Time Limited Psychotherapy

TimeLimitedPsychotherapy

JamesMann

from

HandbookofShort-TermDynamicPsychotherapy

e-Book2015InternationalPsychotherapyInstitute

FromHandbookofShort-TermDynamicPsychotherapyeditedbyPaulCrits-Christoph&JacquesP.Barber

AllRightsReserved

CreatedintheUnitedStatesofAmerica

Contents

ORIGINSANDDEVELOPMENT

SELECTIONOFPATIENTS

THEGOALOFTREATMENT

THEORYOFCHANGE

TECHNIQUES

CASEEXAMPLE

EMPIRICALSUPPORT

CONCLUSION

References

TimeLimitedPsychotherapy

ORIGINSANDDEVELOPMENT

In1962theoutpatientdepartmentofthedivisionofpsychiatryattheBoston

UniversitySchoolofMedicinehadtoofewprofessionaltherapiststoprovide

for a growing list of patients awaiting assignment. Because the outpatient

department was staffed by psychiatry residents at the time, the problem

becamemineasdirectorofpsychiatriceducation.

Not unexpectedly, a review disclosed that a significant number of

patientswerebeingseenregularlyoverlongperiodsoftime,evenforyears.

Sincetheywerebeingtreatedbyresidentswhorotatedfromonepsychiatric

servicetoanothereverysixmonthstheirtreatmentwasinterruptedtwicea

year. An examination of the records of some of these long-term patients

revealedthat,althoughtheyapparentlyrelatedwelltotheirnewtherapists,

theytendedtoreexaminewitheachtherapistmuchofwhathadalreadybeen

discussed. Further, we noted that these patients did not appear to react

strongly to the loss of the previous therapist; thus, we wondered whether

transferencetotheinstitutionandtotheoutpatientdepartmenthadbecome

more significant than transference to the therapist. It would seem that

patientscouldgoonforever,having their dependent needs well gratified—

although their best interests would not be served. Patients awaiting

treatmentremainedatadisadvantage.

Handbook of Short-Term Dynamic Psychotherapy

In1950IhadbeendirectorofthefirstoutpatientdepartmentatBoston

State Hospital, where I experimented briefly with time limited group

psychotherapy, also under the duress of having a small staff and many

patients.Since1947IhadbeenworkingverycloselywithElvinSemradand

hadcometoappreciatenotonlyhisunique,intenselypenetrating,empathic

interview style but also that the resonant chords he always struck in the

hearts and minds of his patients played out the invariable theme of

separation and loss with the psychotic patients he interviewed. He made

apparenttheirneedforanurturantobjectofconstancy.

Having long believed that the line from so-called normality through

neurosis through various mental disorders into psychosis is a continuum

alongwhich,giventherighttoxiccircumstances,anyofuscoulddescendat

almostanytime,Icametounderstandthattherepetitiveseriesofseparations

and losses that every human being endures forms the outline of the self-

imagethateachpersonconstructs.

The significance of time became clear to me in long-term work with

psychotic patients, with psychotherapy patients, and with patients in

psychoanalysis. No matter how long the treatment lasted, and no matter

whichtherapeuticmodel,theprospectoftheendoftreatmentwasalwaysan

unstabilizing experience for the patient and had repercussions in the

therapist.Therealityoftime,withitsmultiplemeaningsofseparation,loss,

James Mann

Time-Limited Psychotherapy

andultimatelydeath,becameofoverridingimportanceineveryinstance.

Confronted years later with the personnel-patient problem at Boston

University,Ifeltitappropriatetoapplymyfifteenyearsofworkandthought.

Idecidedtoimplementaplaninwhichselectedoutpatientswouldbeoffered

twelvesessionsoftreatmentbysecond- and third-year residents. I thought

twelve sessions following an evaluation should be enough in which to

pinpointasignificantissue,elaborateit,andworkitthroughtotermination.

Extant brief therapies did not specify length, although any therapy labeled

briefwouldbeexpectedtohavesomekindoftimelimit.

Iwroteafairlydetaileddescriptionofthemodelandsentittoeachof

the residents, along with a memorandum proposing that each try it. I soon

realized that I was asking for a drastic change from accepted methods and

was not surprised that passive resistance prevailed. I decided that I would

begin a seminar in Time Limited Psychotherapy (TLP) and asked the

residents to select a patient for me to treat in twelve fifty-minute sessions

following the evaluation. I knew that the residents would never choose an

"easy" patient for me. Furthermore, as their experienced psychoanalyst

mentor, I felt it would be instructive for the residents to see me make

mistakes.

At the start the seminar was limited to residents, who observed my

Handbook of Short-Term Dynamic Psychotherapy

work through a one-way mirror. As we progressed, social workers,

psychologists,andpsychiatricnurseswereinvitedandweinstitutedclosed-

circuittelevision.Inabriefmeetingbeforeeachsessionwediscussed what

had gone on in preceding sessions and speculated on what responses we

mightanticipateintheupcomingsession.Aftereachsessionwemetagainfor

furtherdiscussionofthedynamicflowandreactions.

Myprivatepracticewasprimarilypsychoanalytic,butasIfoundthatmy

ideasaboutseparations,losses,andtimeandtheirinfluenceontheimageof

theselfwerebeingverifiedinmyseminarandinmysupervisionofresidents

engagedinTLP,Ibegantotreatanumberofprivatepatientsinthismode.I

stilldo.Overaperiodofsometwenty-fiveyearsofseminars,supervision,and

private practice the elaboration of details, substance, and subtleties

substantiated the importance of what I have called the central issue as a

means of entering immediately into the core of the patient's need for help.

The combination of time and the central issue (Mann & Goldman, 1982) is

very different from the usual concept of focus in brief psychotherapy. The

concept of the central issue incorporating time, affects, and self-image also

enables the therapist to glean a remarkable amount of information very

quicklyfromthepatient.

SELECTIONOFPATIENTS

James Mann

Time-Limited Psychotherapy

With the accumulation of experience our early caution about the

suitability of patients for TLP has given way to the recognition that a wide

variety of patients can be treated by this model. In this connection, the

processinTLPisproductiveofsomuchinformationinthefirstthreeorfour

sessionsthat if a serious diagnostic error has been made andthe patient is

deemed unsuitable for this treatment, a change to some other kind of

treatmentmaybeeasilymade.

Twogeneralizationsaboutselectioncanbemade.First,TLPisindicated

followingapositiveassessmentofegostrengthanditscapacitytoallowfor

rapidaffectiveinvolvementandequallyrapiddisengagement—ameasureof

thecapacity to tolerate loss.The capacity to tolerateloss is assessedin the

evaluativeinterviews,duringwhichthetherapistlearnsfromthepatienthow

theinevitablemultiplelossesoflifehavebeenmanaged.

Second,inspiteofsignificantdefectsinmotheringandtheabsenceofan

earlypredictableenvironment,therearemanypatientswho,forreasonsnot

wellunderstood,enjoyaresiliencethatallowsthemtoemergewithrelatively

intactegoscapableofrapidaffectiveinvolvementandoftoleratingloss.Each

patient, regardless of the presenting complaint or early history, should be

evaluated on his or her own terms with regard to ego strength, without

preconceived theoretical biases. The assessment must be in terms of the

relative success revealed in the life history with respect to work and in

Handbook of Short-Term Dynamic Psychotherapy

relationstoothers.

Thesetwogeneralizationsaside,therearemanyneuroticpatientswith

strongdependentlongingswhomayrefusetobecomeinvolvedonanyshort-

termbasis,whowillattempttoprolongtreatment,orwhomayleaveearlyin

anticipation of termination. However, those who are aware of their

dependencyandhavetriedtocometogripswithpriorlossareofteneagerfor

help. The time limitation may be a very positive challenge for entry into

successful treatment. There are also patients whose dependency may have

beenfosteredbytoomuchtreatmentwithtoomanytherapists.Thiskindof

patientmaydoverywellinTLP.

PatientswithnarcissisticdisordersmaytendtoconsiderTLPasfartoo

brief for their important problems and refuse treatment. But those with

relativelymildnarcissisticdifficultiesmayexperiencethetwelvesessionsasa

challenge and work effectively. They often require approval and positive

feedback from the therapist. They can tolerate loss provided they feel that

theyhavedoneagoodjob.

