Technique

The rapid establishment of the therapeutic alliance is critical to brief individual psychodynamic psychotherapy. (9) Identifying the patient's initial anxieties related to beginning therapy is an important technique in the early sessions of brief individual psychodynamic psychotherapy in order to assure the alliance and to establish the conditions under which the patient can favourably hear and respond to the interpretations that the therapist will later give. As the therapy unfolds, the therapist operates on the hypothesis that each session is related to the previous one. The therapist strives in each session to identify the continuity of meaning related to the treatment focus that is present but hidden.(19 This continuity is driven by the 'experience bias' of the patient, and his or her tendency to experience the world in a certain way due to unique developmental experiences that have moulded his or her perception, interpersonal beliefs, and expectations. (11)

Brief individual psychodynamic psychotherapy is more focused, and more 'here and now' oriented with fewer attempts to reconstruct the developmental origins of conflicts than the extensive reworking of personality undertaken in longer-term psychotherapies. Through the exploration of the patient's metaphors and symbols, both defensive patterns and disturbances in present interpersonal relations are identified in the treatment setting as well as in the patient's life. The importance of being able to hear what the patient has to say and to understand its meaning remains central as in other psychoanalytically oriented treatments.

Free association is part of the technique of brief individual psychodynamic psychotherapy. But what constitutes free association—as in all dynamic therapies—requires thoughtful consideration. In its most basic form, and particularly highlighted in brief individual psychodynamic psychotherapy, free association means that the patient is free to choose what they wish to talk about. This rather direct definition emphasizes that free association is always relative. For the patient who is flooded with thoughts and feelings and/or feels compelled to tell the therapist everything, this definition can highlight the way in which 'true' free association is not present. In addition, in brief dynamic psychotherapy, the patient is always somewhat more task focused that in open-ended treatments or psychoanalysis and this focus should not be discouraged by the therapist. Rather it is the therapist's task to hear the themes in the patient's concerns. The therapist asks questions, directs the patient's attention, and uses benign neglect, i.e. avoids some areas of conflict that cannot be dealt with at this time or in a short period of time. The therapist identifies those spots at which free association breaks down (the presence of a defence) or at which the narrative is carrying a single emotional story out of the patient's awareness. As in all dynamic treatments, often when the patient is able to talk freely and with a coherent narrative about their conflicts, the work of the treatment is completed.

Brief individual psychodynamic psychotherapy emphasizes understanding (a) the mechanisms of defence used by the patient to decrease anxiety and other uncomfortable feelings associated with areas of conflict which are out of awareness, and (b) the characteristic transference relationships which distort the patients response to their adult world. Typically these two areas, defence and transference, create the world of meaning in which the patient lives. The techniques of the brief psychodynamic psychotherapy are directed towards clarifying these areas and presenting them to the patient to increase understanding and in this manner change symptoms and behaviour. Often only one defence is concentrated on in a given brief treatment. As the defence is clarified, the transference relationship may become evident. The developmental narrative of how the patient came to see the world in the way he or she does, provides the 'glue' through which the patient can integrate this knowledge into their life experience and behaviours, and recall it for practice and future use.

The brief individual psychodynamic psychotherapy therapist, similar to longer-term psychodynamic work, must both enhance the patient's observing capacity in order that the transference can be observed by the patient and therapist, and create the therapeutic situation in which the patient can hear the therapist's interpretations in a useful manner. Dreams, as well as slips of the tongue and symptoms, can provide an avenue to the understanding of unconscious conflict which can be taught and explored with the patient. The therapist strives to interpret both the triangle of anxiety (wish-defence-anxiety) and the triangle of insight (transference figure in the present-the therapist/patient interaction-transference figure from the past).

Frequently, when the transference is most evident, other elements of the past are simultaneously experienced in the patient's life. In brief individual psychodynamic psychotherapy these can be particularly important to the patient's understanding the feeling elements of the transference in a mutative manner since the depth and intensity of the transference is much less and much briefer than in long-term work. In contrast, however, the presence of a recent precipitant to the patient's problems, as is usually the case in brief psychodynamic psychotherapy, can considerably intensify transference responses and be a central element in developing the psychodynamic understanding for the patient. The transference experience—the transference, the life experiences being relived, and particularly the precipitant—provide the web of meaning that is the focus of interpretation and the mutative force in brief individual psychodynamic psychotherapy.

Often the transference in brief individual psychodynamic psychotherapy is paternal or maternal, but it has also been noted that, perhaps due to the time-limited nature of the work, sibling and transference figures from adolescence may more often be recalled in brief individual psychodynamic psychotherapy. The transference is rarely as deep as that seen in long-term treatment. It requires a skilled eye to note and bring the transference to the attention of the patient in a manner that is neither intrusive nor offensive.1,» Interpretations rarely reach the ideal of being given in one sentence, in one session. Rather, interpretations more frequently occur over several sessions, usually in the middle or later third of the treatment, during which past, present, and transference experiences are linked together. In the context of the affective arousal associated with this transference experience and the simultaneous understanding of the experience, behavioural change occurs and the patient's ability to perceive previously hidden feelings and relationships as well as his or her view of the future and the past can change.

Countertransference is also an important element in brief individual psychodynamic psychotherapy as in other psychodynamic treatments. (13> Analysis of countertransference reactions can allow the therapist to recognize subtle aspects of the transference relationship and to understand the patient's experience better. Because of the more active stance, the brief psychodynamic psychotherapist can be particularly prone to countertransferences that show up as over-involvement or aggression. In addition, the brief time available for treatment can make recovery from countertransference errors quite difficult.

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