Microsoft Word - Levenson-Eells Chapter.doc

From: T.D. Eells (Ed.), Handbook of Psychotherapy Case Formulation

. New York:Guilford,

pp. 164-197.

CYCLICAL MALADAPTIVE PATTERNS:

CASE FORMULATION IN TIME-LIMITED DYNAMIC PSYCHOTHERAPY

Hanna Levenson and Hans H. Strupp

Historical Background

Time-Limited Dynamic Psychotherapy (TLDP) is an interpersonal, time-sensitive

approach for patients with chronic, pervasive, dysfunctional ways of relating to others. Its goal

is to modify the way a person relates to him or herself and others. The focus is not on the

reduction of symptoms per se (although such improvements are expected to occur), but rather on

changing ingrained patterns of interpersonal relatedness or personality style.

While the framework of TLDP is psychodynamic, it incorporates current developments

in interpersonal, object-relations, and self psychology theories, as well as cognitive-behavioral

and system approaches. The type of formulation we discuss in this chapter--the cyclical

maladaptive pattern--is structured to inform the therapist about the patient's present mode of

relating, the goals for the work, and how to keep the therapy attuned to these goals.

TLDP makes use of the relationship that develops between therapist and patient to kindle

fundamental changes in the way a person interacts with others and him or herself. Its premises

and techniques are broadly applicable regardless of time limits. However, its method of

formulating and intervening makes it particularly well suited for the so-called "difficult patient"

seen in a brief or time-limited therapy. Its particular strengths include: (1) applicability to the

treatment of difficult patients (broad selection criteria), (2) relevance and accessibility for

psychodynamically-trained clinicians who want to work more effectively and more efficiently,

(3) empirical scrutiny of the model, (4) a flexible framework that allows therapists to adapt it to

their own unique therapeutic styles, and (5) avoidance of complex metatheoretical constructs by

staying close to observable data where possible.

A treatment manual describing TLDP was developed for research purposes and published

in book form--Psychotherapy in a New Key: A Guide to Time-Limited Dynamic Psychotherapy

(Strupp & Binder, 1984). A clinical casebook, Time-Limited Dynamic Psychotherapy: A Guide

to Clinical Practice (Levenson, 1995), translates TLDP principles and strategies into

pragmatically useful ways of thinking and intervening for the practitioner. In Key Competencies

in Brief Dynamic Psychotherapy, Binder (2004) outlines basic competencies needed to conduct

dynamic-interpersonal therapy in general with a strong emphasis on TLDP.

Historically, TLDP is rooted in an object-relations framework. It embraces an

interpersonal perspective, as exemplified by the early work of Sullivan (1953), and is consistent

with the views of modern interpersonal theorists (e.g., Anchin and Kiesler, 1982; Benjamin,

1993; Greenberg and Mitchell, 1983). The relational view focuses on transactional patterns

where the therapist is embedded in the therapeutic relationship as a participant observer or

observing participant; transference is not considered a distortion, but rather the patient's

plausible perceptions of the therapist's behavior and intent; and countertransference does not

indicate a failure on the part of the therapist, but rather represents his or her natural reactions to

the pushes and pulls from interacting with the patient.

Conceptual Framework

Principles

The TLDP model adheres to seven basic principles:

1. People are innately motivated to search for and maintain human relatedness.

In attachment theory terms, the infant’s orientation to stay connected to early caregivers

is based on survival needs. We are hardwired to gravitate toward others (e.g., newborns are

more likely to gaze at designs in the shape and structure of a face than at more abstract ones).

The more we are able to establish a “secure [interpersonal] base” (Bowlby, 1973), the more

likely we are to develop into independent, mature, and effective individuals.

2. Maladaptive relationship patterns are acquired early in life, become schematized, and

underlie many presenting complaints.

How one relates as an adult typically stems from relationships with early caregivers in

the following manner. If caregivers (usually parents) are attuned to the needs of the child and

are accessible, the child feels secure and is able to explore the environment—feeling safe and

loved. If the caregivers are inconsistent, rejecting, and/or unresponsive, the child will feel

insecure and could become anxious or avoidant. Bowlby (1973) held that early experiences with

parental figures result in mental representations of these relationships or working models of

one’s interpersonal world. These experiences form the building blocks of what will become

organized, encoded experiential, affective, and cognitive data (i.e., interpersonal schemas)

informing one about the nature of human relatedness, and what is general necessary to sustain

and maintain emotional connectedness to others. The child then filters the world through the

lenses of these schemata which allows him or her to interpret the present, understand the past,

and anticipate the future. Unfortunately, these schema can become a dysfunctional, self-

fulfilling prophecy if early interpersonal experiences are faulty. For example, a child might be

placating and deferential because his parents were authoritarian and harsh toward him. He

would have an expectation that others would treat him badly if he were not compliant. The

danger is not only that his submissiveness might invite the very behavior he was most afraid of

(dominance by others), but also that since his “working model” of the interpersonal world was

out of his awareness, he would continue to be at its mercy.

3. Such patterns persist because they are maintained in current relationships (circular

causality).

This emphasis on early childhood experiences is consistent with the basis for much of

psychoanalytic thinking. However, from a TLDP framework, the individual's personality is not

seen as fixed at a certain point, but rather as continually changing as he or she interacts with

others. Data from neurobiology seem confirmatory; while relationships play a crucial role in the

early years, this shaping process occurs throughout life (Siegel, 1999, p. 4). Although one's

dysfunctional interactive style is learned early in life, this style must be supported in the person's

present adult life for the interpersonal difficulties to continue. To go back to our example—the

placating and deferential behavior of the child becomes well practiced into adulthood. As an

adult, his compliance allows others to take advantage of him at best, and treat him harshly at

worst. If he had experiences as an adult (e.g., being assertive and not being punished, being

treated with respect and like he had a voice) that ran counter to his internalized working model,

from a TLDP perspective he would be expected to shift (over time) to a more robust and

enlivened view of himself and his relational world.

This reasoning is consistent with a systems-oriented approach, which holds that the

context of a situation and the circular processes surrounding it are critical. Pathology does not

reside within an individual, but rather is created by all the components within the (pathological)

system. According to systems theory (Bertalanffy, 1969), if you change one part of the system,

the other parts must also change, since the entire system seeks a new level of stabilization.

4. Therefore, in TLDP, clients are viewed as stuck, not sick

Clients are seen as trapped in a rut which they helped dig, not as deficient.

5. Maladaptive relationship patterns are likely to be reenacted in the therapeutic

relationship.

A fifth assumption is that the patient is likely to interact with the therapist in the same

dysfunctional way that characterizes his or her interactions with significant others (i.e.,

transference), and may try to enlist the therapist into playing a complementary role (i.e.,

countertransference). From an interpersonal therapy perspective this reenactment is an ideal

opportunity, because it provides the therapist with the very situation that gets the patient into

difficulties in the outside world. The therapist is given the chance to observe the playing out of

the maladaptive interactional pattern, and to experience what it is like to try to relate to that

individual. In Sullivan's terms (1953), the therapist becomes the participant observer

mentioned earlier. The relational-interactionist position of TLDP holds that the therapist cannot

help but react to the patient—that is, the therapist inevitably will be pushed and pulled by the

patient's dysfunctional style and will respond accordingly. This transactional type of reciprocity

and complementarity (i.e., interpersonal countertransference) does not indicate a failure on the

part of the therapist, but rather represents his or her "role responsiveness" (Sandler, 1976) or

"interpersonal empathy" (Strupp & Binder, 1984). In such reenactments, the therapist inevitably

becomes "hooked" into acting out the corresponding response to the patient's inflexible,

maladaptive pattern (Kiesler, 1988), or in Wachtel's terms (1993), patients may induce therapists

to act as "accomplices."

That the therapist is invited repeatedly by the patient (unconsciously) to become a partner

in a well-rehearsed, maladaptive two-step has its parallels in the recursive aspect of mental

development. For example, children who have experienced serious family dysfunction are

thought to have disorganized internal mental structures and processes as a result; these

disorganized processes impair the child’s behavior with others, which causes others not to

respond in empathic ways, thereby disorganizing the development of the mind still further

(Lyons-Ruth & Jacobwitz, 1999). It’s a case of the rich get richer and the poor get poorer.

To get oneself unhooked, it is essential that the therapist realize how he or she is

fostering a replication of the dysfunctional pattern, and use this information to attempt to change

the nature of the interaction in a more positive way, thereby engaging the patient in a healthier

mode of relating. In addition, the therapist can collaboratively invite the patient to look at what

is happening between them (i.e., metacommunicate), either highlighting the dysfunctional

reenactment while it is occurring or solidifying new experiential learning following a more

functionally adaptive interactive process.

Since dysfunctional interactions are presumed to be sustained in the present, including

the current patient-therapist relationship, the therapist can concentrate on the present to alter the

patient's dysfunctional interactive style. Working in the present allows change to happen more

quickly because there is no assumption that one needs to work through childhood conflicts and

discover historical truths. This emphasis on the present has tremendous implications for treating

interpersonal difficulties in a brief time frame.

6. TLDP focuses on one chief problematic relationship pattern.

While patients may have a repertoire of different interpersonal patterns depending upon

their states of mind and the particulars of the situation, the emphasis in TLDP is on discerning

what is a patient's most pervasive and problematic style of relating (which may need to

incorporate several divergent views of self and other). This is not to say that other relationship

patterns may not be important. However, focusing on the most frequently troublesome type of

interaction should have ramifications for other less central interpersonal schemas and is

pragmatically essential when time is of the essence.

7. The change process will continue after the therapy is terminated.

The goal in TLDP is to interrupt the client’s ingrained, repetitive, dysfunctional cycle. In

so doing, the intention is to promote forays into healthier behavior, which theoretically would be

responded to differently (more positively) by others, thereby increasing the person’s proclivity to

engage in a more satisfying manner. At the end of a brief therapy, such changes have only

begun to take hold. It is expect that overtime as one had more opportunity to practice such

functional behaviors, the interactions with others and the resulting more positive internalized

schemas would become strengthened. In other words, the therapy sessions end, but the therapy

continues in the real world.

