Alan Eppel

Short-Term
Psychodynamic
Psychotherapy

123
Short-Term Psychodynamic
Psychotherapy
Alan Eppel

Short-Term
Psychodynamic
Psychotherapy
Alan Eppel
McMaster University
Hamilton
Ontario
Canada

ISBN 978-3-319-74994-5    ISBN 978-3-319-74995-2 (eBook)

https://doi.org/10.1007/978-3-319-74995-2

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Preface

It was in the spring of 1976 that I travelled from Union Station

in Toronto to the Gare Centrale, Montreal’s central train station
at the Queen Elizabeth Hotel. The occasion was an interna-
tional conference organized by Habib Davanloo on short-term
psychodynamic psychotherapy. At the time I was a resident in
psychiatry at McMaster University in Hamilton Ontario. Short-
term psychodynamic psychotherapy was still very new in the
wider psychotherapeutic and psychiatric universes.
The conference brought together the leading pioneers in
the field: Peter Sifneos, David Malan and of course Davanloo
himself.
The conference was a thrilling experience because the
presenters showed videotapes of themselves in sessions with
real patients. This allowed the conference participants to test
the well-known clinical adage that what psychotherapists
think they do and what they actually do are not always a
match. In Montreal we had the astounding opportunity to
watch these experts at work and see for ourselves.
I later learned that Malan was so impressed with Davanloo’s
technique that he modified his own approach and subse-
quently collaborated with Davanloo.
Sifneos described his short-term anxiety provoking psy-
chotherapy, STAP, which he was developing at Massachusetts
General and Beth Israel Hospital in Boston. Sifneos would
identify a circumscribed specific chief complaint in order to
reach agreement with the patient on one problem. A require-
ment for his therapy was that the patient had had at least one
meaningful relationship during his life, a relationship charac-
terized by give and take, some flexibility and some altruism.
vi Preface

The patient also needed to demonstrate an ability to inter-

act with the therapist in a flexible way. Motivation for change
was another requirement for acceptance into STAP. Sifneos
practised a focal model of psychotherapy. His technique
involved raising the level of anxiety in the session to an opti-
mal level in order to reduce defenses and facilitate
expression.
David Malan also had adopted a focal conflict methodol-
ogy and a systematic approach to patient evaluation and
therapeutic interventions.
None of this could prepare the audience for Habib
Davanloo. The impact for many was one of shock. Davanloo’s
forceful confrontational style was a dramatic change from the
more gentle and obviously empathetic approaches of the
other therapists.
Davanloo’s approach was powerful and implicitly con-
veyed empathy by the intensity of his commitment to break-
ing through the defenses.
At the time my own supervisors at McMaster had very dif-
ferent styles. Dr. Nahum Spinner used what might be termed
a narrative approach. He would illustrate central concepts by
anecdotes and stories about his colleagues or himself. These
stories had in reality the qualities of a parable illustrating
important therapeutic principles laced with strong doses of
compassion. He rarely used technical jargon. As a first year
resident this puzzled me as I did not know what I was learn-
ing. In retrospect Dr. Spinner exemplified what is now called
a relational approach, an approach infused with a profound
humanism and an existential sensibility. He captured the
essence of psychotherapy in situating the process in the “you-
­me domain”. This had echoes with Martin Buber’s famous
treatise on “I and thou”.
Another of my supervisors, Jock Cleghorn, had trained as
a psychoanalyst but was also interested in the neuroscience of
sleep. Jock was the first to introduce me to the focal conflict
model based on the work of Thomas French. Conflicts were
identified between a disturbing wish or need and a reactive
motive.
 Preface vii

Over the following three decades of practising general

psychiatry in busy inpatient and outpatient settings, I learned
much about the importance of attachment in human relation-
ships. This arose from treating patients with borderline per-
sonality disorder. It was clear that a central feature of these
patients’ difficulty was insecure attachment with avoidant
and preoccupied patterns. The attachment model seemed
much more relevant than the theories of the day.
In 2000 after returning to McMaster University I began to
supervise psychiatry residents in psychodynamic psychother-
apy. I thought it would be useful to acquire one of Davanloo’s
videotapes to show to the residents. No tapes were publicly
available. However in my Google searches I stumbled upon a
DVD produced by Diana Fosha, a psychologist working in
New York City.
I ordered this DVD. My first impression was to dismiss it
as it seemed so radically different from anything I had seen
before. However the more I watched, the more I was stunned
by the complexity and at the same time simplicity of her
approach and its dramatic impact.
Fosha had turned Davanloo’s method “on its head” while
maintaining the fundamental principles of dynamic psycho-
therapy. She described her therapy as “accelerated”, and its
effects were evident right from the opening gambits.
I had to get more of this approach and subsequently
attended AEDP courses and supervision with Eileen Russell
in New York.
Diana Fosha’s approach dramatically changed my own
approach to therapy. The emphasis was now on affect much
more than intellectual insight.
I was anxious to convey these dramatically improved
approaches to residents in supervision.
In the course of supervising residents it became apparent
that experienced therapists were able to choose different
interventions than beginners. This provoked the recollection
of an educational session I had attended as a resident in
­psychiatry presented by Lewis Tauber. Tauber was a group
psychotherapist and supervised group, individual and family
viii Preface

psychotherapy at McMaster University in Hamilton Ontario.

He had introduced us to the concept of “choice points” in
group therapy. I found my old notes and was able to track
down his original 1978 paper online. I felt that it was a bril-
liant tool that could be expanded to enhance the supervision
of residents. I began to use it in the following years. I was able
to communicate by email with Dr. Tauber, and I am glad to
say that he was pleased to hear that his method was again
being used for supervising learners.
Ultimately my experience with this approach led me to
consider writing a manual for residents that subsequently
evolved into the writing of this book.
What is the place of short-term psychodynamic psycho-
therapy in current-day clinical practice? After six decades the
promise of the psychopharmacological revolution has been
only partially realized. Perhaps our expectations were naïve.
Medications while powerful and effective in reducing symp-
toms cannot be expected to address critical emotional and
personal dimensions of illness. Medications belong to a class
of therapeutics that is directed at symptom elimination. On
its own it comprises only one part of the biopsychosocial tri-
angle. The use of medications mechanistically results in the
loss of the essential person-to-person healing relationship.
Access to psychotherapy services remains unequal to the
needs of patients. The methods and level of funding for psy-
chotherapeutic services vary quite considerably from country
to country, e.g. in North America, Europe and Australia.
There is a need for effective short-term psychotherapies.
Cognitive behaviour therapy has a well-established role in
clinical practice and has often displaced psychodynamic
approaches because of its shorter lengths of treatment.
However cognitive behaviour therapy and related approaches
are not effective for all patients, and a broader array of ther-
apy options needs to be available to patients.
Over the past two decades a significant evidence base has
been accumulating to demonstrate that short-term
­psychodynamic psychotherapy can achieve good treatment
outcomes. A manualized approach can lead to more effective
 Preface ix

therapy implementation and outcomes. Manuals can enhance

the training of supervisees and facilitate research studies.
I should stress here what probably is quite obvious: one
cannot become a psychotherapist by learning from textbooks
or manuals. The essence of psychotherapy is the experience
of the therapeutic relationship and using that to alleviate suf-
fering. Descriptions on the written page do not convey the
emotional intensity, the connection between patient and
therapist and the dynamic flow of psychotherapy.
This book describes concepts from neuroscience, attach-
ment theory and decision theory. These disciplines constitute
foundational knowledge for the practice of psychotherapy.
The other sections of the book elaborate the conduct of
therapy drawing on research findings and the deployment of
specific skills. Psychodynamic psychotherapy cannot be done
in a mechanical way. However this book allows therapists to
acquire a model that contains enough definition to produce a
consistent approach. At the same time it retains a flexibility
that allows for moments of spontaneity and creativity.
This book is unique in a number of ways:
• It is not based on a specific school of psychoanalytic or
psychodynamic theory. Rather I have attempted to extract
and integrate key concepts.
• It attempts to move away from language that is derived
from theories and concepts that have been superseded by
advances in psychology and neuroscience.
• It provides definitions of concepts that are more in keep-
ing with scientific understanding as opposed to their meta-
phorical origins.

Description of This Book

Chapters 1, 2, 3, 4, 5 and 6 cover the theoretical underpinnings
of the practice of STPP. Chapter 1 describes the evolution of
the short-term psychodynamic psychotherapies starting in
Europe in the 1920s. Chapter 2 on attachment theory provides
x Preface

a framework for understanding adult relationship patterns

and internal working models.
Chapter 3 reviews the nature of emotions beginning with
Darwin’s momentous observations and then moving forward
to our current understanding of the dual system model of
emotion processing. This chapter reviews the complex rela-
tionships between consciousness and the subcortical origins
of emotions. This knowledge base has direct applicability to
the change process in STPP. Therapists must be able to recog-
nize, elicit and process emotion. This is essential for the prac-
tice of short-term psychodynamic therapy (STPP).
Chapter 4 is a brief but critical overview of the research
literature on short-term psychodynamic therapy.
Chapter 5 discusses the language of psychodynamic psy-
chotherapy and proposes neuroscientific updates in redefin-
ing these fundamental concepts.
Chapter 6 expands on Tauber’s ideas and describes one of
the unique features of this book: “Choice Point Analysis” and
“Action Alternatives” which facilitate the practice and the
supervision of psychodynamic psychotherapy. The evidence
linking key interventions with clinical outcomes is reviewed.
Chapter 7 essentially forms a manual that describes the
objectives, tasks and methods for conducting short-term
dynamic psychotherapy across the phases of Engagement,
Emotion Processing and Termination. The Engagement phase
covers the establishment of the therapeutic alliance and the
beginnings of therapy. The Emotion-Processing phase
involves working with the therapeutic relationship, the rela-
tional focus and processing affect.
Chapter 8 demonstrates how the manual can be applied to
the supervision of trainees and contains extracts of a case
transcript which has been annotated to demonstrate the
choice point method.
The concepts and interventions described in this book
have great utility in a wide range of practice settings. There is
much benefit in adopting a psychodynamically informed
approach to general clinical work.
 Preface xi

Chapter 9 describes the application of STPP principles to

general clinical practice. This is for physicians, psychologists,
social worker and others who may not be in a position to
undertake systematic psychotherapy. Throughout the empha-
sis is on clarity, succinctness and easy readability.

A Note About Terminology

There are numerous variations of psychodynamic psycho-
therapy. Many of these are considered to fall under the
umbrella of short-term psychodynamic psychotherapy
because they embrace the major concepts and approaches
which are reflected in this publication. The terms “experien-
tial dynamic psychotherapy” and “supportive-expressive
psychodynamic psychotherapy” are used to describe these
same approaches. The goal has been to avoid non-generic
jargon and use terminology that is applicable and common
across the disciplines.
This book does not follow one specific school of psychody-
namic psychotherapy. It is an integrated model and contains
elements from many of the leaders in the field. It is based on
a focal approach and incorporates experiential, emotion-­
based and relational interventions.
I have highlighted the implications of research findings
that show that expert clinicians make use of intuition and
experience. This manifests in a level of spontaneity in the
kinds of interventions made by experts. I became very
much aware of this in watching Nate Epstein make rapid
assessments of complex family dynamics. He used intuition
and skills that were invisible to myself and other psychiatry
residents. Trainees and early career psychotherapists do not
have this hidden repertoire to draw upon. For a student of
psychodynamic psychotherapy the task at times seems
overwhelming. Choice Point Analysis and the selection of
Action Alternatives are central to this book in order to
make the learning process more effective. It may poten-
xii Preface

tially open up a new dimension to psychotherapy training,

practice and research.
I would like to acknowledge those who influenced me
along the way. This includes the hundreds of patients I have
treated over the years who have impacted on my own self-­
concept and ways of relating and my supervisors Nahum
Spinner, Jock Cleghorn, Wendall Waters, Ron Ruskin, Emile
Zamora and Gian Bartolucci. A particular thanks to Nate
Epstein, founding chairman of the Department of Psychiatry
at McMaster University and brilliant family therapist, for set-
ting the events in motion that shaped my own trajectory lead-
ing to arrival at this destination. I must recognize my resident
supervisees who provided inspiration as we grappled with the
art and science of psychotherapy. To Elaine Chow and Yu
Jiang thank you for your assistance.
Gratitude and kudos to Diana Fosha, Eileen Russell and
others in the AEDP community for their transforming
influence.
I would like to express appreciation to David Abrahamson
who has provided important advice and ideas since my entry
into psychiatry. His incisive intellect and clarity of reasoning
have been of great value to me. His work as a psychiatrist in
the National Health Service in the UK has been an inspira-
tion in demonstrating integrity and a total commitment to
improving the lives of patients.
To James Bourgeois for his guidance and generous sup-
port. To Ana Hategan for her insights and encouragement to
complete this volume in her inimitable frank and direct way.
To Randi McCabe for her expert advice on developing psy-
chotherapy manuals.
To Molly Ferguson who has done a superb job of creating
delightful illustrations of emotions.
And finally to Nadina Persaud and Prakash Jagannathan
at Springer for their patient assistance and advice.

CanadaAlan Eppel
December 2017
Contents

1 The Emergence of Short-­Term

Psychodynamic Psychotherapy . . . . . . . . . . . . . . . . . .  1
1.1 Origins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   1
1.2 The Triangles . . . . . . . . . . . . . . . . . . . . . . . . . . . .   4
1.3 The Meaning of Time: James Mann . . . . . . . . .   7
1.4 Emotional Crisis and Grief: Erich Lindemann,
Peter Sifneos and Habib Davanloo . . . . . . . . .   7
1.5 Manualized Psychotherapy: Lester Luborsky .  10
1.6 The Third Generation of STPPs . . . . . . . . . . . .  12
1.6.1 Allan Abbass . . . . . . . . . . . . . . . . . . . . . . .  12
1.6.2 Affect Phobia Therapy:
Leigh McCullough . . . . . . . . . . . . . . . . . .  14
1.6.3 Accelerated Experiential Dynamic
Psychotherapy: Diana Fosha . . . . . . . . . .  17
1.6.4 Common Elements of STPPs . . . . . . . . .  20
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   21
2 The Application of Attachment Theory
to Short-Term Psychodynamic Psychotherapy . . . . .   25
2.1 Child Development . . . . . . . . . . . . . . . . . . . . . .  25
2.2 Precursors to Attachment Theory . . . . . . . . . .  26
2.3 Attachment Theory . . . . . . . . . . . . . . . . . . . . . .  28
2.4 The Mutual Regulation Model: Edward
Tronick . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  31
2.5 Attachment Theory and Psychotherapy . . . . .  33
2.6 Understanding Attachment Terminology
and Measures . . . . . . . . . . . . . . . . . . . . . . . . . . .  34
2.6.1 The Strange Situation . . . . . . . . . . . . . . . .  34
2.6.2 The AAI: The Adult Attachment
Interview . . . . . . . . . . . . . . . . . . . . . . . . . .  37
xiv Contents

2.7 Can Attachment Theory Be Applied

to Psychotherapy? . . . . . . . . . . . . . . . . . . . . . . .  40
2.8 Attachment Concepts Used
in Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . .  42
2.9 Future Research: The Research
Domain Criteria Project . . . . . . . . . . . . . . . . . .  43
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   45
3 Understanding and Recognizing
Emotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   47
3.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  47
3.2 In the Beginning…, Charles Darwin . . . . . . . .  48
3.3 The Evolution of Emotion . . . . . . . . . . . . . . . .  53
3.3.1 Paul McLean: The Triune Brain . . . . . . .  54
3.3.2 The Neurocircuitry of Emotion . . . . . . . .  56
3.3.3 A Dual System for Emotional
Processing . . . . . . . . . . . . . . . . . . . . . . . . . .  57
3.4 Damasio Where Do I Feel Emotion? . . . . . . .  60
3.4.1 The Insula . . . . . . . . . . . . . . . . . . . . . . . . .  62
3.5 Why Are Emotions Contagious? . . . . . . . . . . .  62
3.6 Paul Ekman . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  62
3.6.1 Higher-Order Social Emotions . . . . . . . .  63
3.7 Jaak Panksepp . . . . . . . . . . . . . . . . . . . . . . . . . . .  63
3.7.1 The Seeking System . . . . . . . . . . . . . . . . .  64
3.7.2 The Rage/Anger System . . . . . . . . . . . . .  65
3.7.3 The Fear System . . . . . . . . . . . . . . . . . . . .  65
3.7.4 Separation Distress and Social
Bonding Systems . . . . . . . . . . . . . . . . . . . .  65
3.7.5 Sexual/Lust . . . . . . . . . . . . . . . . . . . . . . . .  67
3.7.6 Joy/Rough-and-Tumble Play . . . . . . . . . .  68
3.8 Conclusions: Why Does This Matter? . . . . . . .  68
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   70
4 A Critical Review of Psychotherapy Research . . . . .   71
4.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  71
4.2 History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  72
4.3 Basic Principles of Psychotherapy
Research: Effect Sizes . . . . . . . . . . . . . . . . . . . .  73
4.3.1 Bias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  74
 Contents xv

4.4 Research Methodologies . . . . . . . . . . . . . . . . . .  76

4.4.1 Randomized Controlled Trials
and Meta-­Analyses . . . . . . . . . . . . . . . . . .  77
4.5 Critical Reviews: The Current State
of Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  79
4.6 Process Research . . . . . . . . . . . . . . . . . . . . . . . .  81
4.6.1 Common or Specific Factors:
The Dodo Bird Effect . . . . . . . . . . . . . . . .  81
4.7 Notable Studies of STPP . . . . . . . . . . . . . . . . . .  83
4.8 The National Health Service . . . . . . . . . . . . . . .  85
4.9 Future Research . . . . . . . . . . . . . . . . . . . . . . . . .  86
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   89
5 Updating the Language of Psychodynamic
Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   95
5.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  95
5.2 Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  96
5.2.1 Psychodynamics . . . . . . . . . . . . . . . . . . . .  96
5.2.2 Object Relations . . . . . . . . . . . . . . . . . . . .  96
5.2.3 Affect, Emotion and Feeling . . . . . . . . . .  98
5.3 Defences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  99
5.3.1 Neuroscientific Reformulation
of Concept of Defence . . . . . . . . . . . . . . . 101
5.4 Attachment Theory, Object Relations
and Interpersonal Terms . . . . . . . . . . . . . . . . . . 102
5.4.1 Translating Dynamic Terms
into Attachment Language . . . . . . . . . . . 103
5.5 Memory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
5.6 Empathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
5.7 Therapeutic Change Processes . . . . . . . . . . . . . 106
5.8 Statistical Language . . . . . . . . . . . . . . . . . . . . . . 107
5.8.1 Meta-analysis . . . . . . . . . . . . . . . . . . . . . . . 107
5.8.2 Effect Size . . . . . . . . . . . . . . . . . . . . . . . . . 107
5.8.3 Heterogeneity . . . . . . . . . . . . . . . . . . . . . . 108
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  109
6 Choice Point Analysis and Action Alternatives . . . .  111
6.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
6.2 How Do We Make Decisions? . . . . . . . . . . . . . 112
xvi Contents

6.3 Lewis Tauber: Choice Points and Action

Alternatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
6.3.1 AEDP and Fosha’s Emphasis
on the Dyad . . . . . . . . . . . . . . . . . . . . . . . . 117
6.4 STPP Interventions . . . . . . . . . . . . . . . . . . . . . . 118
6.5 Evidence for Interventions and Treatment
Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
6.5.1 Promoting the Therapeutic Alliance . . . 120
6.5.2 Emotion Focus . . . . . . . . . . . . . . . . . . . . . 121
6.5.3 Transference and Relationship . . . . . . . . 122
6.5.4 Rupture and Repair
in the Relationship . . . . . . . . . . . . . . . . . . 123
6.5.5 The Relational Focus . . . . . . . . . . . . . . . . 124
6.5.6 Humour . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
6.6 Action Alternatives: A Provisional
Hierarchy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
6.6.1 Set 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
6.6.2 Set 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
6.6.3 Set 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  130
7 A Manual for Short-Term Psychodynamic
Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  133
7.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
7.2 The Assessment and Engagement Phase . . . . 134
7.2.1 Overall Objectives of the 
Engagement Phase . . . . . . . . . . . . . . . . . . 134
7.2.2 Initial Tasks . . . . . . . . . . . . . . . . . . . . . . . . 135
7.2.3 Objective: Taking the History . . . . . . . . . 135
7.2.4 History Tasks . . . . . . . . . . . . . . . . . . . . . . . 135
7.2.5 Tasks of Eliciting the Psychodynamic
History . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
7.2.6 Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
7.3 The Relational Focus . . . . . . . . . . . . . . . . . . . . . 140
7.3.1 Identifying the Relational Focus . . . . . . . 141
7.4 Suitability for STPP . . . . . . . . . . . . . . . . . . . . . . 143
7.4.1 Attachment Style . . . . . . . . . . . . . . . . . . . 144
7.4.2 Diagnostic Considerations . . . . . . . . . . . . 144
7.4.3 Contract and Orientation . . . . . . . . . . . . . 145
 Contents xvii

7.4.4 Orientation to Therapy:

A Sample Narrative . . . . . . . . . . . . . . . . . 146
7.5 The Emotion Processing
and Thematic Phase . . . . . . . . . . . . . . . . . . . . . . 151
7.5.1 Tactical Defences . . . . . . . . . . . . . . . . . . . 152
7.5.2 Using the Triangle of Defence
and the Triangle of the Person . . . . . . . . 153
7.6 The Formulation . . . . . . . . . . . . . . . . . . . . . . . . . 156
7.7 Choice Point Analysis and Action
Alternatives in the Therapeutic Phase . . . . . . 158
7.7.1 A Provisional Hierarchy of Action
Alternatives . . . . . . . . . . . . . . . . . . . . . . . . 158
7.7.2 Choice Point Action Alternatives
Set One: Relational . . . . . . . . . . . . . . . . . . 158
7.7.3 Choice Point Action Alternatives
Set Two: Defences and External
Relationships . . . . . . . . . . . . . . . . . . . . . . . 160
7.7.4 Choice Point Action Alternatives
Set Three: Content . . . . . . . . . . . . . . . . . . 160
7.8 Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
7.8.1 Termination Tasks . . . . . . . . . . . . . . . . . . . 165
7.8.2 Termination Tactics . . . . . . . . . . . . . . . . . . 166
7.8.3 Follow-Up and Outcome . . . . . . . . . . . . . 166
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  167
8 Supervision: Applying Action Alternatives . . . . . . . .  169
8.1 Supervision Format . . . . . . . . . . . . . . . . . . . . . . 169
8.2 Supervisory Questions to the Therapist . . . . . 170
8.2.1 Supervisory Questions About
the Patient . . . . . . . . . . . . . . . . . . . . . . . . . 171
8.3 Structured Assessment of Sessions . . . . . . . . . . 189
8.3.1 Verona Coding of Emotional
Sequences: VR-CoDES . . . . . . . . . . . . . . 191
8.4 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  192
9 Psychodynamically Informed Clinical Practice
for ­Non-­Psychotherapists . . . . . . . . . . . . . . . . . . . . . .  195
9.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
9.2 The Therapeutic Alliance and Attachment . . . 196
xviii Contents

9.3 Medication as Object and Psychodynamic

Psychopharmacology . . . . . . . . . . . . . . . . . . . . . 197
9.4 Relational Pattern . . . . . . . . . . . . . . . . . . . . . . . . 200
9.5 History Taking . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
9.6 Michael Balint . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
9.7 Ultrashort-Term Psychotherapy . . . . . . . . . . . . 201
9.8 Thomas Main . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  204
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  207
Chapter 1
The Emergence of
Short-­Term Psychodynamic
Psychotherapy

1.1  Origins
We must look to Budapest Hungary in order to trace the
origins of STPP. It is there in the persona of Sandor Ferenczi
that Freud’s treatment parameters were challenged. Ferenczi
began to experiment with a more active approach [1]. He put
a greater emphasis on emotion as opposed to interpretation.
Another Hungarian and an analysand of Ferenczi, Franz
Alexander was also to figure prominently in the elaboration
of shorter and more focused interventions.
Alexander and French in 1946 introduced the idea of the
“corrective emotional experience” [2, 3]. This idea was ini-
tially rebuffed by mainstream practitioners. However it can
now be seen as a forerunner of the current emphasis on the
relationship aspects of psychotherapy as opposed to
interpretation.
Alexander’s identification of the corrective emotional
experience was an important break with the emphasis on
interpretation as the curative vehicle. Corrective emotional
experiences depend on a strong therapeutic alliance with the
therapist, emotional expression and disconfirmation of the
patients’ feared expectations. Reflecting on the experience,
the self-reflective loop is essential for the therapeutic impact.
This is what distinguishes the corrective emotional experi-
ence from mere catharsis which is not effective.

© Springer International Publishing AG, 1

part of Springer Nature 2018
A. Eppel, Short-Term Psychodynamic Psychotherapy,
https://doi.org/10.1007/978-3-319-74995-2_1
2 Chapter 1.  The Emergence of Short-­Term Psychodynamic

Sandor Ferenczi and the Budapest School are now recog-

nized for introducing major technical shifts that gave rise to
more active interventions emphasizing what are now regarded
as “relational” interventions. Ferenczi diverged from Freud in
the focus on the interactions between patient and therapist.
Alice and Michael Balint, disciples of Ferenczi, moved to
London England from Hungary and had a profound impact
on the outlook of the Independent School of British Object
Relations in particular on Winnicott, Malan and Bowlby [4–
13]. Balint had translated Ferenczi’s work into English. Balint
and Winnicott’s therapeutic styles provide the conceptual
links between object relations theory and Bowlby’s attach-
ment theory (Fig. 1.1).
At the Tavistock clinic in London, Balint influenced and
worked closely with David Malan. Malan by introducing a
dynamic focus and attention to transference interpretations
can be regarded as one of the founding fathers of the modern-­
day short-term dynamic approaches [3–9].
I have illustrated the relationships between these psycho-
analysts and psychotherapists in the adjoining  figures. The
connecting lines are to indicate influence on theory and prac-
tice. These connections are based on my own readings and
may not necessarily be accepted by the authors themselves.
The work of Michael Balint and David Malan marks a
critical point in the breakout of short-term dynamic psycho-
therapy. Balint was a starkly creative and original
psychotherapist.

Freud

Ferenczi

Balint

Winnicott Malan Bowlby

Figure 1.1  Major
contributors to the Fonagy
development of STPP
 1.1 Origins 3

It is to Balint that we attribute the concept of “focal psy-

chotherapy”. His approach while deeply rooted in Freudian
ideas of impulses and defence also contains a revolutionary
interpersonal perspective. This was evident in his 1957 book
The Doctor, His Patient and The Illness. In this he conceives
illness as an interpersonal construct [10].
We normally think of illness as something that is con-
tained within the body of the patient. But Balint brings
attention to focus on the interpersonal dimensions of ill-
ness behaviour and the interactions that ensue between
the patient and physician. The patient “offers” symptoms
and complaints, and the physician makes a counteroffer.
This is a constructivist view long before such ideas became
popular and recognized as such. The patient and the physi-
cian co-construct the illness. Counteroffers could be in the
form of investigations or medications. In addition for
Balint a counteroffer could consist of listening deeply,
“being with” and staying with the patient through his dif-
ficulties. This was quite a radical way to view the physi-
cian’s task. Balint proposed that the doctor him or herself
could be the offering and could take the place of medica-
tion and be administered in different “dosages”. This fore-
shadowed the current emphasis on the relationship in
psychodynamic therapy.
Balint like Winnicott was intensely aware of the nonverbal
and relational dimensions and that the way of relating itself
could be therapeutic. For Malan interpretation dominated
the therapeutic approach until his encounter with Davanloo.
In 1963, Malan published his first book demonstrating
focal psychotherapy [6]. He named his approach “brief psy-
chotherapy” and underlined the importance of interpreting
the transference.
Malan wanted to put psychoanalytic treatment on a scien-
tific basis and to make it more accessible by shortening the
process. He worked on developing selection criteria, thera-
peutic strategies and measures of outcome.
Malan discovered that it was possible to make radical
interpretations of the transference and that this was associ-
4 Chapter 1.  The Emergence of Short-­Term Psychodynamic

ated with better results. Malan made use of the parallels in

the patient’s past relationships, current relationships and
transference relationship. He referred to this as the “triangle
of conflict”. In a subsequent study, Malan found that positive
outcome was related to the percentage of parent-transference
links made by the therapist. This finding would turn out to be
not so straightforward in research conducted in later decades
(Chap. 4).
At this early stage, Malan held that the strategic aim of
brief psychotherapy was to bring emotional conflicts into
consciousness. The focus on a single conflict differentiated
brief psychotherapy from classical psychoanalysis.

1.2  The Triangles

Malan used diagrams of triangles to systematically conceptu-
alize some of the key activities required of the therapist in
psychodynamic psychotherapy.
The origins of this approach are derived from the concept
of “working through” [14]. Working through refers to repeated
interpretations in order to promote insight.
Karl Menninger had described the “triangle of insight” as
a framework for working through [15]. This involves identify-
ing transference patterns and relating them to patterns in
current and developmental relationships. Malan elaborated
on these ideas and named this “the triangle of the person”
(Fig. 1.2).
The first corner of the triangle represents current relation-
ships, the second corner represents past relationships, and the
third corner represents the transference. The triangular repre-
sentation reinforces the idea that the same relationship pat-
tern may be evident in past, present and therapeutic
relationships.
Henry Ezriel, a group psychotherapist also working at the
Tavistock in London England, further developed and struc-
tured the use of transference interpretations.
 1.2  The Triangles 5

Figure 1.2  Triangle Transference Present

of the Person

Past

Ezriel made a huge conceptual leap which presages the

whole relational movement in psychodynamic psychotherapy.
He recognized that although transference patterns are
derived from past relationships, they are operative in the
here-and-now present moment [16].
Ezriel focused on the therapist-patient relationship. He
described the patient’s need to relate to the therapist in a
particular way which he called the “required relationship”. He
also identified “the avoided relationship” which was a type of
relationship that the patient unconsciously wanted to avoid.
This feared relationship was based on the unconscious expec-
tation that it could lead to a “calamitous” outcome. The
feared or calamitous outcome is the result of giving in to the
desire of entering into the avoided relationship.
Malan based his triangle of conflict on similar ideas
(Fig.  1.3). Ezriel’s required relationship is equivalent to
Malan’s defences, the avoided relationship to the wish and
anxiety to the feared outcome.
The major advance that Ezriel made was to distinguish
what had occurred in the past from the activity in the present.
He highlighted that transference is not something that gradu-
ally develops in the course of therapy but that it is active from
the very first meeting between the patient and therapist [15].
Transference is an expectation, a prediction of how our rela-
tionships will play out. It can also be viewed as an attempt to
6 Chapter 1.  The Emergence of Short-­Term Psychodynamic

Defense Anxiety/ Inhibitory feelings

Core emotions/Wishes/Impulses

Figure 1.3  Triangle of conflict

establish or re-create in the here and now a particular rela-

tionship pattern. Ezriel goes on to say:
This means that everything the patient says or does during the
session  – movements, gestures, phantasies, dreams, and even
deliberate lies – is considered as the idiom used by the patient to
give expression to his need in that session for a specific relation-
ship with his therapist [15].

Malan initially maintained the belief that interpretation

was the most important component of the therapeutic pro-
cess. In contrast his mentor Michael Balint felt that the qual-
ity and nature of the therapeutic relationship was critical to
successful therapy.
After studying Davanloo’s methods and results, Malan
came to the conclusion that his prior work at the Tavistock
Clinic based mainly on an interpretive approach was
“inadequate” [5, 7, 8]. And in fact interpretations might get
in the way of allowing the patient to experience his feel-
ings [5]. Malan came to the conclusion that a new approach
was required and believed that Davanloo’s methods pro-
vided some of the essential components for changes in
practice [7, 8].
Malan was now convinced that dealing with emotion was
more important than making interpretations. The strategy in
therapy now becomes getting to the feelings and facilitating
the patient’s deep experience of these emotions.
 1.4  Emotional Crisis and Grief: Erich Lindemann... 7

1.3  The Meaning of Time: James Mann

James Mann was one of the few authors who has grappled
with the unstated and implicit components within short-term
psychodynamic therapies, the concept and meaning of time
[16, 17].
Mann worked at the Boston University School of Medicine
and Medical Center. In 1964, faced with long waiting lists and
heavy demands for service, Mann introduced a time-limited
method of psychotherapy. He implemented a general policy
within his clinic that all patients would be offered 12 treat-
ment hours.
Mann deliberately employed time to achieve the goals of
therapy. The choice of 12 treatment sessions was arbitrary, but
Mann felt that this was the minimal time required for
resolution.
Mann used a focal conflict approach identifying a recur-
rent issue that has led to maladaptive functioning. To empha-
size the importance of time in his approach, the patient was
given the times for each appointment as well as the exact date
of the 12th and final session. This was to prevent the patient
from avoiding thoughts about the ending of therapy and its
associated separation anxiety. Mann described his approach
as designed to overcome the unconscious yearnings for the
timelessness experienced in childhood in relation to the
mother [16].

1.4  E
 motional Crisis and Grief: Erich
Lindemann, Peter Sifneos and Habib
Davanloo
Less widely discussed today is the very significant impact that
Erich Lindemann had on the current practice of short-term
dynamic psychotherapies through two of his psychiatry resi-
dents, Peter Sifneos and Habib Davanloo.
8 Chapter 1.  The Emergence of Short-­Term Psychodynamic

Lindemann developed a rapid therapeutic approach to

individuals experiencing grief and loss following a nightclub
fire in 1945. Lindemann noticed that rapid psychological
change could occur following a major trauma. The trauma of
death often resulted in a breakdown of the normal defensive
barriers and resistance to psychological change. The patient’s
mental state was more “fluid” and amenable to change [18].
Lindemann’s approach to grief involved that the patient
focus on both positive and negative feelings towards the
deceased person. The patient needed to become aware of
psychological factors that blocked the experience of grief in
order to experience the emotional pain of bereavement
rather than avoiding it. His ideas appear to have had an
important influence on Sifneos and Davanloo [19–23].
Davanloo applied some of these principles to psychother-
apy in general [21, 22]. To do this it meant re-creating some of
the same conditions of psychological flexibility in order to
lead to rapid intrapsychic change. The method he developed
was to vigorously confront, to create pressure by focusing
intensely on the transference in order to break through to
unconscious material. Davanloo was also one of the first to
use videotaped recordings of sessions for teaching and super-
vision but also for research. Davanloo called his approach
“Intensive Short-Term Dynamic Psychotherapy”, and his
method is widely practised and taught in Halifax Nova Scotia,
California and elsewhere in the United States, the Netherlands,
Norway, Sweden and the United Kingdom.
Davanloo moved to McGill University in Montréal in the
1960s where he developed and refined his techniques.
Davanloo’s method is intensely experiential facilitating and
amplifying the patient’s experience of emotion which allows
for a reworking of the patient’s perception of himself and
others. The emphasis is on the immediate experience within
the therapeutic session with particular attention to the
patient’s feelings and emotions towards the therapist.
Davanloo’s technique represented a further leap in the
evolution of short-term psychodynamic psychotherapy.
Davanloo’s students went on to branch out and expand this
method.
 1.4  Emotional Crisis and Grief: Erich Lindemann… 9

Davanloo and Sifneos recognized that therapy could be

facilitated by deliberately manipulating the level of anxiety.
Sifneos called his method “short-term anxiety-provoking psy-
chotherapy” [20, 21]. It is well established that there is an
optimal level of anxiety needed to facilitate the learning pro-
cess, so too is this the case with psychotherapy.
Davanloo’s approach takes this a step further by deliber-
ately raising the temperature and increasing the level of ten-
sion in order to break down the defences to get to the
underlying emotions at the bottom of the triangle of
conflict.
This involves a period of “pressure” in which the therapist
identifies contradictions and inconsistencies. Defences are
challenged. This involves very active intervention by the
therapist often interrupting. This in turn intensifies emotional
arousal and feelings of anger.
This activates transference feelings and resistance. These
feelings contain a mixture of anger, sadness, loss and longings
for intimacy. At the same time, the therapist conveys that this
challenging of defences is necessary for the patient’s recovery
and to relieve his suffering. The therapy proceeds working
with cycles of defence, challenge and transference.
Challenge to the resistance in the transference eventually
results in a breakthrough with the expression of unconscious
feelings and memories. Davanloo referred to this break-
through as “unlocking the unconscious”.
This phase facilitates the exploration of outside relation-
ship patterns and again working through cycles of defence
and emotion. This is an iterative process in which relation-
ships are explored and new resistances are addressed with
further challenge.
Interpretations are made linking the resistance in the trans-
ference with conflicts in both current and past relationships
utilising the three corners of the triangle of the person: trans-
ference-current-past, in short “TCP interpretations” [7, 8].
In the history of psychodynamic psychotherapy, perhaps
there has never been such an abrupt and transformational
change in practice and technique.
10 Chapter 1.  The Emergence of Short-­Term Psychodynamic

For those in the early 1970s who viewed Davanloo’s video

recordings, the impact was dramatic. For many this radical
change was shocking and antithetical to the more gradualist
and long-term approach that cut across mainstream psycho-
dynamic psychotherapy. Davanloo’s techniques elicited
intense emotion in the here and now of the therapeutic ses-
sion. This is the basis of the experiential approach.
Despite the objections and repudiation by traditional psy-
choanalysts, Davanloo’s approach was in its essence a distilla-
tion of psychodynamic tenets. He followed the basic sequence
of identifying defences and getting past these to unconscious
material. He made amplified use of the transference to accel-
erate and intensify the process but at the same time mobi-
lized and strengthened the unconscious therapeutic alliance.

1.5  M
 anualized Psychotherapy: Lester
Luborsky
Lester Luborsky trained and worked at the Menninger
Foundation and then with a group of researchers in
Pennsylvania where he developed his core conflictual rela-
tionship theme approach [24]. This was a manual-based
approach for identifying a core transference theme. He used
audio recordings of patient interviews and specific rating
scales (Fig. 1.4).

