An Examination of Mann's Model of Time-Limited
Individual Psychotherapy*
ANTHONY S. JOYCE, Ph.D. CAND. 1 AND WILLIAM E. PIPER, Ph.D. 2
The present study attempted a sensitive test ofthe dynamic
sequence proposed by Mannfor time-limited individual psy-
chotherapy (TLP). Session evaluation ratings were collected
from both patient and therapist. Indices were constructed that
reflected the consistency ofpatient ratings. the consistency
oftherapist ratings, and the congruence between patient and
therapist ratings, in each third of TLP. Measures of sym-
ptoms and social functioning were employed to differentiate
cases of "good" versus "poor" treatment outcome. Ther-
apists' adherence to the TLP technique was assessed by
categorizing all interventions in each session. Fourteen
patients were treated according to the TLP model. Measures
oftherapist behaviour indicated that treatments had been con-
ducted in general accordance with Mann's technical recom-
mendations. Measures ofconsistency and congruence failed
to support the proposed TLP dynamic sequence. Analyses
of mean evaluation ratings indicated a trend towards more
positive evaluations as therapy progressed; "good" outcome
cases were significantly more likely to evidence this pattern.
Results are discussed in terms of interplay between induc-
tive hypothesis building and empirical verification in the
development of theories of psychotherapy.
N umerous theories of brief individual therapy have
emerged in recent years (1,2). Mann (3,4) has proposed
a straightforward model of time-limited individual psy-
chotherapy (TLP) useful to both researchers and clinicians.
The model emphasizes the meaning of time in individual life
development and particularly in the experience of separa-
tion and loss. The therapy model clarifies the function and
*The research reported in this paper was supported by a grant from the
Special Services and Research Committee of the University of Alberta
Hospitals. An earlier version of this paper was presented at the 18th Annual
Meeting of the Society for Psychotherapy Research, Ulm, Federal Republic
of Germany, June, 1987.
Manuscript received January 1989; revised April 1989.
'Therapist. Psychiatric Walk-In Clinic; Research Associate, Psychotherapy
Research Centre, Division of External Psychiatric Services, Department
of Psychiatry, University of Alberta Hospitals, Edmonton, Alberta.
2Professor and Co-director, Psychotherapy Research Centre, Department
of Psychiatry, University of Alberta, Edmonton, Alberta.
Address reprint requests to: Anthony S. Joyce, Research Associate, Psy-
chotherapy Research Centre, Department of Psychiatry, University of Alberta
Hospitals, Walter C. Mackenzie Health Sciences Centre, 8440-112 Street,
Edmonton, Alberta T6G 2B7.
Can. J. Psychiatry Vol. 35, February 1990
41
consequences of a finite treatment agreement, outlines a
sequence of dynamic events held to occur over three con-
ceptually distinct phases of therapy, and provides sugges-
tions for the therapist's interventions within each phase. The
present study attempted to examine the validity of the pro-
posed dynamic sequence and technical recommendations.
The TLP model is oriented towards the brief individual
treatment of life crises reflecting conflict issues of separation-
individuation. The goal of TLP is the mastery of separation
anxiety as a basis for the mastery of other neurotic conflict.
Patients presenting in distress from life crisis considered
suitable for TLP are held to experience conflict in the areas
of a) dependence versus independence, b) passivity versus
activity, c) diminished versus adequate self-esteem and d)
unresolved grief reactions (3).
Mann advocates a therapy contract of 12 sessions and
asserts that the process in each third differs as a function of
the patient's experience of time in the therapy relationship.
In the beginning phase of TLP, the patient's participation
reflects "a surge of unconscious magical expectations that
long ago disappointments will now be undone" (3). The
patient feels optimistic about treatment and his desire for help
meshes well with the information gathering and central
problem formulation activity of the therapist. The therapist
begins and continues to actively support, encourage and edu-
cate the patient. An unambivalent and positive transference
relationship quickly develops and is regarded as responsible
for the symptom relief experienced within the first three or
four sessions. The therapist continues to attend only to the
central issue during the 'middle phase of treatment and the
patient experiences' 'disappointment that a relationship once
wholly unambivalent will once more become ambivalent"
(3). The patient is confronted with the fear associated with
the original genetic conflict, the separation without resolution
from the meaningful, ambivalently experienced object. A
return of symptoms, latenesses and absences, and a sense
of pessimism about treatment outcome are common patient
expressions during this phase. Clarification and interpreta-
tion become important therapist behaviours during the middle
phase of TLP. The final phase of TLP requires an insistence
on the patient's reactions to the impending termination, Ter-
mination is emphasized as an opportunity for the resolution
of earlier ambivalence without the same degree of affective
upset. "The working through of the reactions to separation
must lead to a lessening of ambivalence and a greater capacity
to internalize an object that is experienced as good" (3). The
42 CANADIAN JOURNAL OF PSYCHIATRY
anticipated result for the patient is greater autonomy and
increased self-esteem. The therapist makes a point of
inquiring about the patient's feelings regarding the relation-
ship, continues to offer clarifications and interpretations, and
supports the patient's efforts towards individuation.
