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International Journal of Intensive Short-Term Dynamic PsychotherapyInt. J. Short-Term Psychother. 1, 59 82 (1986)DOI: 10.1002/sho.161

Beyond Interpretation: InitialEvaluation and Technique inShort-Term DynamicPsychotherapy. Part I

DAVID MALANParkers Close, Hartley Wintney, Hampshire RG27 8JG, England

The present article begins by describing the two basic questions in Short-Term DynamicPsychotherpy, namely what are the techniques that maximize success, and how may suitable patients berecognized? A consideration of work at the Tavistock Clinic leads to the conclusion that purely interpreta-tive techniques, whether of short- or long-term therapy, are inadequate. In the authors view, Davanloohas developed a technique that largely overcomes these limitations. This is illustrated by an initialinterview of great length and complexity, which therefore needs to be divided into two parts. The secondpart follows. At the end of the second part the practical and theoretical consequences of Davanloos workwill be considered.

Introduction

The Theoretical and Practical Problems

If such results could be achievedeven exceptionallyin two interviews, howcould an analyst know that he did not overlook such a possibility in a large number ofcases? This case was the beginning of our decision to undertake a systematic studyinto the possibilities of briefer, not superficial and merely supportive, but deeplypenetrating treatment.

This is Franz Alexander describing how he came to found the work of theChicago school on Short-Term Dynamic Psychotherapy. The patient to whom hewas referring, a scientist aged 51, was cured of his severe depressive attacks in twosessions. Alexander brought him to the realization of his intense guilt-laden competi-tiveness with his current colleagues, and traced this to its origins in the relation withhis father and brother in his early life. Follow-up was eight years.

In the following quotations from Alexanders discussion of this case, I havepicked out in italics his reference to certain issues which will play a large part in thepresent article (see Alexander and French, 1946, pp. 146ff):

All thisproves that in psychotherapythere remains an imponderable factor, whichhas to be left to intuition or else to luck . . . In this instance it may have been luck. It isour premise, however, that luck can be replaced by a methodical procedure. . . . .We can make an appraisal of the patients problem in psychodynamic terms and planour tactics accordingly. The technique of planned therapy is an attempt to replacechance with prediction based on valid dynamic principles . . .

Copyright 1986 John Wiley & Sons, Ltd.

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He concludes: Our task, our challenge, therefore, is to discover just in whatcases is such intensive therapy possible, and to establish the techniques necessary to

bring about beneficent results.

I do not know what Alexander would have felt about being compared to Beetho-ven, butas has been said of Beethovens last quartetsthese passages from Alex-ander, published in 1946, remain always contemporary. They describe in theclearest possible terms the main issues facing any investigator of Short-Term Dy-namic Psychotherapy.

It seems that many investigators have started from this same point: the observa-tion that there are certain patients who receive a crucial piece of emotional insight ina few sessions and obtain immediate relief from the problems that brought them totherapy. This observation led to the work of the Chicago school under the leadershipof Alexander, as described above; it led to that of Sifneos (see Chapter 1 of his 1972

book Short-Term Psychotherapy and Emotional Crisis); and it figured very promi-nently in the preliminary discussions of Balints team at the Tavistock Clinic in 1955(see Malan, 1976, p. 349).

The similarities do not end there. The obvious questions that the investigatornow asks are, first, how these patients may be found, and second, what proportion ofthe psychotherapeutic population they represent. Unfortunately, the answers arealmost always the same: these sporadic cases are drawn from a very large populationand are noticed because they are so striking; but anyone who begins systematicallylooking for them cannot find them because they are so rare. However, during thecourse of the investigation a crucial and much more favorable observation emerges,which requires a digression if its full significance is to be understood.

If Alexanders account of the above therapy is examined carefully, then it seemsthat the therapist used certain elements of the technique of interpretative psycho-

therapy and not others. That is, he interpreted the patients denial (defence) of hisguilt-laden competitiveness (anxiety and impulse)the triangle of conflictandhe made the link between this pattern in relation to current people and people in thepasttwo corners of the triangle of personbut it seems he did not need to makeany mention of the third corner of this second triangle, namely the transference.Moreover, the patient showed very little resistance and responded immediately whenhis defences were interpreted. In fact there are two other case histories in the samechapter with exactly similar characteristics.

We are now in a position to describe the crucial observation mentioned above.This is that any well trained investigator in this field soon gets drawn into using thefull range of techniques of interpretative psychotherapy, that is, the working throughof resistance and the completion of both triangles, including interpretation of the

transference and making the link between the transference and the past. He nowdiscovers that this makes his therapy far more powerful, more reliable, and morewidely applicable. The most striking example described by the Chicago school (seeAlexander and French, 1946, pp. 293 299) was the case of a young man of 19complaining of severe depression, whose mother had died in a terrible accident whenhe was three. He showed the greatest resistance against remembering anything abouther whatsoever, let alone any feelings; but he recovered from his depression afterre-living overwhelming feelings of love and grief for her through his relation with hiswoman therapist.

1986 John Wiley & Sons, Ltd. Int. J. Short-Term Psychother. 1, 59 82 (1986)

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Beyond Interpretation 61

This was an exceptionally dramatic case; but others less dramatic yet still verystriking, in which deep-seated and enduring changes result from using the full range

of interpretative techniques, have been observed by many workers in this field. Bythis means the range of patients suitable for Short-Term Dynamic Psychotherapyfor which I shall use the abbreviation STDPis considerably widened. Up to 40sessions may be required in the most difficult cases, but it is something of anunderstatement to say that this is still more economical than a full-scale analysis.

There lies embedded in these case histories a profound theoretical problem thatis crucial to the whole issue to STDP and can be formulated as follows: Our techniqueis powerful enough to enable us to recognize the problems underlying a patientspresenting complaints and to bring these conflicts into the open; but why is it that insome favorable cases this results in unlocking the whole neurotic process, while insome it fails to do so? What is the difference between the two? Or, even if we do notknow the difference theoretically, are there empirical signs by which we can tell thedifference practically? If so, what proportion of the psychotherapeutic population do

these favorable cases represent?

Selection and Technique: The Tavistock System

The Tavistock school has addressed itself to these questions for many years andhas arrived at partial answers. These are expressed in the following selection process:

(1) Patients who are obviously unsuitable, in whom uncovering psychotherapywould be dangerous, are eliminated by taking a careful psychiatric history.

(2) This shades into, or is followed by, a comprehensive psychodynamic history.(3) Provided there are no contraindications, the psychodynamic history is ac-

companied by trial therapy, in the form of carefully chosen interpretations.

