a tran sferen ce neu roses a n d
th e su b stitu tio n of tr a n sfere n c e gra tific atio ns
for real-life experiences. P u tt in g into practice
w h a t h a d been le a rn e d in th e r a p y e n co u rag ed
th e b olsterin g of self-confidence a n d the ov er
co m in g of n e u ro tic im p a ir m e n t . T h e p a ti e n t
d u r i n g th e course of his e x p e ri m e n t in g w ith
n ew p a tt e r n s w a s to be fo r e w a rn e d of failures
a n d the need to a n a ly z e the reaso ns for these
sh ou ld they occur, th u s tu r n i n g th e m to a d v a n
tage.
W i t h th e d e v e lo p m e n t of c o m m u n ity m en tal
h e a lth facilities a n d th e servicing of increasing
g ro u p s of p a tie n ts by staffs dep leted th r o u g h
s h r in k in g bud gets, the necessity of lim itin g

W h il e

c h a lle n g in g

classical

a n a ly tic

te m p o r a r y c o n tr ib u tio n s to d y n a m ic s h o r t-t e rm

th ey could w o r k w ith in te rp re tiv e t h e r a p y . All


of th e t h e r a p is t s involved w e re p sy c h o a n a lytically o rie n te d a n d w illin g to e m p lo y a n
active in te rp re tiv e te c h n iq u e . Sessions totaled
from 10 to 40. It w a s possible, M a l a n w ro te ,
u n d e r these co n d itio n s to o b ta in q u it e farre a c h in g im p ro v e m e n ts not m erely in s y m p
to m s, b u t also in n e u ro tic b e h a v io r p a t t e r n s in
p a tie n ts w ith relatively extensive a n d lo ng
sta n d in g n e u r o s e s . T h e best results w ere
achieved w h e n (1) th e p a ti e n t w a s hig h ly m o t i
v ated, (2) th e th e r a p is t d e m o n s tr a t e d h ig h e n
th u s ia s m , (3) tr a n sferen ce developed early ,
especially neg ative tra n sferen ce, a n d w a s i n t e r
p re te d , a n d (4) g rief a n d a n g e r b ecam e i m p o r
t a n t issues as te r m i n a ti o n a p p r o a c h e d . T h e
p ro gn o sis w a s also best w h e r e th e p a ti e n t a n d

MODELS OF SHORT-TERM THERAPY

th e r a p ist sho w ed a stro n g w illing ness to get in


volved the fo r m e r w ith a n in ten se desire for

needed to develop p r o p e r m o tiv atio n for t h e r


a p y , th a t rigid a n d d eep -se ated issues re q u ire d

help th r o u g h u n d e r s ta n d in g , th e la tte r w ith

m o r e w o r k t h a n th e lim ited tim e could allo w ,

s y m p a th y w h ile in te ra c tin g objectively a n d not


w ith c o u n te rtra n sfe re n c e . Even deep -seated

that

severe d e p e n d e n c e

and

o th e r

u n fa v o r

neu ro tic b eh a v io r p a tt e r n s could be lastingly


ch ang ed. T h e te c h n iq u e if p r o p e r ly used c a r

a b le in ten se tr a n sferen ce feelings w o u ld be


too o bstru ctive, o r th a t dep ressive o r psychotic
d is tu rb a n c e s m i g h t be p r e c ip ita te d o r in t e n

ried few d an g ers , even w h e re p e n e tr a ti n g i n

sified.

te r p re ta tio n s

w ere

made

fr o m

dream s,

Sifneos (1 97 2), c o n firm in g m a n y of M a l a n s

fantasies, a n d th e th e r a p is t - p a r e n t lin k of the

findings, a d d s som e o th e r crite r ia of selection

tra nsferenc e th a t connected th e p re s e n t w ith

for this form of d y n a m ic a n x ie t y - p r o v o k in g


th e r a p y th a t lasts fro m 2 to 12 m o n th s. S u it

ch ildhood experiences. M a l a n
gested

th a t

crucial

modestly su g

in g re d ie n t

in

ch a n g e

m ig h t not be th e te c h n iq u e em plo yed , bu t the


n o n s p e c ific f a c t o r of t h e a n a l y s t a p p l y i n g

a b le

p atien ts

are

those

who

p o ss e ss

five

qu alitie s: (1) existence of a b o v e-av erag e in


telligence, (2) possession of at least on e m e a n

him self e n th u s iastically to his te c h n iq u e ir

ingful re la tio n s h ip in th e p a st, (3) ab ility to

respective of w h e th e r it w a s an aly tic o r n o n analytic.

i n t e r a c t w i t h t h e i n i ti a l i n t e r v i e w e r w h ile
m a n ife stin g a p p r o p r i a t e e m o tio n s a n d a d egree

In a later stud y p u b lish ed in his book


F ro n tier o f B r ie f P sych o th era p y, M a l a n (1976)

of flexibility, (4) ab ility to identify a specific

confirm ed his prev io us conclusions r e g a r d in g


the utility of d y n a m ic s h o r t-t e rm th e r a p y and

oneself, to w o r k on oneself, to recognize o n e s

described som e p rin c ip le s of selection of s u i ta


ble p a tie n ts for th is form of tr e a tm e n t. In

v ealin g th in g s a b o u t oneself, to p a rt ic i p a te ac
tively in th e r a p y , a n d to m a k e rea s o n a b le

M a l a n s sa m p le the p a tie n ts w e re carefully


screened. C h o s e n w ere th ose w h o a p p e a r e d to

sacrifices (Sifneos, 1978).


F o r p a tie n ts w h o a r e selected, sessions are

have the basic stre n g th to sta n d u p to u n c o v e r


ing p s y c h o t h e r a p y , w h o w ere resp on siv e to

held once w ee k ly for 45 m in u te s in face-to-face


interview s. T h e initial interv iew deals w ith

in t e r p r e t a t i o n , a n d w h o could help fo r m u la te

h isto ry tak in g , p a r t ic u l a r ly a ju d ic io u s c o n

a c ircum scribed focus a r o u n d w h ich th e r a p y

fro n ta tio n

c o u ld

ty pe of q u e s t io n s . As a re a s of conflict an d

be

done.

S e v e r i ty

of p a t h o l o g y

or

chief c o m p la in t, (5) w illin gn ess to u n d e r s ta n d


s y m p to m s as psychological, to be ho nest in r e

by

o p e n -e n d e d

and

forced-choice

chronicity w e re no t c onsidered. O f all factors

m a l a d a p ti v e re actio n s o p en u p , th e th e r a p is t

in prognosis, m o tiv atio n for insigh t a n d th e


ability to focus on significant m a te ria l seem ed

asks q u e stio n s th a t will give h im a c le a re r pic

to be of p r i m a r y im p o rta n c e . T h e s e w e re con

able to m a k e a co nn ectio n b etw e en the u n

sidered to be m e a s u re s of successful i n t e ra c
tions b etw een p a tie n t an d th e r a p is t. P a tie n ts
w h o w e re excluded w ere alcoholics, h o m o s e x
uals, d r u g addicts, th ose w h o h a d at on e tim e

d e rly in g conflicts an d th e superficial c o m


p la in ts . Before long, tra n sfe re n c e feelings a re
a p t to em erge. T h e th e r a p is t m u s t th en con
fro n t th e p a tie n t w ith his tra n sfe re n c e feelings

m a d e serious suicidal a tte m p ts , w h o h a d a p e


riod of lo n g -term h o sp ita liz a tio n , w h o h ad
m o re t h a n one course of E C T , w h o suffered

a n d use th e m as th e m a in p s y c h o th e ra p e u tic
to o l . T h i s facilitates tr a c in g of o n e s e m o
tio n al p ro b le m s in the p a st a n d reco gn izin g
h o w conflicts give rise to o n e s sy m p to m s.

fr o m i n c a p a c i t a t i n g c h r o n i c o b s e s s io n a l o r
p h o b ic s y m p t o m s , a n d w h o w e r e g r o s s ly
destructive or self-destructive in ac tin g -o u t. As
w as predicted, reaso n s for rejection w e re th a t
the p a tie n t w o u ld have difficulty in m a k i n g
contact, th a t a g re at d eal of w o r k w o u ld be

t u r e of th e p sy ch o d y n am ics. H e m a y th en be

S o o n e r or later resistance a p p e a r s . T h e w ho le
to n e of the in terview s sta rt to c h a n g e , silences
a p p e a r , th e w h o le i n t e r v i e w s e e m s f r a g
m e n t e d . C o n f r o n t a ti o n a n d clarification a re
em p lo y ed as tools, b ut a tra n sfe re n c e neuro sis

HANDBOOK OF SHORT-TERM PSYCHOTHERAPY

is avoided. T h e p a ti e n t m u s t be c onfronted
w ith his a n g e r a n d his n egativ e feelings, a n d
these m a y flair u p w ith th e t h e r a p i s t s an x iety -

cated y o u n g p e o p le w h o gave freely of th e ir


tim e a n d w e re ea g e r to h e l p . W h il e th es e r e

p ro v o k in g questio ns. In te r p r e t a ti o n s h elp cla

q u ir e m e n t s a r e ideal, th e av erag e t h e r a p is t will


see a good n u m b e r of less s u itab le p a ti e n ts u r

rify the p a t i e n t s reactions. A w a re n e s s of his

g en tly d e m a n d i n g s y m p to m relief w h o se p r o b

o w n co u n te rtra n sfe re n c e is vital, a n d th e t h e r a


pist m u s t m a k e sure he is n ot u sin g th e p a tie n t

lems a r e lin ked to in n e r conflicts a n d w h o do


n ot fulfill the selection r e q u i r e m e n ts of Sifneos.

to gratify his o w n needs. R e p e a te d ly d e m o n

T h e y m ig h t still be co nsidered for d y n a m ic

stra tin g h ow the p a tie n t deals w ith his conflicts

th e r a p y , b u t a n x ie ty -p r o v o k in g
h av e to be avoided.

a n d th e adverse effects on h im , the th e r a p is t


acts as a n u n e m o tio n a lly involved te a c h e r .
T a n g ib l e evidence of p ro g ress is sh o w n by th e

tactics

may

Sifneos h a s no t neglected c o n sid e ra tio n of

p a t i e n t s ability to relate w h a t is g oin g o n to

o th e r classes of p a tie n ts no t qualified for th e


a n x ie ty -p r o v o k in g te c h n iq u e b u t a m e n a b le to

p a st sources a n d by im p ro v e m e n t in his in t e r

a n a n x i e t y - s u p p r e s s i v e f o r m of t h e r a p y .

perso n al re latio n sh ip s. T h e th e ra p ist m ust

S uch t h e r a p y is designed for p a tie n ts w ith

w ork u n in terru p ted ly to w ard term in atio n ,


h a n d li n g his co u n te r tr a n sfe re n c e a n d rea lizin g

w e a k ego s tru c tu r e s w h o h a b it u a ll y h ave p o o r

th a t th e r e a r e ce rta in b e h a v io r p a tt e r n s w h ich

lifelong e m o tio n a l difficulties. H e r e th e goal

c a n n o t be altered by p s y c h o t h e r a p y . At a p r o
pitio us tim e te r m i n a ti o n m u s t be discussed.

is

T h e p a t i e n t s reactio n s such as a n g e r, d e
pression, a n d fear m u s t be a n tic ip a te d an d
han d led .
T h e follow ing o u tlin es technical processes in
Sifneoss te chn iq ue:
1. T h e p a t i e n t is a s k e d to list in o r d e r of u r g e n c y
t h e p r o b l e m s t h a t h e w o u l d like to overcom e.
2. It is es sen tial to d ev elo p a r a p i d t h e r a p e u t i c

in te rp e r s o n a l
to

re la tio n s a n d

d issipate

a n x ie ty

by

a r e disposed to
such

tactics

as

re a s su ra n c e , advice giving, em o tio n a l cath a rsis,


e n v ir o n m e n ta l m a n i p u la t io n , p e rs u a s io n , h o s
p ita liz a tio n , o r m ed ication . W h e r e th e p a ti e n t
h a s a d e q u a t e m o tiv a tio n to receive h elp, reco g
nizes th a t his s y m p to m s a r e psychological, is
able to m a i n ta i n a jo b , a n d is w illin g to c o o p
e ra te w ith th e th e r a p is t , h e h a s th e best o p p o r
tu n ity

for relief.

Sessions

last from

a few

m in u te s to a n h o u r a n d a r e spaced every week,

al l i a n c e w i t h p a t i e n t , since t h e p a t i e n t s po sitive

twice a w eek, o r oftener. B rief crisis s u p p o r tiv e

fe elings t o w a r d t h e r a p i s t c o n s t it u t e a ch ie f t h e r a

t h e r a p y lasts u p to 2 m o n t h s an d is a im e d at
ov ercom ing th e e m o tio n al d ec o m p e n sa tio n .

p e u t i c tool. A g r e e m e n t m u s t be r e a c h e d r e g a r d i n g
th e p r o b l e m to be solved.
3. T h e t h e r a p i s t r a p i d l y a r r i v e s a t a te n t a t i v e
psychodynam ics and the und erly in g em otional con
flicts.
4. T h e focus in t h e r a p y is o n t h e s e conflicts, t h e
ob ject b e i n g to h e l p t h e p a t i e n t l e a r n n e w m o d e s of
so lving difficulties.
5. T h e

therap ist

m ust confront patien t w ith

a n x i e t y - p r o v o k i n g q u e s t io n s , h e l p i n g h i m to face
a n d e x a m i n e a r e a s of difficulty r a t h e r t h a n to av oid
t h e m , a n d e n a b l i n g h i m to e x p e r i e n c e his conflicts
a n d to co n s o l id a te n e w s o lu tio n s for th e m .
6. If successful in r e a c h i n g t h e g o a ls set fo rth , t h e
p a t i e n t s h o u l d be a b l e to u tiliz e his l e a r n i n g to
d e a l w i t h t h e n e w cr itical s i t u a t i o n s in t h e f u t u r e .

It m u s t be re m e m b e r e d th a t th e basis of
Sifneos a p p r o a c h w a s w o rk w ith a clinic
p o p u la t io n of self-referred, relatively w e ll- e d u

P a tie n ts w ith serious difficulties, h o w ever, m ay


re q u i r e s u p p o r t for a p ro lo n g ed period.
A n in terestin g fo rm of d y n a m ic b rief t h e r
a p y h a s been de taile d by M a n n (1973). A few
of th e p rin c ip le s w e re o rig in a lly described by
R a n k (1 9 36 , 1947). S tressin g the subjective
a n d objective m e a n in g s of tim e (e.g., s e p a r a
tion , loss, d e a th , etc.) b oth to th e p a tie n t an d
th e r a p is t, M a n n co ntends th a t am b ig u ity
a b o u t tim e lim ita tio n s of t h e r a p y m a y act as a
d e te r re n t to a cceptance of reality a n d th e w o rk
to be done. P a tie n ts , h e avow s, a r e b o u n d to
child t i m e , a n unco nscio us y e a rn i n g for
e tern ity , a n d m u s t be b r o u g h t to th e a c c e p
ta n c e of realistic lim ited a d u lt t i m e . H e o u t
lines a f ix e d 12 session fo rm of tr e a t m e n t based
o n p s y ch o an aly tic concepts a r o u n d w h ic h he

MODELS OF SHORT-TERM THERAPY

h a s stru c tu r e d a m eth od olo gy . E x p e rie n c e


ha s d e m o n s tra te d th a t 12 t r e a tm e n t sessions is

D e u t s c h s associative a n a m n e s i s (D e utsch ,
1 949) as o ne w a y of w o rk in g .

p ro b a b ly

series of d y n a m ic events to develop, flou rish,

E v en t h o u g h a n u m b e r of conflictual th em es
v ary , a c o m m o n one, th e r e c u r r i n g life crisis

a n d be a vailable for dis cussion, e x a m in a tio n ,

of s e p a r a ti o n -in d i v id u a t io n is th e su b s ta n tiv e

an d r e s o lu tio n .

ba se u p o n w h ic h th e tr e a t m e n t r e s ts . M a s t e r y

The

the

limited

m in im a l

tim e

interview

r e q u i r e d for a

is c o n cern ed

w ith

of s e p a r a ti o n a n x ie ty serves as a m odel for

clarifying w h a t th e p a tie n t seeks from th e r a p y .

o verco m in g o t h e r n e u ro tic a nx ieties. A m o n g

T w o o r m o r e sessions m a y be re q u ire d here.

basic u niv ersa l conflict s itu a tio n s th a t re la te to


th e s e p a r a tio n -in d iv id u a tio n th e m e a r e (1) in

In the course of this in q u iry a f o r m u la tio n of


the ce n tral conflict p ro d u ctiv e of th e p re s e n t

d e p e n d e n c e v e r s u s d e p e n d e n c e , (2) a c tiv ity

m an ife statio ns of distress can be m a d e . . . [the


th erap ist] telling the p a ti e n t w h a t is w r o n g

v e r s u s p a s s i v i t y , (3) se lf-s u ffic ie n c y v e r s u s


i n a d e q u a te self-esteem, a n d (4) un reso lved or

w ith h i m . T h i s m a y or m a y not accord w ith

d elay e d g rie f. M a s t e r y of s e p a r a ti o n - in d i v id

the p a t i e n t s incentive for seeking help. A d e

u a ti o n influences th e m a s te r y of all of th e l a t

lineatio n of o th e r u n co nscio us d e t e r m i n a n t s is

te r conflicts. D u r i n g te r m i n a ti o n of t h e r a p y the

a tte m p te d by e x a m i n in g p a st sources o f th e

p a ti e n t will u n d e r g o a deg ree of a n x ie ty reflec

cen tral conflict. A diag no sis is m ad e , a n d th ere


is a n assessm ent of the p a t i e n t s g en eral p sy

tive of th e a d e q u a c y of his re s o lu tio n of the


s e p a r a ti o n -in d i v id u a t io n p h a s e of his e a rly d e

chological state. T h e r e is th e n an e stim a te of

v elop m e nt. O n e o r a n o th e r of th e fo ur basic

h o w 12 h o u r sessions sho uld be d is trib u te d : 12


full sessions once w eekly, 24 h a lf -h o u r sessions

u niv ersa l conflicts will be activated d u r i n g the


te r m i n a ti o n p hase.

over 24 w eeks, o r 48 sessions of 15 m in u te s

M a n n advises no t to c o m p r o m is e th e 12-

over 48 weeks. T h e th e r a p is t expresses to the

session tim e lim it by m a k i n g a n y p ro m ise s to


co n tin u e t h e r a p y after the allotted p erio d has

p a tie n t his o p in io n of th e p a t i e n t s chief p r o b


lem an d w h a t he believes sh ou ld be done. H e
c onsults his c a le n d a r a n d a n n o u n c e s th e exact

end ed. In this w a y a fixed tim e s t r u c tu r e is

d a te of te r m in a tio n . H e settles dates a n d tim es

e sta b lish in g a d e p e n d e n t r e l a ti o n s h ip a n d of

of a p p o in t m e n t s a n d

w o r k in g t h r o u g h th e crisis of se p a r a tio n an d

discusses the fee.

He

assu res the p a ti e n t th a t if they find th e chosen


central issue e rro n e o u s, th e y will m ove on to

p re s e n te d to th e p a ti e n t in w h ich th e d r a m a of

ach ie v em ent of a u to n o m y is re p e a te d in a set

a n o th e r issue. T h e p a tie n t is th e n given th e

tin g th a t p e rm its a m o re satisfactory solution


t h a n th e in d iv id u al realized in his p a st early

privilege to accept o r reject th e stated c o n d i


tions. A ssu m in g th a t th e p a ti e n t h as sufficient

re la tio n sh ip s . In o th e r w o rd s , w e a r e provided
w ith tw o th e m e s in th e r a p y : th e first, th e

ego s tre n g th to neg o tiate a tr e a t m e n t a g r e e

c e n tra l issue for w h ic h th e p a ti e n t seeks t r e a t


m e n t, a n d th e second, th e m o r e basic s e p a r a
ti o n -in d iv id u a tio n th em e. T h e fact t h a t we
focus on a n a g re e d a r e a of inv estigation an d

m e n t a n d to to le ra te a stru c tu r e d schedule, a r
ra n g e m e n ts for th e r a p y a r e concluded.
T h e interview s a re c o nd ucte d on as h ig h an
em o tio n al level as possible, m ov ing fro m a d a p
tive issues to defenses to genetic o rig in s of c o n
flicts. T h is , of course, re q u ire s th a t th e t h e r a
pist be e m p a th ic an d th a t h e have a high
degree of co m p r e h e n sio n of d yn am ics. T h e
choice of the ce n tral issue will v a ry w ith the
t h e r a p i s t s u n d e r s t a n d i n g a n d e x p e r i e n c e .
Since free association is im p ra c tic a l in s h o r t
te rm th e r a p y , som e o th e r fo rm of c o m m u n ic a
tio n is n e e d e d . M a n n r e c o m m e n d s F e li x

th a t the p a ti e n t possesses k n o w led g e of i m


m i n e n t t e r m i n a ti o n lim its th e e x te n t of r e
gression in th e transference. T h e r a p i d m o b i
lization of a positive tr a n sferen ce in th e first
few sessions will b rin g s y m p to m relief a n d an
o u t p o u r i n g of m a te ria l. A lth o u g h th e focus is
o n th e c e n tra l issue, th e ad a p tiv e m a n e u v e rs of
the p a tie n t an d th e genetic roo ts of th e cen tral
issue will soon becom e a p p a r e n t . T h e t h e r a
pist, h ow ev er, m u s t resist th e te m p ta t io n to

H ANDBO OK OF SHORT-TERM PSYCHOTHERAPY

deviate from th e cen tral th em e. At all times,


th e

th e r a p ist

is active

th e r a p y , a c c o rd in g to M a n n , m ost p a tie n ts are

en

c a n d id a tes except th ose w ith b o rd e rlin e or p s y

c ourag ing , an d e d u catin g th e p a t i e n t . T h i s


does not m e a n giving advice o r gu idan ce.

chotic p ro b lem s. Y o u n g peo ple in a m a t u r a tion al crisis h ave difficulties exq uisitely r e

A bo ut

lated to th e s e p a r a tio n -in d iv id u a tio n p ro c e s s.


R e g a r d in g t h e r a p is t s w h o c an w o rk w ith this

the seventh

in s u p p o r tin g ,

session

the p a tie n t

will

begin to sense d is a p p o in t m e n t in t h e r a p y since


he is not allow ed to talk a b o u t all of th e th ing s
he w a n ts to b ri n g u p a n d m u s t confine him self

m e th o d , M a n n says: It is evident th a t this

to th e cen tral issue. At this p o in t negative


transferen ce will a p p e a r , a n d a m b iv ale n c e re

of skill, kn o w led g e, a n d experience. K n o w l

places positive tr ansference. R esistance re a r s


its h ead, an d sy m p to m s m a y r e t u rn . D esp ite
these reactions th e th e r a p is t m u s t w o r k to w a r d
te r m in a tio n . T h i s will be difficult for b o th p a
tien t a n d th e r a p is t since th e em o tio ns of t e r m i
n atio n an d se p a r a tio n (such as grief a n d a n g e r)
will be disconcerting. T h e p a tie n t will show
m a n y defenses ag ain st te r m i n a ti o n th a t will
have to be h an d led .
In te rp r e t a ti o n of th e p a t i e n t s reactio ns is
im p o r t a n t as th e p a tie n t expresses his a m
bivalent feelings, th e th e r a p is t e n u n c ia tin g the

k in d of p s y c h o th e ra p y re q u ire s a high degree


edge of th e psy ch o a n a ly tic theo ries of m e n ta l
fu n ctio n in g heavily b uttressed by e xp erienc e in
th e lo n g - te rm t r e a tm e n t of p a tie n ts is th e first
p r e p a r a t i o n for this t r e a tm e n t p l a n .
A n o th e r system of d y n a m ic s h o r t-t e rm t h e r
a p y is described by L e w in (19 7 0), w h o , fo llow
in g th e le a d o f B e r g l e r ( 1 9 4 9 ) , c o n s i d e r s
s y m p to m s a c on sequ en ce of psychic m a s o c h
is m , w h i c h is a u n i v e r s a l i n g r e d i e n t of
neu ro ses. T h e need to a p p e a s e guilt th r o u g h
suffering, h e av o w s, c an p re v e n t pro g ress in
th e r a p y . Ideally , th e core of the p a t i e n t s
m a s o ch ism , his b ad in tro ject, shou ld be e x

sta n d a b le since his ex pe ctatio ns a re n ot being

posed a n d rep lac ed, a lo n g w ith his sadistic


conscience. W h il e this m a y no t a lw a y s be

fulfilled. D a t a from th e p a t i e n t s past will


allow for a re la tin g of th e p a t i e n t s reactio ns to

possible, th e least th e th e r a p is t can do is to


c o n f r o n t t h e p a t i e n t w i t h h is m a s o c h is m .

early e xperiences w ith p a r e n t a l figures. T h e


last th ree sessions at least sho uld be devoted to
d ealing w ith the p a t i e n t s feelings a b o u t t e r m i
n ation .

A ssig nin g all of his p ro b le m s a n d sy m p to m s to


s e lf-p u n ish m e n t for guilt feelings in re la tio n to

idea th a t th e p a t i e n t s resp on ses a re u n d e r

As to selection of p a tie n ts for this ty pe of

p a r e n t a l figures provides th e p a tie n t w ith a


focus th a t, a cco rding to L e w i n , helps sh o rten
th e th e r a p e u tic process.

Eclectic Systems
S p u r r e d on by c o m m u n ity need, by stric
tu r e s on the n u m b e r of sessions financed by

m o re innovative, being influenced by beh av io r


t h e r a p y , by th e c o n te m p o r a r y e m p h a s is on ego

th i r d - p a r ty p a y m e n ts , an d by dissatisfaction
w ith th e resu lts of lo n g -te rm tr e a tm e n t, t h e r a

functions, by a n in creasin g interest in p ro b le m


solving as a p r i m a r y m e a n s of e n h a n c i n g
a d a p ta tio n , as well as by a re s u rg e n t flexible
eclecticism (G ra y s o n , 1979). A ccordingly, a
n u m b e r of m odels of s h o r t- t e r m th e r a p y have
been in tro d u c e d , an d som e of these will be
cited as ex a m p les. O t h e r excellent m od els u n
d o u btedly exist, b u t th ey c a n n o t be included
because of lack of space. A n e x a m p l e of how

pists of all d e n o m in a tio n s have ex p e rim e n te d


w ith briefer m e th o d s a n d co n tr ib u te d w ritin g s
to s h o r t-te rm th e o ry a n d practice. Som e of the
te chn iq ues a re a revival of th e m eth o d s e m
ployed in th e p re a n a ly tic a n d e arly an a ly tic
period. Som e a r e replicas of established case
w o r k a n d counseling p ro cedures. O t h e r s are

MODELS OF SHORT-TERM THERAPY


florid th e w ritin g s have become in s h o r t-te rm

re n d e r e d t h a t c a n ta k e th e form of a m in o r

th e r a p y is the a n n o ta t e d b ib lio g r a p h y of W ells


(1976), w h o in review in g th e li te r a tu re u p to

in te rp re ta tio n .

1 974 d e ta i ls 2 4 3 c i t a t i o n s c o v e r i n g m a j o r

w illing to en g a g e i n , in c o n tr a s t to th e p o si
tio n ta k e n by so m e th e r a p is ts like Sifneos to

j o u r n a l s in p sy ch iatry , psychology, a n d social


w o r k . T h e s e a r t i c l e s a r e c a t e g o r i z e d in to
theoretical a n d review articles, in d iv id ua l a d u lt
th e r a p y , indiv idu al t h e r a p y of ch ild ren an d
adolescents, g r o u p th e r a p y , fam ily th e r a p y ,

P sychotherapy

is

p lan n ed

w ith in th e f r a m e w o r k of w h a t the p a ti e n t is

th e effect th a t th e p a ti e n t m u s t fit th e t r e a t
m e n t chosen for h im by th e e x p e r t . In B eliak
a n d S m a l l s m e th o d d r e a m s m a y be elicited,
projective testing like th e T h e m a t i c A p p e r c e p

m a r ita l th e r a p y , an d t r e a tm e n t of ho sp italized

tio n

patients.
In 1965 B eliak a n d S m all w ro te a book (the

b ri n g ou t rep re ssed m a te ria l. A n a t t e m p t is

T est

used,

and

h y p n o sis em p lo y ed

to

m a d e to e stablish cau sal factors in re la tio n to


p re c ip ita tin g inciden ts a n d specific historical

second edition of w h ich a p p e a r e d in 1978)


th a t differentiated em ergen cy fro m b rief p sy

events a n d stru ctu res. J u d i c i o u s use of in t e r

c h o t h e r a p y . T h e y c o n te n d t h a t e m e r g e n c y
tr e a tm e n t is a t e m p o r a r y a p p r o a c h utilized in

p re t a ti o n to i m p a r t in sig ht, r e a s s u ra n c e a n d
s u p p o r t w h e n necessary, co un selin g, g uid anc e ,

crisis, w h ile b rief p sy c h o th e ra p y is a fore


sho rtened ap p lic a tio n of tr a d it io n a l p s y c h o t h e r

co njoint fam ily t h e r a p y , g r o u p t h e r a p y , dru g s,


e le c tr o c o n v u l s iv e t h e r a p y (as in s u ic id a l

apy , called into being e ith e r by th e life s itu atio n

d epression s), a n d e n v ir o n m e n ta l m a n i p u la t io n

of the p a tie n t or by th e setting in w h ic h t r e a t

will call for a good deal of flexibility, d ia g

m e n t is offered. T h e y offer a fo rm of brief p sy


c h o th e r a p y th a t is rooted in o r t h o d o x p sy c h o

nostic a c u m e n , a n d clinical j u d g m e n t on the

an aly tic th e o ry an d directed at s y m p to m s o r

th r o u g h

m a la d a p ta tio n s , av oiding th e re c o n s titu tio n of


pe rs o n ality th a t m ay, nevertheless, com e a b o u t

m a in te n a n c e of th e positive r e l a t i o n s h i p , they

p a r t of th e th e r a p is t. E m p h a s i s in w o rk in g is u p o n

im m e d ia te le a rn in g .

The

auto n o m o u sly . B rief p sy c h o th e ra p y m a y s t a b i


lize th e individual sufficiently so t h a t he m a y

state, avoids a sense of rejection in the


te r m i n a ti n g process a n d p e rm it s th e p a ti e n t to
re ta in th e th e r a p is t as a ben ig n , in trojected

be enab led to c o n tin u e w ith m o re extensive p sy


c h o th e r a p y . T h e tim e sp a n allotted for t r e a t

f ig u re . T r e a t m e n t is end ed by in fo rm in g the
p a ti e n t th a t th e th e r a p is t is ava ilab le in th e fu

m en t is one to six sessions. A positive t r a n s


ference is fostered, free a ssociation avoided, a n d

t u r e w h e n needed.

in t e rp re ta ti o n te m p e re d , b ein g cou pled w ith


o th e r types of in terv en tio n like medical, en vi

special te c h n iq u e s v au n te d by th e a u th o r s as
u n i q u e l y effective fo r s h o r t - t e r m t h e r a p y .
T h e i r e n th u s ia s m is u n d e r s ta n d a b l e because

ro n m e n ta l , etc. B rief th e r a p y , they observe, is


useful in n e a rly every kind of e m o tio n al dis
tu rb a n c e , even psychosis. W h il e extensive r e
s t ru c tu r in g of th e c h a ra c t e r is desired a n d po ssi
ble, o r w h e re a c tin g -o u t exists, how ever, it is
not suitable.
A detailed histo ry is essential w ith a c o m
plete ex p lo r a tio n of th e p re s e n tin g p ro b le m ,
th e p re cip ita tin g factors, the c o n te m p o r a r y life
situ atio n, a n d the d ev elo p m e n ta l histo ry , in
clud in g fam ily re latio nship s. T h e object is to
u n d e rs ta n d the p resen t illness in d y n a m ic
term s a n d related to p rec ed in g genetic, d e
ve lop m ental, a n d c u ltu ra l ev e n ts. O u t of this,
s o m e i m m e d i a t e t h e r a p e u t i c h e l p m a y be

T h e lite r a tu r e is rep lete w ith d e sc rip tio n s of

th e r a p ists becom e skilled in c e rta in m e th o d s to


w h ich they a r e by p ers o n a lity , o p e ra tio n a l
style, a n d theo re tical bias a ttu n e d . L est w e b e
come too r h a p s o d ic over a n y set of m etho ds,
h ow ev er, w e m u s t r e m e m b e r th a t w h ile they
m a y be effective in th e h a n d s of som e, th ey
m a y no t be useful for all th e r a p is ts . M a t c h i n g
p a tie n t a n d m e th o d is also a c h allen gin g p r o b
lem (B u rk e et al, 1979). E x c e p t for a few sy n
d ro m es, such as b e h a v io r t h e r a p y for p h o b ia s
an d p h a r m a c o t h e r a p y for psychoses, o u tc o m e
studies fail to cred it a n y special interv ention s
w ith global s u p e r io rity over o th e r a p p ro a c h e s .
Indeed, statistics in dicate eq u iv a le n t im p ro v e

HANDBO OK OF SHORT-TERM PSYCHOTHERAPY

m e n t rates for a host of av ailable tech niqu es.


N evertheless, a stu d y of th e v ario us m odalities
in c o n te m p o ra r y use is r e w a r d i n g if no m o re
t h a n to provide us w ith m odels th a t m a y selec
tively be useful.
A m o n g th e most c o m m o n tech niq ues, in a d
dition to those previously cited u n d e r d y n a m ic
th e ra p ie s , a re in terp re tiv e m eth ods th a t d r a w
th e ir sub stan ce from classical (F r e u d ia n ) an d
n o n c la s s ic a l ( A d l e r i a n , S te k e l i a n , R a n k i a n ,

16. G u id e d a ffe c tiv e im a g e r y ( K o ch , 1969).


17. H y p n o s i s
F ran k el,
S p iegel,

(C rasilneck

1973;
1 970;

M orra,
S p ieg el

&

H all,

1967;
&

1975;

R a b k in ,

S p ieg el,

1977;

1 978;

S tein,

A d le r ,

1972;

1 97 2; W o l b e r g , 1948, 1 9 64 , 1965).
18. In te r p r e tiv e
A nsbacher,

19 7 2;

D avanloo,

1978;

G illm an,

m e th o d s
Barten,

(K.

A.

1 971;

D avanloo

D.

&

Beck,

1968;

B e n o it,

1978;

1965; M . M o r e n o , 1 96 7 ; S m a l l , 1 971;

W a h l , 1972).
19. M e d ia tio n ( C a r r i n g t o n , 1 977; C a r r i n g t o n &

J u n g i a n , an d R eich ia n ) psych oan alysis as well


as fro m beh avioral m odels. T h e list t h a t fol

E p h r o n , 1975).

lows includes the m o re form al m od alities c u r


ren tly in use:

C lark,

20. M ilie u th e r a p y (B e c k e r & G o l d b e r g , 1 970;


1 9 7 2;

R askin,

G oldberg,

1971;

1 97 3;

S tain b ro o k ,

K nobloch,
1967;

1973;

V isher

&

O S u l l i v a n , 1 9 71 ; W i l k i n s , 1963).
1. A u to g e n o u s

tr a in in g

(Crosa,

1 96 7 ;

L u th e ,

2 2. P e rs u a sio n ( M a l t z , 1960).

1 963; S c h u ltz & L u t h e , 1959).


2. B e h a v io r a l m o d e ls (A yllon

& A zrin,

1968;

B a n d u r a , 1 969; C r o w e et al, 1 97 2 ; F e r b e r et al,


1 974;

Ferster,

W ilson,

1975;

1 964;

Franks,

G hadirian,

1 964;

1971;

F ranks

Hand

&

&
La-

M o n t a g n e , 1 974; H o f m e i s t e r , 1 97 9; L a z a r u s , 1976;
L ic k & B o o tz in , 1 970;
1 974;

P a t t e r s o n , 1 9 7 3 a , 197 3 b,

R ichardson & S uinn,

1 974; S t u a r t ,

1969;

3. B io e n e rg e tic s ( L o w e n , 1958; P a l m e r , 1971).


G lueck

(B lan ch ard

& S troebel,

1975;

&

Young,

Stroebel

1974;

& G lueck,

th e r a p y

(K erns,

1970;

U pham ,

6. C o g n itiv e le a r n in g ( B a k k a r &

B akkar-R ab-

(H .

Young

2 6. P s y c h o s y n th e s is ( T i e n , 1972).
2 7. R e a lity th e r a p y ( G l a s s e r , 1 965; G l a s s e r &
Z u n i n , 1972).
29. S c r e a m th e r a p y ( C a s ri e l , 19 72).
30. S e n s itiv ity

tr a in in g

(Q uaytm an,

1969;

S c h u t z , 19 67 ).
th e r a p y

( B i e r e r,

1 9 4 8;

F leisch l

&

W o l f , 1967).
1974;

th e r a p y

H ayw orth,

(D asberg

1973;

&

H ollister,

Van

Praag,

1970;

K al-

in o w s k y & H i p p i u s , 1969; O s t o w , 1962).

d a u , 197 3; G r e e n e , 1975).
7. C o g n itiv e th e r a p y (Beck, 1 97 1, 1976; Ellis,
1 95 7, 1 96 5 , 1 973; G l i c k e n , 1968; R u s h , 1978).
8. C o n fr o n ta tio n m e th o d s (G . A d l e r & Buie,
1 97 4; G . A d le r & M y e r s o n , 1973; G a r n e r , 1 9 7 0a,
1 97 0 b ; G o d b o l e & F a l k , 1 972; K a s w a n & L ove,

33. S tr u c tu r a l in te g ra tio n (Rolf, 1 9 58 ; S p e r b e r et


al, 1969).
34. S y m b o ld r a m a ( L e u n e r , 1969 ).
35. T r a n s a c tio n a l
Hollensbe,

a n a ly s is

1 97 6; J o h n s o n

&

(Brechenser,

1972;

C h atow sky,

1969;

S h a r p e , 1976).

1 969; Sifneos, 1972).


m e th o d s

p s y c h o th e r a p y

2 5. P sy c h o im a g in a tio n th e r a p y ( S h o r r , 1972).

32. S o m a tic

1 973; W a t t i e , 1 973; A. W o l b e r g , 1965).

9. C o u n s e lin g

24. P ro g ra m m e d
19 74).

31. S o c ia l

19 73).
5. C a s e w o r k

2 3. P r im a l th e r a p y ( J a n o v , 19 7 0).

28. R e la x a tio n ( B e n s o n et al, 19 74).

S u i n n et al, 1 970; W o l p e , 1964).


4. B io fe e d b a c k

21. M u ltim o d a l th e r a p y ( L a z a r u s , 19 76).

(G ross

&

D eridder,

36.

V id e o ta p e p la y b a c k

(A lg er,

1 97 2 ;

B e rg e r ,

1 9 7 0 , 1 97 1 ; G o n e n , 1 97 1; M e l n i c k & T i m s , 1974;

19 66).
10. D a n c e a n d m o v e m e n t th e r a p y ( S m a ll w o o d ,

S ilk, 1972).

19 74).
11. D ecisio n th e r a p y ( G r e e n w a l d , 1974).
12. E m o tio n a l c a th a rsis (N ich o ls, 1974).

Less fo rm al th e r a p ie s h ave d r a w n on th e fol


low ing tech niqu es:

13. E S T (K ettle, 1976).


14. G e s ta lt th e r a p y (P e ris , 1 96 9 ; A. C . S m i t h ,
19 76).
15. G o a l a t t a i n m e n t s c a lin g
C a l s y n , 1978).

1. B u d d h is t S a lip a tth a n a , o r m in d fu ln e s s m e d i
ta tio n ( D e a t h e r a g e , 19 75).

(La F erriere &

2. C o m m u n ic a tio n th e o r y ( K u sn etzo ff, 1 974; R.


C . M a r t i n , 19 68).

MODELS OF SHORT-TERM THERAPY


6. P s y c h o s o m a tic c o n d itio n s ( M e n t z e l ,

3. D r e a m a n a ly s is ( M e r r i l l & C a r y , 19 75).
4. E m o t iv e - r e c o n s tr u c tiv e p s y c h o t h e r a p y
( E R P ) , w h i c h c o m b i n e s t h e u se of i m a g e r y w i t h h y
p e r v e n t i l a t i o n ( F u l c h ie r o , 1976; M o r r i s o n & C o -

7. S e x u a l p r o b le m s ( K a p l a n , 1 97 4 ; L ev it, 1971;
M e a r s , 1 978; S p r i n g m a n , 1978).
8. S m o k in g

m e t a , 1977).
5 . F is c h e r - H o f f m a n

p ro c ess

(A.

C.

S m ith,

1969;

M e y e r , 1 97 8 ; M e y e r & Beck, 1978 ).

h a b its

(M arrone

et al,

1970;

H.

S p iegel, 1970).
9. U n r e so lv e d g r i e f ( V o l k a n , 19 71).

1976).
6. F lo m p m e t h o d ( H a g e l i n & L a z a r , 19 73).

10. U n to w a r d re a c tio n s to p h y s ic a l illn e ss (E . H .


S te in et al, 1 96 9; T u c k m a n , 1970).

7. M o n t a th e r a p y (R e y n o l d s , 19 76).

11.

8. N a ik a n ( Is h i d a , 1969).

W a r n e u r o se s ( P r u c h & B r o d y , 1946).

9. P a ra d o x ic a l i n t e n t i o n ( F r a n k l , 1 9 65 , 1966).
10. S o c ia l s k ills tr a in in g (A rg y le et al, 1974).
11. S o c ia l s y s te m s a p p ro a c h e s ( C l a r k , 1972).

M o r e o v e r , selected in terv e n tio n s h ave been


advised for specific categories of p atients:

12. S to r y te llin g ( D e L a T o r r e , 1972).


13. T e a m

s y s te m s a p p ro a c h e s

( D r e s s i e r et al,

14.

1. A lc o h o lic s ( K r i m m e l & F a l k e y , 19 62 ).
2. D y in g p a tie n ts ( C r a m o n d , 19 70).

19 75).
T h e r a p e u t ic

p a r a d o x t e c h n iq u e

(F u l

3. G e r ia tric p a tie n ts ( G o d b o l e et al, 1 9 72 ; G o l d -

ch ie r o , 19 76).

f a r b & T u r n e r , 1953).

Special tec h n iq u es h ave also been r e c o m


m e n d ed for p a r t ic u l a r sy nd ro m es:

J a c o b s , 1 976; L o r e t o , 1972; W . M i l l e r , 1968).

4. U n iv e r s ity s tu d e n ts ( B r a g a n , 1 9 7 8; K ille e n &

1. C o n v ersio n re a ctio n s ( D ickes, 1974).


2. D e p r e ss iv e re a ctio n s ( C a m p b e l l , 1974; N e u et
al, 1 978; R e g a n , 1965; Sok ol, 197 3 ).
3. H y s t e r i c a l p e r s o n a l i t y d is o r d e r s ( S e i b o v i c h ,

T h e use of s h o r t-t e rm a p p r o a c h e s in p r i
m a r y care an d m edical settin g s has been
described by B leek er (1 97 8), B u d m a n et al
(1979), C o n r o e et al (1978), a n d K ir c h n e r et al
(1978). A lth o u g h no t focused d irectly on s h o r t

4. O b se ssiv e -c o m p u lsiv e d iso r d e rs (Sue ss , 1972).

te r m th e r a p y , th e c o n tr ib u tio n s of S tr u p p
(1972) a n d F r a n k (1973) to re la te d aspects of

5. P h o b ia s ( S k y n n e r , 19 74).

t r e a tm e n t a r e n o te w o rth y .

19 74).

Short-Term Therapy in Outpatient Clinics

T h e urgency in m a n y clinics to a lte r tactics


of p sy c h o th e ra p y in line w ith the re q u i r e m e n ts
of the p a tie n ts being tre ated as well as th e dis
position of th e c o m m u n ity h a s resu lted in the
s h i f ti n g fr o m l o n g - t e r m t r e a t m e n t t o w a r d
eclectic s h o r t-te rm p ro g r a m s . F o r e x a m p le , at
the M o n t r e a l G e n e r a l H o s p it a l in C a n a d a a
c h an g e in th e t r e a tm e n t p h ilo so p h y a w a y from
th e lon g -term objective of p e rs o n a lity r e c o n
stru ctio n w a s necessary for practical reason s:
(1) because the kin d of p a ti e n t p o p u la t io n the
clinic dealt w ith w a s u n a b le to u tilize a

p ro lo n g e d t h e r a p e u ti c re la tio n s h ip an d (2) b e
cause some of th e th e r a p is ts w e re n ot fittingly
t r a in e d or w e re u n a b le to sp en d a sufficiently
long tim e to follow t h r o u g h w ith a p p r o p r i a t e
t r e a tm e n t m e a s u re s ( D a v a n lo o , 1978; S tr a k e r,
1968). T h e resu lt w a s a h ig h d r o p o u t r a t e or
th e ra p i d d e v e lo p m e n t of chro n ic clinic d e
p e n d e n c y . In ad d itio n , w a iti n g lists becam e
so g re a t th a t a c u te e m o tio n al crises could not
receive needed help. A b rief p sy c h o th e ra p y
p r o g r a m w a s sta rte d in 1961 based on p sy
ch o d y n a m ic fo rm u la tio n s . P a tie n ts w h o did

10

H ANDBO OK OF SHORT-TERM PSYCHOTHERAPY

not q ualify for th e p r o g r a m received s u p p o r t-

u n d e rly in g th e p a t i e n t s psychological p r o b

tive kinds of help, p h a r m a c o th e r a p y , social

le m s

service assistance, w a r d care, a n d so on, ac

p ro c es s.
O t h e r clinics th a t have re m o d ele d th e s t r u c

cordin g to th e i r needs. W i t h this p r a g m a ti c


ch an g e the d r o p o u t ra t e decreased over five
times,
greatly

and

staff in terest

stren g th en e d .

an d

m o ra le

w ere

F o llo w -u p studies 2

years after in ta k e revealed th a t 66 p erc e n t of


the total case load h a d benefited sufficiently to

is

th e

key

is su e

in

th e

e v alu a tio n

tu r e of th e ir services a lo n g s h o r t-t e rm lines


also re p o r t an im p ro v e d rem ission ra te a m o n g
p a tie n ts a n d a h eig h ten ed staff m o ral. T h e
n u m b e r of sessions devoted to t r e a tm e n t is con

need no f u r th e r th e r a p y . P a tie n ts selected for

sidered a r b i t r a r y an d h a s ten de d to cluster


a r o u n d lo w er lim its, w h ic h in som e studies

a n d treated w ith b rief p s y c h o th e ra p y show ed

h av e yielded res u lts e q u a l to t r e a tm e n t w ith

a n 84 p ercen t rem issio n rate.

n u m erically

L a rg e ly

th r o u g h

D a v a n l o o s efforts th re e

I n te rn a tio n a l S y m p o sia w e re o rg a n iz e d , in
1975, 1976, a n d 1977, b rin g in g to g e th e r p r o
fe s s io n a ls in t e r e s t e d in b r i e f a p p r o a c h e s .
D a v a n l o o s m e th o d s resem b le th ose of Sifneos
a n d M a l a n . E v a lu a tio n c rite r ia for d y n a m ic
th e r a p y are, first, th e assay of the ability to es
tab lish m ean in g fu l re la tio n s h ip s based on the

higher

se s sio n s .

E rrera

et al

(1967) c o m p a r e d th e resu lts of p a tie n ts a t the


Y a le -N e w H a v e n M e d ic a l C e n te r P sy chiatric
O u t p a t i e n t C lin ic w h o w e re in t h e r a p y for
fro m 6 to 10 sessions w ith a sim ila r p o p u la t io n
w h o received 21 or m o r e t r e a tm e n t sessions
an d fou nd t h a t th e r e w a s no significant d iffer
ence in th e im p ro v e m e n t rates, n e it h e r as
re corded by th e th e r a p is ts n o r e v alu a te d by th e

p a t i e n t s h av in g h a d previo us e m o tio n a l ties

ra te rs.

w ith o th er people. E ven in th e first interview

L in g e rin g d o u b ts as to th e e x te n t of h e lp p a
tients receive h a s been all b u t dissipa ted by the

th e p a t i e n t s cap acity to in te rac t w ith th e t h e r


ap ist will be obvious. Second, th e r e is an esti
m a te of the eg o s cap acity to e xp erienc e an d
tolera te an x iety th a t will be mobilized in th e
interview . T h i r d , m o tiv atio n for tr u e ch an g e
m u s t be differentiated fro m a d esire to satisfy
an infantile need in th e r a p y . F o u r t h , p sy c h o

ex perie nce of clinics th a t h av e converted th e ir


services a lo n g s h o r t-t e rm lines a n d c onducted
follo w -up in q u iries. At th e B oston U n iv e rs ity
M e d ic a l C e n t e r P sy c h iatric C lin ic, for e x
a m p le , a stud y w a s con du cted by H ask e ll et al

logical m in d ed n ess an d cap acity for in tro s p e c

(1969) as to w h a t h a p p e n e d to p a tie n ts after


12 w eeks in s h o r t- t e r m th e r a p y . Significant

tion a re ju d g e d carefully. Fifth, th e most c r u

ch ang es w e re fou nd in th e g r o u p as a w h ole

cial criterio n is the p a t i e n t s ability to resp o n d


c o n s t r u c ti v e ly to i n t e r p r e t a t i o n d u r i n g th e

(a b o u t 71 p e rce n t) on five m e a s u re s of d e
pressio n, a n x iety , a n d o verall im p ro v e m e n t.
E v en th o u g h it w a s felt th a t th e ty p e of p a
tient w h o re s p o n d s to tim e -lim ited t h e r a p y dif
fers m a r k e d ly fro m the ty p e w h o re s p o n d s to
lo n g - te rm t h e r a p y , no cle a r-cu t criteria w ere
apparent.
C linics associated w ith colleges h av e also
n oted excellent re su lts w ith a sm all n u m b e r of
sessions ( M ille r, 1968; Speers, 1962; W h i t

e valu a tio n interview . Sixth, th e degree of in


telligence is an i m p o r t a n t factor in th e choice
of a p p ro a c h . S eventh, the e v a lu a to r m u s t d e
te r m in e the richness an d flexibility of availab le
defenses since these c o rre la te w ith effective
utilizatio n of d y n a m ic th e r a p y . D a v a n lo o is
w edded to classical a naly tic fo rm u la tio n s , such
as the s tru c tu r a l h ypothesis, an d fram e s his
la n g u a g e in these term s. T h e r e is g eneral
ag re e m e n t a m o n g m ost th e r a p ists w ith D a v a n
lo o s belief th a t selection of a p s y c h o t h e ra
peutic focus is vital in s h o r t-te rm t h e r a p y an d
t h a t identification a n d u n d e r s ta n d in g of the
psy cho dy nam ics a n d psychological processes

tin g to n , 1962). B ecause college s tu d e n ts a r e at


a n age level w h e r e p ro b le m s in identity, res o
lutio n of d e p en d e n c y w ith em erg en ce of a u
to n o m y , an d firm in g of sex ual role a r e b eing
w o rk e d th r o u g h , they a re , as a g ro u p , b o u n d
to e x p e rie n c e a good deal of stress. T h e pres-

11

MODELS OF SHORT-TERM THERAPY


ence of a facility th a t can offer th e m crisis-

stud ents.

o riented

s tu d e n ts w h o

p s y c h o l o g ic a l se rv ic e s c a n be e x -

For

e x a m p le ,

a p p lie d for
F ran cisco

review

of 3 ,0 0 0

h e lp at th e C ity

trem ely helpful in fostering a b ette r a d ju s t-

C ollege of S a n

m en t. E x p e rie n c e indicates th a t relatively few

av erag e n u m b e r of con tacts w a s below th r e e

sh o w e d

th a t

th e

sessions a re necessary for th e g re a t m a jo rity of (A m a d a , 1977).

W alk-In Clinics and Crisis Intervention


T h e g ro w th of c o m m u n it y p sy ch ia try has

ing is m o re effective th a n y e ars of passive

pro

w o r k i n g - t h r o u g h . P a tie n ts w h o r e q u i r e m o re

g ra m s o r g a n iz e d for p u rp o s e s of crisis i n t e r

h elp after t h e r a p y en d s a r e invited to r e t u r n

vention a n d the d ealing w ith em ergen cies (Annex ton , 1978; D o n o v a n et al, 1979; D . G o l d

a n y tim e the need a ri s e s , b u t not on a c o n


t i n u in g basis. T h i s a p p r o a c h h a s resulted in a

stein, 1978; R o b b in s, 1978). W a lk - in clinics


th a t b rin g h elp to v irtu a lly t h o u s a n d s of p eo p le

60 p erc en t im p ro v e m e n t r a t e w ith in five visits.


T h i s im p ro v e m e n t ra te , t h a t is a b o u t tw o-

e n c o u rag ed

m u ltitu d e

of s h o r t-te rm

have s p ro u te d th r o u g h o u t th e co un try . A n e x

th ird s of th e

a m p le is th e In ta k e R ece ptio n Service a t th e

s u b s ta n tia te d by m a n y o th e r w a lk -in clinics

p a tie n ts receiving th e r a p y ,

is

Psy chiatric C lin ic of the M a i m o n i d e s M e d ic a l

(G o ttsc h a lk et al, 1967; J a c o b s o n & W il n e r ,

Service in B ro o k ly n , N .Y ., w h ich fun ction s as


a w a lk -in clinic offering im m e d ia te h e lp to

1965). In a larg e stu d y of over 8 ,0 0 0 p a tie n ts


tre a te d on an em e rg en cy basis only 10 p ercen t

an y o n e a p p ly i n g (G elb & A llm a n , 1967). F o u r

required

to eight in divid ual sessions a r e given. If m o re


t h e r a p y is n eed ed, m a x i m a l use is m a d e of

(C o le m a n & Z w e r lin g , 1959). T h e valu e of


s h o r t-t e rm g r o u p crisis in te rv e n tio n h a s also

con tin u in g

long-term

th e ra p y

g ro u p an d fam ily th e r a p y . P rofessionals from


different disciplines a r e used, in c lu d in g p s y

been d e m o n s tra te d . In a stu d y of 78 cases


receiving six g r o u p sessions c o m p a r e d w ith 90

ch iatrists,

so cial

con tro l cases in u n lim ite d g r o u p s o r ind iv idu al

w o rk e rs, a n d psych iatric nurses. A n e x p e r i

th e r a p y , the s h o r t- t e r m g r o u p cases d e m o n

enced th e r a p is t m a y be a c c o m p a n ie d by a t h e r

stra te d g r e a t e r im p ro v e m e n t on a 5 -p o in t scale
of fu n ctio n in g ( T r a k a s & L loy d, 1971).

p s y c h o l o g is t s ,

p sy ch iatric

apist in tr a in i n g , w h o p a rtic ip a te s as a n o b
server. T h u s the session o p e ra te s as a t r a in i n g
tool. In dicatio ns for re f e rrin g a p a tie n t to a
psy chiatrist th e r a p is t a r e an y of th e following:
(1) som atic sy m p to m s, (2) m e n ta l illness in a
p a tie n t w h o is d a n g e ro u s to him self or o thers,
(3) a need for m ed icatio ns, (4) histo ry of a t
tem p te d o r th r e a te n e d suicide, or (5) a special
r e q u e s t for a p s y c h i a t r i s t . T h e a p p r o a c h
utilized is d y n a m ic a lly o rie n te d a n d is n ot co n
sidered, in the w o rd s of G e lb a n d A llm a n
(1967) a n em erg en cy sh o r tc u t o r a p o o r s u b
s titu te for an u n a tt a in a b l e ideal b u t is, in itself,
th e most effective an d h u m a n a p p r o a c h to o u r
p atients. . . . Im m e d ia te , active, e m p h a t ic a n d
acc u rate c o n fro n tatio n w ith n e u ro tic fu n c tio n

W alk-in

clinics

designed

to

p ro v id e

im

m e d ia te g o al-lim ited h elp (B eliak, 1964;


C o le m a n & Z w e r lin g , 1959; J a c o b s o n et al,
1965; N o r m a n d et al, 1967; P eck et al, 1966)
g e n e rally co n c ern them selves w ith crisis in t e r
ven tio n an d u su a lly restrict th e to tal n u m b e r of
sessions to six o r less. R e fe rra l for m o r e ex
ten d ed care is pro v id ed w h e r e necessary. A l
t h o u g h th e w o r k - u p d o n e in different clinics
w ill vary, it g e n e rally includ es som e d y n a m ic
f o r m u la tio n of th e p ro b le m , a n assay of ex ist
in g ego stre n g th s a n d w e akn esses, a n d a n esti
m a t e of the d e g ree of p a th o g e n ic ity of th e c u r
r e n t e n v ir o n m e n t. T o w a r d th is end N o r m a n d
et al (1967) h a v e described a j o i n t initial in t e r

12

HANDBO OK OF SHORT-TERM PSYCHOTHERAPY

view conducted by a p s y c h ia trist-so c ia l w o r k e r

8. T h o s e w h o seek to s o r t o u t t h e i r con flictin g

team . Such a te a m m a x im iz e s th e selection of

id eas. ( H e l p m e p u t t h i n g s in p e r s p e c ti v e . )

a n a p p r o a c h to the existing p ro b le m and


outlines a b lu e p r in t for action. A w o rk in g h y

s t a n d i n g a n d in s i g h t i n t o t h e i r p r o b l e m s . ( 1 w a n t

pothesis

is fo r m u la te d

a tt e m p t in g

to relate

in trap sy ch ic a n d / o r e n v ir o n m e n ta l aspects to
th e d is tu rb e d b e h a v io r or th e sy m p to m s, a n d it
is a r o u n d this hyp oth esis th a t choice of in t e r

9. T h o s e w h o t r u ly h a v e a d e s ire for se lf- u n d e r psych o th erap y . )


10. T h o s e w h o see t h e i r d is c o m f o r t as a m ed ical
p r o b l e m t h a t n e e d s t h e m i n i s t r a t i o n s o f a p h y s i c ia n .
( I need a p h y s i c i a n . )
11. T h o s e w h o re a lly seek s o m e p r a c t i c a l h e l p

ventions is m a d e from a w id e r a n g e of s u p

like d is a b il i t y a s sista n c e , legal a i d , o r o t h e r i n t e r

portive, e d u c a tio n a l, a n d in s ig h t-o rie n te d a p

cessio ns in t h e i r life s i t u a t i o n . ( I n eed y o u r legal

proaches. S h o u ld no im p ro v e m e n t occur, th e
w o rk in g h y p oth esis is re fo rm u la te d . T h i s a p

pow ers )

p ro a c h h as p ro v en itself to be pra ctic al as an


aid to p ro v id in g high q u a li ty m e n ta l h ea lth

c u r r e n t r e l a t i o n s h i p s a n d w a n t t h e clinic to i n t e r

services for th e p o o r
overw h elm in g ly

in the face of even

im p o s s i b le

e n v iro n m en tal

d epriva tion s. T h e r e is a feeling th a t p a tie n ts


from

lo w er socioeconomic classes d o

better

w i t h s h o r t - t e r m c risis i n t e r v e n t i o n t h e r a p y
t h a n w ith a n y o th e r a p p r o a c h (H a sk e ll et al,
1969; M e y e r et al, 1967; Sadock et al, 1968.)
W a lk - in clinics th u s p ro v id e a vital n eed in
the practice of c o m m u n it y p sy c h ia try by m a k
ing tr e a tm e n t im m e d iately a n d easily accessible

12. T h o s e w h o cr e d it t h e i r difficulty to o n g o i n g
cede. ( D o it for m e . )
13. T h o s e w h o w a n t i n f o r m a t i o n as to w h e r e to
get h e l p to sa tisfy v a r i o u s n eeds , a c t u a l l y se ek in g
so m e c o m m u n i t y re so u r c e . ( T e l l m e w h e r e I can
get w h a t I n e e d . )
14. N o n m o t i v a t e d o r p sy c h o tic p e r s o n s w h o a r e
b r o u g h t to t h e clinic a g a i n s t t h e i r will. ( I w a n t
n o th in g . )

W h e r e th e th e r a p is t is p ercep tive e n o u g h to
reco gn ize th e p a t i e n t s d esire a n d w h e r e h e is
c a p a b le of g ratify in g o r at least a c k n o w le d g in g

to all classes of patien ts. M a n y p ro b le m s can


be m a n a g e d th r o u g h this m e a n s th a t o th e rw ise

t h a t he u n d e r s ta n d s th e re q u e s t, he will have

w o u ld go u n a tt e n d e d . O n th e basis of a n a n a l

S h o u ld he by p ass th e p a t i e n t s im m e d ia te p lea

ysis of m a n y

for help or p ro b e for conflicts a n d o t h e r d y

in terv iew s

in

th e p sy ch iatric

been

able

to

s ta rt

a w o r k in g

re la tio n sh ip .

w a lk -in clinic of th e M a s s a c h u s e t ts G e n e r a l

n a m ic forces u n d e rl y in g th e re q u e s t, th e r a p y

H o sp ita l in B oston, w h ich h an d le s a b o u t 4 0

m a y n ever get sta rte d . O b v io u sly , fulfilling the

w a lk -in p a tie n ts each d a y (1 5 ,0 0 0 visits per


y ear), L a z a r e et al (1972) have listed 14 ca te
gories of patie nts.

p a t i e n t s d esire a lo n e m a y no t get to th e b o t
to m of th e p a t i e n t s tr o u b le s, bu t it will be an
av e n u e t h r o u g h w h ich o ne will be ab le to c o o r
d in a te a n d u tilize th e d a ta g a th e r e d in the
dia gn ostic e v a lu a tin g in tervie w . In clinics o r
p riv a te th e r a p y w h e re th e r e is lack of c o n

1. P a t i e n t s w h o w a n t a s t r o n g p e r s o n to pro tect
a n d c o n tr o l t h e m . ( P leas e t a k e o v e r . )
2. T h o s e w h o need s o m e o n e w h o will h e l p th e m
m a i n t a i n co n ta c t w i t h r e a lity . ( H e l p m e k n o w I
am real. )
3. T h o s e

who

feel

so

em pty

th ey

n eed

suc-

co r a n c e . ( C a r e for m e . )
4. T h o s e w h o need so m e clinic or p e r s o n a r o u n d
for se c u rity p u r p o s e s t h o u g h t h e co n ta c t be o cca
si o n a l. ( A l w a y s be t h e r e . )
5. T h o s e r i d d e n w i t h gu ilt w h o seek to confess.
( T a k e a w a y m y g u i l t . )
6. T h o s e w h o u r g e n t l y n eed to t a l k t h i n g s out.
( L et m e get it off m y ch est )
7. T h o s e w h o d e s i re adv ice o n p r e s s i n g issues.
( T e l l m e w h a t to d o . )

g ru e n c e b e tw e e n w h a t th e p a ti e n t seeks a n d
w h a t th e t h e r a p is t decides to prov ide, the
d r o p o u t ra te a fter th e first in terv iew i s 1 as
h ig h as 50 p e rc e n t (B o rg h i, 1968; H e i n e &
T r o s m a n , 1960).
T h e claim t h a t s h o r t- t e r m tr e a t m e n t acco rd s
w i t h s u p e r f i c i a l i t y o f g o a ls h a s n o t b e e n
p ro v e n , especially w h e re t h e r a p y is c on du cte d
a lo n g even m odest d y n a m ic lines. T h u s , a ty pe
of crisis in te rv e n tio n th a t a im s at m o r e t h a n
s y m p to m relief is described by M . R. H a r r i s et
al (19 6 3 ), w h o tr e a te d a g r o u p of 43 p a ti e n ts

13

MODELS OF SHORT-TERM THERAPY


w ith u p to seven sessions w ith th e objective of

assum ption

(1) reso lu tion of th e stress factor p re c ip ita tin g


the req u e st for h elp an d (2) clarifying a n d

w o u n d s . T h a t tim e fails m iserab ly in this task

th at

tim e

its e lf w ill

heal

all

resolving, if no t the basic conflict, th e seco n d

is evident by th e h ig h rate of m o rb id ity an d


m o r ta lity a m o n g survivors fo llow ing th e fatal

a ry derivative conflicts activated by th e c u r

event (K ra u s & Lilienfeld, 1959; Rees & L u t-

re n t stress situ a tio n . O u r h y p oth esis is th a t

kins, 1967; M . Y o u n g et al, 1963).

fa

R eco gn itio n of th ese facts h a s led to some

cilitated th e e sta b lish m e n t of a n ew a d a p tiv e

crisis in te rv e n tio n p r o g r a m s to prov id e s h o r t


te r m h e lp for the bereaved in th e service of

such

e x p lo ra tio n

and

w o r k in g

through

b a la n c e . D u r i n g th e r a p y th e m o tiv atio n for


f u r th e r tr e a tm e n t w a s also evalua ted . T h i r t y eight (88 p erce n t) of the p a tie n ts w e re helped
by b rief th e r a p y . T h i r t e e n (30 percen t) of th e
p a t i e n t s c o n t i n u e d in l o n g - t e r m t r e a t m e n t .
T hree

p a tie n ts

(7

percen t)

returned

for

second b rief series of contacts. D u r i n g in t e r


v iew ing w ith th is tr e a tm e n t, efforts w e re m a d e
to estab lish c onnections b e tw e e n conflicts an d

bo th p re v e n tio n a n d r e h a b ilita tio n (G e rb e r,


1969; Silver et al, 1957; P. R. S ilverm an ,
1967).
their

Success
fu rth er

of th ese

program s

develo p m en t

and

presages

expansion.

G e r b e r (1969) h a s described som e m e th o d s for


fostering e m a n c ip a ti o n fro m th e b o n d a g e of
g rief a n d r e a d j u s tm e n t to p re s e n t realities.
T h e s e in clu de (1) h e lp in g th e client to p u t into

th e p re c ip ita tin g stress since th is e n a b le d th e

w o rd s his o r h e r feelings of suffering, p ain ,

p a ti e n t to be b etter able to cope w ith his

g uilt, notio ns of a b a n d o n m e n t an d a n g e r as

distress an d achieve a n ew psychic e q u il ib


r i u m . H isto ric a l m a te ria l w a s utilized only

well as th e n a t u r e of th e p a st re la tio n s h ip w ith

w h e n it w a s s p o n ta n e o u sly b r o u g h t u p a n d r e
lated directly to the c u r r e n t difficulty. T h e a u

p la n of activities th a t d r a w s u p o n av aila ble

th o r s d eclare th a t w h e re lo n g - s ta n d in g vex

resolving practical difficulties involving h o u s

atio n s exist, m otivation for f u r th e r tr e a t m e n t


m a y in fact be increased by th e e x p erien ce of a

m en ts; (4) m a k i n g essential referrals for m e d i

successful b rief th e r a p e u ti c t r a n s a c t i o n . A d o p
tion of a p s y ch o d y n am ic stan ce in crisis in t e r

th e deceased, good a n d bad ; (2) o rg a n i z in g a


resources a n d friends; (3) len d in g a h a n d in
ing, economic,

legal, a n d fam ily r e a r r a n g e

cal assistance in clu d in g p re s c rip tio n of d ru g s


for d ep ressio n a n d in s o m n ia a n d offering fu tu re

vention can e n h a n c e th e q u a li ty of resu lts, as


L o u is (1966) a n d o th e r s h ave p oin ted out.
O f all d e v a sta tin g stressful ex perien ces, th e
d e a th of a loved one, o r a p e rs o n on w h o m the

assistance. Service to a b ereav ed p erso n is often

su rv ivo r is d e p e n d e n t, is p e r h a p s th e m ost m is

o r o th e r professional o r tr a in e d p a ra p r o fe s sional m a y be necessary before th e client will

m a n a g e d . A p a r t from to k e n consolations, a
c o n s p i r a c y o f sile n c e s m o u l d e r s u n d e r th e

best r e c o m m e n d e d

by the fam ily p h ysicia n,

a n d such r e c o m m e n d a t io n s m a y be a r e q u i r e
m e n t. A n in itial h o m e visit by a social w o r k e r

accept office visits.

Dealing with Unresponsive Patients


D e sp ite o u r best efforts to s h o rte n th e r a p y
th e r e will be som e p a tie n ts w h o will need co n
t in u in g tr e a tm e n t. C linics only too often b e
come clogged w ith such ch ro n ic p a tie n ts w hose

lems. T h i s is n o t to d ep re c ia te th e value of p r o
longed tr e a t m e n t in some lo n g - s ta n d in g e m o
tio nal p ro b le m s. H o w e v e r, from a p r a g m a ti c
s ta n d p o in t, for th e g re a t m a jo rity of ch ron ic

t r e a t m e n t b e c o m e s i n t e r m i n a b l e . T h i s ca n
result in long w a iti n g lists a n d a n en d to ready
access to t h e r a p y for even em ergen cy p r o b

p a tie n ts o th e r m odes of m a n a g e m e n t a r e not


only helpful, b u t ac tua lly a r e m o r e a tt u n e d to
th e c o n tin u in g needs of these patients. S u ch a l

14

HANDBOOK OF SHORT-TERM PSYCHOTHERAPY

terna tiv e m eth o d s involve, p e r h a p s for the r e


m a i n d e r of a p a t i e n t s life, occasional sh ort

co urag ed. In d iv id u al in tervie w s are for 15 to


25 m in u te s to a scertain th e p re s e n t physical

(10- to 1 5-m in ute) visits w ith a professional


perso n on a m o n th ly o r b im o n th ly basis,

an d e m o tio n a l state, to re g u la te th e d r u g in
ta k e if d ru g s a r e ta k e n , to offer r e c o m m e n d a

su pervision of d r u g in tak e, in tro d u ctio n in to a


g ro u p (th erap eu tic , social, o r re h a b ilitativ e),

a p p o in t m e n t for the nex t tim e. T h e p a tie n ts a re

and

u tilizatio n

of a p p r o p r ia t e

c o m m u n ity

resources. W h a t the th e r a p is t tries to avoid for


such a p a tie n t is s tim u la tin g d ep en d e n c y on
him self personally.
An e igh t-y ear e x p e rim e n t at an o u tp a tie n t
clinic dedicated to th e th e r a p y of th e c h r o n

tio n s for in te rv e n in g activities, a n d to m a k e an


th e n r e t u r n e d to th e w a iti n g a r e a for m o re
coffee a n d socialization. F a m i ly a n d couples
th e r a p y a r e d o n e if necessary. F r e q u e n c y of
visits r a n g e fro m w eek ly sessions to once every 6
m o n t h s a lt h o u g h p a tie n ts m a y r e t u r n v o lu n
ta rily if th ey need h elp. S h o u ld the p a tie n t d ro p

ically ill at th e U n iv ers ity of C h ic ag o H o s

ou t of t h e r a p y , he is p e r m it te d to r e t u r n in

pitals an d C linics is re p o r te d by R a d a et al

tim es of stress w ith o u t h av in g to go t h r o u g h a

(1969). T h e clinic is o pen every T h u r s d a y

re a d m iss io n p ro c e d u re . A fter th e clinic h o u r s

afte rn o o n for 2 / i h o u rs , p a tie n ts being seen in


o r d e r of a rriv al. P a tie n ts a re accepted only
after a diag no stic e v alu a tio n a n d initial w o r k

cuss th e d a y s p ro b lem s. T h e tw o a tt e n d in g p sy
ch ia trists d o no t see in divid ual p a tie n ts (except

u p by th e referral sources to m a k e su re th ey

in em ergen cies); they serve as ad m in is tra tiv e

the staff m eets briefly (30 to 45 m in u tes ) to d is

will be su itab le for th e clinic ro u tin es. T h e

sup ervisors a n d active p a r t ic i p a n ts in th e w a i t

staffing

is by psych iatric residents, medical

ing a re a e x p erien ce a n d the staff g ro u p m e e t

stud ents, a social w o rk e r, receptionist, a n d tw o

ings. P a tie n ts see th e sam e th e r a p is t (a residen t)


for 3 m o n t h s to a y e a r an d k n o w th a t th e y will

a tte n d in g staff su p erv isory p sy chiatrists, the


la tter four being the only p e r m a n e n t staff.

be tr a n sfe r re d to a n o th e r p rofessio nal from tim e

U p o n a rriv al, the receptionist greets th e p a


t i e n t a n d if t h e y c o m e , t h e f a m i l y a n d

to tim e. D ia g n o stic cate gories vary , a p p r o x i

bring s the p a ti e n t into th e w a iti n g ro om ,


w h e re light re fre sh m e n ts (cookies an d coffee)

m a te ly h a lf b eing psychotic, th e r e m a in d e r h a v
ing severe n eu ro s e s a n d p e rs o n a lity disorders.
F ees g e n erally s u p p o r t th e clinic an d a r e r e l a

are

tively low.

serve d.

P atien t

in te ra c tio n s

are

en

Short-term Hospitalization and Its Alternatives


S h rin k in g b ud gets h ave m a d e it m a n d a t o r y
to ta k e a h a r d look at costs versus benefits not
only in re g a rd to p sy c h o th e ra p y , bu t also
p ro tra c te d psyc hia tric h o sp ita liz a tio n . A p a rt
from p ra g m a tic d is a d v a n ta g e s or im p ra c tic a litie s of c o s t / b e n e f i t s , p r o l o n g e d i n s t i t u
tio n aliza tio n fosters regression a n d p a ra l y z in g

g r a m D av is et al (1972) d e m o n s tra te d t h a t a
te a m led by visiting n u rses g o in g to the h o m es
of p a tie n ts to oversee p r o p e r m ed ica tion could
p rev en t h o s p ita liz a tio n a n d im p ro v e r e l a ti o n
ships w ith in th e family. A n o th e r e x a m p le is
th e fin din g by Z w e r lin g a n d W i l d e r (1962)
th a t a da y -c a re tr e a tm e n t facility could often

d ep en d e n cies p lu s ex tend ed se p a r a tio n from


c o m m u n i t y life. T h e s e u n f o r t u a n t e c o n t i n
gencies have sp on sore d shifts fro m lon g -term
con fin em ent to s h o r t-te rm d eten tio n o rg a n iz e d
a r o u n d the objective of early d ischarge. A l

act as an a d e q u a t e su b s titu te for an in p a t ie n t


u nit. T h e r e a re , nevertheless, situ atio n s w h e n
h o sp ita liz a tio n is essential, for e x a m p le , to
p ro v id e security for d is tu rb e d o r suicidal p a

te rnatives to h o sp ita liz a tio n have also been e x


plored. F o r e x a m p le , in an e x p e rim e n ta l p r o

t i e n t s o r w h e r e c r i s i s - o r i e n t e d t h e r a p y is
needed an d it c a n n o t be d o n e on a n o u tp a t ie n t
basis. A limited h o psita l stay m a y be all th a t is

MODELS OF SHORT-TERM THERAPY

15

re q u ire d . Even in child ren s h o r t-t e rm h o s p i ta l

w ith i n

ization is som etim es considered (Shafii et al,


1979).

fo llow -u p r o u t in e alm ost t w o -t h ird s of all p a


tients h a d not been re h o s p ita liz e d o r t r a n s

T h a t it is possible to redu ce th e tim e of h o s

ferred after th e 3 -d ay intensive h o spita l t r e a t

1 y e a r of d ischarg e.

At th e

1-year

pitaliz atio n of p a tie n ts a d m itte d to an in s titu

m en t. T h i s c o m p a r e s favo rab ly w ith r e h o s p i

tion th r o u g h a crisis in te rv e n tio n p r o g r a m


u tilizin g a w id e r a n g e of t r e a tm e n t m o dalities

ta liz a tio n ra te s w ith lon ger t e r m th e r a p y .

has been d e m o n s tra te d by D e c k e r a n d S tu bblebine (1972) in a 2 ii y e a r stu d y of 315


you n g adults.

A t th e C o n n e c t i c u t

M ental

T h e function of th e u su a l s h o r t-t e rm h o s p i
taliz a tio n (i.e., 3 to 4 w eeks) is, first, to b rin g
about a rapid

rem issio n of s y m p to m s and ,

second, to p r e p a r e th e p a ti e n t for, a n d to see

H e a lth C e n te r a p r o g r a m of b rief (3 -d ay ) i n

th a t

tensive h o s p ita liz a tio n a n d 3 0 -d a y o u tp a t ie n t

afte rca re p ro g r a m . T h e first objective is ac

c a re has been used to deal w ith p a tie n ts


r e q u i r i n g h o s p i t a l i z a t i o n ( W e i s m a n et al,

com p lish ed by d r u g th e r a p y a n d E C T if n eces

1 9 6 9 ). In t h e h o s p i t a l , c ri s is i n t e r v e n t i o n
m eth od s a re em p lo y ed to w a r d re s to rin g the
p a tie n t to the prev iou s level of fu nctio nin g. O n

a n d m ilieu, o ccu p a tio n a l, a n d re h ab ilitativ e


th e r a p y , all ta ilo re d to th e p a t i e n t s needs. B e
c a u s e of t h e e m p h a s i s o n t h e c o n t r o l of

disch arge th e r e is a 1- m o n th o u tp a t ie n t p eriod


of tr e a tm e n t, w h ich is co nsid ered a fo llow -up

sy m p to m s r a t h e r th a n a lte ra tio n s in th e p e r
son ality s tru c tu r e , crisis-o rien ted b eha vio ra l

m ea su re. A n a g re e m e n t is m a d e in a d v an ce as

a p p ro a c h e s a lo n g eclectic lines a r e m ost com

to this limited tim e a r r a n g e m e n t to in s u re th a t


fect of the tim e -lim ited co n trac t is to establish a

m o n ly practiced. Ideally, b rief h o s p ita liz a tio n


sh o u ld prov id e p sy c h o th e ra p y to p r e p a r e the
p a tie n t for o u tp a t ie n t c a re (A. B. L ew is,

set w h ich p ro m o te s ra p id identification of


p ro b le m a reas an d re q u ire s p a tie n ts to begin

crucial to avoid th e revolving d o o r sy n d ro m e ,

tr e a tm e n t does not go on indefinitely. O n e ef

quickly developing new m odes of d e a lin g w ith


these p ro b l e m s . T h e p a ti e n t is seen e ach day
by several staff m e m b e rs w h o a r e u su a lly
nu rses or aides in o r d e r to d isch arg e d e

th e r e

is

made

av ailab le,

an

adequate

sary, indiv id ual fam ily an d g r o u p tr e a tm e n t,

1973). T h e second objective, a lt h o u g h m ost


is too often neglected. U n less th e p o s th o s p i
tal e n v ir o n m e n t is reg u la te d , e n su in g stress
will a lm o st inev itably p ro d u c e a re la p se in
sym p to m s. A m o n g th e m e a s u re s necessary to

pe nd ence on th e godlike figure of the doctor.

p re v e n t this a r e th e a d ju s tm e n t of living a r

T o expose p a tie n ts to different tactics, a fixed


style of a p p r o a c h is deliberately n ot used.

ra n g e m e n ts so th a t the least s tra in is im posed


o n th e p a t i e n t s cop ing capacities, th e use of

T e a m m e m b e rs also in te ra ct w ith p a tie n ts in


daily g ro u p th e r a p y an d fam ily th e r a p y . Self-

h a lfw a y houses, facilities p ro v id in g day an d


n ig h t care, su pervised d r u g m a n a g e m e n t, an d

relian ce is stressed by focusing on th e p a t i e n t s

r e h a b ilitativ e, social, h e a lth , a n d re c r eatio n al


p ro g r a m s . T h e selective use of c o m m u n ity
o u tp a t ie n t p sy c h o th e ra p y of a no t too intensive
variety w ith an e m p a t h ic th e r a p is t can be most
helpful.

responsibility, especially in m a k i n g p la n s after


discharge. W h i l e concern a n d in terest are
sh o w n , th e staff avoids d o in g th in g s for th e
p a tie n t w h ich he can be e n co u ra g e d to do
h i m s e l f . P s y c h o t r o p i c d r u g s a r e u s e d to
d i m i n i s h t a r g e t s y m p t o m s . T h e r e is e a r l y
fam ily involvem ent, a n d the e n tire h o sp ita l da y
is stru c tu re d w ith activities. As for resu lts, at
the end of brief h o sp ita liz a tio n of th e first 100
patients, 18 p ercen t w ere tr a n sfe r re d for longer
in p a tie n t care after the 3 -d a y intensive e x p e r i
ence since th ey re q u ire d lo ng er te r m h o s p ita li
zation . A n o th e r 19 p ercen t w ere re ho spitalized

T o sa fe gu ard a g a in s t the f r a g m e n ta tio n of


a n aftercare p r o g r a m , c o n tin u ity of tr e a tm e n t
w ith one p rofessional perso n can h elp p rev ent
t r e a tm e n t d e g e n e ra t in g into m a n a g e m e n t of a
series of em ergen cies w ith inevitable r e h o s p i
taliz atio n . T h i s perso n m u s t h ave e stablished a
r e la tio n s h ip w ith th e p a tie n t a n d k n o w th e his
to ry of the l a t t e r s illness a n d so m e th in g a b o u t
th e dy na m ics. W h a t causes most p a tie n ts to

16

HANDBO OK OF SHORT-TERM PSYCHOTHERAPY

r e t u r n to th e ho sp ital is p o o r aftercare p l a n

t h e r a p y can cut d o w n th e need for h o s p i ta l iz a

n in g w ith little or no provision for som e kind


of o n g o in g ind iv idu al o r g r o u p p sy c h o th e ra p y ,
i m p r o p e r m o n i t o r i n g of d r u g m a i n t e n a n c e ,

tion in a c u te cases of d e c o m p e n sa tio n . T o c o m


p a r e th e o u tc o m e of o u tp a t ie n t fam ily crisis
t h e r a p y w ith h o sp ita liz a tio n , F lo m e n h a ft et al

fa ilu re to u tilize em erg en cy m e a s u re s w h e n

(196 9 ) tre a te d w ith th e fo r m e r m o d ality 186

needed (such as E C T ) , stressful living c o n d i


tions, p o o r h o u sin g an d in a d e q u a te provision

p a tie n ts in n eed of a d m issio n to a m e n ta l h o s


p ital. A con tro l g r o u p of 1 50 p a tie n ts received

of essential social a n d re h a b ilita tiv e services.

h o sp ita liz a tio n . T h e

W h e r e possible, the th e r a p is t w h o h a s w o rk ed

av erag e of five office visits, o n e h o m e visit, an d

w ith th e p a tie n t in the ho sp ital shou ld be th e

th r e e tele p h o n e contacts. T h e results of o u t p a


tien t t h e r a p y w e re at least as good as h o s p i ta l i
z a tio n , in a d d itio n to bein g m o re econom ical

one w h o co ntin ues seeing th e p a tie n t a n d d i


recting the afte rca re p r o g r a m . So m etim es th e
ho sp ital m a y p ro vid e som e of th e a ftercare
services, b u t th e a d m i n is tr a t o r s sho uld alw a y s
strive to in te g ra te th e p a tie n t into the c o m m u
nity as r a p id ly as possible. T h i s is u su a lly the
best course. W h e r e r e t u r n to a fam ily w o u ld be

o u tp a t ie n t s received an

a n d less s tig m a tizin g . In a stud y by L an g sley


et al (1 9 69 ) 75 a cute d e co m p e n sa te d p sy
ch ia tric p a tie n ts w e re given a n av erag e o f six
sessions of fam ily crisis t h e r a p y o rg a n iz e d
a lo n g directive a n d su p p o r tiv e lines. A control

d is tu rb i n g for instance, w h e r e m e m b e rs are

g r o u p of 75 received h o sp ita liz a tio n a n d i n p a

too hostile, d e m a n d in g , an d rejecting p lace


m e n t in a h a lfw a y ho use a n d la te r in a foster

tien t tr e a tm e n t. In th e fam ily th e r a p y g r o u p 61


p a tie n ts w e re a b le to avoid h o s p ita liz a tio n a n d

h o m e m a y be advisable.
S h o rt-te r m h o sp ita liz a tio n does no t e lim i

o n l y 14 p a t i e n t s r e q u i r e d h o s p i t a l i z a t i o n
w ith i n a 6 - m o n th perio d. In th e h o s p i ta l iz a

n a te in te rm e d ia te -te r m intensive t r e a tm e n t in a

tion g r o u p 16 p a tie n ts r e q u i r e d r e h o s p ita l iz a


tion after d is ch arg e w ith i n a 6 -m o n th period.

ho spital, th a t is, 130 to 180 days, o r for lo ng er


pe rio d s w h e re th e a im is a p e rs o n a lity change.
H o w e v e r, custodial care in p a tie n ts w h o r e

O n l y a n a v e ra g e of 8.1 day s w e re r e q u i r e d for


im p ro v e m e n t in th e e x p e ri m e n t a l g r o u p as

q u ir e c o n tin u in g m a n a g e m e n t can u su a lly be


achieved ou tside of a h o sp ital facility. W a y n e

c o m p a r e d to 2 4 .3 day s in th e h o sp ita liz e d


g ro u p . T w o y e ars la te r a sim ila r stu d y w as

(1976) h a s a p p r o p r ia t e ly p o in te d ou t th a t w h a t
d eterm in es th e du ra tio n of h o sp ita liz a tio n is

re p e a te d w ith a la rg e r g r o u p of p a tien ts . It
con firm ed t h a t m ost p a tie n ts w ith s h o r t-te rm
f a m il y t h e r a p y c o u ld a v o id h o s p i t a l i z a t i o n

n ot th e diagn osis bu t th e persistence of a h a b i


tu a l d isru ptive life-style, severe fam ily, social,
a n d o c cu p a tio n a l difficulties, a n d th e p resen ce
of a serious physical disability o r h y p o c h o n
driasis. W h e r e th e p ro p e r e n v ir o n m e n t is m a d e
available a n d a fte rca re supervision p ro m o te d ,
even ch ro nic psychotic p e rs o n s can m a k e an
a d ju s tm e n t ou tsid e of a n institutio n.
T h e r e is evidence th a t s h o r t-t e rm fam ily

(L an g sley et al, 1971). At th e E a s te r n P e n n


s y l v a n i a P s y c h i a t r i c I n s t i t u t e t h e s e s t u d ie s
w e re rep lic ated , in d icatin g th e efficiency of
s h o r t-t e rm fam ily th e r a p y (R u b e n s te in , 1972).
F o cal t h e r a p y in a d a y h o s p ita l m a y also be
em p lo y ed as a n a lte rn a tiv e t r e a tm e n t (F ran ce s
et al, 1979).

Short-term Child and Adolescent Therapy


T h e q u e stio n is often asked as to w h e t h e r it
is possible to d o child t h e r a p y on a s h o r t-t e rm
basis since it is ge nerally accepted th a t a lo ng

p erio d of t r e a t m e n t of th e child p a ti e n t a n d
p a r e n t s is c u sto m a ry . T h e r e a re som e studies
ho w ev e r, th a t ind icate t h a t good resu lts m a y be

MODELS OF SHORT-TERM THERAPY

17

ob tain ed w ith s h o r t-t e rm a p p r o a c h e s (C r a m e r ,


1974; K ern s, 1970; M a r t i n , 1967; N egele,
1976; Nicol, 1979; P h illip s & Jo h n s to n , 1954;
R osen th al & L evine, 1970, 1971; S h a w et al,
1968; S k y n n e r, 1974). O t h e r studies verify th e
utility of s h o r t-t e rm g r o u p t r a in i n g for p a r e n t s
in m a n a g in g p ro b le m s in th e i r child ren (G . R.
P a tte rso n et al,

1973a; W a l t e r & G ilm o re ,

o th e r fam ily m e m b e rs. T h e child g e n e rally is


i g n o r a n t of w h y h e is a c tu a lly seeing th e t h e r a
pist, h a s little rea l notio n of his u n d e rly in g
p ro b le m , a n d no m o tiv atio n to d o a n y th i n g
a b o u t it. S h o u ld th e child be a w a r e th a t he is
seeing a

d o c to r ,

he m ay

regard

th is as

p u n is h m e n t for his crim es w h ile believing th a t


th e d o c to r ex pects h im to c h a n g e in accord

1973; W iltz & P a tte rso n , 1974). M a n y t h e r a


pists believe th a t w h e re th e child is u n d e r 7

w ith th e w ishes of his p a re n ts . If, o n th e o th e r

years of age the m a in th e r a p e u ti c w o r k is w ith

m a y ra tio n a liz e it as a ju s tified co n se q u en ce of

th e p a re n ts. F r o m ages 7 to 11 the child and


p a re n t s are seen sep a rately . F r o m 12 on fam ily

u n fa ir d e m a n d s a n d acts by his p a r e n t s a n d
oth ers. It m a y be essential in o r d e r to secure
c o o p e ra tio n w ith th e tr e a tm e n t p la n to w o rk

sessions seem best. P re a d o le sc e n t child ren w ith


acu te p ro b le m s have been m a te ria lly h e lp e d by

h a n d , th e child is c o g n iz a n t of his p ro b l e m , he

w ith th e child u n til he v erb aliz es a p ro b l e m on

p a r e n t g ro u p s focused on discussions of child


m a n a g e m e n t, p o w e r ploys of c h ild ren , a n d a l

w h ic h he w o u ld like to co nc entrate.

te r n a te a p p ro a c h e s to p ro b le m solving. T h e

event th e child seems ig n o r a n t of it is to con


fro n t the child w ith w h a t o th e r s say a b o u t him

ch ildren them selves a r e e n c o u ra g e d to e x p e r i


ment

w ith

m o re

m ature

b e h a v io r

th r o u g h

better w ays of cop ing w ith p eo p le a n d s i t u a


tions (E p stein , 1976).
U tiliz in g a so-called h e a l t h model, W e i n
b erg e r (1971) describes a fo rm of brief th e r a p y
for child ren w h ich sees clients basically c o p
ing a n d a d a p ti n g bu t ex p e rie n c in g p ro b le m s
caused by ig no ra nce , i n a p p r o p r i a t e e x p e c ta
tions,

social

su r ro u n d in g s ,

o r o th e r

factors

w h ich do not im p licate th e p a r e n t s as m alev


olent an d pa tho log ically m o t iv a t e d . T h i s is
seen as a p referred th e r a p y for th e m a jo rity of
child ren in c o n tra st to th e p re v a ilin g model
of s h o r t-te rm tr e a tm e n t, w h ich is e ith e r a

O n e w a y of focusing on th e p ro b le m in the

a n d to h a n d le his re actio n s to th e c o n fr o n ta
tion. W h y does he believe he is seeing th e t h e r
a p is t? O n c e th e child a d m its to a b eh av io ra l
d evia tion , o th e r w a y s of re a c tin g a re suggested
to him . A n y d is to rted w a y th e child conducts
him self w ith th e th e r a p is t m a y be a n i m p o r
t a n t m e a n s of b ri n g in g to his a tt e n ti o n ho w he
behaves, h o w o t h e r p eop le m a y be affected by
his b eha vio r, a n d h o w he h im self suffers the
co nseq uen ces o f th e ir re actio ns. T h e s e c o m
m e n ts a re m a d e w ith o u t a n g e r, d isgu st, accu
satio n , o r t h r e a ts of r e c r im in a ti o n , p ro v id in g
th e child w ith a different e x p e rie n c e in re latio n
to a n a u th o r it y figure. C o n c u r r e n t ly , th e t h e r a

com pressio n of lo n g - te rm tr e a tm e n t m e th o d s
o r a n elo ng ated diagnostic p r o c e d u r e th a t is

pist m a y w o r k w ith th e p a r e n t s o r see th e p a

a p p r o p r i a t e for only 5 to 10 p erc e n t of all


ch id ren sent for help.
As p a r t of the th e r a p e u ti c process, W e i n
b erg er states th a t it is im p o r t a n t to tr y to a s
certain h o w p a r e n t s view th e c h il d s p ro b le m

fam ily in fam ily th e r a p y . In conference w ith


th e p a r e n t s it is im p o r t a n t to alleviate th eir
guilt, to tr y to clarify w h a t is h a p p e n i n g in

an d w h a t th e ir e x p ec tatio n s a r e of the t h e r a
pist. T h i s leads to th e d r a w i n g u p of a verbal
c o n tr a c t of w h a t th e p a r e n t s an d th e r a p is t
expect of each o ther. U s u a lly th e goal is the
e lim in a tio n of u n d esired b ehav io r. T h e tim e
limit set is 6 w eeks d u r i n g w h ic h a m a x i m u m
of 12 sessions a r e a r r a n g e d for the child an d

tien t

to g eth e r

w ith

o th e r

m em bers

of the

th e i r re la tio n to th e child, to e x p la in u n
re a s o n a b le e x p e c ta tio n s a n d d e v e lo p m en tal
n o rm s , a n d to suggest a lte rn a tiv e w a y s of d e a l
ing w ith th e c h il d s b ehav ior. T h e ex te n t of d i
rectiveness of th e th e r a p is t will vary w ith th e
w illin gn ess a n d ab ility of th e p a r e n t s to m a k e
p r o p e r decisions on th e ir o w n.
T h e p la n of action a n d h o w it is c a rr ie d o ut
by th e child a n d p a r e n t s is m o n ito r e d by the

H ANDBO OK OF SHORT-TERM PSYCHOTHERAPY

18

th e r a p is t in the r e m a in i n g sessions, th e p la n it
self being modified o r d iscard ed a n d a n ew one
sub stitute d d e p e n d in g on the p ro g ress t h a t is
being m ad e. A m a j o r p a r t of this w o rk in g
th r o u g h is to h elp th e p a re n ts not only recog
nize an d accept th e ir o w n an d th e i r c h il d s

en m e s h e d in th e i r o w n needs an d p r o b l e m s
(W e in b e rg e r, 1971). B ased o n 5 y e a r s e x p e r i
ence in th e clinic w ith a b o u t 3 ,0 0 0 cases,
W e in b e r g e r e stim ate s th a t 5 0 p ercent of all
child ren can be h a n d le d in b rie f th e r a p y . M o r e
extensive t h e r a p y is r e q u i r e d by 30 percen t,

li m itatio ns, but, to set m o re realistic goals for

an d

themselves as p a re n ts , a n d th e ir child as a
child w ith a u n iq u e life style of his o w n w hich
m u s t be u n d e r s t o o d , r e s p e c t e d , a n d n o t

classes, resid en tial p la c e m e n t, etc.) is re q u ire d

h e lp o t h e r t h a n p sy c h o th e ra p y (special

by 20 percent.

Short-term Group Approaches


M a n p o w e r sho rtage s reinforced by th e fac
to r of c o st/b e n e fit h ave accelerated th e use of
s h o r t-te rm g r o u p th e r a p y , both for h o s p i
talized perso ns a n d o u tp a tie n ts . M a n y g ro u p
p r o g r a m s h av e accordingly been in tro d u ce d ,
u tilizin g te c h n iq u e s th a t d r a w th e ir su bsta nce
from p sy choanalysis, b e h a v io r th e r a p y , co gni
tive th e r a p y ,

have a cc u m u la te d .
S h o r t - te r m g r o u p s a r e usu ally o p en -e n d e d
a n d fre q u e n tly con d u cted by c o th e ra p is ts
( G o o l i s h i a n , 1 9 6 2 ; S a d o c k et a l, 1 9 6 8 ;
S h r a d e r et al, 1969; T r a k a s & L loyd, 1971.
O u tc o m e stu d ies on g ro u p s re p o r t h ig h ly su c

im a g e ry o r a n y o th e r

cessful results, in some in stan ces being co n

th eoretical school to w h ich the t h e r a p is t s a re


dedicated.

a p y ( T r a k a s & L loy d, 1971). T h e uses a n d

1. C r is is
Crary,

g uid ed

gory, (A. W o lf, 1965) a n d since th e n m o re

i n t e r v e n t io n

1 968;

Donovan

g roups
et

al,

(B erlin,

1979;

1970;

M orley

&

B r o w n , 1 969; S t r i c k l e r & A llg ey er, 1967; T r a k a s &


L lo y d , 1971).
2. E x p e r i e n t i a l g r o u p s ( B a c k ,

1972; B u rto n ,

1 96 9; E l m o r e & S a u n d e r s , 1972; L e w is & M i d e r ,


1 973; P eris, 1969; R a b i n , 1971).
3. E d u c a tio n a l g r o u p s {D r u c k , 1978).
4. B e h a v io ra l g r o u p s ( A r o n s o n ,
h eim ,

1971;

M eachem

&

Lazarus,
W iesen,

1968;
1 969;

1974; F e n s t e r -

L ib e rm a n ,
S uinn

et al,

1970;
1970;

W o l p e , 1964).
5. I n s p i r a t i o n a l
G reen b latt,

1975;

g roups

(D ean,

H ersch elm an

&

1970-1971;
F re u n d lic h ,

19 72).
6. P s y c h o d r a m a tic g r o u p s ( C o r s i n i , 1966; M o r
e n o , 1966).
7. T ra n s a c tio n a l g r o u p s ( B e r n e , 1 964; T . H a r
ris, 1967; K a r p m a n , 1972).
8. A c c e le ra te d sh o r t-te r m g r o u p s ( W o l f, 1965).

B etw een 1947 an d 1962 over a h u n d r e d


p a p e r s w ere p u b lish e d on j u s t the last c ate

sidered as m o re effective t h a n in d iv idu al t h e r


ab uses of g r o u p s a r e described by I m b e r et al
(1979).
S h o r t - te r m g r o u p s w ith c h ild re n have been
g a in in g p o p u la r it y ( G r a h a m , 1976; R o se n th a l
& L ev in e 1970), som e r e p o r ts c la im in g su c
cesses e q u a l to th a t in lo n g - te rm th e r a p y
( R o se n th a l & L evine, 1971). A n e x a m p l e is
the stu dy by B u r d o n a n d N eely (19 66 ) w h o
tre a te d 55 boys w ith re p e a te d school failures.
A 5 -y e a r fo llo w -u p sho w ed increased school a t
te n d a n c e w ith 98 p erc e n t p a ss in g a n d 73 p e r
cent e a r n i n g p ro m o tio n s. S om e useful m eth o d s
for w o r k in g w ith c h ild re n in g r o u p s h av e been
o utlin e d by R h o d e s (1 97 3), E p s te in (1976),
a n d L evin & Rivelis (1970). S h o r t - te r m g r o u p
t r e a tm e n t m a y also be helpful for m a la d ju s te d
adolescents (E is e n b e rg , 1975; R iv era & B attagg ia, 1967), d u r i n g b rief in p a t ie n t c are for
adolescents (C h iles & S a n g e r, 1977; M o s e r ,
1975), for d e li n q u e n t a dolescents ( D a n n e r &
G a m s o n , 1968), adolescent d r u g users (D eeth s ,
1970), a n d yo u th fu l offenders in a d e te n tio n

MODELS OF SHORT-TERM THERAPY

19

u n it ( W o u ld & R eed, 1974). T h e need to dis

A n u m b e r of r e p o r ts hav e indicated th a t

ting uish b etw een adolescents w h ose p ro b le m s

s h o r t- t e r m m a r it a l t h e r a p y is at least as effec

a re the p ro d u c t of e n ta n g le m e n ts rela te d to th e

tive in d e a lin g w ith m a r it a l conflict as lo n g

d eve lop m e ntal process an d

th ose w ho se e n

te r m th e r a p y . G u r m a n (1975) re view ed a v a il

co u n te r w ith adolescence stirs u p u nreso lved

ab le d a t a a n d fo un d th a t a 7 6 p e rc e n t im p ro v e
m e n t r a t e w a s achie ved w ith a n a v e ra g e of

conflicts of e a rlie r stages of g r o w th will in flu


ence tech niqu es an d objectives (Sprince, 1968).
G r o u p w o rk w ith p a r e n t s of p ro b le m ch il
d r e n h a s a ls o p r o v e n r e w a r d i n g ( E p s t e i n ,

a b o u t 16 sessions. R eview stud ies by B a rte n


(1 9 69 ), R eid a n d E p ste in (1 97 2); a n d R eid
a n d S h y n e ( 1 9 6 9 ) c o n f i r m t h e s e p o s i ti v e

1970;

resu lts.

