')

6
The Beginning

.,:'- To be brief is almost a condition of being inspired.

George

Santayana

SELECTION
Which patients can benefit from object relations brief psycho therapy and which ones cannot? If a brief approach is used, should
the patient be seen in a supportive model or cal a more demand ing expressive approach
be taken? Which patients should be
excluded from brief therapy? In Chapter 4, I discussed two scllools
of thought, one that is quite exclusive (e.g., Sifneos 1987) alld
restricts the approach
to patients who meet variollS I-estrictive
criteria. The other school of thought is incl1lsive (e.g., Budman al1d
Gurman 1988) and tends to see brief therapy as being of benefit
for most, if not almost all, patients .

I
I

,,

"

132

OBJE (::: 'REU ' O)\)S BR!EF THER,'\P '{

TJ-IE BEGINN!NG

r.ly O\VI t11inkirlg places Jl1e il1 the il1clusive sch . 1 believe
t11at '~.ie!:t l'elations bl'iet- r;sycl1 therapy call be ofbenefit to 10St
patiel1ts . \\' JbCl'g (1.965) states :

'i e best

st.rateg)'irl

opinion is to aSSUI1lethat every patient

i'I'espectj,.'e of diagnosis \vill resp01 d to sJ OIt-terI tl'eatlneI)t ,
y

lll1Jess he pl'O\'eS J1il11sef l'efract ry

i.t. If the therapist

< pI 'acJles each p,ltiel1t '''ith the idea of doing as 1uch as he

ca ( )1' ) 'i ''' ithin the space f, say, up t 20 treat 1ent
sessi IS !)e wil! gi\'e the patient an 0pp rtunity to take advan
tage of ShOIttelI )treatl1 ent to t ! e il it f his p tel1tial. If this
fails, he ca a]\va}'s reS t to pI'ol nged treatment.
[p . 140 ]

' 'j1is idea of COl1sidering brief therapy" for potelltia!ly every

patie11t is sOllnd.lt is COl1sistent VI'ith tlle fact that most tl'eatment
is brief and with tl1e I'esearch that bl'ief therapy is generally high1y
effecti,,'e. MOl'eovel', it is compatible ,vith the rea1ity of the ma aged
cal'e models \vitl1il1 ,vhic!1 much psyc110therapy is now COl1ducted .
Ho,ve\'el', qualificatio s are i order. Wllile the brief tllerapy may
be beneficial, it ay 110t be as extel1sive1y 01' as intensively helpfu !
or gl:o'l'th-PI'O 10ti11g as I011gterm thel'apy. Consider, f r instance ,
the followillg diffel'el1t levels of therapeutic effectiveness: symptom
il1pl' venlellt, sympto 1 eli i ati l, impl'oved coping abilities ,
irlcreased self-a\vareI1ess al1d ullderstanding,
al1d charactero!ogical
change. SYlnpton1 inlpl'ovement
is celtainly a valuable therapy
outcome but it is qLlite diffel'ent fl'om the depth of enhanced se1fawal'eness alld persOlla1ity cllange" Usual1y, but n t al,vays, there is
nlore opportllnity for personality change in ng-term than i brief
t!lelapy .
As discussed in Chapter 2, the nature of time is different
( El1gelnlal1 et al. 1992) when the patie t and therapist experience
t11e11ulnbel ' f sessions as being 1il1ited and brief. Twe ty sessions
t11at al'e vie\ved as eing the total til11e avai1ab1e for therapy wil1
produce qlla1itatively differel1t c1inical matel'ia1 than twenty ses Si01 S t11at al'e seell as n1y palt f a potential1y pen-ended c n tlact. 111son1e cases, patiel1ts 1ay regress 1ess in the service of the
work and llncOnscio1.1S n1aterial is less availab1e (dreams, fantasies ,
associatiol1s) il1 the sessions. 1n othel- i stances, the brevity cre ates al1 affectivel}' intel1sified atln spl1ere that brings out latent
material .

.133

S me patiel1ts \vill require extenc]ed treatn1el1t t pel'n1it

mutati\le l11aterial t either en1el'ge 't be ,vol'ked tI11 lgl1.
Lee (single, 26 )'ears d) s ught thel'apy because f 11el'
difficulty in compJeting assigl1n1ents in her p sitiol1 as a
research assistal1t for a health care polic)' il1stit1.1te. Her '
tl1erapy was limited by financial reS Llrces aJ1d she COllld
afford t come for only t\velve sessions. Tl1e therapy ,vas
successful in that she ,vas able at terl11ination to complete
her job assignments
in a till1ely l1lal1ner but she still
strllggled with serious problen1s of lo\v and f'ragile self
esteem. The self-esteem issues ,vere onl)! touched llpon in
the brieftherapy
contract bllt we did identify 11el're]ation ship ,vith her n10tllel' as an ilnportant conlponent
of her
self-esteem problems. Six mont]1S later, Lee l'etll1'ned to
treatment, this time asking for arl open-ended approach .
Only at this point did she sett]e in al1d develop more of a
receptive capacity. This pel'mitted llS to explol'e the paill ful material of her childhood ,vith a se\!erely b rderline ,
suicidal m ther and her unc nscious identification
\\'ith
the m ther. 1n so doil1g, we began to adcll'ess her dist1.11
'bance in the area of self-esteem .
This case exemplifies an additiona1 benefit of brief tl1erapy t11at
sometilnes occurs-namely,
that tlle expel'ience of a positive, ben
eficial but limited t erapeutic re1ationship in brief tllerapy can sel-ve
as a cata1yst for 10nger term \vork. A positive outcome f S n1e brief
therapies is that the patient then enters a lO g-tel'ln therapy process .
Six Selection Questio .s
1 approach se1ection from a pragmatic rather thal1 theoretica1 stal1d p int: Can this particu1ar person at t11is part.iculal' POil1t il1 ti e
benefit fr m brief ther1 ~ K \\' ~ me? B.indel' .an ~ c leagues ( 19 ~ 7 )
have argued that the $rrln ~ n ~ selectl n crltel'la f the excluslve
m de1s, while theoretical1y appealing, do n t actually predict course
and outcome of brief therapy vel'y \vel!. Object relations brief
therapy can be ?elpf ~ 1 a ~ least in a limited \~~
1e patient can
meet the foll wlng crlterla :
. ;

