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A HANDBOOK OF
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9 PSYCHODYNAMIC
1011
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PSYCHOTHERAPY
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6 Penny Rawson
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First published in 2005 by
Karnac Books Ltd.
118 Finchl!':}' Road, NWJ SHT

CopyriCht 2005 Penny R:'Iwson

111ft right of Penny Rawson to be identified as the aufuor uf


I.his work h:'ls been :'Isserled in :'It":cordance w ith 77 :'Ind 78
of the Copyright Design and Patents Act 1988.

All rights reserved. No part uf this publication may be repro-


duced, stored in a retrieval system, or transmitted, in any
form or by any means, electronic, mechanical, photocopying,
recording, or otherwise, without the prior written permission
of the publisher.

British Library Cataluguing in Publication Data

A c.I.P. for this lxx>k is available from the British Library

978 1855753044

Edited, designed and produced by TIle Studio Publishing


Services Ltd, Exeter EX4 SIN

Prinled in Creal Britain

10987654321

www.kamacbouks.coln
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111 Contents
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9 ACKNOWLEDGEMENTS xi
1011 ABOUT THE AUTHOR xiii
1 INTRODUCTION xv
2 Quick reference note xvii
3 AIMS OF THE BOOK xix
4
5 CHAPTER ONE
6 What is brief psychodynamic psychotherapy? 1
7 An overview
8 Quick reference notes 19
9 Focal and short-term psychodynamic
psychotherapy 20
2011
Suitability of client 21
1
Counter indications to suitability of client
2
for short-term therapy 21
3
Selection of patients 22
4
Motivation 24
5
Basic principles of focal and short-term therapy 25
6
HolmesRahe scale 26
7
Article Focal and short-term psychotherapy
8
in a treatment of choice (Rawson, 1992) 27
9
30 CHAPTER TWO
1 Focus 33
2 Quick reference notes 46
311 Finding the focus 47
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Contents

111 Progressive diagram of question areas inspired


2 by the Heimler Social Functioning Scale 48
3
4 CHAPTER THREE
5 The importance of the first session 51
6 Quick reference notes 60
7 Initial interview in short-term focal therapy 61
8 Aims of initial interview 63
9 Table: Important aspects of the first session
as seen from research case work (Rawson, 2002) 64
1011
1 CHAPTER FOUR
2 Jointly agreed strategic focus: contract part I 65
3 Quick reference notes 73
4 Fixing the focus 74
5 Holding the focus 75
6 The strategic focus 77
7 Homework: Aspects of brief therapy to practise 78
8 Questions for the therapist to think about
9 in relation to the focus 78
2011
CHAPTER FIVE
1
Jointly agreed time scale: contract part II 79
2
Quick reference notes 89
3
Time limited psychotherapy (i) 90
4
Time limited psychotherapy (ii) 91
5
The dynamics of the deadline 92
6
Article: By mutual arrangement
7
(Rawson, 1995) 93
8
9 CHAPTER SIX
30 Flexibility 99
1 Quick reference notes 114
2 Body memory exercise 115
311 Flexibility re skills used by the therapist 122
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111 CHAPTER SEVEN


2 Activity 123
3 Quick reference notes 135
4 Activity 136
5 Working with the client giving them the
6 tools: homework 137
7
8 CHAPTER EIGHT
9 Techniques 139
1011 CHAPTER NINE
1 Endings 151
2 Quick reference notes 161
3 Coping with loss: the end from the beginning 162
4 Loss for the client 163
5 Loss for the therapist in short-term work 165
6 Homework 166
7
8 CHAPTER TEN
9 Review and what next? 167
2011 Quick reference notes 173
1 Letters to the editor: Brief therapy
2 (Rawson, 1999a) 174
3 Supervision nonsense (Rawson, 2003) 177
4 Article: Therapy for the 21st Century
5 (Rawson 1999b) 179
6
7 CHAPTER ELEVEN
8 Conclusion 187
9 Brief psychodynamic psychotherapy:
30 Summary of the basics 189
1 REFERENCES AND BIBLOGRAPHY 191
2
311 INDEX 193
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1011 This book is dedicated to the late Louis Marteau who
1 introduced me to the method of brief psychodynamic
2 psychotherapy.
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111 ACKNOWLEDGEMENTS
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1011 I would like to thank those who have assisted me in
1 compiling this book. I am grateful to those clients who
2 have permitted me to use material from their situations,
3 using a pseudonym. I have amalgamated some of the clin-
4 ical examples for confidentiality and all names are ficti-
5 tious; any resemblance to an individual is therefore
6 chance. I am indebted to Fr Tom, who has read, encour-
7 aged, and supported this work, and to Terry Baker, who
8 has also proof read for me. I will always remember with
9 gratitude the late Louis Marteau, who taught me so much
2011 about this brief method of psychodynamic psychotherapy.
1 Also thanks are due to Karnac for publishing this, my
2 third book.
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111 ABOUT THE AUTHOR


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1011 Dr Penny Rawson has published articles in various jour-
1 nals and has done a great deal of research into her special-
2 ism, brief psychodynamic psychotherapy. She is the
3 author of Short-Term Psychodynamic Psychotherapy: An
4 Analysis of Key Principles, which could be seen as the text
5 book to accompany this basic guide to the practice of brief
6 therapy. She has also written Grappling with Grief, which
7 has been described as a book that normalizes grief.
8 She is the Director of FASTPACE, a consultancy
9 specializing in brief pschodynamic therapy, training and
2011 supervision.
1 She adopted the acronym FASTPACE as her trade
2 name. This seems an apt title for a therapy that is
3 intended to work at a fast pace. The letters actually stand
4 for Focal and Short Term Psychotherapy and Counselling
5 Education. She has served on a number of national
6 committees, including the British Association of Coun-
7 selling and Psychotherapys (BACP) Accreditation and
8 Standards and Ethics. She has worked as a therapist for
9 many years, managing services in higher education, as
30 director of a youth counselling service and as partner of
1 one of the first employee assistance programmes (EAPs) in
2 the country.
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111 INTRODUCTION
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3
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5 Why the book?
6
7 This book has been written in response to the interest
8 shown in the short-term approach. Very many health
9 authorities and doctors surgeries now work predomi-
1011 nantly in the brief approach, as do most university coun-
1 sellors. The profession has begun to offer an increasing
2 number of courses in various forms of brief work.
3 Professionals are seeking to increase their knowledge of
4 short-term therapy with a view to practising it, teaching
5 it, or supervising others who are now working in this way.
6
7
8 Who the book is for
9
2011 This book focuses on the basics for working in short-term
1 psychodynamic psychotherapy. It is aimed primarily at the
2 experienced therapist. The basic tenets of counselling and
3 therapy are therefore assumed to be part of counsellors
4 existing repertoire of skills. This book might also be useful
5 to any other therapist, supervisor, or trainer who wants to
6 think about the basics of brief psychodynamic
7 psychotherapy.
8 Additionally, this book will provide the lay person who
9 is interested in knowing a little more about the brief
30 approach with an outline of the method. In fact, many
1 people are using aspects of counselling and therapy in
2 their day to day dealings with others. The counselling
311 continuum (see p. xvi) indicates the different levels of
4 xv
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111 therapy and counselling that are appropriate for different


2 issues. The recipients expectations and needs are perhaps
3 what define the role. For example, if someone visits the
4 doctor, he or she may well apply counselling skills but the
5 recipient of this does not perceive the doctor to be a coun-
6 sellor or therapist. Friends share and help each other with
7 their problems but do not call themselves counsellors or
8 therapists. Some of the ideas in this book can usefully be
9 taken on board not just by therapists. Having said that, I
1011 want to stress that the method of brief psychotherapy
1 outlined here is a psychodynamic approach and in its
2 entirety is best handled by the trained and supervised
3 therapist. I use the terms psychodynamic counselling and
4 psychotherapy interchangeably.
5 Many supervisors who have not trained specifically in
6 the brief approach find themselves with supervisees who
7 are practising in this way because their workplace
8 demands it. This book will be useful for them to dip into
9 from time to time, especially as it describes the brief
2011 approach as a treatment of choice.
1 Since this book has been based on a series of lectures, it
2 may prove particularly useful for those therapists who
3 want to train others in the brief approach. This might be
4 as a specific training course, or it might be in the process
5 of a training supervision.
6 The quick reference notes, articles and letters with
7 reference to issues of debate in this field come at the end
8 of each chapter and are included as aides-mmoire and to
9 provide additional material for the reader to consider.
30 Each chapter outlines an aspect of the basics of the
1 method. The bullet point notes are intended to draw out
2 the main points of the chapters for quick reference. There
311 is, therefore, repetition of ideas in these.
2 xvi
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111

2011
1011
A Counselling Continuum
LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4
Interest in the persons concerns Depression Depression Psychotic
Broken relationships Unhealed bereavements Suicidal
Homesickness Bereavements Long-standing anxieties
Wrong course Decisions Difficulties re study
Rawson/2/prelims correx

Miserable Anxiety Dont know whats wrong


Broken relationships Work difficulties Suicidal
Work difficulties Homesickness
Bereavements Wrong course
Miserable
Pastoral counselling Counselling Counselling/Psychotherapy Psychiatric/medical/hospitalization
(Listening skills)
Tutors Counsellors Counsellors only Medically
Other students Accredited/ qualified
9/1/05 3:04 PM

Administrative Staff qualified


Family/friends
and also
Nurses/Doctors ?
Student Advisers ?
College Counsellors ?
Accommodation Officers
Page xviii

Careers Advisers
This differs from counselling, Formal contract Formal contract Referral out
which is time-consuming to look at the to look at the
and would interfere with issues. issues.
objectivity of academic process;
danger of tutors getting too
involved.
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111 AIMS OF THE B00K


2
3
4
5 An introduction to brief psychodynamic
6 psychotherapy
7
8
9 This book is intended as a basic introductory guide and as
1011 a quick reference handbook. Those seeking a more in-
1 depth study might be interested in my first book, Short
2 Term Psychodynamic Psychotherapy: An Analysis of Key Prin-
3 ciples. This is a useful text to have alongside this guide and
4 it will be referred to from time to time. I will abbreviate it
5 to Rawson 2002 and the page references for simplicity. It
6 was based on many years research and goes into each area
7 very thoroughly.
8
9
2011 Concepts to be covered
1
2 Concepts to be covered in this guide include basic princi-
3 ples such as focus, contract, flexibility, activity, dynamics
4 of the deadline, importance of the first session and
5 endings.
6
7
8 Bullet point notes
9
30
1 The bullet point notes are ready to use as quick reference
2 guides, aides-mmoire or handouts; they are copyrighted
311 by Fastpace.
4 xix
5
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Aims of the Book

111 My hopes
2
3 I write from a position of faith in the approach. It is a
4 treatment of choice, as you can see in the copy of the arti-
5 cle in the quick reference notes at the end of Chapter
6 One. I have not been compelled through pressure of
7 numbers or financial limits to adopt this method. Rather,
8 I have seen the good effects that can be achieved in a rela-
9 tively short time. I want to see clients helped out of their
1011 pain and towards a more free existence in the shortest
1 possible time. This is an approach that I have practised for
2
some twenty-five years. Having been asked to teach the
3
approach and to supervise those working in it for many
4
years, I am often asked what it is. To answer this I have
5
decided to provide a very basic guide to the practice of the
6
method. This is in the hope that the approach may
7
become more accessible to professionals and that more
8
people may be helped more quickly by counsellors and
9
therapists adopting the method.
2011
I cannot claim that this method of therapy is my own.
1
It is, in fact, rooted solidly in a tradition. Those who are
2
3 interested in the history and development of brief psycho-
4 dynamic psychotherapy might wish to refer to Rawson,
5 2002, pp. 3947. Clearly I have adapted and modified the
6 concept, as any therapist does. I learned the approach
7 from the late Louis Marteau, and refined his eight model
8 approach down to four to six sessions. This approach has
9 been equally successful in colleges, in private practice, and
30 in an employee assistance programme. My approach is not
1 rigid or restrictive. It is flexible and the number of sessions
2 offered is adapted to the particular needs of the client.
311 Even so the mean tends to be four to six sessions.
2 xx
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Aims of the Book

111 By the end of the book it is hoped that therapists,


2 supervisors, and trainers will feel clearer about its basics
3 and more confident about practising as brief psycho-
4 dynamic psychotherapists.
5
6
7 Limitations of this book
8
9 It is important to define the limits of what can be achieved
1011 in a basic guide such as this.
1 The book is short. Although of interest to a wide audi-
2 ence, it is aimed primarily at the experienced therapist
3 and, therefore, all the basics involved in counselling and
4 therapy are assumed. This makes it possible to focus just
5 on those aspects of the therapeutic work that accelerate
6 the process.
7
8
9 These ideas can make a difference
2011
1 It is hoped that you will find that you can put the princi-
2 ples into practice very quickly. Many therapists who have
3 grasped the basic ideas outlined in the first chapters have
4 found their clients respond differently, even though they
5 have not consciously done anything different.
6
7
8 Client and therapist comments
9
30 I have recorded below some comments made by therapists
1 who were attending my courses in brief psychodynamic
2 therapy and who consequently took on board the basics of
311 brief therapy as outlined in this book. Some had been
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Aims of the Book

111 astonished at how their clients, whom they had been


2 seeing for a long time, suddenly seem to shift forwards.
3 For example:
4
My client said it was such a relief to get to the point. I
5
thought we were never going to get on with things.
6
7 Several of my clients seem to feel that they are ready to
8 go now and that weve achieved what they wanted to.
9
I could not believe what we achieved in the last session.
1011
1 I was aware that I had changed gear in my work with the
2 client, I was much more focused.
3
These statements were made after the first session of
4
the course; that would be the equivalent of the first chap-
5
ter here!
6
7
8
Confirming what you already know
9
2011
1 In going through the book you may feel that you have not
2 gained a whole new body of knowledge. You may feel that
3 you knew it all anyway. That is all right. Now, however,
4 perhaps you know that you know and will therefore
5 continue your work in the brief method with more con-
6 fidence. In fact, I expect that, for many of you, it will
7 almost feel as if you now have been given permission to do
8 what youve always done or wanted to do. In the know-
9 ledge that it is part of an approach that has a tradition,
30 that has been around for years and that, indeed, began
1 with Freud, you can feel more sure of what you are doing.
2 For others some of the concepts may be quite new, and
311 that is good too.
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111 What the book is not


2
3 The book will, from time to time, highlight the differ-
4 ences between long- and short-term approaches or,
5 indeed, highlight the similarities. It is not the intention of
6 this work to debate whether one is better than the other. I
7 am clearly expounding the benefits of the brief approach
8 and attempting to give readers a certain knowledge and
9 experience of the approach. It is then for the reader to
1011 make their own assessment as to its merits and whether it
1 is a method that they wish to learn more about and to
2 practise.
3 It would be very easy to become diverted from present-
4 ing the basics of brief therapy into an endless and unpro-
5 ductive debate as to which method is better, and my
6 intention is to remain focused on the task in hand.
7
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111 CHAPTER ONE


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6 WHAT IS BRIEF
7 PSYCHODYNAMIC
8
9 PSYCHOTHERAPY?
1011 AN OVERVIEW
1
2
3 What is the approach? What do we understand by brief
4
psychotherapy?
5
Well, first, what do we mean by short? By short I mean
6
four to six sessions. However, this is flexible. If the client
7
needs more then that will be what they will get. The aim
8
is to complete the work in the shortest time possible so
9
that the client is back on track again quickly. This therapy
2011
is not brief because of financial restraints nor because of
1
pressure of numbers. Brief therapy is short because we
2
hope to achieve what is required quickly. This is so that
3
clients are able to get on with their lives without the
4
5 burden that has brought them to therapy continuing to
6 weigh them down. My research (Rawson, 2002), examin-
7 ing many studies, showed four to six sessions as the mean.
8 This was with counsellors of all orientations and with
9 clients and counsellors who had not intended to work in
30 a brief way at all.
1 Colleges across the country also find that four sessions
2 is average over the year. That means that some clients will
311 be seen only once, while others might be seen as much as
4 1
5
6
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A Handbook of Short-Term Psychodynamic Psychotherapy

111 twenty times. Each contract will be made on an individual


2 basis according to need. The contract is flexible.
3 To sum up, each client will be given what is needed.
4
5
6 Joint approach
7
8 The decision about how long will be made in conjunction
9 with the client. One of the aspects of this approach is
1011 that it is a joint affair. This applies not just to the time
1 scale but also to the focal issue. That is, to the main topic
2 that is to be explored by the client. This joint approach
3 encourages the client to work on their issues, to think
4 about themselves and ultimately to become their own
5 therapist. The therapist is simply facilitating their journey
6 and being alongside them as they travel. The therapist will
7 use all the skills at their disposal to help the client in their
8 exploration. This includes helping the client to make
9 connections with past and often buried issues. The
2011 baggage that remains, when problems have not been dealt
1 with, can weigh heavily. Often, by working with the client
2 on the past issue, they are enabled to move on more freely.
3 One of the images I use with clients to explain this is that
4 of a splinter.
5
6
7 Splinter image
8
9 If you have a splinter in your finger, you can mostly get
30 on with things and ignore the splinter. But as you go
1 along, if you press on the spot where the splinter is it
2 hurts, and you cannot fully use that finger. Therapy helps
311 to remove the emotional splinter. When we remove a real
2 2
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What is Brief Psychodynamic Psychotherapy?

111 splinter we have to open up the wound and it bleeds and


2 hurts, but then the splinter can be removed and we can
3 immediately use the finger fully once again. It may take a
4 little while to heal completely and sometimes a scar may
5 remain, but essentially it is now all right. Similarly, it can
6 be painful to explore emotional wounds. However, once
7 they are brought out into the open and looked at they can
8 be put into perspective. When they are accepted and
9 emoted, then the burden can be put down and the client
1011 can be free to move on. By emoted, I mean that the
1 emotions surrounding the issue and the emotional wound
2 are allowed to be and are acknowledged and expressed,
3 perhaps with tears, or anger, or sadness. It is important to
4 let the emotions out. Again, an image is useful here, this
5 time that of a pressure cooker.
6
7
8 Pressure cooker image
9
2011 The pressure cooker has a safety valve. It steams away. If
1 the valve is blocked the pressure in the cooker can build
2 up, and eventually there could be an explosion. Psycho-
3 logically, the same thing can happen. If we hold on to or
4 bury our feelings anger or grief, for example they can
5 build up and keep slipping out in inappropriate circum-
6 stances. This can cause relationship difficulties in the
7 home or at work. Sometimes emotions are buried for
8 years and then something triggers them or there is such a
9 build-up that, as in the pressure cooker image, the feelings
30 can no longer be contained and there is some sort of crisis.
1 This may take the form of an angry explosion, or perhaps
2 a complete breakdown, where the person can no longer
311 bear to carry on or no longer can bear their burden of
4 3
5
6
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A Handbook of Short-Term Psychodynamic Psychotherapy

111 responsibility. One may see a competent person suddenly


2 totally unable to make decisions or carry out their job
3 effectively. In others, the repressed emotions come out in
4 the body through various illnesses. We see a definite corre-
5 lation. for example. between ill health and the stress that
6 befalls us at the time of a bereavement. If someone has too
7 many stresses and too little support at the time of bereave-
8 ment, ill health can ensue. McGannon (1996) gives some
9 examples of the incidence of this. The scores that he refers
1011 to are in relation to the HolmesRahe scale that he also
1 quotes (see quick reference notes at the end of the chap-
2 ter). This scale is often quoted and is seen in both popu-
3 lar magazines and serious psychology books. It helps
4 people to see how much change they are contending with
5 in their lives, often as a result of a bereavement. It shows
6 the devastating effect too much change all at once can
7 have. We need, of course, to remember that some stress is
8 good for us. Too little and we become bored, and that in
9 itself is a stress, but this type of stress often spurs us to
2011 activity and out of our boredom. So to return to
1 McGannon, he said:
2
3 For those whose changes came too fast or too severe[ly],
4 such as the group who scored more than 300, the chance
5 of developing an illness in the near future (within a three
6 month period) was about 80%, 51% in those who scored
7 between 150 and 299, and 37% in those who scored less
8 than 150. The severity of the illness corresponded to the
9 score. Those diseases like heart diseases, ulcer disease,
30 diabetes, alcoholism, cancers, depression, suicide, and
1 certain infections, to less life-threatening annoyances,
2 such as the common cold and indigestion. [McGannon,
311 1996, p. 188]
2 4
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What is Brief Psychodynamic Psychotherapy?

111 Being aware of the effect of stress, whether caused by a


2 bereavement or some other change or loss, is only the
3 beginning. One cannot rest there. It is the task of the indi-
4 vidual, with or without the help of the therapist, to work
5 out ways of alleviating the stress. Where this is not possi-
6 ble, it is necessary to build in better supports to help the
7 person, as they slowly adapt to the new situation. The
8 therapist can help by giving the support of a listening ear
9 or by helping to unhitch past emotional baggage that has
1011 got caught up with the present situation. One might be
1 unable to do anything to change the present trauma, but
2 if one can release some of the weight of unfinished busi-
3 ness from the past, the present situation might become
4 more manageable. The therapist can sometimes enable the
5 client to see their situation from a different perspective
6 and so make the burden lighter. Simply allowing the client
7 time and space, in a safe environment, to think over their
8 situation and to make sense of what is going on, can also
9 be helpful. In the process, if they are able to see new ways
2011 forward or new ways of approaching difficult situations,
1 this too, can be good.
2
3
4 Psychodynamic
5
6 We call this approach, where the past issues are retrieved
7 and explored, psychodynamic. Brief psychodynamic
8 psychotherapy recognizes the effects of the unconscious
9 and past events on the present situation. We do not just
30 stay in the past. We are, as Louis Marteau (1986) says,
1 reaching through the initial focus into the past to the
2 very roots, but having dealt with the past we need to
311 return to the present to go on, armed with what we have
4 5
5
6
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111 learned from the our past experiences. So we seek the


2 emotional splinter the focal issue.
3
4
5 Names of brief therapy.
6
7 There are many names for this brief approach, some
8 twenty-five or so. These are listed in Rawson, 2002. One
9 is Focal Therapy, a term coined by Balint, one of the key
1011 proponents of this method. One can understand why it is
1 called this, since maintaining and keeping the focus in the
2 approach is one of the factors that shortens the therapy. I
3 shall return to this at a later point.
4
5 Who is brief psychodynamic therapy for?
6
7 This type of therapy is not for everyone. The same actu-
8 ally could be said of any therapy. I believe that we should
9 aim to use the brief approach with everyone and only if it
2011 becomes apparent that it is not possible should we engage
1 in longer therapy. This is entirely consistent with an
2 earlier statement that I made that therapy should be as
3 long as is necessary.
4
5
6 Suitability of clients for brief therapy
7
8 There are certain conditions that need to be met for the brief
9 therapy to be realistically possible. First, the clients need to
30 be able to establish a reasonable rapport with the therapist.
1 Sifneos, one of the early proponents of brief psycho-
2 dynamic psychotherapy, would expect the clients to have at
311 least one meaningful relationship in their life to date.
2 6
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What is Brief Psychodynamic Psychotherapy?

111 Second, the clients need to have a degree of insight and


2 to be prepared to explore the possibility that the problem
3 may have its roots in the past.
4 Third, they need to agree to the contract and to the
5 area that the sessions are to focus on. As Sifneos states:
6 Psychotherapy is always presented to the patient as a joint
7 venture for the therapist and himself . . . If an area of
8 conflict can be agreed upon, treatment will be undertaken
9 (Sifneos, 1968b, from Malan, 1971, p. 23).
1011 Malan also quotes Balint as saying, The patients and
1 therapists aim must be the same (ibid.). This is such an
2 important and obvious statement but is not always heeded.
3 One recalls stories, apocryphal I hope, of clients who leave
4 the college counsellors office wondering why they have
5 been so closely questioned about some issue in their past
6 when, in fact, all they wanted to do was obtain a bus pass!
7
8
9 Can compulsory therapy work?
2011
1 This need for agreement makes me wonder at times as to
2 the wisdom and effectiveness of court orders that compel
3 people to go for counselling before some desired outcome
4 is permitted, e.g., the custody of a child. The British
5 Association of Counselling and Psychotherapys definition
6 of counselling refers to it being a freely entered into activ-
7 ity. College senior staff, not infrequently, refer students as
8 part of a disciplinary procedure; again the compulsion
9 element militates against successful action. Can counsel-
30 lors take on such a client? I would suggest that, if in the
1 first session it is clear that the client is ONLY there
2 through compulsion, it would be questionable to
311 continue. If that is but one of their reasons, and they can
4 7
5
6
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111 be helped to see the intrinsic value of the sessions and,


2 having become aware of this, choose to stay, that is
3 another matter.
4
5
6 Circumscribed focal issue
7
8 There needs also to be an identifiable issue that the client
9 wishes to explore. A circumscribed focal issue, as Sifneos
1011 would express it. This means that the client and therapist
1 can identify a specific emotional area about which the
2 client is concerned, and on which they wish to work. Very
3 often the client will come for therapy in some kind of
4 emotional crisis triggered by a present event or situation.
5 While it can be helpful to see the client in the throes
6 of such a crisis, this type of therapy is not a therapy
7 that deals only with crises. It aims to get to the very
8 roots of a problem and thus help the client deal with the
9 deeper issues, often stemming from the past. Otherwise
2011 these keep rearing their heads in the present to cause
1 problems.
2
3
4 Patterns of adaptive behaviour
5
6 In dealing with past issues the matter does not rest there.
7 The client needs to be helped to deal with the patterns of
8 adaptive behaviour that they may have got into. This may
9 take a while, but does not necessarily mean that they need
30 to be in therapy while they do it. Once they understand
1 some of the ways in which they can break a habit, they
2 can go on their way and be their own therapist. This is
311 one of the features of the brief approach.
2 8
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What is Brief Psychodynamic Psychotherapy?

111 Motivation (Rawson, 2002, p. 159)


2
3 If the client is not motivated to explore their issues, to
4 understand the problem, and to attempt to change, little
5 will happen. This is linked with the point about choice
6 and freely choosing counselling therapy that was made
7 earlier.
8 Therapy is not an easy option. To explore issues that
9 are sufficiently painful to have been covered up, avoided,
1011 or maladapted to is not easy. It can be painful and diffi-
1 cult. Clients leave the therapists office, at times, describ-
2 ing how they feel as follows:
3
I feel like a wet rag.
4
I feel totally drained.
5
I feel exhausted.
6
7 Later, however, this can give way to other statements,
8 such as
9 I felt lighter.
2011 I felt as if I were waking up after a deep sleep.
1 I look back at what I talked about earlier and it was as if
2 all of that belonged to someone else.
3
4
5 Clients who are not suitable
6
7 Clients who are not suitable obviously include those who
8 do not meet the conditions mentioned above. These are
9 people who are unable to show any insight about them-
30 selves and who cannot see the relevance or understand the
1 process of therapy, or those who are unable to find any
2 kind of focus. There are clients who are unable to accept
311 the conditions for brief therapy, who are not willing to
4 9
5
6
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111 work on issues, or are unable to establish a rapport with


2 the therapist. To this I would add someone who is out of
3 touch with reality, someone, for example, seeing little
4 green men who are telling them what to do or say. Such
5 a person needs to see a psychiatrist and to be on the
6 appropriate medication before they attempt therapy.
7 Someone under the influence of drugs or drink would also
8 be an unsuitable candidate for brief therapy, or any talk-
9 ing therapy. If someone is in the throes of a crisis, e.g., a
1011 road accident, exams, a death, this may not be the time
1 for brief therapy, although it might well be the time for
2 some kind of supportive therapy. The client in these
3 circumstances needs to be given options, with client and
4 therapist jointly deciding what to do. For example, one
5 client might decide that they do wish to continue the
6 therapeutic work that had been planned, despite being in
7 the middle of some kind of other crisis. For another client
8 it might be appropriate to postpone sessions altogether,
9 for yet another it might be best to alter the contract to talk
2011 of the current crisis situation and later on resume the orig-
1 inal contract. For yet another, the present crisis might
2 have brought a former trauma to the surface and this
3 could be the trigger point for some useful exploration of
4 the past that, in its turn, helps the present situation.
5 One needs to stress flexibility and negotiation in these
6 situations and these are features of the brief approach.
7 Angela Molnos has listed counterindications for ther-
8 apy (see sheet in the quick reference notes at the end of
9 this chapter, entitled: Selection of patients: dynamic brief
30 psychotherapy notes). She has written about brief psycho-
1 dynamic psychotherapy (Molnos, 1995) and for a while
2 worked at the Dympna Centre, where I trained, and
311 worked alongside Louis Marteau.
2 10
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What is Brief Psychodynamic Psychotherapy?

