VOLUME 6 #{149}NUMBER 4. FALL 1997

Brief PsychodynamicPsychotherapies

Past, Present, and Future Challenges

JERALI) KAY, M.D.

The future educational and research needs of

briefpsychodynamic psychotherapy are

discussed. Spec�fic shortcomings of current

education and training in brief dynamic

therapies are elucidated. Many of these are

relevant to psychotherapy instruction in

graduate medical education in nondynamic

treatments as well. Educational and

technological recommendations are suggested

to remedy these shortcomings.

(The Journal of Psychotherapy Practice

and Research 1997; 6:330-337)

M anaged care has had a dramatic influ-

ence on the recent conceptualization of

psychotherapy models and the delivery of

brief psychotherapy services. The advent of

brief dynamic psychotherapy, however, pre-

cedes managed care by decades; indeed, Freud

himself relieved Gustav Mahler’s impotency

through interpretation in a single four-hour

meeting.

H I S 1’ 0 H I C A I.

I N T R 0 1) U C 1 I () N

Although both Rank, through his focus on

separation, and Ferenczi, through his highly

active therapeutic stance, provide some conti-

nuity for many of today’s briefer treatments, it

was Alexander and French’ who contributed

most significantly to modern brief psychody-

namic psychotherapies.

Like Rank and Ferenczi, Alexander and

French were concerned that psychoanalysis

had become highly intellectualized. They fa-

vored a more emotional experience for the pa-

tient within the therapeutic relationship and

introduced the concept of the corrective emo-

tional experience. The corrective emotional ex-

perience, considered heretical by traditional

analysts up until the recent past, advocated an

intentional assumption by the therapist of a

From the Department of Psychiatry, Wright State Univer-

sity School of Medicine, Dayton, OH 4540 1-0927. Send

correspondence to Dr. Kay at the above address.

Copyright © 1997 American Psychiatric Press, Inc.

KAY 331

JOURNAL OF PSYCHOTHERAPY PRACTICE AND RESEARCH

stance different from that of the patient’s origi-

nal traumatizing or disappointing object. For

example, if the patient as a child experienced

his mother as intensely invasive, the psycho-

therapist would adopt a relaxed, nonintrusive

attitude toward the patient.

Alexander and French were accused of

abandoning therapeutic neutrality by manipu-

lating the patient. They in turn argued that the

corrective emotional experience permitted the

patient to appreciate more clearly the irration-

ality of his or her feelings.

Alexander and French anticipated many

of today’s values and models of brief psycho-

therapy. They disagreed with the traditional

psychoanalytic notion that most important

psychological work occurs within analytic ses-

sions. Most of the work, they argued, should

take place outside of sessions, through reflec-

tion and through encountering new life expe-

riences. They believed, moreover, that some

patients improved more quickly with once-

weekly meetings and that five sessions weekly

promoted significant regression in some pa-

tients and promoted avoidance of real-life ex-

periences critical to enhancing therapeutic

gains. Alexander and French relied on planned

interruptions in therapy that lasted from 1 to 18

months to assess what issues required further

work by the patient. Such interruptions, by

promoting independent functioning, evoked

greater confidence in the patient. These inter-

ruptions also assisted in the decision about ter-

mination and promoted the patient’s ability to

apply more readily that which had been

learned in treatment. Planned interruptions

are highly compatible with today’s managed

care values of episodic treatment.

The systemization of dynamic brief psy-

chotherapy began in the 1970s with the

writings of Malan,2 Mann,3 Sifneos,4 and

Davanloo.5 All four of these authors based

their brief treatments on the psychoanalytic

principles of transference, psychic conifict, and

ego mechanisms of defense and on traditional

drive theory. Each, however, placed different

emphases on the importance of some of these

theoretical constructs. For example, Mann’s

approach is much more comprehensive and

less focused on drive theory than are Sifneos’s

and Davanloo’s. Each of these models, as op-

posed to many of the new brief dynamic treat-

ments, does provide a consistent theoretical

position that explains psychopathology and

mutative factors. Together, these clinicians for-

mulated some of the enduring features of psy-

chodynamic brief treatments. These include

the following characteristics:

#{149}Adefinite time limit to the treatment.

#{149}Selection of a treatment or problem focus

no later than by the second or third ses-

sion.

#{149}Rapid establishment of a therapeutic alli-

ance.

#{149}A high level of therapist activity (com-

pared with psychoanalysis).