J~

'..i.~

'\.,~.,~, 11..,.="
I
_
, ~.!

134 OBJECT RELATIONS BRIEF THERAP)'

1. Can the patient benefit fr rn psych

2. Can a clear f CllSbe defined ?

THE BEGINNING
therapy ?

3. Can the patient quickly devel p a p sitive, c laborative

relationsllip with the therapist ?
4. Can the patient tolerate the f1 stration of a brief approach ?
5. Has the patient responded positively to t1ial interpretations
or i1lte1-ventions in the evaluation session(s )?
6. Can the patient benefit fr rn brief disc nti11u lS c urses
fthel-apy (as 0pp sed t needing a continu us long-terrn
l-elati nship WitJl a therapist in order to change in \vays that
are sigllificant )?
If the answers t aJl of these questions are yes, then I \vouJd accept
the patient for brief thel-apy. AsI discussed in Chapter 4, C1"itsChristoph alld Barbel- (1991) conclude in their review of seJecti n
criteria for brief psychodynarnic
therap)7 that the patient's ability
to f rrn a posi.tive, collaborative relationship was tlle rnost irnp r tant criterion .

SETTING

, I

A FOCUS

This is the aspect of brief therapy that rnost distinguishes it frorn

long-terrn work. To be able to use the lirnited tirne available in brief
approaches
effectively, the therapist and patient cannot follow
every topic in an open, reflective rnanner. To do so allows every '
thing to be touched upon and nothing to be adequately dealt with .
In fact, a patient's persistent resistance to staying with a focus is
often a defense against intirnacy-staying
at a distance and survey ing the field but neve1- getting close to the rnaterial or to the
therapist .
In doing brief dynarnic work, 1 try to set two types of focus .
The first type is a sy ptomatic focus that directs the work toward
the patie1lt's distress a1ld the present-oriented
issues driving the
dist1ess. The seco1ld focus is a dyna nic one that selects a part of the
patient's underlying psycllodyIlarnic structure to c ncentrate n .
It is usually the case (bllt not always obvious) that the two foci are
c nnected and tllat \v rk 1 the dynarnic f cus will aid in the syrnp -

135

t rnatic w rk. It is tlle therapist's j b to st1-ive t unclerstand the

possible links between the foci. Most patie1lts in 1Yexperience \vill
readily agree to worl < n the syrnptornatic f cus but this is s rne tirnes not the case \vith the dlrnanlic one. F01- either fOCllS to be
suitable for treatrnent,
it rnust possess two elenlents. First, the
f cus rnust be lirnited en ugh for gains to be rnade within the con straints of the particular brief contract. Second, it nlust be sorne thing that engages the patient's rnoti"'ation and curiosity sufficiently
so that she is wiIling to work on it .
The therapist rnay not be able to deterrnine a dynarnic focus
within the first fe\v sessions, although it rnay elnelg.e as the therapy
progresses. Whether or not a sllitable dynarnic focus call be found
deterrnines if the therapy \vill be supportive 01' expressi,,'e .
Sifneos (1989) has described bl'ief suppol-tive psychotherapy .
The goal is to return the patient t the previolls IeveI of adaptatioll
even if it was not very stable. Insight and transference
are not llti Iized very pr rninently or actively. "One wOllld expect a dirninu tion in the intensity fthe syrnptorns, an irnproved self-esteern, and
a confidence in the treatrnent as a thera.pelltic rnodality tllat can
be sought in tirnes of future trouble" (p . 1564 ).
Expressive psych therapy airns f r OI-er and illsight is a
rnaj r g al. The therapist atternpts to expl re trans,ference and it
rnay bec rne a rnajor focus f the therapy. Depending n the indi viduaI situati n and the particular dynarnic brief therapy rn deI ,
the therapist and patient rnay have tlle following goaIs beY nd syrnptornatic and functional irnpr vernent: rnore enduring strength and
rnaturity of self-esteern, greater a\vareness of self and others, and ,
perhaps, significant character change .

