Jonathan D. Smith

Form and forming a focus: In brief dynamic therapy

Abstract The author draws upon the work of Kenneth Wright, outlining the function of the therapist in giving shape to the inarticulate felt experience of the patient. Through processes of mirroring, attunement and identifying narrative patterns, and as an alternative to the making of interpretations, the therapist brings the experience of the patient within the jurisdiction of form, and in so doing contains and holds this experience. The author then turns more specifically to the role of the therapist in brief therapy in establishing a focus for the work, and how this can be seen as a way of containing the patients inarticulate felt experience. Whether it arises as a crystallization of the focus, a flash, or as a central maladaptive pattern, establishing a focus can be seen as a way of lending shape to the narrative pattern and of making a fundamental connection to the patients idiom. It can therefore be seen as a containing structure for the work and as a way of bringing the experience of the patient within the jurisdiction of form. The importance of the non-verbal utterances of the therapist in mirroring the patients feelings is noted and links are made to Osimos concept of emotional maieutics in which the therapist acts as a midwife to the patient, enabling him or her to give birth to their hidden feelings. The significance of non-verbal experience in the therapeutic relationship is also linked to Balints notion of a new beginning and Levensons conceptualization of new experiences in brief work. The paper concludes with a case example that illustrates these themes; in it, the author is perceived as a Sherpa guiding the patient on her journey to explore the unfamiliar terrain of her feelings and their freer expression, within the jurisdiction of form provided by the focus.

Time and again: Intermittent Brief Dynamic Therapy

Abstract The author notes that in many of the settings in which Brief Therapy takes place that a client may return after the ending for a further series of sessions. Time-limited therapy has placed an emphasis upon the termination phase of the therapy and linked this to the process of individuation and separation. Such an approach, as articulated by Mann (1973), which draws conceptually from the work of Winnicott (1965) and the notion that the infant achieves unit status from the original undifferentiated merger with the mother, is not easily compatible with Intermittent Brief Dynamic Therapy. The work of attachment theorists and Stern (1985) provide an alternative basis upon which to conceive of the development of the infant. While emphasizing the importance of attending to affects at points of separation and ending, as is evidenced in the work of Della Selva (2004), such a framework is more readily compatible with the development of Intermittent Therapy, and with the realities of the settings in which much brief work takes place. The author also comments upon the flexibility inherent in Winnicotts own practice of brief consultations, and the implications of this for the development of Intermittent Brief Dynamic Therapy. The paper includes a case study that illustrates this debate and which provides evidence for the therapeutic potency of a form of Brief Dynamic Intermittent Therapy where a dynamic focus maintains a structuring pattern to the narrative over a sequence of several periods of Brief Therapy, spread over a number of years.

Panic stations: Brief dynamic therapy for panic disorder and generalised anxiety

The author begins by noting the longstanding interest of psychodynamic writers in the symptom of anxiety yet the complete absence of any reference to short-term psychodynamic therapy in the current National Institute of Clinical Excellence guidelines for anxiety and panic disorder. Drawing upon a plurality of research methods he demonstrates the breadth of the evidence base that supports the use of this treatment modality for anxiety and panic disorder. His review includes randomised controlled trials and their meta-analyses as well as research that explores the aetiology of anxiety and panic disorder. He describes Luborskys core conflictual relationship theme method of identifying a focus and the process research that supports its use. He also outlines Luborskys symptom-context method and the process research that underpins the notion that symptoms, such as panic and anxiety can be meaningfully related to the narrative and therapeutic context in which they emerge. The author concludes by illustrating these themes with a clinical case study.

Steering through storms to safe havens: Playing and reality in Brief Dynamic Therapy

The author outlines the contribution and relevance of Winnicotts thinking to the practice of Brief Dynamic Therapy. Specifically he notes three transitions that can be employed to deepen the therapeutic engagement with the patient and enhance effectiveness. The transitions involve acknowledging the let-down, facing the patients destructiveness and reaching back to what had been good enough in their early experience. The importance of play and spontaneity in the transitional space of brief therapy are also noted as well as their relationship to particular therapeutic techniques. The augmentation that Gustafson has provided to Winnicotts ideas which map the notion of changing a reiterating pattern onto the terrain of the patients current external world as well as in dreams is described. These themes are then illustrated by two case studies.

A leap across a basic fault: Brief Supportive Dynamic Therapy

The author explores the evidence-base and selection criteria for a short-term supportive dynamic approach for patients whose psychological mindedness and quality of object relationships is low. Illustrating this approach with a case example he outlines the central features of Supportive Dynamic Therapy. He describes a psychodynamic conceptual and developmental framework that can be used to guide the therapists interventions and responses, and modulate the patients anxiety. A dynamic focus presented in the form of a central issue is shown to have a significant function both in containing the patients anxiety, and in giving shape to the therapists efforts to support the patients ego-strengths and adaptive abilities. The therapeutic work can be seen to result in an alteration in the trajectory or reiterating pattern of the patients life.