M aizlish

& H u rley ,

1963; T ra c e y ,

R a tin g s

at

te r m i n a ti o n

and

at

an

1970), th e t r a in i n g of p a r e n t s in b e h a v io ral

a v e ra g e of 2 Zi

m eth od s being especially p o p u l a r as a n effec

w ere involved in conjoint m a r it a l t h e r a p y (a


co m p a r is o n of these w ith r e p o r te d resu lts of

tive inte rve ntio n m e th o d (B ijou & R ed d , 1975;


F e r b e r et al, 1974; P a tte rs o n , 1973a, 1973b,
1974; W a l t e r & G ilm o re , 1973). O n e o f th e
most difficult s itu a tio n s for th e th e r a p is t is th e
u n m o tiv ated fam ily of c h ild re n w ith aggressive
b e h a v i o r d i s o r d e r s . A p il o t s t u d y a t th e
U n ive rsity of C h ic a g o School of M e d i c in e by
Safer (1966) describes w o rk w ith 29 such
p a re n t s w h ose ch ild ren ra n g e d in age fro m 4 to

y ears la te r of 49 co up les w ho

ou tco m e stud ies o n in div idu al s h o r t-t e rm p sy


c h o th e r a p y as well as w ith a n o t h e r fo rm of
co njoin t t h e r a p y a n d w ith psych o an aly sis) i n
d icate th a t th e conjoint a p p r o a c h h a s some
technical a d v a n ta g e s over a n d c o m p a r e s fa
vo ra b ly w ith these o th e r typ es of tr e a t m e n t
(F itz g e ra ld , 1969).
S h o r t - te r m fam ily t h e r a p y c o n tin u es to g ro w

16. F a m ily , conjoint a n d in div idu al sessions


pro d u ced im p ro v e m e n t in m ost c h ild ren , an d

in p o p u la r ity . Its tech n iq u e s a r e described by


B a r t o l e t t i ( 1 9 6 9 a , 1 9 6 9 b ) , B lo c h ( 1 9 7 3 ) ,

this w a s m a i n ta i n e d in follow -u p e v a lu a tio n s


after 4 to 16 m o n th s. T h e a r e a s of ch a n g e

D e u ts c h (1 96 6), E isler a n d H e r s o n (1973),


H a le y a n d H o ffm a n (1 96 7 ), F a n g s le y an d

b ro u g h t a b o u t by th e r a p y in families w ith d e

K a p la n

lin q u e n t adolescents h a s exposed som e in t e r e s t


ing findings. F o r e x a m p le , P a rs o n s a n d A le x

(1 96 4 a ), a n d W a tz la w ic k (1963). T h e n u m b e r
of sessions th a t a re o p tim a l for fam ily t h e r a p y

a n d e r (1973) discovered th a t o ne could utilize


in studies fou r in te ractio n m e a s u re s t h a t w ere

is d e a lt w ith in e x p e r i m e n t a l e v a lu a tio n s by
S tu a r t an d T r i p o d i (1973). T h e y r a n d o m ly

not a function of e x tr a n e o u s variables.


M a r ita l th e ra p y is also often conducted on a
s h o r t-te rm basis b oth in g r o u p s (L e ib l u m &
R osen, 1979; W ells, 1975) a n d w ith ind iv idu al

(1968),

P it tm a n et al (1966), S a tir

assigned 73 fam ilies w ith p r e d e l in q u e n t a n d


d e li n q u e n t adolescents to 15-, 45-, a n d 9 0 -d a y
b e h av io rally o rien ted tre a tm e n ts . O u tc o m e
m e a s u re s sh o w e d no difference b e tw een th e

couples (Bellville et al, 1969; F itz g e ra ld , 1969; g ro u p s. T h u s it w a s concluded th a t th e r e is no


K a lin a , 1974; P. A. M a r t i n & B ird, 1963; P. reaso n to choose lon ge r over s h o r te r fam ily
A. M a r t i n & Lief, 1973; S ag e r et al, 1968; tr e a tm e n ts. T h e idea th a t b rie f fam ily th e r a p y
S a tir, 1965; S im o n , 1978; W a tz la w ic k et al, yields su perficial resu lts is c halleng ed by H a u g
1967).
(1971), w h o describes a case w h e r e ego a l t e r a
A n in terestin g m odel is described by V e r- tion coincided closely w ith r a p i d an d p ers istin g
h ulst (1975). H e h as evolved an intensive 3- a lte ra tio n s in the body im age. H o w e v e r, w h e re
w eek a p p ro a c h re sem b lin g cognitive le a r n in g th e a d a p tiv e flexibility of p a r e n t s is blo cked by
(B a k k e r & B a k k e r - R a b d a u , 1973) th a t e m rigid defenses o r th e conflict in th e child is
p h a sizes c o n fro n ta tio n a n d p ro b le m solving m a r k e d ly in te rn a liz e d , tr a d it io n a l lo n g e r te r m
w ith the h elp of active, e n th u s iastic, facilita- p s y c h o th e ra p e u tic m e th o d s a r e p ro b a b ly m o re
tive th erap ists. O t h e r m e th o d s a r e o u tlin ed su ita b le ( H a u g , 1971).
e lsew here (W o lb erg , 1977, p p . 7 3 3 - 7 4 0 ) .
T h e c o m b in a tio n of g r o u p a n d fam ily t h e r

20

H ANDBO OK OF SHORT-TERM PSYCHOTHERAPY

ap y a p p e a r s to possess som e a d v a n ta g e s, as

for w eek ly

K im b r o et al (1967) a n d D u r e ll (1 96 9) have

u tilized m o r e a n d m o r e a n d L a q u e u r (1968,
1972) h as w r it te n extensively on th e ra t io n a l e

poin ted o u t in th e i r re p o r t of a pilot stu d y of


t i m e - l i m i t e d m u l t i p l e f a m il y t h e r a p y w i t h
d istu rb ed

ad o lescents

and

th eir

fa m il ie s .

G r o u p s of th r e e families m et w ith a th e r a p is t

m eetings.

T h is

design

is being

a n d process of b rin g in g p r o b l e m families from


the sa m e b a c k g ro u n d to g e th e r as a w a y of e x
p e d itin g tr e a tm e n t.

Massing Therapy Sessions


A tte m p ts h av e also been m a d e to stu d y the
effect of m a s sin g th e r a p y sessions by literally
im m e r s in g th e p a tie n t in t r e a tm e n t t h r o u g h o u t
th e day. T h u s S w en so n a n d M a r t i n (1976)
tre a te d p a tie n ts on a full-tim e basis for 3 weeks

a p y m u ltip le im pact th e r a p y th a t has


p ro v en successful is described by M a c G r e g o r
(1962). G o o lis h ia n (19 62 ) em p lo y e d th e te c h
n i q u e w ith 60 fam ilies a n d th e ir p ro b le m
adolescents. A te a m consisting of a p s y c h ia

w ith c o m b in a tio n s of different m odalities th a t


they co n sid ered c o m p lem en ted each oth er.

trist, a psychologist, a n d a social w o r k e r m et

Assessing the p r o g r a m on 335 p a tie n ts at the

sessions. G r o u p a n d ind iv idu al t h e r a p y focused

tim e of d is ch arg e revealed significant im p ro v e

on m a jo r d y n am ics a n d self-reh ab ilitatio n .

ment

R esu lts w e re co nsid ered at least c o m p a r a b le to


c on ven tio nal p sy c h o th e ra p y .
M a r a t h o n g r o u p sessions (B a ch , 1966, 1967

in

th e

presenting

sym p to m s,

w ork

c a p a c i tie s , i n t e r p e r s o n a l r e l a t i o n s h i p s , a n d
ge n e ral level o f com fort. A fo llo w -up stu dy
show ed th a t th is im p ro v e m e n t w a s re tain ed .
M a s s e d tim e - li m it t h e r a p y sessions for as

th ree

tim es

w ith

th e

f a m il ie s

for a l l - d a y

a - d ; C a srie l & D eitc h , 1968; T e i c h e r et al,

lo ng as 10 h o u r s consecutively have been given

1974; V e rn a llis et al, 1970, 1972) w h ile no t as


p o p u l a r as in p rev io u s y ears co n tin u e to have

(B e r e n b a u m et al, 1969). A form of this t h e r

th e i r advocates.

Conclusion
S o m e h o w , s h o r t-t e rm th e r a p y has ac q u ir e d
th e re p u t a ti o n of b eing a s u b s ta n d a r d a p
p ro a c h in w h ic h q u a lity of results is sacrificed
on th e a lt a r of expediency. S u perficia lity of

a p y w ith a d u lts , adolescents a n d c h ild ren , as


well as in g ro u p , fam ily a n d m a r it a l th e r a p y .
A n u m b e r of m od els of s h o r t-t e rm th e r a p y

goals, u n c e rta in ty of resu lts, s u b s titu tio n of


sy m p to m s, a n d a g e n e ral glossing over of ef

h ave evolved fro m w h ich te c h n iq u e s m a y selec


tively be a d a p te d to th e w o rk in g styles of
p s y c h o th e ra p is ts tr a in e d in th e v ario u s t h e

fects a re said to be inevitable. T h e s e ideas have


p ro v en grossly in acc ura te. T h e r e is a m p le evi
d ence from th e re p o r te d clinical ex periences
w ith s h o r t-t e rm th e r a p y th a t it h as a utility
n ot only as a n econom ic e x p ed ie n t, b ut also as
a p r e f e r r e d f o r m of p s y c h i a t r i c t r e a t m e n t .
W h a te v e r con tro lled research studies exist,
these s u b s ta n tia te its valu e in in div idu al t h e r

oretical o rie n ta tio n s.


T h e ac tu a l m o dels in use a r e u su a lly c o n d i
ti o n e d by t h e e x p e r i e n c e a n d t h e o r e t i c a l
o r ie n ta tio n of th e p rac tic in g pro fessio nals a n d
th e policies of the agencies, if a n y , u n d e r
w h o se sup erv ision th e w o r k is bein g d on e. T h e
s h o rtc o m in g s of som e of these system s is th a t
th ey ten d to be m on olithic , c ir c u m v e n tin g fac

MODELS OF SHORT-TERM THERAPY

21

tors related to th e specific c o m p la in t a n d to


such elem en ts as th e stage of th e p a t i e n t s

fective le arn in g .

H e m a y utilize th e lessons

read ine ss for c h a n g e a n d p re fe rred l e a r n in g


p a tte rn s. N o t all p erso n s a r e ca p a b le of u tiliz

le a rn e d from p sy ch o an aly sis th a t h elp expose


an d resolve unco nscio us resistances, p a r t i c u
larly tr a n sferen ce a n d actin g -o u t. O b v iou sly

ing th e te ch n iq u e s th a t a re offered. T h i s is not


e x tr a o r d i n a r y since p a tie n ts g enerally h a r m o

for best resu lts th e th e r a p is t m u s t be h ig h ly se


lective a b o u t th e m o d alities h e uses so t h a t he

nize w ith som e in terv en tio n s a n d not w ith

does not s w a m p th e p a ti e n t w ith u n n e cess ary

o th ers. S om e do well w ith a cognitive a p


p ro ac h in w h ic h they can a b s o r b a b stra c t co n

activity. All t h e r a p is t s c a n n o t be e x p e rt in, o r

cepts a n d insights th a t h e lp th e m to a lte r th eir

exists. B ut sufficient flexibility sh o u ld prevail


to p re v e n t a sta le m a te w h e n th e p a ti e n t fails to

s i n g u l a r t h i n k i n g p a t t e r n s . O t h e r s fail to
benefit from such tactics. T h e y do b etter w ith
behavioral tec h n iq u es, e x p e r i m e n t in g w ith dif

even a w a r e of, every a v a ilab le te c h n iq u e th a t

re s p o n d to th e m e th o d th a t th e th e r a p is t is a p
p ly in g at th e m o m e n t.

ferent m odes of action, solidifying successful

T h e fact t h a t th e v a rio u s s h o r t- t e r m t h e r

ones th o u g h rein fo rcem en ts. Still o th e r s learn


by m o delin g them selves after a n a d m ire d a u

ap ies in th e h a n d s of co m p e te n t th e r a p is ts do
b ri n g a b o u t relief o r c u re indicates th a t the

th ority, g e n e rally th e th e r a p is t, b e sto w in g on

p a r t i c u l a r te c h n iq u e s a n d s t ra ta g e m s em p lo yed
are n ot th e o n ly i m p o r t a n t elem en ts re s p o n s i

h im virtues he m a y o r m a y not possess. An ef


fective s h o r t-te rm th e r a p is t is o ne w h o discerns
th e needs a n d le a r n in g proclivities of each p a

ble for im p ro v e m e n t. T h e p ro p o s itio n is inv it

tien t an d is flexible en o u g h to a lte r his m e t h

m e a n s of c o m m u n ic a t io n t h r o u g h w h ic h the

ods as he goes along.


R ig i d t h e r a p i s t s

th e r a p is t e n c o u ra g e s the e m erg en ce of positive,


a n d th e re s o lu tio n of negative, h e a lin g ele

d o g g e d ly

fo llo w

set

ing th a t t h e r a p e u ti c m a n e u v e rs m erely act as a

a g en d a into w h ic h th ey w ed ge all p a tie n ts w ith


little ro o m for eclectic m a n e u v e rin g . Yet one

m e n ts ( M a r m o r ,

h a rd ly ever sees a p a tie n t w h o could not utilize

t h a n w ith a less active one, w ith hy p n o sis

some of the effective in terv en tio n s of different

r a t h e r t h a n fo rm a l inte rv iew in g , w ith b e h a v io r

1966).

If a th e r a p is t feels

m ost c o m fo rta b le w ith a m o r e active a p p r o a c h

systems at successive stages of th e ir tr e a tm e n t.

th e r a p y r a t h e r t h a n a n a ly tic a lly o rie n te d t h e r

T h u s a th e r a p is t m a y w ith the sam e p a ti e n t be


active at some tim es a n d passive at o th ers; he

a p y , h e will p r o b a b l y be a b le to help m o r e p a

m ay

s elec tiv e ly

em ploy

c o n fro n ta tio n ,

re

tien ts th a n w e re he to force him self to use a


p ro c e d u r e w ith w h ich h e is not at ease o r

a ss u ran ce, o r suggestive o r persu asiv e te c h


niques. If fa m ilia r w ith th e m eth o d s, he m a y
utilize role play in g , p s y c h o d r a m a , re la x a tio n ,

a b o u t w h ich he is not en th u siastic. T h i s is not


to d ep re c ia te the v irtu e s of a n y of th e existing

hypnosis,

m i li e u t h e r a p y , s y s t e m a t i c d e n s e n s i t i z a t i o n ,

to o v e re m p h a s iz e te chnical v irtu o sity w h ile


m i n im iz i n g th e vital h e a lin g processes th a t

assertive tr a in i n g , an d o th e r b ehav io ra l te c h
niq u es w h e n necessary. H e m ay em p lo y

em e rg e in th e co urse of th e h e lp in g re l a ti o n
sh ip as a h u m a n experience.

f a m il y

th era p y ,

group

th e ra p y ,

psych otro pic d r u g s w h e n sy m p to m s block ef

models a n d tec h n iq u es. H o w e v e r, w e do tend

CHAPTER 2

A Rationale for Dynamic


Short-term Therapy
S h o rt-te rm th e ra p y g e n erally has three
goals: (1) m odifying o r re m o v in g th e s y m p to m

stra te d in fo llo w -u p studies of p a tie n ts w h o


h ave received a p p r o p r i a t e professional help

co m p la in t

over a brief s p a n . T h o u g h n ot a n tic ip a te d , sig

for w h ich

h e lp

is bein g sought,

w h ich is the im m e d ia te objective, (2) p r o d u c

nificant a n d lastin g c han ges in the self-image

ing

a n d th e q u a li ty of i n t e r p e r s o n a l re la tio n s h ip s

som e corrective

in fluence on

th e

in d i

v id u a ls g en eral a d ju s tm e n t, a n d (3) in itiatin g


essential a lte ra tio n s in th e pers o n ality s t r u c

h a v e been noted.

ture.

te r m t h e r a p y th a t ad d ress them selves to the


goal of p e rs o n a lity re c o n s tru c tio n , w e find th a t

we

W ith
may

p ro p erly

a n tic ip a te

c o n d u c te d

su b s ta n tia l

W h e n w e review th e m a n y system s of s h o r t

treatm en t

or

co m plete

s y m p to m relief as well as som e m odification

the

for the b etter of b eha v io ral coping. H o w e v e r,


w e m a y scarcely have b ro k e n g r o u n d on the

uncon sciou s conflict, a lo n g w ith th e c o n d itio n

m a jo rity

a c k n o w le d g e

th e

o p e r a t io n

of

th ird goal of p ers o n ality reco n stru c tio n . W e

n e u ro tic process. In d y n a m ic form s of th e r a p y


a p r i m e objective is h e lp in g th e p a ti e n t a c q u ir e
g r e a t e r k n o w led g e of oneself in clu d in g o n e s

ing of faulty h a b it resp on ses, as a source of th e

m a y hope, n evertheless, th a t th e exp erienc e of


tr e a tm e n t will have set into m o tio n a process
follow ing th e r a p y th a t over a lo n g -te rm perio d

h id d e n motives. A q u e stio n is w h e t h e r th e k ind

will resu lt in t r u e c h a ra c t e r p e rm u ta tio n s .


T h a t such ch an g es do occur h a s been d e m o n

o f t r e a tm e n t b eing em p lo y ed can lend itself to


th e ac hie vem en t of this objective.

Categories of Short-term Therapy


T h ro u g h o u t

th e

lite ratu re

one

finds

rem o ve sy m p to m s, to a lt e r fam ily h a b it p a t


tern s, a n d to rectify b e h a v io ra l deficits. T o a t
ta in th ese objectives, a v a rie ty of eclectic te c h
n iq u e s a re im p le m e n te d , d e p e n d in g on the
ido syn cratic needs of the p a ti e n t a n d the skills
a n d m eth od olo gical p references of th e t h e r a
pist. T h e n u m b e r of sessions varies, ra n g i n g
fro m 6 to 25. In d y n a m ic s h o r t- t e r m t h e r a p y

ten d e n c y to sub div ide s h o r t-t e rm t h e r a p y into


th r e e distinctive categories: (1) crisis in te rv e n
ti o n , (2) s u p p o r t i v e - e d u c a t i o n a l s h o r t - t e r m
th e r a p y , a n d (3) d y n a m ic s h o r t-t e rm th e r a p y .
T h e goals of crisis in terv e n tio n u su ally differ
from those in th e o th e r b rief m etho ds. H e re ,
after from 1 to 6 sessions, a n a tt e m p t is m a d e
to resto re h a b it u a l balanc es in th e e xistin g life
situ atio n. S u p p o rtiv e -e d u c a tio n a l a p p ro a c h e s ,
such as be h a v io r th e r a p y , co nstitu te form s of
in terv e n tio n th a t a re u n d e r t a k e n , a lo n g w ith
e d u c a t i o n a l i n d o c t r i n a t i o n , to re lie v e o r

the th r u s t is t o w a r d a ch ie v ing o r at least s t a r t


ing a process of p e rs o n a lity re c o n s tru c tio n .
Sessions h e re m a y e x te n d to 4 0 o r m ore.
S o m e form s of crisis in te rv e n tio n t h a t a re
being practiced a r e in d istin g u ish a b le fro m th e

22

RATIONALE FOR DYNAM IC SHORT-TERM THERAPY

23

kind of co unseling co m m o n ly do ne in social

tr a d itio n a l in terv iew in g , b e h a v io r th e r a p y , re

agencies. T h e focus is on m o b ilizin g positive

la x a tio n , h y p n o sis, biofeedback, som atic t h e r

forces in th e ind ivid ual to cope w ith th e crisis


situation , to resolve re m e d ia b le en v iro n m e n ta l

apy , G e s ta l t th e r a p y , sex th e r a p y , g ro u p t h e r
apy , etc., singly o r in co m b in a tio n . T h e n u m

difficulties as r a p i d ly as possible, u tiliz in g if

ber of sessions will vary a c cord ing to th e in d i

necessary a p p r o p r i a t e reso urces in th e c o m m u


nity, an d to ta k e w h a te v e r steps a r e essential to

vid ual th e r a p is t , w h o u su a lly a n c h o rs his deci

forestall fu tu re crises of a sim ila r or re la te d n a


ture. N o a tt e m p t is m a d e at diagn osis o r
p sych od yn am ic fo rm u latio n . O t h e r kin ds of

sion o n h o w lo ng it takes to con trol sy m p to m s


a n d e n h a n c e a d a p ta tio n .
T h e p h ilo so p h y th a t en join s t h e r a p is t s to
em p lo y d y n a m ic s h o r t-t e rm tr e a tm e n t is the

crisis interv ention a tte m p t pro vision ally to d e

conviction

tect u n d e rly in g in trap sy c h ic issues a n d past

p re s e n t b eh av io rs a r e roo ted in needs, conflicts,

th a t

many

of th e

derivatives of

form ative experiences a n d to relate these to

a n d defenses th a t reach into th e past, often as

c u rr e n t p ro b lem s. M o r e extensive goals t h a n

far back as e a rly ch ildhood. S o m e of the most

m ere em o tio nal sta biliz atio n a r e sought.

offensive of th ese c o m p o n e n ts a r e unconscious,

T h e social-counseling form s of crisis i n


terv ention a re g enerally em plo yed in w a lk -in

a n d w h ile th ey o b tr u d e them selves in officious

clinics an d crisis centers w h e re larg e n u m b e r s


of clients a p p ly for help a n d w h e re th e r e is a

tion alize d a n d shielded w ith a tena c ity t h a t is


fr u s tr a tin g b o th to the victim a n d to those

a n d often destructive w ay s, they a re u su a lly r a

need to avoid getting involved too in tim a te ly

a r o u n d him . T h e only w a y , a c cording to p r e

w ith clients w h o m ig h t get locked into a d e

v ailing theo ries, th a t on e can b ri n g these


m ischief m a k e r s u n d e r co n trol is to p ro p e l

p en d e n t rela tio n sh ip . V isits a r e as fr e q u e n t as


can be a r r a n g e d an d a re necessary d u r i n g th e
first 4 to 6 weeks. T h e fam ily is often involved
in som e of th e in terview s, a n d h o m e visits m a y
have to be m ade. T h e in tervie w focus is on th e
p rese n t s itu atio n al difficulty an d often is c o n
cerned w ith th e m ost a d a p tiv e w a y s of coping

th e m into consciousness so t h a t th e p a tie n t


realizes w h a t h e is u p ag ain st. By stu d y in g
h o w th e p a ti e n t utilizes the r e la tio n s h ip w ith
h im , th e th e r a p is t h as a n o p p o r t u n it y to d e
tect h o w th ese b u rie d a b e r r a ti o n s o p erate ,
projected as th e y a re in to th e tr e a t m e n t s i tu a

w ith im m e d iate p ressing p ro b le m s. V ig o ro u s

tion.

edu catio nal m e a s u re s a re som etim es exploited

n o n v e rb a l b eh av io r, a n d tr a n sfe re n c e m a n i
festations a r e co nsid ered a p p r o p r i a t e m e d ia for

to activate the pa tien t. T h e e m p lo y m e n t of


sup p o rtiv e m e a s u re s a n d th e use of o th e r h e lp
ing in dividu als a n d

D ream s,

fantasies, v erb al associations,

e x p lo r a tio n b e cause th ey em b o d y u nc onscious

agencies is e n c o u rag ed .

n eeds a n d conflicts in a sym bolic form . By his

T h e second, m ore a m b itio u s, go al-d ire cted


form s of crisis interv en tion a r e often seen o p e r

t r a in i n g , th e th e r a p is t believes him self cap ab le


of d ecoding these sym bols. Since i m p o r t a n t

a tin g in o u tp a t ie n t clinics a n d p riv ate practice.


If the assigned n u m b e r of sessions hav e been
ex h a u ste d a n d the p atie n t still re q u ire s m ore

un conscious d e t e r m i n a n ts s h a p e o n e s e veryday
be hav ior, th e th e r a p is t tries to estab lish a c o n
nection b e tw e e n th e p a t i e n t s p re s e n t p e r
son ality in o p e r a t io n , such as te m p e r a m e n t,
m oods, m o r a ls a n d m a n n e r s , w ith early p ast
exp erien ces a n d c on dition ing s in o r d e r to help
th e p a ti e n t a c q u ir e som e in sig h t into h o w p r o b

h elp, referral to a clinic o r p riv a te th e r a p is t or


con tin ued tr e a tm e n t w ith th e sam e th e r a p is t is
considered.
B r ie f s u p p o r t i v e - e d u c a t i o n a l a p p r o a c h e s
have sponsored a v ariety of te ch n iq u es, such as

lem s origin ate d.

24

HANDBO OK OF SHORT-TERM PSYCHOTHERAPY

Universality of Dynamic Principles


T h e subdivisions of s h o r t-te rm t r e a tm e n t
t h a t h av e been describ ed na m ely , crisis i n t e r

a p y re q u e s tin g h yp n o sis to e lim in a te his s m o k

sh o rt-term

ing h a b it w a s exposed to m y u su a l in d uc tion


m e th o d . A te c h n iq u e th a t I c u sto m a rily e m

th e r a p y , a n d d y n a m ic s h o r t-t e rm t h e r a p y a re
artificial. In p ractice th e ir b o u n d a rie s becom e

ploy is to ask th e p a ti e n t to lift his left in d ex


finger w h e n he exp erien ces certain th in g s th a t

v e n ti o n ,

su p p o rtiv e-ed u catio n al

diffuse. B ecause p a tie n ts re s p o n d selectively to

I suggest to h im , for e x a m p le , a f a n ta sy in g of

different tec h n iq u es, effective th e r a p is ts in all

ce rta in scenes. At the su ggestion th a t he p ic

th r e e categories of tr e a tm e n t will v ary th e i r in


terv entio ns a cco rd ing to th e im m e d ia te p r o b

t u r e h im self w a lk in g a lo n g th e street a n d th a t
he lift his left fing er (w h ich I to uch ed) as soon

lems a n d needs of th e ir p atien ts . M o r e o v e r, be

as the im ag e ca m e to h im , th e p a tie n t in stead

cause all o p e ra te w ith in th e m a t r i x of a r e l a

lifted his rig h t finger. H e also resisted sug ges


tion s th a t his left a r m w o u ld becom e so stiff

tio n sh ip th a t develops b etw een p a tie n ts and


th e ra p ists, u n d e rly in g p e rs o n a lity p ro b lem s

a n d heavy th a t he could no t move it. O n th e

a n d conflicts will su rface d u r i n g th e r a p y a n d

c o n tr a ry , he s p o n ta n e o u s ly w aved his a r m in

yield vitally significant d y n a m ic m a t e r i a l for


e x a m in a tio n . W h a t th e th e r a p is t does w ith th e

th e air. O n te r m i n a ti o n of th e in d u c tio n , I h u
m o r o u sly p o in te d o ut th ese facts a n d sp ecu

m a te ria l th e p a tie n t b rin g s u p d u r i n g in t e r

la ted

views can affect th e o u tco m e of tr e a tm e n t.


In d eed the techn iqu es a n d in terven tio n s u sed
b y the th era p ist to influence the p a ti e n ts

w a s p ro b a b l y a n ex p res sio n of o p p o sitio n al


tendencies. Said I, sm iling, C o u ld y ou be

sy m p to m s m a y

be less im p o rta n t than

the

fa n ta sies a n d beh avio ra l respon ses th e y evoke

th a t

his

n e g a tin g

of m y

su ggestions

a n o p p o sitio n al c h a ra c t e r w h o w o n t allow
him self to be p u s h e d a r o u n d ? H i s im m e d ia te

in the p a tie n t. F o r e x am p le, some m a n ife s ta

res p o n se w a s to la u g h h e a rtily an d to say th a t


peo ple considered h im a s t u b b o r n cu ss. It

ti o n s reflect p r o j e c t i o n s o f p a s t f e a r s a n d

r e q u i r e d n o g re a t effort to connect his o p p o s i

desires in re latio n to early a u th o r it y figures.

ti on al b e h a v io r w ith a c h ild ho od p a t t e r n of

T h e s e , if u n de tec te d or d is re g a rd e d , m a y effec

ass ertin g h im se lf w ith his p a r e n t s a n d old er


siblings by d is p la y in g n eg ativ is m a n d so m e

tively block th e r a p e u ti c progress. Such t r a n s


ference resistances a r e e x tre m e ly co m m o n and
are p ro b a b ly th e chief rea so n for failure s in
th e r a p y . F r e q u e n t ly th ey a re a p p a r e n t only in
n on v e rb al b eh avior, d re a m s, fantasie s, a n d i n
sidious a ctin g -o u t a w a y from th e t h e r a p i s t s of
fice. T h is is w h y a d yn a m ic a p p ro a ch , d u rin g
w hich the reaction s o f p a tie n ts to the th e ra p ist
a n d to the p e r v a d in g tech n iqu es, c o n sta n tly
assessed a n d taken into con sideration , can
p r o v e useful in a ll fo r m s o f sh o rt-te rm th erapy.
W h il e the in terv iew focus m a y be on s y m p
to m s , e n v i r o n m e n t a l d i s t o r t i o n s , a n d o t h e r
c o m p la in t factors, th e real th e r a p e u tic w o rk
will be o rg a n iz e d a r o u n d p e rs o n a lity reactions
an d conflicts m obilized by th e m a n e u v e rs of
th e th erap ist.
A m a n w ith e m p h y s e m a w h o cam e to t h e r

tim es violence to avoid w h a t h e c onsidered be


ing d o m in a te d a n d c rush ed. I co m m e n te d th a t
I c e rtain ly w a s n o t his p a r e n t , b u t t h a t he
m ig h t react to m e a n d to w h a t I w as d o in g for
h im as if I w a s so m ebody w h o w a n te d to
d o m i n a te a n d c ru s h him . H e could easily block
him self by such a n a tt it u d e fro m benefiting
fro m tr e a tm e n t. M y s t a te m e n t seem ed like a
re velation to h im . H e spec ula ted th a t this w a s
p r o b a b ly w h y his p rev io u s p sy c h o th e ra p e u tic
effort w ith a n o th e r th e r a p is t h a d failed. H e
never could u n d e r s ta n d w h y he w o u ld h ave
flashes of a n g e r t o w a r d th e th e r a p is t an d
w o u ld som etim es m u m b le to him self a fter he
left th e t h e r a p i s t s office, I w o n t let th a t sonof-a-bitch b r a i n w a s h m e . H e felt so a s h a m e d
of these re ac tio n s th a t he h a d concealed th e m

25

RATIONALE FOR DYNAM IC SHORT-TERM THERAPY


from his th e r a p ist, w h o failed to pick u p the
transferen ce resistance. By a n tic ip a tin g his
tra nsferenc e rea ctio n, I w a s able to secure his
coo peration an d to achieve a good res u lt in
tre a tm e n t.
H a d I not utilized hy p n o sis b u t j u s t a n o r
d in a r y in terv iew in g te c h n iq u e or b eh av io r

re con stru ctiv e c h a n g e shou ld th e p a ti e n t tr u ly


d esire to move a h e a d in his d evelo p m en t.
W e m u s t not expect to acco m p lish m iracles
w i t h d y n a m i c s h o r t - t e r m p r o c e d u r e s , even
w h e n executed w ith perfection. A t th e en d of
th e form al b rief tr e a tm e n t period w e usu ally
observe

som e

alteratio n

of

th e

p a t i e n t s

th e r a p y , th e p a ti e n t w o u ld u n d o u b te d ly have

sy m p to m s, a n alleviation of suffering, a n d a

revealed his o p p o sitio n a l tendenc ies w e re I to


look f o r th em if n ot in his b ehav ior, th e n in

c e rta in d egree of beh av io ra l co rrection . If we

d re a m s an d o th e r rep re se n ta tio n s . T h e p r i n

recognized fu n d a m e n ta l c h a ra c te r p ro b lem s

ciple th a t I a m try in g to illu s tra te is t h a t the

th a t a r e likely to c re ate difficulties in th e fu

th e r a p e u tic tactics em p lo yed , w h ile a im e d at


r e l ie v i n g t h e i m m e d i a t e c risis s i t u a t i o n o r

tu r e , a n d d u r i n g the tr e a t m e n t w e m a y have

h a v e diligently searched for th e m , w e will have

s y m p to m a tic up set, will usu ally set into m otio n

been ab le to s t a r t th e p a ti e n t o n a p rod uc tive


p a t h t o w a r d a lte rin g self-defeating p e rs o n a lity

cu sto m a ry resistances a n d defensive o p e ra tio n s

p a tte rn s . U n f o r t u n a te l y , th e la tte r objective is

th a t m a y th e n be closely ex a m in e d a n d w o rk e d

avoided by som e th e ra p ists. In m y o p in io n , in

th r o u g h , if possible, as a m e a n s of in culcatin g

m o st cases, th is is because th e th e r a p is t w rites

essential insights. In o th e r w o rd s, even th o u g h


the m eth od s m a y be n o n a n a ly tic , th e p a t i e n t s

it off as u n a t t a i n a b l e a n d h ence does n ot a p p ly

re actio ns to th e m a n d to th e th e r a p is t become

c a n n o t expect too rad ical a p e rs o n a lity r e o r g a


n iz a tio n w ith in th e limited tr e a t m e n t period.

an i m p o r t a n t e x p lo r a to r y focus, if no m o re
t h a n to deal w ith obstructive tra n sfe re n c e an d
o th e r b a rr ie rs to chan ge. P e rs o n a lity m odifica
tions e ventually m a y evolve from th is as a se
re n d ip ito u s div iden d, on e th a t m a y co n tin u e in

him self to its ac c o m p lis h m e n t. T o r e p e a t, we

T h e m ost to be h o p e d for is th e in itiatio n of


sufficient se lf-u n d e r sta n d in g to ch allen g e som e
values a n d defenses a n d to e n c o u ra g e e x p e r i
m e n ta tio n w ith n e w a n d m o r e constructive

a p ro p itio u s e n v ir o n m e n t for a n indefinite tim e


an d u ltim ately become a p e r m a n e n t change.

w a y s of re l a ti n g to o th e r s a n d to th e self. In

It w o uld seem p r u d e n t , obviously, in view of


the g reat d e m a n d for services from th e r e l a

t i n u in g for m o n t h s an d even y ears a fter the

th is w a y a c h a in reactio n m a y be set off, c o n


tr e a tm e n t p e rio d , th a t will ho pefu lly lead u lti

tively sm all c ad re of a v a ilab le tr a in e d t h e r a

m a tely to extensive p e rs o n a lity chan ge. T h a t

pists, th a t, at th e sta rt, at least, s h o r t- t e r m

such fa r -re a c h in g resu lts a re achie vab le in an


im pressive n u m b e r of p a tie n ts is th e fin din g
a m o n g m a n y th e r a p is ts w h o h av e ap p lied
them selves to a d y n a m ic a p p r o a c h in a dis

th e r a p y should practically be g eared to w a r d


goals of o p tim a l functioning. H o p efu lly , h o w
ever, even a b rief e x p o su r e to th e r a p y will u n
cover fu n d a m e n ta l
th e th e r a p is t, if h e
to scrutinize th e m ,
p a t i e n t s a tte n tio n

p e rs o n a lity conflicts, w h ich


d eem s th e p a ti e n t p r e p a r e d
m a y carefully b ri n g to th e
w ith th e object of inviting

ciplined w ay. T h e y a t t a in e d success because


th e y fo un d a n d w o rk e d on a specific im p o r t a n t
focus d u r i n g th e tr e a tm e n t.

Dealing with Unconscious Determinants


In p atien ts w ith intact p e rso n alities a few
w ell-conducted sessions, h o w e v er superficial
they m a y seem, m a y suffice to b ri n g a b o u t a n

a m e lio r a tio n o f sy m p tom s, a n d n o f u r th e r


tr e a t m e n t will be needed. H o w e v e r , t h e r e a re
m a n y patien ts w hose p ro b lem s are m ore

26

HANDBOOK OF SHORT-TERM PSYCHOTHERAPY

deeply en trenc hed w h o will re q u i r e f o r even


m ere sym p to m re lie f som e resolu tio n of p e r
sonality conflicts th a t a re in cessantly g e n e r a t
ing tro u b le for th e m . E ven le a r n in g b etter
modes

of p r o b l e m

s o lv in g

requires

so m e

in sight into in te rn a l forces th a t govern be


havior.
It is precisely because th e most d is tu rb in g
sources of tu rm o il so often lie b eyond a w a r e
ness th a t efforts in m a n y p a tie n ts a p p lie d e x
clusively to w a r d en v ir o n m e n ta l m a n i p u la t io n ,
pe rs u asio n , suggestion, rea s su ra n c e , re e d u c a
ti o n ,

or reco n d itio n in g

so o fte n

are

resistance. T h e s e in n o v a tio n s have becom e


firm ly in c o r p o ra te d into p sy c h iatric a n d p s y
chological th i n k in g a n d h ave in sp ired p r a c
tically all c u r r e n t system s of p sy c h o th e ra p y .
T h e y a r e in trinsic to o u r c o n te m p o r a r y ideas
a b o u t d y n a m ic a lly based s h o r t-t e rm p sy c h o
th e r a p y .
P s y c h o a n a l y s i s in its l o n g - t e r m c la s sic a l
form has no t p ro v en itself to be a p ractical
form of th e r a p y in th e m a jo rity of cases seek
ing h e lp not o n ly because it is ex pen sive an d

o n ly

d ra g s on for years, b u t also, even w h e r e fi


n ances a n d a w illingness to p a rt ic i p a te in a

pa rtia lly successful. T h i s is no t to d ep reciate

p ro lo n g e d th e r a p e u ti c re la tio n s h ip a re p res en t,

th e effectiveness of su p p o rtiv e a n d ed uc atio nal


m e asu res, for in suitable p atien ts , a p a r t from

only a small n u m b e r of p a tie n ts a r e s u ita b le


ca n d id a te s for th e tech n iq u e . Id entify ing w h o

b rin g in g a b o u t necessary relief from suffering,

m ight

a certain degree of p e rs o n a lity c h a n g e m a y oc

R o u g h ly , p e rs o n s w h o a re not too sick a n d not


too im m a t u r e , a so-called n o r m a l - n e u r o t i c
g r o u p , qualify. T h e s e c o n stitu te only a sm all

c u r th r o u g h

th e ir im p le m e n ta tio n .

U nfortu

nately, lasting ch aracte ro lo g ic a lte ra tio n s a re


r a r e . T h e chances a re th a t if w e really h o p e to
succeed in b rin g in g a b o u t explicit p e rs o n a lity
ch an ge, a ss u m in g th a t this is o u r goal, w e will
have to clarify a n d m a n a g e in n e r conflicts th a t
a re beyond the p e rip h e ry of a w a re n e s s in an
effort to p ro m o te g re a te r self-u n d erstan d in g .
T h e qu estio n in s h o r t-te rm th e r a p y is w h e th e r
th is can be d on e briefly in a specific case a n d ,
if so, h o w best it can be done.
T r a d it io n a l ly , th e m eth o d most often e m
ployed in de alin g w ith u nco nscious conflict is
lo n g - t e r m p s y c h o a n a l y s i s . A g o o d d e a l of
m is u n d e rs ta n d in g , h o w ever, still exists a b o u t
psychoanalysis, som e of w h ich stems from its
m isap p lic atio n to a re a s in w h ich its c o m
petence as a th e r a p e u tic p r o c e d u r e m a y be
challenged. S uch m isdirection h a s tend ed to
shred its au th en ticity . F r e u d s e n d u ri n g legacy
lies in his p e n e tr a ti n g insights into h u m a n b e
hav ior. T h e s e include th e concept of th e u n
conscious, the tr e n c h a n t n a t u r e of beh avio r,
th e indelible im p r i n t of ch ildh oo d e xp erien ce
on c h a ra c te r stru c tu re , the c o n s a n g u in u ity of
a b n o r m a l m e n ta l sy m p to m s an d n o rm a l m e n
tal processes, th e significance of a n x iety , the
s tru c tu r e of sy m bolism , th e n a tu r e of d re a m s ,
and

th e

im p ortance

of

transference

and

satisfacto rily

respond

is

d iffic u lt.

fraction of th e vast a r m y of peop le w h o cluster


a r o u n d clinics a n d p r a c t it io n e r s offices seeking
h e lp for a w id e variety of prob lem s.
A tte m p ts to find o th e r m e a n s t h a n classical
a n a ly sis to ex po se u n d e rl y in g sources of p r o b
lems c o n tin u e to this very day. B locking such
a tt e m p t s a r e o b stru c tio n s to su rfacin g of th e
un con sciou s a n d th e stra n g le h o ld th a t h id d en
needs an d defenses h ave on o n e s valu es a n d
b e h a v i o r . B e c a u s e su c h u n c o n s c i o u s i n
g re d ien ts a re frozen into th e c h a r a c t e r s t r u c
tu r e , efforts to d e m o n s tr a t e th e i r u n r e a s o n a b le
ness a r e resisted w ith a d e s p e r a te tenacity.
A re w e th e n d o o m ed in h e lp in g peo ple re ach
reco nstru ctiv e p e rs o n a lity t r a n s f o r m a t io n s ? It
is fallacious to c onclude th a t a seriously defec
tiv e c h i l d h o o d i m p o s e s a life s e n t e n c e o n
everyone. G r o w t h is possible at all stages of an
i n d i v id u a ls life, corrective e m o tio n al e x p e r i
en ce s b e in g s p o n s o r e d by c o n s t r u c t i v e life
events, p a r t ic u l a r ly m ean in g fu l in te rp e r so n a l
relatio n sh ip s . W h e r e a n in div idu al h a s lived
t h r o u g h a crisis a n d h a s resolved it success
fully, he m a y also be r e w a r d e d w ith n ew a n d
b e tte r p e rs o n a lity resp on ses th a t can serve h im
well in h a n d li n g fu tu re stressful situ a tio n s.
T h e idea th a t th e un con sciou s is forever co n

RATIONALE FOR DYNAM IC SHORT-TERM THERAPY


cealed unless u p ro o te d by form al p s y c h o a n a
lytic th e r a p y is no lo ng er accepted by disciples

27

j u s t to be able to recognize o n e s n eu ro tic


m i s e ry . W h a t e v e r th e involved m e c h a n ism s,

th a t a n individual is not a helpless p a w n of his

the i n d i v id u a ls sense of m a s te ry is helped.


Since the goal of s e lf-u n d e r s ta n d in g re q u ire s

unconscious. R a th e r the indiv id ual exercises a

th e u n co v erin g of at least som e un con sciou s d e

of m o d e rn cognitive a p p r o a c h e s w h o co nten d

certain degree of c o m m a n d over in n e r conflicts,

te r m i n a n ts , th e m a n n e r of th e i r e x p o su r e a n d

con stantly striv ing to m a k e th e m conscious so

th e tim in g a r e especially im p o r t a n t in s h o r t
te r m th e r a p y . G e n e r a ll y , the first few sessions

he can gain m a s te ry over th em . T o an ex tent,


he is even ca p a b le of exercising decisions a b o u t
w h ich aspects of his un conscious to reveal,
titra tin g th eir ex p o su r e ag a in st his to le ran ce of

will reveal d a t a from th e h isto rical m a te ria l


(an d p a r t ic u l a r ly the p re s e n t b e h a v io ral p a t

anxiety. As he w o rk s t h r o u g h his a n x ie ty , he

te r n s of the p a tie n t) th a t offer clues r e g a r d in g


th e o p erativ e dy n am ics. U s u a ll y it is u n w is e to

becomes in creasin gly

p re s e n t the p a ti e n t w ith su ch clues, no m a t te r

aw are

of segm ents of

him self th a t h ave been concealed a n d hence

how

have evaded detection a n d control. C o u n te r i n g


th i s , o f c o u r s e , a r e r e s i s t a n c e s t h a t m a y

h im self ex presses a w a re n e s s of w h a t is going

ob stru ct such a tt e m p t s at self-healing.


T h e virtu e of th e cognitive a p p r o a c h is the
p h ilo so p h y it espouses to the effect th a t te c h
n iq u e s o th e r th a n form al analy sis can be im
m ensely helpful in resolving resistance to the

s i g n if i c a n t

they

m ay

seem ,

u n til

he

on. E v en th e n a n y in t e r p r e ta ti o n s m u s t be c a u
ti o u s l y o ffered in t h e f o r m of te n t a t i v e
p re s e n ta tio n s (W o lb e rg , 1977, pp . 5 8 9 - 5 9 0 ) .
T h e re la tio n s h ip of e x pressed conflictual m a
terial to the p re s e n t c o m p la in t factor is vitally

o p e n in g u p of crucial a re a s for e x p lo r a tio n and

im p o r t a n t if such a r e la tio n s h ip can be d e m o n


strated.

u ltim a tely lead to self-u n d e rstan d in g . Left to


o n e s o w n resources, th e av e ra g e in dividual

to m y office w ith th e c o m p la in t of m ig ra in e

A m ild - m a n n e r e d , soft-spoken p a tie n t cam e

m a y not have sufficient m o tiv atio n, th e for

h eada che s. As he w alk e d into th e ro o m , he

titud e to strug gle w ith th e a n x ie ty inevitable to

tipped

th e

apologized

h a n d lin g

of re p u d ia te d

aspects

of th e

over

ch air

w h ile

and

th e n

a s h e s fr o m

p r o f u s e ly

his c i g a r e t t e

psyche, a n d th e w illingness to a b a n d o n th e
m a terial a n d subversive g ain s a c c ru in g to n e u

spilled over th e ca rp et. D u r i n g the interview I


got the im p re ss io n from his p o stu re , th e set of

rotic indulgence. O n th e o th e r h a n d , the in d i


vidual w h o t u r n s to a carefu lly designed a p
p ro a c h executed by a skilled e m p a t h ic th e r a p is t

his j a w , a n d slash in g m o v e m e n ts of his h a n d s


t h a t his fa w n in g , ob seq u io u s m a n n e r w as a

will lea rn to d eal w ith resistances to self-u nd ers ta n d in g an d s u p p o r t e x p e ri m e n t a ti o n w ith

m i n d I m a d e a c o n n e c t i o n b e t w e e n his
s m o ld e rin g ra g e an d his m ig ra in e . I also

m o re rea lity -o rien ted p a tte rn s.


H o w s e l f - u n d e r s t a n d i n g h e l p s to b r i n g
d eeper p ro b le m s to th e su rface a n d to e n
co urag e h e a lth ie r a d a p ta tio n is n ot entirely
clear. Roy Schafer (1973) expresses it this
w ay: It is im pressive th a t, as th ese ch ang es
t a k e p la c e in th e p a t i e n t s c o n c e p t i o n of
himself, often by d in t of a n d w ith the a c c o m
p a n im e n t of m u c h suffering, he begins to feel
b etter an d to function better. H is sy m p to m s
dim inish in scope a n d persistence; his mood
im proves; his social an d sexual rela tio n sh ip s
a re enh anced . It seems th a t it can be a gain

cover for an in n e r boiling pot of a n g e r. In my

specu lated th a t he w as n ot a w a r e of th e exten t


of his a n g e r a n d ho w he repre ssed it. T o have
con fro nted h im w ith m y h y p oth esis w ou ld
p r o b a b ly h av e e n d ed o u r re la tio n s h ip before it
b egan. Instead , I bided m y tim e u ntil I h ad
m o re evidence to con firm m y im p re ss io n w hile
w o r k in g on e sta b lish in g a closer re latio n sh ip .
A t th e fo u r th session the p a ti e n t spoke of
n eed in g some extensive d e n ta l w o r k because he
g r o u n d his teeth d u r i n g his sleep. T h i s r e i n
forced m y idea th a t his a n g e r, u n d e r control
u su ally , w a s stro n g en o u g h to b re a k th r o u g h
in sleep. R epetitiv e use of such p h ra s e s as

28

HANDBO OK OF SHORT-TERM PSYCHOTHERAPY

T h e m a n is all ch ew ed u p , It kills me
to th in k of h o w p eop le tak e a d v a n ta g e of

w ere too busy to devote them selves to a n y single

w e lfa r e , I sla u g h te re d h im at t e n n i s , an d

p a tie n t. T h i s w a s th e case also w ith som e

so on, en ab le d m e to say, I w o n d e r if you

p a re n ts , in clu d in g his o w n p a r e n t s , w h o had


s p en t little tim e w ith him .

hold back o n y o u r a n g e r w h e n you h av e a


rig h t to be u p s e t ? I th e n re p e a te d so m e i n

W i t h o u t a p o lo g iz in g for m y actions o r a c tin g


in d ig n a n t, I e n c o u ra g e d h i m to tell m e m o r e

cidents th a t he h a d revealed to m e in w h ic h he
ha d felt tak en a d v a n ta g e of b ut h a d failed to

a b o u t h o w h e felt, i m p l y i n g t h a t I a p
p rov ed of his f r a n k n e s s a n d his rig h t to feel
w h a t he felt. As I a n tic ip a te d , h e ba c k tra c k e d ,

assert his righ ts. T h i s led to a n ex p o stu la tio n


nefariou sn ess of peo ple w h o needed to J e w

ap o lo g izin g for his b oldness a n d ru den ess.


T h i s re ac tio n , I rep lied , w a s in service o f his

you d o w n .

guilt, a h a b it u a l p a t t e r n to keep his a n g e r

of in d ig n a tio n a t th e state of th e w o rld a n d the

Freud

w as

H is nex t association w a s th a t
a Jew

and

Freud

w a s a psy

c h o an aly st w h o w a s c u rr e n tly being criticized


in articles he h a d read. Is th e r e , I asked him ,
a n y th i n g I as a p sy ch o an aly tic p s y c h o t h e ra

u n d e r control. B u t , he re to rte d , I re a lly do


like doctors a n d J e w s . A n d th e r e is som e
J e w i s h blood in m y fa m ily .
O p en in g

up

so m e

tra n sfe re n c e

f e e lin g s

pist a m do ing th a t upsets you o r m a k e s you


a n g r y ? W h y , he rep lied asto n ish ed ,
shou ld I b e ? W e l l , I reto rte d , a r e y o u ?

served to h e lp o u r re la tio n s h ip ; a n d to s u p p o r t
his a bility to criticize his fam ily m o r e fr a n k ly

T h e p a tie n t th e n la u g h e d a n d in a n e m b a r

child. A no ticeab le ch an g e o c cu rre d in th e fre


q u e n c y of his m i g ra i n e a tta c k s, a n d at o u r
te r m i n a ti o n d a te he e xp re sse d g re a t satisfaction

rassed w a y talk e d a b o u t his re s e n tm e n t a t th e


fee I ch arg ed , a t th e pu n c tilio u sn ess of m y a p
p o in t m e n t tim es, a n d at th e fact th a t I h a d given
h im a n en d in g d a te w h e n he w a s su re he could
not get well in so sh o rt a p e rio d. T h e tro u b le ,
he insisted, w ith most do cto rs w a s th a t th ey

for som e o f th e w a y s h e w a s h a n d le d as a

w ith the benefits he h a d received fro m th e r a p y


bo th in relieving his h e a d a c h e s a n d giving h im a
g r e a t e r sense of freedom .

Conclusion
All perso ns, irrespective of the d egree of
e m o tio n al illness have a p o ten tial for im p ro v e
m e n t an d g r o w th , both sp o n ta n e o u sly th r o u g h
constructive life experiences a n d , m o r e e x p e d i
tiously, w h e n tre a te d w ith a p p r o p r i a t e p sych o
th e r a p y . F o r rad ic al a n d e n d u r i n g a m e n d m e n ts
in the p e rs o n a lity s t ru c tu r e som e cognitive
alte ra tio n is essential. W i t h o u t such chan ge,
im pro ved h a b it a n d beh av io ral p a tt e r n s a r e a p t
to be short-lived. D u r i n g th e r a p y fa r-re a c h in g
im p ro v e m en ts m a y be a p p ro a c h e d by e x p lo r
ing an d w o r k in g th r o u g h basic conflicts, esp e
c ia lly t h o s e r e v e a l e d in t h e t r a n s f e r e n c e .
W h e r e tran sferen ce is not a p p a r e n t in the
th e r a p e u tic situation , it m a y often be detected
in d isto rtio ns in the in d iv id u a ls re la tio n sh ip

w ith o th e r p eo p le as well as in th e d re a m s ,
fantasies, a n d ac tin g -o u t tendencies. Ir re s p e c
tive of the tec h n iq u e s t h a t a r e b eing em p lo y e d ,
(e.g., n on directive in te rv iew in g , active a n x ie ty p ro v o k in g co n fr o n ta tio n , a n a ly tic i n t e r p r e t a
tion, b e h a v io r t h e r a p y , G e s ta l t a p p r o a c h e s ,
etc.), th e p a ti e n t will re s p o n d to these te c h
n iq u e s w ith a w id e r a n g e o f h a b it u a l c h a ra c t e r o lo g i c r e a c t i o n s a n d r e s i s t a n c e s . T h e s e ,
u tilized as a p ro d u ctiv e focus o n w h ic h to c o n
c e n tr a te d u r i n g th e r a p y , m a y h elp p e n e tr a te
defenses a n d in itiate n ew w a y s of th in k in g ,
feeling, a n d b ehav ing . A p a r t fro m th e fact th a t
tim e in tr e a t m e n t is usu ally too sh o r t to p e r m it
th e d e v e lo p m e n t o f too intensive tra n sfe re n c e
reaction s t h a t re ach a p o in t of a tr a n sferen ce

RATIONALE FOR DYNAM IC SHORT-TERM THERAPY

29

neurosis, it is a c tu a lly n ot essential for th e p a

p rev a ilin g c h a r a c t e r p a tt e rn s , a n d th e i r orig in s

tien t to evolve a n d w o r k t h r o u g h a tr a n sferen ce

in e a rly life ex periences, th e process of re c o n

neu rosis to achieve extensive reconstructive


change. Indeed, th e effect of too g re at a n i n t e n
sification of tra n sfe re n c e m a y be to increase

structive ch a n g e is exp edited . Such ch a n g e m a y


co n tin u e th e r e m a i n d e r of th e in d i v id u a ls life,
p a r t ic u l a r ly w h e r e the p a t i e n t s e n v ir o n m e n t

resistance to t h e r a p y a n d to p ro lo n g tr e a tm e n t.

s u p p o r ts th e c h a n g e a n d h e c o n tin u e s self-

W h e r e a r e la tio n s h ip is fou nd betw een th e p a

o b serv atio n a n d e x p e r i m e n t in g w ith p ro du ctiv e

ti e n ts p re s e n tin g sy m p to m s an d c o m p la in ts,

n e w p a tte rn s.

CHAPTER 3

Criteria of Selection
u n d o u b te d ly

latio n w h o a p p ly to a clinic or priv ate p r a c t i

those w ho a re a d e q u a te ly m otivated for t h e r

W h ile

th e best p a tie n ts

a re

tio n e r for tr e a tm e n t. T h e ch alle n g e is w h e th e r

ap y , intellectually ca p a b le of g ra s p in g i m
m ed iate in te rp re ta tio n s , proficient in w o rk in g

p a tie n ts n o t so b o un tifu lly blessed w ith t h e r a


p eutically positive q u a lities c a n be tre a te d a d e

on an i m p o r t a n t focus in th e r a p y , no t too d e

q u ately

p e n d e n t, have h a d at least o ne good r e l a ti o n


sh ip in the p ast, an d a r e im m ed iate ly ab le to

c han ce of im p ro v in g th e ir g e n e ra l m o de s of

in tera ct well w ith th e th e r a p ist, th ey g enerally


con stitute only a sm all p erc en tag e of th e p o p u

m i n o r degree of p e rs o n a lity reco n stru ctio n .

on

a sh o rt-term

basis w ith

som e

p ro b le m solving a n d p e r h a p s of achie vin g a

Patient Classification
In practice one m a y d istin guish at least five

re a s o n a b le a d a p ta tio n . T h e im p ositio n of th e

classes of p a tie n ts w ho seek help. W e have

crisis ha s d e stro yed th eir cap acities for cop ing


a n d h a s p ro d u c e d a te m p o r a r y regression an d

c ategorized th e m as C lass

1 t h r o u g h 5. In

g en e ral, C lasses 1 to 3 r e q u i r e only s h o r t-te rm


th e r a p y . C lasses 4 a n d 5 will need m a n a g e
m e n t for a lon ger perio d after an initial s h o r t
te r m reg im en of th e r a p y .

e r u p t io n of n e u ro tic m e c h a n ism s. T h e object in


t h e r a p y for th ese p a tie n ts is essentially s u p p o r
tive in th e fo rm of crisis in terven tio n w ith the
goal of re e s ta b lish in g th e p rev io u s e q u ilib r iu m .
R eco nstru ctiv e effects w h ile not expected a r e a

Class 1 Patients

w elcom e dividend. G e n e ra ll y , no m o r e th a n six


sessions a re necessary.
A n e x a m p le of a C lass 1 p a tie n t is a satisfac

U n til th e onset of the c u r r e n t difficulty C lass


1 p a tie n ts have m a d e a good o r to lera b le a d

torily ad ju sted w o m a n of 50 y ears of age w h o


d ro ve a fr ie n d s a u to m o b ile w ith an e x p ire d

j u s tm e n t. T h e goal in th e r a p y is to r e t u r n
th e m to th e ir h a b itu a l level of functioning.
A m o n g such p a tie n ts a re those w ho se stability
h a s been te m p o r a r ily sh a tte re d by a c a ta

license a n d in th e process h a d a severe acci


d e n t, killing th e driv er of th e car w ith w h ich
sh e c o llid e d a n d se v e r e ly i n j u r i n g t w o

stro p h ic life event or crisis (death of a loved


one, divorce, severe accident, serious physical
illness, financial disaster, or o th e r calam ity ).
Som e in div id uals m a y have been b u rd e n e d
w ith extensive conflicts as far back as c h ild

p a s s e n g e r s in h e r o w n c a r , w h i c h w a s
d a m a g e d b eyond re p a ir. She herself sustain ed
a concussion a n d an in ju re d a r m a n d w as
m oved by a m b u l a n c e to a h osp ital, w h e r e she
re m a in e d for a week. C h a r g e d w ith d riv in g
violations, sued by the o w n e r of th e c a r she

hood but u p to the p re se n t illness h ave been


ab le to m a r s h a ll sufficient defenses to m a k e a

b o rr o w e d a n d by th e tw o in ju re d p a ss en g e rs,
she developed a d azed , dep ressed rea ctio n and

30

31

CRITERIA OF SELECTION
th e n perio ds of severe dizziness. T h e r a p y h e re

of th e p a t i e n t s a n x ie ty lay in th e last flight

consisted of a good deal of s u p p o r t, r e a s


su ran c e, a n d h e lp in fin d in g a good la w y e r,

th at

w h o counseled h e r successfully t h r o u g h h e r
e n tan g le d legal co m plications.
S om etim es a crisis o p en s u p closed t r a u

th e

m atic c h a p te rs in o n e s life. In such cases it

consisted of b e h a v io ra l sy stem atic d e se n s itiz a

m a y be possible to link p ast incidents, feelings,


a n d conflicts w ith th e p re s e n t u p se ttin g c ir

tion , w h ich in eig ht sessions resulted in a cure


of th e sym p to m .

c u m s t a n c e s e n a b l i n g t h e p a t i e n t to c la r if y
anxieties a n d h opefully to influence d e e p e r
s t ra ta of p erson ality . In th e case above, for e x
a m p le, the p a tie n t recalled an incident in her
ch ildhood

w hen

w h ile w h e e lin g

her

young

b ro t h e r in a c a rriag e, she accid entally u p set it,


cau sing a g ash in h e r sibling th a t r e q u i r e d s u
tu rin g . S h a m e d , scolded, a n d sp a n k e d , the
f r i g h t e n e d c h ild h a r b o r e d t h e e v e n t t h a t
p o w ere d fear a n d guilt w ith i n herself. T h e

she

had

ta k e n

y ea rs previously.

d is tu rb a n c e in on e of the en gin es re p o r te d to
pass e n g e rs

by

the

pilot

n ecessitated

r e t u r n to th e p o in t of o rig in . Since th a t tim e


M i s s J h a d n ot d a r e d e n te r a p la n e . T h e r a p y

In u tiliz in g th e v a rio u s eclectic tech n iq u e s


th e th e r a p is t a le r ts h im self to p a st p a tt e r n s
t h a t act as a p a r a d i g m fo r th e p r e s e n t
s y m p to m com plex , as well as to m an ifestatio n s
of resistance a n d transfe ren ce. In a certain
n u m b e r of cases th e p a ti e n t m a y be h elp ed to
o v e r c o m e r e s i s t a n c e s t h r o u g h r e s o l u t i o n of
provocative in n e r conflicts a n d in this w a y
achieve results beyond th e profits of s y m p to m
relief.

intensity of h e r feeling s u r p ris e d h e r, a n d th e ir


disch arg e d u r i n g th e r a p y fostered a n a s s u m p
tion of a m o re objective a ttitu d e to w a r d both
th e p ast an d the im m e d ia te crisis event. It m a y
not be possible in all cases, b u t a n a s tu te an d
e m p a th ic th e r a p is t m ay be able to h elp th e p a
tient m a k e im p o r t a n t co nnection s b etw een th e
p ast and p resen t.

Class 3 Patients
T h o s e in w h o m

b o th

s y m p to m s a n d b e

h a v io ra l difficulties a r e connected w ith d eepseated

in tra p sy c h ic

p ro b le m s

th a t

ta k e

the

fo rm of p e rs o n a lity d is tu rb a n c e s a n d i n a p p r o
p r i a te coping m e c h a n ism s m a k e u p th e C la s s 3
classification. Such p a tie n ts h ave fu nctio ned at

Class 2 Patients

least m a r g in a lly u p to th e tim e of th e ir b r e a k


d o w n , w h ich w a s p e r h a p s in itia ted by a n im

T h e chief p ro b le m for C la s s 2 p a tie n ts is not

m e d ia te p r e c ip ita tin g factor. M o s t of th ese p a

a critical s itu atio n th a t h a s o b tr u d e d itself into

ti ents seek h e lp to alleviate th e i r distress or to

th eir lives, bu t r a t h e r m a la d a p tiv e p a tt e r n s of


b ehav ior a n d / o r d is tu rb in g sym pto m s. T h e o b

solve a crisis. S o m e come specifically to achieve


g re a t e r p e rs o n a lity d ev elo p m en t. O n e v a lu

ject h ere is sy m p to m c u re or relief, m o d ifica


tion of destru ctive habits, a n d evolvem ent of
m o re ada p tiv e beh av ioral co nfigu ration s. M u l
tiform tec h n iq u es a re e m p lo y ed for 8 to 20
sessions follow ing eclectic su p p o rtiv e -e d u c a

atio n eith e r th e y a r e de em e d u n s u i ta b l e for


lo n g - te rm t r e a tm e n t, o r extensive t h e r a p y is
believed to be un ne cessary . T h e y often possess
the desire a n d ca p acity to w o r k to w a r d a c q u i r
ing s e lf-u n d e rsta n d in g .

tion al m odels u n d e r the ru b r ic of m a n y term s,


such as s h o r t-te rm b eha vio ra l th e r a p y , s h o r t

T h e goal for C lass 3 p a tie n ts is p e rs o n a lity


reco n s tru ctio n a lo n g w ith sy m p to m a tic a n d b e
h a v io ra l im p ro v e m e n t. T e c h n i q u e s a re usually

te r m reeducative t h e r a p y , a n d so forth.
A p h o b ia to a ir travel exem plifies th e c o m
p lain ts of a class 2 p a tie n t. T h i s w as a g reat
h a n d ic a p for M is s J since job ad v a n c e m e n t

p s y ch o an aly tic ally o rien ted , involving in t e r


v iew ing, co n fr o n ta tio n , d r e a m an d tran sfere nce
in te rp re ta tio n s , an d occasionally the use of a d

necessitated visits to rem o te a reas. T h e o rigin

ju n c tiv e te c h n iq u e s like hypn osis. S o m e t h e r a

32

HANDBO OK OF SHORT-TERM PSYCHOTHERAPY

pists confine the te rm d y n a m ic sh o rt-te rm th er

ou t h e r violent rage. She rea lize d th e n th a t h e r

a p y to this class of p a tie n ts an d often em p lo y a

o b se q u io u s b e h a v io r to w a r d h e r h u s b a n d w as

careful selection process to e lim in ate p a tie n ts


w h o m th ey feel w ou ld n ot w o rk too well w ith

a cover for h e r hostility. A ctin g on th is insight,

th eir

D av an lo o ,

discuss h e r re actio n s w ith h e r h u s b a n d an d the

1978, M a l a n , 1963; Sifneos, 1972; U r s a n o &


D ressie r, 1974).

re a s o n s for h e r rages. T h i s op e n e d u p c h a n n e ls
of c o m m u n ic a tio n w ith a d r a m a ti c res o lu tio n

An e x a m p le of a C la ss 3 p a tie n t is a yo ung
m o t h e r w h o b ro u g h t h e r son in for c o n s u l ta

of h e r s y m p to m s a n d an im p ro v e m e n t in h e r

tion because he w a s gettin g such low m a r k s in

peo ple, con firm e d by a 5 -y e a r follow -up.

tech n iq u es

(B uda,

1972;

she w a s soon a b le to ex p ress h e r a n g e r a n d to

feelings a b o u t h erse lf a n d h e r attitu d e s to w a r d

th e final y e a r of hig h school th a t th e chances


of h is g e t t i n g in to co lle g e w e r e m i n i m a l .
M o r e o v e r, he firm ly a n n o u n c e d his u n w ill in g

Class 4 Patients

ness to go to college, insisting on find in g a job


after g r a d u a t io n so th a t he could bu y a n a u
tom ob ile a n d p u rs u e his tw o hobbies: baseball
an d girls. D u r i n g th e inte rview w ith th e boy it

P a tie n ts of th e C la ss 4 cate go ry a r e those


w h o se p ro b le m s even a n effective th e r a p is t

w a s obvious th a t he h a d m otiv ation n e it h e r for

m a y be u n a b le to m ed ia te in a b rie f sp a n an d
w h o will r e q u i r e m o r e p ro lo n g e d m a n a g e m e n t

f u r th e r college e d u ca tio n n o r for an y k in d of

after th e initial s h o r t-t e rm pe rio d of fo rm a l

t h e r a p e u tic help. It w as a p p a r e n t too th a t his


s tu b b o rn refusal to stu d y a n d to go on to

t h e r a p y h as disclosed w h a t in terv e n tio n s w ou ld

h ig h e r le a r n in g w a s a w a y of fighting off the


d o m in a tio n of his m o t h e r an d step fath e r. Ac

sh o u ld be stressed because n ot all lo n g - te rm


m o da lities need be, an d often a r e not, best

cordingly, the m o t h e r w a s advised to stop n a g


gin g the boy to c o n tin u e his schooling. Instead

vid u als w h o a p p e a r to r e q u i r e help over a n e x

best be indicated. T h e w o r d m a n a g e m e n t

a im ed at in tra p sy c h ic a lte ra tio n s. A m o n g i n d i

she w as u rg ed to p e rm it h im to e x p e ri m e n t
w ith fin din g a jo b so th a t he could learn th e

ten d ed s p a n a r e th ose w h o se p ro b le m s a r e so

va lue of a d o lla r a n d to discover for h im se lf the

for th e m is to keep th e m in re a s o n a b le reality

k ind s of positions he could get w ith so little


education.

f u n c t i o n i n g , w h i c h t h e y c o u ld n o t a c h ie v e

severe a n d dee p -ro o ted th a t all t h e r a p y can do

w ith o u t a p ro lo n g e d th e r a p e u ti c resource.

T h e nex t d ay th e m o th e r tele p h o n e d a n d r e
p o rted th a t she h a d
instru ction s. H o w e v e r,
p o in tm e n t for herself
tense an d suffered from

followed th e d o c to r s
she asked for a n a p
since she w a s overly
bad b ackaches th a t her

C la ss 4 p a tie n ts includ e th e following:


1. I n d i v id u a ls w i t h c h r o n i c p sy c h o tic r e a c t i o n s
a n d psy c h o ses in r e m i s s io n w h o r e q u i r e s o m e s u p e r
v isory i n d i v i d u a l o r g r o u p w i t h w h o m co n t a c t is

o rth o p e d ist claim ed w ere d u e to n e rv e s .


W h a t she w a n te d w a s to learn self-hypnosis,
w hich h e r d o c to r claim ed w o u ld h elp he r
relax . A bidin g by h e r re q u e s t, she w a s ta u g h t

r e g u l a r l y m a d e o v er su fficiently sp a ced in t e r v a l s to

self-hypnosis not only for re la x a tio n p u r


poses, but also to d e te r m in e th e sources of h er

a n d to s u d u e t h e p e r i l s o f p sy c h o tic p ro cess es w h e n

tension. T h r o u g h in terv ie w in g aid ed by in


duced im a g e ry d u r i n g hyp n osis, she w a s able
to recognize h o w a n g r y she w a s at m e for not
satisfying h e r desire to force h e r son to go to
college. Im ag es of a tta c k in g h e r fath er, w h o
fr u s tr a te d an d d o m in a te d her, soon b r o u g h t

provide
ever

som e

tenuous

k in d of h u m a n
t h is

psychotropic d ru g

may

be,

relationship,
to

o versee

how

essential

i n t a k e , to r e g u l a t e t h e m ilieu ,

th e s e a r e p e r i o d i c a l l y release d . S u c h p a t i e n t s d o no t
u s u a l ly r e q u i r e f o rm a l p r o l o n g e d p s y c h o t h e r a p y o r
r e g u l a r se ssio ns w i t h a p s y c h o t h e r a p i s t ; th ey co uld
do

as

w ell,

or

better,

w ith

paraprofessional

counselor. M ilie u th e ra p y , r e h a b ilita tio n p ro ce


d u r e s , a n d social o r g r o u p a p p r o a c h e s m a y be h e l p
ful.
2. P e r s o n s w i t h se rio u s c h a r a c t e r p r o b l e m s w i t h

CRITERIA OF SELECTION

33

ten d en cies t o w a r d a l c o h o lism a n d d r u g ad d ictio n


w h o r e q u i r e r e g u l a r g u i d a n c e , s u r v e illa n c e , g r o u p
a p p r o a c h e s , a n d r e h a b i l i ta t iv e services ov er a n i n
d efin ite p erio d.

8. P a r a n o i d a l p e r s o n a l i t i e s w h o r e q u i r e a n i n c o r
r u p t i b l e a u t h o r i t y for r e a l i t y testin g .
9. I n d i v i d u a l s w i t h s e v e r e l o n g - s t a n d i n g p s y
c h o s o m a t ic a n d h y p o c h o n d r i c a l c o n d i t i o n s , s u c h as

3. I n d i v i d u a l s w i t h u n c o n t r o l l a b l e t e n d e n c i e s

u lc e r a tiv e colitis, o r c h r o n i c p a i n s y n d r o m e s t h a t

t o w a r d a c t i n g - o u t w h o n eed c o n t r o l s f ro m w i t h o u t

h a v e re sisted m i n i s t r a t i o n s f r o m m e d ic a l, p s y c h o

to r e s t r a i n t h e m fro m e x p r e s s i n g i m p u l s e s t h a t will

logical, a n d o t h e r h e l p i n g reso u r c e s . O f t e n these

get t h e m in to difficulties. E x a m p l e s a r e th o se w h o

sym ptom s

a r e o ccasion ally d o m i n a t e d by d a n g e r o u s p e r v e r

p sy c h o tic d i s i n t e g r a t i o n .

sions,

d esires

for

violence,

lust

fo r

are

m a n i f e s t a t i o n s of defen se s a g a i n s t

crim in a l

10. P e o p l e p r e s e n t i n g w i t h d e p r e s s i v e d i s o r d e r s

activities, m as o ch istic n eed s to h u r t th e m se lv e s, a c

w h o a r e in d a n g e r of a t t e m p t i n g su ic id e a n d r e q u i r e

cid en t p r o n e n e s s , se lf- d efeatin g g a m b l i n g , a n d o t h e r

c a r e f u l r e g u l a t i o n of a n t i d e p r e s s i v e m e d i c a t i o n s or

c o r r u p t i o n s . M a n y s u c h p e r s o n s r e c o g n i z e t h a t th ey

e l ectr o co n v u lsiv e t h e r a p y follo w ed by p s y c h o t h e r a p y

n eed c u r b s on t h e i r u n c o n t r o l l a b l e w a y w a r d desires .

u n t i l t h e risk o f a r e l a p s e is over.

4. P e r s o n s so t r a u m a t i z e d a n d fix ated in t h e i r d e
v e l o p m e n t t h a t th ey h a v e n e v e r o v e r c o m e in f a n tile
a n d child ish need s a n d defenses t h a t c o n t r a v e n e a

Class 5 Patients

m a t u r e a d a p t a t i o n . F o r in stan c e, t h e r e m a y be a
c o n s t a n t e n t r a p m e n t in r e l a t i o n s h i p s w i t h s u r r o g a t e
p a r e n t a l figure s, w h i c h u s u a l ly evolve for b o th s u b
j e c t s a n d hosts into a s a d o -m a s o c h i s t i c p u r g a t o r y .
Yet su ch

p e r s o n s c a n n o t f u n c tio n w i t h o u t a d e

In C lass 5 w e p lace th ose in d iv id u als w h o


seek an d r e q u i r e extensive re con stru ctiv e p e r
son ality c h a n g e s an d h ave th e finances, tim e,

p a r e n t a l ag ency .

fo rb e a ra n c e , a n d ego s tre n g th to to le ra te lo n g
te r m p sy ch o an aly sis o r p sy ch o an aly tically

S o m e of th ese p a t i e n t s m a y need a d e p e n d e n c y s u p

o rie n te d p s y c h o th e ra p y . In a d d itio n , th ey have

p o r t t h e r e m a i n d e r of t h e i r lives.
M a n y of t h e p a t i e n t s in th is c a t e g o r y fall into

h a d th e good f o r tu n e of fi n d in g a w e ll-tra in ed ,
ex p e rie n c ed , a n d m a t u r e a n a ly s t w h o is c a p a

devastating fru s tra tin g d ep endency relatio n sh ip s

ble of d ealin g w ith d e p e n d e n t tr a n sferen ce an d

during

o th e r resistan ces as well as w ith o n e s p e rs o n a l


c o u n tertra n sferen ces . P a tie n ts w h o can benefit

p e n d e n c y p r o p , a n d t h e t h e r a p i s t offers h i m s e l f as a
m o r e ob jective a n d

therapy

or

nonpunitive

alternatives

to

therapy

fro m

w h ic h th ey c a n n o t o r will n o t e x t r i c a t e th em se lv e s.
R e a l iz in g t h e d a n g e r s of t h is c o n t i n g e n c y , w e can ,
how ever,

plan

our

st r a t e g y

accordingly,

for e x

a m p l e , by p r o v i d in g s u p p o r t i v e p r o p s o u t s i d e of t h e
t r e a t m e n t si t u a t i o n if s u p p o r t is ne e d e d . N o r need
w e a b a n d o n r e c o n str u c tiv e ob jectives, o n ce w e m a k e
p r o p e r a l l o w a n c e s for p ossible regre ssiv e i n te r lu d e s.
In f o l lo w -u p con tacts, I w a s p l e a s e d to find , t h e r e
h a d b een c h a n g e af ter 5, 10, a n d i n s o m e cases 15
y e a r s in p a t i e n t s w h o I believed h a d little c h a n c e to
achieve p e r s o n a l i t y c h an ge.
5. P e r s o n s

w ith

persistent

and

u n c o n t r o l la b le

a n x i e t y r e a c t i o n s p o w e r e d (a) by u n c o n s c i o u s c o n
flicts of long s t a n d i n g w i t h

e x is tin g d efense s so

f ragile t h a t t h e p a t i e n t is u n a b l e to c op e w i t h o r
d i n a r y d e m a n d s of life o r (b) by a n o x i o u s a n d i r r e
m e d i a b l e e n v i r o n m e n t from w h i c h t h e p a t i e n t c a n
no t escape.
6. B o r d e r l i n e p a t i e n t s b a l a n c e d p r e c a r i o u s l y o n a
r a z o r edge of r a t i o n a l it y .
7. I n t r a c t a b l e o b s e s s iv e - c o m p u l s i v e p e r s o n s
w h o s e re a c t i o n s se rv e as defenses a g a i n s t psychosis.

m o r e from lo n g - te rm reco nstru ctiv e th e r a p y


th a n from d y n a m ic a lly o rie n te d s h o r t-te rm
t h e r a p y a r e often b u rd e n e d by in terfe rin g ex
te r n a l cond itio ns th a t m a y be so stro n g , or by
th e press o f in n e r neu ro tic needs so intense,
th a t th ey c a n n o t proceed o n th e i r o w n t o w a r d
t r e a tm e n t objectives after th e s h o r t-t e rm t h e r a
peu tic p erio d h a s ended. C o n t i n u i n g m o n i to r
ing by a th e r a p is t is essential to p re v e n t a r e
la p s e . In c e r t a i n c ases t h e c h a r a c t e r o l o g i c
d e ta c h m e n t is so g reat th a t th e p a tie n t is u n a
ble to establish close a n d t r u s ti n g contact w ith
a th e r a p is t in a b rief p eriod , a n d a c o n sid e ra
ble b u lk of tim e d u r i n g th e s h o r t- t e r m sessions
m a y be occupied w ith e sta b lish in g a w o rk re la
tion sh ip.
A special g r o u p of p a tie n ts r e q u i r in g lon g
te r m t h e r a p y a r e high ly d is tu rb e d c h ild re n a nd
adolescents w h o h ave been s tu n te d in the

34

HANDBOOK OF SHORT-TERM PSYCHOTHERAPY

process of p e rs o n a lity d eve lop m e nt and w h o

ally con stitu te less th a n o n e - q u a r t e r of the p a

re q u i re a c o n tin u in g rela tio n sh ip w ith a t h e r a


pist w h o functions as a g uid in g , e d u c a tio n a l,

tien t load c a rr ie d by the av e rag e p s y c h o t h e r a


pist. T h e b u lk of o n e s prac tice will g e n e rally

benevolent p a r e n t a l figure.
L o n g -te r m p a tie n ts in C lasses 4 an d 5 u s u

be com po sed of p a tie n ts w h o m a y a d e q u a t e ly


be m a n a g e d by s h o r t-t e rm m ethods.

Conclusion
If we a re p ra g m a tic a lly disposed to tr e a t as
m a n y p a tie n ts as possible for econom ic or

em o tio n a l p ro b le m s c an w ith efficient s h o r t


te r m m e th o d s achieve satisfactory resu lts an d

o th e r reasons, we m ay say th a t all p a tie n ts i r


r e s p e c ti v e o f d i a g n o s i s , a n d s e v e r ity a n d

m a y even go on by them selves, w ith th e l e a r n


ings th ey h ave a c q u ir e d , to a tt a in som e d eg ree

chro nicity of p ro b le m s a r e p o te n tia l c an d id a tes

of p e rs o n a lity g ro w th . A few m a y re q u i r e an

for s h o r t-te rm th e r a p y . S h o u ld a n y p a tie n ts


fail to resp o n d to a b b re v iated m eth od s, w e can

ad d itio n a l visit o r tw o from tim e to tim e to r e

alw a y s con tin u e tr e a tm e n t, h avin g ac q u ir e d in


valu ab le in fo rm atio n d u r i n g th e s h o r t-t e rm ef
fort as to w h a t inte rve ntio ns w ou ld best be in
dicated for th e i r pro b lem s. Even w h e r e th e
yardstick of cost effectiveness is n ot p a r a m o u n t ,
th e m a jo rity of in dividuals w h o seek h elp for

solve som e p ro b le m s th a t they a re u n a b le to


h a n d le by them selves. T h e y t h u s will have
been able t h r o u g h a practical b rief th e r a p e u ti c
a p p r o a c h to h ave been s p a r e d th e expense,
inconvenience, a n d in som e cases th e d a n g e rs
of lo n g - te rm th e r a p y .

CHAPTER 4

A General Outline of
Short-term Therapy
T h e r e obviously a re differences a m o n g t h e r

w o r k in g r e l a ti o n s h ip w ith a p a tie n t. E m p a t h y

apists in the w a y th a t s h o r t-t e rm t h e r a p y is


im p le m e n te d for e x am p le, th e focal a re a s

p a r t i c u l a r l y is a n i n d i s p e n s i b l e p e r s o n a l i t y
q u a li ty th a t h elp s to solidify a good t h e r a p e u ti c

chosen for atte n tio n a n d e x p lo r a tio n , th e r e l a

alliance.

tive e m p h a s is on c u r r e n t as c o m p a r e d to past

G e n e ra ll y , at th e initial in terv iew , the p a

issues, the a tte n tio n paid to tr an sferen ce , the

tient is greeted c ou rte ou sly by n a m e , th e t h e r a

w a y resistance is h a n d le d , th e d e p th of p r o b

pist in tro d u c in g h im self as in this excerpt:

ing, the d ealin g w ith un con sciou s m a te ria l th a t


surfaces, th e precise m a n n e r of in t e r p r e ta ti o n ,

T h . How

do

y ou

do,

W o n t

M r.
you

R oberts,
sit

down

I am
o v er

D r.

the degree of activity, the a m o u n t of advice giv

W olberg.

there

ing, the kinds of in terv en tio n s a n d ad jun ctiv e


devices em p lo yed , a n d the p rescrib ed n u m b e r

a n d I ll see w h a t I can d o to h e l p y o u (p a tie n t

(p o in ti n g to a c h a ir ), a n d w e 'l l t a l k t h i n g s over
g e ts se a te d ).

of sessions. M o r e o v e r, all t h e r a p is t s have to

P t.

T h a n k yo u , d o c to r , (p a u se)

deal w ith th eir o w n p erso nalities, pre jud ices,


th eoretical biases, an d skills, all of w h ich will

A d etac h ed d e a d p a n pro fession al a ttitu d e is

influence th e w a y they w o rk . In spite of such


differences, th e r e a re ce rta in basic principles

p a r t ic u l a r ly fatal. It m ay , by eliciting p o w erfu l


feelings of rejection, pro v o k e protective d efen

t h a t have evolved from th e exp erien ces of a


w ide a s s o rtm e n t of th e r a p is ts w o rk in g w ith

e s ta b lish in g a w o r k in g r e la tio n sh ip .

sive m a n e u v e rs th a t n e u tr a li z e efforts to w a rd

diverse p a tie n t p o p u la tio n s th a t h av e p ro d u ce d


good results. T h e p r a c t it io n e r m ay find he can

It is difficult, of course, to d e lin eate exact


ru le s a b o u t h o w a th e r a p e u ti c allian ce m a y be
establish ed ra p id ly . E a c h th e r a p is t will utilize

a d a p t at least some of these p rin cip les to his


o w n style of o p e ra tio n even th o u g h he co n

him self u n iq u e ly to w a r d th is end in te r m s of

tinu es to em p lo y m eth o d s th a t have p rov en

his o w n tec h n iq u e s a n d cap acities for r a p p o r t.

them selves to be effective w ith his p a tie n ts and

Some

a re not exactly in accord w ith w h a t o th e r p r o


fessionals do. In th e p ages th a t follow 20 te c h

ab ility even d u r i n g th e first session, as th e p a


tient describes his p ro b le m a n d associated feel
ings, of p u tt in g the p a tie n t at ease, of m o b iliz

n iq u es are suggested as a g en eral gu ide for


sh o r t-te rm th e r a p y .

th erap ists

p o ss e ss

an

ex trao rd in ary

ing his faith in the effectiveness of m eth o d s th a t


will be utilized, a n d of s u b d u i n g th e p a t i e n t s
d o u b ts an d concerns. A confident en th u s ia stic
m a n n e r an d a conviction of o n e s ability to
h elp so m e h o w c o m m u n ic a te s itself no n v e rb ally

Establish as Rapidly as Possible a


Positive W orking Relationship
(Therapeutic Alliance)

to the p a tie n t. T h e r a p i s t e n th u s ia s m is an im
p o r t a n t in g red ien t in tr e a tm e n t.
T h e follow ing suggestions m a y p ro ve h e lp
ful:

A n a tm o s p h e re of w a r m t h , u n d e rs ta n d in g ,
an d acceptance is basic to achiev ing as positive

35

36

HANDBO OK OF SHORT-TERM PSYCHOTHERAPY


V erbalize w h a t the p a tie n t m a y be fe e lin g

y ou rself, I see n o r e a s o n w h y y o u c a n t get

P u tt in g into w o rd s for th e p a tie n t w h a t he

b etter.

m ust be feeling bu t is u n a b le to con cep tua lize


is o ne of th e m ost effective m e a n s of esta b lish

W h e r e th e p a tie n t becom es self-d eprecatory

ing contact. R e a d in g betw ee n the lin e s of

a n d m asochistic, the positive aspects of his


re a ctio n s m a y be stressed. F o r e x am p le, should

w h a t th e p a tie n t is ta lk in g a b o u t will yield i n


terestin g clues. Such sim ple s ta te m e n ts as,
You m u s t be very u n h a p p y an d upset a b o u t
w h a t has h a p p e n e d to y o u o r I can u n d e r

he say he is co n stan tly fu riou s, one m ig ht


rep ly , T h i s indicates th a t you a re ca p a b le of
feeling stro n g ly a b o u t th i n g s . If he says he

s ta n d h ow u n h a p p y an d up set you m u s t be

de tac h es a n d does not feel a n y th i n g , the a n

u n d e r the c ir c u m sta n c e s p re sen t th e th e r a p ist

sw e r m a y be, T h i s is a sign y o u a r e tr y in g to

as an e m p a th ic person.

p r o t e c t y o u r s e l f fr o m h u r t i n g . C o m m e n t s

E ncourage the p a tie n t th a t his situ ation is

such as th ese a r e inte n d ed to be protective in


o r d e r to p rese rv e th e r e l a ti o n s h ip w ith th e

n ot hopeless

th e r a p is t. L a t e r w h e n it becomes a p p a r e n t th a t

It is s o m e t i m e s a p p a r e n t t h a t , d e s p i t e
p re s e n tin g h im self for h elp, th e p a tie n t is co n
vinced th a t he is hopeless a n d th a t little will

th e re la tio n s h ip is sufficiently solid, the t h e r a

actually be accom plished from th e r a p y . W h e r e

p is ts c o m m e n ts m a y be m o r e provocative a n d
c h a l l e n g i n g . T h e p a t i e n t s d e fe n s e s b e in g
th r e a te n e d , a n x ie ty m a y be mobilized, b u t th e

p r o b a b ly feel th a t y o u r s itu atio n is hop eless be

p a ti e n t will be su s ta in e d by th e th e r a p e u ti c
allian ce a n d he will begin to u tilize it r a t h e r

cause you have a lr e a d y tried v ariou s th in gs

th a n r u n a w a y fro m it.

the th e r a p is t suspects this, he m a y say. You

th a t h a v e n t been effective. B u t th e r e are th in gs


th a t can be do ne, th a t you can do a b o u t y ou r
situa tio n an d I shall gu ide you to w a r d m a k i n g
an effort. E m p a t h i z i n g w ith th e p a tie n t m ay
be im p o rt a n t: P u tt in g myself in y o u r p o si
tion, I can see th a t you m u st be very u n h a p p y
a n d upset a b o u t w h a t is h a p p e n in g to y o u .
S om etim es it is useful to define the p a t i e n t s
role in d eveloping a n d su s ta in in g his p ro b le m
in a n o n acc u sin g w a y: You p ro b a b ly felt you
h a d no o th e r a lte rn a tiv e t h a n to do w h a t you
d i d . W h a t y o u a r e d o i n g n o w seem s
r e a s o n a b le to you, bu t th e r e m a y be o th e r
w ay s th a t could create few er p ro b le m s for
y o u .
W h il e no p ro m ise is m a d e of a cu re, the
th e r a p ist m u s t convey a n a ttitu d e of conviction
a n d faith in w h a t he is doing.

Deal With Initial Resistances


Among

th e

resistan ces

com m o n ly

en

c o u n tered at the first session a re lack of m o ti


vation a n d d is a p p o in t m e n t th a t th e th e r a p is t
does not fulfill a stereotype. T h e t h e r a p i s t s
age, race, n a tio n a lity , sex, a p p e a r a n c e , profes
sional discipline, a n d religion m a y not c o rr e
sp o n d w ith the p a t i e n t s ideas of so m eo n e in
w h o m he w a n ts to confide.

T h . I n o tice t h a t it is difficult for you to tell m e


a bout your problem .
P t.

( O b v io u s ly in d isc o m fo rt) I d o n t k n o w w h a t
to say . I ex p e c te d t h a t I w o u l d see a n o ld e r
p e r s o n . H a v e y ou h a d m u c h e x p e r i e n c e w ith
cases like m e ?

P t.

I feel h o p eles s a b o u t g e t t i n g w ell.

D o you

t h i n k I c a n get ov er th i s t r o u b l e of m i n e ?

T h . D o you re a lly h a v e a d es ire to get o ver this

T h . W h a t c o n c e r n s yo u is a f ear t h a t I d o n t h av e
as m u c h e x p e r i e n c e as y o u believ e is n eces sa ry
a n d t h a t a n o ld e r p e r s o n w o u l d do a b e t t e r j o b .

t r o u b l e ? If you re a lly do, this is n i n e - t e n t h s of

I c a n u n d e r s t a n d h o w y o u feel, a n d y o u m a y

t h e b attle. Y o u will w a n t to a p p l y y o u r s e l f to

do b e t t e r w i t h a n o ld e r p e r s o n . H o w e v e r , s u p

t h e j o b of g e t t i n g well. I will p o i n t o u t som e

p o s i n g you tell m e a b o u t y o u r p r o b l e m a n d t h e n

t h i n g s y ou can do, a n d if y o u w o r k a t th e m

if y o u w i s h I will refe r you to t h e best o l d e r

37

GENERAL OUTLINE OF SHORT-TERM THERAPY


t h e r a p i s t w h o c a n t r e a t t h e k i n d of co n d itio n

p r o b l e m s y ou h a v e t h a t a r e c a u s i n g te n s io n ,

y o u hav e.

a n d also lift t h e ten s io n. T h i s s h o u l d h e l p y o u r


pain.

T h i s tactic of acceptin g th e resistan ce a n d

P t.

I w o u l d like t h a t . I get te n s e in m y j o b w i t h
t h e p e o p l e I w o r k . S o m e of t h e m a r e c r u m b s .

inviting th e p a ti e n t to tell you m o re a b o u t


him self can be a p p lie d to o th e r stereoty pes

[.P a tie n t g o e s on ta lk in g , o p e n in g u p p o c k e ts o f
a n x ie ty .]

besides age. In a w ell-con du cted inte rview the


th e r a p is t will reveal him self o r herself as an
e m p a th ic u n d e r s ta n d in g p e rs o n , an d the p a
tient will w a n t to c o n tin u e w ith h im or h e r in
th erap y .
A n o th e r co m m o n form of resistan ce occurs
in th e perso n w ith a psych oso m atic p ro b le m
w h o has been referred for p sy c h o th e ra p y an d
w h o is not at all convinced th a t a psychological
p ro b le m exists. In such cases th e th e r a p is t m a y
proceed as in this excerpt.

P t.

tim e being. A ctu ally, as h a s been in dicated , it


m a y be a n essential a d a p ta tio n a l sy m p to m , the
p a ti e n t n eed in g it to m a i n ta i n a n e q u il ib r iu m .
D e a lin g w ith a r e a s of ten sio n u su a lly will h elp
relieve the s y m p to m , a n d as p sy c h o th e ra p y
tak es hold, it m a y m a k e it u n n e c e ss a ry to use
th e sy m p to m to preserv e psychological h o m e o
stasis.
M o tiv a t io n a l lack m a y o b stru c t t h e r a p y in

D r . J o n e s se nt m e h ere. I h a v e a p r o b l e m w ith

o th e r s itu a tio n s, as w h e n a p a tie n t does not

s t o m a c h a c h e s a lo n g t i m e a n d h a v e been se eing

come to t r e a t m e n t on his o w n accord b u t is

d o c to r s for it for a lo ng tim e.

T h . As yo u k n o w , I a m a p s y c h i a t ri s t. W h a t m a k e s
y ou feel y o u r p r o b l e m is p sy c h o lo g ic a l?
P t.

T h e object is to accept th e phy sical condition


as it is an d not label it psychological for the

1 d o n t t h i n k it is, b u t D r . J o n e s says it m ig h t

sent or b r o u g h t by relatives o r c o n cern ed


p a rtie s. A d d itio n a l e x a m p le s a r e ch ild re n or
adolescents

w ith

b e h a v io r

p ro b le m s,

p eo p le

w h o a r e ad d icted (drug , alcohol, food, g a m

be, a n d he sent m e here.

Th . D o you t h i n k it is?

bling), a n d p eo p le receiving p e n sion s for p h y s i

P t.

cal disabilities. C a s e 1 in C h a p t e r 6 illustrate s


the m a n a g e m e n t of a n o n m o tiv a te d a d o le s

N o , I c a n t see h o w this p a i n c o m es f ro m m y
head .

Th . W e l l , it m ig h t be o r g a n i c , b u t w i t h s o m e o n e

cent.

M o r e on h a n d li n g lack of m otiv atio n

w h o h a s suffered as lo n g as y o u h a v e t h e p a i n

is

will cause a go od de al of t e n s io n a n d u pset.

458-470).

detailed

elsew he re

(W o lb e rg ,

1977,

pp.

[T o in sist on th e id ea th a t th e p r o b le m is p s y
ch o lo g ica l w o u ld be a p o o r tactic. F irst, th e
th e r a p is t m a y be w r o n g , a n d th e co n d itio n
m ay

be

o r g a n ic

p r e s e n t- d a y

th o u g h

u n d e te c ta b le

tests a n d e x a m in a tio n s .

by

S eco n d ,

Gather Historical Material and


Other Data

th e p a tie n t m a y n e e d to re ta in h is n o tio n o f th e
s y m p t o m s o r g a n ic ity a n d even to be a b le to
e x p e r ie n c e a tte n u a te d p a in fr o m tim e to tim e
a s a d e fe n s e a g a in st o v e r w h e lm in g a n x ie ty or,
in certa in se rio u s c o n d itio n s, p s y c h o s is . )
P t.

It s u r e does.

T h . A n d t h e te n s io n a n d d e p r e s s i o n p r e v e n t t h e
st o m a c h f ro m h e a lin g . T e n s i o n i n ter fer es w i t h
h e a l i n g of even t r u e p h y sic al p r o b l e m s . N o w
w h e n you re d u c e te n s io n , it h e l p s t h e h e a lin g .
It m i g h t h e l p y o u even if y o u r p r o b l e m is o r
ganic.
P t.

I h o p e so.

T h . So w h a t w e can do is try to f i g u re o u t w h a t

T h r o u g h sy m p a th e tic lis te n in g the p a


tien t is allow ed to tell his story w ith as little
i n t e r r u p t io n as possible, th e th e r a p is t in t e r p o
latin g q u estio n s a n d c o m m e n ts th a t in dicate a
c o m p a s sio n a te u n d e r s ta n d in g of th e p a t i e n t s
situ atio n. T h e d a ta g a th e r e d in the in itial in
terv iew sho uld ho pefu lly p e r m it a ten tativ e
diag no sis a n d a n o tio n of th e etiology a n d p o s
sibly th e p sy ch o d y n am ics. S h o u ld th e p atie n t
not b ri n g th e m a t t e r u p , he m a y be asked w h a t
he considers his most i m p o r t a n t p ro b l e m to
be? W h y h a s he come to tr e a tm e n t at this

38

HANDBO OK OF SHORT-TERM PSYCHOTHERAPY

tim e? W h a t has he do ne a b o u t the p ro b le m to

ou t scoring. T h i s is o p tio n a l, of course. T h e


th e r a p is t does not hav e to be a clinical p s y c h o l

d a te ? H a s he him self arriv ed at a n y idea as to


w h a t is c a u sin g his difficulty? W h a t does
he expect o r w h a t w o uld he like to get from

ogist to do this, bu t he o r she sh o u ld h ave read


som e m a te ria l on the R o rsc h a ch . T h e p a tie n t

th e r a p y ?

m a y also be given a sheet of p a p e r a n d a pencil

It is often a d v a n ta g e o u s to follow an o u t

a n d be asked to d r a w a p ic tu re of a m a n an d a

line* in o rd e r to do as co m plete a histo ry o r

w o m a n . Som e th e r a p is ts p refer s h o w in g the

be hav ioral analy sis as possible d u r i n g the first

p a tie n t

r a p id ly

session o r tw o. T h i s m a y necessitate i n t e r r u p t

Cards.

W hat

ing th e p a tie n t after the th e r a p is t is convinced

t i e n t s respo nses a n d d r a w in g s ? C a n o ne c o r
re la te these w ith w h a t is h a p p e n i n g s y m p to

t h a t he has o b ta in e d sufficient helpful d a ta


a b o u t a n y one topic.
A m o n g the q u e stio n s to be exp lo re d a r e the
following:
1. H a v e t h e r e been p r e v io u s u p s e t s t h a t r e se m b le
t h e p r e s e n t o ne?
2. W e r e t h e p r e c i p i t a t i n g e v e n t s o f p r e v i o u s
3. W h a t m e a s u r e s a g g r a v a t e d t h e p r e v i o u s u pse ts

are

from

the

m ost

h elp is s o u g h t ,

being experienced

depression,

A p p e rc e p tio n

m atic ally ? T h e s e tests a r e no su b stitu tes for


e s s e n tia l p s y c h o l o g ic a l te s ts w h e r e n e e d e d ,
w h ic h can best be d o n e by a n ex p erien ced c lin
ical psychologist. B u t th e y c an fulfill a useful
p u r p o s e in p ic k in g u p gross defects in the

p hy sic al

im p o rtan t

problem

w h at other sym ptom s

(su ch as te n s io n , a n x i e t y ,

sym ptom s,

se x u al

p o t e n t i a l i t i e s , p a r a n o i d a l te n d e n c i e s , d e
pressive m an ifesta tio n s, a n d so on. N o m o re
t h a n 10 o r 15 m in u te s sh o u ld be utilized for

a n d w h i c h alleviated t h e s y m p t o m s ?
4. A p a r t

T h em atic

th i n k in g p rocess, b o rd e r lin e o r sch iz o p h re n ic

u p se ts in a n y w a y s i m i l a r to t h e r ecen t o n e s ?

for w h i c h

th e

d is to rtio n s a p p e a r in th e p a

problem s,

p h o b i a s , obse ss io ns, i n s o m n i a , excessive d r i n k i n g ?