Using Mann's ideas about the dynamic sequence in TLP,
Schwartz and Bernard (5) made predictions about the con-
sistency of patient session evaluations, the consistency of
therapist session evaluations, and the congruence between
the two for each phase of therapy. Therapist session evalua-
tions were expected to remain consistent throughout the
course of therapy since therapists "bring to the treatment
context an image of what the entire course ... and specific
phases of it will entail" (5). Patient session evaluations were
expected to vary in consistency as a function of phase.
Patients would experience the beginning phase in a manner
appropriate to their expectations of being helped by an
interested professional and their evaluations were predicted
to be highly consistent during the initial sessions. The
patient's experience of a return of ambivalence and the
associated disappointment in the middle phase was expected
to be reflected in evaluations of low consistency. In the ter-
mination phase, "patients begin to consolidate the gains of
treatment" and consistency of patient evaluations was again
expected to be high. Congruence between patient and ther-
apist evaluations was also expected to vary as a function of
phase of treatment. Because the therapist's role in the begin-
ning phase is to gather information for the clarification of
the central problem focus, "patients' and therapists' evalu-
ations of this early phase should be relatively congruent. "
Congruence was expected to decline in the middle phase of
treatment. Finally, because patients were assumed to "return
to experiencing therapy in a way that corresponds to that of
their therapists, " congruence was expected to be high during
the final phase.
Schwartz and Bernard (5) had patients and therapists com-
plete rating scales following each session, evaluating the hour
on dimensions of therapist understanding and comfort, patient
expression, self-understanding and hope, and session accom-
plishment. Scores based on a summation of the item ratings
were derived from "early" and "late" sessions in each third
of therapy and employed in all analyses. Consistency in each
phase was assessed by correlating individual participant's
ratings between "early" and "late" sessions. Congruence
was assessed by correlating patient's and therapist's ratings
at each of the six selected points of treatment. Results
indicated that
"patients' evaluations became less consistent on a session-
by-session basis ... while therapists maintained a gener-
ally weak to modest level of evaluative consistency .
[E] valuations were most congruent in the early phase .
and least congruent in the middle and closing phases" (5).
The correlations were generally low, even when significant,
but were nevertheless taken by the authors as supporting the
validity of Mann's (3) sequential model of TLP.
Vol. 35. No.1
We believe that the Schwartz and Bernard (5) study was
not a sufficient test of the validity of the TLP model. First,
the rating scales employed to assess participants' subjective
evaluations of therapy sessions were of unknown psycho-
metric properties and the use of a summed score may have
obscured relationships evident with any of the individual
items. Second, the correlation coefficients that were used in
their study are not sensitive indicators of consistency or con-
gruence. Correlations indicate the relative ranking of two
sets of scores across time or between groups of respondents
but ignore the absolute differences between the two sets of
score values. A high correlation between two sets of scores
indicates only that the ranking of cases is preserved, not that
there is high consistency, i.e. little absolute difference,
between the scores. In similar fashion, a high correlation
between patient and therapist scores indicates only that the
ranking of the dyads is retained, not that the absolute differ-
ences between the participant ratings are small.
Third, since no measures of treatment outcome had been
included, Schwartz and Bernard (5) were unable to test the
predictive validity of the proposed dynamic sequence.
Fourth, aspects of therapists' practice, and their adherence
to the suggestions offered by Mann (3), were not monitored.
The present research was an attempt to carry out a stronger
and more comprehensive test of the validity of Mann's (3)
model of TLP. The present study aimed to: employ indices
of consistency and congruence which would address, respec-
tively, the variation and difference in patient and therapist
session evaluation ratings; compare the pattern of evalua-
tive ratings provided by cases differentiated on dimensions
of treatment outcome; and assess the interventions actually
used by therapists.
