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VOLUME 6 #{149}NUMBER 4. FALL 1997
Brief PsychodynamicPsychotherapies
Past, Present, and Future Challenges
JERALI) KAY, M.D.
The future educational and research needs of
briefpsychodynamic psychotherapy are
discussed. Spec�fic shortcomings of current
education and training in brief dynamic
therapies are elucidated. Many of these are
relevant to psychotherapy instruction in
graduate medical education in nondynamic
treatments as well. Educational and
technological recommendations are suggested
to remedy these shortcomings.
(The Journal of Psychotherapy Practice
and Research 1997; 6:330-337)
M anaged care has had a dramatic influ-
ence on the recent conceptualization of
psychotherapy models and the delivery of
brief psychotherapy services. The advent of
brief dynamic psychotherapy, however, pre-
cedes managed care by decades; indeed, Freud
himself relieved Gustav Mahler’s impotency
through interpretation in a single four-hour
meeting.
H I S 1’ 0 H I C A I.
I N T R 0 1) U C 1 I () N
Although both Rank, through his focus on
separation, and Ferenczi, through his highly
active therapeutic stance, provide some conti-
nuity for many of today’s briefer treatments, it
was Alexander and French’ who contributed
most significantly to modern brief psychody-
namic psychotherapies.
Like Rank and Ferenczi, Alexander and
French were concerned that psychoanalysis
had become highly intellectualized. They fa-
vored a more emotional experience for the pa-
tient within the therapeutic relationship and
introduced the concept of the corrective emo-
tional experience. The corrective emotional ex-
perience, considered heretical by traditional
analysts up until the recent past, advocated an
intentional assumption by the therapist of a
From the Department of Psychiatry, Wright State Univer-
sity School of Medicine, Dayton, OH 4540 1-0927. Send
correspondence to Dr. Kay at the above address.
Copyright © 1997 American Psychiatric Press, Inc.
KAY 331
JOURNAL OF PSYCHOTHERAPY PRACTICE AND RESEARCH
stance different from that of the patient’s origi-
nal traumatizing or disappointing object. For
example, if the patient as a child experienced
his mother as intensely invasive, the psycho-
therapist would adopt a relaxed, nonintrusive
attitude toward the patient.
Alexander and French were accused of
abandoning therapeutic neutrality by manipu-
lating the patient. They in turn argued that the
corrective emotional experience permitted the
patient to appreciate more clearly the irration-
ality of his or her feelings.
Alexander and French anticipated many
of today’s values and models of brief psycho-
therapy. They disagreed with the traditional
psychoanalytic notion that most important
psychological work occurs within analytic ses-
sions. Most of the work, they argued, should
take place outside of sessions, through reflec-
tion and through encountering new life expe-
riences. They believed, moreover, that some
patients improved more quickly with once-
weekly meetings and that five sessions weekly
promoted significant regression in some pa-
tients and promoted avoidance of real-life ex-
periences critical to enhancing therapeutic
gains. Alexander and French relied on planned
interruptions in therapy that lasted from 1 to 18
months to assess what issues required further
work by the patient. Such interruptions, by
promoting independent functioning, evoked
greater confidence in the patient. These inter-
ruptions also assisted in the decision about ter-
mination and promoted the patient’s ability to
apply more readily that which had been
learned in treatment. Planned interruptions
are highly compatible with today’s managed
care values of episodic treatment.
The systemization of dynamic brief psy-
chotherapy began in the 1970s with the
writings of Malan,2 Mann,3 Sifneos,4 and
Davanloo.5 All four of these authors based
their brief treatments on the psychoanalytic
principles of transference, psychic conifict, and
ego mechanisms of defense and on traditional
drive theory. Each, however, placed different
emphases on the importance of some of these
theoretical constructs. For example, Mann’s
approach is much more comprehensive and
less focused on drive theory than are Sifneos’s
and Davanloo’s. Each of these models, as op-
posed to many of the new brief dynamic treat-
ments, does provide a consistent theoretical
position that explains psychopathology and
mutative factors. Together, these clinicians for-
mulated some of the enduring features of psy-
chodynamic brief treatments. These include
the following characteristics:
#{149}Adefinite time limit to the treatment.
