Malan II

8/7/2019 Malan II

1/24

International Journal of Intensive Short-Term Dynamic PsychotherapyInt. J. Short-Term Psychother. 1, 83106 (1986)DOI: 10.1002/sho.166

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

DAVID MALANParkers Close, Hartley Wintney, Hampshire RG7 8J6, England

This is the second part of a two-part article, the first part of which appears in this issue of thejournal. The article considers the basic problems of Short-term Dynamic Psychotherapy, namely (1) howto develop techniques that maximize success, and (2) how to recognize suitable patients. In addition, thereis a deep theoretical problem: why is it that purely interpretative therapy, even when intense dynamicinteraction occurs, only a relatively small proportion of patients experience resolution of their neurosis?Davanloo has developed a technique which leads to solutions to all these problems. The technique isillustrated by an initial evaluation, begun in Part I and completed in the present Part. The article ends witha discussion of the practical and theoretical consequences of this work.

Introduction

Part I of the present article (see Malan, 1985) opened with a statement of the twobasic problems of Short-term Dynamic Psychotherapy, namely how to establishtechniques that maximize success and how to find criteria for recognizing suitablepatients. Some of the principles underlying solutions to these problems appear to bealmost universal: The need to start with a thorough psychiatric and psychodynamicevaluation; the use of some form of trial therapy in the initial interview; the principleof planned therapy; and the use of the full range of interpretation in therapy itself,including interpretation of the transference and the link with the past.

Most schools of Short-term Dynamic Psychotherapy (STDP) use these prin-ciples but depend for their effectiveness on the fulfilment of certain additionalcriteria, as follows: There needs to be some single basic conflict that can be used asthe focus of therapy; the patient needs to become deeply involved in the therapeu-tic process and if possible in the transference relationship; and correspondingly hemust readily respond to interpretation and must not show too much resistance. Inother words, the need is for responsive, highly motivated patients, with an underly-ing simplicity of psychodynamics.

These criteria already put a considerable restriction on the range of suitablepatients, but unfortunately they involve a further restriction as well. This is that theyare necessary but not sufficient conditions, so that even when they are fulfilled thereis no guarantee of success. The result is that when we consider the whole psychother-apeutic population, we find that only a very small proportion receive substantial helpin terms of the resolution of their central conflict.

Of course the obvious solution is to fall back on long-term therapy, but unfortu-nately here the picture is no more favorable. Quite apart from the fact that therapeu-tic vacancies immediately become blocked by long-term patients, the proportion of

Copyright 1986 John Wiley & Sons, Ltd.

8/7/2019 Malan II

2/24

84 D. Malan

these patients who achieve substantial resolution of their central conflict appears to

be relatively small.

These considerations lead to two further practical problems, one concerned withselection and the other with technique. If we wish to improve the efficiency of our

work, then we must achieve one or other, and if possible both, of the following: to

make our selection more accurate and/or to make our technique more powerful.

But there also lies in these observations a profound and as yet unsolved theoreti-

cal problem, which is concerned with the gap between dynamic interaction and

resolution, and can be formulated as follows: We are sure that therapeutic effects,

when they occur, result from dynamic interaction between therapist and patient.

This involves the sequence: material, interpretation, response; which leads to the

acquisition of emotional insight into hitherto unconscious feelings, and the experi-

ence of the transference relationship and its link with the past. There is little difficulty

in selecting patients who will interact in this way, so that this process occurs daily in

the majority of our therapies; yet why is it that in some patients it results in majortherapeutic effects, while in others it fails to do so? What is the difference between

the two?

If for the moment we concentrate on one of the practical problems, namely that

of making our technique more powerful, we may note that all traditional techniques

of dynamic psychotherapy, whether short- or long-term, depend essentially on the

use of interpretation and little else. It therefore appears that purely interpretative

techniques have been carried to the limit and have been found inadequate, and that

unless we are prepared to resign ourselves to this situation, something is needed over

and above interpretation. This has been the starting point of Davanloos

contribution.

The essential element in Davanloos technique consists of challenge to the

resistance, but this needs to be considered in the context of the whole process ofinteraction between therapist and patient, in which the following phases can be

distinguished:

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

of defences.(3) Challenge to each defense the moment it appears.(4) An inevitable rise in transference feelings. These are complex. Upper-

most is almost invariably the patients anger at not being allowed to use hiscustomary defences; but underneath this there often lie many positivefeelings, which include sadness at previous lost opportunities for love and

closeness, together with appreciation for the therapists genuine attemptsto relieve the suffering to which the defences have given rise. The patientdoes not wish to experience or show these painful and conflicting feelings,and the result is a further rise in resistance, which now involves thetransference. The next stage therefore consists of:

(5) Challenge to the resistance in the transference, which leads eventually to(6) Direct experience of the transference feelings.(7) Stage 6 has the profound effect of unlocking the patients unconscious and

mobilizing the therapeutic alliance.

1986 John Wiley & Sons, Ltd. Int. J. Short-Term Psychother. 1, 83106 (1986)

8/7/2019 Malan II

3/24

Initial Evaluation and Technique in Short-Term Dynamic Psychotherapy 85

(8) Now, for the first time, it becomes meaningful both to explore relation-ships outside the transference and to begin to use interpretation.

(9) However, as each new area is explored and some new anxiety-laden areais approached, there is often a return of resistance, so that the cycle beginsagain at stage (3) with further challenge.

(10) The exploration that has been carried out in phase (8) enables the thera-pist to make interpretations linking the resistance in the transference withconflicts in other relationships, both current and past (transferencecurrentpast or TCP interpretations).

(11) This cycle may have to be repeated many times, but in the end theresistance becomes exhausted. It is now possible to explore other relation-ships and to make interpretations about them without reference to thetransference. This is the phase of pure content.

One of the main aims of the two parts of the present article has been to illustratethis process by means of a clinical example. Since Davanloo makes the principle of

trial therapy more central to his selection process than any other worker in this field,the principles of both selection and technique can be illustrated by means of an initialevaluation interview. The only essential ways in which such an interview will differfrom actual therapy arise from the need to take a full psychiatric and developmentalhistory. Therefore these two phases have to be added to those enumerated above.Also, because of repetition and overlapping, the phases of an actual interview areusually more complex than in a schematic description, so that the numbering givenabove is best omitted.

It is important to use as an example a patient interviewed by Davanloo whoshows considerable resistance, and for that reason the following patient was chosen.

The evaluation process occupied two interviews, each of about 1 12

hours.