Luborsky

Leichsenring

Crits-
Hogland Piper Safran
Christoph

Figure 1.4  Second-generation researchers in STPP

 1.5  Manualized Psychotherapy: Lester Luborsky 11

He described his approach As Supportive Expressive

Psychoanalytically Oriented Psychotherapy based on the
model practised at the Menninger. Supportive techniques are
those that enhance and support the therapeutic relationship.
Expressive techniques are those that facilitate the expres-
sions of feelings, thoughts and reflection leading to insight or
understanding. Expressive techniques aim to supply meaning
to what the patient expresses.
Luborsky defined a time-limited version of his approach
named as “SE-TL”. This time-limited version lasted from 6 to
25 sessions with a session frequency of once or twice per
week. He described that his time-limited therapy is “in the
lineage of short-term psychotherapies” which includes Balint,
Malan, Sifneos and Mann [24].
Like these other authors, Luborsky adopts a consistent
therapeutic focus. This involves making a selection early in
the treatment of a primary focus around which the therapy
will be directed. The focus is usually based on a component of
the core conflictual relationship theme and the symptoms
connected with it [24].
The core conflictual relationship theme consists of:
• A wish, need or intention – W
• An executive function which appraises the likely impact of
acting on the wish, need or intention
• The responses from the other person – RO
• The responses of the self
The task of the therapist is to help the patient achieve
insight by working through the multiple examples of the rela-
tionship theme as they are expressed in the transference. This
involves dealing with the defence “resistances” that block the
emergence into awareness of unconscious thoughts and feel-
ings [24]. Examples of wishes include to be assertive, to feel
strong or to be independent. Response from the object could
be in the form of domination, intrusion, rejection, or disap-
proval. Positive responses would be acceptance and caring.
Responses from the self may consist of withdrawal, passively
going along, anger or anxiety.
12 Chapter 1.  The Emergence of Short-­Term Psychodynamic

1.6  The Third Generation of STPPs

Davanloo had a profound influence on three of his students:
Allan Abbass, Diana Fosha and Leigh McCullough who went
on to elaborate or modify his methods (Fig. 1.5).
There is considerable overlap in the work of these three
master therapists (Figs. 1.6 and 1.7).

1.6.1  Allan Abbass

Allan Abbass completed a family practice residency at

McGill University in Montréal. He worked as a family and
emergency physician. He started training with Davanloo in
1990 and subsequently completed psychiatry residency train-
ing in Toronto. He continued to practise the Davanloo model

Lindemann

Davanloo Sifneos

Abbass McCullogh Fosha Osimo Coughlin Alpert

Figure 1.5  The third generation of STPPs

MCCULLOUGH
FOSHA

Figure 1.6
ABBASS
Relationship of
third-generation
STPP to each other
 1.6  The Third Generation of STPPs 13

ISTDP

AEDP APT

Figure 1.7  Experiential dynamic psychotherapies

and set up a training centre at Dalhousie University in Nova

Scotia. He has provided training internationally and has been
a prolific researcher publishing multiple empirical studies of
ISTDP [25–28]. He has demonstrated the economic benefits
of treating psychosomatic disorders with ISTDP.
In his more recent publications, Abbass and his colleagues
in Sweden have replaced the term “unlocking the uncon-
scious” with “mobilization of unprocessed complex emo-
tions” (MUCE) [29]. Therapy is conceptualized as mobilizing
and processing these emotions. This change of terminology is
welcomed as it relinquishes historical terms and introduces
those that have been enriched by advances in neuroscience
and emotion theory. The change in terminology also facili-
tates more compatibility of language between ISTDP and
other forms of emotion-focused experiential treatment.
ISTDP recognizes three levels of emotional arousal and
expressiveness:
• Low rise in which there is little emotional activation and
the dialogue is intellectual. Defences and anxiety are mini-
mally apparent.
14 Chapter 1.  The Emergence of Short-­Term Psychodynamic

• High rise in which complex attachment-related emotions

are evident with anxiety and defences. These defences are
distancing and include gaze avoidance, turning of the body
away from the therapist and becoming more passive in the
interview.
• Partial breakthrough. Complex feelings are at a high level.
The patient experiences feelings of grief.
• Partial unlocking. Patient now experiences deep feelings
such as grief, rage and guilt. Linkages are made to past
attachment trauma.
• Major unlocking strong feelings are experienced towards
the therapist. There is intensification of the treatment alli-
ance associated with memories of significant persons from
the patient’s past.

1.6.2  Affect Phobia Therapy: Leigh McCullough

Affect phobia therapy was developed by Leigh McCullough

[30]. She began research on short-term dynamic psychother-
apy in the 1980s at the Beth Israel Medical Center in
New York.
She later became director of the Psychotherapy Research
Program at Harvard Medical School. Her work has been con-
tinued since her death by Kristin Osborn and Nathaniel
Kuhn.
Her intensive review of videotape sessions led her to
reformulate the process of therapy. She identified that the
fear of experiencing emotions is central to the development
of patients’ difficulties [30–32]. She incorporated aspects of
learning theory and cognitive behaviour therapy into her
model. She felt that fear of affect which she entitled “affect
phobia” was analogous to external phobias such as agorapho-
bia in which the main coping strategy was avoidance. She
applied the same principles of APT treatment that involved
gradual desensitization to the experience of painful emotions.
She  viewed her therapy as an integration of dynamic and
behavioural principles.
 1.6  The Third Generation of STPPs 15

Defences represent avoidance strategies. These include

withdrawal, avoiding eye contact, smiling when talking about
something sad, changing the subject, focusing on physical
symptoms and self-criticism.
APT works with  defences which are used to avoid the
experience of uncomfortable feelings or to maintain them
out of awareness. The principal shift in this form of STPP is
the reconceptualization using concepts from learning theory
and behaviour therapy, i.e. avoidance and the need for expo-
sure. She also included the use of guided imagery to elicit
memories and sensations connected to painful emotions. The
therapeutic process is modelled on systematic desensitization
from learning theory. This involves exposure to the feared
emotion and response prevention by means of discouraging
avoidance of emotions. The gradual exposure to these emo-
tions within the context of an empathic therapeutic relation-
ship fosters healing.
The work of McCullough’s group has involved meticulous
analysis of videotapes broken down into 10-min segments.
Affect phobias frequently involve feelings of grief, anger,
assertiveness, sexuality, aggression, closeness and positive
feelings towards the self [30, 31]. These are considered adap-
tive or activating affects. Anxiety and shame are considered
inhibitory affects.
Activating affects lead to activity, approach, engagement
and opening up. Inhibitory affects lead to withdrawal, avoid-
ance and shutting down.
Affect phobia therapy also makes use of the triangle of
conflict. There is a focus on the impact of inhibitory affects
and defences that block the experience of conflict between
adaptive affects and inhibitory affects.
Treatment is accomplished by means of helping the patient
experience more adaptive affect in a gradual way while
attenuating feelings of anxiety, shame and guilt. Affects are
considered as the primary motivators of behaviour. The expe-
rience of affect is fundamental to therapeutic change.
Affect phobia therapy utilizes graded exposure to the
feared emotion. Over the course of therapy, the patient is
able to tolerate the experience of increasing levels of the
16 Chapter 1.  The Emergence of Short-­Term Psychodynamic

feared affect. The patient is encouraged to stay with his or her

feelings.
Anxiety regulation is another component of AFP.  This
involves ensuring that the anxiety level is not too high. If the
anxiety levels are not modulated, there is a risk of having the
reverse of the intended effect by increasing the sensitization
to the feared affect.
The goal is to free up the inner experience of adaptive
emotions by breaking “the stranglehold that anxiety, guilt,
shame, pain…” have on the experience of healthy adaptive
affect [30].
McCullough’s group is unique in using the GAF (Global
Assessment of Functioning Scale) to assist in determining
patient suitability for the treatment.
Ratings of 50 or above on the GAF are deemed to be con-
sistent with suitability for APT. Ratings below 50 indicate a
need for more a supportive ego building or defence building
intervention. It is felt that the GAF is more useful in assessing
suitability than a particular Axis I or Axis II diagnosis.
McCullogh’s method makes use of the supportive expres-
sive continuum. Those patients scoring lower on the GAF
require more supportive and less exploratory interventions
[30]. For patients with scores above 50, expressive techniques
can be used to challenge defences and evoke underlying feel-
ings. There is a balance between exploration and support in
order to modulate the anxiety level and to maintain and
strengthen the therapeutic alliance.
Expressive techniques include confrontation, interpreta-
tion, challenging and  facilitating the experience of intense
affect. Supportive techniques include validation, empathy,
reinforcing defences, building social supports, coping skills,
advice, reassurance and praise.
A major contribution of McCullough’s group is the
Achievement of Therapeutic Objectives Scale (ATOS) [32].
The ATOS was designed to assess changes in the key
dimensions of psychodynamic psychotherapy: the scale con-
sists of seven dimensions:
 1.6  The Third Generation of STPPs 17

• Defence recognition
• Defence relinquishing
• Affect experiencing
• Affect expression
• Level of anxiety, guilt or shame
• Sense of self and degree of self-compassion and
self-regard
• Sense of others and degree of relatedness to others
This scale is useful across all forms of dynamic psycho-
therapy as it is theory neutral. This scale is rated numerically
from 1 to 100 with anchor points. The ratings can be made on
video and audio recordings or on transcripts of psychother-
apy sessions. Ratings are made for each 10-min segment of
the session.
For example, a patient who had excellent recognition of
maladaptive patterns of thoughts, feelings and behaviours
and full awareness of their impacts will be rated at the top
end of the scale 91–100. Conversely patients who gains no
awareness of the maladaptive patterns even when pointed
out by the therapist or disagrees with the therapist’s interven-
tion would be rated from 1 to 10.
The ATOS is a very useful contribution to the practice and
research of STPPs. It focuses on core components of dynamic
psychotherapy. Kristin Osborn and colleagues have produced
the ATOS Therapist which can be used to assess therapist
competency and adherence to the therapy model [33].

1.6.3  A
 ccelerated Experiential Dynamic
Psychotherapy: Diana Fosha
The next quantum leap in the evolution of short-term
dynamic psychotherapies was the emergence of Diana
Fosha’s AEDP (accelerated experiential dynamic psycho-
therapy). Fosha’s work exploded on the psychotherapy scene
in North America with the publication in 2000 of her tour de
force “The Transforming Power of Affect” [34]. Fosha trained
18 Chapter 1.  The Emergence of Short-­Term Psychodynamic

with Davanloo between 1985 and 1988. She later worked with
Michael Alpert. Alpert had trained with Davanloo between
1980 and 1983. In the 1990s, he set up an STDP clinic in New
Jersey where he worked with Diana Fosha. Alpert called his
approach Accelerated Empathic Therapy [35].
Fosha diverged from Davanloo’s technique. While retain-
ing the same core dynamic features of the triangle of conflict,
she developed interventions to soften and bypass defences.
Drawing on and expanding Alpert’s work, Fosha formulated
an approach to deal with defences in a  manner  very differ-
ent  to Davanloo. Rather than pressure and challenge the
hallmark of Davanloo’s interpersonal style, Fosha’s method
involves “melting” and “bypassing” defences. This is accom-
plished by maintaining a highly empathic and attuned rela-
tional style with patients. The patients’ bodily experience of
emotion is also elicited which can lead to rapid access to
these  emotions. The real relationship is acknowledged, and
self-disclosure regarding the patient’s impact on the therapist
is used therapeutically. This entails recognition of the patient’s
struggles and achievements. These methods are very striking
and can lead to rapid “accelerated” progress of therapy.
Fosha stresses that AEDP is healing orientated with the
goal of transformation. She refers to “innate, wired-in dispo-
sitions for self-healing…” which she has termed “transfor-
mance” [34]. A major strategic aim of AEDP is to work with
these healthy strivings.
Fosha does not stress explicit emphasis on the transference
or use of a specific dynamic focus.
Rather she disconfirms the patient’s unconscious negative
expectations right from the start of the first session: she wel-
comes the patient.
By focusing on the development of a secure attachment,
there is a reduction in the patient’s anxiety which diminishes
the need for defensive manoeuvres allowing access to core
emotions.
“Moment to moment tracking” is an essential task for the
therapist. This requires paying close attention to the patient’s
experiences as well as the therapist’s emotional responses.
 1.6  The Third Generation of STPPs 19

An extremely powerful AEDP technique is “metapro-

cessing”. This consists of reflecting on the therapeutic
interaction: “What is it like to feel that with me here right
now?”
Metaprocessing promotes the development of a coherent
autobiographical narrative and a sense of existing in the
mind of the other person. For Fosha the unit of therapeutic
intervention is not the therapist’s comment but the thera-
pist’s comment and the patient’s response. She is  canny in
her realization that what is most important is the patient’s
experience of the therapist’s intervention and subsequent
response to it.
Fosha has described four psychological states [31]:
State 1: Distress, symptoms, anxiety, shame
State 2: Core emotions
State 3: Transformational affects
State 4: Core state
State 1 consists of the patient presenting in distress with
symptoms and dysregulated emotions. Inhibitory emotions
such as anxiety, shame and guilt may be evident. Defences are
in full force.
Fosha uses therapeutic interventions to help the patient
shift into State 2. This involves empathy, attunement and
identifying defences. State 2 is the experience of core emo-
tions such as sadness, anger, fear, joy and grief. State 2 is
accompanied by feelings of authenticity.
The third stage is facilitated by metaprocessing. Emotions
of pride, joy, gratitude and feeling moved may emerge.
Conversely feelings of sorrow or mourning what has been
lost may arise in response to various reflections.
Fosha calls the deepest level of emotional experience the
“core state”. This includes feelings of compassion, self-­
compassion, wisdom and generosity. The patient experiences
a sense of calmness, things feel “right” with a coherent self-­
narrative [31].
Fosha has developed a very well-elaborated theory and
methodology, and clearly this brief summary cannot do jus-
20 Chapter 1.  The Emergence of Short-­Term Psychodynamic

tice to its complexity and nuances. For further information,

the reader can visit the AEDP website for published articles
and other resources.

1.6.4  Common Elements of STPPs

It is clear from this brief overview of STPPs that there are

many common elements that underpin the workings of psy-
chodynamic psychotherapy. The central and unifying com-
monality is the recognition of the patient-therapist relationship
as the principal therapeutic factor. The incorporation of con-
cepts from attachment theory has enhanced our understand-
ing and our ability to work with this relationship. The process
of working with deep emotions is also common across the
different forms of STPP.
The recognition of defences and getting past these in order
to access emotions are a sine qua non of psychodynamic psy-
chotherapies (Fig.  1.8). Not all of the STPPs make use of a
focus, or central theme. This is a prominent feature of those
using Luborsky’s core conflictual relationship theme
and  includes Leichsenring and his group in Germany who
have published treatment manuals for specific diagnoses [36].
More recently Alessandra Lemma, Mary Target and Peter
Fonagy have described the “interpersonal-affective
focus” [37].

defense

anxiety
emotion

Figure 1.8  Anxiety,

defence and emotion, the
central process in STPP
 References 21

All of these concepts are similar in identifying recurrent

interpersonal patterns as a major focus of psychotherapy.
These patterns contain components of the patient’s sense of
self and his or her feelings towards other people. These pat-
terns are unconsciously repeated and may lead to maladap-
tive relationships and the emergence of symptoms.
In this manual the term “relational focus” is used for this
central thematic idea. In short-term dynamic psychotherapy,
a deliberate stance is taken to work with one principal focus.
These recurring patterns are linked to the presenting prob-
lems and difficulties in the patient’s life.

Key Points
• Exploration and expression of deep emotions is a
principal change process in all short-term psychody-
namic psychotherapies.
• All short-term dynamic therapies aim to access
avoided or unconscious emotions that lead to mal-
adaptive patterns of behaviour.
• Getting past defences is a principal strategic aim of
these therapies.
• Therapy is facilitated by the development of a strong
therapeutic alliance.
• The therapeutic alliance is promoted by the applica-
tion of findings derived from attachment theory.
• Interpretations are less critical than in classical
approaches in contrast to the importance of emotion
processing.

References
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spirit of the Budapest school. London: Karnac; 2012.
2. Alexander F, French TM.  Psychoanalytic therapy. New  York:
Ronald Press; 1946. Reprinted by University of Nebraska Press,
Lincoln, NE 1980.
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3. Palvarini P.  Is the concept of corrective emotional experience

still topical? Am J Psychother. 2010;64(2):171–94.
4. Balint M, Ornstein P, Balint E.  Focal psychotherapy. London:
Tavistock Publications; 1972.
5. Gustafson JP. The complex secret of brief psychotherapy in the
works of Malan and Balint. In: Gustafson JP, editor. The complex
secret of brief psychotherapy. New  York: W.  W. Norton; 1986.
p. 83–128.
6. Malan DH.  A study of brief psychotherapy. London: Tavistock
Publications; 1963.
7. Malan DH.  Beyond interpretation: initial evaluation and tech-
nique in short-term dynamic psychotherapy. Part I. Int J Short-­
Term Psychother. 1986;1:59–82.
8. Malan DH.  Beyond interpretation: initial evaluation and tech-
nique in short-term dynamic psychotherapy. Part II.  Int J
Intensive Short-Term Dyn Psychother. 1986;1:83–106.
9. Malan D.  The frontier of brief psychotherapy. New  York:
Plenum; 1976.
10. Balint M.  The Doctor, his Patient and the Illness. London:

Pitman Med; 1957.
11. Winnicott D.  Transitional objects and transitional phenomena.
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p. 140–52.
13. Phillips A. Winnicott. London: Penguin; 2007.
14. Gabbard GO.  Psychodynamic psychiatry in clinical practice.

Washington: American Psychiatric Press; 1994.
15. Menninger KA. Theory of psychoanalytic technique. New York:
Basic Books; 1958.
16. Ezriel H. Notes on Psychoanalytic Group Therapy II: interpreta-
tion and research. Psychiatry. 1952;15:119–26.
17. Mann J.  Time-limited psychotherapy. Cambridge: Harvard
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18. Bonaparte M.  Time and the unconscious. Int J Psychoanal.

1940;427(21).
19. Lindemann E. Symptomatology and management of acute grief.
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20. Sifneos PE. Short term therapy and emotional crisis. Cambridge,
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21. Sifneos PE. Short-term dynamic psychotherapy: evaluation and

technique. 2nd ed. New York: Plenum; 1987.
22. Davanloo H.  Short-term dynamic psychotherapy. New  York:

Jason Aronson; 1980.
23. Davanloo H.  Basic principles and technique in short-term

dynamic psychotherapy. New York: Spectrum Publications; 1978.
24. Luborsky L.  Principles of psychoanalytic psychotherapy: a

manual for supportive-expressive treatment. New  York: Basic
Books; 1984.
25. Abbass A, Town J, Ogrodniczuk J. Intensive short-term dynamic
psychotherapy trial therapy. Effectiveness and role of “Unlocking
the Unconscious”. J Nerv Ment Dis. 2017;205(6):453–7.
26. Abbass A.  Reaching through resistance: advanced psychother-
apy techniques. Kansas City, MO: Seven Leaves; 2015.
27. Abbass A.  The emergence of psychodynamic psychotherapy
for treatment resistant patients: intensive short- term dynamic
psychotherapy. Psychodynamic Psychiat. 2016;44(2):245–80.
28. Abbass A, Town JM.  Bona fide psychotherapy models are

equally effective for major depressive disorder: future research
directions. JAMA Psychiat. 2016;73(9):893–4.
29. Lilliengren P, et al. Intensive Short-Term Dynamic Psychotherapy
for generalized anxiety disorder. Clin Psychol Psychotherapy.
2017;24(6):1–9.
30. McCullogh L, Kuhn N, Andrews, et  al. Treating affect phobia
a manual for short term dynamic psychotherapy. New  York:
Guilford press; 2003.
31. McCullogh L, Andrews S.  Assimilative integration: short-term
dynamic psychotherapy for treating affect phobias. Clin Psychol
Sci Pract. Spring 2001;8(1):82–97.
32. McCullogh L, Larsen A, Schanche E, Andrews S.  Kuhn

N.  Achievement of Therapeutic Objectives Scale ATOS Scale.
2008. http://www.affectphobiatherapy.com/research-scales/.
33. Osborn K.  ATOS therapist 20 point brief rating guides. The
Psychotherapy Research Program Harvard Medical School
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ated change. New York: Basic Books; 2000.
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36. Leichsenring F, Schauenburg H.  Empirically supported meth-

ods of short-term psychodynamic therapy in depression-­
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therapy. Oxford: Oxford University Press; 2011.
Chapter 2
The Application of Attachment
Theory to Short-Term
Psychodynamic Psychotherapy

2.1  Child Development

The practice of psychodynamic psychotherapy requires an
understanding of child development. Brain development and
consequently psychological development are determined by
the interaction of genes and the environment [1, 2]. While the
growth and development of the brain are genetically pro-
grammed, the external environment has a major impact in
shaping connections between neural circuits. The infant’s
actions and the responses from the environment determine
which neurocircuits are used frequently leading to the growth
and connection of these circuits: “Neurons that fire together
wire together”. Neural circuits and connections that are not
reinforced by activity and experience will be eliminated, a
process known as “pruning”.
Brain development is subject to critical periods. Genetic
programming determines that different neural circuits mature
at different time periods. The first 3–6  years of life have an
enormous impact. Modifications to brain architecture after
these critical periods are much more difficult. Neural circuits
responsible for basic sensory and motor functioning mature
earlier than those for more complex higher-level functions
such as the interpretation of facial expression, language and
communication. It is important that the environment responds
in an age-appropriate fashion in order that optimal develop-

© Springer International Publishing AG, 25

part of Springer Nature 2018
A. Eppel, Short-Term Psychodynamic Psychotherapy,
https://doi.org/10.1007/978-3-319-74995-2_2
26 Chapter 2.  The Application of Attachment Theory

ment occurs. A deficient or hostile environment can lead to

long-lasting alterations in the functioning of the neural cir-
cuits. These alterations are much more difficult to change in
adulthood. Nevertheless there is some degree of plasticity that
can allow for later corrective experiences or intervention.
Childhood development is affected by a range of other fac-
tors. Adequate nutrition and housing are paramount. Poverty,
war and famine are obviously overriding in their importance.
Prenatal nutrition and exposure to toxins or infectious agents
can have profound effects. Social and cultural practices and
values modify the experience of the growing infant.
Of particular interest to psychodynamic therapists is the
relationship between the infant and the mother or other pri-
mary attachment figure. The first 3 years of life are particu-
larly important for laying the foundations for a sense of
identity and self.
The attachment process and its reciprocal separation and
loss are central processes in human life. The attachment sys-
tem provides physical safety and feelings of security. Proximity
to the primary attachment figure regulates the infant’s physi-
ological arousal and emotional states. Caregiver response to
a distressed infant provides soothing, comfort and reduction
in physiological arousal. The secure base provided by the
mother gradually allows the infant to explore the world.

2.2  Precursors to Attachment Theory

John Bowlby, a British psychoanalyst, formulated attachment
theory beginning in the 1950s. Bowlby worked at the Tavistock
Clinic in London, and his theories grew out of the object rela-
tions school of psychoanalysis [3, 4, 5]. He strongly disagreed
with those analysts such as Melanie Klein who focused exclu-
sively on intrapsychic dynamics and neglected the impact of
the external environment.
However other members of the Tavistock Clinic recog-
nized that the relationship between the child and its primary
caregiver was vital. In particular one can see precursors to
 2.2  Precursors to Attachment Theory 27

attachment theory in the ideas of Donald Winnicott [6, 7, 8].

Winnicott was a paediatrician who became a pioneering psy-
choanalyst. He is recognized for his creativity and humility in
his dealings with patients. He observed that childhood devel-
opment depends on the interactions between the infant and
the mother. The mother’s responses to the newborn infant
shape the infant’s emotional and psychological development.
Infants are unable to fend for themselves. They need to be
fed, kept warm and soothed when they feel discomfort or
distress. Infants need to be held, touched and spoken to.
Based on these responses, the infant develops an inner sense
of the external world. Winnicott coined the phrase “the good
enough mother” to indicate that the infant’s requirements
cannot be met 100% of the time and in fact should not be.
Winnicott  felt there was an optimal level of maternal
responsivity to ensure healthy development and the capacity
to become autonomous and confident. Research by Tronick
(see below) supports this viewpoint.
With consistent responsiveness by the maternal figure, the
infant develops an inner sense that the outside world is
benevolent and safe. Over the course of development, he
builds up mental representations of himself and of others. In
object relations theory, these were referred to as self and
object representations. However the fact that the infant’s
needs are not met 100% of the time means that he has to
gradually rely more on his own resources resulting in a modi-
fication of his perceptions of external reality. As the child
grows, the maternal responsiveness is reduced by small doses
allowing the child to develop an increasing sense of indepen-
dence and self-reliance. Winnicott referred to this as a process
of disillusion that fosters the emergence of the infant’s
“capacity to be alone”. The infant has gained some indepen-
dence from the caregivers and can venture forth in the world.
If the maternal environment is not “good enough”, the
child will develop some deficits in his self-representation and
may view the world as dangerous or hostile. If the external
environment is particularly negative, the infant may learn to
suppress his true yearnings and urges leading to the develop-
28 Chapter 2.  The Application of Attachment Theory

ment of a “false self” [7]. Winnicott used this concept to

describe situations in which the true self is concealed by con-
forming to external demands at the cost of suppressing inner
needs [2–4].
In optimal circumstances, the transition to increasing inde-
pendence comes in “small and digestible steps”. The infant
learns that his own needs may have to be deferred.
Winnicott also conceptualized a transitional zone which
bridges subjective experiences and aspects of the external
world. Transitional objects such as soft toys stand in place of
the primary caregiver. By their association with the mother,
they facilitate the development of independence and the
capacity to be alone [6].
Winnicott recognized that independence is not an absolute
quality rather we all maintain some dependence on others,
seeking others and wanting to belong.

2.3  Attachment Theory

Since the time that John Bowlby first conceptualized attach-
ment theory, tens of thousands of articles have been written
on the subject and its applications in psychiatry, medicine,
child-rearing and psychotherapy [3–5].
It is inspiring to go back to some of Bowlby’s original
words because of their clarity and succinctness.
What for convenience I am terming attachment theory is a way of
conceptualizing the propensity of human beings to make strong
affectional bonds to particular others and of explaining the many
forms of emotional distress and personality disturbance, including
anxiety, anger, depression and emotional detachment, to which
unwilling separation and loss give rise. [3].

The essence of Bowlby’s theory is that attachment behav-

iours are genetically programmed.
The infant has an inborn propensity to seek proximity to
its mother. Similarly the mother has an inborn biological
program of caregiving to respond to the infant’s needs
(Table 2.1).
 2.3  Attachment Theory 29

Table 2.1  Key attachment concepts

Proximity The genetic program that causes infants to seek
seeking proximity to their mother or other primary
attachment figure
Separation The distress experienced by an infant when
anxiety separated from the primary attachment figure.
Indicated by fear, crying and agitation
Secure base The feeling of safety and security provided by
the primary attachment figure that allows them
to begin to separate and explore the world
Safe haven The function provided by the secure base when
the infant is in distress and seeks proximity to
the attachment figure. Activated by separation,
strangeness, pain, hunger, fatigue
Primary This is the person who has the most day-­to-­day
attachment interaction with the infant. It may be a parent, a
figure (PAF) grandparent, a sibling or other caregiver
Internal These are emotional and cognitive
working models representations of the external world.
They consist of representations of the self
and representations of others. The early
attachment relationships form the foundations
for emotionally based representations of
relationships with others

Proximity seeking is facilitated by the infant’s vocalization,

smiling, gazing, following and clinging.
These behaviours are evident by 6 or 7 months of age.
The attachment system is an emotional operating system
that is comprised of two components: firstly a behavioural or
action component and secondly the inner feeling states that
trigger and accompany these behaviours. In the infant, the
feeling that corresponds to secure attachment is the feeling of
being loved. For the mother, the reciprocal inner state is the
feeling of loving. Dopamine and oxytocin are two brain
chemicals that are intricately involved in the control and
experience of attachment and love.
30 Chapter 2.  The Application of Attachment Theory

The mother or other primary attachment figures represent

a secure base and safe haven. Proximity to the primary attach-
ment figure allays feelings of fear and separation distress.
When the infant is apart from the primary attachment fig-
ure, he experiences the feeling of sadness or depression and
exhibits behaviours, such as crying, searching and motor
agitation.
These behaviours and vocalizations are signals to the
PAF and evoke a caring response.
The PAF experiences feelings of concern and the desire to
take care of the baby.
If the mother/PAF is unresponsive, the infant experiences
too much separation distress and the accompanying affects of
sadness, grief or depression. A child in this situation may
grow up with a sense of being unloved and unlovable.
Physical and sexual abuses by caregivers are two of the
most extreme forms of failed attachment. Abused children
grow up with extreme insecurity and mistrust in relationships.
Instead of healthy emotion regulation via the attachment
dyad, these children experience the terror and extreme psy-
chological pain of abuse. They grow up with the inability to
self-soothe and modulate their emotions.
Children with profoundly disturbed attachment relation-
ships develop feelings of intense aloneness. Their adult
attachments are insecure and are often characterized by
avoidance or anxious preoccupation. As adults they may be
diagnosed with complex post-traumatic stress disorder and/or
borderline personality disorder.
A child growing up in a nonloving environment may be
forced to suppress his true feelings. This often results from the
need to accommodate a demanding, abusive parent. The child
must suppress his or her authentic emotions and thoughts.
Bowlby described a number of disordered patterns of
attachment behaviour. These patterns may develop if the pri-
mary attachment figure is unresponsive, rejecting or disparag-
ing to the child’s care-eliciting behaviours. Periods of
separation from parents, threats by parents/PAFs to withdraw
love from the child as a means of discipline and threats by a
 2.4  The Mutual Regulation Model: Edward Tronick 31

parent to leave the family have a harmful effect on the devel-

opment of secure attachment. Bowlby felt that threats
bya parent to commit suicide or to kill the other parent were
particularly damaging leading to “anxious attachment”.
Bowlby described a pattern where a parent induces a pre-
mature sense of responsibility in the child. This occurs by
making the child feel guilty or by making threats. This in turn
can lead to the child developing feelings of anger which he or
she cannot express directly. Longings for love and affection
may go unfulfilled.
Bowlby described a second pattern of attachment behav-
iour which he called “compulsive self-reliance” in which the
individual attempts to cope with everything by himself. Such
individuals block their attachment yearnings and deny any
desire for close relationships. They are in fact fearful of devel-
oping close relationships or of relying on anyone else in
“order to avoid the pain of being rejected” or to avoid the
pressure of becoming a caretaker for someone else.
A third pattern described by Bowlby is that of compulsive
caregiving. Bowlby postulated that this pattern emerges when
the primary attachment parent had some form of incapacity
and the only available affectional bond was for the child to
take on the behaviour of a caregiver (cf “false self” above).
All of these patterns of anxious attachment are associated
with unmet longings for love and feelings of resentment and
anger towards those who did not provide it.

2.4  T
 he Mutual Regulation Model: Edward
Tronick
Fundamental attachment concepts have received empirical
support from the work of Edward Tronick and his research
collaborators [10]. Tronick, a developmental and clinical psy-
chologist at the University of Massachusetts in Boston, has
made enormous contributions to elaborating the implications
of attachment theory for childhood development. Tronick
focused on the infant mother dyad. He conceptualized the
32 Chapter 2.  The Application of Attachment Theory

interaction process between mother and infant as one of

emotional regulation. He refers to this as the mutual regula-
tion model (MRM). Tronick’s group has  identified three
types of mother infant interaction:
• Coordinated
• Miscoordinated
• Repair
Coordinated interaction occurs when the mother/PAF  is
sensitive and attuned to the physical, emotional and com-
municative needs of the infant. This is evident by the engage-
ment of the mother and baby and by matching behaviour
and affect. This is associated with positive emotion in the
infant.
Miscoordinated interaction is when there is a lack of attun-
ement or a mismatch between the infant’s needs and the
response of the primary attachment figure. In this case the
infant’s needs are not met, resulting in the experience of
separation distress, fear, discomfort and inner feelings of bad-
ness. If miscoordination is too frequent, the child grows up
with insecure attachment and an internal working model of
the self of badness and unlovableness that forms a major
component of his or her personality. However a certain
amount of miscoordination may be required for the infant to
be able to differentiate himself as separate from the mother.
This is consistent with Winnicott’s ideas about “good-enough
mothering” . 
Repair is the movement from a miscoordinated state back
to a coordinated state. This may require the mother to engage
in soothing and comforting leading to restoration of a mutu-
ally resonant interaction, the elimination of disturbing emo-
tions and the return of positive feelings.
The infant’s repeated experience of repair leads to a posi-
tive inner sense of self, an expectation that things can be
repaired. Repair of empathic misattunement facilitates secure
attachment. Repair may also promote the acquisition of the
capacity to endure deprivation and hardship, that is, the
development of psychological resilience.
 2.5  Attachment Theory and Psychotherapy 33

2.5  Attachment Theory and Psychotherapy

Bowlby initiated the process of applying attachment theory
to psychotherapy. Bowlby emphasized that “present modes of
perceiving and dealing with emotionally significant persons
including the therapist, may be influenced and perhaps seri-
ously distorted by the experiences which he had with his
parents during the years of his childhood and
adolescence…”.
Bowlby’s work ultimately led to a true paradigm shift in
psychodynamic psychotherapy. Fundamentally his theory is a
change of language and concepts that have an analogous
relationship to many of the original psychoanalytic ideas
(Table 2.2). However because his theories are based on more
objective observations, they are more compatible with the
sciences of neurobiology and child development.
Bowlby outlined a number of tasks for the therapist:
• To provide the patient with a secure base
• To join with the patient in exploring himself and his
relationships

Table 2.2  Comparison of attachment and object relations concepts

Attachment theory Object relations
Secure base Therapeutic alliance/holding
environment
Exploration Capacity to be alone
Internal working models Self and object
representations
Attunement Holding environment
Attachment style Defences
Mentalization existing in the heart Reflective functioning
and mind of the other
Implicit memory Unconscious
Attachment relationships Self and objects
34 Chapter 2.  The Application of Attachment Theory

• To point out whether the patient’s expectations and under-

standing of the therapist’s feelings and behaviours towards
him are accurate
• To help the patient see that his relationship patterns and
reactions to other people including the therapist may be
understood in terms of his early attachment experiences
• Bowlby conceptualized the task of therapy as the need to
review with the patient his internal models of attachment
figures and of himself. In this way the patient would come
to see how these models affected his behaviour and
relationships.
Bowlby recognize the importance of non-verbal communi-
cation such as tone of voice, stating that this is at least as
important as anything the therapist may say. The therapist’s
respect for his patient is conveyed nonverbally in his attempt
to understand the patient’s viewpoint.

2.6  U
 nderstanding Attachment Terminology
and Measures
2.6.1  The Strange Situation

The exploration of the literature on human attachment and

its application to psychotherapy is more complicated than it
may appear at first sight. Bowlby’s original descriptions are
characterized by clarity and succinctness the product of a
perceptive and reflective intellect.
Numerous methods and instruments have been developed
to measure attachment in infants, children, adolescents and
adults. These include complex assessment procedures, narra-
tive methods and questionnaires.
The issue of validity is central. Do these instruments all
measure the same thing? The answer is clearly no they do not.
The gold standard for the measurement of attachment
behaviour in children was developed by Mary Ainsworth [11,
12]. This appears true to the heart of Bowlby’s original con-
 2.6  Understanding Attachment Terminology… 35

cepts and observations. However even this methodology has

been criticized as being circular.
Ainsworth developed the strange situation procedure. This
involves interactions between the mother the infant and a
third person. It is applicable to infants between the ages of 12
and 20 months. Each phase lasts 3 min [11].
The parent and infant are brought into a room with a few
chairs and some toys on the floor (Table 2.3).
They settle in for 3 min.
A stranger then enters the room. The stranger plays with
the infant for 3 min. The parent then leaves the room. This is
referred to as the first separation.
After 3  min, the parent returns and the stranger leaves.
This is the first reunion.
The parent then leaves the infant alone in the room for the
second separation.
After 3 min, the stranger enters the room and stays with
the infant.
Three minutes later the parent returns and the stranger
leaves. This is the second reunion.

Table 2.3  The strange situation

Attachment
Action Subjects in room process
Infant and mother enter Infant and mother
Stranger enters Infant, mother,
stranger
Mother leaves Infant and First separation
stranger
Mother returns; stranger First reunion
leaves
Mother leaves Infant alone
Stranger returns Infant and
stranger
Mother returns; stranger Infant and mother Second reunion
leaves
36 Chapter 2.  The Application of Attachment Theory

Attachment security is defined by Ainsworth “as the state

of being secure or untroubled about the availability of the
attachment figure” [11, 12].
This paradigm contains the essential components of attach-
ment behaviour: separation from the mother, the secure base
and then reuniting with her. Strikingly it is the reunion ­behaviour
that is most critical in illustrating the infant’s attachment style.
The attachment classification is based on the infant’s reac-
tion to the mother’s return.
This is determined by whether the infant seeks proximity
and contact with the mother or maintains a distance. Four
attachment categories have been derived from the strange
situation [11].

Secure Attachment B
The infant is able to explore freely; displays signs of missing
the parent particularly during the second separation.
During separation the infant explores less. On reunion the
infant greets the parents with a smile, vocalization or gesture.
If upset, seeks contact with the parent and when comforted is
able to begin exploring again.
Mother is consistently available and responsive to the
infant’s distress providing a secure base.

Avoidant Attachment A
These infants are able to explore without much need to check
on mother.
On separation, the infant exhibits little visible distress
when left alone; on reunion, actively avoids the parent, looks
away and may focus on toys; if picked up by the parent, may
stiffen or lean away and seeks distance from parent.
This pattern is associated with caregivers who are not respon-
sive to the infant’s needs or whose response is unpredictable.

Ambivalent or Resistant Attachment C

The infant is distressed on entering the room and displays
little exploration.
 2.6  Understanding Attachment Terminology… 37

On separation, the infant is very distressed. On reunion,

the infant has difficulty settling and does not find comfort
from the parent. He may vacillate between seeking contact
and angry rejection with tantrums or inactivity. He is reluc-
tant to leave the mother and start exploring again.
These infants have caregivers that are inconsistent and
unpredictable in availability and response.