#{149}Selection of a treatment or problem focus
no later than by the second or third ses-
sion.
#{149}Rapid establishment of a therapeutic alli-
ance.
#{149}A high level of therapist activity (com-
pared with psychoanalysis).
#{149}More frequent use of confrontation and
elicitation of anxiety (especially by Sif-
neos and Davanloo).
#{149}Use of interpretation and transference to
demonstrate the link between past and
present emotional problems.
Important new models of dynamic brief
therapy, largely based on research, were intro-
duced in the 1980s. These included, but were
not limited to, the models of Horowitz, ad-
dressing Short-Term Dynamic Treatment of
Stress Response Syndromes;6 Luborsky’s
Short-Term Supportive-Expressive Psycho-
analytic Psychotherapy;7 and Strupp and
Binder’s Time-Limited Dynamic Psychother-
apy.8 Moreover, there are a number of other
predominantly psychodynamic brief treat-
ments that are either less well known to clini-
cians or, in some cases, lack the scientific rigor
of the previous three treatment approaches. -12
Nearly every major psychoanalytic approach
has a brief therapy model. Accelerated Em-
pathic Psychotherapy’3 based on self psychol-
ogy and brief treatment based on control
mastery theory’4 are but two examples. The
newest psychodynamic approach to the treat-
ment of panic disorder is that of Milrod et al.’5
Although not yet validated, their approach
shows promise as a treatment intervention in
332 BRIEF PSYCHODYNAMIC PSYCHOTHEHAPIES
VOLUME 6. NUMBER 4. FALL 1997
light of the high relapse rates after discontinu-
ation of medication or cognitive-behavioral
therapy of patients with panic disorder.
Conspicuous by its absence in this cursory
review is Klerman et al.’s Interpersonal Ther-
apy (IPT).’6 Although many psychiatrists inte-
grate 1FF with psychodynamic psychotherapy
in the treatment of depression and other dis-
orders, this practice has not been studied. Kier-
man, however, was quite clear that 1FF is not
a psychodynamic treatment. 1FF is based on
Adolph Meyer’s psychobiology theory (which
emphasized adaptation to environment and
the role of life experience), Harry Stack Sulli-
van’s interpersonal process theory, and John
Bowiby’s attachment theory, which highlights
the psychological dysfunction that accompa-
nies disruption and loss of relationships.
S E C E C T E D
RESEARCH FINDINGS
The brief dynamic psychotherapy approaches
currently in use have been comprehensively
examined in two excellent overviews.’7’8
Rather than offer in-depth discussion of all of
these approaches, I present here selected
findings of research into the brief dynamic
therapies.
Compared with 1FF and cognitive-behav-
ioral therapy, most of the brief psychodynamic
psychotherapies have not been supported by
rigorous efficacy or effectiveness research.
Efficacy is determined through the use of ran-
domized controlled studies. Effectiveness and
cost-effectiveness refer to a treatment’s success in
situations that more closely approximate ac-
tual clinical practice. Randomized controlled
studies often have limited generalizability to
clinical practice because in their pursuit of in-
ternal validity they study diagnostically homo-
geneous patient populations, use therapists
who are trained to provide a pure or nonrnte-
grative treatment based on manuals, and em-
ploy monitoring of patient progress as well as
therapist adherence. Some efficacy studies lack
long-term follow-up, which is central to meas-
uring endurance of treatments gains.
By definition, randomized controlled
studies also exclude subthreshold cases
wherein patients present with psychological
problems that cause significant pain or dys-
function but fail to meet DSM criteria for a
particular disorder. These subthreshold cases
are quite common in private practice. Simi-
larly, the problem of comorbidity, which may
be the rule rather than the exception in private
practice, is not addressed in most rigorous con-
trolled studies.
