Psychodynamics, Training, and Outcome in Brief Psychotherapy

326 Pages·1992·23.389 MB·English

by  David Malan and Ferruccio Osimo (Auth.)

Psychodynamics, Training, and
Outcome in Brief Psychotherapy
David Malan DM, FRCPsych
Formerly Consultant Psychiatrist, Tavistock Clinic
and
Ferruccio Osimo MD
Assistant Psychiatrist for Milan Health Authority
Formerly Clinical Associate, Tavistock Clinic
Editorial Work by David Malan
Follow-up Interviews by Ferruccio Osimo
\B_
U T T E R W O R TH
IE I N E M A N N
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First published 1992
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ISBN 0 7506 1545 1
Composition by Scribe Design, Gillingham, Kent
Printed and bound in Great Britain by Billings & Sons Ltd, Worcester
What this book is about
In this book we describe 24 brief therapies conducted by trainees under supervi-
sion at the Tavistock Clinic, representing a continuous series as far as the avail-
ability of follow-up allowed. All 24 are described in detail, from initial assessment,
through therapy, to follow-up many years later. Because the patients were selected
for clear pathology and ability to interact dynamically, they illustrate many aspects
of dynamic psychotherapy with great clarity, including:
1 selection criteria;
2 the principles of therapeutic technique;
3 the way in which events of therapy lead unmistakably to an understanding of
neurosis;
4 the factors leading to therapeutic effects, and
5 the types of change that are found at final follow-up.
In spite of the absence of a control sample, the evidence that improvements
were caused by therapy rather than by spontaneous remission is very strong, and
the results - with certain reservations - are distinctly encouraging. In consequence
of all this the book is much more than simply an account of a particular follow-
up study, but it has become both a series of engrossing (though sometimes tragic)
human stories, and a mine of information about many aspects of the science of
psychodynamics - a term which by now should need little justification. We believe
that the book will be of interest to anyone, at whatever stage in relation to
psychotherapy, who wishes to gain further experience of actual patients, or who
holds the efficiency or the validity of psychotherapy to be important issues.
In our approach we have made a bid to reverse what has been described as the
'flight into process' in psychotherapy research, since in the later chapters we
concentrate more on outcome than on technique. The penultimate section of the
book consists of a detailed analysis of the types of change that may follow from
dynamic psychotherapy, a kind of study which to our knowledge has not been
carried out before. These changes include such subtle but crucial aspects of an
individual's life as the freeing of creativeness, the ability to 'be oneself, and the
discovery of constructive self-assertion, which do not appear in the literature as
criteria by which outcome is usually assessed. There is a surprising uniformity in
the changes that appeared in some of these patients, an observation that is of very
considerable interest. In addition there were a number of patients whose improve-
ments were clearly due to various kinds of false solution - such as withdrawal from
V
νι' What this book is about
the anxiety-provoking situation - the evidence for which is both fascinating and
compelling. This is a type of result which needs to be looked for and taken into
account by all researchers seeking to study the effectiveness of psychotherapy of
any kind.
Of course there were poor results as well, some of them due to serious clinical
mistakes, which emphasises the need for constant vigilance, particularly at initial
assessment. Much can be learnt from these, and their description can perhaps help
to reduce the incidence of similar mistakes by other workers.
The kind of therapy described here was highly skilled, and the therapists, even
though they were trainees, possessed a considerable degree of psychodynamic
sophistication. Nevertheless they were trainees, and our study has therefore
allayed a fear which many of us shared, namely that only experienced therapists
can carry out this kind of work effectively. Moreover, the lower limit for effective
work in terms of skill and experience has not been explored, so that the degree
of sophistication shown by these trainees may not be a necessary condition for
success. We do believe, however, that experienced supervision is an essential
factor. Therefore where supervisors of the right quality are available, the evidence
suggests that brief therapy by trainees can provide an important resource, partic-
ularly for psychotherapeutic centres faced - as so often - with demands for therapy
that are impossible to meet.
Acknowledgments
We wish to express our deep gratitude to those patients who have given permis-
sion for their material to be published. Should any other readers recognise
themselves, may we say that we have tried to disguise their material in such a way
that others will not recognise them; that it is published with sympathy and respect;
and that the ultimate aim is for brief psychotherapy to be better understood and
more generally accepted, and hence for more people to be helped by it.
