Brief Psychodynamic Psychotherapy Research Paper

The number of psychotherapies classified as brief psychodynamic has increased remarkably in recent years. As these numbers continue to grow, the clarity of features that constitute a psychotherapeutic system as brief dynamic becomes blurred. In an effort to provide a prototypical definition of BPP, we have gathered criteria from various authors, including those presented by Crits-Christoph et al. (1991), as follows.

(a) The theory of psychopathology explaining the cause and maintenance of a psychological disorder has a psychoanalytical basis (and thereby makes use of concepts related to such theories as Freudian, neo- Freudian, interpersonal, object relations, and self- psychology). Among the most important constructs one should include unconscious motivations, the formative role of early years on character formation, the tendency to repeat early behavior, the pervasiveness of transference, the importance of anxiety as a signal of underlying conflict, and the role of defenses.

(b) The main treatment techniques employed by the psychotherapist are those described in the psychoanalytic literature such as making clarifications, interpretations, and confrontations and noting transference and countertransference. Despite sharing these techniques, most authors do not consider BPP a brief or condensed form of analysis but rather a distinct treatment of its own. In general, the use of advice and homework, often practiced in behavioral and cognitive psychotherapies, is not recommended.

(c) The length of treatment is planned, often predetermined, and always time-limited. It usually lasts from 12 to 40 sessions depending on the patient’s problems.

(d) Because of its brevity, patients are selected for BPP. Patients have to be screened to ensure that they meet at least some of the requirements for this form of treatment. In the literature, the following requirements have often been mentioned: psychological minded-ness, recognition that present problems are in part of a psychological nature, willingness to change, existence in the present or past of at least one good quality interpersonal relationship, the ability to circumscribe present complaints to one symptom, the capacity to interact flexibly with the interviewer, and adequate ego strength (including the ability to tolerate frustration and ambivalence, adequate reality testing, and the use of neurotic but not psychotic defenses).

(e) In order to maintain brevity, a focus for treatment is implemented, and issues not related to the focal point or central conflict are often considered as having secondary priority. In general, the focus of treatment is developed collaboratively either before therapy starts or immediately following the initiation of therapy. The therapist actively works to maintain the treatment focus on the agreed upon core issue.

(f ) BPP is intended to alleviate specific symptoms and provide limited personality or character change. This is in contrast to psychoanalysis and long-term dynamic therapy where the goal is typically pervasive character change.

Because most brief dynamic psychotherapies do not fulfill all of the aforementioned requirements, these criteria cannot be considered necessary. However, the criteria can and should be viewed as a prototypic definition whereby the more criteria a therapy meets, the more likely it will be designated as brief psycho-dynamic psychotherapy.

1. Historical Background

Modern psychotherapy can be traced to Sigmund Freud’s work that began in the late nineteenth century. During that time, Freud developed a way to investigate the mind that ultimately evolved into a psychological intervention known as psychoanalysis. In psychoanalysis, the analyst attempts to bring repressed unconscious conflicts to the patient’s awareness. In other words, by providing patients an understanding (‘insight’) of the unconscious aspects of their problems, patients have the opportunity to work them through and subsequently master these difficulties. Although Freud originally worked with patients for a small number of sessions, psychoanalytic treatment became increasingly longer over the years. Gradually, psychodynamically oriented psychotherapy, also referred to as psychoanalytically inspired psychotherapy, emerged from the modified use of psychoanalytic principles and therapeutic techniques.

Similar to psychoanalysts, long-term psychodynamic psychotherapists tend to be quiet, waiting for patients to free associate and observing how the patient–therapist relationship (or transference) develops, rather than actively pursuing psychologically meaningful material and addressing transferential material early in the treatment. Despite this similarity, however, psychodynamically oriented psychotherapy differs from traditional psychoanalysis in significant ways. For example, in contrast to psychoanalysts who see patients on the couch four to five times a week, long-term dynamic psychotherapists generally see patients face to face once or twice a week. Nevertheless, consistent with psychoanalysis, psychoanalytically inspired psychotherapy has tended to be a long-term therapy.