There has been insufficient research in-
volving psychoanalysis and long-term psycho-
analytic psychotherapy. In the brief dynamic
therapies as well, sufficient research simply has
not been carried out.’9 It is impossible in many
instances, therefore, to speak of either the effi-
cacy or the effectiveness of many of these treat-
ments. The dearth of investigations, however,
does not substantiate inefficacy or ineffective-
ness; there is broad-based empirical and heu-
ristic support for psychoanalytically informed
psychotherapy.20�’
Pertinent research findings on brief psy-
chodynamic psychotherapy can be summa-
rized as follows:
#{149}Brief psychodynamic psychotherapy,
when compared in two meta-analyses of
19 and 11 studies with other psycho-
therapies, was superior to no treatment at
1 year.22’23 However, these meta-analyses
examined few studies in common, and the
meta-analysis by Crits-Christoph23 used
more rigorous inclusion criteria regarding
patient selection, therapist experience,
and adherence to models. His meta-analy-
sis was able to demonstrate that dynamic
brief treatments are as effective as other
brief therapies. Unfortunately, Crits-
Christoph’s study can be criticized be-
cause it included 3 trials where patients
were treated by therapists using 1FF.
#{149}Time-limited psychotherapy appears to
be as helpful as, but not more helpful than,
unlimited long-term psychodynamic
treatment.2�26 There is a demonstrated
dose-response effect in that the more treat-
333
JOURNAL OF PSYCHOTHERAPY PRACTICE AND RESEARCH
ment patients receive, the more improve-
ment or depth of psychological change
they show.27’28
#{149}There are insufficient data to prove that
any one form of brief psychodynamic psy-
chotherapy is more effective than another.
#{149}Although patients in brief treatment tend
to experience enduring gains,29’30 there is
increasing evidence that further psycho-
therapy is frequently needed, helpful, and
quite common in the treatment of some
disorders and emotional problems.
#{149}Characterological problems tend to re-
quire longer periods of treatment than
do symftoms such as depression and
anxiety.
#{149}Outcome measures employed in many
brief treatment studies do not adequately
reflect the measures traditionally agreed
upon to determine the success of long-
term psychoanalytic therapy and psycho-
analysis.3�
In summary, with regard to the efficacy
and effectiveness of brief dynamic psycho-
therapies, absence of evidence is not evidence
of absence.
i’III; FUTURE OF BRIEF
I)vN��II(; TREATMEN’FS
The Need for Research
Scientific and economic pressures are re-
sulting in less willingness to embrace heuristic
models without outcome measures showing
their effectiveness in the treatment of specific
conditions. While a psychodynamic approach
to clinical interactions continues to be the most
comprehensive approach to the understanding
of the subjective illness experience, loss, con-
flict, and other traumatic or intensely disap-
pointing experiences, it is clearly not the best
treatment intervention for all clinical situ-
ations. Empirical evidence supports some of
the basic psychoanalytic concepts on which all
brief dynamic therapies are based: the uncon-
scious; pathogenic beliefs; and defense mecha-
nisms.3234 However, dynamic brief therapies
will advance only through greater internal vali-
dation. Above all, it is important to remember
that the absence of comparative studies of brief
dynamic treatments and of long-term psycho-
analytic psychotherapy accounts for the con-
fusion in the field. Very few initiatives have
thoroughly evaluated the efficacy or effective-
ness of psychodynamic psychotherapy. In es-
sence, psychodynamic psychotherapy has not
been proven ineffective.
Key research issues that must be ad-
dressed in the very near future for brief and
long-term psychodynamic treatments are
listed in Table i.3’
Educational Challenges:
Psychotherapy Instruction
In addition to the problem of limited re-
search, the most potent threats to the future
psychiatric practice of dynamic psychotherapy
reside in the inefficiency and nonstandardized
instruction of psychotherapy training, the fail-
ure to appreciate the critical skills, attitudes,
and knowledge required to conduct psycho-
therapy, and the confusing psychotherapy
pedagogy.