BUDMAN AND GURMAN'S

TO SETTING A FOCUS

IDE APPROACH

Budrnan and Gurrnan (1988) listed the following as the five In st

c rnrnon f ci in their approach t brief therapy :
Losses: past, present, and anticipated
losses; losse$ of significant others; losses of health, job, status, self-irnage

J36

OBJECT RELA.TIOI ~S BRIEF THERAP

']-]-JEBEl~JNN!NG

''

Table 6-1. Focal Flo'~1CJ.1art

,DevelopJl e tal d,VSy7IC!I o ies: w11en expectations

at particular
trar1sitio11 POi11tS113\'e not been n1et, w11en one's cohorts
,ll'e see11 as having advanced to,val'd theil- goals more than
011eself (e,g" 'i1 tJ1oug11t I'd be 1arl-ied b)' now"; "AIl m )'
fliends are ll1anaget-s irl tl eil- con1panies, what's \'Vl-OI1gwith

I{ey q1lestion: \,\lhy J O\V ?

Is t !is "jsit relatec! t aJ '}of the f'oII \viI g ?
Deve!oplneJ ral
d}'S}'11CI
l'c,'}

Loss

e ?")

137

11 rel'pel'sol a !
cOI flict

te : e -so ai c07 ict,s: most con1mo11!y \vith intil11ate relation -

s!'lips (co\.lple and farI1il)' iSS1les), allt1101'it), flguI-es and co \ voI-kel-s

S)I lptoll atic j rese t(ltioll: patieI1t \V 11tShelp \vith specific symp toms-c!epl-essiol1,
anxiety, il somnia, phobia, sexllal dys t-\.lnction, and so 011
PerS071ality disol-(ler: pe1-sistent patte1-ns of self and relational
pat !!)(ogy
BIldman 11d GLlrl zlI1(1988) have suggested a f10w clart (Table
6-1) to assist il selecting al oIg t11ese focal themes ,
The focus t11at is selected is then examined along iIlterper sonal, c!evelopl eltal a1 d existelltial din ensions, As Budman and
G1,lrll an (1988) state :

' 11eI])E apI 'oach in rJrief tl'eatn1e1 t is a attempt to capture

and u11derstand tlle COI'eintel'pel'sOI1al !ife isslles that are ]ead ing tl1e patieI1t to seek psychotherapy at a given omeI1t in time ,
a1 d to l'el~{te tl1ese iSSlles to the patient's stage of life develop n1eI1t a11d to ]1is 01' !er existential concerns, (Existential con ceI-ns inc]tlde factors SUCllas the meaning and va]ues of o e's
life, alld ultimately t11eissue of confl-o ting one's O\\Inmorta ]ity,) [p , 2

1tl1il k tlis is a llseful scl ema to orgal ize our thinkingabout

focus-setting, To COI pare it to 111)' o\vn conceptualization
of t\VO
levels of fOC\,IS, \v!at 1 11ave descl-ibed as a s)'mptomatic
focus
irlcludes, b1.1tis 1IO(,!in1ited to, B\.ldman alld Gurn1an's fir'st four
foci-!osses, developmental
C!ysyI1chl-onies, interpersonal
conf1icts ,
, 311dsynlptol1 atic pl-eseI1tation. W1 at 1 have described as a dynamic
focus is sill1ilal' to their- per-sol ality disorder fo(:us but 1 would
bt'oadel1 it to include llndel-lying personalit)' issues in general, dis ordel'ed

or otl1er\vise ,

If the patient d es t vie\v t11eabo\'e focal aJ'eaS as l'e]e\:~IIt,

patient de f J1eSthe S)/II ptOI itself as t,l1eaj 'iSS1le,

,)1'

if t]1e

S)'n proI atic t'OC1IS

If t]1e patie t has had repeated pl'esentati<)ns arOlll C!a11y'01' a]! of tl1e
foci above, ,vithout clear benefit, or if C]1a1'acte1issl,les '!ecll1de these
foci because of constant interfel'e ce '\vit!-,t11etheI'ape1ltic 1)I'O(:O:S5
,
Cha!'acter fOCll5
Warni11g: U der circu 1sta ces of acti"e alcol101 01' clrllg abl1se,. tl1is
prob]en1 mU5t be addre5sed before 01- Si 1ultaI eousl,' \vitJ tl e cJe,'elop n1ent of an}' other focal aI'ea ,

~
cr

-,

Dlldlnan

and Gllr 1aJ1 1988, Copyrigl1t

STRUPP AND BINDER'S

TO SETTING A FOCUS

'91988 Gllil[()rd

P,'ess, Usecl \\'itl1 pcrnlissio!1

APPROACH

Strupp and Binder's approach is orga ized 3 \-0111

C\tl1e COl1cept of
the Cyclical Ma!adaptive Pattel-n (ClVIP), TJ1ey state: "The C:l\'IP is a
\vorking n10del , , . of a cent1'a! 01-salient patterl1 of il e\'pel'sol a !
roles in \Vhich patients lr1consciously' cast thelnsel"es; tl e C0111p!ementary roles il 1vhicll t ] ey cast otl1ers; ancl t ] e 111aJadal tiy'e
interaction
sequences,
self-def'eatirlg eXI ec1:;. tions, 11egati e self appraisa]s, and uIlpleasallt affects tl1at l-eSl\]t" (BincteI' al1(] Str-11PP
1991, p, 140), To deve]op the Cl\1P, the ti1el '" pist aJ1(1 patient
examine four areas :

1. 14cts 01selj, Both observable

behaviors and botl1 conscious
included in this category,

and co\-'ert (e,g" feelings)

311dUI1COnSCiOllSactions are

138

THE BECJNNINC

OBJECT RELATIONS BRIEF THERAPY

2. Expectations ab01lt others' 1'eacti011S.Tllese include conscious

and unconscious beliefs abollt the ways other people react
to the person.

