Brief Dynamic Therapy Over Time
For individuals in the U.S. & U.S. territories
In Brief Dynamic Therapy Over Time, Dr. Hanna Levenson demonstrates how a time-efficient therapy can be brief and yet deep—how a short-term therapy can create long-term change. Time-limited dynamic psychotherapy, an empirically supported approach, is a form of brief dynamic therapy that originated within the object relations tradition.
As used by Dr. Levenson, time-limited dynamic psychotherapy is an integrative model incorporating recent developments in attachment, experiential, relational, and systems approaches. This approach provides a specialized method for deriving a therapeutic focus that delineates the client's co-created, chronic, maladaptive ways of relating to others. The goals of the therapy are to create corrective interpersonal experiences and new understandings designed to undermine this dysfunctional cyclical pattern.
In this series of six sessions, Dr. Levenson works with a young woman who is very positive on the surface and who seems to be living a happy life. Working with the time-limited dynamic psychotherapy approach, it becomes apparent even in the first session that the client has suffered for years from depression; there are deep emotions that she has not expressed to anyone because she fears she will be abandoned if she does.
Dr. Levenson works with the client to help her experience and express her feelings within the sessions, and learn why she needed to suppress them earlier in life. As the therapy progresses, the client moves from hiding her emotions to sharing them, both in the session and with those closest to her.
Time-limited dynamic psychotherapy (TLDP) originated as an interpersonal, time-sensitive approach for clients with chronic, pervasive, and dysfunctional ways of relating to others (Strupp & Binder, 1984). However, the premises and techniques of TLDP are broadly applicable regardless of time limits.
The brevity of the treatment promotes therapist pragmatism, flexibility, and accountability (Levenson, Butler, Powers, & Beitman, 2002). Furthermore, time pressures help keep the therapist attuned to circumscribed goals using an active, directive stance (Levenson, Butler, & Bein, 2002).
The focus is not on the reduction of symptoms per se (although such improvements are expected to occur), but rather on changing ingrained patterns of interpersonal relatedness or personality style.
While the scaffolding of TLDP is psychodynamic, the current model is integrative, incorporating recent developments in attachment, interpersonal, experiential, cognitive–behavioral, and system approaches (Levenson, 2003).
Attachment theory holds that people are innately motivated to search for and maintain human relatedness (Bowlby, 1973). Early experiences with parental figures result in mental representations of these relationships or working models of one's interpersonal world. These experiences form the building blocks of what will become organized, encoded, experiential, affective, and cognitive data (i.e., interpersonal schemas) informing the child about the nature of human relatedness.
Although one's dysfunctional interactive style is learned early in life, a TLDP perspective holds that this style must be supported in the person's present adult life for the interpersonal difficulties to continue. This focus is consistent with a systems-oriented approach that stresses the context of a situation and the circular processes surrounding it.
Maladaptive patterns are maintained through their enactment in the current social system, as others (including the therapist) are invited to unwittingly replicate familiar responses from the client's troubled past. When the therapist colludes with the patient to recreate the dysfunctional interpersonal dynamic, it is viewed as "interpersonal empathy" (Strupp & Binder, 1984) or "role responsiveness" (Sandler, 1976) rather than a therapeutic failure.
The TLDP therapist uses this information to change the nature of the interaction in a positive way, thereby engaging the client in a healthier mode of relating. In addition, the therapist can collaboratively invite the client to look at what is happening between them (i.e., metacommunicate) or in outside relationships, either highlighting the dysfunctional reenactment or solidifying new experiential learning.
The TLDP therapist seeks two overriding goals with clients: new experiences and new understandings.
New experiences are actually composed of a set of focused experiences throughout the therapy in which the client gains a different appreciation of self, of therapist, and of their interaction. These new experiences emphasize the affective–action component of change and are designed to subvert or interrupt the client's maladaptive interactive style.
The therapist gives the client the opportunity to disconfirm his or her interpersonal schemas, promoting a corrective emotional–interpersonal experience (Alexander & French, 1946). This in vivo learning is a critical component in the practice of TLDP. These experiential forays into what has been frightening territory for the client can occur with the therapist or with others in the client's life. Such emotionally intense processes make for heightened affective learning and permit progress to be made more quickly.
The second goal of providing new understandings focuses more specifically on cognitive changes. The client's new understanding usually involves an identification and comprehension of his or her dysfunctional patterns.