TABLE 1. Research challenges for psychoanalytic
psychotherapy
#{149}Determining efficacy for specific disorders
#{149}Developing treatment guidelines for interpersonal
problems and personality disorders
#{149}Developing reliable and valid self-report measures
for core conificts
#{149}Measuring potential cost-offset of different therapies
#{149}Determining efficacy of short-term versus long-term
psychotherapies
#{149}Matching patients to treatment on basis of
personality, functional level, or developmental stage
#{149}Examining whether and how experienced therapists
can be trained in short-term psychoanalytic
treatments
#{149}Learning the limits of brief therapy and conditions
or symptoms for which longer term psychotherapy
should be recommended
. Note: List derived from Barber l994.�’
334 BRIEF PSYCHODYNAMIC PSYCHOTFIERAPIES
VOLUME 6 #{149}NUMBER 4. FALL 1997
Psychotherapy educators in psychiatry
have disappointed the field in at least seven
critical areas:
1. They have not developed and introduced
new educational technologies in residency
education.
2. They have not integrated psychotherapy re-
search findings and emphasized that effec-
tive psychotherapy is predicated on clinical
decision making and treatment planning.
3. They have not conducted meaningful re-
search on psychotherapy training.
4. They have not provided integrative mod-
els of psychotherapy, especially those in-
tegrating medication and psychotherapy.
5. They have not acknowledged that al-
though manual-guided training may suc-
ceed in bringing trainees to a criterion level
of adherence to technical procedures, there
is little evidence that it improves therapy
outcomes or that a therapist practices skill-
fully. In short, adherence is not the same
as competency.
6. They have underestimated in some cases
the challenges of leaming and conducting
effective brief dynamic therapy within the
training setting. These challenges include
#{149}The difficulty in selecting a therapeutic
focus in some clinic patient popula-
tions, where significant and complex
psychosocial problems are the rule and
comorbidity is commonplace.
#{149}The ethical concerns and the strong
feelings (often anger toward the clinical
setting and guilt) aroused in trainees
when they are obligated to limit treat-
ment to their patients or to adhere to
forced or unplanned terminations.
#{149}The impact of learning the limitations
of brief interventions with respect to
symptom alleviation and charac-
terological change.
#{149}The daunting challenge of grasping the
importance and role of transference-
and technical concerns about it-within
brief therapies.
7. They have also failed in influencing ac-
creditation processes by not demanding
more specific educational outcomes and
by stipulating pedagogical methods for
maximizing training experiences rather
than emphasizing locations and durations
of rotations.
If psychotherapeutic skills are to remain
in the core professional identity of psychiatrists,
new pedagogical approaches to the teaching of
psychotherapy must be developed and imple-
mented. This need has arisen because
#{149}There are too many idiosyncratic teaching
methods and too little standardization
across training programs.
#{149}Although most programs make use of
clinical experiences, individual super-
vision, and didactics/conferences, little
new has been added to our teaching meth-
ods in 50 years.
#{149}Faculty, for the most part, remain reluc-
tant to conduct psychotherapy in front of
trainees for teaching purposes and their
academic departments for peer review.
#{149}A minority of faculty still attribute difficul-
ties in trainee-administered psychother-
apy wrongly to countertransference issues
and not deficits of knowledge or skill.
#{149}The demise of the comprehensive psychi-
atric or case formulation, not the DSM-III
and its successors, has been responsible
for increasingly superficial assessments of
patients. Case formulation must be revi-
talized to provide residents with a new
pragmatic-but partly causal-methodol-
ogy that will enable them, in the context
of their phenomenological or descriptive
presentations, to suggest reasons for each
patient’s crisis, symptom formation, and
enduring pathological beliefs.
#{149}Many psychoanalysts have long recognized
the disjunction between metapsychology
and psychoanalytic practice. It is time to
jettison metapsychological constructs that
are confusing and superfluous to learning
the basic science of psychodynamics.
KAY 335
JOURNAL OF PSYCHOTHERAPY PRACTICE AND RESEARCH
#{149}Faculty who teach psychotherapy must
have a theory of “cure” to conceptualize
for trainees how behavioral or motiva-
tional change occurs. Without such a tool,
residents become overwhelmed by the
specificity-nonspecificity battle and the
irrelevant biology-versus-psychology
schism.