Into the categories of anxiety, hysterical, depressive, and obsessional

disordersfallahostofdynamicissuesthatareamenabletoTLP.Patientsmay

presentwithavarietyofsymptoms,rangingfromanxietyanddepressionto

conversion reactions or obsessions. Under these headings characterological

James Mann

Time-Limited Psychotherapy

problems may predominate, such as repetitive unsatisfactory love

relationships,problemsinworkorschooladaptation,ordifficultywithpeers.

Maturationalissuesarisewhenanimportantpsychologicalequilibrium

hasbeenbroken,forexample,whenapersonsuffersarealorsymbolicloss

orleavesonephaseoflifeandentersanewone.Allsignificantlifechanges

areexperiencedaslossesandwillbecomemanifestinthevulnerableperson

in symptoms or in maladaptive behavior. For example, entering college,

leavinghome,graduating,choosingacareer,changingjobs,gettingmarried,

becomingaparent,seeingchildrenleavehome,retiring,andgrowingoldare

all states of transition and change, and there are many more. All states of

transitionandchangeentailgivingupsomethingfamiliarforsomethingthat

invariablyisuncertain—nomatterhowmuchpreparationismade—andthe

responseisalwaysareactiontoloss.

ThecontraindicationsforTLParequiteclearandaremostlikelythose

of any kind of brief psychotherapy. Certain diagnostic categories a priori

demandindefinitelong-terminvolvementwiththepatient.Schizophreniain

any of its subtypes, bipolar affective disorder, and schizoid characters are

examples.Obsessionalcharacterswith major and almostexclusivedefenses

of isolation and intellectualization have a limited capacity for affective

experience,althoughtheymayappearotherwise.Theymayseem toengage

rapidly and disengage equally rapidly without any affective concomitants.

Handbook of Short-Term Dynamic Psychotherapy

Workingwiththemislikewritingonwater.

My experience with borderline patients has been somewhat different

whenthepatientspossesssomeeffectiveneuroticdefensesandarenotlikely

tofall intoatransferencepsychosis.Ithasbeenpossible totreatthemwith

referralforlong-termtreatmentoncompletionofTLP.Theinitialworkclears

away much of the defensive manipulation that often consumes one or two

years of therapeutic groundwork before the patient begins to engage the

therapistconstructively.

Finally, the psychological elements involved in such conditions as

rheumatoidarthritis,ulcerativecolitis,regionalenteritis,andsevereasthma

alsodemandlong-termaffiliationwiththetherapist.

THEGOALOFTREATMENT

ThesinglegoalofTLPistodiminishasmuchaspossiblethepatient's

negativeself-image.Symptomsthatmayhavebroughtthepatientinforhelp

andthat haveservedtodefendagainst andtoobscurethe centralissueare

resolvedasabyproductoftheprocess.Resolutionofthecentralissueleadsto

thefollowingchanges.

1.Thepatientexperiencesanexpansionoftheegoandconsequently

agreatersenseofindependenceandofself.

James Mann

Time-Limited Psychotherapy

2.Thealwayspresentharshsuperego,whichhadconstantlyservedto

reinforce the negative self-image, is softened. The patient

comestoregardhimselforherselfmorecharitably.

3. The healing process in TLP, as in all psychotherapy, includes the

introjection and incorporation by the patient of the good

object found in the therapist. A new internal positive

referencesourcebecomesavailabletothepatient.

4.Theautomaticdefensemechanisms,whichhadbeenusedtocope,

albeitineffectively,arereplacedbytheawarenessofchoices.

The patient learns not to respond in automatically

determined,maladaptiveways.

5. Better feelings about the self allow for a broader vision of the

patient's relationships with others and facilitate different

andbetterwaysofresponding.

TheexperienceofTLPishighlyemotional,experiential,insightful,and

cognitive in its effects. The theoretical underpinnings of TLP, an

understandingoftheprocess,andthegoalsandaimsofTLPareallbasedon

traditional psychoanalytic principles. Yet, as in any brief psychotherapy,

engagement with the patient is imperative. TLP is not by any stretch of

imaginationaminiaturepsychoanalysis,nordoesthetherapistaimtomake

consciouswhatwasunconscious.Apsychoanalyticunderstandingoftheory,

process, aims, and goals makes it possible for the therapist to translate

underlying mental processes in terms of the defect the person feels as a

Handbook of Short-Term Dynamic Psychotherapy

chronicallypainfulpartofhisorherbeinganddailyexistence.TLPrequires

neitheracharismatictherapistnoronewithuniqueskillsforcertainpatients.

It requires only the good training that every therapist should have and the

empathicsensitivityreinforcedbypersonalpsychotherapyoranalysis.

THEORYOFCHANGE

TLPexercisesitsuniqueinfluencethroughthetwomajorpointsofthe

treatment proposal, the therapist's statement of the central issue and the

setting of the termination date at the start of treatment. The process these

pointssetinmotionilluminatestherelationshipbetweenpersistentnegative

feelingsabouttheselfoverthelifetimeofthepatientandtheoriginsofthese

feelingsintheinabilitytoeffectseparationswithoutsufferingunduedamage.

Itisfairtosaythatinanyformofbriefpsychotherapyitisnotfeasible

towork slowly through the patient's layers of defense. The central issue as

posedbythetherapistwill,amongotherthings,bypassdefensestemporarily,

control the patient's anxiety, and stimulate the rapid appearance of a

therapeuticorworkingallianceaswellasapositivetransference.Theresult

is the rapid evolution of the therapeutic process. For brief psychotherapy,

timebecomesamajorfactorinitself.

Timeandourconceptoftimearethemeansweemploytointegratein

ourmindsandinourfeelingswhatwas,whatis,andwhatwillbe.Whatwas,

James Mann

Time-Limited Psychotherapy

often consists of events of significance to us, which we recall as memories.

Memoriesareintimatelyrelatedinmostinstancestoimportantpeopleinour

lives.It follows that memories cannot be separated from time. As we recall

memories, knowledge about ourselves increases little by little because

memory and knowledge are the same thing. A good initial psychiatric

interviewandtheworkofcontinuingtherapeuticsessionsservetolinkandto

expandtime.Aswereviewandpickupthreadsofthepatient'spast,present,

andfuturewearealsoexpandingthepatient'sawarenessofwhatwas,what

is,andwhatwillbe.Inallpsychologicaltreatmentthepatientworkstoward

facinguptothepastinordertogainsomemasteryoverthepresentandtobe

freerinshapingthefuture.

Weareallfamiliarwiththeconstrictionsoftimeinourdailylivesand

with the means we employ to escape from its bonds. Relaxation by any

method induces a sense of decreased time pressure. Alcohol, marijuana,

meditation,and anti-anxietymedications,forexample,allinduce thefeeling

thattimeismovingmoreslowly—asdoessimplytakingtimeofffromwork.

Inmysticstatesandinecstaticstatesconnectionsbetweenpast,present,and

future are broken so that time is experienced as unending. By contrast, in

fragmented states such as depersonalization, derealization, and acute

psychotic decompensation time is without meaning, empty and exquisitely

painful. I have written earlier (Mann, 1973) of my experience with “golden

memories"inpatientsinanalysis,whoderivedasenseofgreatwarmthand

Handbook of Short-Term Dynamic Psychotherapy

familiarity from them but were unable to place them in time or in space.

Furtheranalysisrevealedearlyrecollectionsandfantasiesaboutthemother

andthewishtobecomforted,warmed,andnurturedendlessly.

In states of health one does not feel the passage of time; there is no

senseofgrowingolder.Onpleasurableoccasionstimeseemstomoveswiftly

andin painful circumstances time moves very slowly. Forthe therapist, for

instance, it is common experience for a session to pass very quickly with a

motivated, psychologically minded, hard-working patient but very slowly

withaplodding,circumstantialpatientwhoneverseemstogettothepoint.

Wethinkoftimeincategoricalandinexistentialterms.Thecategorical

istimeasnotedonclocksandcalendars,whereasexistentialtimeislivedin

andexperienced.Thedevelopmentoftimesensegoeshandinhandwiththe

developmentofrealitysense.Prisonersorhostagesinisolation,forexample,

canmaintainrealitybykeepinganaccuraterecordofthedayanddate.

