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A leap across a basic fault: Brief Supportive

Dynamic Therapy

Jonathan D. Smith*

South London & Maudsley Mental Health Trust

(Received September 2007; final version received November 2007)

The author explores the evidence-base and selection criteria for a short-term supportive dynamic approach for patients whose psychologicalmindedness and quality of object relationships is low. Illustrating thisapproach with a case example he outlines the central features ofSupportive Dynamic Therapy. He describes a psychodynamic con-ceptual and developmental framework that can be used to guide thetherapists interventions and responses, and modulate the patientsanxiety. A dynamic focus presented in the form of a central issue isshown to have a significant function both in containing the patientsanxiety, and in giving shape to the therapists efforts to support thepatients ego-strengths and adaptive abilities. The therapeutic work canbe seen to result in an alteration in the trajectory or reiterating pattern of

the patients life.

Keywords: Brief Supportive Dynamic Therapy; evidence-base; dynamicfocus; ego-strengths; super-ego; contextual transference; focusedtransference; basic fault

Introduction

Counsellors and psychotherapists have increasingly been working in settings

such as Primary Care in the NHS, Student Counselling Services and

Employee Assistance Programmes where two factors converge. The first of

these is that the work they are required to undertake with their patients is

short-term; often they are expected to work to a limited time frame of six or

twelve sessions. The second is that they are usually required to work

therapeutically in some way with almost anyone who arrives through the

door of the service. Patients often present with high levels of disturbance

and a severely damaged internal world where the quality of their internal

and external object relationships is poor. Sometimes it is possible to refer a

Psychodynamic Practice

Vol. 14, No. 4, November 2008, 421439


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patient on for longer-term therapy, but often this will not be possible either

because the patientss motivation to engage in longer-term work is low or

because they have little insight into their difficulties at the time of their initial

presentation. Frequently one can categorize such patients as being low in

psychological mindedness. Sometimes it is also the secure nature of the

setting, such as a familiar GP practice, that results in the patients wish to be

seen by the therapist so that he or she is unwilling to be referred on

elsewhere, or it becomes evident that the secure base provided by the setting

provides an opportunity for the development of a therapeutic relationship

which may not be easily replicated elsewhere. The question that is then

posed is how can the therapist work with such patients and achieve a

positive therapeutic outcome within a time-limited framework?

Historically, short-term dynamic work that is essentially interpretative

or exploratory in nature, which is concerned with uncovering unconsciousconflicts, has in its assessment criteria excluded many of the types of patients

presenting with more damaged internal worlds (Malan & Osimo, 1992;

Sifneos, 1987). Practitioners working with more damaged patients have in

consequence turned to more supportive dynamic approaches.

The term Supportive Therapy carries a number of connotations and

associations. These include the notion that it may be very limited in the

depth of its effectiveness, that it will require fewer psychodynamically-based

skills and that it will therefore be less satisfying for the practitioner. These

connotations are likely to be compounded when the words Brief Dynamicare added to the term. In contrast Rockland has commented

Too often supportive therapy is viewed as simplistic, not requiringpsychodynamic sophistication. Yet when supportive psychotherapy isgrounded in psychodynamic understanding and carried out in accord withpsychodynamic principles, it becomes a very creative, exciting and intellec-tually stimulating exercise (Rockland, 1989, p. 4).

It has also been noted that until recently there has been no unifying

theory that provides a conceptual basis for the practice of supportivetherapy and that as a consequence there has been very little attention paid to

supportive therapy in the literature or in clinical training programmes (Piper

et al., 2002, p. 33). It is my aim to show how Brief Supportive Dynamic

Therapy can make a significant contribution to the work of psychodynamic

practitioners in many settings, with many of the patients who present with

more damaged internal worlds, and moreover that there is a growing and

sophisticated theoretical underpinning and evidence base to its practice.

Bronwyn: The only pebble on the beach

Bronwyn, who was aged 45 years, was referred to me in my work as a

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history of depression, which had included referral to the Community Mental

Health Team about two years prior to this. She had experienced suicidal

ideation some while before this referral to the CMHT but at the time she

was seen in the team her mood had stabilized. It was noted that she found

socializing difficult and that she had a mild learning difficulty. Her sleep was

erratic and she experienced difficulty in concentrating. She was offered some

support through the Welfare Rights Department and then subsequently

discharged back to the care of her GP. The referral to me from the GP also

indicated that she was experiencing difficulties with her 19-year-old son who

was in trouble with the police.