Goals

The TLDP therapist seeks to provide a new experience and a new understanding for the

patient.

New experience.

The first and major goal in conducting TLDP is for the patient to have a new experience.

"New" is meant in the sense of being different and more functional (i.e., healthier) than the

customary, maladaptive pattern to which the person has become accustomed. And "experience"

emphasizes the affective-action component of change--behaving differently and emotionally

appreciating behaving differently. From a TLDP perspective, behaviors are encouraged that

signify a new manner of interacting (e.g., more flexibly and independently) rather than specific,

content-based behaviors (e.g., being able to go to a movie alone).

The new experience is actually comprised of a set of experiences throughout the therapy

in which the patient has a different appreciation of himself or herself, of the therapist, and of

their interaction. These new experiences provide the patient with experiential learning so that

old patterns may be relinquished and new patterns may evolve.

The therapist determines the type of new experiences that are particularly helpful to a

particular patient based on the therapist's formulation of the case. The therapist identifies what

he or she could say or do (within the therapeutic role) that would most likely subvert the patient's

maladaptive interactive style. The therapist's behavior gives the patient the opportunity to

disconfirm his/her interpersonal schemata. This in vivo learning is a critical component in the

practice of TLDP. The patient has the opportunity actively to try out new behaviors in the

therapy, to see how they feel, and to notice how the therapist responds. This information then

informs the patient's interpersonal schemata of what can be expected from self and others.

These experiential forays into what for the patient has been frightening territory make for

heightened affective learning. A tension is created when the familiar (though detrimental)

responses to the patient's presentation are not provided. Out of this tension new learning takes

place. Such an emotionally intense process is what "heats up" the therapeutic process and

permits progress to be made more quickly than in therapies that depend solely upon more

abstract learning (usually through interpretation and clarification). As Frieda Fromm-

Reichmann is credited with saying, what the patient needs is an experience, not an explanation.

There are parallels between the goal of a new experience and procedures used in some

behavioral techniques (e.g., exposure therapy) where clients are exposed to feared stimuli

without negative consequences. Modern cognitive theorists voice analogous perspectives (e.g.,

Safran & Segal, 1990) when they talk about interpersonal processes that lead to experiential

disconfirmation. Similarities can also be found in the Plan Formulation Method of Harold

Sampson and Joseph Weiss (1986; see also Weiss, 1993) in which change occurs when therapists

pass their patients' "tests".

The concept of a corrective emotional experience described 60 years ago is also

applicable (Alexander & French, 1946). In their classic book, Psychoanalytic Therapy:

Principles and Applications, Alexander and French challenged the then prevalent assumption

concerning the therapeutic importance of exposing repressed memories and providing a genetic

reconstruction. In TLDP a therapist can help provide a new experience by selectively choosing

from all of the helpful, mature, and respectful ways of being in a session those particular aspects

that would most effectively undermine a specific patient's dysfunctional style.

With sufficient quality or quantity of these experiences, patients can develop different

internalized working models of relationships. In this way TLDP promotes change by altering the

basic infrastructure of the patient's transactional world, which then reverberates to influence the

concept of self. This emphasis on experiential learning allows TLDP to benefit a wider range of

patients (broader selection criteria) than many other types of psychodynamic brief therapies that

emphasize understanding through interpretation.

New understanding

The second goal of providing a new understanding focuses more specifically on cognitive

changes than the first goal which emphasizes the affective-behavioral arena. The patient's new

understanding usually involves an identification and comprehension of his or her dysfunctional

patterns. To facilitate a new understanding, the TLDP therapist can point out repetitive patterns

that have originated in experiences with past significant others, with present significant others,

and in the here-and-now with the therapist. Therapists' disclosing their own reactions to the

patients' behaviors can also be beneficial. Patients begin to recognize how they have similar

relationship patterns with different people in their lives, and this new perspective enables them to

examine their active role in perpetuating dysfunctional interactions.

Although the two TLDP goals have been presented as separate entities, in actuality the

new experience and the new understanding are part of the same picture. Both perspectives are

always available, but at any one time one becomes figure and the other ground. New

experiences, if they are to be more than fleeting events, have elements of representations

(understandings) of self and others. Similarly, new understandings, if they are to be more than

mere intellectualizations, have experiential and affective components.

However, in teaching TLDP a conceptual division is made between the idea of a new

experience and a new understanding for heuristic reasons; it helps the trainees attend to aspects

of the change process that are helpful in formulating and intervening quickly. In addition, since

psychodynamically-trained therapists are so ready to intervene with an interpretation, placing the

new experience in the foreground helps them grasp and focus on the "big picture"--how not to

reenact a dysfunctional scenario with the patient.

The Cyclical Maladaptive Pattern

In the past, psychodynamic brief therapists used their intuition, insight, and clinical savvy

to devise formulations of cases. While these methods may work wonderfully for the gifted or

experienced clinician, they are impossible to teach explicitly. One remedy for this situation was

the development of a procedure for deriving a dynamic, interpersonal focus--the Cyclical

Maladaptive Pattern (CMP) (Schacht, Binder & Strupp, 1984).

Briefly, the CMP outlines the idiosyncratic "vicious cycle" of maladaptive interactions a

particular patient gets into when he or she relates to others. These cycles or patterns involve

inflexible, self-perpetuating behaviors, self-defeating expectations, and negative self-appraisals,

that lead to dysfunctional and maladaptive interactions with others (Butler & Binder, 1987;

Butler, Strupp & Binder, 1993). The CMP comprises four categories that are used to organize

the interpersonal information about the patient:

1. Acts of the self. These include the thoughts, feelings, motives, perceptions, and

behaviors of the patient of an interpersonal nature. For example, "When I meet strangers, I think

they wouldn't want to have anything to do with me" (thought). "I am afraid to take the

promotion" (feeling). "I wish I were the life of the party" (motive). "It seemed she was on my

side" (perception). "I start crying when I get angry with my husband" (behavior). Sometimes

these acts are conscious as those above, and sometimes they are outside awareness, as in the case

of the woman who does not realize how jealous she is of her sister's accomplishments.

2. Expectations of others' reactions. This category pertains to all the statements having

to do with how the patient imagines others will react to him or her in response to some

interpersonal behavior (Act of the Self). "My boss will fire me if I make a mistake." "If I go to

the dance, no one will ask me to dance."

3. Acts of others toward the self. This third grouping consists of the actual behaviors of

other people, as observed (or assumed) and interpreted by the patient. "When I made a mistake

at work, my boss shunned me for the rest of the day." "When I went to the dance, guys asked me

to dance, but only because they felt sorry for me."

4. Acts of the self toward the self

. In this section belong all of the patient's behaviors or

attitudes toward oneself--when the self is the object of the interpersonal pattern. How does the

patient treat him or herself? "When I made the mistake, I berated myself so much I had

difficulty sleeping that night." "When no one asked me to dance, I told myself it's because I'm

fat, ugly and unlovable."

In addition to the four categories of the CMP, the therapist should also consider his or her

reactions to the patient. How are you feeling being in the room with this patient? What are you

pulled to do or not do? The therapist's internal and external responses to the patient provide

important sources of information for understanding the patient's life-long dysfunctional

interactive pattern. One's reactions to the patient should make sense given the patient's

interpersonal pattern. Of course, each therapist has a unique personality that might contribute to

the particular shading of the reaction which is elicited by the patient, but the first assumption

from a TLDP perspective is that ideally the therapist's behavior is predominantly shaped by the

patient's evoking patterns (i.e., the influence of the therapist's personal conflicts is not so

paramount as to undermine the therapy).

The CMP provides an organizational framework which makes comprehensible a large

mass of data and leads to fruitful hypotheses. A CMP should not be seen as an encapsulated

version of Truth, but rather as a plausible narrative, incorporating major components of a

person's current and historical interactive world. It is a map of the territory--not the territory

itself (Strupp & Binder, 1984). In addition, a successful TLDP formulation should provide a

blueprint for the entire therapy. It describes the nature of the problem, leads to the delineation of

the goals, serves as a guide for interventions, enables the therapist to anticipate reenactments

within the context of the therapeutic interaction, and provides a way to assess whether the

therapy is on the right track--in terms of outcome at termination as well as in-session mini-

outcomes. Yet the CMP is a fluid working formulation that is meant to be refined as the therapy

proceeds. The focus provided by the CMP permits the therapist to intervene in ways that have

the greatest likelihood of being therapeutic. Thus the therapy can be briefer and more effective

at the same time.

Inclusion/Exclusion and Multicultural Considerations

TLDP was developed to help therapists deal with patients who have trouble forming

working alliances due to their life-long dysfunctional interpersonal difficulties. However, from a

relational point of view, many symptoms (e.g., depression, anxiety) and problems in living (e.g.,

marital discord) stem from one’s impaired relatedness to self and other; consequently a wide

range of clinical issues and presentations could be successfully addressed using TLDP.

Five major selection criteria are used in determining a patient's appropriateness for TLDP

(Strupp & Binder, 1984).

First, patients must be in emotional discomfort so they are motivated

to endure the often challenging and painful change process, and to make sacrifices of time,

effort, and money as required by therapy. Most therapists have confronted the enormous (and

frequently insurmountable) problem of trying to treat people who are court-referred or "dragged"

into the consultation room by an exasperated family member.

Second, patients must come for appointments and engage with the therapist--or at least

talk. Initially such an attitude may be fostered by hope or faith in a positive outcome. Later it

might stem from actual experiences of the therapist as a helpful partner.