The Case of the Man from Southampton

Recapitulation

The patient, a man of 47, had already been in therapy over a total span of 20years, including a period of analysis at three times a week on the couch. All thistreatment had achieved little more than a reinforcement of his defences, and hearrived at the interview already in a state of resistance, which took the form ofvagueness and distancing. He even seemed unable to describe the problems forwhich he was seeking help. Thus phase 1 (pressure) and phase 2 (resistance) became

telescoped. The therapist tried to pin him down, without much success. The resis-tance reached a peak when the patient, on being asked to describe his actualexperience of a particular feeling (in this case guilt) said that he used the word guiltbecause that was the label given to it by one of his previous therapists. Since he hadsaid exactly the same about the word anxiety, the interview was clearly goinground in circles. This initiated the phase of challenge to the resistance. The therapistfirst forcefully pointed out the patients vagueness and then challenged each tacti-cal defence as it arose, e.g., the use of phrases such as I guess, maybe, etc.,which served the purpose of distancing the patient from his feelings.


8/7/2019 Malan II

4/24

86 D. Malan

Here it is essential to emphasize that if the patient had shown any signs of beingunduly disturbed by this approach, thus indicating deeper, possibly borderline or

psychotic pathology, the therapist would have immediately changed his techniqueand become more supportive.As the interview proceeded, various nonverbal cues began to make clear that the

patient was beginning to become angry with the therapist because of the repeatedchallenge to his defenses, but that he was trying to conceal this.

The therapist was not yet ready to bring the anger to the surface and continuedhis exploration. Two important pieces of information now emerged; first that thepatient suffered at times from violently angry feelings which he found difficult tocontrol; and then that he experienced a barrier which prevented him from gettingemotionally close to his children.

Since the patient was clearly both angry with the therapist and maintaining anemotional barrier against allowing the therapist close to him, there was now anopportunity to try and bring the transference into the open. The patient admitted

under pressure first that he was a little annoyed, and then that he was veryfrustrated. At the same time the nonverbal cues intensified the patient wassweating, fidgeting, taking deep breaths, and covering his feelings by smiling. It wasat this point that the therapist introduced the first interpretation, making the linkbetween the defences and the underlying feelings by pointing out that the smiling andfidgeting were ways of dealing with his anger.

However, this interpretation represented only a passing moment. Sensing thatthere was now the maximum tension between the patients feelings and his resis-tance, the therapist introduced the most powerful challenge of all, the head-oncollision. This consisted of forcefully pointing out that if the patient continued withhis vagueness and distancing, the present interview would be useless to him as his 20years of previous therapy had been.

Suddenly there was a major change in atmosphere, for the patient began crying,thus revealing that beneath the anger there lay sadness and regret, and alsoasbecame clear laterwarm feelings for the therapist, whose attempts to relieve him ofhis defenses expressed genuine concern for his welfare.

This open emergence of transference feelings, first negative and then positive,produced a marked rise in the therapeutic alliance. The patient was now able tospeak of his rage with his wife, which had led to serious accident-proneness, andwhich he himself interpreted as an expression of suicidal impulses.

The therapist capitalized on this to offer a further interpretation in the form of aquestion, asking whether there was a self-punishing pattern running through thewhole of the patients life, with which the patient fervently agreed.

Enquiry now revealed that the patient had seen five psychiatrists in all during thepast 20 years. This led to a most moving moment, in which the patient spoke with

deep appreciation of the therapists approachaddressing him by nameand con-trasting it with the ineffectiveness of his previous therapists.The active mobilization of the patients therapeutic alliance, which resulted from

the open expression of these feelings for the therapist, led to another crucial mo-ment. Once more the patient gave his interpretation, now linking the transferencewith the past, by explaining his withdrawn state at the beginning of the interview interms of the expectation that the therapist would ridicule him if he expressed what hereally felt, which was exactly what his father had done.

We may resume the account of the interview at this point.


8/7/2019 Malan II

5/24


The First Phase of Enquiry: Developmental History

The therapist took the opportunity to enquire into the patients background withspecial reference to the father.The patient is the fourth of five children, with three older sisters and a brother

one year younger. He described his father as authoritarian, a forbidding figure, ofwhom he was always frightened, and in whose eyes nothing he did was ever any good.His father suffered from high blood pressure resulting in headaches and attacks ofheart failure, and at times used to go into states of withdrawal in which he refused tospeak to anyone. Twenty-one years ago he had suffered a serious exacerbation of hisphysical condition which had prevented him from attending the patients wedding.He had died not long afterwards.

This enquiry now enables the therapist to proceed with the next phase, whichconsists of the systematic interpretation of the resistance. In this phase he repeatedlyinterprets two corners of the triangle of conflict, namely the underlying feeling and

the defense against it, and two corners of the triangle of person, namely thetransference and its parallel to the relation with the father (transferencepast or TPinterpretations). In interviews with other patients it is often important to include thethird corner of both triangles, i.e., the anxiety on the one hand, and current relation-ships on the other, but in this particular interview it was not necessary.

Systematic Interpretation of the Transference Resistance in Terms of theRelation with the Father

The therapist detects further signs of tension in the transference and thereforebreaks in with a question about the here-and-now. The patients relatively openresponse shows that his resistance, though by no means at an end, has been consider-ably loosened. It is worth noting here the extraordinary way in which the transfer-ence situation picks out coincidences and parallels between the present and the past:

TH: How do you feel right now?PT: I feel much as I would feel with him at that time when he would oblige me to

be more specific.TH: Oh, he used to be the kind of person who wanted you to be more specific?PT: Or he expected me to see things his way and if he was not satisfied with my

viewpoint thats when he would ridicule me for having a different viewpointfrom him.

TH: So then the relationship there was of a kind, with your father, that if you did

not follow his views or you did not see the way he wanted you to see, then hewould ridicule you. And what was your reaction toward that?

The patients reply specifies the underlying feeling and the defense against it inrelation to the father, i.e., two corners of the triangle of conflict and one of thetriangle of person:

PT: I would become angry and I would not want to continue.


8/7/2019 Malan II

6/24

88 D. Malan

The therapist makes the defense more explicit and then links this with thetransference, thus adding a second corner to the triangle of person:

TH: So then the situation with your father was that he was demanding, hmmm?He was demanding but at the same time also everything had to be in his wayand if the thing was not in his way this would mobilize anger in you. And theway, and the mechanism that you dealt with your anger was detachment.Am I right then to say this is very clear, hmm? Now is that in operation herewith me? Do you see what I mean?