Method
Patients
Patients who presented at the University of Alberta
Hospitals' Psychiatric Walk-In Clinic (PWIC) in Edmonton
complaining of difficulties related to issues of separation-
individuation (for example, leaving home for university, ter-
minating a relationship) were seen as potential candidates
for TLP. The critical selection criteria were first, a capacity
for rapid affective involvement and second, evidence of
appropriate disengagement from significant relationships
which ended in the past. The intake therapist would assess
these criteria during a regular assessment interview and
his/her judgement would then be reviewed by the consulting
psychiatrist in a rounds interview immediately afterwards.
Fourteen outpatients were treated with the standard,
12 session TLP approach. The sample of 14 was equally
divided in terms of sex, marital status (with versus without
a partner) and referral source (self versus referral by a phy-
sician/hospital/agency). The average age of the sample was
30.0 years (SD = 6.7 years). Eleven patients reported
receiving previous psychiatric treatment but none reported
previous hospitalizations for emotional problems. One patient
received a DSM-III (6) Axis I diagnosis of Major Depres-
sion, six a diagnosis of Adjustment Disorder, and three a
February, 1990 MANN'S TIME-LIMITED THERAPY
V-code diagnosis of Uncomplicated Bereavement. Other
Axis I diagnosis included Marital Problem (two) and No
Diagnosis (two). On Axis II, two patients received a primary
diagnosis of Dependent Personality Disorder. Of the 12
patients given No Diagnosis (nine) or Diagnosis Deferred
(three) on Axis II, six were assigned traits associated with
personality disorders. Avoidant traits were listed on five
charts, compulsive traits on three and dependent traits on
two charts. Axis IV and V ratings suggested an average level
of psychosocial stress in the" moderate" to "severe" range
and an average level of adaptive functioning in the "good"
range.
Therapists
Eight full time staff therapists of the PWIC were involved
in the study. Therapists were from various professional dis-
ciplines; five social workers, a psychologist, an occupational
therapist and a psychiatric resident participated. Therapists
had an average of four years experience conducting individual
and group forms of dynamically oriented psychotherapy. One
therapist provided six cases, one had two cases, and six ther-
apists provided one case each. Therapists followed Mann (3)
as a guide to conducting TLP and received weekly clinical
supervision in the model from a staff psychiatrist. In addi-
tion, data-based feedback from completed cases regarding
therapist behaviour in TLP was communicated to
participating therapists on a regular basis.
Measures
I. Session ratings. Following each treatment session,
patients and therapists each completed two self-report rating
scales. The Therapy Feedback Questionnaire (TFQ) (5) con-
sists of six 4-point Likert items. Four item ratings inquired
about I. the therapist's understanding of the patient, 2. the
clarity with which the patient expressed what was "really"
troubling him/her, 3. the patient's hope and optimism about
therapy and 4. the participant's sense of accomplishment in
the session. The two remaining items dealt with dimensions
of therapist comfort and were not seen as directly important
to a test of the proposed dynamic sequence. The Session
Evaluation Questionnaire (SEQ) (7,8) is a measure of ses-
sion "impact" and consists of 24 bipolar adjectives in the
7-point semantic differential format. The factor scores exa-
mined included two evaluative dimensions (Depth-Value and
Smoothness-Ease) and one post-session affect dimension
(Positive Feeling). In summary, seven variables (four from
the TFQ and three from the SEQ were rated by the patient
and the therapist after each therapy session.
2. Therapist behaviour ratings. Independent observers
attended sessions or worked from audiotapes of each ses-
sion and categorized therapist interventions according to the
Therapist Behaviour Categories (TBC) system, modeled after
the checklist of Lieberman, Yalom and Miles (9). We have
applied this modified system to group (10) and individual
modalities. The TBC system consists of 19 subcategories sub-
sumed under five general categories of therapist behaviour
43
(Evocative Behaviour, Cognitive Learning, Support,
Management and Therapist Use of Self). The intent of each
intervention determines category assignment. Categorizations
of therapist behaviour in individual sessions requires only
that one TBC category (therapist requests member seek feed-
back) be omitted. Interrater reliability was assessed by means
of the kappa coefficient (11,12). The average reliability in
six preliminary applications of the system was .81. Periodic
reliability assessments were conducted during the course of
the study (one quarter of all sessions). Average reliability
for specific categories was .65 (SD = .10, range = .44 to
.87) while the average reliability on general categories was
.74 (SD = .09, range = .55 to .94). There were no differ-
ences when categorizations were conducted in-session or
from audiotapes.