#{149}Although the practice of having residents
undergo psychotherapy has recently
fallen out of favor, its possible functions
in educating and professionalizing resi-
dents should be revisited and, if indicated,
new models for providing quality and
reduced-fee treatment to residents should
be developed. Psychotherapy may pro-
vide firsthand experience for residents
with the patient role, the power of the
doctor-patient relationship and transfer-
ence, the role of the unconscious, the cen-
trality of empathy, and the impact of
correctly timed and framed interpreta-
tions.
#{149}More than any other portion of the resi-
dency curriculum, psychotherapy instruc-
tion varies from program to program.
Master clinicians must assume leadership
in establishing a standardized curriculum,
not a model curriculum, for psycho-
therapy education. The development of
text material must be accompanied by
computer-assisted instructional formats
portraying model treatments by master
clinicians in addition to decision-making
exercises in psychotherapeutic interven-
tions.
#{149}Lessening the divergence between psy-
chotherapy research and practice35 is an
educational issue. Research findings
should be integrated into educational pro-
grams; case studies should no longer be
disparaged (they can be scientifically rig-
orous in testing a hypothesis); researchers
should include clinical vignettes and de-
tails about their techniques when describ-
ing their research; research should be
undertaken to determine what types of
psychotherapy research is helpful to clini-
cians; and further study is needed of the
accessibility and comprehensibility of re-
search findings.36
Educational Challenges:
Is There a Need for
New Supervisory Models?
Most therapists have never been trained
in any method of supervision. At least in psy-
chiatry, “see one, do one, and supervise one”
remains the pathway to becoming a supervisor.
Although this model remains prevalent in
medical education, it is no longer particularly
attractive. In many psychotherapy training
situations, faculty are unclear how to assist
trainees in defining the goal of treatment and
in identifying a core conflictual theme, focus,
cyclical maladaptive pattern, or central issue.
In short, current supervision in many pro-
grams is theoretically diffuse and unfocused.
New methods that assess the helpfulness of
supervision to the trainee and the impact of
supervision on the quality of care provided by
the trainee are desperately needed.
As increasing pressure to generate larger
parts of their salaries diverts faculty from teach-
ing, the professional development of the young
psychotherapy supervisor is in jeopardy. Al-
though manual-driven treatments have ad-
vanced psychotherapy research and patient
care, we do not have a manual for supervision
or standards that address knowledge, attitudes,
and skills necessary for effective supervision.37
Audio-visual (A-V) model cases for super-
visors should be developed to promote knowl-
edge, skills, and helpful attitudes about the
challenges and techniques of supervising train-
ees. Similarly, A-V practice tapes that would
assist the trainee in recognizing a therapeutic
focus or transference are greatly needed.
Supervising of supervisor and trainee could be
improved through the use of computer-as-
sisted and interactive video technology.
Examples of innovative programs can be
found at the University of Pennsylvania. Dr.
Aaron Beck’s program uses phone supervision
for trainees conducting cognitive-behavioral
336 BRIEF PSYCHODYNAMIC PSYCHOTHERAPIES
VOLUME 6. NUMBER 4. FALL 1997
therapy. This apparently has been quite helpful
for volunteer faculty, who, after reviewing the
trainee’s taped therapeutic sessions, can ad-
dress issues of behavior, style, and adherence
to manual treatment. Dr. Lester Luborsky, at
the same institution, has employed creative
group and peer supervisory models with his
residents, placing them each in the supervisory
position and the position of being supervised,
as well as integrating process notes and A-V
portions of the treatment itself. Roleplaying is
occasionally used also.
Consolidation of therapeutic gains in all
brief dynamic treatments requires close atten-
tion to the termination phase. However, there
is great variability among programs in the con-
ceptualization and teaching of the termination
phase, as there is also in the literature. Super-
visory exercises that elucidate the important
technical concerns of the termination would
be welcomed.