Third, patients must be willing to consider how their relationships have contributed to

distressing symptoms, negative attitudes, and/or behavioral difficulties. The operative word here

is willing. Suitable patients do not actually have to walk in the door indicating that they have

difficulties in relating to others. Rather, in the give-and-take of the therapeutic encounter, they

must evidence signs of being willing to consider the possibility that they have problems relating

to others.

Fourth, patients need to be willing to examine feelings which may hinder more successful

relationships and may foster more dysfunctional ones. Also, Strupp and Binder (1984) elaborate

that the patient needs to possess "sufficient capacity to emotionally distance from these feelings

so that the patient and therapist can jointly examine them" (p.57).

And fifth, patients should be capable of having a meaningful relationship with the

therapist. Again, it is not expected that the patient initially relates in a collaborative manner.

But the potential for establishing such a relationship needs to exist. Patients cannot be out of

touch with reality or so impaired that they have difficulty appreciating that their therapists are

separate people. It would be impossible to conduct an interpersonal therapy if the patient did not

know where he or she ended and the therapist began.

The exclusionary criteria for TLDP are very similar to criteria for red-flagging patients in

other brief dynamic approaches (MacKenzie, 1988). Specifically, the TLDP exclusionary

criteria are:

* Patient is not able to attend to the process of a verbal give-and-take with the therapist

(e.g., patient has delirium, dementia, psychosis, or diminished intellectual status).

* Patient's problems can be treated more effectively by other means (e.g., patient has a

specific phobia or manic-depressive illness).

* Patient cannot tolerate the interpretative, interactive therapy process, which often

heightens anxiety (e.g., patient has impulse control problems, abuses alcohol and/or substances,

or has a history of repeated suicide attempts).

Since TLDP acknowledges that both therapist and client bring their own personal

qualities, history and values to the therapeutic encounter, it is potentially sensitive to the

interactive factors involved in treating clients from different races, cultures, sexual orientations,

etc. However, as pointed out by LaRoche (1999), proponents of the interpersonal-relational

approach could do a much better job of explicitly considering the larger context in which any

therapy takes place. “It seems crucial to extend . . .[the notion] of transference to include the

organizing principles and imagery crystallized out of the values, roles, beliefs, and history of the

cultural environment “ (p. 391, emphasis added). Thus, it is of paramount importance that the

therapist be aware of and understand how cultural factors (in the inclusive sense of the word)

may be playing a role in the patient’s lifelong patterns and in interpersonal difficulties including

those that might manifest between therapist and patient. From a relational point of view, the

client’s interpersonal style outside of the therapy office is an amalgamation of one’s specific

problems, attachment history, sociocultural context, strengths, life stage, familial factors, and

values, just to mention a few. All of these contribute to the client’s assumptive world, or

working models. If a therapist did not consider these factors, important interactive dimensions

could be missed or misunderstood, thereby endangering the entire therapeutic process and

outcome.

As part of this understanding, the therapist should have some comprehension (based on

the available clinical and empirical data in the literature) of the normative interpersonal behavior

and expectations for people with similar backgrounds (cultural data). And this should be

distinguished (to the extent possible) from the individual’s idiosyncratic CMP. For example, in

the case to be presented below, the therapist is a Caucasian man who has a medical degree. The

client is an African-American woman, an office administrator, and old enough to be his mother.

She complains of other people keeping her at arm’s length and feeling inferior. Is this to be

understood as part of her idiosyncratic CMP, or as part of set of experiences she shares with

other women of color in our society. And if it is shared by others with a similar cultural

background, is her manifestation of it more extreme? In this particular case, the client describes

how she longs for closeness with her female relatives, and feels different from them in her ability

to achieve this intimacy. Thus, our hypothesis that these experiences have an idiosyncratic

component is strengthened.

In addition, within the therapy office, the therapist must also consider how cultural

factors take on an active role. Perhaps this client is saying she feels held at arm’s length because

she is working with a white male (a cultural transference-countertransference reenactment). If

this is the case, her therapist could make a seriously erroneous error by inferring that this is a

more global problem for her. From a TLDP perspective, it is important to be aware of the

dangers of making assumptions based solely on transference-countertransference enactments.

This again highlights the importance of a comprehensive and evolving formulation using the

CMP categories.

The best way to judge if a CMP is more an artifact of differences between therapist and

client, is to gauge the therapist-patient interactions in the here and now of the therapy sessions in

light of what the patient says about expectations of and behavior from other people (especially to

the extent that they are of the same race, gender, age, or other relevant parameters). In this case,

the therapist noted that the client felt her female relatives were not trustworthy and that she

needed to protect herself from them by distancing herself. Having said this, however, the

therapist must always be vigilant for cultural ignorance and bias having an untoward effect on

the therapy.

Regarding multicultural considerations of the short-term nature of TLDP, it has been

found repeatedly that most people regardless of background prefer briefer therapies (Sue, Zane,

& Young, 1994). However, until there are research data to inform us, “mental health

professionals should exercise caution in using brief models with diverse populations and should

adapt them to the unique cultural and social situation of the client” (Welfel, 2004, p.347).

To our knowledge there is no TLDP outcome research examining the influence of cultural

variables. However, there are some intriguing (albeit limited) relevant publications. Using

Asian American students, participants were randomly assigned to read either a cognitive therapy

(CT) or TLDP treatment rationale for depression (Wong, Kim, Zane, Kim, & Huang, 2003).

Those with low levels of white identity rated the rationale of CT as more credible than that for

TLDP, while those with high white identity, however, did not rate the two treatment rationales

differently. However, further analyses reveal that these students (who were not actually clients)

were only moderately involved in the task, possibly limiting generalizability to actual patient

populations. On the other hand, Li (2003), in a theoretical study, makes the case for how TLDP

is well suited to the needs of Chinese Americans by examining the parallels between ten TLDP

values and the core principles of Confucianism, Taoism, and Buddhism. She optimistically

argues that TLDP may someday become the psychotherapeutic treatment of choice for the

Chinese American population.

With regard to use of TLDP with different age groups, we have seen patients from 18-92

in our studies and clinical practices. Noting that conflicts in current, close relationships are

commonly presented complaints by older clients, Nordhus and Nielsen (1999) extended the

application of TLDP to elderly adults by presenting a case illustration. “We find the cyclical

maladaptive patterns format especially valuable for the therapeutic endeavour itself as well as for

supervising the process (p. 946).”

Flasher (2000) also makes a case for using TLDP formulation with an age group at the

opposite end of the continuum—children. She notes that while TLDP was developed for use

with adults, “this interpersonally-based model is viewed as consistent with recent literature in

child development and psychopathology which emphasizes the centrality of peer relationships,

interpersonal schema, and social attribution biases in the development of maladaptive

interpersonal behavior (p. 239).” Flasher demonstrates with a case study that TLDP formulation

can be used to individually tailor treatment for children with aggression, rejection, and other

problematic interpersonal patterns.

With regard to gender bias, Levenson and Davidovitz (2000) found that male therapists

devoted a significantly greater percentage of their clinical time to brief therapy than did their

female counterparts, and were more likely to prefer shorter-term therapies. However, little is

known regarding brief therapy outcome depending upon the therapist’s gender.

Steps in Case Formulation

------------------------------

Insert Table 1 here

---------------------------------

Table 1 contains the steps in TLDP formulation and intervention. These "steps" should

not be thought of as separate techniques applied in a linear, rigid fashion, but rather as guidelines

for the therapist to be used in a fluid and interactive manner. In the initial sessions, the therapist

lets the patient tell his or her own story (Step 1) rather than relying on the traditional psychiatric

interview, which structures the patient's responses into categories of information (e.g.,

developmental history, education, etc.). By listening to how the patient tells his or her story

(e.g., deferentially, cautiously, dramatically) as well as to the content, the therapist can learn

much about the patient's interpersonal style. The therapist then explores the interpersonal

context of the patient's symptoms or problems (Step 2). When did the problems begin? What

else was going on in the patient's life at that time, especially of an interpersonal nature? By

using the four categories of the CMP and his or her own reactions (Step 3), the therapist begins

to develop a picture of the patient's idiosyncratic, interpersonal world, including the patient's

views of self and expectations of others' behavior. The therapist listens for themes in the

emerging material by seeing commonalities in the patient's transactional patterns over person,

time and place (Step 4). As part of interacting with the patient, the therapist will be pulled into

responding in a complementary fashion, recreating a dysfunctional dance with the patient. By

examining the patterns of the here-and-now interaction, and by using the Expectations of Others'

Reactions and the Behavior of Others components of the CMP, the therapist becomes aware of

his or her countertransferential reenactments (Steps 5 & 6). The therapist can then help the

patient explore his/her reactions to the relationship which is forming with the therapist (Step 7).

By incorporating all the historical and present interactive thematic information, the therapist can

develop a narrative description of the patient's idiosyncratic primary CMP (Step 8). From this

formulation, the therapist then discerns the goals for treatment (Step 9). The first goal involves

determining the nature of the new experience (Step 10). The therapist discerns what he or she

could say or do (within the therapeutic role) that would most likely subvert or interrupt the

cyclical dynamic nature of the patient's maladaptive interactive style. Consistent with this way

of conceptualizing a new experience, Gill (1993) suggests that what is needed are specific

mutative transference-countertransference interactions. The therapist-patient "interaction has to

be about the right content--a content that we would call insight if it became explicit" (p. 115).

Traditionally in TLDP the most potent intervention capable of providing a new

understanding (Step 11) is thought to be the examination of the here-and-now interactions

between therapist and patient. It is chiefly through the therapist's observations about the

reenactment of the cyclical maladaptive pattern in the sessions that patients begin to have an in

vivo understanding of their behaviors and stimulus value. By ascertaining how the pattern has

emerged in the therapeutic relationship, the patient has perhaps for the first time the opportunity

to examine the nature of such behaviors in a safe environment.