(4) The patients response to interpretation is monitored.

The most suitable patients are then those who show the following characteristics,which constitute the selection criteria:

(1) There are no contraindications.(2) The evaluator is able to make a comprehensive psychodynamic formulation.(3) This formulation reveals an underlying simplicity in terms of a clear-cut

central theme running through the patients lifehis life problem.(4) The patient has responded positively to interpretations on this theme. That is

he has given responses that confirm them, he has shown the capacity to work withthem without becoming unduly disturbed, and his motivation to work with them has

either been high from the beginning or has shown a marked increase.

The therapeutic process now consists of using this central theme or life problemas the focus of a planned therapy: directing interpretations towards this problemwherever possible, and using the full range of interpretative techniques, includingtransference interpretations and the link with the past.

I believe that most of these principles are fundamental to short-term interpreta-tive therapy and are therefore applicable to other schools as well. Indeed, all of themwere already formulated, at least implicitly, by Alexander and French in the 1940s.


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The Tavistock System: The Question of Effectiveness

The crucial question, of course, is how effective are such systems, both qualita-tively in terms of therapeutic results, and quantitatively in terms of the proportion ofpatients with whom they are successful? Here, once more, I shall describe theTavistock conclusions.

Qualitatively speaking, the best results seem to involve nothing less than thepermanent and total resolution of the patients neurosis. If this seems a large claim,then all I can say is that in certain patients no trace of the original disturbances couldbe found in a follow-up interview up to seven or eight years since termination. Inother patients, though a small residue of problems could be detected, it was clear thattrue resolution of a major part of the central problem had taken place. In these casesselection and technique were clearly powerful and effective.

Thus this systematic work on a fairly large sample of patients 60 patientstreated, 48 followed updemonstrated something of immense importance, namelythe feasibility of producing deep-seated and permanent changes with a technique ofSTDP that, by employing all the possible components of interpretative psychother-apy, shirked nothing and went to the heart of the patients problems.

What about quantitative considerations? Here, unfortunately, the picture ismuch less favorable. There are two questions: (1) What proportion of patientsreferred to us are selected for short-term therapy, and (2) What proportion of thesegive total or near-total resolution, i.e., how accurate is the selection process?

The answers to these two questions are: (1) that no more than a few percent ofpatients referred to us are selected, and (2) that of these about a quarter give themajor therapeutic results desired. If we refer back to patients of the type described atthe beginning of the present article, who can hardly be found at all, then this factor ofa quarter is obviously a great improvement. On the other hand, the situation couldalso be described more pessimistically, by saying that only a very small proportion of

patients is considered suitable, and of these another relatively small proportion isactually suitable.We can therefore reformulate both the theoretical and the practical problems as

follows: We are sure that therapeutic effects follow from strong dynamic interactionbetween therapist and patientinterpretation and response, the transference expe-rience and its link with the pastand at initial interview we have no difficultywhatsoever in selecting patients who will interact in this way; we believe that thosewho give favorable therapeutic results will come from amongst patients with thiscapacity, i.e., that this is a necessary condition; but it is not a sufficient condition, andthe problem of telling the favorable from the unfavorable patients at the beginningremains unsolved. There is a major gap between dynamic interaction on the onehand, and resolution of the neurosis on the other.

These two points taken togetherthe small proportion selected and the rela-

tively small proportion of these who recovermean that we are facing somethinglike the second order of small quantities, which in mathematics is often consideredas equivalent to zero. In other words we are almost back to where we started: It istrue that we have made an observation of great theoretical significance; and we arenow able to use short-term methods in practice to transform the lives of a fewfortunate individuals; but we have not fulfilled our fundamental aims, which cannotconsist of anything less than significantly reducing the over-all burden of neuroticsufferingor, if this should seem to be an over-inflated ambitionat least signifi-cantly easing the pressure on busy psychotherapeutic clinics.


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Long-Term Therapy

Of course long-term therapy is in a basically similar position. Here we can also

describe the situation at the Tavistock. A higher proportion of those referred to usare regarded as suitable for long-term than for short-term individual therapy; but thisis balanced by the fact that vacancies immediately become blocked by these verypatients, so that for the vast majority individual therapy is simply not available. Andagain, in a recent follow-up study (not yet published), of 84 patients who hadreceived more than 40 and up to 900 sessions, only about a fifth showed majorresolution. Moreover, as yet we have no inkling of how to distinguish between thisfifth and the other four-fifths in whom these changes do not occur. To echo Alexan-der, it seems to be a matter of luck.

The Relation between Improvement and Response to Interpretation

Once more we can formulate the problem, now covering the whole of interpreta-tive psychotherapy, in terms of the following paradoxical situation:

The theory of the origin of neurosis in unconscious conflict whatever theskeptics may sayis as firmly established as most scientific theories can be; this hasled to a highly refined technique of interpretative therapy, the principles of which areequally well established and understood; and this technique is used with confidenceand skill in our day-to-day contact with patients. Our patients can then be describedon a continuum: At one end are those highly resistant patients who never respondwith anything but purely intellectual insight, and of course no one is surprised whenthese show no improvements; at the other end are those relatively rare individualswho not only respond but achieve deep emotional insight and recover; but in themiddle are the great majority, who respond almost daily to our interpretations,apparently achieving emotional insight, but failing to show the therapeutic effectsthat we are seeking. What then had happened to one of the central tenets of dynamicpsychotherapy, that when the unconscious conflict is brought into the open, experi-enced, and worked through, the neurosis is resolvedwhere id was, ego shall be?

Traditional psychotherapists have no answer to this theoretical question; and theonly solution that they know to the practical issue is to go on as before, making dailyinterpretations, trusting to luck, and keeping alive the hope that eventually thisprocess will lead to the desired therapeutic effectswhich indeed it sometimes does,but as our follow-up studies have shown, all too seldom.

Purely Interpretative Psychotherapy: Summing Up

The only possible conclusions are, first, that purely interpretative therapy,whether long-term or short-term, has been carried to the limit and has been found

inadequate; and second, that unless we are prepared to accept this fatalistically, thenwe need some more powerful kinds of intervention which can be used over and aboveinterpretation. This leads us back to the title of the present article, Beyond interpre-tation, because it is this that I believe to be Davanloos most important discovery.