3. Acts %lllers

toward lhe selj. This category

looks at the
in some way

actions of otl1ers tl1at appear to be connected

witll acts of self.
4. Acts o/seljtoward selj(introject). These are actions that indicate tlle ways that a person relates to him/herself
(e.g., selfsoothing, self-deprecating,
self-attacking, etc.).
The CMP is used as a collaboratively developed working focus
that becomes more fine-tuned as therapy progresses. An example
of a CMP would be a pattern of interpersonal
passivity coupled with
expectation
of rejection. The foregoing summary of Strupp and
Binder's ideas illustrates how groullded their work is in the relational life of their patients. While they emphasize interpersonal
conceptualizations
their work also addresses the world of internal
objects relations (e.g., acts of self toward self).

HOW TO SET A FOCUS

SettiJlg a meaningful focus \vithin a short time is one of tl e most
challel ging tasks for therapist al d patient. Binder (1977) has criti cized several models (e.g., Sifneos, Mann) for, in effect, avoiding
this problem by having predetermined
the fO,t::altheme for their
patients. He writes, "They tend to < ir ~ lJ Y\;nt the problem of
focusing
by pl'esetting it. Either
the ;;:111')0
ti~
at ttutse patients . who
,

_. ~ II .),-v
don t fit, or they make all patlents fit a procrustean
focus" (Blnder
1977, p. 233). What 1 aJ11suggesting is that the brief therapist not
initiate the process of focus-setting with preconceived
notions of
what. the focus should be. Rather, she should approach it as a pro cess of n utual discovery that places the highest priority on the
uniquenes5 of the patiel t. It can be very easy for therapist and
patient to deal with the anxiety of "not knowing" by jumping
prematurely
to a readily available but superficial
focus. Balint
and colleagues (1972) quote a former supervisor of Balint's, Max
Eitingon, as l'emarking, "Every new patient must be treated as if
he had come directly from Mars; and as no one has met a Martian ,

t:.

everything
unknown"

about each
(p . 126 ).

patieJlt

J11Ust be considered

139

as utterly

A brieftherapist
and patient may develop an initial focus \vithin
the first session or can spend many hours to develop it. M a an ( 1976 )
has preseJ1ted one of the most detailed and thorough approacl1es
to selecting a dynamic focus. He investigates the question through
the fol10wing :
1.
2.
3.
4.
5.
6.

Psychiatric history
Psychodynamic
history
History of interpersonal
relationships
The patient's present outside relationships
The relationship
made with t]1e theJ-apist
Projective tests .

When he finds a common theme running tl1rough most ot- these

six areas ofinquiry, he then has identified the focal conflict for the
therapy .
Attention to all of these areas is usually beneficial. In practice ,
however, such rigor is usuaJly not necessary to identif)i a suitable
initial focus to launch treatment. The brief theJ-apist often does 110t
need to invest the amount of time and energy thatMalan
does if
she is willing to use the initial foci as wO'rking tool5 that \vill be fine tuned as therapy progresses and is also willing to be flex.ible \vitl
technique as the therapy unfolds in its own unique manner. Selec tion and highly fine-tuned focus are most important wllen the theJ'a pist is planning to approach the patient from a strongly and acti\'ely
interpretive model .
If one takes a more flexible approach
in \vorking \vith the
patient, the follo\ving considerations
often pJ-ove adequate
in
developing \vorking foci and can usually be accomplished
in one
to three hours. The therapist strives to J ave the patiel t be an
active participant in the focus-setting .
History
In even very brief theJ-apy, for example a three-session employee
assistance program (E, ~ P) contract, it is essential to develop an
understanding
of the patient through taking a istory. In a typical

",

l.'

140

OBJEC.: 'REL\'rIO

brief t!1Cl'. P)' (f.)l t : (lI:t 1 ivO '. !c! speI)( ~l clt ]east an hOUl' obtaini11g
histl 'icaJ ii'lf.:'i'rI1atic,!',. lf 1 h ~l{i ()l .!)', sa)', t11ree sessions, I'd try to
clc,,'()te at. !east t\\iCllt)' lnilli,ltes t() it ...f.~111011gtJ1e most ilnportant
iSSlle:, tl J(.Jdl"ess:

.
2.
::\.
4.
!'i.
6.

J:'atient's iJ pl'cssiol1S ofpar'e ts, other members of the fam i.i)1 c,f' (}!,jgiI , ,'.:1 otllel' in 110l'ta t figures that contributed
to t]1C ~atje]ltspel'S()l ( 1.]it} ~ tl'!cture
}<ecl j'J'i]1g pattel'riS ()f 111, el-pe]'Sona] il tel'actions (e.g .,
l'epcJteltlj ' ] eilig ill an abused pc,sitioJl in relationsl1ips )
Best , d 'I\'i)I'Stlevels 01' past fLlnctionirlg
l~
'I'e\'iol,lS expel'ierlce 'I\,jtJ t!lel'ap )'
f ~anli17' istoJ 'o!'PS}'CflOlc'gica] distl.ll'bance including sl.lb5l<J.I ce .:JLIS
(:
F',lSt s ', icic!al, se]f-defe ~{ting, psychotic, or othel' regressive
bel avior ,

T\"lalarJ(19'i6 ) ] 3S J oted t ] at often taki g a l1istory itself can

be t ]' erapel lic, 'I'J (.~ < ltic11l is abJe to see (so 1etilnes for t1 e first
tinle) t!1<).ttl1(;I'e 3J'e ~;()r11el ']I(!erst " dable j atterns in his life while
it !l ; cl bef()!'e seelnec! Cll:.lotic an(1 il scl'utable .