#{149}More frequent use of confrontation and

elicitation of anxiety (especially by Sif-

neos and Davanloo).

#{149}Use of interpretation and transference to

demonstrate the link between past and

present emotional problems.

Important new models of dynamic brief

therapy, largely based on research, were intro-

duced in the 1980s. These included, but were

not limited to, the models of Horowitz, ad-

dressing Short-Term Dynamic Treatment of

Stress Response Syndromes;6 Luborsky’s

Short-Term Supportive-Expressive Psycho-

analytic Psychotherapy;7 and Strupp and

Binder’s Time-Limited Dynamic Psychother-

apy.8 Moreover, there are a number of other

predominantly psychodynamic brief treat-

ments that are either less well known to clini-

cians or, in some cases, lack the scientific rigor

of the previous three treatment approaches. -12

Nearly every major psychoanalytic approach

has a brief therapy model. Accelerated Em-

pathic Psychotherapy’3 based on self psychol-

ogy and brief treatment based on control

mastery theory’4 are but two examples. The

newest psychodynamic approach to the treat-

ment of panic disorder is that of Milrod et al.’5

Although not yet validated, their approach

shows promise as a treatment intervention in

332 BRIEF PSYCHODYNAMIC PSYCHOTHEHAPIES

VOLUME 6. NUMBER 4. FALL 1997

light of the high relapse rates after discontinu-

ation of medication or cognitive-behavioral

therapy of patients with panic disorder.

Conspicuous by its absence in this cursory

review is Klerman et al.’s Interpersonal Ther-

apy (IPT).’6 Although many psychiatrists inte-

grate 1FF with psychodynamic psychotherapy

in the treatment of depression and other dis-

orders, this practice has not been studied. Kier-

man, however, was quite clear that 1FF is not

a psychodynamic treatment. 1FF is based on

Adolph Meyer’s psychobiology theory (which

emphasized adaptation to environment and

the role of life experience), Harry Stack Sulli-

van’s interpersonal process theory, and John

Bowiby’s attachment theory, which highlights

the psychological dysfunction that accompa-

nies disruption and loss of relationships.

S E C E C T E D

RESEARCH FINDINGS

The brief dynamic psychotherapy approaches

currently in use have been comprehensively

examined in two excellent overviews.’7’8

Rather than offer in-depth discussion of all of

these approaches, I present here selected

findings of research into the brief dynamic

therapies.

Compared with 1FF and cognitive-behav-

ioral therapy, most of the brief psychodynamic

psychotherapies have not been supported by

rigorous efficacy or effectiveness research.

Efficacy is determined through the use of ran-

domized controlled studies. Effectiveness and

cost-effectiveness refer to a treatment’s success in

situations that more closely approximate ac-

tual clinical practice. Randomized controlled

studies often have limited generalizability to

clinical practice because in their pursuit of in-

ternal validity they study diagnostically homo-

geneous patient populations, use therapists

who are trained to provide a pure or nonrnte-

grative treatment based on manuals, and em-

ploy monitoring of patient progress as well as

therapist adherence. Some efficacy studies lack

long-term follow-up, which is central to meas-

uring endurance of treatments gains.

By definition, randomized controlled

studies also exclude subthreshold cases

wherein patients present with psychological

problems that cause significant pain or dys-

function but fail to meet DSM criteria for a

particular disorder. These subthreshold cases

are quite common in private practice. Simi-

larly, the problem of comorbidity, which may

be the rule rather than the exception in private

practice, is not addressed in most rigorous con-

trolled studies.

There has been insufficient research in-

volving psychoanalysis and long-term psycho-

analytic psychotherapy. In the brief dynamic

therapies as well, sufficient research simply has

not been carried out.’9 It is impossible in many

instances, therefore, to speak of either the effi-

cacy or the effectiveness of many of these treat-

ments. The dearth of investigations, however,

does not substantiate inefficacy or ineffective-

ness; there is broad-based empirical and heu-

ristic support for psychoanalytically informed

psychotherapy.20�’

Pertinent research findings on brief psy-

chodynamic psychotherapy can be summa-

rized as follows:

#{149}Brief psychodynamic psychotherapy,

when compared in two meta-analyses of

19 and 11 studies with other psycho-

therapies, was superior to no treatment at

1 year.22’23 However, these meta-analyses

examined few studies in common, and the

meta-analysis by Crits-Christoph23 used

more rigorous inclusion criteria regarding

patient selection, therapist experience,

and adherence to models. His meta-analy-

sis was able to demonstrate that dynamic

brief treatments are as effective as other

brief therapies. Unfortunately, Crits-

Christoph’s study can be criticized be-

cause it included 3 trials where patients

were treated by therapists using 1FF.