It is usually helpful for the therapist to share his or her formulation with the patient at

whatever level the patient can comprehend it, and to collaborate with the patient to derive a

mutual understanding of the dysfunctional nature of his or her interactions. However, the degree

to which a patient can join the therapist in elaborating a new life narrative is limited by such

factors as his or her intellectual ability, capacity for introspection, psychological-mindedness,

and the quality of the therapeutic alliance.

The therapist can help depathologize (Step 12) the patient's current behavior and

symptoms by helping him or her to understand their historical development. From the TLDP

point of view, symptoms and dysfunctional behaviors are the individual's attempt to adapt to

situations threatening interpersonal relatedness. For example, in therapy a passive, anxious

client began to understand that as a child he had to be subservient and hypervigilant in order to

avoid beatings. This learning enabled him to view his present interpersonal style from a

different perspective and allowed him to have some empathy for his childhood plight.

The last step (13) in the formulation process involves the continuous refinement of the

CMP throughout the therapy. In a brief therapy, the therapist cannot wait to have all the "facts"

before formulating the case and intervening. As the therapy proceeds new content and

interactional data become available that might strengthen, modify, or negate the working

formulation.

Application to Psychotherapy Technique

We consider the formulation to be essential to the understanding of the case. It is not

necessarily shared with the patient, but may well be depending on the patient's abilities to deal

with the material. Rather than presenting intellectual generalizations to the patient, the shared

understanding of what is important to work on in the therapy is a collaboratively derived process.

For some patients with minimal introspection and abstraction ability, the problematic

interpersonal scenario may never be stated per se. Rather, the focus may stay very close to the

content of the presenting problems and concerns of the patient (e.g., wanting to be accorded

more respect at work). The therapist, however, is constantly using the CMP to inform him or

herself regarding how to facilitate a new experience of self and other in session (e.g., the

patient's experiencing himself as a respected and responsible partner in the therapeutic process).

Some patients enter therapy with a fairly good understanding of their own self-defeating

and self-perpetuating interpersonal patterns (e.g., "I have decided to come into therapy at this

time because I can see I am going to get fired from this job, just like all the other jobs, if I don't

stop antagonizing my boss"). In these cases, the therapist and patient can jointly articulate the

parameters that foster such behavior, generalize to other situations where applicable, and readily

recognize its occurrence in the therapy.

The CMP is critical for guiding the therapist in the direction of the most facilitative

interventions. The following examples of two patients with seemingly similar behaviors but

differing CMPs will illustrate. Marjorie's maladaptive interpersonal pattern suggested she had

deeply ingrained beliefs that she could not be appreciated unless she were the entertaining,

effervescent ingenue. When she attempted to joke throughout most of the fifth session, her

therapist directed her attention to the contrast between her joking and her anxiously twisting her

handkerchief. (New experience: The therapist invites the possibility that he can be interested in

her even if she were anxious and not cheerful.)

Susan’s life-long dysfunctional pattern, on the other hand, revealed a meek stance

fostered by repeated ridicule from her alcoholic father. She also attempted to joke in the fifth

session, nervously twisting her handkerchief. Susan's therapist listened with engaged interest to

the jokes and did not interrupt. (New experience: The therapist can appreciate her taking center

stage and not humiliate her when she is so vulnerable.) In both cases the therapist's interventions

(observing nonverbal behavior; listening) were well within the psychodynamic therapist's

acceptable repertoire. There was no need to do anything feigned (e.g., laugh uproariously at

Susan's joke), nor was there a demand to respond with a similar therapeutic stance to both

presentations.

In these cases the therapists' behavior gave the patients the opportunity to disconfirm the

patients' own interpersonal schemata. With sufficient quality and/or quantity of these

experiences, patients can develop different internalized working models of relationships. In this

way TLDP promotes change by altering the basic infrastructure of the patient's transactional

world, which then reverberates to influence the concept of self.

Case Example

At the time of her therapy, Mrs. Follette was a 59-year-old, African-American, employed,

widow with three grown daughters. She had been in individual and group therapy several times

in the past. Her therapist was Dr. David, a male fourth year psychiatry resident who was a

trainee in the Brief Therapy Program run by the first author. During his first session with Mrs.

Follette, Dr. David was unsure how he could be of help to her. She presented with no clear

agenda--only saying that she had some memory difficulties. She had been referred by the

Neurology Service when they could find no evidence of an organic problem. Dr. David did

some formal mental status testing, but also did not find any discernable memory impairment. By

the third session, Mrs. Follette said her memory was "no longer bothering me." At this point it

was not clear what she wanted to accomplish in the therapy.

However, Dr. David relied on the TLDP case formulation procedures to help him begin

to understand why Mrs. Follette was there and what he could do to help—to discern the

“dysfunctional mental working model and corresponding maladaptive interpersonal pattern that

is hidden in plain sight” (Binder, 2004, p. 141, emphasis added). He used the categories of the

CMP to gather, classify, and probe for interpersonal information. Table 2 contains some of Mrs.

Follette’s dialogue (in parentheses) in the first session organized according to the four

components of the CMP.

----------------------------------------------

Insert Table 2 about here

----------------------------------------------

When initially formulating the CMP, some therapists become concerned about whether

they have correctly placed what the patient is saying into the right category. There are simple

guidelines, such as the patient’s own behavior toward others usually go under Acts of the Self,

whereas behaviors directed toward the self usually go under Introject. But sometimes the

meaning of a particular behavior (whether it is directed at others or toward the self) is not so

obvious. Fortunately, one need not become obsessed with the correct placement because these

categories are primarily designed to be of heuristic value—to help the therapist elicit, assess, and

organize large amount of incoming data; eventually all components will be combined into one

narrative.

Following the TLDP steps to case formulation, Dr. David also observed how and what he

was feeling and thinking in her presence. He became aware of the emotional tone and sequence

of transactions with her as the sessions progressed. He took note of how her descriptions of her

interactions with others displayed redundant themes which could be woven together into

recurring patterns. By the end of the third session, Dr. David was able to discern a style of

relating that he conjectured was quite problematical for Mrs. Follette. Based on her interactions

with him, what she said about her relationships with others, and his reaction to her, he derived a

narrative version of her CMP. (See Table 2.)

Since Dr. David was able to derive a cyclical maladaptive pattern, and Mrs. Follette met

the basic selection criteria for TLDP with no exclusionary criteria, she was accepted into

treatment. The patient, however, could not come to therapy on a weekly basis. Every other

week she had to take business training classes during the time she would ordinarily meet with

Dr. David. So a revised schedule was agreed on; Mrs. Follette would come to therapy every

other week. In total, she was to receive ten sessions spread over twenty weeks.

Dr. David summarized Mrs. Follette's interpersonal narrative as follows: This is a

woman who puts out signals that she does not need anything from anyone, because she fears no

one will be there for her if she were vulnerable. She keeps her guard up, so as not to get harmed,

but her distancing behaviors (her pseudoindependence) puts others off, ensuring the very

reaction she most fears.

From this initial formulation, Dr. David derived the two goals of treatment. The new

experience was for Mrs. Follette to experience herself as letting down her guard and becoming

vulnerable while interacting with a therapist who neither backed away nor intrusively made

demands of her. The new understanding was for her to begin to appreciate how her distancing

behaviors caused others to move away.

How Formulation Relates to Treatment Interventions

Dr. David could now see how Mrs. Follette's CMP had been reenacted in the early

sessions with him. At the beginning of the therapy, he had felt detached and confused in the

sessions. After constructing Mrs. Follette's CMP, Dr. David began to appreciate how his

reaction to the patient was not a hindrance, but rather an in vivo example of what needed to shift

if the therapy were to be beneficial.

The first few minutes of the fifth session (which took place during the tenth week of

therapy) captures the patient's interactive style. Although Dr. David had derived his

understanding of Mrs. Follette's maladaptive interactional pattern some weeks before, he found

this present interchange quite consistent with his working formulation. Comparing ongoing

clinical material to the CMP is one way of constantly refining the working formulation.

Therapist: Any thoughts?

Patient: Not really. No. Not any real thoughts. Things are just moving along. Do you got

any thoughts? What about your thoughts? (Laugh) Oh, goodness!

Therapist: What kind of thoughts were you speaking of?

Patient: You mean what kind of thoughts that I was speaking of when I asked you what your

thoughts were?

Therapist: Uh huh.

Patient: Oh, your thoughts about me, [Uh huh.] and what we've been doing. (pause) If it

is helping you.

Therapist: If it is helping me?

Patient: Yeah, right, to accomplish your goals.

Therapist: Hmmm. What do you see as being my goal?

Patient: Well, must be to become a--what--a psychiatrist or what? What? A psychiatrist?

Therapist: Uh huh.

Patient: How is that coming?

Therapist: It's interesting that you would view therapy as being something to help me [Yeah,

it is. . .] in my goal.

Patient: . . .isn't it?.

Therapist: I suppose in general everything I'm doing is leading me towards that. Ah, but I

wonder if you think of our meeting as being more for me than for you? It sounded

like that is what you were suggesting.

Patient: Hmmm. Well, I think for both, really. You know, this is a dual purpose situation.

I come in here and this is to help you get, I guess your certification or whatever it is.

And, ah, you're helping me, and I'm helping you--in a way.

Therapist: Does that, I wonder, if that leaves any room for caring?

In this exchange, Dr. David's responded (briefly) to the realities of his being in training.

He confirmed the patient's perception that he was getting something for himself out of their

meeting, but then turned the discussion back to the larger issue of their interaction. In an attempt

to introduce an affective tone into the you-scratch-my-back-I'll-scratch-yours nature of the

interchange, Dr. David brought up the possibility of caring.

According to Mrs. Follette's CMP, she does not believe others will be there to provide

closeness when needed. By suggesting that caring might be an important ingredient of their

relationship, Dr. David was providing a mini new experience that ran counter to Mrs. Follette's

expectation of how others behave. In the middle of the same session (Session 5) termination

issues are discussed. Because sessions were every other week, her treatment was half over at

this point.