With any kind of treatment the patient will have unconscious

expectations of some kind of magical cure, of fulfillment, of becoming

transformedintowhatheorshealwayswishedtobe.Thereisanexpectation

thatthetherapistwillturnbacktimeandwillrepairwhatwas,tomakeanew

presentandensureadifferentandbetterfuture.Ibelievethistobetrueinall

treatment, whether it be medical, surgical, psychopharmacological,

James Mann

Time-Limited Psychotherapy

behavioral,psychotherapeutic,orpsychoanalytic.Thegreatertheambiguity

inregardtothedurationoftreatmentis,themorewhatIcallchildtime,with

its endless expectations of total fulfillment, predominates. Thus we see the

regression that invariably occurs in long-term psychotherapy and in

psychoanalysis. The structure of these approaches facilitates planned

regression so that over the long term there will occur the slow but steady

analysis of layers of defense, of varied transference manifestations, and of

powerfuldependentwishesanddemands.Themorespecificthedurationof

treatmentis,themorerapidlyischildtimeconfrontedwithrealtimeandthe

worktobedone.Inthissense,TLPpresentsadeadlineforthepatienttomeet

fromthestart.

Thewayapersonassessesongoinglivedtimeisdeterminedbyhowhe

or she perceives personal adequacy in the face of some challenging reality.

Therealitymaybeoutsidethepersonorentirelyintrapsychic.Inthelatter,

theegoperceivesasituationthatitdeemsimportanttoitswell-being,toits

needsandaspirations.Asaresult,aninternalquestionarisesofwhetherand

how the person can cope. In other words, intrapsychic reality becomes a

challengetotheself.Theassessmentofourcapacitytocopecanbemadeonly

onthebasisofpastexperience.Ifwedoubtouradequacyorbelievethatwe

areinfactinadequate,thentensionariseswithintheegoandisfeltasanxiety

ordepressionorboth.Anxietyspeakstouncertaintiesaboutthefuturewhile

guiltspeakstothepast("Ishouldhave")andtothefuture("Ishould").The

Handbook of Short-Term Dynamic Psychotherapy

perception of a potential threat to our adequacy leads to anxiety ("I am in

danger and I must mobilize myself to act"). The belief that inadequacy is

actualleadstodepressionandinsevereinstancesmeansapersonishopeless

andhelplessandwillalwaysbeso.Inmostcases,bothanxietyanddepression

are present and the patient is covertly transmitting doubts about the

existenceofafuture.

TECHNIQUES

TheCentralIssue

In any form of brief psychotherapy it is essential to get as quickly as

possibleinto the core of a significant problem, perhaps one of a number of

problems that the patient presents. It is the entrance into and the

establishmentofthepatient'scoreproblemthatIcallthecentralissue;the

central issue is very different from the more usual concept of focus of

treatment.

The first step in arriving at the central issue is to engage in a way of

listening that we may find too unfamiliar. As we take a history we listen

attentively to the facts of the case; as the patient relates painful events we

discoverhowthepatientreactedtoandfeltabouteachofthem.Butthereisa

furtherdimensiontolistening.Asthepatientrelatesmanypainfulincidents

James Mann

Time-Limited Psychotherapy

we must ask ourselves this question: How must this person have felt about

himself or herself as he or she was experiencing, living, and enduring the

particularincident?Itisnotaquestionthatthepatientcanansweratthetime

sincethecomplaintsorsymptomshaveservedtodefendagainstawareness.

Ratherit is for the therapist silently to ask and to answer the question, for

thisquestionandtheanswertoitmeasurethetherapist'sempathiccapacity.

Itisintheanswerstothisquestion,repeatedmanytimes,thatthetherapist

will arrive at the central issue. What I look for in the patient's history are

recurrent painful events, especially those that, although they may be very

different, are experienced and reacted to symbolically as if they were the

same.Iamlookingforthepatient'schronicandpresentlyenduredpain;this

ispainthatthepatientfeelsheorshehasalwayshad,hasnow,andexpectsto

haveinthefuture.Intheabsenceofchangethereisnosenseofpast,present,

orfutureinthepatient'srigidlyheldconceptionsoftheself;thepatientholds

theparallelconvictionthatnothingabouttheselfcanchange.

Thepatient'schronicandpresentlyenduredpaincanbefurtherdefined

asbeingaprivatelyheld,affectivestatementbythepatientabouthowheor

she feels and has always felt about himself or herself. The central issue is

linked with the patient's time line or history and the various affects

associatedwithit.Thisaffectivestatementabouttheselftotheselfhasnever

beenrevealedtoothersandhasbeenallowedtoenterconsciousnessonlyin

fleeting moments, when it has been promptly warded off by automatic

Handbook of Short-Term Dynamic Psychotherapy

adaptive,copingdevices.Asimplifiedbutcommonexampleisthepersonwho

has a profound need for acceptance to verify her own worth but who

repeatedly finds rejection and automatically responds with a smile, which

effectivelykeepsthepainoutofsight.Althoughthechronicpain,thenegative

feeling about the self, is obscured defensively, it remains preconscious and

when posed to the patient is experienced as a clarification and not as an

interpretationofanunconsciousconstructneverbeforeinconsciousness.

The recurrent painful events that feed the sense of a chronic and

presentlyenduredpainarealsotheaffectivecomponentofthepatient'sbelief

that he or she has been victimized. It is difficult to discern any neurotic or

emotionalconflictin whichthepatientdoesnotfeel unjustly victimized.As

childrenallofuswere"victims"inasmuchasallexperiencedhelplessnessin

the face of parental demands ranging from mild to abusive. The childhood

victimizationtends to becomeperpetuatedas aguidingfictioninthelifeof

theadult.Thatistosay,theadultcontinuestofindandtorespondtocertain

eventsinthesameaffectivewayheorsheexperiencedandreactedtothemas

achild.Whatwasoncerealinthelifeofthechildcontinuesintoadultlifeasa

fiction about the self. The misrepresentation of the self is enhanced by the

additionofunconsciousfantasiessurroundingthepainfuleventsfromearly

childhoodandfromadolescence.Achildmayfeelthatheorsheisbadwhen

facedwiththequestionwhyparentsnolongerlivetogether.Theadolescent

in the same situation may not only feel that he or she is bad but may also

James Mann

Time-Limited Psychotherapy

suffer"bad"sexualfantasiesaboutoneparentortheother.

Aclinicalvignettewillillustratetheselectionofthecentralissue.Aman

in his late forties complains of depression, feeling blocked in his work, and

beingpreoccupiedwithuncertaintyabouthisfuture.Heisfullyawarethathe

has been successful in his work and equally aware that his work has been

recognized by others whose opinions he has valued. Recently he was

expectinganappointmenttoapositionofferingevengreaterrecognition,but

hefailedtowinit.Hishistoryrevealedthathewasthesonofsuccessfuland

manipulativeparentswhohadimpressedhimwiththeneedtocarryhimself

in appearance, style, and behavior as though he were not of the immigrant

groupfromwhichhisparentshadcome.Heyieldedtothedemands,always

successfully until the recent failure. Many additional details in the history

madeclearthataslongashecouldrememberhehadcarriedwithinhimthe

profound sense of being a phony; at every step of his career he suffered

anxiety, which he never understood, in the form of constant terror that he

would be found out. The symptoms that brought him for help served to

concealanddefendagainsttheawarenessandconvictionabouthimselfasa

phony.Hehadneverponderedorspokenaboutthesenseofbeingaphony.

Rather,therehadbeenonlyflashesofawarenesswithimmediatedefenseto

remove the discomfort. As he recounted the many painful events of his life

andasIaskedmyselfhowhemusthavefeltabouthimselfasheenduredeach

particularevent,itbecamepossibletotellhimthatIrecognizedthenatureof

Handbook of Short-Term Dynamic Psychotherapy

hisproblemandcouldexpressitintermsofhisnegativeimageoftheself,an

image he had carried all his years, carries now, and will carry into the

expectable future, along with a sense of despair about ever being able to

changetheimage.

Allpatientshaveaconsciousandunconsciouswishforredressoftheir

grievances. It is conscious in that the patient wishes for appropriate

recognition of his or her need in his or her own world. The person's

contemporarieshavenowayofrecognizingthatneedsincetheyareregularly

confrontedwiththeperson'sadaptivedevices,whicheffectivelydisguisethe

pain. Unconsciously the patient wishes for reunion with early important

persons because the patient believes that those who are held directly

responsible for the pain would be the most desirable healers. In this

connection the time limit of TLP with its induction of magical expectations

facilitateshopethatreunionwiththeoriginalfigureswillbeeffected.