PT: Yes.TH: Hmm?PT: Yes.TH: You want to keep things in a state of limbo, hmm? Perhaps or guess

and so forth, hmm?

PT: I think, Dr. Davanloo, that . . .TH: And the idea is that I am demanding.PT: Yes, when I was a child with my father I was . . . it was very difficult to

accept the fact that I could not please him if he kept showing me how wrongI was. It was very difficult to accept that and so now probably I continue thesame kind of behavior with anybody who I see to be in a position ofauthority.

The above was spoken with deep feeling. It would be easy to make the mistake of

accepting this and not to see that it completely avoids the issue on which the therapistwas concentrating, namely the transference, and thus is still a manifestation ofresistance. The therapist relentlessly pursues his interpretation of the transference

resistance. The importance of this is quickly demonstrated:

TH: Mm hmm. Could we look into that, because you are talking about yourfather and his demanding attitude and things have to be his way, okay.Then this mobilizes anger in you and the way you dealt with your anger waswithdrawing and detaching, okay. Now my question was, if that is inoperation with me, namely anger in relationship with me and then with-holding? I am questioning if that is in operation also here with me?

PT: I believe it to be when you talk to me about it, when you ask me. I dontrecognize it until you ask me.

TH: Here with me you have experienced your anger and irritation, havent you?

PT: Yes, but until we talk like this now I havent. What Im saying is that I dont

recognize that what I feel is anger. Now that youve talked to me about it Irealize that I would like to say, For Christs sake leave me alone. Dontkeep asking me these questions.

Although the words as written might still seem to be rather indirect, in fact thetherapist knows from the patients manner that they represent the true experience ofanger and will lead to considerable relief. It is important to note that, in order to betherapeutic, this experience of anger does not have to be dramaticand indeed if the


8/7/2019 Malan II

7/24


patient starts shouting and screaming at the therapist, or threatening him, thensomething has gone wrong.

The therapist now searches for the relief, but still pursues manifestation ofresidual resistance. This is a further example of the analogy with a bacterial infectionmentioned in Part Ithe bacteria, or the resistance, must be not merely knockedout but counted out.

TH: Mm hmm. How do you feel right at this moment?PT: A little more relaxed just because Ive been able to see that I do in fact feel

anger because you keep saying to me . . .TH: Have you noticed that when you get irritated with me, you move your eyes

away from me?PT: Yes.TH: Mm hmm?PT: Yes, Ive noticed.

Once more the therapist makes the TP link.

TH: Mm hmm. How was that with your father? I am talking about the eyecontact. You avoided him?

PT: I probably did because he was a very frightening figure.

The above passage marks the end of the analysis of the resistance in thetransference. From now on it is possible to explore other relationships directly and ina highly meaningful way. Resistance does return, but it can be dealt with relativelyquickly and without further mention of the transference.

The Phase of Pure Content

TH: How far back goes your earliest memory of your father? And what do youremember you were doing in the past?

The patient said he was somewhat closer to his mother than to his father. Hewent on to speak of his sister Diana who was attractive and their fathers favorite. Hehas memories of her sitting on her fathers lap and receiving constant praise andadmiration from him. This led to his speaking of his brother, one year younger, who

also used to sit on their fathers lap and have good times with him, and in addition wasthe favorite of their mother and the three sisters.Thus the evidence suggested that the patient felt very much an outsider in his

own home. This was seriously exacerbated by World War II. The family home wasin Southampton, England, which was a main target for German bombing from 1940onwards. The parents remained in Southampton but the children were evacuated tovarious safer areas. Two sisters were sent away together to one foster family, and thepatients younger brother and the remaining sister to another; while the patient saidthat he himself was singled out to be sent away alone, at the age of five, to a family in


8/7/2019 Malan II

8/24

90 D. Malan

the country. He spent five unhappy years with that family. They had four daughtersranging in age from 6 to 9, which to some degree mirrored the situation in his own

family. One memory was of sexual play with these four girls. He was caught andpunished severely by his foster parents.He then mentioned, however, that the foster family lived near enough to enable

his parents to visit him at some weekends. This led to a moment illustrating the degree

to which the resistance had been weakened and the unconscious therapeutic alliancemobilized by all the previous work on the transference. There suddenly emerged

spontaneously a fresh memory revealing an entirely different aspect of the relationwith his father.

There had been a timeas is found so oftenwhen there was uncomplicated

warmth between the two of them. Again, as is found so often, this aspect of therelation had been repressed by all the subsequent bitterness, and it emerged againstconsiderable resistancethus illustrating the tension between the resistance and thetherapeutic alliance. Now, however, challenge is no longer necessary and resistancecan be handled much less forcefully:

PT: In fact that reminds me that even before the War I remember looking for my

father when he would return from work. I could see the pathway that hewould take approaching the house.

Recognizing the significance of this, the therapist directs the patients attentionto it:

TH: What is your memory of that path?

Resistance returns and the patient gives an evasive answer:

PT: It was just a path across the field.

The therapist encourages the patient to go on:

TH: Mm hmm.

The patient does go on but uses the defenses of wandering off into details,

leaving out the emotional content of the memory altogether:

PT: And I would see him walking from . . . he had to leave back and walk down

by the river and across the pathway and I would see him. We lived in a blockof. . .

The therapist simply brushes aside this defense and gives a direct interpretationof the underlying feeling, putting the emotional content into words:


8/7/2019 Malan II

9/24


TH: So you looked forward to your father.

The patient has been brought to a state in which this interpretation is enough to

bring out the feeling, with the emergence of another fresh memory:

PT: Yes, I did, and we lived on the top of a block of flats and I ran down to meet

him and fell down the stairs and knocked myself out. I cut my chin and had

to be taken to hospital. I just remembered that.

TH: Mm hmm. So then you must have felt close to your father.

PT: Yes. I guess I was.

He then revealed an all too familiar pattern of a serious deterioration in the

relation with his father around the time of puberty, in his case at the age of 11, whichwas probably greatly intensified by the fact that he had just returned from five years

of separation. His sister Diana was a good student and the patient worked hard and

became an excellent student himself, but in spite of his efforts and good performance

all he got was anger and criticism.

PT: . . . because he seems to have stopped me progressing.

TH: He was an angry person, hmm? What was he like when he was angry?

PT: He was very frightening. You asked me to describe him earlier. I didnt

describe him. He was physically very forbidding. He was dark-haired and

dark-eyebrowed and a very grim face.