111 Malans review of his own research team and that of


2 other experts in the field observes that: It is important to
3 note the conspicuous absence of severe psychopathology
4 as a contraindication. This also accords with our own
5 evidence (Malan, 1971, p. 23). This is another way of
6 saying that brief therapy is for a much wider group of
7 patients than some would believe. As Wolberg, one of the
8 key early proponents of the method, says: The best strat-
9 egy, in my opinion, is to assume that every patient, irre-
1011 spective of diagnosis, will respond to short term treatment
1 unless he proves himself to be refractory to it (Wolberg,
2 1965, p. 140).
3
4
5 How is brief therapy done?
6
7 How do we make therapy brief? In beginning to examine
8 this, it may be helpful to think about the analogy of a
9 sprint versus a long-distance race. A sprinter has a certain
2011 pent up energy that is used in the burst of activity
1 required in this type of race, which lasts but a short time.
2 This is quite different from the long-distance run that
3 requires a different sort of energy. An energy that has to
4 be more sustained, conserved, and measured out so that
5 the long-distance runner reaches the goal. In brief therapy
6 we are sprinting. This applies to both therapist and client.
7 I will return to this analogy later. Let us explore how one
8 does this brief therapy.
9
Focus
30
1 One needs to be very focused. There is not time to explore
2 every avenue, so one needs to target the key issues and
311 work hard around these or those closely linked with them.
4 11
5
6
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111 Activity
2
3 Brief therapy involves a certain activity on the part of the
4 therapist, who has to draw the client back if they wander
5 off the subject, or question how this seemingly unrelated
6 area fits in with the agreed focus.
7
8 Therapeutic alliance
9
1011 It is important for the client and therapist to have an
1 agreed focus and time frame. This will be reached after a
2 period of exploration. This process already involves the
3 client in the therapeutic relationship and creates the ther-
4 apeutic alliance. In searching with the therapist for the
5 focus and in explaining why they are there, the clients
6 motivation becomes apparent. If they are not motivated it
7 will be very hard to come to this agreement.
8
9 Flexibility
2011
1 The therapist needs to be very flexible in working briefly,
2 being ready to adapt skills to fit the client and to renego-
3 tiate both contract and time scale if this seems necessary.
4 I believe that if the therapist has experience this helps to
5 speed the therapy. This is because the experienced thera-
6 pist is less afraid to experiment. The person with experi-
7 ence has a range of skills to call upon and has seen many
8 problems over the years, all of which contribute to the
9 body of knowledge now available to the therapist.
30 Flexibility of skills means that the therapist will use what-
1 ever tool seems appropriate at the time. This approach
2 allows for a fusion of skills and experience. I like this
311 word, one that Wolberg uses in his writings about short-
2 12
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What is Brief Psychodynamic Psychotherapy?

111 term therapy in the 1960s. So, as you see, this approach
2 is not a new one at all! Nowadays, the word used would
3 probably be integrative, the term eclectic having seen
4 better days. The concept of fusion seems to me to imply
5 a seamlessness in the use of many skills and that is how I
6 believe it should be.
7
8
9 Who can do it?
1011
1 Because we are, so to speak, sprinting in this method of
2 therapy, there is a certain energy required of the therapist
3 and an alertness, and attention to detail. I believe that the
4 approach is best handled by an experienced therapist. This
5 is simply because the experienced therapist will perhaps be
6 less thrown by anything that the client brings up, will
7 have more skills at their disposal, and more confidence to
8 adapt and try new things than the newly qualified coun-
9 sellor. There is, however, debate about this issue, since
2011 often the experienced counsellor may have a certain preju-
1 dice against the brief approach and will therefore block
2 progress by virtue of this. The new therapist, who has
3 come freshly to the approach and who is prepared to
4 believe in it, can in fact achieve very good results despite
5 inexperience. So there are pros and cons here!
6
7
8 Involvement
9
30 I have already alluded to the sprinting idea and to the
1 flexibility of skills that make the approach an active one.
2 The therapist is active and so is the client. The client is
311 expected to be involved and indeed involvement is seen to
4 13
5
6
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111 be a very important principle in the approach. In fact,


2 based on my own research into this method, my conjec-
3 ture is that client involvement is central to the shortening
4 process (Rawson, 2002, p. 276).
5
6
7 Ability to handle stress
8
9 There is another aspect to be considered by those think-
1011 ing of working in the brief method. The therapist work-
1 ing in this way needs to be able to sustain a large amount
2 of stress. There is a quick turnover of clients if you are
3 seeing people for just a short time. Therefore, one sees a
4 high number of different traumatic situations in peoples
5 lives in the course of a year. A full-time counsellor, who is
6 abiding by the guidelines of, for example, the university
7 therapist, and who sees, say, four people per day or sixteen
8 per week for a number of sessions each, may well see
9 between eighty and 150 different clients a year. I have
2011 found that as I have become more experienced I can see
1 less clients per day if I am to do each one justice. I think
2 that four is sufficient for one day. I have found that other
3 experienced colleagues who were also working in the brief
4 approach agree with this. Earlier in my career I used to see
5 more but I now realize the folly of this. Is it that one
6 builds up a certain residue of pain in ones encounters
7 with clients and there are limits to this, despite the
8 detached involvement we endeavour to acquire in our
9 training and the protection afforded by supervision and
30 therapy? One of the tasks of supervision is to help thera-
1 pists to separate their own issues from the clients. It also
2 provides a place where the therapist can debrief after a
311 heavy session with a client and offload if necessary.
2 14
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What is Brief Psychodynamic Psychotherapy?

111 Therapy is a compulsory part of training for most thera-


2 pists and contributes to the therapist being able to remain
3 unentangled from their clients material. Ongoing super-
4 vision is a professional requirement for the accredited
5 therapist (see British Association of Counsellors and
6 Psychotherapists (BACP) regulations).
7 Because there is a frequent turnover of clients the
8 therapist needs to be able to handle loss well. This will be
9 covered later on.
1011 One has to be ready to change gear very quickly, not
1 just within each session but also between each client. All
2 the clients will be at different stages of their process and
3 each brings a very different issue. I suggest that, because
4 the turnover is greater than with longer term clients, this
5 is a more wearing experience than may be the case for
6 longer term work.
7
8
9 Therapists comments
2011
1
2 Having stressed the more difficult aspects of this, I want
3 also to emphasize that there is great satisfaction in seeing
4 clients move on positively after such a brief time. This is
5 very rewarding and stimulating.
6 Therapists attending courses to learn about the brief
7 approach describe their feelings about the experience
8 using words such as: exciting, thought provoking, chal-
9 lenging, interesting, energizing. Others observe that it
30 is: tiring, active, focused, freeing, incisive, stimulat-
1 ing, intriguing.
2
311
4 15
5
6
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111 A great privilege and joy


2
3 Practitioners who are alongside clients who come into the
4
counselling suffering and who leave after just a few
5
sessions clearly more able to cope and happier, describe
6
the experience as a great privilege and joy.
7
8
9 Therapist optimism
1011
1 The therapist sets the scene for optimism and for the
2 effectiveness of the approach. It is good to point out that
3 belief in the approach is one of the criteria for enabling it
4 to happen. The therapists attitude will affect how the
5 process is talked about and worked with. This will influ-
6 ence the client and the outcome. The reader wanting to
7 practise in this way, needs to take this on board so as not
8 to sabotage the possibility of the work being brief.
9
2011
1 Belief in the method
2
3 Since one of the facets of this approach is to inspire hope
4 that the work can be achieved in a short time, it must be
5 realized that it will not be so if, deep down, the therapist
6 does not really believe it.
7 How can one learn to believe in it? By talking to those
8 who have worked in this way, but with an open mind. By
9 reading about the method and the results that can be
30 achieved, as you are doing here. By trying it for yourself,
1 but with an open mind. By attending a training course in
2 the method for yourself. By talking to clients who have
311 worked in this way successfully. By undergoing a brief
2 16
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What is Brief Psychodynamic Psychotherapy?

111 contract of therapy for yourself. By realizing that therapy


2 to overcome an issue or problem is quite different from a
3 training therapy or from therapy to understand the maxi-
4 mum possible about yourself.
5
6
7 Summary of basic principles
8
At this point it is relevant to highlight some of the key
9
principles to which we have already drawn attention. I
1011
take for granted the motivation of the client. Then we
1
referred to the short number of sessions, the active and
2
focused approach, the joint enterprise of client and thera-
3
pist, the flexibility of the therapist, and the enabling of the
4
client to become their own therapist. In relation to the
5
latter point, one of the ways that we do this is by teach-
6
ing. We explain to the client what we are doing and why,
7
and help them actively to explore their own issues.
8
9
2011 Detective image
1
2 I often use the image of a detective in trying to explain
3 the process of therapy to a client. In a way, both client and
4 therapist are detectives, examining the evidence rigor-
5 ously. Just as a detective or forensic scientist might be
6 examining minute pieces of evidence under a microscope,
7 in our focusing on one area, the key issue, we are doing
8 likewise. We piece together bits and pieces of facts,
9 memories, and feelings and attempt to help the client to
30 make sense of it. This is not just an academic or theoret-
1 ical exercise. We help them to re-experience feelings and
2 emotions as necessary and to learn new patterns or ways
311 of reacting. In this we are also taking on a teaching role.
4 17
5
6
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111 Incisive and sensitive


2
3 Two other principles are very important: incisiveness and
4 sensitivity. We will be returning to these and other aspects,
5 such as the importance of the first session, and the thera-
6 peutic alliance or agreement as to what is to be worked
7 upon. I have not, as yet, stressed the early establishment of
8 this alliance. It is important that this agreement is reached
9 very soon in the process, so that the work begins straight
1011 away. To achieve this the therapist will, at times, be quite
1 incisive and probing, especially as the initial focus is being
2 established. Sensitivity, however, is an overriding princi-
3 ple, so this incisiveness and, indeed, the quickness must
4 not appear to be intrusive or superficial. Rather, this is
5 experienced as holding and reassuring, as the client feels
6 that the therapist is fully on their wavelength and really
7 understands their pain. The therapist, in this way, inspires
8 hope that something can be done about it and that they,
9 the clients, are in control.
2011 Following the quick reference notes below we return to
1 the various aspects mentioned in the overview above to
2 examine them in more detail, beginning with the focus.
3 The reader is reminded that the bullet point notes that
4 follow are intended to draw out the maiun points of the
5 chapter for quick reference and possibly for use as hand-
6 outs or aides-mmoire.
7
8
9
30
1
2
311
2 18
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111
2
3
4
5 QUICK REFERENCE NOTES
6
7
8
9
1011
1
2
3
4
5
6
7
8
9
2011
1
2
3
4
5
6
7
8
9
30
1
2
311
4 19
5
6
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111 Focal and short-term


2 psychodynamic psychotherapy
3
4
Focal psychotherapy is especially useful in short-term
5
psychotherapy.
6
Average 46 sessions, but can be as few as one session
7
and as many as are needed.
8
Focal and short-term psychotherapy is an approach
9
where client and therapist work together on an agreed
1011
focal area within a specific time scale.
1
It is an approach that allows for a wide range of ther-
2
3 apy methods to be used.
4 It utilizes the clients capacity to think about them-
5 selves and ultimately to become their own therapists.
6 Since client and therapist are working on a clear
7 focus, this facilitates evaluation of the work achieved.
8 It is psychodynamic since it recognizes the effects of
9 the unconscious and past events in the present situa-
2011 tion for the client.
1 It is best used in the hands of an experienced thera-
2 pist who is able to adopt a flexible approach.
3 It is an active approach.
4
5
6
7
8
9
30
1
2
311
2 20
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What is Brief Psychodynamic Psychotherapy?

111 Suitability of client


2
3 Has to be able to find a focus at least a general one.
4 Has to show indications of insight.
5 Has to agree to the terms on offer.
6 The clients need not the therapists.
7 Has to wish to work on the issues in order to change
8 or move on.
9 Has to be able to establish a rapport with the thera-
1011 pist.
1
2
3 Counter-indications to suitability of
4 client for short-term psychotherapy
5
6 Out of touch with reality.
7 Inability to understand the process of therapy; i.e.,
8 unable to agree a contract to work on issues.
9 Resistence (undue and persistent) to any concept of
2011 the influence of the past events on the present.
1 Under the influence of drugs or drink.
2 Under pressure to attend for therapy by external
3 authorities.
4 In the throes of a crisis, e.g., a death, an exam
5 (supportive therapy more likely to be required at this
6 time but client and therapist need to discuss options).
7
8
9
30
1
2
311
4 21
5
6
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111 Selection of patients dynamic brief


2 psychotherapy (Molnos, 1987, personal
3 communication)
4
5 1. EXCLUSION CRITERIA
6 Who is not suitable for DBP with [its] strong initial
7 confrontation of defences.
8
9 Principal diagnostic exclusion criterion:
1011 Thought processes get disturbed under confrontation of
1 resistance
2 Psychological exclusion criterion:
3 Weak ego
4
5 Psychiatric exclusion criteria:
6 Previous psychotic decompensation
7 Paranoid conditions
8 Poor impulse control
9 Pathologies and factual exclusion criteria:
2011 Very long-term psychiatric in-patient treatment
1 Repeat ECT-treatment
2 Destructive acting out against others, i.e. physical
3 violence
4 Serious suicide attempt (especially manic depressive or
5 schizophrenic)
6 Other gross self-destructive acting out (e.g.anorexia,
7 bulimia, etc.)
8
9 2. SELECTION CRITERIA:WHO IS ESPECIALLY
30 SUITABLE FOR BDP?
1 Psychological selection criteria:
2 Motivation for change (as distinct from wanting only
311 symptom relief)
2 22
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What is Brief Psychodynamic Psychotherapy?

111 Ability to relate to the therapist


2 Ego strength to withstand confrontation
3 Capacity for insight.
4 Pathologies:
5 Neuroses with oedipal focus
6 Neuroses with focus on loss
7 Obsessional and phobic neuroses with more than one
8 focus
9 Long standing pscyhoneurotic disorders and charactero-
1011 logical problems with no clear focus.
1 3. FURTHER REMARKS ON SELECTION
2 In principle, the earlier the damage the more the defences
3 are likely to have grown and to be part of the psychic
4 structure. If this is the case and the defences are chal-
5 lenged by the therapist, the patient will feel attacked in
6 his inner core. As a result he might drop out and /or his
7 thought processes might get disturbed. On the other
8 hand, strong initial confrontation, leading to a successful
9 breakthrough, is possible even in cases of early damage
2011 provided the patient has ego strength.
1
2 4.LITERATURE
3 H. Davanloo ed. 1980 pp. 75189
4 D. H. Malan 1979 pp. 209253
5 P. E. Sifneos 1979 pp. 2239
6 L. R. Wolberg 1980 pp, 3034.
7
8
9
30
1
2
311
4 23
5
6
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111 Motivation
2
3 Quotation from Frontier of Brief Psychotherapy, with
4 regard to assessing the clients motivation
5
6 We have emphasized the importance not merely of moti-
7 vation for treatment, but motivation for insight; in
8 Sifneos statement, There should be motivation for
9 change, not motivation for symptom relief (1968b), the
1011 words are different but the meaning is essentially the
1 same.
2 The criteria relevant to motivation to which Sifneos
3 directs his attention are as follows (these are taken from
4 Sifneos, 1968a: see also Sifneos, 1972, pp. 85ff):
5 1. An ability to recognize that the symptoms are
6 psychological in nature.
7 2. A tendency to be introspective and to give an honest
8 and truthful account of emotional difficulties.
9 3. Willingness to participate actively in the treatment
2011 situation.
1 4. Curiosity and willingness to understand oneself.
2 5. Willingness to change, explore, experiment.
3 6. Realistic expectations of the results of psychotherapy.
4 7. Willingness to make reasonable sacrifices in terms of
5 time and fees.
6
To these criteria, McGuire(1968) has added two that are
7
probably implied by Sifneos, namely:
8
9 8. That the patient should not demand that particular
30 symptoms should be relieved.
1 9. That he should not regard the problem as being
2 purely concerned with the present situation or as being
311 purely external. [Malan, 1976, pp. 2223]
2 24
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What is Brief Psychodynamic Psychotherapy?

111 Basic principles of focal and short-term


2 psychotherapy
3
4 (It is a pre-requisite that the client is MOTIVATED!)
5
6 Active
7
Focused
8
9 Importance of first session
1011 Early establishment of the therapeutic alliance
1 Joint venture
2 Therapist attitude
3
Time limited
4
5 Flexible therapist
6 Psychodynamic
7 Teaching
8
Enabling client to become own therapist
9
2011 Incisiveness
1 Sensitivity
2
3
4
5
6
7
8
9
30
1
2
311
4 25
5
6
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111 HolmesRahe scale


2
3 Table 1 The scale of stressors for major life events
4 Event Points
5 Death of a spouse 100
6 Divorce 73
7 Marital separation 65
8 Death of close family member 63
9 Change in health of a family member 44
1011 Death of a close friend 37
1 Source: McGannon (1996), based on Holmes & Rahe (1967).
2
3
4
5 Table 2 The scale of stressors for changes in way of life
6 Nature of change Points
7 Being fired from job 45
8 Retirement 45
9 Type of work 36
2011 Living conditions 25
1 Recreation activities 19
Social activities 19
2
Sleeping habits 19
3 Number of family meetings 15
4 Eating habits 15
5
Source: See Table 1.
6
7
8
9
30
1
2
311
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What is Brief Psychodynamic Psychotherapy?

111 Focal and short-term psychotherapy is a


2 treatment of choice (Rawson, 1992,
3 Counselling)
4
5
6 I read, with interest, Stephen Palmers interview of
7 Professor Windy Dryden with reference to brief short-
8 term psychotherapy (February 1992). Professor Dryden
9 quotes John Rowan as saying, We are short-changing
1011 individuals who come for counselling if we dont encour-
1 age them to see that counselling is an opportunity for
2 them to reflect on themselves in the context of their
3 entire life. We cant do that, says John, if we are only
4 offering brief psychotherapy.
5 I would like to ask whos short changing whom?
6 I believe the principles of brief and focal psychotherapy
7
make it clear that we are not short-changing clients by
8
offering them this type of counselling/therapy. Brief and
9
focal therapy is a treatment of choice not simply a
2011
method to use because financial or resource restraints so
1
dictate, as Professor Dryden implies.
2
I have been spurred to write this article in the hope
3
that many potential clients may benefit as more counsel-
4
lors become aware of the value of the focal and brief
5
approach.
6
In my experience a large number of individuals
7
approach counselling/therapy with the assumption,
8
encouraged by popular opinion and their therapist that
9
30 their problem will take a very long time to resolve. This
1 may be the case if, for example, their presenting depres-
2 sion has been with them for several years. Some will have
311 been receiving medication for many years, and will
4 27
5
6
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A Handbook of Short-Term Psychodynamic Psychotherapy

111 anyway be sceptical as to whether a counsellor can help.


2 It is my contention and experience that very many people
3 can be helped significantly in less than ten sessions, many
4 in as few as 26 sessions. By significantly, I mean reach a
5 point
6
7 (1) where they understand the roots of their depression,
8 often from a traumatic experience in childhood;
9 (2) where they have discharged the emotions relating to
1011 that; and
1 (3) where they are in a position to say, I feel I can cope
2 with my life now Ill know how to deal with similar
3 events if they occur.
4 I believe the majority of people approach counselling
5 therapy because they are unhappy there is usually
6 something they wish to change and they hope to feel
7 better. Many more people would approach counselling/
8 therapy if they had confidence that they could be helped
9 in a few (210) sessions. These they could afford
2011 whereas the idea of ongoing therapy for six months or
1 years may prevent them even considering therapy. Many
2 more could be helped in this way if they were aware of
3 the focal and short-term method.
4
5
6 The focal and short-term method
7
8 So, what is it? It is not simply a limited contract in terms
9 of sessions, although the limited time helps, of course.
30 Who does not know the effect of a deadline? Having a
1 limited time is a powerful way of concentrating the mind
2 and effort. Focal and brief therapy is more than this. It
311 is also about the focus of the sessions. The presenting
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What is Brief Psychodynamic Psychotherapy?

111 problem is the starting point. In focal therapy the client


2 and therapist need to agree the focus of the sessions.
3 Sifneos (1968) says: Psychotherapy is always presented to
4 the patient as a joint venture. If an area can be agreed
5 upon, treatment will be undertaken. The client also
6 needs to be able to grasp the idea that the problem may
7 well have its roots in the past. As client and therapist
8 explore the presenting issue in the search for the focal area
9 and the contract the work has already begun. A simple
1011 question like, When do you first recall being depressed?,
1 can lead directly through the presenting problem of
2 depression to the traumatic episode of the child. It is
3 likely that this area of the persons life will become the
4 focal area to be explored and the counselling work will
5 focus around the repercussions of this for the client.
6 The therapists expectation that change can occur in a
7 relatively short time no doubt serves as a motivator and
8 has a certain power of suggestion. It can also inspire hope.
9 Perhaps the rapid results I see have something to do with
2011 my own confident expectation that change can occur in
1 a very limited time if the client is prepared to work on
2 themselves.
3
4
5 Resistance
6
7 Resistance is tackled as it arises; clients being helped
8 gently to voice fears about change and being challenged
9 to continue working on the agreed contract or not it
30 is, of course, their choice! Here again the limited number
1 of sessions agreed helps. The fact that the whole painful
2 process may be completed in maybe eight sessions makes
311 it possible for the client to stay with the process.
4 29
5
6
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111 Counselling is painful. Clients talk of it being drain-


2 ing, exhausting, feeling like a wet rag, and so to know
3 it has a definite end is reassuring and enabling.
4 The focal and brief approach can be a particularly
5 intense and demanding form of therapy for both client
6 and therapist. The particular approach I use is a psycho-
7 dynamic one using the newer therapies. I am inclined to
8 the view expressed by Wolberg (1965) that the focal and
9 short-term approach required a sophistication born of the
1011 wisdom of experience. There is not the time to make
1 mistakes to miss cues. Also the greater the experience of
2 the therapist the more flexible she/he is likely to be, with
3 more psychotherapeutic tools at his/her disposal. Flexi-
4 bility on the part of the therapist is important. Awareness
5 of dependency, transference issues, resistance, body
6 language, the use of silence, fantasy, etc., are important.
7
8
9
Activity
2011
1 Activity is essential in focal and brief therapy again to
2 quote Wolberg (1965), Anathema to short-term therapy
3 is passivity in the therapist.
Activity is also asked of the clients. They are encour-
4
aged to become their own therapist and to work on them-
5
selves between sessions to do homework.
6
As one client wrote after shed completed her therapy
7
in eleven sessions:
8
9 If I were to visualise the whole experience, Id say
30 it was as if I was trying to paint my life but the only
1 colours I had were black and white. Counselling
2 gave me the primary colours to add depth and
311 texture but most importantly I held the brush.
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111 The method of Focal and Brief Psychotherapy is not


2 new Freuds treatment of Gustav Mahler was achieved
3 in a few hours and his analysis of Sandor Ferenczi was
4 also limited to a number of weeks. Alexander and French
5 were exponents in the 1940s, Malan, Sifneos, Wolberg,
6 and Balint in the 1960s and 1970s, and Davanloo more
7 latterly. I am, myself, indebted to Louis Marteau, Direc-
8 tor of the Dympna Centre (London) who taught me exis-
9 tential short-term therapy in the 1970s. That is a flexible,
1011 active, time limited psychodynamically based integrative
1 approach. An overriding view that stays with me from the
2 years I spent training, both in the long- and short-term
3 methodology, is the most persuasive aspect of cost-effec-
4 tiveness that is the alleviation of peoples pain in the
5 shortest time possible. In the process of the therapy, they
6 will acquire skills that will remain with them. They do
7 not need a therapist to ensure ongoing development. I
8 find in my twenty years of practicing [sic] this method
9 that the number of sessions to achieve real change and
2011 free a particular block has reduced and may now be as few
1 as one!
2 A median number is four, with 1012 being the usual
3 maximum. The number of sessions offered will vary from
4 client to client and is negotiated.
5
6
7 The context
8
9 I believe the context in which the therapy is undertaken
30 may influence the number of sessions. For example,
1 working within a GP practice or an education institution
2 may facilitate rapid progress. These contexts have already
311 implicitly contributed to the establishment of trust,
4 31
5
6
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111 confidentiality and credibility. In private practice it may


2 be necessary to spend more time, perhaps two or three
3 sessions, ensuring these essential features of the relation-
4 ship are established. This would take the median number
5 of sessions to six or seven, and would seem consistent
6 with the findings (referred to by Rogawski, 1981) of
7 Butcher and Koss (1978 and Garfield (1978). They
8 found that a large percentage of clients termination after
9 68 sessions. This, it should be noted, related also to
1011 clients of therapists who did not claim to advocate the
1 short-term approach.
2 Dr Dryden hopes that educational and training estab-
3 lishments will begin to inform students about this
4 approach and I wholeheartedly endorse this, although I
5 think there are more issues to be addressed as to whether
6 the training should be geared to the experienced or to
7 beginners. Can a beginner be as effective in this method
8 as someone with more experience? A trainee counsellor
9 will not have the experience or knowledge of a variety of
2011 therapeutic approaches to bring to the therapy and so
1 might be less effective. However, neither will they have
2 developed therapist resistance to the brief approach and
3 so might prove more effective in this method than some-
4 one trained in longer-term methods first.
5 There are already training programmes in specific
6 approaches to brief therapy in existence in this country.
7
8
9
30
1
2
311
2 32
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111 CHAPTER TWO


2
3
4
5
6 FOCUS
7
8
9 The importance of having a focus has been pointed to
1011 earlier. How then do we arrive at this focus and, having
1 found it, how do we keep to it?
2
3
4 Finding the focus
5
6 The therapist can ask many questions that can help the
7 client to find the focus. Important ones include the
8 following:
9
2011 What made you come to see a therapist at this time?
1 When did the feeling/ problem start?
2 Have you felt this way before?
3 Can you give me an example?
4 Can you tell me about it?
5
6 The therapist invites the client to say what it is that has
7 brought them to therapy and what it is that made them
8 do so at this point in time. These are very important ques-
9 tions that begin to help the client to focus on their prob-
30 lem. A general statement such as: I am depressed would
1 need to be unwrapped somewhat. One could ask what
2 that means. Is the person sad? Are they suicidal? What
311 does the depression make them feel like doing?
4 33
5
6
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111 Beware of making assumptions


2
3 One needs to be careful not to make assumptions. As
4 weve already observed, the word depressed can mean
5 very different things to different people. For one person,
6 it can indeed mean that they are thinking of killing them-
7 selves, for another it is simply that they are feeling a bit
8 down or fed up. To understand what it means to the indi-
9 vidual we need examples and detail.
1011
1
2 Be specific
3
4 Both client and therapist need to have a clear idea as to
5 what they are working on a clear focus for the ther-
6 apy to work well, so asking for specifics and examples
7 helps to do this. Sometimes it may take more than one
8 session to really get to the focus but the search for it is
9 imperative. Only when we know what we are working on
2011 can we in some sense assess a successful outcome.
1 Sometimes there is an initial focus and as we begin to
2 explore this with the client a more strategic one emerges.
3 This strategic focus then is what we focus on. Sifneos
4 talks of circumscribing the focus as one of the shorten-
5 ing factors. I refer to the strategic focus. Balint named his
6 method of therapy focal therapy. All of us are highlight-
7 ing the importance of knowing what it is and of working
8 with it.
9 In searching for the focus one goes for the jugular,
30 pins the patient to the floor, gets to the point. These
1 phrases are used in talking of finding the focus. I have
2 sometimes been challenged about what seems like vio-
311 lent language. One is merely stressing the importance of
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Focus

111 keeping to the central point and not waffling around. In


2 fact, the client is usually relieved that the therapy is
3 getting to the point. It gives them hope and confidence
4 that the therapist has understood where their issue or
5 problem lies. They themselves may be more clear as to the
6 problem because the therapists questions may have
7 enabled them to be less confused. If we went to the doctor
8 with a bad hip and he started to ask about our hand or
9 arm we would feel rather impatient and wonder why he
1011 was wandering off the point of our visit. In the psycho-
1 logical sphere, I suggest, it is the same. There may be
2 interconnections between the different pains in our bodies
3 as there can be interconnections in the emotional and
4 psychological spheres as well. However, the client needs to
5 feel that we have listened to their original problem. From
6 there we may move to related areas when necessary.
7
8
9 Questions to help the client focus
2011
Questions that we might use to focus down on the clients
1
issue might be as follows:
2
3
When did you first experience this problem?
4
How old were you at the time?
5
Can you give me an example?
6
Can you be more specific?
7
8
9 How does this feel to the client?
30
1 On my courses I ask trainees how they have felt as client
2 when I used such questions with them. The students
311 make comments such as the following:
4 35
5
6
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111 I felt pinned down . . . but that was good.