Securing a base on the frontline: of a Primary Care Counselling Service

The author begins this paper by noting the continued growth of counselling in Primary Health Care and that increasingly counselling is being delivered in Managed Care services. He describes his own role as a manager and supervisor of one such service operating on the front line of an inner city. He outlines the contribution that a regular meeting time for the counsellors has made to their ongoing support. The fortnightly Organizational meeting has provided a reflective space for the counsellors in which it has been possible for them to share the pain and the difficulties of their work in their respective surgeries. This in turn has contributed to their ability to maintain depressive-position functioning in the face of the complex emotional demands of their work. The author goes on to describe how he applied open systems theory in identifying and defining the nature of his own role and tasks as manager of the service. By placing himself at the boundary of the service, and attending to the various boundaries that the service had with the external environment, he shows how he was thereby more able to facilitate the counsellors in their own work and practice in the surgeries. This in turn contributed to the ability of the service to remain focussed upon its Primary Task, and to lessen the likelihood of it developing a self-assigned impossible task. The author explores the compatibility of his role as supervisor with his role as manager in a counselling service where the managerial role is facilitatively placed on the boundary. The paper concludes with a description of a crisis in the counselling service that required a re-focussing of attention on new boundaries with the external environment.

Transference, triangles and trajectories

In this article the author addresses the issue of the need to lessen the likelihood of a regressive transference neurosis in short-term therapy. He examines the role that active interpretation of the transference can have in shaping the transference so that it remains at the level of the transference that is ubiquitous. He explores the relationship between such an active interpretative approach and the need for the therapist to be empathic and sensitive to the patient and to allow space for a patients independent discoveries. The author describes the role of the Central Therapeutic Focus, as a constellation of the Triangles of Insight, in guiding the therapist to select those manifestations of the transference to interpret, and in enabling the therapist to retain a stance that is sensitive and empathic. The Central Therapeutic Focus is contrasted with the concept of the Central Issue, and with the latters more specific attention to the contribution that it makes to the therapists communication of their empathic understanding of the patients difficulties. The nature of the relationship between the therapist and the patient in short-term therapy is explored further and the connections between companionable interaction, ego-relatedness and the matrix of the transference are outlined. The author proceeds to consider the nature of the process of working through in short-term therapy and of the need to attend to the patients external world as the place in which this can occur. The contribution of the Central Therapeutic Focus in shaping the trajectory through which the patient and therapist attend to the external world is examined. This in turn is linked to the identification of a patients ordinary solution to their problem as a means of resolving their Dilemma. The article concludes with a case example that illustrates these themes.

A tapestry of red thread and emotional blueprints: Poetic feeling in brief dynamic therapy

The author notes the contribution that both the Triangle of Conflict and the Triangle of Persons have made to the conceptualisation of a focus and its use in clinical work in brief dynamic therapy. He goes on to point out how the Triangle of Conflict has a more central position in those approaches which focus upon eliciting affect, whereas the Triangle of Persons has retained a more predominant position in the process of identifying narrative patterns in relational approaches. He outlines the ways in which narrative patterns contribute to the development and maintenance of the personality and how this in turn has major implications for clinical practice. He identifies a newly developing synthesis of those approaches which employ the Triangle of Conflict to elicit affect and those which employ the Triangle of Persons to explore narrative patterns. He illustrates these themes with a case example.

Editorial for Psychodynamic Practice Issue 24:2

A few hours before sitting down to begin writing this editorial, I saw the new film the Shape of Water directed by Guilermo Del Torro. It’s a film in the genre of magical realism, in which a creature from the depth of the sea experiences a mutually mirroring intimacy through which his form acquires a benign and indeed beautiful shape. Of the creature, the leading female character says to her friend, ‘he really sees me’. Meanwhile, outside the snow has thawed. The ‘Beast from the East’ had merged with ‘Storm Emma’ to produce a blizzard which for a while caused unpredictable havoc and disruption across the land. Amusingly it prompted BBC2’S Newsnight to play the last few verses of Bob Dylan’s song ‘Shelter from the Storm’ with the accompanying advice to avoid certain activities such as taking selfies in the snow! Hearing the song again had reminded me of these strikingly meaningful lyrics from one of the verses of the song:-

No moral high ground, only a shattered wasteland: A modern fable with Blood on the Tracks

Some years ago I suffered bereavement. It did not arise from the loss of a spouse, a close family member, a friend or even a pet. I had lost part of my work. Though it was a part-time job, it was nonetheless a deeply meaningful part of my working life, to which I had been very committed. Much creativity flowed from the work itself and the working relationships that arose from it had resulted in significant bonds and attachments with colleagues and service users which were of some considerable emotional depth. The loss itself had resulted from the closure of the service in which I had been working for several years. The word bereavement fully resonated with my felt experience, for subjectively I experienced a lengthy period of mourning which was still ongoing several months later. I had been appointed as a manager to set up a service nearly six years before the events resulting in the closure of the service. I had spent many long hours designing the service which addressed a need that had hitherto been unmet within the field of community-based mental health. At the time of designing the service, the funding prospects were very good and the organisation of which the service was a part welcomed and actively supported the initiative. Another colleague joined me as deputy manager and she contributed to the overall management of the service. Within a few months, we had recruited staff and were soon developing plans for the delivery of a complex and innovative service initiative. We linked well and skilfully with relevant community groups and soon the demand for the service grew and as the reputation of the service blossomed, the financial security of the service seemed to become assured and stable. The service thrived and within a year or two, I had begun to relax and to begin to feel secure in our accomplishment. Alongside the service which my colleagues and I created and developed, another similar service catering for a related but different group of service users was also being developed by another branch of the same organisation. The model of service delivery for this service was much more centralised, and