We are greatly indebted to the following colleagues for clinical material: Janette
Albrecht, Austin Case, Cecilia Clementel-Jones, Barbara Cottman, Philip
Crockatt, Graham Davies, Laraine El-Jazairi, Andreas Giannakoulas, Alberto
Hahn, David Heath, Christopher Holland, Jill Leonard, Remy Meyer, Marilyn
Miller-Pietroni, Samuel Packer, Susan Phillips, Andrea Pound, Gustav Schulman,
Rafael Springman, Arturo Varchevker, and Kenneth Wright.
We should also like to give our grateful thanks to Mrs Jocelyn Gamble for her
dedicated work as research assistant in this study.
VII
1
Beginning at the end
The Nurse Mourning her Fiancé
Interviewer (FO, one of the present authors): Can you tell me how you feel now
that you're here for this follow-up interview?
Patient (now aged 39): I got out of the car and I felt very nervous. It reminded
me of the first time I came. I remember sitting here, and then I was crying a lot
while going home. When I first got the letter from Dr Malan asking me to come
for follow-up, those days didn't seem part of my life any more. It was as if they
never happened.
Interviewer: Can you tell me what feelings you can recall from that first session
6 years ago?
Patient: It didn't seem real somehow. It seems so different now for the last 3 of
4 years that it seems impossible I was in such a state.
Interviewer: Can you tell me what it is that's different?
Patient: Well, I am quite happy now. I do get upset, but it's not a lasting feeling.
Then, I just didn't feel anything.
Interviewer: So now you do feel something?
Patient: Yes ... for instance, a few days ago when I heard of the soldiers killed
in the Falklands, I was moved and cried. Six years ago, when I first came, I
wouldn't have cried. I would have been shut off. Last August, my stepmother was
very ill, in hospital, and I did become very upset. But it seemed to be just normal
upset, I was able to get over it. Crying made me feel better afterwards. And you
can see the opposite feeling as well - in those days I didn't laugh any more.
Interviewer: So now you are participating in both happy and sad events?
Patient: Yes, in everything somehow. I was just existing for 4 years. It seemed
perfectly normal to me at the time. But, looking back ... then, I couldn't care less
about anything, really.
Interviewer: Can you say at all how this change took place?
Patient: I can't really pinpoint it to anything. Not that everything was better at
once, but gradually things began to fall into place.
Interviewer: Can you say what things, and what you mean by 'falling into place?'
Patient: I think, after I left here, I didn't immediately feel I was better, but I
feel now that I am. I don't know how it happened. It is difficult to put into words.
With my stepmother last year ... it was pneumonia, and some friends were
blaming somebody else for giving her the initial cold. I thought I was possibly the
one, and I told my husband. I felt it was my fault. I was very upset, but we talked
3
4 Psychodynamics, Training, and Outcome in Brief Psychotherapy
it over and then I was better. Before, I would have shut it inside without saying
anything to anybody, and felt awful.
Interviewer: So you were able to talk it over with him?
Patient: Yes. It was a bit difficult to begin talking - I suppose I still have got
the ability to shut things off, but I deliberately try not to.
Interviewer: Why is that?
Patient: Because it makes me feel better.
Interviewer: Why couldn't you do it before?
Patient: Because I thought it would be too painful to do it.
Interviewer: What made you change your mind?
Patient: I don't know. The first time when I was crying, it was the initial feeling
of relief.
Interviewer: You didn't cry at all before that first session?
Patient: Not for years.
Interviewer: What made you cry?
Patient: I suppose it made me feel something. I was worried about coming here.
It was a relief when I saw I could get through the hour.
Interviewer: What were you afraid of before coming?
Patient: I was afraid she was going to ask me all those questions I was trying to
forget about.
Interviewer: Can you try and say why you came back for the second session?
Patient: Well, I came back for more relief.
Interviewer: So there was a difference between the doctor you expected and the
real one. Can you say what?
Patient: Yes, I suspect ... She didn't ask direct questions that I couldn't avoid
answering. So I suppose I felt ... sort of safer, because she wasn't threatening me
directly ....
Interviewer: Was she like that subsequently?
Patient: Yes, occasionally she asked things but not often. Most of the time I can't
really remember what happened. The first time I particularly remember, the rest
of it I don't remember anything really.
Interviewer: Now can you perhaps tell me about your engagement and your
marriage? As I understand it, you didn't think it possible ever again to become
close to a man.