Therapist: The one thing that I'm thinking about too, is what you brought up earlier in the

session about therapy's ending and, you know, where the, ah, we sort of talked about

the last week of this will be the first week of June, [Uh huh.] which is June fourth.

I'm wondering how you feel about that and how that's affecting . . .

Patient: I feel very fine about that because, ah, I don't have any burning issues . . .

It is important in a time-limited therapy for both patient and therapist to be aware of the

finiteness of the therapy. Here the therapist asks the patient for her feelings about the impending

ending date, to which the patient replies that she "feels fine." However, the therapist,

understanding the patient's tendency to pull back during times of perceived vulnerability,

explored Mrs. Follette's reaction as illustrated in the next interaction.

Therapist: The one thing you said once though was, ah, you wanted to make sure that you

didn't start to depend on 2:30 on Thursdays. [Uh huh.] Because when that ends then

you're left without, without that [Hmmm.] and that would be a very uncomfortable feeling. [Uh

huh.] So it just makes me wonder, ah, that your comfortable feeling about ending June fourth,

ah, is OK because the feeling that, well, I'll just make sure that I don't get too dependent on this,

and make sure that I hold back to a certain degree. Then we could end June fourth and it won't

matter, because I never will have allowed myself to depend on this in the first place.

Patient: Well, that's a form of protection, you know. If I don't protect me, who will, you know?

And I'm not saying that's true, but it could be, you know, it could be.

Here the therapist did not take the patient at face value and blankly accept what she had

said. Nor did he contradict her or infer that his perceptions were superior to hers. What he did

was question her "comfort" in terms of other things she has previously mentioned. He reminded

her that she had said she did not want to depend on their sessions. He then wondered out loud if

she were feeling comfortable about ending soon because of her fears about becoming dependent.

Several times during the fifth session, Dr. David gently confronted Mrs. Follette with

what she herself said in previous sessions. These interventions led the patient to justify her

"holding back" as a form of "protection," so that she did not become a "babbling nut." Here

again, Dr. David explored her strategy of avoiding becoming a "blithering basket case."

The patient disagreed that she had fears about becoming devastated should she get into

this "old stuff" too deeply, because she had other "release valves" in her life. Again, Dr. David

reminded her of what she said earlier in the therapy: "And yet you said before that that's one of

the things you might do for protection is never to get involved in the first place as a way to make

sure you were together when you walked out the door." In this way, Dr. David confronted Mrs.

Follette's disavowal of her tendency to avoid and distance.

Dr. David used gentle confrontation several times throughout this fifth session. He

stayed very close to the material Mrs. Follette was introducing, and used this information in an

empathic way to confront her rigid, withdrawn stance. His approach combined content and

process. What he said is important in terms of her defensive pattern, but how he said it in the

context of their relationship was even more significant. Dr. David was providing Mrs. Follette

with a series of new experiences in which she was being heard and responded to--he was helping

her wrestle with facing her fears.

Mrs. Follette then talked about how she and Dr. David need to be on the "same plane."

She told him she was aware that he always had an "agenda." Midway into the session she

launched into an acknowledgement of how she and Dr. David talked about the "relationship

between the therapist and the client."

Patient: So, so we sit in here and we talk about the relationship between the therapist and

the client. (Laugh)

Therapist: What do you think about that?

Patient: (Laugh) I think it's fun! I really do.

Therapist: Uh huh. What do you think about that? Anything come to mind? What's coming up

for you . . .talking about our relationship?

Patient: Well, it certainly makes for a better ra . . . ah, feeling, you know, to come out here [Uh

huh.] and see and talk to you, you know, because we do have that type of relationship, ah, you

know, it always helps. [Uh huh.] Ah, you know, ah, you know, it help me. We won't talk about

whether it helping you or not. But anyway, a dimension, ah, that, ah, that may be something else

that we, I may need to throw out on the table, ah, for us to discuss.

When the patient said that talking about their relationship was fun, she said it in a very

open and honest manner. At that moment she appeared to be more present and more affectively

connected to Dr. David than she had been previously. Talking about the relationship within the

context of that relationship is a very intimate thing to do. The very process demands trust.

Continuing with the last interchange, Dr. David picked up on the patient's "hint" that there might

be something else that she might need to discuss.

Therapist: Something particular in mind that you were . . . [Huh?] Something particular

in mind that you were thinking of when you said that?

Patient: Uh huh, yeah, uh huh.

Therapist: What, what was that?

Patient: (Chuckle) It is funny, you know, ah, of all the therapy sessions I've been in, I've never

brought up the fact that my step-father, ah, (pause) demanded, when I was about, what, 20, 21,

whatever. Ah, my mother had, ah, gone to Chicago for the summer and ah, you know, we were

there, and, ah, you know, and it's pretty hard to say he made me have sexual intercourse with

him. But you know, it came down to that. And that didn't bother me until, oh, I guess about

maybe ten years ago, and then, you know, whatever, it came back very vividly. And, ah, out of

all the therapists that I've been to and talked to, I've never brought that one little aspect up. And,

you know, I was really curious about that. You know, I was wondering about that, ah, why I

never, you know, brought that up as an issue, that it happened. . . .

Therapist: (Softly, in measured tones) That's a pretty heavy duty [Uh huh.] thing to have gone

through. [Uh huh.] This was not just a step-father but he raised you like . . .

Patient: Well, right, yeah. I always looks at him as my father, right. And, ah, ah, you

know, someone that you think of as your father, when they do one of those, you know,

and what not, it make you very, ah, very distant, very distant.

The patient was able to tell her therapist a secret she had been keeping for 39 years.

However, she told about the rape in her characteristic, intellectualized ("I was really curious"),

minimizing ("that one little aspect") manner. Dr. David did not engage with the patient on this

level, but rather responded affectively in content and tone. He correctly ascertained that to

engage with Mrs. Follette in a discussion about understanding the timing of her sharing her

secret would be colluding with her avoidance of her need to be comforted and acknowledged and

would inhibit their connecting on a more affective level. His commenting on the "heavy duty"

nature of her experience is similar to his introducing the concept of "caring" earlier. Dr. David

was trying to see if Mrs. Follette could relate to him and to her own experience on an emotional

level. His affective reaction to hearing her secret also validated his perception that she had

endured a truly traumatic incident when she was younger.

After hearing the secret, experienced therapists can imagine several different

therapeutically valid ways Dr. David could have gone (e.g., referral to an incest survivor group).

However, he chose to stay within the frame of the CMP and continue focusing on Mrs. Follette's

vulnerability, trust, and distance issues. The patient herself, after revealing her secret, talked

about an interpersonal consequence consistent with Dr. David's conceptualization

(pseuodoindependence vs. intimacy). "It make you very, very distant--very distant." Dr. David

maintained the focus by asking Mrs. Follette if she had felt more distant from her father since

then, and then expanded this specific behavior to the broader implications of her distancing style

with other people in general. This pattern recognition helps patients discover motifs in their

manner of relating; "It must have made it very difficult to have anybody that you could trust, if

your own father did this to you." The patient readily agreed to this interpretation.

In the closing minutes of this same session, Dr. David explored with the patient how he

experienced a change in her manner of interacting with him in the session.

Therapist: I just want to point something out. I've commented before about that feeling of there

being a shell around you--that distance. I noticed when you came in today, there was very much

that feeling again [Of what?], there being a shell around you [Oh.] But that somewhere in the

middle of the session it feels like that shifted. [Uh huh.] I feel a lot more openness and warmth

about you [Uh huh.] now as opposed to early in the session. [Um huh.] Are you aware of that?

Do you feel any difference?

Patient: Um . . .(pause). Yeah, I think I do. I think so. I've reached some, I've reached some,

ah, real, ah, decisions about, you know, about myself and about where I want to go. And the fact

is, I can't move on if I'm holding all these things. You know, I can't move. [Yeah.] I mean, I

can't be a part of, you know, be with other people and feel comfortable [Uh huh.] as long as I'm

keeping a whole lot of stuff. . . . But you know, I feel a lot looser, and alot more at ease, and a

lot. . . You know, I want to let go of some of these things I've been holding. You can't hold

something, what, ah, 37, 8 years and it not affect you. You have to let it go.

Therapist: So, in other words, you think holding some of these things inside helps to create a

distance between you and other people?

Patient: Yeah. I guess so. I think so. Ah huh, I think so.

In this interaction, Dr. David shared the positive changes he observed in Mrs. Follette,

consistent with his formulation. In brief therapy especially, one needs to make the patients

aware of what they are doing right. We need to build on their strengths and make their positive

changes obvious to them. Quite often when patients begin relating in a more positive way, they

are completely unaware of it. Therapists can be quite helpful to patients in pointing out these

changes. Unfortunately, often with a medical model, we become more accustomed to pointing

out dysfunctions and deficits. When Dr. David introduced what Mrs. Follette was doing

differently, he did so by examining its interpersonal effect on him. He said that he felt a lot more

openness and warmth somewhere in the middle of the session; it was Mrs. Follette who made the

connection between appearing more open and sharing her secret.

As the session was about to come to an end, Mrs. Follette mentioned that although she

ordinarily would skip a week, she thought she might be able to get away in time to make an

appointment with Dr. David the very next week. We understand this as in-session evidence that

she felt more trusting and safer with Dr. David. She had taken risks in this fifth session and Dr.

David had not exploited her increased vulnerability. It seemed she could now extend herself

even further and let herself become more involved in her therapy with him.

By the end of therapy, both patient and therapist thought the brief therapy had been quite

helpful. Mrs. Follette responded to several self-report measures to assess outcome in TLDP

(SCL-90R, Derogatis, 1983; Inventory of Interpersonal Problems, Horowitz, Rosenberg, Baer,

Ureno, & Vallasenor, 1988). Her symptomatic distress level dropped to a quarter of what it was

on intake. For example, at intake she indicated that a loss of sexual interest or pleasure was

causing her moderate distress; at termination she reported this problem was not bothering her at

all. Similarly, Mrs. Follette's interpersonal distress level dropped in half. For example, at intake

she responded that trusting other people too much was causing her quite a bit of distress; by

termination this had ceased being a problem. Furthermore, at termination, Mrs. Follette stated

her problems were much better and Dr. David likewise thought that she had made considerable

progress.