Becauserecurrentpainfuleventsandresponsesarewhatissignificant

in this context, it follows that not everything a patient may tell us is

important. Time is often wasted in brief psychotherapy listening to

circumstancesoreventsthatdonothaveanexistenceovertime;thatis,there

is no affective connecting link from event to event. Therapists are familiar

withtherigidobsessionalpatientwhomaywanderthroughawholesession

ofunrelatedminutiae.InTLPthetherapist'sattentionisdirectedthroughout

James Mann

Time-Limited Psychotherapy

thetwelvesessionstoinformationthatisdirectlyorindirectlyrelatedtothe

centralissue. Informationfeltto beunrelatedtoitshouldbeunderstoodas

resistance to further progress. The most fruitful approach to removing the

obstacle is to turn it aside by interrupting (many therapists hesitate to

interruptapatient)andsuggestingthatthepatientgobacktosomespecific

itemfromearlierinthesessionorfromthepreviousweek.Therearetimes

whenanunusuallyenlighteninganddifficultsessionmaybefollowedinthe

nextmeetingbythepatient'sapparentneedtotakeabreatherandspeakof

unimportantdetails.Therewillbenoobjectionbythepatientifthetherapist

appreciatestheneed,allowsitforsometenorfifteenminutes,andthenhelps

thepatienttoresumetheimportantwork.

Thestatement ofthecentralissue intermsofthe chronicpainarising

out of the negative self-image reverberates from the deepest levels of the

unconscious, through the layers of ego defense, and into the patient's

consciousexperienceofself.Itspansthepatient'sexperienceoftimefromthe

remote past through the immediate present into the expectable future. It

speakstotheexquisitepoignancywithwhicheachpersonprivatelyendures

hisorherbeing.

ComponentsoftheCentralIssue

The central issue includes time, affects, and the negative image of the

Handbook of Short-Term Dynamic Psychotherapy

self. A statement is made at the very beginning of treatment that links a

profound notion about the self to factors of time (as duration) and intense

affect.Theabilitytotagtraumaticeventsasoccurringataparticularmoment

isless important than the fact that each patient remarkson the "always"—

that he has always felt that way about himself. Powerful traumata deeply

influence unconscious guilt or narcissistic equilibria or both. They affect

relationships back to the primary internal objects, the parents. Since the

feelingshavetheirorigininchildhood,whentheearliestintrojectionsoccur,

objectivetime is obliteratedas far as the affectiveexperience is concerned,

andthefeltmythabouttheselfisexperiencedasalwayshavingbeenthere.

Theaffectiveresultoftraumablursaperson'sperceptionoftime,which

inturnincreasesnegativeaffect,whichincreasesthesenseofhopelessness.

Ourpatientsspeakthereforeofanimpossiblepast,anunhappypresent,anda

forbidding future in which the pain of the past and present must be

continued.Itistheinclusionofthesefactorsthatmakesthecentralissueso

effective.Theformulationisinvariablyexperiencedasa powerful empathic

statementinwhichthetherapistisexperiencedasstandingbothwithinand

alongsidethepatient.Theusefulnessofthecentralissueisfurtherenhanced

bythefactthatitneverincludesconflictwithimportantothersinthelifeof

thepatient.Thesewillemergesoonenoughinasettingoftrustandpositive

transferenceastheseareencouragedandstimulatedbythecentralissue.

James Mann

Time-Limited Psychotherapy

Since the awareness of this kind of central issue is warded off by the

automatic adaptive devices of the patient, it follows that the complaints

broughtbythepatientasthereasonsforseekinghelpwillneverincludethe

central issue. Rather, we hear the familiar ones—anxiety, depression,

symptomsthatsubstitutefordepression,difficultieswithothers,andthelike.

Conversely,thepatient'scomplaintswillneverbethecentralissueinTLP.

Considerthefollowingcase.Awomaninherlatefortiesconsultedwith

me about her rebellious teenage daughter, who, she said, was driving her

crazy. This might appear to be an instance that called for counseling the

patient about alternative ways of managing a teenager. Never assuming

anythingwithoutfirsttakingacarefulhistory,Isoonlearnedthatthiswoman

wasin fact caringand sensitively attuned tothe needs of her daughter and

that she had tried a variety of acceptable means to bring reason into their

relationship.Herhistory further revealed that at theages of three and four

thepatient,inresponsetohermother'saspirations,hadperformedpublicly

onthestage.Sherecalledbeingdirectedinonescenetoenterafrightening

dungeon.She was terrifiedbut did it and never forgot theterror. Later she

was pressed into ballet and music, always submitting to her mother's

ambitions,whichalsoincludedsuperiorschoolperformance.This remained

the story of her developmental years, including the college years, during

whichshelivedathome.Sheescapedonlywhenshemarriedandmovedto

anothercity.

Handbook of Short-Term Dynamic Psychotherapy

Ihavehighlightedsomeoftherecurrentpainfuleventsearlyinherlife;

there were many more later. In all of these experiences her automatic

response had been obedience. The central issue that was formulated and

proposedtobeourworkforthetwelvesessionswasasfollows:"You area

woman of recognized ability and talent but what troubles you now and

alwayshasisyourreadinesstofeelcontrolledandhelpless."Thestatement

elicitedanimmediateaffirmativeresponse;theworkoftherapywastolearn

withherwhathadhappenedinthecourseofherlifetoleadhertofeelthis

wayaboutherself.Weconcludedthattherebelliousdaughterhadexercised

control over her as only a teenager can, a circumstance that rekindled her

ownexperienceofhelplessnessandconsequentlydistortedherrelationship

with the girl. Once the mother was relieved of the myth that she was still

readilymadetofeelhelpless,sheandherdaughterbecamebetterabletoget

alongwitheachother.

Thevarietiesofchronicpainoutofwhicharisenegativefeelingsabout

the self are limited by the finite range of feelings available to all human

beings.Thelimitedrangemaybesummarizedasglad,sad,mad,frightened,

orguilty:

Glad:loving,happy,contented,euphoric,peaceful,feelingwanted

Sad:unhappy,discontented,depressed,feelingunwanted

James Mann

Time-Limited Psychotherapy

Mad:irritated,annoyed,irked,angry,raging,furious,feelinglikeabad

person

Frightened:anxious,nervous,afraid,feelinghelpless

Guilty:troubled,uneasy,ashamed,feelinghumiliated

Any other feeling is derivative of or within the range of these five.

Becausethefeelingsareuniversal,anegativestatementabouttheselfcanbe

identified in everyone regardless of social class, education, cultural

background,oreconomicstatus,andwhenidentifiedreinforcesthepatient's

motivationforhelp.Eachlifestoryisuniqueinthekindsofpeopleinvolved

andintheeventsthathavetranspiredbuteachisthesameinsofarasoneor

another of the feelings has been experienced by all. There is no person or

group who possesses some unique, never previously recorded feeling.

Cultural differences may make the expression of complaints different—for

example,onepersonmaywailandshriekwithminimalpain,anothermaybe

spartan;onepersonmayreferallcomplaintstothebody,anothertovarious

hexesorspirits—butthepainfulfeelingsdisguisedbythecomplaintsarethe

onesweallshare.

The central issue directly links the past, present, and future that

constitutethepatient'stimelinewiththeaffectsthataccompanymemories,

regressions,fantasies,developmentalarrests,andspurts.Alloftheseemerge

as the unspoken, painful, negative self-image. A person evaluates ongoing

Handbook of Short-Term Dynamic Psychotherapy

lived time in accord with his or her assessment of adequacy; the affective

assessment of the self links present circumstances with future outcomes in

lightofpastoutcomesinsimilar(realorsymbolic)situations.

Consideranothercase.Awomaninherthirtieswasdepressed,anxious,

and sleeping poorly. She had been in psychotherapy for ten years and had

developedanintenseerotictransferencewhichalmostassumedthecharacter

ofadelusion.Whenatonepointshelearnedthathertherapisthadseparated

from his wife she was certain that he would reach out to her; when he

divorced she felt that at last her chance had come. Yet he had never made

overtphysicalmovesorsuggestionstoher.Further,sinceshehadterminated

treatmentherselfsomesixmonthsearliershehadtriedtoeffectrelationships

with other men and found herself choosing the wrong kind of person and

beingfrightenedbyanyovertures.Herhistorydisclosedthatearlyonshehad

beeninsharpcompetitionwithanoldersisterfortheaffectionoftheirfather

and felt she had succeeded until adolescence, when her father seemed to

withdraw from her completely. She recalled being admired by a highly

desirable high school classmate and feeling that something must be wrong

withtheboybecauseheadmiredher.Shetoldofotherexperienceswithmen

who seemed interested in her and then withdrew without warning. The

centralissueproposedtoherwasthis:"Youareawomanwhoissuccessfulin

yourworkandyoualsohaveanumberofcreativeinterests.Neverthelessyou

are troubled now and always have been troubled with the deep sense that

James Mann

Time-Limited Psychotherapy

thereissomethingaboutyouthatmakesyouunworthy."