2 I felt backed into a corner . . . I guess Id have had to deal
3 with what I came for.
4 I wasnt going to be let off the hook.
5 I felt you really wanted to understand exactly what I was
6 saying.
7 I felt relief. Someone was really going to help me sort
8 what was going on.
9 I felt really uncomfortable but safe all at once. I found
1011 myself saying things I didnt know I knew.
1 It made me feel hopeful.
2
Interestingly, the observing members of the training
3
group often perceive the process as almost brutal and are
4
at times cringing for the one working with me. They are
5
then surprised at the positive comments that come back
6
7 from the client. That is, that they have felt held, listened
8 to, understood, kept to the point, homed in on, not allowed
9 to deviate from the task in hand.
2011 I have found, too, that when a training group practises
1 the art of trying to focus, some will have had the experi-
2 ence of losing focus and being allowed to wander off the
3 point. They discover that as client they feel disappointed
4 and let down at the deviation and prefer the more actively
5 focusing approach. This is so, even though at times they
6 felt almost pinned down and uncomfortable, because it
7 also gave them a sense that they were getting to where
8 they needed to.
9 Louis Marteau used to use the analogy of nailing one
30 foot to the floor; he meant by this that once the focus was
1 set the client could move all around it, but just so far. He,
2 too, was challenged about the use of a brutal kind of
311 image. It is simply a graphic analogy to make a point.
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Focus

111 I wonder if the client feels held, an expression that is


2 so often used in therapy, in the same way that babies
3 would seem to prefer, a firm hold rather than a wishy-
4 washy one. It perhaps makes them feel more safe. Is this
5 what we really mean by it in this therapy context? This has
6 prompted me to go to the dictionary for definitions. It is
7 hard to see which of the meanings, which cover a whole
8 column, can be applied to the way that we tend to use this
9 word in therapy. If this were a live course it would be
1011 opportune to spend a few moments wondering with the
1 group. However, mindful of the one foot to the floor we
2 need to very soon relate the discussion or, in this context,
3 the diversion, back to the point, i.e., finding the focus and
4 how the questions that zoom in can give the client the
5 feeling of being held.
6
7
8 Naming the focus sets the scene
9
2011 Once one has found the focus we have a kind of heading
1 for our work. Thereafter, the thoughts or memories that
2 surface seem to relate even though, initially, the relation-
3 ship may not be very clear. For example, once I was teach-
4 ing a class of children religious education (RE) and for
5 this particular lesson I played a piece of classical music
6 and asked them to write a poem. All thirty pupils wrote
7 the most lovely prayers, assuming that that was expected
8 because it was, after all, an RE lesson. I then went on to
9 an English class; I played the same music and asked them
30 also to write a poem inspired by the music. None of these
1 was religious in any way at all but referred to a range of
2 subjects. It would seem that the title of the lesson gave the
311 backcloth and therefore inspired appropriately. I suggest
4 37
5
6
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111 that once we have named our focal area everything else
2 then relevant to that tends to emerge.
3 Some techniques are particularly useful in helping the
4 client to find the focus, e.g., a body memory exercise. This
5 will be explained in greater detail in a later chapter.
6
7
8 Triggers for emotional problems
9
1011 Anniversaries
1 Anniversaries may be the trigger for a problem. The
2 anniversary of a death, or losing a job, or the breaking up
3 of a relationship may be the trigger. The body somehow
4
remembers these traumatic events even though,
5
consciously, we have moved on and forgotten all about
6
them. It sometimes only emerges as we explore the situa-
7
tion, because the client has come to us complaining of
8
depression and one asks: Is this time of year or this date
9
of any significance? Often, it then transpires that there
2011
was a death, or a break-up of the family, a redundancy, or
1
an accident exactly at this time, but years ago. Sometimes
2
the memory is immediately accompanied by tears or
3
anger. There is often a sense of recognition by the client
4
5 as they see that this is what is the cause of their present
6 depression.
7
World events
8
9 World events can trigger problems for our clients, perhaps
30 a memory or an actual event in the here and now. For
1 example, someone whose father or husband or daughter is
2 off to war. Or where another member of the family has
311 been killed or injured, or is fighting overseas and is in
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111 danger. The therapist needs to be aware of what is going


2 on, as far as possible, and alert enough to at least question
3 in this area if it seems appropriate. Even television soaps
4 can lead to a number of clients coming to the therapist
5 with similar problems that have been opened up by what
6 they have seen.
7
8
9 Jean
1011
1 A situation arose with Jean that exemplifies this. The ther-
2 apy had been progressing nicely around her issues and
3 then one day she came into the session and seemed to
4 have gone backwards a long way.
5 Jean said, I felt as if I had been making progress and
6 in fact had been feeling really good since last week, but
7 then yesterday I suddenly seemed to be so miserable and
8 depressed and I still am.
9 I asked, Can you recall when you were last OK?
2011 Jean: Yes, until about 4 oclock when I collected the
1 children from school. It was after that.
2 I asked her to retrace every step of what happened after
3 that. Something must have happened. You may recall the
4 detective idea referred to earlier. If we can examine the
5 time period with a magnifying glass we may well make
6 sense of this change of mood. So Jean thought back
7 through what she had been doing. I pointed out to her
8 that sometimes it can be something as little as a small
9 paragraph in a newspaper that can remind us of some-
30 thing and send us plummeting down to the depths. So I
1 requested that she be very specific about what she had
2 done, who she had been with and what they had been
311 talking about. She mentioned a TV soap that she had
4 39
5
6
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111 watched. As it happened I had watched the same pro-


2 gramme; there had been an episode of a miscarriage in it.
3 Although this was not the subject that had been the focus
4 of our sessions, she had mentioned a miscarriage inciden-
5 tally when talking about the number of children that she
6 had. Jean mentioned the programme and went on to the
7 next thing that she had been doing. Because I had seen
8 the programme I had a hunch that the miscarriage scene
9 was the cause of her lowered mood. I stopped her story
1011 and asked her to go back to the programme.
1 Penny: Can you remember what it was about? Jean
2 skirted over the story, so I asked, Were you feeling all
3 right before it?
4 Jean: Yes.
5 Penny: So was there anything in the programme that
6 upset you?
7 Jean then recalled the miscarriage scene and began
8 to be a little tearful. As we talked about her own miscar-
9 riage it became clear that this programme had indeed been
2011 the trigger for her sudden gloom. While the sadness was
1 real and present it did not mean that the other work
2 we had been doing together had gone back to square
3 one. This had been her fear and had added to her concern.
4 Attaching the feeling of sadness to where it belonged
5 enabled her to move on once more with her other
6 concerns.
7 In this instance, I was in a lucky position in that I had
8 happened to see the programme and was able to put two
9 and two together and so questioned her carefully about
30 the programme. Jean was also fortunate because she had
1 been conscious of feeling quite good and then had very
2 recently noticed the change. I always stress with the client
311 that if they find themselves, as Jean did, with a sudden
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Focus

111 change in mood that seems inexplicable, it is really worth


2 examining very, very carefully every single thing that has
3 happened between the time of being all right and not
4 being all right. Our minds react quickly and the mood
5 change follows on quickly, too. It might be a passing
6 thought, a word, a memory, something done or not done
7 by someone else, something weve read or heard, a tune, a
8 bird song, or a place. Anything can trigger thought and
9 therefore our moods. If we are to become our own thera-
1011 pists on such occasions, we need to look very carefully
1 at our situation. Teaching the client to become their
2 own therapist is, you will recall, one of the aims of brief
3 therapy.
4
5
6 Changes
7
8 Changes in the context that the person is living in can be
9 the cause of the problem. Sometimes there are just too
2011 many negatives all at once and they weigh the client
1 down.
2
3
4 The Heimler social functioning concept
5
6 The Heimler social functioning concept indicates a
7 balance of stresses with which we can cope and one where
8 it becomes unsustainable and the person finds it very diffi-
9 cult to cope. There is a three-year course that one can take
30 in this approach and one then can register to be a practi-
1 tioner of the concept. However, there is still merit in
2 touching on the ideas held here. Essentially we look with
311 the client at the key areas in life.
4 41
5
6
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111 The questions are divided into two sections, the first of
2 which deals with:
3
4 (i) work and hobbies, since these are often the areas that
5 people find easiest to talk about;
6 (ii) finance and whether the clients can save;
7 (iii) primary family;
8 (iv) secondary family;
9 (v) how they feel about themselves.
1011
1 The second section is very revealing, in particular with
2 respect to a question that is looking for any indication of
3 suicidal thoughts. The very fact that the question is asked
4 gives the client permission to reveal their feelings in this
5 regard very quickly. These questions cover :
6
7 (i) whether alcohol or drugs are a problem;
8 (ii) whether the person ever wishes they were dead;
9 (iii) some general question as to how they feel about life
2011 in general.
1
2 Of the first five areas a person can usually handle as
3 many as three of these being bad, but at four they are
4 becoming rather wobbly and with five even worse.
5 However, we can help them to strengthen each of the
6 areas. We can ask if they would like to explore these vari-
7 ous areas with us so that we can enable them to build up
8 sufficient positives to be able to dare to look at the real
9 problem areas. For example, if work is hated, we can
30 encourage greater focus on hobbies, if finance is in trou-
1 ble, we can encourage them perhaps towards a part-time
2 job, or in exploring how they spend their money, which
311 may allow us to encourage less eating out and more home
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Focus

111 cooking, for instance. We can ask how much is spent on


2 cigarettes and drink. Or whether the private schooling for
3 their children is really necessary, or the holiday abroad.
4
5
6 Be aware of the ordinary
7
8 It is relevant to be aware of the ordinary things such as
9 whether the client sleeping and eating. Students, for
1011 example, especially around the times of exams, sometimes
1 tend to forget this. If they study through the nights and
2 do not sleep or eat they can end up hallucinating and
3 being utterly stressed out, scarcely able to think straight.
4 Before calling in the psychiatrist it is often a good thing
5 to check when they last ate or slept.
6
7
8 Picking up the emotion
9
2011 In the encounter with the client, the therapist needs to be
1 aware all the time of the music beneath the words. At
2 times, the clients outer exterior does not reflect what is
3 being expressed in words. The words do not tally with the
4 body language, the tone of voice, or the expression on the
5 face. Sometimes the patient may be smiling or seeming
6 quite chirpy, but they are in fact expressing something
7 really sad. It is often to cover up the depth of real feeling.
8 This needs to be explored with the client.
9 At times, this contradiction needs to become the focus
30 of the session, rather than the agreed focus. I have
1 formerly stressed the need for an agreed focus and this is
2 not a contradiction. The emotion that one detects is in
311 the here and now in the counselling room and so, if we
4 43
5
6
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111 check that our peception is right, it is true and real. We


2 need to see what it is about; it may connect with the orig-
3 inal agreed focus and may take us more deeply into that.
4 It may also reveal a more important issue that needs to be
5 addressed and then the focus needs to be renegotiated.
6 There is no point in looking at a theoretical or academic
7 issue, even if previously agreed, if the emotion is clearly
8 elsewhere.
9
1011
1 Projective identification: an aspect
2 of countertransference
3
4 Sometimes the therapist picks up the emotion of the
5 client in their own body, or in the feeling present in the
6 room.
7
8
9 Clients body language
2011
1
When the client has decided to trust the therapist and is
2
willing to open up and reveal the real reason for their visit,
3
very often their body will turn towards the therapist.
4
5
6
Under the microscope
7
8
9 Once we have a focus, we put it under the microscope so
30 that it is examined in great detail. It will contain elements
1 of other conflicts and patterns. Having this focus concen-
2 trates the mind of the therapist and client, as does having
311 a time limit.
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Focus

111 In the first session


2
3 This process of finding the focus and beginning the work
4 of therapy takes place in the first session. The first session
5 is very important in the brief approach and merits a chap-
6 ter of its own (Chapter Three).
7
8
9
1011
1
2
3
4
5
6
7
8
9
2011
1
2
3
4
5
6
7
8
9
30
1
2
311
4 45
5
6
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111
2
3
4
5 QUICK REFERENCE NOTES
6
7
8
9
1011
1
2
3
4
5
6
7
8
9
2011
1
2
3
4
5
6
7
8
9
30
1
2
311
2 46
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Focus

111 Finding the Focus


2
3 General exploratory questions
4
What brought you here?
5
When did it first start?
6 Has this happened before?
7 When did you last feel like this?
8 What are you feeling like right now?
9
1011 Use of techniques
1
2 Body tension exercise
3 Where is the tension in your body?
4 Focus on the tension, make it worse.
5 Let your mind float. What comes to mind?
6 REPEAT encouraging the client to get smaller and
7 smaller.
8 (This exercise will be shown in more detail in a later
9 chapter.)
2011
1 Anniversaries
2 Is this date/day important? Did anything dramatic
3 occur around this time last year/previous years (e.g.,
4 death/abortion/break-up of relationship)?
5
6 Loss
7
8 Have you lost a loved one recently/Has anyone died
9 recently/Have you had a broken relationship?
30
Awareness of world events
1
2 How is the war affecting you and your family?
311 How is the recession affecting you and your family?
4 47
5
6
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111 Awareness of the clients context and change


2 What major changes have occurred lately (e.g., child
3 gone to school/leaving home/being unemployed/
4 becoming a student/getting a promotion/moving
5 house/exams)?
6 Is there anyone close to you in hospital/ill?
7
8 Heimler social functioning theory
9 What balance of positives and negatives is there in
1011 main areas of life work/finance /family (primary/
1 secondary)/feelings about self.
2
3
4 WORK
5 STUDY
LEISURE FINANCE
6 EARNINGS
7 SAVINGS
DEBTS
8
9 SELF
MARITAL
2011 STATUS
1 CHILDREN
SEX
2 FRIENDS
3 SOCIALISING
4
5
6 PRESENT
7 FAMILY
PARTNER
8 PRIMARY
9 FAMILY
PARENTS
30
1
2 Figure 1. Progressive diagram of question areas inspired by the
311 Heimler Social Functioning concept.
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Focus

111 Practical considerations


2
Are you eating/sleeping/relaxing?
3
What is preventing you? (If relevant)
4
5 Listening to the music to find THE focus
6
7 Where is the emotion:
8 in the voice?
9 in the body?
1011 in the tears?
1 What does the client say is the reason for coming to
2 therapy?
3 What does the client want?
4 Does the client want to explore the focal area identi-
5 fied as carrying the emotion? If not, explore/chal-
6 lenge.
7
8
9
2011
1
2
3
4
5
6
7
8
9
30
1
2
311
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5
6
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111
2
3
4
5
6
7
8
9
1011
1
2
3
4
5
6
7
8
9
2011
1
2
3
4
5
6
7
8
9
30
1
2
311
2
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111 CHAPTER THREE


2
3
4
5
6 THE IMPORTANCE OF THE
7 FIRST SESSION
8
9
1011 The importance of the first session has already been
1 mentioned briefly. The manner in which the first session
2 is dealt with is critical to the shortening of the therapy. In
3
particular the therapist should pay very careful attention
4
to the client and to every detail of what happens in
5
therapy, from the very first moments of the encounter with
6
the client. This is essential to the brief approach and a very
7
important factor in the shortening process.
8
9
2011
Careful attention in the first moments
1
2
3 The words that the client uses in the opening sentences of
4 the therapeutic encounter are crucial and often contain
5 the kernel of the whole contract. Therefore, it is vital that
6 the therapist notes every word that the client says in those
7 first few minutes. Right from the moment that the thera-
8 pist first encounters the client, the therapist needs to be
9 paying very careful attention, to both what the client is
30 saying and how they are saying it. If the client has actu-
1 ally stated why they have come or what it is that they want
2 from the sessions once, they will feel that it has been said.
311 They may then, quite reasonably, make the assumption
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5
6
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111 that the therapist and they are on the same track. But this
2 may not be the case.
3
4
5 Dont miss the moment
6
Often, clients will blurt out what they have come for in
7
the first few minutes. At times therapists are too busy with
8
their own agenda of, say, putting the client at their ease.
9
For example, asking if they found the venue all right,
1011
explaining about confidentiality, and taking some factual
1
information, name address, referral agent, etc. All of this
2
may be done in the good intention of helping the client
3
to relax and because the information is, indeed, required.
4
These matters are important, but I suggest that some-
5
times, in this process, something important can be lost.
6
We may well overlook what the client is actually saying.
7
We may miss the moment. One must avoid the first
8
session being a kind of throw-away, warming-up, or intro-
9
ductory session.
2011
1
2 The sacred moment
3
4 Winnicott used to refer to the sacred moment. He found
5 that the children who were coming for therapy had been
6 waiting perhaps some days for their appointment. They
7 would rehearse what it was that they wanted to say and
8 would blurt out why they had come in the first few
9 moments. It is important not to lose this. An example of
30 this is client F (Rawson, 2002, p. 184). I asked, What has
1 brought you here? Her answer: Ive been depressed
2 well, since I was nine years old, gave the clue to the whole
311 of her problem.
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The Importance of the First Session

111 Intake sessions


2
3 In the light of what has been said about the first moments
4 of a therapy session, I question the system of intake
5 sessions, which is a very common way of working in
6 counselling centres. This is where the client has already
7 seen a therapist for assessment and is then referred on to
8 the therapist who will continue to see them. Has the
9 sacred moment then been lost? I suggest that it might
1011 have been. The intake or assessment worker needs to be
1 very aware of the importance of those first moments. If
2 this is not attended to, there is the real danger of the key
3 first comments not being passed on in the summary that
4 is given to the counsellor who is to see the client. The
5 client, because they have said it once, whatever it is, may
6 not realize the necessity of saying it all again to the new
7 person. There can, then, be an important gap in the
8 proceedings. It is not insurmountable. The issues will no
9 doubt reappear at a later stage since, as Patrick Casement
2011 observes, the clients give us prompts all sorts of them
1 (2004, p. 15). In this way the client does, in a manner of
2 speaking, supervise the therapist. If, however, we want to
3 keep therapy as short as possible, then we need to avoid
4 the necessity of this happening and to be tuned in from
5 the first moment. In this way the sacred moment will not
6 be lost and the true work of the therapy begins straight
7 away, arising out of these key first words.
8
9
30 Find a way to recreate a first session
1
2 Where there is an intake and referral-on system, we need to
311 find a way to ensure that we do know exactly why the client
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5
6
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111 has come for therapy. Even if the therapist has been given
2 very accurate notes from the intake worker, the therapist
3 needs to satisfy themselves that they and the client are
4 working on the same issues. I think it is helpful to almost
5 recreate a first session. One has to make sure that the client
6 does not feel as if they are just repeating things that they
7 have already said to the intake worker and are getting
8 nowhere. The therapist might approach this from the
9 following angle: Since some time has elapsed now since
1011 you saw the assessment worker, perhaps you could fill in
1 what was going on for you at that time and what the situa-
2 tion is now. Or one might say something like: I know that
3 you have spoken already to the intake worker and they have
4 passed on to me a summary of your conversation, as they
5 told you they would, but I would find it most helpful if you
6 could tell me in your own words what made you decide to
7 come for therapy, so that I can be quite sure I have under-
8 stood what it is that you are seeking from the sessions.
9
2011
1 The beginning of therapy
2
3 In the brief approach, session one is very much the begin-
4 ning of the therapy. The therapist will endeavour to be
5 very focused as to what their client wants and expects
6 from therapy. They will attempt to tease out the issues and
7 to pin down their client to gain clarity as to the issues.
8 This process of clarification helps both client and thera-
9 pist and ensures that both are working on the same issues.
30 In this process the therapy begins from the first moments
1 of the encounter and one can be working at depth from
2 this first session, utilizing any appropriate skills. The
311 client often tries, whether consciously or unconsciously, to
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The Importance of the First Session

111 avoid the real and painful issue. At times, as a defence, the
2 client will talk of issues that are not really where the pain
3 is. The therapists task is gently to help them to have suffi-
4 cient confidence in the situation to dare to reveal the real
5 issue. It is the therapists task to help the client to open up
6 in this way. Observation of the clients body language will
7 often reveal where the real issue is. It is important that the
8 therapist stays where the emotion is even if the discussion
9 is moving in another direction. The emotion is in the now
1011 and is of paramount importance. For example, client
1 Oliver rattled off a number of issues that he wanted to
2 speak about, so many that I wrote them down. Then I
3 read them back to him, asking him which he wished to
4 start on. As I read there was one where I observed tears
5 welling in his eyes, but he did not choose that one to
6 discuss. I gently queried the fact that he had not chosen
7 the one that seemed to be upsetting him most and
8 suggested that, really, this one might be the most helpful
9 for him to explore with me. The tears once again welled
2011 and he began to share the painful area with me.
1
2
3 Touching the pain
4
5 At times one session may be enough. There are some prac-
6 titioners who work as one session therapists and produce
7 good results. One aspect of the first session that is of
8 prime importance is to touch the clients pain. In doing
9 this the client is given hope that the therapist knows
30 where the pain is, that they can handle it, and that it is
1 not going to destroy the therapist. In touching on the sore
2 spot, painful as that might be, the opening up is already
311 begun and the healing process is started. In touching the
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5
6
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111 pain we are also letting the client know that we can bear
2 it. It is not going to destroy us. The client needs to know
3 this and one can often be aware of the client testing us out
4 as therapists. Almost like dipping a toe in the water:
5
Is the therapist going to hear me?
6
Is the therapist going to be alert to my clues?
7
Is the therapist going to be shocked, or judge, or preach.
8
Will they know what to do?
9
Can they handle my problem?
1011
Can they bear my pain?
1
2 It is hoped that by the end of the first session the client
3 will feel that the therapist has understood their issue and
4 will have the hope that they will be helped with it.
5 Table 1 provides a useful summary of the many aspects
6 to be borne in mind in the first session (see the quick
7 reference notes, p. 64).
8
9
2011 The first session needs to begin
1 the therapy
2
3 The first session is indeed an introductory session and one
4 in which the therapist and client get to know each other
5 and about the process of therapy. It may be good, for
6 instance, to allow a few minutes at the start of a session to
7 help the client to arrive and to get off their chest any-
8 thing that is impeding them from going straight
9 into the work of the contract. For example, if they have
30 just witnessed a road traffic accident on their way to the
1 therapists office, they may well need to offload about this
2 before getting down to the issues they booked the
311 appointment for. Even if such a need is apparent, the ther-
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The Importance of the First Session

111 apist needs to continue to be fully alert and to be noting


2 exactly what is said and how it is said and to very quickly
3 focus on the clients reason for being there. To do this one
4 might say something along the following lines: As you
5 know we only have a limited number of sessions. Are you
6 ready to continue with what we had decided to work on
7 or would you prefer to spend some time talking about the
8 impact of the accident on you? The therapist and client
9 then come to a decision about what the focus of this
1011 session is to be. If the witnessed accident is clearly more
1 prominent in the clients mind than their original issue
2 this is likely to become the focus.
3
4
5 Negotiating and renegotiating
6 the contract
7
8
This process of negotiation and renegotiation is a feature
9
of the brief approach. We need to be very much in tune
2011
with where the client is, and the work of therapy needs
1
to be explicitly agreed. So, such renegotiation of the con-
2
tract may occur more than once within the course of a
3
brief contract, or even in a session. For example, if the
4
client, in becoming more focused on their issues, realizes
5
that their presenting issue was masking a deeper one, the
6
deeper one then becomes the focus of the work.
7
8
9
30
Setting the end from the beginning
1
2 When a short-term contract with a client begins, the
311 brevity of the contract is pointed out. We highlight the
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5
6
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111 limited time available and begin the countdown. We are


2 setting the end from the beginning, which is one of the
3 shortening factors in the approach.
4
5
6 Countdown of sessions
7
8 Even from the first session the client needs to be aware of
9 the countdown of sessions, as this puts a certain urgency
1011 into the situation, and reminds them that they need to
1 bring to the fore whatever is bothering them. There is no
2 time for procrastination.
3
4
5 Brief group therapy
6
7
This brief contract work can be undertaken with a group
8
also. Eight sessions seems to work well for groups.
9
2011 In this instance, over a period of days before the group
1 starts, each member of the group is seen individually for
2 half an hour by the group leader. This is to acertain what
3 it is that each one wants from the sessions. Together they
4 get to a point where there is one sentence to sum up what
5 the client wants to achieve in the eight sessions. This will
6 be shared in the group at the first session, each member
7 of the group reading out what it is that they want to
8 achieve by the time the group contract ends. In this way
9 all the group members can help each other to reach their
30 objectives. I have surprised even myself at how much one
1 can achieve in the half-hour pre-group contracting
2 session. One has to be extremely focused, active, and inci-
311 sive, and both the client and therapist need to be aware of
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The Importance of the First Session

111 the time limit for this session, i.e., half an hour. It is this
2 half-hour that begins the work of the therapy. I believe
3 that it should be undertaken by the therapist who is to
4 lead the group.
5
6
7 Starting therapy at a sprint
8
9 This chapter has stressed the need to start the work of
1011 therapy at a sprint, with the therapist being intensely alert
1 to the client from the very first moments of the encounter.
2 The first session thus begins the work of therapy, it is not
3 just an introductory session. Having stressed the impor-
4 tance of the first session, in the next chapter I say a little
5 more about the focus, that central facet of brief therapy.
6
7
8
9
2011
1
2
3
4
5
6
7
8
9
30
1
2
311
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5
6
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111
2
3
4
5
6 QUICK REFERENCE NOTES
7
8
9
1011
1
2
3
4
5
6
7
8
9
2011
1
2
3
4
5
6
7
8
9
30
1
2
311
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The Importance of the First Session

111 Initial interview in short-term


2 focal therapy
3
4 The following is an example of a first interview with a
5 client:
6
7 (1) What made you decide to come for counselling?
8 (Expect to discover the referral agent, precipitating
9 event, desire for change, expectations of what therapy
1011 can offer.)
1 (2) What do you expect from counselling/hope to
2 achieve from the counselling sessions?
3 (This is an opportunity to bring unrealistic expecta-
4 tions down to earth. There are no magic answers, we
5 facilitate the clients search for their own answers
6 using our facilitative skills. This is an opportunity to
7 outline the method of therapy here, e.g., talking
8 about the situation, getting in touch with feelings,
9 looking for links with the past, etc.)
2011 (3) How will you measure your success in relation to the
1 therapy? For example, a male client wanting to
2 improve confidence in relation to girls might see invit-
3 ing a fellow student he likes to a coffee as a measure of
4 success i.e., a limited, achievable specific goal.
5 (4) How do you feel about this situation now that you
6 have taken this important step? Do you want to ask
7 me anything about the process?
8 (The therapist may outline here a little more about
9 the counselling process in terms of contract, number
30 of sessions, frequency of meetings, etc.)
1 (5) The therapist:
2 checks if the client still wants to continue
311 confirms what they are both working on
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5
6
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111 summarizes the general focus


2 obtains agreement as to accuracy and joint
3 contract and concludes the session.
4 (For example, in this summing up, the therapist will
5 draw on material noted in the answers to the early
6 questions, such as the desire for change, how the
7 client and therapist will know theyve succeeded in
8 their goal, what the general focal issue is. Often it is
9 the opening few words that give the clue for this.)
1011
These questions are examples only. The flexibility,
1
experience, and instinct of the therapist in relationship
2
with the client dictates the format and the language that
3
can elicit the necessary information to fulfill the aims.
4
5
6
7
8
9
2011
1
2
3
4
5
6
7
8
9
30
1
2
311
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The Importance of the First Session

111 Aims of initial interview


2
3 1.
4 The aim is that the client:
5 (a) leaves with a clearer idea as to what therapy is all
6 about;
7 (b) has established a rapport with the therapist;
8 (c) is clearer as to the problem area;
9 (d) has a feeling of being listened to, and that the
1011 therapist has understood the nature of the prob-
1 lem as shown by accurate empathy and summary;
2 (e) has hope, since the limited contract implies that
3 movement can occur quite quickly;
4 (f ) has a feeling of being contained but not
5 constrained by the limited contract.
6 2.
7 The aim is that the therapist has:
8 (a) established a relationship with the client;
9 (b) a clear idea as to the focal area to be explored;
2011 (c) established a working alliance with the client;
1 (d) a contract in terms of focus;
2 (e) agreed the time frame for the contract.
3
4
5
6
7
8
9
30
1
2
311
4 63
5
6
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111 Table 1. Important aspects of the first session as seen from


2 the research case work.
3 (a) The clients assessment of the situation
4 (i) Learning what therapy is
5 (ii) Testing out the therapist and the therapy situation
6 (iii) Deciding if its trustworthy
7 (iv) Deciding if it meets their needs
8 (v) Giving clues
9 (b) The therapists role in the situation is:
1011 (i) Teaching what therapy is
1 (ii) Demonstrating what therapy is by getting started
2 (iii) Enlisting the adult as co-therapist
3 (iv) Helping the client to become their own therapist
4 (v) Dealing with the defences
(vi) Recognizing the clients pain and issue and commu-
5
nicating this
6 (vii) Assessing if client is suitable for therapy, ie. is the
7 client motivated/insightful/able to relate/has an issue
8 to work through.
9 (c) The joint task
2011
(i) Client and therapist seeking and finding the focus
1
(ii) Client and therapist agreeing to the contract in rela-
2 tion to the focal issue and the number of sessions
3
Source: Rawson, 2002, p. 192, Table VII.
4
5
6
7
8
9
30
1
2
311
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111 CHAPTER FOUR


2
3
4
5
6 JOINTLY AGREED STRATEGIC
7 FOCUS: CONTRACT PART I
8
9
1011
In this chapter I return to importance of the focus in brief
1
2 therapy and of holding the client to the focus. I also elab-
3 orate on the idea of the strategic focus.
4
5
6 The focus in session two and onwards
7
8 Earlier in the book I have outlined ways to find the focus
9 in the first session. In subsequent sessions it is important
2011 to allow the the client a little time to say where they are
1 since the last meeting, to arrive and to get off their chest
2 anything that is impeding them from going straight into
3 the work of the contract. This might simply be done by
4 asking if they are ready to continue with the agreed
5 contract or whether there is something more pressing on
6 their minds. I usually allow a client up to ten minutes for
7 this, if needed, and then would check whether we stay
8 with the new topic or continue with the previously agreed
9 work. They may be quite ready to go on straight away
30 with the contract, and some do continue almost as if the
1 previous session were five minutes ago. For others, the
2 events of the week may be powerfully acting on their lives
311 and distracting from the focus. By checking if these now
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5
6
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111 are preferred as the focus, or whether it is appropriate to


2 continue where we left off, we become focused once more.
3
4
5 On becoming more focused
6
7 Therapists who have experimented with being more
8 focused and with attending more to the very first words
9 of their clients often find that things move more quickly
1011 than they had formerly thought possible. Therapists have
1 said, for example:
2 My client has achieved more than I would have believed
3 possible in just one session.
4
5 I couldnt believe how deep we were going so soon.
6 I dared to be more challenging than I would normally be
7 and kept the client very focused.
8
9 I really must share with the group about my client whom
2011 I have seen for several months. I checked at the start of
1 the session whether we were focusing on the issues that
2 she felt she needed to. This set her off on a different tack
3 altogether. She opened up far more than she had done
4 previously and some really painful issues emerged that she
5 had not mentioned before.
6 Several of my clients decided that it was time to leave
7 therapy soon. I felt that this was something to do with the
8 course but was not really conscious of having done
9 anything different.
30
1
2
311
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Jointly Agreed Strategic Focus: Contract Part I