Davanloos Technique: Overview

What are these interventions? First of all, it needs to be emphasized that they donot replace interpretation but are used before interpretation. The central interven-


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tion is systematic challenge to the resistance, but this needs to be considered in thecontext of the whole process of interaction between therapist and patient, in which it

is possible to distinguish the following phases:

(1) Systematic pressure on the patient to experience his true feelings.(2) An inevitable rise in resistance, which appears in the form of a series of

defences.(3) Systematic challenge to each defence the moment it appears.(4) An inevitable rise in transference feelings, which the patient does not wish to

experience or show, and which therefore lead to a further increase in resistance.(5) Systematic challenge to the resistance, now in the transference, leading

eventually to(6) Direct experience of the transference feelings.(7) This has profound effects. The patient experiences great relief, his uncon-

scious becomes unlocked, and there is a major mobilization of his therapeutic

alliance.(8) As a result:(a) it is now possible for the first time to begin to make use of

interpretations;(b) it is also possible to begin to explore relationships outside the transfer-

ence, both current and past, in a meaningful way;(c) the patient may begin to make his own interpretations.

(9) Thus in phase (8) the technique begins to become much more like that ofinterpretative therapy. However, as each new area is explored, there is often a returnof resistance, so that the cycle begins again at phase (3) with further challenge.

(10) The exploration that has been carried out in phase (8)(b) now enables thetherapist to introduce a new element, namely interpretations linking the resistance inthe transference with defence against feeling in other relationships (transference-

current-past or TCP interpretations).(11) This cycle, which may have to be repeated many times, eventually leads tothe phase of pure content, in which the patients conflicts in other relationships canbe explored and interpreted without reference to the transference.

Davanloo makes the principle of trial therapy, mentioned above, more central tohis selection process than any other worker in this field, and therefore an initialinterview can be used to illustrate both of the twin issues of selection and techniquewith which the present article is concerned. (For further reading see Davanloo, 1978and 1980.)

Davanloos System of STDP: Technique and Selection Illustrated by an

Initial Interview

The Case of the Man from Southampton

The evaluator deliberately keeps himself ignorant of all details of the patient, theaim of which is that everything should come out in a dynamic fashion for bothparticipants in the interview. The patient may be psychoneurotic, but equally he maybe borderline or may suffer from an even more serious condition such as schizo-phrenia or manic-depressive psychosis. The evaluator watches with the utmost


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vigilance and may receive clues about these conditions early in the interview, orindeed the moment the patient walks into the room. In this case he will start from the

beginning with an entirely different technique. Otherwise he begins trial therapy inthe form of exerting pressure at once, but he watches for signs that the patient isbecoming unduly disturbed by this and he then immediately becomes lessconfronting.

The opening phases of the interview may follow a number of different patternsaccording to how accessible the patients feelings are, how resistant he is, and whathe feels about the situation in which he finds himself. This particular patient, a manof 47, shows one of these typical patterns: he has had many years of previouspsychotherapy which had achieved little more than a consolidation and ossificationof his defences, as is evident from the very first moment of the interview. With such apatient the two initial phases described above become telescoped. Also, because ofrepetition and overlapping, the later phases are more complex than in the abovescheme, so that it is better not to number them.

From now on I shall refer to the evaluator by the less unwieldy term therapist,which of course is entirely accurate in an interview of this kind.

The Phase of Enquiry, Pressure, Resistance

TH: Could we start to see what is the nature of the difficulties that you have and youwant to get help for them?

PT: (sigh)TH: What are the problems?PT: I dont know, its been a long time that Ive been seeing doctors and in all that

time I dont know that I would be able to identify the problem. . . .TH: What is it that bothers you, the difficulties that you have?PT: Well a lot of anxiety relating I think during the past year or so with the therapist

that I was seeing. I guess I became aware that I was feeling very guilty aboutmany things such as my sex life. Very guilty about my relationship with my wifeand my father, my family. Ive left my family in England by coming here toCanada and I havent had much communication with them and I havent beenhappy about it. I havent been happy about . . . about my situation in life. Ivespent too much time working.

The whole atmosphere conveyed by this passage is of vagueness, lack of specific-ity, skating over the surface, and flitting from one subject to another. Thus hementioned anxiety which apparently has some connection with guilt, but he doesnot make clear what the connection is. He then speaks of guilt in a number of

different areas but in only one of them does he say what the guilt is aboutnamelylack of communication with his family. The statement, I havent been happy aboutmy situation in life is hardly very informative. Finally, I have spent too much timeworking may perhaps imply that he feels guilty about neglecting his personalrelationships, but he does not say so and leaves the listener to make his owninference.

This is a point at which the interpretative technique and that of Davanloo show acrucial divergence. In the interpretative technique the therapist might make theabove inference about neglecting personal relationships and help the patient out by


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putting it to him in the form of a clarifying interpretation. If he received a positiveresponse he might go on to ask a question of the patients unconscious: why should

you need to neglect your personal relationships?There is no doubt that this approach would probably produce a drop in tensionand some useful dynamic information, but it entirely neglects the patients basicposition of resistance. Unless this can be brought into the open and resolved no trueunlocking of the patients unconscious will ensue.

Therefore the therapist carefully does not help out in this way; and since thepatient is showing so much resistance against even making clear the nature of hisdifficulties, the therapist continues to put pressure on him to do exactly that, with theaim of bringing the resistance more and more into the open.

In response there is further vagueness and then a moment of greater specificity:

PT: I started seeing a doctor for therapy a long time ago, about 20 years ago and uh. . . I have seen doctors on and off since. Always for the reason that there seems

to be something wrong, things seem not to be going well. I seem to be veryworried and uh . . . Of course I would uh . . . I have suffered from a very severeoutburst of temper occasionally.

The therapist now increases the pressure by deliberately bringing in a strongerword than temper:

TH: Outburst of anger you mean?PT: Yes.

This, however, did not seem to be the reason why the patient is now seekingtreatment. He returned to the word anxiety and the therapist now employed

a standard question which constitutes the next stage in the process of pressure.The ultimate aim of all dynamic psychotherapy is that the patient should ex-perience to the full the true feelings against which he has been defending himselfbecause they are loaded with anxiety or pain. In this phase of the interview,therefore, the therapist deliberately exerts pressure towards the experience offeeling. If the patient mentions some situation about which he has, or ought tohave, feelings, this pressure takes the form of asking What do you (or did you)feel about that? If the patient mentions a feeling, the next question is Whatis it like when you feel. . .? or How do you experience. . . whatever it isthat he has mentioned.

With highly responsive patientswho, as described above, are extremely rarethis may lead to the actual experience of feeling and to therapeutic effects, and ifso well and good. Far more often, however, the patients unconscious becomes

alarmed, and the result is an increase of resistance. Thus, as the pressure is kept up,the resistance comes more and more into the open, where it can be dealt with. In thecase of a patient such as the present this increase in resistance was inevitable. Whathappened was that, in response to the word anxiety, the therapist asked, What isit like when you feel anxiety? to which the patient said that he used the wordbecause that was the label given to him by his therapist. Intellectualization anddistancing could hardly be carried further.