Pre. ~eI t J~e7)el

THE BEGINNING

~5 6RiEF TI ER.',P'j '

o!FI.llICtiollill.g

is t]le p<ltieI1tf _lnctioning in the arel1as of ,vork, schoo ],

frieI1ds!1iJ s, il1til1<te ]'elatic)I S ) ips, alld ot11el' interpersona]
inter actit)ns? \Vj'lat is t]1e \: tieIlt's pl'esentil g prob!em : nd current ]eve ]
f distl'ess ? \,',lt. is the patie t's \'ie\v of hilnself?

1-lt)\\' \Vt ~]]

Trial Foci
One wal' to assess the suitability of a fOCLlSis to tentatively pJ'eSe11t
it to the patient aI1d see what the respo11se is. Does t]1e fOC lS SeeJ
to make sense to the atie]1t in te ]'] s ofhis pJ'eSe]1t unde]'stal1ding
of the problem? Is his curiosit), t11gaged by the focus? Does t]1e
patient seem to be defensi\:e and resistal t to it? Does the patic ] t
seem (0 be able to respond 0]11y to the 5yn ptol1 atic le\'eJ of the
fOCllS-if 50, he nlay at t !at pOillt, on!y be abJe to (10 SLippol'ti-,'e
therapeutic vol'k .
Psychological

Testi7lg

In n Y experience, usuaJly the p]'e\'ious!y listed considel'ations

\vil !
yield preliminaf)' foci a ; d I do not ]'egularJy use psycllo10gical test ing. Ho\vever, if the brief thel'apist is stl'l.lg'gling to de\'elop a
d}'namic focus vith a particulal' patient, psycl1010gical testing
( especially projective testing) can be very l.lseful. An exa]nple of tl1is
is presented below in the case of Diane .

SETfING

A FOCUS: UNCOMPUCATED

CASE-RONALD

Ronald, a 24-year-old single an, had just be g 11his sec ,

ond semester in la v school and was aCl tely a]1xiOllS
because of his so-so pe]'formance
during tJ e first sel11es,
ter. He was havil g great difficulty sleepi]1g, he couldll't
concentI'ate his studies, he felt out of control, a d \vas
viciously self-critical about tl is reaction. He felt ]1LI iliated
fOl' being so out of control. His i ] sllrance \vould covel ' 0 ]1])'
fifteen sessions of ps)'chothel'ap)'
and he 1vanted therap )
to be conducted \vithin that a ]10unt of time. ROI ald said
that he expected it would take ]ess tile t ] "n that "if it he!ps
at all ."
1n the first session witl1 Ronald 1 was impl'essed by
his narcissistic isslles and \vas a\Val'e of a nUll1bel' of fee !ings and reactions. First, 1 felt saddel ed b}' how a]'d he
1

Relatio

"!

l ij li,itli tl'e T11e,'apist

,<\ sk tlle ! aticII !'\\~, lL ~ Ile tlli ]:,S tl1e pl'obJel1 is, I O\\' s11euI derstands
it, aJld \..11'lt she ,vallts to C11 pl Clsize,WI at is it like sittil1g \vith this
patiel t? \ ~!ll;lt t)'pes of'1'e:,pol1ses does she evoke il tl1e therapist ?
"[ t <!'" t extel1t is t.lle ! atient
,lble tl) iI1ter'peJ'S011a!])' CO!lnect \,rith
the thel'aj ist ?

]41

'"

142 OBJECT REL TIONS BRJEF THEIt PY

THE BEGINNING

\ vas n 11imself al1d by h \v difficult it seemed t be f r

him t accept himself. He talked n1\.ngly ab ut illm st
always being disapp inted with himself. 1 f und my \ \ln
tl ughts g ing t \vard s me f my \ \ln Iack f self acceptance (a c nc rdant identificati n, see Chapter 3 ).
1 \vas feeling s me m derately str ng sense that I'm
g ing t be disapp ilting t im because 1 w n't meet his
. standards
(an ther c ncordant
identificati n). Lastly ,
1 was feeling s me irritati n at an arl ' gant, entitled qual ity t hil11 (a c mplementary identification).
F r example ,
wl1en 1 explained to him that I expected my patients t
file tI eir wn insurance f rms, he replied, "I realize that
tl1at's the way you d it f r ther pe ple, but c uldn't Y u
make an exception f r me ?"
At the end f the first session we agreed to work n
the symptol11atic focus ftrying t get his a xiery t a more
manageable level and t help him be able t c ncentrate
well en ugh to study. In law sch , a student can easily
fall h pelessly behind in just a few weeks. 1 also made a
tentative suggestion to R nald that 1 was impressed by
the extl'emely high standards that he set f r himself and
th ught that they may be c nnected "in some way" with
the intensity ofhis anxiety reacti n. He seemed to accept
that idea, and the issue fhis high r "all or n thing" stan dal'ds became the beginning
of ur dynamic f cus t
examine a part f his narcissistic character .
In tl1e sec nd sessi n, 1 t k a hist ry \\lith Ronald
and we began to see some of the f rmative factors affect ing his personality. (R nald's hist ry and c urse f treat ent [fifteen sessi 1S]al'e desclibed in Chapters 8 and 9 .)