111 Holding the focus


2
3 A while ago I went to see the well known pair, Torville and
4 Dean, performing their dances on ice. While there and
5 enjoying the performance I observed the way that the
6 spotlight followed the couple wherever they went around
7 the skating rink. This prompted me to reflect about an
8 aspect of brief therapy: the focus. The spotlight keeps the
9 dancers in focus the whole time. The operator of the light
1011 ensures that the beam follows them round the rink; their
1 every movement and twist and turn kept in the spotlight,
2 they are never allowed to drift out of that focus into
3 obscurity.
4 In the same way the therapist needs to keep the agreed
5 focal area in mind the whole time.
6
7
8 Synchronicity
9
2011 There are other elements of Torville and Deans perfor-
1 mance that I mused upon also in relation to brief therapy.
2 It demonstrates synchronicity, mirroring, absolute togeth-
3 erness and complementarity. These are all parallels for
4 brief therapy and, indeed, any therapy.
5
6
7 Zooming in
8
9 The skating performance was also on the closed circuit
30 television. My musings continued as I observed the
1 camera zooming in on different aspects of the couple,
2 giving close-up views of them. At one time the camera
311 zoomed in and focused on the intricate footwork, at
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111 another on the couples faces, and so on. Then the camera
2 would shift once more to the overall picture, still holding
3 the couple in the spotlight but showing their full figures,
4 as they went at considerable speed around the rink. Only
5 at the end of the performance did the camera take in the
6 wider scene, with some shots of the audience to put the
7 whole scene in context.
8 What a superb analogy for the way focused therapy can
9 work. There is the overall focus, which is kept in mind the
1011 whole time, but as we work with the client on this we
1 focus on different aspects of it, examining these in detail.
2 Then it is all related to the main heading or focus that has
3 been agreed. Periodically, the main focus is also related to
4 the overall picture and how it fits in with the rest of the
5 clients life.
6
7
8 The strategic focus
9
2011 The issue of focus is so central to the approach of brief
1 psychodynamic therapy that more needs to be said about
2 it. We have already seen some of the ways to home in on
3 the key issue for the client and to hold the client to this.
4 We endeavour not to get distracted into exploring irrele-
5 vant sidetracks and if seemingly unrelated issues come in,
6 then we check how these relate to the contract. The
7 contract is the agreement as to what we are working on
8 with the client and the time scale that we agree to work
9 to. More will be said about contract in the Chapter Five.
30 The strategic focus is where the present and past pain
1 is. This will be apparent in the emotion shown by the
2 client, in the body language, in the atmosphere in the
311 room, or, at times, in the therapists own body awareness.
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111 The client usually has a sense of where the real issues lie.
2 However, they do not always reveal these to the therapist
3 straight away. As we said when looking at the importance
4 of the first session, there is often a certain testing out of
5 the therapist. Will they understand my pain? Can they cope
6 with my pain? Will they know what to do? Will they pick up
7 my hints? Sometimes, intentionally or unintentionally, the
8 client will give us a focus that masks the real issue. It is
9 part of our task to enable them to bring the strategic issue
1011 to the surface, the one that is at the heart of the problem.
1 At times clients will try to talk about an absent other. This
2 is of relevance only if it aids the client in response to that
3 other. It is the clients trip and no one elses.
4 I have occasionally heard supervisors and therapists
5 discussing their clients, saying, for example: I really think
6 he/she needs to do more work on x or y or z. and I think
7 she/he is acting this way because of a or b or c. While,
8 perhaps, there is a place for such speculation in training
9 as examples of what might be going on, we need to be
2011 very careful to facilitate our clients trip and not allow it to
1 become an interesting exercise for the therapist. Also, we
2 need to limit the work we do with a client to what they
3 wish to explore. That is not to limit the therapists free-
4 dom to challenge and to reflect blind spots of the clients
5 to them, this as a challenge to encourage them, possibly,
6 to explore wider issues, and simply to stress the need to
7 keep the clients needs as the focus.
8
9
30 Roots in the past
1
2 Once the strategic focus has been narrowed down and
311 both therapist and client are clear about it, the therapist
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111 also needs to help the client to see that this may have its
2 roots in the past, since this is where the problem proba-
3 bly comes from. Louis Marteau refers to this underlying
4 problem as the nuclear crisis i.e., stemming from an
5 emotional crisis in childhood (Marteau, 1986, p. 81).
6 He also observes that
7
8 If this presenting crisis is truly nuclear, then getting it out
9 at the roots must be the aim of the therapy while the
1011 process will be to reach through the present crisis to grasp
1 the very roots. This means that the presenting crisis needs
2 to be the major focus through which we will attain the
3 roots. The true resolution of the presenting crisis, which
4 means reaching the roots, will be the test of the success-
5 ful outcome. [ibid.]
6
7
8 Renegotiation
9
2011
At times, the focus that we initially agree upon turns out
1
not to be the most important issue to explore. If this is the
2
case then a process of renegotiation of the contract needs
3
to take place. This can happen for all sorts of reasons.
4
Perhaps the client has been testing us and now wants to
5
look at the real issue. Perhaps life circumstances have
6
changed and now something in the new situation is more
7
pressing. Maybe the client had not realized that one topic
8
had masked a more serious and strategic problem. The
9
30 important thing is that client and therapist are clear about
1 and are in agreement as to what they are working on,
2 jointly agreeing a change of contract if that is what is
311 required.
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111 Refocusing
2
3 At other times, it is not a change of contract that is
4 required but a refocusing on what has already been agreed.
5 Sometimes we need to get the client back on course,
6 perhaps by reminding them what the contract was, or
7 maybe asking how the topic now being talked about
8 relates to what they came for. Also, it is good to keep the
9 time limit before the client and point out the need to
1011 prioritize in order to achieve what they want in the time
1 agreed.
2
3
4 Homework
5
6 One of the elements of brief therapy is the use of home-
7 work. Some people dislike that word because of its
8 connotations with school. Essentially, we encourage the
9 client to work on their issues in some way at home in
2011 order to speed up the process. Clearly, in relation to the
1 rest of a persons life, the traditional fifty-minute hour is
2 very little. Therefore, if the client can give a little time
3 throughout the week to their issues, great progress can be
4 made in a short time. It also encourages the client to
5 become their own therapist, which is another aspect of
6 the method. Thus, they take with them into the rest of
7 their life the skills that they learn in the therapy situation.
8 One example of how this might work from early on is
9 if the client is having trouble narrowing down what they
30 want of the therapy. There may be several issues that are
1 bothering them. At home work in this instance might be
2 to ask the client to think about all the different things
311 they want to cover and to select the one or possibly two
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111 that they would like to focus on in the next session. The
2 therapist should encourage them to choose the one they
3 most want help with, in view of the brief nature of this
4 type of work. It is worth pointing out that it is often the
5 most painful one that is most important to look at.
6 Sometimes more than one of the issues will be selected by
7 the next session. It is relevant to hear why the client has
8 chosen the two and often it becomes apparent that in
9 some way they interlink with each other. The client
1011 usually has a pretty good idea about what they want from
1 therapy, even if initially they have difficulty in verbalizing
2 it. Asking the clients to be specific helps them to begin to
3 tackle the issue and keeps them thinking and working on
4 their issues between sessions. Often a great deal can
5 change in the course of the week.
6 Homework needs to be integrated into the work of the
7 session and to arise from what has gone on there. It can be
8 thought about with the client. It may be a suggestion made
9 by the therapist or can be very open-ended, e.g., It might
2011 be helpful to think a bit more about that during the week.
1 More is said about homework in Chapter Seven. The quick
2 reference notes suggest some homework for the therapist!
3 The focus that we have examined further above and the
4 time limit are negotiated with the client to form a contract
5 for the work of therapy. In the following chapter we exam-
6 ine further the importance of time limits in brief therapy.
7
8
9
30
1
2
311
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111
2
3
4
5 QUICK REFERENCE NOTES
6
7
8
9
1011
1
2
3
4
5
6
7
8
9
2011
1
2
3
4
5
6
7
8
9
30
1
2
311
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111 Fixing the focus


2
3 1. Fixing the focus
4
5 Agree contract and focal area, i.e., not just the now
6 area, but how this links with the past. For instance, at
7 the point where the emotion is, help client to reflect
8 on similar feelings from earlier times, e.g., (to a client
9 grumbling about the boss) Is that how Dad treated
1011 you? That sounds like a small childs reaction. How
1 are you feeling in relation to me here and now and we
2 talk about this?
3 Homework to think about the work of the session
4 and about the agreed focal area, or, if the focus not
5 yet clear and agreed , to think about the work of the
6 session and see if by the next session they can be more
7 specific as to what they want from therapy and what
8 they wish to focus on.
9
2011
1
2
3
4
5
6
7
8
9
30
1
2
311
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111 2. Holding the focus


2
3
CLIENT/THERAPIST AGREEMENT AS TO
4
THE FOCUS IS ALWAYS REQUIRED
5
6 At the start of the session allow time for client to talk
7 about issues on the surface and predominating since the
8 last session, readjusting the focus if necessary; e.g., if
9 agreed focus is break-up of a relationship but since last
1011 week a close relative has died, focus probably needs to
1 shift to that if the client wants to do so.
2 If the agreed focus stands then work can begin after a
3 few minutes, e.g., We were going to talk about . . .
4
5
REACHING THROUGH THE GENERAL FOCUS
6
7
Going deeper, e.g., if the focus is about difficulty in
8
developing equal relationships, how does it relate to the
9
2011 childhood?
1
ZOOMING IN
2
3 Be alert for any opportunity to home in on the focal
4 issue, e.g., if the client says, I feel depressed, some ques-
5 tions to ask are as follows:
6
7 When do you feel depressed?
8 When was the last time you felt that way?
9 Give me an example.
30 Tell me more about that.
1 What happened?
2 Where were you?
311 Who was there?
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111 What were you doing?


2 What were you feeling?
3 What did you want to do?
4 How old do you feel as you tell me about that? How old
5 were you? How old are you?
6
7 N.B. Change of tense in the question can move the client
8 into a childhood/past memory or feeling.
9
THERAPISTS ROLE TO HOLD THE BOUNDARIES
1011
1 to hold the focus once agreed
2 to facilitate clients search for meaning re the issue
3 to facilitate the clients dealing with unfinished busi-
4 ness and emotions
5 to facilitate the clients applying their learning to their
6 lives
7 to facilitate the changing patterns of behaviour and
8 habits
9
2011 THERAPIST USES A VARIETY OF SKILLS
1 FLEXIBLY
2 Tone of voice
3 Silence
4 Empathic response
5 Emoting
6 Challenge
7 Gestalt/fantasy/questions/observations/body work,
8 etc
9 education, e.g., grief symptoms
30
1 The focal therapist makes particular use of selective
2 inattention/selective attention/selective neglect /selective
311 follow-up.
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111 The strategic focus


2
3 That is the issue where the present and past pain is, i.e.,
4 tears, silence, body language, weight of emotion in the
5 room.
6
7 Where the clients reflective instinct dictates the focus
8 to be.
9
1011 Where the therapists own body awareness picks up
1 the clients emotions if these are agreed by the
2 client.
3 When the clients body language shifts towards the
4 therapist.
5 It is the clients choice of focus the therapists task is
6 to highlight possibilities by reflecting back to the
7 client and then to hold the focus once agreed.
8 The focus could be a mutual search for the focus or
9 key to the depression/anxiety, etc., within an agreed
2011 time limit. The time limit will help the strategic issue/
1 focus to emerge probably in the penultimate session.
2 The focus needs to be related to the clients blocks,
3 feelings, awarenesses in relation to his or her world.
4 Exploring the motivations or psychopathology of an
5 absent other may be of relevance, but only if it aids
6 the client in his/her response to that other.
7
8
9
30
1
2
311
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111 Aspects of brief therapy to practise


2 (homework)
3
4 Be more aware of reaching a clear focus in the first
5 session.
6 Agree the number of sessions with the client.
7 Be more aware of where the emotion is in the first
8 session.
9
1011
1 Questions for the therapist to think about
2 in relation to the focus
3
4
5 Therapist task
6
The aim of the therapist is to find and fix the focus, help-
7
ing the client to be very specific and teasing out exactly
8
what it is that they want to work on.
9
2011
Have I avoided getting sidetracked?
1
Have I enlisted the clients co-operation in this search
2
for the focus?
3
Have I negotiated the time frame for the sessions and
4
have we agreed the number?
5
Have I picked up the clues and homed in on key
6
emotional issues whether verbal or non-verbal?
7
Have I been afraid to begin the therapeutic work in
8
the first session even though convinced that the thera-
9
peutic alliance has been clearly established?
30
1
2
311
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111 CHAPTER FIVE


2
3
4
5
6 JOINTLY AGREED TIME SCALE:
7 CONTRACT PART II
8
9
1011
1 The importance of the jointly made
2 contract re focus and time
3
4 In brief therapy one of the elements that helps to speed
5 the process is the making of a contract. This is worked out
6 jointly with the client and therapist. The contract includes
7 three essential elements: the focus, the time scale, and the
8 joint agreement about both of them. The focus has
9 already been looked at in some detail in earlier chapters,
2011 and the joint nature of the work of brief therapy also.
1 Here, I explore more about the time aspect. Those who
2 wish to explore the aspect of contract in more depth
3 might wish to consult Rawson, 2002, pp. 137158.
4
5
6 Time/number of sessions
7
8 How long should the contract be? For those readers who
9 come from a long-term therapy background, I am aware
30 that there may be some resistence to the idea of brief
1 work, although the fact that you are reading this is
2 perhaps sign of openness to the concept. I find the follow-
311 ing exercise is quite useful.
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111 Time exercise


2
3 I wonder how you would feel if asked, say at a training
4 group, to do the following exercise. This exercise is one
5 that is quite often used to heighten our awareness and
6 sensitivity to disabled issues and also as an exercise in trust.
7 You are asked to pair up. One then would be blindfolded
8 and the other would be asked to lead their partner around
9 and to experience this situation for 10 minutes. What
1011 would be your reaction? Usually, if I do this in a training
1 session, most in the group are horrified at the time scale
2 and the whole exercise and are wondering if they can keep
3 it up for that time and what is the point, etc. They are
4 much relieved when I say they do not to have to do it! I
5 then ask them to be very aware of what they feel as I go on
6 to the next exercise. I suggest you try it, too. I repeat the
7 above, but say we will do it for just one minute. In the feed-
8 back that follows they are all much more positive; even if
9 they cant see the point they are prepared to go along with
2011 it for that short time as it feels manageable and the issues
1 of trust also seem more possible for that length of time.
2 Some have quite strong and visible reactions to both ideas,
3 but all are much more relaxed with the short one.
4 This exercise, I believe, may help the reader to be a
5 little in touch with how some clients may feel about the
6 brief time and to see it in a positive light.
7
8
9 The contract time limit
30
1 How does this relate to the client and the contract? As we
2 explore the issue of how long should the contract be, I am
311 aware that many therapists fear that the client will think
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111 that a few number of sessions will not be long enough for
2 the client to resolve their problem. But, in fact, many
3 clients are much relieved to know that the contract might
4 be short. It is cheaper for one thing. It is less of a disrup-
5 tion to their lives, as coming for counselling surely is, and
6 it inspires hope that they may be out of their pain soon.
7 Having a time limit provides the client with a certain
8 safety and perhaps allows them to open up because it is
9 only for a little while. There is a certain pressure, if there
1011 is only a little time, that pushes the client to think Id
1 better get on with it. There is an aspect of loss that is both
2 a positive and negative thing. The good side of it is the
3 idea that they can get on with their life and, hopefully, feel
4 better soon. The less good side is that they are losing their
5 good relationship with the therapist. That can be noted
6 and brought into the sessions. Often, the ending of the
7 therapy contract brings back other losses. There is depen-
8 dence upon the therapist even though the contract is
9 brief; this is almost a necessary part of the trusting
2011 process. It is limited, though, by the knowledge that the
1 end is there right from the beginning. We will look
2 further at the issue of loss later on.
3
4
5 Spacing and length of sessions
6
7 The number of sessions and spacing of sessions for the
8 contract needs to be agreed with the client. This may
9 take the form of a certain number of sessions or a period
30 of time. The sessions do not have to be on a weekly basis.
1 In fact, a fortnightly gap can suit some people very well,
2 time seems to go so quickly. The gap allows sufficient time
311 for the client to have put into practice any aspect of
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111 homework that arose from the session. (We return to the
2 concept of homework later in more detail.) In an
3 Employee Assistance Programme (EAP) I worked with in
4 Somerset, many of the clients opted for fortnightly
5 sessions, if given the choice. There is nothing sacrosanct
6 about the weekly session except, I would suggest, custom
7 and practice. Equally, the same could be said of the fifty-
8 minute hour or hour sessions, another tradition. Again in
9 the Somerset practice, where either therapist or client
1011 travelled maybe four hours return to get to the venue of
1 the session, a longer session at less frequent intervals made
2 sense in terms of economy of time. The therapeutic work
3 did not seem to be disadvantaged by this. I believe that
4 there are also some therapists who practise a kind of
5 marathon session of several hours in one go. I do not
6 know enough about that to express an opinion of its effec-
7 tiveness. I, personally, would be unable to concentrate for
8 more than a couple of hours in one stretch. Although
9 supervision is a different exercise from therapy, I find the
2011 hour and a half sessions that most of my supervisees opt
1 for a very good span of time, in terms of both allowing a
2 lot of content to emerge and concentration.
3 Having challenged assumptions a little here, most ther-
4 apists still prefer the hour, or fifty-minute hour, sessions,
5 and that applies to the brief psychodynamic model too.
6 Sessions can be organized in other formats. They can be
7 tapered off, for example, maybe three sessions on a weekly
8 basis and then a follow-up session three weeks later. It can
9 be appropriate to take account of public holidays, such as
30 Christmas or Easter, or term times as the deadline, and
1 then work out how to space sessions up to that time. I tend
2 to offer four sessions and then a review. At the same time I
311 sow the seed of the idea that probably four or six will be
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111 sufficient, since that is what most of the clients tend to


2 choose. The time is specified along with the focus, so that
3 we can say something along the lines of We will look at x
4 for y weeks and then see where we have got. This approach
5 is less rigid than some brief models, for example, Manns
6 (1973), where twelve sessions are offered rigidly and much
7 is made of the cut-off point. There is mileage in letting the
8 client think that there is a definite cut-off point, i.e., only
9 four or six sessions. This enables us to harness the deadline
1011 effect best. It is not necessary for the client to know
1 initially that more sessions are available if they are needed.
2 It is enough that the therapist knows this. However, I have
3 found with most of my clients that the more flexible
4 approach, where the client does know that more sessions
5 can be negotiated if needed, works equally well and I
6 prefer to work in this way. This more flexible approach to
7 the number of sessions relies more heavily on the joint
8 aspect of the decision. Given the statistics that I have cited
9 elsewhere, the number of sessions still tends to average
2011 around four to six. This is true, even when my clients are
1 fully aware that more sessions will be available, if they need
2 them. I tend now to make a rigidly fixed ending only with
3 clients who seem poorly motivated or who want to
4 procrastinate, or ones who have great difficulties with
5 letting go and with loss. A firm cut-off point can bring
6 these deeper loss issues to the fore and they can then
7 become the work of the sessions, if this is appropriate.
8
9
30 Interruptions
1
2 Interruptions are quite acceptable in this approach. By that
311 I mean that we might work with a client on a particular
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111 issue for, say, four sessions. This being satisfactorily tackled,
2 the client then goes on their way to assimilate the learning
3 from this work for a number of weeks. Later they may
4 return to explore a further issue. In long-term work much
5 the same process happens, except that the client will
6 continue to attend sessions with the therapist during the
7 assimilation period. Learning tends to happen in peaks,
8 and then there is a plateau stage as we come to terms with
9 new concepts or practise new ways of responding to situa-
1011 tions. In the brief approach, the client works in the plateau
1 stage on their own. This is cheaper for them and does not
2 encourage the dependence on the therapist that is the case
3 in longer term work. The comparison is made, not to get
4 into a debate about which is better or worse, but simply to
5 highlight the difference and some of its consequences. In
6 fact, is this not how we work with physical problems? We
7 go to the doctor when there is something specifically
8 wrong. That is treated and we dont go near the doctor until
9 some other matter causes us a problem.
2011 I referred earlier to the energy required in this method.
1 I think that if this energy is lacking in the initial phase of
2 therapy the therapy can tend to slip into a different mode,
3 a slower and more ponderous one that will probably
4 extend it. All is not lost if this happens; one simply needs
5 to review with the client, see if we are achieving what the
6 client wants, and refocus. Then we are able to proceed to
7 work at the agreed focus and pace.
8
9 The dynamics of the deadline
30 (Rawson, 2002, p. 64)
1
2 There is a deadline effect induced by the limited contract.
311 We will all have memories of times when we rushed to
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111 meet a deadline, whether it was an essay, or collecting the


2 children from school, or catching a train or plane. A dead-
3 line has the effect of concentrating the mind wonderfully.
4 We become very focused on the task in hand. We ignore
5 anything that does not pertain to the goal to be reached
6 by the set time. This is called selective inattention if we
7 apply it to brief therapy. How many of us have taken our
8 time preparing, perhaps for an evening out? If we are
9 unexpectedly invited out, with only a little time to get
1011 ready, we surely manage it in a very short time. Are we any
1 more ready, or have we just speeded up the preparation?
2 The agreed number and spacing of sessions provides a
3 kind of safety and containment, as well as a little pressure.
4 The clients knows where they stand. This also has an
5 economic angle since, if the client is contracted for six
6 sessions to work on their strategic issue, they can work out
7 the cost. While there are no guarantees as to outcome,
8 there can be a reasonable expectation of progress. The
9 short number of sessions also inspires hope. If the thera-
2011 pist thinks it can be dealt with in that time, it cant be that
1 terrible.
2 You will recall that in an earlier chapter I placed
3 emphasis on the therapist believing in the method. Some
4 centres offer a brief contract initially, but then put their
5 clients on a waiting list for proper therapy, i.e., long-
6 term. This type of approach militates against brief therapy
7 being effective.
8
9
30 The end from the beginning
1
2 In the brief approach we need reminders of the end from
311 the beginning and can almost count down to the end
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111 session by session. For example, This is session four, so


2 we have two more to complete the work you wanted to in
3 that time. We will need to allow some time for review in
4 the last session. Often a great deal emerges in the penul-
5 timate session. Or we might say on day one. We have
6 four sessions and have decided that we are looking at x, so
7 where would you like to begin?
8
9
1011 Joint nature of brief therapy
1
2
In brief therapy it is important for client and therapist to
3
work together to find and fix the focal area and the
4
number of sessions involved for this. They need to arrive
5
jointly at the contract by finding the focus and agreeing
6
the time scale. In the process of doing this the therapist
7
8 needs to avoid getting sidetracked. The client, who will
9 no doubt be giving clues as to their problem, may also
2011 offer some resistance and throw in some red herrings.
1 This was shown in the table summarizing what goes on
2 in the first session. Such red herrings can be part of
3 the testing out of the therapist by the client. The client,
4 so to speak, is wondering: Will the diversion be noticed?
5 Can they stand my pain? Are they able to tell the wood from
6 the trees?
7 When the therapist picks the client up on a deviation
8 and brings them back to the focus, the client may actually
9 feel relieved and begins to trust the therapist more. The
30 client in this situation feels held, listened to, taken seri-
1 ously, given hope, excited. The therapist may be amazed
2 at the amount of material that comes up in just a short
311 time, even in the first session.
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111 High energy therapy


2
3 Therapists working with this more interventionist
4 approach are aware of high energy levels. It is an active
5 approach. You may recall the sprinter analogy referred to
6 earlier. Therapists express surprise that very deep material
7 surfaces so quickly, and that the level of trust is also estab-
8 lished so quickly. Their fears that the client will be opened
9 up and then abandoned seem to dissipate as they find
1011 that, since both client and therapist know of the time
1 limits, both are working to have a proper closure. In fact,
2 the client is not left all open and raw and should not be.
3
4
5 Effect of time limit on therapist
6
7 Many therapists new to the brief approach say how good
8 it is to have permission to get cracking and to move the
9 session along, which this tradition gives, since it feels
2011 natural to them. Previously they have held back because
1 being so active was not allowed by their particular tradi-
2 tion of therapy. In beginning the therapeutic work more
3 quickly than they would previously have dared to do, they
4 have found it worked well.
5
6
7 The approach is not rigid
8
9 In the above we have examined the aspect of time in the
30 contract and the joint nature of the contract has been
1 stressed once more. More than once the idea of renegoti-
2 ation has come up, emphasizing that the therapist and the
311 approach is not rigid. The approach discussed here is one
4 87
5
6
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111 that expects the therapist to be flexible in many respects,


2 and this flexibility is the subject of Chapter Six.
3
4
5
6
7
8
9
1011
1
2
3
4
5
6
7
8
9
2011
1
2
3
4
5
6
7
8
9
30
1
2
311
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111
2
3
4
5
6 QUICK REFERENCE NOTES
7
8
9
1011
1
2
3
4
5
6
7
8
9
2011
1
2
3
4
5
6
7
8
9
30
1
2
311
4 89
5
6
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111 Time limited psychotherapy


2
3 The limited contract
4
5 (i) Fixed number of sessions.
6 (ii) Agreed circumscribed focal area.
7
(i) The fixed number of sessions provides the following
8
for the client:
9
1011 Safety, e.g., Itll be over soon.
1 Containment, e.g., The real feelings can be allowed
2 out because its only for a little while.
3 Hope, e.g., If the therapist thinks they can help in six
4 sessions it cant be so bad after all.
5 Pressure, e.g., Ive only got four/eight sessions so Id
6 better get on with it/say it. Id better work between
7 sessions to get the most out of the therapy hour.
8 Loss: anticipation of the last session from the begin-
9 ning.
2011 Independence (positive), e.g., I can leave all this
1 behind soon.
2 Independence (negative), e.g. I cant cope with the
3 loss. This can be turned to positive as the focus
4 becomes that of dealing with loss/past losses/echoes.
5 Dependence (positive), e.g., Its only a short time so
6 I can lean on the therapist for a while.
7 Dependence (negative), e.g., Its not long enough.
8 The focus needs to deal with what does not enough
9 mean and with loss/past echoes/losses/neediness.
30
1 N.B. A new contract can be made at the therapists discre-
2 tion and various ways of being flexible can be used to suit
311 client need.
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111 Flexibility is based on experience/instinct and negotia-


2 tion with the client is required.
3
4 (ii) The circumscribed focal area
5
6 Agreed general focus concentrates the mind of
7 client and therapist.
8 Provides a backcloth triggers appropriate/related
9 material for the client.
1011 Provides direction enables the client to achieve the
1 original goal.
2 Avoids client/therapist getting lost in interesting side-
3 tracks.
4 Under the microscope allows sufficient time for all
5 the detail in one incident/ issue to be investigated
6 Microcosm contains elements of other conflict/
7 problems. Patterns emerge.
8 Strategic focus may emerge through examination of
9 general focus. Through this to the past pattern or
2011 event.
1
2 NB: Flexibility required of the therapist. Focus can be
3 renegotiated with client as appropriate or the material
4 brought back to the original agreed focus. Experience/
5 instinct/and negotiation are necessary.
6
7
8
9
30
1
2
311
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5
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111 The dynamics of the deadline


2
3 Which of us is not familiar with the effect of the deadline?
4 The assignment date for the student, the committee meet-
5 ing where one has to have read certain reports, the check-
6 in time at the airport or station, these are all familiar
7 events to most of us. Such events have a remarkable way
8 of concentrating the mind and energy. We tend to focus
9 on the essentials that will achieve the desired end. The
1011 student abandons the longer term academic projects and
1 other tasks to focus on whatever is necessary to meet the
2 immediate deadline. The committee member perhaps
3 closes the door on those making demands to concentrate
4 on the report, and so on.
5 In therapy, the same deadline effect can operate. Which
6 counsellor or therapist has not seen a client make rapid
7 strides in the limited time available before emigrating or
8 leaving the area? Would the same people have reached
9 such a satisfactory position in such a short time if they
2011 had had no deadline in sight?
1 In college counselling/therapy sessions, the deadline is
2 built in by term ends, by exams, industrial placements,
3 and holidays. In more general settings, events such as
4 moving jobs or house can end sessions.
5 How many therapists deliberately capitalize on the
6 endings effect? Those who do report the remarkable
7 strides clients make in very few sessions.
8 Those therapists who contract a limited number of
9 sessions and keep careful note of the pattern of work may
30 notice the particular importance of the sessions nearing
1 the deadline.
2 The number of sessions to produce considerable
311 change can be so few that many would be sceptical. Four
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111 to six sessions would be a reasonable span to achieve real


2 change with many people when working focally, strategi-
3 cally, and psychodynamically.
4
5
6 By mutual arrangement (Rawson, 1995)
7
8 Focal therapy is a psychotherapy approach where client
9 and therapist work together on an agreed focal area of the
1011 clients life. They do this within an agreed and limited
1 time-span.
2 The focal area is negotiated. Often clients present an
3 initial problem which is bothering them. This may then
4 become the initial general focus of the sessions. However,
5 as exploration goes ahead, it may become apparent that
6 there is an underlying problem relating to the initial
7 focus. This will then become the specific focus of the
8 remaining sessions of the contract.
9 The term contract is used because in this approach
2011 the mutual agreement as to the focus of the sessions is
1 important. Once client and therapist have agreed on the
2 general area to be explored, it is then the therapists task
3 to ensure that this happens. If it becomes apparent that
4 the agreed focal area is no longer relevant, a revised
5 contract is negotiated.
6 The clarity as to what the therapy is about serves to
7 concentrate the minds and energy of both client and ther-
8 apist. This is a particularly intense form of therapy and
9 requires alert attention to every aspect of the therapeutic
30 relationship.
1 Every word, expression, hesitation, body language and
2 the emotional atmosphere need to be monitored carefully
311 by the therapist. In so doing, important clues are gained
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5
6
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111 to move the therapy on so that positive results are