The therapist kept up his probing and in the teeth of this kind of resistanceeventually managed to get clear that the patient suffers from long-standing problems


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in his personal relations. The patient made the vague and general remark, Withwomen I have a lot of problems, so the therapist kept up the pressure on this

defence by asking him to give a specific example, but he was unable to do so. Hewould only say that he hides away.During the course of this probing some factual information emerged: the pa-

tient has been married for 21 years, has been separated from his wife for the past twoyears, and for the past few months has been living with another woman. He said thathe feels more comfortable with her and that sexual relations are better than with hiswife though he still feels some guilt.

It is worth noting that in the following passage the therapist carefully does notask What do you feel guilty about? which would be only too likely to lead to furtherintellectualization. Instead he concentrates on trying to explore the actual experienceof guilt. The patient first gives an answer which does little more than paraphrase thestatement of guilt (I felt I should not be doing what I do); and then, when thetherapist persists, the patients unconscious becomes alarmed, and he falls back on

using the same defence as he had used for anxietyso that the interview is clearlygoing round in circles:

PT: I still feel somewhat guilty about it but. . . .TH: What is that you refer to as guilt when you say. . . .?PT: Well I have always felt that I should not be doing what I do.TH: Hmm. What happens to you after sex that you refer to as guilt?PT: I refer to it as guilt because this is what its been labelled by, by therapists

previously.

The Phase of Challenge to the Resistance

The therapist has been waiting for this point, where the resistance has become somanifest and so apparently immovable, and the next phase of the interview begins.This may be described as follows:

The resistance is made up of individual defences, some of long standing such asthe distancing and intellectualization already mentioned, and some more tactical,designed at any given moment to keep feelings away or to divert the therapistsattention from sensitive areas.

The therapist now brings in a new kind of intervention, namely challenge to eachnew defence as it arises, which become more and more powerful in step with theincrease in resistance.

These challenges lie far from the traditional interpretative technique and requireconsiderable discussion. They range from simply pointing out the patients defence,through forcing the patient to make up his mind, challenging questions, the use of

deliberate irony, to using almost scathing language. The following are examples:

(1) The patient is distancing himself from his feelings by using the phrase Isuppose;TH: But you say you suppose.(2) The patient keeps his statement tentative:TH: Was it satisfactory or wasnt it?(3) The patient makes out he cannot remember:TH: How is your memory usually?


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(4) The patient says he thinks his sex life was not satistactory:TH: You think? You are not sure?

(5) The patient has been keeping everything vague:TH: You constantly want to keep things in a state of limbo.

It is very important to describe the tone of these challenges, which is notadequately conveyed by the written word alone. Though the words themselves maysometimes seem harsh, the tone is always both firm and gentlethe iron hand in thevelvet glove. The challenges are directed not against the patient but against hisdefences, in such a way as to make them feel useless and counterproductive. This hastwo opposite effects: the part of the patient that is identified with them wishes moreand more desperately to cling onto them; while beneath this another part begins toturn against them and to wish to be freed from them. The therapist reinforces thelatter by always putting his challenges in such a way as to convey that he is entirely onthe patients side: that his only aim is to enable the patient to feel the full range of his

emotions, to become free of his suffering, and to achieve his potential; and that hewill stop at nothing to enable the patient to reach this pointcertainly he will notspare him pain, but this pain will be far more bearable than the patient fears, and inthe end will be wholly beneficial. When patients speak about their feelings atfollow-up, this is the message that they remember. They do not feel that the therapisthas been in any way aggressive.

Side by side with these two opposite feelings about the defences, there arise twoopposite feelings about the therapist. In other words there is a rapid and intense risein transference, against which the patient defends himself in turn, which leads to afurther increase in resistance. This will be discussed more fully later, but for the timebeing it is crucial for the therapist to realize that throughout the phase of challengethe mounting resistance begins to have an increasingly important transferencecomponent.

We may now take up the interview where we left off. The therapist opens byconfronting the patient with his vagueness and distancing:

TH: Now could we then clarify a few things, because I wonder if you notice yougeneralize issues or difficulties that you have? You generalize it and somehowalso you remain vague. You see, for example, you say sexual difficulties or yousay you are not able to initiate, or you say you feel guilty, okay? These are alllabels, they are vague and we dont understand what really you mean by any ofthese issues. Do you notice that?

PT: Yes except that I dont know how to say what Im trying to say.

The patient went on to speak further about his marriage, in which there had been

problems of very long standing. However, he remained vague and repeatedly usedphrases such as I guess, I dont know, and maybe. Phrases such as these arevery easily overlooked as just a manner of speaking, but in fact they are used by manypatients as tactical defences designed to distance them from any feeling they may bedescribing. Maybe I feel so-and-so converts a declaration of feeling into a hypo-thetical idea.

The therapist now decides to heighten the tension by enquiring for further detailin the area of sexuality. In this passage the patients tactical defences are very much inevidence. They are put in quotation marks to draw attention to them:


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TH: How was sexual life before marriage?PT: Well looking back I dont think it was very good although for me at the time it

was good.

The therapist handles this defence by deliberate irony:

TH: You say you think. You mean you are not sure?PT: I dont think it was very different from what it was after.

The therapist responds by demanding greater specificity:

TH: Hmm. Now what was it like?PT: For me it was exciting and I suppose it was more or less satisfactory.

Here the therapist simply draws attention to the defence:

TH: But you say suppose.PT: Well otherwise I would not have wanted to. . . .

The distancing in this remark is achieved by making it into an intellectualinference, so that the patient keeps himself at one remove from the situation he isdescribing. The therapist responds by demanding a direct statement:

TH: Was it satisfactory or wasnt it?PT: I guess not.TH: But you say you guess.

Finding that every verbal defence is challenged the patient falls back on silence.Thus his resistance has become intensified, and the therapist immediately respondsby escalating the tension with stronger challenge:

TH: Do you notice you want to leave things in the state of limbo? You know,guess, perhaps, hmm? Is it like that always?

At this point the patient gives an involuntary smile, which may be used tointroduce an important discussion.

In this technique the therapist is conducting a dialogue as much with the patientsunconscious as with his conscious. He therefore must exert the utmost vigilance indetecting and responding appropriately to anything that the patients unconscious isrevealing. Often this may take the form of nonverbal communications, of which

involuntary smiles are an important example. These smiles are complex and usuallycontain a mixture of components, serving both defensive and expressive functions.In the present case the patients smile probably has the following components: (1) arecognition of one of his long-standing patterns, (2) the communication that somefeeling, probably anger, has been touched off in him by the therapists repeatedchallenge, and (3) a way of covering this anger at the same time as revealing it.