SETTING A FOCUS: COMPLlCATED

CASE-DIANE

When she came into my ffice, this 32-year-old m ther was

depl'essed and said that she would 11avekilled herselfwere
it n t f r the fact that she c uldl t do such a terrible thing
t er four children (ages 7 t 12). She had been acutely

u .

suicidal f r the past t\\l\\ leeks. This f I\ \led 11el'al'rest

f r embezzling $30,000 fr n1 her el11pl yel'. The stealing
ccurred d zens f times ver the c urse f t\\l years in
diss ciated states. These acti ns were particularly il' nic
since she \\las married t a "nail 'em andjail 'en1" pr s ecuting att rney. The husband had had S11e limited c n tact with me during the previ us year when 1 had d ne
s me c nsulting with his rganizati n. Money was under standably tight and her il1surance w uld n t c ver seeing
me (their insurance was thr ugh an HMO). Als , she still
h ped that she and the family C uld f II w thl ' ugl1 n
their plans t m ve t rural N rth Cal ' ina in ab ut six
m nths .
The d minant feelil g I had in tl is first sessi n \\las
ne ffeeling ve \lhelmed-What
in the \\l'ld can 1 d
in six m nths? As a c nc rdant identificati n, this gave
me an experiential sample f s me f the ve vhelming
feelings she was experiencing. This feeling \vas intensified
when 1 tOk a hist ry il the next sessi n and leal'l ed the
f II wing. She was the dest ff ur siblings and was the
cust dial child after her father left the family \\lhen sl e
was 7. She ften denied herself("as tl1e substitute pal'ent ")
in deference
t the ther cl ildren. Her m ther was
described as being nice but als a perfecti nist \\lh W uld
beat Diane f r small things (e.g., n t cleaning up her r m
adequately). The first time Diane st e fr m her c mpany
was t get m6ney t save her n1 tler fr n1 being evicted
fr m her apartment. She described her father as being a
r tten man wh was alc h ic and \vh beat her m ther .
She had little t d with hel' father after he m ved ut .
When Diane was 7 she was sexually abused by tl1e
nephew f a babysitter. Fr m 15 t 19 she had a steady
b yfriend wh m sl1e described
as the !ove f her life
despite the fact that he W uld beat her. He died in a
motorcycle accident when she was 19. Als , 11erfather died
fa heart attack when she was 19 f Iwing an argument
with him (her paternal grandm ther blamed her f r his
death). Additi nally, she had a hist ry of epis des f

143

--========--=~---_._----_._-

144

iI1lptlJsi\'e, s()metirlles 'v10lent self-destructive behavior that

Plll ctllated (ptlllct1lred, 1 t,ll011g11t)generally responsible ,
cOl1velltio aJ bel1a\10r, Diane 11ad ne\'er stblen before but
l-epol-ted a history of overspendil1g .
Tlle syn1ptomatic
fOC11Swas straightfor,vard:
,ve
decided to ,vork 011dill1inislling her suicidal feelingsand
to deal ,,,itI1 the stl-ess ofthe impending legal proceedings
against el-, But ''lhat ,"ould be a realistic dynamic focus
over tl1e 11ext six 111011ths?This \vas a woman ,,,ith a his tory of m1lltiple tl-aul as involving loss and abuse who had
serio1ls pl-oblell1S with in1pulsivity alld perhaps a border line cllaracter structure. 'fo try to determil e this fairly
quickl)', 1 referl-ed her to another pSyCl1010gist for testing .
1 also felt that it ,vould perhaps be 1lseful in the legal pro ceedings for testing to be done .
The results of tl e psychological testing indicated that
she did in fact have a borderline personality disorder with
er ego being cl aracterized
by multiple splits al d particu la)-I)' a split bet,,,eeI a self with strict self-punitive perfec ti01 is ( UI COl1scious idel tification with her nl0ther) and
al10tl er self that was imp11lse-ridden and irresponsible
(unconscious
idel1tification ,"ith her father). The testing
also )-evealed a high degree of conscious suppression
of
painful expel-ience and much shame but little guilt .
1 received the test results from tl e testing psycholo gist and interpl-eted them to Diane. In the interpretation
,
1 explained ,,,hat the diagnosis of borderline personality
n1eant. 1 said that, in part, it was a personality character ized by mal ')pOI-tiol1S that are 1lnconscious and not inte grated togethel" so that the split parts clash and sudden
changes can OCC1ll-that seem baffling to the person. Such
a personality stl cture causes the person to often feel over ,,, helmed and out of cOl1trol. 1 gave the following illustra tiOI: "Ho,,, can we undel-stand how a person who is so
dedicated to hel- fan ily can suddenly, witllout thinking ,
do things tl1at .are so destructive to 11er and to tllem ?"
This description ofher personality seemed to be quite
poignant for her and she said tearfully that she had been .
. ,,
!.'