Thetherapeuticprocessthatfollowedisfamiliartoanyonepracticedin

psychoanalyticpsychotherapy—it is similar in content but very different in

process. In TLP the process is so accelerated, the dynamic events so

telescopedthatamajortaskforthetherapististokeepup,tounderstandand

be prepared to respond to the flow of past and present events within the

purviewof the central issue. Positive and negative transference, resistance,

countertransference, and the ready and evident appearance of all the ego

defenses occur as in any psychotherapy. In this particular case, our work

aroundthecentralissueservedtoundotheerotictransferenceandleadher

toseekacceptablemen.Shehadbeenstrugglingallherlifewiththefeelingof

herunworthiness;shehademployedvariousmeanstocopewithit,butthe

unrelentingpaincontinueddespiteherbestefforts.Shehadfoughtthegood

fightforherfather'sattentionandadmirationandtothedegreethatshefelt

shehadbeensuccessfulincompetitionwithhersister,shehadfeltherselfto

beworthy. Whenherfatherwithdrew fromherinher adolescenceshewas

correctinherperceptionbutcouldunderstanditonlyintermsofherlackof

worth.Itneveroccurredtoher,forexample,thathiswithdrawalmighthave

had to do his own discomfort at being confronted by her blooming

womanhood.

Adegree of helplessness is the lot ofevery child insofaras control by

Handbook of Short-Term Dynamic Psychotherapy

adultsisinevitable.Thepainofseparation,withitsaccompanyingfeelingof

abandonment, is also inevitable because even in the best of circumstances

separationisneverachievedwithoutpain.Multiplerepetitionsofseparation

throughoutlifearesimplyagivenforeveryone.Eachseparationmeansaloss,

givingupsomething. Unconsciously separation means giving upnurturance

in all its meanings and has ambivalence as a consequence. Each separation

brings into the preconscious the sense of leaving and of being left. At the

conscious level each separation is experienced in the person's accustomed

automatic adaptive mode. Depending on the nature and meaning of the

particularpersonorcircumstancetheconsciousexperiencemayrangefrom

ego syntonic sadness to total denial of the separation's significance to

counterphobic behavior to overt depression to degrees of psychological

disintegration.Further,witheachseparationanditsaccompanyingsenseof

lossthereisalwaysthepossibilityofanotherdecrementintheimageofthe

self—of feeling more helpless, more controlled, more unworthy, more

unlovable,moreinferior,moreundeserving,orthelike.

Summary

The messages in the central issue are quite clear. First, and very

important,thereisrecognitionof thepatient'seffortstomasterthechronic

pain.Second,thetherapist'sstatementrevealsawarenessofhowthepatient

feelsandhasalwaysfeltabouttheselfdespitehisorherbestcopingefforts.

James Mann

Time-Limited Psychotherapy

Ineachinstancetheworkoftreatmentconfinesitselftolearningwhatevents

inthelifeofthepatienthaveledtothiskindofconclusionabouttheself.Itis

welltonotethatthecentralissueasformulatedandpresentedtothepatient

becomestheparadigmofthetransferencetofollow.Thus,itistobeexpected

intheterminationphaseoftreatmentthatthemanwhofeelsunwanted,even

irrelevant,willfeelthattreatmentcomestoanendbecausethetherapist,too,

does not want him around. Or the woman who feels stupid and a phony is

certain that the therapist finds her so and is pleased to send her away. Or

anotherpatientcomestofeelthat thetherapistfindshimtobesecond-rate

andunacceptable.

Noteagainthatthecentralissueincludestime,affects,andthenegative

image of the self; it is formulated by the therapist after having gained

sufficientinformationintheevaluation.Itisthenpresentedtothepatientas

thetherapist'sviewoftheproblemthatbroughtthepatientforhelp.

Thenextstepistogainthepatient'sreactiontothecentralissue.Inmy

experience, instances in which patients have rejected the statement of the

centralissueareveryrare.Anoccasionalpatienthasremarkedthatthestated

problemwasnotwhyheorshecameforhelp.Iaskifthereissomethingmore

importanttoexamineabouthimselforherself.Theanswerhasalwaysbeen

no.SomepatientsrespondwithsuchenthusiasmthatIamsignaledtowatch

foranadaptivemode;thepatientmaytrytoohardtoplease.Suchamodeis

Handbook of Short-Term Dynamic Psychotherapy

significantinthecourseoftreatment.Thepatientmayneedtopleasesothat

hisorherdesirabilitymaybeconfirmedthroughthetherapist'sagreeingto

continue treatment indefinitely. There are some patients who hesitantly

acceptthecentralissueandexpressdoubtaboutitbutarewillingtoconsider

it.OccasionallypatientswillaskhowIfoundoutaboutthemsosoon.Inany

case,eachpatientisgiventheopportunitytoobjectandtorejectortoaccept

theformulation.

Thequestionmaybeaskedwhethertheformulationofthecentralissue

posesdifficultiesforthelearner.Ibelievethatitisfairtosaythatanyonewho

choosestobeapsychiatristorclinicalsocialworkerorclinicalpsychologist

possessesalong-cultivated,evenifoutofconsciousness,empathiccapacity.I

haveremarkedearlierthattheformulationofthecentralissueisameasureof

thatcapacity.Forsometherapiststheabilitytoappreciatehowthisorthat

patient has always felt about the self comes readily and may need only the

confidence that comes with experience. Others are not so ready to allow

themselves to feel what the patient feels without becoming lost in

identification with the patient. To meet that problem I have used group

formulationofthecentralissuefollowedbyweeklygroupsupervisioninthe

instanceofonepatient.Itisessentialthatthegroupbeexperiencedinlong-

term psychotherapy and enjoy mutual relationships that will allow for

constructive supervisory sessions. In group formulation, one member

volunteers to present a new case and the group then works together to

James Mann

Time-Limited Psychotherapy

formulateoutofthedatapresented thecentralissue.Slowlythereemerges

out of the contributions of the members a growing consensus and then

agreementonthefinalformulationaseachpondershowthepatientmustfeel

abouttheselfinrelationtotheinformationavailable.

It may be helpful to have further illustrations of the central issue as

derivedfromthepatient'shistory.

•Toathirty-six-year-oldmemberofaminoritywhofoundhimselfin

a conflictual situation in his field of work and became

physically sick followed by depression: "You are a man of

abilityinyourparticularfieldandhavedoneverywellinit.

Yet you feel and have always felt that there is something

aboutyouthatmakesyoufeelthatyouareunwanted,even

irrelevant."

•Toaforty-two-year-oldwomanwhosufferedanacutedisorganizing

experience which led her to consider divorce: "You have

triedhardallyourlifetobeandtodotheacceptablethings.

Whathurts younowandalwayshas isthefeelingthat you

arestupidandaphony."

•To atwenty-two-year-oldman, a graduatestudentstrugglingwith

thequestionofstayinginorleavingschool:"Youareaman

ofhighintelligenceandyouknowit.Youalsoknowthatyou

can succeed in the work you have begun. However, what

bugs you now and always has is the feeling that you are

second-rate,unacceptable."

Handbook of Short-Term Dynamic Psychotherapy

• To a thirty-five-year-old professional man with an acute phobia:

"Youareabigman[physicallyandinhisfieldofwork]who

has achieved successfully and yet when you are alone you

feelhelpless."