Six months after Mrs. Follette ended her brief therapy, the Director of the Brief Therapy

Program (HL) contacted her for a semi-structured follow-up interview. In this interview Mrs.

Follette was asked some general questions about her therapy with Dr. David. The following

excerpt comes after the patient talked about what she had gained from the therapy.

Interviewer: And have you been able to use what you've experienced and learned in your

therapy since then? Has it made a difference?

Patient: Oh, yes. Oh, yes. Oh, yes. I think the amazing thing about it is that because I've come

into my own, my relatives treat me differently. And I don't know if maybe instead of my being . . .

Hmm. (pause) I don't know how to put it. But it seems as though they recognize the newness in

me, and therefore things they said and did before they did not do. And maybe because they felt

like, I have not become defiant or anything, but I've become my own person.

Interviewer: And somehow you communicated that to them?

Patient: Right. Right. Without saying that. Right.

Interviewer: Do you have any idea what they're picking up?

Patient: I have no idea. I guess it's, ah, (pause) I don't know. I have no idea. Maybe the

video, one can see oneself. But in so much as I cannot mentally see myself, I don't

know what it is that I'm now throwing out to other people that they're getting. There

is a new Joan Follette. It's not the old Joan Follette. And even people that I haven't

seen in a long time, there's something about me that's different and they mention it.

Interviewer: They do?

Patient: Either you've become prettier or something. They don't know what it is. And I know

what it is. Because I have decided that, that ah, I guess I have a lot more confidence in myself.

And I think that's the thing that maybe's coming out and they see. (pause) So it's been a real

growing process. In other words, I've come of age.

This interchange illustrates the chief principle whereby TLDP is thought to generalize

outside the therapist's office. Hopefully, a patient's experience in the brief therapy helps

disconfirm his or her ingrained dysfunctional interpersonal expectations and thereby encourages

him or her to try out new, but shaky behaviors with other people. In this particular case, Mrs.

Follette was able to be more vulnerable, trusting, and self revealing (i.e., removed the "shell"

surrounding her) in her sessions, encouraged by Dr. David's positive therapeutic stance (e.g.,

nonintrusiveness, empathic understanding, gentle confrontation) and adherence to the thematic

interpersonal issue. In this follow-up excerpt Mrs. Follette clearly evaluated the benefits from

therapy in interpersonal terms. She gave evidence that she was trying out more available,

approachable attitudes and behaviors with her relatives who began seeing her as literally more

attractive. She then related how her relatives in turn "treat me differently." She was unsure ("I

have no idea") exactly what she was communicating to them to get them to act differently, but

she knew they saw "something about me that's different." What is critical here is not the

patient's precise understanding of some abstract principle about her CMP, but rather her ability

to generalize her experiential learning with Dr. David to others in her life. Here then are the

beginnings of a cyclical adaptive pattern. Although the brief therapy sessions had ended, Mrs.

Follette continued the therapeutic work.

Training

Clinical Aspects of Training

For the reader who is curious to learn more about TLDP case formulation and

intervention, we recommend a multifaceted approach including reading, supervision,

consultation (expert or peer), and workshops with instructional videotapes. There are presently

two TLDP manuals available: Psychotherapy in a New Key: A Guide to Time-Limited Dynamic

Psychotherapy (Strupp & Binder, 1984) describes the basic principles and strategies of TLDP;

Time-Limited Dynamic Psychotherapy: A Guide to Clinical Practice (Levenson, 1995) provides

a practical and pragmatic casebook approach. Instructional videotapes are also commercially

available.

After reading further about TLDP, we advise becoming familiar with the steps in

TLDP formulation and intervention outlined in Table 1 and reviewing the Vanderbilt

Therapeutic Strategies Scale (VTSS) and accompanying manual included in the appendices of

the Levenson (1995) book. Next, therapists can practice devising CMP formulations and TLDP

goals for their problematic patients (e.g., those with poor therapeutic alliances). Going through

this exercise even for on-going patients in long-term therapies can be quite informative for

helping therapists see more clearly where they might be unintentionally colluding with patients

in some dysfunctional dynamic. For those therapists who wish to try out a TLDP therapy, we

advise video or audio-taping sessions, and then reviewing these sessions using the VTSS to

assess adherence and deficient areas needing further attention and/or guidance. Peer (or if

possible, expert) consultation is invaluable in becoming aware of nuances in the therapeutic

interchange that inform the CMP. A new learning format is now available, consisting of an

interactive website where those learning TLDP can submit their formulations on three target

cases, and then receive an expert’s version (Levenson, in press). In addition, workshops on

TLDP occur nationally and regionally through universities and professional associations.

When teaching TLDP to clinicians (whether they be neophytes to the field or experienced

professionals), we have preferred to use small-group supervision focusing on video- or

audiotapes of therapy hours in combination with didactic sessions, also using videotapes to

illustrate teaching points (Levenson & Strupp, 1999).

As trainees watch the tapes of these

sessions in a stop-frame approach, they are asked to say what is going on in the vignettes, to

distinguish between relevant and irrelevant material, to proposed interventions a therapist might

use, to justify their choices, and to anticipate the moment-to-moment behavior of the patients.

This learning approach is consistent with the teaching format of “anchored instruction,” where

knowledge to be learned is specifically tied to a particular problem using active involvement of

the learner in a context that is highly similar to actual conditions (Binder, 1993, 2004; Schacht,

1991).

Each trainee videotapes a patient for an entire therapy (up to 20 sessions) and then

privately reviews his or her entire videotape of that week’s session and selects portions to show

in the group supervision. This format allows trainees to receive peer and supervisory comments

on their technique as well as to observe the process of a brief therapy with other patient-therapist

dyads. In this way, trainees learn how the model must be adapted to address the particular

dynamics of each case and also what is generalizable about TLDP across patients. At the

beginning of therapy, trainees devise a CMP and goals for their patients. Changes are made in

the formulations as clinical knowledge grows, allowing trainees to observe the reciprocal process

of formulation informing the direction of the therapy, which then informs the nature of the

formulation.

Levenson has delineated ten similarities between supervision in TLDP and TLDP itself

(e.g., work actively with trainee resistance; focus on trainees’ having a new experience as well as

gaining knowledge; expect trainees will continue to incorporate and integrate what they have

learned after the training rotation is over) (Levenson, Butler & Bein, 2002). The reader who is

particular interested in TLDP training is referred to the book by Levenson (1995), since it

contains actual transcripts of exchanges between supervisor and trainees as they deal with

clinical and didactic material.

Research Studies of Training

Strupp and his research group undertook a direct investigation into the effects of training

on therapist performance. These studies (Vanderbilt II) explored the effects of manualized

training in TLDP for 16 experienced therapists (8 psychiatrists and 8 psychologists) and 80

patients. The main results indicate that the training program was successful in changing

therapists' interventions congruent with TLDP strategies (Henry et al., 1993b), and that these

changes held even with the more difficult patients (Henry et al., 1993a). However, a later

analysis suggested that many of these therapists did not reach an acceptable level of TLDP

mastery (Bein, et al., 2000).

Among the more striking findings were differences in training effects due to whether the

therapist was in Trainer A's or Trainer B's group. Trainer A's therapists showed greater changes

in adherence to TLDP. Inspection of differences between the two trainers styles indicated that

Trainer A's approach was more directive, specific, and challenging. This finding led the

investigators to suggest how to maximize training effects:

- Choose competent but relatively less experienced therapists.

- Select therapists who are less vulnerable to negative training effects (e.g., less hostile

and controlling).

-Assume that even experienced therapists are novices in the approach to be learned.

-Provide close, directive, and specific feedback to therapists and focus on therapists' own

thought processes.

Regarding the training of beginning therapists, Kivligan and his colleagues found that the

clients of novice TLDP therapists reported more therapeutic work and more painful feelings than

those seen by control counselors (1989), and live supervision was more likely to foster TLDP

skills when compared to videotaped supervision (1991). Multon, Kivlighan, and Gold (1996)

demonstrated that prepracticum counselor trainees were able to increase their adherence to

TLDP strategies with training; furthermore, a related study (Kivlighan, Schuetz & Kardash,

1998) found that the more trainees focused on learning as an end in itself they better they did. In

another training study, Levenson and Bolter (1988) found that trainees’ values and attitudes

toward brief therapy became more positive after a six month seminar and group supervision in

TLDP. Other research has supported these findings (Neff, Lambert, Lunnen, Budman, &

Levenson, 1997).

In an innovative study, LaRue-Yalom (2001) sought to study the long term (average =

nine years) outcome of training in TLDP. Participants were 90 professionals who previously (on

average, nine years ago) learned TLDP during their 6-month outpatient rotation at a large

medical center. Results indicated that these professionals still used TLDP and called upon

aspects of their TLDP training in their daily work. Many said they had integrated TLDP

strategies into their long-term work as well.

Research Support for the Approach

The background for TLDP comes from a program of empirical research begun in the

early 1950's. Strupp (1955, 1960) found that therapists' interventions reflected their personal

(positive or negative) attitude toward the patients. Later work (Strupp, 1980) revealed that

patients who were hostile, negativistic, inflexible, mistrusting, or otherwise highly resistant,

uniformly had poor outcomes.

Strupp reasoned that the difficult patients had characterological styles that made it very

hard for them to negotiate good working relationships with their therapists. In such cases the

therapists' skill in managing the interpersonal therapeutic climate was severely taxed, and they

became trapped into reacting with negativity, hostility, and disrespect. Since the therapies were

brief, this inability to form a therapeutic alliance quickly had deleterious effects on the entire

therapy.