HE BECINNI

OBJEC 'REL TJONS BRIEF THER. PY

,C

115

\' ery tl"oubled f'OI'a long til'lie abollt thp. chaotic atL11'eof
heI' personaJity aI1d rllat it h<IC!caused 11ej't ( t-eeJ cl-azy ,
The i relii11illal'}' d}'l1anlic f'ocus \"e set, ll1ell, ,vas to
expJore the nleanillg arld ir act of t.Ilese splits alld the
" enlotional stornls" (as she ci.llled tllen1) tJlat \vere ,1 COIsequence of thenl. She \','as cleal-l )' 11 Oli\'ated lO explo!"c
this pal-ticulal- tJleI'ne dlle in part to its eillg cC>Ilnected
in 11er o\"n mil1d \vit.h feelirlgs ofbeing ove -\ vhe!med and
out of control , t is 11ore\vol-thy tJ1at t]1ese \':el-e Stl-Ollg
feelings that 1 had 11ad ill t]1e fil"s( sessiol1 \Vit]1tlel- and
were, as already noted, a concordaJlt projecti\'e iclelltifi cation. As the t]lerap)' pl-oceeded o\'er a coul-se of"t\-vellty five sessions this focus becanle nlore fil1ely tLlrled al1cl is
described. in Chapters 8 and 9 ,

DEVELOPING

THE WORKING

ALLIANCE

believe that good brief therapy is veI 'silnilar (0 good long-teI-11

,vork. Too mUC}lhas been made oftl e differellces bet\veen tl e t\VO,
The differences al"e significallt bllt uch of\\'hat is lelpful in 1011gterm \vork is also helpful il1 bl-ief tJ el-apy. This point applies to
developing the ,vorking alliance. TJ e il11portallce of tlle tl1el-apist
operating from a stance of empathic attLlllelnent, sel1sitively and
nonjudgmentally
trying to understand
the patient's COllcerllS, and
interacting with the patient in a manner- tllat conveys I-espect, com petence, and compassiol cannot be exaggerated
in its I"ole in
developing a \vorking alliance in any fOI"m of psyc]1otherap )',
However, tinle is limited and at a prenliun1 il1 bl-ief tllerap )'
and it raises the challenge to not ol y deve]op a \-vorking al1iance
but to do so qLlickly. The following al-e sOlne e!ements that cal1
facilitate the swift developl11ent of a working alli<l11ce.
Be Aware o!the Common Coulztertrall-S!erellce

o!Impatiel

ce

The therapist needs to take care to 110tpush tJlis pl-ocess faster thall
the patient can tolerate. When 11e tries to speed up tlle thel'apy
without adequate respol1siveness
to the patient's I-eadilless, tlle

11"

I'

l..~,

"
146

OBjECT RELA.TIONS BRIEF THERAPY

patient may experience a repetition of earlier unempathic relation ships or the patiel1t n1ay defensively idealize the therapist. As dis cussed in Chaptel- 2, the brief tl1erapist n1ust be awal-e of the com mon countertransfel-ence
of impatience in the face of the time and
resource constI-aiI1ts. A rapid developmel1t of the \vorking alliance
is differeI1t from a hasty development.
I have had the opportunity
ovel' tl e last few years to supervise a number of therapists doing
brief work. As might be expected, less experienced therapists tend
to el-r 011 the side of setting a focus quickly al1d running \Vith it
before the patient as truly made an adequate a1liance. On the other
hand, mOl'e experienced, predominantly
long-term therapists tend
to err on the side of needing a great deal of evidence of an alliance
before proceeding \vith a focus, consuming much of the limited time
they have .

Direct Attentio

to the Patient's Pain and His View o!It

When it is clear to the patient that the focus will speak to his pain
and suffering, tl e focus strongly promotes the therapeutic alliance .
Acknowledgment
of the patient's suffering and his tInderstanding
of it certainly help the patient to believe that this is someone that
\vill take hin1 seriously. What is less obvious is that the therapist may
internally be aware ofit but only overtly inform the patient ofwhat
she thinks is 1'eally going on .
For example, a married man arrives for his first session
saying, "1 don't see any reason for being here, my wife said
I had to come or she'd leave me .... I think therapy is
ridiculous." Tl1e therapist learns tl1at the patient can be ,
vel vel'bally abusive and was the target of much verbal
abuse hiI self as a child. To move the therapy along the
therapist says, "It sounds like your wife is angry with you
because you seem to verbally attack her a lot. This may
COIe from your own childhood and we need to under stand tl1is better." While this statement
may be quite
accurate, it is so farfrom the patient's o\vn experience at
this moment (he doesn't think that he's abusive toward
her) tl1at he feels criticized and misunderstood
and is even