Educational Challenges:
Integrating New Technology
Most psychotherapists are unaware of the
high-quality, home-based, two-way cable net-
works that operate, especially in the western
part of the United States. Not only can such
systems be used to teach diabetic care in the
home, they can also be used to evaluate pa-
tients for psychotherapy and provide mecha-
nisms for consultation about disruptive
behavior in children and adults. They provide
the potential for conducting most or all of a
brief psychotherapy from long distance.38 Of
greater importance is the possibility of multi-
site cable-based supervision for one psycho-
therapy program or a consortium of programs.
In such a format, supervisors can model tech-
nique and maintain communication with
supervisees through the use of immediate
viewer response systems.
Psychotherapy educators have trailed far
behind other health care professionals in the
development of compact disc multimedia in-
teractive programs. These programs integrate
actual clinical encounters with self-learning
principles embedded in text. The Internet pro-
vides other opportunities for continuing edu-
cation without the constraints of production
delays associated with print material. Perhaps
someday it may be possible to have the psy-
chotherapist appear in the home of the patient
as a hologram. (Shades of Star Warr the psy-
chotherapist as the “Force.”)
C 0 N C I. U S I 0 N
There has been a long-standing tradition
within psychoanalysis and psychoanalytic psy-
chotherapy of developing brief, effective thera-
peutic models. Given the breadth and depth
of psychoanalytic theory, many of these heu-
ristic approaches have held promise; however,
few have been validated in the same fashion
as other, nondynamic brief treatments. Lack-
ing robust scientific data in both efficacy and
treatment effectiveness, many brief dynamic
therapies are under attack now from psycho-
therapy researchers, clinicians, and managed
care organizations. At present it can be said
that, as a group, the brief dynamic psycho-
therapies have received promising but limited
support from research.
Because the majority of all patient encoun-
ters, at least in American psychiatry, involve
some form of psychotherapy, and many of
these interventions are based on the principles
of psychodynamic psychotherapy, the field
must move forward and complete the research
that will substantiate the helpfulness of brief
dynamic approaches, either when used as the
only intervention or in conjunction with other
interventions such as medication.
R E F E R E N C E
1. Alexander F, French TM: Psychoanalytic Therapy:
Principles and Applications. New York, Ronald Press,
1946
2. Malan DH: The Frontier of Brief Psychotherapy. New
York, Plenum, 1976
3. Mann J: Time-Limited Psychotherapy. Cambridge,
MA, Harvard University Press, 1973
4. Sifneos P: Short-Term Dynamic Psychotherapy and
Emotional Crisis. Cambridge, MA, Harvard Univer-
KAY 337
JOURNAL OF PSYCHOTHERAPY PRACTICE AND RESEARCH
sity Press, 1972
5. Davanloo H: Short-Term Dynamic Psychotherapy.
New York,Jason Aronson, 1978
6. Horowitz MJ: Stress Response Syndromes, 2nd edi-
tion. Northvale, NJ,Jason Aronson, 1986
7. Luborsky L: Principles of Psychoanalytic Psychother-
apy: A Manual for Supportive-Expressive (SE) Treat-
ment. New York, Basic Books, 1984
8. Strupp HS, BinderJL: Psychotherapy in a New Key:
A Guide to Time-Limited Dynamic Psychotherapy.
New York, Basic Books, 1984
9. Garfield SL: The Practice of Brief Therapy. New York,
Pergamon, 1989
10. Bellak L: Handbook of Intensive Brief and Emer-
gency Psychotherapy, 2nd edition. Larchmont, NY,
CPS, 1992
11. Gustafson JP: The Complex Secret of Brief Psycho-
therapy. New York, WW Norton, 1986
12. Benjamin LS: Use of structural analysis of social be-
havior to guide intervention in psychotherapy, in
Handbook of Interpersonal Psychotherapy, edited by
AnchinJC, Kiesler DJ. New York, Pergamon, 1982,
pp 190-212
13. Fosha D: The interrelatedness of theory, technique and
therapeutic stance: a comparative look at intensive
short-term dynamic psychotherapy and accelerated
empathic therapy. International Journal of Short-
Term Psychotherapy 1992; 7:157-176
14. WeissJ, SampsonJ: The Psychoanalytic Process: The-
ory, Clinical Observations and Empirical Research.