Ten of the 19 specific behaviour categories were used in
the present study to define five aspects of therapist practice
as described by Goodman and Dooley (13). Summing over
particular categories provided rough indices for the following
therapist practice aspects:
Practice Aspect Component Categories
A. Information Gathering 1. Questioning
2. Confrontation
B. Guiding Patient Behaviour 1. Setting Goals/
Procedures
2. Managing Time
C. Explaining Patient Behaviour I. Explain/Clarify
2. Interpretations/New
Concepts/Reframing
D. Showing Empathy 1. Reflection
2. Support
E. Therapist Use of Self 1. Reveals Feelings
2. Draws Attention to
Self
3. Outcome variables. Patients and therapists completed
evaluations of the entire course of therapy after the close of
the last treatment session. The Therapy Evaluation Form (5)
for each participant inquired about I. patient satisfaction with
treatment, 2. patient-perceived treatment benefit, 3. extent
of problem change, and 4. extent of change as a person on
separate 5-point Likert scales. A global treatment evalua-
tion score based on a sum of the four item ratings was also
calculated for each participant. In addition, patients were
administered two self-report outcome measures at pre- and
post-treatment and six month follow-up. The Symptom
Checklist (SCL-90) (14) is a 90 item inventory constructed
to assess psychopathology on nine primary dimensions (for
example, Depression, Anxiety) and four global dimensions
(for example Global Severity Index). Numerous studies have
documented the SCL-90's sensitivity to treatment effects, for
example symptom change following brief psychotherapy
(15). The Progress Evaluation Scales (PES) (16) are made
up of seven dimensions, each consisting of five levels, with
the characteristics of each level anchored by brief descrip-
tions of functioning. The levels for each area range from the
44 CANADIAN JOURNAL OF PSYCHIATRY
most pathological to the higher levels of adaptive functioning
observed in the community. The seven scales include Family
Interaction (dependence versus independence), Occupation
(primary occupational role functioning), Getting Along with
Others (friction in social interaction), Use of Free Time (sub-
Iimatory processes), Feelings and Mood (affective regula-
tion), Problem Distress (coping capacity) and Attitude
Towards Self (self-esteem). The psychometric properties of
the instrument are well documented in the source article (16).
Procedure
Patients suitable for TLP were provided explanations of
the research procedure and their informed consent was
obtained at the close of the session, during which the cen-
tral issue had been stated and the treatment contract offered
by the therapist. Patient pre-treatment outcome ratings were
collected at this time or immediately prior to the first con-
tracted session. Participant ratings on the respective Therapy
Feedback Questionnaire and SEQ and coded therapist
behaviours were collected for each session. At the conclu-
sion of treatment, both participants completed the respec-
tive Therapy Evaluation Form and patient outcome measures
were administered. Six months after termination, patients
were asked to return to the PWIC for a follow-up adminis-
tration of the outcome measures and a brief interview
focusing on the felt need for further treatment, change in
problem status, effectiveness of therapy and satisfaction with
services received.
Analyses
Correlations among the patient session evaluation rating
variables indicated that five of the seven were relatively
independent. The variables had an average absolute inter-
correlation of .25 and only one coefficient was above .40.
Included in this set were the Session Accomplishment and
Patient Clarity variables from the Therapy Feedback Ques-
tionnaire and the Depth-Value, Smoothness-Ease and Posi-
tive Feeling variables from the SEQ. These five process
measures were used to test the validity of the proposed
dynamic sequence.
The measure of patient or therapist consistency used was
the variance of the respective session evaluation rating across
sessions within each phase (third of therapy). The measure
of congruence used was the average absolute difference
between patient and therapist ratings over the sessions com-
prising the phase. The mean of patient and therapist ratings
within each phase comprised the third type of measure sub-
ject to analysis. The fourth type of data examined involved
the mean proportion of each therapist practice aspect (see
above) in each phase of TLP. As a result, six distinct sets
of data were subject to analysis: 1. patient consistency (mean
variance) for each phase; 2. therapist consistency (mean var-
iance) for each phase; 3. patient-therapist congruence (mean
absolute difference) for each phase; 4. mean level of patient
ratings for each phase; 5. mean level of therapist ratings for
each phase; and 6. the mean proportion of therapist practice
aspects in each phase.
Vol. 35, No.1
Correlations among the outcome measures (residual gain
scores for the SCL-90 and PES, and participant post-
treatment evaluation ratings) were examined and five which
proved relatively independent were selected (see below).