THE BEGINNING

147

Iess Iikely to make a therapeutic a1Iiance. The patiel1t's OWl1

definition of the problen1 is that he's af]'aid of IOSi]1ghis
marriage, and he doesn't cleal'Iy know \VJ1Ybt!t his wife is
upset with him .
A more useful therapeutic intelllention
at this POil1t
might be, "Your wife is threatening to Ieave you al1d you 'I'e
baffled by this, Iet's see if we can understand
this better .
You I'eally don't \Val1t 11er to lea'v'e and want to fil1d so ] e
way to get her off of your back." The patient ight feel
more understood
\vith this i]1tel'ventiol1 and be more
willing to explore his inteJ'actions \vitl1 his \vife iJ1 this
context. Eventually, of COul'se, he wil! need to tak,e S011e
responsibility
himself fOI' the problems
but tl1at can
emerge more gradually. This iSStle of \vorking \vith the
patient within his perspective is particularly important with
personality-disordered
patients because quite frequel1tly
the therapist rather quickly can see aspects of the prob lem more clearly than the patient does. The only catch is
that the therapist's view is so diffel-ent frol11 tllat of tl1e
patient that it is unusable as a direct inteIIlention (a1thOtlgh
it may be quite valuable as a piece of tlnderstanding
that
the therapist contains fOI-the time being ).

Take the Histo as a Shared Process O!Discovery

The very act of taking the history can be therapelltic. In Chapter 3
I described some of the brief therapy with Rita, a 32-year-old col lege instructor who entered therapy depressed ovel- hel' I'elation sl1ips with men. As part of the histo - taking, r ask patieI1ts to give
me personality sketches of importaI1t people in their Iives and 1
asked her about her father and two husbands. Rita \vas surpl'ised
by how similar her descriptions were. They weI'e all ratl er exciting
objects-engaging,
interested in many pursuits, sexually flirtatious ,
but also very self-involved, \vith limited interest (or capacity?) fOl'
empathy or emotionaI giving. Rita had nevel' befol'e seen these simi Iarities and it gave her hope in two \vays. First , O\Vtl1at the pat tern was identified she could wOl'k to\vard changing it. Second, if a
m ~ or pal't of her problem involved selecting meI \ vith ceI'tain

148

O .13 ECT REL. ~ TJONS BRIEF THEP-",Py '

c ! aractel-istics, s]1e fe!t thal: peJ'h ~lpS tl1ej-e \\'ere othel' men out thel'e
\ vho igl-lt be able to bettel' meet 11el-neecls. TJ1e J eaJ1i11g of h.er
se!ectiol of SLI(:hn1eJl in 11el-life becanle tl1e clyllan1ic fOCL1Sof the
tJ1eJ-apy.
:nle Collabo/-ati .' e Proces_~ o! Setting tlle Focus Can
A._5sistill Allial ce Buildi g

111a bl'iet' theJ'apy co text, 1 typically iIclicate t]lat, for the tl1erapy
to t~ usef'ul \vitl1in tlle limits that we ha,-e, ,ve ,vil! need to decide
\ That \ve can realistically accol 1plis11. 101'eover, 1 state that this \vill
il voI,le decidillg what issues we call focus 0]1 and \vllat_\\'e \\'il1110t
be able to address. Especially \vith therapeutically nai'le patients the
pl'ocess of focus-setting
is frequentl)T a holding and containing
experience
in that it can n1ake the tl1eral eutic process seem less
vague and formless. Patients witl1 strong fears about intimacy
and dependency
ma)T fiJ d tl1e emphasis on a focus to be anxiet )'reducing sil1ce it dil'ects the patient to center 011 a shared, some \\' hat strllctured task. Tl1e fOcLls'setting described previoLlsly with
P,onald and Diane helped to build therapeutic alliances witl1 tllem .
Utilize tl e Kllow[edge o..ftl~e Patiel t !rom
Tra 1S!ere ce a d COU tertral s!erel ce Reactions
Tlle eal-Iy cOlltacts with a patient can often pl'ovide tlle therapist
\ vitl1 il pol'tant infol'n1ation that can be llseful in solidifying a work il1g alliance. Rita 11ad a 11istory of sexually cl1arged, exciting object
relationships witl1 ] en, and 1found yselfin tl1e fil'St session think ing sOl1etl1ing along tl1ese lines: What a compelling, sexy woman ;
1 wisl1 1 11adl1't lnet 11el'in tl1erapy. 011, I'd disappoint her anyvvay .
Tl1e qllick el'otizatioIl of tl1e therapeutic
l'elationsl1ip and n1Y
sel1se tllat l'c1 Llltimatel)' clisappoil1t her were pl'ojective identifica tions tl1at alel'tec ! l e to el'otic and exciting object isslles being
pron1i11el1t fOl' her iI1traps}'chically alld interpersonally.
Her descrip tion of tl1e pl'esentillg problen1 did not overtly i11clude those ele el ts. Tl1ey did come out, as 'noted above, in the histOl taking . 1
didn't i11itial1}'intel'p]'et wl1at 1 saw bLlt ratl1er sat witl it and tried
to n1alze SOl1e sense ofit. In my experience, early interp]'etation
of

THE BEGJNNJNG

149

such materia] often impedes a!liance-bui]ding.

As 1 discLlssed il1
Chapter 3, Rita did come [0 see e by the sixth sessiOl1 as yet
another disappointing, excitil1g, and ultinlate!y rejecting mal1. Some
of the most importa11t work that we did ,vas around this transfel -ence to me. 1 ,vas ab!e to be more l'esponsive to it tllroug]l 111
)'
awareness of the countertransference
fantasies 1ad !ad in t]le fi]-st
session .