New York, Guilford, 1986
15. Milrod B, Busch F, Cooper A, et al: Manual of Panic-
Focused Psychodynamic Psychotherapy. Washing-
ton, DC, American Psychiatric Press, 1997
16. Klerman GL, Weissman MM, Rounsaville BJ, et al:
Interpersonal Therapy of Depression. New York, Ba-
sic Books, 1984
17. Crits-Christoph P, Barber JP (eds): Handbook of
Short-Term Dynamic Psychotherapy New York, Basic
Books, 1991
18. Messer SB, Warren CS: Models of brief dynamic psy-
chotherapy: a comparative approach. New York, Guil-
ford, 1996
19. Roth A, Fonagy P: What Works for Whom: A Critical
Review of Psychotherapy Research. New York, Guil-
ford, 1996
20. Lazar SG: The effectiveness of psychodynamic psy-
chotherapy for depression. Psychoanalytic Inquiry
1997; (suppl):51-57
21. Doidge N: Empirical evidence for the efficacy of
psychoanalytic psychotherapies and psychoanaly-
sis: an overview. Psychoanalytic Inquiry 1997;
(suppl): 102-150
22. Svartberg M, Styles TC: Comparative effects of short-
term psychodynamic psychotherapy: a meta-analysis.
J Consult Clin Psychol 1991; 59:704-714
23. Cnts-Christoph P: The efficacy of brief dynamic psy-
chotherapy: a meta-analysis. Am J Psychiatry 1992;
149:151-158
24. Orlinsky DE, Howard KI: Process and outcome in psy-
chotherapy, in Handbook of Psychotherapy and Be-
havior Change, 3rd edtion, edited by Garfield SL,
Bergin AE. New York, Wiley, 1986, pp 311-381
25. Koss MP, ButcherJN: Research on brief psychother-
apy, in Handbook of Psychotherapy and Behavior
Change, 3rd edition, edited by Garfield SL, Bergin AE.
New York, Wiley, 1986, pp 627-670
26. Koss MP, ShiangJ: Research on brief psychotherapy,
in Handbook of Psychotherapy and Behavior Change,
4th edition, edited by Bergin AE, Garfield SL. New
York, Wiley, 1994, pp 664-700
27. Howard KI, Kopta SM, Krause MS, et al: The dose-
effect relationship in psychotherapy. Am Psychol
1986; 41:159-164
28. Kopta SM, Howard KI, LowiyJL, et al: Patterns of
symptomatic recovery in psychotherapy. J Consult
Chin Psychol 1994; 62:1009-1016
29. Nicholson RA, BermanJS: Is follow-up necessary in
evaluating psychotherapy? Psychol Bull 1983;
93:261-278
30. Lambert MJ, Shapiro DA, Bergin AE: The effective-
ness of psychotherapy, in Handbook of Psychotherapy
and Behavior Change, 3rd edition, edited by Garfield
SL, Bergin AE. New York, Wiley, 1986, pp 452-481
31. BarberJP: Efficacy of short-term dynamic psychother-
apy: past, present, future.J Psychother Pract Res 1994;
3:108-121
32. Weiss J: Unconscious mental functioning. Sci Am
1990; 262:103-109
33. Vaillant GE: Ego Mechanisms of Defense: A Guide
for Clinicians and Researchers. Washington DC,
American Psychiatric Press, 1992
34. Horowitz MJ, Milbrath C, Stinson CH: Signs of de-
fensive control locate conflicted topics in discourse.
Arch Gen Psychiatry 1995; 52:1040-1047
35. Stiles WB: Producers and consumers of psychotherapy
research ideas.J Psychother Pract Res 1992; 1:305-307
36. Talley PF, Strupp HH, Butler SF (eds): Psychotherapy
Research and Practice: Bridging the Gap. New York,
Basic Books, 1994
37. Rodenhauser P: On the future of psychotherapy super-
vision and psychiatry. Academic Psychiatry 1996;
20:82-91
38. Kaplan EH: Telepsychotherapy: psychotherapy by
telephone, videotelephone, and computer videocon-
ferencing.J Psychother Pract Res 1997; 6:227-237
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