2 achieved.
3 The agreed time limit or limited number of sessions
4 also concentrates mind and energy. It encourages client
5 and therapist to stick to the point and to selectively
6 ignore material that has no bearing on the focus agreed.
7 However, this does not mean that there will not be wide
8 areas of the persons life referred to. What it does mean
9 is that like a person creating a tapestry every thread will
1011 be woven in to contribute to the original theme to make-
1 up [sic] a complete picture so that any theme that emerges
2 in the therapy session will be related to the overall agreed
3 focus.
4 Since the clients are helped to clarify what it is they
5 need from the therapy, they will thereby be helped to
6 explore related areas of their lives. It is as if one is placing
7 an aspect of life under a microscope. By obtaining a clear
8 picture, the tangles and patterns can be clearly seen and
9 unravelled.
2011 The first step is to see clearly. This will not be simply
1 a cognitive experience but will expect to touch on the
2 emotions. In many cases, this will mean a reliving of a
3 long-forgotten or deeply-buried painful experience. This
4 remembering will be a cathartic experience and a heal-
5 ing experience.
6 In this way, the focal therapy is seen as a psychody-
7 namic approach. The client is encouraged to see/explore
8 their problem in relation to any childhood links or past
9 events. This remains focussed [sic] and relating to the
30 present issue.
1 It is not thought necessary in this approach to go
2 through the whole childhood but rather to focus on the
311 issue still affecting the present. The unfinished business
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111 belonging to the past will tend to lead people to patterns


2 of behaviour that attempt to resolve the unfinished busi-
3 ness often in a maladaptive way. It may be this that
4 unknowingly brings the client to therapy.
5 Maintaining the focus requires activity on the part of
6 the therapist. Techniques such as gestalt, or fantasy or
7 bodywork are used to move the sessions on.
8 At times, the client will show resistance to the work.
9 One must remember that no one relishes the exploration
1011 of painful and traumatic areas, so such resistance is wholly
1 understandable. It will be tackled by [the] therapist and
2 brought immediately into the work of the session.
3 The resistance will be explored. The contract will be
4 renewed does the client want to work on the issues at
5 this time or not? The choice is theirs. This challenge
6 often galvanises the client into facing the difficult area.
7 If, however, the client decides to withdraw from ther-
8 apy, this should not be seen as a failure on the part of
9 either therapist or client. Rather, it indicates that this may
2011 not be the right time for the topic to be looked at.
1 It is important to remember that people have lives
2 outside the 50 minutes per week when they see the ther-
3 apist. Events may be impinging externally that make
4 withdrawal from counselling expedient for example,
5 taking on a new job or sitting an exam. The day before
6 such events would not be the time to open up old
7 wounds from the past. Instinctively clients will know this
8 and resist the therapists attempts to facilitate their work-
9 ing on the agreed issues.
30 However, clients do not always think to alert their
1 therapist to such external life factors. Therefore it is up to
2 the therapist to check out, where possible, such mitigat-
311 ing [sic] circumstances.
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5
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111 Resistance might also reflect a kind of self-preservation


2 response or an attempt not to disrupt the status quo. For
3 example, the adult survivor of child abuse might be reluc-
4 tant to continue therapy if the logical conclusion would
5 be to expose the abuser. This might disrupt a whole
6 family network of relationships that the survivor believes
7 needs to remain intact.
8 Since this type of therapy is based on a therapeutic
9 alliance of an agreed contract, such resistance can be
1011 talked about and explored. The work will either continue
1 or cease both by agreement. This involves activity on
2 the part of the therapist and the ability to deal with both
3 the clients anger and pain.
4 It is the therapists task to pin down the client. Sensi-
5 tively but firmly, rather as a surgeon needs to be firm and
6 incisive, the therapist needs to facilitate the client in
7 exploring the area of pain.
8 Once the client decides to continue the work, the
9 therapist needs to hold to the contract firmly and to move
2011 on. Such resistance may well indicate that they are close
1 to the issue that is to be the most important of the
2 session.
3 This is likely to be the most frightening and the most
4 painful to the client. The client needs to be sure that the
5 therapist is there for them and that she can handle the
6 situation. Some of the resistance may be about these
7 issues. The client is attempting to seek reassurance that it
8 is safe to explore with this therapist, that what is so terri-
9 fying will not destroy them both.
30 The time limit facilitates this process. There is not time
1 to skirt round the issues. This therefore mobilises the
2 efforts of the client to get through the resistance and to
311 undertake the work seen to be necessary. That is, to talk
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111 about, and get in touch with, the emotional and painful
2 events of their past or present.
3 The therapists activity will draw on experience and a
4 wide range of therapeutic interventions. The structure of
5 the approach affords little time to waste so if one
6 avenue does not move things along, another can be tried.
7 Each client draws different skills from the therapists
8 repertoire but these must be integrated into the thera-
9 pists way of work, not used haphazardly or artificially
1011 applied.
1 The analogy of horse and rider is perhaps appropriate
2 here. A skilled rider will adapt to their mount, using their
3 equestian skills flexibly at one time, firm; at another,
4 gentle.
5 Every horse will draw out a different response and
6 needs a particular understanding and approach. The ther-
7 apist needs such a flexible and adaptable approach to
8 every client. Each individual therapeutic relationship is
9 unique and it is in this uniqueness that the mystery of the
2011 therapy works.
1
2
3
4
5
6
7
8
9
30
1
2
311
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5
6
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111
2
3
4
5
6
7
8
9
1011
1
2
3
4
5
6
7
8
9
2011
1
2
3
4
5
6
7
8
9
30
1
2
311
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111 CHAPTER SIX


2
3
4
5
6 FLEXIBILITY
7
8
9 It is important that the therapist can be flexible. This
1011 applies to techniques, to the time scale and to the possi-
1 bility of renegotiating the contract in respect of both focus
2 and time as necessary.
3
4
5 Pinpoint the issues
6
7 In holding the focus and working with the client we need
8 to pinpoint the issues, help the client to discharge the
9 emotions that reside with these, and help them to change
2011 the situation in the present. The reason for this is so that
1 they can move forward somewhat more freely.
2 With one client there may be no need to do anything
3 other than ask, What brought you to the counselling? for
4 it all to pour out clearly and lucidly. Another client may
5 be barely able to get out a few disjointed thoughts as to
6 their emotional state and the therapist needs to be able to
7 help them, applying appropriate skills flexibly.
8
9
30 Education
1
2 The flexibility of the therapist is called into play in find-
311 ing and holding the focus. One of the ways to do this is
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5
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111 that of education. This is an area that is sometimes over-


2 looked. I believe that we need to help clients to be aware
3 of psychological processes, to teach them how to become
4 their own therapists. For example, so many people are
5 utterly ignorant as to the many effects that grief can have
6 on them. Very often, once they are aware of this they no
7 longer require therapy. I have so often heard clients say,
8 Oh, I thought I was going mad. Now I understand what
9 is happening, I think I can cope.
1011 The anniversary effect is particularly important for
1 them to know about in relation to grief. See Grappling
2 with Grief (Rawson, 2004, Chapter Three.)
3
4
5 Jacques
6
7 I cite Jacques as an example where a range of skills were
8 required, including education. He is referred to in
9 Grappling with Grief (Rawson, 2004). Jacques was an art
2011 student who was referred to me by one of his tutors
1 because he had become aggressive suddenly and seemed
2 utterly unable to produce any artwork. The tutor realized
3 that there was something wrong, but Jacques was very
4 reticent with him and would not open up about his prob-
5 lem. The tutor thought that the lad might speak more
6 freely with someone who was not his tutor, who met him
7 every day in class, and so brought Jacques to see me in the
8 counselling service.
9 Jacques was French and was in this country for his
30 course. He could speak and understand English, but this
1 was not his first language. He would barely look at me and
2 I gently suggested that it might help if he talked since
311 clearly there was something that was bothering him.
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111 So, here I was working with Jacques, a sixteen-year-old


2 student who avoided my eye contact, who would only look
3 at the floor, and who wouldnt say anything. I needed to
4 establish some kind of rapport. I was sending signals of
5 empathy and understanding, etc., non-verbally, but ver-
6 bally I began to tell him about counselling and therapy
7 and how it might help, and the sorts of things people came
8 to therapy with. I refer to this as part of the educational
9 role of the therapist. At intervals I would pause to see if he
1011 could tell me what was up and how I might help. He had
1 decided to come for the appointment, so clearly did want
2 help. I wondered if he might be able to draw whatever was
3 troubling him, stressing that it need only be diagrammatic,
4 not a great work of art. I indicated the pencils, felt tips,
5 and paper on the coffee table between us. This resulted in
6 some activity on his part. He took up the paper and began
7 to draw. He chose a black felt tip. A rectangle appeared,
8 then some grass around it, then it was heavily filled in, and
9 then came the tombstone. When he had drawn that he put
2011 the paper down abruptly and, equally suddenly, got up
1 and went to stand staring out of the window of my office.
2 All this time he had not spoken and I had remained silent
3
too, attempting to just be with him.
4
5 Not wanting to break the atmosphere in the room where
6 I felt that he was reliving his pain and in some silent way
7 allowing me to share it with him, I stayed silent.
8 However, I went to the window and stood beside him,
9 taking the picture he had drawn with me. After more
30 minutes had passed silently I said, Someone close has
1 died, havent they? Although there was no reply verbally,
2 I understood that I was on the right track. Once again we
311 shared a period of silence. Can you tell me about it? I
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5
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111 asked quietly. I eventually gathered that it was his mother


2 who had died suddenly in France very recently. Once he
3 had managed to reveal that it was his mother who had
4 died the intense heavy atmosphere in the room light-
5 ened. Jacques then went back to his chair and I returned
6 to mine. This profound silence had lasted for twenty
7 whole minutes. I cannot say what happened to him in
8 that period of time. I do know that I shared a very deep
9 experience within that silence with him and that it some-
1011 how moved him on with his grief. [Rawson, 2004, p. 18]
1
2 I was very present to Jacques in the silence and I
3 believe that he was aware of my being fully with him in
4 his pain.
5 In this example, then, I have, in addition to the normal
6 counsellors repertoire of empathy, noting body language,
7 use of tone of voice, etc., employed the skills of education,
8 art therapy, and silence, as well as pertinent questions. I
9 also moved from the chair to be by him at the window. I
2011 believe that this was important for him. I was there with
1 him, but silently, not intruding. Following Jacques and
2 myself returning to our respective chairs and his opening
3 up about the death of his mother, I spoke a little about
4 bereavement and its effects, thus educating once more,
5 this time about psychological processes. In doing this I
6 was attempting to normalize what he was feeling and
7 perhaps put what he was feeling into words and thus
8 make it more manageable. As we find in Shakespeares
9 Macbeth Act IV. Sc.III:
30
1
2 Give sorrow words: the grief that does not speak
311 Whispers the oerfrought heart, and bids it break.
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111 After we had sat down again I spoke of


2
many different reactions people have [to grief], including
3
confusion, anger, and a loss of creativity, all of which he
4
had been exhibiting in the classroom. I verbalized for him
5
how sad he must be, and the pain he was in, and that it
6
would get better, that his feelings on losing a loved one
7
were normal \and not to be frightened of. Our session
8
ended with a much lighter feel. Jacquess hunched-up
9
stance had now become more upright and open, and he
1011
was almost able to look at me and even managed a small
1
smile as he went off. We made another appointment to
2
see how things were going. By the next session he was no
3
longer being aggressive in class and he was back to being
4
able to get on with his creative work again. [Rawson,
5
2004, pp. 1819]
6
7
8 The importance of being with
9 the bereaved
2011
1
No doubt therapists are well aware of how important just
2
being with the client in their pain of loss is. I also encour-
3
age those who are close to a person in grief to be aware of
4
it, too. We often learn much from our clients; it was
5
Jacques who taught me the this important lesson and I
6
7 would like to share with the reader . . . just how impor-
8 tant presence is to the one who is bereaved. It is not so
9 much our words that can help but the being there with
30 the person in their loss. So often people say I dont know
1 what to say, but they do feel for and with the person in
2 their loss. This feeling and awareness, empathy and
311 support are tangible and can be of real help in the
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5
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111 persons grief and loss. To stay present in the silence can
2 be a gift any friend or companion can give to the
3 bereaved. Obviously with sensitivity and to speak or not
4 speak as appropriate. Sometimes, the friend who simply
5 stays nearby the bereaved, reading their paper or who
6 quietly gets on with some little job, can be a comfort.
7 There, but not intruding. There, if called upon to share
8 a memory or thought . . . [Rawson, 2004, p. 19]
9
1011
1 Each client draws different skills
2 from the therapist
3
4 Returning to flexibility, each client will draw different
5 skills from the therapist appropriate to their particular
6 case. Linda, in the example that follows, also needed a lot
7 of help to be able to share her problem. Again we see a lot
8 of silence and education about counselling and therapy,
9 but other skills also.
2011
1
2 Linda
3
4 Linda came and slumped in the chair, looking at the floor.
5 In response to my gentle questions, I got grunts, nods, or
6 shakes of the head. I decided to explain a little more about
7 how counselling works, i.e., that people who have some-
8 thing on their minds which is bothering them come and
9 talk to a counsellor, who has no axe to grind, or judge-
30 ment to make, but who will listen and help to clarify. I
1 went on to explain how the therapist will use the skills
2 they have learned to help the person come to terms with
311 what is troubling them, or to express the emotions that
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Flexibility

111 they are bottling up. I explained how this can help the
2 individual move on more freely and be able to get on with
3 their life once more. I could tell that Linda was listening
4 intently, but still she said nothing. I asked, Have you
5 come of your own volition?, and I got a nod. Do you
6 want to share something with me but dont know how?
7 Another nod. I decided to list a few of the problems that
8 people bring. People come here with all sorts of problems
9 and issues, relationship breakdowns, difficulties with
1011 parents, unwanted pregnancies, trouble with their tutors
1 or with the course and their studies, assault, rape, or diffi-
2 culties with flatmates, or a death. When I mentioned rape
3 there was a tangible increase in the heaviness in the room
4 that had been there since Linda came in. I went silent
5 again and waited. I could feel a squirmy sort of feeling in
6 my tummy. I knew this was nothing to do with my own
7 situation and that this in some way related to her. After
8 quite a long silence, when she still seemed quite unable
9 to speak, I asked, Im wondering if you perhaps have a
2011 kind of squirmy feeling inside? At this I got a real res-
1 ponse. She looked at me directly, with astonishment, and
2 nodded. I said, Something pretty scary must have
3 happened. Again she nodded, holding my gaze. Can you
4 tell me about it? I asked. It might help to share it. Was
5 it one of the topics I mentioned? Another nod. I said that
6 I guessed one of the most difficult to talk about might be
7 being raped; was it this? This time she began to talk and
8 told me about a most horrific incident of rape by a former
9 boyfriend. It had been a deliberate and vicious attack but
30 in her own home, which she had allowed him to enter.
1 Because of this she perceived it to be her fault and was
2 loath to tell the police about it. In fact, in time she did.
311 The woman police specialist who had dealt with rape
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5
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111 victims for some twenty years said it was the worst rape
2 case that she had ever dealt with, causing a lot of internal
3 damage to the girl.
4 The work of therapy continued but the point of this
5 extract is to see how we can arrive at the focus of the
6 sessions. In this example it was achieved by using silence,
7 countertransference/projective identification, education,
8 questions, noticing the body language and picking up on
9 the weight of feeling in the room, and providing a suffi-
1011 ciently safe environment for the client to open up. This
1 demonstrates the flexibility of the therapist.
2
3
4 Body memory
5
6 Another technique that is extremely valuable I call the
7 body memory exercise, and it is one that can speed up the
8 process very much. An example of this used in practice
9 follows, and an example of how to lead this is shown in
2011 the quick reference notes at the end of the chapter. It is
1 especially useful when a client is depressed but has
2 absolutely no idea why. Once we have explored the obvi-
3 ous, already mentioned things with them, such as anniver-
4 saries, key life events, and so on, I will then suggest that
5 we try an exercise and I explain how it works. It was used
6 with the following client.
7
8
9 Rob
30
1 Rob was terrified of going into lectures and was in danger
2 of dropping out of the course. He had no idea why, but
311 simply found himself unable to go into the lecture hall.
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111 Having explored various ideas and drawn a blank I asked,


2 When you think about going into the lecture theatre,
3 what happens in your body? Do you experience any
4 tension? He wasnt sure. I suggested that we might try an
5 exercise to see, explaining that sometimes the body will
6 remember a trauma that the conscious mind has forgot-
7 ten. If we can get in touch with the body memory we can,
8 sometimes, bring the trauma into the consciousness so
9 that it can be dealt with. Rob was happy to try. So I asked
1011 him to shut his eyes, relax and then to think about going
1 to the lecture theatre, to visualize himself walking towards
2 it and to be very conscious of what was happening in his
3 body as he did this. He felt a tension across the palms of
4 both his hands. I asked him to be very aware of this
5 tension and concentrate on it and then to imagine himself
6 getting smaller and smaller and to see if an image or
7 person or situation came to mind. I asked him to indicate
8 with his hand if he did have a mental picture but to stay
9 with the picture. This was all said in a quiet and gentle
2011 tone, so as not to intrude into the situation. In fact he did
1 have a memory, so I asked him to tell me about it. Where
2 are you? He was in Africa. How old are you? What are
3 you wearing?
4 I deliberately use the present tense as I ask these ques-
5 tions so that it pushes the client further into the memory
6 and the reliving of that memory. In the memory, he was
7 a little boy of about five and he was standing in front of
8 his uncle, who was beating him across the palms of his
9 hand with a stick. This was in front of a large number of
30 people. He had been asked to run and fetch the milk from
1 the other side of the forest and had been too terrified to
2 do so, so had not obeyed. He felt utterly humiliated to be
311 shown up in front of all these people. I asked what the
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111 little boy wanted to say to the uncle. He couldnt say, so I


2 asked him to go into the scene as his adult self and to
3 stand with the little boy and speak for him.
4 What do you want to say to the uncle?
5 Leave him alone. Hes much too small to have been
6 asked to go to the other side of the forest on his own.
7 Dont you realize hes never done that before? And its not
8 fair to chastise him in front of everyone. Youre a bully!
9 I asked, What do you want to do with the little boy?
1011 I want to take him in my arms and comfort him, but
1 that would shame him, too. So Id take him by the hand
2 and say to the uncle, Ill go with him across the forest
3 and fetch what is needed. Now go and fight someone your
4 own size. Out of sight of the others, I would want to
5 hold the little one in my arms and comfort him and tell
6 him its all right and all right to be frightened, because he
7 would have got lost and that it was not fair of the uncle.
8 I then asked Rob, when he was ready, to come back to
9 the counselling room, bringing the little boy if he wished,
2011 so that we could look at what had happened. He did so,
1 surprised at the memory. He had forgotten all about that
2 incident.
3 Together then we explored how this episode could
4 relate to the lectures. He found it easy to make the link.
5 The crowds! The people! Being asked to speak in front of
6 them all! It being a, sort of, school-like situation, a learn-
7 ing one, as it had been at five, with someone in charge,
8 the lecturer, like his uncle. Since he was African, in a
9 strange place, where he still didnt know his way around
30 and sometimes not even the language very well, this
1 linked, too. And so we had discovered the focal area and
2 he had re-experienced the painful emotions of the time
311 and to some degree put the situation right in retrospect.
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111 He was still, however, left with the residue of the panic
2 with regard to the lecture hall, since this now was a habit.
3 We needed to address that too. I tackled that in two ways.
4 First, I taught him a very simple relaxation exercise that
5 he could do several times a day and could also do espe-
6 cially when approaching the lecture hall, or any crowded
7 situation. The more practised he could become at this the
8 quicker the actual exercise could work to help him. It is a
9 very simple exercise of clenching and relaxing the muscles
1011 bit by bit all over the body. Eventually, just by clenching
1 a hand, the body should go into relaxation mode.
2 The second thing that I suggested he do was to take the
3 little boy by the hand as he approached any of these scary
4 situations. Then, he had to consciously remind the little
5 one, in his imagination, that he, the adult, was with him
6 now and that he could answer back and speak up for the
7 two of them. The situation, therefore, was not as it had
8 been in front of his uncle. I wondered if there had been a
9 pet name that he might have been called as a little boy,
2011 because that could help in this exercise. In fact, Bobby was
1 the childs pet name. I further suggested that he could
2 perhaps devise a short-cut code to remind himself that he
3 was not in the forest and that hes not five but thirty-five.
4 This is to help keep him in the present and not get
5 hooked into the past. For example, he might simply have
6 to say, Its OK Bobby, Roberts here or Im Robert or
7 Bobby, you go and play Ill see to this, or whatever
8 helps!
9 So he had a lot of homework to do. When he next
30 came to see me he had begun to go to classes and felt very
1 much better. The progress continued. After just three
2 sessions he felt that he had no further need of therapy. He
311 was now fine, not only attending classes but even speaking
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111 in a hall about some political issue to some three hundred


2 people! I was delighted, of course, if a bit surprised. I asked
3 what had helped, expecting some reference at least to the
4 body exercise that we had done, which seemed to me to be
5 a vital component and on which I had been congratulating
6 myself! This, however, got no mention at all. He said it was
7 the relaxation exercise that had done the trick. He had
8 practised this thirty and forty times a day. When I prodded
9 a little (hopefully!?) for what else might have helped he
1011 said, God! Well, that put me in my place! I thought. I
1 could not deny that one, but persisted, and asked if the
2 work around the uncle had also helped. He thought that
3 perhaps it had. I believe it had played a major part in the
4 remarkable shift, but readers will have to make up their
5 own minds. The body work here was combined with a
6 gestalt exercise. Once we had actually pinpointed the
7 painful memory, we moved straight into that while the
8 moment was right.
9 Again, in this example there are a number of skills
2011 employed by the therapist and it demonstrates the flexi-
1 bility required, to maintain the energy and pace of the
2 work. By changing what is happening in the picture that
3 emerges from the body memory the issues also alter.
4
5
6 Fantasy exercise
7
8 The same can happen with a fantasy exercise, such as in
9 the example below. Although the therapist asks a question
30 that leads the client into such a fantasy exercise it is very
1 much in the hands of the client as to where they go with
2 it. It is the therapists job to support and ensure that the
311 client ends in a safe place with it.
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111 Client E
2
3 In Rawson, 2002, pp. 9799, there is an example of me
4 relying very much on where the client led. Although I was
5 with her in her fantasy journey, I had absolutely no idea
6 what was coming next. I endeavoured, at each stage, to
7 help her to make it safe or possible, but she was the one
8 who worked out how, mostly to my total amazement. An
9 extract below, in which P stands for me and E for the
1011 client, demonstrates what I mean. I was aware of time
1 being short and wanted to bring E out of the fantasy and
2 back to the room. She had created a horse as a symbol of
3 safety for herself and they were out: in a plain . . . its
4 green and theres lots of space.
5
6 P: Can you get to the College, to the classroom. Will the
7 horse bring you?
8 E: Yes, hes here Ive opened a window and his heads
9 poking in.
2011 P: Thats not very practical can he change again to be
1 closer?
2 E: Yes hes changing shape, hes a dragon draped around
3 my shoulders.
4 P: Can he get smaller; hell frighten the others.
5 E: Yes, hes quite small now under my collar like a
6 necklace around my neck comforting.
7 P: Has he a name?
8 E: Yes Horace. That came up this morning. (and she
9 told me of an incident that morning.)
30 P: So how do you feel about what weve been doing
1 today?
2 E: Good it feels like integration. I dont think Ill lose
311 this its easier to hold on to images.
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111 As you can see, Im being very matter of fact, observ-


2 ing the problem of size but leaving her to work out how
3 to solve it, which she does: Yes, hes changing shape . . .
4 So the moral here is to be alert, go with the client, help
5 them to make it safe and to move it along, but trust the
6 client to have the answers. It is their trip, we are just facil-
7 itating, but by our presence we are both catalysts and
8 safety nets. But as observers, outside the emotional
9 entanglements, we can make suggestions in order to make
1011 it safe. You recall that with Rob I encouraged him to bring
1 his adult self in to speak up for little Bobby. Had he found
2 that difficult, I might have brought myself into the picture
3 saying something like: Well, Id like to take the child by
4 the hand and say to uncle . . .
5 Really one has to react at the time to the situation that
6 is presented. One reacts with common sense and compas-
7 sion combined with whatever skills one has at ones
8 disposal.
9
2011
1 Practice and supervision
2
3 If you are not familiar with this type of work I suggest that
4 you can try this exercise on your own, or with a
5 colleague,or perhaps in your supervision, until you feel
6 comfortable enough with it to try it with clients.
7
8
9 Homework
30
1 As mentioned previously, I give the clients homework. In
2 this way they can progress the work during the week. I
311 return to it here as one would in the therapy, session by
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111 session. If the client does not do the homework, that too
2 can be part of the learning process. Why havent they?
3 What were the obstacles? If it is not done, it is not the role
4 of the therapist to be in any way punitive. It may well be
5 that the work suggested was way off the mark from where
6 the client was. It is something to explore with the client.
7
8
9 Activity
1011
1 The flexibility required of the therapist in this method
2 also points to an activity of the therapist which is unfa-
3 miliar to some. Chapter Seven addresses this.
4
5
6
7
8
9
2011
1
2
3
4
5
6
7
8
9
30
1
2
311
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5
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111
2
3
4
5 QUICK REFERENCE NOTES
6
7
8
9
1011
1
2
3
4
5
6
7
8
9
2011
1
2
3
4
5
6
7
8
9
30
1
2
311
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111 Body memory exercise


2
3 Before using the body memory exercise with
4 the client
5
6 The client needs to be aware of the rationale behind this
7 exercise and to agree to give it a try. So one explains to the
8 client that the body remembers even things that, with our
9 conscious minds, we do not, and that using a body memory
exercise we can sometimes get in touch with such memo-
1011
ries. Then these memories can be dealt with appropriately,
1
so that they no longer inhibit our freedom in the present
2
time. It helps to give the cliient an example as to how this
3
can work; for instance, as with Rob, who was cited earlier.
4
Then see if the client would like to try this method.
5
6 A great deal can emerge in this exercise
7
8 Therapists new to this exercise are often astounded at how
9 much can emerge from it. The memories that come up
2011 often move the therapy along very quickly; at times, it can
1 be very emotional and powerful. Sufficient time needs to
2 be allowed for it within the session so that the client ends
3 in a good place. If the exercise is begun near the start of
4 the session there should be time enough to do the exercise
5 and to talk about the material that has come up before the
6 end of the session. I suggest that ten minutes is allowed
7 for the client to say where they are since the last session
and to settle into the therapeutic work once more, and
8
then twenty minutes for the exercise and twenty minutes
9
to talk about it afterwards.
30
1
Creativity required of the therapist
2
311 The therapist needs to be able to work with the client to
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111 move the emerging scenes on. In using this method one
2 needs to be very creative and work with where the client
3 is, but remember the client can be creative, too. Some-
4 times one wonders where the scene is going and what to
5 do with it, but one can say things like, Can you find a
6 way of dealing with that? Invariably the client can and
7 does.
8
9 A safe place
1011 One needs to help the client to reach a safe place with
1 their story. I have referred to E above, and the full exam-
2 ple appears in Rawson, 2002, pp. 9799. This is is an
3 example of me relying very much on where the client led.
4 Although I was with her in her fantasy journey, I had
5 absolutely no idea what was coming next. I endeavoured,
6 at each stage, to help her to make it safe or possible, but
7 she was the one who worked out how, mostly to my total
8 amazement. I was aware of time being short and wanted
9 to bring the client out of the fantasy and back to the
2011 room. She had created a horse as a symbol of safety for
1 herself and through her imagination, she was able to
2 transform this into a manageable symbol of a necklace.
3
4 How to begin
5
6 After the explanation about what the exercise is, it may
7 begin as follows:
8 If youd like to close your eyes so that you do not get
9 distracted and just breathe normally. Be aware of any
30 tension anywhere in your body. Indicate in some way if
1 you have found any tension, raise a hand or finger
2 perhaps. (Wait until the client has responded a minute
311 or two.) Be very aware of the tension and make the
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111 tension worse. See if it moves. If it does move, follow it to


2 where it is now, be very aware of it and make it worse. See
3 if it stays put or if it moves again. If it moves, follow it,
4 be aware of it, make it worse. Continue to do this until it
5 remains in one place and indicate when it has settled in
6 the one place. (If the client seems stuck you can encour-
7 age by repeating the words: be very aware of the tension
8 and when it stops in one place just indicate so that I know
9 youre there.)
1011 Good. Now concentrate again on the tension. Be very
1 aware of it. Let your mind float free, with you getting
2 smaller and smaller and see what pops into your mind, no
3 matter how irrelevant it seems. Try to catch that thought,
4 or picture, or thing, and if you have one indicate in some
5 way so that I know.
6 Can you share it with me?
7 If the client is clearly staying within the scene in their
8 minds, e.g., having their eyes still closed as they answer
9 this, the therapist may continue straight on with the exer-
2011 cise, leading the client into the scene as follows.
1 The therapist helps the client to fill in the detail in the
2 scene. What is happening? . . . How old are you? . . .
3 Who else is there?. . . or, if the client opens their eyes and
4 clearly is back in the present talking about the situation
5 that they have seen, then the therapist will adopt more of
6 a discursive tone to find out what was going on in the
7 fantasy and might speak thus: Did a memory or picture
8 or situation come to mind?.
9 Some clients do have a memory, some do not. If not,
30 it is not important. Now that they have run through the
1 technique, it is one that they can try on their own. On
2 their own, they may feel more free and less inhibited and
311 can share what emerges at the next session.
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111 Sometimes what comes up can be very dramatic, elicit-


2 ing tears, or anger, or shock. At times it is something quite
3 ordinary, and often it is something that they had
4 completely forgotten about.
5
6 Bringing the client back to the room
7 (If the client is slow to open their eyes, repeat: When you
8 are ready come back to the room and open your eyes so
9 that I know that you are ready . . . or later: Even if you
1011 have no image or picture slowly come back to the room
1 and open your eyes . . .)
2
3 Time running out
4
5 If the client is not ready when the time is running out the
6 therapist can say something along the lines of: If youre
7 not quite finished with your scene, either finish off now
8 or tell everyone there that you have to go now but youll
9 be back later, and then gently return to the room and
2011 open your eyes . . . and a little later, if needed, Ill chivvy
1 a bit more: Come back to the room now, please, so find
2 a safe place for all in the scene and come back to the room
3 and open your eyes.
4
5
From the recent memory repeat the exercise to find
6
an earlier picture
7 Sometimes it is a very recent memory or event that they
8 picture and they cannot see why it should be a cause of
9 the tension. This often happens. What one needs to do
30 then is to repeat the exercise using this memory as the
1 starting point and see if an earlier memory comes up.
2 Often there are links to be found, at a later point, between
311 the last and the earlier scenes. The term smaller and
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111 smaller is used rather than younger and younger because


