Practical problems in brief psychodynamic psychotherapy

The choice of focus is perhaps the most important and the most difficult aspect of brief individual psychodynamic psychotherapy. It is helpful to identify several foci during the evaluation process, recognizing that there are inevitably several conflict areas active at any one time in a patient's life. Then the therapist can begin the process of thinking through what the treatment of each focus would entail (Table,,,,!).

Identifying the TdciI -conflict Expiare Prtíipiuni: d1 syrnpmrm E.irly I ft Iraumas RcpcciUre pulcerm arbchvnmr Lilien fee mhil iiD^s'i>o dincc Wjtch V íMillkii atoui iJtctsi is well Ji t0¡¡j¥jiKjra

Sr-lrctmn nrnDfij icw-riLfüci Chwit the Ittu ihn iL prtupclyieinc Use (riilin(erpr«jmQ(i w identify jciiy* feiUS Sclrct frKui 'ebtrd ttanlyäin transference fifu'c-

Table 7 Identifying and selecting the focal conflict in brief dynamic psychotherapy

The therapist can begin to decide which focal conflict will be more difficult to reach in a brief period of time, which will threaten the therapeutic alliance more and therefore require a deeper working relationship that may take more time, and which focus requires interpreting more primitive defences and therefore may be more complicated.

Choice of a particular focus can also create more family or external disruption or support which can aid or disrupt the treatment.

Use of medication requires carefully explaining to the patient the relationship of the medication to the psychotherapy. Often the medication treatment will continue beyond the psychotherapy. If repeated complicated medication alterations are needed or if serious side-effects of the medication occur, the psychotherapy plan may have to be altered to allow time to understand them from the patient's perspective.

New therapists are often concerned about setting the date of termination at the time of the evaluation, fearing that they may not be able to complete the work by the deadline. Supervision with an experienced colleague can be very helpful to assure confidence and avoid mistakes that may lengthen the treatment. Alternatively, the new therapist may feel too much relief in setting the termination date when treating a very dependent patient and therefore miss the intensity with which the patient is attached and experiencing the therapist as an important, needed, or feared figure from the past.

The management of missed sessions should be made clear at the beginning of treatment. Usually it is best not to 'make up' the sessions, but to keep to the termination date. If the therapist is concerned about this as a potential issue in the treatment, the therapist may wish to plan several additional sessions in the overall treatment to assure this can be discussed and understood therapeutically. Of course if an emergency arises it is always appropriate to schedule appointments as needed for the health and safety of the patient.

The patient who 'divulges' new 'secret' information near the end of the treatment is a challenge to all therapists. Understanding to what extent this represents narcissistic, or sociopathic issues, fear of the therapist or the treatment, or the emergence of hope for the future or a transference enactment will determine how to respond.

Brief individual psychodynamic psychotherapy is best learned in conjunction with the skills of longer-term psychodynamic psychotherapy. In the longer work, the therapist will be able to see more easily the possible conflict areas and think about the sequencing of the treatment of these, i.e. which is closer to the patient's awareness or which is more defended. In addition there is more time to correct errors and repair untoward events in the therapeutic relationship. The brief individual psychodynamic psychotherapist will have less time to correct mistakes and must more quickly identify conflict areas and assess their relative importance and potential for resolution through treatment.

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