Dynamic Change in Crisis Intervention

PAUL A. JERRY, M.A., C. PSYCH.'k

The author describes his work integrating psychodynamic theory and
therapeutic methods in a crisis center. Crises can be seen as situational
mediators that place an individual's typical defenses and resistances in
question. This state of crisis can allow for dynamic change, beyond the relief
of symptoms typically expected in crisis work.
THE APPLICATION OF WINNICOTTS AND MALANS METHODS
IN A COMMUNITY SOCIAL SERVICE SETTING
In this day of managed care and increasing demands for economy in the
psychotherapeutic process, clinicians are often forced to explore methods
of treatment that are limited in duration. For those clinicians who were
trained or supervised within a psychoanalytic framework, the idea of brief
therapy can be troublesome. Traditionally, methods of therapy thought to
promote dynamic change in the client were believed to be of longer
duration (i.e., more than 25 sessions) and required careful management of
both the content of the sessions and the frame within which the therapy
occurred .
Fortunately, a large body of literature has grown over the years which is
devoted to the description and development of brief psychodynamic
Interestingly, Levenson notes that much of the pioneering
work in brief dynamic psychotherapy is only 15 to 20 years old, and
continues to build on the work of such authors as Sifneos,' Mann,8 and
others.
Glick and Meyerson9discuss the use of psychoanalytic concepts in crisis
intervention. They suggest that any crisis has dynamic implications and
likely dynamic underpinnings. Although crises are typically defined as
external events that overwhelm an individual (e.g., relationship break-
down, financial loss, natural disaster), internal responses to external situa-
tions are just as important in precipitating a failure of coping.1° For this
reason, a crisis may be approached as both an external situation that
requires management and an internal dynamic process that requires atten-
*Instructor, Addictions Counselling Program, Medicine Hat College. Mailing address: Division of
Health Studies, Medicine Hat College,299 College Dr. SE, Medicine Hat, Alberta, T1A 3Y6.
AMERICAN
JOURNAL OF PSYCHOTHERAPY,
Vol. 52, No. 4, Fall 1998
 Dynamic Change in Crisis Intervention

Present Others Transference Anxiety Defence

Past Others Hidden Feelings

Triangle of Person Triangle of Conflict

Figure 1.
T H E TRIANGLES O F PERSON AND CONFLICT (adapted from Malan14).

Winnicott's Contribution
The therapeutic consultation was a concept developed by Winnicott in
his work with children. A specific method for conducting a therapeutic
consultation is not systematically delineated in Winnicott's writing, except-
ing a short description in his Psycho-analytic exploration^^^ (pp. 3 18-324).
In surveying Winnicott's writings, there does seem to be a number of
common structural and process-orientated directives that begin to define
the therapeutic consultation20 (p. 137). Elsewhere, I have introduced the
therapeutic consultation as developed and applied in a brief/crisis therapy
setting, and would refer the reader for further detaiL21
Malan 's Contribution
Malan6J4 describes a method of psychodynamic psychotherapy that is
both systematic and comprehensive. In Malan's discussion of the process of
dynamic psychotherapy, he envisioned an inquiry centered on issues repre-
sented schematically by two downward-pointing triangles: the Triangle of
Person, and the Triangle of Conflict14 (p. 80).
"Anxiety" and "Defence" constitute the upper two points of the Tri-
angle of Conflict. At its lower point, MaIan labelled "Hidden Feelings,"
often an inner experience that is being a ~ o i d e d In
. ~ context, the client
usually presents with some kind of anxietyldefense dynamic that consti-
tutes a central part of the presenting or referring symptom(s).According to
the Triangle of Conflict, there lies deeper impulses or Hidden Feelings that
are the drive under the obvious, presented Anxiety. Typically, the Defence
 Dynamic Change in Crisis Intervention