In addition to the long-term approach to dynamic therapy, there has also been a small group of therapists who have attempted to keep psychoanalytically inspired psychotherapy brief and concise. These clinicians continued the work originated by Ferenczi (1950), Rank (1936), and Alexander and French (1946), who recommended the maintenance of an active stance in therapy to hasten the exploration of unconscious material. In spite of their efforts, however, most psychodynamic clinicians continued to view brief dynamic therapy as inferior to the lengthier psychoanalytic treatment. It was not until Malan (1976) Mann (1973), Sifneos (1979), and Davanloo (1980) that brief psychodynamic psychotherapy was deemed a valuable treatment option. Malan’s emphasis on the importance of careful patient selection through the screening of inappropriate referrals and through trial interpretations attuned therapists to the fact that BPP can be effective for a subset of the patient population. Malan and Sifneos were also among the first to stress the significance of defining and maintaining a therapeutic focus and the relevance of such focus for being an appropriate candidate for BPP. Malan explicitly illustrated some of the cornerstones of psychodynamic treatment through the descriptions of two triangles. The first triangle is the ‘triangle of conflict.’ Its apexes correspond to the labels ‘defense,’ ‘anxiety,’ and ‘underlying feeling or impulse.’ The second triangle is the ‘triangle of person’ and has the labels of ‘relationships with current figures, ’‘relationship with the therapist (representing transference),’ and ‘relationships with important figures from the past’ (e.g., parents) for its apexes. According to Malan, the therapist’s task is to expose the underlying feelings and impulses that the patient has been protecting via defense mechanisms and to elucidate the role of the defenses in reducing the anxiety that the feelings create. He posited that the patient’s hidden feelings were originally experienced in relation to the parental figures at some time in the past and since then have frequently recurred with other significant figures in the patient’s life including the therapist. During therapy, the patient must understand the hidden impulses underlying each of the relationships described in the triangle of person. Typically, insight into a current relationship (either with a significant other or the therapist) is achieved first and is then related back to the parental figures. Today, the writings of Malan (1976), Mann (1973), Sifneos (1979), and Davanloo (1980) are considered the four ‘traditional’ approaches to brief dynamic therapy (Crits-Christoph et al. 1991). Their work was the initial driving force for the development of modern BPP and fueled the debate that brief therapy can be as successful as longer-term therapies.

In the last 20 years, a new generation of brief dynamic therapists appeared on the clinical scene. Among the most important are Luborsky (1984), Horowitz et al. (1984), Strupp and Binder (1984), and Weiss et al. (1986). This new group of brief dynamic therapists can be distinguished from previous generations by their interest in the empirical status of their treatment approaches. Perhaps resulting from their interest in research, this new generation has written intricately detailed descriptions of their clinical approaches that are very helpful for training and monitoring clinicians in the adequate use of their techniques. In fact, many of these books are considered treatment manuals and have been used in empirical research addressing the efficacy of these therapeutic methods.

2. Efficacy Of BPP

During the 1980s, researchers began to explore the efficacy of BPP relative to that of other psychotherapies. Representing the trend toward methodological rigor that has prevailed throughout the 1980s and 1990s, manualized BPPs have slowly been incorporated into research studies to provide the standardization of treatment that is needed for the studies to be credible. Despite this methodological improvement, very few high quality studies have been conducted to examine the efficacy of BPP.

Anderson and Lambert (1995) published a comprehensive meta-analysis of 26 BPP efficacy studies that indicated that although BPP is more effective than minimal or no treatment, it is neither superior nor inferior to other forms of therapy. In spite of the fact that these data indicate that BPP is an effective treatment, it is not often recognized as such. One possible reason for the lack of recognition is the small number of studies that have examined the efficacy of BPP for specific disorders. For example, only one study has examined the efficacy of BPP for depression (Gallagher and Thompson 1982) and that study only included elderly depressed patients in its subject pool. Hence it is hardly surprising that many therapists do not find the data supporting the efficacy of BPP sufficiently convincing.

In addition to the interest in examining the efficacy of brief dynamic therapy, researchers and clinicians have consistently been curious about the processes of change underlying BPP. Strong findings in the literature on process research indicate that both nonspecific therapeutic factors, such as a positive therapeutic alliance, and specific therapeutic factors, such as accurate interpretations of the patient’s core interpersonal conflicts, are associated with good therapeutic outcome.

3. The Future Of BPP

During the last two decades, the popularity of BPP has grown. This shift can be attributed to the increased financial pressure from managed health care to shorten the average number of sessions in a treatment program, the patients’ wish to receive help only for their specific complaints rather than for changing their personality, and the patients’ wish to save money.

There is little reason to believe that the multiple causes influencing the trend in the late 1990s toward increased implementation of brief treatments including BPP will subside any time in the early part of the twenty-first century. Rather, it seems that efficiency and empirically demonstrated efficacy define future ideals. Consequently, it is likely that therapists will see an even larger increase in the use of brief therapy. In order to ensure that BPP will be one of the modalities recommended by the various governmental, insurance, and professional entities that are ‘certifying’ treatment modalities, there is an need for evidence of its efficacy for specific psychiatric disorders.

Without a doubt, ensuring that the quality of psychotherapy remains high is a major objective of all psychotherapists; however, other factors must also be considered with regard to the future status of brief dynamic psychotherapy. First, a large proportion of the training of psychiatrists and psychologists remains in the realm of long-term psychotherapy, although the trend toward training psychotherapists for short-term interventions might be occurring. Nevertheless, increased training of clinicians in the domain of brief therapy is required for patients to receive maximum benefit from this form of treatment. Also, psychotherapists should strive to implement the BPPs designed for specific diagnostic patient populations in their treatment of these patients. This task may prove to be especially difficult since the descriptions of symptoms and syndromes of particular disorders according to psychodynamic theory do not always correspond to those listed in the most recent version of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) of Mental Disorders.

Modern psychotherapy, including BPP, is becoming increasingly more integrative and eclectic in its treatment approach. As a result of this greater eclecticism, examining the efficacy of the actual treatments used in clinical settings and defining a given treatment delivered by a specific clinician as BPP are becoming perpetually more difficult tasks. Psychotherapy, including BPP, must constantly evolve to fit with the fast paced nature and current trends of the modern world. Thus, maybe future practice of BPP will include more components from other psychotherapies.

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