5. W h a t t r a n q u i l i z e r s , e n e r g i z e r s , h y p n o t i c s , a n d
o t h e r m e d i c a t i o n s a r e b e in g t a k e n ?

Statistical d a ta a re r a p id ly recorded (age,


e d u catio n , o c cu p atio n , m a r ita l statu s, how
long m a r r ie d , a n d ch ild ren if any). W h a t w as
(an d is) the p a t i e n t s m o th e r like? T h e f a th e r?
A n y p ro b le m s w ith b ro th e rs o r sisters? W e r e
th ere a n y p ro b le m s ex perienced as a child (at
hom e, at school, w ith h e a lth , in re la tio n sh ip s
w ith o th e r ch ild re n )? A ny p ro b le m s in sexual
d eve lop m e nt, c a re e r choice, o c c u p a tio n a l a d
ju s tm e n t? C a n th e p a tie n t re m e m b e r any
d re a m s , especially n ig h t m a r is h an d repetitiv e
d re a m s ? W e r e th ere previo us psychological or
psych iatric tr e a tm e n ts ?
T o o b ta in f u r th e r d a ta , th e p a ti e n t m a y be
exposed to the R orsc hach card s, gettin g a few
resp on ses to th ese u n s tr u c tu r e d m a te ria ls w i t h

this p u rp o s e .
An e x a m p l e of ho w R o rsc h a c h c ard s can
help reveal u n d e rl y in g im p u ls e s no t b r o u g h t
out by r e g u l a r in te rv ie w in g m e th o d s is illu s
tr a te d in a severely d ep re sse d m a n w ith a co n
trolled, o bsessional c h a ra c t e r w h o se passivity
a n d in a b ility to ex p ress aggression re s u lte d in
o th e rs ta k in g a d v a n ta g e of h im at w o r k a n d in
his m a r r ia g e . W h e n q u estio n ed a b o u t feelings
of hostility o r agg ressio n, he d enied th ese w ith
som e pride. T h e follow ing w e re his resp on ses
to th e R o rs c h a c h C a rd s.

1. T w o t h i n g s flyin g a t each o t h e r .
2. S o m e t h i n g sa i li n g i n t o so m e th i n g .
3. T w o

fig u res

pulling

som e thing

apart;

tw o

adults pulling tw o infants a p a rt.


4. A n i m a l s fu r s p r e a d o u t. X - r a y (d ro p s ca rd )
5. F l y i n g in sect, su r g ic a l i n s t r u m e n t , forcepts.
6. A n i m a l o r insect sp lit a n d f la tte n e d out.
7. X - r a y

fluo ro sco p e of e m b ry o ;

ado lescen ts

l o o k i n g a t e a c h o t h e r w i t h t h e i r h a i r w h i p p i n g u p in
th e w in d .
8. T w o

a n i m a l s c l i m b i n g a tree, o n e o n each

side; fe m a le o r g a n s in all of th e s e c a r d s.
* F u r t h e r details on history ta k in g a n d conve nient a p p r o p r i a t e f o r m s m a y b e f o u n d in W o l b e r g , 1 9 7 7 , p p . 401
4 0 9 ,1 1 7 6 -1 1 7 8 .

9. F o u n t a i n t h a t goes u p a n d s p i l l i n g blo od.


10. U n d e r w a t e r sc ene, fish s w i m m i n g , c r a b s , I n
side of a w o m a n s body.

39

GENERAL OUTLINE OF SHORT-TERM THERAPY


T h e conflicts re lated to aggression a n d being

E x a m p le /. A sy m p to m a tic fo cu s

to rn a p a r t so a p p a r e n t in th e re spo nses becam e


a p rin cip a l th e r a p e u tic focus a n d b ro u g h t forth

T h . I get t h e i m p r e s s io n t h a t w h a t b o t h e r s you
m o st is te n s io n a n d a n x i e t y t h a t m a k e s it h a r d

his repressed a n g e r at his m o th er.

for y o u to get a lo n g . Is it y o u r fe eling t h a t w e


s h o u l d w o r k t o w a r d e l i m i n a t i n g th ese?
P t.

Select the Symptoms, Behavioral


Difficulties, or Conflicts that You
Feel are Most Amenable for
Improvement

Yes. Yes, if I c o u ld get rid o f feelin g so u p se t, I


w o u l d be m o r e h a p p y . I m so i r r i t a b l e a n d
j u m p y a b o u t everything.

E x a m p le 2. A fo cu s on a p re c ip ita tin g even t

T h . W h a t you a r e c o m p l a i n i n g m o st a b o u t is a
se nse of h o p e le s sn e s s a n d d e p r e s s i o n .

T h e selection w ith the p a tie n t of a n i m p o r


ta n t p ro b le m a r e a o r a d is tu rb i n g s y m p to m on
w h ich to w o rk is for th e p u rp o s e of av oid ing

If w e

fo cuse d on these a n d w o r k e d t o w a r d e l i m i n a t
in g t h e m , w o u l d y o u a g r e e ?
P t.

I s h o u l d say so, b u t I w o u l d also like to see

excursions into reg ion s th a t , w h ile p e r h a p s

h o w I c o u ld i m p r o v e m y m a r r i a g e . I t s been

ch allenging, will d ilu te a m ean in g fu l effort.

g o i n g d o w n h i l l fast. T h e last fight I h a d w ith

T h u s , w h e n you have decided on w h a t to co n


cen trate, in q u i re of th e p a ti e n t if in his op in io n
these a re w h a t h e w o u ld like to e lim in a te or
c h a n g e . A g r e e m e n t is i m p o r t a n t t h a t th is
chosen are a is significant to th e p a tie n t a nd

m y h u s b a n d w a s t h e lim it.

T h. W ell, suppose we take u p the p roblem s you are


h a v i n g w i t h y o u r h u s b a n d a n d see h o w th ese
a re connected w ith your sym ptom s.
P t.

I w o u l d like t h a t , d octo r.

w o r th y of c o n c e n tra te d a tte n tio n . If th e p a tie n t


co m p la in s th a t the selection is too limited, he is
assured th a t it is best to move one step at a
time. C o n tr o l li n g a sim p le situ a tio n o r a lle v ia t

E x a m p le 3. A d yn a m ic fo cu s
W h e n e v e r possible the th e r a p is t sh o u ld a t
te m p t to link the p a t i e n t s s y m p to m s a n d c o m

ing a s y m p to m will h e lp s tre n g th e n th e p e r

p la i n ts to u n d e rl y in g factors, th e connections

sonality, a n d p e rm it m ore extensive prog ress.

w ith w h ic h th e p a ti e n t m a y be only dim ly


a w a r e . C a re fu lly p h ra s e d in t e r p r e ta ti o n s will

T h u s the focal difficulty a r o u n d w h ich t h e r


a p y is o rg an iz ed m a y be d ep re s sio n , an x iety ,

be re q u ire d . It m a y not be possible to detect

m a y be a s itu a tio n a l p r e c ip ita tin g factor o r a

basic conflicts in th e first in tervie w , only sec


o n d a r y o r deriv ativ e conflicts being a p p a r e n t .

crisis th a t h a s im posed itself. It m a y be a d is


tu r b in g p a tt e rn o r som e le a r n e d a b e r r a ti o n . It

th e r a p is t all th e facts d u e to resistance, guilt,

m a y be a pervasive difficulty in re la tin g o r in

o r an xiety. O r facts m a y be defensively dis

fu nctioning. O r it m a y be a conflict of w hich


the p a tie n t is a w a r e or only p a rtia lly a w a re .
O n c e a g re e m e n t is reac h e d on th e a r e a of
focus, the th e r a p is t m a y succinctly su m u p
w h a t is to be done.

torted . It is often helpful (w ith the p erm iss io n


of th e p a tie n t) to in terv iew , if possible, the
spouse or a n o t h e r in divid ua l w ith w h o m the

tension, o r som atic m a n ifesta tio n s of tension . It

T h . N o w t h a t w e h a v e d ecided to focu s on the


p r o b l e m \d esig n a te] t h a t u p s e t s you , w h a t w e
will

do is try to u n d e r s t a n d

what

it is all

a b o u t , h o w it st a r t e d , w h a t it m e a n s , w h y it
c o n tin u e s . T h e n w e ll e s t a b l is h a p l a n to do
s o m e th i n g a b o u t it.

M o r e o v e r, th e p a tie n t m a y not h ave given the

p a tie n t is related after th e first o r second in t e r


view. T h e s u p p l e m e n t a r y d a ta o b ta in e d m ay
com p letely ch a n g e th e in itial h y p o th etical
a s s u m p tio n s g lean e d from th e m a te ria l exclu
sively revealed by th e p a tie n t.
N eve rth eless, som e in v a lu a b le o b serv atio n s
m a y be m a d e from th e historical d a ta an d in
terv iew m a te ria l th a t will lend them selves to
in te r p r e ta ti o n for definin g a focus. T h u s a p a

40

HANDBO OK OF SHORT-TERM PSYCHOTHERAPY

tient p res en tin g g rea t inferiority p ro b le m s an d

in

repetitive difficulties in w o rk s itu a tio n s w ith

d is tu rb e d o r rejec ting perso n fro m w h ic h th e

supervisors, w h o as a child fought b itterly w ith

p a ti e n t ca n n o t e x tric a te him self is a n e x a m p le .

an

unsatisfacto ry

relatio n sh ip

w ith

an old er sibling, w a s told the following: It is

It m a y be necessary to e n c o u ra g e c o n tin u in g

possible th a t y o u r presen t a n x ie ty w h ile r e

c on versatio n

lated to ho w you get a lo n g w ith y o u r boss

ask in g po in te d q u e stio n s in the effort to help

touches off tro u b les y o u ve ca rrie d a r o u n d w ith


you for a long tim e. You told m e you a lw ay s

th e p a ti e n t see the re la tio n s h ip b etw een his


sy m p to m s a n d w h a t he m a y h ave considered

felt in ferior to y o u r b ro th e r. In m a n y cases this

u n re l a te d no x io u s events. S h o u ld th e p atie n t

sense of inferiority c on tin ues to b o th e r a p e r

fail to m a k e th e con nections, th e th e r a p is t m a y

son

spell th ese ou t, ask in g p e r t in e n t q u estio n s th a t

in

relation

to

all

kind s of n ew

old er

b rothe rs. It w o u l d n t be m y s te rio u s if this w e re

about

suspected

p re c ip ita n t,

m a y h elp th e p a ti e n t g ra s p th e association.

h a p p e n in g to you. W h a t do you t h i n k ? T h i s
c o m m e n t sta rte d off a p ro d u ctiv e series of
rem iniscences re g a r d in g his exp erien ces w ith

Evolve a W orking Hypothesis

his b ro th e r, a focus on w h ich resulted in con


sid erab le u n d e r s ta n d in g a n d b e tte rm e n t of his

A fter the first session th e th e r a p is t sho uld

c u r r e n t relation ship s.
As has been indicated, m o re f u n d a m e n ta l

h ave g a th e r e d e n o u g h d a ta from th e p rese n t


a n d p a st h isto ry , fro m a n y d r e a m s th a t are

n u c le a r

revealed, a n d from th e g en eral a ttitu d e a n d be

conflicts

may

be

revealed

in

later

sessions (for e x a m p le , in the above p a tie n t an

h a v io r of th e p a tie n t to p u t to g e th e r some

alm ost classical oedipal conflict existed), espe


cially w h e n tra n sferen ce an d resistan ce m a n

f o r m u la tio n a b o u t w h a t is g oin g on. T h i s is

ifest themselves.

e m p lo y in g concepts w ith w h ich th e p a ti e n t h as


som e fa m ilia rity . T h is fo rm u la tio n should

Define the Precipitating Events

a l a r m i n g th e p a tie n t. R a t h e r a concise, r e
s tra in e d , o p tim istic pictu re m a y be p a in te d

p re s en ted to th e p a tie n t in sim p le la n g u ag e ,

never be couched in d is m al term s to avoid

It is essential th a t w e identify clearly the


p re c ip ita tin g factors th a t led to the p a t i e n t s
p rese n t upset o r w h y th e p a tie n t ca m e to t r e a t
m e nt at this time.

w i t h o u t t r o u b le u ntil y o u r d a u g h t e r told you


a b o u t t h e af fa ir she is h a v i n g w i t h t h is m a r r i e d
m a n . D o y ou believe th is s t a r t e d you off on th e
d o w n s li d e ?
D octor,

I c a n t tell y ou the sh o ck th is w a s to

me. J a n i e w a s su ch a n ideal child a n d ne ver


w a s a bit of a p r o b l e m . A n d t h e n t h is t h i n g
happened

S h e s c o m p le te ly

h ypo th esis should

id e a l ly

b rack et th e

im

m ed ia te p re c ip ita tin g agencies w ith w h a t h as


g on e on before in th e life h isto ry a n d , if possi

T h . It se em s as if y o u w e r e m a n a g i n g to get a l o n g

Pt.

m a k i n g this co n tin g e n t on th e p a t i e n t s c o o p e r
a tio n w ith th e t h e r a p e u ti c p la n . Aspects of the

changed, and

ble, ho w th e p a t i e n t s p e rs o n a lity s t ru c tu r e h as
influenced th e w a y th a t he h a s reacted to the
p re c ip ita tin g events.
A w o m a n ex p e rie n c in g a severe a n x ie ty a t
tack revealed th e p r e c ip ita tin g incident of dis
covering h e r h u s b a n d s m a r it a l infidelity. As
she discussed this, she disclosed the pa in fu l
episode of h e r f a t h e r s a b a n d o n in g h e r m o t h e r
for a n o th e r w o m a n .

c a n ' t u n d e r s t a n d it.

T h . Is it p o ss ib le t h a t y o u a r e a f r a id y o u r h u s b a n d
S om etim es th e events a r e obscured o r denied
b e c a u s e th e p a t i e n t h a s a n i n v e s t m e n t in
su sta in in g s itu a tio n a l ir rita n ts even w h ile he
seeks to escape from th eir effects. Involvem ent

will d o to y ou w h a t y o u r f a t h e r d id to y o u r
m other?

Pt.

(b r e a k in g o u t in tea rs) O h , i t s so te r ri b l e . I
s o m e ti m e s t h i n k I c a n t s t a n d it.

GENERAL OUTLINE OF SHORT-TERM THERAPY


Th. S t a n d his l eav ing you o r t h e fact t h a t he h a d

Pt.

I h a d g r e a t p a i n s a n d t r o u b l e fi g h ti n g for m y
r i g h ts w h e n I w a s s m a l l a boss y m o t h e r a n d

a n affa ir ?

Pt.

41

I m e a n if he w o u l d

f a t h e r w h o d i d n t care. I g u e s s I f inally gave

T h. Yo u w o u l d forget w h a t h a d h a p p e n e d ?
Pt. p a u s e ) Y es Yes.
Th. H o w y ou h a n d l e y o u r se lf will d e t e r m i n e w h a t

T h . D i d yo u give u p t r y i n g to a d j u s t a t h o m e o r

If it co uld e n d r i g h t n o w ,

u p.

sto p , it (p a u se).

h a p p e n s . Yo u can see t h a t y o u r p r e s e n t up se t

w ork?

Pt.

Not

exactly .

But

f ig h tin g

never

g ets

any

w h e r e s . P e o p l e j u s t d o n t listen.

is p r o b a b l y l in k e d w i t h w h a t h a p p e n e d in y o u r
h o m e w h e n y ou w e r e a child. W o u l d you tell

Make a Tentative Diagnosis

m e a b o u t y o u r love life w i t h y o u r h u s b a n d ?

T h e focus on th e r a p y w a s th e re a fte r c o n

D e sp ite th e fact th a t o u r c u r r e n t nosological

cerned w ith th e q u a li ty of h e r r e la tio n s h ip

system s leave m u c h to be d esired, it m a y be


necessary to fit the p a tie n t into som e diagn ostic
schem e if for no o th e r re a s o n t h a n to satisfy in

w ith h e r h u sb a n d . T h e r e w ere evidences th a t


the p a tie n t herself p ro m o te d w h a t in w a rd l y
she believed w a s a n in evitable a b a n d o n m e n t.

s titu tio n a l r e g u la tio n s a n d in s u ra n c e r e q u i r e


m ents. T h e r e is a te m p ta t io n , of course, to

T h e th e r a p is t in m a k i n g a te nta tive th r u s t at
the dy n am ics of a p ro b le m sh o u ld p re s e n t it in

c o o rd in a te d iagn osis w ith accepted labels for

sim ple term s th a t th e p a tie n t can u n d e rs ta n d .

w h ich re im b u r s e m e n t will be m ad e. T h i s is

T h e e x p la n a tio n should not be so do g m atic ,


how ever, as to p rec lu d e a revision of the h y
pothesis at a la te r d ate, sho uld f u r th e r elicited
m a te ria l d e m a n d this. T h e p a tie n t m a y be
asked ho w he feels a b o u t w h a t th e th e r a p is t

u n f o r tu n a te since it te n d s to lim it flexibility


a n d to in v alid a te utilizing case records for p u r
poses of statistical research . Even th o u g h clini
cal diagn osis b e a r s little r e l a ti o n s h ip to p r e

h as said. If he is h azy a b o u t th e con ten t, his


confusion is e xp lored a n d clarification con

ferred th e r a p e u ti c tech n iq u e s in som e sy n


d ro m e s, in o t h e r sy n d ro m e s it m a y be helpful
to w a rd
in s titu tin g
a ratio n a l
pro g ram

tinued.

(W o lb e rg , 1977, p p . 6, 6 2 - 6 3 , 4 1 0 - 4 1 8 ) .

F o r e x a m p le , a p a tie n t w ith m i g r a i n e is
p resented w ith th e h y po thesis th a t a n g e r is
w h a t is creatin g his sy m p to m . T h e p a tie n t
then m ak es a c onnection w ith p a st re s e n tm e n ts
an d the denial defenses th a t he erected, w h ich
a p p a r e n t ly a re still op erativ e in the presen t.

T h . Y o u r h e a d a c h e s a r e a g r e a t p r o b l e m ob vio usly
since t h e y block you in y o u r w o r k . O u r a i m is
to h e l p r e d u c e o r e l i m i n a t e t h e m . F r o m w h a t
you tell m e, th ey s t a r t e d w a y b ack p r o b a b l y in

Convey the Need for the Patient's


Active Participation in the
Therapeutic Process
M a n y p atie n ts , accu sto m e d to d e a lin g w ith
medical doctors, expect th e th e r a p is t to p r e
scribe a f o r m u la o r give advice th a t will o p e r
ate a u to m a tic a lly to p a llia te th e p ro b le m . An

w i t h c e r t a i n e m o tio n s. F o r e x a m p l e , u pse t feel

e x p la n a tio n of w h a t will be expected of th e p a


tient is in ord er.

in g s

y o u r ch ild h o o d . T h e y a r e a p p a r e n t l y co n n ected
for

T h . T h e r e is no m a g i c a b o u t g e t t i n g well. T h e w ay

h e a d a c h e s, bu t t h e r e m a y be o t h e r t h i n g s too,

w e can best a c c o m p l i s h o u r g o als is to w o r k

like r e s e n t m e n t s . W h a t w e will do is e x p l o r e

t o g e t h e r as a p a r t n e r s h i p t e a m . I w a n t y o u to

and

ten sio n s

are

often

basis

w h a t goes o n in y o u r e m o t i o n s to see w h a t

tell m e all t h e i m p o r t a n t t h i n g s t h a t a r e g o ing

co n nections

O ften

o n w i t h y o u a n d I will t r y to h e l p y o u u n d e r

r e s e n t m e n t s o n e h a s in the p r e s e n t a r e th e

s t a n d t h e m . W h a t w e w a n t to do is to develo p

resu lt of s i t u a t i o n s s i m i l a r to t r o u b l e s a p er so n

n e w , h e a l t h i e r p a t t e r n s . M y j o b is to see w h a t

h ad in c h ild ho o d.

is b lo ck in g yo u f ro m a c h i e v i n g t h is objective by

we can

com e

up

w ith.

42

HANDBO OK OF SHORT-TERM PSYCHOTHERAPY


p o i n t i n g o u t so m e t h i n g s t h a t h a v e a n d a r e still
blo ck in g y ou.

Pt.

Y o u r j o b is to act to p u t into

p r a c t i c e n e w p a t t e r n s w e decid e a r e n ecessary,

A n y t h i n g y o u sa y, do cto r. If m o r e a r e neces
sary, O K .

T h . It is r e a lly best to k eep t h e n u m b e r o f se ss io ns

y ou telling m e a b o u t y o u r e x p e r i e n c e s a n d feel

as lo w as po ssib le to av oid g e t t i n g d e p e n d e n t

ings. P s y c h o t h e r a p y is like l e a r n i n g a n e w l a n

o n t h e m . S o w e ll p l a y it by e a r .

g u a g e . T h e l e a r n e r is t h e o n e w h o m u s t p r a c

Pt.

T h a t s fine.

tice t h e la n g u a g e . If t h e t e a c h e r did all the


ta l k i n g , t h e s t u d e n t w o u l d ne v e r be a b le to
c a r r y o n a co n v e r sa tio n . So r e m e m b e r you a r e

T h e a p p o i n t m e n t tim es m a y th en be set a n d
th e fee discussed.

g o in g to h a v e to c a r r y t h e ball, w i t h m y h e l p of
course.

Utilize Whatever Techniques are


Best Suited to Help the Patient
with Immediate Problems

Make a Verbal Contract With The


Patient
T h e r e sho uld be a n a g re e m e n t re g a r d in g the
frequ ency of a p p o in t m e n t s , th e
sessions, a n d th e te r m i n a ti o n date.
E x a m p le 7.

num ber

of

W h ere L im ita tio n o f the

N u m b e r o f Sessions is D e e m e d N ecessa ry in
A dvance

F o llo w in g th e in itial in terv iew , te c h n iq u e s


th a t a re ac cep tab le to th e p a tie n t, an d t h a t a re
w ith i n the tr a i n i n g r a n g e a n d c o m petence of
th e th e r a p is t, a r e im p le m e n te d , b e a ri n g in
m in d th e need for activity a n d flexibility. T h e
te c h n iq u e s m a y in clude s u p p o rtiv e , e d u c a
tio na l, a n d p s y c h o an aly tically orien ted in t e r
ventions a n d a host of a d ju n ctiv e devices, such

T h. W e a r e g o i n g to h ave a to tal of 12 sessions. In


t h a t t im e w e s h o u ld h av e m a d e a n i m p a c t on
y o u r a n x i e t y a n d d e p r e ss io n . N o w , l e t s c o n
sult t h e c a l e n d a r . W e will t e r m i n a t e t h e r a p y
o n O c t o b e r 9, a n d I ll m a r k it d o w n here. C a n
you also m a k e a n o te of it?
P t.

W i l l 12 sess ions be e n o u g h ?

Th . Yes. T h e least it co uld do is to get you on the


r o a d to re a l l y w o r k i n g o ut th e p r o b l e m .
P t.

W h a t h a p p e n s if I m n o t b e t t e r ?

Th . Y o u a r e a n in tellig en t p e r s o n a n d t h e r e is n o
r e a s o n w h y y ou s h o u l d n t be b e t t e r in t h a t
tim e.

as p sy ch o tro p ic d ru g s , h y pn osis, biofeedback,


b ehav io ral a n d g ro u p a p p ro a c h e s , a n d so on ,
in w h a te v e r c o m b in a tio n s a r e n ecessary to
s a tisf y th e p a t i e n t s i m m e d i a t e a n d f u t u r e
needs. A n e x p la n a tio n m a y be given th e p a
tien t a b o u t w h a t will be done.

T h . A t t h e s t a r t , I believ e it w o u l d be h elp fu l to
r e d u c e y o u r te n s io n . T h i s s h o u l d be beneficial
to y o u in m a n y w ays. O n e of t h e bes t w a y s of
d o i n g this is by t e a c h i n g y o u s o m e r e l a x i n g e x
ercises. W h a t I w o u l d like to do for you is to
m a k e a r e l a x i n g cas ette t a p e . D o you h av e a
casette t a p e r e c o r d e r ?

S ho uld the th e r a p is t dally a n d c o m p ro m ise


his confidence in th e p a t i e n t s cap acity to get
well, the p a tie n t m ay in ad v an ce cancel the

Pt. N o , I h a v e n t.
T h . Y o u c a n b u y o ne q u i t e i n ex p en s iv ely . H o w do

te r m in a tio n in his o w n m in d in favor of an


in d e te rm in a te fu tu re one.

Pt. It s o u n d s g reat.
T h . O K . O f co u r se, t h e r e a r e o t h e r t h i n g s w e will

you feel a b o u t this?

do, b u t t h is s h o u l d h e l p us get off to a good

E x a m p le 2. W hen th e T erm in a tio n D a te is


L eft O pen

T h. It is h a r d to e s t im a t e h o w m a n y se ss io ns w e
will r e q u i r e . I like to k eep t h e m below 20. So
let us b eg in on t h e bas is of t w ice a week.

st a rt .

M a n y t h e r a p is t s p ra cticin g d y n a m ic s h o r t
t e r m t h e r a p y ask th e ir p a tie n ts to reveal an y
d r e a m s th a t o ccu r d u r i n g th e r a p y . S o m e p a
tien ts insist th a t they ra r e ly o r never d r e a m or

GENERAL OUTLINE OF SHORT-TERM THERAPY


if th ey do, th a t they do no t re m e m b e r th e ir

Pt.

43
(p a u se ) Y o u k n o w , d o c to r , I m a f r a id o f losing
c o n t r o l , of w h a t m i g h t c o m e out.

d ream s.

I gu ess I

d o n t t r u s t a n y b o d y .

T h. It is i m p o r t a n t to m e n t i o n a n y d r e a m s t h a t

T h . A f r a i d of w h a t w o u l d h a p p e n h e r e , of w h a t I
m i g h t do if you s h u t y o u r ey es? (sm ilin g )

c o m e to you.

Pt. I c a n t get ho ld of t h e m . T h e y slip a w a y .


T h. O n e t h i n g y o u c a n d o is, w h e n you r e tire , tell

Pt.

(la u g h in g )

I g u e s s so. Silly. B u t t h e t h o u g h t

c a m e to m e a b o u t s o m e t h i n g se x u al.

y o u r se lf y ou will r e m e m b e r y o u r d r e a m s .

Pt. W h a t if I c a n t r e m e m b e r .
T h . K e e p a p a d of p a p e r a n d a pencil n e a r t h e
h e a d of y o u r bed. W h e n you a w a k e n as k y o u r
self if yo u

dream t.

Then

w rite the d ream

d o w n . Also , if y o u w a k e u p d u r i n g t h e n ig h t.

Study the Patient's Reaction and


Defense Patterns

While the Focus at all Times is on


the Present, be Sensitive to How
Present Patterns Have Roots in the
Past
E x a m i n in g h o w th e p a ti e n t w a s re a r e d an d
th e re la tio n s h ip w ith p a r e n t s a n d siblings is
p a r t ic u l a r ly
to

estab lish

revealing.
p attern s

An

a tt e m p t

th at

have

is m a d e
operated

T h e utilization of a n y te c h n iq u e or strat e g e m w ill set in t o m o t i o n r e a c t i o n s a n d

th r o u g h o u t th e p a t i e n t s life o f w h ich the c u r

defenses th a t a r e grist for th e t h e r a p e u ti c mill.


T h e p a tie n t will disp lay a r a n g e of p a tt e r n s
t h a t you can study. T h i s will p e rm it a d r a

tion. T h i s d a ta is for th e t h e r a p i s t s o w n co n
s u m p tio n a n d shou ld no t be too ex hau stiv e,
since th e p a ti e n t if en c o u ra g e d to e x p lo re th e

m atic d e m o n s tra tio n of th e p a t i e n t s defenses


an d resistances in actu al o p e ra tio n r a t h e r t h a n

p a st m a y go on endlessly, a n d th e r e is no tim e
for this. At a p ro p itio u s m o m e n t, w h e n th e p a

as theories. T h e p a t i e n t s d r e a m s a n d fantasies
will often reveal m o re th a n his actions o r v e r

tient a p p e a r s to h ave som e a w a re n e s s of co n

b alizatio ns, an d he sho uld c o n tin u a lly be e n


couraged to ta lk a b o u t these. T h e skill of the
th e r a p is t in w o rk in g w ith a n d in t e r p r e tin g th e
p a t i e n t s s i n g u l a r p a t t e r n s w ill d e t e r m i n e
w h e t h e r th e s e w ill be i n t e g r a t e d o r w ill
g e n e ra te f u r th e r resistance. G e n e ra lly , a c o m
passio nate, tentative ty pe of in te r p r e ta ti o n is
best, s p r in k lin g it if possible w ith a casual
light h u m o r o u s attitud e. A p a ti e n t w h o w a n te d

nections of his past w ith his p re s e n t, a p r o p e r


in te r p r e ta ti o n m a y be m ade. A t th a t tim e a r e
la tio n s h ip m a y be cited b etw een genetic d e
te r m i n a n ts , th e ex istin g p e rs o n a lity p a tte rn s,
a n d th e s y m p to m s a n d c o m p la in ts for w hich
t h e r a p y w a s o rig in a lly sought.

Watch for Transference Reactions

a f ra id I c o u l d n t d o it. W h a t y o u d t h i n k of

T h e im m e d ia te re a c h in g for h e lp en co u rag es
proje ctio n o n to th e th e r a p is t of positive feelings
a n d attitu d e s re late d to a n idealized a u th o r it y
figure. T h e s e sh o u ld no t be in t e rp re te d o r in
an y w a y dis co u rag ed since th e y act in th e in
terest of a llev iatin g tension a n d s u p p o r tin g the
placeb o elem en t. O n th e o th e r h a n d , a n eg a tive
tra n sferen ce re a c tio n sh o u ld be d e a lt w ith
r a p i d ly a n d sy m p a th e tic a lly since it will in t e r

me. T h a t I d fail. I g u ess I m a f ra id of docto rs.

fere w ith th e th e r a p e u ti c alliance.

hy pn osis to con tro l s m o k in g a p p e a r e d restless


d u r i n g induction:

T h . I n oticed t h a t w h e n I a s k e d y o u to lean b ack in


t h e c h a i r a n d t r y r e l a x i n g to m y su gg e stio n s,
y ou w e r e q u i t e u n e a s y a n d k e p t o n o p e n i n g
y o u r eyes. W h a t w e r e yo u t h i n k i n g a b o u t ?

Pt.

r e n t stress s itu a tio n is a n im m e d ia te m a n ife s ta

(e m o tio n a lly ) M y h e a r t s t a r t e d b e a t i n g . I w a s

M y h u s b a n d is t r y i n g to get m e to see a g y n e
cologist.

T h. B u t you kep t o p e n i n g y o u r eyes.

T h . [n o tin g th e p a tie n t's h e s ita n t s p e e c h ] Y o u seem


to b e u p se t a b o u t s o m e th i n g .

44

HANDBOOK OF SHORT-TERM PSYCHOTHERAPY

Pt. W h y , s h o u ld I be u p s e t ?
T h . Y o u m i g h t be if I did s o m e t h i n g y o u d i d n t
Pt.

H e is alw a y s

relieved as th e session h o u r comes to an end.

(p a u se) N o I m a f r a id , j u s t a f r a i d I m no t d o

H e recognizes th a t his reac tion s a r e co un te r th e r a p e u tic , a n d he ask s him self if th ey a re

I still h a v e t h a t p a n i c k y feeling f ro m t i m e to
tim e . D o o t h e r p a t i e n t s d o b e t t e r ?

T h . Y o u se em to be c o m p a r i n g y o u r s e l f to m y o t h e r
patients.
I I I gu ess so. T h e y o u n g m a n t h a t c a m e
before

m e.

He

se em s

so self-confid ent

and

really ju stified . T h e im age of his o w n m o t h e r


th en comes to his m in d , an d he realizes th a t he
h a d m a n y of th e sa m e feelings of e x a s p e r a tio n ,
d is p lea su re, a n d disgust w ith his o w n p a re n t.
R eco g n izin g t h a t he m a y be tr a n s f e r r in g in

ch eerful. I g uess I felt in f e rio r , t h a t you w o u l d

part

find fau lt w i t h me.

w h ose physical a p p e a r a n c e an d m a n n e r r e

T h . D o you t h i n k I like h i m b e t t e r t h a n I do y o u ?
Pt. W e l l , w o u l d n t y o u , if h e w a s d o i n g be tte r
than I was?

T h . T h a t s in t e r e s t i n g . T e l l m e m ore.
P t.

feeling a n n o y e d a n d e n rag ed .

like.
in g w h a t I s h o u l d . I ve been h e r e six ti m e s a n d

Pt.

p erio dically he finds him self scolding h e r and

I ve been t h a t w a y . M y p a r e n t s , I felt, p r e

som e of th ese a ttitu d e s to his p a tie n t

m in d h im of his m o th e r, he is b etter ab le to
m a i n ta i n objectivity. S h o u ld self an aly sis, h o w
ever, fail to h a lt his a n im o sity , he m a y decide
to send th e p a ti e n t to a n o th e r th e r a p is t.

ferred m y o ld e r b r o t h e r . H e a l w a y s c a m e
in o n top. T h e y w e r e p r o u d o f his a c c o m p l i s h
m e n t s in school.

T h . So in a w a y y o u feel I s h o u l d be a c t i n g like

Constantly Look for Resistances


That Threaten to Block Progress

your parents.

Pt. I c a n t h e l p feeling t h a t w ay.


T h . D o n t y ou t h i n k t h is is a p a t t e r n t h a t is really
se lf-defeatin g ? W e o u g h t to e x p l o r e t h is m o re.

Pt.

(e m o tio n a lly ) W e l l ,

I re a lly t h o u g h t t o d a y you

w e r e g o i n g to se n d m e to a n o t h e r d o c to r b e
ca u s e you w e r e sick of me.

T h . A c tu a lly , t h e t h o u g h t ne v e r o c c u r r e d to m e to

O b s tr u c tio n s to successful th e r a p e u ti c ses


sions a r e n u r t u r e d

by m isco nceptio ns a b o u t

th e r a p y , lack of m o tiv atio n , needs to m a i n ta i n


c e rta in benefits th a t ac crue fro m o n e s illness,
a n d a host of o th e r sources, conscious a n d
unconscious. W h e r e resistances a re too s t u b

o u t b e c a u s e w e w ill be a b le to e x p l o r e so m e of

b o rn to b u d g e re ad ily o r w h e re they o p e ra t e
w ith little a w a r e n e s s th a t th ey exist, th e few

y o u r i n n e r m o s t fears a b o u t h o w p e o p l e feel

sessions assigned to s h o r t- t e r m th e r a p y m a y

a b o u t you.

not suffice to resolve th em . O n e w a y of de alin g

do t h a t . B u t I m g lad y ou b r o u g h t t h i s m a t t e r

w ith resistances once th ey a r e recognized is to

Examine Possible
Countertransference Feelings
If you notice p ersisten t irritability, b o red o m ,
an g e r, e x tr a o r d i n a r y in terest in o r a ttra c tio n to
an y p a tie n t, ask yourself w h e th e r such feelings
an d attitu d e s do n ot call for self-exam in atio n.
T h e i r c o n tin u a n c e will a lm o st ce rtain ly lead to
interference w ith a good w o rk in g rela tio n sh ip .
F o r e x am p le, a th e r a p is t is tr e a tin g an u n s t a
b le m i d d l e - a g e d fe m a le p a t i e n t w h o m he
r e g a r d s as a p lu m p is h , slo p p y biddy w h o sticks
h e r nose into o th e r p e o p le s affairs. H e tries to
m a i n ta i n a n im p a rt ia l th e r a p e u tic stance, bu t

b ri n g th e m ou t o p en ly in a n o n c o n d e m n in g
m a n n e r . T h i s can be d o n e by s ta tin g t h a t the
p a ti e n t m a y if he desires hold on to th e m as
defenses, bu t if this is so, he m u s t suffer the
consequences. A f r a n k discussion of w h y th e
resistances h av e value for th e p a tie n t a n d th e ir
effects on his tr e a t m e n t is in o rd er. A n o th e r
te c h n iq u e is to a n tic ip a te resistances fro m th e
p a t i e n t s p a st m o des of a d a p t a t i o n , d re a m s ,
a n d the like, p re s e n tin g th e p a ti e n t w ith th e
possibility of th e ir a p p e a r a n c e an d w h a t could
be d o n e a b o u t th e m sho uld they a p p e a r . T h e
t h e r a p i s t s h o u l d w a t c h fo r m i n i m u m a p
p e a ra n c e s of resistance, h o w e v e r m i n o r th ey
m a y be, t h a t w ill se r v e a s p s y c h o l o g ic a l

45

GENERAL OUTLINE OF SHORT-TERM THERAPY


ob structio ns. M e r e ly b rin g in g these to th e a t

Even a bit of insig h t m a y be a saving g race. As

ten tio n of th e p a tie n t m a y r a p i d ly d issip ate

soon as feasible, m oreov er, ask th e p a ti e n t to

them .

review his idea of th e e volution of his p ro b le m

P t.

I d i d n t w a n t to co m e h ere. L a s t t i m e I h a d a

c ir cu m stan ces th a t reinforce th e p ro b le m or

t e r r i b l y se vere h e a d a c h e .

alleviate his sy m p to m s. P ra ctice schedules m a y

a n d w h a t he c a n do to co n tro l o r re g u la te the
I felt d i z z y in the

h e a d , (p a u se)

Th . I w o n d e r w h y . D i d a n y t h i n g h a p p e n h e r e t h a t
u p se t you; did I do a n y t h i n g to u p se t y o u ?
P t.

N o , i t s f u n n y b u t it s s o m e t h i n g I c a n t u n d e r
sta n d . I w a n t to co m e h e r e , a n d I d o n t. I t s
like I m afra id .
(P a u se; p a tie n t flu s h e s .) I c a n t u n d e r s t a n d it.

some cues r e g a r d in g h o w he m a y w o r k on

P e o p le a r e a l w a y s t r y i n g to c h a n g e me. As far

h im self to reverse som e basic destructive p e r


sonality p a t t e r n s t h r o u g h such m e a s u re s as

b ack as I c a n r e m e m b e r , at h o m e , at school.

T h . A n d you resen t t h e i r t r y i n g to c h a n g e yo u.
P t.

a c q u ir in g m o r e u n d e r s ta n d in g a n d insig ht, r e
w a r d i n g h im se lf for positive actions, self-hy p

Yes. I feel t h e y c a n t leave m e alone.

T h . P e r h a p s you feel I m t r y i n g to c h a n g e you.


P t.

(a n g rily ) A r e n t y o u ?

T h . O n l y if y o u w a n t to c h a n g e . In w h a t w a y do
y ou w a n t to c h a n g e , if a t all?
P t.

want

to

get

rid

of

my

headaches,

and

st o m a c h a c h e s , a n d all t h e rest of m y aches.

Th . P .t y ou d o n t w a n t to c h a n g e to do this.
Pt.

T h . A r e yo u s u r e the w a y y o u w a n t to c h a n g e will

F o r e x a m p le , th e follow ing suggestion w as


m a d e to a p a ti e n t w h o ca m e to t h e r a p y for
h e lp to a b a te m i g ra i n e attacks:

T h . W h a t m a y h e l p you is u n d e r s t a n d i n g w h a t
t r ig g e r s off y o u r h e a d a c h e s a n d m a k e s t h e m

h e l p you get rid o f y o u r s y m p t o m s ?

w o r s e . S u p p o s i n g you k e e p a d i a r y a n d j o t

B u t t h a t s w h y I m c o m i n g h e r e so y o u w ill tell

d o w n t h e f r e q u e n c y o f y o u r h e a d a c h e s . E v ery -

me.

ti m e y o u get a h e a d a c h e w r i t e d o w n t h e

T h . Bu t y ou r e s e n t m y m a k i n g su g g e stio n s to y ou

P t.

nosis, a n d so on. T h e s e tactics m a y be p u rs u e d


bo th d u r i n g t h e r a p y an d fo llow ing t h e r a p y by
oneself.

W e l l , d o c to r , th is i s n t tr u e . I w a n t to c h a n g e
th e w a y I w a n t to.

P t.

m a y be e n jo in e d to keep a log re g a r d in g in
cidents th a t e x a g g e ra te his difficulties an d
w h a t th e p a ti e n t h a s d o n e to avoid o r resolve
such incidents. T h e p a tie n t m a y also be given

T h. A f ra i d ?
P t.

be a g reed on t o w a r d o p p o sin g the situ a tio n s o r


tendencies th a t r e q u i r e co n trol. T h e p a tie n t

day

and

tim e .

Even m ore

im portant,

write

b ecau s e s o m e h o w y o u p u t m e in t h e clas s of

d o w n t h e ev en ts t h a t i m m e d i a t e l y p r e c e d e d th e

e v e r y b o d y else w h o y o u believ e w a n t s to t a k e

onset

y o u r i n d e p e n d e n c e a w a y . A n d t h e n you s h o w

th o u g h ts

r e sis ta n c e to w h a t I a m t r y i n g to do.

h e a d a c h e is s t o p p e d by a n y t h i n g t h a t h a s h a p

(la u g h s) I s n t t h a t silly, I re a l l y d o t r u s t you.

pened, or

T h . T h e n s u p p o s i n g w h e n yo u b e g in to feel you

of

the

headache

you h ad th a t

or

the

brought

feelings
it o n.

by a n y t h i n g y o u t h i n k

or

If a

about or

fig u re o u t , w r i t e t h a t d o w n , a n d b r i n g y o u r

a r e being d o m i n a t e d y o u tell m e, so w e can

diary w hen

ta l k it o u t . I r e a lly w a n t to h e l p y o u a n d n o t

about w hat has happened.

y ou c o m e h e r e so w e c a n ta l k

d o m i n a t e you.
P t.

T h a n k yo u , d o c to r , I d o feel b e tte r .

Give the Patient Homework

Keep Accenting the Termination


Date if O ne was Given the Patient

Involve the p a tie n t w ith a n a ss ig n m e n t to

In p r e p a r i n g th e p a tie n t for te r m i n a ti o n of

w o rk on h o w his sy m p to m s a re re lated to h a p
pen ing s in his e n v ir o n m e n t, to attitu d e s, to
fallacies in th in k in g , to d is tu rb e d in te rp e r s o n a l
relation sh ips, or to conflicts w ith in him self.

t h e r a p y , th e c a le n d a r m a y be referred to p rio r
to th e last th r e e sessions a n d th e p a tie n t
re m in d e d of th e d ate. In som e p a tie n ts th is will
activate s e p a r a ti o n a n x ie ty a n d n egativ e tr a n s-

46

HANDBOOK OF SHORT-TERM PSYCHOTHERAPY

ference. Such responses will necessitate active

t h e e n d of t h e five sessions, y o u s h o u l d be a b l e

in te rp re ta tio n of the p a t i e n t s p ast d ep en d en cy


a n d fears of a u to n o m y . E vidences of p ast re a c

to c a r r y on.

tions to se p a r a tio n m a y h elp th e p a tie n t ac


q u ir e an u n d e r s ta n d in g of the u n d e r p i n n in g s
of presen t reactions. T h e th e r a p is t sh o u ld e x
pect a recrudescence of th e p a t i e n t s sy m p to m s
as a defense ag a in s t being on his o w n a n d as
an

ap p e a l

for c o n tin u in g

tr e a tm e n t.

These

m an ifestatio ns a re dealt w ith by f u r th e r in t e r


p re ta tio n . D o n o t p ro m ise to co n tin u e t h e r a p y

P t.

B u t s u p p o s i n g I d o n t m a k e it?

T h . T h e r e yo u go, see, a n t i c i p a t i n g failu re. T h i s is


a g e s t u r e to h old on.
P t.

W e l l , d o c to r , I k n o w y ou a r e r i g h t. I ll keep
w o r k i n g o n it.

Terminate Therapy on the Agreedupon Date

even if the p a ti e n t predicts failure.


W h il e som e th e r a p is ts do not co n sid er it
P t.

I k n o w w e re s u p p o s e d to h a v e o n ly o n e m o r e
se ss ion.

But

get

scared

not

having

you

wise to invite th e p a ti e n t w h o h a s p ro g ressed


satisfactorily to r e t u r n , o th e r s find it a helpful

T h . O n e o f o u r a i m s is to m a k e y o u s t r o n g e r so

a n d r e a s s u ri n g aid for m ost p a tie n ts to do so at


the final session. I g e n e ra lly tell th e p a ti e n t to

around.
you w o n t n eed a c r u t c h . Y o u k n o w e n o u g h

w rit e to m e so m e tim e to let m e k n o w th in g s

a b o u t y o u r se lf n o w to t a k e s o m e ste p s o n y o u r

a r e co m in g alo ng . In th e event p ro b le m s d e

o w n . T h i s is p a r t of g e t t i n g well. So I w a n t

velop th a t on e c a n n o t m a n a g e by oneself, th e

you to give y o u r se lf a chance .

p a ti e n t sho uld call for a n a p p o in t m e n t . R a re ly

M a n y p a tie n ts will resent te r m i n a ti o n of

is th is in vitatio n ab u se d a n d if th e p a tie n t does


r e t u r n (w h ich is n ot too c o m m o n in m y e x p e r i

t h e r a p y after th e d e sign ated n u m b e r of sessions


have ended. At the m idd le p o in t o f t h e r a p y ,

ence) th e difficulty can be r a p i d ly h a n d le d ,


e v e n tu a tin g in re in fo rc e m e n t of o n e s u n d e r

th erefo re, the th e r a p is t m a y b rin g u p this


possibility. T h e th e r a p is t sho uld search for in

stan din g.

cidents in the past w h e re se p a r a tio n s have

T h . T h i s is, as y o u k n o w , o u r last se ss ion. I w a n t

created u n t o w a r d reactio ns in th e p a tie n t. I n

y ou n o w to t r y t h i n g s o u t on y o u r o w n . K e e p

div id u als

who

w ere

se p arated

fr o m

th eir

practicing the things 1 ta u g h t you the re la x a

an

early

age,

had

school

tio n exercise s \w h e r e th e se h a v e b een u se d ],

p h o b ias p ro d u c e d by in ability to b re a k ties


w ith the m o th e r, a n d w h o a re excessively d e
p e n d e n t a r e p a rtic u la rly v u ln e ra b le a n d a p t to
re s p o n d to te r m i n a ti o n w ith anx iety, fear,
an g e r, an d d epressio n. T h e te r m in a tio n p ro c
ess h e re m a y con stitu te a p r i m e focus in t h e r
ap y a n d a m e a n s of e n h a n c i n g ind iv id u a tio n .

the figuring out w h a t brings on your sym ptom s

p a re n ts

at

who

a n d t a k e s t h e m a w a y , a n d so f o rt h . Y o u s h o u l d
c o n t i n u e to get be tte r . B u t se tb a c k s m a y o c c u r
f r o m t i m e to tim e. D o n t let t h a t u p se t you.
T h a t s n o r m a l a n d y o u ll get ov er t h e setback.
In fact, it m a y h e l p y o u f i g u re o u t b e t t e r w h a t
y o u r s y m p t o m s a r e all a b o u t . N o w , if in t h e
f u t u r e you fin d y o u n eed a little m o r e h elp ,
d o n t h e s i ta te to call m e a n d I ll try to a r r a n g e

T h . W e h a v e five m o r e sessions, as you k n o w , a n d

an appointm ent.

t h e n w e w ill t e r m in a te .
P t.

I r e a l i z e it, b u t I a l w a y s h ave t r o u b l e b r e a k i n g
a w a y . M y wife ca lls m e a h o l d e r - o n e r .

T h . Yes, t h a t s exactly w h a t w e w a n t to avoid, the


d e p e n d e n c y . You a r e likely to r e s e n t e n d i n g
t r e a t m e n t for t h a t r e a s o n . W h a t d o yo u t h i n k ?
P t.

(la u g h in g ) I ll t r y n o t to.

A ctually relatively few p a tie n ts will tak e


a d v a n ta g e o f th is inv itatio n, b u t th ey will feel
r e a s s u re d to go o ut on th e i r o w n k n o w in g th ey
will not be a b a n d o n e d . S h o u ld they r e t u r n for
an a p p o in t m e n t , o nly a few sessions w ill be

T h . W e l l , k e e p t h i n k i n g a b o u t it a n d if y ou h av e

needed to b rin g th e p a tie n t to a n e q u i l ib r iu m

a n y b ad r e a c t i o n s l e t s t a l k a b o u t it. I t s i m p o r

a n d to h e lp le a r n a b o u t w h a t p ro d u c e d th e r e
lapse.

t a n t n o t t o m a k e t r e a t m e n t a w a y o f life. By

47

GENERAL OUTLINE OF SHORT-TERM THERAPY

Stress the Need for Continuing


Work on Oneself

ti ents will re q u i r e lo n g - te rm th e r a p y . In this


reference th e r e

a re som e p a tie n ts w h o will

need h e lp for a p ro lo n g ed p erio d of tim e; som e


re q u i r e
T h e m a tte r of c o n tin u in g w o r k on oneself
after te r m in a tio n is very m u c h u n d e re s tim a te d .
P a tie n ts will usu ally re t u r n to a n e n v ir o n m e n t
th a t co ntinu es to sp o n so r m a l a d a p ti v e re a c
tions. T h e p a tie n t will need some c o n sta n t
re m in d e r th a t old neu ro tic p a tt e r n s la ten tly
a w a it revival a n d th a t he m u st alert h im se lf to
signals of th eir a w a k e n in g . In m y p ra c tic e I
hav e found th a t m a k in g a re la x in g t a p e (a
tec h n iq u e detailed in C h a p t e r 15) s p rin k led
w ith positive suggestions of a n e g o-buildin g

only

an

occasional

c on tac t

th e r e

m a i n d e r of th e i r lives. T h e co ntac t does not


h a v e to be intensive or fr e q u e n t. P erson s w ith
an

e x tr e m e

d ep en d e n c y

character

d is o rd er,

b o rd e rlin e cases, a n d s ch izo p h ren ics often do


well w ith sh o rt visits (15 to 2 0 m in u tes ) every
2 w eeks o r lo ng er. T h e idea th a t a su p p o rtiv e
p e rs o n is av aila ble m a y be all th a t the p a tie n t
d e m a n d s to k eep h im in hom eo stasis. I n t r o d u c
ing th e p a tie n t into a g r o u p m a y also be h e lp
ful, m u ltip le tran sferen ce s d ilu tin g th e hostile

n a tu r e serves the in terest of c o n tin u e d g ro w th .

tran sferen ce th a t so often occurs in individual


th e r a p y . A social g r o u p m a y even suffice to

In th e event the p a tie n t h a s d one well w ith


h o m e w o rk d u r i n g the active th e r a p y period ,

prov ide th e p a ti e n t w ith

th e sa m e processes m a y c on tinu e. In s titu tio n of


a p r o p e r ph ilo so ph ica l outlo ok m a y also be in

referral to a n o t h e r th e r a p is t w h o specializes in
a different te c h n iq u e , for e x a m p le , to som eone

o rd e r p ri o r to disch arge. Such a ttitu d e s m a y be


e n c o u rag ed as the need to isolate the past from

w h o does biofeedback, o r b e h av io ral t h e r a p y ,

th e

p rese nt,

th e

re a liz a tio n

th a t

som e m e a n s of a

h u m a n re la tio n sh ip . Som e p a tie n ts will need

or a n o th e r m o dality.

certain

a m o u n t of tension a n d a n x ie ty a re n o r m a l, the
need to ad ju st to h a n d ic a p s an d realistic ir r e

T h . N o w , w e h a v e c o m p le te d th e n u m b e r of
se ssio n s w e a g re e d o n . H o w do yo u feel a b o u t

m ediab le conditions, th e urg en c y to w o r k at

m a tte r s n o w ?

correcting rem e d ia b le e le m e n ts in o n e s en vi
ro n m e n t, th e recognition of th e forces th a t tr ig

P t.

ger off o n e s p ro b le m s a n d the im p o rta n c e of

T h . T h a t s h o u ld get b e tte r a s tim e goes o n . 1

B e tte r, d o c to r, b u t n o t w ell. I still h a v e m y in


s o m n ia a n d feel d isc o u ra g e d a n d d e p re ss e d .
s h o u ld lik e to h a v e you c o n tin u e w ith m e in a

rectifying these, a n d the w isd o m of sto p p in g

g ro u p .

reg re ttin g the p a st and of avo idin g a n tic ip a tin g


disaster in the fu tu re. It m u s t be recognized
th a t w hile the im m e d ia te a c c o m p lis h m e n ts of
s h o r t-te rm t h e r a p y m a y be m odest, the co n
tin u ed a p p lic a tio n of the m e th o d s th e p a tie n t
ha s learned d u r i n g his t h e r a p y will help b rin g
a b o u t m ore s u b s ta n tia l changes.

P t.

Y ou m e a n w ith o th e r p e o p le I ve h e a rd o f it.
It sc a re s m e, b ut I d lik e to do it.

W here

th e

p atie n t

is to

be

referre d

to

a n o t h e r th e r a p is t, he m a y be told:

T h . Y ou h a v e g o tte n a c e rta in a m o u n t o f h e lp in
c o m in g h e re , b u t th e k in d of p ro b le m s you
h a v e w ill be h e lp e d m o re by a sp e c ia list w h o

Arrange for Further Treatment if


Necessary

d e a ls w ith su ch p ro b le m s. I h a v e so m e o n e in
m in d fo r yo u w h o I b eliev e w ill be a b le to h elp
you.

If yo u a g re e , I sh a ll te le p h o n e h im to

m a k e su re he h a s tim e for you.

T h e qu estio n m a y be asked r e g a r d in g w h a t
to do w ith the p atie n t w h o at te r m i n a ti o n
show s little o r no im p ro v e m e n t. C e r t a i n p a

P t.

I d lik e th a t. W h o is th e d o c to r?

T h . D r _________ If he h a s n t tim e. I ll get som eone


else.

48

HANDBO OK OF SHORT-TERM PSYCHOTHERAPY

Conclusion
T w e n t y o p e ra tio n s a re re c o m m e n d e d for an

a lo n g d y n a m ic lines. T h e s e m ay b e c ro w d e d in to a

effective d y n a m ic a lly o rie n te d s h o r t-te rm t h e r

s p a n of a few w eek s, o r th e y m ay be d is tr ib u te d o v er

a p y p ro g r a m . T h e y consist of (1) e stab lish in g a


r a p i d positive w o rk in g re la tio n s h ip ( t h e r a

a n u m b e r of m o n th s. S om e th e r a p is ts p re fe r to see

p e u ti c a l l i a n c e ) , (2) d e a l i n g w i t h i n i ti a l
resistances, (3) g a th e r in g historical d a ta , (4)

tw ic e a w eek th e o p tim a l fre q u e n c y . In so m e cases

selecting

focus for

th e r a p y ,

(5) defining

p recip ita tin g events, (6) evolving a w o rk in g


hy pothesis, (7) m a k in g a te n ta tiv e diagnosis,

th e ir p a tie n ts o n a o n c e -a -w e e k b asis; o th e r s find


4 0 to 50 se ssio n s a r e still c o n s id e re d a c c e p ta b le for
s h o r t- te rm co v erag e. T im e lim its a r e o ften set in
a d v a n c e w ith th e p a tie n t.
2. S e le c tio n o f cases. A li ty p e s o f p ro b le m s of
a c u te a n d c h ro n ic d u r a tio n a r e c o n sid e re d s u ita b le .

(8) conveying the need for th e p a t i e n t s active

E v en p a tie n ts w ith s e rio u s p sy c h o p a th o lo g y a r e c a n

p a rtic ip a tio n

in the t h e r a p e u ti c process, (9)

d id a te s . S o m e th e r a p is ts w h o c o n fin e th e m se lv e s to

m a k in g a verbal con tract, (10) utilizin g a p p r o

d y n a m ic s h o r t- te rm th e r a p y b eliev e selectio n o f a p

p ria te tech n iq u es in a n
m a n n e r , (11 ) s t u d y i n g

p r o p r ia te p a tie n ts is m a n d a to ry .

active an d flexible
th e r e a c t i o n s a n d

defenses of the p a tie n t to the tec h n iq u es being


em p lo yed , (12) re la tin g p re s e n t-d a y p a tt e r n s to
p a tt e r n s th a t have o p e rated t h r o u g h o u t th e p a
t i e n t s life, (13) w a tc h in g for tran sfe re n c e re a c
tions,
ference

(14) e x a m i n in g possible c o u n t e r t r a n s
fe elin g s,

(1 5 )

a le rtin g

oneself

to

3. G o a ls. R e c o n stru c tiv e c h a n g e s a r e d ee m e d n ot


o n ly d e s ira b le b u t also o b ta in a b le in s u ita b le p a
tie n ts ,

e sp e c ia lly

w ith

th e

u se

of d y n a m ic

ap

p ro a c h e s , p ro v id e d th e r e e x is ts p r o p e r m o tiv a tio n
a n d c o n c u rre n c e o f re c o n s tru c tiv e objectiv es on th e
p a r ts of p a tie n t a n d th e r a p is t.
4. D e g r e e o f th e r a p is t a c tiv ity . A re la tiv e ly h ig h
d e g re e of a c tiv ity is g e n e ra lly p re fe rre d .

resistances, (16) assig nin g h o m e w o rk , (17) a c

5. F o c u s o f th e r a p y . A r e s tric tio n of focus to a

centing the te r m i n a ti o n d ate, (18) te r m i n a ti n g

z o n e a g re e d on by p a tie n t a n d th e r a p is t is im p o r

th e r a p y , (19) assign ing c o n tin u in g self-help


activities, a n d (20) a r r a n g i n g for f u r th e r t r e a t

ta n t, if n o t e s s e n tia l. If a n u c le a r co n flict is id e n tifia


ble a n d th e p a tie n t does n o t d efen siv ely av o id it too
m u c h , its c o n s id e ra tio n a s a focus is d e s ira b le in d y

m e n t if necessary.
T h e s e o p e ra tio n s m a y be utilized in toto o r

n a m ic a lly o rie n te d a p p ro a c h e s . C o n s id e re d sig n ifi

in p a r t by th e r a p is ts w h o can a d a p t th e m to
th eir styles of w o rk in g . Irrespective of th e

c a n t a r e tr a n s fe re n c e p h e n o m e n a , w h ic h in som e

oretical

p e rs u a sio n ,

th e r e

are a n u m b e r of

a re a s of g en eral a g re e m e n t a m o n g different
professionals p racticin g s h o r t-t e rm th e r a p y :

sy ste m s m ay o c c u p y a p o sitio n o f c e n tra l im p o r


ta n c e .
6. T e c h n iq u e s . T h e full r a n g e o f eclectic s u p p o r
tiv e, e d u c a tio n a l, a n d re c o n s tru c tiv e te c h n iq u e s a re
u se d in c lu d in g , in d y n a m ic a p p r o a c h e s , tr a d itio n a l

a n a ly tic te c h n iq u e s of tra n s fe re n c e a n a ly s is, in te r


T im e . T h e m ost f re q u e n tly d e s ig n a te d n u m b e r p r e ta tio n of re s is ta n c e , d r e a m a n d fa n ta sy e x p lo r a
of se ssio n s ra n g e fro m 3 to 6 for crisis in te rv e n tio n ,
tio n , a n d th e re la tin g o f tr a n s fe re n c e to g e n e tic d e
1.

fro m 6 to 12 fo r su p p o rtiv e -e d u c a tio n a l a p p ro a c h e s ,


a n d fro m 12 to 2 0 for m o re e x te n siv e p sy c h o th e ra p y

te r m in a n ts .

CHAPTER 5

The Initial Interview


A. Common Questions
T h e initial interv iew is p e r h a p s th e most

his u n d e rly in g p ro b le m an d a n assay of w h a t

vital of all sessions since in its conduct rests the

h e can do to h e lp him self. N a t u r a l l y , m o st p a

fate of the th e r a p e u tic a llian ce a n d , even m ore

tien ts will r e t u r n for m o re sessions unless the

im p o rta n tly , th e e v en tu a lity of w h e th e r or not


the p atie n t will re t u r n for f u r th e r tr e a tm e n t.

th e r a p is t has failed to incite th e i r confidence or


h a s c o m m i t t e d s e r io u s e r r o r s in a p p r o a c h
(d e ta ch m en t, belittling a ttitu d e s, frig h ten in g

H o w m u ch tim e should ideally be sp en t on h is


tory ta k in g ? S h o u ld th e in terview be la rgely

th e p a tie n t w ith d e p th

in t e rp re ta ti o n s , h o s

tility, etc.).

diagnostic or th e r a p e u tic ? W h a t degree of co n


fro n tatio n can safely be e m p lo y ed ? T h e s e an d

H o w t h o r o u g h s h o u l d h i s t o r y t a k i n g b e in
the in itial in te rv iew ?

m a n y o t h e r q u e s t i o n s c h a l l e n g e th e i n t e r
viewer.

In the p re sen t c h a p te r som e of the

po ints m en tio n ed in the last c h a p te r will be e x

D u r i n g th e initial in terv iew exh au stive, r i

p o u n d e d by p re s e n tin g relev an t q u e stio n s (a nd


a n sw e rs) b ro u g h t u p in teac h in g a n d s u p e r

tualistic tak in g of a h isto ry is u nn ecessary. All

visory

fo rm a tio n to allo w for tr e a tm e n t p la n n i n g a n d

sessions

w ith

th e r a p is ts

th a t is re q u ire d is the g a th e r in g of sufficient in

of different

p e r h a p s for th e m a k i n g of a ten tativ e d ia g

theoretical p ersuasio ns.

nosis.

W o u ld you c o n sid e r the


t h e r a p e u t i c o r d ia g n o s tic ?

In la te r sessions on e m a y fill in this

skeletal o u tlin e of history . M o r e in fo rm a tio n


will be revealed as th e p a ti e n t g ain s confidence
in th e th e ra p ist.

first sessio n

W h il e the initial in terv iew is co nd ucted for


the p u rp o s e of assessing the p re s e n tin g p r o b

In a p p r a i s i n g t h e d e g r e e o f t h e p a t i e n t s
m a l a d j u s t m e n t at t h e i n i t i a l i n t e r v i e w ,
are th e re an y c rite ria th at can be a p p lie d ?

lem an d p la n n i n g tr e a tm e n t strategy , it sho uld


be m a n a g e d so th a t it registers a co nstru ctive
im p act on the p a tie n t. It m ust be stressed th a t

T h e r e a r e a n u m b e r of a d ju s tm e n t scales

a sizable n u m b e r of p atie n ts , especially those


t h a t come to o u tp a t ie n t clinics, do n ot r e t u r n
for a second interview . F o llo w - u p stu dies show
t h a t th e initial interview c an have a definite
t h e r a p e u tic effect a n d m ay even s ta rt the p a

th a t a re in use, no n e of w h ic h is perfect. It is
helpful to view the p re s e n t difficulty ag ain st
th e b a c k d ro p of p rev io u s m a l a d a p ta t io n s , p a r
ticu larly th ose d u r i n g ch ildhood. T h e d a ta
h e re is not e n tire ly definitive since th e p a tie n t
could, in spite of a d is o rg a n iz e d e a rly life h is

tient on the ro a d to recovery. T h e th e r a p is t,


therefore, sh ou ld assum e th a t the first in t e r
view will be the only o p p o r t u n it y to w o rk w ith

tory, still m a k e a re a s o n a b le a d u lt a d ju s tm e n t
u n d e r p ro p i ti o u s circu m stan ces. T h e second
item one m a y consider is th e q u a lity of the

the p a tie n t a n d th u s th a t e n o u g h w o rk m u s t be
done so th a t the p a tie n t can leave th e session

p re s e n t p e rs o n a l re la tio n sh ip s , th e a d ju s tm e n t
to o n e s m a r it a l p a r t n e r a n d ch ild ren , th e e x

w ith so m ething positive to g ra p p l e onto. T h e


initial interview shou ld be co nd ucted in such a
w a y as to give the p a tie n t a b etter idea a b o u t

te n t of creativity, an d th e v alues th a t m o ld be

49

50

HANDBOOK OF SHORT-TERM PSYCHOTHERAPY

havior. T h i r d , one m ay e s tim ate th e degree of

em otion s u n d e rlie th e p a t i e n t s m anifest b e

an x iety th a t is manifest or th a t expresses itself

hav ior. V e ry fr e q u e n tly these e m o tio n s ca n n o t


be exp ressed in w o rd s, a n d th e th e r a p is t will

in term s of such sy m p to m s as depressio n and


psychosom atic m anifestations.
A fo u rth possibility is to e x a m in e th e n a tu r e

have to m a k e a s s u m p tio n s th r o u g h o bserva tion


of th e p a t i e n t s behavior. F o r in stance, in th e

of defenses a g a in st anxiety, for instance, th eir


ability to co n tain th e an x ie ty an d the effect

event th a t a d e li n q u e n t boy is referre d for t h e r


ap y, the boy m a y sulk in his c h a ir, fidget, be

th a t th ey have on th e to tal functioning. Fifth,

evasive, a n s w e r in a d is a r m i n g m a n n e r , ex

we p o n d e r the ex ten t of a d a p ta tio n a l collapse.


H e r e even th o u g h th e p a tie n t seems to be m a k

press disinte rest, or show negativism . T h e


th e r a p is t m a y g ain the im pre ssio n from o b se rv

ing a good a d ju s tm e n t, we m u s t ask at w h a t


expense. T h u s , a d etac hed perso n m a y show

ing the attitu d e s of the boy t h a t th e boy resents


b eing at th e interview . H e , therefore, m ig h t

on the surface a fairly good a d ju s tm e n t. C o n

say to th e boy, Y ou p ro b a b l y res en t co m in g


h e r e , o r P ro b a b l y you feel th a t you o u g h t

seq uen tly, it is essential to estim ate h o w tru ly


a d e q u a te this is in te r m s of w h a t is h a p p e n in g
to the indiv idu al as a w hole. H e m a y be e s c a p
ing a n x ie ty a n d w o rk in g a d e q u a te ly on ly by
th e tactic of isolating him self from people. O r a
d ep e n d e n t p erso n m ay be fun ctio nin g solely by

no t to h ave com e h e r e , or I can u n d e r s ta n d


th a t you feel k in d of m a d a b o u t this s i t u a t i o n .
Such a r e m a r k cuts into th e em o tio n of th e boy
a n d m a y en a b le h im to perceive th a t his feel
ings a re u nd ers to o d .

a tta c h in g him self to a p a re n t a l figure. T h e

A n o th e r e x a m p l e is th a t of a w o m a n r e

kind of a d a p ta tio n h elps us to d e te r m in e the


degree of s u p p o r t th a t will be re q u ire d at the

ferred by a social agency on th e basis t h a t th e

sta rt of tr e a tm e n t, the a m o u n t of p a rtic ip a tio n


one m a y expect from th e p a tie n t a n d h o w ac
tive the th e r a p is t should be in the re latio n sh ip .

Is it a d v i s a b l e to s p e n d m o r e ti m e o n t h e
i n i t i a l i n t e r v i e w t h a n o n o t h e r se ssion s?
If possible, yes. So m uc h h a s to be do ne d u r
ing th e first in terv iew th a t th e usual 45 o r 50
m in u tes of tim e allotted for a session m a y be
insufficient. E x te n d i n g th e tim e, how ever, m ay
not be p ractically possible. H ence, tw o sessions
m a y be necessary in som e cases to accom plish
all essential tasks. A n ex pe rien ced in terv iew e r,
h o w ever, m ay re q u ire no m o re th a n one
session.

agency believes she is suffering fro m an e m o


tion al p ro b le m for w h ich she sh o u ld get help.
Even if she is n ot yet p r e p a r e d to receive this
help , she m a y still a p p e a r for t h e r a p y in o r d e r
to a p p e a s e th e ca se w o rk e r o r as a m ean s
t h r o u g h w h ic h she can g ain f u r th e r aid from
th e a g e n c y .

H e r m o tiv atio n , c o n seq u en tly ,

w o u ld be to give as little in f o rm a tio n as possi


ble a b o u t he rself o r to be as evasive as she can
w ith o u t offending. U n d e r th ese circu m stances,
once th e th e r a p is t realizes w h a t is going on, he
m ig h t say the following:

T h . I c a n very w ell see th a t yo u w o u ld feel r e s e n t


ful o r u n c o m fo rta b le a b o u t c o m in g h e re . Y ou
p ro b a b ly do n o t feel th a t it is n e c e ssa ry an d
m ig h t b elieve th a t yo u c o u ld v ery e a sily do
w ith o u t th e r a p y . I do n o t b la m e y o u for feelin g

Is it im p o s s i b l e to w o r k w i t h a n u n m o t i
v a t e d p a t i e n t , a n d if so, c a n y o u g iv e
s o m e e x a m p l e s o f h o w t h is c a n b e d o n e ?
It is not at all im possible pro vided one deals
w ith w h a t is b ehin d th e lack of m otiv atio n. T o
do this the th e r a p is t m ay try to retrie ve u n e x
pressed or u nc onscious em o tio n s th a t a re a c t
ing, o r will act, as resistances to th e r a p y . Such

th is w a y in a s m u c h a s you d id n o t re a lly com e


to th e a g e n c y in o r d e r to seek h e lp fo r a n e m o
tio n a l p ro b le m .

T h i s e x p la n a tio n p ro b a b l y w o u ld re la x the
w o m a n co nsid era bly , since she w o u ld sense in
th e th e r a p is t a s y m p a th e tic perso n . S he m igh t
th e n begin to ex press h e r feelings a b o u t the

THE INITIAL INTERVIEW: COM M O N QUESTIONS

51

agency and at th e end be w illin g to talk a b o u t

v erbalize freely sh o u ld soon estab lish a t h e r a

herself a n d h e r p roblem s.
A co m m o n p ro b le m is pro vid ed by th e p a
tient w h o views p s y c h o th e ra p y in th e sam e
light as c on sulting an internist. T h e p a tie n t

p eu tic a lliance, an d t h r o u g h th is th e p a tie n t

tells the doctor a b o u t d is tu rb in g sy m p to m s,

p atien ts

a n d th e doctor prescribes a rem edy. T h e p a

ag a in s t th e ir free will, such as c o u rt cases,

tient, co nseq uen tly, will b o m b a r d the th e r a p is t


w ith a flood of sy m p to m s a n d co m p la in ts w ith

spouses of c o m p la in in g m ates, p e rs o n s collect


ing disability p a y m e n ts, a n d in d iv id u als d e

the ho pe th a t e v eryth ing will th en be ta k e n

riv in g stro n g seco n d ary g ain s from th e ir


sy m p to m s t h r o u g h avo idin g h a r d w o rk , s u p

care of in som e m ysteriou s w ay. T h e p a tie n t


really has n o m ean s of u n d e r s ta n d in g w h a t is
supposed to go on in th e r a p y o th e r th a n
th r o u g h exp erien ces w ith p reviou s h e a lth v e n
dors. T h e d is a d v a n ta g e w ith such a n a ttitu d e

m a y be helped to com e to g rip s w ith his w o r


ries an d conflicts.
A final e x a m p l e is p ro v id e d by th e host of
who

are

sheparded

in t o

th erap y

p o rt in g d ep en d e n c y needs, a n d ge ttin g a tt e n
tion a n d sy m p a th y . Such p a ti e n ts ca n n o t be
forced to ch a n g e. T h e p r i m a r y task here, as in
th e case of th e p syc ho som a tic p a tie n t, is to first

is th a t once th e p a tie n t h a s e la b o r a te d the


p ro b le m , respo nsib ility for it is tra n sfe re d to

establish a t h e r a p e u ti c alliance. N o h a r d - a n d -

the th e r a p is t an d a c u re will be expected.

r e q u i r e i n n o v a t i v e s t r a t e g e m s d e s i g n e d for
th e ir special situ atio n s. P a tie n ts receiving d is a

S ho uld th e th e r a p is t become a w a r e of th is a t
titude, he m a y offer th is in te rp re ta tio n :
T h . It is u n d e r s ta n d a b le th a t yo u h a v e su ffered so
lo n g th a t y o u feel it is im p o ssib le for you to do
a n y th in g a b o u t y o u r p ro b le m

y o u rself. It is

n a tu r a l fo r y ou to w a n t so m e b o d y to ste p in
a n d do fo r y ou w h a t you h a v e n t b een a b le to
do fo r y o u rself. B u t y o u a n d I h a v e to w o rk
to g e th e r as a te a m . I sh a ll h e lp you to u n d e r
s ta n d w h a t is h a p p e n in g to y o u , a n d you
w ill find th a t y o u can do m a n y c o n stru c tiv e

fast ru les can be given since each p a tie n t will

bility checks a r e p a r t ic u l a r ly difficult to co n


vince th a t a n y th i n g psychological keeps th e m
fro m r e t u r n i n g to w o rk . O n e tactic is n ever to
im p ly th a t th e p a tie n t is in a n y w a y p sy c h o
logically m a n u f a c tu r in g his s y m p to m s because
this will o b stru c t th e e sta b lish in g of a w o rk in g
rela tio n sh ip . T h e a p p r o a c h at first m a y , as
in th e p sy cho som atic p a tie n t, be o rg an iz ed
a r o u n d tension re d u ctio n to h e lp th e p a tie n t

th in g s fo r y o u rself. T o g e th e r w e sh o u ld m a k e

assu ag e suffering. As tensio n is lessened, the


p a ti e n t will begin ta lk in g m o r e a b o u t him self

p ro g re s s.

a n d p e r h a p s a b o u t some fam ily a d ju s tm e n t

T h e p a tie n t w ith a psych oso m atic p ro b le m


is often unconvinced th a t his physical s y m p to m
is or can be e m o tio n ally d ete r m in e d . T h e best
w a y of losing such a p a tie n t is to insist th a t his
p ro b le m is psychological. Since the p a tie n t
m a y , at least te m p o ra r ily , need his sy m p to m ,
the th e r a p ist is wise at th e s ta rt of t h e r a p y to
allow the p a ti e n t to re ta in th e idea of its organicity. H e m a y inform th e p a tie n t t h a t a ny
sy m p to m , even a n o rg a n ic sy m p to m , creates
tension because of discomfort o r p ain . T h e te n
sion delays healing. W h a t needs to be d o n e is
to reduce tension , an d this can stim u la te the
h ealin g process. T e a c h in g th e p a ti e n t sim ple
r e la x in g m eth o d s a n d a llo w in g th e p a ti e n t to

p ro b le m s. T h e th e r a p is t m a y soon be a b le to
in q u i re a b o u t th e hopes, a m b itio n s, a n d goals
of th e p a tie n t. Q u e stio n s m a y be asked such as
W h a t w o u ld you like to d o ? H o w w ou ld
you like to feel? W h a t d o you en joy m o s t?
V e ry often w h e n th e p a tie n t realizes th a t the
th e r a p is t does no t expect c o n fo rm ity to s t a n d
a rd s th a t o th e r s set for the p a tie n t, a t h e r a
p eutic allian ce will begin. Reflecting the p a
t i e n t s a n g e r w ith o u t c o n d e m n in g it h elp s c o n
vince th e p a ti e n t th a t he is n ot b ad for feeling
th e w a y he does. H o w th e p a ti e n t can go a b o u t
fulfilling his o w n goals is th e n p la n n e d . A n in
teresting article on te c h n iq u e s of d ealin g w ith
such u n m o tiv a te d p a tie n ts has been w r it te n by
S w a n so n an d W o o ls o n (1973).

52

H ANDBO OK OF SHORT-TERM PSYCHOTHERAPY

If a p a t i e n t is r e f e r r e d
for tre a tm e n t, how
p r e p a r e t h e p e r s o n to
th e rap ist w h e n th ere
r e c e iv e h e l p ?

w h o is u n p r e p a r e d
does a c o u n selo r
a c c e p t r e f e r r a l to a
is n o i n c e n t i v e to

A n e x a m p le m a y illu s trate th e situ atio n . A


college stu d en t is referred to a co un selor by h e r

possible for you to rectify this. P e r h a p s th e r e


is n t an y desire to go o u t because th e r e a re
fears of e x po sing yo urself to som e sort of co n
ta c t . T h e p a ti e n t m a y t h e n d en y this v e h e
m ently.
If th e c ou nselo r h a s g o tten th e s tu d e n t to

school advisor because she w as b ecom ing m o re

ta lk a b o u t herself, the ch an ces a re she will ask


for a n o th e r co nference w ith th e counselor. At

an d m o re of a recluse, avo id in g social activities


an d even stay ing a w a y from classes. O n in t e r

th e nex t visit she will p e r h a p s say th a t she h as


th o u g h t th e m a t te r over a n d she does feel th a t

view she is m anifestly depressed. H o w e v e r, she

p e r h a p s she m ig h t be co n cealing from h erself

h a s no desire for th e r a p y a n d no idea th a t


th e r e is a n y th i n g w ro n g w ith the w a y she is

re aso n s w h y she does n ot w a n t to go out.


U n d e r these circu m sta n c es th e co un selor m a y

behaving. She insists in d ig n a n tly th a t th e r e is

in fo rm h e r th a t th e r e a r e c e rta in p e rs o n s w h o

n o th in g w r o n g w ith h e r m in d . B ecause she


refused to go o u t does n ot m e a n she needs a

th e p a st p s y c h o th e ra p is ts w e re looked u p o n as

p sychiatrist. T h e q u estio n is h o w to get this

p eo p le w h o m in is te red to only severe e m o

girl to accept psyc h o th erap y .

tion al difficulties, b u t in recen t years they h ave

specialize in h a n d li n g p ro b le m s of this type. In

In h a n d lin g this ty pe of p ro b lem , th e first

been h a n d li n g bo th m i n o r a n d m a j o r p ro b le m s

th in g the c o un selo r w o u ld w a n t to do is es
tablish som e sort of a n incentive for th e r a p y .
W i t h o u t th is incentive, it w o u ld be useless to

of n o r m a l p eople; p eop le w h o could be m u c h


m o r e h a p p y w ith i n them selves a n d m o re effi
cient

refer the p a tie n t to a th e r a p ist. H o w to create


an incentive is th e case in p oint. O n e w a y is to

p s y c h o th e ra p e u tic help.
Before re f e rrin g a p rosp ectiv e p a ti e n t to a

ask if she is com pletely satisfied w ith

th erap ist

her

in

th e ir

it

w ork

w ou ld

or

be

stu d ies w ith

im p o rtan t

fo r

som e

th e

p re s e n t-d a y life a n d a d ju s tm e n t. If she says


t h a t e ve rythin g is g oin g a lo n g well, th e t h e r a

c ou nselor (1) to estab lish th e existence of a

pist m a y say: It is very g ratify in g to feel th a t


yo u a r e c o m p l e t e l y sa tis f ie d , a n d u n d e r

to deal w ith o r to clarify w h a te v e r resistan ce


t h e r e m a y e x is t t h a t m a k e s t h e p e r s o n

s tan d a b ly u n d e r th ose circu m stances, you will

re lu c ta n t to con sult a th e r a p is t, a n d (3) to c o r


rect a n y e x isting m isco nce ptio ns a b o u t p sy c h o
th e r a p y . H o w tr u ly m o tiv ated for tr e a tm e n t

w a n t to do very little a b o u t yourself. T h e r e


m ay, how ever, be certain a r e a s th a t a r e not as
p le a s a n t for you as you m ig h t w a n t. A re you
satisfied the w a y e v eryth ing is going in every
a r e a ? S ho u ld th e a d a m a n t reply be th a t
th in g s n ow a re perfect, th e th e r a p is t m a y have
no a lte rn a tiv e t h a n to b rin g o ut the p re v a ilin g
a d ju s tm e n t difficulties, such as stay in g a w a y
from classes. At the end of the session th e still
unconvinced s tu d e n t is invited to r e t u r n at a n y
tim e she feels she w a n ts to talk th in g s over.
O n th e o th e r h a n d , the s tu d e n t m a y a d m it
th a t w h ile th in g s a re no t too b a d , th e r e is th e
p ro b le m th a t she does n ot seem to h ave th e
e n erg y to go o u t w ith boys t h o u g h she likes
boys. T h e cou nselo r re to rts : If you really
have a desire to get m o re energy, it m a y be

definite p ro b le m for w h ic h help is nee d e d , (2)

th e p a ti e n t will be w h e n a th e r a p is t is co n
sulted will d e p e n d on h o w good a j o b th e
co u n selo r h a s do ne. B u t, g ettin g th e p a ti e n t to
a th e r a p is t is th e first step.

S in c e t h e p r e s e n c e o f e m p a t h y is u s u a l l y
m e n t i o n e d as t h e k e y n o t e to a t h e r a p e u t i c
a l l i a n c e , w h a t h a p p e n s if y o u s i m p l y c a n
n o t e m p a th iz e w ith a p a rtic u la r p atien t?
D o e s t h is m e a n y o u c a n n o t t r e a t t h a t p a
tient?
It often h a p p e n s th a t a th e r a p is t does not
like th e k in d of h u m a n bein g th e p a ti e n t is at
th e tim e he p re s e n ts h im self for t r e a tm e n t, n o r
m a y th e th e r a p is t be a b le to co n d o n e th e life

53

THE INITIAL INTERVIEW: CO M M O N QUESTIONS


the p a tie n t h a s led, n o r a p p r o v e of his a t
titudes, m orals, values, o r objectives. T h i s does
no t m e a n one c an n o t w o r k w ith th e p a tie n t.
P ro b le m s develop w h e re th e th e r a p is t because
of in t o l e r a n c e , is h o s t il e o r j u d g m e n t a l .
P a rtic u la rly destructive to e sta b lish in g a w o r k
ing re latio n sh ip is re petition by th e th e r a p is t of
th e sam e kin d of a r b i t r a r y a n d d is a p p ro v in g
m a n n e r disp layed by o th e r a u th o r itie s w ith
w h o m th e p a ti e n t h a s come in to contact. T h e
p a tie n t h a s a lr e a d y set u p defenses ag a in s t

m ig h t as well co m m it suicide. (2) I feel d e


g ra d e d th a t I h a v e finally h a d to resort to p sy
ch iatric help. (3) If a n y b o d y finds o u t a b o u t
th e re a l m e, it will be too b a d for me. (4) I will
p ro b a b l y be b la m e d , rejected o r h ated . (5) I feel
foolish to com e h ere. It is silly for me to t h i n k I
need h elp for m y m in d . (6) T h i s m u s t m e a n I
a m g oin g in sane.
T h e th e r a p is t sh o u ld also c o u n te n a n c e w h a t
m a y be going on in th e t h e r a p i s t s o w n m ind.
T h e s e th o u g h ts a r e very ra r e ly a ckn o w led ged ,

these a u th o ritie s th a t will block his d eveloping

let

confidence in a th e r a p is t w h o m h e identifies
w ith past au th o rities. If the th e r a p is t can e x

f o r m u l a t i o n s s u c h as t h e fo l lo w in g : (1) I
w o n d e r if I m going to like this p a tie n t? (2) I

ercise control over im p ulses to v erbalize d i s a p

w o n d e r if he is going to like m e ? (3) I w o n d e r

p rov al,

criticism

if I m able to h e lp this p a ti e n t o r w h e t h e r his

gestures,

k in d of p ro b le m is th e sort th a t I can tr e a t? (4)


I w o n d e r if he can p a y m y fee a n d h o w a m I

th ro u g h

an d

can

facial

avoid

d is p la y in g

exp ressio n s

and

aspects of th e p a t i e n t s p e rs o n a lity will so on er


o r late r come t h r o u g h th a t m a y kindle w a r m
feelings in the th e ra p ist. M a n y p a tie n ts a t th e
s ta rt often tr y to test a th e r a p is t by d is p lay in g
a n g e r o r by p re s e n tin g the most sh ock in g or

alo n e

faced.

They

involve

all

sorts of

go in g to h a n d le th e s itu atio n in th e event th a t


h e is u n a b le to afford t r e a tm e n t w ith m e?
A s s u m in g on e can h a n d le o n e s o w n feel
ings, th e th e r a p is t m a y d ip lo m a tic a lly a sk the

d isag reeable aspects of them selves. If th e t h e r a


pist does n ot fall into this tr a p , th e w o r k in g r e

p a ti e n t q u e stio n s such as I w o n d e r if y ou a re

latio n s h ip m a y very well develop even in the


first session.

q u estio n s

H o w can y ou c o m m u n ic a te e m p a th y ?

suggested by o b se rv ing th e p a t i e n t s reaction s


a n d r e a d in g b etw e en the lines of w h a t th e p a
tien t is saying.

u p set a b o u t co m in g h e r e ?
about w hat

Do

I m ight

you have

be t h i n k in g

a b o u t y o u ? Y o u m a y feel this is the last


r e s o r t ! O t h e r q u e stio n s a n d c o m m e n ts will be

O n e m ay sh o w interest in w h a t th e p a tie n t
is saying by listen ing carefully, by ask in g
p ro p e r q uestions, a n d by d is p la y in g a p p r o
p r i a te facial expressions. S o m etim es c o m m u n i
catin g w h a t m u s t be on th e p a t i e n t s m in d
from clues given, v erbally a n d n o n v erb a lly , can
be helpful. T h e th e r a p is t m a y a sk him self,
W h a t goes o n in the p a t i e n t s m in d as h e sits
th e r e ta lk in g ? If one can p e n e tr a te b eyond
the facade of th e p a t i e n t s m anifest v e rb a l iz a
tions a n d get to th e core of w h a t he m a y
actu a lly be feeling, w h a t fears, a n d anxieties
exist, one m a y m a k e a stro n g im p ress io n on
th e patient. W h e n the p a ti e n t first comes to

Is t h e r e a n y w a y o n e c a n e x p e d i t e e m
p a th y to w a rd a p e rs o n w h o com es fro m a
socio eco no m ic g r o u p w ith w h ic h a t h e r a
p is t h a s li t t l e a f f in ity ?
In listening to a p a tie n t w h o belongs to a
s t r a t u m of society w ith w h ic h on e is n ot too fa
m ilia r, o ne m a y tr y to u n d e r s ta n d th e e x
pressio ns a n d id iom s th e p a ti e n t em p lo y s and
to utilize th e s a m e la n g u a g e form s so th a t one
c a n c o m m u n ic a te o n th e sa m e w av e length.
O n e m a y also tr y to find o u t if th e destructive
p a tt e r n s the p a ti e n t ind u lges a re th ose co m m o n

th e r a p y , he is u su a lly q u it e up set, fearful,


an g ry , o r fru stra te d a n d he m a y a n tic ip a te to o r co nd on ed by the p a t i e n t s su b c u ltu ra l
co un terho stility or d is a p p ro v a l. T y p ic a l ideas g ro u p , for e x a m p l e alcoholic excesses, d a n
th a t occupy the p a t i e n t s m i n d a re these: (1) g ero u s d r u g u sag e, o r delin q u en cy . It is neces
T h i s is m y last resort. If th is d o e s n t w o rk , I sary to m a k e su r e at th e s ta rt th a t o ne does not

54

H ANDBO OK OF SHORT-TERM PSYCHOTHERAPY

convey d is a p p ro v a l o r disgust at in dulgences


the p a tie n t m a y co nsider n o rm a l. L a t e r on,
w h e n a w o rk in g r e la tio n s h ip exists w ith the
p a tie n t, it m ay be possible to p o in t o ut d e s tru c
tive p a tt e r n s th a t s u p p o r t the p ro b le m s for
w h ich h elp is bein g sought. T h e th e r a p ist m a y
also keep ask in g himself, especially w h e n th e
p a tie n t comes from a d isad v a n ta g e d g ro u p ,

I n s p it e o f a ll t h e e f f o rts y o u m a k e to be
t o l e r a n t , w h a t d o y o u d o if y o u still f i n d
y o u rself b ein g u n sy m p a th e tic , even
actually disliking th e p atien t?
If y o u r feelings interfere w ith y o u r do ing
t h e r a p y , sim ply tr a n sfe r th e p a tie n t to a n o th e r
th e r a p is t. B u t, in all p r o b a b ility th e p a tie n t
will leave you first.

ho w the th e r a p is t w ou ld feel a n d w h a t he
w ou ld do if he h a d to e n d u r e th e into leran ces
an d abuses th e p a tie n t w e n t th r o u g h in th e p a
t i e n t s p ast life. W o u ld he be a n y different?
T h e th e r a p is t m a y th e n b e tter be able to e m p a
th iz e w ith the patient.

W h a t d o y o u d o if a p a t i e n t t u r n s o n y o u
a n d a tta c k s y o u v e r b a l l y d u r i n g t h e i n i t i a l
in te rv iew ?

H ow w o u ld y ou show a p a tien t you are


to le ra n t of b e h a v io r a b o u t w h ich the p a
t i e n t p e r s o n a l l y is a s h a m e d a n d c a n n o t o r
w ill n o t do m u c h a b o u t?
S o m e p a ti e n ts will expect you, p e r h a p s even
w a n t you to d is a p p ro v e of th e ir b eh av io r. If
you co m p ly w ith th is w ish, it m a y te m p o r a r ily
be stab ilizin g by fu r n is h in g th e p a ti e n t w ith an
outside control. T h e im p ro v e m e n t, h ow ev er,

w h e n they come to th e in itial interview . T h e

will be short-lived as long as th e p a ti e n t h a s a


stake in destructively actin g o u t p a tte rn s . T h e

M any

p a tie n ts a re in w a rd l y very hostile

reaso ns for this vary. T h e p a tie n t m a y r i g h t

p a ti e n t will th e n defy you o r deceive you by

fully resent w a itin g for an a p p o in t m e n t , the

p e r p e t u a ti n g th e p a t t e r n s secretly at th e sam e

r o u tin e of a clinic, the fee to be p ay ed, a n d


o th e r facts of life. O r hostility will stem from

ti m e th a t a n g e r a n d gu ilt a c c u m u la te . T h e

in n e r sources not at all relate d to reality. T h e


th e r a p ist m u st accept this hostility a n d n ot act
th r e a te n e d by it n o r re s p o n d in a n y adverse

best w a y to m a n a g e a n y rev elation of conduct


a b o u t w h ich th e p a tie n t seem s gu ilty is to
r e m a r k th a t th e p a tie n t a p p e a r s to be guilty

w ay . H ostility sho uld be h a n d le d by b rin g in g


it out in the op en d u r i n g th e in terv iew , clarify

a n d a s h a m e d of w h a t he or she is doing. T h e
follow ing ex cerpts illu s trate h o w I h a n d le d tw o

ing the reaso n for th e d is tu rb in g reality s i tu a

such cases:

th e r a p e u tic allian ce will, th erefo re, suffer. T h e

tion if o ne exists. O r w h e re hostility is not e x


plicable, a c asu al sta te m e n t m a y be m a d e such
as th e following:

T h . So w h a t?

T h . It is u n d e r s ta n d a b le th a t you h a v e su ffered a

T h . W e ll w h a t? Is th a t w h a t y o u ca m e to see m e

P t.
P t.

g r e a t d eal fro m y o u r p ro b le m . P e o p le w h o su f

I w a n t y o u to k n o w th a t I a m h o m o se x u a l.
(p a u se) W e ll?
a b o u t?

fer a g re a t d e a l o ften a r e re s e n tfu l of th e su ffer

P t.

in g th e y h a v e e x p e rie n c e d a n d th e ineffective

T h . Y ou

n ess of th e m e a s u re s th ey h a v e a d o p te d to g a in

N o , b u t h o w do yo u feel a b o u t it?
m u st feel th a t

I d is a p p ro v e o r sh o u ld

d is a p p ro v e .

h e lp . Y ou m ay be a n g ry a t th e fact th a t you

P t.

a r e ill, o r b ecau se of w h a t h a s h a p p e n e d to

T h . W h y sh o u ld I if i t s so m e th in g yo u w a n t to do.

D o n t y o u ?

yo u . M o s t p e o p le do feel re s e n tfu l of w h a t h a s

Y ou

h a p p e n e d to th e m . T h is is u n d e r s ta n d a b le . It

a n x io u s a good d e a l o f th e tim e . I s n t th a t

is n a tu r a l n o t to w a n t to ta lk a b o u t o n e s feel

to ld

m e th a t

y o u w e re d e p re ss e d

and

w h a t yo u ca m e to see m e a b o u t?

in g s of r e s e n tm e n t, too. T h e re a so n I a m te ll

P t.

Y es, it is.

in g y ou th is is th a t it is p o ssib le yo u m a y even

T h . So l e ts w o rk at th a t. N o w , if y o u r ch o ice o f a

feel a n g r y a t m e o r a t th e c lin ic as a re s u lt. If

s e x u a l p a r tn e r h a s so m e th in g to do w ith th ese

y ou d o , do n o t feel g u ilty if y o u ta lk a b o u t it.

s y m p to m s w e ll ta lk a b o u t th a t.

THE INITIAL INTERVIEW: COM M O N QUESTIONS


P t.

[o b v io u sly re lie ved \

F in e ,

I k n e w you w e re

lib e ra l a b o u t th ese th in g s.

h ave for m a n y y ea rs em p lo y ed it in c a se w o rk on
a s h o r t- t e r m basis. S im ila rly som e c o un selin g

A p a tie n t in h e r m id dle 60s ca m e for h elp to


relieve p ain follow ing a b reast a m p u t a t i o n for
cancer.

a p p r o a c h e s h av e o p e ra te d a r o u n d a s i m i la r e x
p o s u r e of th e i m m e d i a te c o m p la in t factor. B oth
ca se w o rk a n d co u n selin g h a v e often s u b s ta n ti
ated im p ro v e m e n t b ey on d th e m e r e a lt e r a t io n of
th e

P t.

I h a v e to tell y o u , d o c to r (la u g h s ) th a t I h a v e a
little

h a b it th a t

I am

55

asham ed

en v iro n m en tal

d istu rb a n c e s

or

sym p-

tom ic u p sets th a t initiated th e c o n su lta tio n s.

to tell you

a b o u t.
T h . A re y ou a fra id o f w h a t m y r e a c tio n w ill be?
P t.

N o , I g u ess 1 d o n t lik e it m yself. I t s th a t


w h e n e v e r I go in to a sto re , I lift-sn e a k a little
th in g in m y p u rs e o r bag.

T h . H o w d o y o u feel a b o u t it?
P t.

I g u ess I do it fo r th e e x c ite m e n t. I u su a lly


d o n t n eed th e tr in k e t. I g u e ss y o u d call it
k le p to m a n ia . I re a d a b o u t it.

T h . Y ou m u st d is a p p ro v e of it, o r d o e s n t it b o th e r
you?
P t.

M y h e a rt tre m b le s fo r h o u rs a f te rw a rd . W h a t
if I m c a u g h t? T h e d isg ra c e .

T h . If it d o es b o th e r y ou e n o u g h , w e o u g h t to ta k e
P t.

H o w d o e s a t h e r a p i s t k n o w w h e t h e r h is
a p p r a i s a l o f a c h o s e n f o c u s is t h e c o r r e c t
one?
A t h e r a p i s t s j u d g m e n t c o n c e rn in g existing
core p ro b le m s involves sp ecu latio n s t h a t are
not a lw a y s con sistent w ith w h a t a n o th e r t h e r a
pist m a y hy po the size. G iv en th e sam e d a ta ,
different t h e r a p is t s will v a ry in w h a t th ey co n
sider is th e m ost significant a r e a on w h ic h to
focus. In a sm a ll e x p e r i m e n t th a t I c o nd ucte d
th r e e e x p erie n c ed th e r a p is ts tr a in e d in the
sa m e a n a ly tic school w itn essed the first tw o

it u p in o u r ta lk s h e re .

s e s sio n s

D o you th in k

t h r o u g h a o n e -w a y m i rro r . E a c h th e r a p is t h a d
a s o m e w h a t different idea of w h a t m e an in g fu l

I ca n get o v er th is h a b it? It

s ta rte d sh o rtly a fte r m y h u s b a n d d ied .


T h . P e r h a p s you felt d e p riv e d . B u t if y o u re a lly
w a n t to g et o v e r it, t h a t s n in e - te n th s o f th e
b a ttle .

A re r e a s o n s f o r s e e k in g h e l p at t h e t i m e o f
c o m i n g fo r h e l p a g o o d t h i n g to fo c u s o n ?
H a r r i s et al (1964) describe a 3 -y e ar project
at th e L an g ley P o r t e r N e u ro p s y c h i a tr i c I n
s titute in S an F ra n c isco w h e re a m e th o d of u p
to seven sessions w a s designed a r o u n d th e focus
of th e factors th a t enjo in ed th e p a tie n t to come
to th e clinic. T h e q u estio n s e x p lo re d w e re w h y
the p a tie n t w a s seeking h e lp a t th is tim e an d
w h a t he or she expected o u t of th e contact w ith
the clinic. T h i s a p p r o a c h served n ot only as a
satisfactory in ta k e m e th o d , b u t also p ro d u c e d a
r e t u r n to a d e q u a t e fu n c tio n in g in a significant
n u m b e r of patien ts. F o r the r e m a in i n g p a tie n ts
the brief ex perien ce help ed d e lin e a te th e p r o b
lem, clarified th e exten t of m o tiv atio n , an d
acted as p r e p a r a ti o n for c o n tin u in g h e lp or in
tensive tr e a tm e n t. F o cu sing on the h elp -seek in g
factors is n o th in g new . S o cia l-w o rk agencies

cond u cte d

by

fou rth

colleague

topic w a s best o n w h ic h to focus. In m y


o p in io n , such differences a re n ot significant b e
c au se m u ltip le p ro b le m s c an exist a n d these
a re u su ally in te rre la te d . Even w h e re one
strik es

th e

p a t i e n t s c o re

d if fic u ltie s

tan-

g entially, o ne m a y still reg ister a n im p a c t an d


s p u r the p a tie n t o n t o w a r d a b e tte r a d a p ta tio n .
A fter all, a re a s o n a b ly in tellig en t p a t i e n t is
c a p a b le of m a k i n g con nection s a n d even of c o r
rectin g the m isp e rc e p tio n s of a th e r a p is t w h e re
a good w o r k in g r e l a ti o n s h ip exists a n d the
th e r a p is t does not re s p o n d to b eing criticized
too d ras tica lly w ith a d isp lay of w o u n d e d n a r
cissism. F r o m a p r a g m a ti c s ta n d p o in t, the
focus is an a c c u ra te on e if th e p a ti e n t re s p o n d s
positively to it.