Thus, by means of his smile, the patients unconscious is informing the therapistboth that the defences are beginning to be loosened, and that the next phase of theprocess, namely a rise in transference feelings, has begun. Much further work must


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be done before this can be brought into the open, but what the therapist must doimmediately is to draw attention to the smile. This has the effect of telling the

patients unconscious that it is betraying feelings that he is trying to conceal, whichheightens the tension further.

TH: You smile when I said that. Hmm? Do you notice that you repeatedly use Iguess, maybe?

PT: Yes.TH: Is this only here or is this always in every issue, that you are uncertain

about. . . .?PT: Thats typical, yes.

The therapist is content with this for the time being and returns to enquiry.Although there is still much resistance, the loosening of defences eventually leadsinto the crucial area of violence. The patient said that he never felt close to his wifeand was very often impotent. He described his wife as a bad housekeeper, which, hesaid, frustrated him. This word frustrated is often used as a way of watering downanger or rage. His response to his wife was to become detached, withdrawn, anddepressed. After much probing he eventually admitted that he had episodes of angertowards her, with a great deal of lashing out; and he described an incident in whichshe had struck him with a chair.

The therapist wishes to get a picture of the degree of physical danger in this kindof situation. This is part of the psychiatric enquiry:

TH: Where, struck you where? On your head you mean?PT: She tried to hit my head.TH: And then.

PT: I deflected the blow with my arm and she threw the television to the floor, a largeportable, she threw it to the floor and broke it.

TH: And then?PT: So she expressed her anger much more violently than I did mine. She always

did.

The patient said that as far as actual physical acts were concerned he went nofurther than slapping her face. However, under pressure, he got as far as saying thaton occasions, I said to myself, I will kill you.

TH: So far then what you describe is there has been this lashing back and forthbetween you and your wife and then your wife has been physical and then there

have been occasions that you have slapped your wife, and there have beenoccasions that you have felt intense rage, but you have held on to your intenserage with your wife. Does this occur with any other relationship, with any otherperson, colleagues, friends, any other situation?

PT: It has occurred but not in recent years.TH: When?PT: It occurred in a store I remember. In a store downtown. I dont remember the

details but I was frustrated by the clerk in the store. I went so angry so quicklyI. . . I was holding an umbrella and I smashed the umbrella on the counter.


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TH: You mean actually you did it?PT: Yes.

TH: You must have been very angry then?PT: Yes.

The therapist now attempts to undo the obvious displacement of the impulsefrom a person to a thing, which results in two phenomena already described,namely distancing accompanied by an involuntary smile:

TH: Did you feel that you wanted to smash it on his head?PT: I guess so.TH: But you say you guess. You smile when you. . . .

The patient is thoroughly alarmed by having his violence against a person

brought into the open. He quickly interrupts and falls back on a new defence, loss ofmemory, which is forcefully challenged:

PT: Because I dont remember distinctly that I. . .TH: How is your memory usually?PT: Not very good.TH: Your memory is not good. Hmm. What work do you do?PT: Im in public relations.TH: You mean you have problems with your memory in your work in public

relations?PT: I guess my memory regarding my personal life is not very good.TH: My question was, do you have problems with your memory in your professional

life?

PT: No.TH: No. So then your memory is good, otherwise you would have difficulty in your

work in public relations.PT: Well I dont have difficulty with day-to-day or current . . .TH: But when it comes to your personal life you find. . . .PT: Recalling matters with my personal life, I have much more difficulty.

Having thus brought home to the patient that his loss of memory is a defensivemove against feelings in personal relations, the therapist returned to further enquiry.It emerged that the patient has two sons, aged 18 and 16. His wife (from whom, it willbe remembered, he is separated) had a great many problems with their eldest son andwants to put him out of her home. The patient wants to bring him into his own home.

He described his relation with his sons as polite and civilized and he admitted thathe was unable to get emotionally close to them.This is a moment of great importance and considerable complexity. In order to

understand the issue involved we need to return to the discussion of the effects of thetherapists repeated challenges, which was begun at the opening of the previoussection.

It was stated there that these challenges have two opposite effects on thepatients attitude to his defences, namely to wish to cling on to them, while under-neath there is a wish to be freed from them. At the same time the patient is


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responding in two opposite ways to the therapist himself. On the one hand, hebecomes more and more angry at not being allowed to use his customary defences;

while underneath this he is responding with many positive feelingwarmth, love,and sadnessto the caring expressed in the therapists efforts to establish emotionalcontact with him and make him free. These are realistic, direct responses, and as suchcannot be described as transference; but since the conflict between anger and lovelies at the heart of most human neuroses, the patients feelings for the therapistimmediately link with all his important past relationships, and thus they becomeoverwhelmingly transference in nature.

The patient now redoubles his efforts to keep these transference feelings atbaythe negative feelings for fear of rejection or loss of control, and the positivefeelings because in the past closeness has been associated with disappointmentandthus his resistance steadily increases. The therapist watches for signs both that theresistance is now in the transference, and that the tension between defences andunderlying feelings has reached a certain pitch. These signs are often nonverbal, e.g.,

the patient may sit more and more immobile, grip the arms of the chair, clench hisfists, or carefully avoid the therapists eyes. The therapist then directs all his effortstowards bringing the underlying transference feelings into the open. The procedureis usually to break in and ask the patient how he feels at the present moment, andthen to challenge the ensuing series of defences in the same way as before. Almostinvariably it is the anger that needs to be dealt with first. Thus the next and mostcrucial phase of the interview begins.

The Phase of Challenge to the Resistance in the Transference

The therapist makes use of the opportunity provided by mention of the patientslack of emotional contact with his children, which of course parallels the transference

situation:

TH: You find a barrier between yourself and your children?

The patient begins an intellectualized answer which the therapist interrupts, thusdeliberately interfering with the patients defensive thought process:

PT: Yes, as a child matures, I guess, becomes more. . . .TH: Is this with other people as well?PT: I think so, Ive always. . . .TH: But you say you think so.PT: I have always. . . .

The therapist now opens up the issue of transference:

TH: Let me to question you: how do you feel when I repeatedly bring to yourattention about this keeping things in the state of limbo? Do you see what Imean?