Once more the patient begins to cry.

TH: Grim face?

PT: Very large strong hands which would hurt when he would punish me.

TH: He used to punish you physically?

PT: Sure.

TH: Mm hmm. What way he used to punish you?

PT: What with?

TH: What way he would?

PT: He would hit me either with his hand or with a strap.

TH: A strap. Where?

PT: On my backside.TH: On your backside.

PT: Well, he would begin on my backside but of course since I would try to

avoid him the strap would go everywhere.

TH: Mm hmm. Mm hmm. So he was aggressive with you then, hmm?

PT: Yes.

TH: He was aggressive with you?

PT: Yes.


8/7/2019 Malan II

10/24

92 D. Malan

The therapist has noted that the patients brother got on much better with thefather. Therefore he now opens up the relation with the brother, with special

reference to this triangular relationship, which he knows is likely to be highlysignificant:

The Relation with the Brother

TH: This aggression was especially with you or was he like that with yourbrother?

It emerged that he and his brother fought a great deal.

TH: Who had the upper hand in the fight?PT: Who had the upper hand?TH: Mm hmm. Who was the stronger?PT: I think we were quite close. My father bought boxing gloves.TH: Oh your father bought boxing gloves?PT: My father bought two pair of boxing gloves and made us fight like this in

order to settle differences between us. He said, if you want to fight you haveto fight properly.

TH: How did you use to fight before he bought the gloves?PT: Just scrapingly, kicking, wrestling on the floor.TH: Mm hmm. Who was physically stronger?PT: We were very close.TH: Mm hmm.

PT: We were very close. Just by the fact that my brother was younger we werevery close in size.

TH: Mm hmm. But who was the winner?PT: It was close enough so that . . .TH: Did you have the upper hand?PT: No, there was never a constant victor.TH: Mm hmm.PT: He would win, I would win, but it finished finally my brother had the upper

hand.TH: Oh.PT: Yes, because . . .TH: How did it come that he had the upper hand?

PT: Because my father bought boxing gloves and taught us to fight with these.TH: Mm hmm.PT: And my brother happened to hit me so successfully that he knocked me

back into the china cabinet and broke the cabinet and that was the end of thefighting because my mother wouldnt allow it any more.

TH: Do you remember that incident?PT: Yes, mm hmm.TH: You mean, what do you remember when you try to remember . . .PT: I remember only that my brother hit me so hard.


8/7/2019 Malan II

11/24


TH: Where?PT: On the chin, on the face. He knocked me right back and I crashed into the

cabinet and of course we couldnt have any more of this kind of fighting,and so that was the end of it and so I guess in my memory my brother wasvictorious because in the last . . .

Throughout the whole of this passage the therapist has had in mind the fact thatthe patient had previously acknowledged a self-sabotaging tendency in himself. The

mechanism behind this often appears to consist of the following: the patient takes abeaten position in relation to other people as a way of defending himself against,and punishing himself for, intense hostile feelings against some important person inthe past. The therapist prepares to bring this out:

TH: So you ended up being the beaten . . .

PT: Not only the black sheep but . . .TH: The beaten boy.PT: I guess so.

At this point the patient reveals by another involuntary smile that somethingimportant has been touched. The therapist points this out and then goes straight forthe buried feeling:

TH: Youre smiling. How did you feel when he knocked you down? Did youfeel that you wanted to get at him?

Resistance at once returns:

PT: I dont know. I suppose I did. I dont know. I dont remember that I did butI suppose I did.

TH: You say that you used to fight back, hmm. Now you are badly hurt and youare knocked down and humiliated, hmm. Hmm?

PT: Mm hmm.

TH: Then the question is how you felt.PT: I dont know how I felt.

Once more the therapist senses that resistance has been sufficiently weakened to

make it possible to break through by concentrating on the buried feeling or impulserather than by challenging the defenses. He therefore makes use of what has alreadyemerged in the relation with the patients wife:

TH: Hmm? We know that when you get into a fight and your wife humili-

ates you, banging the chair on your head and then throwing the televisionand breaking things, at that time there is the feeling that you wish that youcould kill her.


8/7/2019 Malan II

12/24

94 D. Malan

PT: Yes.TH: Hmm?

PT: Yes.TH: So the question is this. Was there any time the wish that you could do that toyour brother?

This brings a major response:

PT: Im sure there was. Yes, because on one occasion I remember fighting withhim out of the home in the field.

TH: In the field, mm hmm.

PT: And I remember him walking away and when I remember him walkingaway it reminds me of my son, it reminds me of my son, my younger son.My brother was more calm, more placid, I guess.

TH: Mm hmm.PT: Than I was. I was more excited and I did a terrible thing when he walked

away. I took a stone from the ground and threw it at him and hit him on the

back of the head.

Relentlessly the therapist pursues the implications of this incident, forcing thepatient to be explicit:

TH: If you didnt have a brother what would have happened?PT: Well, I would not have had a rival in the family would I?TH: Mm hmm. So in a sense if you didnt have a brother that means then you

didnt have a rival.PT: Thats right.TH: And the rival is the one that in a sense knocked you down and beat you and

humiliated you.PT: Yes.TH: Now the question is, so then what does that mean? If you didnt have a

brother?

PT: Well, that I would not have been beaten and humiliated obviously.TH: But what does if you didnt have a brother mean? Hmm? What is the

meaning of not having the brother? Hmm?PT: I dont know. Only that there would have been no one between my father

and myself, I imagine.TH: Mm hmm. There would not have been anybody . . .PT: Between.

TH: I mean there would not be in between you and your father, hmm? So thenthere was a sibling rivalry between you and your brother, hmm?

This brings other spontaneous memories, with fresh insight:

PT: Certainly. Certainly. I was very guilty also of . . . I remember now since


8/7/2019 Malan II

13/24


you talk about it. Ive never thought about this before in my relationshipwith my brother. But now I realize that there were many other ways much

less violent in which I was also humiliated and made to appear inferior tomy brother. When we were a little older and in socializing with the familywe would play cards . . .

TH: Mm hmm.PT: And my brother was always able to play cards very successfully even as a

young boy. I could not. I could not take enjoyment from them and couldnot grasp the game very well.

TH: Mm hmm.PT: So he was a very successful participant in this kind of family game.TH: So there also you were the loser.PT: So I was the loser there. Also another thing comes to mind. At a very young

age it seems he became very adept in making electrical repairs, doing thatkind of thing. When something needed wiring, some attachment needed to

be done, he would do it. I couldnt do it.TH: Mm hmm.