C a n a p e r s o n g e t w e ll w i t h o u t n e e d i n g to
w o r k o n b a s ic n u c l e a r c o n flic ts?
G e tti n g well e m b r a c e s m a n y d egrees of
im p ro v e m e n t. M o s t p eo p le m a k e a fairly good
a d a p ta tio n w h ile re t a in i n g som e aspects of

56

HANDBO OK OF SHORT-TERM PSYCHOTHERAPY

th e ir deepest conflicts. In s h o r t-t e rm th e r a p y


we usually deal w ith seco nd ary derivative co n
flicts because of th e lack of tim e for d e p th
p ro b in g a n d the w o r k in g - th r o u g h of resistance.
H o w e v e r, p e rs o n a lity c h a n g es can result over a

H o w w o u l d y o u a c c o u n t f o r t h e fact t h a t
e v e n t h o u g h fe w o r n o p s y c h o d y n a m i c s
m a y b e a p p a r e n t d u r i n g t h e f irs t i n t e r
v i e w , t h e p a t i e n t still m a y e x p e r i e n c e a
g o o d d e a l o f re li e f ?

period follow ing th e r a p y if th e p a tie n t co n

T h e r e a re m a n y reaso n s for this. F ir st, th e

sistently w o rk s on h im self an d his p ro b lem s.

e m p a t h ic u n d e r s ta n d in g of th e th e r a p is t e n a

A p p a r e n tl y n u c le a r conflicts m a y som etim es be

bles th e p a tie n t to u n b u r d e n h im self o r herself


in a n a tm o s p h e r e sh o r n of b la m e a n d a u th o r -

influenced t h r o u g h re solu tio n of th e i r m a n i


festations in s eco n d ary conflicts. H itch coc k a n d
M o o n e y (1969), for e x a m p le , have w ritte n
h o w in m e n ta l h ea lth c o nsultio n d ealin g w ith

atativ e p res su re. S im p ly relieving o neself of


p a in fu l t h o u g h t s reduces ten sion . B u t m o r e i m

th e c o n su ltee s w o rk -e g o function a lo n e can

p o r t a n tl y , p u t t i n g into w o rd s feelings th a t float


a r o u n d in a n e b u lo u s w a y ten ds to identify

h ave a m o re th a n superficial effect. D. Beck

th e m an d h elps the p a tie n t g a in co ntrol over

(1968) h as also w rit te n an in tere stin g article

th em . M o r e o v e r , reve alin g ideas a n d e x p e r i

accentin g th e valu e of w o r k in g on derivative

ences to a n a u th o r it y w h o does no t re s p o n d th e
w a y o th e r p a st a u th o r itie s h ave acted, o r the

conflicts. In m a n y types of s h o r t-t e rm th e r a p y


o p e n in g u p a b a g of w o r m s t h r o u g h b lu n t
in t e rp re ta ti o n of a n u c le a r conflict m a y create

w a y th e p a ti e n t im a g in e d th e y w o uld act or

m o r e p ro b le m s th a n it solves. T h e th e r a p is t

im ag e an d relieves guilt. F a i t h a n d tr u s t a re
kindled. T h e placeb o ele m e n t to the effect th a t

m u s t j u d g e h ow re a d y th e p a tie n t is for a n in
t e r p r e t a t i o n th a t is, h o w conscious th e p a
tien t is of an e x istin g conflict before e x p lo r
ing it. W h e r e th e p a ti e n t h a s such a n a w a r e
ness a n d w ishes to deal w ith his conflict, th ere
is no reaso n to avoid it.

sh o u ld

act,

softens

th e

intro jected

p a re n ta l

so m e th in g is a v a ilab le th a t can h elp a n d th a t


m a t te r s a r e no t hopeless, a n d th e im p a c t of d i
rect o r in direct sug gestions m a d e by the t h e r a
pist m a y in s p ire th e p a tie n t t o w a r d ta k i n g a
corrective p a th of t h i n k in g a n d beh avin g. O f
course, th e e x te n t of th e p a t i e n t s ta k i n g a d

S u p p o s e , in e v o l v i n g a w o r k i n g h y p o t h e
sis o f t h e p r o b l e m , t h a t t h e t h e r a p i s t h a p
p e n s to b e w r o n g . W o u l d it n o t b e b e t t e r
to w a it u n t i l m o r e facts a r e a v a i l a b l e
b e f o r e s p e c u l a t i n g a b o u t w h a t is g o in g
on?
W h il e th e th e r a p is t will w a n t to develop a
w o r k in g h y p oth esis of th e p ro b le m , he m u st
consider it te n tativ e at best. N o t all of th e facts
m a y be a vailab le d u r i n g th e first few in t e r
views. E ven if th e th e r a p is t is w r o n g or

v a n ta g e of these positive e le m e n ts will d ep e n d


on his re ad ine ss for ch ang e. W h e r e a re ad in ess
for c h a n g e exists in good m e a s u re , th e im p act
of th e first interv iew c an be d r a m a ti c even
t h o u g h basic n u c le a r conflicts a r e no t touched.
A n d th e p a ti e n t m a y be able to achieve an
e m o tio n al e q u il ib r iu m at least e q u iv a le n t to
th a t w h ich p re v a iled p r i o r to the onset of th e
p re s e n t illness.

C a n o n e p ro g n o stic a te fro m th e severity


o f s y m p t o m s o r t h e s ic k n e s s o f a p a t i e n t
the p o ssib ility of im p r o v e m e n t o r cu re?

p a rt ia l ly w r o n g in th e initial analysis, he will


be able to co rrect o r modify his ideas late r on.
If a c onnection w ith p e rs o n a lity factors o r in
n e r conflicts is n ot a p p a r e n t at the beginn in g,
o r if th e p a tie n t is not re a d y to co u n te n a n c e th e

N o . S o m etim es th e sickest p a tie n ts , even


h a llu c in a tin g psychotics, recover ra p id ly , w hile
w h a t seems like a mild d ep res sio n , a n x ie ty , or

im p licatio n s of such c on nections, i n t e r p r e t a


ti on s m a y be confined to the im m e d ia te en vi

c h a r a c t e r p ro b le m will scarcely budge. M a n y


v a ria b le s obviously exist o th e r th a n th e c u r r e n t

ro n m e n ta l p re c ip ita n ts w h ile w a itin g for m o re


d a t a before lin k in g th ese to u n d e rly in g in n er

sy m p to m s, w h ic h a re re la te d to th e p a t i e n t s
la t e n t ego s t r e n g t h , f l e x ib i li ty o f d e fe n s e s ,
read in ess for ch an g e, seco nd ary g a in , selective

difficulties o r m o r e o bscure e x te r n a l events.

THE INITIAL INTERVIEW: CO M M O N QUESTIONS


resp on se to tech niqu es, capacity for develo pin g
a th e r a p e u tic alliance, skill a n d p e rs o n a lity of
th e th e ra p ist, an d m a n y o th e r factors. T h e s e
will all influence th e outcom e. T h e effect of
these variab les ca n n o t be a n tic ip a te d in a d

57

comes to t h e r a p y w ith some basic tr u s t in the


t h e r a p is t as a professional w h o can help.
N a t u r a l l y , th e r e a r e a lw a y s la ten t som e ele
m e n ts of fear

and

d is tru s t, th e degree d e

vance since th ey display them selves only after

p e n d e n t on p rev io us e xp erie nce s w ith i r r a


tio nal a u th o r it y a n d w ith in c o m p e ta n t p ro fe s

th e r a p y has started .

sionals. It is u su a lly no t necessary to focus on


th e

Is t h e r e o n e f a c to r y o u w o u l d c o n s i d e r
t h e m o s t i m p o r t a n t o f all in i n s u r i n g g o o d
r e s u l t s in t h e r a p y ?

re la tio n s h ip

un less th e r e a r e evidences,

from th e b e h a v io r a n d v e rb a liz a tio n s of th e p a


tien t, th a t th e r e la tio n s h ip is no t going well o r

T h e r e a r e m a n y factors th a t a r e o p erativ e,

th a t tr a n sfe re n ce exists th a t is a c tin g as a


resistence to t r e a tm e n t. A s lo ng as the re l a ti o n

b u t I w o uld co nsid er th e q u a li ty of th e r e l a

sh ip a p p e a r s to be good, th e r e is no re a s o n to

tio n sh ip b e tw een th e th e r a p is t an d p a ti e n t th e

p ro b e o r c h a llen g e it.

most im p o r t a n t of all factors.

H o w m u c h c o n fro n ta tio n can be u tiliz e d


d u r in g the in itial in te rv iew ?
T h e r e a re v a ry in g o p inio n s. W h e r e th e first
in terview is e m ploy ed as a screen in g device to
de te rm in e the suitability of a p a tie n t for an
a n x ie ty -p ro v o k in g typ e of th e r a p y , such as
practiced by Sifneos, co n fr o n ta tio n is p a r t of a
selection p ro c ed u re. As a g en e ra l ru le, h o w
ever, w ith the a v e rag e p a tie n t, co n fro n ta tio n is

D o e s n o t t h e r e l a t i o n s h i p its e lf s p o n s o r
re c o n stru c tiv e ch a n g e w h e r e the th e ra p ist
is a c c e p t i n g a n d t o l e r a n t ?
A n a s s u m p ti o n is often m a d e th a t everyone
h a s w ith in oneself th e ca pac ity to achieve
th e r a p e u ti c c h a n g e , p ro v id e d th e r e is a n on j u d g m e n t a l , n o n p u n it iv e a tm o s p h e r e in w hich
to ex p ress feelings w ith o u t fear of re ta lia tio n
o r censure. G r o w t h is said to be co n tin g e n t on
th e c onstructive r e l e a rn i n g th a t comes a b o u t as

best delayed u n til a good t h e r a p e u ti c allian ce

a b y -p ro d u c t of a n o n t r a u m a t i c rela tio n sh ip .

h a s been established to su s ta in th e p a t i e n t s
hostility a n d anx iety . O t h e r w is e the p a ti e n t is

The

ap t

to d ro p

o ut of t r e a tm e n t

p r e m a tu r e ly ,

in d iv idu al

h a s a n o p p o r t u n it y h e re to

revise in h e r e n t concepts of a u th o r it y o ut of a
n ew e x p e rien ce w ith th e th e r a p is t w h o o p e r

n er as an atta ck o r because he is u n a b le to

ates as a different kind of p a r e n t a l sym bol. In


practic e this h a p p y result does not often follow

h a n d le th e em o tio n s stirred u p in h im se lf as a
re sult of the po in ted challenges. In som e cases,

because th e in div idu al, even in a com pletely


n o n cen so rio u s e n v ir o n m e n t, will u su a lly p e r

how ever, the th e r a p is t is ca p a b le o f setting u p


a w o rk in g r e la tio n s h ip r a p i d ly in the first

ju stified a n d un ju stifiab le a ss u m p tio n s. Even

e 'th e r because h e m istakes th e th e r a p i s t s m a n

p e tu a te p e rs o n a l p ro b le m s by cling in g to u n

se s sio n , u n d e r w h i c h c i r c u m s t a n c e c a r e f u l

th o u g h

em p a th ic con fro n tatio n m a y be g ainfully e m


ployed.

p a r e n t a l attitu d e s o r d isp lay th e ir in tolerance,


th e p a tie n t m a y react as if th e o rig in a l a u t h o r
ities w e re still presen t. T h i s is because the

S h o u l d n o t t h e t h e r a p i s t c h o o s e as a
p r e f e r r e d fo c u s t h e r e l a t i o n s h i p b e t w e e n
h im s e lf a n d th e p atien t?

p ro b le m h a s been in te rn a liz e d a n d forces the


p a ti e n t to o p e r a t e w ith a sense of values th a t,
merciless as it is, is u n c o rrecte d by reality.
In d eed, the p a ti e n t m a y even becom e in d ig n a n t
to w a r d th e t h e r a p i s t s to le ra n t s ta n d a r d s an d

Effective le a r n in g can proceed only in the


m e d iu m of a good in te rp e r s o n a l re latio n sh ip .
T h e la tter serves as th e m a t r i x for w h a te v e r
th e o r e ti c a l a n d m e t h o d o l o g i c a l s t r u c t u r e s
fashion the tr e a tm e n t m a n e u v e rs of th e t h e r a
pist. O n e u su ally a ssu m es th a t th e p a tie n t

th e

th e rap ist

does

not rep eat

th e

b e h a v io r as offering te m p ta t io n s for w h ic h one


will late r p a y d early . T h i s serves as resistance
a g a in s t a lte rin g o n e s values. W e , nevertheless,
tr y to p ro m o te ch a n g e by detection of negative

58

HANDBO OK OF SHORT-TERM PSYCHOTHERAPY

attitu d e s a n d tra n sferen ce feelings an d by th eir


in te rp re ta tio n an d w o rk in g - th ro u g h .

H ow im p o rta n t are o p tim ism an d


th u siasm on th e p a rt o f th e th e ra p ist?

en

V e ry im p o rta n t. O p tim is m an d e n th u s ia s m
in sp ire faith a n d tr u s t an d tend to n e u tr a liz e
d e s p a ir and hopelessness. T h e th e r a p i s t s belief
in him self an d in his tec h n iq u es m u s t, of
course, be real, since sim u la te d o p tim ism will
easily be detected a nd will d a m a g e th e r e l a
tionship.

cord in gly tries to correct attitu d e s th a t will i n


terfere w ith estab lish in g a th e r a p e u tic alliance.

S h o u ld the th e ra p ist p r e p a r e the p a tie n t


f o r t e r m i n a t i o n o f t r e a t m e n t at t h e first
in te rv iew ?
P r o p e r p r e p a r a t i o n of th e p a tie n t for t e r m i
n a tio n is a n ex tre m e ly i m p o r t a n t, yet th e most
grossly neglected, aspect of tr e a tm e n t. T h e
t h e r a p is t sh o u ld be ale rte d for signs, even in
th e first interview , of i m p e n d in g p ro b le m s w ith
t e r m i n a ti o n since the e n d in g of tr e a t m e n t can
be e x trem ely difficult an d d is tu rb i n g for som e
p atien ts . M o r e o v e r , th e th e r a p is t will need to

T h e r e is s o m e c o n t r o v e r s y a b o u t t h e r o l e
o f p o s it iv e e x p e c t a t i o n o n t h e p a r t o f th e
p a t i e n t in p r o m o t i n g c h a n g e . D o e s e x p e c
tatio n in flu e n ce s h o rt-te rm th e ra p y ?

d e p e n d e n t on h im . T h e th e r a p is t m a y co nsid er
t h e t e r m i n a t i o n o f t r e a t m e n t a f o r m of

be a w a r e o f his o w n guilt at d is c h a rg in g som e


p atien ts , p a r t ic u l a r ly th ose w h o h ave become

As is usual in som e q u estion s, the a n s w e r is

a b a n d o n m e n t. O n th e p a t i e n t s p a r t , t e r m i n a

yes an d no. E x p e c ta tio n th a t one will ch an g e

tion m a y k in d le p re vio us u p se ttin g re actio ns

acts as a place bo e n h a n c in g th e p a t i e n t s faith

w ith exp erien ces of s e p a r a ti o n o r loss even as

in th e th e r a p is t a n d

in the o p erativ e te c h

far back as child ho od . T h e p a ti e n t m a y in t e r

n iq ues. T h e t h e r a p e u ti c s itu atio n itself is a

p re t te r m i n a ti o n as a sign of th e t h e r a p i s t s ir

suggestive a r e n a th a t p ro m o te s e x p ecta tio n s of


change. O n the o th e r h a n d , e x pec tatio n m a y

resp on sibility or lack of concern a n d this will


activ ate a d evalu ed self-image. If a t th e first in

be bridled to certain a s s u m p tio n s a b o u t th e


t h e r a p i s t s p o w e r an d invincibility th a t can be

terv iew th e th e r a p is t discusses w ith th e p a tie n t

unrealistic. W h e n the p atie n t learn s th a t the


th e r a p is t h as no m agic a n d th a t th e p a tie n t

tr e a tm e n t w ith re s e n tm e n t a n d feelings of loss,

h im self m u st w o r k to achieve c han ge, his e x


p ecta tions m ay d w in d le to n o th in g a n d m ay
even act as a negative placebo.

Is y o u r i m m e d i a t e i m p r e s s i o n o f w h e t h e r
y o u lik e a p e r s o n o r n o t a g o o d g a u g e o f
h o w t h e r e l a t i o n s h i p w ill d e v e l o p ?
T h a t d ep e n d s on w h e th e r th e th e r a p is t is
able to a n a ly z e his o w n c o u n te rtra n sfe re n c e
an d prejudices. In itial im p ression s a re often
the p ro d u cts of p ast ex periences w ith a perso n
o r p erson w h o m the p atie n t resem ble s o r of in
toleran ce related to th e p a t i e n t s race, religion,
sex, age, facial ex pression , m a n n e r , speech,
a n d th e like. M isco n cep tio n s can a b o u n d , but
a m a t u r e th e r a p is t keeps a n a ly z in g his ow n
reaction s to see w h e th e r th ey a re the result of
co u n te r tr a n sfe re n c e o r prejudice, an d he ac

t h a t som e p a tie n ts re s p o n d to te r m i n a ti o n of
this m a y ease, th o u g h no t entirely dissipa te,
th e p a t i e n t s even tua l reactio n of a n g e r an d
d is a p p o in tm e n t.
W h e r e the histo ry reveals a n e arly loss of,
s e p a r a tio n from , o r a b a n d o n m e n t by a p a r e n t ,
th e th e r a p is t m u s t be trip ly m ind fu l of th e
need to p r e p a r e th e p a tie n t for te r m i n a ti o n an d
to w a tc h for e a rly signs of a n g e r, d ep ression ,
a n d grief. T h e p a tie n t, as p a r t of tr e a tm e n t,
should be en co u ra g e d to talk a b o u t develo ping
s e p a r a tio n re actio ns as well as past se p a r a tio n
experiences. A m o n g th e e m e r g in g se p a r a tio n
reactio ns will be a r e t u r n of old c o m p la in ts
a n d the d ev elo p m e n t of n ew sy m p to m s such as
an x iety , d e pre ssio n, an d p sy cho som atic c o m
plain ts. S om e p a tie n ts re s p o n d to te r m i n a ti o n
by d enial; w h e re th e r e a re signs of th is, th e
th e r a p is t m u s t actively in t e r p r e t th e resp on se.
V astly im p o r t a n t is the need for th e th e r a p is t

THE INITIAL INTERVIEW: CO M M O N QUESTIONS

59

not to consider the p a t i e n t s hostility as a p e r

w a iti n g list after a n in itial interview . F o r e x

sonal affront.

a m p le , in on e stu d y (S loan e et al., 1975) 94

A re p s y c h o lo g ic a l tests n e c e s s a r y in s h o r t
te rm th erap y ?

p a tie n ts w ere seen initially by ex perienced


th e r a p is ts a n d th e n ra n d o m ly assigned to (1) a

G e n e ra lly , no, A ra p id e x p o su r e of th e p a

w a iti n g list, (2) s h o r t-t e rm b e h a v io r t h e r a p y ,


a n d (3) s h o r t- t e r m p sy c h o an aly tically o rien ted

tient to the R o rsc h a ch c a rd s an d to a m a n w o m a n d r a w i n g , t h o u g h th e y a r e s t r ic t ly

p s y c h o th e ra p y for 13 or 14 sessions. F o llo w - u p


after 4 m o n th s by assessors sh o w ed th a t ta rg et

sp eak in g not tests in the form al sense, a re

sy m p to m s in all th r e e g ro u p s im p ro v e d , but
so m e w h a t m o re so in the tre a te d g ro u p s . W o r k

som etim es helpful d iag no stically a n d to w a rd


sp ottin g a d y n a m ic focus. T h e sam e c a n be
said for the T h e m a t i c A p p e rc e p tio n C a r d s .

W hat ab o u t the M in n e so ta M u ltip h a sic


T e st?

an d social a d ju s tm e n t sh o w ed no differences.
A ll th ree g ro u p s 1 y e a r an d 2 years after the
initial in tervie w h a d im p ro v e d significantly
re gard less of w h e th e r o r not f u r th e r t r e a t
m e n t w a s received d u r i n g this p e r i o d . W e

A g re at deal of in fo rm a tio n can be gotto n

m ig h t c onclude fro m this th a t w ith the n o

from the M M T , a lth o u g h a good in terv ie w er


can get sufficient m a te ria l to w o rk on th r o u g h

t r e a tm e n t g r o u p d o in g a lm o st as well as the
tre a te d g ro u p s after 4 m o n t h s a n d fully as well

o r d i n a ry history tak ing . M o s t th e r a p is ts do not

after 1 a n d 2 years, form al p s y c h o t h e ra p y w as

give th e ir p a tie n ts r o u t in e tests like th e M M T ,


intelligence tests, an d the like, unless th e r e are

d ispensable.

special reason s for testing.

T h e fallacy of this a s s u m p tio n is th a t w e fail


to credit th e in itial in terv iew w ith th e t h e r a
p eu tic im p act th a t it c an score by itself even

Is it a d v i s a b l e to m a k e a n i n i t i a l d i a g n o s i s
o n e v e r y case?
Yes, for m a n y reasons. T h e initial diagnosis,
how ever, m a y have to be c h a n g e d as m o re in

w h e re no f u r th e r professional h elp is secured.


N o r is it tr u e th a t a p a ti e n t on a w a iti n g list
la ng uish es w ith o u t e x p lo itin g o th e r h e lp in g
resources. O fte n after a good in itial interv iew

fo rm a tion is o b ta in ed d u r i n g th e r a p y .

the p a tie n t will h av e o b ta in e d sufficient s u p


p o rt, r e a s s u ra n c e , a w a re n e s s , a n d h o p e to

A re p a s t d r e a m s i m p o r t a n t to e x p l o r e in
the in itial in te rv iew ?

ble h e lp in g aids ou tsid e of form al tr e a tm e n t.


W e sho uld , th erefo re, con sider even a single

m u s te r latent co p in g capacities or to find s u i ta

V e ry m u c h so. D r e a m s often reveal th e o p


erative d y n a m ic s not o b ta i n a b le th r o u g h u su al
interview tech niqu es. R epetitive d r e a m s an d
n ig h tm a r e s a re especially im p o r t a n t. A sk in g
for d re a m s th a t th e p atie n t can re m e m b e r from
ch ildhood m a y also be valuable.

It h a s b e e n s ta te d t h a t p a t i e n t s w h o w e r e
i n t e r v i e w e d a n d p u t o n a w a i t i n g lis t d i d
a l m o s t as w e ll o n t h e i r o w n as t h o s e w h o
w e r e a c c e p te d f o r f o r m a l t r e a t m e n t . If
th is is t r u e , is n o t t h e r a p y s u p e r f l u o u s ?

in ta k e interview a form of s h o r t- t e r m th e r a p y .
T h a t even o n e or tw o sessions have on fol
lo w -u p registered them selves th e r a p e u tic a lly
on p a tie n ts h a s been r e p o r te d by a n u m b e r of
observers, such as M a l a n et al (1975). N o t
o nly h a d s y m p to m a tic im p ro v e m e n t occu rred ,
b u t in so m e ca ses th e s o l i t a r y i n t e r v i e w
a p p e a r s to h a v e r e l e a s e d fo rces p r o d u c i n g
noticeable, a n d in som e cases significant an d
lastin g d y n a m ic , changes. At the B eth Israel

Some skeptics d o w n g ra d e p s y c h o th e ra p y byp o in tin g ou t th a t th ere is no a d v a n ta g e in

Flospital in B oston a sizable g r o u p of p a tie n ts


w ere given a d iag n o s tic inte rview in th e form
of a tw o-session eva lua tion . N o o th e r th e r a p y
w a s a d m in is te re d . A follow -u p in terview 1

formal tr e a tm e n t to sim p ly being placed on a

m o n th

late r revealed

a subgroup

who

im

60

HANDBO OK OF SHORT-TERM PSYCHOTHERAPY

p rov ed w ith no o th e r th e r a p y . T h e results


co nfirm the con ception of th e diagn ostic in t e r
view as a d y n a m ic in te rp e r s o n a l process a n d
ad ds s u p p o r t to th e evidence th a t b rie f psy
c h iatric contac t d u r i n g tim es of stress can

su stain

or co n tin u e th e ir im p ro v e m e n t will

p ro b a b l y d e p e n d on th e n a t u r e of th e ir t r a n s
f o r m a t i o n , t h e i r p r e v a i l i n g m o t i v a t i o n to
c h a n g e , t h e i r a b i l i t y to r e l e a s e th e m s e l v e s
fro m th e ir m a l a d a p ti v e co p in g p a tt e rn s , a n d

p ro d u c e significant c han ges in affect a n d b e

w h e th e r o r no t th e i r e n v ir o n m e n t reinforces o r

h a v io r . W h e t h e r p a tie n ts w h o im p ro v e will

d isco ura ges th e dev elop in g a lte ra tio n s.

CHAPTER 6

The Initial Interview


B. Case Histories

A lth o u g h every initial interv iew will be co n


ducted so m e w h a t differently d e p e n d in g o n the

terview s th a t b ri n g ou t som e salient featu res


c o m m o n ly en c o u n te re d in first, a d e v e lo p m e n

p rese ntin g p ro b le m , the ca p a city for v e rb a l iz a

tal p e rs o n a lity p ro b le m , second, a n obsessive

tion, the p e rs o n a lity of th e p a tie n t, th e initial


resistances, co u n te rtra n sfe re n c e a ro u s a l, a n d so

n eurosis,

on, certain basic tech n iq u es a re m anifest. T h i s

te r m th e r a p y .

and,

th ird ,

schizoid p e rs o n a lity

d is o rd er, w h o is no t d eem e d s u ita b le for s h o r t

c h a p te r consists of th ree tra n sc rib e d in itial i n

Case 1
boy w ho se

a b o u t his difficulties, b u t to con fro n t th e p a

p a re n ts called for an a p p o in t m e n t , say in g th a t


he w as failing at school, defying his p a re n ts ,

tient. C o n f r o n t in g this boy w ith his resistan ce

f i g h ti n g w i t h

as a shock s tim u lu s s ta rtin g h im off to w a r d e n

The

p a tie n t

is a

16 -year-old

so m e o f h is c l a s s m a t e s

and

a n d v e rb a liz in g his rig h t to be a n g ry m a y act

W h a t concerned

listing the th e r a p is t as an ally to m a n i p u la t e

th e m most, h o w ever, w a s his go ing steady w ith


a girl. T h e y d id no t a p p ro v e on th e basis th a t

th e p a r e n t s to a b id e w ith his o w n desires. In


this w a y a re la tio n s h ip gets sta rte d th a t m ay

he w a s too y ou ng for a serio us relatio n sh ip .


T h e y w ere d e sp e r a te for som e direction as to

have th e r a p e u ti c p o ten tialities.

w h a t to do. T h e boy h ad resisted going to see a

T h . So th e y fin a lly c a p tu r e d y o u a n d b r o u g h t you

th e r a p ist un til th ey cut off his allow an c e , an d

h e re , h u h ? ( T h e r a p is t sm ile s a n d th e p a tie n t

then he consented to one a p p o in t m e n t . T h e

lo o k s u p , o b v io u s ly su rp ris e d . H e p a u s e s , th en

gen erally being o bn oxious.

b re a k s o u t in an e m b a r ra s se d la u g h .)

p a re n t s a c co m p a n ied h im a n d sat in th e w a i t
ing roo m . T h e session b rin g s ou t h o w to deal
w ith a defiant adolescent so th a t he m a y co n
tinu e in th e r a p y as well as h o w to select a d y
n am ic focus.
At the a p p o in te d tim e th e p a tie n t en te re d
my office, slouched into a chair, an d looked
a b o u t the ro o m in a n o n c o m m itta l w ay. T h e

P t.

Y es sir.

T h . A r e n t yo u so re a b o u t it?
P t.

N o , I g u e ss n o t.

T h . I d be fu rio u s , if I w e re in y o u r p o sitio n .
P t.

N o , I m n o t.

T h . A fter a ll, w h y w o u ld y o u co m e to see m e, e x


cept th a t th e y in v eig led y o u in to th is ? (s m ilin g
as i f jo k i n g )

tactic I have found useful in de alin g w ith such


reactio ns is not to engage in criticism s o r accu

T h . H o w d id th e y s p r in g it on y o u ?

sations, an d no t even to qu estio n th e p a tie n t

P t.

P t.

I fo rg o t a b o u t th is u n til last n ig h t.
W e h a d a n a p p o in tm e n t a t 1 0 :3 0 , th e y said.

62

HANDBO OK OF SHORT-TERM PSYCHOTHERAPY

T h . W h a m , j u s t lik e t h a t for w h a t re a so n d id
th e y give y o u ?
P t.

T h . W h a t do th e y ob ject to a b o u t h e r?
P t.

I d o n t k n o w th e y th in k I m sick I guess.

d o n t

T h . Y ou m e a n th e y th in k y o u re m e n ta lly sick?
P t.

P t.

m y m o th e r felt sh e s h o u ld n t h a v e called u p , I

u p so m e th in g is w ro n g .

g u ess. I s h o u ld h a v e ju st g o n e th e r e a n d m et
h e r. I d o n t k n o w w h a t it w as.

N o.

T h . In o th e r w o rd s, w h a t th e y a r e tr y in g to do is to
b r e a k th is th in g u p ?

th e sto ry o n th a t?

P t.

1 d o n t k n o w i t s j u s t th e w a y I get a lo n g

T h . A h h h , is th a t w h a t th e w h o le sto ry is a b o u t?
P t.

Yes.
w ith y o u r p a r e n ts ?

P t.

W e ll, ju s t so m e tim e s th e y re d iffe re n t, I d o n t


k n o w , th ey h a v e d iffe re n t v iew s a b o u t k id s an d

I d o n t k n o w . I g u ess it s tw o w ays.

th a t. T h a t s th e big g est g rip e , w ith th a t g irl.

T h . A re yo u g iv in g th e m a h a r d tim e ? A re you

T h . W ho

re a lly ? W h a t a re you d o in g ?

do

you

get

a lo n g

w ith

b e tte r ,

your

m o th e r o r y o u r fa th e r?

I d o n t k n o w , I d o n t go o u t of m y w a y , b u t I

P t.

have

T h . N e ith e r o n e of th e m . T h e y re b o th d ifficu lt

little

g ru d g e

a g a in s t

th e m .

I d o n t

k n o w , (p a u se)

sa m e th in g ? (p a u se) D o you th in k th a t if you

th e g ru d g e ?

g av e u p th is g irl th e y d be a n y d iffe re n t?

I d o n t k n o w .

P t.

T h . T h e y m e n tio n e d so m e th in g o n th e te le p h o n e .
Y o u re a t sch o ol n o w , a w a y fro m h o m e a n d
y o u ve g o t

N e ith e r.
r ig h t a t th is tim e ? A n d th ey b o th h a r p on th e

T h . W e ll, w h a t h av e th ey d o n e do th e y d eserv e

(p a u se) S o ?

g ir lf r ie n d is

th a t

th e

[ / n o te th a t th e p a tie n t se e m s

I d o u b t it.

T h . T h e y d p ick on so m e th in g else?
P t.

sto ry ?

a n g ry a n d fid g e tty . I d ecid e to s h o w h im th a t

I d o n t k n o w , you k n o w m y s is te r a n d I a re
very close, (p a u se)

T h . Y o u r sis te r a n d you a r e very close.


P t.

A n d yo u k n o w , s h e s u p a t co lleg e r ig h t n o w .

in c o n tr a st to h is p a r e n ts I b elieve h e h a s the

W e w rite . S h e w ro te m e a le tte r th a t i t s so

rig h t to ch o o se h is o w n c o m p a n y .] W h y do

d is a p p o in tin g

y ou th in k th e y stick th e ir nose in to th a t th in g ?

a n y tim e th a t sh e fin d s a b o y frie n d , o r a n y tim e

I d o n t k n o w .

T h . D o n t y ou re se n t it? D o y o u tell th e m e v e ry
th in g ?

to c o m e

hom e

because

th a t

I fin d so m e o n e w e ll, th is is re a lly th e first


g irl

I ve b een

p r e tty

s e rio u s

o v e r I d o n t

k n o w , th e y find ex cu ses a n d th e y re th e w o rst

I tell th e m to a d e g re e . T h e y fin d o u t a n y h o w .

T h . H ow
P t.

Yes

T h . A n y th in g else? A ny o th e r beefs th a t yo u have

p a tie n t m a y be fe e lin g .]

P t.

I d o n t k n o w , a n d th e r e w a s a c a m p re u n io n
W e w e re g o in g to h a v e a c a m p re u n io n , a n d

tim e ? \H e r e I a m tr y in g to v e r b a liz e w h a t th e

P t.

her

I d o n t k n o w . I th in k th ey th in k I m m ix ed

can ta lk a b o u t th a t. A re th ey g iv in g yo u a h a rd

P t.

B e cau se

w h a t th e re a l p ro b le m is.

T h . Y o u r r e la tio n s h ip s , (p a u se ) W e ll, m ay b e w e

P t.

fo rth .

a n d h e r m o th e r let h e r go on th e b u s w ith m e.

w ith th e m o u r re la tio n s .

P t.

so

sp o k e n to th e m ex cep t b riefly . So I d o n t k n o w

T h . H o w w o u ld th e y get th a t c o n c e p tio n ; w h a ts
P t.

and

h e r b ir th d a y for d in n e r once.

T h . D o yo u feel y ou a r e m ix ed u p ?
P t.

h e r,

T h . So, w h a t s th e b ig d e a l a b o u t th a t?

T h . W h a t do th ey th in k in w h a t a r e a ? I h a v e n t

P t.

lik e

p a r e n ts th e y in v ite d m e o v er to h e r h o u se on

I d o n t k n o w th e y th in k s o m e th in g is w ro n g
I g u ess.

T h e y sa y h e r p a r e n ts a r e to o fo rw a rd , th ey

w o u ld th e y find o u t if yo u k e p t it to

ex cu ses. I m e a n th e y re re a lly b a d . T h e y h av e
t h e ir re a so n s . T h e y say y o u c a n t do th is, you

y o u rself?

c a n t d o th a t. W e ll, D o tty s a id lik e w h e n sh e

I d o n t k n o w . S o m e tim e s I see h e r, th e n I ll

c a m e h o m e last tim e sh e sa id it w a s a d is a p

co m e h o m e , a n d th e n th ey seem to find o u t.

p o in tm e n t to h e r. H e r v a c a tio n s ta rte d w h e n

T h . H o w w o u ld th e y k n o w th a t y o u see h e r?

sh e w e n t b ack to school. S h e sa id sh e w a s m o re

P t.

If so m e o n e sees m e w ith J a n e , th e n th e y tell

h u r t w h e n sh e c a m e h o m e lik e, sh e s a id , w h e n

th e m .

y o u re a w a y , e v e ry th in g

T h . Y ou m e a n th e y r e p o rt o n y o u ?
P t.

is p ro g re s s in g

an d

w h e n y o u com e h o m e , i t s ju s t a s s ta g n a n t as

W e ll, so m e o n e m u st b ecau se I k n o w I once

i t s a lw a y s b een , a n d , I d o n t k n o w , it looks

w e n t o v er to h e r h o u se . N e x t tim e w h e n I w as

p r e tty b a d . T h e y w o n t c h a n g e .

n o m e , th e y sa id . " Y o u saw h e r , d id n t y o u ?

T h . A n d you m u st k n o w , th e y h a v e th e ir o w n ideas

63

THE INITIAL INTERVIEW: CASE HISTORIES


a n d th e y co m e fro m a d iffe re n t w o rld th a n you

P t.

T h . Is sh e y o u r s te a d y g irlfrie n d n o w ?

com e fro m . I m e a n , y o u r frie n d s a n d y o u r a s

P t.

so c ia tio n s a n d y o u r p h ilo s o p h y a r e d iffe re n t

T h . I m e a n a r e y o u g o in g ste a d y ?

th e s e d a y s th a n in th e ir d a y . So you m u s t feel

P t.

th e y a re tr y in g to im p o se o ld -fa s h io n e d ideas

T h . W o u ld you m a r r y a g irl lik e th is ?


P t.

I d o n t k n o w , p r e tty m u c h tr y in g to p u t th e ir

T h . E v e n tu a lly ?

id e a s o n m e. L ik e if th e y say y o u c a n t see h e r,

P t.

to go w ith o th e r g irls, I m e a n , b u t a t th e b e

y o u re all set to fig h t th e n e x t lin e.

g in n in g th e y sa id she h a d n o th in g in co m m o n
w ith m e. I m n o t s a y in g s h e s n o t in co m m o n
w ith m e, b u t I m sa y in g (p a u se).

I k n o w . R ig h t n o w m y p a r e n ts n o tice it, a n d

T h . W e ll, sh e d o es h a v e s o m e th in g in co m m o n
w ith y o u ; y o u w e n t to c a m p to g e th e r.

t h a t s v ery u p se ttin g , b u t a n y tim e th e y s ta rt to


ta lk to m e, I d o n t k n o w , I get set for a fig h t o r

P t.

tiv e g irl, I d o n t k n o w , S h e s s m a rt m y p a r e n ts

T h . B e cau se y o u feel th e y re c ritic a l of you. W h a t

say.

w o u ld be th e w o rst th in g th a t co u ld h a p p e n if

T h . Is sh e a g o o d -lo o k in g g ir l? S e x y ? S o -so ?

you co u ld see th is g irl a ll you w a n te d ?


N o th in g , b u t th e y feel th a t. W e ll, it sta rte d

P t.

off I w a s a lw a y s se e in g o n e g irl. It w a s h er.

T h . A n d s h e s e asy to ta lk to ?

T h is w a s a fte r last s u m m e r, a n d th e n th e y said

S h e s n o t sex sta rv e d , b u t s h e s all rig h t.

P t.

Y e a h , w e sit a r o u n d a n d ta lk , a n d w ith h e r

I c o u ld n t go o u t w ith o n e g irl, a n d yet I h a d

p a r e n ts .

b een o u t w ith h e r o n ly th re e tim e s. I h a d been

p a r e n ts a n d h e r b r o th e r.

We

all

get

a lo n g

real

g ood,

o n ly th re e tim e s? D o you give th e m a n a c

P t.

I g u e ss e v e ry o n e does.

T h . E v e ry b o d y s o w n p a r e n ts a r e n o g o o d , you
m ean?

c o u n tin g of e v e ry th in g th a t goes o n ?
P t.

I d o n t tell th e m a n y th in g .

T h . Y ou feel t h a t s y o u r b u sin e ss, r ig h t? H a v e you

Y eah .

T h . S h e h a s a m o th e r a n d fa th e r.

th o u g h t y o u sh o u ld go o u t w ith o th e r g irls too

P t.

ju s t to p le a s e th e m ?

T h . B u t h e r p r e s e n t s te p fa th e r is a nice g u y ?

I c a n , b u t I m a d e th e m ista k e th e n , yo u k n o w .

P t.

to

d a te

one

g ir l, th e n a n o th e r ,

th e n

W e get a lo n g good lik e w h e n I go o v er th e re .

T h . C a n t y o u ta lk th a t w a y w ith y o u r o w n d a d ?

a n o th e r . If I w a n te d I could d a te th is g irl, th e n

P t.

u p , a n d th e n th e y fin a lly sa id , Y o u c a n t go

I d o n t k n o w , I c la m u p w h e n I m a r o u n d h im .
I d o n t k n o w w h y .

a n o th e r a n d a n o th e r , see. A n d I d id n t follow

T h . D o you feel h e s lo o k in g d o w n on y o u , o r h e s
c o n d e m n in g y o u ? O r w h a t?

o u t w ith h e r .
P t.

T h . A t a ll?
P t . A t a ll, th is is

a lo n g tim e

tin u e d to see

h e r a little

d o n t

la s t

know ,

I th in k h e r f a th e r d ied .

H e a n d I w ill s ta r t ta lk in g fo r a w h ile .

I k in d o f u n d e r s ta n d it, b u t th e n th e y sa id I
had

her

T h . D o y o u lik e h e r p a r e n ts b e tte r th a n y o u rs?

o v er h e r h o u se a n d stu ff lik e th a t.
T h . H a v e y ou b een o v er since y o u ve b een h o m e

ag o , a n d th e n I c o n
b it, a n d th e n w e, I

T h a n k s g iv in g , w e

had

I d o n t k n o w w h a t it is, b u t h e b o th e rs m e a n d
I w is h h e d i d n t.

T h . Y o u d lik e to g et h im off y o u r b ac k ? I d lik e to


h e lp yo u get h im off y o u r b a c k , re a lly , if th a t is

w h a t yo u w a n t, b u t h o w ? [H e r e I a m j o i n in g

p r e tty b a d w eek e n d .

th e p a t i e n t s fe e lin g s . T h is is in lin e w ith th e

T h . O h , y ou m e a n th e last tim e yo u w e re h o m e ?

d e sire to fo r m an a llia n c e w ith th e p a tie n t. ]

T h e fu r w a s fly in g ?
P t.

Y e a h , th e r e s a lo t of th a t stu ff a n d s h e s n o t
a th le tic in th e m u s c u la r se n se, b u t s h e s a n a c

so m e th in g .

P t.

I m e a n I m n o t g o in g to sta y w ith h e r fo r th e

U s u a lly w h e n th e y sa y , Y o u c a n t see h e r ,

see h e r, in w a rd ly y ou s ta r t re b e llin g .

P t.

I d o n t see w h y n o t.

re st o f m y life u n til I g e t m a r rie d . I m b o u n d

T h . In o th e r w o rd s, th e m in u te th e y say y o u c a n t

P t.

No

o n yo u .

I d o n t k n o w , I t s a lw a y s th e sa m e excuse.

P t.

I d o n t c o n s id e r it; m y p a r e n ts say so.

Y es, th e n th ey sa id , fin a lly , Y o u c a n n e v e r see

P t.

h e r a g a in . W e ll call h e r if w e th in k i t s n eces

T h . I d o n t k n o w if I c a n , b u t I ll tr y , if y o u give

I h o p e you can .

sa ry . W e ll sp e a k to h e r p a r e n ts a n d tell th e m

m e a n id e a w h a t I ca n do. W h a t I co u ld tell

th a t th e y re b rin g in g u p th e ir c h ild w r o n g .

h im is th a t th e ta c tic s th e y a r e u sin g a r e n ot

M a y b e i t s n o t fo r m e to say , b u t w h o a r e th e y

th e r ig h t ta c tic s. A ll th e y do is a n ta g o n iz e you.

to sa y th e y re n o t b rin g in g u p th e ir ch ild rig h t?

A fter a ll, th is g irl is n t g o in g to do a n y th in g

64

HANDBO OK OF SHORT-TERM PSYCHOTHERAPY


te r rib le to y o u . [ / a m n o t su r e w h e th e r o r n o t

T h . G o a w a y to co lleg e yo u m e a n ? W h a t a r e you
g o in g to do th is su m m e r?

th e p a tie n t is g iv in g m e th e rig h t d a ta a b o u t
th e p r o b le m . H e s o u n d s re a so n a b le in re se n t

P t.

ing, a t h is age, th e in te rfe r e n c e o f h is p a r e n ts

T h . W e ll liste n , b e tw e e n y o u a n d m e, w h y c a n t

in w h a t se e m s to be an a vera g e b o y - g ir l rela

y o u go a r o u n d w ith o th e r g irls a n d th e n do
w h a t you w an t an y w ay s?

tio n sh ip . I f w h a t h e sa y s is co rrect, it is th e
p a r e n ts

who

n e e d s o m e c o u n s e lin g

about

a d o le sc e n t n ee d s a n d p r o b le m s a n d th e p r o p e r
P t.

I d o n t k n o w yet.

P t.

(la u g h in g )

T h . Y ou k n o w you c a n h a v e a r u n n in g b a ttle g o in g

w a y to m a n a g e th e m se lv e s. ]

o n w ith th e m all th e tim e th e w a y th in g s a re .

I d o n t k n o w , s h e s k in d o f c u ltu re d in a w ay.

T h e r e s no se n se to it, b e c a u se th e y ll get very

T h . S h e s c u ltu re d .

u p se t a n d s ta r t b u s tin g y o u r re la tio n s h ip s u p .

P t.

Y e a h , I d o n t k n o w w h a t th e y g ot a g a in s t h e r.

A p p a r e n tly , yo u d o n t w a n t th e m b u ste d u p.

S h e k n o w s h o w to b eh a v e a t d iffe re n t tim es.

Y o u ve got to be s m a rt a b o u t th e s e th in g s . I m
n o t tr y in g to give yo u a n y a d v ic e o n h o w to

Y o u k n o w sh e k n o w s ju s t h o w to act.
T h . S h e so u n d s v ery nice.

c o n d u c t y o u rse lf, b u t I k n o w th a t th e s e th in g s

P t.

c a n get v e ry , v ery stick y . Y ou c a n g e t y o u rse lf

T h a n k y o u , t h a t s w h a t sh e is, b u t do you
k n o w a b o u t F a irv ie w w h e re w e live. T h is n ew

in to

elite a n d th e n th e v illag e?

n o m ic a lly d e p e n d e n t o n th e m fo r a w h ile a n y

a ja m

w ith

th e m ,

and

yo u

are

eco

T h . (sm ilin g ) Y o u m e a n t h a t s w h e re all th e k id s

w a y s. So w h y c a n t yo u give th e m a n id e a th a t

th a t h av e p a r e n ts w h o h a v e p ro b le m s live. T h e

y o u r e g o in g o u t w ith o th e r g irls to o ? M a y b e

P t.

p a r e n ts h a v e p ro b le m s n o t th e k id s? (la u g h in g )

b r in g o n e o r tw o a r o u n d y o u k n o w . W h a t s

O h (la u g h in g ). W e ll, m y f a th e r sa id th e re a so n

th e b ig d e a l, yo u co u ld go o u t w ith o th e r g irls

th ey d i d n t lik e h e r , sh e w a s u sin g m e a s a b a it

if yo u w a n te d to, c a n t y o u ? [In g iv in g th e p a

to c lim b so cially.

tie n t th is a d vice, I a m te s tin g m y o w n c a p a c ity


to in flu e n c e h im a t th is p o in t. I a m n o t su r e he

T h . D o e s y o u r g i r l s fa m ily com e fro m a lo w e r eco

w ill ta k e m y a d vice to d e fu s e th e s itu a tio n .]

n o m ic s ta tu s class?
P t.

I d o n t th in k so. T h e y u sed to live in Q u e e n s ,

P t.

w h ic h is n t g o o d , a n d th e y m oved to w h e re

T h . I m e a n , y o u d o n t ev en h a v e to te ll th is gal
a n y th in g a b o u t it if you d o n t w a n t to.

th e y a r e n o w . A nice h o u se , b u t th e n m y f a th e r
said so m e of h e r b est frie n d s a r e k id s th a t m y

P t.

W e ll, y o u see lik e la s t n ig h t, I w a s su p p o s e d to

fa th e r lik es. So I to ld h im I th o u g h t th is w o u ld

go to a p a r ty . W e ll, I to ld m y p a r e n ts it w a s

m a k e h im lik e h e r o r s o m e th in g , a n d h e said

g o in g to be a p a r ty . It w a s k in d a m y fa u lt. I

w h a t sh e is d o in g is sh e is c lim b in g , sh e is u s

sa id it w a s C h r is tm a s E v e, a n d if sh e w a s

in g th ese frie n d s to c lim b u p th e la d d e r. All

g o in g to be a t th is p a r ty a n d if sh e w a s g o in g , I

sh e w a n ts is h e r frie n d s in o u r a r e a for th e

w a s g o in g w ith m y b est frie n d a n d som e g irl he

m o n ey , etc.

k n e w . A n d I w a s g o in g to go, a n d I a sk ed m y
m o th e r, a n d sh e sa id I co u ld go p r o v id in g

T h . H o w d o es h e k n o w th a t, he d o e s n t even k n o w
P t.

I ca n .

h e r?

a n d t h a t s o n ly o n e th in g w e a s k you to do a n d

I th in k h e s seen h er.

t h a t s n o t to see th is g ir lj u s t lik e th a t. A n d

T h . H o w ca n h e a n a ly z e w h a t sh e is d o in g w ith o u t

sh e sa id , Y o u ll h a v e to give y o u r f a th e r a ll

ta lk in g to h e r. [ / a m d e lib e r a te ly s id in g w ith

th e d e ta ils , e tc ., h o w th e p a r ty is g o in g to be,

P t.

th e p a tie n t to f i r m u p o u r r e la tio n s h ip .]

h e w a n ts to k n o w m o re a b o u t i t . So I to ld m y

I d o n t k n o w , b u t th is is w h a t he sa y s. S h e s

frie n d to go a h e a d a n d see h is g irl la s t n ig h t.

tr y in g to c lim b so c ially , a n d s h e s j u s t g o in g to

A n d w h a t w e w e re g o in g to d o ? W e w e re

d r o p m e. T h is is w h a t h e says.

g o in g to p la n a good o n e th e r e w o u ld be in
v ita tio n s.

T h . T h a t s w h a t h e sa y s, b u t th a t d o e s n t m e a n i t s
so, is it? [again, s id in g w ith th e p a t ie n t to p r o

T h . Y o u re le ttin g so m e b o d y else do th e in v itin g ,


a n d y o u re ju s t b e in g in v ite d to a p a r ty ?

m o te a n id e n tific a tio n ]
P t.

I k n o w , b u t h o w ca n I a rg u e w ith h im ? I d o n t
k n o w , th e w a y 1 fig u re it is I w o n t be h o m e
th a t lo n g a n d th e re w ill be a c o u p le o f a r g u
m e n ts o r so, a n d th e n I ll go a w a y .

P t.

I d o n t k n o w . T h e y u s u a lly fin d o u t a b o u t th a t
stu ff a n y h o w .

T h . W e ll, lo o k , w h a te v e r th e y fin d o u t, t h a t s it.


Y ou d o n t h a v e to tell th e m e v e ry th in g you do
at your age, do you?

THE INITIAL INTERVIEW: CASE HISTORIES


P t.

N o , I d o n t in te n d to.

65
P t.

T h . A ll rig h t, if y o u w a n t m e to I ll tr y to tell th e m

sc re w e v e ry g irl I see.

th a t th ey a re m a k in g a big fu ss o v er n o th in g .

T h . W e ll, w h a t y o u d o is y o u r o w n b u sin e ss, t h a t s

[I g e t th e im p re ss io n th e p a ti e n t n e e d s an a lly ,

th e p o in t. W h a t yo u do is y o u r o w n b u sin e ss

a n d 1 a m p r o p o s in g a n a d vo ca cy ro le on m y

y o u c a n sc rew th e g irls y o u w a n t if t h a t s w h a t

p a r t.]
P t.

Y o u , I m e a n th a t I m n o t g o in g to go o u t a n d

See,

y o u w a n t.
if y o u

tell

th e m

t h a t I d o n t

S o m e tim e s th e y a lw a y s h a v e good sto rie s, like

[s u p p o r tin g th e p a t i e n t s rig h t to

a u to n o m y ]

know .
P t.

W h a t I m e a n is if th e y r e g o in g to a ct lik e if

s o m e th in g w ill go o n in th e h o u s e y o u k n o w

th o s e a r e th e ir m o tiv es for b r e a k in g th is u p

b etw een m y m o th e r a n d I a n d th e n w h e n m y

th e n th e y ll do it w ith th e n e x t g irl a n d th e

f a th e r co m es h o m e a n d I liste n to h e r te llin g
h im w h a t goes o n . Y o u k n o w , it n e v e r w e n t

n e x t g irl.
T h . T h e y m ig h t, th e y m ig h t, i ts p o ssib le , b u t th e

on.

facts a r e

if y o u w a te r th a t s itu a tio n d o w n ,

T h . So th a t m a k e s y ou v ery fu rio u s.

y o u ll p ro b a b ly g e t th e m off y o u r b ack . W h a t

P t.

I m e a n th e y ca n tw ist a sto ry so th a t th e y re

y o u d o p riv a te ly is y o u r o w n b u sin e ss, a n d if

th e w h ite k n ig h ts. I m e a n w h e n th e y re h e r e

y o u sc rew a n y b o d y , I g u ess yo u h a v e e n o u g h

i t s n o t u s a n d h e g o es o u t I do go o u t for

se n se to

a r g u m e n ts I m e a n , w h e n th e y m a k e m e a n g ry .

ch a n c e s. Y o u k n o w w h a t I m e a n ? B u t t h a t s

u se a r u b b e r a n d

d o n t ta k e a n y

T h . W e ll, it m u st m a k e you f u rio u s a n d yo u p r o b a

y o u r o w n b u sin e ss a n d n o b o d y ev er n eed k n o w

bly feel y o u ll sp lit a g u t u n le s s y o u com e o u t

a b o u t it yo u n e v e r n eed tell th e m o r a n y b o d y

w ith y o u r feelin g s. Y o u see w h a t th e y object

else, [again, b a c k in g th e p a t i e n t s r ig h t o f a u
to n o m y ]

to , I th in k , th e y d o n t lik e to h a v e you lie.


T h e y d o n t like to h a v e you p u t o n e o v er on

P t.

th e m . T h e y say y o u re n o t s u p p o s e d to d o it,

s u d d e n ly sa id , G iv e m e y o u r w a lle t, a n d she

a n d th e y ex p ect th a t y o u w o n t d o it. N o w ,

w e n t th r o u g h it a n d I h a d a r u b b e r stu c k in
th e in sid e of it.

o b v io u sly , it w o u ld be silly to e x p e c t y o u to
give u p s o m e th in g th a t is v ery v a lu a b le to y o u ,

T h . D id sh e fin d it?

b u t yet th e y still h av e a fe e lin g y o u re still ju s t

P t.

fig u re d it w a s fo rg o tte n . A n d th e n m y f a th e r

A n d som e p a r e n ts n e v e r get o v e r th a t feeling

w e w e re g o in g to get p iz z a o r s o m e th in g a n d

a b o u t th e ir k id s. T h e y w a n t to be p ro te c tiv e ,

he s ta r ts a s k in g m e d id yo u ev e r u se it, w h e n

a n d th ey com e th r o u g h as c o n tro llin g . T h e y

d id yo u u se it, a n d so o n . A n d I sa id , W h a t

d o n t re a liz e th a t y o u h a v e y o u r o w n n eed s,

am

a n d y o u r o w n life, a n d e v e ry th in g else. A n d

p o se d to sa y J a n e a n d I d id t h i s o r S u e an d

I s u p p o s e d to s a y ? T h e n

I m n o t s u p

th e y w o n t get off y o u r b ack on th a t a c c o u n t.

I , a n d It w a s on th e th ird n ig h t o f M a y o r

W h a t y ou h a v e to d o is re a s s u re th e m say to

s o m e th in g .

c a n re a s s u re th e m

is to c o n v in c e th e m

T h . T h is is y o u r o w n p r iv a te a ffa ir, a s lo n g a s you


are

th a t

c a re fu l

and

y o u d o n t get y o u rse lf too

to o s e rio u s a b o u t th is b u s i

d e e p ly m essed u p a n d in v o lv ed . T h a t s y o u r

n e ss th e r e s n o th in g too s e rio u s a b o u t y o u r

o w n b u sin e ss a n d y o u re r ig h t in re s e n tin g h e r

se e in g th is g irl a n d th a t y o u re n o t g o in g to

ta k in g y o u r p o c k e t b o o k a n d g o in g th r o u g h it,

t h e r e s n o th in g

m a r ry h e r. [m o r e a d vice g iv in g to test o u r rela


tio n sh ip ]

an y w a y s .
P t.

T h a t s tr u e ,

and

o h , th e o th e r th in g , th ey

D o y ou th in k th e y feel I a m ? ( T h e p a tie n t acts

fo u n d P la y b o y s in m y ro o m , so o h h h h h h h h , no

su r p ris e d .)

s m u t in th e h o u se , a n d th e y s ta r t y e llin g a n d a t

T h . T h e y m ay feel y o u re g o in g to be so se rio u s
th a t y o u m ay ev en get h e r p r e g n a n t o r so m e

th e sa m e tim e , I k n o w , I d o n t see a n y th in g
w r o n g w ith it.
T h . T h e r e is n t a n y th in g w ro n g w ith it, b u t w h a t

th in g . Y o u ll be in a j a m th e n .
P t.

Y es, a n d sh e to o k it. S h e d i d n t say m u c h a n d I

th is b ig (in d ic a tin g a s m a ll s iz e w ith fin g e r s ) .

th e m w h a t is tr u e . I th in k th e best w a y you

P t.

O n e d a y , fo r so m e re a so n o r o th e r , m y m o th e r

W e ll, if th e y d o th is w ith ev ery g irl, I m e a n , if

th e y a p p a r e n tly feel is th a t th e y w o u ld like to

th e y feel w e re g o in g to h a v e th ese g r e a t tim es

h a v e a son th e id e a l, m o r a l, s tu d io u s k in d of a

and

g u y . I th in k m o st p a r e n ts w o u ld lik e to p ic tu re

e v e ry th in g ,

i t s g o in g to

tim e . T h e y h a v e to a d m it it.
T h . A d m it w h a t?

happen

every

th e ir c h ild re n a s th a t. I m e a n fro m a n ideal


s ta n d p o in t, a n y th in g th a t goes b elo w th a t ideal

66

HANDBO OK OF SHORT-TERM PSYCHOTHERAPY


a n d th ey s ta r t b la m in g th em se lv e s, s ta r t feeling

T h . N ig h tm a r e s ?

g u ilty , feel y ou m ay be h e a d in g fo r a lot of

P t.

tro u b le . I w o u ld th in k th e ir a n x ie tie s a re n ot

T h . H o w a b o u t d r u g s ? T a k i n g a n y p ills o r th in g s ?

to h u r t y o u th e ir a n x ie tie s a r e m o tiv a te d by a

P t.

c o n c e rn a b o u t y o u . T h e i r m o tiv es a r e p ro b a b ly

N o , n o th in g . S o m e o f th e k id s ta k e g ra ss . I
d o n t lik e it.

h o n o ra b le o n es, you k n o w w h a t I m e a n ? A t

T h . N o w tell m e a little a b o u t y o u r m o th e r.

least th e y h av e a d e s ire to see th a t you d o n t

P t.

get in to p ro b le m s , th a t yo u d o n t get c a u g h t by
a n y g irl, th a t you d o n t get a n y g irl p r e g n a n t,

W hat

c o u ld

tell.

She

P t.

p ro b a b ly w h a t th e ir m o tiv es a re . T h e y m ay be

T h . H o w a b o u t y o u r fa th e r?

liv in g in th e last g e n e ra tio n a n d n o t in th is

P t.

your

p r o b le m

is.

Is

th a t

w hy

th e y

T h . I d o n t th in k y o u re m ix ed u p in so f a r a s w h a t

I c a n t g et to h im . H e d o e s n t

W e g et a lo n g fine. I c a n ta lk to h e r. W e used
to fig h t w h e n I w a s sm a ll. W e lik e each o th e r
now .

T h . H o w d id yo u get a lo n g w h e n yo u w e re a k id ,

d o m in a te a n d c o n tr o l h im .]
I d o n t k n o w I w a s g o in g to ask you.

I to ld y o u .

H o w do y o u get a lo n g ?
P t.

b ro u g h t y ou h e re ? [I a m d e fe n d in g th e p a r e n ts
th e ir p u r e ly se e k in g to

N o.

T h . H o w a b o u t y o u r sis te r, s h e s a few y e a rs o ld e r.

to see i f I can g iv e h im a n o th e r m e a n in g f o r
th e ir b e h a v io r th a n

f a th e r

u n d e r s ta n d .

a n d n eed ed ad v ice a n d th a t 1 s h o u ld e v a lu a te
w hat

my

T h . S c a re d o f h e r?

th a t y ou d o n t get a v e n e re a l d ise a se . T h e s e a re

d ay s. I su p p o s e th e y felt yo u w e re all m ix e d u p

bosses

a r o u n d . K eep s te llin g m e w h a t to do.

on e. T h e y m a y n o t k n o w w h a t goes on th ese

P t.

I d o n t re m e m b e r.

a t h o m e , a t sch o o l?
P t.

O K , I g u ess.

T h . N o p ro b le m s?

you h a v e to ld m e is c o n c e rn e d . [ / g e t th e im

P t.

p re ss io n th a t w e are d e v e lo p in g a re la tio n s h ip .

T h . H a v e m a n y frie n d s ?

N o , n o n e I ca n th in k of.

T h e p a tie n t trie s to m o v e h is c h a ir clo ser to

P t.

m e.] So fa r y ou h a v e n t to ld m e a th in g th a t is

T h . A n y p re v io u s tr e a tm e n t w ith a p s y c h ia tris t o r

a b n o r m a l. \A t th is p o i n t I in tro d u c e q u e s tio n s
a b o u t o th e r s y m p to m s a n d c o m p la in ts.]

O h , yes.
p sy c h o lo g ist?

P t.

N o.

T h . I w a n t to a sk y o u a few q u e s tio n s a b o u t an y

[ / d e c id e to s h o w th e p a t i e n t th e R o rsc h a c h

sy m p to m s y o u m a y h av e. H o w a b o u t te n s io n ?

c a rd s to see i f I can p ic k u p a n y u n d e r ly in g d y

D o you feel te n s e ?

n a m ics. F ro m th e d a ta h e h a s g iv e n m e I c a n

S o m e tim e s I m e a n , yes. N o t a lw a y s.

n o t y e t d isc ern p r o b le m s o th e r th a n p a r e n ts

P t.

T h . U n d e r w h a t c irc u m sta n c e s ?

a n d a d o le sc e n t in co n flic t o v e r b e h a v io r th a t is

P t.

n o t too u n u s u a l. H is sto r y m a y co n cea l o th e r

W h e n I get u p se t a t th in g s.

T h . A n y a n x ie ty , a feelin g y o u re fa llin g a p a r t?
P t.

a sp e cts th a t h e d e lib e r a te ly or u n c o n s c io u sly is

W h y no.

h o ld in g back. I t is p o s s ib le th a t s o m e th in g w ill

T h . D e p re s s io n ?

com e

P t.

R o rsc h a c h cards o r in d ra w in g s. ]

N o t to o b ad .

th ro u g h

in

h is

re sp o n ses

to

th e

T h . P h y sica l c o m p la in ts o r sy m p to m s , lik e h e a d

T h . I m g o in g to sh o w y o u so m e c a rd s, a n d I w a n t

ac h e s, sto m a c h tr o u b le , b o w el tr o u b le , a n d so

y o u to tell m e w h a t yo u see. T h is re a lly is n o t

on?

a te s t ju st a n id e a o f y o u r im p re ss io n s . ( /
s h o w h im th e fi r s t card)

P t.

I d o n t th in k so.

T h . H o w a b o u t se x u a l p ro b le m s?
P t.

T h . P h o b ia s o r fe a rs o r th o u g h ts th a t c ro p u p th a t
P t.

A re th o se th e p ic tu re s yo u look a t a n d I m

su p p o s e d to say w h a t it looks lik e ?


T h . T h a t s r ig h t ev e r seen th e m ?
P t.

N o.

T h . W h a t does th a t look lik e ? (fir st card)


P t.

S le e p O K .

T h . D o y ou d r e a m a little o r a lot?
P t.

OK

frig h te n y o u ?
T h . H o w do y o u sle e p ? A ny in s o m n ia ?
P t.

P t.

N o th in g lik e th a t.

A lo t, b u t I d o n t re m e m b e r a n y d re a m s.

I ve h e a rd a b o u t th e m .
I d o n t k n o w , a n in se ct. C a n I tu r n th is a n y
w a y I w a n t?

T h . A n y w a y yo u w a n t.
P t.

O r a m ask .

T h . R e m e m b e r a n y c h ild h o o d d re a m s ?

T h . A n y th in g else?

P t.

P t.

L ik e o f fa llin g , sc ary .

N o.

THE INITIAL INTERVIEW: CASE HISTORIES


T h . O K . W h a t d o es th a t look lik e ? (se c o n d card)

67
P t.

A n y th in g th a t com es to y o u r m in d . So fa r you

T h . A ll rig h t. N o w I m g o in g to a s k y o u to d ra w

a re d o in g v ery w ell.
P t.

I d o n t k n o w ,

it lo o ks lik e a fo o tp rin t o r

so m e th in g . I d o n t k n o w , a face o r so m e th in g .
T h . W h e r e s a face?
P t.

It looks lik e th e a n a to m y o f so m e b o d y I
d o n t k n o w , ( h a n d s c a r d b a ck)
m e a p ic tu r e of a p e rso n .

P t.

A p e rs o n ?

T h . Y es, a n y th in g yo u w a n t. T h is is n o d r a w in g

T h a t.

c o n test.

T h . S h o w m e.

P t.

P t.

T h e r e , th e lo w e r p a r t th e ey es th e n o se

T h . A n y th in g j u s t a p ic tu r e a n y th in g yo u w a n t.

th e eyes.

P t.

I say

I c a n say th e r e s n o th in g se rio u s ly w ro n g w ith

D o y ou m e a n rac e -w ise ?

y o u r m in d .
P t.

W h a t s th e p u r p o s e of h a v in g m e d r a w th is?

T h . I ll tell y o u w h e n you get th r o u g h O K , now

I d o n t k n o w th e y look lik e b o th m en an d

d r a w m e a p ic tu r e of a p e rso n .
P t.

T h . W h a t m a k e s th e m look like m e n ?

A w om an?

(P a tie n t d ra w s an

u g ly w o m a n

w ith large b re a sts h o ld in g a s tic k .)

T h e r e , (p o in ts to p r o je c tio n )

T h . N ow a m an.

T h . Y ou m ean th is is a p e n is ?

P t.

R ig h t.

Y ou d o n t m in d if i t s in s id e ? ( H e d ra w s a
m u s c le m a n liftin g w e ig h ts .)

T h . A n d w h a t m a k e s th e m look lik e w o m e n ?
P t.

D id

y o u re n o t n u ts if t h a t s w h a t y o u re a fra id of.

w o m en .

P t.

w e ig h ts .

T h . N o . Y ou d id p r e tty g ood. I c o u ld testify th a t

T h . N o , n o , a r e th e y m e n , w o m e n ?

P t.

liftin g

It lo o k s lik e tw o p eo p le d a n c in g it looks like

T h . A n y th in g else? W h a t k in d of p e o p le a r e th e y ?

P t.

about

tw o p e o p le d a n c in g b ack to b ack th e o th e r
w ay .
P t.

I ll d r a w

a n y th in g w ro n g w ith th o se p ic tu re s ?

T h . H e r e s th e th ird one.
P t.

Boy o r g ir l?

T h . It d o e s n t m a tte r . [ / g e t th e im p re ss io n fr o m

T h e y look like th ey h a v e b re a s ts r ig h t h ere.

h is re sp o n se s to th e R o rsc h a c h ca rd s th a t h e is

T h . N o w , th is is th e fo u rth one.

im m e r s e d in in c o m p le te se p a r a lio n -in d w id u a -

P t.

U g h , it lo o k s like a d e a d r a b b it. A lso looks like

tio n , fe e ls c r u s h e d

a b a t o r so m e a n im a l th a t got h it w ith a ste am

w ith a p r o b le m in id e n tity ( th ir d card). I co n

ro lle r.

je c tu r e th a t th e w o m a n w ith a stic k in h is fi r s t

(fo u rth

a n d s ix th

cards)

T h . A ll rig h t, h e r e s th e fifth one.

d r a w in g is h is stro n g , p u n i ti v e m o th e r a n d the

P t.

m a n , h is c o m p e n s a tin g m a s c u lin e s e lf] N o w ,

T h a t looks lik e a b a t, th a t re a lly does.

T h . A n y th in g else?

you see I g av e yo u a te s t, a n d th e test w o u ld

P t.

se em to in d ic a te th a t y o u r basic d efen ses a re

N o.

T h . A ll rig h t, h e r e s th e n e x t one. (six th card)

p r e tty good a n d th a t y o u ve g o t a lot of o o m p h ,

P t.

s p a rk , a lot of fire [an a tte m p t a t re a ss u ra n c e ].

It looks like a cat th a t k in d of got h it.

T h . P u ssy cat?

B u t you d o w ith d r a w a n d you do in h ib it w h en

P t.

th in g s g et to o to u g h fo r y o u [sparse re sp o n ses

I d o n t k n o w , so m e so rt of c a t, n o th in g else.

T h . O K , th is is th e sev en th one.
P t.

on ca rd s]. Y ou p u ll b a c k a n d you ju s t d o n t let

A re th ese a n y sp ecial p a tte r n s ?

y o u rse lf co m e o u t o f y o u rself. It a lso in d ic a te s

T h . N o , ev ery b o d y h a s d iffe re n t a sso c ia tio n s.

th a t

P t.

m a s c u lin ity , th a t so m e h o w y o u re n o t too co n

U m m m m m n o th in g .

T h . W e ll, look a t it closely.


P t.

O h,

oh,

it

looks

lik e

are

w o rk in g o u t

y o u r feelin g s of

fid en t a b o u t y o u r feelin g s of m a s c u lin ity a t th e


tw o

p e o p le

d a n c in g

a g a in th e y re w e a rin g a s k ir t o r d resses o r
w h a te v e r. H a v e lo n g h a ir d o s. T h a t s all.
T h . O K , h e r e s th e n ex t o n e. (e ig h th card)
P t.

yo u

p re s e n t tim e . W h y d o y o u sm ile ?
P t.

I fo rg e t. [I g e t th e fe e lin g f r o m th e n o n v e r b a l
re sp o n ses to th e in te r p r e ta tio n s I h a v e m a d e
th a t th e in te r p r e ta tio n s a re co rrect a s s u m p

T w o m en h a n g in g o n to s o m e th in g . T h is w a y it

tio ns. H is r e m a r k I f o r g e t in d ic a te s to m e an

looks lik e a face. I guess th a t looks like a

a c tiv e d e s ire to d e n y . T h e d y n a m ic fo c u s to be

b o m b , (n in th ca rd ) I d o n t k n o w m ay b e som e

w o r k e d o n , i f I a m correct, w o u ld th e n be

m u sc u la r g u y o r s o m e th in g s ittin g in th e back.

h is

Y ou k n o w th e b ack an g le .

p r o b le m s .]

T h . O K , h e r e s th e last one.

s e p a r a ti o n - in d i v id u a ti o n

and

i d e n t it y

T h . A ll r ig h t, n o w w h e re w o u ld th ese p ro b le m s
com e fro m ? F ro m

y o u r r e la tio n s w ith y o u r

68

HANDBOOK OF SHORT-TERM PSYCHOTHERAPY


m o th e r a n d y o u r fa th e r? D o th e y h a v e a lot of

T h . L o o k , y o u ll n e v e r p ro v e it th a t w a y . I t s b e tte r

tr o u b le to g e th e r?
P t.

to k e e p a w a y fro m fig h ts b ec a u se a ll it w ill do

Y e a h a little b it a lot.

is c re a te p ro b le m s fo r you. [ / a m p u s h i n g a d

T h . Y ou see a p erso n is b r o u g h t u p in a fa m ily a n d

vice h o p in g th a t I h a v e e s ta b lis h e d s u ffic ie n t

y ou see h o w th e m o th e r a n d f a th e r g et a lo n g

c r e d ib ility f o r h im to fo llo w th is a d vice sin c e h e

to g e th e r a n d

c o u ld g e t in to se rio u s tro u b le tr y in g to p r o v e

you

b eg in

to

p ick

up

id eas

h is m a s c u lin ity th ro u g h vio le n c e a n d fig h tin g .]

a b o u t h o w m a le s fu n c tio n w ith fem ales. D oes


sh e kick h im a r o u n d ? d o m in a te h im ?
P t.

P t.

Y e a h , I k n o w , lik e th e la s t tim e I w a s h o m e.
L ik e o n e k id s a id , H o w s sc h o o l? a n d I sa id ,

S o m e tim e s m o st o f th e tim es.

T h . T h a t m a k e s a w o m a n a s tro n g p e rs o n in th e

I t s n o t b a d , a n d h e sa id , It m u st be a

c o n c e p tu a l th in k in g o f a boy. H e w o u ld lik e to

p a n s y s c h o o l o r so m e th in g lik e th a t. A n d I

id e n tify w ith a s tro n g f a th e r w h o is a b le to

sa id , L o o k i t s k in d a h a r d , a n d h e sa id ,

s ta n d u p to h is w ife, to k eep h e r fro m being

W e ll, th e n it m u st be a g o o d sc h o o l, a n d

to o

th e n h e sa id , If y o u re g o in g th e r e , th e k id s

c o n tr o llin g ,

and

s to p

h er.

W h e r e th e

w o m a n is to o s tro n g in th e fa m ily , i t s a p t to

m u st be a b u n c h o f J O s . A n d g o in g on like

reflect o n th e b o y s feelings th a t w o m e n a r e th e

th is. T h is is o n e k id I h a te . A n d it w a s j u s t

s tro n g p e o p le . N o w , th is h a s a n im p a c t o n th e

y e s te rd a y a n d I w e n t to to w n j u s t lo o k in g for

b o y s d e v e lo p in g sense o f m a s c u lin ity . A n d th is

h im . A n d th e n b efo re I left for sc h o o l th e last

is th e o n e p ro b le m it d o e s n t m a k e you daffy

t im e I j u s t w e n t a ll o v e r to w n lo o k in g for o n e
kid.

o r a n y th in g lik e th a t, b u t it is s o m e th in g th a t

P t.

y ou h av e to w o rk o u t y o u h a v e to b eg in to

T h . T o b e a t th e h ell o u t o f h im ?

d ev elo p a d iffe re n t c o n c e p tu a liz a tio n o f y o u r

P t.

h a p p e n e d b e tw e e n m e a n d a g ir l o r so m e

s tr o n g in te r p r e ta tio n , b u t I b elieve I a m rig h t.

th in g lik e t h a t a n d h e w a s th e ca u se o f it. It

I w o n d e r h o w th e p a ti e n t w ill h a n d le th e in te r

w a s n t th is

p r e ta tio n . 1} h e d e n ie s it o r b y p a sse s it, a g re a t

re a lly m a d th e n , a n d I to ld th e g irl, T e ll h im

g irl J a n e a n o th e r g irl.

I w as

d e a l o f w o r k w ill be n ecessa ry on h is d efenses.

if I see h im a g a in , I ll look for h im to m o r r o w .

W h e re a p e r s o n s id e n tity p r o b le m s a re too

T h e n so m e k id ca lle d m e u p , o n e o f h is frie n d s,

s tr o n g

w h o m u st be a s e n io r n o w , a n d h e sa id , If

and

w h e re

th e y are

re sp o n sib le fo r

m a n y a d ju s tm e n t d iffic u ltie s, lo n g -te r m th e r

yo u lay a h a n d o n h im , I ll k n o c k th e sh it o u t

a p y m a y be n eed ed . ]

o f y o u , a n d I g ot a m a r in e frie n d w h o is g o in g

W e ll,

know

w hen

w as

in

to

e le m e n ta ry

do th is to

m a rin e s ,

sc h o o l I d o n t k n o w w h y b u t it u sed to be if

th e

y o u .
a rm y ,

Y ou

know

lik e th a t.

th e

A nd

w h o le
I sa id ,

th e boys w a n te d to sh o w off befo re th e g irls,

W e ll, th is is j u s t b e tw e e n m e a n d h im , you

th e y d j u m p

I u sed to be s m a lle r an d

k n o w ; if h e s so to u g h let h im be t h e r e . I

e v e ry th in g a n d th e y d say le ts j u m p o n th e

d o n t k n o w I sp e n t th e w h o le d a y in to w n , he

m e.

n e v e r ca m e a r o u n d .

fag o r so m e th in g lik e th a t.

T h . Y ou ca n h a v e beefs w ith k id s, a n d m a y b e you

T h . W h o w o u ld say th a t?
P t.

If I co u ld j u s t fin d h im . B e cau se so m e th in g

self a s a s tr o n g m a s c u lin e p e rso n . [ T h is is a

s h o u ld be ab le to d efen d y o u rself. T h e r e s no

O h , so m e o f th e kids.

T h . T h e k id s w o u ld say to w h o m ?

r e a s o n w h y y o u s h o u ld n t le a r n h o w to defen d

P t.

T o m e. T h e y d j u m p on m e a n d th e y d say

y o u rse lf,

th is to th e o th e r k id s t h a t s I k in d a I ve

m a tte r.

been

d o in g

w e ig h t s t h a t s

p ro b a b ly

th e

P t.

but

to

look

for fig h ts is a n o th e r

I th in k j u j it s u is k in d o f for th e b ird s. I m e a n if

re a so n I d re w th a t. T h e n th e o th e r d a y , I w e n t

y o u get in to a fig h t, y o u k n o w . I u sed to th in k

d o w n to w n j u s t lo o k in g for a fig h t I d o n t

J u d o is p r e tty good u n til la s t y e a r. I sa w a k id ,

k n o w , m a y b e to p ro v e m y self w h o k n o w s.

a n d h e sa id , I ta k e j u d o , a n d th e o th e r kid

[ T h e p a t i e n t s a d m issio n th a t h e h a d concern

s ta rte d la u g h in g lik e a n y th in g , a n d th e n he

a b o u t o th e r s c o n s id e rin g h im h o m o s e x u a l, h is

j u s t stood th e re la u g h in g , a n d th e n th e kid

re a liz a tio n th a t h is d r a w in g refers to h im se lf,

s ta r ts th e fancy a d v a n c e s, a n d th e n th e n e x t

h is in sig h t a b o u t p r a c tic in g w ith w e ig h ts a n d

th in g yo u k n o w th e j u d o e x p e r t w a s o n th e

lo o k in g f o r f ig h ts to c o m p e n s a te f o r h is fe a r o f

g r o u n d , a n d he s ta rte d b le e d in g .

la ck o f m a s c u lin ity are g o o d signs. ]

THE INITIAL INTERVIEW: CASE HISTORIES


T h . D o th ey h a v e to u g h k id s in th a t p la c e y o u re

69
Pt.

in ?

I d o n t k n o w , to give m e a c e rta in feelin g o r


so m e th in g .

Pt. N o t w h e re I live, b u t d o w n to w n , yes.


T h . W e ll, liste n , I th in k th a t yo u a r e co n c e rn e d

T h . B u t I t h in k y o u c a n be m u c h s m a r te r th a n

a b o u t d e fe n d in g y o u rse lf b e c a u se o f y o u r o w n

d o in g is jo in in g in o n a b a ttle w ith th e m . Y ou

d o u b ts of y o u r o w n c a p a c ity to d efen d y o u rse lf

are

a n d y o u r o w n feelin g s o f low m a s c u lin ity . B u t

h a v e n t g o t a c h a n c e w ith th e m u n le s s yo u use

y o u ve b e e n ,

y ou w a n t to co m e a n d see m e a n d ta lk a b o u t

lo w

m an

w hat

on

th e

yo u
to te m

have

b een

p o le. Y ou

a n o th e r k in d o f tactic.

t h a t s a p ro b le m y o u w o n t w o rk o u t by fig h t
in g . Y o u w o rk it o u t b y ta lk in g a b o u t it, a n d if

th e

b ecau se

Pt. H o w ?
T h . Y ou h a v e to be k in d of s m a rt in c o m m u n ic a t

th e se th in g s , I ll b e g la d to see y o u . B ecause

ing w ith th e m . L et th e m k n o w y o u r feelings,

y ou ca n d o a lo t b e tte r by v e rb a liz in g th a n you

b u t d o n t te ll th e m e v e ry th in g a b o u t w h a t you

ca n by fig h tin g , jI m te s tin g m y e ffe c tiv e n e ss in

d o, a b o u t th e s e g irls . Y o u ca n tell th e m w h a t is

th e in te r v ie w h ere. H a v e I e s ta b lis h e d a rela

tr u e . W h y n o t sa y a b o u t y o u r g irl, T h is is n t

tio n sh ip a n d d o es h e h a v e su ffic ie n t co n fid e n c e

s e rio u s . If th e y say , A re yo u g o in g to see

in m e to s ta r t th e r a p y w ith m e ? H is re sp o n se

h e r ? yo u co u ld say , L o o k I h a v e c e rta in

to m y in v ita tio n w ill tell. ]

th in g s th a t I h a v e to k e e p to m yself, a n d I m

Pt. T h a t s w h a t J i m sa id , yo u k n o w J i m S lo a n ,

g o in g to k e e p th e m to m yself. I m n o t g o in g to

m y frie n d . I to ld h im y e s te rd a y . H e w a n te d to

do a n y th in g th a t w ill e m b a r ra s s y o u , o r h u r t

go o u t a n d I to ld h im I g o tta sta y h o m e , a n d I

you. I m n o t g o in g to m a r r y a n y b o d y , I m n o t

to ld h im I w a s g o in g to see a p s y c h ia tris t. A n d

g o in g to g e t a n y b o d y p r e g n a n t.

h e sa id , y o u re re a lly lu ck y 'c a u s e th e y ca n do

Pt.

I to ld th e m o ften . W e h a d a b ig a r g u m e n t o n e

a lo t o f g o o d fo r y o u . H e said w h e n yo u w a lk

n ig h t. I sa id s o m e th in g lik e, I d o n t k n o w

in th e re , tr u s t h im , h e sa id , so m e tim e s it m ay

w h a t y o u re so c o n c e rn e d a b o u t r ig h t n o w . I m

ta k e a few tim e s, to tr u s t h im eo u g h to ta lk to

n o t g o in g to la tc h o n to o n e g irl u n til I m a r ry

h im , b u t o n ce y o u c a n , y o u re lu ck y . I d i d n t

h e r . I sa id . D o n t w o rry . I m n o t stu p id ;

believe h im . I d i d n t w a n t to com e, b u t I m

I m n o t g o in g to get in to t r o u b le . T h e y get

g lad I cam e.

u p s e t if a g irl is n t o u r re lig io n . I t s a big

T h . W e ll, if y o u ca n c la rify som e th in g s for y o u r

th in g . T h e y j u s t w a n t to k n o w , I d o n t k n o w ,

self, y ou a r e lu ck y . B elieve m e, in sig h t a n d

b u t th e r e s a w h o le b u n c h o f th e s e a r g u m e n ts ,

u n d e r s ta n d in g ca n be th e g re a te s t sa v io r of

a n d I sa y , D o n t w o rry a b o u t th is , th is is n t

y o u r life. If y ou h a v e a n id e a o f w h a t s co o k in g

g o in g to h a p p e n , a n d

w ith y o u a n d w h e re it o r ig in a te d , y o u ca n ta k e

g o in g to see J a n e , a n d so f o rth a n d so fo rth .

a s ta n d

h a v e n t th e

B e c a u se th e o th e r n ig h t I c a m e h o m e a n d m y

fa in te st id e a of w h a t s g o in g o n , a ll y o u feel a re

m o th e r h a d g o n e to sle ep a n d it w a s a b o u t

a g a in s t

it.

B u t if yo u

th ey say , A re you

em o tio n s a n d b a d feelin g s, a n d th e n y o u ve g ot

1 1 :0 0 o clock I ca m e in, a n d h e s ta r ts to ta lk to

to g e t rid o f th ese feelings. A n d b e fo re you

m e. I h a d th is feelin g h e w a n te d to h it on

k n o w it, y o u re in a m ess. Y ou d o n t solve

s o m e th in g , a n d I sa id , G e t to th e p o in t, D a d ;

a n y th in g . A lo t o f th e feelin g s y o u ve b een h a v

w h a t is i t ? A n d he sa id , I m n o t h ittin g on

in g w ith y o u r p a r e n ts a r e th e s e b a d feelings

a n y th in g . I j u s t lik e yo u to g o o u t w ith o th e r

th a t a re c o m in g u p b ecau se you c a n t co m

g ir ls , a n d so fo rth .

m u n ic a te w ith th e m . N o w , m a y b e i t s im p o ssi
ble to c o m m u n ic a te . I d o n t k n o w w h a t y o u re

T h . W h e r e a b o u ts is th e p la c e th a t y o u re g o in g to
school ?

b o th of th e m . B u t I d o b elieve th e y m u st h av e

Pt. H a v e r s to w n .
T h . I w o n d e r if I co u ld fin d a p e rs o n for you to

u p a g a in s t w ith th e m b e c a u se I d o n t k n o w
y o u r w e lfa re a t h e a r t. T h e i r m o tiv es a t least

ta lk to lik e y o u re ta lk in g to m e. W o u ld you

a re g o o d , b u t th e w a y th e y e x p re s s th em se lv e s

w a n t to see so m e o n e to ta lk th in g s o v e r. [-Smce

m ay b e b a d .

H a v e r s to w n is f a r fr o m N e w Y o rk , I a m co n

Pt. D o y ou re a lly feel th a t o r a r e you j u s t sa y in g


th a t?

T h . W h y sh o u ld I say th a t to you if I d id n t m e a n
it?

te m p la tin g

r e fe rr in g

th e p a tie n t

to a n o th e r

th e r a p is t w h o liv e s in th e n e ig h b o r h o o d o f th e
sch ool. ]

Pt. T h a t w o u ld be p r e tty good.

70

H ANDBO OK OF SHORT-TERM PSYCHOTHERAPY

T h . Y ou h a v e n t g ot c o m m u n ic a tio n w ith y o u r

Pt.

p a r e n ts . Y o u n eed c o m m u n ic a tio n w ith so m e


body. B e cau se y o u re g e ttin g too b o ttle d u p

to a s s u m e re s p o n s ib ility f o r h is o w n tre a tm e n t.

w ith in y o u rself. T h e s e k id s a t sch o o l, y o u c a n t

In m y m i n d I a lre a d y h a v e d e c id e d th a t I w ill

ta lk to k id s th e w a y yo u w o u ld ta lk to a th e r a

see th e p a r e n ts also, w h o w ill m a k e u p f o r th e

p ist. T h e y d o n t k n o w w h a t i t s all a b o u t.

s m a ll fe e th e b o y can a ffo rd to p a y . T h e y w ill

Pt. M y sister is p r e tty s m a rt.


T h . S h e s fine. Y o u ca n ta lk to h e r , b u t s h e s n o t

know

Y o u rse lf, d e p e n d s on h o w m u c h yo u co u ld af
fo rd to p a y w h a t co u ld you affo rd to p a y ?

Pt.

in to to w n , b u t it w o u ld be b e tte r if y o u h ad
so m eb o d y n e a rb y . T h a t w o u ld be g re a t. H o w

too th a t th e b o y is c a r r y in g h is o w n

tr e a tm e n t costs.}

Th

aro u n d .

Pt. T h a t s tru e .
T h . I ll b e g la d to see you w h e n e v e r you ca n com e

It d e p e n d s if I c o u ld sen d yo u m y a llo w a n c e
fro m school.

Th

w o u ld you feel a b o u t th a t?

I w o u ld n t w a n t to ta k e a w a y y o u r allo w a n c e ,
I d w o rk o u t so m e th in g . W h a te v e r y o u could

Pt. T h a t w o u ld be p r e tty good.


T h . B u t th e re m a y n o t be a n y b o d y a r o u n d th e r e in

a ffo rd to p a y . I ll w o rk th a t o u t w ith y o u n ex t
t im e .

H a v e rs to w n .

Pt.

S u p p o se I w a s to be p a y in g fo r th is. [77!!* is a
g o o d sig n a n d in d ic a te s th a t th e p a ti e n t w a n ts

W e ll,

l e t s le a v e

w h e n e v e r y o u ca n

it

t h is

w a y th a t

co m e in to to w n , let m e

k n o w a c o u p le d a y s in a d v a n c e . T h is w ill be

h av e a frie n d in o n e of th e te a c h e rs . E v e ry so

ju s t b e tw e e n y o u a n d m e. T h e y w o n t h av e

o ften h e ll tell m e to d r o p in to h is ro o m , h is

a n y I m

a p a r tm e n t, a n d m ay b e w e ll h av e a ta lk o r

a b o u t w h a t w e ta lk a b o u t. I t s th e o n ly w a y I

so m e th in g like th a t.

ca n w o rk w ith a p e rs o n . If I w e re to rev eal

I t s a h ic k to w n ; i t s r ig h t n e a r n o th in g . B u t

not

g o in g

to

tell

th e m

a n y th in g

T h . Y ou n eed so m e b o d y w h o h a s m o re tr a in in g ,

a n y th in g yo u to ld m e, it w o u ld d e s tro y o u r r e

re a lly m o re e x p e r t in th is ty p e o f th in g . Y ou

la tio n s h ip , a n d it w o u ld n t be h e lp fu l p a r tic u

n eed so m e b o d y w h o k n o w s a b o u t d y n am ics,

la rly . T h e o n ly th in g I ca n te ll th e m a b o u t m y

a b o u t e m o tio n a l p ro b le m s, a b o u t re la tio n s h ip s

ta lk w ith y o u to d a y is th a t, in m y o p in io n , you

w ith

d o n t h a v e a n y th in g se rio u sly w ro n g w ith you,

and

b etw e e n

p a r e n ts ,

th e in v o lv em en t

w ith o n e s o w n sense of self. T h is is a h ig h ly

th a t

sp e cialized a n d c o m p lic a te d b u sin e ss. A n e d u

n o r m a l w a y , a n d th a t th e y h a v e to e s ta b lis h

c a to r u s u a lly d o e s n t h a v e th is ty p e of t r a i n

b e tte r c o m m u n ic a tio n w ith y o u . A n d th ey h av e

ing.

to

(p a u se) If th e r e s n o b o d y tr a in e d n e a r

H a v e rs to w n , I ll su g g e st th a t you com e a n d see

sto p

g o in g

and

th r o u g h

d e v e lo p in g

your

p o ck ets.

in

T hat

w o u ld be g re a t if I co u ld p u t th a t ac ro ss to

m e as o ften as you ca n . H o w o ften can you


com e in to th e c ity ?

y o u r e e v o lv in g

th e m , w o u ld n t it?

Pt.

T h a t w o u ld be fin e, b u t so m e tim es, I m a y be

Pt. P re tty o ften .


T h . C a n y o u ? I ll be g lad to see y o u w h e n e v e r you

w ro n g , b u t so m e tim e s I feel th e y th in k th ey

can get a w a y . Y ou k n o w it w ill also m a k e y o u r

of a ta lk . I d o n t k n o w , th e y sa y , Y o u ve h a d

p a r e n ts feel a s if y o u re n o t g o in g to get y o u r

it to o easy , w e ve g iven you e v e r y th in g . T h e y

self in to tro u b le . Y ou k n o w , y o u h a v e a lot on

say w h y w e d o n t tr u s t you is b ecau se you

Pt.

can get th r o u g h to m e by g iv in g m e so m e th in g

th e b a ll, a n d y ou h av e a lot o f very good stu ff

w e re

in yo u . I w o u ld n t say th a t yo u a r e a b n o rm a l,

J a n e . T h e y d o n t e x p e c t m e to say I m n ot

b u t you c a n get in volved in tro u b le w ith all

g o in g to go th e re , a n d if sh e m e a n s a n y th in g to

th ese feelin g s to act o u t, th is fe a r of n o t b e in g a

m e, th e y d o n t e x p e c t m e to sa y I m n o t g o in g

m a n . Y ou h a v e to w o rk it o u t on a n o th e r level.

to go. A n d th e y a r e tr y in g to c o r n e r m e in to

I d o n t m e a n to be u n ta c tfu l, b u t h o w m u ch

sa y in g I ll n e v e r go a n d give m y w o rd th a t I

d o es o n e visit co st?

T h . I h a v e a slid in g scale. In o th e r w o rd s, d e p e n d -

th e r e

anyw ay,

m e a n in g

about

seeing

w o n t go.

Th

W e ll, I ll do m y best. I m tr y in g to fig u re o u t

in g u p o n w h a t a p e rso n ca n p a y ; in o th e r

w h a t I c a n tell th e m to tr y to h e lp th e s itu a

w o rd s, if a p e rs o n is a b le to p a y a h ig h fee, i t s

tio n . I ll tell th e m th a t w e ta lk e d th in g s over

g o in g to cost m o re. If h e c a n t p a y a h ig h fee, I

a n d th a t I th in k th a t it w o u ld be b e tte r fo r you

scale it d o w n .

to ta lk to so m e b o d y else th a n to ta lk to th e m ,

THE INITIAL INTERVIEW: CASE HISTORIES


a n d th a t I to ld y ou I d be v ery h a p p y to see

Fa. W e ve b e e n ta k in g it.

you. If a n y p ro b le m s com e

u p , you w o u ld be

T h . Y o u ve

ab le to d iscu ss th e m w ith

m e. H o w fa r fro m

been

r e a l ly

ta k in g

it?

S u r v iv in g ?

W h a t s b een h a p p e n in g ?

Fa. I t s b een to u g h , th e so n , h e s been b e llig e re n t,

N e w Y o rk C ity is H a v e rs to w n ?
P t.

71

A ll I k n o w is th a t it s a b o u t 75 m iles.

and

h e s b een

w a lk in g w ith

sh o u ld e r

P t.

K n o ck it off, you k n o w . T h e r e s n o ta lk in g to

Th.

P t.

O h , I co u ld ta k e a tr a in in.
Y ou co u ld com e in o n ce in

tw o w eek s, o nce in

to ta lk

is n t b ad .

n o th in g .
to h im ?
M o . I c a n t.

I m se rio u s.

Fa. I j u s t c a n t get th r o u g h . I d o n t lik e w h a t s d e


v e lo p in g , d e v e lo p in g in h im .
T h . I d o n t lik e w h a t s d e v e lo p in g in h im e ith e r,

th a t if an y p ro b le m s com e u p , yo u w ill w a n t to

b e tw e e n

d iscu ss th e m w ith m e. I ll tell th e m th a t I ve

h im se lf in to a h ell of a lot of tr o u b le th e w a y

seen y o u , a n d I th in k it w o u ld be v ery h e lp fu l
if I co u ld h av e so m e ta lk s w ith y o u . I ll tell

you

and

m e,

because

he

ca n

get

he feels.
M o . W e ll, h e s he d o e s n t w a n t to do a n y th in g .

th e m th a t y ou h a v e n o se rio u s in te n tio n of g e t

H e j u s t lik es to d o n o th in g . I t s v ery h a r d to sit

tin g y o u rse lf so c o m p le te ly im m e rs e d a n d in

a n d w a tc h th is for h o u rs , I g u e ss. I feel, I a l

volved w ith a n y b o d y t h a t s g o in g to in te rfe re

m o st feel I d o n t give a d a m n .

w ith y o u r free d o m . Y ou k n o w , give th e m som e

T h . I c a n u n d e r s ta n d y o u r e m o tio n s. I k n o w you

k in d of a s s u ra n c e so th a t th e y w ill sto p b u g

ta k e it on th e c h in . H e s a v ery h a n d s o m e boy

g in g y o u a b o u t th is th in g . Y o u k n o w w h a t I

w ith a lot of stu ff on th e b a ll, b u t he is n o t liv

m e a n ? T h a t s if y ou a g re e , I sh o u ld tell th em

in g u p to h is o w n p o te n tia l. H e s a c tin g o u t

th a t.

a n d so o n . I g a v e h im so m e te s ts to see w h a t s

I m e a n I a g re e w ith yo u a b o u t w h a t y o u re

w h a t. H e s g ot a lot o n th e b a ll, b u t h e s ju s t

g o in g to te ll th e m , b u t h o w a m I su p p o s e d to

fu ll o f e m o tio n . H e s a n e x tre m e ly e m o tio n a l

a c t? S u re w e can sit h e re a n d ta lk , b u t I h av e

kid , re a d y to e x p lo d e a n y tim e , b u t h is defenses

to live w ith th e m .

a r e p r e tty good. I m e a n h e s a b le to h o ld o n to

T h . Y ou h av e to live w ith th e m , I k n o w . W h y c a n t

h is e m o tio n s. T h e

o n ly

b asic p ro b le m

th a t

y ou j u s t say , L o o k , M o m a n d D a d , I d o n t

com es u p is o n e c o m m o n a t h is ag e , a fe a r of

w a n t to fig h t w ith you. I d o n t w a n t to go b e

h is o w n c a p a c itie s as a g ro w in g boy, a n e e d to

h in d y o u r b ack a n d do th in g s th a t a r e b a d . I

p ro v e h is o w n

can a s su re y o u th a t I m g o in g to go o u t w ith

w ith ex e rc ise s a n d w e ig h t liftin g is O K , b u t

m a s c u lin ity .

P ro v in g h im se lf

o th e r p e o p le , b u t I also p ro b a b ly w a n t to see

w a n tin g to g et in to fig h ts th is is a se rio u s

J a n e .

p ro b le m th a t I to o k u p w ith h im . H e need s

I c o u ld n t say th a t to th e m ; th e y w o u ld s ta rt

th e r a p y . N o w , i t s g o in g to be v ery d ifficu lt to

an

is m e n

fin d a n y b o d y a r o u n d H a v e r s to w n . T h e r e s n o

a rg u m e n t.

b o d y in th a t a r e a w e ca n c all o n . I believe I

A n y tim e it h a s b een m e n tio n e d in th e p a s t,

w a s a b le to get to h im , to c o m m u n ic a te to h im ,

a rg u m e n t.

tio n e d , th e r e

A n y tim e
is g o in g

th a t
to

be

nam e
an

t h e r e s a n a r g u m e n t. A n d I k n o w i t s a very

to r e la te w ith h im . I th in k he tr u s ts m e, a n d he

se n sitiv e su b je ct. W h a t could I sa y ?

o p e n e d u p w ith m e. H e c a m e in v ery d e fe n

T h . W h y n o t say sim p ly : L o o k , I m g o in g to ta lk
P t.

to h im . T h e r e s no r a p p o r t, th e r e s

ta lk to m e, n o k id d in g a b o u t it?

like to com e a n d ta lk th in g s o v er w ith m e a n d

P t.

th is big.

T h . (A d d r e s s in g th e m o th e r ) C a n y o u g e t th r o u g h

O n c e a m o n th I co u ld com e in.

T h . Y o u tell th e m th e n th a t you w o u ld v ery m u ch

P t.

w id e ly )

h im . I k n o w I c a n t get th r o u g h to h im . I try

th re e w eek s, o n ce a m o n th . Y ou k n o w th a t

T h . D o y ou re a lly w a n t to com e a n d see m e a n d


P t.

(se p a ra te s h a n d s

a c h ip on his

T h . H o w w o u ld y ou get h e re ?

sively as yo u k n o w . I w a s a b le to c u t th ro u g h ,

th in g s o ver w ith D r. W o lb e rg . G e t th e id e a ?

b u t y o u c a n ju d g e th a t b e tte r w h e n y o u ta lk to

OK

h im . I th in k th e w o rst th in g yo u can do is k eep

T h . I b e tte r see th e m

for a c o u p le of m in u te s.

p u ttin g

in ju n c tio n s o n

h im ru le s.

H e w ill

(P a tie n t w a lk s o u t- p a r e n ts co m e in a n d sit

b r e a k th e m d o w n ; yo u w ill n o t be a b le to sto p

d o w n .)

h im

at

th is

p o in t.

W ith

so m e

th e r a p y

he

72

HANDBOOK OF SHORT-TERM PSYCHOTHERAPY


s h o u ld

be

a b le

to

c o n tro l

h im self.

At

th e

T h . T h e n I ll ta lk to h im ; so m e d a y h e c a n p a y m e.

p re s e n t tim e h e is fo cu sin g e v e ry th in g on a

Mo. H e w a n ts to co m e th e n ?

b a ttle w ith y o u , w h ic h is n t so u n u s u a l a t th is

T h . I th in k he v ery m u c h w a n ts to com e. H e w a s

ag e w h e n h e is b re a k in g h is d e p e n d e n c y on

te llin g m e th a t h e w a s ta lk in g to a frie n d last

you.

n ig h t a n d said th ey (m e a n in g y o u ) w a n t m e to

Mo. W h a t k in d of ru le s, ex cu se m e, w h a t k in d of

see a p s y c h ia tris t. T h is o th e r k id sa id , Y ou

ru le s ? [A p p a r e n tly , sh e is q u ite d e fe n s iv e .]

k n o w y o u re v ery lu c k y , y o u r e v ery lu ck y you

T h . H e w o n t p a y a tte n tio n to ru le s.

ca n see so m e b o d y to ta lk t o .

Mo. T h e r e a r e n t a n y ru le s.