Henry, Schacht, and Strupp (1986) found that for poor outcome cases (no change in the

patients’ introjects) therapists and patients manifested more hostile communications, and

amount of therapists’ hostile and controlling statements were related to the number of patients’

self-blaming statements. Furthermore, therapists whose pretherapy self-ratings revealed more

hostility directed toward themselves were more likely to treat their patients in a disaffiliative

manner. And all of this occurred by the third session of therapy! A later investigation (Hilliard,

Henry, & Strupp, 2000) further demonstrated that patients’ and therapists’ introjects have a

direct effect on the therapy process, which affects outcome.

Quintana and Meara (1990) found that patients intrapsychic activity became similar to

the way patients perceived their therapists treated them in short-term therapy. A study

examining relational change (Travis, Binder, Bliwise, & Horne-Moyer, 2001) found that

following TLDP, patients significantly shifted in their attachment styles (from insecure to

secure) and increased the number of their secure attachment themes.

Johnson, Popp, Schacht, Mellow, and Strupp (1989), using a modification of the CMP,

found that for a single case, relationship themes were identified that were similar to themes

derived using another psychodynamic relationship model (Core Conflictual Relationship Theme

method, CCRT; see Chapter 5, this volume). (See Henry, 1997, for more information on this

CMP modification and interpersonal case formulation.)

The VA Short-Term Psychotherapy Project--the VAST Project--examined TLDP process

and outcome with a personality-disordered population (Levenson & Bein, 1993). As part of that

project, Overstreet (1993) found that approximately 60% of the 89 male patients achieved

positive interpersonal or symptomatic outcomes following TLDP (average of 14 sessions). At

termination, 71% of patients felt their problems had lessened. One-fifth of the patients moved

into the normal range of scores on a measure of interpersonal problems.

A VAST Project long-term follow-up study of this population (Bein, Levenson, &

Overstreet, 1994; Levenson & Bein, 1993), found that patient gains from treatment were

maintained and slightly bolstered. In addition, at the time of follow-up, 80% of the patients

thought their therapies had helped them deal more effectively with their problems. In a

naturalistic effectiveness study of 75 patients treated with TLDP, neurotic and psychosomatic

patients evidenced significant improvement at termination, as well as 6-month and 12-month

follow-ups (Junkert-Tress, Schnierda, Hartkamp, Schmitz, & Tress, 2001). Those diagnosed

with personality disorders also improved, but to a lesser degree.

Hartmann and Levenson’s (1995) study using the VAST Project data found that TLDP

case formulation is relevant in a real clinical situation. CMP case formulations written by

treating therapists (after the first one or two sessions with their patients) conveyed reliable and

valid data to other clinicians. Perhaps most meaningful is the finding that better outcomes were

achieved the more these therapies stayed focused on topics relevant to these patients' CMPs.

References

Alexander, F., & French, T.M. (1946). Psychoanalytic therapy: Principles and applications.

New York: Ronald Press.

Anchin, J.C., & Kiesler, D.J. (Eds.) (1982). Handbook of interpersonal psychotherapy. New

York: Pergamon Press.

Bein, E., Anderson, T., Strupp, H.H., Henry, W.P., Schacht, T.E., Binder, J.L., & Butler, S.F.

(2000). The effects of training in time-limited dynamic psychotherapy: Changes in

therapeutic outcome. Psychotherapy Research, 10, 119-132.

Bein,E., Levenson, H., & Overstreet, D. (1994, June). Outcome and follow-up data from the

VAST project. In H. Levenson (Chair). Outcome and follow-up data in brief dynamic

therapy: Caveat emptor, caveat vendor. Symposium conducted at the annual

international meeting of the Society for Psychotherapy Research, York, England.

Bertalanffy, L. von (1969). General systems theory: Essays on its foundation and development

(rev.ed). New York:Braziller.

Binder, J.L. (2004). Key competencies in brief dynamic psychotherapy: Clinical practice

beyond the manual. New York:Guilford.

Binder, J.L. (1993). Is it time to improve psychotherapy training? Clinical Psychology Review,

13, 301-318.

Bowlby, J. (1973). Attachment and loss. Vol.2, Separation, anxiety, and anger. New York:

Basic Books.

Connolly,M.B., Crits-Christoph, P., Demorest, A., Azarian, K., Muena, L., & Chittams, J.

(1996). Varieties of transference patterns in psychotherapy, Journal of Consulting and

Clinical Psychology, 64, 1213-1221.

Derogatis, L.R. (1983). SCL-90R administration, scoring and procedures manual

for the revised version. Baltimore,MD:Clinical Psychometric Research.

Flasher, L.V. (2000). Cyclical maladaptive patterns: Interpersonal case formulation for

Psychotherapy with children. Journal of Contemporary Psychology, 30, 239-254.

Gill, M.M. (1993). Interaction and interpretation. Psychoanalytic Dialogues, 3, 111-122.

Greenberg, J.R., & Mitchell, S.A. (1983). Object relations in psychoanalytic theory. Cambridge,

Mass.: Harvard University Press.

Hartmann, K., & Levenson, H. (1995, June). Case formulation in TLDP. Presentation at the

annual international meeting of the Society for Psychotherapy Research meeting,

Vancouver, Canada.

Henry, W.P. (1997). Interpersonal case formulation. In T.D. Eells (Ed.), Handbook of

psychotherapy case formulation (pp.223-259). New York:Guilford.

Henry, W.P., Schacht, T.E., Strupp, H.H., Butler, S.F., & Binder, J.L. (1993a). Effects of t

raining in time-limited dynamic psychotherapy: Mediators of therapists' responses to

training. Journal of Consulting and Clinical Psychology, 61, 441-447.

Henry, W.P., Strupp, H.H., Butler, S.F., Schacht, T.E., & Binder, J.L. (1993b). Effects of

training in time-limited dynamic psychotherapy: Changes in therapist behavior. Journal

of Counseling and Clinical Psychology, 61, 434-440.

Horowitz, L.M., Rosenberg, S.E., Baer, B.A., Ureno, G., & Vallasenor, V.S. (1988). Inventory

Of Interpersonal Problems: Psychometric properties and clinical applications. Journal

of Consulting and Clinical Psychology, 56, 885-892.

Johnson, M.E., Popp, C., Schacht, T.E., Mellon, J., & Strupp, H.H. (1989). Converging

evidence for identification of recurrent relationship themes: Comparison of two methods.

Psychiatry, 52, 275-288.

Junkert-Tress, B., Schnierda, U., Hartkamp, N., Schmitz, N., & Tress, W. (2001). Effects of

short-term dynamic psychotherapy for neurotic, somatoform, and personality disorders:

A prospective 1-year follow-up study. Psychotherapy Research, 11, 187-200.

Kiesler, D.J. (1982). Confronting the client-therapist relationship in psychotherapy. In

J.C.Anchin and D.J. Kiesler (eds.), Handbook of interpersonal psychotherapy. New

York: Pergamon Press.

Kiesler, D.J. (1988). Therapeutic metacommuniation: Therapist impact disclosure as feedback

in psychotherapy. Palo Alto, CA: Consulting Psychologists Press.

Kivlighan, D.M. Jr., Schuetz, S.A., Kardash, C.M. (1998). Counselor trainee achievement

Goal orientation and the acquisition of time-limited dynamic psychotherapy skills.

Journal of Counseling Psychology, 45, 189-195.

Kivlighan, D.M. Jr., Angelone, E.O., & Swfford, K. (1991). Live supervision in individual

counseling: Effects of trainees, intention use and helpee’s evaluation of session impact

and working alliance. Professional Psychology: Research and Practice, 22, 489-495.

Kivlighan, D.M. Jr. (1989). Changes in counselor intentions and response modes and in

Client reactions and session evaluation after training. Journal of Counseling Psychology,

36, 471-476.

LaRoche, M.J. (1999). Culture, transference, and countertransference among Latinos.

Psychotherapy, 36, 389-397.

La-Rue-Yalom, T. (2001). The long term outcome of training in time-limited dynamic

psychotherapy. Dissertation Abstracts International, 61(9-B),4991.

Levenson, H. (in press). An interpersonal approach: Time-limited dynamic psychotherapy. In

A. Rochlen (Ed.), Counseling theory applications. New York:Pearson Education Inc.

Levenson, H. (2003). Time-limited dynamic psychotherapy: An integrative approach. Journal

of Psychotherapy Integration, 13, 300-333.

Levenson, H. (1995). Time-limited dynamic psychotherapy: A guide to clinical practice. New

York:Basic Books.

Levenson, H., & Bein, E. (1993, June). VA Short-term psychotherapy research project:

Outcome. In D.A. Shapiro (Chair). Long-term outcome of brief dynamic psychotherapy.

Symposium conducted at the annual international meeting of the Society for

Psychotherapy Research, Pittsburgh, PA.

Levenson, H., & Bolter, K. (1988, August). Short-term psychotherapy values and attitudes:

Changes with training. In H. Levenson (Chair), Issues in training and teaching brief

therapy. Symposium conducted at the convention of the American Psychological

Association, Atlanta, GA.

Levenson, H. & Burg, J. (2000). Training psychologists in the era of managed care.

In A.J. Kent & M.Hersen (Eds.), A psychologist’s proactive guide to managed

health care. Mahwah, NJ:Lawrence Erlbaum, 113-140.

Levenson, H., Butler, S.F., & Bein, E. (2002). Brief dynamic individual psychotherapy. In R.E.

Hales, S.C. Yudofsky and J.A. Talbott (Eds.), The American Psychiatric Press textbook

of psychiatry. Washington: American Psychiatric Press.

Levenson, H. & Davidovitz, D. (2000). Brief therapy prevalence and training: A national survey

of psychologists. Psychotherapy, 37, 335-340.