#{149}Time-limited psychotherapy appears to

be as helpful as, but not more helpful than,

unlimited long-term psychodynamic

treatment.2�26 There is a demonstrated

dose-response effect in that the more treat-

333

JOURNAL OF PSYCHOTHERAPY PRACTICE AND RESEARCH

ment patients receive, the more improve-

ment or depth of psychological change

they show.27’28

#{149}There are insufficient data to prove that

any one form of brief psychodynamic psy-

chotherapy is more effective than another.

#{149}Although patients in brief treatment tend

to experience enduring gains,29’30 there is

increasing evidence that further psycho-

therapy is frequently needed, helpful, and

quite common in the treatment of some

disorders and emotional problems.

#{149}Characterological problems tend to re-

quire longer periods of treatment than

do symftoms such as depression and

anxiety.

#{149}Outcome measures employed in many

brief treatment studies do not adequately

reflect the measures traditionally agreed

upon to determine the success of long-

term psychoanalytic therapy and psycho-

analysis.3�

In summary, with regard to the efficacy

and effectiveness of brief dynamic psycho-

therapies, absence of evidence is not evidence

of absence.

i’III; FUTURE OF BRIEF

I)vN��II(; TREATMEN’FS

The Need for Research

Scientific and economic pressures are re-

sulting in less willingness to embrace heuristic

models without outcome measures showing

their effectiveness in the treatment of specific

conditions. While a psychodynamic approach

to clinical interactions continues to be the most

comprehensive approach to the understanding

of the subjective illness experience, loss, con-

flict, and other traumatic or intensely disap-

pointing experiences, it is clearly not the best

treatment intervention for all clinical situ-

ations. Empirical evidence supports some of

the basic psychoanalytic concepts on which all

brief dynamic therapies are based: the uncon-

scious; pathogenic beliefs; and defense mecha-

nisms.3234 However, dynamic brief therapies

will advance only through greater internal vali-

dation. Above all, it is important to remember

that the absence of comparative studies of brief

dynamic treatments and of long-term psycho-

analytic psychotherapy accounts for the con-

fusion in the field. Very few initiatives have

thoroughly evaluated the efficacy or effective-

ness of psychodynamic psychotherapy. In es-

sence, psychodynamic psychotherapy has not

been proven ineffective.

Key research issues that must be ad-

dressed in the very near future for brief and

long-term psychodynamic treatments are

listed in Table i.3’

Educational Challenges:

Psychotherapy Instruction

In addition to the problem of limited re-

search, the most potent threats to the future

psychiatric practice of dynamic psychotherapy

reside in the inefficiency and nonstandardized

instruction of psychotherapy training, the fail-

ure to appreciate the critical skills, attitudes,

and knowledge required to conduct psycho-

therapy, and the confusing psychotherapy

pedagogy.

TABLE 1. Research challenges for psychoanalytic

psychotherapy

#{149}Determining efficacy for specific disorders

#{149}Developing treatment guidelines for interpersonal

problems and personality disorders

#{149}Developing reliable and valid self-report measures

for core conificts

#{149}Measuring potential cost-offset of different therapies

#{149}Determining efficacy of short-term versus long-term

psychotherapies

#{149}Matching patients to treatment on basis of

personality, functional level, or developmental stage

#{149}Examining whether and how experienced therapists

can be trained in short-term psychoanalytic

treatments

#{149}Learning the limits of brief therapy and conditions

or symptoms for which longer term psychotherapy

should be recommended

. Note: List derived from Barber l994.�’

334 BRIEF PSYCHODYNAMIC PSYCHOTFIERAPIES

VOLUME 6 #{149}NUMBER 4. FALL 1997

Psychotherapy educators in psychiatry

have disappointed the field in at least seven

critical areas:

1. They have not developed and introduced

new educational technologies in residency

education.

2. They have not integrated psychotherapy re-

search findings and emphasized that effec-

tive psychotherapy is predicated on clinical

decision making and treatment planning.

3. They have not conducted meaningful re-

search on psychotherapy training.

4. They have not provided integrative mod-

els of psychotherapy, especially those in-

tegrating medication and psychotherapy.

