TIME PSYCHOTHERAPY

Current developments in the different orientations (I)

We will outline some of the new psychotherapies that are representing important
and "revolutionary" innovations in the therapeutic models referred to in other
sections of the text.

6.1. Psychodynamic psychotherapy: The time-limited psychodynamic

psychotherapy of Strupp and Binder (1989).
Traditionally, psychoanalytic therapy and brief dynamic psychotherapies have
considered that interpersonal relationships could be real or distorted based on the
transference. The transfer would be characterized by a rigidity in the construction
and interpretation of reality based on previous relationships. The theoretical and
practical proposal of Strupp and Binder starts from reconceptualizing transfer
rather as the effect of a dyadic interpersonal relationship based on previous
relationships. This is not a distortion based on previous relationships, but rather the
reproduction of previous relationships by those involved in them in the here and
now of the relationship.

The therapist involved with his behavior favors or disconforms the

transference/countertransference binomial that occurs between the client and
himself.

Brief dynamic psychotherapy of limited time (PDTL) integrates clinical concepts

from different psychodynamic perspectives. The objective of it is not so much the
modification of symptoms but the structure of the patient's character that is
expressed through his chronic maladaptive interpersonal relationships. Early
difficulties with significant others have led to maladaptive and self-defeating
interpersonal patterns. When the patient relates to a significant person, including
the therapist, his personality structure comes into play through the relationship
established between both protagonists. The PDTL tries to search for the
interpersonal models that appear in the patient-therapist relationship and through
them produce relevant changes both at a subjective level (cognitions and feelings)
and in their interpersonal relationships.

The PDTL approach places emphasis on two aspects: the current transactions
between patient and therapist; and increasing the patient's understanding of their
role in functioning in their life. To do this, the therapist makes use of the relational
dyad where he uses empathic listening, psychodynamic understanding of relational
difficulties in the context of his personal history and clarification of his self-defeating
character as the main tools. To achieve this, the therapist will also take into
account the patient's resistance aimed at making the therapist's efforts fail.

The theoretical foundations of PDTL are based on psychoanalytic principles

referring to transference, countertransference, resistance and defensive functions
of the ego. It also incorporates the concepts of interpersonal psychodynamic
theorists such as HSSullivan; Cerner's theory of object relations; the applications of
Watzlawick, Weakland and Fish's theory of systemic change; and the ideas of a
more active psychoanalytic psychotherapy along the lines of Alexander and
French.

The PDTL has also generated an extensive body of research that has proven its
effectiveness (Vanderbilt project) and has generated a manual, all in the new line
of approaches that aim to demonstrate its effectiveness.

This approach is characterized by a series of similarities and differences with

respect to traditional psychoanalytic therapy and other brief psychodynamic
approaches. Its main features are:

(1) The selection of patients for this approach is made not so much by the type of
symptomatology presented but rather by their ability to engage in a therapeutic
relationship evaluated in the initial interviews (footer "test interpretations").

(2) A dynamic theme or focus is sought on which to focus the therapeutic work,
which unlike other dynamic psychotherapies focused on themes such as the idyllic
focus (Siphons), separation (Mann), parent-other transference (Mallan) or the
resistance (Davalo); here the focus is on cyclical patterns of interpersonal
relationships.

(3) The main area of work focuses on therapeutic transfer; But unlike Mallan's
orientation, it is considered that this derives not only from previous relationships
with parents, but that the therapist has an active role in its current maintenance or
modification.

(4) Initial treatment duration limits are established: 25 to 30 sessions lasting 1 hour.

(5) Patients of the other brief dynamic psychotherapies are selected if they present
a formulation of their difficulties such as: "I am currently a person with a specific
conflict, and that conflict derives from my previous and inadequate relationships
with my parents in the childhood". However, the PDTL observes that not all
patients provide historical and current material that fits the previous scheme, and
that therefore, they are erroneously discarded for psychotherapy. Patients have
personal and idiosyncratic, subjective and particular "narrative styles." The PDTL
takes into account these subjective differences and how they occur in the
therapeutic relationship.

(6) The PDTL rejects metapsychological terminology and concepts whose clinical
relevance is more than questionable. It is about being closer to clinical
observations, avoiding as much as possible complex theoretical formulations that,
rather than bringing the therapist closer to the transference relationship, conceal it
from apparently irrelevant knowledge.
(7) PDLT is an approach that can be proven effective compared to other
therapeutic approaches and offers a psychodynamically oriented framework
adaptable to community mental health services.

The patient's problems are considered a consequence of inadequate interpersonal

relationships. The child's early learning through interpersonal relationships with
significant people involves various functions, among which the following stand out:
nutrition, personality structuring, basic socialization, acculturation, which includes
language acquisition and providing models. identification. Deficiencies in any of the
above areas can lead to neurotic or psychotic disorders.

The patient, as a result of his early childhood learning and current relationship
dynamics, has unrealistic expectations of himself and others and frequently feels
bad. Due to the avoidance of painful feelings related to unfinished business with
significant figures, these relational aspects and their causes are excluded from
awareness, although they continue to affect you in your current relationships. The
patient's behavior not only perpetuates previous conflicts but also currently
deprives him of opportunities for their modification.