The therapist continued to focus on the patients hostile relationship with hisbrother. It became clear that the turning point at which the patient had begun to takea beaten position coincided with the final deterioration in his relation with his father.He was so critical of me. Everything I did was wrong. The situation eventuallybecame so bad that a cousin offered to take him into her home.

Other Family Relationships

The patients resistance was now so loosened that it became possible to conduct asurvey of all the patients relationships in this large and complex family.

Description of the serious deterioration in the relation with the father led to anew memory, now involving the triangular relation with the mother. The fatherbecame angry with the mother and called her a pig, at which the patient stood in frontof his mother and raised his fist, wanting to attack his father, who said that he woulddisown him as his son.

The therapist then explored another triangular relation, namely that involvingthe brother and the mother. Further memories emerged indicating that the brotherwas the mothers favorite, and that the patient felt the black sheep of the family,utterly excluded.

Next, the relationship with his sisters. He said he had sexual feelings for two of

his sisters, Diana and Nancy. He was very attracted to Dianas body and particularlyher large breasts. He was constantly curious to see as much as he could and as he grewolder his sexual interest became stronger and he had recurrent dreams about playingwith her genitals and other sexual activities.

There now emerged a link with the patients later life. He said that his wife andDiana have very similar builds and that his wife had been very attractive to him in thepast, but not any more. He then revealed that he was also very curious about hismothers body when she was dressing, and that with her too it was her large breaststhat attracted him.


8/7/2019 Malan II

14/24

96 D. Malan

The Link between the Past and the Patients Current Life

All this enabled the therapist to give interpretations pointing out that there mustbe a link between these early relationships and the patients later difficulties withwomen, although there was no time to explore this area in any depth:

TH: How do you feel talking about these things? You see, the picture is becom-ing much more clear that in a sense in these early years there is this battleground of you, your father, the hostile relationship between you and yourfather. So there is also this hostile relationship with your brother, okay? Butthen there are a lot of women around, hmm? So you are surrounded withwomen, hmm? Now one thing that we know, okay, is that in your currentlife you have a serious problem with women.

PT: Mm hmm.TH: So the fundamental question to ask is what is in the past of your life in

relationship to all these women which in a sense plays a role in yourproblem in relationship with women in the current life. Do you see what Imean?

PT: Yes.TH: This is a fundamental basic issue that has to be looked at, that you have.

One can say that there are two sides in the early part of your life. One side isthis tremendous hostile relationship between you and your father, you andyour brother. Now we know it was a very devastating situation therewith your brother and so forth, but then you are surrounded by manywomen. . . .

The Fathers Death

At the beginning of the present interview, all that the patient could remember ofhis feelings towards his father consisted of hostility and fear. After the experience ofwarm feelings towards the therapist, and probably in consequence of it, he discov-ered memories making clear that the early relation with his father had been warmand close, and that the hostility had arisen from a serious deterioration after thepatients return from evacuation and around the time of puberty. This discovery ofan earlier good relation is a pattern frequently encountered; and a further pattern isthat as the father ages and mellows, and particularly if he becomes ill and is about todie, the possibility of warmth returns. However, this warmth is so contaminated byguilt-laden hostility and grief about disappointed love, that it may be largely re-pressed; and when the father dies the exceedingly painful feelings of loss may never

see the light of day and the whole process of mourning may be aborted. Nevertheless,when the patients resistance against experiencing his true feelings has been loosenedby the process described above, it is possible to reach all these buried feelings withthe help of exactly the same technique as is used in crisis therapy, namely byre-creating the memories and scenes surrounding the loved persons death. This istrue even whenas in the present case the death may have occurred as much as 20years before. The therapist knows that the de-repression of these feelings is anessential step in the therapeutic process, and that it must be undertaken before theinterview ends.


8/7/2019 Malan II

15/24


The passage that follows illustrates very clearly both the return of resistance andthe fact thatafter the long process leading up to the true experience of both

negative and positive feelings for the therapistthe resistance can be penetratedrelatively easily and without further reference to the transference.

TH: Do you remember when you saw your father last? Before he died? Howlong before he died did you see him?

PT: I saw him in March.TH: What do you remember? Where was he when you saw him?PT: In bed. Sick.TH: At home?PT: Yes.TH: What do you remember? How did he look like?PT: Sick.TH: Could you describe the way he looked?PT: Weak. No, I dont think I can. I can remember only . . . I mean I dont have

a clear picture of him and the picture that I have of him is a much earlierpicture.

TH: Hmm?PT: The picture I have of him in my mind is a much earlier period . . .TH: Mm hmm.PT: When he was more vital, more aggressive and more frightening. Then he

was in bed sick. He was an old man but I dont have a clear picture of him inmy mind.

TH: Mm hmm.PT: No, I must have seen him the last occasion on the day that I left to return to

Canada.

TH: You visited him?PT: Yes, but I dont remember actually seeing him.TH: What was his sickness?PT: He suffered constantly from attacks of heart failure. Finally he deteriorated

and died.TH: How did you feel toward him when you were visiting him and he was dying?

The patient skates around the really painful aspects of his feeling:

PT: Well, I explained earlier that I felt much less angry towards him because I. . . by then I had begun to realize that I had been feeling angry towards himand had never realized it before.

TH: But my question was how you felt toward him because now he was a beaten. . .

PT: I felt sorry, very sorry.

The therapist makes the source of the pain more explicit:

TH: He was now a beaten dying man and toward this beaten dying man at onetime you had wished that you could wipe him out.


8/7/2019 Malan II

16/24

98 D. Malan

PT: I felt very sorry at that time that we had not been closer, that I had not beenable to be closer to him. I felt very sorry that I had not been able to know

him better and be able to talk to him, and I felt very sorry that I could donothing for him when he was in that condition.TH: So it must have been very painful.PT: Yes, it was. It was very sad. And I remember that just a few months later

when he died and I heard that he had died it was extremely difficult then.

The therapist now sets about re-creating one of the most emotionally ladenmoments:

TH: Do you remember the last good-bye to your father?

The patient is immediately defensive:

PT: No, I just told you. I dont remember.TH: The last good-bye.

PT: No, I dont remember the last occasion when I said good-bye to him.

The therapist simply ignores the defense and reacts as if the patient had said heremembered this occasion very clearly:

TH: How did he react to you?

PT: He didnt have much to say. He wished me well in my forthcoming

marriage.TH: He wished you, hmm. Do you remember the occasion when he wished you

well?