5. They have not acknowledged that al-

though manual-guided training may suc-

ceed in bringing trainees to a criterion level

of adherence to technical procedures, there

is little evidence that it improves therapy

outcomes or that a therapist practices skill-

fully. In short, adherence is not the same

as competency.

6. They have underestimated in some cases

the challenges of leaming and conducting

effective brief dynamic therapy within the

training setting. These challenges include

#{149}The difficulty in selecting a therapeutic

focus in some clinic patient popula-

tions, where significant and complex

psychosocial problems are the rule and

comorbidity is commonplace.

#{149}The ethical concerns and the strong

feelings (often anger toward the clinical

setting and guilt) aroused in trainees

when they are obligated to limit treat-

ment to their patients or to adhere to

forced or unplanned terminations.

#{149}The impact of learning the limitations

of brief interventions with respect to

symptom alleviation and charac-

terological change.

#{149}The daunting challenge of grasping the

importance and role of transference-

and technical concerns about it-within

brief therapies.

7. They have also failed in influencing ac-

creditation processes by not demanding

more specific educational outcomes and

by stipulating pedagogical methods for

maximizing training experiences rather

than emphasizing locations and durations

of rotations.

If psychotherapeutic skills are to remain

in the core professional identity of psychiatrists,

new pedagogical approaches to the teaching of

psychotherapy must be developed and imple-

mented. This need has arisen because

#{149}There are too many idiosyncratic teaching

methods and too little standardization

across training programs.

#{149}Although most programs make use of

clinical experiences, individual super-

vision, and didactics/conferences, little

new has been added to our teaching meth-

ods in 50 years.

#{149}Faculty, for the most part, remain reluc-

tant to conduct psychotherapy in front of

trainees for teaching purposes and their

academic departments for peer review.

#{149}A minority of faculty still attribute difficul-

ties in trainee-administered psychother-

apy wrongly to countertransference issues

and not deficits of knowledge or skill.

#{149}The demise of the comprehensive psychi-

atric or case formulation, not the DSM-III

and its successors, has been responsible

for increasingly superficial assessments of

patients. Case formulation must be revi-

talized to provide residents with a new

pragmatic-but partly causal-methodol-

ogy that will enable them, in the context

of their phenomenological or descriptive

presentations, to suggest reasons for each

patient’s crisis, symptom formation, and

enduring pathological beliefs.

#{149}Many psychoanalysts have long recognized

the disjunction between metapsychology

and psychoanalytic practice. It is time to

jettison metapsychological constructs that

are confusing and superfluous to learning

the basic science of psychodynamics.

KAY 335

JOURNAL OF PSYCHOTHERAPY PRACTICE AND RESEARCH

#{149}Faculty who teach psychotherapy must

have a theory of “cure” to conceptualize

for trainees how behavioral or motiva-

tional change occurs. Without such a tool,

residents become overwhelmed by the

specificity-nonspecificity battle and the

irrelevant biology-versus-psychology

schism.

#{149}Although the practice of having residents

undergo psychotherapy has recently

fallen out of favor, its possible functions

in educating and professionalizing resi-

dents should be revisited and, if indicated,

new models for providing quality and

reduced-fee treatment to residents should

be developed. Psychotherapy may pro-

vide firsthand experience for residents

with the patient role, the power of the

doctor-patient relationship and transfer-

ence, the role of the unconscious, the cen-

trality of empathy, and the impact of

correctly timed and framed interpreta-

tions.

#{149}More than any other portion of the resi-

dency curriculum, psychotherapy instruc-

tion varies from program to program.

Master clinicians must assume leadership

in establishing a standardized curriculum,

not a model curriculum, for psycho-

therapy education. The development of

text material must be accompanied by

computer-assisted instructional formats

portraying model treatments by master

clinicians in addition to decision-making

exercises in psychotherapeutic interven-

tions.

#{149}Lessening the divergence between psy-

chotherapy research and practice35 is an

educational issue. Research findings

should be integrated into educational pro-

grams; case studies should no longer be

disparaged (they can be scientifically rig-

orous in testing a hypothesis); researchers

should include clinical vignettes and de-

tails about their techniques when describ-

ing their research; research should be

undertaken to determine what types of

psychotherapy research is helpful to clini-

cians; and further study is needed of the

accessibility and comprehensibility of re-

search findings.36

Educational Challenges:

Is There a Need for

New Supervisory Models?

Most therapists have never been trained

in any method of supervision. At least in psy-

chiatry, “see one, do one, and supervise one”

remains the pathway to becoming a supervisor.