To facilitate such a new understanding, the TLDP therapist can point out repetitive patterns that have originated in experiences with past significant others, with present significant others, and in the here-and-now with the therapist. Therapists' judicious disclosing of their own reactions to clients' behaviors can also be beneficial.
In this method the therapist is both an emotionally engaged participant (who initially may countertransferentially reenact the dysfunctional cycle), as well as a process consultant–observer. All interventions are considered relational acts. The therapist uses strategies emanating from the context of the therapeutic relationship, and because of time-limited dynamic psychotherapy's integrative stance, the therapist has many potential interventions that can foster the goals.
TLDP was developed to help therapists deal with patients who have trouble forming working alliances due to their lifelong dysfunctional interpersonal difficulties. However, from a relational point of view, many symptoms (e.g., depression and anxiety) and problems in living (e.g., marital discord) stem from one's impaired relatedness to self and other; consequently a wide range of clinical issues and presentations could be successfully addressed using TLDP. For a formal set of selection criteria, see Levenson (1995).
TLDP would not be the treatment of choice for problems that can be treated more effectively by other means (e.g., simple phobia, bipolar disorder) or when patients cannot tolerate the interactive, interpersonal, circumscribed therapeutic process (due to impulse control problems, psychotic symptoms, or substance abuse disorders, for example).
In order to focus the therapeutic work, the TLDP therapist identifies a client's cyclical maladaptive pattern (Binder & Strupp, 1991), which describes the idiosyncratic vicious cycle (Wachtel & McKinney, 1992) of maladaptive interactions that a particular client manifests with others. These cycles or patterns involve inflexible, self-defeating expectations and behaviors and negative self-appraisals that lead to dysfunctional and maladaptive interactions with others (Butler, Strupp & Binder, 1993).
A successful TLDP formulation should provide a blueprint for the therapy. It should describe the nature of the problem, lead to the delineation of goals, serve as a guide for interventions, and enable the therapist to anticipate reenactments and understand countertransferential reactions.
Implementation of TLDP does not rely on a set of techniques. Instead, it depends on therapeutic strategies that are useful only to the extent that they are embedded in a larger interpersonal relationship. Because the focus is on experiential interpersonal learning, theoretically any intervention that facilitates this goal could be used.
Training and Research
For the therapist wanting more information on training in this model, the therapist recommends a multifaceted approach that includes reading, on-going supervision, consultation (expert and peer), and workshops with instructional videotapes (see Binder, 2004; Levenson, 1995, 2006, 2007, 2008). This is one of the few models where there are research studies on training outcomes (Henry et al., 1993).
For a summary of the empirical research on TLDP, see Levenson (2007).
The professional career of Hanna Levenson, PhD, reflects a 30-year dialectic between intrapsychic and relational perspectives, insight and experiential learning, and clinical practice and scientific inquiry. Originally trained in personality theory and social psychology at Claremont University in California, she later retrained in clinical psychology at the University of Florida, Coral Gables, then interned at Langley Porter Institute (University of California, San Francisco, School of Medicine) in 1976.
She has been specializing in the areas of brief psychotherapy and clinical supervision for over 25 years. She is professor of psychology at the Wright Institute in Berkeley, California, and director of the brief psychotherapy program at California Medical Center in San Francisco. For the past 20 years, she was clinical professor in the Department of Psychiatry of the University of California School of Medicine and director of the brief psychotherapy program at the San Francisco VA Medical Center.
Dr. Levenson is the author of over 75 papers and two books, the Concise Guide to Brief Dynamic and Interpersonal Psychotherapy (2002), and Time-Limited Dynamic Psychotherapy: A Guide to Clinical Practice (1995; Spanish edition, 1997), selected by the Behavioral Science Book Service as a "book-of-the-month." She also has two professional videos, Making Every Session Count (Psychotherapy.net, 1999) and Time-Limited Dynamic Psychotherapy (APA, 2008).
In 2000, she founded the Levenson Institute for Training (LIFT), a center where mental health practitioners can receive in-depth training and certification in integrative, focused therapy. She also maintains a private practice in San Francisco and Oakland, California.
Dr. Levenson is a member of the American Psychological Association, the California Psychological Association, the Society for Psychotherapy Research, and the Society for the Exploration of Psychotherapy Integration.
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