with the assumption that any crisis has roots in inner conflict, exploring
dynamic issues should be central to any attempts at crisis intervention.
Also useful in assessing the degree to which dynamic change has been
worked through in therapy sessions is a scheme originally presented by
P e t e r f r e ~ n dH
. ~e~suggests that there are observable markers of dynamic
change that include: emotional expression associated with relief of tension/
anxiety; new awareness regarding the current life situation; links estab-
lished between the present and the past; old memories that resurface
confirming the links between past and present; experiences and verbaliza-
tion of archaic/primitive/disordered states; the client's active recall of
details from the past (not generalizations); the client's feelings of being
understood (rapport); and the client's ability to see new options for
acting/feeling in the future. These criteria are evident in the case material
that follows.
The Work Setting
The clinical work discussed in this presentation was done in a social
service crisis center in western Canada that provides short-term crisis and
long-term drug counseling at no fee to the clients. All staff are trained
professionals. The center also provides the city's 24-hour crisis phone line
answered by trained volunteers. Clients range from ages 10 to over 65 years.
There is no agency model for conducting therapy. Thus, many theoretical
perspectives are represented on staff.
Clients seen in the center are between the ages of 25 and 35 years and
present with some combination of relationship breakdown (60%), recent
pattern of violence or abuse (44%),and symptoms of anxiety (34%) and/or
depression (27%). Clients who present with a primary issue of substance
abuse account for 15% of the referrals (percentages are not cumulative). In
cases serious enough to warrant a DSM-IV24diagnosis,mood disorders and
anxiety disorders, as well as substance abuse/dependence, would be most
typical. For the year 1996, the average number of sessions per client was
less than five and the average counselor conducted approximately 1,200
sessions. As a result, there is an ongoing interest in the practice and
development of brief but substantive methods of therapy. There is no
mandate for education or research, therefore, research and professional
writing is done by interested therapists on their own time.
As will become apparent, work in a social-service setting differs from
other environments where dynamic psychotherapy is practiced. Typically,
clinicians making use of dynamic brief therapies are cautioned about
selection of clients suitable for the method with varying degrees of strin-
44 1
 Dynamic Change in Crisis Intervention

Triangle of Conflict) and how she had been coping thus far (her use of
Defence on the same triangle). L. made an association to a break up with
her first serious boyfriend about a month before Christmas. She then noted
that her pattern of dealing with stressful events was to withdraw and avoid
contact with others. I rephrased her statements in terms of the Triangles.
Withdrawal (and the symptoms of depression which were mild enough to
serve as a buffer from others) was a defense against intimate connection
with others in the present. (This interpretation was ill formed from the
point of view of Malan's ideal case14 [pp. 74-94]). This connection was
suggested in an attempt to link her defense of withdrawal with her
symptoms of unease.
In the course of the first half-hour, L. had disclosed the bulk of the
dynamics that had been driving her for over 10 years. She had internalized
her father's suicide as a personal rejection, devaluing her worth as a person.
This traumatically acquired self-concept colored her interpersonal relations
throughout her teens and early adulthood. Whenever there was a chance of
a closer intimate relationship, she would react with feelings of unease and
withdraw. The withdrawal served to protect her from deeper feelings of
lack of worth and fear of abandonment.
At this point in the session, I showed L. a list of Peterfreund'sZ3
description of working through and explained the concept. L. agreed that
many of the points fit her present feelings around the issues we had
discussed. The first session ended with a statement I made in response to
her obvious reaction of insight. I remarked that "just because you feel a
certain way, does not mean that you are that way." This disconnection of feelings
from her state of being served as a motto for the rest of L.'s sessions.
L. attended two more sessions for a total of three, over a three-week
period. In the second, a hypnoanalytic technique was applied which served
to emphasize the insights gained in, and after, the first session. The third
session was taken up with tallung about the events of the past two weeks
and how she had unexpectedly taken action in regards to her ex-boyfriend
and had written him a letter expressing her feelings toward him. L.'s
situation lent itself well to the process of psychodynamic crisis intervention
and relief was rapid. Moreover, the resolution did not simply address a
return to premorbid functioning but included some alleviation of a past
trauma and its influence in the present.
Case 2
In contrast to L. who presented with relatively mild symptomatology
and a circumscribed chief complaint, D. came to the Centre with a severe
 Dynamic Change in Crisis Intervention