Disorganized Attachment D
The child’s behaviour appears illogical without a goal and
exhibits confusion and fear. Behaviour is contradictory with
false starts and immobilization. The child appears fearful or
apprehensive of the parent and lacks a coherent pattern.
Disorganized attachment is associated with a history of
abuse or neglect by the caregiver.

2.6.2  The AAI: The Adult Attachment Interview

The adult attachment interview consists of 20 questions

focusing on the individual’s relationships with his or her par-
ents during childhood. The patient is asked to describe each
parent in turn using five adjectives and then is asked for spe-
cific memories illustrating each of these adjectives. The same
process can be used for other significant attachment figures
[13].
The patient is asked to identify which parent or attach-
ment figure they felt close to as a child and who they would
seek help from when they were upset, hurt or ill and to sup-
port this with examples.
The interviewee is asked to describe separation experi-
ences from the parents: whether the patient experienced the
loss of either parent as a child or as an adult. They are also
asked about the current relationship with parents and whether
they ever felt rejected or threatened. The interviewees are
asked to reflect on how these early experiences may have
affected their personality.
The AAI is quite different from the strange situation
which is based on observable behaviours. The AAI is a
38 Chapter 2.  The Application of Attachment Theory

­ easure of psychological constructs or “states of mind” with

m
respect to the person’s attachment experiences [13].
The AAI identifies five categories:
Secure Autonomous F
The subject is able to express a coherent account of attach-
ment experiences. He or she is able to express compassion for
his or her parents. The subject can be flexible and display
balanced perspectives. He or she is able to appreciate
humour.
Dismissing D
These subjects provide an account that lacks coherence. The
history is inconsistent or contradictory. They have difficulty
with recall. They may display contempt towards particular
events or people.
These subjects describe themselves as being strong and
independent. They do not identify feelings of needing or
depending on others. They minimize negative experiences or
present them in positive terms. They are unable to discuss
attachment experiences. They are more likely to feel con-
tempt towards attachment figures than sorrow.
Preoccupied E
These subjects have low scores for coherence and high scores
for passive or angry preoccupation with their experiences of
their parents.
They may provide inaccurate history. They are excessively
wordy. Much of what they say may be irrelevant. They are
ambivalent and oscillate between blaming and praising the
attachment figures.
Unresolved U
These subjects exhibit periods of silence and irrational
thoughts. There is a lack of logic in their accounts
Unorganized/Cannot Classify CC
The narrative is incoherent and difficult to follow. The indi-
vidual may attempt to frighten the interviewer or refuse to
speak during the interview [13].
What turned out to be really very dramatic was that parent
attachment classification based on the AAI narrative
 2.6  Understanding Attachment Terminology… 39

approach was predictive of their children’s attachment based

on the strange situation methodology [13].
Mary Main realized that the nature of the individual’s dis-
course concerning attachment-related issues was an indica-
tion of their own internal working model of attachment.
The adult attachment interview assesses “the patient’s
state of mind with respect to attachment”. Narratives that are
accurate, not contradictory, succinct, relevant and clear are
indicative of secure attachment states of mind. Conversely an
account that lacks coherence and relevance reflects insecure
and disorganized attachment states of mind [13].
Individuals who have difficulty being coherent are contra-
dictory. Their responses are brief with little to say about the
attachment figures. There may be periods of silence. They
cannot recall much about their experiences with key figures.
This indicates a dismissing form of insecure attachment.
Individuals who are tangential, are vague and are difficult
to follow reflect a preoccupied attachment state mind.
Dissociation and loss of continuity in responses are com-
mon in individuals with unresolved or disorganized attach-
ment templates.
It is very important to note that the terminology for differ-
ent attachment styles and states of mind varies depending on
which instruments or paradigms are being employed.
Thus the AAI refers to adult internal working models of
attachment, and the nomenclature used is different to that
used in Mary Ainsworth’s strange situation categories
(Table 2.4).

Table 2.4  Comparison of attachment terminology

Adult attachment interview Strange situation
Mary Main Mary Ainsworth
Secure (autonomous) B Secure
Dismissing Avoidant
Preoccupied or entangled Ambivalent
Unresolved/disorganized Disorganized
40 Chapter 2.  The Application of Attachment Theory

Adults with a dismissing attachment template are often

clinically categorized as having obsessional, narcissistic or
schizoid personality traits. They are fearful of closeness and
intimacy and are not in touch with their core emotions. A pat-
tern of devaluation of others and a defensive structure of
superiority may be referred to as narcissistic. These patients
cannot tolerate genuine intimacy or complements because
this risks activating feelings of dependency and vulnerability
which was not tolerated by their parents.
Patients who develop a preoccupied state of mind with
respect to attachment are “merger hungry” and constantly
strive to be in a close relationship. This includes individuals
with so-called borderline and histrionic personality types who
are very sensitive to separation, loss and abandonment. They
display emotional dysregulation and may connect with others
via a pattern of helplessness and proximity seeking. Sexuality
may be a vehicle to obtain attachment.
Individuals with unresolved/ disorganized attachment
models display breakdown in their narrative of experiences
of trauma and loss. They are prone to dissociation and projec-
tive defences.
One of the effects of psychotherapy may be to create new
internal working models that displace some of the older mod-
els that arose in childhood. The patient’s experience of the
nonjudgmental, attuned and securely attached therapist may
be a major therapeutic change process.

2.7  C
 an Attachment Theory Be Applied
to Psychotherapy?
Bowlby believed that there was a continuity between infant
attachment patterns and adult patterns in close
relationships.
This is crucial to the legitimacy of applying attachment
theory to psychotherapy.
There are fundamental questions pertaining to whether or
not the attachment model is just another metaphor or
whether it represents a valid psychobiological process.
 2.7  Can Attachment Theory Be Applied… 41

The answer to this question is an empirical one. It depends

on studies of infants with prospective follow-up as well as
studies of adult behaviour. Indeed there is considerable evi-
dence that childhood attachment patterns have a major
impact on adult relationships, ability to regulate affect and to
maintain positive intimate relationships. There is also consid-
erable empirical literature on the correlation between inse-
cure attachment and the development of psychiatric illness.
Adults who are securely attached appear less anxious and
more confident in their day-to-day interactions. They are
more readily able to express and reflect on their feelings.
They exhibit an appropriate balance between autonomy and
dependence. They are able to initiate and maintain intimate
relationships, to give and accept help  and to be trusting of
others.
Conversely avoidant or dismissing adults have difficulty
with intimacy and openness. They prefer to keep their feel-
ings private and appear socially aloof. They do not like to
accept help from others preferring to rely on their own
resources. Instead they utilize “deactivating strategies” con-
cealing their inner distress and vulnerabilities by maintaining
a composed outward appearance. They are reluctant to
accept help or comfort as this may unhinge their inner dis-
tress. This may be expressed cognitively in devaluing the abil-
ity of others to be helpful and exhibiting a preference for
self-sufficiency.
Individuals with preoccupied attachment are very insecure
in their intimate relationships, fearful of abandonment and
tend to be overly possessive clingy and jealous. They struggle
with feelings of rejection and aloneness. They may adopt
hyperactivating strategies to maintain proximity in their inti-
mate relationships with intensification of emotional dysregu-
lation [9]. They may attempt to please or placate intimate
others at the expense of their own needs and by being self-­
critical. Their partners may feel pressured and engulfed.
Adults with disorganized attachment may have chaotic rela-
tionship patterns and appear disconnected and prone to dis-
sociation. They may exhibit alternating patterns of preoccupied
42 Chapter 2.  The Application of Attachment Theory

and avoidant attachment. They have difficulty regulating their

emotions. They become flooded by overwhelming emotions
and under extreme stress may become immobilized.
Is the attachment metaphor superior to the Freudian
metaphor? I believe the attachment metaphor is approxi-
mates more to scientific evidence. That is because there is a
vast research literature on attachment behaviour as well as a
solid neuroscientific understanding of this particularly in the
work of Panksepp [14].
In this regard adult attachment patterns may be continu-
ous with childhood.
However validity depends on the construct validity of the
instruments used to measure attachment. For the adult the
gold standard of measurement is the adult attachment inter-
view. Unfortunately this instrument requires extensive training
and is also very time-consuming so that the vast majority of
studies do not use it. Instead numerous other instruments, fre-
quently self-report questionnaires, have been substituted with
attempts to validate them against the AAI. This requires that
any review of the attachment literature requires particular
attention to the measurement instruments and whether have
good correlation with the AAI and have construct validity.
One striking difference between infant attachment and
adult attachment is that in adulthood there is more of a sym-
metrical and reciprocal relationship. In adulthood a sexual
relationship is a component of romantic pair bonds.

2.8  A
 ttachment Concepts Used
in Psychotherapy
Attachment theory has been applied to short-term psychody-
namic psychotherapy in two  principal areas. Firstly under-
standing the patient’s psychological development and how
early attachment experiences have shaped adult relationship
patterns. The concept of internal working models implies that
future relationships will be strongly influenced by the experi-
ence and internalization of early relationship interactions.
The concepts of secure and insecure attachment are
extremely relevant for the conduct of psychotherapy.
 2.9  Future Research: The Research Domain... 43

Identification of the patient’s attachment style is very helpful

in understanding his or her views of themselves, of others and
relationship patterns.
The second main area of application is in the formation of
the therapeutic alliance and the nature of the patient
therapist dyad.
Concepts of attunement, responsiveness and provision of a
secure base can be applied to the conduct of psychotherapy.
The therapist can facilitate optimal emotional regulation
within the session by appropriate attunement and responsive-
ness to the patient’s emotional signals. In order to do this,
therapist must be attuned on a moment to moment basis to
affective changes in the patient [15]. This requires attention to
subtle clues and alterations in the patient’s facial expression,
posture, eye gaze and gesture. Psychotherapy is most effective
when there is an optimal level of emotional regulation.
Overregulation blocks access to core emotions. Conversely
underregulation prevents exploratory work.
The process of rupture and repair which arises out of
Tronick’s work is extremely relevant to psychotherapy.
As with the primary attachment figure in childhood, the
therapist cannot always be in synchrony and attunement with
the patient. Inevitable mismatches occur leading to a rupture
in the relationship. These ruptures need to be explored and
resolved. The repair of ruptures in infancy leads to height-
ened resiliency. Similarly in psychotherapy the repair of a
rupture is extremely therapeutic leading to a corrective emo-
tional experience and greater insight.

2.9  F
 uture Research: The Research Domain
Criteria Project
In 2009, the National Institute of Mental Health made a stra-
tegic decision to develop new ways of classifying mental dis-
orders based on observable behaviour and neurobiological
measures. The goal of this strategy is to improve research in
mental illness. NIMH felt that the existing psychiatric classi-
fications have been problematic for research. The new
approach taken by NIMH is known as the Research Domain
44 Chapter 2.  The Application of Attachment Theory

Criteria (RDoC) project. It provides a new framework for

carrying out research based on dimensions rather than cate-
gories [16]. This is in contrast to clinical classification systems
such as DSM 5 and ICD 11. By “building from the ground up”,
it is hoped that the RDoC methods will develop classifica-
tions that have construct validity.
NIMH has identified five domains in the RDoC matrix:
negative valence systems, positive valence systems, cognitive
systems, systems for social processes and arousal/regulatory
systems. The RDoC construct that is most relevant here is
affiliation and attachment.
It is likely that this research will lead to increasing refine-
ment and elaboration of attachment theory and its subcom-
ponents. These concepts will be broken down into more
specific dimensions that will facilitate future research.
The concept of attachment embraces selective affiliation
to particular individuals. It is determined by activity in neural
circuits. It requires the normal functioning of information
processing  systems to enable  social cues and social
motivation.
For the normal development of attachment to occur, there
needs to be adequate functioning of learning and memory.
The infant must be able to recognize facial expressions and
other non-verbal signals of emotion in order to form attach-
ments [16].
Future research using these constructs may enhance our
understanding of the underlying neurobiology of attachment
processes and the effects of disrupted attachment, separation,
loss and abuse.

Key Points
• An understanding of childhood development is
essential for the practice of short-term psychody-
namic psychotherapy.
• Attachment theory provides a framework for under-
standing the development of relationship patterns.
 References 45

• Attachment theory explains the development of

one’s sense of self and identity as well as our expecta-
tions and predictions about the behaviour of other
people.
• Early attachment relationships have a primary influ-
ence on the development of internal working
models.
• Internal working models provide a map of the exter-
nal human environment.
• Internal working models determine our expectations
and responses to other people.

References
1. Davies D.  Child Development. A Practitioners Guide. 3rd ed.
Guilford; 2011.
2. National Scientific Council on the Developing Child. 2007. The
Timing and Quality of Early Experiences Combine to Shape
Brain Architecture: Working Paper #5. http://www.developing-
child.net.
3. Bowlby J.  The making and breaking of affectional bonds Brit.
J. Psychiat. 1977:130:201–10 and 421–31.
4. Bowlby J.  Attachment and loss. Vol. 1: Attachment. 2nd ed.
New York: Basic Books; 1982.
5. Bowlby J.  Attachment and loss. Vol. 2: Separation: anxiety and
anger. New York: Basic Books; 1973.
6. Winnicott D.  Transitional objects and transitional phenomena.
Int J Psychoanal. 1953;34:89–97.
7. Winnicott DW.  Ego distortion in terms of true and false self:
in the maturational processes and the facilitating environment.
London: Hogarth Press and Institute of Psychoanalysis; 1965.
p. 140–52.
8. Phillips A. Winnicott. London: Penguin; 2007.
9. Obegi J, Shaver P, Mikulincer M. A framework for attachment-­
based psychotherapy with adults. New Therapist. 2009;61:10–21.
10. Tronick E.  Dyadically expanded states of consciousness and

the process of therapeutic change. Infant Mental Health J.
1998;19:290–9.
46 Chapter 2.  The Application of Attachment Theory

11. Ainsworth MDS, Blehar MC, Waters E, Wall S.  Patterns of

attachment: a psychological study of the strange situation.
Hillsdale: Erlbaum; 1978.
12. Solomon J, George C.  In: Cassidy J, Shaver P, editors. The

measurement of attachment security and related constructs in
infancy and early childhood: handbook of attachment. 2nd ed.
New York: Guilford Press; 2008. p. 552–98.
13. Hesse E.  In: Cassidy J, Shaver P, editors. The adult attachment
interview: protocol, method of analysis and empirical atudies
in: handbook of attachment. 2nd ed. New York: Guilford Press;
2008. p. 552–98.
14. Panksepp J.  Affective neuroscience. New  York: Oxford

University Press; 1998.
15. Fosha D. The transforming power of affect: a model for acceler-
ated change. Basic Books. 2000.
16. Kozak MJ, Cuthbert BN.  The NIMH research domain criteria
initiative: background, issues, and pragmatics. Psychophysiology.
2016;53(3):286–97 .
Chapter 3
Understanding
and Recognizing Emotion

3.1  Background
One of the essential tasks in the practice of psychodynamic
psychotherapy is to assist the patient in identifying and
expressing deep emotions.
This requires the therapist to have a good understanding
of the range of human emotions and to recognize the subtle-
ties of their manifestations.
The emphasis on emotions is one of the principal distinc-
tions in the practice of psychodynamic psychotherapy in
contrast to “top-down” cognitive therapies.
The study of emotion is fraught with extraordinary diffi-
culties. To begin with, there are no agreed definitions of the
terms “emotion”, “feeling” and “affect”. The literature can be
confusing because the terms affect, feeling and emotion are
used differently by different authors.
Terminology varies according to the theoretical frame-
work in which the authors are writing and also in the meth-
odologies used in their research. There are large divergencies
between researchers coming from a background in cognitive
neuroscience and  those working within  the  framework of
affective neuroscience. Methodologies are different.

© Springer International Publishing AG, 47

part of Springer Nature 2018
A. Eppel, Short-Term Psychodynamic Psychotherapy,
https://doi.org/10.1007/978-3-319-74995-2_3
48 Chapter 3.  Understanding and Recognizing Emotion

Panksepp’s work is based on painstaking animal research

over several decades [1, 2]. Damasio, a neurologist, studied
patients with brain injuries [3, 4]. Functional neuroimaging
provides another viewpoint.
While these divisions are artificial, it is nonetheless impor-
tant to be aware of them in order to understand the literature
on emotion.
There is still strong polarization between the cognitive and
affective neuroscience views of the nature of emotion. At the
basis of this dichotomy is differing views about the relative
roles of subcortical and cortical brain systems in the experi-
ence and expression of emotion. Cognitive behaviour therapy
is based on cognitive neuroscience and learning theory.
Psychodynamic psychotherapy emphasizes affective neuro-
science, emotions and relational dynamics.
The scientific and intellectual debates have led to multiple
research projects including empirical trials of therapy as well
as extensive studies of neuroimaging.
These opposing conceptualizations have real-world impli-
cations in the application to treatment and treatment out-
comes; this in turn has political ramifications in terms of
healthcare funding and support.
This division is far from superficial and reflects profoundly
different views of the nature of human consciousness and the
origins of human emotion.
It is helpful for the psychotherapist to understand the
underlying brain mechanisms in the generation of emotions
and feelings as this has relevance to the conduct of psychody-
namic therapy and the process of change. But first let us look
at the clinical aspects of identifying emotions.

3.2  In the Beginning…, Charles Darwin

It was the work of Charles Darwin that established the
understanding of the links between body posture, movement
and facial expression and the inner experience of emotion [5].
Darwin described the intricate connection between emotion
and adaptive action.
 3.2  In the Beginning…, Charles Darwin 49

Darwin was the first to identify that the expression of emo-

tions was common across most cultures and within the animal
kingdom. In his classic work The Expression of the Emotions
in Man and Animals published in 1872, Darwin described the
external manifestations of the emotions, facial expression and
bodily movements [5].
The muscles of facial expression are able to convey minute
variations associated with specific emotions. Slight changes in
the degree of contraction of the facial muscles, subtle altera-
tions in body posture, the pacing of speech, voice characteris-
tics, pitch, amplitude, prosody, variability in laughter, smiling,
rapidity of movements and the direction of gaze all help to
paint a picture of the underlying emotions.
Darwin identified the following emotions:
• Low spirits, anxiety, grief, dejection and despair
• Joy, high spirits, love, tender feelings and devotion
• Distain, contempt, disgust, guilt and pride
• Surprise, astonishment, fear and horror
• Anger, rage and hatred
• Sadness, grief and melancholy
Smiling occurs across cultures and is evident in newborn
infants. About 4–5  months after birth, the human infant is
able to discriminate among faces and smile differentially [1].
Smiling involves raising of the upper lip, elevation of the
cheeks, brightening and sparkling of the eyes and wrinkling
of the lower eyelids (Fig. 3.1).
Guillaume-Benjamin Duchenne distinguished between
genuine and false smiles. The genuine smile involves involun-
tary contraction of the zygomatic muscles elevating the cor-
ners of the lips in association with contraction of the
orbicularis oculi which causes muscle contraction around the
eye and wrinkles at the corners of the eye. The eye opening is
narrowed, and the cheeks are raised. The false smile does not
include the eye wrinkles and raised cheek. Only truly felt
smiles involve the orbicularis oculi. There are also differences
in the rate of onset and dissipation of the muscle contractions.
A brief upward movement of the eyebrows may also occur in
smiling.
50 Chapter 3.  Understanding and Recognizing Emotion

Figure 3.1  Joy. (Illustrations by Molly Ferguson www.

MollyFergusonArt.com)

The facial expression of sadness involves downward curva-

ture of the corners of the mouth. The inner corners of the
eyebrows are drawn up, and the inner corner of the upper
eyelid is raised.
 3.2  In the Beginning…, Charles Darwin 51

Voice characteristics: during mood elevation, there is

increase in pitch variability and increased loudness.
During sadness there is decreased frequency level and
range of pitch. There is an increased monotone and reduced
loudness. In sadness the ends of sentences may drop down to
a lower pitch.
Darwin demonstrates exquisite powers of observation of a
woman sitting beside him in a train carriage:
An old lady with a comfortable but absorbed expression sat
nearly opposite me in a railway carriage. Whilst I was looking at
her, I saw that her depressores anguli oris became very slightly,
yet decidedly, contracted; but as her countenance remained as
placid as ever, I reflected how meaningless was this contraction,
and how easily one might be deceived. The thought had hardly
occurred to me when I saw that her eyes suddenly became suf-
fused with tears almost to overflowing, and her whole counte-
nance fell. The could now be no doubt that some painful
recollection, perhaps that of a long lost child, was passing through
her mind. As soon as her sensorium was thus affected, certain
nerve cells from long habit instantly transmitted an order to all
the respiratory muscles, and to those around the mouth, to pre-
pare for a fit of crying. But the order was countermanded by the
will, or rather by a later acquired habit, and all the muscles were
obedient, excepting in a slight degree the depressores anguli oris.
The mouth is not even opened; the respiration was not hurried
and no muscles affected except those which draw down the cor-
ners of the mouth [5].

Perhaps no one has more succinctly and evocatively

described the complex processes that are the subject of this
chapter. Darwin can be an inspiration to psychotherapists
learning to identify even the most subtle shifts in facial mus-
cles and tearing of the eyes. Once these glimmers of emotion
are observed, it can allow the therapist to facilitate emotional
expression. Darwin concludes:
…… we can understand how it is, that as soon as some melan-
choly thought passes through the brain, there occurs a just
perceptible drawing down of the corners of the mouth, or slight
raising up of the inner ends of the eyebrows, or both move-
ments combined, and immediately afterwards a slight suffusion
of tears.
52 Chapter 3.  Understanding and Recognizing Emotion

The expression of low spirits, grief or dejection, due to the con-

traction of this muscle has been noticed by everyone who has
written on the subject. To say that a person is “down in the
mouth” is synonymous with saying that he is out of spirits [5].

Darwin’s description of rage is equally masterful: he

describes changes in circulation and respiration leading to
changes in facial colour and distention of veins, heaving of
the chest and dilation of the nostrils.
The body is commonly held erect  ready for instant action, but
sometimes it is bent forward towards the offending person, with
the limbs more or less rigid. The mouth is generally closed with
firmness, showing fixed determination, and the teeth are clenched
or ground together [5].

Gestures such as raising of the arms or clenching of the

fists are common. There may be a glaring of the eyes which
are kept open wide (Fig.  3.2). The eyes appear bright. The
pupils are contracted. Darwin notes that the retraction of the
lips exposing the teeth during rage simulates a threat to bite
the offender.
Anger is a less intense form of rage; again the eyes become
bright, the respirations increase in rate, the nostrils may
widen, the head is erect, the chest wall is expanded, and the
feet are planted firmly on the ground (Fig. 3.2). The fists may
be clenched. Interestingly the raising of the corner of the
mouth on one side exposing the canine tooth is compared by
Darwin to that of a snarling dog and may foreshadow aggres-
sion. Darwin believes that a sardonic smile is a more attenu-
ated expression of this [5].
I have quoted Darwin at some length to indicate his
unique powers of observation and description. Experienced
therapists learn to automatically attend to subtle changes in
facial expression, voice and posture to help identify and
elicit affect. Darwin’s work was the first to show the rich-
ness and complexity of the expression of emotions. Careful
study of his descriptions and the illustrations in this chapter
will enhance the readers’ powers of detection of emotional
signals.
 3.3  The Evolution of Emotion 53

Figure 3.2 Anger. (Illustrations by Molly Ferguson www.

MollyFergusonArt.com)

3.3  The Evolution of Emotion

To understand the psychodynamic model in a more contem-
porary fashion, we need to draw upon the literature of human
and mammalian emotion, neuroimaging and studies of con-
sciousness and self-representation.
54 Chapter 3.  Understanding and Recognizing Emotion

These are extremely complex areas. Emotion research has

been enhanced by functional MRI and other neuroimaging
technologies. However these technologies and paradigms
remain limited due to small sample sizes. They are subject to
confounding variables and artefacts.

3.3.1  Paul McLean: The Triune Brain

A useful starting point is the framework developed by Paul

McLean known as the triune brain [6]. While this is an over-
simplification and requires modification, it is nevertheless a
model that has great heuristic value. McLean compares the
layered nature of the brain to the building of a house where
additions are made from the ground floor upwards (Fig. 3.3).
From an evolutionary point of view, the oldest part of our
brain is referred to as the “reptilian brain”. This evolved hun-
dreds of millions of years ago. Its main function is
­self-­preservation. The reptilian brain controls cardiorespira-
tory functioning, movement and vision. The reptilian brain is

Neocortex

Limbic

Midbrain
Basal Ganglia

Figure 3.3  The triune brain

 3.3  The Evolution of Emotion 55

driven by survival needs. The reptilian brain consists of primi-

tive sensory cortices, the midbrain, the spinal cord, the cere-
bellum, the upper brainstem, the pons, the thalamus, the
reticular system and the basal ganglia.
The reptilian brain is hardwired to produce stereotypical
behaviours such as establishing territory and finding a home,
hunting, homing, mating, breeding, imprinting, forming social
hierarchies and selecting leaders. The establishment of terri-
tory is necessary for mating and breeding [p.10]. These are
genetically inherited sequential programmed behaviours.
The reptilian brain is the locale of basic instinctual pro-
grammes. These are hardwired action processes which con-
tain the machinery for exploration, aggressive dominance
displays, sexuality and feeding.
The centre of organization for the reptilian brain is com-
prised of the basal ganglia. These are located deep in the
brain and control the repetitive, stereotyped and ritual-
ized  reptilian behaviours. These do not require conscious
control. These repetitive behaviours include seeking shelter,
seeking food, lying in the sun, courtship and aggressive and
submissive displays. [As an aside the repetitive behaviours of
obsessive-compulsive disorders may have their origins in
these neural circuits.]
The paleomammalian or limbic brain has a cortical layer
and overlays the reptilian brain. The word limbic means
“forming a border around”, and it surrounds the brainstem.
The overlay does not replace what is beneath but rather
allows exploitation of the reptilian hardwiring and applica-
tion to additional functions.
The limbic brain comprises a hub for  the emotions and
neurocircuits related to interpersonal and social behaviours.
This includes attachment, separation, maternal caregiving
and play.
The limbic system includes the anterior cingulate gyrus,
the hippocampus and the amygdala.
The third part of the triune model is the neo-mammalian
brain which is coterminous with the neocortex. The neocortex
is the site of cognitive and executive functioning. It includes
56 Chapter 3.  Understanding and Recognizing Emotion

reflection, reasoning, logical thinking, planning, language,

symbols and metaphor.
McLean likens the limbic cortex to a primitive television
screen giving the mammal a better picture for adapting to its
internal and external environment. This appears to be analo-
gous to Damasio’s core consciousness. The neocortex can be
compared to a much more sophisticated television screen
which includes linguistic representations, speech and sound.
McLean [6] states “that the neural machinery does not
exist for the reptilian and limbic brains to communicate in
verbal terms”. With great foresight McLean recognized the
implications of this for psychotherapy : verbal insight may be
not sufficient for successful treatment.
What is critical is that each of these three domains is
superimposed on each other through the course of evolution.
The reptilian brain is not replaced by the old mammalian
brain which in turn is not made redundant by the neo-­
mammalian brain. The newer areas of the brain may be able
to override the lower levels of function but not replace them.
The link between emotion and action is essential for the
survival of the species. The link between fear, changes in
facial expression, vocalizations and the action of fight or
flight has great survival value. This is both in terms of signal-
ling to conspecifics and parents and preparing the individual
to take action in defence or by escape.

3.3.2  The Neurocircuitry of Emotion

Emotional expression involves a sequence of signal, percep-

tion, fast appraisal or slow appraisal then action. The hypoth-
esis that there are two routes for processing of emotions
referred to as the low road and the high road was popularized
by LeDoux [7–10]. The low road mediated at the subcortical
level is faster and provides survival value in rapidly r­ esponding
to external dangers. The high road is slower and is mediated
via the cortex and involves cognitive appraisal.
 3.3  The Evolution of Emotion 57

The amygdala has a central function in the emotional neu-

rocircuits. It is connected both to cortical and subcortical
areas and plays a special role in the perception of danger and
the arousal of fear. The amygdala and its connection to sub-
cortical circuits permit an automatic unconscious response to
external threat and the activation of appropriate adaptive
actions. External visual, auditory, olfactory or tactile sensory
input can activate the amygdala without cortical or conscious
processing.
The amygdala is responsible for coding the salience or
relevance of incoming stimuli and initiating adaptive action
via motor systems to which it is connected.
This may explain human response to nonverbal behaviour
occurring outside of awareness. This may have particular rel-
evance to understanding “gut feelings”, “love at first sight”,
empathy, projection and projective identification.

3.3.3  A Dual System for Emotional Processing

Beatrice de Gelder and her group at Maastricht University

have proposed a dual system theory of emotional body lan-
guage with the amygdala as the linchpin of two separate cir-
cuits [11, 12].
The role of the amygdala in emotion processes has been
known for many decades based initially on lesion studies and
in primates involving bilateral ablation of the amygdalae
(Fig. 3.4).
(a) A subcortical circuit involves the retina, superior collicu-
lus, pulvinar nucleus of the thalamus, the striatum and
amygdala. This mediates the rapid and unconscious per-
ception of emotional body language. This is similar to the
nonconscious recognition of faces [7]. This circuit pre-
pares and initiates adaptive behaviour and automatic
defensive responses such as withdrawal or freezing. The
amygdala assigns valence to incoming stimuli. There is a
link to the reward system through the stratum.
58 Chapter 3.  Understanding and Recognizing Emotion

basal ganglia

pulvinar amygdala

superior
colliculus

Figure 3.4  The Subcortical Circuit

(b) A cortical pathway includes the frontoparietal motor

areas and connections between the amygdala, the prefron-
tal cortex and the ventromedial prefrontal cortex. In this
system the incoming stimulus is decoded in the context of
past experience and memory. This system analyses at a
higher level and computes a decision on a course of action
to respond to the stimulus (Fig. 3.5).
These two systems have numerous interconnections. The cor-
tical system involves reflection and decision-making. The mean-
ings of incoming sensory signals need to be interpreted within
specific contexts and environments. Also ritualized social ges-
tures and body language may require cognitive interpretation.
There are different terms for describing the subcortical
processing of emotional information.
The term “unconscious” is derived from psychodynamics
and has theoretical origins. In the research and experimental
literature, the term “nonconscious” is used. This is operation-
ally defined as an emotional process in which the subject does
not report the presence of a stimulus, and there is evidence
that the stimulus has in fact been processed based on changes
 3.3  The Evolution of Emotion 59

anterior
cingulate cortex

somatosensory
VMPFC
cortex

insula

Figure 3.5  The Cortical Circuit

in behaviour or physiological measures. The term “auto-

matic” is also used for this subcortical level of processing.
Most of the research and observational work has been based
on incoming visual stimuli with particular emphasis on facial
expressions. However de Gelder and colleagues have demon-
strated that other emotional stimuli follow the same root and
include body posture. Nonconscious processing of emotional
stimuli is accompanied by physiological changes in heart rate,
pupillary dilation and rate of eye blinking. There are also
changes in facial expression that may be picked up by
observers.
Interestingly automatic nonconscious changes in facial
expression are mediated by the basal ganglia. Intentional
changes to facial expression are controlled by the cortex via
the pyramidal motor system. This may explain the difference
between genuine and nongenuine smiles as described by
Duchenne.
Although this has been described as a dual processing sys-
tem in actual fact, there are many feedback loops between
60 Chapter 3.  Understanding and Recognizing Emotion

the subcortical and cortical centres involved in these neuro-

circuits. The two systems modulate each other. The cortical
level may inhibit activity in the subcortical areas. Conversely
subcortical areas may activate the orbitofrontal cortex and
anterior cingulate cortex.
The dual system of emotional processing has great rele-
vance to the practice of psychodynamic psychotherapy. Key
processes in therapy involve eliciting core emotions which
have their origins in the subcortical neurocircuits. These emo-
tions need to be processed then to be reflected upon and
related to past memories and current context. This is referred
to as meta-therapeutic processing and is one of the key
change factors in psychodynamic psychotherapy.

3.4  Damasio Where Do I Feel Emotion?

Over several decades Antonio Damasio, a neurologist and
brain researcher at the University of Southern California, has
made a major contribution to understanding the neurobio-
logical basis of emotions [3, 4]. A major thesis of Damasio’s
theory is that “feelings” are mental experiences of bodily
states. He famously coined the phrase “Descartes’ Error”. In
his book of the same name, he argues that Descartes’ felici-
tous mantra “Cogito ergo sum” was completely wrong [13].
Descartes’ mistake was to insist on a separation between the
body and the mind. Damasio’s views are the exact opposite:
that the experience of affect and of consciousness are firmly
rooted in the body. Damasio distinguishes “having a feeling”
from “knowing the feeling” and from reflecting on feeling.
Bodily state changes are topographically mapped onto the
upper brainstem and cerebral cortex. Changes in these neural
maps initiate action programmes, corrective responses to the
deviations from the body baseline. Examples of action
­programmes include fight and flight and freezing in the face
of aggressive threats [4].
Emotional stimuli may come from the outside world in the
form of threats leading to fear. They can also come from
 3.4  Damasio Where Do I Feel Emotion? 61

internal changes. The brain can activate the emotional body

state representations even in the absence of specific external
or internal triggers.This can be done through, for example,
imagination. This implies that there is some form of central
representation of bodily changes.
This point is very important for psychotherapists in that it
allows us to understand the emotions of others as well as
predict our own future emotional response by means of simu-
lating these emotions within ourselves. This also may be the
basis for empathy. (See Chap. 5 of this volume.)
Damasio has also proposed that each basic emotion cat-
egory is correlated with a distinct body state. This refers to
the “felt changes” associated with different emotions. For
example, happiness is associated with increased sensation in
the whole body, whereas anger involves increased sensation
in the arms, head and torso. Sadness is associated with
decreased feeling in the arms and legs and increased feelings
in the chest. Disgust is accompanied by increased sensation
in the throat and digestive track. This supports the idea that
emotions do have distinct physiological and felt bodily
patterns.
The source for the sensation of bodily changes comes
from interoceptive signals from the viscera, skeletal muscles
and the internal milieu [3]. The interoceptive system consists
of neural pathways and nuclei that detect and map signals
from the body and internal organs. This includes perception
of pain, temperature, proprioception and vestibular
sensations.
The vagus nerve conducts signals from the cardiovascular,
respiratory, gastrointestinal and genitourinary systems to the
lower brainstem.
All this information is collected in the upper brainstem in
an area known as the periaqueductal grey (PAG) which may
be the locus for the formation of whole body maps of body
states and provides the basis for the emergence of feeling
states [4]. Neuroimaging studies have suggested that the
insula has an important role in mediating interoceptive inputs
and the generation of feelings.
62 Chapter 3.  Understanding and Recognizing Emotion

3.4.1  The Insula

Craig [14] writes that the insula contains a neural representation

of the state of our body and is a substrate of how we feel. The
insula is an interoceptive cortex that receives inputs from the
viscera, proprioception, vestibular sense, pain and temperature.
The insula is connected to the anterior cingulate cortex
and regions of the prefrontal cortex. The insula may provide
a continuously updated representation of the current state of
our body and how we feel [11].

3.5  Why Are Emotions Contagious?

Another quality of emotions is that they are contagious. This
may have a role in regulating social behaviour. The process of
empathy allows us to know how another person is feeling. It
may be a form of internal simulation. This may account for
the so-called mirror phenomena whereby our own feelings
are activated when observing the experience of another per-
son. For example, another person experiencing anger or dis-
gust may lead to our own feelings of anger or disgust. The
experience of empathic emotional contagion depends on the
closeness of the relationship to the person being observed.

3.6  Paul Ekman

Ekman surveyed emotion researchers and asked which emo-
tions they felt were empirically validated out of the following
choices:
Fear, anger, awe, compassion, contempt, disgust and
embarrassment
Envy, gratitude, guilt, shame, pride and hatred
Happiness, love and surprise
There was a general agreement among the researches that
the following five emotions have been empirically
­established [15]:
 3.7  Jaak Panksepp 63

Table 3.1  Core and First order Second order

Social Emotions
Anger, rage Envy, jealousy
Fear Guilt, shame
Sadness Jealousy
Happiness, Pride
joy
Disgust Contempt

Anger, fear, disgust, sadness and happiness (Table 3.1).

3.6.1  Higher-Order Social Emotions

These emotions are complex and have meaning only in a

social context. They are cognitively experienced and require
rational thought, evaluation and deliberation. These emo-
tions may serve a social rather than an interpersonal function.
For example, shaming is a method of social control that may
be exercised in the interests of the social group superseding
those of the individual. Similarly guilt ensures conformance
to socially demanded behaviours.
• Pride
• Shame and embarrassment
• Guilt
• Jealousy
• Envy
The experience of jealousy requires a higher cortical rea-
soning capacity, the ability to appreciate the intentions and
emotional experience of others [cf. mentalization].

3.7  Jaak Panksepp

Panksepp was the most prominent pioneer in the study of
animal and human emotions. He identified the critical impor-
tance of genetically hardwired subcortical affective systems.
64 Chapter 3.  Understanding and Recognizing Emotion

He coined the term “affective neuroscience”. He was critical

of Ledoux’s early work for not recognizing the importance of
the subcortical basis of emotions. He also did not agree with
Damasio’s conceptualizations. Damasio, who had written the
book Descartes’ Error [13], led Panksepp to refer to
“Damasio’s Error”. In contrast to Descartes’ “I think there-
fore I am”, Panksepp suggested that “I feel therefore I am”
may be closer to the truth [1].
Jaak Panksepp conducted animal research over many
decades and elucidated seven basic emotional systems that
are common to all mammals. He referred to these as the
“blue ribbon, grade A” emotional systems [1]. Panksepp iden-
tified neural circuits that are the basis for these emotional
systems. He believed that these seven emotional systems are
genetically programmed. In addition he identified key neu-
rotransmitters connected to the circuits. He used capitaliza-
tion to distinguish the circuits from the everyday use of these
words and originally named them as follows: SEEKING,
RAGE, FEAR, LUST, PANIC, CARE and PLAY.
According to Panksepp, the basic emotional systems are
located in the subcortical areas of the brain. Damage or
removal of the cortex does not interfere with the circuits.
Such animals continued to exhibit seeking behaviours, fear,
anger, sexuality, maternal care and playfulness.
The emotional systems are activated by internal and exter-
nal stimulations that are related to survival. The emotional
systems are experienced as visceral affect and are linked to
specific action patterns.
During the course of infant development, cognitive repre-
sentations of the primary emotions develop in the neocortex.
An analogy may be a television set where information is
activated along various electrical and radio circuits that at a
higher level are translated into coherent images.