2 it is less specific.
3 I explain that we are going to once again get in touch
4 with the tension, starting with the picture that has already
5 emerged and seeing if we can access the earliest memory
6 that is linked with that tension. We will do this by being
7 aware of the tension once more: Visualise that situation
8 as clearly as you can and then see if you have any tension
9 in your body. Again the tension will be followed around
1011 the body until it settles in one place and then: Let your
1 mind float free, then capture any image that comes, no
2 matter how seemingly irrelevant. The therapist then helps
3 the client to go into the scene and to fill in as much detail
4 as possible. We encourage the client to give the people
5 voices and actions: what do they want to say, first one
6 then another, what do they reply, what do they do? Do
7 they want to take someone else into the scene, e.g., the
8 tutor or therapist, an older self, or some other trusted
9 person who can be on their side? What do they want that
2011 person to do or say? At times, if it seems necessary, Ill put
1 myself as therapist into the scene and ease the situation
2 that is emerging there. This can help the client to move
3 on within the scene. To facilitate the client developing the
4 scene that has come up for them, the therapist asks ques-
5 tions such as Where are you? . . . What are you doing?
6 . . . What is the place like? . . . What are you wearing?
7 . . . Who else is there? . . . How old are you? This time,
8 the therapist helps the client to get the people in the scene
9 talking to each other. The therapist asks questions such as:
30 What do they want to say? . . . What do they reply?
1 . . . What do they do? . . . Do you want to take some-
2 one else into the scene, perhaps a tutor or therapist, or
311 your older self, or some other trusted person who can be
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111 on your side? . . . What do you want that person to do


2 or say? . . . As the client shares what they are picturing at
3 each stage, the therapist needs to go with the flow, adapt-
4 ing their questions to help move the scene along and to
5 help the client to benefit from the experience.
6 Sometimes the client remains fairly silent, alone with
7 their scene. One can discuss with them, once they have an
8 idea as to how the exercise goes, whether they want to
9 share at each stage or to be allowed simply to go into the
1011 picture on their own and then to share. The fact that the
1 therapist is there is enough to provide the feeling of safety
2 for the client. The exercise might then proceed along the
3 following lines:
4 Close your eyes to block out the room and become
5 aware of the tension in your body, chase it round as before
6 until it stops. Then let your mind go free and see if a
7 picture or image or scene pops into your mind no matter
8 how irrelevant and catch it. Please indicate when you have
9 found one. Now you have a few minutes to go into the
2011 scene as I suggested before, see what happens and when
1 youre ready come back to the room slowly and open your
2 eyes so that I know you are back. I then allow a few
3 minutes. If there seems an overly long delay I gently say
4 something as shown above along the lines of: If youre not
5 quite finished with your scene, either finish off now or put
6 it on hold until later and then gently come back to the
7 room and open your eyes and a little later, if needed, Ill
8 chivvy a bit more: You need to finish now, please, and
9 open your eyes.
30 The client and therapist would then explore together
1 what came up in the exercise.
2
311
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111 Tone of voice


2
The tone of voice used when leading the client into this
3
exercise needs to be very quiet and gentle, almost
4
soporific, as one tries to lead as unobtrusively as possible.
5
6
7
8
9
1011
1
2
3
4
5
6
7
8
9
2011
1
2
3
4
5
6
7
8
9
30
1
2
311
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111 Flexibility re skills used by the therapist


2
3 In focal and brief therapy, the range of skills and the flex-
4 ibility of the therapist in applying these is paramount.
5 This type of therapy requires activity on the part of the
6 therapist.
7
8 Examples of range of skills
9
1011 Use of all usual therapy techniques blended to chal-
1 lenge/coax/hold/ the client as required.
2 Use of the therapeutic relationship.
3 Use of Rogerian approach, e.g., unconditional posi-
4 tive regard.
5 Use of transference working with it and within it.
6 Use of some aspects of behavioural work.
7 Use of psychodynamic principles past influencing
8 the present.
9 Skills to access the past body work/gestalt/fantasy/
2011 use of voice (almost hypnotic), intellectual research
1 also (homework for the client sheet).
2 Use of art/music/writing/ imagery.
3 Focusing techniques selective inattention.
4 Skills with tone of voice, body language, silence.
5
6
7
8
9
30
1
2
311
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111 CHAPTER SEVEN


2
3
4
5
6 ACTIVITY
7
8
This approach to therapy is active. It is not just the ther-
9
apist who is active but also the client. The client doing
1011
homework, or work between sessions on their own is one
1
aspect of this. This has already been touched upon. It is a
2
very important way in which the therapy is speeded up.
3
On average, the client, one must remember, sees the ther-
4
apist for just an hour per week. If clients can be helped to
5
work on their issues between sessions, progress will be
6
quicker.
7
8
9 Working with the client/homework/
2011 giving them the tools
1
2 The joint aspect of the therapy work is emphasized in
3 their working on the issues between sessions. This home-
4 work may take the form of a specific exercise, or it may be
5 suggested that the client seek out relevant people in their
6 past lives to talk to, or they might decide to research a
7 particular time in their lives. The homework might be to
8 be aware of a particular emotion that occurs as they go
9 about their day to day activities and to monitor it. This,
30 initially, is just to heighten awareness. Later on, the client
1 and therapist may discuss and look for alternative ways
2 that the client might respond that might change a situa-
311 tion for the better. More will be said about this idea later.
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5
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111 The important thing with regard to the homework is that


2 it arises out of the session and that it takes the work
3 forward.
4 In the following example we can see how useful some
5 homework can be. Again, this is combined with some
6 education. People are often very unaware of the psycho-
7 logical and emotional impact of situations and they need
8 to be taught about them, so that they are empowered to
9 become their own therapists.
1011
1
2 Jane
3
4 Jane was very upset about how her child reacted when she
5 went out for the evening. Her child became very upset
6 every time she went out. I asked what happened. It turned
7 out that the child wanted to know where her mother a
8 single parent in her late twenties was going and when
9 she would be back. This, for Jane, had echoes of her teens
2011 and early twenties when her own mother had questioned
1 her in this way. She was reacting to her child, Holly, as if
2 it were her mother talking. So she refused to tell her. I
3 asked how old was her child. Holly was seven. I said that
4 it seemed quite reasonable to me that a child should be
5 able to access her mother when she went out, and that,
6 maybe, the babysitter could be given the number so that,
7 if there was a problem, the child could make contact. I
8 wondered whether perhaps she was forgetting that she was
9 the mother and Holly just a child. A child who was
30 dependent upon her and therefore felt lost, abandoned,
1 and threatened when she was just left with the babysitter
2 and, especially, because of Janes refusal to tell her
311 anything, she was frightened. None of this had occurred
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111 to Jane, she was so deeply into the transference. I sug-


2 gested that she might give it a try. I asked how old she felt
3 when this happened? She began to realize that she was
4 indeed projecting feelings from her teenage years on to
5 her little daughter. She could see that they really related to
6 the unfinished business with her mother. We explored
7 that further, but she also tried giving more information to
8 the babysitter and she let her daughter know that the
9 babysitter had the contact numbers.
1011 When she returned for her next session the situation
1 was quite different. She had devised a card system for her
2 daughter and she had written all the numbers where she
3 could be contacted if necessary, and the babysitter knew
4 of this. Additionally, she gave her daughter a special treat
5 and time for the two of them to be together on another
6 day in the week, to emphasize that she loved being with
7 her, too, but also needed time with adult friends as well
8 and hence her nights out. The daughter now had no prob-
9 lem letting her go and no longer caused any fuss at all.
2011 In this instance, she both did the homework and more
1 than we had agreed together. She had made it her own.
2
3
4 Parentadultchild interactions
5
6 Another useful way of looking at relationships and at the
7 interactions between people, is the idea often associated
8 with transactional analysis (TA). As for the Heimler Social
9 Functioning scale referred to earlier, one can undertake a
30 three-year course in this method. Once again, the basic
1 concept can be very useful and clients can readily learn to
2 monitor their relationships using it. Essentially, we all
311 tend to relate to each other as parent, adult, and child. We
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5
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111 take up different roles, at different times. We may be


2 parentparent, or childchild, or adultadult. We are, at
3 times, childparent, or adultparent, or childadult. In
4 the example of Jane, above, we saw her in an inappropri-
5 ate role with her child, Holly. Jane was acting the child
6 and putting her seven-year-old daughter Holly in the
7 parent role. That is, until she realized what was happen-
8 ing. Then she retrieved her parent role in relation to her
9 daughter, her adult role in going out for some adult
1011 company and relaxation, and her internal child was back
1 in place once more. This instead of being the rebellious
2 teenager, determined to have a night out whatever her
3 mother thought. It might be that, in the having fun out
4 with her mates, the inner child could also have appropri-
5 ately surfaced once more.
6 This theory is often depicted as two triangles, each
7 representing a person, with each point representing either
8 parent, adult, or child. The interactions can then be
9 drawn out between the two triangles. A couple can learn
2011 to monitor their moves between the roles. It is clearly not
1 desirable if both are permanently in child mode, or even
2 parent mode. Equally, it is not so good if one is always the
3 parent and one always the child. There are, of course,
4 times when two adults might both be in adultparent
5 role, for example, as they decide their childrens schooling,
6 or chores around the house, or discipline, or child role as
7 they have fun together. If one partner is upset, the other
8 may take on a temporary parent role, at another time the
9 other partner may assume that role. It is a matter of
30 common sense and balance and such a concept is easily
1 grasped by the clients. They can then keep a watchful eye
2 on their own relationships, and in seeing, begin to effect
311 change if it is needed.
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111 Non compliance with homework


2
3
4 If a client does not do the homework it is important not
5 to be punitive. They may have moved on and our sugges-
6 tion is irrelevant. We may be too far away in our sugges-
7 tion from their real issue, they may simply not have had
8 time, or perhaps it is altogether too scary to undertake on
9 their own. Sometimes this can be the case, and they prefer
1011 to undertake the homework task in the counselling room,
1 with us there, or simply to talk about the particular thing
2 they had intended to do. It needs to be a task that they
3 can see to be useful. It may be relevant to query why it
4 was not done, but they are adults and if it is not helpful
5 then that is fine. The sessions are for their benefit, and the
6 therapist is merely the facilitator, so needs to work harder
7 to find what is helpful. However, it might also indicate a
8 certain lack of rapport, or a mismatch with regard to the
9 contract have we contracted to look at what they really
2011 want to work on? Or there may be a disparity with regard
1 to expectations as to how therapy can work, or a lack
2 of commitment to the therapy. Some clients expect the
3 therapist to wave a magic wand and all their problems will
4 be resolved; that is not what happens. Our role is to facil-
5 itate their journey. We can use all our skills to help but,
6 ultimately, it is their trip. It may be that they simply want
7 to come along for some support and do not want to
8 change anything. This can happen.
9 I recall Janina, who was in a relationship with four
30 different men simultaneously. She was finding this very
1 problematic and exhausting, as she juggled her life to keep
2 each part of it secret from the other. She had absolutely
311 no intention of rationalizing her situation, but she did
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5
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111 want to share with me her difficulties in running her life


2 like this. This was not a contract I could see as feasible,
3 since she simply wanted to have a periodic moan. Had she
4 wanted to change anything in her situation, or to explore
5 why she was choosing to live in this way, we could have
6 proceeded. As it was, there was no place for brief therapy.
7
8
9 Situations that cannot be changed
1011
1 There are times when support is all that is possible. There
2 are situations that cannot be changed, such as when some-
3 one is a carer, or in an impossible job, and unable to
4 change it. In these circumstances I would see it as
5 perfectly appropriate for a therapist to be there for the
6 client, but this would not be a brief therapy contract.
7 Such circumstances could go on for some time, even
8 years. It might become a brief contract, or series of brief
9 contracts, by the person coming periodically for a few
2011 sessions to see the therapist in order to look at particular
1 aspects of their circumstances and to explore options or
2 attitudes to these. The important angle here is that both
3 client and therapist are in agreement as to what they are
4 about and that the therapist is in a position to offer what
5 is required.
6
7
8 Client F
9
30 Another example of the value of homework can be found
1 in Rawson, 2002, p. 77, in the case of F, who has already
2 been mentioned in passing in this book. This client had
311 had no faith whatsoever in the idea of therapy and had
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111 turned up for the appointment just to please the nurse


2 who had sent her. Her opening words had given me the
3 clue to her issue: Ive been depressed since I was nine.
4 I explained to her how therapy works, how the root to
5 the problem is often in the past, and if not dealt with
6 can cause us ongoing problems, including depression. I
7 told her the sorts of issues that might have occurred
8 to cause a problem, including bullying at school, moving
9 home and changing schools or jobs if relevant, illness
1011 in the family, a death, break-up of relationship, or change
1 of circumstance of some kind or another. F was utterly
2 sceptical and totally unconvinced. I wagered that she
3 would discover that something of significance had
4 occurred and that it had affected her around the age of
5 nine. She remained sceptical and doubtful. I strongly
6 challenged her to see for herself and to try to find out.
7 Her homework was to create a chronology of events
8 from as far back as she could remember, and to help her
9 with this I suggested that she might ask members of
2011 her family and friends about what had happened in
1 the family, especially when she was nine. I asked her to let
2 me know how it went in the next session. I left her free to
3 do it or not, as she chose, but requested that she let me
4 know if she did not intend to keep her appointment. I
5 also told her that if she did not find anything significant,
6 I still believed that I could help her with this long term
7 depression and we could continue to explore the situa-
8 tion. In fact, before her next session, I received a long
9 letter from her in which she had indeed discovered that
30 enormous things were going on for the family around
1 when she was nine. F was now a convert to the idea of
2 therapy and looking forward to her session to explore it
311 all further!
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5
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111 Homework to alter patterns of behaviour


2
3 A client who reacts in a particular, but undesirable, way
4 in certain circumstances can be given homework to begin
5
the process towards altering the pattern of the unwanted
6
behaviour. For example, in the first instance, they can be
7
asked simply to note the behaviour. This is the first step
8
to awareness. The next stage might be to see what were
9
the circumstances leading to this behaviour or reaction.
1011
Catching themselves in the middle of the reaction or just
1
afterwards they might ask themselves: How old do I
2
feel?; What am I feeling right now?; What do I want to
3
do in this situation?; Who does this person remind me
4
5 of? They can then explore some of these situations with
6 the therapist at the next session. As we explore with the
7 client what was happening when they were ten, or twenty,
8 or whatever age they have discovered, so we are into the
9 psychodynamic aspect of brief therapy. Equally, we see the
2011 psychodynamic aspect as the client realizes that they feel
1 murderous, at times, towards their boss because they see
2 him as their dad, who was equally unreasonable with
3 them as a child. It is their transference that they are
4 discovering and with which we are to work. Then, with
5 greater understanding, as they continue to observe the
6 instances of the unwanted behaviour, they can begin to
7 change it. They can rehearse a different way of respond-
8 ing. For example, if x always provokes an angry response
9 when they do y, now the client, with their greater under-
30 standing, might change the angry retort into the real
1 emotion they have become aware of, such as: I feel hurt
2 when you do or say that. This, in itself, will change the
311 pattern of what has been happening.
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111 An aspect of transference


2
3 The question: How old do you feel?, or, if you are a ther-
4 apist practising the exercise on yourself: How old do I
5 feel?, can often bring up all sorts of memories that may
6 be colouring the present for us. People transfer their reac-
7 tions and feeling on to a present situation. These behav-
8 iours, however, are often inappropriate to the present. The
9 past and present need to be disentangled, so that the
1011 person is free to behave appropriately in the present.
1
2
3 Frasier
4
5 There was a good example of transference in a Frasier
6 programme from the television series. Frasier is going out
7 with a PE teacher, who derides a girl who is rather bad at
8 PE and holds the class back until this child has climbed
9 the ropes. This reminds Frasier, who observes the inci-
2011 dent, of himself at school, when he was the one who
1 couldnt do the PE task. He and the viewer immediately
2 see his current girlfriend as if she was the old male teacher,
3 who can only be described as rather grizzly-looking and
4 very hairy. Having this picture in his mind rather cools his
5 relationship with his girlfriend; that is, until he eventually
6 challenges her about her rough handling of the less able
7 pupil. In doing this, he is making a challenge he had been
8 unable to make as a child and so freeing himself of the
9 entanglement of his transference. His girlfriend accepts
30 his comments and the situation is resolved. The viewer
1 once again sees the pretty girlfriend on the screen as
2 opposed to the rather less than pretty male PE teacher of
311 Frasiers youth. All is well until he makes a comment like
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5
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111 That little girl reminded me of myself at that age in PE.


2 Immediately, his girlfriend imagines Frasier in a gym slip
3 and with pigtails, like the little girl she had been castigat-
4 ing for being inept. The viewer now sees Frasier as the
5 little girl, incongruously talking authoritatively about the
6 table reservations at the posh restaurant that Frasier and
7 his lady friend were going to. Her transference is now
8 what we are seeing and clearly is blocking the relationship
9 once again. Their story ends there. The aim of therapy is
1011 that the client is helped first to become aware of their
1 transference and then to deal with it, as Frasier did.
2
3
4 Short term, active, flexible,
5 and psychodynamic
6
7 I highlight the above instance to stress the psychodynamic
8 nature of the brief approach. Although it is brief, it is deep
9 and does deal with past issues. It is not a sticking plaster
2011 approach. It does not require forever to access the past. It
1 is, perhaps, the activity of both therapist and client that
2 helps to access the past quickly.
3 Some students attending my courses have seen the
4 approach as more integrative than psychodynamic because
5 they have a different concept of psychodynamic, one that
6 would even recommend that the therapist should sit on
7 her/his hands rather than gesticulate. I was astonished at
8 this idea. Where lies the idea of congruence in it, I
9 wonder? I recall the story of a man who had been so
30 advised and found himself totally unable to articulate
1 without using his hands. I fully support the views of
2 Wolberg, who states that the activity required of the
311 aspiring short-term therapist assumes an involvement of
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111 oneself as a real person, and open expression of interest,


2 sympathy and encouragement, are permissible (Wolberg,
3 1965, p. 135). As I observe This is in stark contrast to
4 the stoical and expressionless passivity that somehow has
5 become synonymous with doing good psychotherapy
6 (Rawson, 2002, p. 113). Other early proponents echo
7 this, too. Malan, for example, observes that the face to
8 face method of therapy encourages interaction and activ-
9 ity (ibid.)
1011 For those who wish to look more at the psychodynamic
1 roots of the approach I would refer you to Rawson, 2002,
2 pp. 6882.
3
4
5 Fusion of skills and still psychodynamic
6
7 The therapist is active in many ways: actively questioning,
8 using techniques and skills from a range of disciplines.
9 The method allows a fusion of skills, as we have already
2011 seen when we explored the flexibility of the therapist in
1 this approach. While I like the word fusion here, I do not
2 see it as so different from the word integrative. The
3 important thing is that one can combine skills, as Wolberg
4 suggests, but stay firmly within the psychodynamic tradi-
5 tion. You will recall that the early proponents of the brief
6 approach in the 1940s and 1960s, who were mostly
7 analysts by profession, also recommended this flexibility
8 of skills (Rawson, 2002, pp. 82110). We noted earlier
9 this flexibility in looking at the experienced therapist, who
30 has access to more skills simply because theyve been
1 around in the therapy world longer. The experienced ther-
2 apist may dare to step out of the rigidity of their original
311 training to take on board the value of other approaches.
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5
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111 Having stressed activity, it must be pointed out that this


2 does not preclude silence. At times maybe as much as
3 twenty minutes might pass without a word being spoken.
4 An example of this was quoted earlier when I worked with
5 sixteen-year-old Jacques.
6 Having talked a lot about activity and the use of a
7 range of skills, it is time to actually look at some of these
8 in the next chapter. These might be employed by the ther-
9 apist to speed the work along. The wider the therapists
1011 experience and skills, the more able they are to adapt to
1 the clients need.
2
3
4
5
6
7
8
9
2011
1
2
3
4
5
6
7
8
9
30
1
2
311
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111
2
3
4
5
6 QUICK REFERENCE NOTES
7
8
9
1011
1
2
3
4
5
6
7
8
9
2011
1
2
3
4
5
6
7
8
9
30
1
2
311
4 135
5
6
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111 Activity
2
3 Activity of therapist
4 by holding the focus, keeping the spotlighton
5 the agreed focus;
6 by holding boundaries;
7 by actively holding a silence;
8 by facilitating, e.g., use of questions, use of art,
9 fantasy exercises, body memory exercise, use of
1011 transference, countertransference;
1 by being in sprint mode, sensitively aware of
2 inflections, body movements, hesitations, actively
3 holding client to agreed contract;
4 by being flexible re techniques and contract,
5 moving with client to a new contracted
6 focus/time scale as necessary;
7 by explaining the processes of counselling and
8 how various techniques might be helpful, i.e.,
9 teaching the client how to be their own therapist;
2011 by giving information, e.g., psychological process
1 of grief;
2 by being actively involved while remaining
3 appropriately detached;
4 by researching subjects as necessary.
5
6
7
8
9
30
1
2
311
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111 Working with the client giving them the


2 tools: homework
3
4 A joint enterprise
5
6 For example,
7 Youre the one who needs to be doing the work.
8 You can speed the process up by doing some work-
9 ing between sessions.
1011 We need to be a little like detectives exploring
1 together we need to look in detail at . . .
2
Tools for clients to become own therapist
3
4 The next time you experience the feeling take note of
5 the events preceding it and what had just happened.
6 Where were you? What were you doing, etc? then
7 we can talk about it next session.
8 The next time you are in that situation see how old
9 you feel and well talk about it in the next session.
2011 Write the whole incident down if it helps.
1 The next time you feel that emotion note where the
2 tension is in your body and do the body memory
3 exercise weve used together and see what comes up.
4
5 Other homework to move therapy on
6 Check your diaries to see if these dates are important.
7 Can you talk to any of your relatives about what was
8 happening at that time in your childhood?
9 Try to be aware of when you do x (whatever the
30 client is trying to change).
1 Plan how youd like to change this and try it!
2 Reward yourself each time you notice the behaviour,
311 manage to modify it or change it.
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5
6
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111 Record your dreams.


2 Write about the key events of your life.
3 Paint/draw the emotion.
4 Write a poem/letter to the person you miss/love/hate
5 not to send.
6 Write down the feelings and thoughts you have as
7 openly as possible bring them to the session or burn
8 them.
9 Decide on a course of action and take at least one
1011 step to achieve it, e.g., enrolling at an evening class,
1 attending the next lecture.
2 Act out a symbolic ritual, e.g., light a candle as a
3 meaningful way of remembering/making
4 amends/saying goodbye.
5 Think about which of the areas youve mentioned
6 you want to explore and thats where well begin
7 next time.
8 Talk to the child see what he/she has to say.
9 Use the relaxation exercise every time you feel tense.
2011 See whether you are behaving as parentadult or
1 child in the relationship in what role is the other
2 person?
3
4 BE YOUR OWN THERAPIST!
5
6
7
8
9
30
1
2
311
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111 CHAPTER EIGHT


2
3
4
5
6 TECHNIQUES
7
8
9 The following techniques call upon different skills and
1011 demand activity either on the part of both client or ther-
1 apist or on the part of the client.
2
3
4
Working with body tension
5
6 One way of working with body tension has been shown
7 earlier, both within the text in case examples and in the
8 quick reference notes as an outline of a body memory
9 exercise. Tension in the body is often present because of
2011 some stress or another. Often it is not clear as to what
1 is causing the tension. There are other ways to work
2 with this symptom of stress. One of these ways is as
3 follows.
4 I ask the client, Would you like to try a fantasy exer-
5 cise to see if we can do anything with the tension?
6 Assuming a yes answer, I would then say, Feel free to stop
7 at any time or to ask questions.
8 Close your eyes to cut out the distractions in the
9 room.
30 Now become very conscious of the tension in your
1 body . . .
2 Tell me about it/more about it . . . Has it got a colour?
311 . . . What shape is it? . . . What texture? . . .
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111 It is then up to the therapist to help the client work


2 creatively with this. Examples of directions you might
3 give are:
4 Can you make it smaller/bigger/ make a hole in it,
5 take it out and discard it/transform it? . . . Can you bring
6 light into it? . . . Can you bring in anyone else to help?
7 . . . You can bring me in if you like . . . What do you want
8 them/me to do? . . . What is happening now? . . . Can you
9 change that to make it safer/ok/easier/lighter/etc? . . .
1011 When you feel it is the right moment to end the exer-
1 cise, either because it has reached a good point or because
2 the time is running out, make comments like:
3 That seems a really good place to end, so can you leave
4 it there/bring that with you/file that away for a look at
5 later, or file it in the archives or in the bin/find a way to
6 leave comfortably what you have been doing and come
7 back to the room and open your eyes.
8 The client may well come up with a surprising way
9 to end.
2011 Client and therapist then discuss what has happened,
1 and what can be learned from the exercise and any follow-
2 up that makes sense in relation to it. Always allow at least
3 ten minutes for this part of the exercise. I would suggest,
4 ideally, to aim to end the fantasy twenty minutes before
5 the end of the session.
6 A rough guide might be to see the session in three
7 blocks of twenty minutes the first seeing where the
8 client is and deciding to try this technique, twenty
9 minutes for the fantasy activity, and then the review and
30 decision for future action.
1
2
311
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111 Fantasy exercise using body tension


2 and imagery
3
4 There is another type of fantasy exercise that could be
5 used working with body tension. This is similar to the
6 above but using different imagery. The first part of the
7 exercise would be the same as above.
8 I ask the client, Would you like to try a fantasy exer-
9
cise to see if we can do anything with the tension?
1011
Assuming a yes answer, I would say, Feel free to stop at
1
any time or to ask questions. Then
2
Close your eyes to cut out the distractions in the
3
room.
4
Now become very conscious of the tension in your
5
body.
6
Can you name an animal/bird that depicts the feeling?
7
What is it like?
8
What are its qualities?
9
2011 Can you let it leave your body?
1 Where is it now?
2 What do you want to do with it?
3 Do you need anyone or anything to help you with it?
4 If so bring whatever helps into the situation . . .
5 When you have achieved what you wanted to, come
6 back to the room and open your eyes.
7 The first question I would want to ask is, What has
8 happened to the tension that was in your body?
9 I would expect a considerable change in the feeling,
30 and often quite a lot of thoughtfulness, subsequent to the
1 fantasy exercise. At times, the client has new insight into
2 what might be causing their tension. At other times, they
311 find that what came up is intriguing but cannot relate it
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5
6
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111 to their situation. In this case, we explore possibilities and


2 I ask them to fill me in on what has gone on, if that has
3 not been happening stage by stage through the exercise.
4 It is perhaps better to ask the client at each stage what
5 is happening, so that one can adapt and go with the flow
6 as to the next question. In this, one needs to be creative,
7 use common sense and seek for a safe place to end. If a
8 neat ending is not possible in the time available, then, at
9 least, one seeks for a safe holding place. The client is
1011 usually well able to find one.
1
2
3 Fantasy for a relationship difficulty
4
5 This animal/plant/object fantasy could be used differ-
6 ently, for example, if the client was having difficulty in a
7 relationship or with a boss. They could be asked to
8 Visualize the other person as an animal/plant/bird or
9 object without any reference to body tension. The rest of
2011 the exercise could continue as follows.
1 What qualities does the chosen creature have?
2 How does it make you feel?
3 What animal /plant/bird do you see yourself as?
4 What qualities do you have?
5 How does it respond to you?
6 How do you respond to the other creature?
7 What do you want to do?
8 What does it tell you about yourself in the situation?
9 Can you change yourself into a different animal/plant/
30 object so that you can cope better or enjoy the situation
1 more?
2 Can you bring anyone else into the situation to help?
311 Can you find a positive way to complete the story, or
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Techniques

111 to safely put it in abeyance and return to the room? If


2 you are in difficulty with this let me know so that I can
3 help.
4
5
6 Talking to the block
7
8 In a similar way, if someone finds themselves stuck or
9 blocked from doing something, and not knowing what
1011 it is about, they might try talking to it. Authors often
1 talk of writers block and this exercise could be useful.
2 I recall a student, Geoff, who was totally unable to get
3 on with the assigned essay. Normally he was well able
4 to do his work so this was unusual. When I asked the
5 subject matter, it was about alcoholism. The obvious
6 question seemed to be whether he knew of anyone in
7 his family or close circle who was alcoholic. It transpired
8 that there was indeed. His mother had recently been hopi-
9 talized for this problem. Once he had made the connec-
2011 tion to his own personal life he was well able to separate
1 the two and deal appropriately with the essay. It is not
2 always that easy. In other cases of such a block one could
3 try to engage the block in conversation, adapting the
4 questions above or combining with one of the visualizing
5 exercises above. For example, one could give the block a
6 shape or colour as a starting point. I recall Anthony, who
7 was finding that his knees were bothering him to the
8 extent that he was unable to walk. He talked to them and
9 it emerged that he really had no inclination to go to where
30 he was due to go. Once he had put his finger on the real
1 issue he found that the knees were no longer so painful
2 and in fact he was able once more to move more or less
311 freely.
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5
6
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111 Talking to the inner child