She arrived on time for this first appointment. She presented as rather

awkward and hesitant at first but began to relax in response to my empathic

attentiveness and was soon able to tell me about her current life and the

earlier narrative. She began by telling me about her 19-year-old son and howhe had been in care when he was 17 years of age but had returned to live

with her. She wanted to be there and available for him as his mother but he

was verbally abusive towards her and bullying her in a way that was

exacerbating her anxieties and depression. She had had a number of

partners in her life who had been abusive and violent towards her and she

noted the similarity to the pattern of her sons verbal abuse and added that

she would not have put up with such aggressiveness if a partner rather than

her son had behaved towards her in such a threatening way. She was

currently unemployed and although she had attended a short vocationalcourse 2 years earlier she had been unable to subsequently obtain a job.

Her social isolation was very evident and she gave little indication of

having any current friendships apart from her former partner. He had had

quite an active social life centred on a local pub. She had found herself

becoming increasingly anxious and self-conscious when she joined him in

the pub and dealt with these anxieties by binge drinking. Their relationship

became platonic and subsequently Bronwyn found the inner resources to

stop binge drinking without it seems having sought out any external help

with this difficulty. She remained friends with this former partner and theymet up occasionally but the fact that they no longer had a sexual

relationship clearly troubled her. She described herself as shy and it seemed

that she was increasingly withdrawing herself from social relationships and

friendships.

Bronwyn had been born in a small mining town in South Wales. Her

mother had died when she was only 5 years old. She lived with her father

and older half-sister until she was 11 years of age. She described her father as

having mental health problems and then he too died when she was aged 11

years. She then went to live with her maternal uncle and his wife. Her half-

sister went to live with her own father and Bronwyn had subsequently lost

all contact with her. Her uncle and his wife already had a large family and

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the family. When she was 15 years of age and feeling very depressed she took

an overdose of tablets. She was then placed in care because her uncle and his

wife no longer felt able to provide a home for her. Bronwyn commented

with some poignancy that there was simply no-one for her to turn to for help.

When she was 18 years of age she left the childrens home and travelled

to Swansea. She noted here that she had a tendency to run away from things

just as her son does. She met a man and became pregnant and gave birth to a

daughter but, depressed and demoralized, she felt unable to look after her

baby. Her daughters father, from whom Bronwyn had by now separated,

took over the care of her daughter and she subsequently had little direct

involvement in her daughters care. Three years later she met a man who was

12 years older than herself and they married.

Bronwyn then told me, in a way that that left me feeling quite taken

aback, that she had been present when her husband was murdered in a knifeattack. In some way she blamed herself, her swings of mood and her own

depression, and the fact that she was still maintaining some contact with her

daughter, for the fatal attack on her husband. The sequencing of her

thoughts about this was vague and my efforts to elicit more clarity yielded

little further information.

Towards the end of the first assessment session Bronwyn asked me a

series of questions such as whether I myself had children which left me

feeling placed on the spot and uncomfortable. When I tried to interpret

these questions as an indication of her uncertainty and anxiety aboutwhether I would be able to understand her experience as a mother she

seemed to become bemused and a little agitated.

As I listened to this bleak and disturbing narrative it was clear that there

was a poverty in the quality of Bronwyns object relationships both

internally and externally, in relation to her past childhood experiences as

well as in her current life. Her current social isolation was reflected in her

own description of herself as the only pebble on the beach. Her

psychological mindedness, her capacity to make use of interpretive links

also seemed very limited although she had some ability to notice thereiterating patterns of her life. That she had a mild learning disability

seemed to be confirmed by the rather bemused way in which she responded

to my interpretative links. Above all, however, I noted how she expressed so

little affect as she recounted traumatic losses and severely disrupted

attachments. I surmised that powerful primitive defences were operating

to keep deep feelings at bay and that her fragile psychological coherence

could be easily destabilized were I to confront her defences in order to

release her hidden affects (Malan, 1976; Malan & Della Selva, 2006). I

questioned in my own mind whether there was much that I could do

therapeutically in a further 12 ongoing sessions that I could offer her. In the

Mental Health Trust which employed me 12 sessions after assessment was

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Towards the end of this first assessment session I picked up a patterned