During the following passage several important issues need to be borne in mind.The therapist has said a number of things that are likely to have made the patient


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annoyed, but on the face of it nothing to make him intensely or violently angry.However, such a judgment ignores three factors: first, the therapist is forcing the

patient towards experiencing his lifelong pain; second, we know from informationalready given (the relation with his wife, and the man in the store) that the patientsanger is potentially extreme and physically violent; and third, we may infer withsome confidence that it has its roots in immense unexpressed anger aroused in thedistant past, i.e., that it is transference in the true sense of the word; and thus,although it possesses the as if quality of all transference feelings, it is right toregard it as of great intensity. Therefore the therapist knows the degree of defensive-ness contained in such words as frustrated or a little annoyed, and, armed withthis knowledge, he has the confidence to challenge everything the patient says shortof acknowledging the true quality of what he is feeling.

Now taking up the interview where we left off:

TH: . . . . Do you see what I mean?

PT: Yes, Im, Im (laughs), I feel a little annoyance at it but then I realizethat. . . .

The therapist draws attention to the laugh and follows with the standard ques-tion directing the patient towards his actual experience:

TH: But you say you feel annoyance with me and then at the same time you smile.You notice that, huh? What is it like when you feel annoyed with me?

The patient first gives a watered down description of anger and then quicklymoves away to many descriptions of the physical manifestations, not of anger, but ofanxiety:

PT: Well Ive been sitting here very frustrated. Im sweating, you know. Imsweating and getting very uncomfortable. I cant even talk to you very comforta-bly and very relaxed about things.

TH: But when you say you dont feel comfortable, what is the way you experiencethis here with me?

PT: I smoke, I dont know what to do with my hands, Im sweating.TH: Hmm. So one is sweating, one is fidgeting. What else do you experience? You

said annoyed.

The patient begins to reveal his inner tension by taking deep breaths, butcontinues with a remark that contains the defences of distancing, intellectualization,and passivity:

PT: I guess I experience a feeling of inferiority because I feel that you (sigh) . . .

The therapist draws attention to the nonverbal cues:

TH: And you frequently take a deep sigh, isnt that? You smile again. Now letslook to your annoyance. You said you feel annoyed. What is the way you ex-perience this being annoyed?


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The patient gives a much more strongly felt response, but the therapist sensesthat he is still avoiding the true quality of his feelings. Almost always, when the

patients response contains a mixture of communication and defence, it is thedefence that the therapist must challenge:

PT: I guess I swear to myself when you . . . when you point out to me my behavior. Isay, Jesus Christ, again, again and again.

TH: Now you are avoiding the issue of annoyance. You said you felt annoyed withme. What was the way you experience that?

PT: Well as far as I know thats the way I experience it. If thats not explaining. . . .

The therapist now opens up the issue of violence:

TH: Did you feel that you wanted to lash out at any moment?PT: No, no, not that bad, no.

TH: It was not that level huh?PT: (Laughs) No I dont think I need to hit you.TH: Hmm. Now you are reassuring me that you dont, but you felt angry with me,

hmm?PT: Yes.

The Issue of Interpretation

Careful study of the whole of the interview so far will reveal that it contains notrace of an interpretation. This is the major difference between the present techniqueand that of other workers in this field. In the opening stages of the interview the aim isnot to give an interpretation, which essentially tells the patient what he feels, but to

use a question which asks him what he feels, and then to deal with his ways ofavoiding answering it.The trouble with telling the patient what he feels, even when this is accompanied

by showing him how he is defending himself against it and why (in other wordsinterpreting the triangle of conflict), is that the therapist is saying it for the patientand thus inviting him to cling on to some of his resistance and avoid the trueexperience of his feelings. Only the most responsive patientswho, as describedabove, represent only a small proportion of the psychotherapeutic populationrefuse to take advantage of this invitation.

As will be seen, interpretation does play a crucial part in the present technique,but only when the patients unconscious has been brought close beneath the surface.

In fact the therapist now senses that this is beginning to happen, and therefore hegives the first true interpretation in the whole interview, linking the impulse of anger

in the transference with the patients defence against it. However, this is only apassing moment, and the therapist returns very quickly to challenging the defences.

The First Interpretation

TH: And one way you dealt with your anger was smiling, hmm?PT: I dont know.TH: And another was fidgeting hmm?


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PT: I guess I dont recognize that as anger really, I mean I dont recognize what youidentify as anger. I have not recognized it as anger until you started to talk to me

about it.TH: But you yourself said that you felt annoyed.PT: Yes when you asked me. I didnt . . .TH: And yet if I hadnt asked you what . . .PT: I would not have realized that I was angry with you for trying. . . .TH: You mean you had not realized or would not have declared that you were

annoyed?PT: Well I think I would not have realized maybe until later than I would have had a

chance to think about what happened here and I would have realized that I wasangry. Im angry because you are putting me on the spot. Youre trying to. . . .

The Phase of Head-On Collision with the Resistance Leading toPartial Breakthrough

Thus, although the therapist knows that the patients unconscious is closebeneath the surface, he also realizes that the patients responses in the above passageare highly resistant, consisting of intellectualizing about his feelings rather thanexperiencing them. This situation of maximum tension between unconscious andresistance is the moment to bring out the most powerful intervention of allthefinal pushnamely the forceful demonstration to the patient of the consequencesof maintaining his resistant position.

This intervention is of a kind that plays no part in interpretative therapy and itrequires considerable discussion. It appears to consist of nothing more than exhorta-tion, a type of intervention that in psychoanalysis has been utterly discredited by longand bitter experience. It is true that it is exhortation, but it is being used in particularcircumstances, with the patient in a specific inner state, to which he has been broughtby all the previous events of the interview. One of Davanloos most importantobservations is that, even in a patient as resistant as this, the part of the unconsciousthat is striving to communicate itself to the therapist and obtain relief the uncon-scious therapeutic allianceis potentially an even more powerful force than theresistance. All the time that the therapist has been challenging the defences, thepatients unconscious has been being activated and brought nearer to the surface.This is the point at which the therapist senses that it is right to throw in his reserves,which have been held back for this very moment. The therapists exhortationthen become a major reinforcement to the therapeutic alliance and his most power-ful tool.

In addition, there are many other important components to this intervention.