3.7.1  The Seeking System

The seeking system is a motivational system that instigates

exploration and anticipates excitement. This system pro-
grammes interest in the external world and exploration.
 3.7  Jaak Panksepp 65

This  exploration is critical to human development and the

learning process. The seeking system is essential  to survival.
Exploration of the environment permits the discovery of food
and shelter. At the secondary level, this involves curiosity and
motivates the individual to search for things that they need or
desire. It is the basis for human curiosity. Underactivity of this
system is associated with depression; overactivity of the sys-
tem may be the basis for manic-type behaviours. The seeking
system is necessary for animals to acquire the needed resources
for survival. The seeking system allows the animal to find and
store food. It is associated with the ventral tegmental area and
nucleus accumbens. It is related but not identical to the more
widely used concept of the reward system.
The seeking system is directed towards environmental
rewards and associated with addictive seeking behaviours
and dopamine neurotransmission.

3.7.2  The Rage/Anger System

Rage and anger develop when the animals’ actions are

blocked. This system is essential for survival and is required
for defence against predators and rivals (Fig. 3.2).

3.7.3  The Fear System

This system is activated by danger and threat. This circuit is

associated with fight, flight and freezing. Maladaptive
­functioning of the system may be the basis for clinical anxiety
disorders (Fig. 3.6).

3.7.4  S
 eparation Distress and Social Bonding
Systems
These are the circuits that underlie the inborn programmes
for attachment behaviour: proximity-seeking and separation
distress (Fig. 3.7). There is a reciprocal circuit in the mother
which activates responsivity to the infant with caring behav-
66 Chapter 3.  Understanding and Recognizing Emotion

Figure. 3.6 Fear. (Illustrations by Molly Ferguson www.

MollyFergusonArt.com)

iours. The second-order representation of this circuit includes

feelings of affiliation and love.
Panksepp discovered that opioids relieved separation dis-
tress in animals. This may be the link between problems of
opioid addiction and individuals with severe disorders of
attachment. Oxytocin also alleviates separation distress.
 3.7  Jaak Panksepp 67

Figure 3.7 Sadness. (Illustrations by Molly Ferguson www.

MollyFergusonArt.com)

3.7.5  Sexual/Lust

The neural circuits involved in sexuality are influenced by a

number of hormones and neuropeptides. This includes oxyto-
cin, endorphins, prolactin and vasopressin.
68 Chapter 3.  Understanding and Recognizing Emotion

3.7.6  Joy/Rough-and-Tumble Play

This neural circuit promotes social engagement and interac-

tions that we refer to as play. These behaviours lead to feel-
ings of joy and exhilaration. Playfulness is essential for early
psychological and social development.
Panksepp conceptualized reciprocal interactions
between the subcortical and cortical regions in the expres-
sion and regulation of emotions. When emotions are gener-
ated in the subcortical neural circuits, they may lead to
activation of the cortical centres. He agrees that the corti-
cal regions are involved in appraisals of emotion which
involve perception, attention and memory retrieval; corti-
cal regions can suppress or “turn off” the subcortical emo-
tional responses. These connections however are
bidirectional so that cortical regions may activate the sub-
cortical emotional systems. In other words emotional
expression and experience entails both top-­down and bot-
tom-up interactions.

3.8  Conclusions: Why Does This Matter?

This model has some explanatory relevance to methods used
in psychotherapy. Psychotherapy involves the facilitation of
new conscious emotional experiences while old memories are
reactivated. Memories are then reconsolidated within the
hippocampal cortex.
Conscious experience of unconscious emotions seems to
be required in psychotherapy. Representations are made
available to working memory which is necessary for long-­
term memory consolidation [16].
In simple terms, the debate between affective neurosci-
ence and cognitive neuroscience revolves around the relative
importance of subcortical emotional forces in contrast to
emotion modulation  that is based on cortical processes
(Fig. 3.8).
 3.8  Conclusions: Why Does This Matter? 69

cognitive
appraisal based
on internal
working models
and memories

stimulus body response

detection
ouput

non conscious
appraisal

Figure. 3.8  Dual Processing of Emotion

Key Points
• There is agreement among researchers that several
key emotions are universal.
• The ability to recognize emotional cues is essential
for psychodynamic psychotherapists.
• The dual processing theory of emotion is applicable
to psychodynamic psychotherapy and explains the
working through of emotions and the therapeutic
effect of reconsolidation of memories.
• Emotions are conveyed by verbal and non-verbal
communication.
• Emotions are experienced viscerally, psychologically
and bodily.
70 Chapter 3.  Understanding and Recognizing Emotion

References
1. Panksepp J. Affective neuroscience. Oxford; 1998.
2. Panksepp J. Textbook of biological psychiatry. Hoboken: Wiley-­
Liss; 2004.
3. Damasio A. The feeling of what happens: body and emotion in
the making of consciousness. Orlando: Harcourt; 1999.
4. Damasio A, Carvalho G.  The nature of feelings: evolutionary
and neurobiological origins. Nat Rev Neurosci. 2013;14:143–52.
5. Darwin CR. The expression of the emotions in man and animals.
1st ed. London: John Murray; 1872.
6. Maclean P. A triune concept of the brain and behaviour. Toronto:
University of Toronto Press; 1973.
7. LeDoux JE. Emotion circuits in the brain. Annu Rev Neurosci.
2000;23:155–84.
8. Pessoa L, Adolphs R.  Emotion processing and the amygdala:
from a “low road” to “many roads” of evaluating biological sig-
nificance. Nat Rev Neurosci. 2010;11:773–82.
9. Adolphs R. Emotion. Curr Biol. 2010;20(13):R549–52.
10. Adolphs R. The biology of fear. Curr Biol. 2013;23:R79–93.
11. de Gelder B. Towards the neurobiology of emotional body lan-
guage. Nat Rev Neurosci. 2006;7:242–9.
12. Tamietto M, de Gelder B.  Neural bases of the non-­

conscious perception of emotional signals. Nat Rev Neurosci.
2010;11(10):697–709.
13. Damasio A.  Descartes’ error: emotion, reason, and the human
brain. New York: Penguin; 2005.
14. Craig AD.  How do you feel? Interoception: the sense of

the physiological condition of the body. Nat Rev Neurosci.
2002;3(8):655–66.
15. Ekman P.  What scientists who study emotion agree about.

Perspect Psychol Sci. 2016;11:31–340.
16. Smith R, Lane RD.  The neural basis of one’s own conscious
and unconscious emotional states. Neurosci Biobehav Rev.
2015;57:1–29.
Chapter 4
A Critical Review
of Psychotherapy Research

4.1  Background
Evidence-based medicine has had a profound effect on
research in the health sciences. Over the course of three
decades, the standards for conducting and evaluating research
have undergone a major transformation. The double-blind
randomized controlled trial has been established as the “gold
standard” for determining treatment outcomes [1–3].
Evidence-based medicine has been adopted internation-
ally and has given rise to parallel paradigms in psychology
and related disciplines. The American Psychological
Association adopted the term “evidence-based practice in
psychology” which requires similar standards of evidence [4].
The widespread adoption of evidence-based principles has
resulted in researchers and clinicians becoming much more
critical and sceptical in their thinking. Students in the health
sciences are now required to develop critical appraisal skills
in order to determine the validity and applicability of
research studies. Clinicians are better able to identify meth-
odological shortcomings of studies and to adopt a more scep-
tical attitude to published research. This is a healthy change.
Conversely the quality of published research has come under
scrutiny. So much is this the case that several leading scholars
claim that the majority of published medical research is
methodologically flawed and even false [5]. This is quite an

© Springer International Publishing AG, 71

part of Springer Nature 2018
A. Eppel, Short-Term Psychodynamic Psychotherapy,
https://doi.org/10.1007/978-3-319-74995-2_4
72 Chapter 4.  A Critical Review of Psychotherapy Research

astonishing claim from such eminent authorities. These con-

cerns can lead to a nihilistic attitude to research endeavours.
It is therefore essential for psychodynamic psychotherapists
to understand the scientific literature in order to evaluate
which treatments work for which problems.

4.2  History
Historically psychodynamic psychotherapy has faced long-­
standing criticism about its effectiveness. Since its inception
the scientific legitimacy of psychoanalysis has been ques-
tioned. Many distinguished philosophers of the scientific
method including Karl Popper believed that psychoanalysis
was a “pseudoscience” [6].
Freud’s original goal had been to develop a scientifically
based model of the human brain. This was not possible due to
the limited understanding of neurophysiology and neurosci-
ence at the time. As an alternative he devised a theory of
psychological functioning based on meticulous observation
of individual patients. Freud’s conceptual model was based
on analogies and metaphors. Concepts such as the ego, the id
and the superego are not entities in themselves and do not
correspond to any neuroanatomical or neurophysiological
structures. They are conceptual proxies. The language of psy-
choanalysis was of necessity essentially metaphorical but
nevertheless has had enormous influence in understanding
psychological processes.
Central to the critique of psychoanalysis was that none of
its tenets could be subject to refutation a sine qua non of the
scientific method formulated by Karl Popper [6].
Pseudosciences have been characterized by Lilienfeld as
lacking methodological safeguards against confirmation bias
[7]. Confirmation bias is the tendency to seek out evidence
consistent with the practitioner’s hypotheses and to dismiss
evidence that does not support his theory.
Karl Popper’s criticisms of psychoanalysis as practised in
the last century have validity. However over the past three
 4.3  Basic Principles of Psychotherapy Research: Effect… 73

decades, the study of psychodynamic psychotherapy has

made substantial progress, and it has been possible to formu-
late hypotheses and predictions that are subject to falsifiabil-
ity and refutation. Many prospective studies have been done
to determine the impact of childhood events on the future
development of personality and behaviour. This has provided
more valid information in contrast to psychoanalysis which
relied on retrospective study based on patients’ reports. The
impact of therapeutic methods has been studied in dozens of
randomized controlled trials, and it has also been possible to
study specific components of psychodynamic therapy and
formulate refutable hypotheses.
Cognitive behavioural therapy has been the most exten-
sively researched psychotherapy. Randomized controlled tri-
als have been carried out for the treatment of depression,
anxiety disorders, post-traumatic stress disorder, eating disor-
ders, pain, insomnia, substance use, schizophrenia and physi-
cal symptoms. There have been far fewer randomized
controlled trials in psychodynamic psychotherapy. However,
over the past three decades, there has been a growth in high-­
quality research of psychodynamic psychotherapy. Active
research groups exist in the United States, Canada, Germany,
the Netherlands, Sweden, Denmark and the United Kingdom.

4.3  B
 asic Principles of Psychotherapy
Research: Effect Sizes
The basic principles of outcome research involve testing one
treatment against a proven active treatment and a placebo.
Samples are drawn from a defined population. Measures of
outcome are evaluated according to significance and effect
size (Fig. 4.1). Effect sizes are the most important measures in

statistical
sample diagnosis treatment outcome
methods

Figure 4.1  The research process

74 Chapter 4.  A Critical Review of Psychotherapy Research

studies of psychotherapy and other treatments. To demon-

strate that the therapy is effective, it must have an effect size
greater than zero. The effect size must be large enough to be
clinically relevant. For example, consider a study comparing
the outcomes in the treatment of depression using a specific
form of psychotherapy and an inactive control. A valid mea-
sure of outcomes is essential, and in this hypothetical exam-
ple, let us say that the Beck Depression Inventory (BDI) was
used. In the active psychotherapy group, the average (mean)
reduction in BDI scores was 8 points. In the inactive group,
the reduction was 5 points. These results were found to be
significant, meaning that the results were unlikely to have
been produced by chance. The question of interest however is
whether the difference in effect sizes is clinically relevant.
Does a difference of 3 points on the BDI support the use of
the active treatment?
To answer this question we need a standardized statistical
measure of effect size. There are several such measures, but
Cohen’s d is one of the most frequently cited in psychother-
apy studies. Cohen’s d is calculated from the mean differences
of an effect. An effect size is considered small if d  =  0.2,
medium if d  =  0.5 and large if d  =  0.8 or higher. However
these values must be related to the clinical impact. Small
effect sizes can be associated with important clinical
benefits.

4.3.1  Bias

Research methodology is predicated on the attempt to elimi-

nate bias and false conclusions.
Bias is a systematic error leading to erroneous results. Bias
may lead to false-positive or false-negative results. Bias can
occur at any phase of a study.
Selection bias refers to differences between the popula-
tions that are to be compared. To prevent this, subjects in all
study groups must be selected randomly. There must not be
any selection of subjects that are more likely to respond to
one treatment or another. Subjects must be allocated to the
 4.3  Basic Principles of Psychotherapy Research: Effect… 75

treatment groups in a random fashion. Random allocations

are made in sequence and must be hidden from those making
the allocations. This is known as random sequence
generation.
If subjects or therapists are aware of the treatment, this
may bias the responses to interventions or rating of treatment
outcomes. Therefore raters of outcomes must be “blinded” as
to which treatment the subject received.
Allegiance bias may occur when the researchers have a
particular allegiance to one method of psychotherapy leading
to unconscious bias. This can be assessed by measuring the
correlation between therapist allegiance and outcome
measures.
Publication bias refers to the higher likelihood that studies
with beneficial outcomes will be published in journals.
Research with positive results are more likely to be submitted
for publication and more likely to be published. This is why
all clinical trials need to be registered prior to initiation. That
way the results of nonpublished trials can be used in analyses.
Publication bias can be assessed by a number of methods.
One of these methods is known as a “funnel plot”. This
involves plotting effect sizes against sample sizes. If the
resulting graph is shaped like a funnel, it indicates that there
is no publication bias.
Reporting bias refers to investigators publishing only
those outcomes that are significant.
Bias may also result from participants dropping out of
studies and being lost to follow-up.
This results in incomplete outcome data. The impact of
dropping out must be included in any analysis using “intent-­
to-­treat” analysis. Studies must be of adequate duration with
follow-up to determine if treatment effects are maintained.
Sample sizes must be large enough to avoid results that
may occur by random chance alone. Comparison groups must
be similar.
In medication trials those administering the treatments are
blinded to active treatment versus placebo. Placebos are
made to look identical to the comparator active drug. In the
case of psychotherapy research it is not possible for the thera-
76 Chapter 4.  A Critical Review of Psychotherapy Research

pist or the patient to be blind to the treatment method.

Psychotherapy is not unique in this. There are similar difficul-
ties in carrying out surgical research. It has been estimated
that 40–50% of surgical patients are receiving treatment that
is not evidence-based [8].

4.4  Research Methodologies

The randomized controlled trial is considered the highest
standard of evidence in medical science. A hierarchy of evi-
dence has been outlined by Haynes et  al. in their work on
evidence-based medicine [1]. The American Psychological
Association identified empirically supported psychological
treatments to demonstrate equal effectiveness to biological
treatments [4]. Empirically supported psychological treat-
ments generally require a manualized approach that has been
studied in randomized controlled trials for specific diagnostic
indications.
A second research methodology involves the analysis of
process measures in relation to outcomes [9–21]. This type of
research is greatly facilitated by video recordings of individ-
ual sessions and analysis of  detailed segments. Leigh
McCullough and the Harvard group established a 10-year
programme of this type of research which is being continued
by her associates following her untimely death [22]. This
approach has trans-theoretical application by identifying the
relational mechanisms of change (Chap. 1). Different schools
of therapy may utilize different concepts and terminology
which may in fact have an underlying common basis or
mechanism.
Evidence-based medicine pioneered at McMaster
University in Hamilton Ontario advocates the identification
of the best available evidence to bring to bear within the
clinical encounter. The best available evidence is combined
with the patient’s particular needs and preferences.
 4.4  Research Methodologies 77

Evidence-based approaches are not universally accepted

as applicable to psychotherapy or even to psychiatry. Gupta
[23] has been an outspoken critic of EBM based on its under-
lying epistemological assumptions. She questions the implicit
values and premises of evidence-based medicine and whether
it can be ethically applied to psychiatry.
Choice of measures is often determined by the theoretical
framework of the therapeutic method. The most straightfor-
ward measures are established and validated measures of
symptom improvement such as depression or anxiety rating
scales. However the therapy may not be directed solely to
symptom change. In the case of cognitive behaviour therapy
for depression and anxiety, outcome measures are quite
straightforward and include such well-established instru-
ments as the Beck Depression Inventory, the DASS and
GAD 7. In psychodynamic therapy, outcomes are broader and
include improvement in self-image and self-perception,
improvements in relationships with others, relinquishing of
maladaptive interpersonal patterns and improved access to
emotions. Measurement of these changes can be difficult.

4.4.1  R
 andomized Controlled Trials and Meta-­
Analyses
To overcome the problem of small samples, the method of
meta-analysis is used.
This is a statistical procedure in which the results of mul-
tiple studies are combined in order to yield an adequate
sample size.
In order for a meta-analysis to be valid, it is important that
each of the individual studies is measuring the same thing in
similar populations. This means that diagnostic assessments
and treatment outcomes must meet the same standards and
that measures are the same or at least compatible. This fol-
lows the well-known maxim “garbage in leads to garbage out”.
78 Chapter 4.  A Critical Review of Psychotherapy Research

The results of a meta-analysis can only be as good as the stud-

ies on which it is based.
In studies of psychiatric disorders, it can be difficult to
ensure that diagnostic groups are equivalent. This is an intrin-
sic problem within psychiatry and psychology because of the
still rudimentary nature of the classification of mental illness.
Criteria for many different diagnoses overlap. As a
result patients are often diagnosed with multiple “co-­morbid”
disorders. This comorbidity is in part an artefact of our clas-
sification systems and has led the National Institute of
Mental Health to develop an alternative approach using
dimensions: the Research Domain Criteria Project [24].
Heterogeneity refers to the case when there are differ-
ences between the studies included in a meta-analysis. Studies
may differ in the type of patients included, the type of inter-
ventions and the measures of outcome. There may also be
statistical and methodological differences. If differences are
found between studies, the results of the meta-analysis may
not be valid. Studies cannot be pooled. Statistical tests are
available to measure the degree of heterogeneity.
Meta-analyses can be performed with the assumption that
all the studies are sufficiently similar with similar effects. This
is referred to as “the fixed effects model”. When it is assumed
that the effect is not the same in all studies, a different statisti-
cal procedure is used known as “the random effects model”.
The fixed effects model is more powerful. When a fixed
effects model is used even though heterogeneity exists, the
combined pooled estimate of results may give too much
weight to larger studies. The choice of using a fixed or random
effects model can have a major impact on the pooled results.
The results of a meta-analysis are graphically portrayed in
a “forest plot” also known as a “blobbogram”. The studies
included in the meta-analysis are listed showing effect sizes
with point estimates and confidence intervals. The pooled
results are displayed at the bottom of the plot.
In the centre of the plot is the “vertical line of no effect”. If
the results cross this line, it means there is no effect of the
intervention.
 4.5  Critical Reviews: The Current State of Research 79

4.5  C
 ritical Reviews: The Current State
of Research
A major overview of research in psychotherapy was under-
taken by Dragioti et  al. [25]. This contained 173 individual
studies and 247 meta-analyses. Treatments included CBT,
psychodynamics, family systems therapy, cognitive remedia-
tion, dialectical behaviour therapy, IPT, mindfulness, problem-­
solving therapy, acceptance and commitment therapy,
supportive therapy and counselling. A lesser number of stud-
ies of behavioural activation, behaviour modification, EMDR,
motivational interviewing, prolonged exposure and trauma-­
focused therapy were included.
Of these published results, 196 showed significant benefits
of the psychotherapy. The authors however felt that only 16
meta-analyses, that is, 7%, provided “convincing” evidence of
psychotherapy effectiveness. Six of these studies were of CBT
and one of meditation therapy.
The authors felt that there was a large degree of heteroge-
neity in 130 of the meta-analyses. The impact of small-study
effects and overrepresentation of studies with positive signifi-
cant findings brought into question the conclusions of these
studies. They found problems with systematic biases includ-
ing bias related to the researchers’ allegiance to a particular
school of therapy. They ascertained that allegiance bias could
inflate treatment effects by almost 30%. Publication bias was
also deemed to overestimate effect sizes. These authors pin-
pointed problems with inadequate randomization, small
sample sizes and incomplete reporting. Dragioti et al. chose a
threshold of 1000 participants as an adequate sample size.
Only 16 meta-analyses out of 247 met this threshold and met
the standards for “convincing evidence”.Of these, five involved
CBT; seven involved “mixed” psychotherapy. Very few psy-
chodynamic psychotherapies were included in the  247
meta-analyses.
Jan Scott in an editorial in the same issue of the journal
described research in psychotherapy as “imperfect and still
80 Chapter 4.  A Critical Review of Psychotherapy Research

evolving” [26]. Factors that are difficult to define in

­meta-­analyses are the skill level of the therapists and the
fidelity to the therapy model. Scott calls attention to the need
to monitor potential harms as well as benefits when evaluat-
ing psychotherapy outcomes and the need to conduct
more studies to determine which specific therapies work for
which types of patients.
Dragioti’s study had some limitations of its own. Only ran-
domized controlled trials that were contained in meta-­
analyses were included resulting in 173 eligible RCTs. This
methodology may have excluded relevant randomized con-
trolled trials that were not part of any of the meta-analyses
studied.
They also excluded meta-analysis that contained less than
ten individual trials and may have missed meta-analyses with
large total sample sizes though with less individual studies.
Contrary conclusions were reached by Pim Cuijpers from
the University of Amsterdam [27]. He accessed a database of
500 published randomized controlled trials of different psy-
chotherapies for the treatment of depression in adults. The
database was made up of trials of CBT, IPT, short-term psy-
chodynamic psychotherapy, problem-solving therapy and
other modalities.
Cuijpers concluded that psychotherapies are about equally
as effective as medications and that combination treatments
of psychotherapy with medications are more effective than
either of these alone.
In comparing psychotherapy versus control groups, CBT
had an effect size of 0.71. STPP effect size was 0.61. Both
groups had significant heterogeneity.
The author concluded that overall the effect sizes from the
different types of psychotherapy were not significantly differ-
ent and that all of the therapies have comparable effects.
The conclusions of this vast study imply that common fac-
tors in psychotherapy are more important than specific fac-
tors. However the statistical power of the studies was too low
to verify this. Large effect sizes were associated with the use
of diagnostic criteria for depression, treatment manuals,
 4.6  Process Research 81

therapist training and assessment of treatment integrity.

Larger sample size, independent randomization, blind assess-
ment of outcome and intention to treat analysis were also
important factors [27].

4.6  Process Research

The aim of process research is to identify which treatment
variables contribute to good outcomes. Patient characteristics
determine 25–50% of the outcome variance. The therapeutic
relationship accounts for 5–10% of the variance and therapist
characteristics 8%. The specific method of psychotherapy
used accounts for only 5–8% of the variance. These figures
represent averages across a range of studies and methods.
There is much room for improvement in treatment results.
This will require answers to the question “which type of psy-
chotherapy works best for which patients and with which
problems?”
Process studies have identified the following key factors
for effective therapeutic relationships: the working alliance,
empathy, agreement on goals and collaboration.
Patient factors that influence therapy outcomes include
functional impairment, patient expectations, attachment style
and level of resistance.
These relationship factors cut across the different schools
of psychotherapy. Process research supports transdiagnostic
and trans-theoretical approaches to psychotherapy. However
the evidence base is not as rigorous as that of randomized
controlled trials focusing on specific disorders.

4.6.1  C
 ommon or Specific Factors: The Dodo
Bird Effect
Based on current research findings, some authors have con-
cluded  that all forms of psychotherapy are about equally
effective. This is known as the Dodo bird effect in reference
82 Chapter 4.  A Critical Review of Psychotherapy Research

to a character in Alice in Wonderland who stated that “every-

body has won and all must have prizes” [28].
Jerome Frank in a widely acclaimed book identified com-
mon elements for all forms of psychotherapeutic methods
[29]. He described six features that he felt were common to
all psychotherapies:
• An intense, emotionally charged, confiding relationship
with the helping person
• A rationale or myth which explains the cause of the
patient’s distress and a method for alleviating it
• The provision of new information concerning the patient’s
problems and possible alternative ways of dealing with
them
• Strengthening the patient’s expectations of help and the
fostering of hope
• The provision of success experiences which increase the
patient’s hopes and enhance his sense of capability
• The facilitation of emotional arousal which is required for
attitudinal and behavioural change
These six components have not lost their relevance during
the intervening five decades since Frank described them.
They are the focus of much current research.
Saul Rosenzweig may have been one of the first to bring
attention to the importance of common factors in 1936 [30].
He ascertained that there are many implicit non-verbalized
factors that lead to therapeutic change. He postulated that
therapeutic results may be independent of specific theory
as long as the theory is consistent. He recognized that dif-
ferent therapies may achieve change in different ways and
different directions but could still lead to the required
result because of the interrelationship of psychological
variables. Theory and effectiveness do not have to be
correlated.
Luborsky et al. found no difference in outcomes between
different treatment models among 17 meta-analyses [31].
Messer and Wampold in a review of this controversy assert
that common factors such as the therapeutic alliance and
 4.7  Notable Studies of STPP 83

therapist characteristics account for most of the variance in

treatment outcome equal to 5% to 7% of the variance [32].

4.7  Notable Studies of STPP

One of the most extensive and comprehensive meta-­analyses of
STPP was carried out by Abbass et al. in a Cochrane review.
The authors undertook an extensive review of the literature,
and based on selection criteria, 33 randomized controlled trials
of short-term psychodynamic psychotherapy were selected for
the meta-analysis [33]. Each study was rated on a range of cri-
teria to estimate risk of bias at any stage in the trial process.
The trials were heterogeneous in nature and covered a range
of diagnoses including depression, anxiety and a variety of
somatic disorders. Overall results showed positive outcomes
versus controls which included treatment as usual, waiting list
controls or a comparator active treatment. The authors qualify
their findings based on several methodological considerations.
They concluded that short-term psychodynamic psychotherapy
for 40  weeks or less may be effective for  a range of common
mental disorders with evidence of modest to large treatment
effect sizes. The authors advised that the results should be inter-
preted with caution in view of the heterogeneity between studies
and some loss of outcome significance at long-term follow-up.
Driessen, Abbass, Cuijpers and associates in 2015 updated
a previous meta-­analysis of short-term psychodynamic psy-
chotherapy for depression carried out by this group com-
pleted in 2010.
This entailed 54 studies of which 33 were randomized con-
trolled trials representing 3946 subjects [34].
No significant differences were found between individual
STPP and other psychotherapies at post-treatment (d = −0.14)
and follow-up (d  =  −0.06) in analyses that were adequately
powered to detect a clinically relevant difference. STPP was
significantly more efficacious than other psychotherapies on
anxiety measures at both post-treatment (d = 0.35) and fol-
low-­up (d = 0.76).
84 Chapter 4.  A Critical Review of Psychotherapy Research

In another study Driessen et al. undertook a randomized

controlled trial of 341 adults meeting diagnostic criteria for
major depression; they compared the efficacy of cognitive
behavioral therapy (CBT) and psychodynamic therapy
[35, 36].
Patients were randomized to 16 sessions of individual
manualized CBT or short-term psychodynamic supportive
psychotherapy. Severely depressed patients (HAM-D  >  24)
received additional antidepressant medication according to a
protocol.
STPP was significantly more effective than control condi-
tions at post-treatment on depression, general psychopathol-
ogy and quality of life measures (d  =  0.49–0.69). STPP
pretreatment to post-treatment changes (d = 0.57–1.18) indi-
cated significant improvements on all outcome measures,
which either significantly improved further (d = 0.20–1.04) or
were maintained from post-treatment to follow-up.
Steinert et al. performed a meta-analysis to test the equiv-
alence of psychodynamic psychotherapy to other empirically
supported treatments [37]. They selected 23 randomized con-
trolled trials involving 2751 patients. They found that manual-­
guided psychodynamic therapy in adults was equivalent to
other treatments with demonstrated efficacy.
In this study nonequivalence was statistically defined as
the minimum difference that would be considered clinically
significant between treatments. Twenty three randomized
controlled trials published between 1983 and 2016 where
included. Minimal sample size for each treatment was 20 in
each group. The studies totalled 2751 patients. In most cases
psychodynamic psychotherapy was compared with CBT.  In
two of the studies, the comparator was antidepressant medi-
cation. Studies varied in principal diagnosis. The authors
concluded that psychodynamic therapy was as efficacious as
other treatments including CBT.
Nevertheless the limitations of these and other meta-­
analysis have been pointed out.
The largest studies in Steinert’s meta-analysis were those
by Driessen et al. [35] and by Connolly Gibbons et al. [38].
 4.8  The National Health Service 85

Driessen’s study compared 177 patients who received psy-

chodynamic therapy with 164 patients who had CBT. Diagnosis
was that of major depression with Hamilton Depression
score greater than 14. Each group had 11 sessions. Outcomes
were measured on the basis of symptoms.
Connolly Gibbons’ trial compared 118 patients with psy-
chodynamic therapy versus 119 patients with CBT each
receiving 16 sessions of therapy for major depression.
Outcomes included psychosocial functioning in addition to
target symptoms. This study is notable for its relatively large
sample size of 237 patients. Treatment was conducted at a
single outpatient community mental health centre in
Philadelphia, Pennsylvania.
The patients received 16 sessions of dynamic psychother-
apy based on Luborsky’s model. The Hamilton Depression
rating scale was the primary outcome measure. Remission
rates in both groups were only 22%.
The study found that dynamic therapy was not inferior to
cognitive therapy in decreasing depressive symptoms.
However it should be noted that there was no inactive con-
trol condition. The absence of a control group and the fact
that 78% of participants did not respond to either treatment
means improvement could be attributed to the passage of
time.

4.8  The National Health Service

It is important also to consider the level of evidence required
when discussing healthcare systems and funded services. The
National Health Service in the United Kingdom has pio-
neered the provision of psychological services. Based on the
National Institute for Healthcare Excellence (NICE)  guid-
ance, the NHS implemented a programme entitled “Improving
Access to Psychological Therapies” (IAPT) in 2008.
Pybis et  al. compared the outcomes of cognitive behav-
ioural therapy and counselling in over 30,000 patients [39].
The principal outcome measures were the PHQ 9 and the
86 Chapter 4.  A Critical Review of Psychotherapy Research

GAD 7. The authors  undertook a multilevel analysis that

considered number of sessions, baseline severity and the loca-
tion at which the services were delivered.
The majority of patients suffered from depressive or anxi-
ety disorders. “Reliable and clinically significant improve-
ment” was defined as a reduction in PHQ 9 scores of 6 points
or more. The mean number of sessions attended was 8.5 with
a median of 7.
For CBT 46.6% of patients made reliable improvement.
For those who had received generic counselling, 44.3%
improved. There are no comparison data for other jurisdic-
tions. These results appear to be good with the strong caveat
that there was no randomization or blind ratings.
Even so 55% of patients did not improve leaving a need to
identify more effective treatment approaches.
Therapy type was not a significant predictor of change.
There was significant variability across treatment sites con-
trolling for patient variables and number of sessions attended.
It was not possible to measure therapist variables and to
completely account for possible variations in case
complexity.

4.9  Future Research

How can the quality of future of research be improved?
Kocsis and colleagues have developed a 25-item question-
naire, the Randomized Controlled Trial of Psychotherapy
Quality Rating Scale (RCT-PQRS) [40]. Items are rated on a
0 to 2 scale. The items rated include:
• Criteria for inclusion and exclusion.
• Diagnostic methods.
• Definition of the treatment used and how it is delivered.
This requires review of transcripts or tapes, therapist train-
ing and experience and therapist supervision.
• Description of concurrent treatments.
• Use of validated outcome measures that are rated blindly.
 4.9  Future Research 87

• Assessment of post-termination long-term outcome fol-

lowing the end of the therapy.
• Use of the intent-to-treat method for data analysis.
• Adequate sample size.
• Comparison groups should be from the same population
and studied within the same timeframe.
Using this rating scale, 94 randomized controlled trials of
psychodynamic psychotherapy published between 1974 and
2010 were examined. Sixty-three of these studies were rated
as having adequate quality. Thirty-nine studies included an
active comparison treatment. A total sample size of at least
250 was estimated to yield enough power to detect differ-
ences between the experimental group and the active com-
parator. Smaller sample sizes are unable to detect the degree
of difference sufficiently to establish a finding of “no differ-
ence”. If the sample is large enough, then a finding of no
difference between treatment methods indicates equal
efficacy.
The same group of authors applied the same rating scale
(RCT-PQRS) to assess the quality of randomized controlled
trials of cognitive behavioural therapy for depression [41, 42].
One hundred and twenty randomized controlled trials of
CBT were selected. It was possible to compare the quality
rating score in 113 of these and 87 psychodynamic therapy
studies. There was no significant difference in the psychody-
namic and CBT quality scores. CBT trials had a mean quality
rating of 25.5 with a standard deviation of 9.13. Psychodynamic
trials had a mean quality rating of 25.1 and standard devia-
tion of 9.04.
Studies rated with low quality were associated with an
inflated outcome with larger effect sizes. Lower quality was
also related to greater variability in outcomes. There is thus
an inverse relationship between methodological quality and
effect size. This may indicate that higher quality studies pro-
duce more valid results. It is important to note that the qual-
ity of the studies in both groups improved over time between
1975 and 2010.
88 Chapter 4.  A Critical Review of Psychotherapy Research

The regular use of the RCT-PQRS could help to improve

the quality of psychotherapy  research in general and STPP
research in particular. Optimal standards for psychodynamic
research should include [41, 42]:
• Randomized controlled trials with adequate sample sizes.
• A manualized approach.
• Adequately trained therapists in the same method.
• Oversight to ensure fidelity to the method. The ideal
would be video recordings of sessions.
• Valid outcome measures in all dimensions: symptomatic,
functional, relational and subjective.
• Trials should include two control conditions: the first con-
trol condition, requires  an active validated therapy in
which the same standards are met (adequate sample size,
adequate training of therapists, fidelity measures and
adherence to a treatment manual). The second control
condition would comprise of no active treatment such as
weekly check-in meetings with a non-therapist or the
completion of rating scales.

Key Points
• Randomized controlled trials and meta-analyses are
considered the gold standards for conducting
research on treatment outcome.
• Psychotherapy research involves particular difficul-
ties in meeting all methodological requirements.
• Sample sizes, heterogeneity, fidelity to treatment
models and therapist training are critical factors.
• Diagnostic homogeneity may be difficult to achieve.
• Biases include reporting bias, publication bias and
allegiance bias.
• Much of the literature for all forms of psychotherapy
do not meet adequate levels of quality.
• The best available evidence is that psychodynamic
psychotherapy demonstrates positive outcomes in
comparison to no treatment or treatment as usual. In
head-to-head studies with active treatment, it may be
equivalent.
 References 89

• Larger randomized controlled trials using the same

methods and populations are required and need to
be replicated by different research groups to defini-
tively demonstrate treatment effectiveness.
• STPP has demonstrated effectiveness in a range of
psychiatric disorders including depression and anxi-
ety in comparison to treatment as usual or inactive
treatment.
• In comparison to proven active treatment such as
cognitive behavioural therapy, the evidence points to
equivalence, but this is a less robust finding at this
point.
• The debate regarding the role of common and spe-
cific factors in the effectiveness of psychotherapy has
not been resolved.
• Research should continue to identify better indica-
tions for specific therapy types.
• A distinction should be made between therapies that
are primarily symptom orientated and those that are
directed at changes in relational variables.

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pretations in dynamic psychotherapy: do they really yield sus-
tained effects? Am J Psychiatry. 2008;165(6):763–71. https://doi.
org/10.1176/appi.ajp.2008.07061028.
22. McCullogh L, Kuhn N, Andrews, et  al. Treating affect phobia
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Guilford press; 2003.
23. Gupta M. Is evidence-based psychiatry ethical? Oxford: Oxford
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24. Cuthbert BN. Research domain criteria: toward future psychiat-
ric nosologies. Dialogues Clin Neurosci. 2015;17(1):89–97.
25. Dragioti E, Karatnanos V, Gerdle B, Evangelou E. Does psycho-
therapy work? An umbrella review of meta-analyses of random-
ized controlled trials. Acta Psychiatr Scand. 2017;136:236–46.
26. Scott J.  The science and practice of psychotherapy: the critical
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27. Cuijpers P.  Four decades of outcome research on psycho-

therapies for adult depression: an overview of a series of meta-­
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Chapter 5
Updating the Language
of Psychodynamic
Psychotherapy

5.1  Background
The vocabulary of psychodynamic psychotherapy is rich and
expressive. It originates from many different schools of psy-
chodynamic theory each with its own spin on terminology:
classical instinctual conflict theory of Freud; object relations
theory of Melanie Klein, Donald Fairbairn, Michael Balint
and Donald Winnicott; Kohut’s self-psychology; and combi-
nations of instinctual and object relations such as Edith
Jacobson and Otto Kernberg. New terms have been added
more contemporaneously from Bowlby’s attachment theory,
relational psychoanalysis and emotion-focused
psychotherapies.
Yet there is a large lexicon of psychodynamic terminology
that is shared across the various schools and systems. A
shared conceptual repertoire may appear divided by termino-
logical nuances. If psychodynamic psychotherapy continues
to develop and be relevant, it must update its terminology to
incorporate contemporary advances in affective and cogni-
tive neurosciences. It must discard or modify terminology
derived from theories that have been superseded by new
models of psychological and interpersonal dynamics.