PT: I remember the day of the wedding when I dressed and went to say good-byeto him.

TH: Oh, you went to see him before you went to the wedding, hmm?

PT: Yes, because I was staying in the house.TH: Hm hmm. Many years back he was an aggressive, hostile man, but now he

was so sick that he couldnt come to your wedding.PT: I dont remember realizing that he was close to death. I didnt realize it at the

time.TH: But he was so sick that he couldnt attend, hmm?PT: Yes.TH: How did he relate to you then?PT: I remember only that he was more friendly towards me than he had been for

a long time.TH: Mm hmm. It was a warmer . . .PT: Yes.TH: Mm hmm.PT: And simply because he didnt have the vitality. It seemed that he didnt have

the vitality to be . . .


8/7/2019 Malan II

17/24


TH: Then it must have been a very painful occasion for you because at one timeyou wished him out.

PT: Yes.TH: Hmm?PT: Yes.TH: How do you feel now when you remember dressing up and going down and

visiting your father before you went to your wedding? How do you feel?PT: I feel sad. I feel sad because I know I was sad at the time when he was in the

condition that he was in.TH: So there was a part of you that wished . . .PT: I felt very sorry. I have felt very sorry for many years now since I have

begun to get an understanding of the conflict which existed between uswhich I didnt recognize before.

The therapist now concentrates on another highly emotional occasion:

TH: Now what do you remember of the funeral, his . . .?PT: I didnt attend the funeral.TH: Did you want to go to the funeral?PT: Yes.TH: And what happened.PT: I didnt have the money available at the time to travel to England.TH: Was that the only factor or it was less painful for you?

PT: I dont remember considering whether I should or should not go.TH: But this is not you, is it?PT: I beg your pardon?

TH: You see, I mean you are a sensitive person, arent you? And you felt thatyou wished, you were wishing of the father that you didnt have. Youwanted, hmm? So you were very much touched when he was incapacitated.

PT: Yes, I was very affected.TH: Mm hmm. And then we know a part, I mean you are a sensitive person or

arent you?PT: Yes.TH: Hmm? So do you think that in a sense a part of you wanted to go but a part

of you didnt want to face it, hmm? A part of you didnt want to face thatdead body, hmm? That you wanted to avoid, hmm? Where is he buried?

The breakthrough has occurredthe patient is crying, very sad.

PT: He was cremated.

TH: Mm hmm.PT: And the ashes disposed of in the grounds of the crematorium in Southamp-

ton. I have never visited there.TH: You have never visited? Did you wish to visit?PT: Sometimes, but when Ive been to England I have not visited.TH: Mm hmm. But did you feel that you wanted to?


8/7/2019 Malan II

18/24

100 D. Malan

PT: Yes, I did.TH: Mm hmm. So it is a sort of avoiding . . .

PT: I have not wanted to reveal that I wanted to.

The patient is sobbing.

TH: Mm hmm. Mm hmm. So there is a very painful thing there, isnt there?Hmm?

PT: Yes.TH: But avoiding it is not going to resolve it, is it?PT: No.TH: Hmm?PT: No.TH: So then you have been in the process of . . . and your not going to

Southampton, maybe also part of it had to do with finance, but if we look at

it you felt much more comfortable to avoid it, isnt it.PT: Yes, yes.TH: So then you have a lot of mixed feelings about your father, isnt there?PT: Yes, yes, I remember little things.

The revived mourning process is beginning, but time is running short and thetherapist has to begin to close up the interview.

Final Phase: The Patients Response to the Interviews

The therapist now explores the patients reaction to the interviews, watching

particularly for motivation to continue:

TH: But do you think that in a sense of course in these two session we onlytouched the surface of your difficulties, your problems, very very surfacepart, okaybut do you think what we did, if you did it on a more regularbasis rather than to continue to avoid, to face all your feelings, all theseburied feelings that you have, this might be of help to you?

PT: Yes, because although I find it very uncomfortable to talk to you in thisway, to be obliged to try to face these things and give answers. . . .

TH: But do you think it might be . . .PT: Yes.TH: Hmm?

PT: Yes, the practice which have gone through of being on the couch and beingallowed to try to make progress at my pace has obviously not been veryfruitful because I keep avoiding the issue. I simply have to learn . . .

TH: To face this.PT: To face.TH: Because, if you come to put all the memories and all feelings that you have

in the right perspective, then you dont have to continue like this. Then youcan hopefully, possibly, be a free man, hmm? Because in a sense you arereally repeating the life of the past.


8/7/2019 Malan II

19/24


The therapist ends by saying that the patient will be contacted later aboutstarting treatment.

Summary of the Course of the Interview

To recapitulate, the essential features of the technique consist of the first sixphases enumerated above:

(1) Pressure towards the experience of true feeling,(2) Rise in resistance,(3) Challenge to resistance,(4) Rise in transference, with resistance now in the transference,(5) Challenge to resistance in the transference, leading to(6) Direct experience of transference feelings.

With the simpler and less resistant patients this sequence may need to occur onlyonce. With a patient such as the one just described, who arrived at the interviewalready in a state of high resistance, it may have to be repeated several times.

A condensed account of this repeated sequence shows the following;The patients initial resistance takes the form of vagueness and distancing, which

the therapist systematically challenges (phases 1 to 3).Soon nonverbal cues indicate that the patient has become angry at not being

allowed to use his defenses, but is trying to conceal this and not to acknowledge iteven to himself (phase 4).

The therapist now breaks in, asking the patient how he feels at this very moment.He systematically challenges the patients evasion, ending up by the head-oncollision with the resistance. This consists of forcefully pointing out that if thepatient continues in this fashion the interview will be as useless to him as all hisprevious treatment has been.

This repeated cycle enables the patient to begin to acknowledge and finally toexperience fully all his complex feelings in the here-and-now. These consist, first, ofanger with the therapist, then of intense sadness at the prospect of repeating all hispast failures and going away from this interview empty-handed, and finally of deepwarmth and appreciation at the therapists genuine concern for his welfare (phase 6).

The true experience of all these feelings produces an unlocking of the patientsunconscious and a marked rise in the therapeutic alliance. The result is that, as thecycle is repeated, interpretation begins to play an increasing part. In the early part ofthe cycle the therapist did in fact give one interpretation, pointing out that thepatients smiling and fidgeting were ways of defending himself against his anger.

Even more important, the patient began to make his own interpretations, e.g., thathis accident-proneness was a form of suicide. This culminated in his spontaneouslyexplaining his resistance at the beginning of the interview as due to his expectationthat the therapist would behave like his father and ridicule him if he showed his realfeelings.