First, the therapist conveys that the responsibility lies entirely with the patient if hewants relief he must give up his defences. Second, by the use of the word we thetherapist conveys his willingness to collaborate with the patients therapeutic alli-ance. Third, the therapist repeatedly makes the link between the emotional barrierin the transference and the barrier that the patient puts up between himself and otherpeople (the transference-current or T-C link). This kind of intervention is, oncemore an interpretation. Fourth, there are examples of speaking to the patientsunconscious, when the therapist describes the patient as making him useless andlater emphasizes the self-defeating nature of this. The deeply hidden ideas conveyed


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by these implied interpretations are concerned with the patients need to combine hisrevenge, his defence against it, and his guilt, by making his attack on the people who

have failed him take the form of self-sabotage. Finally, there is also compassion forthe patients predicament, and the readiness to extend the hand of warmth andcloseness the moment the patient is readybecause the therapist knows that be-neath the lifelong hatred lies the patients own love, and the grief about what he hasmissed first through circumstances and then through his own vindictiveness. For it isthese feelings that this most powerful intervention will eventually uncover:

TH: So then the situation is of a kind that you want to be vague, you want to keepthings uncertain and in the limbo stage, and I am attempting to focus on yourdifficulties, hmm? Isnt that? And you constantly want to keep things in the stateof limbo. Hmm?

PT: Yes.TH: And then what this brought up is you felt annoyed with me, and we saw the way

you dealt with your annoyance with me, okay? Now let me to question you this.If you remain vague and if you remain evasive and continue to generalize andnot be specific, then what would be the end result of this session with you hmm?You said you have had 20 years treatment, and it hasnt got you anywhereobviously. So then the end result of this session would be of no use to youwouldnt it? Hmm.

PT: Not very much use.TH: So in a sense if you continue to be vague and if you continue to be evasive and

generalize and keep things in a state of limbo then we would not get tounderstand the core of your problem, the end result would be that I would beuseless to you like the 20 years of your past therapy, okay? Now my question isthis. Why do you want to do that? Because obviously it is very evident that you

say there is a problem that you put a barrier between yourself and other people.Is that barrier here between you and me? Hmm? How do you feel right now?Hmm?

The therapist has clearly timed his intervention well, for this highly resistant,apparently emotionless patient now puts his head in his hands and begins to cry. Thisis the first emergence of the positive feelings beneath the negative, but it is stillessential to continue dealing with the negative feelings and the resistance againstthem.

TH: How do you feel right now? Hmm?PT: What youve told me made me feel angry for sure.

TH: But what was it like when you felt angry?PT: (Recovering from his bout of crying). . . . I felt angry, I guess I wasdisappointed.

TH: Mm hmm. What was it like when you felt angry with me? You experienced that,didnt you?

PT: Yes.TH: So what was it like when you felt angry with me? Was it similar to how you feel

with other people or different?PT: I guess it was similar.


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TH: Hmm?PT: It was similar I suppose. I just dont know.

TH: Mm hmm. Mm hmm. Now you had.. . .

Again the patients eyes fill with tears:

PT: I got very upset just now because what you were saying indicated to me that forwhatever reason there is no good in your sitting there and talking to me like thisunless we can get something out of it.

TH: Mm hmm.PT: As you say it would be pointless to spend some time together and not make some

progress of some sort.TH: Mm hmm.PT: Which indicated that you would. . . .

TH: But that is probably one of the major problems that we should focus on.PT: Yes. I know.

Dealing with resistance shows an important parallel with eliminating a bacterialinfection with an antibiotic in order to prevent a recurrence it is essential tocontinue with treatment long after the condition has apparently disappeared. Thebacteria must be not merely knocked out but counted out. Therefore the therapistcontinues to hammer at the defences:

TH: Because what we see is this: you are putting a barrier between yourself and me.Is it that or isnt it?

PT: Yes it is.TH: You are hiding behind a wall.PT: Yes.TH: And up to the time there is this wall, then obviously we cannot get to understand

the core of your problem. So the question is, what are we going to do with thiswall. Because I assume this is the problem in any other relationship. Am I rightto say that possibly this is the way that it is in every other relationship, that youset up a barrier between yourself and the other person?

PT: Probably right, yes.TH: Have you ever had a person in your life that you felt that you wanted . . .?

The patient, now much less resistant, is ahead of the therapist and interrupts:

PT: A person with whom there was no barrier at all?PT: Mm hmm.PT: No.TH: Mm hmm. So this is a lifelong problem hmm? (The patient looks away) Do you

notice that when you become tearful you avoid me? Hmm? You avoid both theeye contact as well as not looking at me. Why? Because you are talking about thecloseness, hmm? (Long silence) And still you are avoiding me.

The patient is sobbing.


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Further Exploration, Including the Psychiatric Enquiry

Sensing that the patient needs relief from this intensity of feeling for the timebeing, the therapist first explored the way the barrier manifests itself with otherpeople, and then took the opportunity for some psychiatric enquiry. The patient saidI feel inferior. I always sell myself cheap and let myself be exploited.

This led into his talking about episodes of depression. Enquiry revealed that hehas suicidal ideas, e.g., the thought of jumping from a high building, but he had nevermade or planned a suicidal attempt. However, his resistance was now so muchweakened that his therapeutic alliance provided an important piece of information,together with his own interpretation of it, namely that he is accident-prone an-other way of suicide. The therapist at once asks for details, which leads into somemajor dynamic work outside the transference. In the following passage there is muchevidence for weakening of defences: the patient is spontaneously communicatinghighly dynamic material, he shows clear and genuine insight, and his therapeutic

alliance almost directs the therapist to enter into the world of very disturbingimpulses. In other words the patients unconscious has begun to be unlocked, whichhas happened as a consequence of the previous intense transference experience.

Dynamic Exploration of a Current Relationship

PT: . . . Suicidal.TH: Mm hmm.PT: Even if you dont want to recognize it . . .TH: What are they exactly like, these accidents that you have had?PT: You mean what were the circumstances?TH: Mm hmm. I mean one example.PT: One example is very closely related to my relationship with my wife.TH: Mm hmm.PT: Many years ago when we were intending to leave the city and would drive to the

coast on holiday and we had plans to leave early in the morning and we had toprepare clothes and pack the car and so on and this process of a woman gettingready took so much longer than I was prepared for that I became very angry. Ididnt show it to her. I didnt talk about the fact that she was late and that she wastaking the whole wardrobe just to go to the coast for two weeks, I didnt talkabout it. But then I drove the car very dangerously because I was so angry and Idrove through a stop sign. I didnt see it.

TH: You mean you didnt see the stop sign, mm hmm?PT: And I drove right into a truck, so we were very fortunate that my wife was not

killed because the truck hit the car.TH: You were driving the car and then the truck . . .PT: Came from the right-hand side.TH: Mm hmm. And that is the side that your wife was, mm hmm. And who would

have been killed first?PT: My wife.TH: But then you said on the spell of your rage when you get this attack of rage with

your wife you have thought to yourself of killing your wife. Hmm? Hmm?PT: Before I knew my wife I had a bad car accident when I turned the car over going


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through the mountains and the snow, when the conditions were such that if onewere very careful it was very easy to drive.