A brief consideration of the evaluative interviews out of which the

central issue is formulated is in order. A proper evaluation depends on the

experience and skill of the interviewer in promoting the willingness of the

patient to speak freely about him or herself. Generally, a one-hour history-

taking interview should suffice to warrant a tentative formulation by the

therapistofthecentralissue.Asecondinterviewisconductedtoclarifyorto

obtaindetailsaboutaspectsofthepatient'shistorytoilluminatestillfurther

the central issue. Most often during the third meeting between patient and

therapistthetherapistoffersthecentralissueashisorherdefinitiveviewof

thepatient'sproblem.Athirdpreliminaryinterviewmaybenecessarysince

somelifehistoriesaremuchmorecomplicatedthanothers.Ihavefoundthat

ifacentralissueremainselusiveafterthreeorfourinterviews,aseverekind

of pathology may be present that in itself warrants as prolonged an

evaluation as necessary to establish a clear diagnosis. The claim that

evaluativeinterviewsarealreadypartofthetreatmentprocessistruetothe

extent that patient and therapist are sizing each other up and that for the

patientthefirstmeetingmaywellbetheendingaswellasthebeginningofa

relationship.Because thecentralissueassetforthhereisso differentfrom

what the patient expected to be the therapist's diagnosis and because the

James Mann

Time-Limited Psychotherapy

complaints that bring the patient for help are never the central issue, the

designated first of the twelve sessions to be offered the patient is the

beginningofanovelexperienceforthepatient.

Oncethepatienthasacceptedthecentralissue,thenextstepisforthe

therapisttoinformthepatientofthetreatmentschedule,thedurationofeach

session,andthedateofthefinal,twelfthsession.Ihavefounditmostuseful

toseeeachpatientonceeachweekforforty-fiveorfiftyminutesratherthan

moreoften,onthegroundsthateachsessionbecomesquitestressfulforthe

patientasmuchpainful,affect-ladenmaterialpoursout.Thepatientcanuse

the weekly interval to react and to respond alone before the next meeting.

Invariablythereismuchforthepatienttodigest.

Upon being told of the schedule, the patient is asked to react and

respond.ThemostcommonquestionishowIknowthattwelvemeetingswill

beenoughtomakeprogressontheparticularissue.Iregardthisquestionas

real and as an unconscious resistance to the idea of a known date of

separationandloss.Myusualresponseistoturnthequestionbackbyasking

what makes the patient feel that twelve sessions will not be enough. The

patientrealizesthatheorshetrulydoesnotknowandwillhavetoawaitthe

turn of events. Agreement to the twelve sessions follows. There are also

unconscious reasons for the acceptance of the treatment proposal. These

havetodobothwithmagicalexpectationsofchangeoverashortperiodof

Handbook of Short-Term Dynamic Psychotherapy

timeandwiththeunconsciousexpectationofrepairandreunionandtheend

ofloss.

PhasesofTreatment

Mostcasesproceedinapredictablepattern.TLPisuniqueinthat the

patient knows exactly when treatment has begun, the precise midpoint of

treatment,and the end date of treatment. These become guideposts forthe

therapist, although they are farther from the patient's awareness. Almost

withoutexception,patientstendtosuppressandoftenrepresstheenddate.

Asaresulttheymaybeconsciouslyunaware,forexample,ofarrivingatthe

midpointoftreatmentatsessionsix.Unconsciously,however,manypatients

respondtothemidpointwithcertainbehaviors.Thesameappliesastheend

oftreatmentapproachesandthepatientseemsoblivioustotheendathand.

Thestatementofthecentralissueinvariablystimulatesanoutpouring

of information. Frequently the information consists of associations that

corroborate the central issue. During the first three or four sessions the

patientbringsforthamassofinformationabouthimselforherself,thefamily,

andothers,withrecollectionsofpainfuleventsthatthepatientmaynothave

thoughtaboutconsciouslyformanyyears.Withthefloodofinformationthere

isalsopalpableevidenceofthepatient'spositivetransference.

Asthesixthsessioncomesorispassedpatientsoftensaynothingabout

James Mann

Time-Limited Psychotherapy

thetime left.Instead,whatwasa positiveattitudemay becomeambivalent.

Nothingmagicalhasoccurredandthepatientisstillthesameperson.There

may be complaints that a symptom has become worse or that nothing has

changedinanywayeventhough the patient may have spoken gladly about

feelingbetterbythefourthorfifthsession.Theambivalenceisunconsciously

determined by the shadow of the impending separation. The ambivalence

that marked earlier separations arises once more within the transference.

Thepatientmayremarkwithevident annoyance that everything that could

be said has already been said and that there's nowhere to go. Rather than

reacting with anxiety based on uncertainty, the therapist recognizes the

meaningofthepatient'sbehaviorandencouragesfurtherelaborationofthe

patient's ambivalence so that significant associations to many other

separationsandthefeelingsthatwere experienced are seen as importantly

connectedwiththecentralissue.

Ifbytheninthortenthsessionthepatienthasmadenoreference,direct

orindirect,totheapproachingendoftreatment,thetherapistmustbringup

thesubject.Onesimplemethodistoaskthepatientifheorsheknowshow

manymeetingsareleft.Inanycase,theendoftreatmentmustbemadethe

subject of discussion for the last three (or four, if the patient brings it up)

sessions.Theterminationphaseisinvariablypainfulforthepatientandoften

forthetherapistaswell.

Handbook of Short-Term Dynamic Psychotherapy

The central issue is experienced in vivo within the transference and

mustberesolvedasmuchaspossible.Ihaveremarkedearlierthatthereare

reasons for the patient's ready acceptance of the limit of twelve sessions.

When patients are offered only twelve sessions they may conclude that

perhaps they are not doing as poorly as they had thought. As I have

mentioned,theyunconsciouslyexpectsomekindofmagicalcure.Withinthe

transferencethebrieftreatmentmeansalsothatreliefwillcomeinrelationto

theimportantearlysignificantsourcesofthepain.Further,atthebeginning,

threemonthsoftreatmentseemtothepatientstobeforever.Wemaythink

aboutbutnotaffectivelycomprehendwhatwewillfeelaboutaneventthree

monthshence.Also,thelimiteddurationoftreatmentsuggeststhatpatients

will not become tied to the therapist; their independence, however muted,

willbepreserved.Thislastfactorisofspecialimporttoadolescentpatients

(includingpatientsofcollegeage)whoarefearfulofthechallengearisingout

oftheconflictbetweentheirwishtobefullyindependentandtheirdesireto

remain dependent. The structure of TLP offers from the start a measured

dependencewithanassuredend.

Theterminationphaseisacrucialaspectoftheprocess,asitisinany

kindofpsychotherapy.Themajorworkofthisphaseliesintheinterpretation

ofthe transferenceintermsof thepatient'sfeelingsaboutthetherapist.By

thistime,agreatdealofevidencehasbeenobtainedconfirmingthepatient's

repetitivefeelingsaboutthetherapistinthesametermsasexperiencedwith

James Mann

Time-Limited Psychotherapy

earliersignificantpersons.Thesefeelingsarealsodirectaffirmationsofthe

originofthepatient'snegativeself-regard.Interpretationsarebestmadein

the familiar triangular configuration—that is, in terms of the therapist,

importantpeopleinthepatient'spresentsituation,andtheoriginsofaffects

inrelationtoimportantpersons inthepatient'spast. Ifweunderstandthat

thecentralissueisthe consequence of a host of unconscious, preconscious,

andconsciouselementsthateventuateineveryoneasenseofwhatoneis,it

follows that the interpretations made are not about aggressive or libidinal

needsandintentionsbutratherareabout derivativesofthese expressed in

living,existentialterms.Forexample, inanykindof brieftreatment,forthe

therapist to recognize the patient's unconscious fantasy of castration and

thentoexpressitinthosetermsisnonsense.Itismeaninglessevenforthe

sophisticated patient to speak in such a way. Genuine affective meaning is

reflected when the same fantasy is conveyed to the patient through the

central issue and therefore in terms of the patient's feeling unmanly or

defectiveorlacking.

Asatisfactoryterminationisoneinwhichthepatientleavestreatment

feelingsad.Ambivalence,whichpreviouslyhadalwaysledtofeelingsofanger

ordepressionwithconcomitantself-derogation,haschangedintoawareness

ofpositivefeelingseveninthefaceofseparationandloss.Sadnessinplaceof

depression allows for separation without self-injury. The goal of TLP is

explicit and single-minded in every case. It is to help patients diminish, to

Handbook of Short-Term Dynamic Psychotherapy

reduce as much as possible, the negative feelings about the self. Symptoms

thatpatients mayhavebroughtamong theircomplaintsare addressed,ifat

all, in terms of the central issue. In most instances, the symptoms are not

addressed at all and diminish or disappear as a byproduct of the process.

Reliefofsymptomsisnotthegoaloftreatment.

TheTherapistandTLP

Inexperiencedtherapistsmaybeimmediatelyenthusiasticaboutdoing

TLP. The promise of relatively rapid therapeutic returns is enticing. But

resistance to TLP among experienced therapists is common and must be

understood.