Levenson, H. & Evans, S.A. (2000). The current state of brief therapy training in American

Psychological Association-accredited graduate and internship programs. Professional

Psychology: Research and Practice, 31, 446-452.

Levenson, H. & Strupp, H.H. (1999). Recommendations for the future of training in brief

dynamic psychotherapy. Journal of Clinical Psychology, 55, 385-391.

Li, W. (2004). Confucius on the couch: Time-limited dynamic psychotherapy and the Chinese

American population. Dissertation Abstracts International, 65 (1-B) 445.

Lyons-Ruth, K., & Jacobwitz, D. (1999). Attachment disorganization: Unresolved loss,

relational

violence, and lapses in behavioral and attentional strategies. In J. Cassidy & P.R. Shaver

(Eds.), Handbook of attachment: Theory, research and clinical applications (pp. 520-

554). New York:Guilford.

MacKenzie, K.R. (1988). Recent developments in brief psychotherapy. Hospital and

Community Psychiatry, 39, 742-752.

Multon, K.D., Kivlighan, D.M., & Gold, P.B. (1996). Changes in counselor adherence over the

course of training. Journal of Counseling Psychology, 43, 356-363.

Nordhus, I.H., & Geir, H.N. (1999). Brief dynamic psychotherapy with older adults. In Session:

Psychotherapy in Practice, 55, 935-947.

Overstreet, D.L. (1993). Patient contribution to differential outcome in time-limited dynamic

psychotherapy: An empirical analysis. Unpublished doctoral dissertation, Wright

Institute, Berkeley, CA.

Quintana, S.M., & Meara, N.M. (1990). Internalization of the therapeutic relationship in short

term psychotherapy. Journal of Counseling Psychology, 37, 123-130.

Safran, J.D., & Segal, Z.V. (1990). Interpersonal process in cognitive therapy. New York:

Basic Books.

Sampson, H., & Weiss, J. (1986). Testing hypotheses: The approach of the Mount Zion

Psychotherapy Research Group. In L.S. Greenberg and N.M. Pinsof (Eds.), The

psychotherapeutic process: A research handbook. New York: Guilford.

Sandler, J. (1976). Countertransference and role-responsiveness. International Review of

Psycho-Analysis, 3, 43-47.

Schacht, T.E. (1991). Can psychotherapy education advance psychotherapy integration?

A view from the cognitive psychology of expertise. Journal of Psychotherapy

Integration, 1, 305-319.

Schacht, T.E., Binder, J.L., & Strupp, H.H. (1984). The dynamic focus. In H.H. Strupp & J.L.

Binder, Psychotherapy in a new key: A guide to time-limited dynamic psychotherapy.

New York: Basic Books.

Strupp, H.H. (1955). Psychotherapeutic technique, professional affiliation, and experience

level. Journal of Consulting Psychology, 19, 97-102.

Strupp, H.H. (1960). Psychotherapists in action: Explorations of the therapist's contribution to

the treatment process. New York: Grune & Stratton.

Strupp, H.H. (1980). Success and failure in time-limited psychotherapy: Further evidence

(Comparison 4). Archives of General Psychiatry, 37, 947-954.

Strupp, H.H. (1989). Psychotherapy: Can the practitioner learn from the researcher?

American Psychologist, 4, 717-724.

Strupp, H.H. (1993). The Vanderbilt psychotherapy studies: Synopsis. Journal of Consulting

and Clinical Psychology, 61, 431-433.

Strupp, H.H., & Binder, J.L. (1984). Psychotherapy in a new key. New York: Basic Books.

Sue, S., Zane, N., & Young,K. (1994). Research on psychotherapy with culturally diverse

populations. In A.E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy

and behavior change (4

ed., pp. 783-820). New York: Wiley.

Sullivan, H.S. (1953). The interpersonal theory of psychiatry. New York: W.W. Norton.

Travis, L.A., Binder, J.L., Bliwise, N.G., & Horne-Moyer, H.L. (2001). Changes in clients’

attachment styles over the course of time-limited dynamic psychotherapy.

Psychotherapy, 38, 149-159.

Wachtel, P. L. (1993). Therapeutic communication: Knowing what to say when. New

York:Guilford.

Weiss, J. (1993). How psychotherapy works. New York: Guilford.

Welfel, E.R. (2004) The ethical challenges of brief therapy. In D.P. Chapman (Ed.), Core

processes in brief psychodynamic psychotherapy, Mahwah, NJ:Erlbaum (pp.343-359).

Wong, E.C., Kim, B.S.K., Zane, N.W.S., Kim, I.J., & Huang, J.S. (2003). Cultural Diversity

and Ethic Minority Psychology, 9, 88-96.

Table 1

Steps in TLDP Formulation and Intervention

1. Let the patient tell his or her own story in his or her own words.

2. Explore the interpersonal context related to symptoms or problems.

3. Use the categories of the CMP to gather, categorize, and probe for information.

4. Listen for themes in the patient's content (about past and present relationships) and manner of

interacting in session.

5. Be aware of reciprocal reactions (countertransferential pushes and pulls).

6. Be vigilant for reenactments of dysfunctional interactions in the therapeutic relationship.

7. Explore patient's reaction to the evolving relationship with the therapist.

8. Develop a CMP narrative (story) describing the patient's predominant dysfunctional

interactive pattern.

9. From this CMP, outline the goals for treatment.

10. Facilitate a new experience of more adaptive relating within the therapeutic relationship

and/or with others in the patient’s life consistent with the CMP (Goal 1).

11. Help the patient identify and understand his or her dysfunctional pattern as it occurs with the

therapist and/or others in his or her life (Goal 2).

12. Assist the patient in appreciating the once adaptive function of his or her manner of

interacting.

13. Revise and refine the CMP throughout the therapy

Table 2. Mrs. Follette's Cyclical Maladaptive Pattern

Acts of the Self: Patient feels self-conscious in the presence of others, particularly peers in a

non-working environment. Patient maintains a "shell" around herself which allows her to keep

others at "arm's length." (“I don’t want to be depending on anyone. I don’t care what other

people think.”) Although she longs for closeness and acceptance, she fears intimacy. (“It makes

me nervous when other people get too close to me.”) As a result, she remains somewhat isolated

and alone. (“I spend most of my time alone and that suits me fine. I’m doing very well, thank

you.”) Patient believes she does not need other people. She repeatedly sets professional goals for

herself which she eventually meets, but is then left feeling unfulfilled.

Expectations of Others: Patient believes others are not dependable. (“If you depend on people,

you will be disappointed every time. When you need someone, they will not be there. Other

people always want you to do things for them. They really don’t care about one.”) She believes

others are not willing to provide closeness and nurturance when needed. She expects others will

be hurtful to her if she depends on them, and thinks others will treat her better the more she is

independent. Patient believes others are often not honest with her. She also expects that others

will perceive her as inferior.

Acts of Others Towards Self

: Patient’s fears of allowing others to get close to her or to know her

by revealing things about herself leads others to feel alienated and distanced. (“My aunt is just

concerned with herself, and really isn’t interested in what I have to say. My daughters have each

other and don’t need me much.”) Others view the patient as being strong and independent and

not interested in, or in need of their help or friendship. Some others treat the patient as if she

were inferior. (“All the support I’ve gotten in the past has been misleading. Members of my

family said I wasn’t college material.”)

Acts of the Self Toward Self (Introject)

: Patient sees herself as having an inferior mind, and

therefore feels she is inadequate. (“Once I reach my goals, I feel unsatisfied with myself. My

memory is failing me and that really bothers me. Maybe the way I am is because my umbilical

cord was wrapped around my neck when I was born.”) She considers herself to be unlovable.

Patient feels guilty. She sees herself as vulnerable with a need to preserve control and appear

strong. She has a heightened sense of responsibility for her own well being.

Therapist’s Reaction to Patient: Dr. David felt superfluous and put off by her seeming self-

sufficiency and apparent disinterest in his help.

Notes

1. Recently some clinicians and researchers have appropriately questioned the inevitability of

in-session dysfunctional reenactments of the most pervasive pattern displayed with

significant others (e.g., Binder, 2004; Connolly et al., 1996).

2. The goal of a new experience presented here and elsewhere in more detail (Levenson, 1995)

is a modification of that originally presented by Strupp and Binder (1984).

3. Previously we endorsed the TLDP selection criteria as outlined by Strupp and Binder (1984).

Now one of us (HL) considers that TLDP may be helpful to patients even when they may

not quite meet these criteria, as long as the therapist is able to discern the redundant themes

involved in their interpersonal transactions.

4. Of course one cannot overlook the fact that this client may see her relatives (i.e., people of

the same race) as untrustworthy because of introjected racism from the dominant white

culture. Thus, the TLDP therapist is wise to adopt the point of view that cultural parameters

and interpersonal working models are inextricably intertwined.

5. Whereas all clinicians and researchers are well aware of the multiple factors that could

account for such a positive self-report of treatment outcome (e.g., need to please the

interviewer, avoidance of conflict, justification of investment in the therapy), Mrs. Follette’s

demeanor during the interview (e.g., more eye contact, more relaxed posture, more use of

“I,” less vague statements, etc.) were consistent with her account of the changes she had

experienced in her life.

6. For instructional videotapes contact: Hanna Levenson, Levenson Institute for Training, 2323

Sacramento Street, 2

Floor, San Francisco, CA 94115 ([email protected]); American

Psychological Association, 750 First Street NE, Washington, DC 20002; Psychological and

Educational Films, 3334 E Coast Highway #252, Corona del Mar, CA 92625.

7.See Levenson and Strupp (1999) for specific recommendations concerning training in brief

dynamic psychotherapy.

8. For further discussions about training, see Levenson and Burg (2000), Levenson and Evans

(2000), and Levenson and Davidovitz (2000).

Acknowledgements

Portions of this chapter are reprinted from Time-Limited Dynamic Psychotherapy: A Guide to

member of Perseus Books, LLC).