This led to a new phase in which the therapist systematically analyzed theresistance in the transference by interpreting it in terms of the patients relation withhis father.

Now it was possible to enter the phase of pure content, in which the patients


8/7/2019 Malan II

20/24

102 D. Malan

conflicting feelings could be explored and interpreted in all his relations throughouthis life, without any further reference to the transference.

During this phase some patients show very little resistance and their unconscioustherapeutic alliance actively collaborates with the therapist. In the patient this activecollaboration had already been shown previously by his spontaneous interpretations,particularly his making the link between the transference and his father. In thephase of pure content he showed a different pattern, namely that of going intoresistance as each new anxiety-laden area was explored. Now, however, all thetherapist needed to do was not to employ challenge, but to sweep the resistance asideby persisting in his questioning. Then the therapeutic alliance came into operation.In the most dramatic example the therapist asks the patient what he felt when he wasknocked down and humiliated by his brother, to which he answers I dont know howI felt. The therapist then points out that the patient had openly expressed the wishto kill his wife, and this quickly brings out the incident in which the patient had hit hisbrother on the back of the head with a stone.

The final example of this penetration of the resistance by simply persisting with aline of questioning occurred in connection with the fathers death. The patient sayshe doesnt remember considering whether or not he should go to England for thefuneral. The therapist says But this is not you. You are a sensitive person. Thepatient says he has never visited the crematorium: But did you wish to visit?Sometimes, but I havent done so. But did you feel that you wanted to?, Yes Idid. So it is a sort of avoiding. I have not wanted to reveal that I wanted to, andthe patient is sobbing.

The Patients Psychopathology

In the end it is possible to reconstruct the whole of the patients psychopathol-ogy, which is very complex and can only be briefly summarized here. Foremost is the

feeling of exclusion from his family, enormously intensified by his evacuation duringthe war, and compounded by the fact that his siblings were sent away in pairs,whereas he was sent away alone. This gave rise to violent jealousy and hatred of hisrivals in several triangular situations, particularly that involving his brother and hisfather. Next there is the whole area of his buried hatred of his father, beneath whichlay love and grief, the whole made unbearable by his fathers final illness and death.Then there are his complex relations with the women in his family, which includesjealousy, hostility, and guilt-laden sexual feelings. It is clear that all this has causedserious inhibitions in his relations with women ever since. There are also indicationsthat he experiences a repetition of his early family situation in the form of jealousy inthe triangular relation involving his wife and his sons. The end product of all theseconflicts has been a severely and chronically impoverished character, who usesintellectualization, distancing, and serious self-directed aggression as his main defen-

sive mechanisms. Yet these character defenses have been penetrated in two inter-views, revealing the intense, guilt-laden, and almost unbearably painful feelingsunderneath.

Essential Features of the Technique

Of all the features of this interview there are two that need special emphasis. Thefirst is tactical, the technique of challenging resistance rather than interpreting it.


8/7/2019 Malan II

21/24


The second is more strategic and does involve interpretation, namely the systematicdissolution of resistance, mostly in the transference, over and over again as each new

aspect arises. These strategic principles are identical with those of psychoanalysis;but whereas there the process takes hundreds of hours (if indeed it can be accom-plished at all), here the defences can be exhausted within two interviews.

The consequences all follow from the extraordinary power of the technique interms of its capacity to dissolve resistance. These can be described under thefollowing headings:

Therapeutic Consequences

After an interview of this kind the patients whole psychic system is madepermanently more fluid. During subsequent days and weeks most patients experi-ence an upsurge from their unconscious in the form of fresh memories and significantdreams. Their motivation to continue working in this way, which starts so low,

remains permanently enhanced, and they are prepared to wait almost indefinitely fora chance to do so. When therapy begins, often with a therapist different from theoriginal evaluator, the therapists task is made much easier. Of course resistancereturns, but it often can be removed quite easily, and it rarely if ever needs such aprolonged challenge as was necessary in the first interview.

As a result, though a certain amount of working through is necessary, instead ofthe therapeutic process appearing to go round in circlesas it does in so muchlong-term therapysteady progress is made towards the resolution of each aspect ofthe neurosis as it arises. It is then possible to deal with every aspect of even a complexneurosis like that of the patient just described. In such a patient, therapeutic effectsusually begin to appear within the first 58 sessions, and therapy should be com-pleted within 20 30 sessions, with total resolution of the neurosis at termination andfurther confirmed at follow-up many years later.

Consequences in Terms of Selection

The first consequence is concerned with the accuracy of selection. After aninterview of this kind, the evaluator can be virtually certain that a skilled therapistcan achieve total resolution of the neurosis within the limits of short-term therapy. Inother words, whereas with the Tavistock technique the evaluator could only say thatsuccessful results will come from among patients with certain characteristicsi.e.,could define the necessary conditionswith this technique the evaluator can definethe necessary and sufficient conditions.

The difference clearly comes from the power, and hence the completeness, ofthe process both of initial evaluation and of therapy. In the patient described above it

seems that all his neurotic conflicts were either reached directly or brought close tothe surface at initial evaluation; and not only does this predict that they can bereached and worked through in therapy, but the very completeness predicts that totalresolution will follow. In other words the gap between dynamic interaction andresolution, described at the beginning of the present article, has been closed.

On the other hand, the value of much of the Tavistock work is confirmed, in thesense that many of the selection criteria and the basic principles of the selectionprocess hold equally well in Davanloos system, and are thus probably shown to begeneral principles fundamental to STDP. These are as follows:


8/7/2019 Malan II

22/24

104 D. Malan

(1) The need for a comprehensive psychiatric history;(2) The elimination of unsuitable patients;(3) The use of trial therapy;

(4) The formulation of positive selection criteria:(a) The ability to make a comprehensive psychodynamic formulation;(b) The ability to plan therapy:(c) A positive response to trial therapy, especially in terms of response to

interpretation and an increase in motivation.

The Tavistock principle that does not apply in Davanloos technique is the needfor a basic simplicity or focality in the patients problems. As mentioned above,the power of the technique is such that even problems of great complexity can beresolved within the limits of short-term therapy, each aspect of the neurosis beingbrought into the open and resolved in turn.

It is very important that this difference between the two systems should beemphasized, since after the publication of the Tavistock work the principle of

focality or simplicity of psychodynamics has been widely accepted as a necessarycondition to all forms of STDP. In Davanloos system this is no longer so.