Patient: I thought I must try and let myself get really involved. I had boy-
friends but I would never get really close to them. There was a long time when
I couldn't allow myself to think what it had been like with my fiancé. Then I
started thinking about what happened before his death. I remember I was talking
to a girl-friend, and saying I wish there was someone I really cared about - a
two-way relationship, security. It wasn't enough just to go out with different
men. I felt I had missed out. There had been a time when I started relying on
a man and I provoked great rows. I did it on purpose so that it would come to
an end.
Interviewer: Why didn't you do the same with your future husband?
Patient: I felt too strongly that the relation with him was worth risking.
Interviewer: Do you sometimes get angry?
Patient: Yeah!
Beginning at the end 5
Interviewer: Can you give me an example?
Patient: With my husband sometimes. It doesn't last long. I feel more irritated
than angry.
Interviewer: What about with other people?
Patient: The other day, when the pupils went out for an excursion, two boys had
been to a pub and came back to the school a bit drunk and caused a disturbance
[the patient is a qualified nurse who works as matron in a mixed boarding school].
I was furious, I shouted at them, I really did shout and tried to make them feel
as awkward as possible.
Interviewer: Were you successful?
Patient: Yes, with one of them anyhow.
These extracts from the follow-up of a 31-session therapy, 5M years since termi-
nation, illustrate many features which will form important themes in the pages to
follow.
The first issue is concerned with the validity of dynamic psychotherapy. Perhaps
we may start by saying that the patient should really be called 'the Nurse who
couldn't mourn her Fiancé', because the point of her story is that after her fiance's
sudden death in an accident 4 years before she came to us, she had not only been
unable to cry, but had virtually lost the power to feel anything. The process of
putting her in touch with her feelings began in the very first session. This is power-
ful evidence that her recovery was really due to her therapy, and that therefore it
is justifiable to speak of 'therapeutic results' rather than the non-committal
'changes that were found at follow-up' - for it is very difficult to maintain that a
disturbance lasting for several years should 'just happen' to begin to remit sponta-
neously within 1 hour of starting treatment.
The evidence for one of the important therapeutic factors is also highly
suggestive. Surely it is clear that the patient's ability to cry, after the lapse of
as many as 4 years, could not possibly have been caused by nothing more than
the relief of managing to survive the session, and that the therapist must have
done much more than simply refrain from asking awkward questions; for the
patient really implied that she found in her therapist a 'holding' atmosphere in
which she felt that she now dared to face her pain. It was certainly the thera-
pist's aim to create this atmosphere. Her account of the session included not
only many sympathetic interventions but also the following: 'At one point I was
thinking that very often the only way to help people in grief is to sit silently by
their side' - an example of the sensitivity and maturity possessed by many of
these trainee therapists, which will be illustrated repeatedly in the following
pages.
This story also illustrates the features of a complete therapeutic result. Although
of course the evidence is much more extensive than in these brief extracts, much
of it can be found there: in addition to the lifting of depression, the patient's new-
found ability to experience appropriate feelings within the situation that caused
them, the relief that followed, the entirely changed attitude to feelings of all kinds,
the abandonment of the determination never again to become involved with a
man, the closeness that she achieved with her husband, the clear evidence that this
relation is not idealised, and the ability to feel anger and to assert herself.
Therapeutic results possessing such completeness are rare in any form of therapy,
but we can state unequivocally that they do occur.
6 Psychodynamics, Training, and Outcome in Brief Psychotherapy
Also illustrated is the fact that for many patients their therapy is like a dream,
which sinks into unconsciousness when the dreamer enters the waking state. This
patient remembered little other than silence from the first session (and indeed
there was much silence), but in fact - as mentioned above - the therapist made
many interventions, and towards the end the patient reached a crucial piece of
insight: that during the silences she was thinking irrelevant thoughts in order to
stop herself from thinking painful ones; but this device no longer worked, and that
was why she was depressed. It was in fact this moment of insight that brought on
her tears, which began to come at that point in the session, and not afterwards as
she remembered. The rest of therapy also contained much interaction and was
sometimes quite dramatic.