Fa.

T h . Y o u tell h im n o t to see th is g irl. I w o u ld advise


y o u I d o n t k n o w if y o u can do it to lay off
th a t

s itu a tio n

fo r

th e

tim e

b e in g .

H e to ld u s a b o u t it. T h e in te r e s tin g th in g is
th e fellow

he says sa id

it, h is m o th e r a n d

fa th e r, c a n t get a lo n g w ith h im .

D o n t

c o u n te n a n c e it a n d d o n t c o n d o n e it, b u t d o n t
a g re e d it w o u ld be b e tte r for h im to see o th e r

( T h e p a tie n t c a m e for a session th e next


w eek, a g a in acc o m p a n ie d by his p a re n ts . At

p e o p le . I to ld h im it w o u ld be o n ly se n sib le for

t h a t tim e I convinced th e p a r e n t s to co n tin u e

q u iz h im a b o u t it. W e ta lk e d a b o u t it, a n d he

h im n o t to re s tric t h im se lf to th is g irl. It is n t

in th e r a p y w ith me, b o th singly a n d to ge the r,

as se rio u s a s you th in k . H e a g re e d it w o u ld be

d u r i n g w h ic h

a good th in g if h e d id n o t re s tr ic t h im se lf to

v elo p m en tal re q u i r e m e n ts of adolescents a n d

o n e p e rso n . T h e basic th in g is he n eed s so m e

th e need to en c o u ra g e th e ir s o n s in d e p e n d e n t

b o d y to ta lk to. H e n eed s to c o m m u n ic a te w ith


so m e b o d y , to o p e n u p w ith so m e b o d y , b ecau se
h e s a v o lcan o in sid e , re a d y to b u st w id e o p e n .

I counseled th e m on th e d e

strivings. It b eca m e a p p a r e n t th a t th e chief


p r o b l e m in t h e f a m il y n e u r o s i s w a s th e

o u t. I to ld h im , I ca n see you a n y tim e you

m o t h e r s need to control a n d d o m i n a te bo th
h e r h u s b a n d a n d h e r c h ild re n to a p o in t th a t

co m e, if y ou call m e in a d v a n c e .

th ey h a d to obey w ith o u t q u e stio n to avoid h e r

W e w e re ta lk in g a b o u t th a t o u tsid e .

T h . A n d h e sa id to m e, W h a t d o you c h a r g e ? I

hysterical displays. T h e fa th e r w a s in tro d u ced


to a g r o u p w h o ch allen ged his passive y ielding

sa id , I c h a rg e a s lid in g scale, w h a t a p erso n

to his wife a n d en co u ra g e d his sta n d in g u p to

A n d if h e v e rb a liz e s, h e s n o t so lik ely to act

Fa.

co u ld a ffo rd to p a y . H e sa id , I d like to p a y

h e r an d ta k in g h e r s o n s side. T h e m o t h e r

fo r th is m y se lf o u t of m y a llo w a n c e . so I sa id ,

re c e iv e d a b o u t 4 0 s e s sio n s o f p s y c h o a n a lytically o rie n te d t h e r a p y a lo n g w ith a b o u t 10


sessions o f g r o u p th e r a p y . T h e boy him self

A ll r ig h t, w e ll w o rk o u t s o m e th in g . W e ll
w o rk o u t s o m e th in g b etw e e n th e tw o of u s,
w h a te v e r y o u ca n a ffo rd to p a y , b e c a u se a f te r all
y o u c a n t a ffo rd a h ig h fee a n d I do see som e
p e o p le h e re a t a lo w fee sc a le . It w o u ld be b e t
te r fo r h im to feel h e ca n h a n d le it by h im self, so
h e c a n sen d m e five b u c k s o r w h a te v e r it is.

Mo. T h a t s h is allo w a n c e .

benefited sufficiently from 5 m o r e sessions to


d is co n tin u e t h e r a p y greatly im pro v e d . O n fol
lo w -u p th e e n tire fam ily s tr u c tu r e an d r e l a
tio n sh ip b etw e en m e m b e rs o f th e fam ily had
ch an g ed re m a rk e d l y for th e b etter.)

Case 2
T h e follow ing illu strates the active, s u p p o r
tive first-session m a n a g e m e n t of a n a c u te e x
a cerb a tio n of a n x ie ty in a ch ron ic obsessivecom pulsive p a tie n t. In deciding to te r m i n a te
th e r a p y after a few sessions, I toyed w ith the
altern ativ e possibility of en g ag in g in a lo n g

te r m process, b u t felt th a t th e risks of e n h a n c


ing th e p a t i e n t s d ep en d e n c y on m e m i g h t be
too great. A ctually, the p a ti e n t herself e x
pressed an inab ility to c o n tin u e in p ro lo n g e d
th e r a p y . M y objective th e n w a s to b rin g h e r
ra p id ly to a n anx iety -free e q u il ib r iu m , offering

THE INITIAL INTERVIEW: CASE HISTORIES

73

som e insig ht into h e r d y

h a v in g a lot o f fin a n c ia l tr o u b le . T h e r e w a s a

nam ics, w h ich h opefully could in tim e, if she


utilized it, hav e some reco nstru ctive effect.

lot of w o r ry a n d h ig h te n s io n in th e h o u se . I

T h e r e w as no illusion th a t th is brief tr e a tm e n t

w h e r e a s m y sis te r a n d b r o th e r d i d n t re a lly

h e r,

if possible,

suppose

I to o k

th is m o re o r less to h e a r t,

b eliev e in a ll th e c o m p la in ts , th e u su a l k in d s of

in te rlu d e w o uld forestall fu tu re attacks. H o w

th in g s th a t go o n . O n e tim e I w a s u p in m y

ever, it w a s felt th a t if th e p a tie n t could be

b e d ro o m a n d I w a s j u s t so rt of like p r a y in g to

tided over h e r im m e d ia te crisis, she m ig h t be

G o d th a t e v e ry th in g w o u ld w o rk o u t a n d it

helped to a b e tte r a d ju s tm e n t. Since tension

w o u ld be a ll r ig h t. I k n o w I w a s feelin g d e

w a s th e m o to r th a t released h e r obsessional
sy m p to m s, h elp in g h e r to le a r n to co ntro l te n

fia n c e a n d I k n o w h o w th is w o rk s, b u t I said
to m yself, W e ll, if I c a n t p r a y to G o d to

sion by re la x a tio n w a s th e tactic I decided to

m a k e e v e ry th in g all r ig h t, m a y b e if I say J e s u s

utilize.

C h r i s t o v e r a n d o v er a g a in it w i ll . W e ll, I
s ta rte d

Pt.

I called th e C o n s u lta tio n S erv ice a n d 1 sp o k e to


D r . G . a n d to ld h im w h a t I n ee d e d a n d he re c

to

rep eat

th a t

in

my

m in d

and

it

seem ed re p u lsiv e .
T h . J e s u s C h r is t?

o m m e n d e d yo u . H e sa id th a t yo u w e re th e p e r

P t.

son to tell m e yes o r n o . [ T h e p a tie n t sp e a k s

T h . T h e re p e titio n of J e s u s C h r is t, w a s it so rt of a

r a p id ly a n d se e m s u p s e t a n d p e r tu r b e d . I g e t
th e im p re ss io n th a t sh e n e e d s a g o o d d e a l o f

T h a t s it.
d e fia n t g e s tu re ?

P t.

I su p p o s e it w as. I d o n t q u ite u n d e r s ta n d it.

re a ssu ra n ce w h ic h m a y o r m a y n o t be o f h elp

W e ll, I c o u ld n t sto p r e p e a tin g th is th in g in

to her.}

m y m in d . It w o u ld ju s t go on a n d on a n d o n,
w h ic h n e v e r h a p p e n e d a c tu a lly b efo re. I d id n t

T h . Y ou m e a n , w h e th e r m y k in d of th e r a p y w o u ld

k n o w w h a t to d o. F in a lly , I to ld m y m o th e r

be o f v a lu e to y o u ?

Pt. T h a t s rig h t.

a b o u t it, a n d w e w e n t to o u r fa m ily d o c to r. I

T h . W e ll, su p p o s in g you give m e a n id e a o f y o u r

w a s 15 a t th e tim e. I a m 21 n o w . H e se n t m e

p ro b le m , a n d th e n I w ill tell yo u w h e th e r I can

to a p s y c h ia tris t. T h is g u y w a s a p sy c h ia tris t

be o f a n y p o ssib le h e lp to you.

a n d n e u ro lo g ist. N o w , w h e n I w e n t to h im , it

Pt. C a n you tr e a t m e? I h a v e o b se ssio n s th a t

w as

s h o rt

tim e.

m a tte r

of a few

f a r a s th a t goes. I to ld h im th e sa m e sto ry

T h . If y o u h a v e th e d e s ire for h e lp , th a t is u su a lly


[B ec a u se sh e is so

w h ic h I w ill tell you n o w th a t th e r e is so m e

u p se t, 1 d ecid e to re a ssu re h e r r a th e r th a n to

th in g th a t h a p p e n e d to m e w h e n I w a s 8 y e a rs

e x p lo r e w h a t sh e m e a n s b y o b se ss io n s. ]

o ld. I can re m e m b e r w h e n th is th in g first cam e

n in e -te n th s o f th e b a ttle .

Pt.

for a

m o n th s. H e d id a b s o lu te ly n o th in g for m e, a s

c ro w d in to m y m in d a n d u p se t m e.

W e ll, t h a t s w h a t

I a m . I a m re a lly obsessive,

o u t. I a m p o sitiv e a b o u t it. I a m te llin g th e


sa m e r o tte n sto ry . I h a te m y se lf fo r th is b e

v ery b ad ly .
T h . T e ll m e a b o u t it. H o w b ad is it?

c a u se it w a s j u s t a w a s te of e v e ry th in g . W e ll,

Pt.

f in a lly , a f te r a b o u t 5 m o n th s I re c a ll th a t it

W e ll

I w ill tell you th e sto ry . I get very u p se t

o v er it. ( T h e p a tie n t p a u s e s a n d is m a n ife s tly

s ta rte d

a n x io u s .)

w o r d s a n d I g ot back to b e in g m yself. J u s t

W hen

let

d o w n th is

r e p e a tin g

o f th e

b e in g m yself. P e rio d . [ 772^ o u tc r o p p in g o f th e

T h . T a k e y o u r tim e [m o re re a ss u ra n c e ].

Pt.

to

I w as 15, th is first ca m e o u t a n d it

o b se ssio n a l s y m p to m
a n x ie tie s ,

r e a lly b o th e re d m e. A w o rd ca m e to m y m in d ,

is a d e r iv a tiv e o f m a n y

so m e p e r h a p s u n c o n sc io u s, d a tin g

a n d I felt forced to r e p e a t it. (p a u se ) It is th e

b ack to h e r c h ild h o o d . T h e p a tie n t re co g n izes

r e p e a tin g of th e w o rd (p a u se).

th e c o n n e c tio n .]

T h . T h e re p e a tin g o f th e w o rd .

T h . D u r in g th is p e rio d th a t yo u w e re se ein g th e

Pt. Y es, you see I com e fro m a very re lig io u s


fam ily . I, m yself, a m n o t re lig io u s o r a n y th in g

p s y c h ia tris t w h a t h a p p e n e d ?
P t.

Yes.

1 w ent

to h im

on

and

off, a n d

th e n

like th a t. I d o n t k n o w if you k n o w w h a t I am

e v e n tu a lly he ju st to ld m e th a t he re a lly sp e

ta lk in g a b o u t. In th e fam ily th a t I cam e from

c ia liz e d in n e u ro lo g y a n d th e r e w a s n ot a d a r n

th e re w e re c o n s ta n t p r a y e r s . W e ll, a s a c h ild ,

th in g he co u ld do for m e. A n d if I c o u ld , I

w h e n I w a s a b o u t 15, I re m e m b e r m y f a th e r

w o u ld h a v e r a t h e r av o id ed th is. I w a s a ju n io r

74

HANDBOOK OF SHORT-TERM PSYCHOTHERAPY


in

h ig h sch o o l at th e tim e th a t

I w a s 15.

T h . It m u st h a v e u p se t you a good d e a l.

T o w a r d th e en d of th a t y e a r it m o re o r less

P t.

w ent aw ay and

T h . T h a t s 5 m o n th s ago.

I w o u ld fo rg e t a b o u t it. 1

w o u ld r a t h e r th in k th a t it h a d n o th in g to do

P t.

It d id , th is p a s t A p ril.
I h a v e sp o k e n to som e p e o p le since th e n b e

w ith m e a n d th a t I co u ld sta n d it. I w a s all

c a u s e m y h u s b a n d a n d I w a n t a la rg e fam ily

rig h t in m y s e n io r y e a r in h ig h school. I w as

n a tu r a lly . M y h u s b a n d a n d I w a n t to p la n on

all

r ig h t

in

my

fre s h m a n

year

in

college.

a fa m ily , a n d I d o n t w a n t to h av e c h ild re n b e

M a y b e it w o u ld s ta r t co m in g u p , b u t I could

c a u s e I w ill be su ffe rin g w o rse th e n . B ecau se,

so rt o f fig h t it d o w n . W h e n I w a s a s o p h o m o re

if it is a n a n x ie ty , o r w h a te v e r y o u call it,

in college, I w e n t a w a y to school.

w h e n I g e t it, re a lly get it, I a m m ise ra b le .

T h . Y ou w e re all r ig h t a s a fre s h m a n in college?

Y ou c a n t re m o v e it so m e tim e s ly in g th e re ; you

P t.

Yes. T h e n I w a n te d to go a w a y to school an d

ju s t d o n t k n o w w h a t it is. I t s lik e y o u r scared

live in a d o rm . It w a s a n ew e x p e rie n c e . G e t

o f s o m e th in g , b u t yo u d o n t k n o w w h a t you

tin g a w a y a n d , o f c o u rse , th e c h a n g e o f e n v i

a r e sc are d of. It is v ery h a r d to say . I h a d

ro n m e n t su d d e n ly . E v e ry th in g w a s g o in g a lo n g

sp o k e n to som e p e o p le a b o u t th e th in g th a t

w e ll, a lth o u g h

happened

it w a s n ew a n d I h a d n ev er

av o id ed e v e ry th in g a n d e v e ry b o d y . T o m e if I

b e tte r, th is th in g g ot h o ld o f m e. Y ou k n o w

am n o t feelin g g u ilty a n d it is n o t b o th e rin g

w h at I m ean?

m e, I a m fine. I re a liz e n o w th a t it is so m e

T h . Y o u m e a n th e o b se ssio n s s ta rte d a g a in ? W h e n
P t.

th in g th a t w ill be r e c u r rin g u n til I fin d o u t

w a s th a t? H o w lo n g a g o ?

w h a t it is th a t is n e e d e d , o r d e s tro y it, o r p u t it

T h is w a s w h e n I w a s 18. I t s n o t so m u ch th e

d o w n . I sp o k e to a few d o c to rs, b u t n o th in g

r e p e a tin g of th e w o rd , a c tu a lly , a lth o u g h th a t

ste a d y .

T h . A ny o th e r trie s a t p sy c h o th e ra p y ?

o c c u rre d .

T h . T h e sa m e w o rd , J e s u s C h r is t?
P t.

to m e in A p ril. I got p e trifie d . I

b een a w a y fro m h o m e. B u t b efo re I could get

P t.

J u s t th e o n e tim e th a t I to ld you a b o u t. I h a d a

Yes, b u t it c h a n g e d to a ll k in d s of sy m p to m s

g irl frie n d ta lk in g to m e once. I n e v e r to ld a n y

a c tu a lly .

sa y in g , J e s u s

b o d y a b o u t it b ecau se I a m d e a th ly a s h a m e d of

C h r i s t , b u t I k n o w w h e re all th is ca m e fro m .

it, a n d d e a th ly a s h a m e d th a t a n y o n e sh o u ld

I s ta rte d j u s t

w ith

I w ill go b a c k , b u t I ju s t w a n te d to ta k e it from

k n o w . A n y w a y , th a t b o th e rs m e a n a w fu l lot.

h e re . F in a lly , w h e n I w a s a s o p h o m o re , a t th e

S h e w a s te llin g m e a b o u t w h e n sh e w a s a w a y

en d o f m y so p h o m o re y e a r, I g ot h o m e a n d

on e tim e. S h e s tu tte r s . S h e h a d g o n e to a p e r

e v e ry th in g w a s fine. It d id n t b o th e r m e th a t

so n , w h o I b elieve is a p s y c h ia tris t, w h o ta u g h t

m u c h e ith e r th a t y e a r as m u c h as it d id th e

h y p n o sis to o th e r d o c to rs o r so m e th in g of th a t

first tim e. T h e n I b ecam e e n g a g e d . I w a s fine

so rt, a n d sh e w a s te llin g m e th e sto ry o f how

a n d I th o u g h t it w o u ld n t even b o th e r m e a n y

sh e w a s re g re sse d to e a r lie r tim e s of h e r life.

m o re . I g o t m a r rie d . M y h u s b a n d a n d I h av e a

S h e w a s re g re sse d to th e tim e w h e re sh e first

v ery

m a rria g e .

s ta rte d to s tu tte r . H e r m o th e r to o k a k nife to

[U p to th is p o i n t th e p a tie n t d o es n o t p r e s e n t

nice

m a r ria g e a

successful

o n e o f h e r b r o th e rs w h e n sh e w a s 2 y e a rs old,

too c o h e r e n t a sto ry . S h e se e m s so c o n c e rn e d

w h e n it h a p p e n e d th a t sh e s tu tte r e d . A fter she

a n d u p se t w ith h e r o b se ssio n a l s y m p to m th a t

fo u n d o u t a b o u t th a t, th e n sh e b e g an to ta lk .

sh e b yp a sses im p o r ta n t d e ta ils th a t I sh a ll e x

[T h is c o n v e n tio n a l n o tio n o f th e p a th o g e n ic ity

p lo r e la te r ./

o f b u r ie d m e m o r ie s , a n d th e ir n e e d to d is

T h . H o w old w e re y ou w h e n you g ot m a r rie d ?

g o rg e th e m f o r cu re, se n d s so m e p a tie n ts in

P t.

q u e s t o f th e r a p is ts w h o can su rg ic a lly d issect

N in e te e n . I m 21 n o w .

T h . Y o u h av e b een m a r rie d a lm o st 2 y e a rs?

in to

P t.

a b o u t th a t, th e n sh e b eg a n to ta lk . W e ll, from

A y e a r a n d 3 m o n th s. I w a s m a r rie d for 10

th e

u n c o n s c io u s .)

A fter

sh e fo u n d

out

m o n th s th is is w h y I a m h e re n o w th is p a st

w h a t I h ad re a d a b o u t h y p n o sis a n d th in g s like

A p ril I w a s h u m m in g in b ed , a n d , you see

th a t, I th o u g h t th a t m a y b e , m a y b e th is is o n e

a c tu a lly w h e n I a m o u t a n d activ e a n d e v e ry

w a y of g o in g b ack a n d fin d in g o u t w h y I h a d

th in g , a n d if th is s ta rts to b o th e r m e, I can ju s t

th is tro u b le . W h a t is it c o v e rin g u p ? I k n o w

get in v o lv ed in o th e r th in g s a n d so rt o f k eep it

th is m u ch a t le a s t. W h e n I w a s 8 y e a rs o ld , I

d e p re ss e d , k eep it d o w n . W h e n it ca m e to th e

h av e th re e b r o th e rs , a n d a n o ld e r b r o th e r, w h o

su rfa c e a g a in , th a t re a lly b o th e re d m e.

is 6 y e a rs o ld e r th a n I th e r e w a s a lot of sex

75

THE INITIAL INTERVIEW: CASE HISTORIES


p lay b etw een th e tw o of u s. I w a s b ro u g h t u p

ro o m , b u t sh e ca m e in w ith m y a u n t, a n d I

in a v ery stric t h o m e. Sex w a s s o m e th in g th a t

w a s g o in g to tell h e r, b u t sh e w a s w ith m y

w a s n e v e r ta lk e d a b o u t, a n d so fo rth . T h e w ay

a u n t a n d I c o u ld n t. I looked a t h e r a n d sa id ,

I feel a b o u t it, I h av e n o t a b a d a d ju s tm e n t. I

"M o m m y ,

h av e h a d a v ery good a d ju s tm e n t in m a rria g e .

a u n t b u rs t o u t la u g h in g . I w o u ld b u rs t o u t

O f c o u rse , m y

I c a n t u n d e r s ta n d h o w o n e h a s a n y th in g to do

la u g h in g if it w a s a n y b o d y else. T h e y j u s t sh u t
it off. It w a s j u s t n o th in g . S o m e k in d of silly

m e m b e r fro m m y y o u n g c h ild h o o d life. T h is

b u sin e ss a n d th a t w a s th e e n d of it. W e ll, to

th in g is b o th e r in g m e. T h e r e w a s no a c tu a l in

th is d ay n o b o d y k n o w s a n y th in g a b o u t it e x
cep t th is d o c to r th a t I sp o k e to .

lik e m a s tu r b a tio n . H e w o u ld to u c h m e, a n d I

T h . Y o u r b r o th e r w a s 14 at th e tim e ?

w o u ld to u c h h im , a n d so fo rth . \ W h a t th e p a

P t.

Y es. W h e n th is w a s g o in g o n , h e w o u ld send

tie n t w a n ts is h y p n o s is to u p r o o t im p o r ta n t

m e o u t o f th e ro o m , a n d I n e v e r k n e w w h y . It

m e m o rie s.

T h is , in m y o p in io n , is n o t w h a t

w a s w h e n h e w o u ld re a c h a n o rg a s m a n d th e

w ill h e lp her. N a tu r a lly , sh e is n o t to ld th is

sp e rm w o u ld be co m in g o u t. O n e tim e I ask ed

sin c e it m a y d isc o u ra g e h e r to lea rn th a t th e

h im w h y , a n d h e let m e sta y , a n d I saw th e

te c h n iq u e th a t sh e b elieves w ill save h e r c a n n o t

sp e rm c o m in g o u t, a n d h e to ld m e, T h a t s

do so. L a te r , w h e n I h a v e a w o r k in g r e la tio n

w h a t m a k e s you p r e g n a n t . I b ec a m e , a s a

sh ip w ith her, I w ill be in a b e tte r p o s itio n to

c h ild of 9 a n d

a p p r is e h e r o f w h a t I b elieve ca n h e lp her.]

sp e rm . T h in g s th a t m y b r o th e r w o u ld to u c h I

T h . Y ou

rem em b er

th e

in c id e n t

to d a y

w as

q u ite

a f ra id

to

10, I b ec a m e v ery a fra id of


to u c h

for fe a r

I w o u ld

get

p r e g n a n t. S o m e tim e s I w a s sc a re d in m y m a r

a c u te ly ? Y o u w e re o n ly 8 y e a rs of ag e th e n . It
still b o th e rs y o u ?

rie d life. I ca n u n d e r s ta n d it ra tio n a lly , b u t I

1 r e m e m b e r ev ery sin g le th in g th a t h a p p e n e d .

do n o t w a n t to h a v e a p re g n a n c y , a n d I a m
m o re sc are d o f b e c o m in g p r e g n a n t ju s t fro m

T h . D o you r e m e m b e r if yo u felt se x u a l ex c ite m e n t

sp e rm th a n I th in k a n o rm a l p e rso n w o u ld be.

a t th e tim e ?
P t.

p r e g n a n t.

w ith th e o th e r. T h is is th e o n ly th in g I can r e

te rc o u rs e th a t to o k p la c e a t a ll, b u t th e re w a s

P t.

I am

I a m q u ite s u re o f th a t.

N o t m e.

T h . N ot you?

T h . D o you u se c o n tra c e p tiv e s?

P t.

P t.

W e ll, it is a fu n n y th in g . If I w e re to be t r u t h

Yes. I b ec a m e v ery a f ra id to to u c h a n y th in g

fu l, I d say th a t I k n e w th a t I lik ed it. B u t h e re

th a t m y b r o th e r to u c h e d . If I w o u ld , th e n I

is th e sto ry . Y ou see, w h e n w e first s ta r te d

w o u ld

th is w e n t o n fo r a v ery s h o rt tim e , b u t it

h an d s, an d w ash m y h ands.

w a s n t ju s t o n e tim e th a t it to o k p la c e b etw e e n

rid ic u lo u s , b u t I h a d to do it. If th a t is c o m p u l

th e tw o of u s w h e n it first s ta rte d , I k n ew

sio n , w ell, th e n th a t is c o m p u ls io n . I d o n t

ru n

and

w ash

my

hands, w ash my
It w a s g e ttin g

n o th in g a b o u t sex. I w a s j u s t a b o u t 8 y e a rs

k n o w w h a t it is. T h e n , o f c o u rse , I th in k th a t

o ld. I d i d n t even k n o w w h a t it w as. D u r in g

fro m th a t m a y b e yo u w o u ld d e te r m in e th a t I

th e tim e th a t th is w a s g o in g o n , a ll th e g irls

w a s to u c h y . T h a t d o e s n t b o th e r m e m u ch .

w e re g e ttin g to g e th e r a n d s ta rtin g to ta lk a b o u t

W hen

sex. T h e n I re a liz e d w h a t I w a s d o in g a n d th a t

p r a y e r b o o k a n d s ta r t to re a d . W h e n I w o u ld

w h a t I w a s d o in g w a s w ro n g . T h a t m a d e m e

co m e to th e en d o f th e se n te n c e , o r so m e th in g

I w a s y o u n g e r, I w o u ld p ick u p th e

lik e th a t, I w o u ld h a v e to sa y , J e s u s C h r i s t

feel d iffe re n t, (p a u se)


T h . It m a d e y ou feel g u ilty ?

o v er a n d o v er to m yself. It g ot to th e p o in t

P t.

w h e r e I c o u ld n t re a d w ith a n y b o d y , a lth o u g h

N o w , I w a s o n ly 8, b ut I r e m e m b e r on e tim e.
M a y b e it w a s e x tr a nice o r so m e th in g like

I d i d n t say a n y th in g . T h e n th is w o u ld com e to

th a t. It w a s th e su m m e rtim e in m y h o u se . I

m y m in d . As I g re w u p , I g u ess it su b sid e d a n d

w a n te d to tell m y m o th e r. I h a d to get th is

d id n t b o th e r m e, w ith th e h a n d w a s h in g an d

th in g o u t of m e. I can re m e m b e r g o in g to m y

th in g s

ro o m

A lw a y s d e a th ly

te e n a g e life I a lw a y s w a s a fra id I w a s g o in g to

a fra id th a t I w a s p r e g n a n t. E v en th o u g h , a s I

b eco m e p r e g n a n t. E v en as a c h ild . It o n ly w e n t

say , I k n e w I c o u ld n t be, b u t I w a s sc a re d th a t

on fo r a s h o rt p e rio d , a m a tte r o f m o n th s. I

I w as. I w a s sc a re d all of m y te e n a g e life th a t

d o n t re a lly re m e m b e r h o w lo n g . W e ll, it w as

an d

c ry in g

about

it.

lik e

th a t ,

a lth o u g h

all

th r o u g h

my

so m e d ay I w o u ld be p r e g n a n t fro m th is th in g .

d u r in g th is tim e th a t I s ta rte d to r e p e a t J e s u s

I re m e m b e r m y m o th e r ca m e u p s ta ir s to m y

C h r i s t to m yself. A n d ev er sin c e th a t tim e ,

76

HANDBOOK OF SHORT-TERM PSYCHOTHERAPY


th is th in g h a s j u s t b een g ro w in g a n d g ro w in g

w o rd s co m e u p in th e sa m e c o n te x t a s J e s u s

a n d g ro w in g . N o w it sto p s, n o w it fla re s u p ,
n o w it d o e s n t. T h e last tim e w a s in A p ril. It

C h r is t?
P t.

h a s n t b o th e re d m e for q u ite a w h ile . A lth o u g h


I co u ld fig h t it d o w n , I a m p u rp o s e ly n o t fig h t

b u t it d o e s n t b o th e r m e in th e le a s t a c tu a lly .
T h . T e ll

in g it d o w n fo r th e sim p le re a so n th a t I w a n t
to g et rid o f it b ecau se n a tu r a lly w e w a n t to

O n ly if I tr y to co v er it u p w ith a s w e a r w o rd ,
me

little

b it

m o re

about

o th e r

sy m p to m s . D o yo u get te n s io n d u r in g th e d a y ?
P t.

Do

yo u

m ean w hen

h a v e a fam ily . I k n o w th a t I c a n n o t m a k e a

r e g u la r d a y ?

d e c e n t m o th e r w ith th is so rt of a tta c k co m in g

T h . R e g u la r d a y .

u p o n m e. O n e o th e r th in g th a t b o th e rs m e I

P t.

g u ess th is is b ecau se I a m o v e rse n sitiv e to th e

I am

u p se t o r j u s t a

I k n o w I h a v e a lo t o f in fe rio ritie s . I ca n tell


yo u th a t m u c h . H e r e is a c u r io u s th in g . I d o n t

p r o b le m it is th a t w h e n w e to ld o u r fam ily

know

d o c to r, I w a s a f ra id , I a m n o w sc a re d th a t

s tr e n g th e n u p th r o u g h tim e o r n o t. A t o n e tim e

if

th is

m eans

th a t

your

eg o

does

ev ery b o d y k n o w s. I a m so a fra id th a t p eo p le

I felt lik e I w a s th e u g lie st th in g in th e w o rld . I

w ill find m e o u t. T h e p e o p le a r o u n d C o n

w o u ld w a lk d o w n th e h a lls th is m y p re ju d ic e

n e c tic u t, w h e re I live, a r e n o sy . I believe, I

c o m in g u p a n d if th e co lo red g irls w o u ld w a lk

th in k it n o w .

by m e, I w o u ld th in k , Y o u k n o w y o u a r e j u s t

T h . F in d o u t a b o u t y o u r o b se ssio n ?

th e u g lie st th in g in th e w o r ld . A n d y et, it

P t.

W h e n it d o e s n t b o th e r m e a n d I th in k th a t

d o e s n t

so m e o n e k n o w s, I ju s t la u g h it off. I th in k , So

b o th e re d m e since. I h a v e h a d th e o th e r tw o a t

w h a t, w h a t ca n I do a b o u t it. I c a n t h e lp it. It

ta c k s m o re o r less w h ic h h a v e b een j u s t a s b ad .

me

at

a ll

now , and

h a s n t

is o v e r a n d d o n e w ith . It is a silly th in g . In

A n d y et, w h e n I w a s a s e n io r in h ig h sch o o l, I

fact,

c o u ld n t c o m p e te in m y s o ro rity , w h ic h m u st

I ca n

re m e m b e r

a c tu a lly

la u g h in g

at

m y se lf in -b e tw e e n tim e s to th in k th a t I w o u ld

h a v e b e e n a sh o c k to m y ego. N o w it re a lly

d o s o m e th in g lik e th a t. A lth o u g h th a t b o th e rs

d o e s n t b o th e r m e a n y m o re . I h a v e tw o siste rs,

m e a lo t, sw a llo w in g so m e tim e s is a sy m p to m .

o n e is a y e a r o ld e r th a n I. I k n o w I w a s h eld in

Th.

S w a llo w in g ? T e ll m e a b o u t

P t.

It is j u s t n o th in g . A ll o f a s u d d e n I ju s t

th a t.

h e r sh a d o w .
c a n t

T h . I see. D id y o u h a v e a n y o th e r k in d s o f p r o b

sw a llo w . It d o e s n t b o th e r m e a lo t. I t is all of

lem s a s a c h ild ? D id yo u h a v e a n y tics o r

a su d d e n . I a m n o t d o in g it n o w . I a m ju s t

sp e ech p ro b le m s o f a n y k in d , in sta n c e s o f b e d

ta lk in g a b o u t th is w h o le th in g , p a r tic u la r ly th e

w e ttin g o r w a lk in g in y o u r sle e p ?

w o rd re p e a tin g .

h a v e fo c u s e d m o r e on th e c o m p e titiv e n e s s w ith

T h . T e ll m e a b o u t th is. W h a t o th e r w o rd besides

fo r m a tio n as p o s s ib le in th is in te r v ie w to h e lp

I d o n t a lw a y s sa y J e s u s C h r i s t . I c h a n g e
th e w o rd a ro u n d so th a t I d o n t h a v e to say
th a t

p a r tic u la r

w o rd .

[ / c o u ld

h e r sister, b u t I w a n te d to g e t as m u c h in

J e s u s C h r is t co m es o u t?
P t.

b o th e r

I w o u ld

say cocka-

d o o d le o r so m e th in g lik e th a t.

m e in d e s ig n in g a tr e a tm e n t p la n .]
P t.

I n e v e r w a lk e d in m y sle ep , n e v e r w e t m y bed.
I d o n t k n o w if th is h a s a n y th in g to d o w ith it,
b u t I o n ce a sk ed m y m o th e r, a lth o u g h I c e r

T h . C o c k a d o o d le ?

ta in ly d o n t re m e m b e r b a c k th a t f a r m yself. O f

P t.

I d o n t k n o w . J u s t a n y th in g in o r d e r to avoid

c o u rse , m y s is te r h a s a b a b y n o w , a n d I lik e

sa y in g th e w o rd th a t I a m th in k in g of. B u t

th e w a y sh e is b rin g in g h e r u p . S h e lets h e r do

so m e tim e s I w ill ju s t be d o in g a n y th in g a n d it

th in g s a s sh e com es of ag e a n d t h a t s h o w sh e

w ill com e o u t j u s t like th a t.

c o n tro ls h erself. I su p p o s e d ly n e v e r w e t m y

T h . W h e n it co m es o u t, it gives y o u a n x ie ty ?

p a n ts , a n d by a y e a r o r s o m e th in g lik e it I

P t.

n e v e r bed w e t. I ca n n e v e r re m e m b e r a n y o n e

O h , yes.

T h . A g re a t d e a l of a n x ie ty ?

tim e in m y life w h e re I d id b e d -w e ttin g . A s fa r

P t.

a s tics a re c o n c e rn e d , w h ic h m e a n s s w a llo w in g

N o t a lw a y s . B u t w h e n I a m feelin g fin e, a n d
a ll o f a su d d e n it com es o u t, I ju s t p r a y th a t it

o r so m e su c h fu n n y th in g , I d o n t k n o w h o w

is n t g o in g to com e to th e su rfa c e , I d o n t p ra y .

old I w a s , b u t you k n o w h o w yo u ca n click

I d id n t m e a n it th a t w a y . I j u s t get sc a re d a n d

y o u r th r o a t o r s o m e th in g . I u sed to do th a t,

tr y to av o id it. B ecause I k n o w h o w I ca n get

b u t n o t a lo t. N o t th a t it b o th e re d m e. I n e v e r

so inv o lv ed a n d en g u lfed in th is th in g .

g ot

T h . A ll rig h t. N o w , a p a r t fro m th is , do a n y o th e r

w o r rie d

about

it.

M aybe

y e s te rd a y

s o m e th in g it m ig h t h a v e h a p p e n e d .

or

THE INITIAL INTERVIEW: CASE HISTORIES


T h . H o w a b o u t d e p r e s s io n s ? D o y o u g e t d e
P t.

77
P t.

c u rio u s a b o u t th e w h o le th in g a n d w h e n w e

T h e o n ly tim e 1 get d e p re ss e d is w h e n I g et th e

w e re little te llin g jo k e s . A t th e tim e I w a s ju s t

a tta c k . R ig h t n o w I m n o t d e p re ss e d . If m y
h u s b a n d w a n te d to go to a p a r ty a n d h a v e a

c u rio u s.

T h . Y o u r s e x u a l a d ju s tm e n t n o w , w o u ld yo u say it

g o o d tim e , I d go. W h e n I feel a ll r ig h t in b e

is a good o n e ?

tw e e n a tta c k s , I a m j u s t lik e a n y o th e r p e rso n .

P t.

S o m etim es I feel b lu e o n e d a y , b u t c e rta in ly

T h . W ith a c lim a x ?

n o t d e p ressed . If so m e b o d y c a lls a n d w a n ts to

P t.

go so m e p la ce, o k a y . B u t I d o get v ery , very


d o w n h e a r te d

w hen

th is th in g g ets m e.

B e

in th a t sen se. W h a t a m I g o in g to d o ? I c a n t

h a v in g co m p le te free d o m in sex. B u t a fte r a

T h . So th a t y o u a re u n in h ib ite d m o re o r less se x
u a lly ?
P t.

T h . D o you g et a n y h e a d a c h e s?

feel a b o u t it.

n e u ro tic

T h . H o w a b o u t w h e n y o u h a v e a few d r in k s ? D u r

sy m p to m , p re ss in g o n th e sid e s. I get a ll th is

in g th e tim e s w h e n yo u h av e a n x ie ty does alc o

know

th is

m eans

i t s

stu ff. I h a v e g o tte n th is p re ss in g feelin g ev er

h o l h e lp ?

sin ce th e a tta c k s s ta rte d , fro m th e tim e th is

P t.

s ta rte d w h e n I w a s a ch ild .

T h . H o w a b o u t tr a n q u iliz e r s ? H a v e y o u ta k e n an y

T h . T h is d e p re ss in g feelin g ?
P t.

I o n ce w e n t to a d o c to r w h o g av e m e a p ill.

to r to g et a p h y sic al c h e c k u p b e c a u se I w a s

T h e firs t p s y c h ia tris t w h o m I w e n t to w h e n I

g e ttin g so ex cited a n d so sc a re d in sid e th a t I

w a s 15 g a v e m e so m e p ills, b u t h e to ld m e

w o u ld a c tu a lly w o rk a fever u p in sid e m yself. I

r ig h t to m y face, h e sa id , Y o u k n o w y o u r c u re

c a n t e x p la in it. I g et so sc a re d a n d so p e trifie d

is n o t in th e b o ttle . W h ic h , o f c o u rse , I k n o w .

t h a t I d o n t k n o w w h a t to d o . W e ll, I k n o w

T h is last tim e , I sp o k e to th is o n e d o c to r I

w h e n I g et a fever. W h e n I g e t a r e a l fever, I

j u s t w e n t to h im

k n o w th a t I a m sick, b u t w h e n I g e t th is k in d

p r e s c r ip tio n

of a h o tn e s s o r so m e th in g . . . n o w

d o w n a n d I w o u ld fo rg et a b o u t it, so m e th in g

I ca n

once an d

w h ic h

h e sa id

he g av e m e a
w o u ld ca lm

me

r e la te th a t to s o m e th in g w h e n I re fe r back.

lik e th a t. I to o k th e p ill, a n d it d i d n t do a

W h e n I w a s 8 y e a rs o ld , I c a n re m e m b e r d u r

th in g , a n d I k n o w m y se lf th a t a p ill is n o t g o

in g th e sex p la y b etw e e n m y b r o th e r a n d I, I

in g to c u re m e.

T h . D o yo u k n o w w h ic h p ill h e g a v e y o u ?

so w a r m o r so h o t. N o w I d o n t k n o w if th e re

P t.

is a n y d ire c t c o rre la tio n b e tw e e n th e se . I d o n t

T h . S o u n d s lik e L ib r iu m .

even k n o w

if it is th a t w h ic h is c a u s in g it.

P t.

It w a s a g re e n a n d b la c k one.
Y es, it w a s L ib r iu m .

M a y b e it is co m p letely su b c o n sc io u s. B u t for

T h . It d i d n t h e lp ?

so m e re a so n I a lw a y s r e la te it to th a t. B u t it

P t.

m a y h av e n o th in g to d o w ith it.

It d id n t do a th in g . I t s all u p h e re p o i n t s to
h e a d ). [I g e t a b e tte r fe e lin g a b o u t h e r basic

T h . D o y ou r e la te th e fever to th a t in c id e n t w ith

str e n g th s. S h e h a s m a d e a g o o d s e x u a l a d ju s t

y o u r b r o th e r?

m e n t a n d h a s so m e u n d e r s ta n d in g o f h e r p r o b

N o , it w a s fro m m y b r o th e r se em in g to g et e x

lem .}

c ited o r s tim u la te d , o f c o u rse . W a r m th w a s

T h . H o w a b o u t d r e a m s ? D o y o u d r e a m a g re a t

j u s t p a r t o f th e se x u a l s tim u la tio n . I re m e m b e r
w o n d e rin g a b o u t it esp e c ia lly w h e n I h a n d le d
h is p en is.

T h . W h e n y o u h a n d le d h is p e n is , d id y o u h a v e a n y
feelin g s a b o u t th a t?
P t.

I d o n t d r in k .
m e d ic a tio n ?

P re ss in g n o t d e p re ss in g . I h a d to go to th e d o c

co u ld n e v e r u n d e r s ta n d w h y th e a ir a lw a y s felt

P t.

M y h u s b a n d a n d I h av e com e to a n a g re e m e n t.
W e b o th e n jo y w h a t w e d o , a n d t h a t s h o w w e

Yes. I k n o w w h e n I g et a h e a d a c h e a n d w h e n I
d o n t.

P t.

A ll th e tim e. Y es. W h e n w e firs t g ot m a r rie d ,

few m o n th s , it w a s fine.

b r e a k o u t. W h a t s th e u se o f g o in g on fro m
h e re . It is j u s t rid ic u lo u s , (p a u se )

Yes.

th e o n ly th in g I c o u ld n t g et o v er th e id e a of

ca u se , w h a t ca n I d o ? R ig h t n o w I a m a ll rig h t

P t.

In th e b e g in n in g , it d id n t sc a re m e. I w a s very

p re sse d ?

M e ? S e x u a lly ?

T h . D id it ex cite you o r sc a re you?

d e a l o r do yo u d r e a m v e ry little ?
P t.

In fact, I h a d a d r e a m th is m o rn in g . I h ave
been a little a n x io u s a b o u t c o m in g h e re . I h av e
d re a m s . C e r ta in o n e s h a v e sto o d o u t, b e c a u se I
k n e w so m e d a y I w o u ld be te llin g so m e b o d y m y
sto ry a n d

I sh o u ld re m e m b e r th e s e d re a m s.

T h e y a r e a b o u t th in g s , a n d I w ill p la c e m y

HANDBOOK OF SHORT-TERM PSYCHOTHERAPY

78

o ld e r sis te r d o in g th e m , a n d th e n I w ill p r o b a

w a s v e ry , v ery h u r t w h e n I w a s a b o u t 11 o r 12

bly w a n t to d o th e sa m e th in g . T h is m o rn in g I

o r 13. Y ou see, m y s is te r w a s a y e a r o ld e r th a n

h ad a d re a m a b o u t m y sis te r a n d I. N o w w h e n

m e, a n d sh e w o u ld go in a n d s ta r t ta lk in g to

w e w e re little , w e used to fig h t, a t least I d call

m y m o th e r a b o u t h e r b o y frie n d s a n d th in g s

it

my

lik e th a t. O n c e o r tw ic e w h e n I trie d to go in to

siste r, w h o is a y e a r o ld e r th a n I a m , h a d a n

th e k itc h e n , a n d ju s t get to g e th e r, th e tw o of

a cc id e n t w h e n sh e w a s a sm a ll c h ild , a n d so

u s, a n d s p e a k a n d tr y to ta lk to h e r, it w a s a l

th a t,

b ecau se

I d

r e tre a t.

G e o rg e tte ,

sh e w a s a lw a y s co d d led a n d e v e ry th in g w h e n

w a y s as if O h , y o u a re ju s t a k id ; y o u r b o y

sh e w a s a b o u t 3 y e a rs o ld . S h e b ro k e o n e leg,

frie n d s a r e n o th in g ; ju s t little p la y m a te s .

sh e b ro k e a n a r m , a n d th in g s lik e th a t. If w e h it

d o n t

h e r, she w a s g o in g to fall a p a r t. A n y w a y , it is
th e t r u th . I r e m e m b e r th a t w e used to fig h t an d

your

silly

little

H o w d id yo u r e la te to h im ?
P t.

I a lw a y s lik ed m y fa th e r. I a lw a y s lik ed m y
m o th e r, to o , b u t I co u ld n e v e r g et close to h er.

T h . Y ou c o u ld n t ta lk to y o u r f a th e r e ith e r?

th e tw o of u s w e re fig h tin g a n d she w a s h ittin g

P i.

N o . W e ll th a t is so m e th in g to th in k a b o u t for a

m e a n d re a lly h u r tin g m e, a n d yet I c o u ld n t

seco n d . I felt th a t I w a s in w ith m y fa th e r,

r e a lly h it h e r b ack . B u t I w a s h o ld in g b a c k all

so to s p e a k , a n d th a t w a s all rig h t. M y fa th e r

m y s tr e n g th , w h ic h is so m e th in g th a t a lw a y s

is w h e r e a ll th e re lig io n co m es to o u r fam ily .

h a p p e n e d w h e n w e w e re c h ild re n . [ T h e p a ti e n t

H e is a v ery re lig io u s p e rs o n , p se u d o -re lig io u s

c o n tin u e s to re fe r to h e r r e la tio n s h ip w ith h e r

p e rs o n . I t d e p e n d s on h o w y o u look a t it. H e is

s is te r as a so u rce o f k e e p in g h e r d o w n a n d

v ery w ell e d u c a te d , in c u ltu r e , b a c k g ro u n d ,

her.

A c tu a lly , h e r s ib lin g

riv a lry,

a n d th in g s lik e th a t.

n e v e r reso lved , in la te r se ssio n s tu r n e d o u t to be

[A t th is p o in t th e p a tie n t is s h o w n th e R o rsc h a c h

a co re p ro b le m .]

cards. ]

T h . A n d y ou h a v e a lw a y s h eld b a c k ?

[ I

w o u ld h a ve

T h . N o w I m g o in g to sh o w you so m e c a rd s a n d I

lik e d to h a v e g o n e in to h e r r e la tio n s h ip w ith

w a n t to a s k you to te ll m e w h a t yo u see in

h e r sis te r a t th is p o in t,

th e s e c a rd s. W h a t does th is o n e look like?

b u t I r e a liz e d th is

w o u ld h a v e c o n s u m e d th e re m a in in g m in u te s

P t.

o f th e sessio n . ]

T h . A ll rig h t. H o w a b o u t th is seco n d o n e ?

Yes.

P t.

A b u tte rfly , a c ra b , (p a u se)


It looks lik e tw o e le p h a n ts w ith th e ir n oses u p
a n d to g e th e r.

T h . W h a t a b o u t y o u r m o th e r a n d fa th e r? W h a t

T h . A n y th in g else?

k in d of p e o p le a r e th e y ?
M y m o th e r is a p e c u lia r p e rso n . M y fam ily is

P t.

th e h ig h - s tr u n g ty pe.

T h . T h is is th e th ird c a rd .

T h . H o w d id you r e la te to y o u r m o th e r w h e n you

P t.

No
Two

p e o p le

b e n d in g

over

and

to u c h in g

s o m e th in g to g e th e r. N o th in g else.

w e re a ch ild ?
P t.

about

a ll th is o th e r stuff. T h is m o rn in g I d r e a m t th a t

c r u s h in g

P t.

hear

th in g s . S o I k e p t e v e ry th in g to m yself.

w a s b la m e d fo r th in g s a n d a lw a y s g ot h it an d

P t.

to

T h . H o w a b o u t y o u r d a d ? W h a t so rt of m a n is h e ?

I w o u ld n e v e r let m y self go to re a lly h it h e r


b ack . In o th e r w o rd s, I w a s a lw a y s th e o n e th a t

w ant

M o th e r a n d I w e re n o t close. T h e re a so n th a t

T h . A n d n o w th e f o u rth c a rd .

I d id w h a t m y b r o th e r w a n te d m e to d o I

P t.

k n o w th is is b ecau se I g ot a lot o f love from

T h . T h e n e x t c a rd .

m y b r o th e r. I w o u ld say m y g r a n d m o th e r, w h o

P t.

A b e a r fu g . (p a u se) T h a t s all.
I m th in k in g of a g re a t b ig b u m b le b e e w e h a d

d id n o t live w ith u s, w h e n I w o u ld see h e r, I

in th e c a r th e o th e r d a y w ith a big f u rry co at

w o u ld feel r e a l tr u e love. N o w th e re is so m e

o n it.

th in g w ro n g w ith m y re la tio n s h ip w ith m y

T h . A f u rr y b u m b le b e e .

m o th e r a n d fa th e r. I co u ld n e v e r ta lk to m y

P t.

m o th e r. M y o ld e r sis te r w a s a lw a y s sa fer. T h is
I k n o w . 1 h a v e a lw a y s felt th a t w ay . I a m close

Y es, g ig a n tic w ith b ig w in g s. It also lo o k s like


a b u tte rfly .

T h . I b elieve th is is th e six th c a rd .

to m y s is te r n o w . It w a s n t u n til I g ot m a rrie d

P t.

th a t

T h . T h is is th e sev en th .

I co u ld a c tu a lly go o v er a n d

look m y

m o th e r s tr a ig h t in th e face, a n d j u s t sit th e re
a n d ta lk a n d h a v e a r e g u la r c o n v e rsa tio n as a
m o th e r a n d d a u g h te r sh o u ld . A s a te e n a g e r, I

P t.

T h a t looks like a sc a re d c at. (p a u se)


It j u s t

r e m in d s

m e o f c h e ru b s

c h u rc h o r so m e th in g .
T h . A n y th in g else h e re ?

in sid e o f a

79

THE INITIAL INTERVIEW: CASE HISTORIES


P t.

A fter lo o k in g a t it, I ca n see w h e re th e re m ay

o r o u tsid e of th e fa m ily . Y ou d id n o th in g th a t

be tw o c h ild re n o r so m e th in g lik e th a t.

is p a r tic u la r ly d iffe re n t o r b a d . B u t y o u r r e a c

T h . T h is is th e e ig h th c a rd .
P t.

tio n to th e s e in c id e n ts w a s a b n o r m a l. P e r h a p s
in a

th e r e a s o n w h y yo u in te r p re te d th is a s su ch a

bio lo g y la b o r a to ry . ( P a tie n t te n ta tiv e ly tilts th e

h o r rib le a n d te r rib le th in g w a s th a t , p r io r to

c a rd .)

th e se x -p la y in c id e n t, yo u w e re a lr e a d y se n

T h is looks lik e a sk e leto n

I o n ce saw

T h . Y o u can h o ld it u p sid e d o w n if yo u w ish .

sitiz e d to b e in g b a d . A te r r ib le th in g , a b ad

P t.

p e rs o n , a h o r rib le p e r s o n .p a u s e ) . [I a m m a k

I see n o th in g else.

T h . T h is is th e n in th c ard .

in g a c tiv e e d u c a tio n a l e ff o r t s th a t , th o u g h

P t.

a im e d a t re a ssu ra n c e a re p r o b a b ly n o t g o in g to

T h is o n e so rt o f lo o k s lik e a v o lcan o .

in flu e n c e h e r u n d e r ly in g g u i lt fe e lin g s .

T h . H o ld it a n y w a y you w ish , (p a u se ) T h is is th e
P t.

Y et I

b e lie v e th is is w h a t sh e w a n ts to h e a r fr o m

last c ard .

m e .\

T h is in a w a y r e m in d s m e of th e w av es on th e
w a te r w h e re th e w a te r goes th r o u g h . T h is

P t.

looks like tw o c ra b s. T h e r e a r e o th e r u n d e rs e a

I w a n t to say o n e th in g . W h e n I w a s a k id , I
w a s a lw a y s to ld th a t I a m b a d a n d r o tte n a n d
no g o o d , a n d w h e n I w a s to ld t h a t , I a lm o st

fishes.
T h . N o w w e c a n ta lk a b it a b o u t y o u r p ro b le m . I

c o u ld n t ta k e it. If th e y w o u ld sa y , Y ou a re

get th e im p re ss io n th a t th e se x u a l e x p e rie n c e s

p r e tty o r nice o r a good g i r l, I w a s a lw a y s th e

w ith y o u r b r o th e r a t th e ag e of 8 in itia te d a

b a d , r o tte n , good for n o th in g . [ T h e p a tie n t is

good d eal o f g u ilt in you. N o t th a t yo u m ig h t

v e r y e m o tio n a l h ere. H e r fa c e is flu s h e d , h e r

n o t h av e felt g u ilty a b o u t y o u r feelin g s before,

fi s ts a re clen ch ed . T h e r e a re te a rs in h e r eyes.]

esp ecially to w a rd y o u r m o th e r a n d sis te r. \In

T h . T h is is e x a c tly th e so rt of th in g th a t I a m ta lk

a p p ra is in g h e r d y n a m ic s , it w o u ld a p p e a r th a t

in g a b o u t. T h a t s e x u a l e x p e rie n c e m a y h av e

th e p a tie n t h a s a n o v e r w h e lm in g , p u n i ti v e s u

b een m e re ly g ris t for th e m ill. T h e n y o u w e n t

p e r e g o th a t p u n is h e s h e r f o r h o stile fe e lin g s ,

a lo n g w ith th e re lig io u s e x e rc ise s a n d p ra y e rs .

p r o b a b ly to w a r d h e r sis te r a n d m o th e r . S h e

Y ou d id th is p r o b a b ly w ith a g re a t b u rd e n on

h a d to re p ress a g g ressio n to w a r d h e r s is te r be
ca u se h e r sis te r w a s w e a k . H e r o b se ssio n o f

y o u r soul.
P t.

d e fia n tly re p e a tin g J e s u s C h r i s t " se rv e s as an


o u tle t f o r a g g ressio n a n d as a w a y o f re s tr a in
in g h e r a g g ressio n .

A n x ie t y

T h . Y ou w e n t a lo n g tr y in g to a b so lv e y o u r g u ilt for

re su lts as even

m in im a l h o s tility co m e s th r o u g h .]

N ow

m a n y th in g s . B u t th e e x p e rie n c e p ro v e d to you

sex

th a t you d id a b a d th in g . T h a t m a d e y o u , in

p lay b etw e e n b r o th e rs a n d sis te rs is n o t too

y o u r th o u g h ts , a b a d p e rs o n . N o w w h y do you

u n c o m m o n even th o u g h you r a re ly h e a r a b o u t
it. [ T h is is an a tte m p t a t re a ssu ra n c e .]
P t.

th in k y o u p r a y e d ?
P t.

I k n o w , I le a rn e d a b o u t th a t a s I g re w u p .

T h . A ch ild h a s to d ev elo p som e id e a s a b o u t se x

I w a n te d to be fo rg iv en . I w a n te d G o d to fo r
give m e.

T h . W h e n you m a d e th ese p r o n o u n c e m e n ts , th ese

u a lity b efo re h e o r sh e g ro w s u p . S e x u a lity is

re lig io u s p ro n o u n c e m e n ts , th e y m a y h a v e b een

like w a lk in g . Y o u h a v e to le a r n it. O u r c u ltu re

is p ro h ib itiv e . S ex is re g a rd e d as h id e o u s , t e r r i

th o u g h t,

ble u n til o n e g ets m a r rie d . B u t lik e a n y o th e r

w h e n I k n o w th a t I a m su c h a h o r rib le , aw fu l

b o d ily fu n c tio n sex h a s a b e g in n in g e a rly in

a n d te r rib le p e r s o n . T h e p h r a s e J e s u s C h r is t

life. O b v io u sly , y o u r e x p e rie n c e s d id n t d o too


m u c h d a m a g e to y ou b ecau se yo u tell m e you
fu n c tio n w ell se x u a lly n o w . [M o r e re a ssu ra n ce
is g iv e n h e r, p lu s th e a tte m p t to g e t h e r to
fo c u s a w a y fr o m

P t.

I d id , I d id . I felt I d id n t d ese rv e to p r a y , th a t
I w a s a h y p o c rite .

sig n

of p u r ity .
H ow

B ut

co u ld

th e n
I p ra y

you

m ay

and

h av e

a c t holy

seem s to sy m b o liz e so m e th in g fo r you.


P t.

Y es, b u t w h e n I d say it, I felt h y p o c ritic a l;


th e n I d g et d e fia n t a n d sp it.

T h . It is p r o b a b le th a t re lig io n h a s m a n y m e a n in g s

an e v e n t sh e co n sid e rs ir

for you. W h a t y o u m a y h a v e felt w a s th a t o n ly

re p a ra b le, th e r e b y e s ta b lis h in g th e h o p e le ss

a te r r ib le p e rso n lik e y o u rse lf ac ts d e fia n t in

ness o f h e r c o n d itio n .]

p r a y e r . B u t th e r e is a so rt of h e a lth y co re to

B u t is n t it w ro n g ?

de fia n c e to o . Y ou w e re f ig h tin g b a c k . [ W h a t I

T h . Y o u c o n sid er it w ro n g . C h ild r e n in e a rly life

a m tr y in g to do w ith th e se te n ta tiv e in te r p r e ta

e x p lo re th e se x u a l a r e a . O fte n th e re is sex p lay

tio n s is to g iv e h e r so m e e x p la n a tio n f o r h e r

th a t goes o n a m o n g c h ild re n w ith in th e fam ily

s y m p to m s to s h o w h e r th a t th e y h a v e a m e a n

80

HANDBO OK OF SHORT-TERM PSYCHOTHERAPY


in g a n d fu n c tio n .

P t.

T h is m a y g e t h e r to c o n

w e re n o t sp o k e n in h e r fa m ily , in d e e d w e re

c e n tr a te in la te r se ssio n s on p o s s ib le so u rces o f

fo rb id d e n . H e r o u tb u r s ts w e re a n in d ic a tio n to

h e r co n flic t r a th e r th a n on h e r s y m p to m s , on

h e r th a t sh e w a s a h o r rib le p e rs o n . E x a c tly th e

h e r d e v a lu e d se lf-im a g e a n d th e n o tio n th a t sh e

s a m e th in g y o u h a v e , b u t u s in g a d iffe re n t k in d

is h o p e le s sly ill a n d b a d " because s h e c o m

of sy m b o l. T h e w o rd s u sed d o n t m e a n a th in g

m itte d a s e x u a l crim e . ]

in th e m se lv e s. I t s w h a t s b e h in d th e m . [S o m e

(e x c ite d ly ) Y o u a r e r ig h t. I d say , I ll show

tim e s th e u se o f an e x a m p le o f a case w ith

th e m . W h o d o th e y th in k th e y a r e . [I decide

p r o b le m s s im ila r to th e p a t i e n t s p r o b le m s r e in

to u tiliz e th e p a t ie n t's e m o tio n to o ffe r h e r

fo r c e s an in te r p r e ta tio n . ]

m o r e a c tiv e i n t e r p r e t a t io n s ,

r e a l iz in g

th a t

P t.

fe c t. B u t I a m s tr iv in g f o r a r a p id re la tio n

h y p n o sis to fin d o u t th in g s ?

s h i p .]

o b v io u s ly n o t g o in g to g iv e u p e a s ily in h e r

T h . A nd

w hy

s h o u ld n t you

be ag g ressiv e

re p re s se d m e m o r ie s . ]

p o s itio n ? N e g a te d a s a h u m a n b e in g ; a p erso n

T h . N o w , I d o n t th in k th a t y o u a r e g o in g to find

w h o c a n t act in h e r o w n r ig h t. Y ou m ay h av e

a n y d e e p r e m a rk a b le d isc o v e rie s o r se c re ts in

felt y ou w e r e n t su p p o s e d to be a n g r y , forced

y o u r p a s t. I re a lly do n o t, I believe th a t h y p

to be n a m b y -p a m b y , to ld th a t y o u w e re no

n o sis m ay b rin g you b ack to y o u r c h ild h o o d

good.

th a t

a n d h e lp yo u e x p e rie n c e so m e o f th e o rig in a l

got involved w ith th e w o rd J e s u s

fe a rs a n d a n x ie tie s . B u t a good m a n y o f y o u r

A nd

so m e h o w

th e n

th e

d e f ia n c e

cam e

C h r is t. P e r h a p s you felt th a t J e s u s C h r is t m u st

m e c h a n is m s se em to be o n th e su rfa c e . O n c e

k n o w w h a t a n a w fu l p e rso n yo u felt y o u rse lf to

yo u a b s o rb w h a t h a s frig h te n e d y o u , a ll th ese

be. T h e re f o r e y o u sh o u ld defy h im .

th in g s , a n d re a liz e h o w in c o n s e q u e n tia l th ese

O h , yes, yes. [ T h e p a tie n t is q u ite m o v e d , w ip

th in g s r e a lly a re , you m a y fin d y o u rse lf liv in g


in th e p r e s e n t, n o t fe a rfu l o f th e p a s t o r te r

in g tea rs f r o m h e r eyes. ]

rifie d by th e f u tu re . O n c e yo u firm u p y o u r

T h . It co m es o u t of y o u r d e p th s , o u t o f y o u r d e e p
e m o tio n s, w h ic h in d ic a te d to yo u w h a t a h o r r i

id e a s a b o u t w h a t is g o in g on in y o u , th e n ex t

b le, te r rib le , ev il, u g ly p e rs o n you w e re . B u t

ste p is u tiliz in g th is in sig h t in th e d ire c tio n of

y ou c o u ld n t c o u n te n a n c e th is . I t w e n t a g a in s t

c h a n g e . H e r e h y p n o sis m ay b e o f h e lp to you.

you

It m ay a lso be a b le to h e lp y o u c o n tro l y o u r

w a n te d to be. A fe a r d ev elo p ed th a t p eo p le

te n s io n a n d a n x ie ty w h e n e v e r th e s e p o p u p

w o u ld find o u t th a t y o u w e re re a lly a te r rib le

a g a in .

p e rso n .

o b se ssio n a l p a tie n ts to h e lp th e m c o n tr o l a n d

your ow n

P t.

[ T h e p a ti e n t is

q u e s t to d ig u p a n d e x te r m in a te d e te r m in in g

and

a n g r y w h e n y ou feel p u t in to such a te r rib le

P t.

D o c to r, yo u k n o w so m e th in g , I m b e g in n in g to
feel b e tte r , a lot b e tte r. D o yo u t h in k w e ll use

in s ig h t a t th is sta g e h a s la rg e ly a p la c e b o e f

id e a s of th e k in d

o f p e rso n

w ill

o fte n

u tiliz e

h y p n o s is

in

tu r n o f f " th e ir to r tu r e d r u m in a tio n s .[

W h a t frig h te n s m e m o re th a n a n y th in g else is
th a t ev ery b o d y w ill k n o w I a m b a d a n d h o r r i

[/

P t.

D r . W o lb e rg , I w a s sc a re d o f c o m in g h e re for
th e s im p le r e a s o n th a t I th o u g h t th a t I w o u ld

ble. (cries) B u t so m e tim e s I d o n t feel th is w ay .


T h . W h a t I d lik e to h a v e y o u do is to b e g in n o tic

leav e th is office a s I h a v e left too m a n y o r n o t

in g s itu a tio n s w h e r e yo u feel y o u rse lf to be a

h e a r a n y th in g b u t w h a t I w a n te d to h e a r. I

te r rib le p e rso n . D o es th is h a v e a n y th in g to do

m e a n it. Y o u j u s t c a n t im a g in e h o w I feel in
side.

w ith p e o p le o r situ a tio n s , o r d o es th is a ll com e


u p fro m th e in sid e a t tim e s w h e n y o u feel

T h . H o w do yo u feel in sid e ?

u n d e rm in e d . [ / a m a ssig n in g th e p a tie n t a ta sk

P t.

to
P t.

ke e p

h e r s e lf a le r te d f o r

so u rces

o f her

O h , If I c o u ld get rid o f th is th in g , it w o u ld be
th e g re a te s t th in g in th e w o rld . I so m u c h w a n t

s y m p to m s . ]

to h a v e a fa m ily a n d be a b le to be a m o th e r

B u t w h y a m I th is w a y ?

a n d a good w ife to m y h u s b a n d , a n d n o t th e

T h . T h e m e c h a n is m is p ro b a b ly a n e x tre m e ly co m
p le x

one.

It

ta k e s

m any,

m any

f o rm s .

w a y I w a s w h e re I c o u ld n t even cook d in n e r . I
w a s j u s t to o sc a re d to m ove. I h a v e a lw a y s h ad

re c e n tly h a d a g irl j u s t a b o u t y o u r ag e w h o

d e p re s s io n s , a n d a n y d o c to r I w e n t to , e s p e

w o u ld co m e u p w ith e x p o s tu la tio n s of fo u r-le t

c ia lly o n e I w e n t to w h e n I w a s 15, I w o u ld sit

te r s w e a r w o rd s th a t frig h te n e d h e r. T h is to

h e r e , a n d he w o u ld sit o v e r a t th e d esk a n d I

h e r w a s h o r rib le b e c a u se th e d i r ty w o rd s

w ill tell h im a sto ry . H e w o u ld p ra c tic a lly fall

THE INITIAL INTERVIEW: CASE HISTORIES

81

a s le e p o n m e. I k n o w it is fu n n y a n d e v e ry

to r u n a w a y fro m th is im a g e b e c a u s e in y o u r

th in g , b u t it w o u ld h u r t m e so m u c h . I w o u ld

o p in io n it w a s su c h a h o r rib le th in g to look at.

w a lk o u t o f th e re b e in g th e sa m e h o p e le ss p e r

P t.

so n .

T h . Y ou a r e still y o u n g , a n d if y o u h a v e th e d e sire

No

h e lp , n o c h a n g e n o th in g .

I d id n t

k n o w w h a t is g o in g o n in sid e o f m e. W h e n it

to d o so, yo u s h o u ld be a b le to g et o v e r th is.

first cam e o n , I ju s t re a lly th o u g h t I w a s g o in g

T h e test I g av e y o u seem s to in d ic a te th a t you

o u t of m y m in d . Y o u d o n t k n o w w h a t is h a p

r e a lly a r e n o t to o b a d ly off, th a t y o u h av e

p e n in g to you.

f a i r ly g o o d p o te n t ia l s .

T h . W h a t I sa id , d o es it m a k e se n se to y o u ?
P t.

[E m p l o y i n g h e r e x

p o s u r e to th e R o rsc h a c h c a rd s as a re a ss u rin g

O h , yes. Y o u see, you a r e th e firs t p e rso n w h o

to o l a n d as p r o p to h e r to w o r k in g a t h e r p r o b

h a s ev er e x p la in e d it to m e, in w o rd s lik e th is.

lem ]

I a lw a y s

th o u g h t

w a s r o tte n ,

m ise ra b le ,

P t.

h a te d by e v e ry b o d y else, a lw a y s . I a lw a y s d id
a m o n g g irls . I w a s th e w o rst o n e th e re . (7 7 m

H o w lo n g w ill I h a v e to c o m e ? Y ou see i t s
h a r d for m e to tra v e l h e r e , a n d b esid es I c a n t

h a v e te r rib le in fe rio ritie s w h e n I w a s a girl

affo rd it.

T h . I t is h a r d to say h o w lo n g . S o m e tim e s it ta k e s

can o ffe r fe r tile fie ld s f o r e x p lo r a tio n la te r on

tim e to in te g r a te th in g s yo u le a r n . Y o u h ave

in v o lv in g h e r d esire to be a to m b o y a n d h e r in

to te d th is th in g a r o u n d for y e a rs a n d y e a rs a n d

fe r io r ity fe e lin g s a b o u t h e r f e m i n i n i t y .]

y e a rs. H o w lo n g w ill it be b efo re yo u co m

T h . A p p a r e n tly , you felt u n d e rm in e d w h e n you


w e re little . Y ou n e v e r seem
w arm

close

re la tio n s h ip

w ith

p le te ly d is c a rd it, I d o n t k n o w . B u t if you

to h a v e h a d a

h a v e th e r ig h t fo rm u la to w o rk o n , a n d if you

y o u r m o th e r.

a p p ly y o u rse lf, yo u w ill g r a d u a lly u n d e rm in e

A n d you h a d a f a th e r yo u c o u ld n t c o m m u n i

th is m isc o n c e p tio n of y o u rse lf. P e r h a p s w h a t

ca te w ith to o w ell. A n d you felt you h ad no

w e c a n d o is to h a v e a few m o re sessions

r ig h t to c o m p la in . Y ou c o u ld n t a ct n o rm a l

to g e th e r. I ll te a c h y o u se lf-re la x a tio n so you

w ith

ca n c o n tro l y o u r te n s io n a n d h e lp y o u r u n d e r

your

sis te r

e ith e r .

The

h e a lth y

th in g

w o u ld h a v e b een to fig h t b ack , to b e a t th e devil

sta n d in g b e tte r. A n d th e n w e w ill see w h a t

o u t of h e r w h e n sh e b e a t y o u , th e n k iss a n d

happens.

m a k e u p la te r. Y o u w e re a p p a r e n tly f ru s tra te d

P t.

C a n I get o v er th is ?

P t.

C a n I a sk a n o th e r q u e s tio n ? I to ld y o u th a t I

a n d h a m s tr u n g . Y ou c o u ld n t e x p re s s y o u rself,

h a v e a h o r rib le fe a r o f p e o p le k n o w in g th in g s

a n d , to b o o t, w h e n y o u w a n te d to p itc h in to

a b o u t m e. W e to ld o u r fa m ily d o c to r. T h e o n ly

h e r, y ou w e re c o n sid e re d to be a n evil, b a d ,

th in g th e fa m ily d o c to r w a s to ld , w h a t m y

h o r rib le p e rso n w h o d id te r rib le th in g s to a

m o th e r p r o b a b ly sa id w a s , M y d a u g h te r h a s

sis te r w h o w a s so fra il a n d w e a k . [A ctive in te r

J e s u s C h r i s t r u n n in g a r o u n d h e r m in d , a n d

p r e ta tio n s a re m a d e r e p e a tin g th e th in g s th e

so o n . H e se n t m e to so m e b o d y else. N o w ,

p a tie n t a lre a d y k n o w s , b u t w ith th e fo c u s on

w h e n I w a s w a itin g in th is p s y c h ia tr is ts office

h e r n e e d to re p ress h e r fr u s tr a tio n a n d ag

o n e tim e , I m et m y g ir lf r ie n d . S h e j u s t said

g re ssio n .]

h e llo a n d th a t w a s th e e n d o f it. S h e sa id ,

I w a s a lw a y s th e o n e w h o g ot h it even if w e

W h a t a r e you d o in g h e r e ? a n d I sa id , I

g o t in to fig h ts, a n d a f te rw a rd m y s is te r w o u ld

w a s j u s t g o in g to ta lk to h i m . I felt a w fu l th a t

tell m y m o th e r even if it w a s n t m y fa u lt. I w a s

sh e k n e w I w a s th e re . W h e n th is th in g b o th e rs

th e o n e w h o got h it a n d p u n is h e d a n d h a d to

m e,

say, I m s o r r y .

p e trifie d , w h e n I th in k p e o p le you k n o w k n o w

T h . So, th e re a g a in , th e n o rm a l im p u ls e w o u ld

I b eco m e p e trifie d , a n d

I re a lly

m ean

a b o u t it.

h av e b een to e x p re ss a g g re ss io n to g e t it o u t of

T h . T h is is p a r t o f th e p ro b le m , th e c o n s ta n t co n

y o u r sy stem , to sc rea m a t y o u r m o th e r , if n e c

c e rn w ith p e o p le w ill k n o w . T h e y w ill k n o w

e s sa ry to fig h t b ack w ith y o u r sis te r. So fa r as

w h a t a h o r r i b le p e rso n y o u a re . A g a in th is

se x u a l c u rio sity in c h ild h o o d , th e r e is n o th in g

is p r o b a b ly y o u r g u ilt feelin g sh o w in g in th e

so u n u s u a l a b o u t th is. B u t to yo u th e se w e re

fo rm o f a fe a r th a t p e o p le w ill see th e te rrib le

in d ices of h o w te r rib le yo u w e re . A n a w fu l

im a g e you see in y o u rself. R e m e m b e r you a re

p e rso n . Y o u m u st h a v e c a r te d th is im a g e of

th e o n e w h o is d e s ig n in g th is im ag e. \A g a in ,

y o u rse lf a r o u n d a ll y o u r life, a n d you h a v e had

a ctive, stro n g , a u th o r ita tiv e in te r p r e ta tio n s to


b o lste r h e r a g a in st a n x ie ty . I fe e l I h a v e a

82

P t.

HANDBOOK OF SHORT-TERM PSYCHOTHERAPY


w o r k in g r e la tio n s h ip w ith h er.] I m a fra id o u r

herself a n d on h e r re la tio n s h ip w ith h e r old er

tim e is u p . W o u ld you lik e to see m e a g a in ?

sister. H e r g uilt feelings for h e r re s e n tm e n t

O h , yes.

tow ard

T h . W h e n w o u ld y ou lik e to see m e?
P t.

I h a v e tw o m o re y e a rs of school befo re I fin ish .


I h a v e d ecid ed m ay b e n o t to go to school th is
co m in g y e a r a n d m ay b e w o rk th is se m ester.

T h . W e ll, th e n , s u p p o s in g I see yo u a few m o re

sister, an d

to w a r d

p r e s e n t life,
u p s u r g e s of

a n x ie ty w e re relieved bo th by h e r re la x in g e x
ercises a n d

by h e r re la tin g the u p s u r g e of

do

sy m p to m s to p rovocative co m petitive incidents

th e re a fte r. P e r h a p s a fte r a few tim e s y o u ll be

in h e r p re s e n t e n v iro n m e n t. A 5 -y ea r follow-

tim e s,

P t.

h e r m o t h e r an d

t r a n s f e r e n t i a l f i g u r e s in h e r
g r a d u a l l y lifte d . M o m e n t a r y

and

th e n

w e ll

d isc u ss

w hat

to

ab le to go o n by y o u rself. T h e n you can com e

u p indicated a significant ch a n g e in h e r self-

b ack if n e c e ssa ry for a n o c c a sio n a l session.

im age. A d r e a m she sent m e reflected this dif


ferent con ception of herself.

I know

m y h u s b a n d w a n ts to ta lk to you.

T h e r e a r e c e rta in th in g s th a t m y h u s b a n d does
n o t k n o w . H e sh o u ld k n o w . H e w a n ts to k n o w

L a s t n ig h t I h a d tw o d re a m s . In o n e I d re a m t

if I re a lly n eed it b ecau se he d o e s n t th in k

th a t I w a s in a fa sh io n sa lo n lo o k in g a t a fu ll-le n g th

th e r e is a n y th in g b a d a b o u t m e.

o y s te r- w h ite b e a v e r co a t b e in g s h o w n to m e on a

T h . O f co u rse , I ll be g la d to see h im if th is is n e c
e ssary .
P t.

A nd

live m o d el. T h e co at w a s a d u p lic a te o f o n e I h a d


seen y e s te rd a y on th e T V sh o w . In th e o th e r d r e a m

d o c to r,

a n o th e r

th in g ,

you

k n o w , th e

n a m e I u sed is n o t m y re a l n a m e .

I w a s in a v ery la rg e p riv a te h o m e a b o u t 10 m iles


fro m w h e re I live. T h e h o m e b elo n g e d to a lad y

T h . (la u g h in g ) I g u ess you felt so a s h a m e d of y o u r

p s y c h ia tris t, m y p s y c h ia tris t. S h e h a d given m e a

id e n tity th a t y ou d ecid ed to co n ceal y o u rse lf

p a r tia l p h y sic a l e x a m in a tio n (I liste n e d to m y h e a rt)

u n d e r a n a ssu m e d n a m e . W h ic h is p a r t o f th e

a lth o u g h I r e m e m b e r h o ld in g th e en d o f th e ste th o

p ro b le m , is n t it?

scope to m yself. T h e h o u se w a s full o f m a n y p eo p le,

Y es (sm ilin g ). W h e n sh a ll I com e b ack ?

all w a n tin g to see h e r, b u t th e y w e re in a p a r ty -lik e

P t.

T h . N e x t w eek a t th e sa m e tim e.

m ood,

P t.

k itc h e n , etc. S h e a n d I w e re ta lk in g a b o u t m y h a v

V e ry good (a rises). G o o d b y e.

T h . G o o d b y e , see you n e x t w eek.

t a l k in g ,

w a l k in g

a ro u n d ,

e a t in g

in

th e

ing a b a b y , w h ic h w a s fine w ith h e r. S h e a sk e d m e


to p le a se b rin g th e b a b y to h e r so th a t sh e m ay h av e

T h e p a tie n t r e t u r n e d for th r e e m ore sessions,

a p eek a t it a f te r it w a s b o rn . (I th in k I felt th e b a b y

d u r i n g w h ich w e m a d e a re la x in g ta p e * for

w o u ld be a g irl.)

p u rp o s es of re la x in g w ith h e r tensions, p u s h
ing obsessive th o u g h ts ou t of a tte n tio n , and

S h o rtly

reinforcing h e r insights. O u r focus soon co n

p re g n a n t .

cen tra ted

b ro u g h t
ing the
a n x ie ty
num ber

on h e r u n d e r m in e d conception of

* T h e te c h n iq u e of m a k in g a re la x in g ta p e will be found
in C h a p t e r 15.

after

th is

A te m p o r a r y

th e

p atien t

becam e

u p s u r g e of an x ie ty

h e r in for tw o m o re sessions. F o ll o w
b irth of h e r child, a brief p erio d of
w a s co ntro lled also w ith a lim ited
of sessions.

Case 3
Som e p a tie n ts a re no t suited for s h o r t-te rm
th e r a p y an d r e q u i r e a lo n g -term su p p o rtiv e
a p p r o a c h until sufficient m o tivation is d e
veloped for a m o re prod uctive ty pe of t r e a t
m ent. O ften such p a tie n ts seek a p a re n ta l ty pe

of r e l a t i o n s h i p w i t h th e t h e r a p i s t t h a t
ev entu ally , if th e th e r a p is t is n ot a w a r e of
w h a t is h a p p e n i n g n o r k n o w s h o w to deal
w ith the evolving s itu ta tio n , becomes a n in t e r
m in a b le sad om asoc histic e n c o u n te r t r a u m a t ic

THE INITIAL INTERVIEW: CASE HISTORIES

83

to both p a tie n t an d th e r a p ist. T h e s e p a tie n ts

h a d a d r e a m a n d th e d r e a m to ld m e th a t I

frequ en tly refuse to accept a re fe rral to a clinic

w o u ld feel lik e a p r o s titu te if I sle p t w ith h im .

or a th e r a p is t ex perienced in d ealin g w ith th e ir

N o w th is is im p o r ta n t to m e, so th e n e x t d a y I

typ e of p ro b le m since t h e r a p y is no t w h a t they

a sk e d H a n s . W e g ot to ta lk in g a b o u t it, a n d

w a n t. T h i s is illustra ted in th e next initial in

h is first e x p e rie n c e s . I m ig h t a d d h e w a s fro m


C h ile , a G e r m a n w h o lived in C h ile . A ll o f th e

terview. T h e p a tie n t is a y o u n g single w o m a n


w h o asked for a n in terview t h r o u g h a lette r in

w o m e n he h a d sle p t w ith w e re p r o s titu te s . M y


su b c o n sc io u s m in d p ic k e d it u p . A n d b e c a u se I

w hich she co m p la in e d of tensio n a n d of h avin g


tr o u b l e d d r e a m s . A ta l l a t t r a c t i v e w o m a n
en tere d m y office at th e a p p o in t m e n t time,

w a s v ery w illin g to liste n to m y u n c o n sc io u s, I


fo u n d it v ery a c c u ra te .

T h . W e ll, w e m ay be a b le to ta lk a b o u t th is specific

so m e w h a t aggressively seatin g herself in the

q u a lity ,

c h a ir after w e in tro d u ce d ourselves.

w h e th e r i ts a m o re g e n e ra l q u a lity .
P t.

T h . W o u ld y ou lik e to tell m e a b o u t y o u r p ro b le m ?
P t.

W e ll, for m e in d iv id u a lly , I p u t it to u se all th e


tim e , {p a u se)

It d o e s n t m a tte r , e x c e p t th a t I th in k you need

T h . Is th a t so?

to k n o w w h a t y ou n eed to k n o w , a n d since I

P t.

d o n t k n o w y o u , I d o n t k n o w w h a t in f o rm a

T h . H o w ? D o you a s k y o u rse lf q u e s tio n s ? H o w do

tio n you w ish . [H e r in itia l re sp o n se s to th e in


te r v ie w a re c e r ta in ly u n u s u a l a n d stra n g e.]

O h yes, a lw a y s.
yo u do th is ?

P t.

T h . A ll rig h t. S u p p o se y ou give m e a g e n e ra l idea

A p ro b le m is th e r e , for e x a m p le . Y ou a r e in
th e m id d le a tte m p tin g to fin d a s o lu tio n . I find

o f th e p ro b le m , a n d th e n w e w ill decid e th e

th e b est w a y is to lie d o w n a n d re la x c o m

b est th in g th a t ca n be d o n e for y o u r p ro b le m .

p le te ly . A n d I u se a v ery f u n n y e x p re ss io n , I

T h e p ro b le m is th is. I h av e fo u n d th a t belief,

w ill to w ill th e w ill o f G o d , w h ic h m a k e s m e

j u s t b elief, ra ise s a tre m e n d o u s ro le in th e lives

re la x . W h ic h is v ery , v ery g o o d for m e. A n d in

o f h u m a n b ein g s. W h a t th e y believe in an d

th is

h o w th e y believ e; a n d I d o n t h a v e to tell you

w h ic h I su sp e c t is a fo rm o f h y p n o s is , th e a n

k in d

o f s ta te

o f su s p e n d e d

a n im a tio n ,

q u o te m ira c le c u re s u n q u o te , a n d th in g s o f th is

s w e r to th e p ro b le m w ill com e to m e.

n a tu r e . I d lik e v ery m u c h to k n o w h o w th is

T h . It w ill co m e to yo u a lm o st lik e in s p ir a tio n ?

o p e r a te s a n d h o w w e can tu r n th is to good

P t.

use. I d lik e to k n o w v ery im p o rta n tly h o w th e

T h . A k in d of feelin g . D o yo u g e t th e im p re ss io n

su b c o n scio u s m in d fu n c tio n s b e c a u se in m y e x
p e rie n c e th is is a p e rfe c t m e c h a n is m . It a lw a y s

N o t lik e a n in s p ir a tio n , b u t lik e a feeling.


th a t it co m es fro m th e o u ts id e w o rld ?

P t.

te lls th e p e rso n ex a c tly w h a t is r ig h t for th e in

N o , I do n o t. S o m e tim e s w h e n I d o n t like
w h a t s c o m in g o u t, I sto p it y o u see.

d iv id u a l. N o w is th is c o m m o n ? [A g a in , h e r

T h . W h a t co m es o u t?

q u e r ie s a re stra n g e , a n d I g e t th e im p re ss io n

P t.

th a t sh e is q u ite a sick p e r s o n . ]

O h , I d o n t k n o w , m a y b e I k in d of h a v e a
p ro p e n s ity of m a k in g o n e ch o ice, a n d a n o th e r

T h. H a v e y ou in y o u r e x p e rie n c e fo u n d th a t th is
P t.

M o r e g e n e ra l.

say.
P t.

T h . Y ou w o u ld r a t h e r h av e m e ask q u e stio n s .

P t.

to y o u rse lf o r

ca n be p u t to so m e c o n s tru c tiv e u se, a s you

y ou k n o w w h a t I m d o in g ? S o yo u a sk q u e s

P t.

i t s u n iq u e

T h . T h e n w e c a n d isc u ss it in te r m s o f w h e th e r it

E x a c tly w h a t is it you n eed to k n o w so th a t


tio n s an d I ll try to a n s w e r.

w h e th e r

o n e is p o k in g i t s n o se in.

I h a v e th e im

w o rk s fo r y o u ?

p re ss io n o f a d o u b le la y e r in m y m in d , of a

W o rk s c o n s iste n tly fo r m e.

th o u g h t c o m in g u p th r o u g h . T h is m ay be a n

T h . G ive m e a n e x a m p le of th a t.

a s so c ia tin g

P t.

Y es, I can give you a v ery c le a r e x a m p le of

had

th a t. I t s re a lly a v ery fu n n y o n e, to o . I w a s

F re u d a n d h is th e o rie s o r a n y th in g a b o u t h im .

g o in g w ith a y o u n g m a n th a t I liked v ery m uch


a n d I w a s tr y in g to m a k e u p m y m in d , d o I

issu e w ith

F r e u d , h o w e v e r.

I ve

th is s e n sa tio n lo n g b e fo re I ev er k n ew

I t s a p h y sic a l feelin g .

T h . I see. N o w I d lik e to h a v e yo u tell m e so m e

like h im e n o u g h to sle ep w ith h im o r d o n t I.

th in g a b o u t y o u r p ro b le m s , th e th in g s th a t

A nd

r e a lly b o th e r you a n d u p se t y o u . [ N o w th a t th e

se e m e d

to

need

h is

a f fe c tio n

and

w a r m th , a n d in th e m id d le o f th e d ecisio n I

p a tie n t is b e g in n in g to

ta lk

m o r e fr e e ly ,

84

P t.

HANDBO OK OF SHORT-TERM PSYCHOTHERAPY


b elieve 1 can be m o r e d e m a n d in g o f h e r to te ll

re m e m b e r th is , b u t m y m o th e r te lls m e, I r e

m e a b o u t h e r re a l p r o b le m s . ]

m e m b e r l a te r w h e n I h a d a r e a c tio n s im ila r to

Y o u m e a n as a n in d iv id u a l?

th a t. T h e firs t g irl I p la y e d w ith I th in k w as

T h . A s a p e rs o n , yes.
P t.

a b o u t 2 a n d m o th e r sa id if sh e d id n t w a tc h ,

T h a t is w h a t I w a n t to d o, 1 believe tw o m ain

I w o u ld co m e r u n n in g in to th e h o u se ju s t b lack

p ro b le m s.

afflicted w ith

a n d b lu e b ecau se if I w a n te d s o m e th in g a n d w e

v ery b ad feet, w h ic h th r o w s m y sp in e o u t of

w e re s h a r in g s o m e th in g o r it w a s m y tu r n o r

I am

u n f o rtu n a te ly

b a la n c e c o m p le te ly w h ic h k eep s m e a little

so m e th in g a n d M a r y d id n t lik e th e id e a , she

tire d all of th e tim e. I d e e p ly re se n t th is. It also

j u s t s im p ly b e a t m e u p . I still c a n t be p u t

m a k e s m e a little n e rv o u s a n d a lw a y s gives m e

a g a in s t a w a ll.

a co n scio u sn ess of b e in g

p r e tty w ell a d ju s te d to.

tied

to

m y body,

w h ic h in m y case is a v ery b a d th in g b ecau se

Th

H a v e yo u g o tte n a lo n g fa irly w ell a ll th r o u g h

b e in g ta ll a n d h a v e a sense o f b ein g d iffe re n t.

c h ild h o o d ?

T w o , I fin d it v ery d ifficu lt to believe th a t I m

P t.

N o , no.

a n a c c e p ta b le in d iv id u a l to o th e r p e o p le . N o w ,

Th

T e ll m e so m e th in g a b o u t th a t.

th e r e is n o b asis for th is, e x c e p t th a t I so m e

P t.

ta c t w ith o th e r p e o p le , h a s b e e n o n e o f s tr a in ,

th e s e a r e d eriv e d fro m th e feelin g itse lf a n d n ot

te n s io n , o f sh y n e ss a n d m a la d ju s tm e n t. N o w
I m re a c h in g th e p o in t w h e re th is is n o lo n g e r
tr u e . A s a m a tte r o f fact, a few y e a rs ag o I

T h is is a b lock th a t I w o u ld lik e v ery m u c h to

w e n t th r o u g h p r e tty th o r o u g h th e r a p y a n d got

get over.

q u ite a n u n d e r s ta n d in g of it.

T h . W h a t a b o u t y o u r se lf-co n fid e n ce? D o you feel

Th

O h , is th a t so?

c o n fid en t?

P t.

B u t it d o e s n t re liev e th e sh y n e ss, yo u see.

N o , I d o n t.

Th

W h o w e re yo u tr e a te d by?

T h . N o co n fid en ce a t a ll?
P t.

M y w h o le h is to ry a s a n in d iv id u a l, a n d in c o n

tim e s d o v ery foolish a n d clu m sy th in g s. B u t

T h . I see.

P t.

A n d in y o u r life s itu a tio n h a v e yo u a d ju s te d ?

I m v ery ta ll. A n d so I b eco m e co n scio u s a b o u t

fro m a n y th in g in h e r e n t in m e.
P t.

N o w , th e s e a r e th in g s I m

P t.

H e w a s a d o c to r a n d th e y p ro v id e d th is service
fo r stu d e n ts , a n d I w e n t th r o u g h th e w h o le

N o . I w o n t say e x a c tly n o co n fid en ce. I t s a


v ery fu n n y th in g . W h e n I m a lo n e , a n d w h en

b u sin e ss w ith th e R o rsc h a c h s a n d th e I Q tests

I m w o rk in g , a n d w h e n I m d o in g s o m e th in g I

a n d th in g s lik e th a t.

lik e to d o , I h av e a v ery b asic self-confidence. I

Th

th in k so m o re th a n m o st p e o p le . I k n o w I m

P t.

It w a s th e r a p y .

rig h t. I ve a c tu a lly m a d e very few m ista k e s in

Th

H o w m a n y tim e s a w eek d id y o u go?

m y life in te rm s of ju d g m e n t a n d in te rm s of

P t.

I w e n t tw ic e a w eek for 6 m o n th s.

w hat

It a lw a y s seem s to

Th

D id yo u fin d o u t m u c h a b o u t y o u rse lf?

so m e h o w w o rk o u t, b u t th a t d o e s n t m e a n th a t

P t.

N o th in g I d id n t k n o w before.

o th e r p e o p le w ill ac c e p t m y p e rs o n a lity . A n d

Th

I see, b u t it d id h e lp y o u ?

y ou see I w a n t to be acce p te d .

P t.

I w a n te d

to d o.

A n d d id yo u get a n y th e r a p y ?

I t h e lp e d b ec a u se I lik ed th e d o c to r, a n d I h a d

T h . I see. N o w to get b a c k to th e b u sin e ss a b o u t

th e sense th a t he lik ed m e, a n d th a t so m e o n e

y o u r b elief, th a t is, y o u r feelin g th a t y o u a r e

w h o is in te llig e n t a s w ell a s lik a b le w o u ld lik e


m e is s o m e th in g I n ee d e d very b ad ly .

n o t ac c e p ta b le .
P t.

I th in k I ca n give y o u th e re a s o n s for th is.

Th

th in k m a n a g e d to solve, b u t y o u ca n im a g in e

I see, y o u w e n t th r o u g h co lleg e, a n d w h a t do
yo u d o n o w ?

O n e , m y f a th e r is a p a r a n o ia c . T h is p ro b le m I
P t.

I m a se c re ta ry . T h is is a lo n g sa d sto ry , th is
b u sin e ss of m y o c c u p a tio n . I d o n t re a lly w o rk

h is possessiv e love, a n d m y re je c tio n of th is

v ery w ell fo r o th e r p eo p le.

o v e rd o m in a tio n a n d of h is h e a v y -h a n d e d w ay
o f h a n d lin g p e o p le a n d s u p e rs e n sitiv ity . So you

Th

Is th a t so? W h a t a r e y o u r g o a ls ?

reject it, a n d c o n s e q u e n tly it i s n t n ice to reject

P t.

T h is is th e w h o le p o in t. I b e g a n in th e a te r as
a n a c tre ss , a n d I m ig h t a d d I w a s a v ery good

fa th e r, so y o u d o n t like y o u rself. T w o , I d i d n t

actress.

lik e m y sis te r a r riv in g a t th e tim e sh e a rriv e d .


young

Th

O h , is th a t so?

p la y m a te s w e re very u n f o rtu n a te . N o w , I d o n t

P t.

B u t I a m to o ta ll a n d c o n s e q u e n tly I d i d n t get

T h re e ,

my

f ir s t

e x p e r ie n c e s

w ith

THE INITIAL INTERVIEW: CASE HISTORIES


th e p a r ts I w a n te d . I c o u ld n t get th e m . T h e r e

85
P t.

w e re n o le a d in g m en for m e. T h e y d id n t e x
p la in th is to m e. N o o n e h e lp e d ; n o o n e to o k
th e tim e to say , L o o k , y o u re j u s t too ta ll,

I j u s t h a v e to k n o w p e o p le a lo n g tim e. T h e n
th e r e is n o p ro b le m . W h e n I feel ac c e p te d , I
h a v e n o d ifficu lty .

T h . W h a t a b o u t p h o b ia s ?

d o n t t r y . T h e y j u s t d id n t sa y a n y th in g , an d

P t.

let m e go o n a n d m y basic la c k o f co n fid en ce

T h . A n y th o u g h ts th a t com e in to y o u r m in d th a t

in c re a se d , y ou see, so th a t I h a d n o th in g left. I
tu r n e d to w r itin g , a n d I m v ery good a t th is.

N o n e th a t I ca n th in k of.
to r tu r e y o u o r b o th e r y o u ?

P t.

O n e , a n d th is is th e sto ry o f th e c a t-m o u s e s .

T h . I see.

T h . T e ll m e a b o u t th e c a t-m o u se s.

P t.

P t.

B u t I h a v e a te rrific block a g a in s t w r itin g . I

a n d it d i d n t w o rk v ery w ell. I m p a y in g off a

th is is th e ir r ita tin g p o in t. A s a c h ild I w a s

r a th e r

9 I w ro te a sto ry a b o u t a d o g a n d a little boy

m o u se s a r e d is to rte d c h ild re n . T h e y a re , as

w h o fo u n d th e d o g , a n d h e loved th e d o g , a n d

y o u n o tic e , p a r t m o u se a n d p a r t c a t. A n d so

he c o u ld n t k eep th e d o g . H e h a d r u n a w a y

th e firs t tim e I h a d th e d r e a m I se n sed w h a t it

fro m h o m e . A n d I r e m e m b e r h e w e n t d o w n to

w a s a n d I d i d n t lik e it, so I tu r n e d it in to a

c o m p lic a te d a n d rid ic u lo u s c h ild ish sto ry . A n d

T h . In th e d r e a m ?

m y fa th e r w h o th o u g h t he c o u ld w r ite , a n d

P t.

N o , n o a fte r, a n d so la te r m y su b c o n sc io u s
k e p t te llin g m e, a p p a r e n tly

h a p p e n e d . T h e sto ry is a v e ry b a d ly h a n d le d

I d islik e d w h a t

a b o r tio n I h a d , a n d I m e a n b a d ly h a n d le d , it

I t s th is re je c tio n y o u see. N o w I u n d e r s ta n d

w a s j u s t aw fu l.

h is ego c o u ld n t let h im say it w a s a ll r ig h t to a

T h . Is th a t so?

9 -y e a r-o ld ch ild . H e h a d to p ro v e h im se lf as

P t.

A n d so y o u see th e r e la tio n s h ip , a n d th is is th e

b e in g s tro n g e r a n d c ritic iz in g . It d o e s n t h elp

sto ry , a n d

th e re a c tio n .

u n d e r c e rta in

th is th in g

o c c a s io n a lly p o p s u p ,

t e m p e r a t u r e c o n d itio n s , a n d

so m e tim e s j u s t b efo re m y p e rio d w h e n th e re

r a t h e r r a p id ly . H o w old a r e y o u ?

a re cram p s and

T w e n ty -n in e .

p h y sic al feelin g a s d u r in g th e o p e ra tio n .

T h . E v er m a r rie d ?

I feel tig h t. It is th e sa m e

T h . I see. W a s th e o p e r a tio n d o n e by a p e rso n w h o

N o.

T h . H o w a b o u t te n s io n , d o y o u feel te n s e ?
P t.

fo r it. T h e c a t-

sh re d s. I n e v e r g o t o v er it q u ite .

T h . N o w , I m g o in g to a s k you a few q u e s tio n s

P t.

p e n a lity

p ro b a b ly co u ld h a v e a t o n e tim e , to re it to
T h . Is th a t so?

P t.

la rg e -s iz e d

w h im sic a l th in g I co u ld like.

th e r a ilro a d tra c k s o r so m e th in g . It w a s a very

P t.

T h e c a t-m o u se s . W e ll, I trie d to do so m e th in g ,

ca n tell y o u th is to o . I k n o w th e s e th in g s a n d

is c o m p e te n t a t a ll?
P t.

V e ry m u ch .

By a n e x c e lle n t d o c to r. T h e th in g th a t w e n t
w r o n g w a s th a t I h a d h a d se v era l sh o ts befo re

T h . A g o o d d e a l o f te n sio n ?

th e n in o r d e r to avoid th e o p e r a tio n itself. So

T h . W h a t a b o u t d e p re ss io n ?

th e fetu s h a d sh ifted , a n d th e d o c to r w h o d id

P t.

A w eek b efo re m y p e rio d ev ery m o n th . T h is is

th e

ch em ical. I feel th is c o m in g o n .

d id n t to u c h it so c o n s e q u e n tly tw o d a y s la te r on

o p e r a tio n

th o u g h t

it w a s a p o ly p a n d

T h . Yes. W h a t a b o u t p h y sic al sy m p to m s ?

a t r a in g o in g h o m e , I w e n t in to v io le n t la b o r

P t.

p a in s .

M y b ack , sp o n d y litis .

T h . A n y fa tig u e o r e x h a u s tio n ?
P t.

M ild a n e m ia also .

T h . A n y h e a d a c h e s?
P t.
P t.

No

T h . S to m a c h tro u b le ?
P t.

N o.

th a t

w as w hen

it a c tu a lly

P t.

Y es, w h ic h is th e u n f o rtu n a te p a r t you see. If I


h a d n o t, I th in k it w o u ld h a v e b een b e tte r.

T h . It lo o k ed lik e a c a t-m o u se ?
P t.

It d id n o t. It lo o k ed lik e a ch ic k e n h e a rt.

T h . L ik e a c h ic k e n h e a r t.
P t.

U h - h u h , e x a c tly .

T h . W o u ld y ou say you h a d a n y s e x u a l p ro b le m ?

T h . H o w m a n y m o n th s p r e g n a n t w e re y o u ?

P t.

S o m e in h ib itio n , u n le s s I k n o w th e m a n e x

P t.

tre m e ly w ell. I m ju s t n o t a c a s u a l p e rso n .

T h . W e ll, th a t is n t to o long.

T h . Yes.

oc

T h . D id y o u see th e fetu s?

V e ry seld o m .

T h . D iz z in e s s?

A nd

c u r r e d a n d th a t w a s j u s t a m essy m ess.

P t.

I d sa y 6 w eek s, a little o ver.


O h , no.

86

HANDBO OK OF SHORT-TERM PSYCHOTHERAPY

T h . W e ll, l e ts ta lk a b o u t th o se c a t-m o u se s a little

P t.

P t.

I d id th a t b e c a u se of i t s k in d of a tric k . I

m o re. G iv e m e a n id e a of w h a t th e d re a m s

s h o u ld n t h a v e d o n e it. A m o n g o th e r th in g s I

w e re .

w r ite a d v e rtis in g copy. I t s m y b u sin e ss to i n

T h e d r e a m s a ll h a v e th re e th in g s in c o m m o n

te re st p e o p le , so I u se tric k s b ecau se p e o p le a r e

h e a t th e se n sa tio n of b o d ily h e a t. T h a t s w h y
I h a v e th e m m o re o ften in s u m m e r. I t s very

a ttr a c te d by th is so rt o f w h im sic a l th in g .
T h . I see, it is n t re a lly a p ro b le m th e n .

h o t, w a te r , a th in g o f b e in g in w a te r o r n e a r

P t.

w a te r , o r s u r r o u n d e d by w a te r , a n d d is to rte d

T h . A ll r ig h t, fin e, n o w ?

a n im a ls , p e c u lia r a n im a ls , I m e a n . S om e of

P t.

th e m a r e v ery c h a r m in g a n d v ery w h im sic a l.