Median splits on each of the five selected outcome variables
differentiated the sample into "good" and "poor" outcome
groupings. Within each of the six datasets and for each out-
come measure grouping, a "mixed" ANOV A (17)
represented the analytic approach; the outcome grouping
represented the between-subjects factor and phase of therapy
the within-subjects factor. This strategy resulted in 25 ana-
lyses (five post-session rating variables or five therapist prac-
tice aspects by five outcome grouping variables) for each of
the six datasets .
Of interest in the analyses were phase effects which were
supportive of the TLP model, for example less patient con-
sistency and participant congruence in the middle phase of
therapy, greater interpretive activity on the part of the ther-
apist in the middle and termination versus beginning phases.
Of primary interest, however, were interaction effects which
indicated different patterns of participant evaluation or ther-
apist behaviour across the three phases for cases differen-
tiated as attaining "good" versus "poor" outcome.
Results
Treatment Outcome
Before proceeding to the analyses of the six datasets, note
should be made of the treatment outcome evidenced by the
entire sample. Significant (p < .01) pre- to post-treatment
improvement was shown on all SCL-90 symptom scales
except Somatization, and all SCL-90 global summary scales.
Significant pre- to post-treatment improvement was also evi-
dent on five of the seven PES variables. Comparisons
between post-treatment and six month follow-up scores for
the 12 patients who returned evidenced no significant differ-
ences for SCL-90 or PES variables, implying that the gains
evident at the end of therapy had been maintained by patients
during the subsequent follow-up period.
In addition, participants provided highly positive evalua-
tions of the therapy experience on post-treatment Therapy
Evaluation Forms. The four patient item ratings averaged
4.6 on a 5-point Likert scale; the mean for the summary
patient evaluation score was 18.4 (SD = I. 5) out of a pos-
sible 20. The four items provided by the therapist averaged
4.3 on a 5-point Likert scale; the mean for the summary ther-
apist evaluation score was 17.2 (SD = 1.7) out of a possible
20.
As no control group comparison was possible, SCL-90 and
PES scores at pre- and post-treatment were contrasted with
nonpatient normative data for each instrument. At pre-
treatment, the sample proved to be significantly different
from nonpatient "normals" on 12 of 13 SCL-90 dimensions
and all seven PES scales. At post-treatment, the sample was
significantly different from the nonpatient norms on only
three of 13 SCL-90 dimensions and a single PES scale. These
patterns substantiate the conclusion that the treatments had
been successful.
February, 1990 MANN'S TIME-L1MIl'ED THERAPY 45

Table I
Summary of Significant Effects by Dataset

TYPE OF DATA Outcome Phase of Outcome X Phase

OUTCOME GROUPING Grouping Therapy Interactive
Process Variable Main Effect Main Effect Effect
Participant Consistency: Patient
THERAPIST TEF
Depth-Value 6,31 **
PES OTHER
Patient Clarity 6.22**
Participant Consistency: Therapist
PATIENT TEF
Patient Clarity 6,73*
Positive Feeling 5,56*
SCL-90 GSI
Patient Clarity 4,00*
Participant Congruence
THERAPIST TEF
Session Accomplishment 3.54*
Depth-Value 8,21*
PES OTHER
Positive Feeling 3.43*
PES SELF
Session Accomplishment 5.53*
Participant Mean Ratings: Patient
THERAPIST TEF
Session Accomplishment 4.33*
Patient Clarity 5,50*
Smoothness-Ease 3.75*
Positive Feeling 4.03*
PATIENT TEF
Session Accomplishment 4.63*
Patient Clarity 6.36**
Smoothness-Ease 6.72** 11.82***
Positive Feeling 5.02* 4.86*
SCL-90 GSI
Session Accomplishment 4.25*
Patient Clarity 5.88**
Smoothness-Ease 3,52*
Positive Feeling 3,70*
PES OTHER
Session Accomplishment 4.55*
Patient Clarity 5.59**
Smoothness-Ease 3.72*
Positive Feeling 3.76*
PES SELF
Session Accomplishment 4.21*
Patient Clarity 5.60**
Smoothness-Ease 3.52*
Positive Feeling 3.69*
Participant Mean Ratings: Therapist
THERAPIST TEF
Session Accomplishment 4,12*
Patient Clarity 4.03*
PATIENT TEF
Session Accomplishment 5.14* 3.39*
Patient Clarity 3,90*
46 CANADIAN JOURNAL OF PSYCHIATRY
Table I continued
SCL-90 GSI
Session Accomplishment
Patient Clarity
PES OTHER
Session Accomplishment
Patient Clarity
PES SELF
Session Accomplishment
Patient Clarity
Therapist Practice Aspects
THERAPIST TEF
Therapist Use of Self
PATIENT TEF
Therapist Use of Self
SCL-90 GSI
Information Gathering
Therapist Use of Self
PES OTHER
Information Gathering
Therapist Use of Self 7.74*
PES SELF
Information Gathering
Therapist Use of Self
Note: Outcome grouping variables are abbreviated as follows: THERAPIST TEF = Therapist Therapy Evaluation Form summary score;
PATIENT TEF = Patient Therapy Evaluation Form summary score; SCL-90 GSI = Symptom Checklist Global Severity Index; PES
OTHER = Progress Evaluation Scales Getting Along with Others; and PES SELF = Progress Evaluation Scales Attitude Towards Self.
