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SHORT TERM PSYCHODYNAMIC PSYCHOTHERAPY: an Analysis Of SHORT TERM PSYCHODYNAMIC PSYCHOTHERAPY: An analysis of the key principles The copyright of this thesis rests with the author. No quotation from it should be published without the written consent of the author and information derived from it should be acknowledged. One Volume by Penelope Mary Hamilton Rawson for Doctor of Philosophy degree University of Durham Department of Continuing Education 1998 N qq9 ABSTRACT This qualitative study seeks to discover the key principles of short term psychodynamic psychotherapy to answer the question: What is it? In uncovering its essential features it also aims to reveal the factors that influence the shortening process. The findings are based on an empirical study using eleven cases from practitioners who expect real change within a flexible time scale that is individually agreed with each client. The average number of sessions in this sample was 6.6, the median being between 4 and 6. The findings are seen to be underpinned by the work of the early proponents and also to have moved on from these. They both support and challenge contemporary authors on the subject. The author concludes that there are key principles that help to shorten the process of therapy. The conclusions fill a gap in the existing literature. They contribute to the body of knowledge available and are presented in a conceptual framework that brings both an original perspective and a new clarity to our understanding of brief psychodynamic therapy in the late nineteen nineties. The author goes one step further and concludes with a conjecture as to what it is about these principles that contributes to the shortening effect. 1 TABLE OF CONTENTS Page Abstract Table of Contents 1 Index of Appendices and Tables 2 Index of Illustrations 3 Declaration and Acknowledgements 4 Chapter 1 Introduction 5 Chapter 2 Setting the Parameters 17 Chapter 3 Theoretical Framework and Methodology 21 Chapter 4 Findings from the Initial Cycles of Analysis 35 Chapter 5 Part I 63 Analysis of the Emergent Key Themes: Findings from the In-depth Cycle of Analysis (i) What is Understood by the Phrase "Short Term" 67 (ii) Psychodynamic Roots 79 (iii) Flexibility 96 (iv) Activity 127 (v) The Focus in Focal and Short Term Psychotherapy 159 (vi) The Therapeutic Alliance and Motivation 182 (vii) Importance of the First Session 196 Part II 222 Summary of the Findings from the In-depth Analysis of the Key Themes and Provisional Conclusions Chapter 6 Introduction 229 (i) Commentary Client C 230 (ii) Commentary Client M 233 (iii) Client / 237 (iv) Client /'s Comment on the Therapy Experience 258 Chapter 7 The Analysis within the Wider Context of the Latest 261 Thinking in the Field Chapter 8 Inconsistency in the 'Universal Characteristics' seen in 283 the Literature Chapter 9 Concluding Chapter 289 Appendices 315 Bibliography 322 2 INDEX OF APPENDICES AND TABLES Page Appendix I Rawson 1992 'Focal and Short Term Therapy 315 is a Treatment of Choice' Appendix H Selected reviews, Substantive Early Works 318 and Status of Authors Appendix III Rawson 1995 'By Mutual Arrangement' 321 Table I Key Themes from Case Studies 38 Table II Analysis of Colleagues' Case Studies Against My Own 41 Categories Table III Proponents of Short Term Psychotherapy Consistently 43 Referred to in the Literature Table IV Main Ideas Emerging as Common Elements in Short 55 Term Psychotherapy from the Reviews Table V Ideas/Themes Introduced by some of the Reviewers 56 Table VI Analysis of Cases Against Key Themes Drawn from 58 Authors' Reviews Table VII Important Aspects of the First Session as seen 220 from the Research Casework 3 INDEX OF ILLUSTRATIONS Page Illustration I B's Illustration - Herbert/Fred/Alison 146 Illustration II B's Illustration - Mouth 148 Illustration III B's Illustration - Ali/B 151 Illustration IV /'s Illustration - Entrapped 239 Illustration V /'s Illustration - Imprisoned 240 Illustration VI /'s Illustration - X is shot 244 Illustration VII /'s Illustration - "Real justice Ha Ha" 245 Illustration VIII /'s Illustration - A safe haven 247 Illustration IX /'s Illustration - When will it end? 249 Illustration X /'s Illustration - The key 250 4 DECLARATION AND ACKNOWLEDGEMENTS I would like to gratefully acknowledge the help received in completing this research. This includes the financial support and time allowed by my employers: Thames Valley University, The London Institute, and Off The Record. In particular I would like to thank friends and family, especially my parents and Fr. Tom More for their support and encouragement, without which the work would not have reached completion. Thanks are also due to colleagues who have allowed their work to be analysed or offered comment, in particular B. Nolan, C.Swan, G. Dargert, A. Mann, F. Winch and Dr F. Lannon and to those involved in the typing side of the