A n d in o n e I r e m e m b e r I h a d a b s o lu te ly to get

I t s a little u n p le a s a n t.

It i s n t a p ro b le m ;

th e y ll go a w a y .
T h . Y ou h a v e a n x ie ty in y o u r d r e a m s w ith th is

rid of th e a n im a ls . I h a d to k ill th e m , a n d it
w o k e m e u p b e c a u se I c o u ld n t.

It is n t re a lly a p ro b le m .

sy m b o l?
P t.

I d o n t k n o w if i t s a n x ie ty o r n o t. I t s j u s t a

T h . Y o u c o u ld n t?

fo rm o f te n s io n a n d a fo rm of a n x ie ty of b e in g

P t.

I j u s t c o u ld n t. I ju s t a b s o lu te ly c o u ld n t to u c h

forced to do s o m e th in g I d o n t w a n t to d o. A

th e a n im a ls.

v ery o b v io u s re a s o n . T h e a b o r tio n , it w a s very

T h . T h ese

c a t-m o u se s ,

are

th e r e

m any

in

th e

d ream or ju s t one?
P t.

p a in fu l a n d v ery u n p le a s a n t.
T h . T h is sy m b o l o n ly o c c u rre d a f te r th e a b o r tio n ?

O h , th ey c h a n g e ; th e y re n o t a lw a y s a cat-

P t.

m o u se . T h is is ju s t th e n a m e I ve given to th e

T h . A n d you feel v ery w ell sa tisfie d th a t th is is th e

c re a tu r e th a t evolved th r o u g h th is. T h e y can


be a n y th in g , b u t th e y a r e a lw a y s c o m b in a tio n s.

b asis of th is ?
P t.

T h . B u t th e c a t-m o u se s sy m b o l itself?
P t.

C a ll it a c a t-m o u se sy m b o l.

P t.

T in y , th e y re a lw a y s very sm a ll, th e y re a l

P t.

n ig h t.

L ik e a m o u se.

T h . O n ly d u r in g th e d ay .
P t.

T h e o rig in a l o n e w a s lik e a c a t a c a t s h e a d
a n d a m o u s e s body.

P t.

u n d e r s ta n d

w h im sy a n d

P t.

w ho

M y f a th e r is a v ery in te llig e n t m a n . A s a c h ild


h im

b e in g

v e ry

w o n d e rfu l

m a n a n d h e a d o re d c h ild re n . H e still does,

d u ll p e o p le .

b u t h e is a p a r a n o ia c . I d o n t m e a n a p a r a n o ia

T h . I see.

p e r s o n a lity , I m e a n a p sy c h o sis p a r a n o ia c . H e

T h is I ve d o n e , a n d w r itte n som e v ery c h a r m

is also a n alco h o lic.

in g little p ieces w h ic h I w ish I co u ld tu r n in to

T h . H o w d id h e r e la te to y o u ? W a s h e close?

so m e m o n ey if I co u ld .

P t.

T h . H o w d o y o u feel? D o you th in k a b o u t th ese


P t.

your

T h e y a re . It w o u ld be su c h a sto ry .

I re m e m b e r

h a v e a sen se o f h u m o r, a n d d o g -fish es a r e ju s t

P t.

b it a b o u t

T h . W h a t so rt of p e o p le a r e th e y ?

W e ll, th e c a t-m o u se s a r e p e o p le w ith w h im sy


ca n

N o w , te ll m e a little

m o th e r a n d y o u r fa th e r. A re th e y liv in g ?

W e ll, to a d o g -fish now .

w ho

B u t i t s lik e ly to be w a r m , a n d I ll be d ressed
a n d ly in g d o w n .

T h . OK.

T h . A d o g -fish n o w ?
and

O n ly th is. H o w e v e r, I n e v e r h a v e th is ex cep t
w h e n I m ta k in g a n a p . I d o n t h a v e th is a t

T h . A n d th e y w o u ld sh ift?

P t.

th is e x

N o , I ca n p u t m y se lf to sle ep in s ta n tly .

T h . G o o d , W h a t a b o u t n ig h tm a re s ?

T h . A n d th e c a t?

P t.

if y o u u n d e r s ta n d

b ig is it?

T h . T h e b o d y w h a t d o es it look lik e?

P t.

o v er,

T h . N o w , do y o u h a v e a n y in s o m n ia ?

w a y s little .
P t.

It clicked

p re ss io n . It felt rig h t.

T h . C a t-m o u s e sy m b o l, ca n you d esc rib e it? H o w


P t.

I ve n e v e r h a d it before. N e v e r.

A s a c h ild , v ery close. W e w e re v ery , very


close.

c a t-m o u se sy m b o ls a good d e a l?

T h . D id you re a lly love h im ?

N o , as a m a tte r o f fact I d o n t.

P t.

D e e p ly , I still do. T h is p r e s e n ts a p ro b le m .

T h . T h e y d o n t b o th e r you?

I ve b een u n a b le to solve it b e c a u s e h is w h o le

P t.

p e r s o n a lity s tr u c tu r e is so o b n o x io u s to m e th a t

N o.

T h . Y o u seem to be r a t h e r p re o c c u p ie d a b o u t th a t
in th e le tte r y o u se n t m e.

I h a v e h a d to sp lit it off. A n d to love th e m a n ,


th e

in d iv id u a l,

th e

th in g s

u n d e r n e a th ,

and

THE INITIAL INTERVIEW: CASE HISTORIES

87

w h a t I k n o w is th e re a n d a v o id th e p e rs o n a lity

P t.

as

T h . N o w , I m g o in g to sh o w y o u th e R o rsc h a c h

if it

w e re

th e

p la g u e .

To

w a tc h

th e

d e g e n e ra tio n of a m in d a n d a h u m a n b e in g is
n o t a p le a s a n t th in g fo r a c h ild .
T h . I sh o u ld
P t.

say n o t, ev en a s

c a rd s r a th e r r a p id ly .
P t.

a c h ild

he w a s

P t.

I b e g an to p ick it u p a b o u t 9. T h a t s w h e n he

Th.

s ta rte d to d r in k . T h a t s w h e n a lot o f th e t r o u
P t.

It w ill ta k e ju s t a b o u t 5 m in u te s w ith m e. ( /
M o u n ta in s , c ra b , sea c ra b s , w o m a n p ra y in g ,
th e s e a r e th e m o st p r o n o u n c e d .

is sh e ?

T h . A ll r ig h t. T h is is th e seco n d o n e.

M y m o th e r is also tw o p e o p le . S h e is th e p e r

P t.

B e a rs , tw o little b e a rs, te d d y b e a rs , I a lw a y s

son she w a s 10 y e a rs ag o , a n d th e p e rso n sh e is

h a v e to th in k th is is a te m p le , th e w h ite p a r t in

now ;

th e c e n te r. A n d I a sso c ia te , th e o ra n g e p a r t

sh e

is w a s a v ery

sta b le

p e rs o n a

b e a u tifu l w o m a n .

w ith m e n s tr u a tio n blood.

T h . H o w did y ou get a lo n g w ith h e r ?


P t.

T h e la s t tim e it to o k m e 3 h o u rs .
h a n d h e r th e f i r s t c a rd .)

T h . H o w a b o u t y o u r m o th e r? W h a t so rt o f p erso n
P t.

O h , I ve h a d th a t (la u g h in g ).

T h . I k n o w . J u s t to give m e a n id ea.

d e g e n e r a tin g th e n .

ble b eg a n , a n d w e w e re n e v e r h a p p y since.

N one.

W o n d e r f u ll y ,

ju s t

w o n d e r f u lly .

T h . A ll rig h t. T h is is th e th ird c a rd .
O h,

we

P t.

sc ra p p e d a little b it, b u t w ith th a t k in d of a

O h , I r e m e m b e r th ese, th e s e a r e m y little c a n
n ib a l w o m e n . T h e y a r e c o o k in g , th e little g u y

fa m ily if w e get m a d , w e sa y s o m e th in g . I

w h o sits in th e tw o c o rn e rs h e re , {fo u rth card)

m e a n m o th e r th r e w p la te s a n d I sto m p e d o u t

T w o tire d b ird s s ittin g b ack to b ack . T h e y a re

o f th e h o u se , b u t it n e v e r m e a n t a n y th in g . I

v ery tire d , (fifth card) I a s so c ia te th a t w ith th e

m ean

th e re

w as never any

g ru d g e s h e ld

b e e r belly , a v e g e ta b le , a n d I c a n n o t tra c e it.

o v e rsh a d o w in g , lo n g te n s io n p e rio d s.

T h e to p is a s o ld ie r s h e lm e t. W o m e n chiefly

T h . D o y o u h a v e a n y b r o th e rs a n d siste rs?

w o m e n , p r o b a b ly n u r s in g o r a b le to n u r s e a n d

P t.

so m e h o w a sso c ia te d w ith c h ild re n in th is case.

I h a v e a y o u n g e r b r o th e r a n d y o u n g e r sister.

T h . H ow young?

T h . T h is is th e six th one.

P t.

P t.

M y y o u n g e r s is te r is 2 y e a rs y o u n g e r sh e is
m a r rie d a n d h a s tw o c h ild re n . M a r r ie d a m a n

w in g s.

j u s t like m y f a th e r w h o is also a n alco h o lic. So

T h . W h e r e do yo u see th e w in g s th e r e ?

sh e refu ses to sta y m a r rie d , a n d a s lo n g as

P t.

th e y re d iv o rced a n d live to g e th e r, life is fine.

of it. (se v e n th ca rd ) T h e s e a r e th e c h ild re n .


I m

bly is d u e to a b r a in in ju ry . S h e h a s b een sick

tio n s fro m b efo re . L ittle c h ild r e n , fa c in g o n e

a ll of h e r life. M y b r o th e r is 19, is se n sitiv e

a n o th e r , in k in d o f a b a lle t d a n c e r s po se , th is

and

w a y . (e ig h th ca rd ) T h is is th e m o st, I ca n ta k e

in te llig e n t, te r rib ly d e p re ss e d

and

in

by

th e

w a y , som e r e a c

th e co lo rs; i t s a w e ird c o m b in a tio n h e re , it h a s

th a t y ou re m e m b e r?

a k in d of offbeat lik e ja z z m u sic , th e o ra n g e

I d i d n t re m e m b e r a d a y w h e n I d i d n t h av e

a n d th e p in k . It h a s a w a te r y fe e lin g to m e.

an y .

T h ese

T h . W h a t fo rm d id th o se e m o tio n a l u p se ts ta k e ?

a re

th e

p o la r

b e a rs o v e r h e re , very

s tro n g ly sh a p e d . A n im a ls of so rts a r o u n d a

By e m o tio n a l u p se ts d o y o u m e a n ta n tr u m s o r

w h e e l,

o u tb re a k s ?

s o m e th in g . I m so rt of a ttr a c te d to th e a n im a l

so rt

of d is to rte d

p a tte r n .

I a lw a y s felt p u sh e d in to a c o r n e r a n d forced

T h . U h - h u h . T h is is th e n in th one.

off, a n d m y o n ly free d o m w a s w h e n I w a s by

P t.

is th e o n e

I d i d n t lik e.

B e cau se i t s

v io len ce a n d in se c ts, a n d th is is s o m e th in g I

m e n t p r io r to se ein g th e co lleg e d o c to r?
N one.

T h is

m essy , v ery m essy , b ec a u se it r e m in d s m e of

T h . A n d y o u r p re v io u s tr e a tm e n t, a n y so rt o f t r e a t

T h . T a k in g a n y m ed icin es o r tr a n q u iliz e r s ?

I n o ticed

w o rld .

O u tb r e a k s o r n e rv o u sn e ss. It w a s a re p re ssio n .

m y se lf a n d liv in g in d a y d r e a m s e s se n tia lly .

P t.

r e m e m b e rin g ,

it a p a r t m o re . T h is o n e I r e m e m b e r lik in g . I t s

T h . A s a c h ild d id you h a v e a n y e m o tio n a l u p se ts

P t.

T h e w h o le o u tsid e , th e f e a th e rs , a n d th e s h a p e

S h e a tte m p te d to c o m m it su ic id e . T h is p r o b a

h ib ite d . 1 sh o u ld say b a sic a lly ju s t a fin e boy.

P t.

N a v a h o ru g s , b e a r ru g s, I h a v e a s e n sa tio n of

d islik e .
T h . V io le n c e , insects.
P t.

W h e n p e o p le a r e r o u g h a n d v icio u s in a w ay .

88

HANDBO OK OF SHORT-TERM PSYCHOTHERAPY

T h . D o y ou see a n y th in g else th e r e ? . . . Y ou can

T h . Is th a t so. Y ou w o u ld a lso be v ery good in a n a

h o ld it a n y w a y yo u w ish . . . . A ll r ig h t, th is is
th e la s t on e.
P t.

ly z in g d re a m s , a n a ly z in g th e u n c o n sc io u s.
P t.

C h ild r e n th a t a r e lik e sea h o rse s , a n d a g a in


slig h tly h y ste ric a l m o d e rn a r t. I lik e th is one.

So i t s u n b e lie v a b le . A side fro m m yself, as lo n g


a s I d o n t th in k a b o u t it.

T h . So yo u d o h a v e th is fa c ility , b u t th is very

N o w I g et a n E iffel T o w e r im p re ss io n from

fa c ility ca n c re a te p ro b le m s for you.

th is im m e d ia te ly , w h ic h I a u to m a tic a lly sw itc h

P t.

o v er in to a p re fe rre d sy m b o l. A n d th is is th e

T h . Y o u re e x tre m e ly se n sitiv e , to o se n sitiv e. Y ou

feelin g I h av e. T h is o n e is g ood, so m e h o w ,

feel slig h ts , you get v ery te n s e , yo u a r e ju s t lik e

even th o u g h it seem s d is c o rd a n t a n d d isc o n

a w e a th e r v an e. Y ou j u s t sw in g w ith th e w in d ,

n ected . It h a s a c o h e re n c e of w a r m th a n d good

a n d b ec a u se of th a t , y o u m ay n eed so m e so rt of

feelin g th a t co m es so m e tim e s w ith good th in g s.

h e lp . N o w , I w o u ld th in k th a t y o u co u ld do

[T h e

th e

v ery w ell w ith t h e r a p y m a y b e n o t too in te n

in te n s ity o f fe e lin g in th e la st th re e ca rd s p o i n t

sive th e r a p y b u t se ein g so m e o n e a b o u t o nce

d is o r g a n iz a tio n

o f th o u g h t

and

to a s c h iz o p h r e n ifo r m - lik e te n d e n c y . ]

Y es, it does.

w eek ly .

T h . A g o o d feelin g ?

P t.

P t.

T h . S o m e b o d y th a t w o u ld s ta b iliz e you a n d w o u ld

P la y fu l is th e w o rd I w a n t.

T h . N o w , I h a v e a little b e tte r id e a of th e p ro b le m

e n a b le you to g et som e s ta b ility b e c a u se y o u re

th a n I d id b efo re. So v ery ra p id ly I m ju s t g o


in g to giv e y ou m y id eas, b u t I m a y n o t be

too m u c h lik e a w e a th e r v an e.
P t.

I k n o w , it w o u ld d riv e m e w ild , yo u see, a n d

a b s o lu te ly a c c u r a te a n d I w a n t y o u th e n to tell

t h a t s p a r t of th is w h o le th in g .

m e y o u r im p re ss io n s . \In p r e s e n tin g in te r p r e ta

tr a c k of th is id e a o f u sin g h y p n o s is a s a fo rm of

tio n s to th e p a ti e n t o r in g iv in g h e r a h y p o th

re s e a rc h ; n o w , I m n o t a d v e rs e to w o rk in g on

I ve g o tte n

esis o f th e p r o b le m , I m u s t be c a r e fu l th a t sh e

m yself. I d o n t m e a n to u se it a s a n easy w ay

d o es n o t re g a rd w h a t I sa y as an a tta c k , o r as

o u t. I w o rk a w fu lly h a r d for e v e ry th in g I ve

b e in g c r itic a l o f her. S h e h a s a lre a d y to ld m e

e v er h a d , a n d I d o n t m in d . I even e n jo y it, I

th a t w h a t sh e se e k s fr o m m e is a p p r o v a l a n d

h a v e a feelin g n o w o f g e ttin g so m e th in g t h a t s

s u p p o r t. ]

g o in g to m e a n e n o u g h to s te a d y m e d o w n .

T h . N o w , y ou a r e a n e x tre m e ly se n sitiv e a n d c r e a

T h . I m s u re th a t yo u co u ld u tiliz e h y p n o sis v ery

tive p e rso n . Y o u h av e a g re a t m a n y ta le n ts a n d

effectively.

th e a b ility to p erceiv e n u a n c e s a n d to a rriv e

P t.

v ery r a p id ly to in tu itiv e feelings. T h a t s b e

T h . A re y o u ?

ca u se you live v ery close to y o u r u n c o n sc io u s.

P t.

Y o u h a v e a r e m a rk a b le fa c ility in th a t d ire c
d o n t. Y ou ju s t seem to h a v e th is facility . F o r

I m v ery g o o d a t it, by th e w a y .
I ve d o n e a little b it o f it, j u s t e n o u g h , a n d if I
u se m y eyes it w o rk s lik e a c h a rm . I ju s t go

tio n . T h e r e a r e p e o p le w h o do a n d p e o p le w h o

r ig h t o u t.

T h . Y ou can c e r ta in ly u tilitz e y o u r facility in a

th a t re a so n m a n y of th e p h e n o m e n a th a t a re

very a p p r o p r ia te w a y . A s fa r a s y o u re c o n

o r d in a rily

c e rn e d , I d o n t th in k h y p n o s is is a b s o lu te ly

re p re sse d

and

are

n o t o rd in a rily

p erceiv ed a r e a v a ila b le to you. S o, yo u ca n b e

n e c e ssa ry . It w o u ld n t m a k e too m u c h d iffe r

co m e a w a r e of m a n y sy m b o ls th e a v e ra g e p e r

en ce as fa r a s y o u r g e ttin g so m e th in g b en eficial

son o v erlo o k s. Y o u can also be in flu e n ced by

P t.

J u s t to stu d y it o u t.

o u t o f th e r a p y .

y o u r u n c o n scio u s. Y ou th e n c a n p o se q u e s tio n s

P t.

to y o u r u n c o n sc io u s a n d g et th e a n s w e rs . N o w

T h . Y ou u n d e r s ta n d w h a t I m e a n ?

T h a t w a s n t th e p o in t. (la u g h in g )

th is is n o t a v e ra g e . I d say m o st p e o p le c a n n o t

P t.

d o th is.

T h . So w e re ta lk in g in tw o d iffe re n t fra m e s of re f

Y es, I k n o w w h a t you m e a n .

T h e n you see m y in te re s t in th is field b ecau se

e ren ces: h y p n o sis is o n e th in g a n d a lso yo u as

I m a w a r e o f th is. I ll tell y o u so m e th in g else

a p e rs o n

th a t m ig h t in te re s t you. If I ta lk to so m e o n e for

s o m e th in g m e a n in g fu l o u t o f o th e r k in d s of

2 h o u r s a n d let th e m ta lk to m e, I c a n tell you

th e r a p y . A s a m a tte r o f fact, I d o n t th in k h y p

in te r m s o f y o u r c a p a c ity

to get

w h ic h p a r e n t h a s c a u sed th e tr o u b le in th e p e r

n o sis w o u ld be th e b est th in g for y o u . Y ou a r e

s o n ju s t in stin c tiv e ly .

too im m e rs e d in y o u r u n c o n s c io u s n o w , a n d it

THE INITIAL INTERVIEW: CASE HISTORIES

89

w o u ld be m u ch b e tte r for you to s ta b iliz e an d

ta n g e n ts . \ T h e p a tie n t is o b v io u s ly s e e k in g a

b u ild u p a little m o re re p re ssio n so th a t you

p r o lo n g e d

a re n o t b e in g b o m b a rd e d all th e tim e by y o u r

p r o b a b ly a ll sh e can u se a t th is tim e . S h e is

u n c o n sc io u s.

| M y fe e lin g is th a t th e p a tie n t

q u ite close to a s c h iz o p h r e n ic b re a k , in m y

w o u ld u tiliz e h y p n o s is to s tir u p too m a n y

o p in io n , b u t sh e s till h a s g o o d d efen ses, a n d

fa n ta s ie s

a n d in

th is

w ay

w o u ld fr ig h te n

m ig h t,

h erself. ]

co m e on a o n c e -a -w e e k b asis to ta lk th in g s

i f sh e is m o tiv a te d , b e n e fit f r o m

is

th e

to a h o s p ita l c lin ic w h e r e s h e c o u ld receive


g o o d th e r a p y . ]

T h . W e ll, give m e a n id e a of w h a t you can affo rd ,

o v er. Y o u ll feel a n a n c h o r a g e th e re . A n d in
th a t refe re n c e I m a y be a b le to re fe r you to

a p p r o x im a te ly .

Pt.

so m e b o d y w h o m ay be a b le to h e lp you.

T h a t I c o u ld m a k e , I co u ld m a n a g e th is.

T h . A ll r ig h t, I th in k I ca n fin d so m e b o d y for you

n a n c ia l b u sin e ss.

at o n e of th e clin ics. I sh a ll te le p h o n e h im th is

T h . T h a t s o n e of th e th in g s I m ig h t be a b le to h e lp
y o u w ith b y a r r a n g in g for th e r a p y in te r m s of
y o u r b u d g e t a n d in te rm s of y o u r o w n a b ility
to p a y w h a te v e r y ou c a n . T h e r e a r e p la c e s in

G e e , i t s so a w fu lly tig h t th a t even s o m e th in g


a s little a s $ 1 0 a w e e k w o u ld be too m u ch .

1 d o n t h a v e

a n d y ou see I m re a lly in a c o r n e r o n th is fi

a fte rn o o n a n d let y o u k n o w .

Pt.

A ll rig h t.

T h e p a tie n t w a s referred to th e h ead of a

I d o n t n eed th a t k in d o f h elp . I n eed a fa th e r,

clinic in the n e ig h b o r h o o d , w h o m I te lep h o n ed


a n d in fo rm ed a b o u t h e r p ro b le m . T h e clinic

D r . W o lb e rg . N o , th is is t r u e , I n e e d so m e

w a s w illin g to ta k e h er, b u t the p a tie n t n ever

b o d y th a t is v ery stro n g , a n d v ery sta b le a n d

accepted th e referral. A te le p h o n e call from me


to h e r w as n ev er r e tu rn e d .

th e city w h e re y ou ca n receive som e good h e lp .

Pt.

w h ic h

m ild n e u r o le p tic . 1 h a v e in m in d re fe rr in g h e r

in th e r a p y w ith so m e b o d y to w h o m you could

B e cau se th is co sts m o n ey a n d th is

r e la tio n s h ip ,

p r o p e r ty p e o f tr e a tm e n t a n d p e r h a p s so m e

Pt. W e ll, you k n o w th a t w a s p a r t of th e idea.


T h . N o w , I th in k th a t you p r o b a b ly w o u ld do w ell

Pt.

s u p p o r tiv e

w o n t la u g h a t m e w h e n I get off on o n e o f m y

CHAPTER 7

Choosing an Immediate Focus


h a v io ra l

M a n y p a tie n ts come to th e r a p y convinced

im p ro v e m e n t,

to

sim p le

su p p o r tiv e

som e p re c ip ita tin g factor in th e i r e n v iro n m en t.


A n alcoholic h u s b a n d , a dis a stro u s in v estm ent,

cessitate a seriou s look at u n d e rl y in g p e r


son ality factors th a t a re s t irr in g u p obstructiv e

a b ro k en love affair, a serious accident, these


a n d m a n y o th e r real o r e x a g g e ra te d calam ities

tr a n sferen ce a n d o th e r in terferences to change.


In p ractically all p a tie n ts som e im m e d ia te

m a y be bla m e d . W h a t p eop le u su a lly w a n t


from tr e a tm e n t is h elp in gettin g rid of pain fu l

stress situ atio n , u su a lly o ne w ith w h ich th e in


div idu al is u n a b le to cope, sp a r k s th e decision

o r d isab ling sy m p to m s th a t a re often ascribed

to get help. U s u a ll y th e p a tie n t considers


him self to be th e victim r a t h e r t h a n p e r p e t r a

to such offensive events. T h e sy m p to m s include

and

resistance

th a t th eir p ro b le m s w ere b ro u g h t a b o u t by

reed ucative tactics m a y

ne

to r of his identified tro u bles. T h i s , in some


cases, m a y be tr u e ; in m ost cases it is false. It

an x iety , d ep ressio n, p h ob ias, in s o m n ia, sexual


difficulties, obsessions, physical p ro b le m s for
w hich no o rg a n ic cause can be fou nd , a n d a

is necessary, therefore , in all p a tie n ts to a p

g re a t m a n y o th e r c o m p la in ts a n d afflictions.

p ra is e the d e g ree of p e rs o n a l p a rtic ip a tio n in

E ven th o u g h w e m a y be correct in o u r
a s s u m p t i o n t h a t th e b a sic t r o u b l e s re s id e

th e ir difficulties.
Since w e a re a c tu a lly d e a lin g w ith situation s

elsew h ere t h a n in e n v ir o n m e n ta l o r s y m p to
m atic co m p lain ts, to bypass the p a t i e n t s im

th a t

generate

te n s io n

and

a n x iety ,

it

is

e s s e n tia l to v ie w e n v i r o n m e n t a l in c i d e n t s
th r o u g h the lens of th e ir special m e a n i n g for

m e d iate con cern s is a serious m istak e. L a te r


w h en th e r e is firm evidence of th e u n d e rly in g

th e ind ivid ua l. W h a t m a y for one p e rs o n co n


stitute a n i n s u r m o u n t a b le difficulty m a y for

causes, for e x a m p le , faulty p e rs o n a lity o p e r

a n o t h e r be a bo on to a d ju s tm e n t. D u r i n g
W o r l d W a r II, for in stance, th e L o n d o n b o m b
ings for som e citizens w e re s h a t te r i n g a ssau lts
o n e m o t i o n a l w e l l - b e i n g ; for o t h e r s t h e y
b ro u g h t fo rth laten t p r o m p ti n g s of c o o p e r

atio n s o r unco nscio us conflict, a good in t e r


view er should be able to m a k e con nections b e
t w e e n t h e p r e c i p i t a t i n g e v e n ts o r e x i s t i n g
s y m p t o m s a n d t h e less a p p a r e n t d y n a m i c
sources of difficulty. T h e r e will th e n o ccur a
ch an g e in focus. T h i s shift, h o w ev er d esirab le
it m a y seem, is no t alw ay s necessary because
w e m a y find t h a t o u r objectives a r e re ached ,
an d th a t the p a tie n t achieves stab iliz atio n ,
w i t h o u t d e l v i n g in to c o r r o s iv e c o n flic ts o r
stirr in g u p ghosts of th e past. It is o nly w h e re

atio n , b ro th erlin e ss, a n d self-sacrifice th a t lent


a n e w an d m o r e co nstructiv e m e a n i n g to th e
i n d i v id u a ls existence. In d e e d , w a r t i m e w ith its
th r e a t to life m a r s h a ll e d a n in terest in survival
a n d s u b d u e d n e u ro tic m a l a d ju s tm e n t, w h ich
r e t u r n e d in pea cetim e to p la g u e th e ind iv idu al.
T h e u n d e r s ta n d in g of stress necessitates ac
k n o w le d g in g t h a t th e r e is no objective m e a s u r e
of it. O n e c a n n o t say th a t such a n d such a n e n
v ir o n m e n t is, for th e a v e rag e ad u lt, 7 0 p erc e n t

goals go bey on d s y m p to m relief or be hav ioral


im p ro v e m e n t t h a t w e will, in th e h o p e of
initiatin g som e d e e p e r p e rs o n a lity a lte ra tio n s,
delve into d y n a m ic p ro b le m areas. E ven w h e re
th e objective is m e re s y m p to m relief or b e

stressful a n d 30 p e rce n t n u r t u r a n t . N o m a t te r

90

CHO O SING AN IMMEDIATE FOCUS

91

how benevolent o r stressful th e en v iro n m e n t,


th e in dividual will i m p a r t to it a special m e a n
ing as it is filtered th r o u g h his con ceptu al n e t
w o rk . T h i s shad es his w o rld w ith a signifi

b rin g s p u n is h m e n t . T h e y a r e c o m m o n ly re
ferred to as lo s e rs. A p a ti e n t of m in e co n
sta n tly w o u ld involve him self w ith finan cial in

cance th a t is largely subjective. C o n c e p tu a l dis


t o r t i o n s p a r t i c u l a r l y t w i s t fe e lin g s t o w a r d

v estm ents th a t a lm o st in evitably w o u ld tu r n


o ut to be less th a n profitab le. H e w o u ld then
react w ith d ep res sio n , rag e, a n d s h atte re d self

o th e r h u m a n beings a n d especially t o w a r d th e

esteem . Yet no so o n er w o u ld he accu m u la te

self. A self-image th a t is h ateful o r in a d e q u a te

an y s u r p lu s of fu nds, th en he w o u ld a g a in

m a y p la g u e the individ ual th e r e m a i n d e r of his

p lu n g e into fanciful schem es th a t e nd ed in


d isaster. It w a s only after w e h a d ex po sed his

life an d causes h im to in t e r p r e t most h a p p e n


ings in relation to his feelings th a t he does not
h ave m uc h value. M o s t of w h a t h a p p e n s to

in n e r need to fail th a t he w o u ld recognize ho w


he b ro u g h t his tr o u b le s on him self. F o r a w hile

h im in life will be viewed as c o n firm in g his


o w n conviction th a t he is n ot m u c h good an d

it w a s w i t h t h e g r e a t e s t effo rt t h a t he
re s tra in e d h im se lf from in d u lg in g in w ildcat

t h a t n o th in g th a t he does will a m o u n t to
a n y th in g . Such a pervasive belief, of course,

g am bles. I felt th a t h a d he n ot needed to a n


sw e r to me, he still w o u ld hav e ta k e n im p o ssi

m akes n ea rly

ble risks.

any

o ccurren ce

p rod uctive

of

c onsiderable stress.
W i t h this as an in tro d u c tio n , it m a y be

C h a r a c t e r d is to rtio n s e n g e n d e re d by defects

asserted th a t th ere is such a th i n g as realistic

in d ev elo p m en t, such as e x tr e m e d e p en den cy ,


d e ta c h m e n t, ag g ressio n , m aso ch ism , p erfec

e n v iro n m e n ta l stress:

tio nism , o r com pu lsive a m b itio u sn e ss , a r e w h a t


u su a lly p re v e n t th e in d ivid ua l from fulfilling

1. T h e e n v ir o n m e n t m a y e x p o s e th e in d iv id u a l to
g ra v e th re a ts in th e fo rm o f g e n u in e d a n g e rs to life
a n d to se c u rity . E x a m p le s a r e e x p o s u re to d isa ste rs
su ch a s w a r , floods, sto rm s, a n d a c c id e n ts as w ell as
sev ere d e p riv a tio n of f u n d a m e n ta l n eed s for food,
sh e lte r, love, re c o g n itio n , a n d o th e r b io lo g ical a n d
social u rg e s e n g e n d e re d by a cru el o r b a r re n e n v i

him self a n d ta k i n g a d v a n ta g e of e n v ir o n m e n ta l
o p p o rtu n itie s . T h e y m a k e for th e c re a tio n of
a b n o r m a l goals a n d values t h a t m a y seriously
i n t e r f e r e w i t h a d j u s t m e n t a n d t h a t a c t as
sources of stress irrespective of th e en v iro n m e n t.
It is r a r e th e n

th a t e n v ir o n m e n ta l stress

2. T h e e n v ir o n m e n t m a y be p a r tia lly in im ica l,

a lo n e is the sole cu lp rit in a n y em o tio n a l p r o b


lem. In im ical, frig h te n in g , a n d d e s p e r a te s i tu a

th e in d iv id u a l n o t h a v in g th e re so u rc e s to rectify it.

tions do arise in th e lives of people, b u t the

T h e e n v iro n m e n t m ay be b e n e fic e n t e n o u g h , b u t th e

reaction s of the indiv idu al to h a p p e n in g s a re

in d iv id u a l, p e r h a p s th r o u g h e a rly fo rm a tiv e e x p e r i

w h a t d e te r m i n e th e ir p a th o lo g ic a l pote ntia l.

en ces,

U n d e r these c ir cu m stan c es m in o r e n v ir o n m e n
tal stress can ta x co pin g cap acities a n d b re ak
d o w n defenses so th a t a n e v e n tu a tin g a n x ie ty
will p ro m o te regressive devices like protective
p h o b ia s . It is, th erefore, essential th a t an y
p re c ip ita tin g incident th a t b rin g s a p a ti e n t into

ro n m e n t.

n ev er

d ev elo p ed

th e

a b ility

to

u se

th o se

re so u rc e s th a t w e re p o te n tia lly a v a ila b le .


3. T h e e n v ir o n m e n t m a y c o n ta in

a ll e le m e n ts

e s se n tia l f o r a g o o d a d ju s tm e n t, yet th e in d iv id u a l
m a y , a s h a s b een c ite d , be u n a b le to ta k e a d v a n ta g e
of it b ecau se o f a p e rs o n a lity s tr u c tu r e th a t m ak es
h im

e x p e rie n c e e s se n tia l n e e d s a s p ro v o c a tiv e of

d a n g e r. S u c h d efects m a y ca u se h im to p r o je c t o u t
in to th e e n v ir o n m e n t h is in n e r d issa tisfa c tio n s, a n d
he

m a \ a c tu a lly crea te c ir c u m sta n c e s th a t b rin g

th e r a p y be re g a r d e d as m erely o ne ele m e n t in
a n assem bly of etiological factors, th e m o st im
p o r t a n t v a ria b le bein g th e deg ree of flexibility

escape.

a n d in tegrity of the p e rs o n a lity stru c tu re . It is


this v a ria b le th a t d e te r m in e s a h a r m o n io u s in
te ra ctio n of forces th a t p o w e r in trap sy ch ic

Som e perso ns in v ariab ly re g a r d th e ir env i


ro n m e n t as on e in w hich th e i r assertiveness

m e c h a n ism s w h e n security a n d self-esteem are


th r e a te n e d by adv ersity fro m th e o u tsid e an d

u p o n h im s e lf th e v e r y h a z a r d s f r o m w h ic h h e se e k s

HANDBO OK OF SHORT-TERM PSYCHOTHERAPY

92

by c om m o n d ev elo p m en ta l crises th a t im pose


them selves from w ith in . By focusing on w h a t is

tion for its in fluence, good o r b ad, o n th e p a

re g a rd e d as a p re c ip ita tin g incid ent we m a y be

tient. A n u n d e r s ta n d in g of th e h o w a n d w h y of
its im p a c t m a y prove in v alu ab le. S o m etim es

able n ot only to in itiate re m e d ia b le e n v ir o n

th e in itia tin g factor m a y seem like a trivial

m e n ta l correction s but also to o p en a w in d o w

s p a r k to th e th e r a p is t , b u t a n e x p lo r a tio n of
th e p a t i e n t s p a s t h isto ry , his attitud es, a n d his

into h idd en p e rs o n a lity resources.


F r o m a p ractical v ie w p o in t th erefore, an y
e n v ir o n m e n ta l stress w a r r a n t s close e x a m i n a

values m a y reveal the e m o tio n a l explosive m i x


t u r e th a t a w a its d eto n atio n .

Focusing on Symptoms
Because

sy m p to m s

are

freq u en tly

by

p ro d u c t of stress, tension, a n d anxiety , it m ay


be helpful to e x a m in e th e ir d ev elo p m e n t a nd

Anxiety and Its Defenses


A vast a m o u n t of h u m a n p s y c h o p a th o lo g y is

m e a n i n g w ith in the m a t r i x of a d a p ta tio n . As

covered

long as a p e rs o n is ca p a b le of cop ing w ith his

c h a ra c te riz e d by a violent bio chem ical an d


n e u ro p h y s io lo g ical reactio n th a t d is r u p ts the

c u rr e n t life situ a tio n , as long as he c an gratify

by th e

g eneric te r m

anx iety.

It is

his most im p o r t a n t needs a n d dispose of o th e r s


th a t he is u n a b le to satisfy, as long as h e can

p hy sical, intellectu al, e m o tio n a l, a n d b e h a v

su sta in a sense of security a n d self-esteem, a n d

of a collapse o f a p e r s o n s h a b it u a l security

as long as he is able to m e d ia te tro u b le s th a t


vex h im , he will not ex pe rie nce stress b eyond

s t ru c tu r e an d his successful m e a n s of a d a p t a
tion. So u n c o m f o rta b le a r e its effects t h a t th e in

th e p o in t of a d a p tiv e b alan ce. W h e n , h ow ev er,

div id u al a tt e m p t s to escape from it t h r o u g h

this is not possible, th e th r e a t is registered as a

v a rio u s m a n e u v e rs. T h e s e a r e u su a lly self-de

state of tension, w ith altere d h o m e ostasis af

feating because th ose very m a n e u v e r s a re often

fecting the viscera, th e skeletal muscles, an d

regressive in n a t u r e t h a t is, they revive o u t


m o de d ch ild ish w a y s of d e a li n g w ith discom fort.
T h e y on ly f u r t h e r in terefere w ith assertive a n d

th e psychic a p p a r a t u s . T h e p erso n mobilizes


him self to cope w ith the stress a n d if he is suc
cessful, hom eostasis is resto red . W h e n a tte m p ts
at a d a p ta tio n keep failing, th e c o n tin u in g p r e s
ence of tension in t u r n sabotages the dev elo p
m e n t of m o re effective coping p a ttern s.
O v e rs tim u la tio n re sultin g fro m co n tin u ed
stress is b o u n d to register its effect on the
bodily in tegrity ( e x h a u stio n r e a c t io n ). B o m
b a r d m e n t of th e viscera w ith stim uli will tend
after a w h ile o rg a n ically to d is tu rb th e fu n c
tions of the v ario us o rg a n s a n d systems. T o
such e n su in g d is tu rb a n c e s Selye (19 50 ) h as
given th e n a m e disease of a d a p t a t i o n . As in
sidious as a re the physical effects of tension,
th e d ev elo p m en t of a c a stastro p h ic sense of
helplessness p ro d u c e s th e m o re d is tu rb in g p h e

ioral fu nction s of th e in divid ual. It is indicative

p ro d u ctiv e co o rd in atio n s.
W h e r e a n x ie ty is u n co n tro lle d , a n actu al
r e t u r n to in fantile he lplessness w ith co m plete
loss of m a s te ry m a y th r e a te n . R eality testin g
m a y totally d isin te g ra te , e n d in g in confusion,
d e p e rs o n a liz a tio n , a n in a b ility to locate the
lim b s in space, in c o o rd in a tio n , an d loss of c a
p acity to differe ntia te th e m e fro m th e no t
m e . T h i s th r e a t to in te g rity m a y in itiate
p a r e n t - i n v o k in g tactics r a n g i n g fro m q u iet
se a r c h in g for s u p p o r t to sc re a m in g , t a n t r u m s ,
be w ilde re d cries for help, a n d fain ting . Such
co m plete re la p se to infancy is ra r e , o c c u rrin g
only in in d iv id u a ls w ith fragile p e rs o n a lity

n o m e n o n of a nx iety . A n d it is often an x ie ty

stru c tu res.
A n x iety does not alw a y s h ave to be h a rm fu l.

th a t bring s th e p a tie n t to th e r a p y .

As a m a t te r of fact, som e a n x ie ty is a n a d a p

CHO O SIN G AN IMMEDIATE FOCUS

93

tive necessity; its release acts as a signal to

F ir st, th e re is a vast un d iffere n tiated , e x p lo

alert the ind iv idu al a n d to p r e p a r e h i m for

sive d is ch arg e of tension w h ic h d iso rg a n iz e s

em ergency action. S m all a m o u n t s of a n x ie ty


sp on sor so m atic an d visceral re actio ns th a t

th e physiological r h y t h m of every o rg a n an d

lead to attac k o r flight. A n x ie ty even facilitates

d u lar,

in fo rm atio n p rocessing in th e fo re brain. T h e

n it o u r i n a r y ,

p h y s i o lo g i c a l

tin u e d excitation s m a y p ro d u c e psy cho som atic


d is o rd e rs a n d u ltim a te ly even irre versible o r

and

b i o c h e m ic a l

pattern s

of

an x iety a re in n a te in th e o rg a n ism . Its p sy


chological in g red ien ts a re u n iq u e to th e e x p e r i
en ces a n d c o n d i t i o n i n g of t h e i n d i v i d u a l .
T h e s e , co n stitu tin g the security a p p a r a t u s , are
o rg anized to redu ce a n d to rem o ve t h r e a ts to
th e integrity a n d safety of th e individual.
T h e signal of an x iety , therefore, activates

tissue in th e body, in c lu d in g m u s c u la r, g l a n
card iovascular, gastro in testin al, ge
and

special

senses.

Long

co n

ganic changes. T h u s , w h a t starts o u t as a


g astric d is o rd e r m a y t u r n in to a sto m a c h ulcer;
bow el irrita b ility m a y becom e a colitis; h y p e r
te nsion m a y re s u lt in c a rd ia c illness, an d so on.
Second,
stro p h ic

th e r e

feelings

is a p re c ip ita tio n
of helplessness,

of c a ta
insecurity,

ad ap tiv e reserves s tim u la tin g som atic a n d p sy

a n d d e v alu a te d self-esteem. T h e victim often

ch o lo g ic a l

fo r a n

voices fears of fatal physical illness, like can cer

em ergency. T h e in dividu al le arn s to react to

or h e a r t disease o r b r a i n t u m o r , as i n t e r p r e t a
tions of th e p e c u lia r so m atic sen sation s o r

m ech a n ism s

to

prepare

m in im a l cues of a n x ie ty w ith a con structiv e d e


fensive reactio n th a t dispels th e a n x ie ty an d
p e r h a p s e lim in a tes its source. B u t w h e re the
defenses fa il to operate, a n x ie ty can reach a

sy m p to m s th a t a r e being released by anxiety.


T h i r d , th e r e is a w e a r in g d o w n of r e
pressio ns

to

th e

p o in t

w here

they

become

p itch w h ere it can not be d isp elled . So m atic

p a p e r th in in c e rta in areas. C o n s e q u e n tly , a

reactions of a diffuse, un differen tiated, a n d


destructive n a t u r e th en flood th e body. P s y

b r e a k t h r o u g h of re p u d ia te d th o u g h ts , feelings,
a n d im p u l s e s , o r d i n a r i l y c o n t r o l l a b l e , n o w

c h o lo g ic a l

becom e d iso rg an ize d .

m a y o ccur at r a n d o m . T h e s e o u tb u r s ts f u r th e r

Regressed, childish kind s of beh av ior, w h ic h


solve little to w a r d h a n d li n g a n a d u lt a nx iety

u n d e r m in e secu rity a n d p r o d u c e a fear of being

situa tion , m a y th e n em erge. B ecause th e in d i

F o u r t h , v a rio u s defenses a re m ob ilized , th eir


v ariety an d a d a p tiv e n e ss d e p e n d in g u p o n the

responses

vidual c a n n o t cope w ith intense an x ie ty , he


m a y w a n t som eone to tak e over for him .
W h a t g ene rally sh a tte rs th e defenses of th e
p e r s o n so t h a t h e r e s p o n d s w i t h g lo b a l
an x iety ? T h e p rovocative a g en t m a y be a n y e x

o ut of c on trol, of n ot k n o w in g w h a t to expect.

flexibility a n d m a t u r i ty of th e in div id ual. If


th ese strateg ies fail to co ntrol or d is sip a te th e
sense of te r r o r , th e n a f u r th e r set of m a n e u v e rs
is in itiated.

te rn a l d a n g e r o r in te rn a l conflict, recognized

Solution s for a n x ie ty will d e p e n d o n the

or un rec o g n ize d , th a t d iso rg a n iz e s th e in d i

source of th e a n x ie ty as well as th e s in g u la r

v id u a ls reality sense, crushes his secu rity and

p e rs o n a lity c o n fig u ratio n s of th e in dividu al.

self-esteem b eyond m e d ia tio n , an d fills h im


w ith a cata str o p h ic sense of helplessness to a
po in t w h e re he ca n n o t stabilize him self. It is
th e m ean in g to th e ind iv idu al of an ex perien ce

T h e specific ty p es of defense a r e chosen by


th e in div idu al for re a s o n s th a t a re not, at o u r
p re s e n t state of k no w led ge, fully k n o w n . T h e
follow ing factors a re p ro b a b le . (1) T h e in d i
v id u a ls u n iq u e ex periences a n d cond itio ning s
focus e m p h a s is on p ro b le m s a n d coping m e c h
a n is m s developed d u r i n g certain pe rio d s in his

o r a conflict th a t is the f u n d a m e n ta l criterio n


as to w h e th e r h e will re s p o n d w ith u n c o n
trollab le anxiety.
L et us proceed

w ith

e x a m i n a ti o n of the

physiological a n d psychological m a n ifestatio n s


of th e in d i v i d u a l s u f fe rin g fr o m e x t r e m e

life. F o r instan ce, as a child th e in d iv id u a ls


d ep en d en cy needs m a y no t have been satisfac
torily resolved, cau sin g h im to m e a s u r e his

anx iety since these m a y be chosen as a focus in


th erap y .

self-esteem chiefly in te r m s of ho w well loved


he w a s by his p a r e n t s (an d later th e ir in t e r

94

HANDBO OK OF SHORT-TERM PSYCHOTHERAPY

nalized im ages in his conscience). H e will be

ing h e r h o m e, except p e r h a p s in the presence

insecure w h e n c onfronted w ith circ um sta nce s


w h e re he m u s t ta k e a n in d e p e n d e n t stan d . (2)

of h e r m o th e r. T h e p h o b ia u ltim a te ly re s u lts in
h e r in c a p a c ita tio n , in terfe rin g w ith h e r liveli

C e r ta i n defenses a p p e a r in child ho od t h a t net

hood an d h e r c a p a city to estab lish n o r m a l r e l a

th e child a special g ain. S uch defenses, if su c

tio n sh ip s w ith people. She m a y , as a resu lt,

cessful, establish a p a tt e r n of b eh a v io r th a t

u n d e rg o a s h a t te ri n g of self-esteem, a n d h e r
feelings of in fe riority m a y stim u la te a f u r th e r

m a y be p u rs u e d la ter on. T h u s w h e re violent


an d aggressive d isp lays in tim id a te p a r e n t s into
yielding to the c h il d s d e m a n d s , he m a y ten d to

a tt e m p t to isolate herself fro m o th ers. H e r


hostility, w h ic h is u su a lly directed at h e r

have o u tb u r s ts of a n g e r a n d to in tim id a te
o th e rs as a p referred w a y of dea lin g w ith o p

p a r e n t on w h o m she is so helplessly d e p e n d e n t,

position. (3) U n reso lv ed childish fears, needs,


an d strivings, w ith persistence of arch aic co n

culty in ex p re s sin g o r even a c k n o w le d g in g h er


h a t e f u l fe e lin g s b e c a u s e t h e y t h r e a t e n h e r

cepts of reality,

will influence th e p a tt e r n s

sta n d in g w ith h e r m o th e r. T h u s , w h ile she has

ad o p ted in the face of stress. F e a rs of th e d a r k


o r of being alon e m ay r e t u r n w h e n e v e r stress is

em plo yed a defense to shield h e r fro m an x iety ,

excessive, w h e re these w ere manifest in c h ild


hood. (4) Defensive reactions a re often c o n d i
tioned by p a r e n t a l neu ro tic a ttitu d es a n d ill
nesses, w h ich th e in div idu al m a y tak e over

m a y becom e e x tr e m e , an d she m ay h ave diffi

she h a s suffered fro m gross difficulties in her


fu n ctio nal r e la tio n sh ip s w ith life a n d people.
T h e d e fe n s e a g a i n s t th e o r i g i n a l a n x i e t y
p lu n g e d h e r into difficulties as g re a t or g re a te r

th r o u g h the process of im itatio n . A m o t h e r s

t h a n the stress th a t in itially insp ired h e r re a c


tion.

t e r r o r o f l i g h t n i n g s t o r m s o r r e c o u r s e to
he ad ach es w h e n difficulties come u p m a y be

c u lt y fo r w h i c h

ad o p ted by h e r child.
T h e neu rotic individual th u s revives early

so u g h t a n d because th ey fr e q u e n tly a r e a n i m
m e d ia te focus in tr e a tm e n t, it m a y be p r o d u c

tec hn iqu es of a d a p ta tio n th a t o rig ina lly helped

tive to ela b o r a te on h ow a n d w h y th ey evolve.

solve the difficulties in his ch ildhood. Since


these tech n iq u e s h av e long outlived th e ir use
fulness, th ey create m a n y m o re p ro b lem s th a n

In g en era l, fou r levels of defense a r e e m


ployed as o u tlin e d in T a b l e 7 - 1 : (1) conscious
efforts at m a i n ta i n in g co n tro l by m a n i p u l a

th ey solve. N ev erth eless, the individual is a p t

tion of the e n v ir o n m e n t, (2) cha ractero log ic

to im p le m e n t th e m in a reflex m a n n e r , a lm o st

defenses a im e d at m a n i p u l a t i n g in te rp e r so n a l

as if th ey w e re th e most n a t u r a l of devices to

re latio n s, (3) repressive defenses th a t m a n i p u

em ploy u n d e r th e circum stances.


M a n y defensive responses to a n x ie ty th a t
a r e directed to w a r d th e re duc tion of a n x ie ty

late th e in tra p sy c h ic forces, a n d (4) regressive


defenses th a t re g u la te physiological m e c h a
nisms. T h e in d iv id u a l m a y stabilize at an y
level, w h ile r e ta in in g s y m p to m s a n d defenses
cha rac teristic of prev iou s levels. At different
times, as stress is alleviated or e x a g g e ra te d o r
as ego s tre n g th e n in g o r w e a k e n in g occurs,
th e r e m a y be shifts in the lines of defense,
eith e r u p o r d o w n . T h e m a n n e r in w h ic h these

m a y lead to a c rip p lin g of a p e r s o n s flexibility


an d adap tiven ess. T h e defensive te c h n iq u e of
th e p h o b ia illustra tes the destructive influence
th a t a m e c h a n ism of defense m a y yield. T h e
in hib ition of function c h aracteristic of p ho bic
states is calcu lated to isolate the in d ivid ual
from certain sources of d a n g e r o nto w h ich he
h a s projected his in n e r anxieties. F o r instance,
a w o m a n fearful of yielding to u n re s tra i n e d
sexual im pu lses m ay develop stro n g anx ieties
w hile w a lk in g outd oo rs. She m a y shield h erself
from such a n x ie ty attacks th r o u g h the s y m p
to m of a g o ra p h o b i a , th a t is, by av oid in g leav

B ecause defenses so often a r e sources of diffi


p s y c h o t h e r a p e u t i c h e l p is

four levels of defense a re em p lo y ed in a d a p t a


tion is as follows:
F i r s t - l e v e l d e fe n s e s : C o n t r o l m e c h a n i s m s

W h e n ten sion s a n d a n x ie ty a r e ex pe rien ced ,


th e first m a n e u v e r on the p a r t of an in d iv idu al
is to m a n i p u la t e th e e n v ir o n m e n t to fash ion it

CHO O SIN G AN IMMEDIATE FOCUS

95

TABLE 7-1. M echanism s of Defense


M A N IF E S T A T IO N S and S Y M P T O M S
T h re a ts to A daptation
A D A P T A T IO N
SY N D R O M E
1st Line of Defense
CONTROL
M E C H A N IS M S

2nd L ine of Defense


C H A R A C T E R O L O G IC
D EFEN SES

3rd Line of Defense


R E P R E S S IV E
D EFEN SES

SY N D RO M ES

tension
anxiety
physiological reactions

A nxiety states
Physical conditions arising
from m ental factors
(psychosom atic illness)

Rem oving self from sources of stress


Escape into bodily satisfactions & extroversion
W ish-fulfilling phantasies
Suppression, rationalization, philosophical credos, self-control, emo
tional outbursts, im pulsive behavior, thinking things th ro u g h
Alcoholic indulgence excessive alcohol intake
Sedation, narcotics drug overindulgence

Substance use disorders


(alcoholism , drug
dependence)

S T R IV IN G S of an IN T E R P E R S O N A L N A T U R E
1. Exaggerated dependency {religious fanaticism , etc.)
2. Submissive technics (passivity)
3. E xpiatory technics (m asochism , asceticism)
4. D om inating technics
5. Technics of aggression (sadism)
6. Technics of w ithdraw al (detachm ent)
S T R IV IN G S D IR E C T E D A T S E L F -IM A G E
1. N arcissistic strivings (grandiosity, perfectionism )
2. Pow er im pulses (com pulsive am bition)

Educational disorders, habit


disorders, w ork problem s,
m arital problem s, adjustm ent
disorders, conduct disorders,
sexual disorders and
perversions, delinquency,
crim inality, personality
disorders

P o sttrau m atic stress disorders


C onversion disorders
D issociative disorders
Phobic disorders
Com pulsive disorders

E F F O R T S D IR E C T E D at R E IN F O R C IN G R E P R E S S IO N
1. General: (a) reaction form ations, (b) accentuation of intellectual
controls w ith com pensations and sublim ations.
2. Inhibition o f function:
a. D isturbed apperception, attention, & thinking
b. D isturbed consciousness (fainting, increased sleep, stupor)
c. D isturbed m em ory (antegrade and retrograde am nesia)
d. Em otional dulling, indifference, or apathy (em otional inhibi
tions)
e. S ensory defects (h y p o e sth e sia a n aesth esia , am aurosis,
ageusia, etc.)
f. M otor paralysis (paresis, aphonia)
g. V isceral inhibitions (im potence, frig id ity, etc.)
3. D IS P L A C E M E N T & P H O B IC A V O ID A N C E (phobias
4. U N D O IN G & IS O L A T IO N (com pulsive acts
rituals)

&

B. R E L E A S E of R E P R E S S E D M A T E R IA L (direct o r symbolic)
1. Im pulsive break thro u g h w ith acting-out (excited episodes)
2. O bsessions, (excessive revery & dream like states)
3. D issociative states (so m n a m b u lism , fu g u e s, m u ltip le p e r
sonality)
4. Psychosom atic d iso rd e rs (sensory, som atic, v isceral; tics,
spasm s, convulsions)
5. S exu a l perversions (fetishism scoptophilia, etc.)
6. Internalization of hostility (depression)
7. Projection

O bsessive-compulsive disorders

C onversion disorders

4th Line of Defense


R E G R E S S IV E
D EFEN SES

A. R eturn to helpless dependency


B. R epudiation of and w ithdraw al from reality
1. D ereistic thinking; disorders of perception (illusions, hallucina
tions), disorders of m ental content (ideas o f reference, delu
sions)-, disorders of apperception and com prehension; disorders
of stream of m ental activity (increased or dim inished speech
productivity, irrelevance, incoherence, scattering, verbigeration,
neologisms)
2. Defects in m em ory, personal identification, orien tatio n , reten
tion, recall, thinking capacity, attention, insight, judgem ent
C. Excited acting-out (hostile, sexual, and o ther im pulses)
D. Internalization of hostility (depression, suicide)

to his needs, to escape from it, o r to c h a n g e his


m ode of th in k in g a b o u t it. T h u s he m a y avoid
certain activities o r places o r people. H e will
try to m a n a g e in som e different w a y w h a te v e r
he feels to be th e source of stress. H e m a y

N eurotic depression
P aran o id al reactions
Psychotic episodes
Schizophrenic disorders
P aran o id disorders
M anic-depressive disorders
Involutional psychoses

c h a n g e his j o b , his wife, his h a ir c u t, his nose


sh a p e , o r his domicile. O r he m a y try to
ch an g e ex istin g a ttitu d es, a tt e m p t in g to th in k
th in g s th r o u g h a n d to a rriv e at som e n e w in
tellectual fo r m u la tio n s a b o u t w h a t his life is all

96

HANDBO OK OF SHORT-TERM PSYCHOTHERAPY

ab o u t. In this re g a rd he m a y tr y to su p p ress

veloped ea rly in life, p r i m a r i ly in co pin g w ith

certa in th o u g h ts, to keep his m in d on m o re

th e p a r e n t a l figures w h o a r e th e first sou rce of


a c h il d s security. C e r ta i n c h a r a c t e r styles w ere

positive c h an n e ls, to exercise self-control, o r to


re a d self-help books th a t stim u la te h im to
th i n k th r o u g h a n ew p h ilo so p h y of life. H e

p ro m o te d by th e p a r e n t s , a n d th e child lea rn s
t h a t th e r e is a ce rta in m a n n e r in r e l a ti n g to

m a y develop different leisu re-tim e activities in

pe op le a n d events th a t h a s th e best c h a n c e of

q u est of satisfactions in a n ew ho bb y, a n ew
social activity, or different friends. H e m a y try

k eep in g h im free of a n x iety . L a t e r in life,


w h e n a n x ie ty is ex p erien ce d , th e r e is an u n w i t

to get outside h im self, or, j u s t th e opp osite,

tin g r e t u r n to th e m od e of life th a t w o rk ed

he m a y become m o r e a b so rb ed in bodily satis

m ost effectively in th e past.

factions such as eatin g o r d rin k in g . H e m ay

T h u s these m odes of defense m a y be te rm e d


m a n i p u l a t i n g o n e s i n t e r p e r s o n a l r e l a t i o n

d e a d e n his feelings w ith sedatives, s tim u la te


th e m w ith en erg iz ers, or d r o w n th e m in alco
hol. D a y d r e a m i n g of a w ish-fulfilling n a tu r e

s h i p s . If d e p e n d e n c y is cha ra c te ristic for a

m a y h elp in escap in g the p ain fu l realities of his

abjectly d e p e n d e n t. If d e ta c h m e n t is th e w a y in
w h ic h a p e rs o n h a n d le s u n t o w a r d exp erien ces,

daily troubles.
H is e m o tio n al e q u ilib r iu m m a y also shift, so

p erso n , th e n in tim e of stress he m a y becom e

th e n a serious tra g e d y will cause h im p a t h

t h a t h e p e rm its h im self e m o tio n a l o u tb u rsts ,


fits of crying o r la u g h in g , a n d im p ulsiv e o u t

ologically to isolate a n d w i t h d r a w

b re ak s designed to release tension.

m od e th a t is th e key to u n d e r s ta n d in g this

All these, a n d o th e r m a n e u v e rs like th em ,


are th e first a tt e m p t s to be m a d e w h e n a p e r

second level of defense.


It is typical of th e e x a g g e ra te d m a n e u v e rs of

son feels th e u n co m fo rta b le tension t h a t in


dicates a b r e a k d o w n in h om eosta tis. E very

th e second defense line th a t th e y get th e in d i


vid ual into in te rp e r s o n a l difficulties. If a h ig h

perso n alive at vario u s tim es e m p lo y s som e of

school p rin c ip a l is accused by his te a c h e rs of


b eing too co ntrollin g, th e p rin c ip a l m a y b e

these
en v iro n m en t-m an ip u latin g
dev ices.
P athological e x p lo ita tio n of c e rta in first-line

for long

period s. It is th e e x a g g e ra tio n of th e u sual

come th r e a te n e d . W h e n th r e a te n e d , he fears

and

th a t h e is lo sing co ntrol ov er his teac h ers a n d

d r u g s can cau se addictive d iso rd ers such as

reacts p e r h a p s by a sk in g th a t th ey s u b m it to
h im m o r e co m p le te lesson p l a n s an d th a t th ey

d e fe n s e s,

how ever nam ely,

a lc o h o l

alcoholism a n d d r u g ad dictio n. O t h e r first-line


d e fe n s e s, su c h a s a t t e m p t s a t i n t e l l e c t u a l
u n d e rs ta n d in g re g a r d in g th e basic n a t u r e of
o n e s conflicts a n d anxieties, m a y h elp pro v id e
som e degree of relief. O n th e o th e r h a n d , a hito r - m i s s a p p l i c a t i o n o f s e l f-h e l p m e a s u r e s ,
w ith o u t a w a re n e s s of th e n a t u r e of o n e s diffi
culties, m a y lead to n o th in g , n ecessitating the
use of the nex t line of defense.
S econ d-level defenses: C h aracterologic
defenses
In situ a tio n s of in creasin g th r e a t it is typical

sign o ut of th e

b u ild in g w h e n

leav ing for

lu nch . It is th is very co n tro l t h a t th e tea c h ers


objected to in th e first place, a n d the in t e r p e r
sonal conflict becom es ex a g g erate d .
E x a m p l e s of p a t h o l o g i c a l l y e x a g g e r a t e d
c h a ra c t e r d rives include m a n y k ind s of i n t e r
p e rs o n a l, v ocatio nal, a n d e d u c a tio n a l difficul
ties. T h e fo llo w ing a r e typical. E d u c a tio n a l
a n d w o r k d is o rd e rs m a y be s y m p to m a ti c of
such excessive d ep en d e n c y th a t on e is u n a b l e to

for a p erso n to ex p lo it in e x a g g e ra te d form his


n o r m a l c h a r a c t e r o l o g i c d ri v e s . A g g r e s s i o n ,
w it h d r a w a l , a n d a b n o r m a l self-image r e s t o r a

p u r s u e a n y i n d e p e n d e n t , a s s e r t i v e l i n e of
th o u g h t o r action. T h e w r it in g of a te r m p a p e r
o r th e m a k i n g o f a business call m a y r e p r e s e n t
th e exercise of p e rs o n a l resp o n sib ility ; a n i n d i
vid ual w ith a dev alu e d self-im age m a y n o t be

tio n a re ex am ple s.
Idiosy ncratic a d a p ta tio n s to stress a r e d e

able to p u r s u e such a n activity on h is o w n .


M a r i t a l p ro b le m s, so u b iq u i to u s in o u r society,

CHO O SIN G AN IMMEDIATE FOCUS


an d

parental

m is h a n d lin g

97

of th eir c h ild ren

m a y re p resen t the e x a g g e ra tio n


several c h a ra c t e r strivings.

of a n y

or

pressio ns of e m o tio n s ; a n d (4) a blo cking in


behavior.
T h e necessity of m a i n t a i n i n g rep ressio n can

D e lin q u e n c y an d c rim in a lity a r e sy n d ro m e s


re p re se n tin g th e excess of hostile aggression.

a b s o r b th e e n e rg y resou rces of th e ind ivid ual.


C o n s ta n t ly th r e a te n e d a r e b r e a k d o w n s in th e

S exual d iso rd ers often p o r t r a y th e n a t u r e of

repressive b a r r ie r s , a filtering of th e sealed-off

the in te rp e r so n a l d isord er.

H y p o c h o n d r ia c a l

c o m p o n e n ts in to consciousness, a n d a m o b i

p re o ccu p atio n s m a y depict th e fear of in ju ry ;

liza tion of a n x iety . T h e in d iv id u al m a y c o n

p sy c h o p a th s d e m o n s tra t e th e e x tr a v a g a n t c a ri

s eq u en tly be victim ized by a ceaseless stress

c a tu r e of m a n y in te rp e r so n a l needs; im m a t u r e ,
obsessive, schizoid pe rso n s h ave all, u n d e r the

rea ctio n, his physical system bein g in a p e r


p e tu a l u p r o a r . V u ln e r a b l e o r g a n system s m a y

th r e a t of a n x ie ty , p ressed th e ir life-styles to ex

becom e d iso rg a n iz e d w ith o u tb r e a k s of o rg a n ic

tr e m e lengths. U su ally , second-line defenses do


n o t w o r k effectively. R a t h e r t h e y p l u n g e

illness. At th e sam e tim e a sym bolic d is ch arg e


(id is p la c e m e n t o f affe c t) m a y o c c u r in a t

people into such in te rp e r s o n a l difficulties th a t

t e n u a t e d o r d is to rte d forms, w h ic h will pro v id e

conflict a n d stress a re h eig h te n e d r a t h e r th a n

so m e g ra tific atio n for th e re p u d i a te d drives. At


p h a se s w h e n rep ressed needs becom e p a r t i c u

reduced.

The

chronic

em p loy m ent

of d e

p end ency reaction s, for e x a m p le , is e v en tu a lly


resented by o th e r s on w h o m on e leans, serving

larly u rg e n t, or for som e re a s o n o r o t h e r a re

to alien a te th e p erso n from his sources of s u p

p revio usly q uiesc ent sexual drive s tirr in g d u r

p ort. R a t h e r th a n hav e his needs g ratified, he

ing adolescence) o r e x p e rie n tia lly (as w h e n an


in s u lt excites s lu m b e r i n g rag e a n d aggression),

drives o th e rs a w a y a n d is m o r e alone. T h e
em otiona lly p o o r get p o o re r if th e r e is a blind
re petition at th e sa m e p a tt e r n . B ecause of th e
u ltim a te ineffectiveness of th e second line of
defense, th e in d ivid ua l u su a lly goes o n to the
n ext level.

activated by physiological factors (such as a

a direct e xp re ssion

m a y o ccur follow ed by

re trib u tiv e re a ctio n s w h ic h will a p p e a s e guilt


feelings a n d serve to resto re repression s.
T h e u n d e r s ta n d in g of the rep ressive line of
defense can best be seen in tw o g ro u p in g s:
tho se efforts a im e d at rein fo rcin g re p ressio n

T h ird -level defenses: R ep re ssiv e m an eu vers

a n d th e d irect o r sym bolic release of rep re ssed


m a te ria l.

T h e th i r d level of defense consists of th e


m a n i p u la t io n of o n e s in tra p sych ic stru c tu r e . It

o r h eig h te n e d m o r a lity as a cover for p erverse

is a n a tt e m p t to gain peace by p u s h in g tro u b le s

sexual

F ir st, reaction fo rm a tio n s (such as ch astity


or

an tiso cial

desire)

may

becom e

ou t of o n e s m in d . In repression a b a r r i e r is set

p ath o lo g ically e x u b e r a n t in th e u r g e n t n eed to

u p to th e m o t o r d ischa rge of needs, im pu lses,


m em ories, ideas, o r a ttitu d es, a w a re n e s s of
w h ich will set off an xiety . T o avoid a n x iety ,
selected id eatio n al seg m en ts a r e sealed off

d e n y th e existence of forbid de n im pulses.


S econd, th e r e is a n in h ib itio n o f fu n ctio n ,

a long w ith an y asso ciatio n al m em o ries or


links, th e activatio n of w h ic h m a y cha llen g e
the repression. In this process th e r e m a y be (1)
a b lo c k i n g in t h e p e r c e p t i o n , p r o c e s s i n g ,
storage, a n d retriev al of ex periences; (2) a n in
hib ition o r d is to rtio n in th e fu nction s of in

in a tte n d s to c e rta in u p s e ttin g aspects of o n e s


in n e r o r o u te r w o rld . D is t u r b e d consciousness
m a y ta k e th e fo rm of faintin g, s tu p o r, o r e x
cessive needs for sleep. D is t u r b e d m e m o r y to
th e p o in t of a m n e s ia m a y develop. E m o tio n a l
d u llin g can be seen in a p e rs o n w h o exhib its
indifference o r a p a t h y as a defense a g a in s t be
ing involved in a p o te n tia lly th r e a te n i n g s i tu a
tion. S en so ry defects, m o to r p ara ly sis , an d

telligence, such as a tte n tio n , le a rn in g , d is c rim i


natio n , ju d g m e n t, reas o n in g , a n d im a g in a tio n ;
(3) a blocking in th e o p e ra tio n s a n d e x

d is tu rb e d a p p e r c e p t io n , a tt e n ti o n , c o n c e n t r a
tion, a n d th i n k in g o c cu rrin g as o ne selectively

98

HANDBO OK OF SHORT-TERM PSYCHOTHERAPY

even visceral in h ib itio n s m a y be conversion

s y m b o l i z a t i o n of f o r b i d d e n

reaction s th a t serve to block o u t th e direct

t h r o u g h obsessional th in k in g d r a i n s off e nerg y

i n n e r im p u l s e s

a w a re n e ss of a n an x ie ty -p ro v o k in g th o u g h t or

b u t p ro m o te s a n x ie ty in th e i r release. T h e in

deed. T h u s one m a y literally not be ab le to feel

div idu al m a y m u r d e r , r a p e , o r to r t u r e special

a frig h ten in g object, see a t h r e a te n i n g event, or

p eo p le in his fantasie s o r m a y ex p lo d e th e

ex perience a

w o rld w ith a to m b o m b s to his o w n d is m a y a n d


a n x io u s discom fort. H e m a y th e n n e u tr a li z e
his released im p u lses by e n g a g in g in c o m p u l

sexu ally

a ro u s in g s t im u lu s if

such a w a re n e ss w o u ld provoke u n d u e anxiety.


A n o th e r effort at reinforcing re p ressio n is
the d evelo pm ent of a p h o b ia . In p h o b ia fo r m a

sive ritu als, w h ic h on the surface m a k e no

tion th ere is a d is p la c e m e n t fro m a fearsom e

sense b ut w h ic h sym bolically a p p e a s e his guilt

in n e r drive to an e x te r n a l object th a t sy m

o r div ert his m in d from his p re o c c u p a tio n .

bolically comes to re p r e se n t this drive. T h u s a

Thus

fear of snakes in a w o m a n m a y conceal a n e x

h a n d w a s h in g as a clean sing ritual.


A th i r d m e a s u r e for lib e ra tin g re p r e sse d m a
terial is t h r o u g h d isso cia tive states, such as

a g g e rated b u t rep ressed in terest in th e m ale


sexual o rg an . A fear of heigh ts m a y be a cover
of a m u r d e r o u s im p u lse for w h ic h on e m ay
a n tic ip a te re tr ib u t o r y p u n is h m e n t.
F u r t h e r a tt e m p t s to g a in peace th r o u g h
repression a re th r o u g h u n d o in g an d isolation.
By these

m a n e u v e rs

the ind iv idu al,

alm o st

ev il th o u g h t s m a y in s p ire re p e a te d

so m n am b u lism ,

fugues, a n d

m u ltip le

per

sonality. Acted o u t a re th e rep re sse d im p ulses,


too t h r e a te n i n g to be in te g ra te d into o n e s c o n
scious activities, b u t not r e m e m b e r e d w h e n the

m agically, ro bs a forbidden im p u ls e of an y vi

u s u a l consciousness is restored.
P sych o so m a tic d iso rd ers m a y be a fo u r th ev

tality. W h e n he th in k s an a n g ry th o u g h t, he

idence of th e release of ten sion s th a t h ave not

qu ickly follows it w ith a th o u g h t th a t u n

made

d o e s the first th o u g h t. O r he does not feel

S ensory,

the th o u g h t, an d so he believes his sex ual or

reflect th e in n e r conflicts of an in d ivid ua l.


T ic s , sp a s m s a n d convulsions a r e often sy m

hostile im p ulses have no re al significance for


him .
T he release o f rep ressed m a te ria l th r o u g h
direct or sym bolic m e a n s is th e second fo rm by

th e ir

w ay

in to

so m a tic a n d

conscious

aw a re n e ss.

visceral ch an g e s m a y

bolic revelation s of in n e r psychic processes th a t


ca n n o t find d irect expression.
T h e fifth m e a n s a r e th e sexu al p e rve rsio n s,

w h ich repressive m a n e u v e rs a tt e m p t to m a i n
tain a psychic e q u ilib r iu m . As we h ave ju s t

such as fetishism , e x h ib itio n is m , a n d th e like,

noted, the first form of repressive m a n e u v e r


reinforces th e re pression itself. T h i s second

come u n co n tro llab le.


T h e use o f the s e lf as an o bject f o r ag

form allow s for a n in te rm itte n t direct o r s y m


bolic d ischarg e of th e rep ressed m a te ria l.
O n e such ty p e of release is sim ply a n i m p u l
sive b r e a k t h r o u g h of som e fo rb idd en w o rd or
th o u g h t o r im p ulse. O cc asio n ally an excited

g ressio n is a sixth m e th o d by w h ic h u n acce p ted


im p u lses g ain som e m e a s u r e of expression.

episode of acting ou t som e im p u ls e can be


noted in a pe rs o n w h o o th e rw ise relies heavily
on rep ressio n as his typical form of defense.

d epression , a feeling th a t o n e is a m iserab le


c re a tu re . T h e c o n tin u in g s elf-rec rim in atio n s
th a t th e d epressed p erso n in d u lg es served to

T h e fighting d r u n k m a y a c tu a lly be a sober


C a s p e r M ilq u e to a s t w hose rep ressio n s are

d is ch a rg e his hostility a lb eit in the w r o n g d i


rection. T h e r e m a y also be d a n g e r o u s ab uses

t e m p o ra r ily de a d e n e d by alcohol, p e r m it ti n g a

of the self, w ith accident p ro n e n e s s, m u tila tio n

hostile release.
O b se ssio n , t h a t

tendencies, an d even suicide.


is th e r e p e t i t i v e u se of

th a t d is c h a rg e erotic tensio n w h e n th es e be

A n g ry im p u lses o rig in ally directed at o th e rs


are rep resse d a n d th e n directed a g a in s t th e
self. T h e re s u lta n t cond itio n m a y be n e u ro tic

reveries an d d a y d re a m s , is a second m e a n s th a t

F in a lly , a defense m e c h a n is m th a t allow s for


releasin g rep ressed m a te ria l is p ro jec tio n . P r o

serves to d ra i n a w a y th e repressed m a te ria l. A

je c tio n is a m e a n s of r e p u d i a t i n g in n e r drives

CHO O SING AN IMMEDIATE FOCUS

99

th a t a r e painful an d a n x ie ty p ro v o k in g by a t

a re th e last in s tr u m e n ta l it y w ith w h ic h to es

tr ib u t in g th e m to o utside agencies a n d in f lu

ca p e the pain fu l d e m a n d s of reality. T h e r e m a y

ences. T h u s in n e r feelings of h ate, too d a n

be a r e t u r n to co m p lete ly h elpless d e pe nd enc y,

gerous to accept a n d m a n a g e , a r e e x te rn aliz ed

a r e p u d i a ti o n o f an d w i t h d r a w a l fro m reality,

in the conviction of being h a te d o r victim ized


by a n o p pre ssor. A varice m a y be concealed by

excited a c tin g -o u t im p u lses w ith o u t referen ce to


reality d e m a n d s, and d ep ressio n th a t has

a belief th a t on e is being exp lo ited. H o m o s e x

reach ed d elu sio nal a n d suicidal p r o p o r tio n s . In

ual drives m a y be credited to perso n s of the


s am e sex to w a r d w h o m the in div id ual is sex

this fo u r th level of defense th e ind iv idu al show s


evidence of psychotic fu nction ing . T h e r e m a y be

u a ll y a t t r a c t e d . T h e p r o j e c ti v e m e c h a n i s m

dereistic th in k in g , d iso rde rs of p e rc e p tio n (illu

serves th e p u rp o s e of objectifying a forb idd en


a n d repressed d a n g e r th a t will ju s tify certain

sions, h a llu cin a tio n s), d is o rd e rs of m e n ta l co n


te n t (ideas o f reference, d elu sio n s), d is o rd e rs of

m easu res, such as the e x pression of ag gression

a p p e rc e p t io n a n d c o m p r e h e n s io n , d is o rd e rs in

w ith o u t guilt.

In this w a y p u n is h m e n t a nd

self-blame a r e avoided. By p ro jectin g im p ulses


a n d desires on to the ou tsid e w o rld o ne m ay
insidiously gain acceptance for his o w n fo rb id

stream

of

m en tal

a c ti v it y

(increased

or

d im in ish e d speech p ro d u c tiv ity , irrelev ance, in


coherence, sc attering , n eologism s), a n d defects
in m e m o ry , p e rs o n a l identification, o rie n ta tio n ,

den drives. F o r e x am p le, insisting u p o n th e

re te n tio n , recall, t h i n k in g cap acity, a tte n tio n ,

fact th a t th e w o rld is sexu ally p reo cc u p ie d , a n d

insigh t, a n d ju d g m e n t . T h e r e is evidence th a t

finding p r u r i e n t e x a m p le s for this p o in t of

special sy n d ro m es, such as m a n ic-d ep ressive

view, a sexually fearful ind iv idu al m a y try to

p sy c h o sis a n d sch izo p h ren ia , h ave genetic c o m

lessen the severity of his o w n conscience th a t

p o n e n ts th a t b rin g o ut th e i r p e c u lia r c h a r a c

p u nish es h im for his sexual needs.

teristics in th e face of stressful experiences.


T h e s e fou r levels of defense m u s t no t be
re g a r d e d as a r b i t r a r y , static states. E a c h level

F ou rth -level defenses: R eg ressive defenses

n ever occurs in isolation. E a c h level is alw ay s

W h e n all o th e r m e a s u re s a r e failing to r e

m ix ed w ith m a n ife sta tio n s of o th e r defensive

store em o tio n al e q u il ib r iu m , psychotic states

levels.

Conclusion
O n ce w e h av e d e te rm in e d w h y at th is tim e

concern to th e p a tie n t, such as incidents in life

the p a tie n t h as p resen ted him self for th e r a p y


an d e x plo red w ith h im his ideas a b o u t his
situ ation in c lud ing w h a t he believes is b e h in d

th a t h ave p re c ip ita te d th e s y m p to m s for w hich


he seeks help. In focusing on p r e c ip ita tin g fac
to rs one m u s t g a u g e th e p a t i e n t s v u ln e ra b ility
to stress as well as th e virility of the stress fac

his troubles, an d w h a t he w a n ts to achieve


from tr e a tm e n t, we m a y th e n select a n i m
m ed iate focus an d o rg a n iz e o u r t r e a tm e n t s t r a
tegies. A too early c o n c e n tra tio n on the p a
ti e n ts p sy ch op ath olo gy a n d p ast c on dition ing s
th a t have created his conflicts a n d c i r c u m
scribed his g ro w th , h o w e v e r im p o r t a n t these
m ay be, will s u p p o r t regression and e n c o u ra g e
lon g -te rm lin g erin g in tr e a tm e n t. R a t h e r , we
sh ould begin to focus on w h a t is of im m e d ia te

to r itself. In focusing on sy m p to m s the t h e r a


pist shou ld view th e m as an assem b ly of re a c
ti on s to a n x ie ty as well as c o nsequ ences of
m e c h a n ism s of defense.
D u r i n g th e e x p lo r a tio n s it is im p o r t a n t to
c o n c e n tra te on p ro b le m solving, w h ile e x a m i n
ing, e n c o u ra g in g , an d h e lp in g the release of
w h a te v e r positive a d a p tiv e forces a r e p re s e n t in
th e p a tie n t, focusing on th e resistances th a t

HANDBO OK OF SHORT-TERM PSYCHOTHERAPY

100

block th e ir o p era tio n . In th e course of doing

P o w e rfu l resistance to t r e a t m e n t m a y m a k e a

this w e m a y be co nfron ted by th e p a tie n t w ith


his e arly fo rm ativ e experiences, b u t th ese a re

focus on d y n a m ic s essential. O b v io u sly , th e


th e r a p is t will d e lib erately hav e to select d y

ha n d le d in the context of e x p la in in g o b s tru c

n a m ic

tions to effective fun ctio ning in th e p resent.

p ed ie n tly , av o id in g or d e a lin g ta n g e n tia lly

A m p le o p p o rtu n itie s will be found la ter on to

w ith even n oticeab le conflicts th a t do n ot seem

sw itch

the focus to a re a s

related

to

som e

cen tral d y n a m ic th e m e by estab lishin g some


connection b etw e en it an d c u rr e n t p ro b le m s
a n d concerns shou ld this be dee m e d d esirab le .

aspects

th a t

he can

w o r k w ith

ex

offensive a n d w o u ld be difficult or im possible


to

h a n d le

th e r a p y .

in

th e b rie f p e rio d

allo tted

to

CHAPTER 8

Choosing a Dynamic Focus


A. Probing into the Past

L ittle tim e is av ailable in s h o r t-t e rm th e r a p y


to ex p lo re th e p ast. M u c h b e tter use can be

t h a t have been i n s tr u m e n ta l in la y in g do w n

m a d e of th e t r e a tm e n t h o u r by d ealin g w ith

th e fo u n d a tio n s of the p a t i e n t s c h a ra c t e r s t ru c
tu re. B ecause b e h a v io r reflects to a g r e a t e r o r

p e rtin e n t elem ents in th e h e re a n d no w . H o w


ever, w h e re the th e r a p is t can d e te r m in e i m p o r

lesser degree co n d itio n in g s set u p in the p a st, it


m a y be difficult to u n d e r s ta n d it fully w ith o u t

t a n t p a st events a n d contingencies th a t have


m olded the p e rs o n a lity o rg a n iz a tio n , this will

reference to w h a t h a s g on e on before. F r o m a

facilitate a b e tte r u n d e r s ta n d in g of the p a

is no t possible to devote m u c h effort in e x p lo r

t i e n t s illness a n d h e lp select a n a p p r o p r i a t e

ing th e p a st b ey o n d p ro v id in g the p a ti e n t w ith

d y n a m ic focus. E n o u g h d a ta m a y be av ailab le
from ta k in g a good h istory to m a k e a s s u m p

som e g uidelines to p u r s u e on his o w n after the

tions of ho w th e p ast has e n te re d into the


f o rm atio n of p e rs o n a lity d is to rtio n s th a t b u r

T h i s c h a p te r c on stitu tes a review of dev elo p


m e n t fro m a p sy ch o d y n a m ic perspective. It is

den p re s e n t-d a y a d a p ta tio n s . M o r e im m e d ia te

includ ed in this vo lum e as a n in tro d u c tio n to

clues m a y be g ain ed from th e tra n sfe re n c e th a t

th e m o r e clinically i m p o r t a n t c h a p te rs th a t fol

serves as a vital link to th e kinds of e a rly r e l a

low.

practic al p o in t of view in s h o r t-t e rm t h e r a p y it

fo rm a l th e r a p y perio d h a s ended.

tion sh ip s th a t existed in a c tu a lity o r fa n tasy

Transference
O f vital significance to p sy c h o th e ra p ists of
all p e rs u asio n s w a s F r e u d s crucial p e rcep tio n
th a t to a g r e a t e r o r lesser d eg ree p a tie n ts tend
to project o n to a u th o r it y figures th o u g h ts,
w ishes, a n d feelings identical to th ose form e rly
h a rb o r e d t o w a r d i m p o r t a n t p a st p ers o n ag es

recovering gratifica tio n s a n d resolving fears


t h r o u g h th e in s tr u m e n ta l it y of th e th e r a p is t,
w h o is e n d o w e d w ith p o w e r a n d a ttrib u te s
such as a n in fa n t h a r b o r s t o w a r d p a re n t a l
agencies. T h e r e m a y be e xh ibited also to w a r d
the th e r a p is t in tran sferen ce a host of a b e r r a n t
a ttitu d e s, such as rebelliousness, hostility, s u b
missiveness, a n d sex ual exc item e nt. Such feel
ings m a y also develop o u tsid e of th e t h e r a

(p aren ts, p a r e n t a l su bstitutes, siblings). R e a n i


m ated d u rin g th e r a p y a re tr a n sferen ce re a c
tions, w holly in a p p r o p r i a t e for th e p re s e n t, b ut
reactions th a t r e c a p itu la te a n tec e d e n t e m o peu tic s itu a tio n w ith a n y kin d of a n a u th o r it y
tion al situations. It is as if th e p a ti e n t seeks to o r sibling figure. T r a n s f e r e n c e is d iagn o stically
relive the p erio d s of in fancy a n d childh oo d, im p o r t a n t, since it is a la b o r a to r y revival of

101

102

HANDBOOK OF SHORT-TERM PSYCHOTHERAPY

m u ch of w h a t

w ent cn

in the in d iv id u a ls

childhood. It m a y e x p la in a good deal of c u r


rent

b ehavior

th at

on

th e

surface

see m s

ap is t a n d failing to resp o n d to the th e r a p e u tic


tec h n iq u es t h a t a re being used. T h e d etec
tion

an d

m a n a g e m e n t of tran sfe re n c e m ay,

illogical a n d m a la d a p tiv e . It m a y also co ntain

th erefo re, be cru cial a n d decisive a p a r t from

th e key to w h y th e p a tie n t is resistin g th e t h e r

h e lp in g to select a pivotal d y n a m ic focus.

Synthesizing Factors of Personality


Development
In o rd e r to u n d e r s ta n d h o w a n d w h y the

by v ario u s social scientists of th e incidence an d

p a st survives in the p rese n t a n d the mischief it


invokes, it is necessary briefly to s u m m a r i z e

p rev alence of em o tio n al p ro b le m s in different


p a r t s of the w o rld ; analy sis of reac tion s of in

some of th e c u rr e n t findings on p e rs o n a lity d e

div id uals to p sych otrop ic d ru g s ; accou nts by

velop m en t th a t come from th e biological an d


social fields. A tte m p ts a re co n stan tly being

eth ologists of a n im a l b eh av io r in a n a t u r a l set


ting; an d re s ea rc h findings of a n im a l ex p eri-

m a d e to brin g objectivity to the d a ta on d e

m e n to rs w h o have subjected h ig h e r m a m m a l s

velop m en t by s tu d y in g m a te ria l from a n u m b e r


of different sources. T h e s e include observatio ns

to a rtifa cts in u p b r i n g in g o r to m o tiv atio n al


conflicts.

by tra in e d w o rk e rs of n e w b o r n babies at h o s

O bjective a p p r a i s a l of this vast d a ta re q u ire s

pitals, institu tio ns, a n d d a y -care centers; ex

a m o r e a less precise ap p lic a tio n of th e scien


tific m e th o d . U n f o r t u n a te l y , inv estigators in

periences of teac h ers w ith ch ild re n at n u rs e ry


schools, k in d e r g a rte n s , and g ra d e schools; r e
po rts of p a re n ts d escribing th e beh av io r of
th eir offspring; studies o r recordings of plays,
a rt p ro d u c tio n s, d re a m s, fantasies, a n d s p o n
ta n e o u s v e rb a liz a tio n s of p r e s u m a b ly n o rm a l
children; psychological tests of child ren , espe
cially projective tests; investigations by social
w o rk ers, co rrectio nal w o rk e rs, an d p sy c h o l
o g ists of th e s o c io e c o n o m ic e n v i r o n m e n t ,
fam ily relation ship s, an d o th e r a re a s of p o te n
tial conflict a m o n g m a la d ju s te d , d e lin q u e n t,
an d crim in al y o u ng sters an d adu lts; s c ru tin y of
case records of child ren w ith severe em o tio n a l
p ro b lem s w h o have been hospitalized in m e n
tal in stitu tio ns; o b servations of p s y c h o t h e ra
pists tr e a tin g ch ild re n in th e i r p riv ate p r a c
tices o r in o u tp a t ie n t clinics; e x p lo r a tio n of
m em ories, d re a m s , and tran sferenc e p h e n o m
e n a th a t reflect childhood experiences of a d u lt
p a tie n ts receiving p sychoanalysis; field studies
of a n th r o p o lo g ists r e p o r tin g on th e customs,

the field of p e rs o n a lity re s e a rc h a r e h a n d i


ca p p e d by fo rm id ab le m etho do log ical p ro b le m s
in a tt e m p t in g to subject th e ir o b serv atio n s to
clinical research. M o r e o v e r, c u rr e n t th eo ries of
h u m a n b eh av io r a re so com p lex , th e ir in h e r e n t
te r m s so o p e ra tio n a lly indefinable, th e ir d e r i
vation s so diffuse, th eir im p lica tio n s so global
t h a t w e a r e u n a b le to e xp ose th e m read ily to
scientific e x p e rim e n t.
In

s p i te of th e s e s e e m in g l y

in su p e ra b le

obstacles, it h a s been possible to sc ru tinize


m a n y of the events associate d w ith th e d evelo p
m e n t of p e rs o n a lity a n d to e x a m in e a n d a n a
lyze this d a ta , m a k i n g a p p r o p r i a t e co n n e c
tions, d isc e rn in g c o m b in atio n s, a n d o th e rw ise
sy n th esizin g th e m a te ria l in a co nstructiv e
w a y . O u t of th is s y n t h e s i s a n u m b e r of
p ro p o s itio n s h av e em erged th a t m a y clarify
pa tho lo gica l evolvem ents on w hich th e t h e r a
pist m a y w ish to focus.

folkways, creative artistic exp ressio ns, modes


of c h ild r e a r i n g , a n d f a m il y s t r u c t u r e of

a m o rp h o u s

va rio u s c u ltu ra l gro u p s; d e m o g r a p h ic surveys

a d u lt c a p a b le

1.

T h e ta s k of h u m a n g ro w th is to tr a n s f o rm a n
c r e a tu r e ,

th e

in fa n t,

of liv in g a d a p tiv e ly

in to

a civilized

in a co m p lex

103

CHO O SIN G A DYNAM IC FOCUS: PROBING THE PAST


social

fram ew ork.

T o w ard

this

end

the

child

cu ltiv ates r e s t r a i n t s o n his biological im p u l s e s , a c

p e r s o n a l i t y o p e r a t i o n s t h e i n d i v i d u a l sa tisfies even
t h e m o st e l e m e n t a l of his needs.

q u i r e s skills in i n t e r p e r s o n a l r e l a t i o n s h i p s , evolves

9. D i s t u r b e d o r n e u r o t i c b e h a v i o r r e p r e s e n t s a

v a l u e s t h a t a r e c o n s o n a n t w i t h t h e society in w h i c h

c o llap s e in t h e i n d i v i d u a l s c a p a c itie s for a d j u s t

he lives, a n d perfe cts t e c h n i q u e s t h a t a l l o w h i m to

m e n t . T h i s co llap s e is s p o n s o r e d by a p e r s o n a l i t y

fulfill h i m s e l f creatively w i t h i n t h e b o u n d s of h is p o

s t r u c t u r e t h a t c a n n o t s u s t a i n t h e i n d i v i d u a l in th e

tentials.

face of his i n n e r conflicts a n d t h e e x t e r n a l d e m a n d s .


of de

I n h e r e n t in every n e u r o s i s is a n a t t e m p t a t a d a p t a

v e l o p m e n t a l l a w s for in stan c e, l a w s of m a t u r a t i o n

t i o n t h a t strives to r e s t o r e t h e p e r s o n to so m e k in d

c o m m o n to t h e e n t i r e species, l a w s p e c u l i a r to t h e

of h o m e o sta tic

c u l t u r a l a n d s u b c u l t u r a l g r o u p of w h i c h t h e i n d i

p e d i e n c e s t h a t a r e e x p lo ite d a r e u l t i m a t e l y d e s t r u c

2. G r o w t h

is g o v e r n e d

by

num ber

balan ce.

U n f o rtu n a te ly , the e x

v id u a l is a p a r t , a n d , finally , l a w s u n i q u e to him self,

tive to a d j u s t m e n t , c r i p p l i n g t h e i n d i v i d u a l in his

p a r c e ls of his p e r s o n a l e x p e r i e n c e t h a t w ill m a k e his

d ealings w ith the w orld.

d e v e l o p m e n t u n l i k e t h a t of a n y o t h e r i n d iv id u a l.

10. T h e first few y e a r s of life a r e t h e m o s t cru cial

3. W h i l e g r o w t h is b r o a d l y s i m i l a r in all h u m a n

in p e r s o n a l i t y d e v e l o p m e n t , e s t a b l is h i n g t h i n k i n g ,

in f a n ts a n d c h i l d r e n , t h e r e is g r e a t d iffe rence in i n

feeling, a n d b e h a v i o r a l p a t t e r n s t h a t will in flu en ce

div id u al styles a n d t h e r a t e of g r o w t h .

t h e i n d i v i d u a l t h e r e m a i n d e r of t h e life. W h e r e e x

4. D e v e l o p m e n t m a y c o n v e n i e n t l y be d ivid ed into

p e r i e n c e s w i t h t h e p a r e n t a n d w i t h t h e e a r l y en v i

a n u m b e r of stages of g r o w t h c o r r e s p o n d i n g r o u g h l y

r o n m e n t a r e h a r m o n i o u s , t h e ch ild is e n c o u r a g e d to

w i t h c e r t a i n a g e levels. W h i l e t h e r e is s o m e v a r i a

evolve a sy s tem o f se c u rity t h a t r e g a r d s t h e w o r l d as

tio n in t i m i n g a n d r a t e , t h e a v e r a g e in d iv id u a l a p

a b o u n t i fu l p la c e a n d to d e v e lo p a se lf-esteem t h a t

pears

p r o m o te s a s se r tiv e n e ss a n d se lf-confide nce. T h e

to

f o l lo w

th ese

stages

w ith

su rp risin g

s e q u e n t i a l r e g u l a ri t y .

ch ild w ill be c o n v in ced o f h i s c a p a c it i e s to love a n d

5. T h e v a r i o u s sta ges a r e c h a r a c t e r i z e d by spe ci

to b e loved, a n d this will f o rm t h e f o u n d a t i o n of a

fic need s t h a t m u s t be p r o p i t i a t e d , c o m m o n stres ses

h e a l t h y p e r s o n a l i t y . O n t h e o t h e r h a n d , w h e r e the

t h a t m u s t be reso lved, a n d special skills t h a t m u s t be

ch ild h a s b een d e p r i v e d o f p r o p e r s t i m u l a t i o n a n d

d evelop ed . A h e a l t h y p e r s o n a l i t y s t r u c t u r e d evelop s

c a r e , o r w h e r e h e h a s b een rejected , o v e r p ro t e c te d ,

on t h e b asis of t h e a d e q u a c y w i t h w h i c h th e s e n eeds

i m p r o p e r l y d i s c ip lin e d , o r u n d u l y i n t i m id a t e d , the

a r e su p p l i e d , stres ses m a s te r e d , a n d skills l e a r n e d at

w o r l d will c o n s t it u t e for h i m a p la c e of m e n a c e . A

p r o g res siv e ag e levels.

p e r s o n a l i t y o r g a n i z a t i o n s t r u c t u r e d o n t h e b ed ro ck

6. Difficu lties m a y a r ise at each sta ge of g r o w t h

of su c h u n w h o l e s o m e c o n d i t i o n i n g s is b o u n d to be

t h a t e n g e n d e r a p a r t i a l o r c o m p l e t e f a ilu re in t h e

u nsubstantial

sa tis faction of needs, t h e s o l u tio n of c u r r e n t c o n

i n d i v id u a t io n ,

flicts,

r e s e n tm e n t,

and

the

learning

of

skills.

Such

failu res

h a n d i c a p t h e i n d i v i d u a l in a d a p t i n g to t h e m o r e

and

shaky.

I n c o m p le te se p a ra tio n -

e x a g g e r a te d d e p e n d e n c y ,

g u ilt,

sa d o m a so c h is tic

in te n s e

im p u ls e s ,

im

p a ir e d in d e p e n d e n c e , a d a m a g e d se n se o f id e n tity

e l a b o r a t e d e m a n d s a n d r e q u i r e m e n t s t h a t co n s t it u t e

a n d se lf-im a g e , d e ta c h m e n t, a n d a h o s t o f c o m

th e su c ceedin g stages of g r o w t h .

p e n s a to r y

7. W h e re e sse n tia l p e r s o n a lity q u a litie s ch a ra c

m e c h a n is m s

i n te r fe r e

w ith

a p ro p er

a d a p ta tio n .

teristic o f m a tu r ity a re n o t evo lv e d , th e in d iv id u a l


w ill be b u r d e n e d u n th re sid u a l c h ild h o o d n eeds, a t
titu d e s, a n d w a y s o f h a n d lin g stress. T h e s e a n a c h
r o n i s m s t e n d to clash w i t h t h e d e m a n d s of a h e a l t h y
biological a n d social a d j u s t m e n t . P r i m i t i v e striv in g s
a n d c o n c e p tio n s of t h e w o r l d , e a r l y fears a n d guilt
feelings, a n d def en se s a g a i n s t th e s e u s u a l ly su rviv e

P sy ch o p ath o lo g y becomes m ore u n d e r


s ta n d a b le w h e n view ed a g a in s t th e b a c k d ro p
of p e r s o n a l i t y d e v e l o p m e n t . D e v e l o p m e n t a l
studies, as h a s been in dicated above, sho w th a t
p e rs o n a lity s tre n g th o r w e a k n e ss is m o r e or

b r o a d fab ric t h a t covers ev ery facet of m a n s i n t e r n a l

less d e te r m in e d by th e exp erien ces d u r i n g


child ho od . T h e child will te n d to identify w ith
the cha rac teristics of th ose w h o m h e ad m ires,
a n d to evolve a n id ealized im ag e of him self
(ego ideal) fashio ned after th e person o r p e r
sons h e ven erates. If, in the first few y ea rs of
life, th e indiv id ual h a s developed a feeling of

a n d e x t e r n a l a d j u s t m e n t . T h r o u g h t h e m e d i u m of

security, a sense of reality, a good m e a s u r e of

in t h e i r p r i s t i n e fo rm t h o u g h t h e y a r e n o t a l w a y s
m anifest. T h e y t e n d to c o n t a m i n a t e a n a d u l t t y p e of
i n t e g r a t io n .
8. P e r s o n a l i t y , evolving as it d oes f ro m a b l e n d of
h e r e d ity a n d e x p e r ie n c e , is n o t m e r e l y a r e p o s i t o r y
of special ab ilities, a t t i t u d e s , a n d beliefs.

It is a

104

HANDBOOK OF SHORT-TERM PSYCHOTHERAPY

a s s e r ti v e n e s s , p o s itiv e s e lf-e s te e m , a n d c a

tive security system, d isto rte d co ncep tio ns of

pacities for self-control, he will p r o b a b l y be


a b le to e n d u r e c o n s i d e r a b l e e n v i r o n m e n t a l

reality,

h a rd s h ip s th e r e a fte r a n d

still evolve in to a

h e a lth y ad ult. O n th e o th e r h a n d , e a rly u n f a


vo rab le d ev elop m ent h a n d ic a p s th e child in
m a n a g i n g even th e u su al vicissitudes t h a t are

im perfect social co ntro l over bodily

f u n c t i o n s , v i t i a t e d sen s e of a s s e r ti v e n e s s ,
s t u n t e d i n d e p e n d e n c e , i m p a i r e d s e lf-e s te e m ,
in a d e q u a te f r u s tr a tio n to lera n c e, im p r o p e r m a
stery of sexual a n d hostile im pu lses, in c o m
plete id entificatio n w ith m e m b e rs of o n e s ow n

c o m m o n to g ro w in g up . T h i s does n ot m e a n

sex, deficient g r o u p identification, fau lty in

th a t all child ren w ith a good p e rs o n a l s u b

te g ra tio n of p re v a ilin g social values, a n d i m

s tru c tu r e will

ad u lts since a n overly h a r s h e n v ir o n m e n t can

p a ir e d acc eptanc e of o n e s social role. P re s s u re


of e a rly unsatisfied needs, a n tic ip a tio n of th e

i n h i b i t d e v e l o p m e n t a t a n y p h a s e in th e
g ro w th process. N o r does it im p ly th a t a child

sa m e kin d s of tu r m o i l th a t existed in child ho od


o r th e ac tu a l setting u p of cond ition s th a t

w ith a n in a d e q u a te p e rs o n a lity s tru c tu r e m a y


no t in the face of favo rab le circum stanc es o ver

p revailed in o n e s e a rly life, a n d survival of


a n a c h ro n is tic defenses, s y m p to m s, a n d th e ir
sym bolic ex tensio ns, all a r e in c o r p o ra te d into

inevitably em e rg e as h e a lth y

come severe early im p e d im e n ts in g r o w th and


m a t u r e to satisfactory ad u lth o o d . W e r e w e to

th e p e rs o n a lity s tru c tu re . C o m p u ls iv e in n a

subscribe to the pessimistic p h ilo so p h y th a t all

tu re , they p e r m e a te every p h a se of th o u g h t,

early

per

feeling, an d action ; they g o vern th e r a n d o m

m a n e n t, we w o u ld blin d ourselves to th e ef

a n d p u rp o s e fu l activities of th e in div idu al,


forcing h im to co nfo rm w ith th e m in a m e r c i
less w ay.

p sy c h ic

dam age

is i r r e p a r a b l y

ficacy of p s y c h o th e ra p y th a t is p re d icated on
th e a ss u m p tio n th a t it is possible t h r o u g h th e
em otion ally corrective e xp erienc e p ro v id e d by
tr e a tm e n t to o vercom e m a n y ch ildh oo d p e r

W h il e th e p e rs o n a lity s t ru c tu r e is tr e m e n
dously co m plex a n d is u n d e r s ta n d a b l y different

sonality disto rtions.