2
3 At times, the client is well aware that they are responding
4 to a situation as if they were a child. They feel about
5
twelve, for example. They can be encouraged to imagine
6
themselves at twelve and to have a conversation with their
7
inner child.
8
9
1011 Kate
1 Can you remember an instance when you were that age?
2 Where are you?
3 What was happening?
4 What were you wearing?
5 Did you have a pet name as a child? For example,
6 Kitty?
7 Talk to little Kitty. What does she want to say to you?
8
What do you want to say?
9
What does she reply?
2011
These exercises can be very powerful and very reveal-
1
ing. They can move the client along very quickly. Not all
2
clients find it easy to do this. That is all right. Try some-
3
thing else! It may, however, still be worth explaining the
4
exercise to the client, in case they wish to try it on their
5
own at home. Some find this useful and easier to do alone
6
rather than with the therapist present. For those who fear
7
the powerfulness of the exercise and wonder if what
8
9 emerges can be contained, one must remember that the
30 client has been containing whatever it is for many years
1 and is basically in charge. Whatever was so terrifying or
2 awful that it was buried by the child may not be that terri-
311 ble for the adult who now looks at it.
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111 Fantasy exercises


2
3 The fantasy exercises I referred to above can be very effec-
4 tive as we saw in case example E, earlier, which is cited in
5 more detail in Rawson, 2002, pp. 9599. I do not know
6 why the fantasy work works, I just see examples in my
7 practice where it does. It seems that the client can change
8 their reality by changing the fantasy. Does working with
9 the fantasy perhaps make it more safe for the client, does
1011 it tune in to the unconscious and allow those forces to be
1 altered so that it also alters the conscious? Does it in some
2
way consciously reprogramme a habitual maladaptive
3
pattern lying deep in the unconscious? When I suggest to
4
clients that we try such an exercise, I openly admit that I
5
do not know why it works but that I have seen its good
6
effects. As Patrick Casement said in an interview with
7
Clare Pointon, I think theres a real skill in not having to
8
know (Casement, 2004, p. 12). I will leave the reader to
9
explore that more fully, but the methods are there for use
2011
if wanted.
1
2
Caution
3
4 If we are working with a client who is barely in touch with
5 reality, then fantasy work is not appropriate, and ground-
6 ing types of activity, keeping firmly to reality and fact,
7 should be used. In the section on suitability for therapy,
8 which was examined in Chapter One, we noted that the
9 client who is out of touch with reality is not a suitable
30 candidate for therapy. From time to time, however, we
1 may find ourselves, for example, in an intake session, with
2 such a client and we need to take care to keep them as
311 grounded as possible.
4 145
5
6
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111 Gimmicks/techniques: cautionary note


2
3 It is important that different skills are used appropriately
4 and seamlessly. It is also important to explain to the client
5 the idea behind the technique. Skills are not used simply
6 as gimmicks but to enable the client in some way.
7
8
9 Art work
1011
1 For example, we may use art work where speech seems to
2 be difficult or where a client simply cannot articulate what
3 they are feeling. Drawing, painting, and the use of colour
4 may enable the client both to convey what they want to
5 the therapist and to actually release some of their pent-up
6 feelings.
7 Relationships can be represented on paper, not great
8 works of art, but symbolically to indicate how members
9 of the family, for example, relate to each other. The
2011 colours chosen and where people are placed are the
1 important factors, not artistic prowess.
2 In Rawson, 2002, pp. 211220, Client I was a gifted
3 artist, but the drawings of her abuser, drawn in the heat
4 of an emotional moment, are in stark contrast to the more
5 controlled and sophisticated artwork of some of the other
6 pictures. All of them are expressive but, I suspect, that the
7 most therapeutic are those on pp. 215216, which could
8 be taken for the work of a young child. Art in therapy is
9 about what helps.
30
1
2
311
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111 Chair work


2
3 Introducing chair work, i.e., inviting the client to address
4 the absent person by imagining them in a chair in the
5 room, can be helpful. This idea needs to be explained, as
6 far as we can, to the client. We, as therapists, may be
7 familiar with the concept, but it is a rather strange idea for
8 the client. Some will, indeed, find it impossible to do this
9 kind of imaginary work, at least in front of the therapist.
1011 However, they may try it at home and find that it is
1 useful.
2
3
4 Writing
5
6 It can be helpful to the client to write to the person whom
7 they need to address. Then they have a record of what
8 they have said and at times it seems almost as if the words
9 take off and they are sometimes surprised at what they
2011 find themselves writing.
1
2
3 Tape recording
4
5 Some therapists record the sessions with their client and let
6 the client take away the tape to listen to. As they then
7 listen to the tape of the session the client is asked to make
8 notes about points that strike them as significant in some
9 way. These then can be discussed further with the thera-
30 pist. If this is to be done, it is best to wait a few days after
1 the recording before listening to the tape, so that one hears
2 it better. You may have noticed that when you proof read,
311 even a letter or short piece of writing, that if you read it
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5
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111 after a few days you notice mistakes that you overlooked
2 when reading it soon after writing it. It seems that a little
3 distance makes for a certain clarity in such instances.
4 Perhaps, certainly in the case of the tape, ones defences
5 drop a little so that we find ouselves facing the reality.
6
7
8 Stones/buttons/interlocking Russian dolls
9
1011 Some therapists will make use of different shaped stones
1 to get a picture of the clients relationships. They ask the
2 client to choose a stone for each person and to say why
3 they have chosen that one. Then the client is asked to
4 place each stone on the surface and to say why they are
5 putting them where they do in relation one to the other.
6 This can be a very powerful exercise and very revealing,
7 and can help the client to articulate what is going on for
8 them. It can enable the client to see more clearly what is
9 happening in the family dynamic and it can continue to
2011 be used creatively as therapist and client explore the
1 changes the client wishes to make. Buttons or other
2 objects can be used to equally good effect. The different
3 sizes and shapes give plenty of choice to the client as they
4 remind them of significant others in their lives. The dolls
5 that fit inside one another in different sizes can also be
6 useful in this sort of exercise. I believe that they are
7 commonly known as Russian dolls.
8
9
30 Goodbye letter
1
2 In Grappling with Grief, there are a number of suggestions
311 of activities to help oneself or others, especially at times of
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111 grief (Rawson, 2004, Chapters Five and Six, pp. 73106).
2 Some of these can be adapted to fit other issues also.
3 One that come to mind is the idea of writing a good
4 bye letter to a loved one (ibid. p.76).
5
6
7
Symbolically letting go
8 A dramatic and powerful symbolic action of letting go can
9 be made using helium balloons. This might be thought
1011 about if one is ready to let go of someone who has died
1 or who is no longer in ones life through a divorce or a
2 break-up of a relationship. It could equally be applied to
3 something that is no longer available for us, such as a job
4 or career or something that is no longer wanted in our life,
5 like a bad habit. I would suggest that a nice place is found
6 to release the balloon and that one takes time to reflect
7 and think a little about both the good and the bad side of
8 the situation that is being let go; the idea being to release
9 one to get on with ones new life, enriched by the good
2011 that has been part of ones past life and unencumbered by
1 the bad that may equally have been present. With regard
2 to both the good and the bad, one hopes that lessons have
3 been learned that will help us to enhance the good and
4 avoid the bad as we continue lifes journey.
5
6
7 Symbolic remembering
8
9 Another idea is that of symbolically remembering a
30 deceased person, e.g., planting a bush or tree as a symbol.
1 The actual planting can be a ceremonial act. It can be a
2 way of putting a full stop and going on with life, a way of
311 saying goodbye (Rawson, 2004).
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111 Practice and supervision


2
3 I suggest that the therapist needs to have practised these
4 various ideas, at least on themselves and ideally with other
5 therapists. Appropriate supervision needs to be built in.
6 The topic of supervision is returned to in a later chapter,
7 but now we turn to the ending of therapy.
8
9
1011
1
2
3
4
5
6
7
8
9
2011
1
2
3
4
5
6
7
8
9
30
1
2
311
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111 CHAPTER NINE


2
3
4
5
6 ENDINGS
7
8
9 In a one to one contract the last session would consist of
1011 some work but also a review of what the client has
1 learned, whether they have achieved what they wanted to,
2 and what remains to be done.
3 The client can be helped to see what they have learned,
4 including new skills that they can utilize in their day to
5 day life.
6 Some of the questions that will be in the therapists
7 mind are as follows:
8
9 Does their learning from the sessions correspond with
2011 what they had hoped to learn?
1 Are there still things that they need to explore?
2
3 The client needs to come to a clear view as to what they
4 would still like to learn.
5
6 Do they need the therapist to help them with this or
7 are they now better equipped to do it on their own?
8
9
30 Last session
1
2 The last session provides therapist and client with a fixed
311 deadline and this puts a certain pressure on both not to
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111 waste any time. As in the short piece, which was seen in
2 the quick reference notes entitled The dynamics of the
3 deadline, we all know the effect of a cut-off date for
4 essays, job applications, or a report for a board meeting.
5 A deadline has a wonderful way of concentrating the
6 mind. Many people seem unable to achieve results with-
7 out a deadline to work to. Brief therapy clearly capitalizes
8 on this.
9
1011
1 Great achievements in little time, if that is
2 all one has!
3
4 Therapists will be able to cite many examples of client
5 work, which has miraculously speeded up when the client
6 is emigrating, moving, ending term, or having to stop
7 therapy for some other reason.
8
9
2011 Joan: one session therapy
1
2 Once I had a student come to see me on the last day of
3 term. She had walked out of an exam because she simply
4 could not seem to do it. She was a good student and knew
5 the material, but couldnt get on with the exam. She went
6 to the station some forty minutes away in order to go
7 home but, sitting there, she remembered that, at the
8 student induction session a couple of years earlier, I had
9 said, Before you pack your bags to go home come and see
30 me. So she turned around and came back. I made a space
1 to see her. We explored the obvious possibilities for her
2 block, such as, had she felt prepared for the paper?; did
311 she want to pass?; did she like the course?, and all seemed
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111 positive. I asked what exactly had happened. Could she


2 talk me through exactly what she had done and where it
3 all went wrong. She had, in fact, gone quite normally into
4 the exam room and started to look at the paper but It all
5 seemed so pointless and unimportant . . . she trailed off.
6 As she spoke she had curled up in a ball, her head almost
7 below her knees, in foetal position as far as sitting in a
8 chair would allow. She was almost hidden behind her
9 long, flowing hair. I became silent and waited, having
1011 noted the words pointless and unimportant. After a bit I
1 (P) asked:
2 What is happening?
3 She (J) said, Im feeling so sad. She maintained the
4 same position.
5 P: Do you know what that is about?
6 J: Im thinking of my brother.
7 P: Can you tell me?
8 It transpired that her brother had committed suicide a
9 few years earlier, just as she was doing a set of important
2011 exam papers, as she had been on this occasion. The family
1 had never talked about what had happened, but had just
2 pretended he had never existed and simply gone on with
3 their lives. It had all seemed so unreal.
4 Joan had wanted to talk about what had happened, and
5 what she felt, and the effect it had on all the family. The
6 guilt, the questions, the anger and hurt. She had failed the
7 last exam previously, and felt that she had not received the
8 support and help she had needed at the time.
9 Joan had come to me on the last day of term en route
30 for home to take up a holiday job literally hundreds of
1 miles away. There was therefore no chance of continuing
2 therapy at this time, so we had to get as far as possible in
311 this one session. There seemed to be a clear link, which
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111 made sense to both of us, with the previous important


2 exams and with these ones. It would seem that the latter
3 was the trigger for the memory and the unfinished busi-
4 ness from the loss of her brother. Having talked and cried
5 about her brother and the whole family situation and
6 made the connection about the exam, we needed to
7 decide what to do next. There were practicalities in terms
8 of informing tutors and arranging resits, etc. She felt well
9 able to sort these things. She wanted to feel free in the
1011 family to talk about the suicide and her brother. She
1 wanted them to know how awful it was for her. She
2 wanted them to acknowledge how bad it was for them,
3 too. She hoped that they might all be able to share their
4 loss, pain, and grief. I talked a little about loss and differ-
5 ent reactions and suggested that, now she had managed to
6 talk and experience her deep feelings about it all with me,
7 perhaps she could be the one to open the subject with her
8 parents. It was a very emotional session and I was a little
9 concerned at the fact that she was going so far away from
2011 support, should she need it. I gave her the address of the
1 British Association of Psychotherapy and Counselling,
2 who could put her in touch with a counsellor/therapist in
3 any part of the country should she need it, and offered her
4 a telephone session if she needed it before the next term
5 started.
6 I also suggested that she take a little time out before
7 setting off home again and that I would be available if she
8 wished to return before the end of the working day.
9 However, I saw this as precautionary, rather than really
30 expecting her to avail herself of it. I quote it as an example
1 of flexibility. Two sessions in one day would be very
2 unusual, but so were her circumstances and, as it hap-
311 pened, I had the space that day. The offer of a telephone
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111 session is also an example of flexibility and appropriate in


2 this particular circumstance. The very fact that she was
3 given the opportunity to do this would in itself be a
4 support. I did not actually anticipate that she would do so.
5 By chance, I crossed paths with Joan at the start of the
6 following term, and she approached me in the corridor. I
7 barely recognized this confident, self-possessed looking
8 student. She had gone home later that day and had tack-
9 led her parents about her brothers death, how he died,
1011 how awful it all had been, how she had been so affected,
1 especially by the secrecy and ignoring of the whole situa-
2 tion. She found that they, too, were glad to talk and that
3 they had all shared a great deal over the holidays. This had
4 resulted in the family situation being very much
5 improved. She had also organized her resit, talked to the
6 tutors, taken and passed the exam and was raring to go for
7 the new term.
8 The one session had indeed helped. A real case of the
9 client becoming not just her own therapist but that of the
2011 family too!
1
2
3
Loss for the client
4
It is not just the client who can feel loss at the end of a
5
therapy contract, it can also be a loss for the therapist.
6
First, though, I will look at loss for the client.
7
8 End of therapy as a step forward
9
30 One hopes that the end of therapy is seen as a step
1 forward, as a moving on in a positive way. Some will be
2 glad to regain the time that they have given up for ther-
311 apy, and will be quite pleased to move on from looking at
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5
6
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111 painful areas. At times, because of what has been shared,


2 the client who is ready to move on will be glad that they
3 can leave behind the therapist and that part of their lives
4 that they have shared. It is as if they are starting over.
5 There may also be sadness at moving on and never seeing
6 the therapist again, since a lot will have been shared.
7 Surely these reactions are natural. The therapist has been
8 there as a dependable person and, at times, as a real life-
9 line and someone entrusted with deep secrets.
1011
1 Defence mechanisms or unfinished business
2
For some there will be defence mechanisms against the
3
4 forthcoming loss and comments such as It was no good
5 anyway can come into play. Not owning that anything
6 has changed or that what has taken place in therapy has
7 helped, is another ruse. Here the therapist can remind
8 clients of things that have changed, as they probably will
9 have, and remind them of some examples of things that
2011 do seem different now. Sometimes the original problem
1 rears its head again. Again the therapist helps the client to
2 see how the original problem is not quite the same now.
3 These may be simply defence mechanisms and, as they
4 are explored with the client, they dissipate, and the client
5 acknowledges that indeed change has occurred and that
6 they are ready to go it alone.
7 However, the clients reluctance to end may also indi-
8 cate that there is some unfinished business, and this needs
9 to be addressed before the client can leave therapy in a
30 positive way. A new brief contract might be required to
1 conclude the work, or this may be very quickly dealt with
2 in the remaining time available within the existing
311 contract. This will be jointly negotiated, as has been high-
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111 lighted elsewhere. The brief therapist perhaps needs to ask


2 themselves if they have kept the client to the agreed focus
3 as well as they could have. It may be that the originally
4 agreed focus has been allowed to go out of focus a little,
5 and that this is the reason for the unfinished business.
6 As the end of the sessions are nearing, other issues of
7 loss may emerge for the client, triggered by the end of
8 therapy. For example, on rare occasions the client may feel
9 rejected or abandoned. In this situation it may be that a
1011 separate endings contract may be required. One hopes,
1 however, that these feelings would have emerged in the
2 first session; for example, with a client who resists the idea
3 of a short contract. In exploring such a clients fears that
4 a few sessions may not be enough, earlier losses may have
5 been revealed; these need to be addressed. I would antic-
6 ipate that these would be bound up with what the client
7 wants to address in therapy. In this case they would
8 become part of the initial contract.
9
2011 Shift back to equality
1
2 In therapy or as a student, we allow ourselves to depend
3 somewhat on the therapist or tutor. Towards the end of a
4 therapy contract one often notices a sort of equalizing that
5 occurs. Many therapists will recognize the slight shift that
6 takes place between client and therapist as they near the
7 end of their contract, where there seems to be a more
8 equalizing aspect within the relationship. Often this is
9 indicated by a small thing such as the client recognizing
30 that one might be looking tired, or the client might
1 comment on a change in the room, or ask where one is
2 going on holiday. Whereas in the early days of a contract
311 the therapist might bat such a comment back, querying
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111 why the question was important, now they might simply
2 answer the question or acknowledge the comment. In the
3 earlier part of the contract the client is often too absorbed
4 in their issues to be able to notice anything outside of
5 that. Or, on the other hand, they might be using a more
6 personal comment as a way of avoiding their issues.
7
8
9 Loss for the therapist
1011
1 For the therapist, too, there can be loss. The therapist, for
2 a brief period, has been intensely involved in the clients
3 story. The therapist needs to be able to let go, to encour-
4 age the client to go it alone and to trust that they can. In
5 the phrase teaching the client to become their own ther-
6 apist we are, in effect, giving away our skills and teaching
7 them to do without us. The therapist needs to maintain a
8 certain detachment at all times; despite the involvement
9 referred to earlier it is a detached involvement.
2011
1 Respect for and trust in the clients ability to cope
2
3 The therapist, therefore, needs to have a great deal of
4 respect for the other persons ability to cope and to trust
5 this. As therapists, we are both teacher and facilitator. This
6 perhaps demands a certain humility on the part of thera-
7 pists, as they acknowledge that they are not indispensable.
8 The therapist needs to be flexibile, to allow for more
9 sessions later, if that is what is required. A good parent has
30 to allow the child to move away, but is always there in the
1 background. The doctor deals with the presenting issue,
2 but is still available if the patient returns with another
311 unconnected, or related issue. The therapist, at times, can
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111 see areas that perhaps the client could benefit from work-
2 ing on, and these might be voiced, but it is not the ther-
3 apists business to lead the way, that is the clients task.
4 When the time is right, if they have had a good initial
5 experience of therapy, then they will not hesitate to take
6 it up again, if it is needed.
7
8 Ripple effect in therapy
9
There is a ripple effect in therapy. When one issue is
1011
resolved it tends to have a knock-on effect on other areas
1
of a persons life. (See Parables, Rawson, 1990.)
2
3
Demanding on the therapist
4
5 The quick succession of clients with the very intense and
6 deep work of brief therapy is very demanding for the ther-
7 apist. The therapist has to be very ready to let go of their
8 clients. This sort of work is very stimulating, challenging,
9 and rewarding but, pleased as we must be at their
2011 progress, there is a loss as the client with whom we have
1 worked moves on. We rarely get to hear of the long-term
2 outcome, since we are but a small part of the clients jour-
3 ney and one that they may be pleased to leave well behind
4 with its associated painful memories. It can feel, as for
5 client I almost as if the client is a stranger to the person
6 they now are. Client I read what I had written about our
7 work together and said:
8
9 After reading the report my mind began to remember how
30 I felt during those sessions and this seemed so far removed
1 from what I feel today. I realised that I was justified in
2 being so angry and that I used this anger to shield the
311 pain. When reading this there was no pain, no anger, only
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111 sadness about this strangers childhood and the solace


2 she sought in drink and drugs. [Rawson, 2002, p. 228]
3
4
5 Review
6
7 As we have seen above, in the last session of therapy we
8 review with the client what has been covered and what
9 needs to be covered further. In the next chapter I under-
1011 take a similar exercise with regard to this book.
1
2
3
4
5
6
7
8
9
2011
1
2
3
4
5
6
7
8
9
30
1
2
311
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111
2
3
4
5
6 QUICK REFERENCE NOTES
7
8
9
1011
1
2
3
4
5
6
7
8
9
2011
1
2
3
4
5
6
7
8
9
30
1
2
311
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5
6
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111 Coping with loss the end from the


2 beginning
3
4 Setting the expectation from session one that there is
5 an end in view. e.g., Lets look at x for y sessions, then
6 well review and see if weve achieved what youve
7 come for.
8 or
9 I normally work in a focused way for xy sessions
1011 with people and usually theyre able to cope on their
1 own after that . . .
2 Introducing the client to the idea of helping them-
3 selves by thinking between sessions. This way it
4 speeds up the process
5 Dealing with the it doesnt seem long enough queries
6 from clients, e.g., Are there other situations in your
7 experience where you didnt feel you had enough?
8 What was it you wanted from (parent or whoever)?
9 this may then become the focus of the sessions and
2011 will probably relate to the presenting problem.
1 (Transference is there from session one. The its not
2 enoughexploration is also dealing with the resis-
3 tance.)
4 The countdown of sessions serves as an ongoing
5 reminder of the pending end the loss and also the
6 deadline effect impact, e.g., Weve two more sessions
7 and then the review.
8 The penultimate session is often the key session
9 Exploration of feelings about the end; this needs to be
30 flagged up prior to the review session.
1
2
311
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111 Loss for the client


2
3 The client is attached to the therapist as a:
4
5 lifeline;
6 listener;
7 dependable person;
8 trusted person;
9 person who has been entrusted with the clients deep
1011 secrets and inner world, hence the loss of the thera-
1 pist can be painful.
2
3 Hoped for reactions
4
That the loss of the therapist will be seen:
5
6
as good;
7
as a mark of progress, change and moving on;
8
as a relief that the painful exploration to reach this
9
stage is now over;
2011
as appropriate, since the therapy relationship is an
1
unreal, one-sided relationship;
2
as appropriately sad, since the therapy relationship is
3
an intense and special relationship dealing with very
4
deep issues.
5
6 The following ordinary reactions to loss and grief,
7 if present, would point to some unfinished business
8 or premature ending
9
30 Feeling bereft.
1 Feeling deserted.
2 Feeling left.
311 Feeling rejected.
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5
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111 Feeling isolated.


2 Overwhelming sadness.
3
4 Ordinary defence mechanisms can come into play,
5 also pointing to unfinished business
6 denial;
7 rubbishing, e.g., no good anyway;
8 re-emergence of presenting problem;
9 not owning the importance of the sessions/changes
1011 that have occurred.
1
2
3
4
5
6
7
8
9
2011
1
2
3
4
5
6
7
8
9
30
1
2
311
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111 Loss for the therapist in short-term work


2
3 Loss because of
4 intensity of therapeutic relationship deep but
5 brief;
6 constant turnover of clients.
7 This is very demanding for the therapist.
8
9 It challenges the therapists ability:
1011 to let go of the client;
1 to encourage growth and independence;
2 to trust that change can happen without him/her;
3 to keep to the contract;
4 to be flexible in negotiating a new contract;
5 to ignore therapeutic detours;
6 to give away expertise.
7
8 It requires of the therapist the attitude of:
9 a teacher;
2011 a facilitator;
1 optimism;
2 respect for the persons ability to cope;
3 trust in the persons ability to cope;
4 availability e.g., the therapist can be there if
5 more sessions are required later. Similar to the
6 way parents are in the background as children
7 grow up and lead their own lives;
8 flexibility, open to new contract or review sessions
9 or staggered sessions.
30
1
2
311
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5
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111 Homework
2
3 Be more aware of the following ideas:
4
5 Client as own therapist.
6 Giving the client the tools.
7 Focusing.
8 What is the contract?
9 The end from the beginning.
1011 Issues of loss for client and the therapist.
1 The dynamics of the deadline.
2
3
4
5
6
7
8
9
2011
1
2
3
4
5
6
7
8
9
30
1
2
311
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111 CHAPTER TEN


2
3
4
5
6 REVIEW AND WHAT NEXT?
7
8
9 What has been covered?
1011
1 In these pages I have encompassed the material that would
2 normally be presented in a three-day course to give prac-
3 tising therapists a working idea of the basics of brief
4 psychodynamic psychotherapy. I have briefly covered all
5 the points in the following summary, which is repeated in
6 the quick reference notes at the end of the concluding
7 chapter for the readers convenience as a final summary.
8
9
2011 Brief psychodynamic psychotherapy
1
2 Summary of the basics
3 The contract
4
5 PRE-REQUISITES FOR BEST RESULTS
6
Experience required of the therapist
7
Motivation on the part of the client
8
9 Key principles of brief psychodynamic
30 psychotherapy
1
2 1. Understanding of psychodynamic principles.
311 2. Importance of the first session.
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5
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111 3. Therapy as short as client need allows.


2 4. Early establishment of the therapeutic alliance.
3 5. Therapist attitude.
4 6. Teaching.
5 7. Enabling clients to become their own therapists.
6 8. Activity.
7 9. Focus.
8 10. Flexibility and fusion.
9 11. Incisiveness.
1011
1 Principle of principles and key permeating feature
2
12. The sensitivity of the therapist in order to be in tune
3
with the client.
4
5
HOPED FOR CONSEQUENCES WITHIN SESSIONS
6
7 Hope >> Involvement >> Intensity >> Magic
8
9 HOPED FOR CONSEQUENCES AS A RESULT OF
2011 THERAPY
1
1. Client is capable of being own therapist
2
2. Client is free from past to cope with present
3
4
5 A new slant
6
7 I suggest that it is the early application of an appropriate
8 combination of the above that is a contributing factor in
9 the shortening of therapy. All of the key facets need to be
30 held in mind simultaneously.
1 This outline of the basics is an abbreviated version
2 of the conceptual framework that I formulated as the cul-
311 mination of several years of academic work based on
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111 practice. Those of you who wish to know how I arrived at


2 the conceptual framework, or to read the fuller version
3 need to turn to Short Term Psychodynamic Psychotherapy:
4 An Analysis of Key Principles (Rawson, 2002). There I have
5 detailed the lengthy research which led to this and provide
6 a more in depth exposition of the principles.
7
8
9 Sensitivity; incisiveness; involvement;
1011 intensity; magic
1
2 Before ending, there are some points to which I want to
3 draw especial attention. These are: sensitivity and inci-
4 siveness, involvement, intensity, and magic. These
5 aspects of short-term therapy have been implied, inferred,
6 or referred to on and off throughout the book. They are
7 very special.
8
9 Magic
2011
The magic that I mention is hard to describe, but thera-
1
pist and client will, I think, recognize those moments of
2
insight, awareness, being, to use a word from Martin
3
Buber, or change, that defy description but definitely
4
happen.
5
6
Intensity, involvement and incisiveness
7
8 There is something about the intensity and involvement
9 of both client and therapist that contributes to the magic
30 referred to above. To facilitate change quickly requires a
1 certain incisiveness on the part of the therapist. I believe
2 that this is possible, in the brief time, because of the
311 intense involvement of client and therapist. This, in turn,
4 169
5
6
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111 only happens because of the sensitivity of the therapist


2 and the attunement of the therapist to their client.
3
4 Sensitivity
5 I refer to sensitivity as the Principle of Principles and the
6 Key Permeating Feature of the Short term Psychodynamic
7 Psychotherapy approach: The sensitivity of the therapist
8 in order to be in tune with the client (Rawson, 2002
9 p. 270).
1011
1
2 Next step
3
4 The best next step for students wanting to take their
5 learning further in brief therapy is, in my view, to find a
6 supervisor skilled in the method, either individually or
7 within a group. If there is a group training supervision,
8 where role playing and practice of exercises is possible, this
9 would be very good. There is no reason why this cannot
2011 be supervision that would count towards any requirement
1 for professional and accreditation purposes. Different
2 professional bodies have various requirements for super-
3 vision and these are complex for group supervision.
4 Therefore, group members need to ensure that the time
5 allowed for supervision meets the requirement of their
6 particular professional body.
7
8
9 The question of supervision
30
1 To work in this brief way, I suspect, does require that one
2 has a supervisor who is familiar with it, or at least sympa-
311 thetic to it. It may be, however, that one has to change
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111 supervisors to find one who helps. Some therapists have


2 begun to work in the brief method and have come up
3 against adverse comments from their supervisor. This is a
4 problem. It is important to see what was happening in the
5 therapeutic setting and what specifically was the super-
6 visors objection. However, mostly in these situations it
7 would seem to be an ideological objection rather than one
8 that, as a brief therapy advocate, I could agree with.
9 I sympathize with students or therapists in this posi-
1011 tion. I myself trained in the long-term analytical work and
1 in the short-term simultaneously. I had different supervi-
2 sors in each setting. Each setting expected a different way
3 of working and one had to follow what was required
4 within each. However, thankfully, once one is no longer a
5 student, to be assessed in a certain way of working, one is
6 free to choose from the good that one has learned on ones
7 journey and fuse these to the best effect for our clients. In
8 my case, as I was training in long- and short-term psycho-
9 dynamic work simultaneously, I observed clients coming
2011 with similar issues to the long-term centre and to the
1 short-term centre. In the first centre clients left after
2 perhaps forty or fifty sessions, and in the short-term
3 centre after eight. It seemed to me that if similar clients
4 and issues could be dealt with quickly, then that was to be
5 preferred. This led to my interest and research in the brief
6 model. I have now moved on from the rigid eight sessions.
7 I now advocate, as already stated, a more flexible
8 approach: as many sessions as the client needs. This, as we
9 saw earlier, tends to be around four to six sessions. Once
30 out of the student milieu, just as we can choose how we
1 work, we can usually also choose our supervisors. In some
2 workplaces, however, that is not so, and this presents
311 another difficulty, but not perhaps particular just to brief
4 171
5
6
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111 therapy. It is, perhaps, more for the therapist then to seek
2 help from their professional organization, or maybe to
3 seek a situation compatible with their own ideals.
4 Incidentally, if a therapist really does not wish to work in
5 the brief way and if this goes against the grain for them,
6 I question whether it is really wise for them to work in
7 this way at all.
8
9
1011 Supervision: how much?
1
2 There is ongoing debate in the profession about super-
3 vision in general and for brief therapy in particular, and
4 my responses to some of the opinions that have been
5 published appear below in the quick reference notes
6 (pp. 177185).
7
8
9 Brief therapy for the twenty-first century
2011
1 There is also in the quick reference notes that follow, a
2 copy of an article entitled Brief therapy for the twenty
3 first century, which seems an appropriate summary as we
4 near the end of this book (pp. 174176).
5
6
7
8
9
30
1
2
311
2
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111
2
3
4
5
6 QUICK REFERENCE NOTES
7
8
9
1011
1
2
3
4
5
6
7
8
9
2011
1
2
3
4
5
6
7
8
9
30
1
2
311
4 173
5
6
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111 Letter to the editor BACP journal