work, especially Sheena Atkinson and Sally Kimber. Louis Marteau, who could be said to have inspired the whole initiative, merits a special place in these acknowledgements. I am especially grateful to the clients who permitted their work in therapy to be used in this research, many of whom took the time and trouble to write their own version of the experience to aid the analysis. Some of the case work has been changed in order to protect confidentiality and some of the material excluded altogether for the same reason. All names used in the case material are fictitious and any resemblance to any individual is therefore chance. I am indebted to Durham University for providing the opportunity for this research, also to Professor Bill Williamson and to my supervisor Dr Tim Bond, whose encouragement led to my approach to Durham and who facilitated the work for my PhD. The copyright of this thesis rests with the author. No quotation from it should be published without her prior written consent and information derived from it should be acknowledged. 5 CHAPTER I INTRODUCTION This research has as its focus short term psychodynamic psychotherapy. It aims to discover and analyse the key principles involved. It aims to enrich the understanding of an approach to therapy that is already of benefit to many in our community but that could reach very many others if it were better known and understood. There is currently a gap in awareness and knowledge about the approach. The focal and short term psychodynamic model is not being advocated as the method of therapy but as a method of therapy. It is not the only method of brief therapy that is being practised today but it is the only approach that is to be studied here. My concern here is not for example, about Cognitive Analytical Therapy as advocated by Anthony Ryle or Solution Focused Therapy as expounded by Steve de Shazer, which are two of the better known contemporary brief therapies. It is not my intention in this study either, to be arguing the case for the efficacy of this model over and against other models of therapy, whether brief or longer term, it is simply to respond to the question I am so often asked: What is short term psychodynamic therapy? In order to answer this question in a way that the model could be accepted as an authentic method of practice, it needed to be more than simply the way my colleagues and I practised. It needed to be rooted within a tradition and be seen to link with the work of other professionals acknowledged as experts in the field. It needed to be examined in sufficient detail to reveal its constituent parts. I decided to undertake a qualitative and empirical study, using my own casework and that of colleagues as the starting point. I acknowledge the limitations that the small number of cases and the particular client group impose but, with Lincoln, remind the reader that, in the new paradigm enquiry chosen, which will be discussed in the methodology, there is a relational aspect which recognises the value of 'relationships between the inquirer and those who participate in the inquiry'. (1995:278). I began with the following questions. Were there common elements to be found in each case? Were these principles thought to be important by earlier exponents of the method? Who were the earlier exponents? In order to discover this and to be able 6 to locate the approach within the appropriate professional context, I searched the literature for key proponents of this brief approach. When I began this research there were few substantive works on brief therapy. However others, too, have clearly thought this area of knowledge deserved greater recognition and a number of new volumes have been published during the time span of this study, each addressing different aspects of the brief therapy work. A Dictionary of Counselling by Feltham and Dryden published three years after my research began also has a definition of brief therapy. (1993:22). However, I am not beginning the thesis with such a definition, since I want the reader to join with me in the process of discovery chosen for this research. Narrowing the focus of the research The main task of the research was to tease out in detail what is meant by short term psychodynamic therapy as revealed through the research cases, the key proponents and the literature. Clearly as Lincoln observes 'texts are always partial and incomplete' and I acknowledge this freely. (1995: 280). This text is limited and aims to examine in detail only one area of therapy within the wider therapeutic community and within brief approaches: The focus is: What is short term psychodynamic therapy? In the process of this discovery it is hoped that shortening factors are to be highlighted. The intention is to remain concentrated on this task and to include other material only in so far as it contributes to the primary focus.
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