© Springer International Publishing AG, 95

part of Springer Nature 2018
A. Eppel, Short-Term Psychodynamic Psychotherapy,
https://doi.org/10.1007/978-3-319-74995-2_5
96 Chapter 5.  Updating the Language of Psychodynamic

Very fundamentally we are still stuck with the mind-brain

problem. Neurobiological research has been based on neuro-
logical lesion studies, animal studies and neuroimaging
(Chap. 3). All of these lead to the conclusion that the experi-
ence of emotion, consciousness and human attachment, the
very essence of the human experience, is derived from our
neural circuits, neurons and synapses.
In this chapter some of the fundamental concepts and
ideas that are generally utilized by experienced psychody-
namic therapists are defined. Where the terminology is
obscure or peculiar to a particular school of psychodynamic
thought, a translation is proposed.

5.2  Definitions

5.2.1  Psychodynamics

This term conveys a sense of opposing forces. It is an active

rather than static process. It implies interaction rather than
disengagement. The word arises from Freud who used it to
describe an interplay of forces in opposition to each other. To
translate this into current paradigms, we might say that
dynamics refers to cognitive and emotional processes that are
constantly changing and reacting to internal and external
stimuli. In particular, there is a dynamic interaction between
the patient and the therapist.

5.2.2  Object Relations

The term object can lead to some confusion. Its use in psy-
chodynamics comes from Freud and the German word
“objekt”. In psychodynamics it does not refer to “a thing” but
to a person. The use of this word can only be understood by
reference to Freudian instinct theory. For Freud instincts had
“aims”. The person towards whom the instinctual aim was
directed or attracted to was termed “the object”. For example,
the sexual instinct may be directed towards a specific person
who is described as “the object of the instinct” [1]. Similarly
 5.2 Definitions 97

the target of a person’s affection is termed a “love object”. To

avoid perplexity, it may be time to replace the word “object”
with “other person”.
Object relationship refers to an inner representation of
interactions between two people: the self-representation and
the object representation. An individual’s ways of interacting
with others depend on multiple differing internalized self-­
object interactions.
Donald Winnicott stressed that the formation of a sense of
self depended on the interaction between the child and the
environment. In this respect Winnicott is the forerunner of
Bowlby’s attachment theory. He theorised that the
­environment shapes the infant’s development. The mother or
mother substitute is the principal component of the environ-
ment in the early years of development. The term “good-
enough mother” refers to the provision of sufficient caring,
responsiveness and nurturance in order to ensure healthy
development. This requires that the mother figure is respon-
sive to differing needs that arise as the infant develops.
In the early stages of development, the infant is not aware
of the boundary between himself and the external world. In
Winnicott’s terms, the infant has not yet differentiated the
“me” from the “not me”. In an adequately responsive environ-
ment, the infant develops a sense of himself. If the environ-
ment is not safe and the needs of the infant are not optimally
met, this may lead to the development of “a false self ” . The
false self masks the inner true self as a means of protection
against a hostile or unloving environment. In adults a false
self results in a lack of access to authentic inner emotions. The
person is emotionally detached, “unreal” and unable to form
meaningful relationships.
Transitional object is a term conceived by Winnicott to
describe an area of experience between the inner mental
world and the external world. This is an area where “me” and
“not me” intersect. The words “transitional object” are univer-
sally recognized in describing a child’s choice of a blanket or
a soft toy from which he is inseparable. This object represents
the mother or mother figure and stands in for her when she is
not available to comfort the child. Transitional space includes
those mental experiences that contain a mixture of inner real-
98 Chapter 5.  Updating the Language of Psychodynamic

ity and the external world. Aspects of play and culture repre-
sent transitional phenomena. For example, a painting contains
representations of external reality but also contains aspects of
the artist’s own personality and inner reality.
One of the key functions of “good-enough mothering” is
to convey to the infant that he is seen and recognized. This is
a process of mirroring and responding. When this happens,
when the infant is seen, his existence is confirmed.
“Holding environment” is the environment and atmo-
sphere created by the mother that ensures the infants’ safety
and survival. It is characterised by predictability, acceptability
and empathic responsiveness.

5.2.3  Affect, Emotion and Feeling

One of the thorniest problems in psychotherapeutics is to

develop a consistent definition of the terms “affect”, “emo-
tion” and “feeling” (Chap. 3). Affect and emotion are often
used interchangeably to describe biologically hardwired,
genetically programmed processes that are experienced as
visceral “in the gut”. Wherever possible I have used the word
emotion instead of affect in this book.
Emotions are made up of physiological, physical, psycho-
logical and hormonal patterns. They are intrinsically linked to
preparatory physical states and actions. They arise from sub-
cortical neurocircuits.
Feeling is often defined as the conscious experience of
affect or emotion. Feelings arise from the cognitive percep-
tion and appraisal of emotions in areas of the neocortex.
Emotions can be classified into two main groups: adaptive
and inhibitory. Adaptive emotions facilitate a healthy rela-
tionship with the external environment and consist of:
• Sadness/sorrow/grief
• Anger/irritation/rage/assertiveness/mastery
• Fear
• Happiness/joy/pride
• Attachment/love/compassion/care
• Sexual desire/lust
 5.3 Defences 99

Inhibitory emotions tend to shut down adaptive behav-

iours leading to withdrawal and avoidance.
They include shame, humiliation and embarrassment
which are activated in response to behaviour that is unaccept-
able to one’s sense of self and society.
Guilt and self-blame are inhibitory and arise in response
to behaviour that breaches social, family and cultural norms.
Disgust and contempt inhibit attachment and closeness.
Depression and mania are pathological emotional states
which are qualitatively different from normal emotions.

5.3  Defences
A defence is psychological operation automatically and
unconsciously deployed when an individual is facing a psy-
chological threat. Defences protect the person by keeping
certain thoughts and feelings out of awareness.
In Freudian conflict theory, the threat is from internal
drives and impulses (aggressive, sexual) that threaten the ego
resulting in anxiety. In object relations theory, the threat
arises out of interactions with other people. Defences serve to
keep the undesirable feelings related to a self or object repre-
sentation out of awareness.
Interpersonal threats may threaten one’s self-esteem or
sense of identity. Threats may come from external events,
dangers or losses. Threats may be to bodily integrity such as
illness or injury. Defences are described as adaptive when
they enhance functioning. Defences are maladaptive when
they lead to impaired functioning, problems in relationships
or symptoms. 
Denial: sensory information regarding unpleasant external
events is kept out of awareness.
Projection: inner feelings, impulses and thoughts are expe-
rienced as belonging to another person.
Projective identification: this consists of projection with
the addition that the other person begins to behave and feel
in accordance with what has been projected.
100 Chapter 5.  Updating the Language of Psychodynamic

Splitting: self and other people are experienced as all good

or all bad. This may shift back and forth.
Idealization: attributing to another person superior char-
acteristics. Idealization provides the patient with a sense that
they are going to be taken care of by an all-knowing and
­all-­powerful attachment figure. Devaluation is the converse
in which the person is experienced as disappointing, incom-
petent and of no value.
Somatization: the individual focuses on physical sensations
to the exclusion of painful emotions.
Acting out: feelings are expressed through action rather
than words.
Identification: unconsciously taking on characteristics,
behaviours, attitudes and mannerisms of another person.
Displacement: the unconscious redirection of feelings
associated with one person on to another.
Rationalization: providing logical explanations or excuses
for unacceptable feelings, attitudes or behaviours.
Intellectualization: avoidance of feelings by focusing on
logical and cognitive explanations.
Isolation of affect: separating thoughts from their associ-
ated emotions.
Reaction formation: the transformation of unacceptable
feelings, wishes or impulses into their opposite.
Repression: the exclusion from awareness of feelings,
thoughts or impulses arising internally.
Undoing: an attempt to neutralize unacceptable aggres-
sive, sexual or shameful feelings by elaborating contradictory
behaviours or thoughts.
Controlling: distraction from feelings by means of control,
organization and regimentation of tasks and other people.
Sexualisation: focuses on sexual aspects of another person
defending against the experience of painful emotions.
Dissociation: alteration in the awareness of current events,
surroundings and time in the presence of full consciousness.
Humour: the automatic unconscious use of humour to
divert focus from unpleasant feelings.
 5.3 Defences 101

Humour may represent the disguised expression of feel-

ings without personal discomfort and may conceal feelings or
behaviours that are unacceptable to others. 
Sarcasm: the expression of anger disguised as humour.
Passive aggression: the indirect expression of aggression
through deniable behaviours such as lateness, procrastina-
tion, forgetting to do things and inconveniencing others.
Externalization: the attribution of the responsibility for
one’s feelings or behaviours to external factors or people.
Altruism: behaviour is directed towards the needs of
­others rather than to one’s own needs and desires.
Sublimation: the unconscious diversion of emotions,
desires and behaviours into socially productive activities.
Masochism: self-sacrifice of one’s own needs, wishes and
gratifications as a defence against feelings of guilt, shame or
anger.
It should be emphasised that defences are not the same
as “coping mechanisms”. Coping mechanisms are con-
sciously deployed to reduce distressing emotions and
thoughts.
Coping mechanisms include conscious suppression of
thoughts, feelings and behaviours. The coping strategy of
anticipation entails postponing immediate gratification of
feelings and wishes in the expectation of future benefits. The
conscious as opposed to unconscious use of humour is also a
coping mechanism.

5.3.1  N
 euroscientific Reformulation of Concept
of Defence
Defence mechanisms can be understood in terms of the Dual
Processing model of emotion (Chap 3).
External physical threats trigger an appraisal by the organ-
ism and a fight or flight response. This involves the activation
of various control centres including the autonomic nervous
system, the attentional and motor systems.
102 Chapter 5.  Updating the Language of Psychodynamic

Psychological threats are triggered by internal or exter-

nal stimuli that undergo fast or slow appraisal by means of
either the subcortical low road or the cognitive high road.
Strategies employed at the cognitive level are more cor-
rectly called coping strategies that are made on a conscious
basis.
Defence mechanisms operate on the low road and occur
automatically leading to activation of different behavioural
and emotional responses; certain outputs are activated while
others are inhibited. This must be mediated through a control
centre that computes the values of the alternative responses.
If safety is restored, the computation changes in value and
may allow the individual to  risk vulnerability and disclose
feelings. Therapeutic interventions are designed to enhance
safety and reduce defences  thereby permitting emotional
expression.
Transference is the re-experiencing of feelings towards
another person based on internal working models. This leads
to expectations and attributions which may not be accurate to
the current interaction.
Countertransference comprises  the transference feelings
that the therapist has towards the patient which are deter-
mined by his or her own internal working models.

5.4  A
 ttachment Theory, Object Relations
and Interpersonal Terms
Internal working models develop in the early years of child-
hood based on attachment experiences. Internal working
models are made up of multiple experiences of self in rela-
tion to others (Table  5.1). Self-representations consist of
emotional, cognitive and physical attributes and are linked
to representations of others. These self-other templates are
linked by emotion, bodily feelings, cognitions and
memories.
 5.4  Attachment Theory, Object Relations… 103

Table 5.1  Definition of attachment theory concepts

Proximity The genetic programme that causes infants to
seeking seek proximity to its mother
Separation The distress experienced by an infant when
anxiety separated from the primary attachment figure.
Indicated by fear, crying and agitation
Secure base The feeling of safety and security provided by
the primary attachment figure that allows the
infant to begin to separate and explore the world
Safe haven The function provided by the secure base when
the infant is in distress and seeks proximity to the
attachment figure. Activation of this is brought
about by separation, strangeness, pain, hunger,
fatigue
Principal This is the person who has the most day-­to-­day
or Primary interaction with the infant. It may be a parent,
attachment grandparent, sibling or other caregiver
figure (PAF)
Internal These are emotional and cognitive
working representations of the external world.
models They consist of representations of the self
and representations of others. The early
attachment relationships form the foundations
for emotionally based representations of
relationships with others

5.4.1  T
 ranslating Dynamic Terms into Attachment
Language
It is possible to redefine psychodynamic terminology using
attachment theory concepts (Table 5.2). I often use the anal-
ogy of Pythagoras’ theorem which states that “in a right-­
angled triangle, the square of the hypotenuse is equal to the
sum of the squares of the other two sides”. This is rather cum-
bersome and archaic language. The same concept can be
much more concisely and clearly expressed using the lan-
guage of algebra (Fig. 5.1):
104 Chapter 5.  Updating the Language of Psychodynamic

Table 5.2  Comparison of attachment and object relations concepts

Attachment theory Object relations
Secure base Therapeutic alliance
Exploration Capacity to be alone
Internal working models Self- and object
representations
Attunement Holding environment
Attachment style Defences
Mentalization- existing in the heart and Reflective functioning
mind of the other
Implicit memory Unconscious
Attachment relationships Self and objects

Figure 5.1  A Right-angle triangle

A2 + B2 = C2 where C is the longest side of the triangle and

A and B are the other two sides.
I compare the language of Euclidean geometry to that of
many psychodynamic terms: very rich, descriptive, at times
poetic and beautifully structured. However attachment the-
ory, like algebra, is more consistent with contemporary sci-
ence and for students easier to grasp.

5.5  Memory
There are two main categories of memory: explicit memory
and implicit memory.
Explicit memory is also known as declarative memory and
refers to memories that are conscious and available for recall.
 5.6 Empathy 105

Declarative memory stores specific facts, events, people’s

names, places and information.
There are two subcategories for explicit memory:
Autobiographical (episodic) and semantic memory.
Autobiographical memory consists of events connected to
a specific time and place. It includes memories of oneself as a
participant in the event. Autobiographical memories provide
a sense of continuity and hence identity. Autobiographical
memory includes the memory of associated feelings.
Semantic memory consists of general knowledge, facts and
meanings of words and data that are not attached to specific
times or places.
Implicit memory operates outside of awareness and
encompasses procedural memory. Procedural memory is also
known as non-declarative memory.
Procedural memory refers to actions that are carried out
automatically. They do not involve consciousness. An exam-
ple of this is riding  a bicycle, the memories of which are
stored in the basal ganglia and cerebellum. Relationship pat-
terns depend on implicit relational knowledge and generally
unfold automatically.

5.6  Empathy
Empathy has also been described as biographical, semantic
and procedural [2].
Procedural empathy is synonymous with emotional conta-
gion and refers to the automatic synchronization of facial
emotions between two people. This form of empathy is
unconscious and appears to be inborn. An example of this is
yawning. This appears to be dependent on visual and motor
neural circuits (Fig. 5.2).
Semantic empathy is expressed verbally. It is the ability to
consciously identify, recognize and name facial emotions
(top-down).
106 Chapter 5.  Updating the Language of Psychodynamic

Figure 5.2  Empathy

biographical

semantic

procedural

Biographical empathy draws on personal life experience

and has emotional and verbal components.
Projective identification may in fact represent procedural
empathy.
Empathy involves both sharing of emotions and being able
to understand the other person’s point of view. The latter
requires the activation of the therapist’s own mental repre-
sentations and memories.
Empathy can  thus be viewed as the activation of the
therapist’s own personal neural circuits and mental repre-
sentations of the state that is being observed. This can be
referred to as emotional  empathy as opposed to cognitive
empathy which is a deliberative top-down activation.
Cognitive empathy entails consciously “stepping into the
other’s shoes”. It is a process of imagination and deliberate
recall of associated memories.

5.7  Therapeutic Change Processes

This refers to the processes that bring about changes in symp-
toms, self-other representations/ internal working models and
relationship patterns.
 5.8  Statistical Language 107

Lane et al. propose that therapeutic change results from a

three-step process [3].
• Reactivating old memories
• Engaging in new emotional experiences that are then
incorporated into the reactivated memories by
reconsolidation
• Reinforcing the changed memory structure by practising
new ways of behaving in multiple contexts [3]
This requires optimal arousal of emotion in therapy ses-
sions in accordance with the Goldilocks rule (Chap. 6).

5.8  Statistical Language

5.8.1  Meta-analysis

Meta-analysis is a statistical procedure that is used when indi-

vidual randomized control trials are not large enough to
make valid conclusions. The process of meta-analysis is a
mathematical procedure that combines the results of multiple
individual studies [4, 5].
The detailed procedures of carrying out a meta-analysis
are beyond the scope of this book. The calculations can be
done by specific software programmes.
The results of a meta-analysis are displayed in a “forest
plot”. This is a graphical display in which all of the individual
trials are listed on the left-hand side.
Results are displayed in horizontal lines that contain point
estimates and a 95% confidence interval. The confidence
interval is an estimate of the range  in which the true effect
size lies in the population of interest.

5.8.2  Effect Size

Effect size is a standardized measure that allows comparison

of results from different studies. Effect sizes are the most
108 Chapter 5.  Updating the Language of Psychodynamic

important outcome measures in psychotherapy research

studies.
Cohen’s d is a commonly used effect size in psychotherapy
research. Cohen’s d is calculated from the mean differences of
an effect. An effect size is considered small if d = 0.2, medium
if d = 0.5 and large if d = 0.8. However these values are arbi-
trary and should be related to the clinical impact of the
findings.
An alternative measure is Hedge’s g. Population effect
sizes are estimated on the basis of the study samples and may
overestimate the true population effect. The calculation of
Hedges g is used to correct for this bias particularly when
sample sizes are small.
Another group of effect sizes is based on correlation and
indicated by the letter r.

5.8.3  Heterogeneity

Heterogeneity refers to the level of differences between stud-

ies included in the meta-analysis. There may be differences in
inclusion criteria for patients in the study. There may be dif-
ferences in measures of outcome and other methodological
differences. This is the proverbial problem of comparing
apples and oranges! Measures must be employed to deter-
mine if the level of heterogeneity is too high which would
indicate that the results of the meta-analysis are not valid. It
is important to check for measures of heterogeneity when
appraising the results of a meta-analysis.

Key Points
• The language of psychodynamics is based on multi-
ple theories and schools of thought.
• Concepts need to be redefined to take into account
advances in affective and cognitive neurosciences.
• Defences can be conceptualized as implicit emotion
regulation systems.
 References 109

• Effect size is a standardized measure that allows

comparison of results from different studies.
• Effect sizes are the most important outcome mea-
sures in psychotherapy research studies.

References
1. Laplanche J, Pontalis J-B.  The language of psychoanalysis.
London: Karnac; 2006.
2. Guilé JM. Disentangling cognitive processes from neural activa-
tion and psychic mechanisms: the example of empathy. J Physiol.
2010;104:337–41.
3. Lane RD, Ryan L, Nadel L, Greenberg L. Memory reconsolida-
tion, emotional arousal, and the process of change in psychother-
apy: new insights from brain science. Behav Brain Sci. 2015;38:e1.
https://doi.org/10.1017/S0140525X14000041.
4. Hak T, Van Rhee HJ, Suurmond R.  How to interpret
results of meta-analysis. (Version 1.0). Rotterdam: Erasmus
Rotterdam Institute of Management; 2016. www.erim.eur.nl/
research-support/meta-essentials/downloads.
5. Greenhalgh T. How to read a paper: the basics of evidence-based
medicine. 5th ed. Chichester: Wiley; 2014.
Chapter 6
Choice Point Analysis
and Action Alternatives

6.1  Background
The fundamental process in psychodynamic therapy consists
of a back and forth interactive dialogue between the therapist
and the patient: the patient speaks; the therapist listens; the
therapist speaks; the patient responds. What the therapist says
is an “intervention”.
At any instant during a therapy session, the therapist has
to choose from multiple possible interventions.
These are “choice points” and “action alternatives” . Lewis
Tauber describes a choice point as “a critical point requiring
action on the part of the therapist” [1]. Tauber called his sys-
tem “choice point analysis”. The options or choices which are
available to the therapist are referred to by Tauber as “action
alternatives” .
This model involves the therapist considering what would
be the most effective intervention at any moment in the
therapeutic process. The therapist must consider which of the
options will best facilitate the flow of therapy at each point.
A choice point occurs when there is a need for the thera-
pist to make an intervention.
Examples where this need may be identified:
• The session is “not going anywhere”.
• The content of the session is superficial and insignificant.
• The patient appears angry or withholding.

© Springer International Publishing AG, 111

part of Springer Nature 2018
A. Eppel, Short-Term Psychodynamic Psychotherapy,
https://doi.org/10.1007/978-3-319-74995-2_6
112 Chapter 6.  Choice Point Analysis and Action Alternatives

• The patient confronts the therapist.

• The patient is disengaged.
• The patient displays an emotional shift.
• The therapist experiences an emotional shift.
• Silence.
• There is an intensification of anxiety in patient or
therapist.
In order for the therapist to identify choice points and
action alternatives, he must constantly track what the patient
is saying, nonverbal cues, signs of emotion and his own
responses to the patient. The therapist listens attentively and
needs to pay attention to facial expressions, gesture, posture
and tone of voice.
At a choice point, the therapist must opt to make an inter-
vention. He has to decide to speak.
What should he say? Which interventions should the
therapist make? Which interventions when applied over the
course of treatment result in better outcomes?
How does the beginning therapist learn what to say and
when to say it? To answer this question, I first review key
ideas on clinical decision theory and then describe the
method developed by Dr. Lewis Tauber when supervising
trainee psychotherapists [1].

6.2  How Do We Make Decisions?

There is an extensive literature on decision-making pro-
cesses. This has major relevance in many disciplines. The
issue for the therapists and for teachers is whether clinical
decisions can be based on rational choices as opposed to
intuition. Psychologist Daniel Kahneman studied the deci-
sion-making process in Economics and found that this is
not an exclusively cognitive procedure [2, 3]. He subse-
quently won the Nobel Prize in Economics for the develop-
ment of his dual processing view of decision-making which
entails two systems which he termed “System 1” and
“System 2”.
 6.2  How Do We Make Decisions? 113

System 1 operates automatically and is the faster of the

two systems, with “little or no awareness of effort and no
sense of voluntary control” [3]. This is “intuitive” and
non-analytic.
System 2 refers to a conscious reasoning process that makes
choices and is associated with the “subjective experience of
agency, choice and concentration”.This appears to be similar to
the ideas of conscious and unconscious, explicit or implicit
thought processes in psychodynamics and psychology.
System 1 and System 2 are continuously active. System 1
constantly generates impressions, intuitions, tensions and
feelings. System 2 may appraise these inputs and convert to
voluntary behaviour. Similar concepts were elaborated by
Metcalfe and Mischel which they described as “hot” and
“cool” thinking [4].
Kahneman’s theories have been applied to clinical
decision-­making in order to reduce error, to eliminate cogni-
tive biases and to make diagnoses more accurate. The current
consensus is that clinical reasoning and decision-making
involve continuous interaction of both System 1 and System
2. Intuitive and deliberative processes work simultaneously.
System 1 processes are based on pattern recognition. This
in turn depends on memories and prior experience. The
expert is responding to a cue that triggers access to informa-
tion stored in memory [3].
Studies by Geoff Norman and Jonathan Sherbino and oth-
ers at McMaster University [5] have shown that experienced
clinicians often rely more on System 1 processes then on
analytical reasoning.
The results of their research have demonstrated that “gut
feeling” plays an important role in clinical decision-making.
This finding is surprising as it has long been thought that
expert clinicians make decisions based on greater knowledge,
the ability to utilize deductive reasoning and the application
of rational diagnostic and treatment algorithms. Because of
the role of System 1 in clinical work, the novice is often puz-
zled by a  supervisor’s ability to make more rapid decisions
about diagnosis or treatment. Yet when novices rely on “gut
feeling” , it is more likely to lead to error [5].
114 Chapter 6.  Choice Point Analysis and Action Alternatives

The answer to this paradox is that gut feelings of the nov-

ice and gut feelings of the expert are very different. System 1
operates rapidly based on unconscious pattern recognition
arising from experiential implicit memories acquired over
many years. The student does not have this memory “bank”
from which valid predictions are generated.
Kahneman [3] distinguishes true expert judgement from
false confidence which produces an illusion of validity. The
conditions for expert intuition require a body of knowl-
edge that contains regular components that are predict-
able. It must be possible to acquire this knowledge through
prolonged practice. Kahneman describes the game of chess
as an example of a body knowledge that leads to regular
and predictable results. The chessmaster relies on System 1
intuition when moving his chess pieces. Experts like chess-
masters and seasoned physicians are able to respond to
specific cues that trigger stored experiences and memories.
This is in contrast to trying to predict the stock market in
which the process lacks sufficient regularity! Intuition can-
not be correct in an unpredictable environment. The envi-
ronment must contain some stable regularities that can be
learned [3].
With regard to psychotherapy, Kahneman notes that psy-
chotherapists can develop expertise about the effect of in-­
session interventions. A psychotherapist  is able to observe
the immediate response of the patient, and this feedback
results in learning and storage of memories. However psycho-
therapists are unable to make good predictions about long-­
term outcome because they receive insufficient feedback
about this to  influence their modes of practice. Short-term
and long-term predictions depend on the environment and
context. For example, physicians working in specialties in
which they only see patients on one occasion will not be in a
position to make longer-term predictions about new patients
because they receive no long-term feedback about the out-
comes of their treatment.
Without feedback  longer-term predictions are based on
lack of stored data and more prone to cognitive biases such
as overgeneralisation.
6.3  Lewis Tauber: Choice Points and Action Alternatives 115

Although Norman and Sherbino’s studies [5] concern

the diagnostic process, it is reasonable to extrapolate that
System 1 and System 2 processes are at work when deciding
to make a therapeutic intervention in psychotherapy. The
therapist also has to make an appraisal (“diagnosis”) and
match this to the intervention that is most likely to be
useful.
At this point we do not have extensive empirical evidence
as to which intervention is the best at any one moment in
time. There is substantial process research to guide us, but
there is a need for future research and refinement. This in
turn will help to answer what are the main research questions
of psychotherapy: which intervention for which patients for
which disorders? Unfortunately the answers to these ques-
tions are not readily available. Research is difficult. There is a
need for large sample sizes, for therapists to have standard-
ized training and manualized methods.

6.3  L
 ewis Tauber: Choice Points and Action
Alternatives
Lewis Tauber developed a system for use in supervising
trainee therapists which he called “choice point analysis” [1].
Tauber’s concept of choice points distils the essence of the
therapist’s task. At any one moment during therapy, the
therapist must consider more than a dozen or so possible
interventions. The therapist must choose the most effective
intervention in the therapy session to advance the goals of
treatment. Tauber describes seven groups of “action alterna-
tives”. The following are ones that have relevance to individ-
ual psychotherapy:
I. Action alternatives
(i) Silence.
(ii) Pursue affect. This can be intensifying affect or down
regulating affect.
(iii) Pursue content.
116 Chapter 6.  Choice Point Analysis and Action Alternatives

II. Direction alternatives

The therapist can direct his intervention towards the
patient or towards himself.
III. Time alternatives
The therapist can choose the here and now, the past or
the future to frame his intervention.
IV. Precision alternatives
The intervention may be general or specific. If general
the intervention may refer to a group of people rather
than specifically to the patient. The phrasing can be nar-
rowed to achieve “surgical” precision.
V. Stance alternatives
The therapist’s stance can be neutral, supportive and
empathic, confrontational or directive.
VI. Focus alternatives
These refer to the therapist’s objectives at a particular
point. This includes collecting information, reflecting
reality, producing insight or producing emotional release.
Tauber’s aim was to teach the student to reflect on inter-
vention alternatives and select the one that would promote
the attainment of therapy goals. We can conceptualize this
now as making implicit System 1-based decisions explicit and
subject to System 2 decision-making.
Tauber supervised students in small groups. He felt one
supervisor and three supervisees were optimal. He used vid-
eotaped recordings of the students’ sessions. During the
supervision, the recording is stopped at various points, and
alternative actions are discussed. The use of alternative inter-
ventions could be demonstrated with role-playing. This assists
the supervisees to determine which is the preferred
intervention.
Since the time of Tauber’s work, there has been an evolu-
tion of interventions in the field of psychodynamic psycho-
6.3  Lewis Tauber: Choice Points and Action Alternatives 117

therapy (Chap. 1). Theories and techniques have been

developed in the works of Gabbard [6, 7], Malan [8–10],
Davanloo [11], Luborsky [12], Fosha [13], McCullogh [14],
Abbass [15] and others.
The psychotherapy process literature identifies several
interventions that correlate with positive outcome. Across all
therapies the therapeutic alliance predicts a significant
amount of the variance in treatment outcome. Other critical
areas include interpretation of the transference, processing of
affect, focusing on the relationship between the patient and
the therapist, identifying ruptures in the relationship and
undertaking repair.

6.3.1  AEDP and Fosha’s Emphasis on the Dyad

Diana Fosha has evolved a vigorous but highly empathic

emotional focus in accelerated experiential dynamic psycho-
therapy [13]. Fosha states that the unit of intervention is not
the therapist’s comment but the therapist’s comment and the
patient’s response. It is the patient’s experience of the inter-
vention that determines its therapeutic impact. The therapist
can make an empathic intervention, but it is necessary to
explore whether or not the patient experiences it as empathic.
Fosha identifies three main groups of intervention [13]:
• Relational strategies which include the therapist’s expres-
sion of support, affirmation and empathy. Relational inter-
ventions help get past defences. These interventions
indicate collaboration such as “I am here to help”,“You are
not alone” and “We are in this together. Fosha emphasizes
the use of the word “we” to foster the attachment relation-
ship and the shared nature of the therapeutic journey.
Relational strategies include acknowledging and repair of
ruptures, self-disclosure and acknowledgement of thera-
pist errors.
Fosha has highlighted the relational process of
“metaprocessing” . Metaprocessing is one of AEDP’s most
powerful contributions to the practice of STPP [13]. The
118 Chapter 6.  Choice Point Analysis and Action Alternatives

dual processing model of emotion (Chap. 2) provides a

neuroscientific rationale for effect this intervention has for
therapeutic change. Metaprocessing involves reflecting on
the experience of experiencing. It is the cognitive aware-
ness of the “feeling” of emotions that have their origins in
subcortical processes.
• By experiencing and processing core emotions in the
therapy session, negative valences attached to specific
memories can be altered. The memories are then recon-
solidated without the negative emotional “tags”.
• Restructuring strategies: identifying, labelling and clarifi-
cation of defences. Pointing out the maladaptive aspects of
defences and reinforcing alternatives.
• Experiential-affective strategies. These include helping the
patient to become aware of deep emotions. It involves
tolerating the experience of emotions in the present
moment and staying with the emotion long enough to pro-
cess it. Incidentally this strategy is consistent with
McCullogh’s view that exposure to emotion is a major
therapy change factor [14].
The experience of emotion can be enhanced by amplifying
techniques. These include focusing on the bodily experience
of emotion and the use of portrayals: imagined interactions.

6.4  STPP Interventions

Moving beyond Tauber, we need to determine which inter-
ventions are utilized in short-term psychodynamic psycho-
therapy and which ones are associated with successful
outcomes. Leichsenring and colleagues [16] have identified
prototypical interventions the psychotherapy process Q-set.
The PQS is a 100-item questionnaire used to rate an ideal
therapy session. Experts in supportive-expressive psycho-
therapy, a form of STPP based on Luborsky’s method, rated
audiotapes and videotapes of sessions to determine and rank
order the items that were most and least characteristic of
supportive-expressive psychotherapy.
 6.5  Evidence for Interventions and Treatment Outcomes 119

This  study found that the following interventions were

typical of therapists engaged in supportive-expressive ther-
apy and psychoanalysis. Examples include:
• Identifying a recurrent theme
• Nonjudgemental acceptance and empathy
• Noting mood and feelings including those unacceptable to
the patient [16]
The following interventions were among those used in
supportive-expressive therapy but not by the psychoanalytic
therapists [16]:
• Asking for information
• Discussing current life situation
• Addressing termination
• Discussing patient’s interpersonal relationships
• Adopting a supportive stance
• Discussing patient’s goals
• Explaining the rationale for the therapeutic approach
• Encouraging the patient’s independence of action or
opinion
• Addressing a specific focus
• Encouraging the patient to try new ways of behaving with
others
This list of prototypical interventions provides a unique
way to compare different forms of psychotherapies. This can
more systematically identify overlapping techniques. The
items detailed in the lists of interventions can be considered
“action alternatives”.

6.5  Evidence for Interventions

and Treatment Outcomes
In order to select the priority choice points, it is necessary to
examine which interventions are correlated with good treat-
ment outcomes.
120 Chapter 6.  Choice Point Analysis and Action Alternatives

The research literature identifies a number of interven-

tions that correlate with positive outcome.
Across all therapies, the therapeutic alliance accounts for
a significant portion of the variance in treatment outcome.
Therefore interventions promoting a good alliance should
rate high on our list of choice points. Other critical areas
include interpretation of the transference, processing of
affect, focusing on the relationship between the patient and
the therapist, identifying ruptures in the relationship and
undertaking repair.

6.5.1  Promoting the Therapeutic Alliance

Horvath et  al. reviewed over 200 studies involving 14,000

patients on the relationship between alliance and the out-
comes of individual psychotherapy [17].
The overall effect size of 0.275 was statistically significant.
Even though this only accounted for a small proportion of
the total variance in treatment outcome, it is one of the stron-
gest predictors of treatment success [17]. The therapeutic alli-
ance in individual psychotherapy accounts for approximately
7.5% of the variance in treatment outcomes.
The development of a “good-enough” alliance early in
therapy is vital for therapy success.
The therapeutic alliance can also be conceptualized in
attachment terms. Bowlby (Chap. 2) postulated that the
therapist provides “a secure base” for the patient. In early
childhood development, the infant is able to explore its envi-
ronment only after it has established a secure attachment and
internalized a sense of a secure base.
Short-term dynamic psychotherapies including experien-
tial dynamic therapy emphasize explicit therapeutic interven-
tions to establish and deepen the therapeutic alliance.
Diana Fosha’s relational interventions are very effective in
establishing a secure attachment between patient and thera-
pist [13]. The patient and the therapist’s own attachment sta-
tus will affect the development of the therapeutic alliance.
 6.5  Evidence for Interventions and Treatment Outcomes 121

6.5.2  Emotion Focus

Exploring emotion is another prototypical item in STPP.  It

requires the therapist to help the patient to identify and
express feelings that may have been avoided or which may be
unconscious.
Diener [18] undertook a meta-analysis of 10 studies com-
prising of 150 subjects examining the relationship between
outcome and the adoption of an affective focus. The authors
found that this was positively associated with improvements
in treatment. The overall effect size of r = 0.30 represents a
medium effect size.
Ablon et  al. [19] studied 17 patients with panic disorder
treated by 7 psychodynamically orientated therapists at the
Massachusetts General Hospital Psychiatry outpatient
department. They used the psychotherapy process Q-set to
rate audiotapes. These process measures were then correlated
with outcome.
Interventions focusing on feelings had the highest associa-
tion with positive outcome.
The item “Therapist emphasizes patient’s feelings to
deepen them” had a robust effect size of 0.70. The effect size
for the item “Therapist draws attention to feelings patient
regards as unacceptable” was 0.43. Interestingly the use of
humour yielded a 0.52 effect size.
However it may not be possible to consider process mea-
sures as independent of each other. In a study of 101 patients
attending a university outpatient clinic, Fisher [20] examined
the interplay between emotional experience, therapeutic
­alliance and patient functioning. They found that a strong alli-
ance and the experience of deep emotions act synergistically
to improve the patients’ functioning and wellbeing. McCarthy’s
paper [21] adds a further dimension of complexity to the story.
In a study of 33 patients randomized to treatment with
psychodynamic psychotherapy for patients with major
depressive disorder versus pharmacotherapy and placebo,
McCarthy and co authors found that process variables had a
curvilinear relationship to outcome. Too many or too few
122 Chapter 6.  Choice Point Analysis and Action Alternatives

psychodynamic and process-experiential interventions were

less effective than intermediate levels. They referred to this as
the “Goldilocks effect”.

6.5.3  Transference and Relationship

Identifying and working with the transference has  been

regarded as a sine qua non in all forms of psychodynamic
psychotherapy. The concept of transference and countertrans-
ference is viewed as one of Freud’s most important contribu-
tions to the field of psychoanalysis and psychotherapy. David
Malan with colleagues at the Tavistock Clinic in London was
among the first to systematically examine the impact of trans-
ference interpretations on treatment outcome [8–10]. In a
series of studies, Malan found that the frequency of transfer-
ence interpretations when linked to experiences with parents
or siblings was associated with better treatment outcome.
Habib Davanloo [11] placed working with intense trans-
ference feelings at the heart of his method.
Marziali replicated Malan’s findings on the outcome link
to the frequency with which the therapist referred to emo-
tions in the transference [22]. These interpretations con-
nected the transference with similar emotions experienced
towards parents and other important figures. Marziali used
audiotapes of sessions from 25 patients unlike Malan who
had used written transcripts.
The subsequent literature has demonstrated that the asso-
ciation between a focus on transference and outcome is not a
straightforward linear relationship. In a series of in-depth
studies carried out as part of the First Experimental Study of
Transference (FEST) at the University of Oslo, Høglend and
colleagues found that the impact of a transference interpreta-
tion is dependent on a number of other variables: the thera-
peutic alliance, the patient’s quality of object relations, the
number of transference interpretations per session and the
timing [23, 24]. There was an interaction effect: the alliance
had a significantly different impact on effects of transference
 6.5  Evidence for Interventions and Treatment Outcomes 123

interpretation, depending on the quality of object relations.

The impact of transference interpretation on psychodynamic
functioning was more positive within the context of a weak
therapeutic alliance for patients with a low quality of object
relations. For patients with more mature object relations and
high alliance, the authors observed a negative effect of trans-
ference work. These findings run completely counter to the
conventional view.

6.5.4  Rupture and Repair in the Relationship

Safran et al. found that a key to therapeutic change is nego-

tiation of ruptures in the alliance [25, 26]. Metacommunication,
talking about what is being enacted in the therapeutic rela-
tionship, is critical. The focus is on “the here and now” rather
than “the developmental origins of what is being enacted in
the therapeutic relationship”.
Safran identified two main types of rupture: withdrawal rup-
tures and confrontation ruptures. The therapist must have the
skills to be able to identify that there has been a rupture. Then
the patient’s feelings need to explored and worked through.
Ruptures may be signalled by postural changes such as
gaze aversion or crossing of the arms. Other indications
include silence, interrupting, demanding, a  sarcastic or
­mocking tone. Other more obvious signs include criticisms of
the therapist’s personality or competence.
Clara Hill also stresses the centrality of processing the
therapeutic relationship [27]. Hill uses the term “relation-
ship” to include the real relationship, the therapeutic alliance,
transference and countertransference.
Processing involves working in the here and now, inquiring
about reactions to the therapist, drawing parallels with other
relationships, processing ruptures or boundary crossings and
disclosing feelings of closeness to or lack of closeness from
others. “Metacommunication” refers to this communication
about the relationship and includes addressing feelings about
each other.
124 Chapter 6.  Choice Point Analysis and Action Alternatives

Diana Fosha’s method of accelerated experiential dynamic

psychotherapy (AEDP) described above is consistent with
the approaches taken by Hill and Safran. The use of self-­
disclosure about the patient’s impact, acknowledging errors,
repairing therapeutic ruptures and metaprocessing are all
critical to the AEDP approach.