First, most therapists gradually take on a therapeutic stance and

process with which they become familiar and comfortable. To be asked to

engage in a very different process immediately creates anxiety. Therapists

who have established their competence to their own satisfaction may

experience the new stance as a threat to their ability as well as to their

adaptability.

Second, the time limit raises the hackles of some therapists. We

therapistsare usedtohavingasmuchtimewithourpatientsasbothdeem

necessary.Itisnotatallunusualforapatient'sdependencetobefortifiedby

the therapist's practice and by a need by both participants to maintain the

James Mann

Time-Limited Psychotherapy

dependence.

Third,theargumentisoftenmadethatthedurationoftreatmentshould

be negotiated by patient and therapist. In fact, not much surrounding

psychotherapy is negotiated these days. Fees are now set at all outpatient

departments with little or no leverage for the patient; therapists rarely set

feesthatarebestforthepatient.Nordotherapistssetthedatesandduration

of treatment against their own best interest. A colleague once told me that

TLPwas"money-limitedtherapy."Perhapsobjectingtothetimelimitcanbe

seenasarationalizationtoprotectagainstanevengreaterresistance.

Settingaterminationdateatthestartoftreatmentisverydifficultfor

therapists since it is easier to work slowly toward an indeterminate end.

Terminationsaredifficultforbothpatientsandtherapistssincepatientsand

therapists alike suffer the scars and sometimes the open wounds of

separationsandlosses.Toannouncewhatseemslikeagoodbyeatthestart

resonates in the same way in both patients and therapists. Patients' most

readydefenseistosuppressorrepresstheenddateasifbargainingtofeel

bettersoon.Therapists'defensemaybetoogreatareadinesstofindpatients

tobeunsuitableforTLP.

Finally, there may arise the very interesting situation in which the

centralissueproposedtothepatientastheworkoftherapyisasimilarissue

Handbook of Short-Term Dynamic Psychotherapy

forthetherapist.Surelyfew,ifany,therapistsofanypersuasiondonotlive

withsomedegreeofnegativeself-image.Inthebestinstancesnegativeself-

imagehasbeenmodifiedinpersonaltherapy.Inafewothersthetherapist's

negative feelings may not contaminate the therapeutic process. Certain

safeguardscanbetakentoavoidinterferencefromthetherapist'sproblems.

First, TLP is for experienced therapists. Second, a background of sound

training and experience in the dynamics of the unconscious, transference,

resistance,defense,andcountertransferenceisessential,whichmeanshaving

sufficientexposuretoandworkwithlongtermpsychotherapytohavelearned

to bear and to understand patients' anxiety without reacting against them.

Finally, a most desirable addition to therapist's training would be personal

psychotherapy—or,better,apersonalpsychoanalysis.

CASEEXAMPLE

Asamplecasepresentedindetailwillshowsomeaspectsoftheprocess

from start to finish. The patient was a forty-two-year-old married woman

whosefamilyconsistedofherhusband,onesoninhighschool,andanotherin

thefifthgrade.Totalobsessionwithherolderson'sschoolgradesbroughther

for help. She would follow every test that he took and would look into his

bookbagtoseewhatheshouldbestudying.Shewasawareofnagginghim

aboutschoolworkbutcouldnotstopherself.Unlessheachievedatopgrade

inanytestshecouldfeelherselfgrowcoldtowardhim,evenphysicallycold.

James Mann

Time-Limited Psychotherapy

Shedreamedabouthisgradesandwasadamantthathegetintoaprestigious

college.Sheconcludedthatshewascrazyandhadbetterdosomethingabout

itbeforehersonhadtoapplytocollege.

Shehadbeenintherapyforabouttwoyearsasagraduatestudent. It

was“thethingtodo,"butshereallywenttofindoutifshewascrazy.Years

later she was treated briefly about a problem with her husband. She

presentedherselfasaslender,attractive,neat,andarticulatewoman.Shewas

physically well and slept well, but in her waking hours she was almost

constantlytenseandseemeddesperateforhelp.

Shewas the onlychildofimmigrantparents.Herfather heldamenial

job and both parents could barely speak English, even after years in the

United States. She stated that father was "irascible, primitive, always

hollering."Hehaddiedsomeyearsbeforeandthepatientwasproudthather

interventionshadresultedinanadditionalyearoflife forhim.Sherecalled

being embraced by him in his happiness when she was admitted to a

competitivehighschool.Hermother wasaliveandresided inadistantcity.

The patient had never gotten along with her, feeling that her mother was

snobbish, that she put on airs and felt that everyone she knew was a bad

person.The parents continuallyfought and her father wouldtend to blame

thepatientfortheirbattles.Shewishedherfatherwerestillalivebecauseshe

hadcometofeelmuchwiserabouthim.

Handbook of Short-Term Dynamic Psychotherapy

She had gone to a state university and then on to graduate school to

prepareforaprofession.Atgraduateschoolshefeltherteacherstobepoor;

she failed in part and left with a master's degree. Three years later she

decidedtocompleteherstudiesandgraduatedatanotheruniversity.Married

about twenty years, she experienced her husband as more attached

emotionally to the children than to her. She described her older son as

healthyandagoodkiddespitehernagging.Atonepointhehadsaidhehated

bothhisparentsandclosedhimselfinhisroomforalmosttwodays.

Sheimpressedmeasanobsessionalwomanwithaneedforperfection

not realized within herself which she projected onto her son with the

unspoken demand that he make her whole by being accomplished

intellectually, socially, and in his chosen career. She could then borrow his

statusasherownandtherebybecomewhatshefeltsheneverhadbeen,was

not,andnevercouldbebyherself.Therewereotherdetailsthatclarifiedthe

centralissue. Forexample,hergraduate schoolteacherswerenotinreality

poor. In fact, the small class was a select group drawn only from the best

universities. It was in that class that she found herself asking, "What am I

doinghere?"Afterall,shehadcomefromthefamilyofanuneducatedfather

withhismenialwork,apathologicallysuspiciousmother,andverycramped

and unattractive living quarters. How must this very intelligent and alert

youngwomanhavefeltaboutherselfassheobservedherfatherasamodel,

andhow must she have feltabout herself havinga snobbish motherwhose

James Mann

Time-Limited Psychotherapy

"superiority"wassoonevidentascraziness?

Thecentralissuepresentedtoherasourworkinthetwelvemeetings

wasasfollows:"Youareawomanofabilityandtalent.Youareawarethatyou

have not capitalized professionally on your ability and talent because what

troublesyounowandalwayshasisthefeelingthatyouareunworthy,even

defective."SheagreedthatthiswassoandyetwassurprisedthatIhadcome

upwiththisstatementinthelightoftheproblemthatbroughthertome.She

could readily acknowledge the accuracy of the central issue but wondered

whetherworkingonthisaboutherselfcouldbeofhelptoherson.Isuggested

thatwewouldfindoutinthecourseofourworktogether.

Shecorroboratedthecentralissuewithanumberofassociations:how

shehadneverhadaroomofherown,howshehadhadtobeaparenttoher

parentssince she wouldread and translateletters in English and makeout

checks and other forms for them. She always behaved well but would be

struck with terror when her father glared at her in anger. Sometimes she

thought of herself as a witch; sometimes she felt that her parents never

understoodherneeds.Iemphasizedherfeelingsofvictimizationbothinher

pastandthenbyherson.Howmuchnicerherworldcouldbeifhejustgot

goodgradesandtherebymadeherfeelbetteraboutherself,evenifonlyfor

themoment.Earlyintreatmentshebroughtapictureofherwithherparents

takenwhenshewassixorseven.Shewassurprisedtofindthattheylooked

Handbook of Short-Term Dynamic Psychotherapy

soniceasafamily.

Aswemovedalonginthetreatmentprocess,shereferredtoherselfas

"killer Sue" in recollection of incidents with her mother in which she felt

responsible for various of her mother's illnesses, each of which led, in her

mind,tothebrinkofdeathforhermother.Shebecameawareofthefantasy

that her anger could kill and the enormous guilt that followed, with its

destructive effects on her image of herself. She saw that nagging her son

carried with it clear tones of anger and was followed by guilt and self-

denigration. Further along she spoke of the kiss of death when her first

therapistsaidthatshewasintuitivelygifted.Shefeltthatpeoplewhowished

toknowhermusthavesomethingwrongwiththemandthatIwasdefectiveif

Iwas interested inseeing her and in dealingrespectfully with her. Positive

transference was manifest very early not only in her wondering if I was

defectiveformyinterestinherbutalsoinherearlyquestioningwhethershe

could continue to see me at least once a month when the twelve sessions

ended.Drivingtoseemewas"likeadream"inthatshecouldhardlybelieve

thatIcouldacceptherasnotcrazy.Ontheotherhandshewantedmenotto

caretoomuchforherbecauseshethoughtIwouldthrowheroutifshegot

angrywithme.