theme that ran through the narrative which Bronwyn herself had noted and

which was captured in her metaphor that she experienced herself as the only

pebble on the beach. Throughout these painful separations and losses, and

particularly when she had felt depressed or distressed, there had beenno-one

there for her to turn to for help. I decided to present this to her as a central

issue or focus in the way that Mann (1973) describes, acknowledging that

this had been the case for so much of her life and that this absence of support

had greatly contributed to her difficulty in sustaining a confidence in her own

abilities and capacities. I also commented that in spite of this she had

struggled to face and overcome many of her problems such as her own binge

drinking and her sons delinquent behaviour. In this way I included the four

components of a central issue recommended by Mann Affects, self-esteem,

time and strengths. My intention was to provide Bronwyn with a focus thatresonated deeply with the conscious and unconscious patterns of her life,

connecting to her idiom (Coren, 2001) and to begin a process of containing

her life experience by bringing it within the jurisdiction of form (Smith, 2006).

Bronwyn responded positively to my presentation of this central issue, which

appeared to resonate deeply in the way in which I intended and she readily

agreed to meet again for a second assessment session.

Assessment for Brief Supportive Dynamic TherapyIn identifying those patients who may be particularly suitable for a more

supportive and less exploratory approach, Rockland (1989) outlines a

number of criteria. Included amongst these criteria is a condition known as

alexithymia, which he defines as a difficulty in experiencing or describing

affects. I had found it especially striking how little Bronwyn had been able to

connect to her feelings, and how flat was her emotional tone, as she

described the disturbing and impoverished narrative of her life. As Coren

(2001) notes the capacity to think in emotional terms about ones life

experience is a key component of the capacity for narrative coherence and islinked to the degree of security that an individual has experienced in their

attachments. Bronwyn seemed to be very insecurely attached to others and

her limited capacity for autobiographical competence and to reflect upon

her emotional life indicated weaknesses in her ego. The emptiness of her

current life, and the absence of interests or activities with which she could

engage suggested that she had a limited capacity to sublimate her impulses.

Her resort to alcohol and her flight from situations with others where she

felt anxious suggested that she had limited capacity to tolerate anxiety.

These were further indications of ego-weakness as was her predominant use

of more primitive defences such as withdrawal, projective identification,

externalization and projection outwards of her own aggressive impulses



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quite severe and therefore a further indication of the suitability of a

supportive approach. It was likely therefore that Bronwyn would strongly

resist an exploratory approach that would focus upon her affects, and that

any attempt to do so could precipitate a severe regression, or a premature

termination. I was also mindful that as she had a history of suicidal ideation

that it might also result in some risk of an attempted suicide.

The fact that Bronwyn had a mild learning disability was another

criterion that Rockland cites as an indication of suitability for a supportive

approach. Her limited psychological mindedness and capacity to make use

of transference interpretations which have already been described were

further indicators that an interpretative approach was contraindicated.

William Piper et al. (2002) have conducted an outcome study which

explores and compares the efficacy of an interpretive/exploratory form of

short-term psychodynamic therapy with a psychodynamically supportivemodel. The Quality of Object Relationships (QOB) and Psychological

Mindedness (PM) of each person included in the study were carefully

assessed, using sophisticated measures. When patients were divided into

high and low QOB and compared across each form of short-term therapy it

was found that those with a high QOB did better at follow-up in the area of

social-sexual functioning where they received interpretative therapy

compared to those with a high QOB who received supportive therapy. In

contrast it was found that

low-QOB patients in supportive therapy did better than low-QOB patients ininterpretative therapy in the area of self-esteem. These findings representreasons to provide interpretative therapy to high-QOB patients and supportivetherapy to low-QOB patients (Piper et al., 2002, p. 117).

High levels of PM were correlated to better outcomes for both

interpretative and supportive therapies though the correlation held less

strongly that those for QOB.