6.5.5  The Relational Focus

The central theme or relational focus is essential for guiding

the therapy process. It provides coherence to interpretive
interventions and is the fulcrum around which the patient
becomes aware of his or her interpersonal patterns and the
impact this has on relationships and emotions. The focus
makes sense out of what is at first an amorphous mass of
information that the patient brings to the therapeutic encoun-
ter. The use of a focus extracts key dynamic elements that
reflect the patient’s internal working models.
Working with the relational theme and the experience of a
corrective emotional experience results in a change in the
internal working models. STPP can be regarded as using the
therapeutic relationship to remodel the attachment-based
internal working models (Chap. 2).
Joyce and Piper [28] in a study of 60 cases using a manual-
ized form of brief psychodynamic therapy found that inter-
ventions related to the focus had positive effects on therapy
outcome. In the same study, however, they noted that a high
frequency of transference interpretations had a negative
impact for patients rated high on a scale of quality of object
relations. This seems to imply that interventions relating to a
focus are beneficial but that the use of transference interven-
tions that are based on the focus can have an opposing affect.
Much of the work establishing the importance of a focus
was done by Luborsky’s group [29]. To be successful, the core
focus should be linked to the patient’s identified problems
and goals.
 6.5  Evidence for Interventions and Treatment Outcomes 125

I attempt to present a provisional focus within the first

three to four sessions and give  it  in written form to the
patient. The patient and the therapist should collaborate on
the development of the relational focus based on the history
of past and current relationship patterns and feelings about
oneself. Over the course of therapy, the focus can be refined
based on new emerging themes, memories and clarifications
(Chap. 7).
The focus helps provide a frame of reference for the con-
duct of therapy and gives unity and coherence to a large
amount of clinical information.
As with all of these choice points, it is artificial to separate
process components without acknowledging that all of these
interact with each other and that outcomes are not a linear or
arithmetic combination of the required elements.
The psychotherapy process is not a closed system and
involves multiply interactive and transactional variables.

6.5.6  Humour

Therapist variables have a significant impact on the course of

therapy and its outcome. This includes the therapist’s own
personality characteristics and attachment style.
There is variation among therapist’s ability to use humour.
The impact of the use of humour on outcomes is infrequently
studied. Nevertheless on the face of it, humour may contrib-
ute to a positive therapeutic alliance.
Some authors have pointed out that humour can poten-
tially be harmful in psychotherapy [30]. There is a significant
risk that the patient may feel that he is being laughed at,
that he is being belittled or that his concerns are being trivial-
ized or mocked. The therapist must be aware of how the
humorous remark or joke will be received. This depends on
the therapist having a good sense of the quality of the thera-
peutic alliance and the patient’s vulnerability to  feeling
shamed.
126 Chapter 6.  Choice Point Analysis and Action Alternatives

Humour can be used judiciously if it is compatible with the

therapist’s own personality and with the patient’s capacity to
receive it. Valentine and Gabbard believe that the use of
humour in therapy can be taught [31]. It may be helpful to
make students aware of the risks, appropriateness and the
limitations of humour in therapy.
There is some evidence that humour has a beneficial
effect. Richman described situations where he felt that
humour in therapy was helpful to patients with depression
and suicidal thoughts. He felt that humour is life-affirming,
reduces stress and promotes symptom relief and social cohe-
sion [32].
There is interesting evidence from the advertising world
that humour can have powerful implicit effects [33]. Humour
in advertising appears to counteract negative associations to
product brands.
In this study among university students in Nijmegen,
Netherlands, these authors showed that humour prevented
the development of negative brand associations. The effect of
humour was more powerful than that of positive or neutral
stimuli.
If we extrapolate these findings to psychotherapy, it may
be hypothesized that humour can alter the negative valence
associated with emotionally charged memories.
Humour can be used to challenge defences, to challenge
the absurdity of patient’s self-blame or feelings of guilt. An
example of this is a patient who was overwhelmed with self-­
blame for being late for a session. The therapist responded
“I’m going to call the police to have you arrested for this!”.
Such intervention can be felt as supportive, an attempt to
diminish the guilt feelings. But there is also the risk that the
patient will feel misunderstood or disparaged.
The therapist may use self-deprecating humour to reduce
feelings of distance and one-upmanship in the relationship.
The humour can convey shared feelings about an external
situation. This implicitly involves exposure of some of the
therapist’s own beliefs and attitudes. This can humanize the
therapist and enhance the therapeutic alliance. In making a
 6.6  Action Alternatives: A Provisional Hierarchy 127

joke, the therapist is moving out of the “frame” into the real
relationship which can be powerfully empathic. This can be
a  moment of empathic attunement, of meeting, connec-
tion and mutual authenticity.
Like all other action alternatives, the expert therapist
draws on intuition and System 1 processes. If humour back-
fires, it can lead to a therapeutic rupture requiring repair and
metaprocessing.
Clearly the use of humour should be avoided with patients
who have a poorly developed sense of reality or are prone to
paranoid misinterpretation.
It is important for the therapist to closely monitor his own
feelings, and countertransference as humour may contain
hidden aggression. Sharing a joke can involve a collusive
irreverence towards a disliked person or institution as a joint
expression of anger.

6.6  A
 ction Alternatives: A Provisional
Hierarchy
Which interventions when?
Based on a review of the evidence above and the conceptual
frameworks used in short-term psychodynamic p ­ sychotherapy,
I have proposed a provisional hierarchy of action alternatives
that can be used to facilitate the therapist’s choice of interven-
tion at any point (Fig. 6.1). This must be qualified by recogniz-
ing that the evidence available so far is based on linear
sequences when in reality interventions occur in repetitive and
iterative cycles. Interventions and responses  are built on
sequences made earlier in the therapeutic session.
Interventions are made to advance the goals of therapy.
The optimal intervention may vary depending on the phase
of therapy and changes in patient presentation. However the
general groupings still apply.
Choices are based on strategies and tactics. Tactics include
getting past defences, maintaining the therapeutic alliance
and working through emotions.
128 Chapter 6.  Choice Point Analysis and Action Alternatives

Figure 6.1  Action

Alternative Priorities

SET 2
DEFENCE

SET 1
RELATIONAL

SET 3
CONTENT

6.6.1  Set 1

Because the research evidence reviewed above points to the

therapeutic alliance as one of the strongest predictors of suc-
cessful therapy, the highest priority choice point action alter-
natives involve the patient-therapist relationship.
Transference interventions may be regarded as a specific
element within this set of interventions.
Within Set 1 the repair of therapeutic ruptures takes prior-
ity. If ruptures are not processed, the therapy may be in jeop-
ardy of breakdown. Secondly the working through of ruptures
is one of the most powerful therapeutic interventions. It is
immediate in the here and now; it involves a corrective emo-
tional experience, a disconfirmation of internal working mod-
els and patient expectancies.
Identification and exploration of emotion also belong in pri-
ority Set 1, because this is a key component of the therapeutic
change process. This comprises helping the patient to identify
and express emotion. It is important to “stay with” the emotions
in order to process the associated feelings and memories [34].
Emotions can be amplified and deepened by use of meta-
phor, humour and mental imagery (portrayals).
Dealing with transference is a subset of relational inter-
ventions. As mentioned above, too many or too little transfer-
ence interventions may have a negative impact on treatment
outcome. There appears to be an optimal window for this.
 6.6  Action Alternatives: A Provisional Hierarchy 129

Metaprocessing is a higher-order working through of the

relationship and leads to a corrective emotional experience
and a deeper sense of attachment.
Interventions relating to the relational focus have high
priority. These can crystallize the patient’s awareness of
recurrent patterns of behaviour and the connections to cur-
rent, past and transference relationships and their associated
emotions.

6.6.2  Set 2

• Dealing with defences either by confrontation or

bypassing
• Exploring present relationships
• Exploring past relationships
• Clarifying content
• Expressing empathy
• Remaining silent
• Validating

6.6.3  Set 3

• Gathering further information about current or past

events
• Providing information
• Psychoeducation

Key Points
• There is evidence to support the importance of the
therapeutic alliance, emotion processing and repair-
ing ruptures in achieving good psychotherapy
outcomes.
• The therapeutic alliance accounts for about 7.5% of
variance in treatment outcome.
• The use of transference interventions may be gov-
erned by the “Goldilocks effect”. There may be an
130 Chapter 6.  Choice Point Analysis and Action Alternatives

optimal “window” for the amount of transference

interventions that is dependent on other variables.
• Choice point analysis can be used to select the most
effective interventions.
• Selection of action alternatives involves System 2
deliberative thinking.
• Expert therapists are able to make more use of
System 1 processes.
• Choice point analysis is an excellent teaching tool.
• Choice points can be recognized by moment-to-
moment tracking of emotion and nonverbal cues:
facial expression, voice, posture and movement.
• Psychotherapy interventions are not linear but are
interactive.
• Psychotherapy is not a closed system. Multiple vari-
ables interact in a non-linear fashion making process
research complex.

References
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Chapter 7
A Manual for Short-Term
Psychodynamic
Psychotherapy

7.1  Introduction
The strategic objectives of short-term psychodynamic psy-
chotherapy are to collaborate with the patient to experience
and process deep emotions within the framework of a
securely attached therapeutic relationship. The goals of STPP
are to enhance health and adaptive functioning.
This chapter provides a manualized approach to the con-
duct of short-term psychodynamic psychotherapy. It details
the stages and interventions of STPP [1–15]. The essential and
common elements of the various approaches to STPP are
synthesized and incorporated into this manual (Chap. 1).
Attachment theory (Chap. 2) informs the critically important
relational interventions. The identification of action alterna-
tives is derived from choice point analysis (Chap. 6).
Three phases of psychotherapy are presented. Although
these are presented sequentially and in a linear fashion in
reality, there is an overlap of the tasks and interventions out-
lined. In practice the boundaries of these phases will shift,
and components of the phases will not remain fixed in place.
Rather like waves and particles in physics, they will change
location and form depending on the dynamics of the observ-
ers, in this case the patient and therapist.
The ability to use these approaches depends on extensive
clinical practice and supervision. Interventions, as presented

© Springer International Publishing AG, 133

part of Springer Nature 2018
A. Eppel, Short-Term Psychodynamic Psychotherapy,
https://doi.org/10.1007/978-3-319-74995-2_7
134 Chapter 7.  A Manual for Short-Term Psychodynamic

on the written page cannot convey the dynamic and affective

nature of the interview process. However this manual can
guide students and practitioners in the course of their train-
ing and clinical practice.

7.2  The Assessment and Engagement Phase

All of the phases interact and are non-linear (Fig.  7.1). The
number of sessions required for assessment and engagement
will vary depending on the strength of the patient’s defences
and attachment style. In some cases, it can be accomplished
within the first session; in others it may require three to ten
sessions. This will depend on the patient population and the
selection criteria being used.

7.2.1  Overall Objectives of the Engagement Phase

Begin to develop a secure base and therapeutic alliance,

assess, take the history, evaluate suitability for STPP, orient to
treatment process and make a treatment contract.

ENGAGEMENT

EMOTION
PROCESSING

TERMINATION

Figure 7.1  Engagement

 7.2  The Assessment and Engagement Phase 135

7.2.2  Initial Tasks

Greet patient. Introduce self [16]. Explain roles and the

nature of interview. Welcome.
Demonstrate respect and interest. Be nonjudgmental,
accepting and authentic in responding to the patient.
Explore the patient’s feelings about coming to the inter-
view and their expectations and fears.
If necessary, attend to any disturbing emotions, express
empathy and understanding and provide clarification regard-
ing any misconceptions about the process.

7.2.3  Objective: Taking the History

History taking is a dyadic process. What emerges depend on

the quality and nature of the interaction between the thera-
pist and patient. The result is a co-constructed narrative. This
is why trainees often have the experience of seeing their
supervisors elicit a somewhat different history than the one
that they had produced.
The components of the history are often determined by
the context of the interview and professional and institutional
requirements. For beginners history taking often follows a
more linear and stilted pattern. For very experienced inter-
viewers, the history emerges fluidly in the process of the
dynamic interchange between patient and therapist.
At some point, a general psychiatric history or psychologi-
cal assessment should be taken. This may have been done
prior to the first psychodynamic assessment session.

7.2.4  History Tasks

Presenting problems and history of presenting problems.

Previous psychiatric or psychological treatment.
Prior suicide attempts.
Medical history, substance abuse.
Family history of psychiatric disorder.
136 Chapter 7.  A Manual for Short-Term Psychodynamic

Evaluate the mental status and specific risks: suicide, self-­

harm and aggression.
Explore the patient’s problems and the issues that the patient
wishes to address with appropriate open-ended questions.
Listen attentively to the patient’s opening concerns and
history without interrupting or directing patient’s response.
Clarify reasons for presenting now, current concerns and
symptoms. Explore the onset of the problems, the context in
which they occurred and evolution of symptoms.
Clarify patient statements that are unclear or need
amplification.
Explore the patient’s beliefs and theories about the causes
and nature of the problems.

7.2.5  T
 asks of Eliciting the Psychodynamic
History
In psychodynamic psychotherapy, the history is expanded to
include more about early childhood relationships, quality of
attachment relationships and patterns of current and past
relationships.
Explore the developmental history, family of origin
composition.
Explore the nature of the relationship with parents and
siblings.
Ask about any specific separations, abuse or trauma.
Explore the attachment style in past and current
relationships.
Explore any repetitive relationship patterns and themes.
Explore the patient’s view of others. Ask for examples of
situations.
Explore the patient’s view of himself/herself. Note interac-
tion pattern with therapist.
Explore early attachment relationships.
Identify primary caregivers, i.e. primary attachment
relationships.
Ask questions about each of the primary attachment fig-
ures (mother, father, siblings, etc.).
 7.2  The Assessment and Engagement Phase 137

Were they loving and affectionate?

During the first session, evaluate the patient’s capacity to
identify and express emotions. Help patient to express
feelings.
Assess patient’s ability to reflect.
Evaluate patient’s response to a trial interpretation.

7.2.6  Methods

Attend to verbal and non-verbal cues. Track affective changes.

Use open-ended and closed-ended questions to promote
the flow of the interview. Avoid jargon and multibarrel
questions.
Allow time for patient to reflect before responding.
Use transitional statements or “signposting” when moving
to different sections of the interview.
State rationale or context for questions when this may not
be obvious to the patient.
Move from general to specific (dilute to concentrate)
when exploring sensitive topics.
Demonstrate appropriate non-verbal behaviour: eye con-
tact, facial expression, posture, position and gestures.
Maintain focus on patient’s concerns. Avoid distraction by
writing notes or using a computer.
Paraphrase or periodically summarize understanding of
what the patient has said.
Use gentle commands [17]: “tell me more about that”; “go
on”; “stay with that”; and “can you elaborate on that?”
Probe assumptions: “why” and “how” questions designed
to challenge patients’ presuppositions and unquestioned
beliefs.
Challenge the patient’s position by asking questions about
alternative viewpoints and perspectives, playing both sides of
the conflict.
Gentle assumptions [17]: “how many drinks do you usually
have on the weekend?”
Use empathic statements: “I sense a lot of pain/sadness.
What are you experiencing right now?”
138 Chapter 7.  A Manual for Short-Term Psychodynamic

7.2.6.1  Attachment-Based Questions

These questions elicit information about early attachment

relationships and the experience of attachment and separa-
tion in adulthood. These provide qualitative information and
are not scored (Table 7.1). These questions can be used sepa-
rately for each of the patient’s primary attachment figures.

Table 7.1  Attachment-based questions

Part one: childhood
When I was a child, my mother/father/primary Mostly Mostly
caregiver: yes no
Was loving
Was affectionate
Was distant
Was critical
Used physical punishment
Was away a lot
Left me alone a lot
Made me feel safe
Made me feel unsafe
Mistreated me
Hugged me a lot
Spent time with me
Abused me
Cuddled me
Showed affection
When I was upset, my mother comforted me
When I was hurt or ill, my mother comforted
me
Was not interested in me
Threatened to leave me when I misbehaved
 7.2  The Assessment and Engagement Phase 139

Table 7.1 (continued)
Part two: separation
When I first went to school, I was happy Mostly Mostly
yes no
I looked forward to going to school
I was fearful and anxious about going to
school
I was very happy when I moved out of my
parents’ home
I was anxious and fearful when I first lived on
my own
I am not able to live alone because I get lonely
I like to travel
I prefer to stay home
Part three: adult relationships
When I am dating, I worry all the time that my Mostly Mostly
boyfriend/girlfriend will leave me yes no
I am possessive of my boyfriend/girlfriend
I need to phone or text my boyfriend/girlfriend
many times a day to make sure he/she still
loves me
I am afraid of getting close to others
Needing someone makes me feel weak
I am able to share my private feelings with
people close to me
I quickly break up relationships when I sense
my boyfriend/girlfriend no longer loves me
I am sensitive to rejection
I easily feel abandoned
I take care of other people so that they won’t
leave me
I prefer to rely on myself not on other people
140 Chapter 7.  A Manual for Short-Term Psychodynamic

7.3  The Relational Focus

The relational focus is a unique component of short-term
dynamic psychotherapies. Michael Balint first described
this concept which he called “focal psychotherapy” [1, 2]
Lester Luborsky [8] developed a similar concept known as
the core conflictual relationship theme which gained wide
­acceptance [10].
The identification of a relational focus or core theme is very
important for the practice of short-term psychodynamic psy-
chotherapies. It helps to limit the scope of the therapy which in
turn reduces the length of therapy. It allows the patient to
develop a more coherent narrative and view of himself. The
relational focus provides insight into relational patterns and
difficulties. It serves as a reference point for interpretations
throughout the course of the therapy. Sharing the relational
focus with the patient in  written as well as verbal form
enhances the collaborative aspects of the therapeutic alliance.
During the course of early childhood the developing brain
begins to build up a picture of the external environment. The
external environment includes the physical as well as the
social environments. The brain constructs a map of the exter-
nal environment in order to enhance survival. The organism
needs to predict what it may encounter in the external world.
In a similar fashion, the child develops internal models
both of himself and of other humans in his environment.
Early relationships with attachment figures lead to the for-
mation of an internal working model (Chap. 2). In object
relations language, this is called internalized self and object
representations. These internalized models form a template
for all subsequent relationships (Fig. 7.2).
The models are referred to as templates, schemas and self-­
object representations depending on the particular theoreti-
cal language one uses.
The internal working models are shaped by the multiple
interactions the child has with the physical environment and
with other people. The first 3–5 years of life are critical for the
development of these templates.
Clearly these templates will be influenced mostly by the
primary attachment figures within the child’s life.
 7.3  The Relational Focus 141

O
I AM AR THE
L F: E R:
SE YO
U

Figure 7.2  The self-other relational focus

An internal working model has two components: a sense,

feeling and image of our self and a sense, feeling and image
of other people. These two components of the model are
joined and are linked by various emotions.
The self-other models comprise part of conscious aware-
ness of ourselves but also nonconscious and implicit informa-
tion (Chap. 3).
These repetitive patterns are evident in current relation-
ships, past relationships and the relationship with the
therapist.
The relational focus is the outward manifestation of the
internal model. It is made up of the patient’s view of himself
and his expectations and views of others (Table 7.2). The patient
may have some awareness of his view of himself and of others
but much of this is implicit and manifests unconsciously.

7.3.1  Identifying the Relational Focus

This is derived from the early interviews based on informa-

tion about the patient’s early and current relationships, his/
her attachment style and most validly from the nature of the
interaction between the patient and the therapist. Various
questionnaires as mentioned in Sect. 7.1 can be used to com-
plement or validate the clinical assessment.
How does the patient experience himself in relationship to
others? What are his implicit expectations about how others
will treat him?
142 Chapter 7.  A Manual for Short-Term Psychodynamic

Table 7.2  The relational focus

Self: I am Other: you are
Unworthy/unlovable/alone Abandoning
Submissive/dependent/passive Dominating
Incompetent/weak/stupid Powerful
Blameworthy Blaming
Shameful Shaming
Undesirable Rejecting/critical
Not good enough/defective Devaluing
Helpless/vulnerable Controlling
Untrusting Abusive
Invisible Dismissive
A failure Humiliating
Deserving of punishment Critical
Any of the self representations in the left hand column can be
paired with any of the other person representations in the right hand
column

How does the patient view others? How do they perceive

him?
A detailed review of precipitating events or major inter-
personal ruptures can help identify core themes. The key
relationship dynamics may be evident. The precipitating
event may contain a crystallization of the core theme and
lead to identification of a primary focus.
The engagement phase continues over one to three ses-
sions. During this period, the therapeutic alliance is fostered
by promoting a secure attachment to the therapist.
This is achieved by means of attunement to the patient’s feel-
ings and the expression of genuine empathy and validation.
The provisional relational focus should be reviewed with
the patient, and a written description of this should be given to
the patient. As therapy proceeds, the focus may become more
defined and specific leading to more accurate interventions.
 7.4  Suitability for STPP 143

YOU ARE
E REJECTING
BL
VA
LO
UN
M
IA

Figure 7.3  Relational focus example

A verbal treatment contract should be negotiated and

an orientation given to the process of therapy and contingen-
cies. The treatment contract can specify a number of sessions,
e.g. 6, 12, 16, 20 or 40, or be based on a specific termination
date. In the latter case, missed sessions cannot be made up
(Fig. 7.3).

7.4  Suitability for STPP

There are some general guidelines that can be used to assess
whether the patient will benefit from STPP and whether they
will be able to successfully engage in it. Even with guidelines,
there are many therapist factors that influence the decision to
engage a patient in treatment. The question of who can ben-
efit from STPP is an empirical one. However because of the
limitations of our diagnostic systems and variations in prac-
tice, it is not possible to be definitive. The status of research
does not provide  an  answer to the ultimate question of
“which patients do best with which form of psychotherapy
and with which type of therapist?” The following guidelines
are based on a synthesis of current practice, literature and
experience:
• A capacity to identify and reflect on emotions
• An interest in reflecting on what is happening in his/her
life as opposed to primarily seeking symptom relief from
practical strategies
144 Chapter 7.  A Manual for Short-Term Psychodynamic

• The patient is curious about his/her role in his/her

difficulties
• Experiencing some distress
• Motivated to make changes
• Has at least one significant relationship
• Has a capacity to form an alliance with the therapist
• The patient displays a positive response to the therapist’s
attempts to understand him/her
• Recurring problematic patterns in interpersonal
relationships
• Problems with self-concept
• Maladaptive defences

7.4.1  Attachment Style

This is reflected in the patient’s narrative style (Chap. 2). If

the patient’s account is poorly organized and lacks coherence,
the patient may have a disorganized attachment style. This
can be further evaluated during the assessment. Patients with
disorganized attachment are not likely to benefit from STPP.
Patients with secure attachment as reflected in their ability
to have successful relationships are excellent candidates for
STPP.
For the other categories of attachment, dismissing, avoid-
ant and fearful, suitability for STPP will depend on the inten-
sity of these attachment characteristics. Some of these
patients will require longer-term psychotherapy.

7.4.2  Diagnostic Considerations

A specific diagnosis is not a necessary or sufficient factor for

suitability for STPP.  Patient characteristics such as intensity
of symptoms and their impact on their ability to participate
in psychotherapy are more important than phenomenological
diagnosis. More often than not, patients have multiple diag-
noses which is an artefact of our classification systems. This
will also depend on the setting in which patients are seen.
 7.4  Suitability for STPP 145

Patients with diagnoses of depression, generalized anxiety

disorder, social anxiety disorder, panic disorder, post-­
traumatic stress disorder and trauma-related problems that
do not meet diagnostic threshold for PTSD  are suitable for
STPP.
Patients with moderate or severe obsessive compulsive
disorder do not appear to benefit from STPP.  Cognitive
behaviour therapy can be effective.
Patients with grief, relationship conflicts and personality
disorder should be considered for STPP.
Patients with obsessive-compulsive personality disorder,
dependent personality and avoidant personality should also
be considered.
Patients with borderline traits may be considered depend-
ing on severity. Patients with high levels of emotional dys-
regulation, frequent self-harm or suicide attempts may
require alternate forms of psychotherapy such as dialectical
behaviour therapy or transference-focused psychotherapy.
Patients with bipolar disorder who are stable on medica-
tions are suitable for STPP.
Treatment with psychotropic medications is not a contra-
indication for STPP.
The patient’s social and occupational environment, should
be relatively stable. If there is ongoing trauma or environ-
mental crises, it will not be possible to focus on the tasks of
therapy. Periodic crises will derail the therapy focus. Therapy
may have to be switched to a supportive crisis intervention
mode.
Patients who have ongoing psychosis or organic cognitive
impairments are unable to participate in STPP.
Patients with high levels of antisocial, narcissistic, schizoid
and schizotypal traits are not suitable for STPP.

7.4.3  Contract and Orientation

Towards the end of the first session, ask the patient to express
his/her goals for the therapy.
146 Chapter 7.  A Manual for Short-Term Psychodynamic

Explain the treatment process.

Emphasize the patient’s active role which will be neces-
sary if the treatment is to be successful. Explain the thera-
pist’s role.
“Your role is to say what you need to say about yourself
about events and about how you feel in the treatment. I will
listen and respond whenever it is likely to be helpful”.
Give the patient an opportunity to express any doubts
about the usefulness of the treatment.
Explore the patient’s ambivalence about changing versus
remaining the same. Explore both sides of the ambivalence.
Discuss the logistics and practical arrangements for the
treatment including duration and frequency of sessions.
Discuss arrangements for missed or cancelled sessions.
Discuss number of sessions or length of treatment and
termination date.
Negotiate one of two methods for contracting
termination:
• A fixed number of sessions between 8 and 40 sessions. In
this method, missed or cancelled sessions may be made up.
• A fixed date ending. In this method therapy is ended on a
pre-agreed date even if some sessions have been missed by
patient.
In either case, there should be a “hard” termination, i.e.
therapy is not extended as the termination process is an
intrinsic part of the therapeutic effect.
Explore the patient’s feelings about time limits: e.g. the
proposal to meet for 12 sessions may be interpreted as “I can
only tolerate you for 12 sessions” or “you are not deserving
of longer treatment”.
Clarify these feelings at the beginning of therapy empha-
sizing the therapeutic reasons for the time limit.

7.4.4  Orientation to Therapy: A Sample Narrative

“At today’s meeting I want to talk with you about how this
therapy works and how it is done.
 7.4  Suitability for STPP 147

The purpose of this therapy is to help you overcome your

difficulties. This form of therapy has been successfully used
for the treatment of many types of problems such as depres-
sion, general anxiety, panic, social anxiety, trauma, interper-
sonal difficulties, dealing with physical illness, grief, loss,
problems in relationships.
This form of therapy is focused on helping you to get in
touch and to express feelings that have been buried or
blocked from your awareness. These feelings are connected
with unresolved issues in your life that affect your view of
your self and your view of other people. These unresolved
issues can interfere with your relationships, mood and levels
of anxiety resulting in problems in your life and clinical
symptoms.
Emotions are central to all that we do. Emotions prepare
us for dealing with our environment. The emotion of fear
prepares us to deal with danger. The emotion of sadness helps
us deal with separation and loss. The emotion of joy allows us
to explore and engage with others. The emotion of love con-
nects us with others. The emotion of anger allows us to deal
with threats to our integrity.
All of us exhibit certain patterns in our close relationships.
These patterns are based on our early relationships and early
environment. In particular they are influenced by our early
attachment relationships. Attachment is the emotional bond
between the infant and its mother. During the child’s develop-
ment there may be several different people that play a pri-
mary role as an attachment figure. Frequently this is the
mother or father but can be a grandparent, older sibling or
other caregiver. The people with whom the infant has the most
contact are known as the primary attachment figures. If the
primary attachment figures respond to our needs as infants for
soothing, affection, warmth and food we will grow up with a
positive sense of ourselves and of the world around us. If on
the other hand the quality of the attachment relationships is
inconsistent, this will lead to insecurities in our view of our-
selves and the world. Finally if we have been exposed to physi-
cal, sexual or emotional abuse this will have a profound
impact on our self-image and our views of other people.
148 Chapter 7.  A Manual for Short-Term Psychodynamic

Our early attachment relationships form the prototype for

future relationships. In a sense we take in to ourselves a tem-
plate of common relationship patterns. These templates are
known as internal working models and are based on the
myriad of relationships and interactions we have in early
childhood. The first 3–5 years of life are especially critical for
laying down some of the basic components of the templates.
These templates shape our expectations and perceptions
when we enter into new relationships; they shape our percep-
tions of the other person’s response to us.
These relationship templates can lead to maladaptive pat-
terns of relating resulting in repeated difficulties in close and
intimate relationships. These maladaptive patterns often lie at
the basis of the problems that bring you into therapy.
In the therapy I will be helping you identify these patterns
and the impact they have on your relationships and your
emotions.
These patterns reoccur in your current close relationships,
in your past relationships but also in your relationship with
me the therapist. This can be difficult to talk about in therapy
but is an essential part of the treatment process.
How Is Therapy Done?
Sessions will be held once or twice a week. We will decide in
advance the number of sessions, e.g. 8, 16, 24, depending on
the nature of your problems. Once the length of treatment is
agreed upon by you and me, this is fixed as it is important to
have a firm ending in order to get the full benefit of the
treatment.
Each session will last for approximately 50 min.
You and I are expected to arrive on time and will commit
to that.
If for any reason you have to cancel the session, it would
be appreciated if you could do that as soon as possible. If
however you frequently miss sessions, this will interfere with
the flow of the therapy, and it may not be possible to con-
tinue. Therapy may have to be ended although could be
reconsidered in the future.
 7.4  Suitability for STPP 149

This type of therapy is generally not about giving advice.

The problems that you are facing cannot be solved by simple
advice. However by means of clarification and understanding
your own inner feelings and wishes, you will be better able to
make your own choices and decisions. It is never a case of the
therapist knows best. Rather you and I work together grap-
pling with the issues to reach clarity and emotional
resolution.
This therapy differs from other approaches such as cogni-
tive behaviour therapy. The primary focus in cognitive ther-
apy is on thinking patterns and exposure to feared situations.
In depression and anxiety, distorted patterns of thinking can
be identified, e.g. catastrophizing, mind-reading and all or
nothing thinking. In dynamic psychotherapy the focus is on
emotional processing although distorted thinking may also be
challenged. It may be conceptualized differently as a form of
defence.
Concurrent Therapies
Prior to starting therapy, you will have had a full psychologi-
cal or psychiatric evaluation to ensure that this form of ther-
apy is suitable for you. It may be necessary to attend to
physical health problems prior to commencing therapy. If so
you will be advised to see your family physician or nurse
practitioner.
In the event that you are being prescribed psychotropic
medications, a  decision will need to be made whether your
therapist or family physician will be in charge of this part of
your treatment. This will of course depend on whether or not
your therapist has prescribing privileges. This will vary from
jurisdiction to jurisdiction.
It is generally recommended that you not engage in differ-
ent forms of psychotherapy concurrently with our therapy. It
may be appropriate following completion of our therapy for
you to engage in other forms of therapy.
How Are Sessions Conducted?
You as the patient have the role of starting off each session.
You are free to speak about whatever is on your mind. Often
150 Chapter 7.  A Manual for Short-Term Psychodynamic

patients at the beginning of therapy worry that they won’t

have anything to say and try to plan or rehearse for the next
session. This is neither required nor beneficial. Very quickly
you will find that you have no difficulty talking about things
that are on your mind. My job will be to help you clarify what
is important to the treatment, to help you identify, express
and experience important emotions and to begin to under-
stand how relationship patterns affect your moods and
relationships.
I will frequently point out evidence of emotions and help
you focus on these emotions and give them expression.
Because this is often difficult, you may find that you have
habitual ways of deflecting or diverting from painful emo-
tions. It is my job to keep you on target so that we can get to
the core feelings. This may involve me challenging some of
your ways of defending yourself emotionally.
In the course of therapy, you may develop strong positive
or negative feelings towards me. This is expected and indeed
is a central part of the treatment process. These feelings will
often parallel components of your relationship patterns. The
ability of us to explore and discuss these feelings and reflect
on them is a very important part of treatment.
Sometimes you may feel that you do want to come to a
session. Maybe you feel angry towards me or feel embar-
rassed or anxious about something you said. It is most impor-
tant at these times that you do in fact come to the session to
discuss these very feelings. These kinds of feelings are often
related to the main issues that you are dealing with and dis-
cussing them with me can be extremely helpful for your
progress.
I will give you some assessment forms to fill out at the
beginning of treatment. This is to provide more detail about
the nature and severity of your problems.
At the end of treatment, you will complete some of the
same measures to see what has changed for the better. There
are also some other outcome measures that we will discuss to
evaluate the effects of the treatment.
The last phase of treatment is called termination. This
word is powerful and somewhat ominous. Nevertheless it is
 7.5  The Emotion Processing and Thematic Phase 151

apt because termination is a very powerful and important

step in the whole process of therapy. Something is ending
and that can create the same types of feelings that one
experiences after a loss or a death of someone close. These
are universal feelings and reflecting upon them is very
helpful for the therapy. In the words of the old French
poem ‘Partir c’est mourir un peu’ – leaving is to die a little.
Loss is painful but when processed can enhance resilience.
I will focus on termination issues in approximately the last
third of our sessions. During this time many of the same
issues may become intensified due to the approaching end
of treatment.

7.5  T
 he Emotion Processing and Thematic
Phase
This is often described as the middle phase of therapy but the
therapy may shift back and forth (Fig. 7.4).

ENGAGEMENT

EMOTION
PROCESSING

TERMINATION

Figure 7.4  The emo-

tion processing phase
152 Chapter 7.  A Manual for Short-Term Psychodynamic

Table 7.3 Defences
Group I Group II Group III
Adaptive or maladaptive Maladaptive Highly adaptive
Repression Projection Altruism
Displacement Acting out Sublimation
Rationalization Dissociation Humour
Intellectualization Splitting
Reaction formation Idealization
Isolation of affect Somatization

Sessions 4 to 16.
Tactically all forms of psychodynamic psychotherapy have
a similar approach which is to get past psychological defences
to reach core feelings.
Core feelings are linked to the patient’s internal working
models. This manifests in the patient’s recurrent interper-
sonal patterns which are related to the presenting problems
and difficulties in the patient’s life.
It is the experience and processing of these often uncon-
scious emotions that are more powerfully therapeutic than
interpretation and insight.
To get to these deep emotions, it is necessary to get past
the patient’s defences.
Davanloo refers to this as “unlocking the unconscious”.
Fosha describes the parallel process as “dropping down” to
core affect and core state.
It is important to be familiar with the range and types of
defences (Table 7.3).
The use of the two triangles, dealing with transference and
countertransference and making interpretations, are also cen-
tral to this phase.

7.5.1  Tactical Defences

The term “tactical defences” was coined by Davanloo [4, 5]

in contradistinction to the traditional defences described
by Sigmund Freud and Anna Freud. These defences are
among the most commonly observed in psychotherapy
 7.5  The Emotion Processing and Thematic Phase 153

Table 7.4  Tactical defences

Vagueness Laughing and Not remembering
smiling
Talking to avoid Blaming Passive compliance
feelings
Alterations in rate Avoiding eye Argumentativeness
of speech contact
Humour and Overgeneralization Rumination and
sarcasm repetition
Use of jargon Seductiveness Shallow weepiness
Helplessness Avoidant posture Intimidation

(Table 7.4). They act to distance the patient from his feel-

ings and to disqualify them. Tactical defences also can
divert the therapist from focusing on important material.
Davanloo introduced the technique of challenging these
firmly but supportively. It is the defences that are chal-
lenged not the patient.