*f < .05, **f < .01, ***f < .001
Correlations among the SCL-90 and PES residual gain
scores and the patient and therapist post-treatment evalua-
tion ratings indicated that five variables were relatively
independent. The variables had an average absolute inter-
correlation of .26 and only one of the ten coefficients had
a value greater than .50. The variables included the sum-
mary scores from the patient and therapist post-treatment
Therapy Evaluation Form, the Global Severity Index from
the SCL-90, and the Getting Along with Others and Atti-
tude Towards Self scales from the PES. Change in sym-
ptoms, social functioning and self-esteem and the
participants' subjective evaluation of therapy benefit were
addressed by these measures. For each variable, a median
split of the distribution was used to define "good" (n = 7)
and "poor" (n = 7) outcome groupings. On all five vari-
ables, this procedure resulted in a highly significant (p < .01
or less, two-tailed r-test) differentiation of the sample into
the two classes of treatment outcome.
In terms of pre- to post-treatment raw score change on the
three standardized outcome variables, "good" outcome cases
evidenced a mean change of 1.2 pre-treatment SD units while
"poor" outcome cases evidenced a mean change of 0.2 pre-
treatment SD units. On the summary score from the patient
and therapist Therapy Evaluation Forms, "good" outcome
cases attained an average of95.4% of the total possible score,
versus an average of 82.5 % for cases designated "poor"
outcomes. The median splits on selected outcome variables
had the result of differentiating the sample into subgroups
of "excellent" and "fair" treatment outcome. The terms
Vol. 35, No. I
4.25*
5.88**
4.55*
5.59**
4.21*
5.60**
5.90**
5.75**
3.70* 3.82*
6.12**
3.34*
6.10**
3.41 *
6.47**
"good" versus "poor" outcome thus suggest a relative
difference in perceived positive benefit.
Table I presents the significant effects which emerged from
analyses conducted on each dataset. The likelihood of com-
mitting a type I error was high when this number of ana-
lyses was conducted. Consequently, we regarded as strong
only those effects on the process measures evident across
analyses that employed different outcome grouping variables.
The reader should also note that, even if large effects were
expected, the small sample restricted our power (II) to iden-
tify significant effects to a moderate level, i.e . .40. Thus,
the possibility of type II errors had to be taken into account.
Participant Consistency
Patient Ratings. A total of 25 ANOV As were conducted
on patient ratings, the index of consistency being the vari-
ance of process evaluations within each treatment phase. A
total of 75 effects were assessed using this strategy; four
effects could be expected to reach significance (p < .05) by
chance alone. Two significant interactions (Depth-Value and
Patient Clarity; p < .01), no significant outcome main effects
and no significant phase main effects were observed. The
few findings emerging from analyses of the patient con-
sistency data were likely due to chance and provided no sup-
port for the TLP sequential model.
Therapist Ratings. A similar approach to data analysis was
taken with the consistency of therapist evaluation ratings
across phases. One significant interaction (Patient Clarity;
p < .05), two significant outcome main effects (Patient
February, 1990 MANN'S TIME-LIMITED THERAPY
Clarity and Positive Feeling; p < ,05) and no significant
phase main effects were observed. Given a marginal yield
of significant effects and the likelihood of these being spu-
rious, analyses of the therapist consistency data also failed
to support aspects of the TLP model,
Participant Congruence
A total of25 ANOVAs were also conducted on these data.