P ers o n a lity tr a its in a d u lt life, ho w ev er, a re

in every h u m a n being by v ir tu e of distinctive


c o n stitu tio n a l m a k e u p a n d u n iq u e c o n d itio n

never an exact red u p lic a tio n of child ho od striv

ings, ce rta in co m m o n in g re d ie n ts m a y be o b

ings. E a r ly c on dition ing s a r e te m p e re d by e x

served in all p e rs o n s in o u r cu ltu re. A m o n g

periences in later life th a t te n d to modify, n e u


tralize, o r reinforce them . M o r e o v e r, th o u g h

th ese a r e (1) aspects of n u c le a r conflicts th a t


accrue in th e course of p e rs o n a lity d evelo p

b ehav ior is influenced by p a tt e r n s rooted in the

m e n t, (2) in te ra c tin g m a n ife sta tio n s of u n r e

past, responses vary w idely in different s i tu a


tions in acc ord ance w ith th e ir sym bolic signifi
cance and the p re v a ilin g social role playe d by
th e perso n at th e time. T h e s u n d r y v a ria tio n s
of p e rs o n a lity strivings in o p e ra tio n a re in
finite. I n c o r p o ra te d a re a ttitu d es, values, an d
p a tt e r n s of b e h a v io r th a t issue o ut of a defec

solved childish p r o m p ti n g s ,
ti on s of c h a r a c t e r drives,
d ep en d en cy , ag g ressio n ,
p end ence, d e ta c h m e n t, a n d
d evalue d self-image. T h e s e

a n d (3) re v e r b e r a
such as excessive
com pulsive in d e
m a n ife sta tio n s of a
a r e rich sources of

p ro b le m s th a t su p p ly i m p o r t a n t a re a s of d y
n a m ic focus.

Possible Assumptions Based on the Past


A n u n d e r s ta n d in g of h ow the past life (see
T a b l e 8 -1 on p e rs o n a lity d ev elo pm ent) of a

p a tie n t h a s influenced th e ex istin g p s y c h o p a thology is t h u s of in estim a ble v alu e in d y n a m ic


(C o n td ,p . 108)

CHO O SIN G A DYNAM IC FOCUS: PROBING THE PAST


TABLE 8-1. Personality D evelopm ent
(See follow ing chart* for corresponding num bers
(1 ) H e r e d ita r y a n d c o n s titu tio n a l e le m e n ts a re th e b u ild in g b lo cks o f p e r s o n a lity . A lo n g w ith
in tr a u te r in e in flu e n c e s th e y d e te r m in e s e n s itiv ity a n d a c tiv ity p a tte r n s a n d th u s re g u la te
th e c h a ra c te r o f la te r c o n d itio n in g s. U n d e r th e p r o m p tin g s o f m a tu r a tio n , n ee d s e m e r g e
a n d sk ills evo lve w ith s u r p r is in g re g u la rity . E n v ir o n m e n ta l fa c to r s , n e v e r th e le ss , m a y
m o d ify th ese p r e n a ta l fo r c e s a n d fa s h io n th e lin e s a lo n g w h ic h th e p e r s o n a lity s tr u c tu r e is
o rg a n ize d .
(2 ) P e rs o n a lity evo lves o u t o f th e c o n d itio n in g s a n d e x p e r ie n c e s o f th e in d iv id u a l in h is rela
tio n sh ip s

w ith

th e

w o rld .

B a sic

needs

m ust

be g r a tifie d

and

a p p r o p r ia te

c o p in g

m e c h a n is m s evo lved , th e c o n s u m m a tio n o f w h ic h , a t a n y a g e level, i f in a d e q u a te w ill


r e ta r d a n d i f sa tis fa c to ry w ill e x p e d ite su ccessive sta g e s o f g r o w th .

T h e so c ia l m ilie u ,

re fle c te d in th e d isc ip lin e s a n d v a lu e s sp o n s o re d b y th e fa m i l y , d e sig n s th e sp e c ific o u tle ts


f o r a n d m o d e s o f e x p r e ss io n o f th e e m e r g in g needs.
(3 ) P e rs o n a lity m a tu r a tio n is c o n tin g e n t on e x e c u tio n o f v ita l ta s k s th a t m u s t be su c c e ssfu lly
fu l f i ll e d a t th e d iffe r e n t age levels.
(4 ) W h a t in h ib its o r d isto r ts g r o w th a re d e p r iv in g e x p e r ie n c e s th a t block th e p r o p e r sa tisfa c
tio n o f n eed s. A n u n w h o le s o m e m ilie u te n d s to fo s te r d e s tr u c tiv e p a tte r n s th a t c ru sh se
c u r ity , u n d e r m in e se lf-e ste e m a n d in te rfe r e w ith th e d e v e lo p m e n t o f e s s e n tia l s k ills a n d
va lu e s th a t a re c o n s o n a n t w ith th e r e q u ir e m e n ts o f a d a p ta tio n .
(5) A t a n y age le v e l co lla p se in a d a p ta tio n m a y be s p o n s o r e d w h e n basic n e e d s a re v itia te d ,
a n d se c u rity a n d se lf-e ste e m a re s h a tte r e d w ith no h o p e o f im m e d ia te re p a ra tio n . I f th e
re se rv o ir o f d e fe n se s is s u ffic ie n tly fle x ib le , c o n sid e ra b le co n flic t m a y be e n d u r e d . O n the
o th e r h a n d , w h e re th e p e r s o n a lity u n d e r p in n in g s a re u n s ta b le , even m in im a l co n flic t m a y
ta x c o p in g ca p a cities. A c o m b in a tio n o f s y m p to m s issu e f r o m th e fa ilu r e to so lv e co n flicts,
a n d in c lu d e , in th e m a in , th e v a r io u s m a n ife s ta tio n s o f a n x ie ty , d e fe n se s a g a in st a n x ie ty , as
w e ll as tech n ics o f c o u n te r a c tin g or s o lv in g th e c o n flic tu a l situ a tio n itself.

W h ile th e

e la b o r a te d s y m p to m s a re u n iq u e f o r e v e r y in d iv id u a l, b e in g in flu e n c e d b y th e sp e cific
e x p e rie n c e s o f th e p e r s o n , a n d b y th e s in g u la r m e c h a n is m s o f d e fe n se he h a s f o u n d su c cess
f u l in p a s t d e a lin g w ith stress, d e fin ite g r o u p in g s o f s y m p to m s a p p e a r w ith su ffic ie n t f r e
q u e n c y to c o n s titu te fa m il i a r s y n d r o m e s . S y m p to m a tic e v id e n c e s o f a f a i l in g a d ju s tm e n t
m a y p e r s is t f r o m o n e age level to th e n e x t, a ccretio n s o f su c c e e d in g d iffic u ltie s b e in g a d d e d
to o r s u b s titu tin g f o r p r o b le m s e x is tin g a t p r e c e e d in g age levels.
(6) R e sid u e s o f d e fe c tiv e re a rin g c o n ta m in a te a d ju s tm e n t b y in flu e n c in g d is o r g a n iz in g rela
tio n s h ip s w ith o th e r in d iv id u a ls. C o n flic t is th u s in c o n s ta n t g e n e r a tio n . T h e sp e c ific d e
p o s its o f d e fe c t d is p la y th e m s e lv e s in lu x u r ia n t fo r m s , th e c u m u la tiv e p r o d u c t o f p a th o
lo g ica l a ccru a ls f r o m o n e age le v e l to th e n e x t.
(7 ) A w a r e n e s s o f fo r m a tiv e e x p e r ie n c e s a n d e la b o r a te d d e fe n s e s m a y be d im m e d b y re p ressio n .
F o r g e ttin g o r r e p u d ia tin g th e m d o es n o t p r o te c t th e in d iv id u a l a g a in s t th e ir fo r a y s in to h is
co n scio u s life in d ire c t o r d e r iv a tiv e fo r m . E a r ly c o n flic ts m a y be re v iv e d sy m b o lic a lly in
d re a m s, th ro u g h th e use o f p s y c h o to m im e tic d ru g s, as a r e su lt o f an o v e r p o w e r in g e m o
tio n a l crisis, d u r in g an in te n se r e la tio n s h ip w ith a p e r s o n a g e w h o re p re s e n ts a p a r e n ta l or
sib lin g fig u r e , o r b y a tra n s fe re n c e n e u r o sis in s p ir e d in th e c o u r se o f p s y c h o th e r a p e u tic
tre a tm e n t.
* F r o m L . R . W o lb e r g , P s y c h o th e r a p y a n d th e B e h a v io r a l S c ie n c e s ( N e w Y o rk , G r u n e & S tr a t to n ,
1 9 6 6 ), p p . 6 2 - 6 3 . R e p r i n te d w ith p e r m is s io n .

TABLE 8-1, cont'd: Building Blocks of Personality


I.

H E R E D IT A R Y E L E M E N T S ( n e u r o p h y s i o l o g i c a l b i o c h e m i c a l , )
I I . I N T R A U T E R I N E IN F L U E N C E S ( M e t a b o l i c , p o s t u r a l , in f e c t i o u s )

1
S en sitivity a n d Activity P o te n tia ls
M A T U R A T IO N A L C O M P O N E N T S AND E X P E R I E N T I A L C O N D IT I O N I N G S
YEAR

1
(In fa n c y )

(2 ) N E E D S

(3 ) T A S K S T O
A C H IE V E

(4 ) B A S I C T R A U M A S

In te n s e a n d u rg e n t d e m a n d s fo r o ra l
s a tis fa c tio n ( n u t r i t i o n a n d s u c k in g
p le a s u r e ); s e n s o ry s tim u la tio n (o p tic ,
a u d i t o r y , ta c tile , k in e s th e tic ) ; lo v e a n d
a p p r o v a l.

F e e lin g s o f s e c u rity a n d
tr u s t .
S e p a r a t i o n o f s e lf fro m
n o n s e lf.
C o o rd in a tio n ; a m b u la
t io n . S y m b o liz a tio n .

In te r f e r e n c e w ith n u t r i t io n ( a c u te o r
c h r o n ic illn e s s , g a s t r o i n t e s t i n a l u p s e ts ,
a lle r g ie s ). In te r fe r e n c e w ith s u c k in g
p l e a s u r e , s e n s o r y s t im u l a t i o n , love a n d
a p p r o v a l ( s e p a r a ti o n fro m , d e a th of, o r
re je c tio n b y m o th e r) .
F a u l t y w e a n in g .

2 -3
(E a rly
C h il d
hood)

In v e s tig a tiv e a n d e x p l o r a t o r y n e e d s ;
g e n ita l m a n ip u la tio n .
B e g in n in g s triv in g s fo r in d e p e n d e n c e a n d
m a s te r y ; a g g re s s iv e a s s e rtiv e n e s s .

F e e lin g s o f a u to n o m y ;
i n c o r p o r a tio n o f d is c i
p lin e s ; t o le r a n c e o f fr u s
t r a t i o n . S o c ia l o u tle ts fo r
a g g r e s s io n . S elfc o n fid e n c e .

H a b it t r a i n i n g (to o la x o r to o se v e re
d is c ip lin e s , a s in r e la t io n to to ile t tr a i n i n g ) .
In te r fe r e n c e w ith in d e p e n d e n c e a n d
m a s te r y (o v e rp ro te c tio n ) .
F a u l t y h a n d l i n g o f ra g e a n d a g g r e s s io n
(to o se v e re r e s tr ic tio n s o r e x c e ssiv e
p e r m is s iv e n e s s ) .
T o o g r e a t o r to o little e m p h a s is by p a r e n t
o n r ig h ts o f o t h e r m e m b e r s o f fa m ily .
I n te r f e r e n c e w ith in v e s tig a tiv e a n d
e x p l o r a t o r y a c tiv itie s . I n te r f e r e n c e w ith
g e n ita l m a n ip u la tio n .
U n c o n s c io u s e n c o u r a g e m e n t o f re b e llio n
by p a r e n t , a l t e r n a t i n g w ith e x c essiv e
p u n is h m e n t.

3 -5
(C h ild
hood)

N e e d fo r e x tr a f a m ilia l g r o u p c o n ta c ts a n d
fo r c o o p e ra tiv e p la y .
K e en in te re s t in sex , g e n ita l d iffe re n c e s ,
a n d b i r t h p ro c esses.

S e x u a l id e n tific a tio n .
O e d ip a l re s o lu tio n .

P ro b le m s re la te d to e n t r y in to n u r s e r y
school a n d k in d e rg a rte n .
In te r f e r e n c e w ith in te re s t in s e x u a lity ;
m a s t u r b a to r y i n tim id a tio n .
P re c o c io u s o r e x c e ssiv e s e x u a l
s tim u la tio n . S e d u c tiv e p a r e n t .
M o t h e r to o d o m in a n t; f a th e r to o p a s s iv e
o r a b s e n t.

5 -1 1
(L a te
C h il d
hood)

N e e d fo r in te lle c tu a l g r o w th a n d
u n d e r s ta n d in g .
N e e d fo r f u r th e r so cial c o n ta c ts a n d for
o rg a n iz e d te a m p la y .
N e e d to b e lo n g to a g r o u p , c lu b , o r g a n g .

G r o u p id e n tific a tio n .

P ro b le m s re la te d to e n tr y in to g r a d e
s c h o o l ( i m p r o p e r s c h o o l a n d te a c h e r s : fe a r
o f r e li n q u i s h i n g d e p e n d e n c y ).
N e ig h b o r h o o d s tre s s e s .
E x p o s u r e to r a c ia l a n d r e lig io u s
p re ju d ic e s .

1 1 -1 5
(E a r ly
A d o le s
ce n ce )

In te n s e s e x u a l fe e lin g s a n d in te r e s ts fo r
w h ic h a so cial o u tle t is n e c e s s a ry
( r e c r e a tio n a l p r o g r a m s , e s p e c ia lly so cial
d a n c in g .)
N e e d to p ra c tic e s k ills fo r s u cc essfu l
p a r ti c ip a t io n in g ro u p s .

S o c ia liz a tio n o f sex


d riv e s . R e s o lu tio n o f
p a r e n t a l a m b iv a le n c e .

C o n flic t b e tw e e n n e e d fo r a n d d e f ia n c e of
p a re n ts.
C o n flic t in r e la tio n to s e x u a l d e m a n d s
a n d s o c ia l re s tr ic tio n s ; m a s t u r b a to r y
c o n flic ts .
T o o la x s e x u a l e n v ir o n m e n t. P o o r
s u p e r v is io n a n d d is c ip lin e . L a c k of
co h e s iv e n e s s in h o m e .

1 5 -2 1
(L a te
A d o le s
ce n ce )

G r a d u a l e m a n c ip a tio n fro m p a r e n ts .
N e e d to m a k e a v o c a tio n a l ch o ic e .
G r o w i n g s e n s e o f re s p o n s ib ility . C o u r t s h ip ;
m a rria g e .

R e s o lu tio n of
dependency.
A s s u m p tio n o f
h e te ro s e x u a l ro le .

C o n flic t b e tw e e n d e p e n d e n c e a n d
in d e p e n d e n c e .
C o n ti n u i n g s e x u a l co n flic t.
S e v e re e c o n o m ic p ro b le m s .

2 1 -4 0
( A d u lt
hood)

G o o d s e x u a l, m a r i t a l , fa m ily , a n d w o r k
a d ju s tm e n t.
C o m m u n ity p a r ti c ip a t io n .

P ro d u c tiv e w o r k ro le
a n d e c o n o m ic in d e p e n
dence. M a rria g e ; p a r e n t
hood. C o m m u n ity r e
s p o n s ib ilitie s . C r e a tiv e
s e lf-fu lfillm e n t.

E x t r a o r d i n a r y fa m ily s tre s s e s .
E c o n o m ic h a r d s h ip s . N a t u r a l d is a s te rs .
Illn e s s , a n d a c c id e n ts .
R a c ia l a n d r e lig io u s d is c r im in a tio n s .

4 0 -6 5
(M id d le
A ge)

A c c e p ta n c e o f a s lo w e r life p a c e ,
p h y s ic a lly a n d c o m p e titiv e ly .
N e e d fo r n e w in te re s ts , h o b b ie s , a n d
c o m m u n ity a c tiv itie s .

M o b i li z a t i o n o f o n e s
to ta l re s o u rc e s to w a r d
a c h ie v e m e n t o f p e r s o n a l
h a p p in e s s , fa m ily
in t e g r a ti o n , a n d so cial
w e lfa re .

M e n o p a u s a l a n d c lim a c te r ic c h a n g e s .
C o n flic ts in r e la tio n to s e p a r a t i o n fro m
c h i l d r e n , u n fu lfille d a m b i t i o n s , s e x u a l
d e c lin a tio n , a n d , in w o m e n , c e s s a tio n o f
c h ild b e a rin g .

A c c e p ta n c e o f p h y s ic a l, s e x u a l, a n d
m e m o ry re c e s s io n .
N e e d to e n g a g e in so cial a c tiv itie s , to
c u ltiv a te n e w fr ie n d s , to d e v e lo p c o m m u n ity
in te r e s ts a n d h o b b ie s .

C o n tin u e d w o r k ,
in te r p e r s o n a l a n d so cial
a c tiv itie s to th e lim it o f
o n e s p h y s ic a l c a p a c itie s .

C o n flic ts in r e la tio n to lo n e lin e s s , d e a th


o f f r ie n d s a n d m a te , in c re a s e d le is u r e tim e ,
re ti r e m e n t , f a ilin g w o r k , p h y s ic a l a n d
s e x u a l a c tiv itie s . Illn e s s .
F e a r fu l a n t i c i p a ti o n o f d e a th .

6 5 on
(O ld A ge)

TABLE 8-1, cont'd: Building Blocks of Personality


I. H E R E D IT A R Y E L E M E N T S ( n e u r o p h y s i o l o g i c a l , b i o c h e m i c a l , )
II. I N T R A U T E R I N E I N F L U E N C E S ( m e t a b o l i c , p o s t u r a l , i n f e c t i o u s )

4
S en sitivity a n d Activity P o te n tia ls
M A T U R A T IO N A L C O M P O N E N T S AND E X P E R I E N T I A L C O N D IT I O N I N G S
(5 ) S Y M P T O M S O F
A D A P T IV E B R E A K D O W N

(6 ) S U R V IV IN G
P E R S O N A L IT Y D IS T O R T IO N S

l D iffu s e a n x ie ty re a c tio n s .
2 . P s y c h o s o m a tic d is o rd e r s : a n o r e x i a ,
v o m itin g , c o lic , d i a r r h e a , b r e a t h i n g a n d
c ir c u la to r y d is o rd e r s .
3 . R a g e r e a c tio n s s c r e a m in g , c r y in g .
4. W i t h d r a w a l r e a c t i o n s d u lln e s s , a p a t h y
s tu p o r .

In s e c u rity ; m i s tr u s t; d e p r e s s iv e n e s s .
P re o c c u p a tio n w ith o r a l a c tiv itie s . S e a r c h
fo r a n id e a liz e d p a r e n t a l fig u r e o r for
n i r v a n a . P r o p e n s ity fo r a d d ic tio n s . A lte re d
b o d y im a g e ; a u s titic re a c tio n s ;
d e p e r s o n a liz a tio n .

4+

1 . A n x ie ty , p h o b ic a n d c o m p u ls iv e -lik e
re a c tio n s . P s y c h o p h y s io lo g ic a l re a c tio n s :
(a ) g a s tr o in te s tin a l d i s o r d e r s fe ed in g
d iffic u ltie s lik e a n o r e x ia ;
c o n s tip a tio n , d i a r r h e a .
(b ) s p e e c h d is o r d e r s s ta m m e r in g .
(c) b o w e l a n d b la d d e r d i s o r d e r s
s o ilin g , e n u r e s is .
2. P e rs o n a lity d is o rd e r s : (a ) ra g e re a c tio n s ,
(b ) w i t h d r a w a l r e a c tio n s , (c) ex c e ssiv e
d e p e n d e n c v , (d ) d i s tu r b e d id e n tity .

L a c k o f s e lf-c o n fid e n c e . S tu b b o r n n e s s .
I n a b ility to c o n tr o l im p u ls e s a n d e m o tio n s .
F r u s t r a t i o n in to le ra n c e .
P re o c c u p a tio n w ith a n a l a c tiv itie s .
P a r a n o id a l id e a s; fe a r o f a u t h o r i t y .
C o m p u ls iv e n e s s . F e e lin g s o f s h a m e .

4+

1. P s y c h o n e u r o tic re a c tio n s : (a ) a n x ie tv
s ta te s , (b ) p h o b ic r e a c tio n s , (c)
p s y c h o p h y s io lo g ic re a c tio n s :
g a s tr o in te s tin a l d is o r d e r s , sp ee ch
d is o r d e r s , b la d d e r d is o r d e r s , s k in
d is o r d e r s , t its .
2 . P e r s o n a lity d is o r d e r s (a s a b o v e ).
3. P r i m a r y b e h a v io r d is o rd e r s .

P e r s is tin g o e d ip a l c o n flic ts ; in a b i l i ty to
id e n tify w ith p e r s o n s o f o w n sex .

2 + to
4+

1. P s y c h o n e u r o tic re a c tio n s : (a ) a n x ie ty
s ta te s a n d a n x ie ty re a c tio n s , (b ) p h o b ic
re a c tio n s , (c) c o n v e rs io n h y s te r ia , (d )
c o m p u ls io n n e u r o s is , (e) p s y c h o s o m a tic
d is o rd e r s : g a s t r o i n t e s t i n a l , b la d d e r,
s p e e c h , s k in , h e a r i n g a n d v isu a l
d is o rd e r s , tics, m u s c le s p a s m s , n a ilb itin g . c o m p u ls iv e o r a b s e n t
m a s tu r b a tio n .
2 . P e r s o n a lity d is o r d e r s (a s a b o v e ).
3. P r i m a r y b e h a v io r d i s o r d e r s le a r n in g
d is a b ilitie s .
4 . J u v e n ile s c h iz o p h r e n ia .

In a b ility to a c c e p t a p r o p e r ro le .
D i s t u r b e d r e la t io n s w ith o th e r s . P ro b le m s
in c o m p e titiv e n e s s a n d c o o p e ra tio n .

0 to
2+

a s a b o v e , p lu s
S c h iz o p h re n ia

S e x u a l a c tin g - o u t. E x c e s s iv e ly h o s tile
a t t i t u d e s to w a r d a u t h o r i t y . P ro b le m s in
i d e n tity . Is o la tio n .

0 to
2+

a s ab o v e

E x c e s s iv e d e p e n d e n c e .
D e v a lu e d s e lf-im a g e .
C o n fu s io n r e g a r d i n g s o c ia l ro le . S e x u a l
in h ib itio n s .

0 to
2+

a s a b o v e , p lu s
A lc o h o lis m
D r u g a d d ic tio n
M a n ic - d e p re s s iv e p s y c h o s is

R e in fo rc e m e n t o f e x is te n t p e r s o n a lity
d is tu r b a n c e s .

0 to
1+

a s a b o v e , p lu s
I n v o lu tio n a l m e la n c h o lia

as above

0 to
1+

a s a b o v e , p lu s
A r te rio s c le r o tic a n d S e n ile p sy c h o se s

as above

0 to
2+

(7 )
R E P R E S S IO N

108

HANDBO OK OF SHORT-TERM PSYCHOTHERAPY

s h o r t-te rm t h e r a p y . W h il e little tim e is a v a il


able to exp lo re th e p ast, as h a s been m e n
tioned, certain a s s u m p tio n s m a y be possible
from the sy m p to m pictu re, a good histo ry ,
d re a m s , a n d p a r t ic u l a r ly tra n sferen ce m a n
ifestations. T h e

im p ac t of th e p a st m a y be

t o w a r d a n y c o m p e tito r w h o m she e q u a te s w ith


th e p re f e rre d a n d privileged y o u n g e r child in
h e r fam ily w h o displaced h e r as th e favorite.
M ech a n ism s d e v e lo p e d in e a rly ch ild h o o d
th a t have in su red a g ra tifica tio n o f needs w ill
con tin u e to be in d u lg ed to a g re a te r o r lesser

s u m m a riz e d u n d e r seven h eadin gs.


U n p ro p itia te d ea rly needs co n sta n tly o b

degree in a d u lt life. T h u s a child in tim id a te d

tru de th em selves on th e in d ivid u a l, p ro p e llin g

re s p o n d s w ith g re a t hostility a n d , in a d efian t

him to w a rd d irect or sym b o lic actions to sa tisfy

m a n n e r , covertly c o n tin u es his practice. L a t e r


th e m a n ife sta tio n of h ostility seem s to be a

these needs. A m a n d ep riv ed d u r i n g infancy of


a d e q u a t e su ckin g p le a s u re m a y co n stan tly be

by his p a r e n t s to avoid m a s t u r b a t o r y activities

ov er-in d u lg in g him self w ith food a n d alcohol

cond itio n p re r e q u is i te for a n y k in d of sexual


e xp ressio n, sex u a l sadism being th e u ltim a te
o utcom e. A n o th e r y o u n g ste r m a y h a v e been

to the

en jo ined by o v e rs c ru p u lo u s p a r e n t s to p e rf o rm

physical

m eticulou sly on all occasions, on th e th r e a t of


th e ir c o n d e m n a tio n o r loss of love. H e n c e fo rth

obsessed w ith a need for m o u th stim u la tio n ,

w om an,

p o in t of obesity a n d
restricted

alcoholism .

as a c h il d

in

activity a n d assertive beh av io r o n th e basis th a t


she w a s a girl, m a y c o n tin u e to envy m e n an d
th eir possession of th e e m b le m of m ascu lin ity,

in du lg enc e of th e tr a it of p erfection ism m a y be


com e a n essen tial factor in his e x p e rie n c in g

th e penis. A ccordingly, she will a tt e m p t to p a t

an y d eg ree of positive self-esteem . A p a m p e r e d

tern h e r life a lo n g lines c o m m o n ly p u rs u e d by

child w ho se t e m p e r t a n t r u m s co m p elled his

m ales, m a s cu lin ity bein g e q u a te d in h e r m in d


w ith freedom a n d assertiveness. W i t h dogged
persistence she will d e n y fem in in e interests,

p a r e n t s a n d siblings to give in to h is w h im s ,

a n d she m a y even clothe herself in m a s c u lin e


like attire , cro p p in g h e r h a i r after the style of
men.

satisfactions. Sensitive to th e slightest rejection,

D efenses e vo lv ed in ch ild h o o d m a y ca rry


o v e r in to a d u lt life w ith an a s to n is h in g
persisten ce. A boy, ov erp ro tecte d a n d sexually
o v e r s t i m u l a t e d by a d o t i n g m o t h e r , m a y
vigorously detach him self fro m her. W h e n he
grow s u p, h e m a y c o n tin u e to avoid contact
w ith w o m en ; a n y a tt e m p t s at sexual p la y m a y
resu lt in in cestuous guilt to a p o in t w h e r e h e is
u n a b le to function. A child rig oro usly an d p r e
m a tu re ly toilet tr a in e d m a y re g a r d his bowel

persists in self-oriented, selfish d e m a n d s on th e


w o rld to s u p p l y h im w ith gratificatio ns an d
he c o nstrues a n y casu aln ess t o w a r d h im as a
designed p e rs o n a l inju ry . T h i s m obilizes ra g e
an d releases coercive b e h a v io r to force p eo p le
to yield to his d e m a n d s .
T h e in d iv id u a l w ill r e p e titiv e ly se t up a n d
a tte m p t to live th rou gh e a rly d estru c tiv e situ a
tion s th a t he has fa ile d to m a ster as a child. A
y o u n g w o m a n rep etitiv ely involves h erself in
co m petitive re la tio n s h ip s w ith older, m o re a t
tractive, m o r e gifted w o m e n in a n a tt e m p t to
su b d u e th e m . T h e feelings she e xp erienc es a n d

activities as disa g reea b le a n d filthy. O v e r


c l e a n lin e s s , o v e r o r d e r l i n e s s , o v e r m e t i c u l o u s

th e situ a tio n s she creates p a ra lle l closely the


riv alry e x p erien ce w ith h e r o lder sister w h o m
she could n ever v a n q u is h . A child is severely

ness ensu e a n d b u r d e n his a d u lt a d ju s tm e n t. A


y o u n g e r sibling m a y c a rr y over into a d u lt life
th e conviction th a t he is sm all a n d ineffectual
in re latio n to a n y perso n m o r e o r less u n c o n
sciously identified as his o ld er sibling. T h i s
will p ro m o te w ith d r a w a l tendencies o r p rovoke
h im to prove him self by fighting a n d p u sh in g
him self beyond his h a b it u a l capacities. A n
old er sibling m a y c o n tin u e to h a r b o r h a tr e d

rejected a n d p hy sically m a l tr e a te d by a n alco


h o lic f a t h e r . W h e n sh e m a t u r e s , s h e is
p assio n ate ly a tt ra c t e d to d e tac h ed , sadistic, an d
p s y ch o p ath ic m e n , w h o se affection she d e s p e r
ately tries to w in . A m a n in p sy ch o an aly sis d e
velops p a r a n o i d a l attitu d e s a n d feelings t o w a r d
th e a n a ly s t, im a g in in g th a t th e a n a ly s t w ishes
to h u m i li a te a n d to r t u r e h im . T h e s e a r e t r a n s
ference m a n ife sta tio n s reflective of th e sam e

109

CHO O SIN G A DYNAM IC FOCUS: PROBING THE PAST


kinds of feelings he h a d t o w a r d his fa th e r d u r

respect oth ers. A boy w h o se fa th e r is passive

ing th e o edip al period.


T he in d ivid u a l often

u n w ittin g ly ex h ib its

a n d deta c h ed identifies w ith a stro n g a g


gressive m o th e r, e m u l a ti n g h e r m a n n e r a n d i n

the sam e k in d o f d estru ctive a ttitu d e s a n d be

terests to th e p o in t of a v oid in g m as c u lin e a t

h avior p a tte rn s th a t he b itte r ly p ro te sts w e re

titu d es a n d goals. A y o u n g s te r w h o w a s dis

m an ifested

c rim in a te d a g a in s t by his a g e m a te s because of

w o m a n re a r e d by a p e tu l a n t, a rg u m e n ta t iv e

his race m a y , fro m th e b eg in n in g of his ex-

m o th e r m ay en g a g e in th e sa m e k ind of b e

tr a fa m ilia l contacts, develop a c o n te m p t for his

h av io r w ith h e r o w n c h ild re n , to tally u n a w a r e

kinfolk a n d a fear of g ro u p s . A girl victim ized

of the co m p ulsiv e n a t u r e of h e r p a tt e r n . A m a n
victim ized d u r i n g his ch ildh oo d by a h y p o

by p r o p e r a n d g e n tle p a r e n t s w h o ca n n o t

chondriacal

to w a rd

him

father

by

may

h is p a re n ts.

h im self

becom e

sta n d scenes is sh a m e d in to a b a n d o n in g an y
d e m o n s tr a t io n of an g er. S he c o n tin u e s to d is

obsessionally c o n cern ed w ith physical illness

p la y a b la n d , forgiving m a n n e r d esp ite ex

follow ing m a r ria g e . T h r o u g h in sid iou s id e n


tification a son m a y becom e a n alcoholic like

p lo ita tio n a n d in tim id a tio n .


T h e in d ivid u a l m a y te n d to revive ch ild h o o d

his m a le p a r e n t , a d a u g h te r th e victim o f m i

sy m p to m s in th e fa ce o f stress. V o m itin g , colic,

g ra in e like h e r m o th e r; th e e x a m p le s of such

a n d d i a r r h e a , w h ic h w e re m a n ife sta tio n s of

identification a r e endless.
T h e in d ivid u a l m a y f a il to d evelo p certain

stress d u r i n g o n e s e arly infancy, m a y be m o b i


lized by la te r episodes of tensio n to th e e m b a r

m atu re p e rs o n a lity featu res. A child severely

ra s s m e n t a n d d is m a y of the p ers o n . F e a r of th e

neglected and rejected d u r i n g infancy comes

d a r k a n d of a n im a ls , w h ic h te r ro riz e d the in d i

into a d u lt life w ith p a th o lo g ical feelings of i m


p e n d in g doom , a co n c e p tu a liz a tio n of him self

vidual in ea rly c h ild ho od , m a y o v e rw h e lm h im


in a d u lt life w h e n a n x ie ty ta x e s his ex isten t ca

as in h u m a n a n d

pacities.

in significant, ten den cies to

d e p e rs o n a liz a tio n , a n d a n in ability to love or

Nuclear Conflicts
T a b l e 8 - 2 s u m m a r i z e s th e chief conflicts,
w h ich we call n u c le a r conflicts, im bed ded in
the psyche of each p erso n , p ro d u c ts of th e
inevitable clash of m a t u r i n g needs a n d reality
restrictions, the m a s te ry of w h ich co nstitutes
one of the p r i m a r y tasks of psychosocial d e
velo pm ent. It m u s t be e m p h a s iz e d th a t these
conflicts a re univ ersal q u alita tiv ely , th o u g h
q u a n tita tiv e ly differing in all p e rs o n s as a
re sult of c o n s t itu tio n a l-c o n d itio n in g v a ria tio n s
a n d the inte grity of th e ex istin g defenses.
T h e earliest n u c le a r conflicts a re o rg a n iz e d
in rela tio n sh ip to the p a re n ts. F o r in stance, th e

an d th e relief of ten sion . At th e sam e tim e th e


absence of m o t h e r becom es linked to dis
com fort, distress, an d p a in . D u r i n g th e last
p a r t of th e first y e a r the child reacts w ith w h a t
is p ro b a b l y a p ri m o r d i a l ty p e of a n x ie ty to
se p a r a tio n from th e m o t h e r, a n d w ith ra g e at
h e r tu r n i n g a w a y fro m h im t o w a r d a n y b o d y
else, child o r a d u lt. T h i s b len d ed g ratificatio nd e p riv a tio n im ag e of m o t h e r is p r o b a b l y the
p re c u r s e r of la te r a m b iv alen cies, p o w e rin g
sibling riv alry a n d th e riv alries d u r i n g the
oed ipal p erio d. It also gives rise to m o tiv atio n s
to co ntrol, a p p e a se , an d w in favors from

in f a n ts association of th e presence of m o th e r
w ith satisfaction of his needs (h u n g e r , th irst,

m o t h e r a n d m o t h e r figures, to v a n q u is h , e lim i
n a te , o r d e stro y co m p e tito rs for h e r in terest

freedom from discom fort an d p a in , d e m a n d for


stim u la tio n ) re su lts in h e r b eco m in g affiliated
w ith gratification of these needs, w ith p le a s u re

a n d a tte n tio n , a n d to p u n is h m o t h e r a n d
m o t h e r figures for actual or fancied d e p r i v a
ti o n s .

The

m other

sym bol

becomes

sy m -

110

H A N D B O O K O F SHO RT-TERM PSYCH O TH ERAPY


T A B LE 8-2. N u cle a r C o n flicts*
R esidual
M an ife statio n s
(repressed o r

Ages
0 - 3 mo.

C o n flictu a l E lem ents


C o n s ta n t freedom from distre ss and pain

L eg en d s
I m ust be ev e rlastin g ly h a p p y an d com
fo rta b le; in stead I su ffe r.

op p o sed by realistic en v iro n m en tal

su p p ressed )
S earch for n irv a n a.
D em a n d for magic.

restrictio n s.
4 m o .- l yr.

1 -2 yrs.

N eed for o ra l, sensory, an d affectionate

I w a n t to be fed, loved, s tim u la te d , and

A m bivalence to w ard

gratifica tio n opp o sed by realistic d e p riv a

kept free from p ain at all tim es; but

m o th er figures.

tions.

m o th er d enies m e th is g ra tific a tio n .

S e p a ra tio n an x iety .

S elf-a ctu aliza tio n op p o sed by essential


restrictive disciplines.

1 w a n t to do w h at I w a n t to d o w h en I
w a n t to d o it, b u t I w ill be p u n ish ed and

Im p u lsiv e aggressiveness.
G u ilt feelings.

told I am b a d .
3 -5

P ow er im pulses op p o sed by sense of h e lp


lessness.
O e d ip a l desires op p o sed by re taliato ry
fears.

I w a n t to be big an d stro n g , b u t I know I


am w eak and little .
I w an t to possess my m o th er (fath er) for
myself, but 1 can n o t co m p ete w ith my

In ferio rity feelings.


C a s tra tio n fears.
C o m p u lsiv e striv in g s for
m ascu lin ity .

fa th er (m o th e r).
6-11

1 2 -1 5

D em and for to tal g ro u p acceptance opposed

1 w an t everybody to like, ad m ire, an d ac

by m anifestations of aloofness and u n

cept m e, but th e re a re som e people w ho

friendliness.

are ag ain st m e an d reject m e .

S exual im pulses opposed by guilt and fear


of punishm ent.

I feel a need for sex u al stim u latio n , but


th is is w ro n g and not a c cep ta b le.

F e a r of rejection by the
g ro u p .

F e a r of lack o f m alen ess


in m en and fem ale
n ess in w om en.

16-21

Independence strivings opposed by de


pendency.

I need to be a gro w n , in d ep en d en t person,

C o n tin u in g dependency.

but I d o n t w an t th e resp o n sib ility . I


w ould like to be a ch ild , b ut th is w ould
m ake me feel like a n o th in g .

* From L. R. Wolberg, an d J . Kildahl, T h e D ynam ics o f P ersonality (New York, G r u n e & Stratton, 1970), p. 56. Re
printed by permission.

bolically link ed to la te r sou rces of g ratific a tio n

z o n e o f con sciou s a w a r e n e s s . W h e n e v e r h a b i

o r d e p riv a tio n . M o r e o v e r , if a d is r u p t i o n of
h o m e o s ta tic e q u i l i b r i u m o ccurs at a n y tim e
la te r on in life o r if for a n y re a s o n a n x ie ty

tu a l co p in g m e c h a n is m s fail th e in d iv id u a l an d
he e x p e rie n c e s a n x ie ty , h e m a y feel th e h e l p
lessness a n d m a n ife st th e b e h a v io r o f a n in fa n t,
a n d h e m a y seek o u t, a g a in s t all logic, a
m o t h e r fig u re o r h e r sy m b olic s u b s titu te (such
as food in co m p u lsiv e e a tin g activities). It is lit
tle w o n d e r th a t m o th e rs, a n d th e i r la te r r e p r e
sentatives (p ro tecto rs, a u th o r it ie s ) , co m e to
possess sym bolic re w a rd (p le a su re ) v alu es
alo n g w ith sy m b o lic a b a n d o n m e n t (p a in ,
a n x ie ty ) p o ten tials. T h i s conflict, dee ply i m
b edd ed in th e unco nscio us, acts as co m p o st for

e r u p t s w i t h a s h a t t e r i n g o f th e s e n s e of
m a s te ry , th e p rim o rd ia l an x ie ty im p rin ts
m a y be revived, a ctiv a tin g s e p a r a ti o n fears
an d m o t h e r-i n v o k in g ten den c ie s a lo n g lines
p u rs u e d by the in div idu al as an infant.
T h e g ratificatio n -d ep riv atio n , se p aratio n a n x ie ty con stellation s, laid d o w n d u r i n g p h ases
of d e v e lo p m e n t e a rly in th e perio d of co n c e p
tu a liz a tio n , will tend to o p e ra te ou tsid e the

CHO O SIN G A DYNAM IC FOCUS: PROBING THE PAST


the fertilization

of a host of derivative a t

titudes, im pulses, a n d drives th a t re m a in w ith


the individual t h r o u g h o u t his existence. O t h e r
conflicts develop in the c h il d s rela tio n sh ip s
w ith th e w o rld , as noted in T a b l e 8 - 2 , th a t are
su p erim p o se d o n the conflicts associated w ith
the d e m a n d for m agic an d for th e co n sta n t
presence of th e m o th e r figure.
T h e actual experiences of in fan ts d u r i n g the

even

in s h o r t - t e r m

111
t h e r a p y e s p e c i a ll y in

d re a m s , tr an sferen ce, a c tin g -o u t b eh av io r, a n d


certain s y m p to m s to observe ho w a n i m p o r
ta n t n u c le a r conflict is c o n ti n u in g to d is tu rb
the p re s e n t a d ju s tm e n t of the pa tien t.
T h e o p e ra tio n of a n u c le a r conflict is e x e m
plified in a p e rs o n w h o h a b it u a ll y relies on a l
cohol as a m e a n s of e scap in g ten sion an d

first years of life, th e degree of need g ra tific a

an xiety. F e elin g s a b o u t d ep riv a tio n s in life are


avoided t h r o u g h th e t r a n q u il iz i n g effects of a l

tions th ey achieve, th e relative freedom from

cohol. At th e sa m e tim e the p erson rea s su res

d ep riv atio n , th eir le a r n in g to to le ra te som e


fr u str a tio n and to accept te m p o r a r y se p a r a tio n

him self, at least as long as h e d rin k s, t h a t a

from th e ir m o th e rs provide th e m w ith co p in g

k eep h im free of p a in .

devices to c o n t r o l t h e i r n u c l e a r c o n flic ts,


w h ich, nonetheless, irrespective of h o w satisfy
ing an d w h o leso m e th eir u p b r i n g in g m a y have
been,

a re still o p erativ e

(albeit successfully

repressed), w a itin g to b r e a k o u t in la ter life


should th e psychological hom eostasis collapse.
N u c le a r conflicts, to re p e a t, a re in h e r e n t in

n u r t u r i n g age nt is availab le to h im th a t will


A n o th e r e x a m p l e of a n u c le a r conflict is evi
denced in a te e n a g e r w h o establishes p s e u d o i n
d e p e n d e n c e t h r o u g h in v a ria b ly do ing th e o p
posite of w h a t his p a r e n t s ask. A re q u e s t to
w e a r a g reen sh irt im m e d ia te ly establishes in
h im an intensely felt desire to w e a r a red shirt.

of the

H i s o w n fears th a t h e will su ccu m b to his


d esire to be d e p e n d e n t on his p a r e n t s d rive him

c h a ra c te r of the en v iro n m e n t. T h i s is not to

to exert his in d ep en d e n ce, little re aliz in g th a t

the

g ro w in g - u p

process

irrespective

say th a t a d ep riv in g or destructive e n v ir o n m e n t

he is still not free because he is n o w im

will not e x ag g erate the effect of conflict or keep

p riso n e d by his o w n needs to be op p o sitio n a l.


A n d m u c h la ter in life, w h e n a su p erv iso r says

it alive beyond th e tim e w h e n it sh ou ld have


subsided; a w ho lesom e e n v ir o n m e n t will tend
to keep in check o p e ra tio n s of conflict, h e lp in g
to resolve it satisfactorily. N u cle a r conflicts are
in p a r t o rdain ed b y b iological elem en ts a n d in

do it this w a y , he m a y still be b o u n d u p in
his need to resist, irrespective of the m e rits of
d o in g a task on e w a y or a n o th e r .
T h e c u rr e n t inab ility of m a n y p e rs o n s to

p a r t are aspects o f the cu ltu re. W e sh o u ld ex

get in v olved m a y be a m a n ife sta tio n of several

p e c t th e ir a p p e a ra n c e in m in o r o r m a jo r
degree in all person s. T h e ir im p o rta n ce is con

n u c le a r conflicts. T o re m a in on e step rem oved

tain ed in the fa c t th at th ey g iv e rise to reaction

ta t o r r a t h e r t h a n a p la y e r m a y be skillfully r a
tio nalized by say in g th a t one does not h ave the

tendencies that, w e ld e d into the p e rso n a lity


stru ctu re, m ay la ter in terfere w ith a p r o p e r

from p a rtic ip a tio n in a cause o r to be a spec

a d aptation . O f clinical con sequen ce, too, is


th eir tendency to stir from d o r m a n c y into o pe n
expression w h e n an x iety b re a k s d o w n th e r a m

tim e, o r th a t th e cause does n ot ju s tify th e ef


fort, o r th a t the c a n d id a te is all too h u m a n , or
th a t th e political p la tfo rm is just so m u ch
w in d o w dressin g. B ut b e h in d these reaso ns

p a rts of the existent defensive fortifications.


T h e e x p o su r e of re pressed n u c le a r conflicts

th a t so u n d good, th e real rea so n m a y be o n e s


sense of helplessn ess a n d th e s u b s e q u e n t de

th a t a re cre atin g p ro b le m s con stitutes a task of


dy na m ic ally o rie n te d th e r a p y , the object being
to d e te rm in e the d isto rtio ns th ey p ro d u c e in

sp a ir a b o u t fin d in g m agical solutions. O r one


m a y not becom e involved because of fear of not
being to tally accepted by a n y g r o u p o r p a rty

the c h a ra c te r stru c tu r e , th e i r affiliation w ith


c u rr e n t conflicts, an d the subversive role th ey
p lay in s y m p to m form atio n. It m ay be possible

t h a t on e jo in s; so it m a y be less p ain fu l not to


expose oneself to such a possible rejection. T h e
n u c le a r conflict is h a n d le d by avoidance.

HANDBO OK OF SHORT-TERM PSYCHOTHERAPY

112

Conclusion
E ven th o u g h tim e does n ot p e rm it a n e x te n
sive p ro b in g of th e past, a n u n d e r s ta n d in g of

c u r r e n t conflicts, a n d th e subversive role th ey


play in in itia tin g a n d su s ta in in g sy m p to m s.

how

p e rs o n a lity vu ln erab ilities m a y be

H a v in g g ra s p e d the significance of h o w th e
p a st h a s e n te re d into p r o m o ti n g a d ju s tm e n t

im p o r t a n t for som e p a tie n ts in s h o r t-te rm t h e r

p ro b le m s in th e p re s e n t, m a n y p a tie n ts becom e

apy. D re a m s and transference p h e n o m e n a


often yield d a t a r e g a r d in g p a st c o nd itio nin gs

o w n after fo r m a l t h e r a p y h a s te r m in a te d . Such

th e

p ro d u ced

past

has

en tered

in t o

and

has

m o tiv ate d to e x p lo re th ese co nn ectio ns o n th e ir

a n d m a y expose som e n u c le a r conflicts t h a t can

h o m e w o r k m a y facilitate a s tre n g th e n i n g of

serve as a focus in th e r a p y . T h e object h e re is

defenses a n d u ltim a te ly act as a m e a n s of p osi


tively influen cin g p e rs o n a lity g ro w th .

to d e te r m in e th e d istortion s th ey p ro d u c e in
th e c h a ra c te r stru c tu r e , th e i r affiliation w ith

CHAPTER 9

Choosing a Dynamic Focus


B. Some Common Dynamic Themes

By th e ir effect on th e p e rs o n a lity s t ru c tu r e

k in d in a d e q u a te s e p a r a tio n - in d iv id u a tio n .

the de velo pm en tal vicissitudes set forth in the


last c h a p te r a re res p o n sib le for a host of

A n d peop le a r e a p t to b la m e th e i r tr o u b le s on

sym p to m s, cop ing m e ch a n ism s, an d defenses

c o rr u p tio n , in fla tion , c o m m u n is m , c a p ita lism ,

th a t provide m a n y d y n a m ic th em es on w hich

o r th e a to m b o m b . M o s t p eop le, h ow ev er,


s o m e h o w m u d d l e th r o u g h , w o r k in g ou t th e ir

we m a y focus. B ecause it is difficult for som e

th e w o rld : th e revolt of yo u th , g o v e rn m e n ta l

p a tie n ts to c o n ce p tu a lize th ese th em es, it m a y


be e x ped ie n t to simplify p e rs o n a lity o p e ra tio n s

tr o u b le s in o ne w a y o r a n o th e r .

an d disto rtio ns by p ic tu rin g th e m as p ro d u c ts


of the o p e ra tio n of five p o w erfu l m o to rs: e x
cessive d ep end ency , r e s e n tm e n t, redu ced in d e

plete a n d d e p e n d e n c y needs too in ten se th a t so

p endence,

dev alued

self-image,

and

It is only

w h e re s e p a r a ti o n - in d i v id u a t io n is too in c o m

d e ta c h

lu tio n s will not be found.


P e o p le w ith p o w e rfu l d e p e n d e n c y n eed s will
often cast a b o u t for in d iv id u a ls w h o d e m o n
s tra te stro n g e r q u a litie s t h a n they them selves

ment.

possess. W h e n a s w im m e r tires, he looks a b o u t


for s o m e th in g o r so m eo n e o n w h o m to lean or

Dependency

w ith w h ic h to g ra p p le . A d e p e n d e n t p e rs o n

O ften at th e core of p ro b le m s is th e first m o


tor, excessive dep en d en cy needs, th a t h a d not

c an be likened to a tire d s w im m e r , a n d he*


w a n t s to find so m eo ne o r s o m e th in g w h o can
do for h im w h a t h e feels he c a n n o t d o for
himself.

W hat

he g e n e ra lly

looks for is a

b e e n a d e q u a t e l y re s o lv e d in c h i l d h o o d . A
h e a lth y b alanc e b etw een d ep en d e n c y a n d in d e

p e rfe c t p a r e n t , a n ideal t h a t exists o nly in his

p end ence is essential for em o tio n a l w ell-being.


W h e r e it does n ot exist, p ro b le m s ensue. M o s t

o w n fancy. A ctu ally , t h e r e a r e no perfect


p a r e n t a l figures w h o a r e a b le o r w illin g to

likely th e av erag e p e r s o n s c h ild ho od y e a rn in g s


for n u r t u r e a n d affection w e re n ot o p tim a lly
met, leaving a residu e of u n m e t needs th a t tend
to e x p r e s s t h e m s e l v e s in t e n s e l y w h e n t h e
p ressures of life m o u n t. O r d e p e n d en cy w a s
p athologically e n co u rag ed by a m o t h e r w h o
utilized the child as a vehicle for h e r o w n
unfulfilled d e m a n d s , h a m p e r i n g th e c h il d s
g ro w th an d strivings for ind ep en d e n ce. U n re
so lved depen den cy is a u b iq u ito u s fo u n ta in -

m o t h e r o r fa th e r a n o t h e r ad u lt. So o u r d e
p e n d e n t p erso n is c o n tin u a lly being f r u s tr a te d
because his h o p es a n d ex p e c ta tio n s a re no t m e t
by so m eo ne else. A m a n w h o w ed s exp ectin g

h ead o f troubles. It stem s fr o m w h a t is p e rh a p s


the m ost com m on conflict bu rd en in g hum an

a n all-giving m o t h e r figu re for a wife is b o u n d


to be d is a p p o in te d . F u r t h e r , if he does find a
p e rs o n w h o fits in w ith his design an d w h o

* T h e generic he is employed to designate both males


and females. T h ere are, however, some distinctive roles
played and effects scored for males and females, which will
be differentiated as much as possible.

113

114

HANDBOOK OF SHORT-TERM PSYCHOTHERAPY

treats h im like a helpless individual, he will


begin to feel th a t he is being sw allow ed up,

blacks, C h ic a n o s , J e w s , C o m m u n is t s , c a p i
talists, an d so on. Self-hate com plicates his

th a t he is losing his in dividuality, th a t he is

e x is te n c e

tr a p p e d . C o n se q u e n tly , he will w a n t to escape

d ep ression . H a t r e d directed o u tw a r d an d th e n

from the re la tio n sh ip . Also, as he senses his


being

t u r n e d in resu lts in m aso ch ism , in the fo rm of


m a j o r an d m i n o r se lf-p u n ish m e n ts. T h e s e m a y

passive like a child. A nd this is frig h ten in g be


c au se he k n o w s th a t he is no t being m a n ly ; he

r a n g e from fouling u p a business deal to


inab ility to accept success, to d a n g e r o u s ac

may

cident p ro n en es s, to physical illness, to foolish,


o u tr a g e o u s, o r e m b a r r a s s in g behavior.

d epen den cy,

actually

he

will

have

feel th a t

h o m o s ex u al

he

is

d o u b ts an d

f e a r s since m a s c u l i n i t y is a s s o c ia te d
activity a n d in dependence.

w ith

W e will call his first m a n e u v e r his de


p en d en cy m otor, w h ich begins to o p e ra te e sp e

b e c a u s e it s p o n s o r s te n s i o n

and

Low Independence

cially at tim es w h e n he is u n d e r p ressure. As


he searches for th e elem en t missing in his p sy

N o w o u r m a n has tw o m o to rs going m ost of

chological diet, n a m e ly a p a re n ta l figure, he

th e tim e w h e n u n d e r p re s su re: the d ep en d e n c y

will most a ssu re dly be disillusioned. W o m e n

m o to r a n d th e re s e n tm e n t m o to r, w ith a c
c o m p a n y in g kickbacks of guilt a n d m asoch ism .

a re no less victim ized by d e pe nd enc y t h a n are


men. A nd th e ir reactio ns a re q u ite sim ila r in
th a t they a re a p t to re g a rd both m ales a n d fe
m ales on w h o m th ey get d e p e n d e n t as p o te n

T h e p ic tu re is not com plete, ho w ev er, w ith o u t


a th i r d m o to r, lo w in depen den ce, w h ich is an

tial n u r t u r i n g m o t h e r figures. T h e y a re also no

L o w in d ep en d e n ce is a feeling th a t on e c a n n o t
g ain, by his o w n reaso n o r s t re n g th , the d e s i r a

less subject to the con seq uen ces of th e o th e r


m o to rs th a t we shall describe.

in v a ria b le

c o u n te r p a r t

of high

d e pen den ce.

ble p rizes of o u r c u lt u re w h e th e r th ey be love


a n d ju s tic e o r w in e , w o m e n , a n d song. A s p i n
off of low in d e p en d e n ce is a feeling of infe

Resentment

riority , a lack of proficiency on achie ving d e


sirab le goals.

P a r t an d p arcel of inferiority

A second m o to r th a t inevitably acco m p anies


the first is the resen tm en t m otor. R e se n tm e n t

feelings is th e u n c e rta in ty a b o u t being m a n ly


a n d m asculin e. S elf-doubts a b o u t o n e s sexual

inv ariab ly fires off because eith er one m u s t find

in te g rity a re to r tu ro u s ; th e u su al sequel is to
try to c o m p e n s a te by b eing the q u in tessen ce of
e v ery th in g m ascu line: overly aggressive, overly
co m petitive, a n d overly d o m i n a ti n g . Pro v in g
him self w ith w o m e n m a y lead to saty riasis a n d

a perfect p a r e n t w h o will ta k e care of h im or


he feels tr a p p e d w h en som eone does take care
of h im a n d he senses his o w n passivity an d
helplessness. R e se n tm e n t breeds guilt because
peo ple j u s t a r e not supp osed to be hateful.
E ven guilt does not alw ay s keep th e hostility
hid den . S o m etim es w h e n o u r m a n h as h a d too
m u c h to d rin k o r w h e n he is very fru stra te d
ab o u t som ethin g, his h a te feelings leak o r p o u r
out. T h a t in itself can be te r rib ly u p settin g be
cause he m a y fear he is g etting out of control;

D o n J u a n i s m . O u r m a n m a y h ave fantasies
a n d im ages in his m in d of stro n g m e n (often
sym bolized by th e ir possessing large penises)
a n d m a y be p a r t ic u l a r ly a ttra c te d to t h e m b e
cause of th eir s tren g th . B ut his a w a r e n e s s of
h ow m u c h he th in k s a b o u t m en m a y c ause h im

o r th e m ere a w a re n e s s of his in n e r a n g ry co n
dition can m a k e h im despise himself. Sad ism
an d sadistic b eh av io r m a y be directed at the
object of his d e p en d en cy w h o he believes is

to w o n d e r if he is h o m o s e x u a l an d to fear th e
very th in g s th a t he ad m ire s. H e m a y a c tu a lly
on occasion be sex ually a ttra c te d to id ealized
m ale figures, a n d he m a y fan ta siz e i n c o r p o r a t
ing th e ir penises into himself.

tr a p p in g h im o r w h o fails to live up to e x p e c
tations. It m a y be d ra in e d off on scapegoats:

Interesting ly , lo w -in d e p e n d e n c e feelings in


w o m e n lead to th e sa m e self-doubt an d c o m

115

CHO O SING A DYNAM IC FOCUS: SOME CO M M O N THEMES


p ensation s as in m en. Such w o m e n will tr y to

an d be d e p e n d e n t. H o w e v e r, giving in to such

re p a i r the fancied d a m a g e to them selves by ac

a desire speeds u p all his m o to rs a n d m ak es

q u ir in g a nd actin g as if th ey h av e th e sym bols


of m ascu lin ity (e.g., by sw a g g e rin g a n d w e a r

h im

ing m ale a p p a r e l )

drive; he co m p etes w ith a n y stro n g figure on

th a t

in o u r

cu ltu re a re

feel even

w orse.

He

p u rs u e s j u s t

the

reverse course fro m his o rig in a l d ep en d e n c y

eq u ate d w ith ind ep en de n ce . T h e y will c om p ete


w ith and try to v a n q u is h an d even figuratively

whom

he

m ig h t

castrate males. In its e x a g g e ra te d form , th ey

adolescent

w ill act t o w a r d o t h e r fe m a le s as if th e y
them selves a re males, d o m i n a ti n g a n d ho-

w h a te v e r his p a r e n t s say. A n d he m a y c o m

m o sexually seducing them .

ing all th e c u ltu ra l sym bols of being a w o r th y


p e rs o n , such as being perfectionistic, c o m p u l

Devalued Self-image

co m p en sato ry

who

to

lean.

disagrees on

He

show s

p rin c ip le w ith

p e n s a te for his dev alue d self-image by e x p lo it

sively a m b itio u s,
mercilessly,
By now in o u r illu s tratio n we h av e a fully
o p e ra tin g fo u rth m otor, a d eva lu ed self-im age.

want

t h e p s e u d o i n d e p e n d e n c e r e m i n i s c e n t o f th e

and

d ri v e s

and

he

p o w e r driv en.
may
m ay

These

preo ccu p y
o rg a n iz e

him

his

life

a r o u n d th em . O n e fa ilu re m e a n s m o r e to h im

W it h th e c o n sta n t re v e r b e ra tin g of his first


th ree m otors, o u r m a n is n o w feeling spiteful

th a n tw e n ty successes, since it is an affirm atio n


of his lowly status.
T h e s e difficulties a re c o m p o u n d e d by the

to w ard

w a y th ey in te ra c t w ith o u r m a n s sexual needs.

h im s e lf.

H e feels h e is m i s e r a b l y

in c o m p e t e n t , u n d e s i r a b l e , a n d u n w o r t h y .
E v e ry w h e re he sees evidence of his in sign ifi
cance: he is not tall eno u g h , he h a s developed

W hen

o n e s d e p e n d e n c y

needs

are

b e in g

gratified, th e r e is often a pervasive feeling of


w ell-being th a t floods o n e s w h o le body. U p o n

a p a u n c h , w o m e n do not seem to p ay a tte n tio n

a w a k e n in g follow ing s u rg ery , for e x a m p le , the

to h im , his h a i r is th in n in g , his jo b is not

confident, sm ilin g face of a n u rs e can suffuse a


m a n w ith g ratefu l, loving feelings, at least p a rt

o u ts ta n d in g ; his car, his house, his w ife


n o th in g is perfect. H e m ay even th i n k his penis
is of in a d e q u a te p ro p o rtio n s . H e feels like a
d a m a g e d p erso n. T h e s e feelings to r m e n t him ,

of w h ich m a y be sexual. T h e sexual feeling is


no t th a t of a d u lt m ale to a d u lt fem ale but
r a t h e r th a t of a helpless child to w a r d a w a r m
m o th e r. Such a feeling is t a n t a m o u n t to a n in

an'* he vows to prove th a t he is not as devalued


as he feels. H e com m its him self to th e ta s k of

cestuous su rg e a n d m a y b ri n g w ith it g reat

being all-p o w e rfu l, a m b itio u s, perfect so as to

conflict a n d guilt. S h o u ld th is d ep en d en cy be

repair

he

the n a tu r e of a h u s b a n d s c o n tin u in g r e l a ti o n

im ag ines he can surely respect himself. If he


can live w ith o u t a single m isstep, all will be

sh ip to his wife, he m a y be u n a b le to function

well. H e tries to boost h im self on his o w n to


the po int w h e re o th ers will have to a p p ro v e of
him . H e m a y only d a y d r e a m all this, o r he
m ay, if events a r e fortuitous, accom plish m a n y
of his o v erco m p en sato ry goals.
If he climbs hig h, he will most likely resent

in a m o t h e r - s o n rela tio n sh ip . O n th e o th e r

his

devalued

self-im age.

Then

those below w h o n o w lean on h im an d m a k e


d e m a n d s on him . T o th ose w h o ex hibit w e a k
ness, he will sho w his an g er. W h il e he m a y be
able to be giving on his o w n te r m s, a n u n e x
p e c te d a p p e a l fr o m s o m e o n e else w ill be
re g ard ed as a v u lg a r im po sitio n. H e actu a lly
w a n ts for him self som eone on w h o m to lean

sexually w ith h e r since h e is v irtu a lly involved


h a n d , if th e n u r t u r i n g figure is a m a n , h o
m o sex u al fears an d feelings m a y arise w ith
e q u a tio n s of the h o s t s p en is w ith a n ip p le . F o r
w o m e n the d e p e n d e n c y situ a tio n does j u s t the
reverse. A n u r t u r i n g m o t h e r figure calls u p in
h e r fears a n d feelings of h o m o s e x u a lity w hich
m a y or m a y no t be acted o u t in passive h o
m o s ex u a lity w ith y e a rn in g s for th e breast.
M o r e o v e r, low feelings of in d e p e n d e n c e m ay,
as h a s been in dicated , in s p ire ideas of defective
m ascu lin ity in m ales w ith im p u lse s to identify
w ith muscle m en . F a n ta s ie s of h o m o s ex u a lity

116

HANDBO OK OF SHORT-TERM PSYCHOTHERAPY

o r direct a ctin g-ou t of h o m o s e x u a l im pu lses

p lu n g e s in a g a in . By n ow his first m o to r of d e

m a y follow. In w o m e n feelings of defective in

p e n d e n c y is really d riv in g him . A n d if h e is

dep en d en ce

may

in sp ire

of the

d e s p e r a te e n o u g h , he m a y a tta c h h im self all

fantasies of possessing a

over a g a in to a figure w h o holds o ut som e

penis, th e sym bol in o u r c u ltu re of p o w e r an d

p ro m is e of b eing th e perfect p a re n t. T h e n the

ind epende nce.

n e u ro tic cycle is on its w a y again . T h e fifth

fem inin e role an d

S a d is m

rejection

and

m a so c h ism

may

also be acted ou t in sexual activities in both


m en an d w om en.

m o to r of d e ta c h m e n t h a s a g ain revived the


first, second, th ird , a n d fo u r th m otors.

T h e re v e r b e ra tin g of all these m a c h in e s calls

T h e s e drives, th ese five m o to rs, a re never

for s tre n u o u s efforts on th e p a r t of o u r subject.


It all b egan w ith the d e p e n d en cy m o to r, w hich

e n tirely q u iescent. In th e a v e ra g e perso n th e re


is in v a ria b ly som e fuel to keep th e m going.

th en activated the re s e n tm e n t m o to r (together

T h e r e is n o one w h o se d e p e n d e n c y needs w ere

w ith its c o m p o n e n ts of aggression, guilt an d

perfectly m e t e a rly in life. T h i s h u n g e r lives


on, a n d w ith this h u n g e r, the m e c h a n is m of

m asochism ). T h i s th r e w into g e a r the th ird


m o to r of low ind ep en d e n ce, w h ich in tu r n
fueled the fo u r th m o to r of self-devaluation w ith
its o v erco m p en satio n s an d sex ualization s.

d ep en d en cy is co n tin u a lly o perative. In o u r


c u ltu re , in this g e n e ra tio n , the u n m e t d e
p en d e n c y needs sets in m o tio n the successive
m o to rs just described. As lo ng as fuel is a v a il
ab le a n d th e speed of th e m o to rs can be co n

Detachment

trolled, th e ind ivid ua l m a y m a n a g e to keep g o


ing, s w itch in g on on e o r th e o th e r m o to rs an d

W h e r e can a m a n t u r n n ext to g a in some

t u r n i n g th e m off if they t h r e a te n to c a rr y h im

sense of c o m p o s u re ? H e often t u r n s to the fifth


m o to r, detach m en t. D e ta c h m e n t is an a tt e m p t

a w ay . T o som e ex tent all p eo p le a re victim s of


th e five m o to rs d e scrib e d to a m in o r d eg ree

at escaping from lifes messy p ro blem s. O u r

at least.

m a n by n o w is fed u p w ith th e ra t race an d

D e p e n d e n c y in evitab ly b re ed s re s e n tm e n t in
o u r c u ltu re . If o utlets for th e re s e n tm e n t are

w a n ts to get ou t. H e says, N o m o re c o m m it
tees, no m o re p arties, no m o re responsibilities,

not a vailable a n d if c o m p e n s a tio n s for a d e

no m o re ex tr a s of a n y kin d, no m o re involve

valued self-im age c a n n o t be p u r s u e d in o th e r

m ent

w o rd s, if th e individ ual c a n n o t read ily sw itch


from on e en g in e to a n o t h e r th e n the conflict

w ith

p e o p le .

He

w a n ts

an

is la n d

fortress, o r at least a castle w ith a m o a t a r o u n d


it, a n d he w o u ld pull u p th e d r a w b r i d g e and

a n d stress reac h p r o p o r tio n s w h e re on e feels

say no to e v e ry th in g a n d everyone. H e is sure


th a t th is is th e solution; he decides no t to b e
com e rich an d fam ous.
B u t it does n ot w o rk. P eople need people.

cata stro p h ic a lly o v e rw h e lm e d . W h e n th e te n


sion m o u n t s excessively an d th e r e seems to be
no w a y of escape, a n x ie ty strik e s w h ic h is th e
feeling th a t o ne is o v e rw h e lm e d a n d lost.

Life is not satisfying alone. O u r m a n finds


loneliness to be a w o rse state th a n w h a t he w as
e n d u r i n g before. H e realizes th a t pe op le co n

O p e r a ti o n s to defend a g a in s t th e a n x ie ty will
be institu te d, b u t the defense is often ineffective
o r m o re b u rd e n s o m e t h a n th e con ditio n it w a s

s titu te one of lifes richest g ratifications. So, he

d esig n ated to com bat.

Case History
T h e p a t i e n t , R o g e r, w a s a m a n in h is m id 3 0 s

g e n t l e m a n p r e s e n t e d h i m s e l f w i t h a n e x p r e s s i o n of

w h o s e wife t e l e p h o n e d m y s e c r e ta r y for a n a p p o i n t -

depression

m ent.

sa id , s t a r t e d w h i l e d isc u ssin g s e e m i n g ly c a s u a l m a t -

At the

initial

in terv ie w

a w ell-groom ed

and

bew ilderm ent.

The

problem ,

he

117

CHO O SING A DYNAM IC FOCUS: SOME COM M O N THEMES


ters w i t h his best f rien d a n d p a r t n e r d u r i n g a l u n c h

C o n t i n u i n g his sto r y , R o g e r sa id t h a t w ild , u n

h o u r . H e w a s o v e r w h e l m e d w i t h a feeling of p a n i c ,

p r o v o k e d fe elings of p a n i c w e r e n o t co n f in ed to his

w i t h violent h e a r t p a l p i t a t i o n s a n d c h o k i n g s e n s a

w o r k . E v e n at h o m e , his h a b i t u a l h a v e n of co m fo rt

tion s, w h ic h forced h i m to e x c u s e h i m s e l f o n the

a n d sa fe ty, h e e x p e r i e n c e d b o u t s o f a n x i e t y , w h i c h

b asis of a s u d d e n i n d isp o s itio n . B a ck at w o r k , h e

b u r s t fo rt h a t i r r e g u l a r in te r v a ls. H i s sleep, too, w a s

of d a n g e r e n

i n t e r r u p t e d by n i g h t m a r i s h fears, w h i c h forced h i m

v elop ed h i m a c o n f o u n d i n g a g o n i z i n g s e n sa tio n ,

to seek r efu g e in h is w i f e s bed. A p e r v a siv e sense of

th e s o u rce o f w h i c h e lu d e d all a t t e m p t s a t u n d e r

h e lp le s sn e s s s o on c o m p l i c a t e d R o g e r s life. F e a r of

recov ered

partly,

but

a sensation

sta n d in g . U p o n r e t u r n i n g h o m e , h e p o u r e d h im se lf

b e i n g a l o n e a n d f ear of t h e d a r k d ev elo p ed . O t h e r

t w o e x t r a j i g g e r s of w h isk e y . H i s f ear slo w ly v a n

f e a r s t h e n o c c u r r e d , s u c h as f e a r of h e ig h ts , of o p e n

ished so t h a t a t d i n n e r t i m e he h a d a l m o s t c o m

w i n d o w s , of c r o w d s , a n d of s u b w a y s a n d buses. In

pletely recov ered his c o m p o s u r e . T h e n e x t m o r n i n g ,

t h e p r e s e n c e o f h is wife, h o w e v e r , th e s e f ears s u b

h o w e v e r , h e a p p r o a c h e d his w o r k w i t h a sense of

sided o r d i s a p p e a r e d . R o g e r c o n s e q u e n t l y a r r a n g e d

fo re b o d in g , a feeling t h a t b e c a m e s tr o n g e r a n d

m a t t e r s so t h a t h is wife w a s a v a i l a b l e as often as
poss ible. F o r a w h i l e sh e se em ed to re l i s h t h is n e w

s t r o n g e r as th e d a y s a n d w e e k s p as sed.

closeness, for sh e h a d r e s e n t e d w h a t sh e h a d c o m
p l a i n e d a b o u t for a lo n g t i m e h is co ld n ess a n d

R og er h a d obviously e x perienc ed a n a n x ie ty
a ttack th e source of w h ic h b e cam e so m e w h a t
cle a re r as h e c o ntinu ed his story.

d e t a c h m e n t f r o m h er.

W h a t a p p a r e n t l y h a d h a p p e n e d w a s th a t
not being ab le to escape fro m th e a n x ie t y - p r o

T h e m o st u p s e t ti n g t h i n g to R o g e r w a s t h e d i s

v ok in g s itu atio n at w o rk , a n d bein g u n a b le to

cover y t h a t his s y m p t o m s b e c a m e m o st v iolen t w h i l e

develop a d e q u a t e first-line defenses to control

at w o r k . H e fo u n d h i m s e l f c o n s t a n t l y ob sessed at

o r n e u tr a li z e h is a n x iety , R o g e r w a s r e t r e a t in g

t h e office w i t h w a y s o f r e t u r n i n g h o m e to his wife.


b u t even

to a n d so u g h t safety in a d e p e n d e n t r e l a ti o n
sh ip w ith his wife (second-line defenses, see p.

a n t i c i p a t i n g r e t u r n i n g to his d esk o n M o n d a y w a s

96) th a t p a ra lle le d t h a t of a sm all child w ith a

W e e k e n d s b r o u g h t t e m p o r a r y su rcea se;

e n o u g h to fill h i m w i t h f o r e b o d in g . H e w a s u n a b l e
to av oid c o m i n g late m o r n in g s , a n d , m o r e a n d m o r e
often he ex cu s ed h im se lf f ro m a p p e a r i n g a t w o r k on
t h e b asis o f a c u r r e n t p h ysic al illness. B e cau se he
re a liz e d fully h o w his w o r k w a s d e t e r i o r a t i n g , he

m o th e r. V a r i o u s fears of th e d a r k a n d of being
a lo n e w e re in dicative of his ch ildlike h e lp le ss
ness. T h i s k in d of a d a p t a t i o n obviously h a d to
fail.

w a s no t s u r p r i s e d w h e n h is frien d to o k h i m to ta s k
for h is deficiency. F o r c i n g h i m s e l f to go to w o r k b e
came

e a s ie r

af te r

Roger

had

consum ed

se vera l

Not

lo n g

a f t e r th is,

Roger continued,

he de

v elo p ed fa n t a s i e s of g e t t i n g into a c c id e n ts a n d h a v

d r i n k s , b u t he fo u n d t h a t h e r e q u i r e d m o r e a n d

in g his b o d y c u t u p a n d m u t i l a t e d . W h e n R o g e r

m o r e alcoh ol d u r i n g the d a y to s u b d u e his te n s io n .

confid ed to his wife t h a t he w a s g r e a t l y u p s e t by

At n i g h t h e n e e d e d b a r b i t u r a t e s e d a t i o n to i n s u r e

th e s e o c c u r r i n g f an tasies , sh e e n j o i n e d h i m to c o n

e ven m i n i m a l sleep.

su lt a d o c to r . H e r ejected t h is ad vice, c o n t e n d i n g
t h a t h e w a s m e r e l y o v e r w o r k e d , a n d h e p r o m i s e d to

T h e surm ise th a t I m a d e at this p o in t w a s


th a t so m ethin g in the w o rk s itu atio n w a s tr ig
gering off his an xiety . I felt th a t R og er h a d a t
tem p ted to gain surcease from a n x ie ty by i m
p lem e n tin g m e c h a n ism s of co ntrol (first-line
defenses, see p. 94) such as try in g to avoid the
stress situa tion s of w o rk a n d d e a d e n in g his
feelings w ith alcohol a n d sedatives. T h e s e ges
tures seemed n ot too successful since he w a s
obliged to re m a in in the w o r k situ a tio n no
m a tte r ho w m u c h he w a n te d to avoid it.

t a k e a w i n t e r v a c tio n , w h i c h h e w a s s u r e w o u l d r e
s t o r e his m e n t a l c alm . F e a r f u l t h o u g h t s c o n t i n u e d to
p l a g u e R o g e r. H e b e c a m e f ri g h t e n e d w h e n e v e r he
h e a r d sto ries of v iolence, a n d he a v o id e d r e a d i n g
n e w a c c o u n t s of su ic id e s o r m u r d e r s . S o o n h e w a s
o bse ss ed w i t h t h o u g h t s of p o i n t e d objects. Kniv es
te r rif ie d h i m so t h a t h e in sisted t h a t h is wife co nceal
t h e m f r o m h im .

T h e r e t u r n to a childish d e p e n d e n t position
a p p a r e n t l y m ob iliz ed fears t h a t in too close a s
sociation w ith a m o t h e r figu re he w o u ld be

118

HANDBO OK OF SHORT-TERM PSYCHOTHERAPY


In a tt e m p t i n g to m a k e a te n tativ e diag no sis

subjected to m u ltila tio n an d destru ction . S e x


ual feelings to w a r d his wife w e re e q u a te d w ith

of R o g e r s c o nd itio n at th is p oint, I w a s co n

fo rb idd en

th e

fro n te d w ith the c o n te m p o r a r y c o n tra d ic tio n s

p e n a lty w a s bloody m u tila tio n . F a n ta s ie s of a c

t h a t p lag u e o u r a tt e m p t s at classification. All

cidents an d b loodshed could be reflections of

e m o tio n al difficulties sp re a d them selves over a

R o g e r s c a stra tio n fears. T h e rep e titio n of th e

w id e p ath o lo g ic al a re a , involving every aspect


of th e p e r s o n s f u n c tio n in g intellectual, e m o

in cestuous feelings for w h ich

o edip al d r a m a t h u s could follow a s h a t te r i n g of


R o g e r s repressive system. A tte m p ti n g to r e i n
fo rce r e p r e s s i o n by r e p r e s s i v e ( t h i r d - l i n e
defenses, see p. 76), R o g e r em ployed p h o b ia
f o rm atio n

striving

to

rem ov e

h im self from

tio nal, physical, a n d b eh av io ra l. Based as th ey


a re on p re s e n tin g c o m p la in ts a n d sy m p to m s,
system s of nosology often lose sight of th e fact
th a t th e e n tire h u m a n being is em b r a c e d

sym bols of m u tila tio n such as knives a n d o th e r

in a n y

cu ttin g in s tru m e n ts .

classification into w h ich a p a ti e n t fits th e n m ay

em o tio n a l

u p h e a v a l. T h e

particular

d e p e n d m erely u p o n th e relative e m p h a s is th e
W hen

asked

if h e

had

other

sym ptom s

or

fan tasies , R o g e r, in a n e m b a r r a s s e d w a y , confided


t h a t in t h e p r e se n c e of forceful o r s t r o n g m e n , h e e x

d iagn ostic a g en t (i.e., the th e r a p is t ) o r the p a


tient p u ts u p o n selected sy m p to m s.
T h i s m a y be illu strated in the case of R oger.

p e r ie n c e d a p e c u l i a r fear, w h i c h he trie d to concea l.

H is

S o m e t i m e s he w a s a w a r e of a d e s ire to t h r o w his

ritab ility , explosiveness, a n x ie ty , d ep ression ,


p sy c h o so m a tic sy m p to m s, p h o b ias , a n d o b
sessive th o u g h ts. In a d d itio n , he exh ib ited a

a r m s a r o u n d m e n a n d to kiss t h e m in a filial w ay.


T h is

im pulse

d isturbed

Roger

greatly,

as did

f a n ta s ie s of n u d e m e n w i t h h u g e g e n i t a l o r g a n s . H i s
se x u a l life c o n t i n u e d to d e t e r i o r a t e . W h i l e he h a d

c o m p la in ts

w e re

tho se

of ten sio n,

ir

c h a r a c t e r d is tu r b a n c e in such m a n ife sta tio n s as

n e v e r b een a n a r d e n t lover, he h a d p r i d e d h im self

ex c ess iv e

o n h is p o ten cy . H i s se x ual p o w e r s n o w se em ed to be

W e r e R og er chiefly co ncerned w ith his p h y s i

d i s a p p e a r i n g , w h e n he a p p r o a c h e d his wife, he w a s

cal a il m e n t s his h ea d a ch es, d yspe psia, list


lessness, fatigue, failing h e a lt h , o r im p o te n c e

im p o t e n t o r h a d p r e m a t u r e e ja c u la tio n s . T h i s upset

subm issiveness

and

dependency.

f u n ctio n well se x u a lly . T o d i s p r o v e this, he forced

w e w o u ld be inclined to re g a r d h im as a p e r
son suffering fro m physical d is o rd ers of p sy

h i m s e l f c o m p u ls iv e ly to a t t e m p t i n t e r c o u rs e , on ly to

chological o rig in , th a t is, a ty p e of so m a to fo rm

be

d iso rd er.

R o g e r a n d c r e a t e d fears t h a t he ne v e r a g a i n w o u l d

rew arded

by

fu rth er

failures.

A nticipatory

a n x i e t y soon m a d e se x u a l r e l a t i o n s a s o u rce of p a i n ,
a n d w h e n his wife su gg e sted t h a t th ey a b s t a i n , he
a g r e e d , b u t he w a s f rig h t e n e d t h a t sh e w o u l d leave
h i m for a n o t h e r m a n .

T h e fear R o ger m anifested of stro n g males,


the desire to act in an affectionate w a y w ith
th em , the te r r o r of h o m o s ex u al a ss a u lts by
n u d e m en w ith hu ge g en ital o rg a n s w ere, if we
follow o u r previou s line of reas o n in g , the
p ro d u c ts of his fear of a tta c k by fath e r figures
irate at his a p p r o p r i a t i o n of the m a t e r n a l o b
ject. A d is in te g ratio n of R o g e r s sexual life w as
inevitable because he w a s re la tin g to his wife
not as a h u s b a n d but as a child. A b a n d o n m e n t
of a m ale role w ith his wife w as, therefore,
necessary to avoid anx iety. W h ile serving as a
sp u r io u s protective device, his sexual in hib itio n
obviously fu r th e r u n d e r m in e d his self-esteem.

S h o u ld

h is a n x i e t y a t t a c k s h a v e

caused h im g re a te st co n cern an d w e re he to
h ave focused his a tte n tio n o n his a n x ie ty , we
m ig h t classify h i m as a n x ie ty d i s o r d e r . In the
event his d e p res sio n w a s of p ri m e in terest, a
d i a g n o s i s of p s y c h o n e u r o t i c o r r e a c t iv e
d e p r e s s io n m ig h t be e n te r ta in e d . If e m p h a s is
h a d been p u t on his obsessive concern w ith
b loody a m p u t a t i o n s , d e ath , a n d po in ted objects,
he m ig h t be called an obsessive d i s o r d e r . H is
fear of heights, su b w a y s, buses, a n d cro w d s an d
of solitude an d th e d a r k a re th ose often fo un d in
p h o b i c d i s o r d e r s . F i n a l l y , h a d h is s u b
m i s s i v e n e s s , p a s s iv it y , a n d o t h e r c h a r a c t e r
defects been considered his most significant
p ro b le m , he m ig h t be labeled as a p e rs o n a lity
d is o r d e r . T h e m a tte r of diag n o sis, th e n ,
w o u ld be essentially a m a t t e r of w h a t seemed
im m e d ia te ly i m p o r t a n t. A ctu ally, we m ig h t say

119

CHO O SING A DYNAM IC FOCUS: SOME CO M M O N THEMES


th a t R og er suffered from a m ixed p s y c h o n e u
rotic d iso rd e r w ith anx iety , depressive, psy-

ch a n g e his job to one th a t d id not im po se too

chophysiologic, obsessive, phobic, a n d d istorted

g re a t resp o n sib ility on him . H e w o u ld be e n


c o u ra g e d to try to d etac h him self m o re from

p e r s o n a l i t y e le m e n ts . T h i s d i a g n o s t i c p o t
p o u rr i is not s u r p ris in g w h e n w e con sider th a t

o n th e basis of th e c u s to m a ry distan ces th a t he

every in dividual w h ose h o m eo stasis h a s b ro ken

erected

d o w n e xploits d y n a m i s m ch a ra cteristics of all

g u id a n c e an d r e a s s u ra n c e m a y m a k e it possible

levels of defense in a d d itio n to d isp la y in g


m a n i f e s t a t i o n s , p s y c h o l o g ic a l a n d p h y s i o

for R o g er to r e t u r n to his o w n b e d ro o m a n d to

logical, of ho m eostatic im b a la n c e a n d a d a p ta -

en a b le h im to fun ction w ith o u t anx iety.

his wife a n d slowly to begin fu n c tio n in g ag ain


b e tw e e n

h im self a n d

o th ers.

Active

ass u m e th e reserve w ith his wife th a t w ould


O n a n o th e r level, the th e r a p is t m ig h t utilize

tional collapse.

b e h a v io r m odification m e th o d s to desensitize
R o g e r w a s as ked w h a t he believed h ad

the p a tie n t to his an xieties as well as to in

p r e c i p i t a t e d his a n x i e t y o r i g in a ll y , he w a s u n s u r e ,

stitu te assertive t r a in i n g to p ro m o te g re a te r

b u t he h a z a r d e d t h a t it m ig h t h a v e been r e l a t e d to a

self-sufficiency a n d ind ep en d e n ce. A p p ro a c h e s

c h a n g e in h is p o s itio n at w o r k . N o t lo n g af ter his

such as these u n d e r s ta n d a b l y w o u ld n ot correct

W hen

t e n t h w e d d i n g a n n i v e r s a r y , a t ag e 33, R o g e r w a s
p r o m o te d to se n i o r m e m b e r of th e firm . H i s elatio n
at th is w a s sh o rt-liv e d as h e b e c a m e c on s ciou s of a
sudden

depressed

feeling,

w hich

progressively

d e e p e n e d . I n e r t i a , b o r e d o m , a n d w i t h d r a w a l fro m
his o r d i n a r y s o u rces of p l e a s u r e follo w ed. E v e n his

an y basic c h a r a c t e r p ro b le m s th a t lay a t the


h e a r t of R o g e r s distress. Yet th ey m ig h t m a k e
it possible for h im to get a lo n g p e r h a p s as well
as he h a d ever d on e p r i o r to th e o u tb r e a k of
his neurosis.

w o r k , to w h i c h he h a d felt h im se lf d evo ted , b e c a m e

Since m y a p p r o a c h w a s a d y n a m ic form of

a ch ore. A l w a y s e a g e r to c o o p e r a t e , he e x p e r i e n c e d ,

s h o r t-t e rm t h e r a p y a im e d at som e p e rs o n a lity


rectification, I p roceeded to e x p lo re as c o m

d u r i n g w o r k h o u r s , a v a g u e d r e a d o f s o m e th i n g
a b o u t to h a p p e n w h i c h he cou ld n ot def ine.

He

co uld not u n d e r s t a n d w h y h e w o u l d r eact to a p r o


m o t i o n t h a t he w a n t e d by g e t t i n g upset.

Sho uld

th e r a p is t

not

be

in terested

in

p letely as I could his p a s t life th r o u g h in t e r


v iew in g a n d to p ro b e for m o r e un con sciou s
m o tiv a tio n a l e le m e n ts t h r o u g h e x p lo r a tio n of
d r e a m s a n d fan tasie s a n d t h r o u g h observatio n
of th e transference.

p u rs u in g the p a t i e n t s s y m p to m s f u r th e r to d e
te r m i n e th eir orig in in early p ast e xpe rie nce or

R o g e r w a s t h e y o u n g e r of t w o b r o t h e r s . H e w a s

in unconscious conflict, in o th e r w o rd s, a v o id

r e a r e d by a d o m i n e e r i n g m o t h e r w h o w a s resentfu l

ing a d y n a m ic a p p r o a c h , a n a b b re v ia te d a p
p ro ac h aim ed at sy m p to m re d u c tio n m igh t

o f h e r r o le as h o u s e w i fe , w h i c h h a d h a l t e d a success

n ow be selected w ith o u t f u r th e r p ro b in g into

love life w i t h h e r h u s b a n d , sh e t r a n s f e r r e d h e r affec

history.
F irst, an effort m ay be m a d e to tr e a t his
sy m p to m s t h r o u g h m ed ica m en ts, like sedatives
or tr a n q u il iz e rs for a n xie ty a n d e n erg iz ers for

ful c a r e e r as a f a sh io n d e s ig n e r. U n h a p p y in h er
tio n to h e r y o u n g e r son , m i n i s t e r i n g to his every
w h i m a n d s m o t h e r i n g h i m w i t h clo y in g a d u l a t i o n .
R o g e r s

brother,

George,

bitterly

c o n tes ted

this

s i t u a t i o n , b u t g e t t i n g n o w h e r e , h e su bje cted his si b


lin g to c ru el r e p r i s a l . R o g e r s f a t h e r , r eco ilin g f ro m

depression. R o g er m ay be enjoined to slow


d ow n in his activities a n d to d etac h h im se lf as

th e no t

to o well con cea le d

re m o v e d

h i m s e l f f ro m t h e f am ily as m u c h as h e

much as possible. H e m ig h t be re q u es ted to


take a vacation, e ng age in h obbies an d re c r e a

co u ld m a n a g e a n d h a d very little c o n t a c t w i t h his

h o s tility of h is wife,

sons.

tions in o rd e r to divert his m ind off his difficul


ties.
A n o th e r w a y of h a n d li n g th e p ro b le m m igh t
be to assu m e th e source of th e difficulty to be
R o g e r s w o rk s itu atio n a n d to get h im to

T h e d y n a m ic s in R o g e r s case b ecam e a p
p a r e n t d u r i n g t h e r a p y . Basic to his p ro b le m
w a s a d is tu rb ed r e l a ti o n s h ip w ith his p a re n ts,
p a r t ic u l a r ly his m o th e r. T h e yielding of her

120

HANDBO OK OF SHORT-TERM PSYCHOTHERAPY

u n m a r r ie d p rofessional statu s to a s s u m e th e

liked for h is f a i rn e s s a n d a m i a b i l i t y . A t college h e

role of housew ife a p p a r e n t l y h a d created in th e

w a s r e t i r i n g , b u t h e h a d a n u m b e r of f rie n d s w h o

m o th e r re s e n tm e n t to w a rd h e r h u s b a n d and

s o u g h t his c o m p a n i o n s h i p b e c a u s e h e w a s so easy to

rejection

get

of h e r

c hild re n.

T h is

in s p ire d

reaction fo r m a ti o n in th e form of o v e r p r o
tection, p a r t ic u l a r ly to w a r d h e r y o u n g e r child,
R oger.

F r u s tr a t e d

a n d unfulfilled, she used

R o g e r as a targ e t for h e r o w n needs a n d a m b i


tions w ith the fo llow ing effects: (a) in R og er,
e n c o u ra g e m e n t

of o verd ep en d e n c e

an d

pas

sivity, stra n g lin g of assertiveness a n d in d e


pendence, an d s tim u la tio n of excessive sexual
feelings to w a r d th e m o th e r a n d (b) in G e o rg e ,
hostility d isplay ed directly to w a rd R o g e r as
a ggression, a n d (c) in h e r h u s b a n d , d e ta c h
m ent.

along

w ith.

su p e rf ic ia l, a n d

H is

ro m an tic

attachm ents

w ere

t h e y o u n g w o m e n he s q u i r e d to

p a r t i e s a d m i t t e d t h a t he w a s a t t r a c t i v e b u t c o m
p l a i n e d t h a t it w a s difficult to get to k n o w h im .

A d o p tin g d e ta c h m e n t as a defense a g a in s t a
d e p e n d e n t in v olv em en t, a n d c o m p lian ce as a
m e a n s of a v o idin g physical h u r t , R o g e r evolved
a c h a ra c t e r s t ru c tu r e th a t en a b le d h im to fu n c
tion at h o m e a n d at school, a lt h o u g h a t th e e x
p ense of co m p letely g ratify in g

r e la tio n sh ip s

w ith people.
U p o n l e a v in g college, h e e n t e r e d a b u sin e ss firm ,
a r r a n g e m e n t s for this h a v i n g b een m a d e b y his

O v e r p r o t e c t e d by his m a t e r n a l p a r e n t , neglected

f a t h e r . H e resisted for t w o y e a r s t h e e x h o r t a t i o n s of

by his f a t h e r , a n d a b u s e d by his b r o t h e r , R o g e r took

his m o t h e r to m a r r y t h e d a u g h t e r of o n e o f h e r best

refu g e in t h e r e l a t i o n s h i p offered h i m by his m o t h e r .

frien d s ; b u t fin ally h e s u c c u m b e d , a n d he se em ed

H i s d e p e n d e n c y on h e r n u r t u r e d s u b m is siv e n e s s a n d

satisfie d a n d h a p p y in his choice. T h e y o u n g co up le

p assiv ity , w i t h a l t e r n a t i v e striv in g s of reb ellio u sn es s

lived in h a r m o n y , a n d he w a s c o n s i d e r e d b y his

a n d fierce r e s e n t m e n t w h i c h h e r e p r e s s e d b ecause

g r o u p to be a n ideal e x a m p l e of a n a t t e n t i v e h u s

t h e y t h r e a t e n e d t h e se cu rity he m a n a g e d to derive

b a n d a n d , a f t e r h is so n w a s b o r n , of a devo ted

t h r o u g h c o m p l i a n t b e h a v io r . R o g e r b o th c h e r ish e d

f a t h e r . H i s s te a d fa s t a p p l i c a t i o n to h is w o r k soon

and

elevated

loath ed

the

crushing

attentiveness

of h is

h is

p o s itio n ,

u n til

he

became

a junior

m o t h e r . T o w a r d his f a t h e r a n d b r o t h e r h e felt a

m e m b e r o f t h e firm . H i s bes t f rie n d a n d co n f id a n t

s m o t h e r i n g fear, w h i c h he m a s k e d u n d e r a clo ak of

was

a d m i r a t i o n a n d co m p lia n c e .

R o g e r b o r e t h e g r e a t e s t r esp ec t a n d a d m i r a t i o n .

one

of t h e

se n i o r

m em bers,

tow ard

whom

T h e w i th d r a w a l of his fa th e r m a d e it dif

H is w o rk a n d m a r it a l life, w h ich w e re m o re

ficult for R o g er to achieve th e identification

or less a r r a n g e d for h im by his p a re n ts , t u r n e d

w ith a m ascu lin e object necessary for a virile


conception of himself. R o g e r t u r n e d to his
m o t h e r for p rotectio n. H e revolted, how ever,
ag ain st too g reat d e p e n d en cy on h er, fearin g
th a t excessive closeness w o u ld rob h im of
assertiveness a n d th a t his a ro u s e d sexual feel
ings w o uld b rin g on h im d is a p p ro v a l fro m his

out to be successful since he w a s able to e m


ploy in th e m his c o m p lia n c e a n d d e ta c h m e n t
m ech a n ism s. T o w a r d his best friend a n d o th e r
sen io r firm m e m b e r s R o g er related passively as
he h a d rela ted p rev iou sly t o w a r d his fath er
a n d b ro th e r. T o w a r d his wife he e x pressed
con ven tion al devotion, k eep in g him self suffi

m o t h e r as well as p u n is h m e n t from his fath e r


a n d b ro th e r. R e p u d ia t in g com petitiveness w ith
the o th e r m ale m e m b e rs of th e family, he a t

ciently d is ta n t to avoid th e t r a p of a te m p ti n g
d e p e n d e n t r e l a ti o n s h ip th a t w o u ld th r e a te n the
in d e p e n d e n t assertive role he w a s stru g g lin g to

te m p te d to w in th e ir a p p ro v a l by a subm issive,
in g r a ti a ti n g attitud e.

m a in ta in .
T h e o n l y d i s t r e s s i n g e l e m e n t in R o g e r s life w a s

D u r i n g a do les cen ce R o g e r e m e r g e d as a q u iet,

his failin g h e a l t h . C o n s t a n t l y f a t i g u e d , he evid en ced

d e t a c h e d lad , ne v e r p e r m i t t i n g h im se lf to be d r a w n

a pallor

i n to ver y i n t i m a t e r e l a t i o n s h i p s .

H e w as an ex

licitous i n q u i r i e s . D y s p e p t i c a t t a c k s a n d se vere m i

cellen t a n d c o n s c ie n tio u s s t u d e n t, a n d he w a s well

g r a i n o u s h e a d a c h e s i n c a p a c i t a t e d h i m f ro m t i m e to

and

listlessn ess t h a t

inspired

m a n y so

CHO O SIN G A DYNAM IC FOCUS: SOME CO M M O N THEMES


tim e. In a d d i t i o n to his p hy sic al s y m p t o m s w a s a
perv asiv e te n s io n , w h i c h co uld be relieved o n ly by

121

rea so n s of b oth statu s a n d econom ics, actu a lly


bein g p u t in a p o sitio n of p a r i ty w ith his friend

r e c r e a t i o n a l a n d social d istractio n s.

violated his defense of passivity, c o m p lian ce,


a n d s u b o r d in a ti o n a n d th r e a te n e d h im w ith

I n n e r co nflict b e tw e e n d e p e n d e n c y , s u b
missiveness, co m p liance, d e ta c h m e n t, a n d a g

th e very h u r t he h a d a n tic ip a te d as a child in


r e la tio n s h ip to his fa th e r a n d b ro th e r. T o ac

g re s s io n , h o w e v e r , c o n s t a n t l y c o m p r o m i s e d

cept th e p ro m o ti o n m e a n t t h a t h e w o u ld be

R o g e r s a d ju s tm e n t, p r o d u c in g a d is ru p ti o n of
h om eostasis w ith tension a n d psy cho som atic

c h a lle n g in g of a n d p e r h a p s t r i m p h a n t over

sym ptom s. H is failing h e a lth , fatigue, p a llo r,

fears of in ju ry a n d d e stru c tio n at th e h a n d s of

listlessness, dysp eptic attack s, a n d m i g ra i n o u s

a p o w e rfu l an d p u n itiv e force he could n e ith e r

h ead aches w ere evidences of a d a p tiv e i m b a l


ance. W h a t in sp ired this im b a la n c e w a s a n in

con tro l n o r v a n q u is h . Yet R o g e r s d esire for

vasion of his capacity to d etac h, p ro d u ce d by


th e d e m a n d s m a d e on h im by his wife a n d a s

m a d e it im p ossible for h im to give u p th a t

f a th e r a n d b r o t h e r figures. T h i s to u c h e d off

a d v a n c e m e n t,

in s p ire d by realistic concerns,

w h ic h he con sidered his due. Since he w as

sociates. In a d d itio n , his subm issive a n d c o m


p lia n t beh avio r, w hile p ro tectin g h im from

a w a r e n e ith e r of h o w fearfully he re g a r d e d a u

im ag ined h u r t , e n g en d ered in h im o v e r p o w e r

childish a ttitu d e s , he w a s n o n p lu s se d by his

ing hostility, w h ich p ro b a b l y d ra in e d itself off

reactions.

t h o r ity n o r of h o w he w a s o p e r a t in g w ith

th r o u g h his a u to m a tic ne rv o u s system p r o d u c


ing physical sy m p tom s.

A dream
se ssion

As

m ight

b e ex p e c te d ,

R o g e r s affa bility

and

n eeds to p lease w o n for h i m t h e p r a i s e of his s u p e r i

revealed d u rin g o n e p sy c h o th e ra p y

w ill

illu strate

som e

of

our

p a t i e n t s

m a n e u v e r s t h a t b e c a m e o p e r a t i v e a n d a p p a r e n t in
therapy.

o rs a t w o r k , a n d he w a s a d v a n c e d a n d finally of
fered a se n i o r p ositio n.

P t.