7.5.2  U
 sing the Triangle of Defence
and the Triangle of the Person
Major objectives of the middle phase are to get past defences
in order to reach core  feelings (in this context the words
“emotions” , “affects” and “feelings” are often used inter-
changeably reflecting the lack of agreement on the defini-
tions of these terms. See Chap. 3).
The triangle of defence provides an excellent tool to
achieve these objectives (Chap. 1).
At any moment in a session, the patient may be experienc-
ing distress in the form of anxiety, guilt or shame, or these
feelings may be pushed out of awareness by the operation of
defences. These two modes are represented on the corners of
the triangle. Emotion is located at the bottom of the triangle.
This represents deep visceral emotion such as sadness, anger,
joy, grief and rage (See Chap. 1) (Fig. 7.5).
The objective is to “get to the bottom of the triangle” , i.e.
to the expression of emotion.
154 Chapter 7.  A Manual for Short-Term Psychodynamic

Figure 7.5  Triangle Defense Anxiety/Distress

of conflict

Emotion

7.5.2.1  Intervention Tasks

The interventions described here  are based largely on the

work of Diana Fosha, Natasha Prenn and David Malan [5,
9, 17].
Continuously track verbal and non-verbal signals.
Observe defensive patterns.
Observe and challenge tactical defences.
Point out defensive patterns. Make explicit the benefits
and costs of the defences [9].
Defences have protected you from terrible pain but led to
maladaptive relationships and symptoms.
Bypass or confront defences.
Explore the feelings behind defences: fear, anger, grief-­
sadness, joy, sexuality and attachment/love.
Identify and stay with core emotions like sadness, alone-
ness, grief, anger, rage and joy:
“How did you feel?”
“How do you feel now...talking about it?”
Attenuate pathogenic emotions of guilt, shame, aloneness
and hopelessness by means of empathy, acceptance and
reframing.
Regulate level of anxiety and emotional arousal by varying
use of supportive and emotion-eliciting interventions.
Identify bodily signs of feeling: where in your body do you
feel it?
Describe what it feels like
…….stay with the feeling.
Get to the bottom of the triangle.
 7.5  The Emotion Processing and Thematic Phase 155

Encourage full expression of emotions and associated

memories.
Enhance the alliance. Convey acceptance, empathy and
validation.
Help reshape/reframe the perceptions and meanings
attached to emotionally charged memories.
Experiential language [17]:
• Use small words.
• Use short statements or questions one at a time.
• Slow down and wait.
• Be specific or be vague. Be specific to challenge tactical
defences and to clarify ambiguity.
Be vague by using incomplete sentences to avoid prema-
ture closure or conclusions:
‘Let’s slow this down’; ‘let’s take a breath here’; ‘we have
time’; ‘let’s pause
here’; ‘let’s go back’; ‘let’s stay here’; ‘let’s stay with this’;
Ask permission ‘can we...?’ [17]
Use short clear words. The interventions should be concise
and not long-winded. Statements are often more effective
than questions. Use simple language. Repeat interventions
for emphasis.
Use visual imagery (portrayals) and metaphor to amplify
experience of emotion.
Explore positive emotions such as joy and pride as well as
painful emotions: anger, sadness, grief and disgust.
Diana Fosha states that the unit of intervention is not the
therapist’s comment but the therapist’s comment and the
patient’s response. What matters is the patient’s experience
of the intervention and his/her subsequent response. The
therapist can make an empathic intervention, but it is impor-
tant to explore whether or not the patient experiences it as
empathic [9].
Metaprocess the experience of the therapeutic relation-
ship: How does it feel to tell me about this? What did it feel like
for you when I said you are too hard on yourself?
How did you feel when I was late?
156 Chapter 7.  A Manual for Short-Term Psychodynamic

Figure 7.6  Triangle of the person. T C

T transference relationship, C
­current relationship patterns,
P past relationship patterns

7.5.2.2  Transference: Triangle of the Person

The relational focus manifests in all of the patient’s

relationships.
It appears in current relationships with family, spouses,
friends, bosses, etc. It is evident in the childhood relationships
with the primary attachment figures. It also becomes appar-
ent in the relationship with the therapist, i.e. in the transfer-
ence relationship.
The therapist can gain insight into the focal pattern by
becoming aware of his own emotional responses to the
patient. His real reaction and countertransference responses
provide useful information and understanding on what is
happening in the therapeutic relationship.
The triangle of the person can be used to point out to the
patient how the relational focus is linked to his early relation-
ships and is evident in his current relationships and his rela-
tionship with the therapist (Fig. 7.6).

7.6  The Formulation

After the first two to three sessions, a provisional formulation
can be developed. The formulation consists of understanding
the relational focus, the associated emotions, the patient’s
defences and the impact of all this on his/her behaviour,
symptoms and psychological functioning.
 7.6  The Formulation 157

The tentative formulation should be shared with the patient

in the session so that the patient can contribute to it and test
the goodness of fit. As part of this therapy protocol, the patient
should be given a written copy of the formulation.
An example of a hypothetical case vignette is presented,
and the formulation is demonstrated in Table 7.3.
Case Vignette 7.1
Veronica is a 37-year-old single woman who has depression
and social anxiety. She describes her parents as having been
emotionally detached showing little overt affection. At the
same time, they tended to be critical. They disapproved of her
choice of career in healthcare. She could never do enough to
please them. She has given up on close relationships as she
always feels taken advantage of. At work she finds that she is
always staying late. When asked to do extra work or coverage
is needed, she is the one that volunteers. She is feeling burnt
out (Tables 7.2 and 7.5).
In therapy Veronica would be made aware of the relational
focus: how repeatedly in close relationships both in the past
and in the present she is self-sacrificing. Her nonconscious
expectation is that she will be dismissed or criticized. One
could predict that in her relationship with the therapist, this
relational theme will emerge. She may feel that the therapist
is uncaring and dismissive despite her efforts to be a model
patient.

Table 7.5  Relational focus written formulation example

Veronica’s view of Unworthy, unlovable
herself
View of others Critical, dismissive
Effects on behaviour Self-sacrificing, needing to please
Associated emotions Resentment, unexpressed, anger,
depression
Defences Reaction formation, repression
158 Chapter 7.  A Manual for Short-Term Psychodynamic

7.7  C
 hoice Point Analysis and Action
Alternatives in the Therapeutic Phase
At any instant during a therapy session, the therapist has mul-
tiple action alternatives to choose from. Lewis Tauber devel-
oped a system which he called “choice point analysis” for use
in supervising trainee group therapists  [18] (Chap. 6). There
are points during the psychotherapeutic session which call for
an intervention or response by the therapist. This could be
signalled by changes in emotion, speech quality, posture and
eye contact. The expression of defences may also need to be
addressed. Silence, avoidance, expression of anger or negative
comments towards the therapist all require exploration.
Many of these action choices become intuitive for experi-
enced therapists, but self-reflection and self-monitoring need
to be exercised. Interventions must be considered in the light
of therapeutic goals and tactics. Interventions are made to
advance the goals of therapy.
In order to guide the therapy process, I have attempted to
group action alternatives into three sets in order of priority.
This is based on my review of the process research literature
examining the effectiveness of different interventions on
treatment outcome (Chap. 6). These action alternatives are
particularly useful for the training and supervision of students
but are also relevant to experienced therapists (Chap. 9).

7.7.1  A
 Provisional Hierarchy of Action
Alternatives
I have grouped the principal action alternatives in three sets
in order of priority (Fig. 7.7).

7.7.2  C
 hoice Point Action Alternatives Set One:
Relational
These consist of actions pertaining to the development and
maintenance of the therapeutic alliance. Because the
 7.7  Choice Point Analysis and Action Alternatives 159

SET ONE SET TWO SET THREE

RELATIONAL DEFENCES CONTENT

Figure 7.7  Choice point actions

therapeutic alliance is one of the strongest predictors of

successful psychotherapy, interventions of this nature are
given the highest priority. These action alternatives relate
to the patient therapist relationship and are referred to as
“relational interventions” [9]. Relational interventions
indicate collaboration: I am here to help, you are not alone,
and we are in this together. The deliberate use of the
word  “we” highlights the attachment relationship in the
moment [9].
Set one action alternatives include the following:
Maintaining the therapeutic alliance.
Acknowledging and repairing therapeutic ruptures includ-
ing transference issues.
Metaprocessing.
Working with the relational focus.
Priority is also given to interventions that facilitate the
expression and experience of emotion.
Emotion-focused strategies include facilitating genuine
expression of core emotions, encouragement to
stay  with and tolerate deepening of emotional
experience.
Amplifying emotion experience by focusing on the bodily
experience of emotion and the use of visual imagery
such as portrayals.
Portrayals involve imagining particular events or scenarios
and describing the feelings experienced as if the events
were occurring in the present moment. This technique
can induce rapid access to intense emotion that is con-
nected it to particular memories.
160 Chapter 7.  A Manual for Short-Term Psychodynamic

7.7.3  C
 hoice Point Action Alternatives Set Two:
Defences and External Relationships
Defences can be dealt with by means of confrontation or
bypassing. A premature or too vigorous confrontation of
defences can lead to their intensification. Confrontation of the
defences as they manifest in the transference is a key strategy
in Davanloo’s intensive short-term dynamic psychotherapy.
However this is carefully guided by monitoring the nature of
the transference and the patient’s level of anxiety [13, 14].
Again Diana Fosha has demonstrated masterful technique
in her approach to bypassing or “melting” defences. By
means of deep attunement to the patient, genuine empathy
and the use of specific forms of self-disclosure, the patient is
able to relinquish defences and access emotions.
Provoking curiosity can be used to arouse the patient’s
interest in examining his/her defences:
It is interesting that every time I ask you how you are feeling
you start to talk about your recent vacation. I noticed that
when we get close to something painful you make a joke. I
wonder why that might be?
For patients with secure attachment, tactical defences can
be directly challenged. This is a major technical innovation
developed by Davanloo. It involves pointing out that the
defence works against the patient’s best interests: when we
talk about your mother’s death, you become vague and ramble
on. How does this help you come to terms with your feelings?
Action two alternatives also include exploring present
relationships and past relationships. These relationships do
not have the same priority as the therapeutic relationship and
the transference.

7.7.4  C
 hoice Point Action Alternatives Set Three:
Content
These actions relate more to content than to process. At times
during therapy, it is necessary to go back to get more history
 7.8 Termination 161

or to clarify information or events. Discrepancies in reported

information may need to be clarified or explored.
The use of silence may be appropriate at certain points in
a session. This has been referred to as “being with” the patient
rather than “doing with”.
Providing information and psychoeducation is included in
set three. This should be evaluated to ensure that this is not
diversionary intellectualization.

7.8  Termination
Termination is difficult for patients but also difficult for the
therapist and perhaps particularly so for beginning therapists
and supervisees. Termination is always lurking in the back-
ground throughout all phases (Fig. 7.8).
The response to termination will depend on how success-
ful the therapy has been. In long-term psychotherapy, therapy
is continued until a mutually agreed termination point. Short-­
term psychodynamic psychotherapy is deliberately different.

ENGAGEMENT

EMOTION
PROCESSING

TERMINATION

Figure 7.8  The termination

phase
162 Chapter 7.  A Manual for Short-Term Psychodynamic

A hard termination is preferred which can be a fixed number

of sessions or specific termination date. This hard termination
is a therapeutic strategy and not just one of maximizing effi-
ciency and resources.
James Mann emphasized the benefits of a fixed termina-
tion which in fact leads to the acceleration of the therapeutic
process. This is somewhat analogous to Parkinson’s law.
Parkinson was a British civil servant who wrote that “Work
expands so as to fill the time available for its completion” [19].
The so-called Stock-Sanford corollary of this states that “if
you wait until the last minute, it only takes a minute to do”.
While these sayings represent folklore surprisingly, they mir-
ror the experience of short- and long-term psychotherapy.
A criticism of long-term psychotherapy is its tendency to
linger and to lose focus. In Freud’s felicitous phrase, this was
“analysis interminable” [20]. Freud wrote this paper in 1937
about a patient for whom he had felt that progress had
stopped. Freud believed that his patient felt comfortable in
the current situation and did not have any wish to take any
step which would bring him nearer to the end of treatment.
Freud resorted to the “heroic measure” of fixing a time limit
for the analysis. He informed the patient that “the coming
year was to be the last one of our treatment, no matter what
he achieved in the time still left to him”. Freud says that the
patient’s resistances shrank in that much was accomplished in
the last months of treatment.
Termination is obviously most difficult when themes of
rejection or abandonment are important or constitute the
relational focus. In those cases, termination should be
addressed much earlier in the therapy, while there is at least
a third of sessions remaining.
The patient may wish to avoid facing the prospect of ter-
mination and display formal and tactical defences: intellectu-
alization, isolation of feeling, diversion, overinclusiveness and
distraction. It is therefore important that the therapist
throughout the course of therapy frequently sets marker
points as to the number of remaining sessions and explores
the patient’s reactions to these reminders along the way.
 7.8 Termination 163

The therapist may also unconsciously wish to avoid facing

termination. This may be due to countertransferential issues
relating to the therapist’s own experiences with separation
and loss. The therapist may be unaware of his/her own sad-
ness at the prospect of termination.
For beginning therapists, the feeling that termination is
going to be painful for the patient may lead to discomfort or
feelings of guilt. The therapist may feel that the patient needs
more time and that they have not completed the job.
This is evident in supervision when the supervisee is
reminded that it is time to address termination issues yet fails to
do so in subsequent sessions. Many supervisees will readily
volunteer that they have difficulty with  termination, and the
conscious barriers to this can be discussed during supervision.
Where therapy has not been effective in whole or in part,
termination may be contentious. Either party may wish that
the therapy could continue. The patient may express disap-
pointment and anger that the promised results have not been
attained. The patient may attempt to pressure the therapist to
extend the length of therapy despite the therapeutic contract
outlining a hard termination. This pressure may go as far as
the patient threatening to complain to the therapist’s supervi-
sor or manager. An attempt to work through these emotions
in the context of the relational focus may be helpful. Freud
described the setting of a time limit as a “blackmailing device”.
He felt that this technique could not be fully effective
because a large amount of the material will be suppressed
under the pressure of the time limit.
Freud did make the important point that once a time limit
has been set, the therapist cannot retract it; “otherwise the
patient would lose all faith in him”. It should be noted though
that Freud’s patient referred to above,  required several fur-
ther months of treatment with him. After he had returned
from the war as a refugee, he needed intermittent treatment
over subsequent years.
We can now say that this issue is one that is subject to
empirical testing. In any case at the time of termination, the
patient may feel that many issues or symptoms are not fully
164 Chapter 7.  A Manual for Short-Term Psychodynamic

resolved. If that is the case, considerations of alternative

forms of therapy and referral to these are quite appropriate.
At the same time, the expression of disappointment or
criticism of the therapist in the context of termination may
represent the relational theme in the transference. It may
reflect the expression of anger directed towards the therapist
for abandoning him/her. This of course needs to be processed
and worked through and may have an important positive
therapeutic impact.
Conversely the patient may express thankfulness and posi-
tive regard towards the therapist which may in fact be a
defensive cover for underlying feelings of anger or sadness at
the ending of therapy. Regardless of the firm contract, the
patient may challenge the therapist insisting that it must be
possible to modify the contract. This anger may be displaced
onto institutional policies.
Patients may of course terminate therapy prematurely.
This action has multiple meanings understandable in the con-
text of the selected relational focus. For those with avoidant
attachment style, dropping out of treatment may represent a
pre-emptive strike to forestall the experience of rejection. In
other cases, it may be an attempt to frustrate the therapist or
to demonstrate the therapist’s ineffectiveness and
incompetence.
An attempt should therefore be made to reengage the
patient in order to explore these themes and work them
through. This can be done by telephoning the patient or send-
ing a letter or email. A letter may be preferable as it allows
the sender and the receiver more time to contemplate the
message and the response. It should be pointed out in the let-
ter that the patient’s desire to terminate therapy early is an
important treatment issue and that exploring this can have
immense therapeutic value.
The question arises as to whether there should be any a
post-termination follow-up. The idea that treatment can be
restarted in the future may undermine the value of the hard
termination contract. An agreement to undertake an out-
come follow-up session after 1 year can be built into the ini-
 7.8 Termination 165

tial contract with the understanding that therapy would not

be restarted regardless of the patient’s status. Referrals to
other treatment can be recommended. The reason for this is
that if therapy is reinitiated or extended at any point, then
there is no possibility of effecting proper termination.
Focus on termination should begin when there are about
one third of the sessions remaining.
Discussion of termination should begin sooner when there
are issues relating to abandonment, rejection or separation.

7.8.1  Termination Tasks

Norcross and colleagues surveyed 65 psychotherapists prac-

tising across five different psychotherapy models to deter-
mine which interventions were used during the termination
process [21]. Surprisingly there was a very high agreement
across the five psychotherapy orientations about these inter-
ventions. The experts worked from an 80-item survey to reach
consensus. Eighteen of these items were endorsed by 80 to
89% of the experts, and 13 interventions were endorsed by
70–79%. The following termination tasks are based on these
findings which had a high level of consensus:
• Explore the patient’s feelings of loss.
• Anticipate both positive and negative reactions in
therapist.
• Beware of countertransference.
• Process patient’s feelings about ending the therapeutic
relationship.
• Anticipate both positive and negative reactions from the
patient.
• Discuss patient’s future functioning and coping.
• Identify high-risk situations for relapse.
• Attribute gains to patient’s effort.
• Express sense of pride regarding the patient’s new
capacities.
• Express pride and satisfaction in the work together.
166 Chapter 7.  A Manual for Short-Term Psychodynamic

7.8.2  Termination Tactics

Action alternatives can be selected in the same way as in

other phases of treatment.
Actively challenge tactical defences to keep focus on emo-
tions related to ending therapy.
Identify and stay with the emotions. Link this with the
central theme.
The relational focus may be activated by the anticipated
loss of the therapist.
Collaborate with the patient to create a written summary
of the therapy for patient to take away. Review what has been
accomplished, what changes the patient has made, what is left
to be done and what worked and what didn’t.
Partir c’est mourir un peu!

7.8.3  Follow-Up and Outcome

To assess outcome, a follow-up meeting 1 year after termina-

tion may be helpful and also allow consolidation of gains.
Ratings on outcome measures can be compared with results
at the start and ending of therapy.

Key Points
• The goals of STPP are to enhance health and adap-
tive functioning.
• It is critical to establish a strong therapeutic alliance
in the early phases of therapy.
• STPP involves three main phases: engagement, emo-
tion processing and termination.
• Action alternatives can be selected based on choice
point analysis.
• A relational focus is collaboratively developed in the
early sessions.
• Getting past defences in order to process deep emo-
tion is a strategic goal of STPP.
• Metaprocessing is a critically important therapeutic
intervention.
 References 167

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15. Kurtz S, Silverman J, Draper J. Teaching and learning communi-
cation skills in medicine. 2nd ed. Oxford: Radcliffe; 2005.
16. Shea SC. Psychiatric interviewing: the art of understanding. 2nd
ed. Philadelphia: WB Saunders; 1998.
168 Chapter 7.  A Manual for Short-Term Psychodynamic

17. Prenn N.  Mind the gap: AEDP interventions translating

attachment theory into clinical practice. J  Psychother Integr.
2011;21(3):308–29.
18. Tauber L. Choice point analysis: formulation, strategy, interven-
tion, and result in group process therapy and supervision. Int
J Group Psychother. 1978;28(2):163–84.
19. Parkinson CN. The Economist. London. November 19, 1955.
20. Freud S. Analysis terminable and interminable. SE V.23 Hogarth;
1937.
21. Norcross JC, Greenberg RP, Swift JK. Do all therapists do that
when saying goodbye? A study of commonalities in termination
behaviors. Psychotherapy. 2017;54:66–75.
Chapter 8
Supervision: Applying Action
Alternatives

8.1  Supervision Format

Tauber’s method was to supervise small groups (Chap. 6) [1].
He felt a group of one supervisor and three supervisees was
optimal. He used videotaped recordings of the students’ ses-
sions. During the supervision, the video is stopped at various
points, and alternative actions are discussed. He utilized role-
playing alternative interventions.
This would allow the supervisees to determine which was
the preferred intervention.
I have used the basis of this approach with psychiatry resi-
dents over the past 6  years. I have used principally audio
recordings of psychotherapy sessions. Video recording would
be superior as it allows observation of non-verbal communi-
cation and cues.
I generally have met residents individually or in groups of
two with or without one other supervisor who may be in
training.
There are a large range of interventions. At any one
moment, the therapist must consider 20 or more possible
interventions. The reader is referred to Chap. 6 for a detailed
description of choice point analysis and action alternatives. I
have grouped therapist interventions into three priority sets
of action alternatives:

© Springer International Publishing AG, 169

part of Springer Nature 2018
A. Eppel, Short-Term Psychodynamic Psychotherapy,
https://doi.org/10.1007/978-3-319-74995-2_8
170 Chapter 8.  Supervision: Applying Action Alternatives

• Relational and emotion-focused

• Defence
• Content
I will describe the supervision process of an audio-­
recorded session. The student gives a brief overview of the
session. He may identify areas of uncertainty or difficulty.
A segment of the recording is played. The group members
track the conversation paying attention to emotional cues:
changes in voice tone, volume or prosody. At any point, any
member of the supervisory group can ask for the recording to
be stopped for clarifications.
The supervisor is alert to “choice point” cues from the
patient that invite a response from the therapist. It is useful
to refer to the triangle of defence to assess if the patient is in
anxiety, defence or core emotion mode (Chap. 1).

8.2  Supervisory Questions to the Therapist

What were you feeling at this point in the interview?
Where did you feel the interview was going?
What action alternatives were you considering? Or humor-
ously, “where are you going with this counsellor?”
What impact was the patient having on you in this
segment?
What were you feeling then?
The supervisor can ask for the recording to be stopped and
ask the group members in turn which action alternatives they
might choose. This can be role-played with another member
of the group taking the role of patient. The group can then
discuss the reasons for the different choices. It is recognized
that there is no one correct choice and that each intervention
is an experiment. The nature of the patient’s response deter-
mines the effectiveness of the intervention.
The supervisor should also point out opportunities where
the therapist can link emotions and events to the selected
relational focus.
 8.2  Supervisory Questions to the Therapist 171

8.2.1  Supervisory Questions About the Patient

What defences is the patient displaying at this point on the

recording?
What feelings is he experiencing?
How did the patient appear to be viewing you?
Where on the triangle was the patient in that segment?

Transcript
Janet was a 44-year-old architect married for 16 years to
a lawyer. She has no children.
Pt: One of my big stumbling blocks is taking on too
much.
[00:00:55.11] Interviewer: Right.
Pt: And that yes...um...and I guess too because I’m
just used to taking most of the responsibility for my
stepfather.
[00:01:11.17] Interviewer: Mmm-hmm...
Pt: But my brother is busy and doesn’t have as much
time as I do to do stuff for her....yeah, but the self-sacri-
ficing issue is interesting for me because I tend not to
delegate well because for some reason I guess I just feel
that I deserve to be overburdened...or that I’m used to
being overburdened...
Action alternatives
Content Affect-emotion Transference Rupture Current
relations

Past relations Empathic Silence Validation Defences

Metaprocess Amplification Portrayal Relational
focus

[00:01:59.17] Interviewer: Is it something that you

enjoy or something that no, you don’t because self-sac-
rifice, it can mean many things to different people...
Pt: Yeah...yeah...I really have thought about that...if I
enjoy it....if I get some kind of a....you know what I
172 Chapter 8.  Supervision: Applying Action Alternatives

think it could partly be is like a...um....I had that con-

cept in my head a minute ago and I can’t think of it....it’s
like a moral advantage...I feel like I get the moral
advantage...by taking most of the responsibility on
myself...
Comment: Intellectual discussion here rather than
going for emotion.
[00:02:52.10] Interviewer: How does that feel?
Pt: Well frustrating for one thing because I am....and
resentful...I feel resentful...because um...yeah I do end
up doing most of the work....and it’s not like dad doesn’t
appreciate it but um....sometimes I get weary of being
the go-to girl for everything...and that kind of also hap-
pens in other situations for me too....
Comment: Therapist goes for feelings but gets discus-
sion about feelings.
Pt: And .....it would be good if I could get that under
control....I think...
[00:03:40.20] Interviewer: We have talked a lot about
the resentment piece and the frustration piece, and at
the same time, when you call it a moral advantage...it
kind of has a positive connotation as well...
Pt: Yeah...
[00:03:53.12] Interviewer: Is that correct?
Pt: Yeah...I feel morally superior...
[00:03:58.26] Interviewer: Mmm....
Pt: And I...I guess I hope that the other people who
aren’t taking as much responsibility are looked on as
not doing their part....and.....um....yeah, I have to think
about that one...it’s a toughie....
Therapist using Set 3 intervention. Patient displays
defences: intellectualizing, vagueness and isolation of
affect. Going for the emotion of resentment might be a
better choice.
 8.2  Supervisory Questions to the Therapist 173

Action alternatives
Content Emotion Transference Rupture Current
relations

Past relations Empathic Silence Validation Defences

Metaprocess Amplification Portrayal Relational
focus

[00:04:26.27] Interviewer: What does that feel like...

to feel morally superior...what kind of emotions does
that bring up for you?
Pt: Well kind of like....like I’ll get a reward of some
sort....I don’t know what kind of reward I’d get but...
[00:04:53.19] Interviewer: Is there a particular feeling
attached to it?
Pt: I’m trying to think of that....well I guess I just feel
better about myself...
[00:05:06.05] Interviewer: Ok.
Pt: Um....I um....I guess I feel virtuous and...well I
suppose and needed...um...and like I’m really doing this
person some good...
[00:05:41.10] Interviewer: Mm-hmm...
Pt: But at the same time, if I do enough of it, I feel
resentful...
[00:05:47.20] Interviewer: Mm-hmm....
Pt: So there’s a balance to be struck....and...
[00:05:54.16] Interviewer: So on the one hand, it
sounds like some positive kind of emotions attach to it...
and then kind of, if you extend yourself too far, it’s this
resentment that comes up..
Comment: Going for feelings seems a good choice.
Action alternatives
Content Emotion-emotion Transference Rupture Current relations

Past relations Empathic Silence Validation Defences

Metaprocess Amplification Portrayal Relational
focus
174 Chapter 8.  Supervision: Applying Action Alternatives

Pt: Yeah....I think at the core of it is that because I’ve

always felt maligned....by doing all this stuff....all these
good works...I am showing other people that I’m not so
bad....
Pt: I think that’s probably at the core of it...because
yeah....um...
[00:06:43.19] Interviewer: It’s very much in line it
sounds like with kind of other things we’ve talked about
like needing to please others...wanting to appear perfect...
being kind of reasonable....they’re all at the core...it almost
seems like it’s yourself being this performer that ….....you
can’t just be yourself...
Pt: Yeah....um....I feel I’m vindicating myself....
[00:07:17.04] Interviewer: Mmm-hmm..
Pt: Yes, by appearing...by being indispensable...
[00:07:23.08] Interviewer: Mm-hmm...
Pt: And that’s a very hard one to get over....I think
that’s at the core of a lot of my issues is just the feeling
of.....of being like I said, maligned...
[00:07:42.14] Interviewer: Mm-hmm...
Comment: The therapist chooses to go with relational
focus, the need to please others because of a sense of self
as worthless.
Pt: And that others don’t have a good opinion of me
and trying to deal with past issues where I felt worthless
and persecuted and...
[00:08:00.05] Interviewer: Well you’ve carried that
with you for some time....
Pt: Mmm-hmmm...
Action alternatives
Content Emotion Transference Rupture Current relations

Past relations Empathic Silence Validation Defences

Metaprocess Amplification Portrayal Relational
focus
 8.2  Supervisory Questions to the Therapist 175

[00:08:03.27] Interviewer: Starting within your child-

hood...where it was always this proving yourself to your
father...
Pt: Yeah....right.
[00:08:12.24] Interviewer: And then at school, that
being the same and moving forward as well...
Pt: Mmm-hmmm....yeah....and I didn’t know before I
started therapy how really deep that problem is....
[00:08:30.28] Interviewer: Mmm-hmm..
Pt: I didn’t really look at that issue in particular very
closely I guess...I knew I had a problem there but I
didn’t know how pervasive....how serious it is....because
it really...is the catalyst for a lot of my actions...yeah....
Comment: Therapist connects relational focus to past
relationships.
Action alternatives
Content Emotion Transference Rupture Current relations

Past relations Empathic Silence Validation Defences

Metaprocess Amplification Portrayal Relational
focus

[00:08:55.26] Interviewer: How does it feel to recog-

nize that?
Pt: It feels some...it feels like....I’m sort of relieved...
relief...a bit of relief because I knew I had a problem
there...in that department....
[00:09:25.02] Interviewer: Mmm-hmm...
Pt: But how much of a problem, I had no idea...and
so I would just think to myself...well my problems are
very small compared to other people’s problems and
they’re not really worth a lot of examination and....and
anybody going to any trouble to help me figure them
out and um...yeah kind of making light of them and that
kind of thing, but no really I guess I feel relief in that it’s
a serious problem that I have right there in that instance,
and uh....it is worth investigating...in fact, it’s very
important to investigate it....yeah...
176 Chapter 8.  Supervision: Applying Action Alternatives

Comment: Could go with transference “anybody

going to any trouble…” is directed to the therapist.
[00:10:24.18] Interviewer: That’s quite a big step.
Pt: Yes...I guess so....I would like to know ways to
deal with it....to improve my self-image in that area...
because I think a lot of my behaviour would...and a lot
of my attitudes would um....could change if I knew that
deep down I didn’t deserve to be given a hard time....
yeah...and I didn’t have to prove to people that I’m a
good person....yeah....
[00:11:11.16] Interviewer: Well certainly I think
you’ve made a lot of personal progress in discovering
what’s behind your actions and the way you interact
with people and the patterns that you’ve had through
your life....so you’ve made a lot of progress that way.....
and you’re right...now, the question is what do we do
with this information...where do we go from here?
Comment: Too much of an intellectual discussion.
One alternative would be going for feelings about being
given a hard time.
Action alternatives
Content Emotion Transference Rupture Current relations

Past relations Empathic Silence Validation Defences

Metaprocess Amplification Portrayal Relational
focus

Pt: Yes.
[00:11:36.22] Interviewer: When I ask that....what
comes up for you?
Pt: Um...well first I’m glad you’re suggesting another
step ....to take another look at it from another angle...
and...cause I think some kind of action has to be taken
on it....yes....I welcome some additional attention to that
matter....I do, yeah....I can’t think of any better way to
describe it....
[00:12:30.13] Interviewer: Well it sounds like it rings
very true for you that you feel like you know....you’d
 8.2  Supervisory Questions to the Therapist 177

like to initiate some sort of change in your life from this

point on....
Comment: There is a misattunement here. The thera-
pist is talking about changes based on the therapy so far.
The patient is talking about a different form of
therapy – CBT.
Pt: Yeah.
[00:12:39.08] Interviewer: I guess my question is....
what kinds of changes have you thought of or what
kinds of things maybe has come up for you in thinking
about this?
Pt: Well I guess the only one I can really think of that
I’ve heard is effective ....and I’m sure there are lots of
other ways to look at it and deal with it that are just as
effective would be cognitive therapy....and um...when
I’ve been reading this book that I have...it has a bunch
of exercises and things to do that are...sound to me to be
very rational....it’s a really rational way to approach
things, I think....
[00:13:28.04] Interviewer: I can see...I can hear where
you’re coming from but I do wonder if part of....I guess
I’m curious as to why maybe you’re own ideas haven’t
come up about how to change things in your life, given
the insight that you’ve gotten, and I wonder if it’s
because you’re still kind of looking at other people to
give you direction...you’re still feeling...
Pt: Yeah perhaps...
[00:13:59.10] Interviewer: Maybe in that self-doubt-
ing role...
Pt: Yeah...yup....perhaps...I think it’s maybe cause
it’s....maybe the only behavioural therapy really that
I’ve looked into with any detail....I think...for instance,
I’m really interested in I guess it’s Jungian-type therapy
where you investigate different archetypes...is that
right?
178 Chapter 8.  Supervision: Applying Action Alternatives

[00:14:29.27] Interviewer: Well I guess I’m just curi-

ous you know....have you got any ideas...outside of any
kind of formal therapy or any kind of...?
Pt: Yeah...
[00:14:49.06] Interviewer: Because my sense is that
you’ve been in this role of pleasing others and doing
things for others...so what are you going to do about it
now?
Comment: Alternative action is to explore feeling.
“What do you feel when you reflect on always pleasing
others?”
Pt: Definitely you’ve been telling me too....to take it
easier on myself so that’s where I’d have to start...that’s
a good place to start...and....that can have many differ-
ent ways of expressing itself, for instance, you know let
up on the perfectionism....and um.....things don’t have
to be so perfect and running like a top all the time...and
if other people have issues with that, it’s their
problem....
[00:15:45.01] Interviewer: Mmm-hmmm...
Pt: For example, I guess I try to do too much in 1 day,
and if I go overboard on one particular task and spend
too much time on it or too much energy on it...then it
really puts me behind doing all the other things
....and then I think to myself...and why do you feel
like that? And it’s because I’ve been knocking myself
out all day to get all this stuff done that would please a
lot of other people and it’s perfectionism....yeah...
Comment: Intellectual defences. Therapist goes along.
[00:18:05.25] Interviewer: How could that be differ-
ent I wonder?
Pt: Mm-hmm.....(chuckles)...yeah that’s a hard one...
that’s a really hard one because....I’m not saying it’s
insurmountable...I think I’ll have to be creative in deal-
ing with that one...because I think a lot of it has to do
with the fact that I am creative....and so I have a lot of
 8.2  Supervisory Questions to the Therapist 179

ideas about what I want to do every day....and...I sort of

set myself too many tasks and it’s out of sheer enthusi-
asm usually...
[00:19:04.08] Interviewer: Ok...
Pt: Yeah...that I just want to do these things and I sort
of feel an impetus to do it too....and uh....I think I have
to curb my enthusiasm...yeah..
[00:19:27.15] Interviewer: I’m just curious...cause I
kind of pushed you there a little bit ...because you gave
me the answer of you know maybe cognitive behav-
ioural therapy and I really kind of tried to push you in
a different direction....what came up for you when I did
that?
Pt: Well I guess I get the vibe really that cognitive
therapy isn’t really particularly on the menu....
Comment: Therapist now switches to address the
transference and metaprocessing.
[00:19:58.14] Interviewer: But what’s the feeling that
you got when I did that?
Pt: Um....my feeling about it...um I guess.....I guess a
bit dismayed...but um...I yeah....I uh...but curious about
other things I could be doing...
[00:20:31.22] Interviewer: So tell me about feeling
dismayed when I did that or....
Pt: Um....
[00:20:49.05] Interviewer: What did that feel like?
Pt: I guess because it’s...yeah...I suppose it’s the only
form of therapy that I’ve been really examining....
[00:20:58.22] Interviewer: Mm-hmm...
Pt: Um closely and uh....
[00:21:04.03] Interviewer: And so what’s the emotion
that came when I kind of....pushed you in a different
direction?
Pt: Oh um....well, a little frustrated...
[00:21:15.18] Interviewer: Mm-hmm..
180 Chapter 8.  Supervision: Applying Action Alternatives

Pt: Yeah...but I guess it’s.....yeah...just a little

frustrated...
[00:21:23.17] Interviewer: Tell me about that
frustration....
Pt: Well I think it’s....it...well I guess it’s something
that I think could possibly do me some good isn’t par-
ticularly like I was saying, on the menu....(chuckles)....
or isn’t recommended...I guess I just kind of feel a little
bit um....uninformed perhaps...I feel like....uh....that my
idea isn’t...acceptable...yeah I guess and um....
[00:22:16.18] Interviewer: I wonder what stopped you
from voicing that in the moment?
Pt: I guess cause I don’t really think about...yeah, I
don’t really think about my objections....or my feelings
about things...I think I tend to take the ....a cooperator
role and...not argue and try to adapt...
[00:22:45.22] Interviewer: Mm-hmm...
Pt: To the new tack....and um....
Comment: Therapist is trying to access emotion but is
running into tactical defences. Some defence work might
help: “I notice that when I try get in touch with your emo-
tions you move to a factual discussion.......”
[00:22:54.17] Interviewer: That’s the sense that I got
as well kind of.....when we had that interaction is this....I
wonder if it’s similar to how you might be kind of with
your husband....
Pt: Yeah, sure....
[00:23:08.24] Interviewer: You know, with your
friends...with other people in your life and maybe how
you were with your father...I don’t know if that rings...
Comment: Therapist links transference to current rela-
tionships, husband and friends.
Pt: Yeah..
[00:23:18.04] Interviewer: Rings true?
Pt: Yes...yeah, a lot of times, I have to settle for what
other people want...and um....a lot of the times...you
know how they say be true to yourself?
 8.2  Supervisory Questions to the Therapist 181

[00:23:32.15] Interviewer: Mm-hmm...

Pt: I’m not true to myself and I don’t get what I
want....out of situation or an experience because I’ve
been too accommodating to others and....yeah and I
feel resentful and frustrated...
Comment: Lots of resentment here. Better option is to
go for the anger.
[00:23:52.02] Interviewer: Mm-hmm....
Pt: Um....and that’s not to say really that other
people’s plans and ideas don’t have merit...I guess I
just...I think I just think of it in terms of well what
would happen if we did this?
[00:24:13.04] Interviewer: Mm-hmm...
Pt: And sometimes I think....with some other peo-
ple...um, they have to have their own way or it’s the
highway, and....they always....I’m not saying you in par-
ticular but other experience I’ve had with other peo-
ple...you basically have to go along with them or they
don’t want anything to do with you, and....I found
myself in with quite a few people like that...
Comment: Time to explore the anger.
[00:24:44.03] Interviewer: And how interesting that
this played out even here...
Pt: Yeah...yes...well I think in the past I had men-
tioned cognitive therapy, and um...I think because it was
quite early on, like a few months ago....really perhaps it
was a little premature to mention it or to be talking
about it....so I didn’t really get a particular warm fuzzy
feeling from you about it...
[00:25:19.12] Interviewer: Mmm.
Pt: I don’t know if something like this could be up for
discussion at this point in time perhaps...
[00:25:26.02] Interviewer: Mm-hmm.....
Pt: But certainly I’m open to other suggestions as
well....
182 Chapter 8.  Supervision: Applying Action Alternatives

Action alternatives
Content Emotion Transference Rupture Current relations

Past relations Empathic Silence Validation Defences

Metaprocess Amplification Portrayal Relational
focus

[00:25:32.26] Interviewer: Mm-hmm...I guess I’m

more curious just about the interaction that we had....
you know, whether it’s cognitive...the subject aside...I
mean certainly we can talk about the role of cognitive
behavioural therapy...I just find it so interesting that...
you know this feeling of being....maybe...um...you know,
not being able to voice your own opinion...even in a set-
ting where we’re here...
Pt: Yeah..
[00:26:10.12] Interviewer: That this pattern is playing
out too...
Pt: Yeah...um yes...I think I tend to see almost every-
body else as superior to me....and um...you know, they
know more than me, or they’re better educated than or
they have more status than me, or...everybody seems to
have some advantage over me in my mind....and I have
to...defer to them..
[00:26:58.01] Interviewer: Mm-hmm....
Pt: And especially professionals...like in the medical
profession or....or teachers or the accountant or the
people at the bank or whoever...yeah....that I think I’ve
mentioned...I always feel at a disadvantage with just
about everybody...yes....I, just as ..an aside I guess one
of the issues I had when my step dad was...I had to take
him to the hospital ..the doctor gave me such a hard
time and he kept coming at me with all of his...you know
that in the hospital you have to basically get in line and
wait your turn and we don’t do this here, we don’t do
that there....and um....and it was all about rule...about
the rules. I had to be...defiant
 8.2  Supervisory Questions to the Therapist 183

I really felt it much easier to kind of....tell like...stick

to my guns about what we wanted...and um...I felt like
a different person...
[00:31:01.07] Interviewer: Mm-hmm...
Comment: Strong relational and transference themes
inviting exploration.
Pt: But I think it shook me to my core...that I had to
behave that way towards authority... and I often think if
it had been a different doctor.....I don’t know if I
would’ve stood up to him.
[00:31:34.10] Interviewer: So what was it like to stand
up to the doctor?
Pt: Yeah, I felt like I was being a real pain.
[00:31:44.25] Interviewer: Hmm....
Pt: And giving and yeah, I felt like....I was really
being a monster....
[00:32:25.18] Interviewer: Mm-hmm...
Pt: But I knew that I just couldn’t let my stepfather
be treated like this....
[00:32:43.03] Interviewer: How was it for you to tell
me that you were feeling frustrated when I kind of
maybe moved the topic away from cognitive behav-
ioural therapy...how was it like for you to express that
you were frustrated?
Pt: Well I do feel like I’m being difficult and um...that
I’m yeah like I’m being cheeky and actually a little...I
had a little glimmer of like the feeling I get standing up
to my dad...
[00:33:23.22] Interviewer: Hmmm....
Pt: Like I’m not allowed...I’m absolutely not allowed
to express...to show my opposition....
[00:33:33.01] Interviewer: Hmm...
Pt: Yeah....yes, and I’m being um....oh...antagonistic...
yeah....mm-hmmm.....
[00:34:13.23] Interviewer: It sounds like any kind of
expression of your own opinion leads you to feel that
way.
184 Chapter 8.  Supervision: Applying Action Alternatives

Pt: Yes....that’s right...