The process index was the average absolute difference
between patient and therapist ratings within each phase on
the respective evaluation variable. Two significant interac-
tions (Session Accomplishment; p < .05), one significant out-
come effect (Depth-Value; p < .05) and one significant phase
effect (Positive Feeling; p < .05) were observed. The har-
vest from analyses conducted on the participant congruence
data was also meager and provided insufficient support for
the TLP sequential model as conceptualized by Schwartz and
Bernard (5).
Participant Mean Level of Ratings
Patient Ratings. The process index for these analyses was
the mean patient evaluation rating within each phase of treat-
ment. When cases were grouped according to the patient's
own summary evaluation of therapy, two significant inter-
action effects were noted'. Good outcome cases provided sig-
nificantly higher mean ratings of Smoothness-Ease (p < .001)
and Positive Feeling (p < .05) during the termination phase
than poor outcome cases. Significant phase effects were evi-
dent on four patient evaluation variables within each anal-
ysis employing a different outcome classification, i.e. a total
of 20 significant phase main effects were observed. All
patients evidenced an increase in ratings across phases on
the dimensions of Session Accomplishment, Smoothness-
Ease and Positive Feeling (p < .05) and Patient Clarity of
expression (p < .01).
Therapist Ratings. A similar pattern was evident in the
results of analyses conducted on the mean therapist evalua-
tion ratings across phases. One significant outcome effect
(Session Accomplishment; p < .05) suggested that therapists
of good outcome cases were more positive across all phases
than therapists of poor outcome cases. Significant phase
effects were evident on two therapist evaluation variables
within each analysis employing a different outcome classifi-
cation, i.e. a total of ten significant phase main effects were
observed. Therapists generally provided progressively higher
ratings of Session Accomplishment (p < .05) and Patient
Clarity (p < .01) as therapy moved towards termination.
The results of analyses on mean participant evaluation
ratings suggested that patients and therapists will in general
regard their treatment in more positive terms as therapy
progresses and, further, that good outcome is related to a
satisfying and well-managed termination phase.
Therapist Practice Aspects
Again, a total of25 ANOVAs were conducted, the depen-
dent measure being the mean proportion of the respective
therapist practice aspect within each phase of treatment. A
47
single significant interaction (p < .05) emerged from the ana-
lyses; a significantly higher level of therapist Information
Gathering activity was evident among good outcome cases
during the beginning phase of therapy. One significant out-
come effect was also noted. Therapists of good outcome cases
evidenced significantly less Use of Self activity across all
phases than therapists of poor outcome cases. While modest,
these effects did point to considerations for the conduct of
TLP. The interaction effect suggested the importance of a
thorough assessment of the problem focus at the initiation
of treatment. The outcome effect suggested that therapists
working with patients who went on to show only minimal
treatment gains felt it necessary to pay more attention to the
transference relationship, perhaps implying a patient
difficulty with this form of therapeutic approach. A total of
eight significant phase effects were evident across the ana-
lyses employing different outcome classifications and indi-
cated that, generally, therapists tended to decline in their use
of Information Gathering interventions (p < .05) but made
more Use of Self (p < .01) as therapy moved towards ter-
mination. Nonsignificant phase effects on the remaining ther-
apist practice aspects were in the directions expected. The
phase effects indicated in broad terms that therapists had con-
ducted the therapy in line with the TLP recommendations.
Discussion
A careful test of certain aspects of Mann's (3) model of
time-limited psychotherapy was conducted. An attempt was
made to improve upon the earlier efforts by such investi-
gators as Schwartz and Bernard (5). Our use of alternative
measures of consistency and congruence was an attempt to
provide a more sensitive test of the proposed dynamic
sequence in TLP. As it turned out, the results for consistency,
congruence and mean level of ratings all failed to provide
support for the proposed dynamic sequence.
The absence of support for the TLP model was not because
the outcome of the therapy was poor. Results of pre-post
comparisons on simple measures of treatment gain and per-
ceived benefit indicated that the sample as a whole evidenced
substantial improvement in symptomatology, social func-
tioning and self-esteem. Similarly, the lack of support for
the dynamic sequence was not because the therapists failed
to adhere to the technical recommendations offered by Mann
(3). Analyses of the proportional emphasis therapists placed
on particular classes of behaviour during therapy sessions
indicated that treatments had been conducted in general
accordance with the TLP model.
One explanation for the failure to provide support for the
TLP dynamic sequence is that the theory is simply wrong.