Yet, although she remembered little of what actually happened, she clearly
possessed complete insight into the basic pathological mechanism involved in her
difficulties: namely, her defences (mainly emotional withdrawal), why they were
needed (to avoid almost unbearable pain), and what she was defending herself
against (overwhelming grief) - or in other words the three corners of the triangle
of conflict, which consists of defence, anxiety, and underlying feeling, and which
represents a fundamental concept in the science of psychodynamics. Moreover,
evidence for the therapeutic effectiveness of this insight is conclusive, for the
patient clearly described using it to prevent the pathological mechanism from
coming into action again and thus leading to similar difficulties - one of the major
aims of dynamic psychotherapy of any kind.
We may now turn to another patient, with whom insight into the therapist's role
and a clear memory of the events of therapy featured much more strongly.
The Girl (now aged 32) and the Mountain Tarn
(She had opened her initial interview with a story of how her father refused to
come with her to climb up to a mountain tarn, which epitomised her lifelong disap-
pointment in him.)
Part of the account of the 7-year follow-up interview, which was carried out by
an experienced psychologist, reads as follows:
She had felt more intelligent than her previous therapist and hadn't respected him, but
this one was shrewder than she'd initially given him credit for. She tested him out in
lots of ways and he wasn't stupid. She remembers one incident particularly. A
colleague from work used to pick her up in his car after her sessions. In one session
she spent the entire time resisting everything, and when she got into her friend's car
she 'had hysterics', screaming and yelling and bashing her head on the dashboard. Her
friend apparently lifted her up bodily, carried her back into the Clinic, and escorted
her to her therapist's room. It was very important that her therapist had taken her
back in, and particularly that his other patients would have to wait. She apparently sat
on the floor and just stayed there for half an hour. Nothing shocked her therapist, he
accepted her, and he wasn't cross, threatening, or rejecting. She spoke of the impor-
tance for her of a solid structure - meaning, on this occasion, both the therapist and
the floor she was sitting on.
This was a situation in which many therapists, however experienced, might well
have found themselves in difficulties, but our trainee evidently passed the test.
Once more we receive evidence about the 'holding' quality of the therapist as an
important therapeutic factor.
Beginning at the end 7
However, this book is not only concerned with successes, as the following two
extracts will show.
The Miner's Daughter
Patient (now 34): It's strange to be here again.
Interviewer (FO): How does it feel?
Patient: I sort of put it all in the past. I started thinking of it again after getting
the letter.
Interviewer: How was it to think of it again?
Patient: It made me feel it wasn't very good, whereas then I wouldn't have allowed
myself these criticisms.
Interviewer: Can you tell me more about your criticisms?
Patient: I came and saw Dr for about 6 months 8 years ago -1 had completely
forgotten her name before seeing the letter. Then she left the Clinic, and it really
was terrible. It was wrong to be abandoned when I wasn't ready, I felt very
rejected. I thought treatment was something helpful and she let me down, even
though she suggested I could see somebody else. But I felt it would be disloyal to
her and she didn't make it clear, as though assuming that I didn't need further
treatment. I was really upset, I never felt I could talk about it then, but I can talk
to you now. I was attached to her and it was really bad that she was going. I felt
hurt. I didn't feel I wanted to see someone else.
Interviewer: How did you feel about Dr 's behaviour?
Patient: Not resentment.
Interviewer: If it's not resentment, what is it?
Patient: I suppose it is resentment really.
It is clear from the above extract that there was some improvement at follow-up,
namely her new-found ability to speak of her real feelings; but in fact there was
little else, and we could wish that these feelings had not included intense un-
resolved resentment against her therapist.
It is also clear that in spite of much effort on the therapist's part, this patient
had been unable to work through her feelings about the bereavement caused by
termination, and who thus was probably selected wrongly for brief psychotherapy.
This is a danger requiring constant vigilance, and yet it is difficult to see how such
patients can be recognised at the beginning.
The Borderline Graduate Clerk
This also was a patient wrongly selected for brief psychotherapy, since the true
depth of his disturbance only became clear in the third session.
The following are extracts from the account of the 5-year follow-up, which was
carried out by an experienced psychiatrist:
I asked him if he could tell me anything about his therapy. He replied that he felt
extremely resentful about the tests that he was initially given here and about the 'author-
itarian system' that operated within the Clinic.
I asked him what he felt he had got out of his therapy. He said, Ί suppose a kind of
confidence with some people to some extent. What happened was that we developed a
fiction of me as a person with a lot of rage which had to be kept down in order for me