[00:34:27.21] Interviewer: Hmm....
Pt: Yeah...I’d say within a lot of...in most situations,
my opinion is either greeted with....is dismissed....like
outright dismissed or treated with disdain or ignored...
[00:34:59.12] Interviewer: And do you think I did
that?
Comment: Therapist does a stellar job of addressing
the transference.
Pt: Well I would hope you didn’t have a....like a....I
didn’t think you were being mean about it (chuckles)...I
uh....
[00:35:29.18] Interviewer: You laughed there a little
bit...
Pt: Yeah....I couldn’t find any better way to describe
it....um yeah I didn’t think your motivation to change
tack was negative...I think just because in your role as
the professional in the...in the um....the professional in
this situation, I guess I just take it to mean to think that
you know best and that I have to um...that uh....I have
to to....I have to trust you so...
[00:36:30.10] Interviewer: If you did feel like I dis-
missed you or ignored you, would you feel comfortable
saying that?
Pt: I think if you....no I wouldn’t...no....
[00:36:50.16] Interviewer: Ok.
Pt: No...but I ....perhaps if you had behaved differ-
ently and I....had cause to feel offended....I wouldn’t
have told you no that I was offended....
[00:37:10.10] Interviewer: There was a twinge of that
though...is my thought...that this pattern of feeling like
your ideas are dismissed or...do you think that that’s
true....that that same feeling came up with me as it has
come up with other people?
Pt: Perhaps to a very small degree...
[00:37:37.03] Interviewer: Mm-hmm..
 8.2  Supervisory Questions to the Therapist 185

Pt: Um....yeah...perhaps...maybe if you were...let’s

say we were just friends chatting...
[00:37:54.16] Interviewer: Mm-hmm...
Pt: Um...yeah, maybe I’d feel more irritated by it
than I would if you are a professional...
[00:38:11.13] Interviewer: Mm-hmm..
Pt: It’s all within the context for me you know of the
situation and the relationship and the....yeah..it’s a lot
about power balance....yeah cause I always feel every-
body else has way more power than I do, especially
doctors (chuckles)....and yeah...
[00:38:41.09] Interviewer: I get the sense that’s one
element of it...and the other element is...at least in my
sense of things is that in many of your relationships...
that it’s very hard to vocalize your own opinion and you
are compliant and that leads to some negative feelings.
Pt: Yes...yeah...really...yes exactly...yeah and um....
yes, and it taints the relationship for me with a lot of
people, and that I can’t be real with them....and it makes
the relationship very unequal...
Comment: Excellent transference work and links to
other relationships.
[00:39:48.19] Interviewer: Mm-hmmm...
Pt: Um...mm-hmm..
[00:39:58.15] Interviewer: So I guess in this case I
wonder you know....I wonder, given that now we’re
exploring that a little bit and maybe talking about some
of the feelings that were behind...when we talked about
cognitive behavioural therapy or didn’t talk about cog-
nitive behavioural therapy....what could you change or
what could be different in our conversation that....
maybe would’ve led to...
Pt: Well I think I could’ve been a little more
persistent...
[00:40:36.09] Interviewer: Mmmm...and what could
you have said?
186 Chapter 8.  Supervision: Applying Action Alternatives

Pt: I think I’d first of all want to know ...why you

seem hesitant to go in that direction....to examine that
direction...
[00:40:56.23] Interviewer: Mm-hmm...so we can
even do this now...as an exercise and also as a way to
kind of....for me to give some information as well...so I
think it’s also interesting....that...the interpretation is
hesitation about exploring cognitive behavioural ther-
apy..... you seem to have a lot of interest in it...I think
the reason why I tried to shift gears is to see if you feel
confident in your own abilities to try to change things
as opposed to....pursuing another therapy, for exam-
ple...., because I have noticed that pattern for you, and
you may disagree with that but you can tell me what
you think.
Pt: Yeah...
Comment: Therapist is metaprocessing.
[00:41:59.03] Interviewer: Rather than feeling confi-
dent in your own ability ....is thinking oh maybe cogni-
tive behavioural therapy will help me...maybe this
therapy will help...maybe someone else can help me as
opposed to yourself helping yourself...and that’s where
I was trying to shift the direction...not so much that
that’s a bad therapy or we shouldn’t consider it...... but,
at the same time, wondering if you feel empowered in
your own self in terms of change without particularly
looking for more therapy.
Pt: Looking to something outside of myself...yes....
[00:42:44.22] Interviewer: Yeah...similarly...
Pt: Yeah..
[00:43:09.25] Interviewer: And so I guess my goal or
hope was to shift some of that external focus into some-
thing more that you can internalize...if that makes
sense...
Pt: Yes, I guess...I’d like to examine that closer...
yeah...and then...find ways that I could do that more..
 8.2  Supervisory Questions to the Therapist 187

[00:43:35.02] Interviewer: And I do apologize if it

seemed more like I was hesitating to go to the cognitive
behavioural therapy part....I think what I wanted to do
was to try to focus maybe on what you feel you might
be able to do for yourself as well...but I do apologize if
it came off to be that way...
Pt: Oh, that’s quite alright...(chuckles)...yeah, uh...
yes, I’d be happy to examine ways I could find health
within myself.....
Comment: Therapist apologizes which has the effect
of validating patient and counteracting her feelings about
doctors being superior.
[00:48:12.21] Interviewer: Ok...how are you feeling
right now...cause I know it’s a lot to kind of....it’s
actually..
Pt: I feel a little tired (chuckles).
[00:48:19.10] Interviewer: It is work to talk about
how our interactions are in the moment...it can actually
be a very tiring...
Pt: Mmm-hmm...yes....yes....well I guess I feel a little
awkward..
[00:48:35.02] Interviewer: Mm-hmm..
Pt: Yeah...um...I guess cause I’m not used to being
real with people...
[00:48:41.29] Interviewer: Mmm....
Pt: And the roof hasn’t caved in (chuckles)...that’s
nice....(chuckles).
[00:48:54.00] Interviewer: I know you say that
jokingly...
Pt: Yeah..or you haven’t stormed out of the office...
saying, I’ll never see you again and that kind of thing...
the world hasn’t come to an end so..
[00:49:07.06] Interviewer: Is that sometimes your
fear....when you do kind of talk in...like you said, a
real way or?
188 Chapter 8.  Supervision: Applying Action Alternatives

Pt: Yeah..with other people...with my friends or with

my husband..I’m always afraid of inflaming people...
yeah...and making them feel uncomfortable...and...and
making them think ill of me and um...yeah...
[00:49:50.14] Interviewer: I could imagine it is actu-
ally quite different to say, for example, that you were
frustrated or...to...it’s a way of kind of being vulnerable
or...or extending yourself in a very uncomfortable way..
Pt: Yes...yes...it almost makes me squirm inside...to
feel like that...to be asking for what I want and being
honest...to be honest with people...yeah cause a lot of
fear comes up...and uh...yeah just a lot of fear...
Comment: Excellent relational work and
metaprocessing.
[00:50:47.02] Interviewer: Mm-hmm....
Pt: I think a lot of the time I invest so much in a situ-
ation or a relationship that yeah..basically the whole
thing is built on my fear that it’s going to end if I’m not
careful...
[00:51:14.16] Interviewer: Mm-hmm..
Pt: And that I could blow it by saying the wrong
thing...
[00:51:22.00] Interviewer: Mm-hmm..
Pt: And that one misstep will destroy it all..yeah..
[00:51:30.13] Interviewer: So there’s always this
inhibition..
Pt: Yeah..that’s right...
[00:51:35.28] Interviewer: Mm-hmm...
Pt: Perhaps that’s why I have so very few outside
relationships...outside the family..I’ve never really had a
lot of friends at one time...and uh....there’s really
nobody that I’ve ever thought of as very close...that I
could confide in...or be really real with...yeah...um....I’ve
always kept people at arm’s length when it comes to
really telling them what I think and being real...
Comment: Patient displays good appreciation of rela-
tional themes.
 8.3  Structured Assessment of Sessions 189

[00:52:28.21] Interviewer: To me, it almost seems like,

in a way, becomes second nature to be compliant all the
time and maybe to not be “real”.
Pt: Yes..
[00:52:45.02] Interviewer: Because even in our inter-
action I think it took a little bit of a pause to really...
recognize that there was some frustration or...do you
think that that was true or did you recognize it right
away..but maybe didn’t want to say anything or...
Pt: Hmm...yes, I guess I didn’t...I recognize the
pause...and..I was a little...you know, a little bit irritated
by it...but I...I don’t think it was something I really felt
compelled, you know...to say anything about..
[00:53:47.13] Interviewer: Mm-hmm...and that’s
kind...that’s kind of your natural tendency or...is
that correct or?
Pt: Yeah..I guess...yeah......I really wasn’t that...
offended or anything by it...now...but even then… I
won’t say anything if it really seriously bothers me and
offends me, and yeah, I won’t say anything then either.
[00:54:32.23] Interviewer: Mm-hmm..
Comment: Therapist comes back to the transference to
reinforce the themes.

8.3  Structured Assessment of Sessions

Many systems have been developed for assessing and coding
process elements in therapy sessions. Leigh McCullough and
colleagues at Harvard developed the Achievement of
Therapeutic Objectives Scale [2, 3]. More than a decade of
research has been undertaken with this scale. This has
involved video recordings and analyses of therapy sessions.
Kristin Osborn, currently director at the Harvard Medical
School Psychotherapy Research Program, has continued
McCullough’s work and developed a therapist rating version
of the ATOS [4, 5].
190 Chapter 8.  Supervision: Applying Action Alternatives

Both of these scales are used with video recordings of psy-

chotherapy sessions. Ratings are made of 10 min segments of
the recording.
Both the ATOS and ATOS Therapist are rated on a scale
of 1 to 100.
The ATOS is an example of a scale that can be used to assess
patient outcome along dimensions that are highly relevant to
psychodynamic psychotherapy. This includes ratings of the
patient’s awareness of maladaptive patterns of thoughts, feel-
ings and behaviours; the patient’s ability to fully experience
emotion; a rating of verbal and non-verbal indications of anxi-
ety, guilt and shame; the ability to express thoughts, feelings,
wishes and needs; and changes in sense of self and sense of
others.
The ATOS scale is based on whether the patient is able to
recognize their defences, whether they can experience and
express emotion, and the level of the inhibitory emotions of
anxiety, guilt and shame.
The ATOS Therapist scale was designed to assess how well
the therapist uses interventions to help the patient achieve
the therapeutic objectives. It also serves as a fidelity measure
to a particular model of psychotherapy. From a supervisory
point of view, the ATOS Therapist can be used to evaluate the
therapist’s use of specific interventions.
The ATOS Therapist includes ratings of the therapist’s
awareness and insight into the patient’s maladaptive patterns
(defences) and his ability to communicate this to the patient,
whether the therapist is able to increase the patient’s motiva-
tion to give up these maladaptive patterns; whether the thera-
pist helps the patient to experience adaptive emotions and
helps to regulate feelings of anxiety, guilt and shame. Does
the therapist assist the patient in improving his image of him-
self and image of others?
Training is available for the use of these scales through the
affect phobia therapy website [3, 4].
 8.3  Structured Assessment of Sessions 191

8.3.1  V
 erona Coding of Emotional Sequences:
VR-CoDES
A completely generic and widely researched coding system
has been developed by the Verona Network on Sequence
Analysis. The aim of this project is to develop a coding system
that can capture how healthcare providers respond to patients’
emotions [6, 7]. This system has been designed to apply to
general healthcare. and creates a common language and cod-
ing system for research purposes. It may well be applicable to
psychotherapy research given its generic language and clearly
operationalized procedures.
The method is based on the study of sequences of patient
cues and healthcare provider responses. It classifies the way
patients express emotion in terms of cues and concerns. A cue
is a verbal or non-verbal “hint” that points to an underlying
emotion. A concern is defined as a clearly stated disturbing
emotion, e.g. I am sad.
The VR-CoDES also provide a descriptive classification of
the providers’ responses. This system is operationally defined.
Responses are classified based on whether they explicitly
refer to the patient’s cue or concern using wording that links
the two and, secondly, whether the healthcare provider pro-
vides space or reduces the space that facilitates further disclo-
sure of the cue or concern.
Explicit responses require the provider to remain focused
on and interested in the patient’s expressions. The provider
must acknowledge explicitly the patient’s emotional signals
and respond empathically.
The provider can allow more space for the patient to com-
municate by encouraging and affirming statements, seeking
clarification and specifically naming the emotion. Other
response include active questioning about the emotional con-
tent or the use of silence.
192 Chapter 8.  Supervision: Applying Action Alternatives

Conversely giving premature advice, minimizing or deval-

uing what the patient has said and devaluing or dismissing the
patient’s emotions can lead to “reducing space” and shutting
down the interview.

Key Points
• Choice point analysis is an excellent tool for psycho-
therapy supervision.
• It requires video or audio recordings of psychother-
apy sessions.
• Supervisors and peers can review the recordings and
identify points for intervention.
• The supervisory group can discuss alternative actions
and decide which may be best to facilitate the ther-
apy process and goals.
• The ATOS Therapist and the VR-CoDES are assess-
ment systems that have potential for more wide-
spread use in supervision.

8.4  Conclusion
Psychotherapy supervision is greatly facilitated by the use of
choice point analysis and selection of action alternatives. This
requires video or audio recordings in a setting of group or
individual supervision. This method can be used for all levels
of trainees in psychiatry, psychology, social work and related
therapy professions.
Areas for future enhancement of this process include the
utilization of instruments such as the ATOS Therapist and
Verona Coding of Emotional Sequences. These types of mea-
sures could also facilitate psychotherapy process research.

References
1. Tauber L. Choice point analysis-formulation, strategy, interven-
tion, and result in group process therapy and supervision. Int J
group Psychotherapy. 1978;28:163–84.
 References 193

2. McCullogh L, Kuhn N, Andrews, et  al. Treating affect phobia

a manual for short term dynamic psychotherapy. New  York:
Guilford press; 2003.
3. McCullogh L.  Achievement of Therapeutic Objectives Scale.
The Psychotherapy Research Program Harvard Medical School.
http://www.affectphobiatherapy.com/research-scales/.
4. Osborn K.  ATOS therapist 20 point brief rating guides. The
Psychotherapy Research Program Harvard Medical School http://
www.affectphobiatherapy.com/research-scales/.
5. Donovan JM, Osborn KA, Rice S.  Paraverbal communication
in psychotherapy: beyond the words. New  York: Rowman &
Littlefield; 2017.
6. Piccolo LD, Finset A, Mellblom AV, Figueiredo-Braga M,
Korsvold L, Zhou Y, Zimmermann C, Humphris G.  Verona
Coding Definitions of Emotional Sequences (VR-CoDES): con-
ceptual framework and future directions. Patient Educ Couns.
2017;100(12):2303–11. https://doi.org/10.1016/j.pec.2017.06.026.
Epub 2017 Jun 21.
7. Del Piccolo L.  VR-CoDES and patient-centeredness. The
intersection points between a measure and a concept. Patient
Educ Couns. 2017;100(11):2135–7. https://doi.org/10.1016/j.
pec.2017.05.007. Epub 2017 May 5. PubMed PMID: 28610822.
Chapter 9
Psychodynamically Informed
Clinical Practice
for ­Non-­Psychotherapists

9.1  Background
Not all clinicians are in a position to practice psychotherapy.
Other work demands may preempt such opportunities.
Institutional and funding policies may also limit job roles.
For healthcare practitioners in primary care, there may be
no time to spend in formal psychotherapy. Nevertheless the
insights and interventions that are part of psychodynamic
psychotherapy can be enormously helpful in all areas of
healthcare.
The psychodynamic framework offers a way to understand
human behaviour, emotions and relationships. All of these
dimensions impact on the experience of illness. The same
variables come into play in the relationships between patients
and physicians, nurses, psychologists, social workers and other
healthcare workers.
This has relevance in all clinical settings whether outpa-
tient, inpatient or community locations. Admission to the
hospital places unique stresses on the individual’s capacity to
cope. There is the loss of autonomy, and forced depen-
dency and assaults on bodily and psychological integrity.

© Springer International Publishing AG, 195

part of Springer Nature 2018
A. Eppel, Short-Term Psychodynamic Psychotherapy,
https://doi.org/10.1007/978-3-319-74995-2_9
196 Chapter 9.  Psychodynamically Informed Clinical Practice

The patient’s defences may be stretched, and his/her abil-

ity to regulate emotions may be impaired. If the healthcare
team reacts on the surface without understanding the under-
lying dynamics, conflict or even rupture in the relationship
between patient and the team may occur.

9.2  T
 he Therapeutic Alliance
and Attachment
Just as in formal psychotherapy, the therapeutic alliance
is  strongly correlated with medication treatment outcomes
[1, 2].
Attachment style is a factor in all relationships and will
influence the therapeutic alliance [3–7]. During the course of
child development, internal working models are created
(Chap. 2 this volume). These internal working models
­determine the patient’s implicit expectations about intimate
and caregiving relationships.
Patients with secure attachment have a positive expecta-
tion of help. They are able to trust healthcare providers.
Patients with dismissing attachment style display relational
patterns in which there is an implicit expectation of rejection.
They have difficulty asking for help as this will make them
vulnerable to rejection. They avoid closeness and have an
overly developed preference for self-reliance. They may mini-
mize the severity of their symptoms and not seek help.
Patients with preoccupied attachment may exhibit greater
emotional dysregulation and anxiety. They have a stronger
need to be in contact with the physician. Their expression of
symptoms has a transactional significance based on the
underlying need for more secure attachments.
Maunder and colleagues studied 119 individuals who com-
pleted an online survey. The results demonstrated the influ-
ence of secure or insecure attachment on the patient’s
experience with healthcare providers [3]. In this study three
factors were identified reflecting the patient’s experience of
the healthcare provider.
 9.3  Medication as Object and Psychodynamic… 197

• The first factor named “support” is derived from patients

who experienced the healthcare provider as safe and
supportive.
• The second factor was termed “averse” and was associated
with patients who experienced the provider as aversive.
• The third factor “want” reflected patient’s desires to have
more and closer contact with the provider.
The second and third factors correlated with attachment
insecurity as measured by the Experience in Close
Relationships questionnaire [3].
In a study of 165 patients and 26 emergency room physicians
[4], patients with higher attachment anxiety and avoidance
were perceived by the physician as more difficult. In this case
the term “difficult” is used not in terms of diagnostic or treat-
ment difficulty but in terms of the interaction between the
patient and the physician. 98% of patients with secure attach-
ment were not perceived as difficult. 17% of patients with pre-
occupied attachment were experienced as difficult. A further
19% of those with dismissing attachment and 39% of those with
fearful attachment were felt to be “difficult” (Fig. 9.1).
The effect of patient attachment style has also been stud-
ied in the care of people with chronic illness and diabetes [5,
6]. In a study of 167 patients who had coronary artery bypass
graft surgery, Kidd et  al. [7] found that attachment anxiety
was associated with both longer lengths of stay and higher
plasma levels of interleukin 6.

9.3  Medication as Object

and Psychodynamic Psychopharmacology
Transference and therapeutic alliance are just as fundamental
in the practice of psychopharmacology as they are in the
practice of psychotherapy. The patient’s attachment style and
relationship templates will colour the interaction with health-
care providers. A patient’s response to the prescription or
indeed lack of prescription of medications will be influenced
198 Chapter 9.  Psychodynamically Informed Clinical Practice

Figure 9.1 Anger. (Illustrations by Molly Ferguson www.

MollyFergusonArt.com)

by their unconscious transference feelings and internal work-

ing models.
Adele Tutter has described how medication can be related
to as if it were an object/person [8]. An individual’s response
to treatment interventions whether it is the administration of
 9.3  Medication as Object and Psychodynamic… 199

medication, a surgical procedure or an investigation is based

on their habitual self-representation/self-image and their
expectancies of the other person along  with associated
emotions.
At an unconscious level, the medication is a transitional
object, a symbol or stand-in for the healthcare provider.
Attributes of the healthcare provider may unconsciously be
linked to the medication. The medication may be felt to rep-
resent the healthcare provider’s compassion and concern.
Conversely it might represent an attempt to intrude, invade,
control or influence the patient’s behaviour or personality.
Medication is a powerful symbol because it is something
external that is taken into the body [9].
Medication also conveys the message that the patient is
defective or ill; this leads to the faulty logic that if the medica-
tion is stopped, the illness no longer exists.
The patient may feel submissive or dependent in acquiesc-
ing to taking medication.
Without a psychodynamic framework, the patient’s behav-
iour is frequently misunderstood and the healthcare provid-
er’s response misattuned.
The offering of medications may trigger feelings about
attachment figures who are obliged to take medications, were
very ill or have used medications.
The giving of a diagnosis can provoke resistance
because of the linkage to a significant figure who had this
diagnosis. This is “guilt by association” but may lead to the
patient refusing treatment or being nonadherent to
treatment.
The offering of medication can be perceived as dismissal
or rejection, a brushoff. Alternatively providing a prescription
may mean to the patient that the prescriber is understanding,
empathic and caring.
Conversely a failure to offer medication can be perceived
as dismissal or rejection depending on the individual patient:
“you don’t take me seriously”.
The same principles apply in maintaining a good therapeu-
tic alliance (Chap. 5).
200 Chapter 9.  Psychodynamically Informed Clinical Practice

Krupnick [1] and Meyer [2] demonstrated that the quality

of the therapeutic alliance contributed very significantly to
positive outcome in treatment with antidepressants.
Adherence to or “compliance with a prescriber’s prescrip-
tion” is influenced by dynamic factors: the therapeutic alli-
ance, transference based on being told to “comply” and
unconscious unwanted identification with family members
who have the same condition.

9.4  Relational Pattern

An individual’s relational patterns will inevitably affect their
responses and reactions. This applies not only to medication
but to other treatment or social interventions made by
healthcare or social service providers.
For example, individuals who view themselves as unwor-
thy may be compliant on the surface because of fears they
will be rejected or abandoned. Those who have a self-­
representation of failure may seek to reassure the prescriber
that they are doing well even if this is not the case. Those with
a self-view of unworthiness or not deserving of love may
attempt to please the prescriber in the hope of being accepted.
Those who feel they are deserving of punishment or mis-
treatment may persist when the treatment causes uncomfort-
able side effects without reporting them.
More complex patterns involve unconscious needs to
reject the physician’s generosity or to mistrust based on prior
experiences of abuse and betrayal.
Some patients may resist the necessary feelings of depen-
dency of having to visit the physician for repeat prescriptions.
Others may feel that medication is “a crutch” (although if
your leg is broken you may need a crutch).

9.5  History Taking

Focusing on dynamic factors can result in more valid elicita-
tion of information as well as promoting a more solid thera-
peutic alliance. This is critical for diagnosis and effective
treatment of patients with all types of illnesses.
 9.7  Ultrashort-Term Psychotherapy 201

Time spent on attending to the interpersonal and dynamic

characteristics of patients will pay off in the long run by estab-
lishing a better alliance and yielding better quality information.
Conversely a reliance on checklists and a barrage of closed-
ended questions will yield poor quality responses, increase
patient anxiety and lower quality of information provided.
Healthcare providers should use the dynamic interven-
tions of empathy, attunement and validation rather than
directive, authoritarian and rapid fire questioning.
Healthcare providers trained to recognize recurrent inter-
personal patterns, and transference expectations can inter-
vene more accurately and appropriately responding to
patients needs. Similarly conflict in the provider-patient rela-
tionship may reflect transference reenactments and insecure
attachment patterns.

9.6  Michael Balint

Balint was a pioneer in emphasizing the usefulness of the psycho-
therapeutic approach in general practice [10]. Balint crystallized
his ideas in his concept of the physician as “drug”. This contains
the idea of the doctor presenting himself to the patient in a cer-
tain manner. Patients present with a hidden agenda; many of the
real transactions are occurring covertly or unconsciously. There is
an unconscious negotiation and implicit testing of the waters.
Balint described the patient’s presenting problems as an
offering and seeking a healing response. Balint recognized
that physicians have difficulty dealing with the patient’s psy-
chological problems due to conventional expectations of the
physician-patient interaction. Teaching psychotherapeutic
skills involves helping clinicians become aware of their own
emotional responses.

9.7  Ultrashort-Term Psychotherapy

Psychiatrists, physicians, psychologists and others who have
time limits that preclude even short-term psychodynamic
psychotherapy may be able to utilize intermittent sessions or
ultrashort-term psychotherapy.
202 Chapter 9.  Psychodynamically Informed Clinical Practice

Donald Winnicott described ultrashort psychotherapeutic

consultations consisting of 2–3  h sessions up to several
months apart. Winnicott’s goal was to elicit from the patient
what was “worthwhile”. He helped the patient to reveal what
they felt was the worst and the best about themselves.
Winnicott believed that we become ourselves “in the eyes of
others”. It follows therefore that we can shape our self-view
by experiencing what others see in us [11].
This is a very profound statement and foreshadows a cen-
tral tenet of the attachment approach to psychotherapy. Our
self-identity is formed through our attachment relationships
and is replayed and open to modification in our relationships
with a  therapist. It involves  the  feeling of being seen and
being held in mind by another person.
Winnicott’s therapeutic virtuosity was in accepting what
the patient felt was “terrible” about himself and by listening
without judgement to the things that the patient felt most
ashamed and guilty about. Winnicott fostered a therapeutic
setting in which the patient could “reveal” his deepest feel-
ings of “badness”.
Winnicott’s genius was then to find a time in the patient’s
life when he felt “worthwhile”. He worked this through by
attending to the most negative feelings about the self and
moving back and forth to what was most worthwhile [11]. The
patient shares his fears and the therapist needs to admire
what is worthwhile in the patient.
Winnicott felt it was important to identify and acknowl-
edge inner feelings of destructiveness and in a complemen-
tary fashion to reach back to recover the goodness that was
lost. This is based on his formulation that loss leads to aggres-
sive and destructive emotions in an attempt to alter the exter-
nal environment. In Winnicott’s words this is an attempt “to
force the environment to take notice”.
The therapist’s task is to acknowledge the loss and disap-
pointment, to face the angry destructiveness and to survive:
“Accept what is terrible and reach for the worthwhile”. I
accept you despite all the bad things which are part of you
(and I am not destroyed) [11].
 9.8  Thomas Main 203

9.8  Thomas Main

A familiarity with the principles of short-term psychody-
namic psychotherapy can help healthcare workers recognize
the impact of their own feelings on their interactions with
patients. Each of us brings with us our own internal working
models and expectancies. These will shape our feelings
towards and responses to patients. Working with individuals
who are very ill can trigger fears and threaten our own sense
of security and identity.
In a magnificently insightful presentation at the Ontario
Psychiatric Association Annual Meeting in Toronto pub-
lished in 1977, Main elucidates a range of personal, adminis-
trative and institutional procedures that defend clinicians
from the feelings they experience in encounters with patients
[12].
Physicians are prone to the same feelings as the rest of
humanity. When faced with psychiatric illness, death and
dying or demanding treatment challenges, a physician may
experience the rise of anxiety that triggers defensive
responses. Main describes one such defence as a retreat into
biological psychiatry. This puts the physician into the role of
“an uninvolved observer”; the subjectivity of the patient
becomes marginalized. Physicians and other healthcare pro-
fessionals may exhibit the defences of isolation of  affect,
intellectualization, devaluation, reaction formation and
humour.
Reaction formation may result in the physician undertak-
ing overzealous and futile treatment endeavours. This can be
motivated by the physician’s own fears of death and dying.
An extreme but potentially lethal example of the impact of
the clinicians own nonconscious feelings towards certain
patients, is described in a classic article about countertrans-
ference hate towards suicidal patients [13]. While this may be
shocking to some readers, it provides some profound insights
into the therapist and clinicians’ responses to alarming and
demanding clinical encounters. Clinicians can be over-
whelmed with anxiety and feelings of helplessness.
204 Chapter 9.  Psychodynamically Informed Clinical Practice

Patients may be objectified to avoid acknowledgement of

their humanity. They may be labelled as a diagnosis rather
than a person: “the diabetic in room 246”. In psychiatry this
objectification may be reinforced by our diagnostic systems
which rely on external symptoms and signs.
Institutional procedures can also lead to the objectifica-
tion of patients. Psychological distance is created which can
protect the staff from the anxiety of having to feel the
patient’s distress. Hospital and clinic roles may be fragmented
so that the patient is reduced from being a whole person to a
series of functions divided among a multidisciplinary staff.
The antidote to these undesirable occurrences starts with
self-awareness and understanding. Supervisory relationships,
peer consultation and team meetings provide an opportunity
for healthcare workers to come to grips with their responses
to patients.

Key Points
• Knowledge of the concepts and principles of short-
term psychodynamic psychotherapy can help general
clinicians improve their interactions with patients.
• It is important for all healthcare providers to be
aware of their own emotional reactions to patients.
• Clinicians should understand the institutional and
personal defence mechanisms that protect them
from experiencing anxiety and helplessness.
• These defences can lead to avoidance of necessary
close encounters with patients.

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Index

A child development, 25–26

Abbass, Allan, 12–14 conceptualize, 28
Accelerated experiential definition, 105
dynamic psychotherapy disorganized attachment D, 37
(AEDP), 17–20, future research, 43–44
119, 120 inborn biological program, 28
Achievement of Therapeutic language, 105–106
Objectives Scale mutual regulation model,
(ATOS), 17, 191 31–32
Action alternatives vs. object relations concepts,
Tauber, Lewis, 117 33, 106
provisional hierarchy, physical and sexual abuses, 30
129–131, 160 to psychotherapy, 33–34,
Adaptive emotions, 100 40–42
Adult attachment interview precursors to, 26–28
(AAI), 37–40 resistant attachment C, 36–37
AEDP, see Accelerated secure attachment B, 36
experiential dynamic STPP, 42–43
psychotherapy strange situation, 34–36
(AEDP) terminology and measures
Affect, 100 adult attachment
Affect phobia therapy (APT), interview, 37–40
14–17 strange situation, 34–37
Allegiance bias, 77 Attachment-based questions,
Amygdala, 57 140–141
Anger, 52 Autobiographical memory, 107
ATOS Therapist scale, 192
Attachment style, 198, 199
Attachment theory B
adult attachment interview, Balint, Michael, 2, 203
37–40 Beck Depression Inventory
avoidant attachment A, 36 (BDI), 76

© Springer International Publishing AG, 207

part of Springer Nature 2018
A. Eppel, Short-Term Psychodynamic Psychotherapy,
https://doi.org/10.1007/978-3-319-74995-2
208 Index

Biographical empathy, 108 classification, 100

Blackmailing device, 165 Damasio’s theory, 60
Blobbogram, 80 Darwin’s theory, 48–54, 62
Bowlby, John, 26 dual system, 57–60
Bowlby’s attachment Ekman survey, 63
theory, 2, 28 evolution, 54
Brain development, 25 facial expression, 49
Brief psychotherapy, 3 neurocircuitry, 57
Panksepp research
affective neuroscience, 64
C fear system, 66
Choice point action alternatives joy/rough-and-tumble
content, 162 play, 68
defences and external neural circuits, 64
relationships, 162 rage/anger
relational, 160–161 system, 65
Choice point analysis, 121, 160 seeking system, 65
AEDP, 119–120 separation distress and
intervention (see social bonding
Interventions) systems, 67
Tauber’s concept, 117–119 sexuality, 68
Cognitive behaviour therapy, 48 processing phase, 153
Compulsive self-reliance, 31 core feelings, 154
Concurrent therapy, 151 defences, 154
Core conflictual relationship, 142 exploration and affective
Countertransference, 205 expression, 154
tactical defences, 154
triangle of defence,
D 155–158
Damasio’s theory, 60–62 social, 63–64
Darwin, Charles, 48–54 study, 47
Davanloo, Habib, 7–10 triune brain, 54–56
Decision-making processes, Empathy, 107–108
114–117 Engagement phase, 136
Defence, 101–103, 198 Evidence-based
neuroscientific reformulation, medicine, 73–74
103–104 Explicit memory, 106
tactical, 154 Expressive techniques, 16
triangle of, 155 Ezriel, Henry, 4
Dodo bird effect, 83
Duchenne, Guillaume-Benjamin,
49 F
Feeling, 100
Ferenczi, Sandor, 2
E Formulation, 158–159
Ekman, Paul, 63 Fosha, Diana, 17–20, 119–120
Emotion, 64–68, 149 Freudian conflict theory, 101
 Index 209

G Lindemann, Erich, 7–10

Goldilocks effect, 124 Luborsky, Lester, 10–11
Good-enough mother, 99

M
H Main, Thomas, 205–206
Heterogeneity, 80, 110 Malan, David, 2
Hill, Clara, 125 Mann, James, 7
History taking, 137 McCullough, Leigh, 14–17
Humour, 127–129 McLean, Paul, 54–56
Menninger, Karl, 4
Mutual regulation model
I (MRM), 31–32
Implicit memory, 107
Inhibitory emotions, 101
Insula, 62 N
Intensive Short-Term Dynamic National Health Service (NHS),
Psychotherapy, 8 87–88
Internal working models, 150 National Institute of Mental
Interventions, 120–121, 171 Health (NIMH), 43
evidence, 121 Neocortex, 56
explore emotion, 123–124 Neurobiological research, 98
humour, 127–129 Neurocircuitry, 57
relational focus, 126–127 Non-declarative memory, 107
rupture and relationship
repair, 125–126
therapeutic alliance O
promote, 122 Object relationship, 2, 98–100
transference and
relationship, 124–125
supportive-expressive P
therapy, 121 Panksepp research
tasks, 156 affective neuroscience, 64
fear system, 66
joy/rough-and-tumble play, 68
J neural circuits, 64
Joy, 50 rage/anger system, 65
seeking system, 65
separation distress and social
K bonding systems, 67
Kahneman’s theory, 115 sexuality, 68
Periaqueductal grey (PAG), 62
Primary care, 197
L Procedural empathy, 107
LeDoux, Joseph, 57 Procedural memory, 107
Limbic brain, 56 Pruning, 25
210 Index

Psychodynamics, 98 Short-term anxiety-provoking

history, 138–139 psychotherapy, 9
theory, 97 Short-term psychodynamic
Psychotherapy research psychotherapy
basic principles, 75–78 (STPP)
bias, 76–78 elements, 20–21
cognitive behavioural emotional crisis and grief,
therapy, 75 7–10
current state of research, manualized approach, 135
81–83 manualized psychotherapy,
effect sizes, 75 10–11
evidence-based medicine, meaning of time, 7
73–74 origins, 1–4
history, 74–75 second-generation
Karl Popper’s criticisms, 74 researchers in, 10
meta-analyses, 80 strategic objectives, 135
methodology, 78–79 third generation, 12–21
notable study, 85–88 triangles, 4–6
optimal standards, 90 Sifneos, Peter, 7–10
patient characteristics, 83–85 Smiling, 49
randomized controlled Social emotions, 63
trials, 79 Statistical language
Publication bias, 77 effect size, 110
heterogeneity, 110
meta-analysis, 109
R Suitability
Randomized Controlled Trial of attachment style, 146
Psychotherapy Quality contract and orientation, 147
Rating Scale (RCT-­ current practice, 145
PQRS), 88 diagnostic considerations, 146
Relational focus, 142–143 orientation to therapy,
identify, 143–145 148–150
Relational patterns, 202 Supervision
Reporting bias, 77 format, 171–172
Reptilian brain, 54 questions about patient,
Required relationship, 5 173–191
Research Domain Criteria questions to therapist, 172
(RDoC) project, 44 structured assessment of
Rosenzweig, Saul, 84 sessions, 191–192
Verona Network on Sequence
Analysis, 193–194
S Supportive Expressive
Sadness, 67 Psychoanalytically
Secure base, 43 Oriented
Semantic empathy, 108 Psychotherapy, 11
Semantic memory, 107 System 1 and 2, 115
 Index 211

T Transitional object, 99
Tactical defences, 154 Triangle of conflict, 4
Tauber’s method, 171 Triangle of insight, 4
Tentative formulation, 159 Triune brain, 54–56
Termination, 152 Tronick, Edward, 31, 32
long-term psychotherapy, 164 Tutter, Adele, 200
outcome, 168
phases, 163
prospect, 164 U
tactics, 168 Ultrashort-term psychotherapy,
tasks, 167 203–204
Therapeutic
alliance, 199
history, 202–203 V
medication, 201 Verona Network on Sequence
medication treatment Analysis, 193–194
outcomes, 198 VR-CoDES, 193–194
Therapeutic change processes,
109
Therapist-patient relationship, 5 W
Transference, 158, 199 Winnicott, Donald, 27, 204