Although this model remains prevalent in

medical education, it is no longer particularly

attractive. In many psychotherapy training

situations, faculty are unclear how to assist

trainees in defining the goal of treatment and

in identifying a core conflictual theme, focus,

cyclical maladaptive pattern, or central issue.

In short, current supervision in many pro-

grams is theoretically diffuse and unfocused.

New methods that assess the helpfulness of

supervision to the trainee and the impact of

supervision on the quality of care provided by

the trainee are desperately needed.

As increasing pressure to generate larger

parts of their salaries diverts faculty from teach-

ing, the professional development of the young

psychotherapy supervisor is in jeopardy. Al-

though manual-driven treatments have ad-

vanced psychotherapy research and patient

care, we do not have a manual for supervision

or standards that address knowledge, attitudes,

and skills necessary for effective supervision.37

Audio-visual (A-V) model cases for super-

visors should be developed to promote knowl-

edge, skills, and helpful attitudes about the

challenges and techniques of supervising train-

ees. Similarly, A-V practice tapes that would

assist the trainee in recognizing a therapeutic

focus or transference are greatly needed.

Supervising of supervisor and trainee could be

improved through the use of computer-as-

sisted and interactive video technology.

Examples of innovative programs can be

found at the University of Pennsylvania. Dr.

Aaron Beck’s program uses phone supervision

for trainees conducting cognitive-behavioral

336 BRIEF PSYCHODYNAMIC PSYCHOTHERAPIES

VOLUME 6. NUMBER 4. FALL 1997

therapy. This apparently has been quite helpful

for volunteer faculty, who, after reviewing the

trainee’s taped therapeutic sessions, can ad-

dress issues of behavior, style, and adherence

to manual treatment. Dr. Lester Luborsky, at

the same institution, has employed creative

group and peer supervisory models with his

residents, placing them each in the supervisory

position and the position of being supervised,

as well as integrating process notes and A-V

portions of the treatment itself. Roleplaying is

occasionally used also.

Consolidation of therapeutic gains in all

brief dynamic treatments requires close atten-

tion to the termination phase. However, there

is great variability among programs in the con-

ceptualization and teaching of the termination

phase, as there is also in the literature. Super-

visory exercises that elucidate the important

technical concerns of the termination would

be welcomed.

Educational Challenges:

Integrating New Technology

Most psychotherapists are unaware of the

high-quality, home-based, two-way cable net-

works that operate, especially in the western

part of the United States. Not only can such

systems be used to teach diabetic care in the

home, they can also be used to evaluate pa-

tients for psychotherapy and provide mecha-

nisms for consultation about disruptive

behavior in children and adults. They provide

the potential for conducting most or all of a

brief psychotherapy from long distance.38 Of

greater importance is the possibility of multi-

site cable-based supervision for one psycho-

therapy program or a consortium of programs.

In such a format, supervisors can model tech-

nique and maintain communication with

supervisees through the use of immediate

viewer response systems.

Psychotherapy educators have trailed far

behind other health care professionals in the

development of compact disc multimedia in-

teractive programs. These programs integrate

actual clinical encounters with self-learning

principles embedded in text. The Internet pro-

vides other opportunities for continuing edu-

cation without the constraints of production

delays associated with print material. Perhaps

someday it may be possible to have the psy-

chotherapist appear in the home of the patient

as a hologram. (Shades of Star Warr the psy-

chotherapist as the “Force.”)

C 0 N C I. U S I 0 N

There has been a long-standing tradition

within psychoanalysis and psychoanalytic psy-

chotherapy of developing brief, effective thera-

peutic models. Given the breadth and depth

of psychoanalytic theory, many of these heu-

ristic approaches have held promise; however,

few have been validated in the same fashion

as other, nondynamic brief treatments. Lack-

ing robust scientific data in both efficacy and

treatment effectiveness, many brief dynamic

therapies are under attack now from psycho-

therapy researchers, clinicians, and managed

care organizations. At present it can be said

that, as a group, the brief dynamic psycho-

therapies have received promising but limited

support from research.

Because the majority of all patient encoun-

ters, at least in American psychiatry, involve

some form of psychotherapy, and many of

these interventions are based on the principles

of psychodynamic psychotherapy, the field

must move forward and complete the research

that will substantiate the helpfulness of brief

dynamic approaches, either when used as the

only intervention or in conjunction with other

interventions such as medication.

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