2 Counselling (Rawson 1999a, p. 181), as
3 part of debate on how much supervision
4 and whether brief therapy is good or bad
5
6
Dear Editor,
7
8 Brief Therapy
9 I recently enjoyed reading Dr Gertrude Manders honest
1011 grapplings with some of the important issues around the
1 supervision of brief therapists and her ensuing struggle
2 with the concept that short can be good (1998). Equally
3 Dr Brian Thornes most readable exploration of brief
4 therapy as good or bad (1999).
5 I have practised the brief approach for more than
6 twenty years, and supervise and train in the approach.
7 The two articles drew my attention and prompted the
8 following response.
9 Dr Manders article raised some questions for me. Her
2011 expectation for example of intensive supervision, i.e. three
1 sessions for a case of five sessions, seems puzzling. I would
2 endorse such intensive supervision only in the case of a
3 trainee therapist or as a training supervision for a therapist
4 learning brief work or for a particularly difficult case or
5 where the therapist is grappling with their own transferen-
6 tial issues and needs much guidance with these. Apart from
7 these instances surely one supervision session might be
8 enough unless a specific issue is raised or needs to be raised
9 by the supervisor. Many people seeing clients for brief
30 contracts may have say sixteen to twenty clients per week.
1 It is not possible that every one is going to be brought to
2 supervision in the way she recommends. In looking at case-
311 work there are common issues and themes and the scrutiny
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111 of one case may well move along others also. Of course any
2 special problem that the therapist may be having with a
3 client may mean that a case will need more than one visit
4 and might even be reviewed every supervision. One of the
5 key principles emerging from my research about brief ther-
6 apy was that of flexibility. This related to both time and
7 techniques. I would also recommend appropriate flexibil-
8 ity for therapist and supervisor. Additionally I am one of
9 the school of thought that believes that each supervisee in
1011 a group benefits from the supervision of other supervisees
1 cases and I have long questioned BACs way of calculating
2 the individual equivalent time of supervision for those
3 who attend group supervision.
4 One or two other aspects of her article drew my atten-
5 tion and an alternative viewpoint.
6 Her student counselling supervisees with unapprecia-
7 tive management, and student clients who have difficulty
8 engaging in the process of counselling, demonstrate only
9 one side of the coin.
2011 The student Counselling Service I managed found that
1 students readily contracted for flexible short-term
2 contracts, attended the sessions with great commitment
3 and seemed to reach satisfyingly positive results. Brian
4 Thornes article refers to my experience of committed
5 student clients too! Also was I exceptionally lucky to
6 have had appreciative management for most of my early
7 career as a College Counsellor in the Higher Education
8 sector?
9 Her suggesting to her supervisee that staff counselling
30 should be referred elsewhere is, I suggest, an over simplifi-
1 cation. Many colleges have built into the counsellors
2 contracts that they see staff for counselling as well as
311 students. So the boundary issues in this regard have to be
4 175
5
6
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111 managed and cannot simply be avoided by referral else-


2 where.
3 Another disturbing point mentioned in passing by
4 Mander is that some people apparently liken brief ther-
5 apy to a death experience. Despite having spent the last
6 few years researching about brief dynamic psychotherapy,
7 this is a new one on me. For whom is it a death experi-
8 ence? The therapist? What is this saying? Is it a reference
9 to the detached involvement required of any therapist? Is
1011 it about the quick turn over of clients and the need for
1 the therapist to be able to let go of the client, which is
2 certainly necessary and requires an ability to sustain loss?
3 Does it refer to the satisfying outcome of the client
4 moving onwards more freely, or leaving their pain
5 behind, or having come to terms with an inevitable situ-
6 ation or excitedly going forward to a new phase of life? I
7 suppose one could liken these positive results to a resur-
8 rection experience?
9 Returning to Dr Thornes article, I believe the power
2011 and intensity of the encounter that he describes, in his
1 Brief Person-Centred experiments, captures the essence of
2 what takes place in brief therapy sessions. In my recent
3 empirical research analysing the key principles of brief
4 psychodynamic psychotherapy, the intensity and involve-
5 ment, which happens consistently within brief therapy
6 sessions, emerged as very important aspects of the
7 process. I do hope this later scepticism dissipates and his
8 original joy at the involvement and speed of progress
9 reasserts itself. So that he dares to spread the heresy of
30 Person Centred Brief Therapy further.
By the way what therapy is not centred on the person?
1
2 Yours sincerely,
311 Penny Rawson (Dr)
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111 Supervision nonsense (Rawson, 2003)


2
3
4 I am writing in response to Alan Picketts letter about the
5 number of supervision hours (CPJ October 2002). The
6 hours for supervision were decided almost 20 years ago.
7 How do I know? I was (dare I say it?) there. The decision
8 was made at a time when the whole accreditation system
9 needed to be tightened up. I hope that the accreditation
1011 revisions contributed to the raising of standards. How-
1 ever, I believe that the time has come to bring this super-
2 vision requirement up to date. In this I am thinking
3 particularly about senior counsellors how one defines
4 that this is a matter of debate. Perhaps by number of
5 client hours seen overall?
6 Many counsellors see fewer clients per week as they get
7 more involved in supervision, training, writing etc. Since
8 the minimum hours of counselling per year has been
9 relaxed some may see a client just now and then and
2011 maybe not weekly. If, for example, a counsellor sees a
1 client for two hours in a month, there is then a nonsen-
2 sical requirement that in that same month the counsellor
3 must have one hour and a half hours [sic] of supervision.
4 A full-time therapist might see 20 clients a week (80
5 sessions a month) and still be required to have the same
6 amount of supervision. Having been at both ends of the
7 spectrum I question this. Even economically it is nonsen-
8 sical. If one saw a client for just one session in a month
9 for say 40, one would then require supervision at say
30 60 per month i.e. counselling at a loss. It is time for a
1 review.
2 Alan Pickett suggested a proportional idea e.g. one
311 hours supervision for every 10 hours of counselling. I
4 177
5
6
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111 would support this idea if we have to have a rule. However


2 I would prefer a system which allowed senior counsellors
3 to seek supervision as and when they felt it to be necessary.
4
5
6
7
8
9
1011
1
2
3
4
5
6
7
8
9
2011
1
2
3
4
5
6
7
8
9
30
1
2
311
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111 Therapy for the 21st century


2 (Rawson, 1999b)
3
4 The fact that this issue of Counselling News is dedicated
5 to the topic of brief therapy in itself shows a radical devel-
6 opment in the public and professional awareness of this
7 approach. Such an event would not have happened
8 earlier. For some inexplicable reason, the secret of short-
9 term therapy seems to get lost time and time again over
1011 the year. It is not new and yet is currently in the throes
1 of being discovered anew. I hope that this article evolving
2 from my research will help to reinforce brief therapys
3 place on the map and its development onwards as we
4 reach the turn of the century.
5 I hope to kindle readers interest to know more, to
6 raise questions as familiar techniques are referred to here
7 in the context of unfamiliar brevity. I hope to challenge
8 those who say this short-term approach cannot achieve
9 good results, with authentic client comments that defy
2011 this assumption. I also aim to encourage those who prac-
1 tise brief therapy reluctantly, because their employers say
2 they must or because clients can afford no more sessions,
3 and who strive to help but dare not believe this is possi-
4 ble in a few sessions.
5
6 What do we mean by short-term?
7 There are many interpretations as to what short means in
8 the context of therapy. The time scale that I am referring
9 to is flexible and is negotiated with the client according to
30 individual need. A case may take one session, the more
1 usual number required ranges between four and six
2 sessions, and sometimes more. Twelve would be consid-
311 ered one of the long cases.
4 179
5
6
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111 From statistics of many college counselling services, for


2 example, it is clear that many cases consist of one session
3 only. These, I would suggest, do not denote failure or
4 imply that it is simply skimming the surface. The client
5 has simply got what they needed at that time.
6 In a college service that I managed, the average over a
7 year was four sessions. In an EAP (Employee Assistance
8 Programme) with which I was recently involved, where
9 the number of sessions was negotiated quite freely, the
1011 average over a year was 5.5 sessions.
1 The question is not how long have we got? It is what do
2 we do with the time we have?
3
4
A joint enterprise
5 I use the term we above advisedly, since short-term ther-
6 apy is a joint enterprise and one in which the time and
7 the subject matter to be worked on is negotiated.
8 I have already referred to a negotiated timescale. If the
9 timescale is to be short, the therapists attitude is all-
2011 important. If the therapist believes in the method, they
1 will convey this confidence to the client, who very often
2 in fact only expected one or two sessions anyway. Some
3 clients however, do think therapy has to be a very long
4 process and if the therapist secretly or openly believes that
5 this is so, then the therapy is likely to be protracted. It is
6 here, especially, that the therapists genuine belief in the
7 process of short-term therapy is important. This, coupled
8 with the natural effect of what I call the dynamics of the
9 deadline, set a promising course for a successful brief
30 therapy contract.
1
2 The history
311 The idea of therapy being short is not a new one, although
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111 it seems as if the concept has to be repeatedly rediscov-


2 ered. Many of Freuds successors were unhappy with the
3 time that analysis seemed to take and began to experiment
4 with different techniques to shorten the process.
5 Ferenczi in the 1920s thought that passivity in the
6 therapist caused the stagnation of analysis and began to
7 be far more active in an attempt to speed things along.
8 Rank, in the 1940s, emphasised the need for the thera-
9 pist to mobilise the clients will in order to shorten ther-
1011 apy, and introduced time limits. Alexander, also in the
1 1940s, recommended gaps in therapy or interruptions
2 which encouraged clients to stand on their own feet and
3 discouraged dependence. This idea fits well with normal
4 human development, with its spurts of growth and then
5 latent periods in which the individual digests what has
6 been learned, and experiments a little with the newfound
7 knowledge. Alexander also stressed the importance of
8 being flexible enough to adapt the technique to the needs
9 of the patient. He experimented with the use of the couch
2011 and chair, with timescales, and with the control and
1 manipulation of the transference. The ideas represented
2 by these early pioneers of the brief approach were consid-
3 ered daring modifications at that time, but are considered
4 normal for the brief therapist working in the late 1990s.
5
Psychodynamic
6
7 Readers will notice the reference above to transference
8 and yes, brief therapy can be psychodynamic. There are
9 now many forms of therapy which are brief in duration,
30 some of the better known being Solution Focused
1 Therapy and Cognitive Analytic Therapy, but form my
2 recent research, there emerged 15 other titles also! It
311 seems, as Gustafson suggests, that the proponents of each
4 181
5
6
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111 approach were ambitious . . . to define a standard tech-


2 nique of their own. He suggests that they then become
3 defenders of their own dogma. Are these approaches
4 really so different or can each learn the best from the
5 other? I prefer to see a fusion of ideas with the clients
6 need to the forefront. These may be from other branches
7 of brief therapy, and other traditions within the thera-
8 peutic world.
9 This article refers to Short Term Psychodynamic
1011 Psychotherapy. (The terms psychotherapy and psychody-
1 namic counselling are used interchangeably.) It incorpo-
2 rates the concepts of transference and it works with the
3 past. As Louis Marteau observes, we need to be reaching
4 through to the very root if any change is to occur. Thus,
5 the brief work is in no way superficial, it is not palliative
6 but anticipates real change. Malan in the 1960s would
7 have referred to this as working at the radical end of the
8 spectrum.
9
2011
Client comments
1 In my own practice, it has led to client comments at the
2 end of therapy such as: I am free; I feel as if Im waking
3 up after a long sleep; I can cope alone now; After read-
4 ing the report, my mind began to remember how I felt
5 during those sessions and this seemed so far removed
6 from what I feel today. I realised I was justified in being
7 so angry and that I had used the anger to shield the pain.
8 When reading this there was no pain, no anger, only
9 sadness about this strangers childhood and the solace
30 she sought in drink and drugs.
1
2 The focus
311 By the 1960s, it was widely agreed that for brief therapy,
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111 a focus is important. Sifneos is particularly noted for his


2 reference to circumscribing the focus and for seeing it as
3 a joint venture, which I fully endorse. However, I want
4 to stress that although client and therapist choose to put
5 the spotlight on the strategic focus in a persons life, this
6 does not mean that the one aspect is examined in isola-
7 tion. In dealing with the one issue, there is a ripple effect
8 and this one issue also affects other aspects of the indi-
9 viduals life. As human beings, it is really not possible to
1011 isolate one aspect of ourselves. If, for example, we have a
1 toothache, does it not dominate our whole being? Is not
2 an emotional ache equally pervasive? It is, of course, true
3 that just as a pain-killer may help the physical ache, so we
4 devise all sorts of ways of numbing the emotional, too
5 not always helpful ways. The flexible techniques alluded
6 to earlier help to uncover some of these devices so that
7 the ache can be dealt with and healing can take place,
8 freeing the person to move forward.
9
The first session
2011
1 The focus needs to be found early on, preferably in the
2 first session, and as we note the need for speed in finding
3 the focus, the need for activity and flexibility on the
4 therapists part also becomes apparent. I believe that the
5 first session is of paramount importance. There are a
6 number of features in the first session that I would wish
7 to draw attention to, but it is perhaps the testing out of
8 the therapist that needs to be highlighted, especially since
9 it is more usual to hear about the therapist assessing the
30 client. I suggest that it is important that the therapist
1 passes the clients test. That is: Is this person able to
2 understand me? Can they bear my pain? Can they pick
311 up the clues I give?
4 183
5
6
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111 To recap, there is the need to focus, to be active, to be


2 flexible and to take especial note of all that takes place in
3 the first session, especially in acknowledging the pain.
4 Despite being rooted in the analytic tradition, even the
5 early brief therapists, who were mostly trained analysts,
6 actively embraced techniques from other traditions.
7 Wolberg in the 60s, for example, referring to a fusion of
8 skills. Is he the precursor of the modern trend for inte-
9 gration of post schoolism, as Clarkson terms it. Cer-
1011 tainly, anyone wanting to work briefly could do well to
1 examine his exposition of the brief approach, which has
2 much to teach us today.
3 Some of the methods I find especially useful involve
4 gestalt techniques, fantasy work and the client doing
5 work in between sessions on their own. This might
6 involve reflecting on the work within the session, or
7 perhaps looking up key dates in their history or under-
8 taking some relevant task. All the above involve the client
9 and I suspect that it is the client involvement that is the
2011 key to success. As Van Kaan says: To be there means that
1 I gather together all my thoughts, feelings and memories.
2 I am wholly with what I am doing, creating, perceiving.
3
Special demands on the therapist
4
5 This being so, there is also a particular sort of involve-
6 ment required of the therapist in working briefly with the
7 clients. This can sometimes be difficult for the therapist.
8 There is an intense relationship for just a short while and
9 then the ending comes, a constant turnover that makes
30 demands on the therapist who has to be prepared to let
1 go and to sustain loss.
2 If the practitioner is in private practice, they also have
311 to trust that new clients will come thick and fast as word
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111 gets round that they can be helped out of pain in a few
2 sessions for a limited amount of money. Where therapy
3 is offered free within, for example, EAPs, there is
4 certainly no shortage of clients and there is a good success
5 rate in the short number of sessions normally allowed.
6
7 Special rewards for the brief therapist
8 The rapidity with which clients move on from their
9 presenting problems to go it alone with confidence is
1011 greatly rewarding. It also serves as a reminder of the
1 resilience of the human being and the privilege we have,
2 in participating briefly but deeply, in the lives of those
3 who choose to come to us.
4
5
6 Bibliography
7
8 Clarkson, P. (1998). Beyond schoolism the implications of
9 psychotherapy outcome research for counselling and
2011 psychotherapy trainees. Counsellor and Psychotherapist
1 Dialogue 1, 1(2): 1319.
Gustafson, J. P. (1986). The Complex Secret of Brief Psycho-
2 therapy. New York: W. W. Norton.
3 Marteau, L. (1986). Existential Short Term Therapy. London:
4 The Dympna Centre.
5 Rawson, P. (1990). Parables. London: FASTPACE.
6 Rawson, P. (1992). Focal and short-term therapy is a treatment
7 of choice. Counselling, 5: 106107.
Rawson, P. (1995). By mutual arrangement. Counselling News,
8
6: 89.
9 Van Kaan, A., (1970). On Being Involved. The Rhythm of
30 Involvement and Detachment in Daily Life. Denville, NJ:
1 Dimension Books
2 Wolberg, L (Ed.) (1965). The Technique of Short Term Psycho-
311 therapy. New York: Grune and Stratton.
4 185
5
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2
3
4
5
6
7
8
9
1011
1
2
3
4
5
6
7
8
9
2011
1
2
3
4
5
6
7
8
9
30
1
2
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111 CHAPTER ELEVEN


2
3
4
5
6 CONCLUSION
7
8
9 To conclude, then, I have presented the reader with a
1011 basic guide as to the key concepts in the practice of brief
1 psychodynamic psychotherapy. This is a brief psychody-
2 namic method that deals with the past through the
3 present, in order to improve the present and future. It is
4 not a superficial, sticking plaster approach. I have not
5 laboured aspects of transference or countertransference,
6 nor other basic aspects of therapy in general, since these
7 are part of the knowledge I would expect of the experi-
8 enced therapist. Rather, I stress aspects such as activity,
9 flexibility, and the fusion of skills, an agreed focus and
2011 time span for the work, and the importance of the first
1 session, all of which can enable the work to move on more
2 swiftly. These aspects were stressed in turn by the earlier
3 proponents of the brief method. One recalls that most of
4 the early proponents were analysts, so the stress on these
5 aspects was really very innovative. In the above pages I
6 have attempted to highlight the key issues and to demon-
7 strate how these ideas can be incorporated into the brief
8 work in practice.
9 I hope that this book may whet the readers appetite
30 and encourage therapists to incorporate some of the ideas
1 into their work in brief therapy. Some may be tempted
2 to read my earlier study that has been referred to from
311 time to time in this book: Short-Term Psychodynamic
4 187
5
6
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111 Psychotherapy: An Analysis of Key Principles. This gives a


2 more in depth exposition, based on several years of
3 research.
4 I have provided here an easily accessible outline of the
5 basics of the approach. One of my aims is to make the
6 brief method of therapy better known and understood. In
7 therapy, people reveal areas of pain in their lives to the
8 therapist. Facilitated by the therapist, they then work with
9 and through these areas of pain to a more free existence.
1011 Brief therapy can accelerate that process. My advocacy of
1 the method is to do with the economy of pain, not of
2 money.
3 One day I would like to see centres available every-
4 where, where people could access short-term psychody-
5 namic therapy, independently and for free. This would,
6 no doubt, require government funding to achieve, but in
7 terms of money lost to the country because of emotional
8 and psychological problems this concept would, I think,
9 prove fiscally economic. I hope that this book will
2011 contribute in some small way towards these objectives.
1 I will end with a repeat of the summary of the basics,
2 referred to in the previous chapter, which provides a clear
3 and simple guide to the basics of the method.
4
5
6
7
8
9
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2
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111 BRIEF PSYCHODYNAMIC


2
3
PSYCHOTHERAPY
4
5 Summary of the basics
6
7 The contract
8
PREREQUISITES FOR BEST RESULTS
9
1011 Experience required of the therapist
1 Motivation on the part of the client
2
3 Key principles of brief psychodynamic
4 psychotherapy
5 1. Understanding of psychodynamic principles.
6 2. Importance of the first session.
7 3. Therapy as short as client need allows.
8 4. Early establishment of the therapeutic alliance.
9 5. Therapist attitude.
2011 6. Teaching.
1 7. Enabling clients to become their own therapists.
2 8. Activity.
3 9. Focus.
4 10. Flexibility and fusion.
5 11. Incisiveness.
6
7 Principle of principles and key permeating feature
8
9 12. The sensitivity of the therapist in order to be in tune
with the client.
30
1
HOPED FOR CONSEQUENCES WITHIN SESSIONS
2
311 Hope >> Involvement >> Intensity >> Magic
4 189
5
6
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A Handbook of Short-Term Psychodynamic Psychotherapy

111 HOPED FOR CONSEQUENCES AS A RESULT OF


2 THERAPY
3
1. Client is capable of being own therapist
4
2. Client is free from past to cope with present
5
6
A new slant
7
8 I suggest that it is the early application of an appropriate
9 combination of the above that is a contributing factor in
1011 the shortening of therapy. All of the key facets need to be
1 held in mind simultaneously.
2
3
4
5
6
7
8
9
2011
1
2
3
4
5
6
7
8
9
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111 REFERENCES AND BIBLIOGRAPHY


2
3
4
5
6
7 Balint, M., Ornstein, P., & Balint, E. (1972). Focal Psycho-
8 therapy: An Example of Applied Psychoanalysis. London:
Tavistock.
9
Casement, P. (2004). Learning from our mistakes. Counselling
1011 and Psychotherapy Journal, 15(06): 1116.
1 de Shazer, S. (1990). What is it about brief therapy that works?
2 In: J. Zeig & S. Gilligan (Eds.), Brief Therapy, Myths,
3 Methods and Metaphors. New York: Brunner/Mazel.
4 Feltham, C. (1997). Challenging the core theoretical model.
5 Counselling, 5: 121125.
Feltham, C. (1997). Time Limited Counselling. London: Sage.
6
Goulding McClure, M. (1990). Getting the important work
7 done fast. contract plus redecision. In: J. Zeig & S. Gilligan,
8 (Eds.), Brief Therapy, Myths, Methods and Metaphors. New
9 York: Brunner/Mazel.
2011 Groves, J. (1992). The Short Term Dynamic Psychotherapies:
1 An Overview in Psychotherapy for the 1990s. J. S. Rutan,
2 (Ed.) London: The Guilford Press.
McGannon, M. (1996). Staying Healthy, Fit and Sane in the
3
Business Jungle. London: Pitman.
4 Malan, D. (1963). A Study of Brief Psychotherapy. London:
5 Tavistock Publications.
6 Malan, D. (1976). The Frontier of Brief Psychotherapy, An
7 Example of the Convergence of Research and Practice, New
8 York: Plenum Medical Books.
9 Mann, J. (1973). Time Limited Psychotherapy. MA: Harvard
University Press.
30 Marteau, L. (1986). Existential Short Term Therapy. London:
1 The Dympna Centre.
2 Molnos, A. (1987). Notes on selection of patients for dynamic
311 brief psychotherapy. Personal communication.
4 191
5
6
Rawson/correx 9/1/05 10:50 AM Page 192

References and Bibliography

111 Molnos, A. (1995). A Question of Time, Essentials of Brief


2 Psychotherapy. London: Karnac.
3 Rawson, P. (1990). Parables. London: FASTPACE.
Rawson, P. (1992). Focal and short-term therapy is a treatment
4
of choice. Counselling, 5: 106107.
5 Rawson, Penny, (1995), By mutual arrangement. Counselling
6 News, 6: 89.
7 Rawson, Penny (1999a) Letters to the editor: Brief therapy.
8 Counselling, Aug: 181.
9 Rawson, P. (1999b) Therapy for the 21st century. Counselling
News, March: 3233.
1011
Rawson, P. (2003). Supervision nonsense. Counselling and
1 Psychotherapy Journal, February: Letters.
2 Rawson, P. (2002). Short Term Psychodynamic Psychotherapy: An
3 Analysis of Key Principles. London: Karnac.
4 Rawson, P. (2004). Grappling with Grief. London: Karnac.
5 Sifneos, P. (1981). Short term anxiety provoking psycho-
therapy. Its history, technique, outcome and instruction.
6
In: S.Budman (Ed.), Forms of Brief Therapy. New York:
7 Guilford Press.
8 Sifneos, P. (1987). Short Term Dynamic Psychotherapy Evalu-
9 ation and Technique. New York: Plenum Medical Books.
2011 Wolberg, L. (Ed.) (1965). The Technique of Short Term
1 Psychotherapy. New York: Grune and Stratton.
Yalom, I. (1931). Existential Psychotherapy. USA: Harper
2 Collins [reprinted London: Basic Books, 1980].
3
4
5
6
7
8
9
30
1
2
311
2 192
Rawson/correx 10/4/05 9:41 AM Page 193

111 INDEX
2
3
4
5
6
7
8
9
1011 abortion, 47 F, 52, 128129
1 activity, xix, 12, 30, 9597, Jacques, 100103, 134
2 113, 122139, 168, 183, Jane, 124126
3 187, 189 Jean, 3940
4 alcohol/drugs, 4, 10, 21, 42, Joan, 152155
143, 160, 182 Kate, 144
5
anger, 3, 38, 96, 103, 118, Rob, 106110, 112, 115
6 153, 159, 182 Casement, P., 53, 145, 191
7 anxiety, 77 caution, 145146
8 compulsory therapy, 67
9 Balint, E., 191 contract, xix, 2, 7, 10, 12, 17,
2011 Balint, M., 67, 31, 34, 191
21, 2829, 51, 5658,
being with the client, 101,
1 6197, 99, 127128,
103
2 136, 151, 155158,
belief in the method, 16, 180
3 165167, 174175, 180,
body language, 4344, 55,
4 189
68, 77, 93, 102, 106,
5 122 counselling continuum, xv,
body memory, 38, 106107, xviii
6
7 110, 115, 136137, 139
break-up (of a relationship), de Shazer, S., 191
8 death, 10, 21, 26, 38, 47,
38, 47, 75, 105, 129,
9 102, 105, 129, 155
149
30 brief group therapy, 5859 experience, therapy as, 176
1 depression, 4, 2829, 3334,
2 case examples 3839, 62, 75, 77, 106,
311 E, 111, 116, 145 129
4 193
5
6
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Index

111 detective image, 17, 39, 137 Holmes Rahe scale, 4, 26


2 dynamics of the deadline, xix, homework, 30, 7172, 74,
3 84, 92, 166 78, 82, 109, 112113,
122125, 127130,
4
ending therapy, xix, 5758, 137, 166
5
81, 8586, 92, 150167
6 initial interview, 61, 63
7 fantasy exercises, 110111, intake sessions, 53
8 116117, 136,
9 139140142, 145 loss for the therapist, 155,
1011 Feltham, C., 191 158, 165
1 Ferenczi, S., 31
first session, importance of, Mahler, G., 31
2
xix, 18, 25, 45, 5165, Malan, D., 7, 11, 2324,
3 31, 133, 182, 191
69, 167, 183, 189
4 flexibility re skills, time, Mann, J., 83, 191
5 contract, xix, 12, 10, Marteau, L., xi, xx, 5, 10,
6 1213, 17, 20, 25, 31, 36, 70, 182, 185,
7 3031, 62, 76, 83, 88, 191
8 9091, 97, 99, 113, McGannon, M., 4, 26, 191
9 115122, 132133, 136, Molnos, A., 10, 22, 191
154155, 158, 165, 168, motivation, 9, 12, 17, 22, 24,
2011
171, 175, 179, 181, 77, 167, 189
1
183184, 187, 189
2 focal issue, xix, 2, 6, 8, 62, 64 negotiation/renegotiation, 10,
3 focal therapy, 6, 27, 29, 34, 31, 44, 57, 70, 72, 78,
4 61, 9394 83, 87, 91, 93, 99, 156,
5 Freud, S., 31 165, 179180
6 fusion of skills, 133, 187
7 Ornstein, P., 191
8 Goulding McClure, M., 191
grief, 3, 76, 100, 102104, pressure cooker image, 3
9 projective identification, 44,
136, 148149, 154, 163
30 Groves, J., 191 106
1
2 Heimler Social Functioning rape, 105106
311 concept, 41, 48, 48, 125 Rawson, P., xx, 1, 9, 14, 27,
2 194
Rawson/correx 10/4/05 9:41 AM Page 195

Index

111 52, 84, 93, 100, 133, supervision, xvi, 14, 82, 112,
2 149, 169170, 174, 177, 150, 170, 172, 174175,
3 179 177178
resistance, 22, 2930, 32, 86,
4
9596 talking to the block, 143
5 talking to the inner child, 144
6 sacred moment, the, 5253 tears, 3, 3839, 55, 77, 118
7 sensitivity, 18, 25, 80, 104, therapeutic alliance, 12, 25,
8 168170, 189 168, 189
9 Sifneos, P., 68, 2324, 29, time exercise, 80
1011 31, 34, 183, 192 touching the pain, 55
1 silence, use of, 30, 7677, transactional analysis (TA), 125
101102, 104106, 122, transference/
2
134, 136 countertransference, 30,
3 spacing of sessions, 8182, 44, 106, 122, 125, 130,
4 85 131, 136, 162, 174,
5 splinter image, 23 181182, 187
6 strategic focus, 34, 65, Frasier, 131132
7 6578, 91, 183
8 stress, 45, 14, 26, 41, 43, under the microscope, 44, 91
9 139
and ill health, 4 voice, tone/use of, 43, 49, 76,
2011
suicide/suicidal, 4, 22, 33, 42, 102, 121122
1 153154
2 suitability/unsuitability, 6, 9, Wolberg, L., 1112, 23,
3 2123, 64, 145 see also: 3031, 132133,
4 caution 184185, 192
5 summary of the basics, 167,
6 188190 Yalom, I., 192
7
8
9
30
1
2
311
4 195
5
6