helping her to quit, and she was once again angry that no one was doing
anything about "the night before, on the morning after" and so the abuse
(now through drug use) continued (the link between Hidden Feelings,
Defence, and Present Others consolidated).
Finally, I suggested that had she not come in to see me this day, she
would have been repeating much of this pattern with me. I told D. that I
had a place in this process which she had indirectly caught on to when she
voiced her anger at the people currently in her life who were not helping
her quit (link from Present Others to Transference). I explained that my
role was to help her quit cocaine use but that I needed her help as I could
not read her mind to figure out when it was "the morning after" when she
needed the help (placing the Transference relationship foremost, linked
with the Hidden Feelings).
By coming, she was acting on the Hidden Feelings in a positive way, one
that allowed for a new pattern to emerge, where she actually did do
something about an incident that happened "the night before, the morning
after." Her presence in my office "the morning after" was proof of this.
Again, D.'s response was an increase in rapport and she said that so far, this
was the longest time she had spent in counselling, and felt it to be one of the
best connections she has ever had with a therapist. I took this as a positive
sign that the inquiry had been both accurate and therapeutic.*j
It was soon after this session that D. stopped cocaine and, so far, has not
resorted to its use again. The therapy then shifted from crisis intervention
to psychotherapy proper with a focus on insight, deep change of personal-
ity patterns, and the addressing of the past trauma of the abuse. Through-
out the course of D.'s contact with me, this fourth session's direct focus on
dynamic patterns served as a guide for our work.
Case 3
Not all forays into dynamic crisis intervention are successful, where
success is measured by engagement, insight, and resolution of the crisis.
Compared with L.'s and D.'s cases, S.'s situation was difficult to address
and the outcome is still in question. S. presented to the Centre in obvious
anxiety, and requested the quickest relief possible for her issues. S. was a
woman in her mid-thirties, married, with children. S. considered herself a
religious woman. More than five years prior to our consultation, she had
had a brief affair which she broke off very soon after its start. Unfortu-
nately, the man involved spent his time stalking her for many months after
the end of the affair. S. was convinced that he continued to stalk her to the
present date. Her present symptoms included feelings of paranoia, obses-
 Dynamic Change in Crisis Intervention

work through the issue. At this point I thought that S. had managed to
resolve the issue and needed the reassurance of a third party before taking
the plunge. Unfortunately, this was not the case.
S. did not stop with her husband. She wanted also to tell her mother
about this long-held secret. She wanted to tell her best friends and the
neighbors she socialized with. She believed that the only relief would come
from a total cleansing which involved baring her shame to the world. I
suggested that this might not be the best course of action and that it might
be useful if we sorted through the consequences of these options. While I
recognized this reaction as fuelled partly by her history of abuse and her
habitual response to a harsh (internal and external) mother and a demand-
ing religious belief, I was not able to impress these points on S. She left the
third session apparently confused about the correct course of action.
Because of her restrictions on my means of contacting her (i.e., her husband
did not know about our sessions), I was not able to contact her to finish the
work.
I included this case with the intent of showing that even with "obvious"
dynamic issues and the insight to appreciate them, a client may not be ready
or able to make use of therapeutic help in this way. S.'s history and present
symptoms fit well with Malan's model and were also typical of the kinds of
issues and distress found in crisis work. Sadly, the shoe may fit, but it may
not be worn. S.'s change of heart between the second and third session (a
six month interval) may have been partly a result of our work in the second
session. She would also likely have fit the kind of profile Malan et al.
discussed in their study of untreated neurotic subjects.12 While S. may yet
have acted on her feelings, change at a dynamic level is questionable.
(There is also the ethical concern that following a strictly dynamic interpre-
tation of the ex-lover/stalker as an externalized projection of her inner guilt
might blind a clinician to the possible reality of danger in cases like this.)
LIMITATIONS
AND CONCLUSIONS
There are obvious limitations to this work. Since Malan's work in the
1970s, the standards and methods of outcome research on psychotherapy
have grown to a point where it is difficult for the average clinician in public
or private practice to conduct studies appropriate for publication. Instead,
clinicians are better suited to addressing the details of therapeutic process,
reporting trends in practice, and commenting on, and contributing to,
theory. In this case, the clinical material was not randomly selected, nor was
it subjected to any form of statistical analysis. Instead, it was chosen for its
ability to demonstrate the process of applying psychodynamic principles to
 Dynamic Change in Crisis Intervention

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