The authors were also able to draw specific conclusions from their data

about the use of transference interpretations by the therapist.For high-QOR patients the greater the use of transference interpretations thestronger the therapeutic alliance. For low-QOB patients, the greater the use oftransference interpretations the weaker the therapeutic alliance. There is alsosome evidence for low-QOB patients that the greater the use of transferenceinterpretations the poorer the outcome (Piper et al., 2002, p. 241).

Although I did not have access to the sophisticated measures of QOB

and PM that Piper et al. used in their studies it was clear that Bronwyns

impoverished relationships with others as outlined in her narrative were an

indication of a very low QOB. Her PM also appeared to be low. The

research findings of Piper et al. (2002), together with the Rocklands criteria

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should be offered a supportive therapy with a minimum use of transference

interpretations.

Refining the focus: Maximizing collaboration

Bronwyn arrived a few minutes late for her second session, and then

proceeded to tell me that she had found a gun amongst her sons

possessions. The immediate impact of this announcement was to evoke

my own anxiety, wondering how I should respond, trying to work out my

own responsibilities for the safety of Bronwyn herself as well as others. As I

listened further she told me that she had at first felt frightened and alarmed

when she found the gun in a holder amongst his clothes which she was about

to wash. She then told me that the gun was in fact a replica. She had

destroyed it and later told her son that she had thrown it away. At this pointI experienced some relief. Bronwyn had not felt able to tell anyone about the

incident. She had thought about confiding in her sons aunt, his fathers

sister, with whom he had frequently stayed and who knew him quite well.

However she thought that that his aunt would be dismissive of the whole

incident, would not take it seriously, and would laugh at her. She added that

she did not think that his aunt was aware of the full extent of her sons

involvement in crime. At this point I decided to interpret whether she was

anxious about how I might respond to the account she had given me. She

agreed that she was indeed anxious that I would either be dismissive of heranxiety or alternatively inform the authorities about the replica gun. I was

aware of the powerful impact that this narrative had made upon my own

counter-transference and of Bronwyns use of projective identification to

communicate her own alarm and anxiety. I noted that alongside her use of

this primitive defence which was another indication of ego-weakness that

she had displayed some ego-strengths in dealing with the situation by

destroying the gun and confronting her son. I then pointed out to her that

once again as she had faced a disturbing situation in her life alone and that

she had felt that there was no-one else to turn to . Here I linked back to thefocus that I had established with her in the first session. She agreed and the

rapport between us deepened. She asked me whether I thought that she had

done the right thing in destroying the gun. I did not reassure her directly but

replied by noting how she had found a way of firmly standing up to her son.

I realized that the capacity to stand up for herself assertively in the face

of violence or in this case threatened violence was another very significant

theme in Bronwyns life. She had frequently been subjected to violent

assaults from partners and witnessed the murder of her husband. It was also

evident from her comments that she was anxious about the impact that her

sons behaviour was having upon her own mental health and that there was

some urgency about addressing this issue. So I suggested that we include the



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work on together, and with the intention of maximizing the collaborative

nature of my stance, invited her to give her opinion on this suggestion. She

readily agreed to the inclusion of this additional dimension to the focus of

our work.

Significantly in the session which followed it emerged that she had herself

linked the two strands of the focus together by speaking to her sons aunt

about her sons behaviour, informing her of the full extent of his

involvement in crime, and her anxieties about confronting this problem.

His aunt had responded quite thoughtfully and supportively by noting that

his father and uncle were also involved in petty crime. (After her husband

had been murdered Bronwyn had established another relationship with her

sons father. He was a drug addict and after her son was born they

separated.) This discussion had the effect of improving Bronwyns morale

and self-esteem as well as enabling her to consider whether in order toprotect herself and her own mental health she needed to ask her son not to

stay with her for a while.

She told me that she was finding it helpful to come to counselling to talk

about these difficulties but she was very cautious about committing herself

to further appointments. I explored this carefully with her, once again

maximizing the collaborative nature of this process, agreeing to book two

further appointments and review with her at the end of these whether she

wanted to book further sessions, while reiterating that the maximum

number of ongoing sessions that I could offer was twelve. She also requestedthat the appointments be spaced fortnightly apart and I agreed to this.