Inthepresenceofasolidallianceandtransferencewecouldnowmove

directlyintothe problem with her son. I was able to tell her that she made

James Mann

Time-Limited Psychotherapy

demandsonhiminordertorepairherownsenseofdefectivenessbutthat

herexpectationscouldneverbefulfilledoutsideofherself.Shesaidthatshe

hadbeguntofeellesspressuretonaghim.Atthetreatmentmidpoint,shefelt

likea"waif,"anorphan,andthatsuchthoughtsmadehertearful.Sheandher

husbandmeshedwell,shesaid:shegaveandhedidn't.Shetoldofarecurrent

dreaminwhichsheisinherparents'bedroomwiththem.Suddenlyshegoes

out the window into the street. She is not hurt although the room is high

above the ground. Actually, during her childhood she had long slept in the

sameroomwithherparents;althoughunconscioussexualaspectsofsuchan

arrangementare presentinayounggirl,Ichoosetointerpretthedreamin

termsofthecentralissue.Inthosetermsthedreamrevealedherfeelingthat

noonecaredaboutwhathappenedtoher.Theinterpretationwasfollowedby

areviewofherfeelingsaboutherselfasalittlegirlwhofoundwaysofdealing

withherabusiveparentsbybeinggoodbutwhocouldnotescapeherprivate

feelingsasonewhowasbad,awitch,akiller,andcrazy.

Theshadowofterminationwasonhermindasshetoldmethatshewas

almostlateforherappointment,although,sheadded,shewasneverlatefor

anything.Shehadmetwithanoldschoolmatewho,tothepatient'schagrin,

waswellestablishedprofessionallyandwhose son was absolutelydestined

for Harvard. The patient felt jealous and angry. On her return home she

quicklysetuponhersonwithherdemands.Iremarkedonhowmuchthevisit

withanoldfriendhadactivatedherownpastwithfeelingsaboutherselfas

Handbook of Short-Term Dynamic Psychotherapy

primitiveandunacceptable.Furtherintotheendphase,sherelatedadream

in which she is bleeding to death. She runs to her internist but he is not

availableandthereisnoonetohelpher.Inherassociationssherevealedthat

the internist was a high school classmate. Again there emerged the feeling

thattherewasneveranyonearoundwhowouldunderstandherneeds.The

desire to remain with me was implicit. She made another attempt at

continuationbytellingmethatshewasawareofadeeploveforhermother

butthattheideaofclosenesswasfrighteninglestshealsobecomecrazy.

Herstruggletoremainwithmebecameexplicitinarepeatofherdream

ofgoingoutoftheparents'bedroomwindowexceptthatthistimethehouse

ismine.InanotherdreamIamlyingbesideherandshefeelsIshouldnotbe

doingthat.Asshehadwithherfather,shefeltthatIdidnotwishtoseeher,

thatIwouldbegladtoberidofherbecauseshewas"intractable."Itwaseasy

formetospeaktoherofherobviousaffectionforme,likethatIhadseenin

herforherfather,fromwhomshefeltshehadnevergainedvalidationforher

womanhoodorforheracceptabilityasawoman.Iaddedthatthisperceived

failure on her part had seriously interfered with her relations with men as

wellascontributedheavilytothesenseofherselfasunworthyanddefective.

Inthelast,thetwelfthsession,shesaidthatshefeltthatIlikedherand

shecould accept that aswell as the ideathat she wasnot crazy. She finally

knewthatsheexpectedhersontosaveher,andshefeltreadytolethimgrow

James Mann

Time-Limited Psychotherapy

upandaway.Shefeltbetteraboutherselfandthoughtshemightbereadyto

become much more active in her profession, even perhaps venturing to

publishsomeofherwork.Shewassadaboutleavingmeandcried.Sheasked

againifshecouldcallme,andItoldherthatsheshouldgiveherselfatleast

six months to digest the work we had done and to experiment further in

makingchanges,thatifshefelttheneedatthatpointsheshouldfeelfreeto

callme.

Oneyearlatersheaskedtoseeme.Shereportedfeelingsomuchbetter

aboutherselfthatshecouldhardlybelieveit.Forthefirsttimeshehadgone

awaywithherhusbandonlyandhadthoroughlyenjoyedit.Hersonhaddone

verywellontheSATsandlifefeltverygood.Beforeleavingsheaskedifshe

could see me the following April, when college acceptances would be

announced.Isaidyes.Atthatvisitshesaidshehadhopedthathersonwould

havechosenauniversityinthearea;insteadhehadbeenwaitlistedatseveral

very good universities but had chosen one that was patently not up to the

others,notveryfarfromhome.Sheknewverywellwhatherchoicewould

havebeenbutwasabletolethimmakehisownandtofeelcomfortableabout

it.

Oneyearlatershecalledagain.Hersonwashappyatcollege,activein

sportsbutnotveryinterestedingettinggoodgrades.Shechosetoseehimas

a fine boy despite that. She was now enthusiastic about her increased

Handbook of Short-Term Dynamic Psychotherapy

professional activities, which were providing enormous satisfaction. With

considerable pride she announced that she had submitted papers for

publicationandhadalreadyreceivedapprovalononeofthem.Ispoketoour

mutual appreciation of her wish for her son to do well in whatever he was

engagedinbutthatnowshenolongerneededhisperformanceasameansof

gainingrespectforherself.Shecoulddothatonherown.

EMPIRICALSUPPORT

TheeffectivenessofTLPisknowntomeandtomycolleaguesthrough

ourexperienceandthroughthefollow-upinterviewsthatwehavedone.The

presetlimitoftwelvesessionshasbecomeincreasinglypopular,althoughthe

theory and technique of TLP have not been adopted. Unfortunately, there

havebeennolarge-scale,carefullyorganizedresearchprojectsontheefficacy

of TLP. A very large project proposed by the psychology department of a

major American university was denied federal funds. At the time TLP may

havebeenregardedastooradical.Thereisanongoing,carefullystructured

research project in TLP being done in Jerusalem. Haim Dasberg and Gaby

ShefleroftheEzratNashimMentalHealthCommunityCenterreportedina

presentation (1989): "Our results suggested that Mann's TLP has clear

positiveoutcomes. The outcomes are consistent with the therapy rationale.

That is, the changes occur in self esteem, social functioning and target

symptoms."

James Mann

Time-Limited Psychotherapy

CONCLUSION

TLP provides a model of psychoanalytically based psychotherapy of

briefdurationthatisteachable.Thestructureisclearlyoutlined;withsome

experience the process becomes almost predictably visible. TLP does not

requireacharismatictherapist;ratheritrequiresbeingpartoforagraduate

of a good general training program in psychoanalytic psychotherapy. It

requiresalsoawillingnesstostepoutofthetraditionalmodeandareadiness

toengagepatientsactivelywithintheframeworkofareasonedapproach.Itis

notashort-termpsychoanalysis,butittouchesveryquicklyonwhatismost

importanttoallpeople:theself-descriptionthatmakesourexistenceeither

quitebearableorriddenwithpain.Withitsspecifictimelimitandtheconcept

ofthecentralissue,TLPbringstotheforefrontofthetreatmentprocessthe

major psychological plague all human beings suffer, namely the wish to be

close, to be as one with another, to be intimate, the fulfillment of which

demandslearninghowtotolerateseparationandlosswithoutunduedamage

toourfeelingsabouttheself.

Handbook of Short-Term Dynamic Psychotherapy

References

Dasberg,H.,& Shefler,G.(1989,June). A randomizedcontrolledoutcome and follow-upstudyof

JamesMann's timelimited psychotherapy in a Jerusalem communitymental health

center.PaperpresentedatthemeetingoftheSocietyforPsychotherapyResearch,

Toronto.

Mann,J.(1973).Timelimitedpsychotherapy.Cambridge,MA:HarvardUniversityPress.

Mann,J.,&Goldman,R.(1982).Acasebookintimelimitedpsychotherapy.NewYork:McGraw-Hill.

James Mann

Time-Limited Psychotherapy