I h a d a d r e a m last n i g h t t h a t u p se t m e. I a m in
bed

w om an,

big

w onderful

I feel c o m p le te ly loved a n d accep te d.

u al feeling t h a t u p se t m e. [H e re R o g e r s y m b o
lize s in d re a m str u c tu r e h is d e p e n d e n c y im

cam e m ore an d m ore ac c e n tu a te d un til finally


he no lo nger w a s ab le to m a r s h a l f u r th e r
defenses. C o lla p se in a d a p ta tio n w ith he lp less

tive self-fulfillment, R o g er w a s ab le to m a k e a
to lera ble a d ju s tm e n t even w ith his psych oso
m atic sy m pto m s. T h e p re c ip a tin g factor th a t
h a d b ro u g h t a b o u t the u n d e r m in i n g of R o g e r s
capacities for a d a p ta tio n w a s his p ro m o tio n to
senior m e m b e rs h ip in th e firm . W h il e R og er
h a d a r d e n t l y d e s i r e d t h i s p r o m o t i o n , for

big

aw o k e from the d r e a m w ith a strong h om osex

H is le gitim ate desires for ad v a n c e m e n t, h o w


ever, enjoined him to accept. H is conflict be

As long as h e h a d been able to satisfy to a


re ason ab le d eg ree his needs for security, a ss e r
tion, satisfaction in w o rk a n d play , a n d c r e a

this

n eg ress. S h e str o k e s a n d to u c h e s m e all over ,


and

escaped the c a ta s tr o p h e th a t finally stru ck him .

ness an d ex pec tatio ns of in ju ry a n n o u n c e d


th e m s e l v e s in a n a n x i e t y a t t a c k d u r i n g
lun cheo n w ith his friend.

w ith

b r e a sts . S h e s m y wife, b u t s h e c h a n g e s in to a

H a d R o g e r at this p o in t refused to accept


senior m e m b e rs h ip in the firm , he m ig h t have

p u ls e s , h is re p u lsio n a g a in st h is d e p e n d e n c y ,
h is in c e s tu o u s d esire, a n d th e re s u lta n t h o
m o s e x u a l re sid u e.]

T h . Yes, w h a t d o y o u m a k e o f t h i s ?
P t.

I d o n t k n o w . T h e w o m a n w a s c o m f o r t i n g a n d
se ductive.

I a l w a y s like b i g - b r e a s t e d w o m e n .

E x c i ti n g . B u t m y wife i s n t as sta ck ed as I d
like h e r , o r as she w a s in t h e d r e a m , (p a u se)

T h . H o w a b o u t t h e n eg ress ?
P t.

I n e v e r liked t h e idea of s l e e p i n g w i t h a co lored


w o m a n . M a k e s m e feel cr e e p y . C o l o r e d p e o p le
m a k e m e feel cre e p y . I k n o w I s h o u l d n t feel
t h a t w ay . L a s t t i m e I w a s h e r e I n oticed you
h a d a t a n like y o u h a d been in t h e sun . I sa id,
M aybe

h e s go t

negro

blood.

I know

s h o u l d n t c a r e if y o u d i d o r no t, b u t t h e idea
sc are d m e for so m e r e a s o n .

HANDBO OK OF SHORT-TERM PSYCHOTHERAPY

122

and u n m ascu lin e

T h . S o u n d s like the w o m a n in y o u r d r e a m w a s
p a r t l y me.
in

[ T h is in te r p r e ta tio n w a s p r o ffe r e d

th e h o p e o f s tir r in g u p s o m e te n sio n

sh it

h a t e myse lf.

I am

to

n o t h i n g a n d I d like to be a s o m e b o d y , b u t I

(p a u se ) T h e id ea sc are s me. W h y s h o u l d I

T h . A p p a r e n t l y it sc are s y o u to be a s o m e b o d y .

w a n t you to m a k e love to m e ? (p a u s e ) By G o d ,

W h e n yo u w e r e p r o m o t e d , y o u s t a r t e d g e t t i n g

c a n t.

fa c ilita te a sso cia tio n s.]


Pt.

\m o to r th re e ], I feel like a

[m o to r f o u r j a n d

m a y b e I w a n t y o u to m o t h e r m e, be giving,
k in d .

u p se t.
P t.

W h y s h o u l d I? I s u p p o s e I feel like I m s t e p

T h . H o w do y o u feel a b o u t m e?

ping

P t.

e n o u g h . T h e w h o l e t h i n g p u z z l e s a n d f ri g h t e n s

I w a n t yo u to be p erfect like a G o d ; to be a c

out

of m y d e p t h .

I m

not

m an

me.

c e p t i n g a n d loving ; to be w ise a n d str o n g . I


r e a l i z e I m d e p e n d e n t \m o to r o n e], I resen t m y

T h . So w h a t d o you d o ?

n eed to be d e p e n d e n t o n y o u

P t.

[m o to r tw o ] .

L ike

I a m c o n s t a n t l y r u n n i n g a w a y [m o to r fiv e ] , I

W h e n you s h o w a n y w e a k n e s s , I a m fu rio u s. I

get so a n g r y a t p eop le. I d o n t w a n t to see a n y

feel g uilty a n d u pse t a b o u t m y feelings. I feel

b od y. I m so u p se t a b o u t myse lf. I t r y n o t to

like killing a n y b o d y w h o c o n t r o l s me. I k n o w I

feel. B u t I c a n t se em to m a k e it on m y o w n .

m u s t face res p o n s i b i li t y , b u t I feel to o w e a k

[ T h e r e in s titu tin g o f m o to r o n e ]

FIG . 9-1. Personality M echanism s*

THE FIVE M OTORS

M OTOR ONE
HIGH DEPENDENCE
"I want you to be perfect, like a God; to be
accepting and loving; to be wise and
strong."

M OTOR TWO
RESENTMENT
HOSTILITY
"I resent my need to be dependent on
you. When you show any weakness, I am
furious. I feel guilty and upset about my
feelings. I feel like killing anybody who
controls me."

M OTOR THREE
LOW INDEPENDENCE
M OTOR FOUR
DEVALUED SELF-IMAGE
"I feel like a shit and hate myself. I am a
nothing and I'd like to a somebody, but I
can't."

"I know I must face responsibility, but I


feel too weak, and unm asculine." (In fe
males: "If I were a man, I would be strong
and independent.")

M OTOR FIVE
DETACHMENT
"I am constantly running away. I get so
angry at people. I don't want to see any
body. I'm so upset about myself. I try not
to feel."

* F r o m L . R . W o lb e r g a n d J . K ild a h l, T h e D y n a m ic s o f P e r s o n a lity (N e w Y o r k , G r u n e & S tr a t to n , 1 9 7 0 ), p . 2 1 5 .


R e p r i n te d b y p e rm is s io n .

CHO O SIN G A DYNAM IC FOCUS: SOME CO M M O N THEMES

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HANDBO OK OF SHORT-TERM PSYCHOTHERAPY

T h e p a tie n t in th e session w as m anifestly

in te r m s of his h a b itu a l p e rs o n a lity responses,

g ro p in g w ith his passiv e-d e p e n d en t strivings


(m o to r one), his ra g e (m o to r tw o ), his feelings

c on nec ting t h e m w ith his ex periences in g r o w


in g u p an d re la tin g th e m to the in cid ents le a d

of low in d ep en d e n ce (m o to r th ree), his d e


valued self-image (m o to r fo u r ), his d e ta c h m e n t

in g to the collapse in his hom eostasis, en a b le d


R o g e r to a p p r o a c h a different re la tio n s h ip

(m o to r fiv e ), to g e th e r w ith c o n co m ita n t u n r e

w ith me. T h i s oc curred a b o u t the tw e n ti e th

solved incestuous drives a n d u n e x p re s se d h o

session an d acted as a n u cle u s for different feel


ings t o w a r d him self. N o t o n ly w a s hom eo stasis
resto red w ith cessation of his sy m p to m s, b u t he

m osexu al im pulses. M a n y aspects of R o g e r s


p e rs o n a lity p ro b le m w ere bein g projected onto
his th e r a p is t in tr ansference.
T h e s e p a tt e r n s a r e delin eate d in F ig u r e 9 - 1 .
In te r p r e t a ti o n o f the p a t i e n t s reac tion s to me

also w a s ab le to accept his post as a senio r


m e m b e r of th e firm w ith subjective a n d objec
tive s t re n g th e n i n g of his ego.

Conclusion
C o m m o n p s y c h o d y n a m i c s a r e s h a r e d by
p e o p le

in

our

cu ltu re.

They

in c l u d e

th e

self-image also leads to c o m p e n s a to r y m e a s u re s

ravages of h ig h d e pen de ncy , re s e n tm e n t a n d

s u c h as p e r f e c t i o n i s m , . a m b i t i o u s n e s s , a n d
p o w e r drives. A nd d e ta c h m e n t often provokes

hostility, lo w ind ep end e n ce, a d e v alu a ted self-

o ne to a b a n d o n o n e s isolation a n d p lu n g e into

im age, a n d d e ta c h m e n t. It is the d egree of


in ten sity of th ese drives th a t d e te r m in e th e ir

co m pu lsiv e g reg ario u sn ess. A n y a n d all of


th ese drives m a y becom e sexu alized, so th a t
o n e s sexual im p u lses becom e linked to feelings

path og enicity . O ffshoots fro m re s e n tm e n t in


clude aggression, p e r h a p s to the p o in t of
sadism , an d also guilt re s u ltin g from th e h a t e
ful feelings, even ev e n tu a tin g in m a sochism .
H ig h d e p en d e n c y is associate d w ith passivity
and

a f e m i n i n e id e n t i f i c a t i o n .

F e e l i n g s of

hostility s p o n s o r guilt, m aso ch ism , a ggression,


a n d sadism . L o w in d ep e n d e n c e p r o m p ts the
o v e rc o m p e n sa to ry strivings of co m pulsive a g
gressiveness a n d com petitiveness, m a k i n g for a
n e u ro tic m a sculine identification. A devalue d

of in cestuo us passivity o r co m p etitive d o m i n a


tion w ith co n se q u e n t fears of re ta lia tio n or
w ith m asoch istic o r sadistic im pulses. W h e n
these drives fail to m a i n t a i n ho m eo stasis a n d
conflict is un reso lved , th e n a n x ie ty res u lts a n d
v a rio u s levels of defense m e c h a n ism s o p e ra te to
cope w ith th e an x ie ty . A g re a t m a n y d y n a m ic
th em es e v e n tu a te (see F i g u r e 9 - 2 ) a n d offer
them selves as possible foci for e x p lo ratio n .

CHAPTER 10

Choosing a Dynamic Focus


C. Presenting Interpretations

T h e most effective focus is o ne th a t deals


w ith a basic repetitive conflict, th e m anifest
form of w h ich is b eing exp ressed t h r o u g h the

good deal of h e r hostility in th e t h e r a p e u ti c


session, she m a y be w illin g to cancel h e r d i

im m ed iate co m p la in t factor. As a n e x a m p le ,

vorce p la n s a n d settle for h a lf a loaf r a t h e r


t h a n n o n e . T h e r e c o n c i l i a t i o n is e x e c u t e d

consider a crisis s itu atio n involving a wife, the

t h r o u g h a s u p p r e s s io n of h e r hostility, w h ich

m o th e r of tw o sm all c h ild ren , w h o insists on a


divorce because of c o n tin u in g d is e n c h a n tm e n t

finds a n ou tlet t h r o u g h sexu al frigidity an d

w ith h e r m a r ria g e . T h e divorce decision a p

h a n d , shou ld th e th e r a p is t recog nize th e core

p e a rs to be th e te r m in a l e r u p t io n of y ears of

conflict t h a t is m o tiv a tin g h e r idea of divorce,

d is a p p o in t m e n t in h e r h u s b a n d s failu re to live
u p to h e r ideal of w h a t a m a n sho uld be like.

t h e r e is a c h a n c e th a t th e p a t i e n t m a y be
h elp e d to a n a w a r e n e s s of h e r m erciless in

After w e cut t h r o u g h endless c o m p lain ts, it be


cam e a p p a r e n t t h a t the s t a n d a r d a g a in s t w hic h

v olvem ent w ith h e r fa th e r a n d th e d estructive


u n re a s o n a b le n e s s of h e r fantasies of w h a t an

she m e asu res h e r h u s b a n d is h e r fath er, w h o m


she w o rsh ip s as th e e p ito m e of success a n d

ideal m a r r ia g e is like. S h e m a y th e n allow


h erse lf to e x a m i n e th e re al v irtu es of h e r h u s

m asculinity. T h is id e a liz a tio n actu a lly has

b a n d a n d the tr u e a d v a n ta g e s of h e r e x isting

little basis in fact, b eing th e r e m n a n t of a n u n

m a r ria g e .

resolved oedipal conflict. Be this as it m a y , it

A d y n a m ic focus sh o u ld , the re fore, be p r o s


pecte d in the co u rse of e x p lo r in g th e im m e d ia te

has th w a r t e d h e r a bility to m a k e a p r o p e r a d
j u s t m e n t to h e r m a r r ia g e , a n d n ow w ith th e

various physical

sym p to m s.

On

th e o th e r

c o m p la in t factor. S u ch a focus is often arriv e d

decision of a divorce th e in teg rity of h e r fam ily

at

is being th r e a te n e d . She comes to t h e r a p y at


the u rg in g of h e r la w y e r w h o realizes th a t she

e m p a th ic , skilled, a n d ex p e rie n c ed th e t h e r a
pist, th e m o r e likely he will be to e x p lo r e th e

is too u pset at p re s e n t to m a k e re a s o n a b le deci


sions.
A th e r a p is t w h o m in im iz es th e im p o rt a n c e

a ctu a l o p e ra tiv e dy n a m ic s. H o w e v e r, no m a t
te r h o w firm ly convinced he is in his i m

of d y n a m ic conflicts m a y a tt e m p t to achieve th e
goal of crisis resolu tio n by in v ok in g logic or
a p p e a ls to co m m o n sense. H e m a y suggest
w ays of p a tc h in g th in g s u p , in sistin g th a t for
the sake of th e child ren a fath er, ho w e v e r
in a d e q u a te , is b etter t h a n no fath er. H e m ay,
u p o n con su ltin g w ith th e h u s b a n d , p o in t out
v ario u s co m p ro m ises the h u s b a n d can m ak e,
an d after th e wife h as v erb ally disg org ed a

in t u i t i v e l y

(B in d er,

1977).

The

m ore

m e d ia te a ss u m p tio n s , h e realiz es th a t th ese a re


b e i n g p r e d i c a t e d on i n c o m p l e t e d a t a . H e
k n o w s th a t his p a ti e n t m a y delib e rately w i t h
ho ld im p o r t a n t in fo rm a tio n , o r t h o u g h th e p a
tie n t m a y rec o g n ize ce rta in conflicts she is still
oblivious to th e i r significance o r com p letely
u n a w a r e of th e i r existence. W h a t e v e r ten tative
th eories com e to th e t h e r a p i s t s m in d , he will
co n tin u e to check a n d to revise th e m as f u r th e r
in f o rm a tio n unfolds. In te rv ie w s w ith relatives

125

126

HANDBOOK OF SHORT-TERM PSYCHOTHERAPY

a n d friends a re ex tre m ely v a lu a b le since th ey


m a y open facets of p ro b le m s not evident in th e

ing course for th e m o m e n ta r y jo y th a t followed


a n o u tb u r s t of aggression.

co nversations w ith th e p a tie n t. M o r e o v e r, once


th e p a tie n t d u r i n g the first en c o u n te r h a s d i

a m p le evidence of th e futility of focusing on th e

vulged d a ta , late r interview s will h elp uncover

E x p erie n ce

w ith

th e

ad d ictio n s

p rovide

dis to rtio n s

d y n a m ic s of a d a n g e r o u s a n d w h a t a p p e a r s on
th e surface to be a d is a g re e a b le w ay of b e h a v

th a t will force th e th e r a p is t to revise his thesis


a n d con cen tra te on a different focus from the

does not nullify th e need to persist in m a k

o ne th a t o rigin ally seem ed so obvious.


N o m a t te r h ow a stu te th e th e r a p is t has been

ing careful i n t e r p r e ta ti o n s in the h o p e of


e v e n tu a lly e ro d in g re sistanc e to th e voice of

in ex po sin g a tr u ly m o m e n to u s focus, the p a


t i e n t s reaction s will d e te r m in e w h e th e r th e e x

reaso n.
W e m a y expect th a t a p a ti e n t in need of

ratio n a liz a tio n s,

p rojections,

an d

ing. B ut, th a t som e p a tie n ts d is reg ard logic

po su re t u r n s o u t to be fruitful o r not. F o r ex

h e lp will c o m m u n ic a te sufficiently to su p p ly

a m p le , even th o u g h a n u n d e rly in g p ro b le m is

essential m a t e r i a l fro m w h ic h a focus m a y be

c a u s i n g h a v o c in a p e r s o n s life a n d is
responsible for th e crisis th a t bring s th e perso n

e x tr a p o la te d .

to th e r a p y , this does not im ply th a t the p a tie n t


will elect to do a n y th i n g a b o u t it. Its em o tio n al

am ong

m e a n in g m a y be so i m p o r t a n t to th e p a tie n t,
th e subversive p le a s u re s a n d seco nd ary gains
so g reat, th a t suffering a n d m isery a re easily

U n d e r s t a n d a b ly ,

th e r e will

be

differences in e m p h a s is a m o n g th e r a p ists, even


th o s e

who

have

re c e iv e d

sim ilar

the oretica l g ro u n d in g . T h e av ailab le m a te ria l


is u su a lly sufficiently rich to en a b le th e r a p ists
to e m p a t h iz e w ith aspects th a t sy n c h ro n ize

accepted as con dition s for th e in du lg ence of


destructive drives even w h e r e th e p a tie n t has

w ith th e ir needs, in tu itio n s , ideas, a n d biases.


Since all p eo p le s h a r e ce rta in conflicts th a t
a re basic in o u r c u ltu re , som e of th ese can co n

full insight in to th e p ro b le m , recognizes its

stitu te the d y n a m i c focus a r o u n d w h ich in t e r

genetic roots, an d realizes th e com plication s

p re ta tio n s a r e m ade. T h u s m an ifestatio n s of


the stru g g le over se p a r a tio n -in d iv id u a tio n fol

th a t inevitably in dem n ify the indulgence. I r e


call one p a tie n t w ho se y e a rn in g for revenge on
a yo u n g er sibling p ro d u ce d a repetitive series

lo w in g th e ideas of M a n n (1973), p ersistence

figures to w a r d w h o m re ta lia to ry hostilities an d

of oedip al fantasies as exem plified in the w o rk


of Sifneos (1972), a n d residu es of psychic
m as o ch ism such as described by L e w in (1970)

violence b ro u g h t forth p u n is h m e n t by e m
ployees, colleagues, a n d friends. A series of

a r e som e of the core conflicts th a t m a y be ex


plo red a n d in te rp re te d . Se nsitiz ing o neself to

ab uses c u lm in a te d in a d is a stro u s incident in


w h ich a physical a ssa u lt on a fellow em ployee
resu lted in th e p a t i e n t s d ischarge from a
p ro m isin g executive position. T h i s h a p p e n in g
w as so w idely publicized in th e in d u s try th a t

ind ica tion s of such conflicts as th ey come


t h r o u g h in th e p a t i e n t s c o m m u n ic a tio n s , the
th e r a p is t m a y rep e a te d ly co nfro n t th e p a tie n t
w ith evidence of h o w he is b ein g victim ized by
t h e o p e r a t i o n s of specific i n n e r s a b o t e u r s .
T h e r e is scarcely a pe rs o n in w h o m o ne m a y

of c o m p e t it iv e

en co u n te rs

w ith

su rro g a te

the p a tie n t w a s u n a b le to secure a n o th e r jo b .


D u r i n g th e r a p y th e p a tie n t w a s co nfro nted
w ith the m e a n i n g of his beh av io r a n d p a r t i c u
larly his revenge an d m asochistic motives; he
read ily recognized an d accepted th eir validity.
T h i s did not in th e least d eter his acting ou t on
a n y occasion w h e n he could vent his rag e on a
sibling figure. At the en d of o u r brief tr e a tm e n t
p erio d , it w a s re c o m m e n d e d th a t he go into
lo n g -te rm t h e r a p y , w h ich he b lu n tly refused to
do. H e seemed reconciled to p u r s u e a d a m a g

no t, if on e searches assidiously e n o u g h , find in


dicatio ns of in com ple te s e p a r a ti o n - in d i v id u a
tion, fr a g m e n ts of th e o ed ip al struggle, an d
su rges of guilt a n d m aso ch ism . It is essential,
ho w e v e r, to sh ow h ow these a re in tim a te ly
connected w ith th e a n x ieties, needs, and
defenses of each p a ti e n t an d h o w th ey u lti
m a te ly have b r o u g h t a b o u t th e sy m p to m s an d
b eh a v io ra l difficulties for w h ich the p a tie n t
seeks help.

CHO O SIN G A DYNAM IC FOCUS: PRESENTING INTERPRETATIONS


Lest we o v ere m p h a siz e the p o w e r of insight
in b rin g in g a b o u t c han ge, we m u s t stress th a t

p ro b le m s

in itiate

e m o tio n a l

127
difficulties

an d

c reate resistan ce to p s y c h o t h e r a p y first, high

to a larg e e x te n t the choice of a focus will

levels of d e p e n d e n c y (the p ro d u c t of i n a d e q u a te

d ep e n d on th e t h e r a p i s t s seeing the p re s e n tin g

s e p a r a tio n -in d iv id u a tio n ), second, a h y p e r t r o

p ro b le m of the p a tie n t th r o u g h th e lens of his

p h ie d sadistic conscience, a n d , th ird , d e v a lu a te d

theoretical convictions. A F r e u d i a n , J u n g i a n ,

self-esteem.

A d lerian , K lein ian , H o rn e y ite , S u lliv an ian ,

o th e r , th ey cre ate needs to fasten o n to a n d to

E x istentialist, o r b e h a v io r th e r a p is t will focus


on different aspects a n d will o rg a n iz e a t r e a t

d i s t r u s t a u t h o r i t y , to t o r m e n t a n d p u n i s h
oneself m asochistically, a n d to w allo w in a

m e n t p la n in acco rdan ce w ith p e rs o n a l ideo l


ogies. W h ile the focus, because of this, will

sw a m p of hopeless feelings of in feriority an d


ineffectuality. T h e y fr e q u e n tly sa bo tag e a t h e r

vary, th ere is co nsid erab le evidence th a t h o w

a p i s t s m ost skilled tr e a t m e n t inte rve ntion s,


a n d , w h e n they m an ifest them selves, unless

th e focus is im p le m e n te d a n d th e q u a lity of the


re la tio n sh ip w ith th e p a tie n t a re at least as i m
p o rt a n t factors in th e cure, if no t m o re so, th a n
th e prescience of the th e r a p is t a n d the in s ig h t
ful bone of d y n a m ic w isd o m he gives the p a

C o e x istin g an d

reinforcin g each

d e a lt w ith d e lib e ra te ly a n d firm ly, th e t r e a t


m e n t process will usu ally reach a n u n h a p p y
end. D e d icated as he m a y be to th e i r re s o lu
tion , th e m ost th e th e r a p is t m a y be ab le to do

tient to chew on. T h a t im p la n t a ti o n s of insight


som etim es do a lter th e b a la n c e b etw ee n the

is to p o in t ou t evidences of o p e ra tio n of these


s a bo teurs, to d elin eate th e ir o rig in in ea rly life

repressed

ex perience, to in dicate th e ir destru ctive im p act


on th e a c h ie v e m en t of re a s o n a b le a d a p tiv e

and

r e p r e s s i v e fo rces c a n n o t be

d isp uted . H o w m u c h th e benefits a re d u e to


this factor a n d h ow m u c h a r e th e p ro d u c t of
the placebo effect of insight, how ever, is dif
ficult to say. W h e r e a th e r a p is t is firm ly co n
vinced of the validity of the focus he h a s chosen
an d he convinces his p a ti e n t th a t n e u ro tic
de m on s w ith in can be con trolled t h r o u g h a c

goals, to w a r n t h a t th ey m a y m a k e a sh am b le s
o ut of th e p re s e n t tr e a t m e n t effort, a n d to e n
co u ra g e th e p a ti e n t to recognize his perso n a l
resp on sib ility in p e r p e t u a ti n g th e i r o p e ratio n .
T h e ten ac iou s hold they can h ave on a p a tie n t
is illu strate d by this fr a g m e n t of a n interview .

c e p ti n g a n d a c ti n g u p o n t h e i n s i g h t s
presented, ten sion a n d a n x ie ty m a y be suffi

T h e p a tie n t, a w rit e r, 42 y ea rs of age, w h o


m a d e a sk im p y living as a n ed ito r in a p u b li s h

ciently lifted to relieve s y m p to m s a n d to p r o


mote pro du ctiv e a d a p ta tio n . E v en sp u r io u s

ing h ouse ca m e to th e r a p y for d ep ressio n a n d


for h e lp in w o r k in g o n a novel th a t h a d defied

insights if accepted m a y in th is w a y serve a


useful p urpo se. W i t h o u t q u estio n , n e v e rth e

c o m p l e t i o n for y e a r s . A n g e r , g u i l t , s h a m e

less, th e closer one comes in a p p r o x i m a t i n g

w h e n e v e r he c o m p a r e d h im se lf w ith his m o re

some of th e sources of th e p a t i e n t s c u rr e n t
troubles, the g re a t e r the likelihood th a t signifi
cant benefits will follow.

successful colleagues. H e w a s in a c u sto m a rily


fr u str a te d , d e s p o n d e n t m o od w h e n he c o m
p la in ed :

In this respect for som e y ears I h ave e m


ployed a schem e th a t I have found v a lu a b le in

P t.

w o rk in g w ith patie nts. T h i s consists of s t u d y


ing w h a t resistences arise d u r i n g the im p le
m en ta tio n of th e tech niqu es th a t I h a p p e n to
be em p lo y in g at the time. T h e resistances will
yield d a ta on the existing d y n a m ic conflicts,
the most obstructive of w h ich is th e n chosen as
a focus.
E x p erie n ce w ith large n u m b e r s of p a tie n ts
convinces th a t th re e co m m o n d ev e lo p m en tal

a n d a host of o th e r e m o tio n s b u b b le d over

I j u s t c a n t get m y ass m o v i n g o n a n y t h i n g . I
sit d o w n a n d m y m i n d goes b l a n k . S t a r i n g a t a
b l a n k piece of p a p e r for h o u r s , I fin ally give
up.

T h . T h i s m u s t be t e r r i b l y f r u s t r a t i n g to you.
P t.

(a n g r ily ) F r u s t r a t i n g is a m ild w o r d , do cto r. I


can kill m y se lf for being su c h a shit.

T h . Y o u re a l l y t h i n k yo u a r e a s h i t ?
P t.

(a n g r ily ) N o t o n ly do I t h i n k I a m a sh it, I am
a sh it, a n d n o b o d y can co n v in ce m e t h a t I m
not.

H ANDBO OK OF SHORT-TERM PSYCHOTHERAPY

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FIG. 10-1. Outline of Personality O perations

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CHO O SIN G A DYNAM IC FOCUS: PRESENTING INTERPRETATIONS


T h . F r a n k l y , F r e d , I m n o t even g o in g to try. B u t
y o u m u s t h a v e h a d s o m e h o p e for yourse lf,
o t h e r w i s e y o u n e v e r w o u l d h a v e c o m e h ere.

Pt.

I f ig u re d y o u c o u ld get m e o u t o f this, b u t I
k n o w i t s n o use. F v e a l w a y s b e e n a tail e n d e r .
i m p re s s io n t h a t y o u ve go t a n i n v e s tm e n t in
h o l d i n g on to t h e i m p r e s s io n yo u a r e a shit.
W h a t d o yo u t h i n k y ou get o u t of t h is?
N o t h i n g , a b s o l u te ly n o t h i n g .

W hy

should

In th e co n d u c t of b rief tr e a tm e n t on e m a y
no t h av e to d eal w ith th e u n d e r l y in g conflicts
such as th ose above as lon g as the p a tie n t is
m o vin g alo n g a n d m a k in g p ro g re ss. I t is on ly
w h en th e ra p y is b o g g ed d o w n th a t sou rces o f

T h . (confronting the patient) Y o u k n o w , I get t h e

Pt.

129

n eed th is?

T h . Y o u tell m e. [In his upbringing the patient


was exposed to a rejecting father who de
manded perfection from his son. The father
was never satisfied with the even better than
average marks his son obtained at school and
compared him unfavorably with boys in the
neighborhood who were prom inent in athletics
and received commendations fo r their school
work. It seemed to me that the paternal introject was operating in the patient long after
he left home, carrying on the same belittling
activities that had plagued his existence when
he was growing up. ]
P t. (pause) T h e r e is n o r e a s o n , (pause)
T h . Y o u k n o w I get t h e i m p r e s s io n t h a t y ou a r e
doing the sam e jo b on yourself now th at your
f a t h e r d id on you w h e n y o u w e r e a boy. I t s
like y o u ve got h i m in y o u r h e a d . [In the first

part of the session the patient had talked about


the unreasonableness of his father and his own
inability to please his father.]
P t. I a m s u r e I do, b u t k n o w i n g t h is d o e s n t h elp.
T h . C o u l d it be t h a t if y ou m a k e y o u r se lf h elp less
s o m e b o d y will co m e a l o n g a n d h e l p yo u o u t ?

[I was convinced the patient was trying to


foster a dependent relationship with me, one in
which I would carry him to success that defied
his own efforts. ]
P t. Y o u m e a n , y o u ?
T h . I s n t t h a t w h a t you said a t t h e b e g i n n i n g , t h a t
y ou c a m e to m e to get y o u o u t o f t h i s t h i n g ?
Yo u see if I let y o u get d e p e n d e n t o n m e it
w o u l d n t re a lly solve y o u r p r o b l e m . W h a t I
w a n t to d o is h e l p you h e l p yourse lf. T h i s will
s t r e n g t h e n you.

resistan ce m u st be u ncovered. T h e s e as ha s
been ind icated , a r e u su a lly ro o ted in th e im
m a t u r e n e e d s a n d d e fe n s e s o f d e p e n d e n t ,
m asochistic, self-d ev alu atin g p r o m p ti n g s . At
som e

p o in t

an

e x p la n a tio n

of w h e r e

such

p ro m p ti n g s o rig in a te d a n d h o w they a r e no w
o p e r a t in g will h ave to be given th e p a tie n t.
T h i s e x p la n a tio n m a y at first fall on d e a f ears,
b u t as th e th e r a p is t c onsistently d e m o n s tra t e s
th e ir existence fro m th e p a t i e n t s re actio n s a n d
p a tt e r n s , th e p a ti e n t m a y e v en tu a lly g ra s p
th e ir significance. T h e desire to m a k e oneself
d e p e n d e n t a n d th e destructiv eness o f this i m
pulse, th e c on ne ctio n of suffering a n d s y m p
to m s w ith a pervasiv e desire for p u n is h m e n t ,
th e m asochistic need to a p p e a s e a sadistic co n
science th a t derives fro m a bad p a r e n t a l introject, th e o p e r a t io n of a d e valu e d self-image,
w ith the subversive gain s th a t a ccru e fro m vic
tim iz in g oneself, m u s t be re p e a te d at every o p
p o rt u n it y , co n fr o n tin g th e p a ti e n t w ith q u e s
ti on s as to w h y he needs to c o n tin u e to sp o n so r
such activities.
S o m etim es a g e n e ra l o u tlin e of d y n a m ic s
(such as a r e de tailed in C h a p t e r 9) m a y be of
fered the p a ti e n t w ith th e object of e ith e r s t ir
rin g u p som e a n x ie ty o r res istan ce o r of p r o
viding th e p a t i e n t w ith a n in t e r p r e ta ti o n th a t
f o s te rs a b e t t e r u n d e r s t a n d i n g

of h im s e lf.

W h il e the d elin e a te d drives a n d defenses a re


p r o b a b l y t y p i c a l in o u r c u l t u r e of b o th
n o r m a l a n d n e u ro tic ind ivid u als, th e specific
m o des of o p e r a t io n a n d the k in d s of sy m p to m s
a n d m a l a d ju s tm e n ts th a t exist a r e u n i q u e for
e ach in d iv id u a l. E v e ry p e rs o n h a s a t h u m b ,
b u t p a t t e r n s of t h u m b p r i n t s a r e all different.
T h e th e r a p is t , e m p lo y in g a b lu e p r in t such as

y o u c a n t get o u t o f t h is t h i n g t h is self
s a b o tag e. ( The patient responds with a dubi

F ig u r e 1 0 - 1 , m a y try to fit each p a t i e n t s


p ro b le m s into it a n d th e n choose for focus
w h a te v e r asp ects a r e most im p o r t a n t a t th e
m o m e n t. F o r e x a m p le , th e p a ti e n t m a y d u r i n g

ous expression on his face and then quickly tries


to change the subject.)

a session c o m p l a in of a severe h e a d a c h e a n d
th e r e a fte r p ro ceed to bea t h im self m a s o c h is

Pt. B u t if I c a n t h e l p m yself, w h a t t h e n ?
T h . F r o m w h a t I see t h e r e i s n t a n y r e a s o n w h y

130

HANDBO OK OF SHORT-TERM PSYCHOTHERAPY

ineffectual. T h e th e r a p is t sho uld th en search to

p ro d u c e d his b re a k d o w n . H e is very m u c h like


a m a n w ith b a c k p a in w h o credits his sci

see h o w this tr e n d affiliates itself w ith guilt


feelings an d w h a t im m ed iate situ atio n insp ired

a t i c a to one incident of lifting a w e ig h t th a t


w a s too heavy, o blivious of the fact th a t for

tically, b la m in g him self for being w e a k an d

such feelings. T h e th e r a p is t m a y discover th a t

m o n th s or y ears he has, th r o u g h faulty p o s tu re

w h a t is beh ind th e guilt is a n g e r in th e p a tie n t

a n d lack of exercise, been a c c u m u la tin g w e a k

at his wife for not living u p to his e x p e ctatio n s

a n d stra in e d muscles.

in executing h e r h o u seh o ld duties. F u r t h e r


p ro b in g m a y reveal a n g e r at th e th e r a p is t for

su s tain ed by a defense of perfectionism , for as

not d oing m o r e for th e p a tie n t. Such t r a n s

far back as he c a n re m e m b e r , will h av e to p e r

ference m an ifestatio n s m a y e n ab le th e t h e r a

fo rm flawlessly even in tin y a n d m o st in c o n

pist to m a k e a co nnection w ith th e p a t i e n t s

seq u e n tia l a re a s of ach ie v em ent. T o p e rf o rm


less th a n perfect is t a n t a m o u n t w ith failu re an d

m o t h e r to w a r d w h o m th ere h as existed since

T h u s a p a ti e n t w h o se self-image is being

child ho od a good deal of a n g e r for h e r neglect


a n d rejection. T h i s will o pen u p a discussion of

signals in fe riority an d a sh a tte re d identity. T h e

th e p a t i e n t s excessive d ep en d e n c y needs an d

a c tu a lly be im p ossib le of fu lfillm ent. At a


ce rta in p o in t w h e n he c a n n o t face u p to d e

th e ine sc apa ble hostility, low ind ep en d e n ce,


a n d d e v a lu e d se lf-e s te e m t h a t d e p e n d e n c y

merciless d e m a n d s he m a k e s on him self m a y

m a n d s in som e tr u ly i m p o r t a n t s itu a tio n , his

be e s

fa ilu re will act like a s p a r k in a n explosive m i x

tablish ed betw e en th e p a t i e n t s hostility tu r n e d


in w a r d an d the m ig ra in e h ea d a c h e s for w h ich

tu re . T h e e v e n tu a tin g s y m p to m s t h a t finally
b ri n g h im in to tr e a t m e n t a r e d ep re ssio n a n d in

th e r a p y w a s so u g h t in th e first place. T h e
th e r a p is t shou ld in this w a y ta k e a d v a n ta g e of

so m n ia. It will r e q u i r e little a c u m e n for a t h e r a


pist to spot th e perfectionistic tr e n d s a r o u n d

every o p p o r t u n it y to show the p a tie n t th e i n

w h ic h the p a ti e n t fash ion s his existence. B u t to

t e r r e l a t i o n s h i p b e tw e e n h is v a r i o u s d ri v e s ,

a r g u e h im

tra its,' a n d sy m p to m s, ke ep in g in m in d th a t

c o u n te r th e b a r r a g e of ra tio n a l iz a t io n s evolved

w hile a ce rta in tr e n d m a y e n co m p a ss th e p a

over a lifetime a r e difficult, if n ot im possible,

ti e n ts chief concern at th e m o m e n t, it never

tasks. W e m ay , nevertheless, a tt e m p t to w o rk
w ith cognitive t h e r a p y a n d select perfection ism

brings

ab out.

An

association

m ay

occurs in isolation. It is re la te d in tim a te ly to


o th e r in tra p sy ch ic forces even th o u g h the co n
nection m ay not be im m e d iately clear.

o ut of his perfe ctio nism a n d to

as a focus, p o in t in g ou t th e d is to rtio n s in logic


th a t go vern th e p a t i e n t s th i n k in g process. N o t

A n individual can m a k e a re a s o n a b le a d ju s t

all t h e r a p is t s h av e th e skill a n d s t a m i n a to do

m e n t for a long tim e even w ith a v u ln e ra b le


c h a ra c t e r stru c tu re . H is p e rs o n a lity m oto rs,
defective as they m ay have been, still o p e ra te
h a rm o n io u s ly ; v a rio u s balan ces a n d c o u n te r

this, n o r do w e yet have sufficient d a ta to testify


to th e efficacy of this a p p r o a c h in m ost cases.

balances m a i n ta i n the psychological e q u il ib


riu m . T h e n because of th e im po sitio n of a n e x

W h a t w o u ld

seem in dic ated

is to review

w ith th e p a ti e n t th e full im p licatio n s of his


perfectio nism , its re la tio n s h ip to his defective
self-image, th e sources of self-d evalu ation in
in co m p lete s e p a r a ti o n -in d i v id u a t io n , the o p e r

te r n a l crisis situ ation o r because of stresses a s


sociated w ith in n e r needs a n d e x te r n a l d e
m a n d s , an xiety , d ep ression , p h o b ias , an d o th er
sy m p to m s a p p e a r . T h e p a ti e n t m a y consider
t h a t his a d ju s tm e n t p ri o r to th e presen ce of

atio n s of m as o ch ism , a n d so fo rth. O b vio usly ,


th e th e r a p is t m u s t have evidence to ju stify
these co nnections, but even th o u g h h e p re s e n ts
a n o u tlin e to th e p a tie n t of possibilities a n d

som e p re c ip ita tin g factor w as satisfactory if not


ideal, w ith no a w a re n e s s of ho w his te n u o u s
p e r s o n a l i t y i n t e r a c t i o n s h a v e b e en s p o n

stim u la te s th e p a ti e n t to m a k e con nection s for


him self, he m a y be able to p e n e tr a te som e of
th e p a t i e n t s defenses. G iv in g the p a tie n t some

sorin g vario u s sy m p to m s a n d u ltim ately had

idea a b o u t p e rs o n a lity d e v e lo p m e n t m a y, as I

131

CHO O SIN G A DYNAM IC FOCUS: PRESENTING INTERPRETATIONS


have indicated, be occasionally helpful, esp e

d e p e n d e n c e ? M i n d y ou, y o u m a y n o t s h o w all

cially w h e re insufficient tim e is a v a ilab le in


th e r a p y to p in p o i n t the precise p ath o lo g y . P a

of t h e t h i n g s t h a t I sha ll p o i n t o u t to y ou, b u t

tients a re usu ally e n th u s iastic at first at h av in g

you.

received som e clarification, a n d th ey m a y even


ack no w led ge th a t segm ents of the p re s en ted
ou tline relate to them selves. T h e y then seem to
lose th e significance of w h a t h a s been revealed
to them . H o w e v e r, in m y ex perien ce la te r on

t r y to f ig u re o u t w h i c h o f th e s e d o a p p l y to
N o w , m o st p e o p l e w i t h s t r o n g feelings of
d e p e n d e n c e will a t t e m p t to find p e r s o n s w h o
a r e s t r o n g e r t h a n th ey a r e , w h o can d o for
th em

w hat

they

feel

they

cannot

do

for

th em se lv e s. It is a l m o s t as if t h e y a r e s e a rc h in g
for id e a liz e d p a r e n t s , n o t t h e s a m e k i n d of

in follow -up, m a n y have b ro u g h t u p p e r t in e n t

p a r e n t s t h e y h a d , b ut m u c h b e t t e r ones. W h a t

details of the ou tlin e a n d h av e confided t h a t it


stim u lated th i n k in g a b o u t them selves. T h u s in

does th i s d o to t h e i n d i v i d u a l ? F i rs t , u s u a l ly he

th e case of R o g e r described in th e last c h a p te r , I

o u t as id e a liz e d p a r e n t a l f ig u re s b ecau s e they

beco m es d i s a p p o i n t e d in t h e p e o p l e h e picks
n e v e r co m e u p to h is e x p e c t a t i o n s . H e feels

gave h im th e follow ing g e n e ral in t e rp re ta ti o n :

c h e a t e d . F o r i n sta n c e , if a m a n w e d s a w o m a n
T h . I believe 1 h a v e a fair id ea of w h a t is g o i n g on
w ith you, b u t I d like to st a rt fro m t h e b e g i n
n in g . I s h o u l d like to give you a p i c t u r e of
w h a t h a p p e n s to t h e a v e r a g e p e r s o n in the
g row ing-up

process .

From

t h is p i c t u r e

y ou

m a y be a b l e to u n d e r s t a n d w h e r e yo u fit a n d
w h a t h a s h a p p e n e d to yo u. Y o u see, a child at
b i r t h c o m es into t h e w o r l d h elp les s a n d d e
pendent.

H e need s a g r e a t d eal of affe ction,

care, a n d s t i m u l a t i o n . H e also need s to receive


th e p r o p e r d isc ip lin e to p r o t e c t h im . In th is
m e d i u m of loving a n d u n d e r s t a n d i n g c a r e a n d
d iscip lin e, w h e r e he is given a n o p p o r t u n i t y to
g r o w , to develop, to e x p l o r e , a n d to e x p r e ss
him self, his i n d e p e n d e n c e g r a d u a l l y in crease s
and

his d e p e n d e n c e g r a d u a l l y decreases,

so

t h a t at a d u l t h o o d t h e r e is a h e a l t h y b a l a n c e b e
t w e e n facto rs of d e p e n d e n c e a n d i n d e p e n d e n c e .
L e t us say th ey a r e e q u a l l y b a l a n c e d in th e
a v e r a g e a d u l t ; a c e r t a i n a m o u n t of d e p e n d e n c e
b e in g q u i t e n o r m a l , b u t not so m u c h t h a t it
cripples the person. N o rm a lly the dependence
level m a y t e m p o r a r i l y go u p w h e n a p e r s o n
gets sick o r in secu re, a n d his i n d e p e n d e n c e will
tem p o rarily

recede.

But

t h i s s h i f t is o n l y

w i t h i n a n a r r o w r a n g e . H o w e v e r , as a r esu lt of
b ad o r d e p r i v i n g e x p e r i e n c e s in ch ild h o o d , a n d
fro m y o u r histo ry , th is se em s to h a v e h a p p e n e d
to y ou to so m e e x te n t [the p a t i e n t s fa t h e r a
sa le sm a n w a s a w a y a g o o d d e a l o f th e tim e a n d
h is o ld er b ro th e r b r u ta lly in tim id a te d h im ] ,
t h e d e p e n d e n c e level n e v e r goes d o w n suffi
ciently a n d t h e i n d e p e n d e n c e level stays low.
N o w w h a t h a p p e n s w h e n a p e r s o n in a d u l t life
h a s excessive d e p e n d e n c y a n d a low level o f i n

w h o h e ex p ects will be a k i n d , giving, p r o t e c


tive, m o t h e r fig u re, he will b eco m e in f u ri a t e d
w h e n she fails h i m o n a n y c o u n t . S eco n d, he
fin ds t h a t w h e n he does r e l a t e h i m s e l f to a p e r
son o n t o w h o m h e p ro jects p a r e n t a l q u a litie s,
he b eg in s to feel h elp les s w i t h i n him self, he
feels t r a p p e d , he h a s a d e s ire to es c a p e from
t h e r e l a t i o n s h i p . T h i r d , t h e feeling of b e in g d e
p e n d e n t , m a k e s h i m feel p as sive like a child.
T h i s is of ten asso ciated in his m i n d w i t h being
n o n m a s c u l i n e ; it c r e a t e s fears of his b e c o m in g
h o m o s e x u a l a n d r e l a t i n g h i m s e l f passiv ely to
o t h e r m e n . T h i s role, in o u r c u l t u r e , is m o r e
a c c e p ta b le to w o m e n ,

b u t t h e y to o f ear e x

cessive passiv ity , a n d t h e y m a y , in r e l a t i o n to


m o t h e r figure s, feel as if th ey a r e b r e a s t - s e e k
ing a n d h o m o s e x u a l .
So h e r e he h a s a d e p e n d e n c y m o t o r t h a t is
c o n stan tly

o p eratin g ,

m ak in g

him

forage

a r o u n d for a p a r e n t a l im age. I n e v ita b ly th ey


d i s a p p o i n t h i m . ( A t th is p o i n t th e p a tie n t in
te r r u p te d a n d d e s c rib e d h o w d is a p p o in te d he
w a s in h is w ife , h o w in e ffe c tiv e sh e w a s, h o w
u n a b le sh e p r o v e d h e r s e lf to be in ta k in g care
o f h im .
th e n

W e d isc u sse d th is f o r a m in u te a n d
c o n tin u e d .)

In

addition

to

the

de

p e n d e n c y m o t o r , t h e p e r s o n h a s a se cond m o
to r r u n n i n g , a r e s e n t m e n t m o t o r , w h i c h o p e r
ate s c o n s t a n t l y o n t h e b asis t h a t h e is e i t h e r
trapped

in

dependency,

or

cannot

find

an

id ealized p a r e n t a l fig ure, o r b e c a u s e h e feels o r


acts p as sive a n d helpless. T h i s r e s e n t m e n t p r o
m o te s t r e m e n d o u s g u ilt feelings. A fter all, in
o u r c u l t u r e o n e is no t s u p p o s e d to hate. But
th e h a t e feelings so m e ti m e s d o t r ic k le o u t in

132

HANDBOOK OF SHORT-TERM PSYCHOTHERAPY


sp ite of this, a n d o n special occasio n s t h e y g u s h

d a m a g e d . F e e l i n g s of s e l f- d e v a l u a t i o n give rise

o ut, like w h e n t h e p e r s o n d r i n k s a little to o

to a ho st of c o m p e n s a t o r y d riv es, like b e in g

m u c h . (The patient laughs here and says this is

p erfe ctio nis tic,

exactly what happens to him.) If t h e h a t e feel

d r i v e n . As lo n g as h e c a n do t h i n g s perfe ctly

ings

and

do

come

out,

the

person

may

g et

o perate

overly a m b i t i o u s ,
w ithout

fla w ,

he

and
w ill

power
r esp ec t

f ri g h t e n e d o n t h e b asis t h a t he is lo sing c o n

h im self. O r , if h e is b r i g h t e n o u g h a n d his e n

trol. T h e very id ea of h a t i n g m a y be so u p s e t

v i r o n m e n t fav o ra b le , h e m a y b oo st h i m s e l f into

t i n g to h i m t h a t he p u s h e s t h i s i m p u l s e o u t of

a success ful p o sitio n o f p o w e r , o p e r a t e like a

his m i n d , w i t h r e s u l t i n g te n s io n , d e p r e ss io n ,

strong au th o rity a n d g a th e r aro u n d him self a

p h y sic al s y m p t o m s of v a r i o u s k i n d s , a n d self-

g r o u p o f s y c o p h a n t s w h o will w o r s h i p h i m as

h a t e . T h e h a t e i m p u l s e h a v i n g been bl ocked is

t h e id e a liz e d a u t h o r i t y , w h o m in t u r n t h e i n d i

t u r n e d b a c k on t h e self. T h i s is w h a t w e call

v id u a l m a y r e s e n t a n d e n v y w h i l e a c c e p ti n g

m a s o c h i s m , t h e w e a r i n g o f a h a i r s h i r t , th e

t h e i r p l a u d i t s . H e will feel e x p l o i t e d b y those

c o n s t a n t s e l f - p u n i s h m e n t as a re s u l t o f feed

w h o e l ev ate h i m

b ack of r e s e n t m e n t . T h e r e s e n t m e n t m a c h i n e

p r i e s t . W h y , he m a y a s k h im self, c a n t I

go es

ru nning

find so m e b o d y s t r o n g w h o m / ca n d e p e n d o n ?

As if t h is w e r e n t e n o u g h , a t h i r d m o t o r gets

s h i p , b u t t h i s role e n t a i l s su c h conflict for h i m

on

good

de al

of the

tim e

al o n g s id e t h e d e p e n d e n c y m o t o r.
g o in g a l o n g

w ith

the oth er

to t h e p o s i t i o n

of a h ig h

W h a t h e seeks a c t u a l l y is a d e p e n d e n t r e l a t i o n
H igh de

t h a t he goes in to fierce c o m p e t i t i v e n e s s w i t h

p e n d e n c e m e a n s low in d e p e n d e n c e . A p e r s o n

tw o .

a n y a u t h o r i t y o n w h o m h e m i g h t w a n t to be

w i t h low fe elings of i n d e p e n d e n c e suffers t e r

dependent.

r ib ly becau s e he does n o t feel sufficient u n t o

So h e r e w e h a v e o u r d e p e n d e n c y o p e r a t i n g

h im self; h e does n o t feel c o m p e t e n t . H e feels

first; se co n d , r e s e n t m e n t , a g g r e s s i o n , g uilt, a n d

n o n m a s c u l i n e , passive, h elp les s, d e p e n d e n t . It

m a s o c h i s m ; t h i r d , d r iv es for in d e p e n d e n c e ; a n d

is h a r d to live w i t h suc h feelings, so h e m a y try

f o u r t h , s e lf- d e v a lu a tio n a n d m a n e u v e r s to o v e r

to c o m p e n s a te by b e in g o v e rly ag g ressiv e,

come

o verly c o m p e titiv e , a n d ov erly m a s c u lin e . T h i s

t i o n i s m , o v e r a m b i t io u s n e s s , a n d p o w e r s t r i v

m a y c r e a t e m u c h t r o u b le for t h e p e r s o n b e

ings, in f a n t a s y o r in reality .

ca u s e he m a y try to o h a r d to m a k e u p for his

t h is

through

such

te c h n ic s as p erfe c

T o c o m p l i c a t e m a t t e r s , s o m e of th ese drives

feelings of loss of m a s c u l in i t y . H e m a y h av e

get s e x u a l i z e d .

f a n ta s ie s

w h e n o n e r e la te s to a p e r s o n t h e w a y a child o r

of becom ing

strong,

handsom e,

In d e p e n d e n c y , for in stan c e,

ov erly activ e se x u al m ale, a n d , w h e n h e sees

i n f a n t r e l a t e s to a p a r e n t , t h e r e m a y be e x p e r i

su ch a figu re, he w a n t s to id entify w i t h him .

en ced a p o w e r f u l su ffu sion of good feeling t h a t

T h i s m a y c r e a t e in h im d es ires for a n d fears of

m a y b u b b l e o v er in to s e x u a l feeling. T h e r e is

h o m o s e x u a l it y , w h i c h m a y te r rif y so m e m e n

p r o b a b l y a g r e a t deal of s e x u a l i ty in all in f a n ts

w h o d o n o t re a lly w a n t to be h o m o s e x u a l .

in a very diffuse f o rm , p r e c u r s o r s of a d u l t se x

I n t e re s t i n g l y , in w o m e n a l o w - i n d e p e n d e n c e

u a lity . A n d w h e n a p e r s o n r e v e r ts e m o t i o n a l l y

level is c o m p e n s a t e d for by h e r c o m p e t i n g w i t h

b ack to t h e d e p e n d e n c y o f in fan cy , he m a y

m e n , w a n t i n g to be like a m a n , a c t i n g like a

r e e x p e r i e n c e diffu se se x u a l feelings t o w a r d th e

m a n , a n d r e s e n t i n g b e in g a w o m a n . H o m o s e x

p a r e n t a l figure . If a m a n r e la te s d e p e n d e n t l y to

u al

a w o m a n , h e m a y s u s t a i n t o w a r d h e r a k i n d of

im p u l s e s a n d fears also m a y s o m e tim e s

e m e r g e as a re s u l t of r e p u d i a t i o n o f fem in in ity .
A

consequence

of

low

feelings

of

inde

i n c e s t u o u s feeling. T h e s e x u a l i ty will be n o t as
a n a d u l t , b u t as a n i n f a n t to a m o t h e r , a n d t h e

p e n d e n c e is a d e v a l u e d se lf-im age, w h i c h s ta rts

feelings

t h e f o u rt h m o t o r g oing. T h e p e r s o n b eg in s to

t r e m e n d o u s gu ilt, f ear a n d p e r h a p s a n i n a b ility

d es p ise him self, to feel h e is w e a k , ug ly, a n d

to fu n c tio n se x u a lly . If th e p a r e n t a l f ig u re h a p

c o n t e m p t i b l e . H e will pick o u t a n y p e r s o n a l

p e n s to be a m a n i n ste a d of a w o m a n , t h e p e r

evidence for th is t h a t he can find, like st a tu r e ,

so n

c o m p l e x i o n , p h y s i o g n o m y , a n d so o n.

m other,

If he

h a p p e n s to h a v e a sligh t h a n d i c a p , like a p h y s
ical d e f o rm i t y o r a sm a ll p e n is , he will focus on
this

as

evidence

that

he

is

irretrievably

m ay

for

still
and

her

may

relate

be

accom panied

to h i m

em erging

by

like t o w a r d

sexual

feelings

will

[ / / the p a
tient is a woman with sexual problems, the
parallel situation of a female child with a
s t i m u l a t e fears o f h o m o s e x u a l i t y .

CHO O SIN G A DYNAM IC FOCUS: PRESENTING INTERPRETATIONS


parental substitute may be brought up. A
woman may repeat her emotions of childhood
when she sought to be loved and protected by a
mother. In body closeness she may experience
a desire to fondle and be fondled, which will
stir up sexual feelings and homosexual fears.}

133

no t a v a i l a b l e to h i m to sa tisfy h is diffe rent


d r iv es a n d if h e c a n n o t r e a d i l y s w itc h f ro m o ne
to t h e o t h e r , h e m a y b e c o m e exces sively ten se
a n d u pse t. I f his te n s io n b u i l d s u p to o m u c h ,
or

if he

experiences

great

tro u b le

in his

life s i t u a t i o n , o r in t h e e v e n t self e s te e m is

In s e x u a l i z i n g d r iv e s for i n d e p e n d e n c e a n d a g

c r u s h e d fo r a n y r e a s o n , h e m a y d ev elo p a

gressiveness, o n e m a y id en tify w i t h a n d seek

c a t a s t r o p h i c feeling of h e lp le s sn e s s a n d e x p e c t a

o u t p o w e r f u l m a s c u l in e fig u res w i t h w h o m to

t i o n s o f b e i n g h u r t . (The patien t here excitedly

fr a t e r n i z e a n d affiliate. T h i s m a y a g a i n w h i p

blurted out that he felt so shamed by his defeat


at work that he wanted to atom bomb the
w orld. H e became angry and weak and
frigh ten ed. H e w anted to g e t aw ay from
everything and everyone. Yet he fe lt so helpless,
he wanted to be taken care of like a child. He
then felt hopeless and depressed. I commented
that his motors had been thrown out of gear by
the incident at work and this had precipitated
excessive tension and anxiety.)

up homosexual

im p ulses . W h e r e agg ressiv e-

sa distic a n d se lf-pu nitiv e m a s o c h is tic im p u l s e s


exist, th e s e m a y , for c o m p l i c a t e d r e a s o n s , also
be fused w i t h se x u a l i m p u l s e s , m a s o c h i s m b e
co m i n g a c o n d itio n for se xu al r elease. So h e r e
w e h av e t h e d e p e n d e n c e m o t o r , a n d t h e re se n tm e n t-a g g re ssio n -g u ilt-m a so c h ism m otor, and
t h e i n d e p e n d e n c e m o t o r , a n d t h e s e lf-d ev alu
ation m otor, w ith the various com pensations
a n d s e x u a l i z a t i o n s . W e h a v e a ver y b u s y p e r

W hen

te n s io n

gets

to o g r e a t ,

and

there

son on o u r h a n d s . (At this point the patient

se em s to be n o h o p e , a n x i e t y m a y hit. A n d the

revealed that he had become impotent with his


wife and had experienced homosexual feelings
and fears that were upsetting him because they
were so foreign to his morals. What I said was
making sense to him.)

p e r s o n w ill b u ild u p defenses to c op e w i t h his

I n t h e face of all th i s t r o u b le , h o w d o so m e

T h e s e defen se s o ften d o n o t w o r k . S o m e , like

a n x i e t y , s o m e o f w h i c h m a y suc ceed a n d so m e
m a y no t. F o r i n sta n c e , excessive d r i n k i n g m a y
be o n e w a y o f m a n a g i n g a n x i e t y . F e a r s , c o m
p u lsio n s , p h y sic al s y m p t o m s a r e o t h e r w ay s.

p e o p le g a i n p e a c e ? By a fifth m o t o r , t h a t of

p h o b i a s , m a y c o m p l i c a t e t h e p e r s o n s life a n d

d e t a c h m e n t . D e t a c h m e n t is a defense o n e m a y

make

tr y to u se as a w a y o f e s c a p i n g lifes m essy

t h o u g h w a y s a r e s o u g h t to d e a l w i t h a n x i e t y

p r o b l e m s . H e r e o n e w i t h d r a w s f ro m r e l a t i o n

th e s e p r o v e to be self-defeating.

it

m ore

difficult t h a n

before.

Even

sh ips, iso lates him self, r u n s a w a y f ro m th in g s.

N o w , w e a r e n o t s u r e yet h o w th i s g e n e r a l

B y r e m o v i n g h i m s e l f f ro m p e o p le , t h e i n d i

o u t l i n e a p p l i e s to you . I a m s u r e s o m e of it

v id u a l t r ie s to h e a l hi m self. B u t t h is does n o t

does, as y o u y o u r s e l f h a v e c o m m e n t e d . S o m e of

u s u a l ly w o r k b ecau s e af ter a w h i l e a p e r so n

it m a y n o t. W h a t I w a n t y o u to d o is to t h i n k

gets terrified by his isolation a n d in a b i l i t y to

a b o u t it, o b se rv e y o u r s e l f in y o u r a c tio n s a n d

feel. P e o p l e c a n n o t f u n ctio n w i t h o u t peo ple.

relations

T h e y m a y succeed for a s h o r t tim e , b u t t h e n

W h i l e k n o w i n g w h e r e y o u fit w ill n o t sto p the

th ey

m o t o r s f r o m r u n n i n g , a t least w e will have

realize

they

are

drifting

aw ay

from

to

people an d

see w h e r e y o u fit.

th in g s; t h e y a r e d e p r i v i n g th e m s e lv e s of lifes

so m e id ea as to w i t h w h a t w e a r e dealin g .

prim e

T h e n w e ll b e t t e r be a b l e to f i g u r e o u t a p l a n

satis factions.

C om pulsively, then,

the

d e t a c h e d p e r s o n m a y tr y to r e e n t e r t h e liv in g a t

c o n c e r n i n g w h a t to do.

m o s p h e r e b y b e c o m in g g r e g a r io u s . H e m a y , in
d e s p e r a t i o n , p u s h h im se lf i n t o a d e p e n d e n c y
si t u a t i o n w i t h a p a r e n t a l f i g u re as a w a y o u t of
his d i l e m m a . A n d t h is w ill s t a r t t h e w h o l e n e u
ro tic cycle all ov er a g a i n .
Y o u c a n see t h a t t h e p e r s o n k eep s g e ttin g
c a u g h t in a w e b f ro m w h i c h t h e r e is no escape.
As lo n g as he h a s e n o u g h fuel a v a i l a b l e to feed
his v a r i o u s m o t o r s a n d k eep t h e m r u n n i n g , he
ca n go o n for a perio d . B u t if o p p o r t u n i t i e s a r e

So m etim es I d r a w a sketch on a b la n k p a p e r
s h o w i n g h i g h d e p e n d e n c e , lo w d e p e n
d e n c e , d eva lue d self-im a g e , re s e n tm e n tg u ilt-m aso ch ism , and d e ta c h m e n t, and
re p e a t th e sto ry of th e i r in te rre la tio n s h ip . I
th e n ask th e p a ti e n t to figure o ut a n d study
aspects th a t a p p ly to h im . If a g e n e ra l d e sc rip
tion of d y n a m ic s is given th e p a tie n t, a lo n g the

134

HANDBOOK OF SHORT-TERM PSYCHOTHERAPY

lines indicated above, a little insight m a y be in


culcated th a t can serve as a fu lcru m for g re a te r
self-u nd erstan d ing . T h e insight m a y be te m p o
ra r ily re a s su rin g at first; th e n it seem ingly is
forgotten w ith a re surgen ce of sym pto m s. A
review of w h a t h a s occu rred to s tim u late a n a t

ta ck of a n x ie ty m a y consolidate the in sig h t an d


solidify b ette r co ntrol. A n im p o r t a n t tool h ere
is self-observation, w h ich the th e r a p is t should
tr y to en c o u ra g e an d w h ich will h e lp th e
w o r k in g - th r o u g h process, w ith o u t w hich
insig ht can h ave little effect.

Conclusion
In d y n a m ic s h o r t-t e rm th e r a p y th e most
productive focus is often on som e aspect of a

tendencies. T h e s e m an ife statio n s will be espe

n u c le a r conflict. Since the p a tie n t u su ally d e

cially p r o m in e n t d u r i n g pe rio d s of resistan ce to


te c h n iq u e s th a t th e th e r a p is t is im p le m e n tin g .

fe n d s h i m s e l f a g a i n s t r e v e a l i n g s i g n if i c a n t
unconscious con ten t, th e th e r a p is t will have to

to w h a t lies b e h in d the p a t i e n t s inab ility or

arriv e at it by o bserving its manifest d e riv a


tives. T h e s e m a y be hig hly disguised a n d s y m
bolized. H o w e v e r, a sensitive a n d astu te t h e r a
pist will be ab le to detect vital u n d e r c u r r e n t
forces from the p a t i e n t s verbal a n d no n v e rb al
behavior, from periodic tra nsferenc e displays,
and from d re a m s , fantasie s an d actin g-out

A ccordingly, th e th e r a p is t sh ou ld a le r t him self


refusal to re s p o n d to tr e a t m e n t in terventions.
A g e n e ral o u tlin e of d y n a m ic s p re s en ted to th e
p a ti e n t w ith th e object of s tirr in g u p som e te n
sion in th e in terv iew an d hence e x p ed itin g e x
p lo r a tio n s, o r of w o rk in g t o w a r d fitting the p a
t i e n t s special p ro b le m s an d m e c h a n ism s into
th e ou tline, is so m etim es helpful.

CHAPTER 11

Techniques in Short-term Therapy


P s y c h o t h e r a p y a s it is p r a c t i c e d t o d a y is n o
lo n g er
it s

a hom ogeneous

m ain stream

branches

of

sciences.
every

are

th e

T h is

o p eratio n .

trib u ta rie s

bio lo g ical

is

because

co n stitu en t

of th e

E n te rin g

from

and

b eh av io ral

behavior
hum an

v ario u s

em braces

b ein g

from

m i g h t be in o r d e r . T h e n th e r e a r e th o s e w h o
p r e f e r a n i n t r a p s y c h i c e x p l a n a t i o n , s e e i n g it a s
a th in k in g d iso rd er th a t
p ro cess,
tio n ,

prim itive,

w ith

excessive

m en t, an d

provokes p rim a ry -

irratio n al,

w ishful

condensation,

idea

d isp lace

th e d isto rte d use of sy m b o ls. T h e

p h y sio lo g ic a l m a k e u p to s p i r i t u a l p r o m p ti n g s .

r e s u l t is a n i n t e r f e r e n c e w i t h p r o p e r e m o t i o n a l

In T a b l e 1 1 - I

m o d u latio n . T h is

t h e v a r i o u s l i n k s in t h e b e h a v

io ra l c h a i n a r e d e l i n e a t e d , a s w e ll as th e fields

v ie w p o in t so m e tim es sp o n

sors a p sy c h o a n a ly tic a p p ro a c h . O n th e in te r

of in terest these e m b ra c e , a n d th e th e ra p e u tic

p e r s o n a l level c e r t a i n a u t h o r i t i e s c r e d it t h e d i s

m o d a litie s r e la te d to e a c h lin k to w h ic h c e r ta in

ease

sy n d r o m e s a r e often assig n ed . T a k e as a n e x

defenses th a t en co u ra g e d e ta c h m e n t, distru st,

a m p le th e s y n d ro m e of sc h iz o p h re n ia .

and

S c h i z o p h r e n i a is a d i s e a s e t h a t is v a r i a n t l y
a ttrib u te d

to

m any

causes.

T here

are

those

to

th e

m isch ief

e x trao rd in ary

apy,

group

oriented

of

regressive,

dependency.

th e ra p y ,

th erapy

and

w ould

archaic

F am ily

th er

p sy choanalytically
fit

in

here.

Social

w h o r e g a r d it a s a b i o c h e m i c a l a f f l i c t i o n , t h e

forces a r e c o n s id e re d b y s o m e to be th e p r i m e

product

c u lp rits,

of

defects

in

th e

fu n ctio n

of

the

in sp irin g

th e

p atien t

to

assum e

n e u ro tra n s m itte r d o p am in e, w h ich , o p e ra tin g

a n o m a l o u s so cial ro le s t e r m i n a t i n g in a l i e n a

in e x c e s s , a f f e c t s t h e m e s o l i m b i c , i n f u n d i b u l a r ,

tio n

and

M illieu

n ig ral

p ath w ay s.

U nder

these

circu m

and

sta n c e s p h a r m a c o t h e r a p y w o u ld a p p e a r to be

th erap y ,

th e

utilized

preferred

approach,

neuroleptics,

for e x

a m p l e , b e in g e m p l o y e d to b lo c k th e a c t i o n of

th ere

dop am in e.

eso teric

O th ers

regard

sch izo p h ren ia

as a

d ev iatio n s

in

ta sk

p erform ance.

t h e r a p y , c a s e w o r k , c o u n s e lin g , social
and
w ith

are

re h a b ilita tiv e

therapy

th ese

in

factors

p ro fessio n als
sp iritu al

who

co u ld

m ind.
prefer

e x p la n a tio n ,

be

F in ally ,
a

m ore

v iew in g

neu ro p h y sio lo g ical d iso rd er, c h a ra c te riz e d by a

sch izo p h ren ia as a u n iq u e a n d sin g u lar m ode

l a c k o f left c e r e b r a l d o m i n a n c e a n d d e f e c t i v e

of

c e re b ro lim b ic fu n c tio n in g th a t s p o n s o r a b n o r

E x iste n tia l th e r a p y a n d a c ro p of p h ilo so p h ical

p erceiv in g

and

ex p erien cin g

reality .

m a li t i e s in l i n e a r c o g n itiv e a b ility . A d h e r e n t s

approaches,

of this v ie w p o in t m ig h t c o n s id e r c e r ta in fo rm s

from

of so m a tic th e r a p y su ita b le u n d e r so m e c ir c u m

a d v o c a te s w h o seek to in flu e n c e th is e lu siv e d i

sta n ces,

m e n s io n .

fo rm s

ECT,
of

for

instan c e,

relaxation

as w ell a s so m e

therapy.

Some

ascrib e

s c h iz o p h r e n ia to fa u lty le a r n i n g a n d c o n d i t i o n
ing, c o n s id e rin g
th e

consequence

it a d e v e l o p m e n t a l
of

severe

fa m ily

use

of th e

child

w ith

projective

who

co m m u n icate

conflictual

m any

E astern

D ifferen t

th u s accord

d eriv in g

th e ir

system s of th o u g h t,

w ith

approaches

m u ltip le

to

su b stan ce
have

th eir

treatm en t

w a y s of re g a rd in g

th e disease. A c tu a lly , s c h iz o p h r e n ia e m b r a c e s

p roblem ,

all o f th e b o d ily s y s te m s , a n d n o o n e e tio lo g ic a l

p athology

facto r can be co n s id e re d exclusively d o m in a n t.

p aren ts

A n d a n y o f t h e m a n y m o d a l i t i e s s i n g l y o r in

d o u b le - b in d ''

c o m b i n a t i o n m a y in so m e c a s e s r e g is te r a b e n e

by

th e m e s. A b e h a v io ra l a p p r o a c h , c o n s e q u e n tly ,

f i c i a l effe c t.

135

136

HANDBO OK OF SHORT-TERM PSYCHOTHERAPY

TABLE 11-1. The Biological and Behavioral Links of Behavior*


T H E B E H A V IO R
C H A IN
Biochemical links

RELATED
F IE L D S
Biochemistry

T H E R A P E U T IC M O D A L IT IE S
P harm acotherapy

SYNDROM ES
Schizophrenia (neuroleptics)
M an ia (lithium )
M ajo r depressions
(antidepressants)
A nxiety states (anxiolytics)
H yperkinetic syndrom es of
childhood

N europhysiological

N europhysiology

links

Biofeedback
Som atic therapy
R elaxation th erap y (m editation,
relaxing hypnosis)
Em otive release

Developm entalconditioning links

D evelopm ental theory


L earning theory

Behavior therapy
Cognitive th erap y
Persuasion
Suggestive hypnosis

T ension states (relaxation,


biofeedback, em otive release)
Suicidal depressions (E C T )
Physical conditions arising from
m ental factors (biofeedback)
Phobic reactions (behavior
therapy)
H ab it disorders (hypnosis)
Behavior disorders (behavior
therapy)
Obsessive-compulsive disorders
(behavior th erap y , persuasion,
cognitive therapy)
A djustm ent reactions
D evelopm ental delays

Intrapsychic links

Psychoanalysis

Psychoanalysis

Personality disorders

C ognitive theory

H ypnoanalysis

N eurotic disorders

Existential analysis
G uided im agery
Interpersonal links

D ynam ic theory

Psychoanalytically oriented therapy

Personality disorders

Role theory

G roup therapy

N eurotic D isorders

G ro u p dynam ics

M arital therapy

Social psychology

Fam ily therapy

M a rita l problem s
F am ily problem s

Psychodram a
Experiential therapy

B orderline personality
D ru g abuse and dependence

T ransactio n al analysis
Cognitive learning
Social links

Sociology
A nthropology
Economics

S piritual links

M ilieu therapy
Social casework

S ituational problem s
Psychoses in remission

C ounseling

Political science

Social therapy
R ecreational therapy

Theology

Religious therapy

R eactive depression

Philosophy

E astern philosophical systems


Existential therapy

Anxiety states

M etapsychiatry

A ddictions

Behavior is a complex entity composed of a chain of interrelated biochemical, neurophysiological, developmentalconditioning, intrapsychic, interpersonal, social, and spiritual links Difficulties in one link will by feedback influence all
other links in the chain. Distinctive fields of interest and special theories related to each link inspire a num ber of thera
peutic modalities that are preferred approaches in certain syndromes even though through feedback interventions
bracketed to other links may also be effective.

137

TECHNIQUES IN SHORT-TERM THERAPY


By the sam e token, p ractically every n e u

d icate o u r u n d e r s ta n d in g a n d e m p a t h y a n d to

rotic o r b eha v io ral d is o rd e r m a y be cau sally

keep h im focused on i m p o r t a n t content. Sec

associated w ith m u ltip le links in th e be hav ioral

o nd, w e h e lp h i m arr iv e at som e p r e l im in a r y

chain. T h e y too m a y be a p p ro a c h e d w ith a v a

u n d e r s ta n d in g s of w h a t his difficulty is all


a b o u t. T h i r d , w e select a m e th o d th a t is t a r

riety of tech n iq u es th a t c o rre sp o n d to different


links. T h i s is the r a t io n a l e of eclecticism,
w hich in s h o r t-t e rm t h e r a p y is a prefe rred
mode of o p era tio n .
T h e fact th a t we have so m a n y different a p

geted on th a t link th a t is c re a tin g greate st diffi


culty for th a t p a t i e n t b ioch em ical, b e h a v
ioral, in trap sy c h ic, in te rp e r s o n a l, o r social.
F o u r t h , w e try to sho w h im h o w he h im self is

p ro ach es to the sa m e em o tio n a l p ro b le m c a n in

n ot an in n o c en t b y s ta n d e r a n d th a t he, in a

itself be confusing. Because th e r e is so little


tim e availab le in brief t h e r a p y , we will w a n t to

m a j o r o r m i n o r w a y , is involved in b rin g in g
his tr o u b le s on himself. F ifth , w e deal w ith

select th e on e m eth o d o r co m b in a tio n of m e t h

a n y resistances th a t he develops th a t block (a)

ods th a t is most ap p lic a b le to the specific diffi

an

culty. In this respect w e can console ourselves


in a m in o r w ay . N o m a t te r w h a t te c h n iq u e we
em ploy, if we a r e skilled in its use, h av e faith

p ro du ctiv e use of th e te c h n iq u e s w e em ploy,

in its validity, an d c o m m u n ic a te this faith to


the pa tien t, a n d if the p a tie n t accepts th e tech

u n d erstan d in g

o f h is p r o b l e m ,

(b) h is

a n d (c) th e a p p lic a tio n of his tr e a t m e n t to w a r d


b eh av io ra l correction. S ix th , w e tr y to ac
q u a i n t h im w ith som e of th e p e rs o n a lity d is to r

n iq u e an d ab so rb s o u r faith, it will influence

tions th a t he carries a r o u n d w ith h im t h a t can


c reate tr o u b le for h im in th e f u t u r e h ow they

h im in some positive w ay. In resolving a diffi

developed, h o w th ey o p e r a t e n ow , a n d how

culty related to o ne d is tu rb e d link in his be

they m a y sh o w u p after he leaves th e r a p y .

hav io ral ch ain , this will in fluence by feedback


o th e r links. T h u s , if we p resc rib e n eu ro lep tic s

A n d , seventh w e give h im som e h o m e w o r k th a t

for a sch izo p h ren ic w ith a d is tu rb i n g th in k in g


diso rder, th e im p a c t on his b ioch em istry will

m a y m in im iz e o r p re v e n t p ro b le m s from o ccu r

register itself positively in v a ry in g degrees on


his neu ro p h y sio lo g y , his g en e ra l b eha v io r, his
i n t r a p s y c h i c m e c h a n i s m s , his i n t e r p e r s o n a l

is a im ed at s t re n g th e n i n g h im se lf so th a t he
r in g la te r on. W i t h i n this b ro a d f r a m e w o r k
th e r e are, of course, w id e differences on how

relatio ns, his social attitud es, a n d p e r h a p s even

t h e r a p is t s w ith v a ry in g th eo retical o r ie n ta tio n s


will o p erate . By a n d larg e, h ow e v e r, p sy
c h o th e r a p is ts w ith a d e q u a t e t r a in i n g sh ou ld

his ph iloso ph ical outlook. A p p ly in g beh av io r

a n tic ip a te satisfactory resu lts w ith the g re a t

th e r a p y to a ph ob ic will in its correction in flu


ence o th e r aspects from th e bio chem ical factors

m a jo rity of th e i r patients.

to sp iritu a l essences. W o r k i n g w ith m o da lities


th a t a re directed at th e in tra p sy c h ic s tru c tu r e
in a pe rs o n ality d is o rd e r th r o u g h p s y c h o a n a l

t e c h n iq u e s a r e ind icated by th e needs o f th e


p a ti e n t an d t h a t a r e w ith in the scope of o n e s

ysis or cognitive t h e r a p y , w e m a y find th a t all


o th e r links in the b eha vio ral c h ain a r e affected
in a gratifyin g w ay. T h i s global response,
how ever, does n ot in th e least absolve us from
try in g to select the best m e th o d w ith in o u r
r a n g e of skills th a t is m ost a tt u n e d to th e p a
ti e n ts u n iq u e le a r n in g ap titu d es .
Be this as it m ay, th e r e a r e som e g en e ra l
principles th a t a re ap p lic a b le to m ost pa tien ts.
F irst, we sta rt th e r a p y by allo w in g the p a tie n t
to u n b u r d e n him self verbally, to tell his story
u n in t e r r u p t e d ly , in te rp o la tin g c o m m e n ts to in

E m p l o y in g w h a te v e r te c h n iq u e s o r g r o u p of

t r a i n i n g a n d e xp erien ce, th e th e r a p is t m a y be
ab le to achieve th e goals ag re ed on in a ra p id
a n d effective w ay. W h e r e th e th e r a p is t h as be
come a w a r e of th e u n d e rl y in g d y n a m ic s, it
m a y be necessary to m e n tio n at least some
salien t aspects an d to enjo in the p a tie n t to
w o r k on th ese by him self after t h e r a p y has
ended. O n the o th e r h a n d , th e th e r a p is t m a y
not be able to achieve d esired goals unless in
te rfering d y n a m ic influences th a t function as
resistance a r e d e a lt w ith d u r i n g the tr e a tm e n t
period because th e p a tie n t is blocked by the
resistance a g a in s t m a k i n g progress.

138

HANDBOOK OF SHORT-TERM PSYCHOTHERAPY

In lon g -term th e r a p y a d y n a m ic th e m e th a t

stitu tes a v a lu a b le m e a n s of h e lp in g a p a tie n t

e x p la in s the p a t i e n t s p e rs o n a lity o p e ra tio n s


a n d resistances g ra d u a l ly reveals itself th r o u g h

to face a n d , if m o tiv atio n is presen t, to a lt e r his


rep etitiv e self-defeating b eh avio r. P o in te d i n

a leisurely stu dy of the p a t i e n t s verb aliza tio n s,


b eha vio ra l proclivities, d re a m s , fantasies, a n d

te r p r e t a tio n s of th e d y n a m ic s u n d e rly in g egosyn ton ic sy m p to m s, traits, a n d b e h a v io r only

tra nsferen ce pro jections. N o such casual in d u l


gence is possible in s h o r t-te rm tr e a tm e n t. P iec

too fr e q u e n tly resu lt in d en ial an d an x iety , for


m a la d a p tiv e as they are, n e u ro tic conflicts a n d

ing to g e th e r d a ta from th e p a t i e n t s history,

needs a r e w elded into th e p a t i e n t s h a b it u a l


cop in g m odes a n d yield florid gra tificatio ns

g en era l d e m e a n o r, in te rp e r so n a l exploits, asso


ciations, an d th e few fantasie s an d d r e a m s th a t
a re available, a n d c o rr e la tin g these w ith re a c
tions to th e r a p y an d to the th e r a p ist, as well as
to a n y brief psychological tests th a t m a y have
been given (e.g., m a n - w o m a n d r a w in g s and
e x p o su re to R orsc h a ch cards), the th e r a p is t

c o m p a r e d to w h ich th e p le a s u re s of h e a lth y
p a tt e r n s pale. W h a t is th e best w a y of d e a lin g
w ith such o b stru c tio n s? A p ith y e p ig r a m in th e
K o ra n co n te n d s th a t G o d is w ith th ose w h o
p e rs e v e re . T h i s c e rta in ly a p p lie s to th e u n
d a u n te d th e r a p is t w h o in th e face of o b stin a te

will be able to m a k e some a s s u m p tio n s a b o u t

resistance do ggedly w o rk s a g a in s t it. In lo n g

the p a t i e n t s dy n a m ic s. T h e s e will be a guide

te r m

in co nfro n tatio n s a n d in te rp re tiv e w o rk.

sistances to a reco gn ition of o n e s d y n a m ic s


an d m a n a g i n g s t u b b o rn o p p o sitio n a l re ac tio n s

As has been a m p ly illu s tra te d in the p ast


c h ap te rs, a n u m b e r of d y n a m ic them es, p re s e n t
in the g re a t m a jo rity of people in o u r cultu re,

therapy

th e ta s k of de alin g w ith

re

to th e r e l in q u i s h in g of destru ctive b e h a v io r

have been rep e a te d ly observed th a t can guide

c o n su m e a bu lk of th e tim e devoted to t h e r a p y
a n d can ta x th e e n d u r a n c e of th e m ost reso lute

in b rin g in g some basic p ro b le m s to light d u r


ing th e r a p y , rec og nizing th a t m a n y c o n fig u ra
tions exist th a t a r e u n iq u e for each individual.

t h e r a p i s t . In s h o r t - t e r m t h e r a p y t h e t a s k
w o u ld seem tc be d o u b ly com plicated since
th e r e is only lim ited tim e to p ro secu te the

A m o n g fa m iliar th em es th a t have been d e

search for conflictual th e m e s a n d to resolve

scribed a re th ose relate d to inco m p lete s e p a r a

resistan ce to th e ir disclosure a n d rectification.

tio n -in d iv id u a tio n , residu al guilt feelings and


needs for self-p u n ish m en t, a n d devalued self

U n d e r s t a n d a b ly , o ne c a n n o t d u p lic a te in 10

esteem. It is r a r e th a t one sees any p a ti e n t in


th e r a p y w h o does not possess an a b u n d a n t
s h a r e of th ese leitmotifs, a lth o u g h th e w ay s
th a t th ey m anifest them selves in the c h a ra c te r
s tru c tu r e an d the k ind s of sy m p to m s th ey
sp o n so r a re distinctively idiosyncratic.
W o r k i n g w ith the op erativ e d y n a m ic s co n

sessions w h a t could be achie ved w ith skillfully


conducted t h e r a p y in 100. Yet, e x p erien ce
b ears ou t th e valu e of b rin g in g to th e p a t i e n t s
atte n tio n a g lim p se of his o p e ra tiv e d y n a m ic s
a n d d e m o n s tr a t in g to h im his respo nsib ility in
b rin g in g a b o u t th e d isasters th a t he h a s h i t h
erto credited to destiny a n d m isfo rtu ne.

Confrontation
O n e tec h n iq u e th a t h a s been advocated by
som e s h o r t-te rm th e r a p is ts to cut th r o u g h
re sistance to u n d e r s ta n d in g o n e s dy n am ics is
t h a t of c o n f r o n t a t i o n . T h i s is s o m e t i m e s
utilized to get at u n d e rly in g tren d s by p r o
v oking an x iety or negative feelings. U su a lly

the p a tie n t will re s p o n d to th e t h e r a p i s t s


challenges of his beh av io r w ith a n g e r th a t m a y
be p ro m p tl y su p p re ssed . W h a t will a p p e a r
instead a re disa vo w al, pro test, self-justifica
tion , a n d self-abasem ent, lay in g the b la m e for
o n e s b e h a v io r o n m alev o le n t c ir cu m stan ces o r

139

TECHNIQUES IN SHORT-TERM THERAPY


the dereliction of others. N eg ativ e tra n sferen ce

a w a y so th a t he can to r m e n t him self w ith

r a p i d l y p r e c i p i t a t e s o u t. O p p o r t u n i t i e s a r e
th u s rich for in te rp re ta tio n of feelings ab ou t

he

an d reaction s to the th e r a p is t. T h i s te c h n iq u e

forces h im to d o a n d h o w th e d is p a rity creates

is d ra m a ti c an d often effective in p a tie n ts w ith


good ego s tren g th . H o w e v e r, it can d ras tica lly

difficulties. T h e c o n tr a st b e tw e e n a h e a lth y c o n

h u r t th e t h e r a p e u ti c re la tio n s h ip in a good

actio ns a n d th e p a t i e n t s e x istin g sadistic c o n

n u m b e r of p a tie n ts if im p le m e n te d too e a rly in

science th a t viciously to r m e n t s a n d p u n is h e s is
po in ted out. It becomes essential for th e p a tie n t

th e r a p y before p ro p e r r a p p o r t h as been es

lon elin ess. T h e p a tie n t is he lped to see w h a t


w an ts

to

do

and

w h a t h is c o n s c ie n c e

science th a t g u id es w h ile in h ib itin g destructiv e

ta blished. T h e p a tie n t is a p t to r e g a r d th e

to recognize t h a t a n in t e m p e r a te a n d merciless

t h e r a p i s t s actions a n d m a n n e r as a r b i tr a r y ,
un ju stifiab le, re c r im in a to r y , m alicious, and

c o n s c i e n c e is t h e c o m m o n e n e m y a g a i n s t
w h ic h th e th e r a p is t is his e g o s stro n g a l l y . N o

reflective of the t h e r a p i s t s ina bility to u n d e r

im m e d ia te in te r p r e ta ti o n s a r e m a d e of specific

stan d him o r to e m p a t h iz e w ith his suffering


an d situ ation . It tak es a g re a t deal of skill to

conflicts. T h e initial co n fr o n ta tio n s a re co n


fined to th e p a t i e n t s need for s e lf-p u n ish m e n t

select th ose w h o a re suited for c o n fro n ta tio n

a n d his m asochistic respo nses to a n g e r .

and

to titr a te th e degree of forcefulness of

T h i s focalization, it seem s to me, is used as

challenges to th e p a t i e n t s existing streng ths.


E x p erie n ced th e r a p is ts a r e c a p a b le of d oin g

an e x p ed ie n t to p ro v id e th e p a ti e n t w ith a

this even in th e first interv iew w ith som e p a

energies.

tients, but the av erag e th e r a p is t will be c o m


pen sated for his efforts w ith an e x tr a o r d i n a r y
n u m b e r of d ro p o u t s from tr e a tm e n t. In most

defense, the th e r a p is t m a y not be too far off if


its existence is p o in te d o u t th a t is, of course,

p a tie n ts

w ho

c o m e for h e l p

a m in im a lly

p rovocative p o s t u re will be indicated at first;

single insight in to w h ich h e c an converge his


S in c e

m aso ch ism

is

com m on

if th e p a tie n t p re s e n ts even slight evidences of


its o p e ra tio n . O bv iou sly, m a s o c h ism is not the

the th e r a p ist shou ld w o rk t o w a r d th e e s ta b lis h

o nly basis for sy m p to m s, a n d th e th e r a p is t


sh o u ld not be side trac ke d by usin g th e e x p la

ing of a good w o rk in g re la tio n s h ip before b a t

n atio n of m a s o c h ism as a stra te g y for b re a k in g

terin g a w a y at th e p a t i e n t s defenses th r o u g h

u p the p a t i e n t s resistance. T h e th e r a p is t will

stro n g co nfro ntation s.


Selection of fruitful a re a s for c o n fro n ta tio n

a d d itio n a l re a s o n s for som e of th e p a t i e n t s

w h e n it is do ne is im p o rt a n t. Since m ost p a
tients possess a n overly p rim itiv e a n d severe

sym p tom s.
O t h e r e x p la n a tio n s th a n m a s o c h ism m a y be

conscience (superego) th a t p rov ok es gu ilt, feel


ings of w ickedness, a n d m asochistic beh avior,

offered by t h e r a p is t s tr a in e d in specific schools


of psychology or p sy c h iatry . O n e un iversal

u su ally discover, if a search is m a d e for th e m ,

th ese patho lo gical zones prov id e a p ro du ctiv e

basic cause is p resen ted for all types of e m o

a re a for atta ck a n d discussion. Som e th e r a p is ts


e m p l o y a t e c h n i q u e t h a t i n t e r p r e t s th e

tio n al illness, a n d this single etiological factor

sy m p to m s of th e p a tie n t, no m a t te r w h a t th ey
m a y be (for e x a m p le , an x iety , d epression ,
w o rry , o u tb u r s ts of a n g e r, co nversion re a c
tions, com pu lsion s, p ho b ias, in s o m n ia , a n o r e x
ia, etc.), as m a n ifestatio n s of s e lf-p u n ish m en t,
the co nsequ ences of a guilty conscience (L e w in ,
1970). E ach s y m p to m is d elin eate d as serving
b oth self-to rm e n tin g needs a n d p rovocative

is to r tu r e d to fit in w ith e v e ry s y m p to m a n d
b eh a v io ra l m a n ifestatio n . T h u s , the p a tie n t
m a y be daz zled by b rillia n t e x p la n a tio n s of the
m a lfu n c tio n s of p re g e n ita l splitting , o r of the
O e d ip u s c o m p le x , o r
im age, o r of subversive
tioned anx iety , o r of
th eo rie s a r o u n d w h ic h

of th e devalued selfa rc h e ty p e s, or of c o n d i
an y of th e countless
c u r r e n t psychologically

a i m s t o w a r d o th e r s . E v e n a n i n d i v i d u a l s
d istu rb ed c h a ra c te r p a tt e r n s a re reduced to the

ideologies a r e o rg a n iz e d . W h il e such single e x


p la n a t io n s m a y not be a c cu ra te, they ce rtain ly
a r e con ven ien t a n d th ey m a y be te m p o r a r ily ef

masochistic need to suffer a n d drive pe op le

fective, especially w h e n d o g m a tic a lly stated.

140

HANDBO OK OF SHORT-TERM PSYCHOTHERAPY

O n e of th e a d v a n ta g e s of d o g m a is th a t it
m ak es critical t h i n k in g u nne cessary . A nd some
p a tie n ts a re on ly too e ag er to h a n d over th eir
m in d s to the th e r a p is t w h o will do th e ir t h i n k
ing for t h e m th a t is, un til th e tr e a tm e n t ends,

W h il e aggressive co n fro n ta tio n u n d e r these


c irc u m stan ce s m a y p ro ve p ro fita b le in som e
p a tie n ts w ith good ego stre n g th , it m a y n o t be
a p p lic a b le to sicker p a ti e n ts unless th e co n
fr o n ta tio n s a re to n e d d o w n to a p o in t w h e re

after w h ich th e p a tie n t will begin to re c o n

th e y a r e executed in a n e m p a t h ic r e a s s u ri n g

stitute his o w n fr a m e of reference a n d e n


thusiastic ally rec rea te th e con d ition s th a t got
h im into tr o u b le in th e first place.

w a y . E v en th e n it m a y be necessary to w ait
u ntil a good w o r k in g re la tio n s h ip h as been es
tab lis h e d , a n d th e n o nly after it becomes

T h i s does not m e a n th a t w e should th r o w


the bab y ou t w ith the b ath . Som e of th e

a p p a r e n t th a t m asochistic m a n e u v e rs a re o b
viously being e m p lo y ed by th e p a ti e n t in the

th eo ries an d e x p la n a tio n s m a y be helpful m ore


th a n te m p o r a r ily w h e n a p p lie d to certa in kinds

i n t e r e s t s of r e s i s t a n c e Y o u se e m to
p u n is h in g yo u rse lf by refusing to get w e ll.

of sy m p to m s a n d p e rs o n a lity p rob lem s. Ac


cident p ro ne ness, obsessional self-to rm e nt, su i

T h e p h r a s in g of q u e stio n s can be crucially


im p o r t a n t in h e lp i n g a p a ti e n t ex p lo re a n d
com e to g rip s w ith d e te r m i n in g p ro b lem s. F o r

cidal tendencies, a n d h y p o c h o n d ria c a l preo ccu


p atio ns, for e x am p le, m a y be indications of a
g eneralized m aso chism . A n e x p la n a tio n such
as th e follow ing m a y be offered: Y ou feel
a n g ry at w h a t y o u r p a r e n t s did to you as a

be

ex a m p le , th e p a ti e n t states, I w ish I h a d a
fa th e r w h o w a s like y o u . T h e th e r a p is t m a y
re p ly v a ria n tly alo n g th e follow ing lines: (1)
A n d I w o u ld like to hav e a d a u g h te r (son)

child. B ut you also feel gu ilty for y o u r a n g e r

like y o u . (2) In w h a t w a y did y o u r o w n

a n d th o ug hts. So you p u n is h yourself for these

fa th e r d is a p p o in t y o u ? (3) Y ou m u s t be very
a n g ry at y o u r f a t h e r . (4) R e a c h in g o u t for

th o u g h ts an d

feelings.

Y o u r sy m p to m s an d

y o u r b eh avio r seem to m e to be th e re su lts of


y o u r p u n is h in g yourself. N o w w h a t a re you

a n o th e r fa th e r figure is n t g oin g to h e lp you

going to do a b o u t w h a t you a re do ing to y o u r

m u c h . Y o u ve got to le a r n to stan d on y o u r

be:

o w n f e e t . (5) Y o u r s a y i n g t h a t is a
m a n ifesta tio n of y o u r c o n tin u in g d e p e n d e n c y .

W h e n e v e r you t o r tu r e yourself w ith u p settin g


th o u g h ts, o r you get d epressed , o r you have

(6) W h a t is th e r e a b o u t m e th a t m a k e s you
say t h a t ? (7) Y ou d o n t k n o w m e well

s y m p t o m s ( e n u m e r a t e th e s e ) a s k y o u rs e lf,
W h y a m I p u n is h in g m y se lf? T e ll yourself,

e n o u g h to be su r e of w a n t i n g m e as a f a t h e r .
(8) W h a t do you th i n k w o u ld have h a p p e n e d

I ve p u n is h ed myself en o u g h so j u s t stop i t !

to you if I h a d been y o u r f a t h e r ? E a c h of

S h o u ld these e x p la n a tio n s a n d in jun ctio ns fail


to p ro d u c e results, som e th e r a p ists resort to
s tro n g e r challenges a n d co nfron tatio ns.

th ese re spo nses will elicit c e rta in im p o r t a n t

self?

M ore

d ir e c t

s u g g e s tio n s

may

re actio ns in th e p a tie n t a n d will in fluence th e


re latio n sh ip .

Interpretive Activities
As

th erap y

moves

on

during

th e

first

sessions, the p a t i e n t s responses to in t e r p r e t a


tion will becom e a p p a r e n t . If th ere is rejection
of i n t e r p r e t a t i o n s , lack o f te n s io n a f t e r a
c h a llen g in g in t e rp re ta ti o n is m ad e, or b iz a r re
responses, p a r a n o i d tendencies, o r a cting -o ut
w ith o u t insight occur follow ing in te rp re ta tio n s,

th e p a ti e n t is p ro b a b l y not a m e n a b le to d y
n a m ic s h o r t- t e r m t h e r a p y . In m ost cases, h o w
ever, it will be possible to m a k e i n t e r p r e ta ti o n s
a n d to h e lp th e p a tie n t a c q u ir e a n u n d e r s t a n d
in g of p ro b le m s a n d defenses.
T h e in te r p r e ta ti o n of resistan ce is indicated
from th e very s ta rt of its a p p e a r a n c e , p a r t i c u

TECHNIQUES IN SHORT-TERM THERAPY

141

larly w h e re it tak es th e fo rm of in terfe rin g


w ith th e w o r k in g re latio n sh ip . S h o u ld a n e g a
tive transfe ren ce a p p e a r e ith e r in d r e a m s o r in
th e p a t i e n t s b ehav ior, th e th e r a p is t m u s t i m
m ed iately deal w ith it in as e x p e d ie n t a w a y as
possible.
F o r e x am p le, the resp on se of a p a tie n t after
th e second h y p n o tic session d u r i n g w h ich a r e

bility th a t she w o u ld reject th e ta p e a n d its


co ntents, even refusing to listen to it.
I felt I h a d a sufficiently good re la tio n s h ip to
offer an im m e d ia te a n d re p e a te d in t e rp re ta ti o n
of resistance a n d negative tran sferenc e. T h i s
did h e lp co nso lida te th e w o r k in g re latio n sh ip .
T h e p a ti e n t c o n tin u e d liste nin g to th e tap e,

laxing cassette ta p e w as m a d e for h e r w a s i r r i


tatio n an d a n g e r at li stenin g to th e tap e. U p o n

a n d she d erived a good deal of benefit fro m it.


U n le ss th e p a ti e n t is hig h ly m o tiv ated a nd
th e th e r a p is t h a s been ab le to estab lish an

u rg in g h e r to tell me h e r reactio n s to th e tap e,

early

she stated the following.

a n x ie ty too soon by focusing on an d i n t e r p r e t

P t.

W h e n 1 t r ie d l i ste n in g to t h e t a p e , I f o u nd m y
m ind

w a n d e r i n g . W h e n yo u sa y, Y o u a r e

tired

and

d ro w sy ,

tired

and

drow sy

are

a n t o n y m s . T i r e d m e a n s n o t r e l a x e d . W h e n you
sa y, E v e n y o u r leg m usc le s a r e r e l a x e d , w h y

firm

w o r k in g

re la tio n s h ip ,

p ro v o k in g

ing defenses will ten d to drive th e p a ti e n t out


of th e r a p y . I n t e r p r e t a ti o n s sh o u ld be b alanc ed
ag a in s t th e s ta te of th e p a t i e n t s w illing ness to
ex p lo re p ro b l e m s a n d th e q u a li ty of th e pat i e n t - t h e r a p i s t rela tio n sh ip . C o n s ta n t e x a m i

relief, s i t u a t i o n a l c o n tr o l, self-esteem , self-su g

n a tio n a n d use of th e tra n sfe re n c e to p o in t ou t


h a b it u a l p a t t e r n s of the p a ti e n t a n d th e origin

g e s t io n s ) I sa y t h e fo u r asses. I r e s e n t e d you.

in p a st re la tio n s h ip s m a y be helpful. U n lik e

I w a n t to a p o l o g i z e for m y feelings. I a m s u r

fo rm al an alysis, tr a n sferen ce n eu ro sis shou ld

p r ised a t m y self for l i k in g you . W h e n you said

be avoided, an d deepest c h a r a c t e r p ro b le m s r e

last t im e y ou m i g h t p r e s c r i b e a d r u g for m y

m a i n u n e x p lo r e d since to m a n a g e th e m w o uld

e v e n ? W h e n y o u sa y t h e f o u r S s ( s y m p t o m

d e p r e s s io n , e m o t i o n a l l y I felt you w a n t e d to
kill m e, to i m m o b i li z e m e w i t h m ed icin e. In
t h e t a p e y o u sa y, Y o u a r e filled w i t h n eg ativ e
th o u g h ts

that

we

m ust

n eu tralize,

w hat

th o u g h t s ? A t t h e e n d y o u say Y o u will r e l a x
o r fall a s l e e p . T h e y a r e i n c o m p a t i b l e . I said

re q u i r e m o r e tim e t h a n is av ailab le in th e sho rt


sp a n devoted to tr e a tm e n t.
T o in t e rp re t un co nscio us o r p a rtia lly co n
scious im p u lses p r e m a tu r e ly is w o rse t h a n use
less. T h e r e a r e th e r a p is ts w h o d iv in in g th e

p e r m e a b l e , u n r e a c h a b l e . I felt th is w a y also

conflicts of a p a ti e n t at th e first in terv iew b o m


b a r d h im w ith in t e r p r e ta ti o n s th a t a r e p r e

a b o u t m y m o t h e r a n d f a th e r. Y o u sa y, You

su m e d to p u t th e p a ti e n t ex p e d itio u sly on th e

will i m a g i n e a b eau tifu l r e l a x e d s c e n e . I c a n t

ro a d to cure. A ctually , a n a s tu te d y n a m ic a lly


o rie n te d in te rv ie w e r m a y be ab le to in du ce a

to m yself a b o u t y ou, H e is so g o d d a m i m

fig u re o u t if I s h o u l d j u s t see s o m e t h i n g o r be
in it p e r s o n a l l y sittin g , ly ing , o r sleepin g.
T h e scene I se ttled o n w a s t h e b a n k o f a river
w i t h a b o a t s u n l i g h t on t h e r iv e r reflected it
on t h e w a t e r . Y e s t e rd a y I p o p u l a t e d t h e w a t e r
w i t h a s w im . Also I t h o u g h t t h is w a s all n o n
sense. I tr ie d to o p en m y eyes, b u t m y lids
w e r e so he a v y th ey w o u l d n t o p e n . Y o u say,
E v e n if you a r e con scio us, t h e su g g e stio n s
will be effective. I a m conscious. T h e w