Since the patient has so clearly acknowledged the self-destructive nature of theseacts, the therapist opens up the question of whether this is a phenomenon pervadingthe whole of his life:

TH: Do you feel that you function at the level of your potentiality or do you feel thatthese difficulties which are diffuse and longstanding have interfered with yourfunctions?

PT: Nobody has talked to me the way you do about identifying the problem, Dr.Davanloo. Nobody ever spoke to me in that way before.

For this tight-laced, inhibited man to address his therapist by name is an

expression of great warmth, and another indication of the amount of freeing that hastaken place.

TH: Mm hmm.PT: And I certainly have not been able to analyze it myself and identify the problem,

put my finger on it.TH: Mm hmm, but the problem is there, basic problem is there, hmm?PT: Yes.TH: So is there then a sort of self-sabotaging and self. . . .PT: Yes.TH: And self-punishing pattern in you.PT: Yes, there is.TH: Hmm?PT: Constantly.TH: That in a sense you carry this suffering with yourself in life.PT: Yes.TH: Mm hmm.

The patient now spontaneously offers another deep interpretation of his ownactions:

PT: I think thats what led to my wife and I staying together for so many years, over along period when we should have realized many years ago for whatever reasonthings were not right.

TH: Mm Hmm.PT: And we should.

. . .

TH: Hm hmm.PT: We should do something about it.TH: Mm hmm.PT: Its been impossible.

The therapist now takes the opportunity to take the history of the patientsprevious treatmenta further part of the psychiatric enquiry.


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Psychiatric Enquiry (Continued)

TH: How many psychiatrists have you seen altogether in the past 20 years?PT: About five.

It emerged that he has been in psychotherapy on and off for the past 20 years,including a period of psychoanalysis at three times a week on the couch. All histherapies ended in an atmosphere of mutual recriminationwith him blaming thetherapist for not having helped him, and the therapist blaming him for not havingworked. He said, I understood that it would finally help me.

This remark produced a transition to a most moving and important moment. Thepatient began contrasting his experience in the present interview with that in hisprevious therapy.

Return to the Transference

PT: There is one big difference with you and thats an interest in my welfare. Yousaid if we spend an hour . . . if we spend time together and I keep avoiding theissue then we dont make any progress. And when you said that I was overcome.I became very . . . (his voice breaks, and at the same time he smiles) . . . see, ithappens again.

Relentlessly the therapist points out the residual defensive contained in thesmile:

TH: What happens? Your feeling, you mean? You smile, isnt that?

This might seem harsh, but it is not, for the patient immediately acknowledges

the defensiveness:

PT: Yes, I try. I guess I smile to cut it out.TH: Maybe could we look at this.

Now we can observe the effects of this constant erosion of the defenses, forsuddenly the patients therapeutic alliance emerges and spontaneously makes a kindof link which represents a crucial step in almost all dynamic psychotherapy.

Further Partial Breakthrough: The Link between the Transference andthe Past

PT: Then I immediately think of my father, and the fact that a more mature personsuch as yourself should express any interest at all in my welfare, thats all.

TH: It brings your father in your mind?PT: Yes.TH: What sort of thought comes to your mind about your father?PT: I find Im not sure really. Just the fact, its very confused. Well, just the fact that

you should express any interest at all in my welfare even from a very profes-sional viewpoint, ahh.

TH: But you say it brings your father into your mind?


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Resistance is not yet at an end:

PT: Just the idea of my father, thats all.

But now it can be penetrated by simply repeating the question:

TH: What sort of thought comes into your mind about your father?PT: Well, I guess the fact that the difficulties which I have trouble discussing with

you are perhaps the kinds of things which I should have been able to discuss withmy father.

TH: You mean there was difficulty in discussing things with . . .PT: Considerable difficulty. I did not discuss anything with him after the time when

he seemed to ridicule me for wanting to talk to him and for having difficulty intalking to him.

TH: He was ridiculing you?

PT: Whether in fact he was or not I dont know but I have the impression that he did.TH: You mean you have memories of the occasions that your father was ridiculing

you? What way he used to ridicule you?PT: The easiest way to explain it would be to make a comparison now and to say that

when you see me getting upset if I do and I start to cry or something, then if youwere to do what my father did, you would point and laugh at me and say look,youre getting upset. Thats exactly what he would do when I was in conversa-tion with him.

So, suddenly the patient has spontaneously explained his resistance againstshowing his true feelings in terms of his expectation that the therapist would ridiculehim, like his father an illustration of the point made above that the patientsfeelings in the here-and-now almost always have roots going back into the distant

past.

Conclusion to Part I

The above passage marks the beginning of a phase of exploration alternatingwith systematic interpretation of the resistance. The exploration is mostly of therelation with the father, and there emerge other parallels between this and resistancein the transference. The therapist is then able to interpret two corners of the triangleof conflict and two corners of the triangle of person, i.e., the defence against theunderlying feeling both in the transference and in the past. The end result is a furtherbreakthrough of feeling in the transference, after which no further reference to the

transference is made, and the interview proceeds by exploration and interpretationof the patients early family relationships. This is the phase of pure content. Thesetwo phases will be described in Part II, which will conclude with a discussion of thepractical and theoretical consequences of the development of this extremely power-ful technique.

For the time being it is worth re-emphasizing the basic principles illustrated bythe interview: pressure towards the experience of feeling leads to resistance; chal-lenge to the resistance leads to intensification of the transference, which in turn leadsto further resistance; further challenge brings the patient to the true experience of


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both negative and positive transference feelings; this results in a massive mobiliza-tion of the therapeutic alliance; and now at last it is meaningful to introduce

interpretation. As is shown by the history of this patients previous therapy, atechnique that employed interpretation alone, without this long and intensive prepa-ration, would almost certainly have been wholly ineffective.

References

Alexander, F. and French, T.M. (1946). Psychoanalytic therapy. New York: Ronald Press. Reprinted byUniversity of Nebraska Press, Lincoln, NE (1980).

Davanloo, H. (1978). Basic principles and technique in short-term dynamic psychotherapy. New York:Spectrum Publications.

Davanloo, H. (1980). Short-term dynamic psychotherapy. New York: Jason Aronson.Malan, D.H. (1976). The frontier of brief psychotherapy. New York: Plenum.Sifneos, P.E. (1972). Short term therapy and emotional crisis. Cambridge, MA: Harvard University Press.


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