It may not be necessary for the patient to experience discon-
firmation of unconscious expectations of fulfillment during
the middle phase in negative terms. Becoming aware that
ambivalent feelings towards the therapist have been carried
over from previous relationships can represent an opportu-
nity for insight and consequently be experienced as positive.
Analyses of patient and therapist mean session ratings indi-
cated that session evaluations did become more positive as
48 CANADIAN JOURNAL OF PSYCHIATRY
the phases of therapy progressed. Moreover, patients who
were identified as attaining "good" treatment outcomes were
significantly more likely to evidence the trend towards
progressively more positive session evaluations.
The inductive approach to theory construction in the area
of psychotherapy is important. Experience with clinical cases
can suggest useful theoretical ideas. However, theoretical
concepts need to be explored in systematic research investi-
gations. In the hypothesis building stage, the levels of many
variables are inferred. In the hypothesis testing stage, careful
measurement of the variables mayor may not lead to con-
firmation of the hypotheses. The lack of confirmation in the
present study does not suggest that the treatment method,
in this case Mann's (3) model of TLP, is not a useful one.
The model, as practised by therapists in the present study,
was certainly found to be useful in terms of treatment out-
come. However, the reasons for the treatment's efficacy may
be different than what had been hypothesized. Disconfirma-
tion of a model's theoretical concepts should serve as a
stimulus to further hypothesis building activity.
There are of course other possible reasons for a failure
to confirm the TLP model. Studies with clinical populations
are often limited by their measures and sample size. First,
the measures used to tap patients' and therapists' subjective
experience of the therapy sessions as they unfolded may not
have been the most appropriate for testing the model. Ratings
requested following the sessions may have been subject to
pressure to reduce dissonance on the part of the patient, or
to appear competent in the face of research evaluation on
the part of the therapist. A more adequate assessment of the
phenomenology of TLP could be gained from observation
of the emotional stance of the participants as they actually
engage in interaction. Second, a relatively small number of
cases were included in the present sample. Over and above
problems with the type I and II error rates, there may have
been little variation in the pattern of patient and therapist
evaluation ratings. In effect, the sample may not have per-
mitted the differentiation necessary to identify the predicted
dynamic sequence and deviations from the expected pattern.
This explanation can account for the absence of confirma-
tory interaction effects in the analyses of the consistency,
congruence and mean level of rating data. However, con-
firmatory phase effects would still have been expected if the
model applied to all cases of TLP conducted according to
Mann's (3) practical outline.
Mann (3) has proposed an interesting and useful theory
of time-limited psychotherapy. Schwartz and Bernard (5)
made an initial attempt to test the theory. The present study
attempted a more careful and systematic assessment of the
propositions regarding the dynamic sequence but did not pro-
vide confirmation of this aspect of Mann's model. We hope
that the results of this study will stimulate other investigators
to engage in further hypothesis building and testing of the
TLP model.
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Resume
On a cherche it tester de maniere precise la sequence dyna-
mique proposee par Mann pour la psychotherapie individ-
uelle de duree limitee. Pour ce faire, le patient et le
therapeute ont evalue separement les seances de therapie.
Pour chaque tiers de la psychotherapie, on a etabli des
indices visant it traduire la coherence des evaluations du
patient, la coherence des evaluations du therapeute et la con-
gruence entre les deux. On a evalue les symptomes et lejonc-
tionnement social afin de distinguer les cas presentant un
"bon" pronostic de guerison de ceux presentant un
"mauvais " pronostic. On a aussi determine dans quelle
mesure le therapeute adherait aux techniques preconisees
pour la psychotherapie individuelle de duree limitee en clas-
sifiant ses interventions au cours des seances. On a traite
quatorze patients selon le modele proposepour la psych other-
apie. Les mesures relatives au comportement du therapeute
indiquent que, dans I'ensemble, ce dernier respecte les
February, 1990 MANN'S TIME-LIMITED THERAPY 49

recommandatlons techniques formulees par Mann. Toutefois,
les resultats pour la coherence et la congruence ne cor-
roborent pas la sequence dynamique proposee pour la psy-
chotherapie. L 'analyse des cotes moyennes donne apenser
que les evaluations deviennent plus favorables amesure que
la psychotherapie progresse; cette tendance s 'observe le plus
frequemmeni, et ce de facon significative, dans les cas ayant
un "bon" pronostic de guerison. La discussion des resultats
porte sur l'interaction entre la formulation inductive
d 'hypotheses et la verification empirique de ces dernieres lors
de I 'elaboration des theories touchant a la psychotherapie.