The child, however, is not a passive being where the influence with his parents is
imprinted in a mechanical and automatic way. As Freud pointed out, the child's
fantasies and the meanings he attributes to his parents' behaviors are very
relevant. He is therefore influenced not only by the actual behavior of his parents
but also by his first theories about the meaning of said behaviors.

The attitude of the PDTL therapist is based above all on the skill of listening.
Basically it is about empathizing with the patient's internal world without being
punitive and avoiding the compulsion to act without understanding the relational
dynamics.

The PDTL work approach is based on the evaluation of four aspects of the
patient's interpersonal transaction:

1st-Problems presented by the patient: Complaints (symptoms) and relational

difficulties presented.

2nd-Acts of oneself: Role that the patient adopts in his or her interpersonal
relationships that includes his feelings and desires toward significant others, his
cognitions (thoughts about himself and others) and his behaviors (behaviors
toward significant others). They can vary in their degree of consciousness

3º-Expectations to other people's reactions: Imagined reactions of other people to

one's own actions. They can be conscious, preconscious or unconscious. They are
formulated in the way: "If I do such. He/She will do which.”

4º-Acts of other people towards oneself: They refer to the behavior of other people
in response to one's own actions.
5th-Acts of oneself towards oneself (Introjection): It is how one treats oneself (self-
controller, self-punisher, etc.). They are connected to the previous sections.

In this way, the interpersonal transaction that constitutes the focus of the PDTL
would be as follows:

Acts of self---> Expectations about other people's reactions-->

Reactions observed in other people--->Introjection--->"Close the circle"

In relation to the PDTL technique, it focuses on two aspects: (1) Providing a new
human experience and (2) Provoking changes through that experience in the
inadequate learning that the patient has carried from the past. The therapist tries to
identify the patient's "unconscious games" through which he constructs his
relationships and tries to induce the therapist to adjust to them. To do this, the
therapist will have three technical aspects: (A) A series of guides to understand the
patient's conflicts, (B) A line of guidance for his interventions and (C) The
identification of resistance and its management.

With respect to the guides to understand the patient's conflict, transference is

considered as the patient's tendency to update their emotional conflicts through the
relationship with the therapist. Here it is about considering that the patient has a
series of pre-existing fixed expectations with which he/she interprets the events of
the relationships. The therapist makes interpretations in this sense of the
transference, taking as data what happens in the now of the relationship, the past
relationships and the "allusions to the transference" (references from the patient,
people and situations external to the therapeutic relationship, the patient's mood,
dreams and the emotional atmosphere of the sessions). With respect to
countertransference, the therapist is attentive to the emotional reactions that the
patient's behavior evokes in himself, and uses them to learn from the patient's
conflict. Countertransference in this approach refers to the actions and reactions of
the therapist, which also include his or her attitudes, thoughts, behaviors, and
fantasies toward the patient, which are evoked by the patient's transference
reactions. The therapist must make some withdrawal and reflect on his reactions
and how they may be part of the patient's relational game; in order to be able to
disengage from it.

Regarding the intervention guide, the PDTL the therapist is attentive to the
therapeutic relationship, uses the focus format referred to above (the four elements
of the transaction) and makes interpretive connections of the patient's relationship
with him, the connections being little used. interpretive with external relations.
Basically interpretation is the most important technical tool. Interpretations of this
approach avoid psychodynamic jargon (penis envy, masochistic attitude...etc.) and
are based on data that both participants have observed over the course of the
relationship, following the four-element transaction.

The greatest obstacles in PDTL come from resistance, which is defined here as the
patient's unconscious operations aimed at maintaining a sense of security and the
avoidance of fears and threats, all governed by unconscious beliefs about self and
others. The clues to identify resistance to therapeutic collaborative work are found
in the way the patient relates to the therapist from the first session. This usually
presents itself as observable behavior through a theme that is often repeated in the
relationship. Generally resistance refers to the patient's difficulty in being aware of
his transference towards the therapist. The therapist manages resistance by being
attentive to topics loaded with affect, where the patient's anxiety will cause him to
seek protection with habitual behaviors (anger, abandonment). The therapist then
points out these modes as a form of avoidance and seeking security.

Resistance can also come from the therapist himself, if he fails to empathize with
the patient or plays a reciprocal role in the transactional game (attacking, being
impatient...). By allowing the patient to explore and evoke his or her feelings about
the therapeutic relationship, the therapist becomes the target of the patient's
fantasies, emotions, and desires; which can generate threats to his self-image and
self-esteem. It is common for the therapist to then adopt defensive reactions of a
rationalized type such as: (1) Telling the patient that he needs more time to
establish the therapeutic relationship before continuing with such painful topics, (2)
Stop insisting on resistant interpretations if the patient does not abandon it, for
another better time and (3) If the patient does not respond to a resistance
interpretation, believe that he has gone ahead to make it. Let us remember, the
interpretation of resistance is based on the patient's difficulties in becoming aware
of the transference towards the therapist. The therapist's own resistance is in turn
based on a difficulty in becoming aware of his countertransference towards the
patient.

Finally, it is important to highlight certain affinities between PDTL, functional

analytical psychotherapy (radical behaviorist) and interpersonal cognitive
psychotherapy. The element of the patient-therapist transaction becomes a central
element in all three approaches.