Quantitative Consequences

Whereas with the Tavistock technique only a few percent of patients are suit-able, with Davanloos technique this proportion is immensely higher. In a consecu-tive series of general psychiatric patients seen at out patient Psychiatric Departmentof The Montreal General Hospitalin contrast to the Tavistock series, where thepatients were carefully selected from those already referred for psychotherapy thefigures were as in Table 1.

Recent work with even more difficult patients suggests that the proportion of

suitable patients can be raised to about 35%.The number of sessions required varies from 1 5 with simple symptomatic

neuroses, to about 40 with highly complex character neuroses.

Theoretical Consequences and Conclusion

Here we may return to the questions that I raised at the beginning whenconsidering the position of purely interpretative therapy, whether short-term orlong-term.

In traditional short-term therapy the situation is as follows: the therapist selectspatients with a clear-cut central problem and aims to work this through to themaximum degree within a limited number of sessions. There is no difficulty in

Table 1. Proportion of Patients Suitable for STDP in Davanloos Series

Total number of general psychiatric patients: 617Taken into STDP with Davanloo: 172 (28%)Successful results (total resolution): 143 (23%)

Proportion of successful results in the 172 treated: 143/172 = 83%Of these 60% had follow-up ranging from two to nine years.


8/7/2019 Malan II

23/24


selecting patients who respond to this process in each session, and it frequently leadsto dramatic responses to interpretation and intense experiences; but in all too many

cases this does not result in the desired resolution of the neurosis.The advocates of long-term therapy as the only true way of achieving deep-seated changes will say that if therapy had gone on for long enough then theresolution would have occurred; and that the reason for the failure of short-termmethods in these cases is the lack of sufficient working through, and the failure todeal with the complexities of the neurosis and all the over-determinations. In somecases no doubt this is true, but every honest psychotherapist will admit that in manyof his long-term cases, probably the majority, something similar happens to theevents that I described in short-term therapy; namely that apparent working throughdoes take place, with daily response to interpretation, fresh insight, and the experi-ence of buried feelingsparticularly in the setting of the transference neurosis butthe therapeutic effects fail to materialize. Systematic follow-up, such as that carriedout recently at the Tavistock Clinic (not yet published), reveals that this observation

is correct. What has gone wrong?It seems to me that Davanloos work has found the answer to this question,

which can only be understood clearly after a long preamble:Traditional therapy is based on obtaining positive responses to interpretation.

Every such response can be placed on a continuum between purely cognitive at oneend and purely affective at the other, with various combinations of the two inbetween. A purely cognitive responseI know what you say is true but I do not feelit is not a positive response. A highly positive response, on the other hand, wouldbe a purely affective one, such as the patient breaking down into tears about the lossof someone dear to him and sobbing without words for a long time.

This does happen, but not very often, and in between the two extremes there arevarious intermediate stages. In traditional interpretative therapy the therapist is

usually satisfied if the patients response shows some or all of the followingcharacteristics: there is a drop in tension and an increase in spontaneity and rapport,the patient is clearly more in touch with his feelings, and fresh communicationsemerge which confirm the interpretation and elaborate upon it. When therapy isgoing well there is then often a leapfrogging process in which (1) the patient goesfurther than the therapist has, (2) the therapist is then able to go further than thepatient has, and (3) the two of them work towards some painful or anxiety-ladenfeeling.

However, it must be remembered that such responses contain a mixture ofaffective and cognitive components, and the question is always whether the affectivecomponent is sufficient for the therapeutic process to be successful. We know fromfollow-up studies that sometimes it is, but from the same follow-up studies we alsoknow that in many casesindeed in the majorityit is not.

We can postulate that each patient contains a kind of reservoir of pathogenicconflictthe analogy of an abscess is often usedand that the aim of therapy is todrain this reservoir until it is empty. According to therapy, each time the patientresponds to an interpretation and thus is brought nearer to the experience of hisunderlying feelings, or each time a link is made, a small amount of pathogenicmaterial is drained from the reservoir. This is what is meant by working through.

But the evidence now suggests that this is not necessarily so. Suppose it were truethat there is a threshold in the cognitive/affective continuum, below which not


8/7/2019 Malan II

24/24

106 D. Malan

merely very little but no working through takes placenothing is drained from thereservoir. If this were true the therapist could go on making interpretations and

receiving responses indefinitely, without any appreciable therapeutic effects whatso-ever. In that way therapy becomes endless.It follows from this that the patient can use response to interpretation as resis-

tance. He keeps the therapist happy by giving the impression that his problems arebeing worked through, whereas in fact nothing of the kind is taking place at all.

The mistake the therapist is making is not to realize that he is operatingbelow the threshold at which true working through takes place, and thereforeto work with the component of response to his interpretations, or the component ofcommunicationwhich indeed is presentrather than the component of resistance.Only when he systematically works with the resistance and eventually brings thepatient to a point above the threshold, where there is sufficient true experience of theunderlying feelings, can genuine therapy begin.

Moreover, it appears from Davanloos work that merely interpreting resistance

is not enough. On the contrary, first the resistance has to be systematically chal-lenged, and then the consequent transference feelings have to be brought into theopen and truly experienced. Only by this means can most patients be brought abovethe threshold where interpretation becomes therapeutically effective. It is these twininterventions that constitute the core of Davanloos technique and his most impor-tant and most original contributions.

These early phases usually need to be followed, as in the above interview, by aphase in which the residual resistance is systematically dissolved by interpretation,including many links with other relationships in the patients life. When this has beendone an immensely important consequence follows, which is an observed fact butwhich traditional therapists may have difficulty in believing. This is that the reservoirdoes not contain a huge volume of pathogenic conflict which has to be drained dropby drop over a long period. Nor is it under such pressure that weakening the defenses

causes it to erupt in uncontrollable explosions of affect such as occur in manyencounter groups. On the contrary, it can often be drained quickly and relativelysmoothly, with quiet yet intense experience, each component being dealt with oncefor all. The final result is total resolutionthe reservoir is left permanently empty.

Perhaps we may end with two statements that sum up one of the main points inthe above argument: The most devastating and pernicious form of resistance isresponse to interpretation; and The greatest mistake a therapist can make is not torecognize when response to interpretation is being used as resistance.

References

Malan, D. H. (1985). Beyond interpretation: Initial evaluation and technique in short-term dynamic

psychotherapy. Part I. International Journal of Short-Term Psychotherapy, 1, 5982.


Malan II

Documents