A conceptual and developmental framework

A key feature of a supportive model of Brief Dynamic Therapy is the aim to

minimize regression. Where ego-strengths are weak or the ego subjected to

distortion, there is a risk that exploratory work may result in a rapid

regression in the transference which cannot then be contained leading to a

de-compensation or a breakdown in capacities to cope with life circum-stances. Establishing a collaborative relationship with the therapist requires

the patient to employ and develop their ego-strengths, lessens the likelihood

of a regression, and therefore plays an important part in supportive therapy.

Collaboration therefore has a therapeutic function that can be linked to the

way in which a parent collaborates and negotiates with a child to face a

difficult or anxiety-provoking situation.

The notion that a psychodynamic developmental framework can form

the basis for the technical procedures of supportive therapy has been well

articulated by Appelbaum (1989). She has identified a correspondence

between parental behaviours and the types of interventions that mark a

supportive approach. The monitoring and regulation of anxiety at an

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therapeutic functions which she identifies as corresponding to those of a

parent. She writes

The conduct of skilful parents, like that of skilful therapists, promotes the

maintenance of an optimal level of anxiety for learning, fosters a sense of self,encourages mature interpersonal relationships, furthers the development ofanticipatory anxiety and aids in the mastery of excessive levels of anxiety andguilt (Appelbaum, 1989, p. 43).

Stern (1984) has noted that it is the state of quiet alertness that most

promotes the development of the infants learning and ego-capacities and

the skilful parent will intervene and sooth the infant with verbal and non-

verbal empathic attentiveness where the infant becomes upset and anxious

or fussing. Similarly in supportive therapy the therapist needs to monitor

the anxiety levels of the patient, intervening with empathic comments ornon-verbal attunements where the patients anxiety reaches levels that begin

to jeopardize the patients capacity to learn from the therapeutic experience.

At the same time the therapist like the skilful parent needs to promote the

capacity of the patient to rely upon their own resources, to acquire the

capacity to sooth themselves, so that calming interventions are introduced

by the therapist only to the level that is sufficient to enable learning and

development to resume. Appelbaum goes on to write:

In adult health the consoling presence of the mother has been absorbed intothe comforting aspects of the super-ego: in adult illness those identificationsfail to perform the soothing function and the presence of the therapist is thenrequired (Appelbaum, 1989, p. 48).

In this context reassurance, the making of direct suggestions to the

patient or even teaching methods of self-soothing such as learning various

relaxation techniques may each make a contribution to soothing the

patients anxiety so that they are able to maintain a level of alert

reflectiveness, corresponding to the infants quiet alertness, and in which

they are most likely to gain from the therapeutic process.Stern has identified ways in which the parents attunement promotes

the play of the infant as well as the development of a capacity for inter-

subjective relatedness. Attunement involves the parent responding in a

different modality to the infants play in such a way that the pace, intensity

or rhythm of the activity is in some way reflected back to the infant.

Appelbaum suggests that the empathic resonance of the therapist in which

the therapist finds words to reflect the feeling state of the patient is the

therapists counterpart to the parents attunement of the infant. She writes

As the acts of attunement of the parent prolong the babys play, so the therapistsaccurate empathic interventions prolong the patients capacity to participate inpsychotherapy rather than disrupting the work with affect storms leaving the



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Empathic responsiveness is also intrinsically mutative, contributing to

the strengthening of the sense of self and consolidating the development of

self-esteem and self-confidence (Kohut, 1984). Interventions that support

the patients self-esteem are considered to be a central component of

Supportive Dynamic Therapy and have been identified as such by Pinsker,

Rosenthal and McCullough (1991). They have also identified two other key

components, namely supporting the patients ego-strengths and fostering the

patients ability to relate more adaptively to others in their current external

environment. In the service of strengthening the patients ego and adaptive

capacities the supportive therapist may make suggestions, offer encourage-

ment, give praise for certain behaviour or achievements and offer direct

advice. The therapist may even prohibit or firmly set limits in relation to

certain behaviours such as behaving in self-destructive or dangerous ways.

In supporting the patients reality testing, a key component of ego-strengths,the therapist may clarify, confront or undermine the more primitive defences

such as projection and splitting.

Appelbaum also suggests that the patients ego can be strengthened by

decreasing the strain on the ego, through altering the balance between the

drive demands, the super-ego and environmental pressures. Partial

gratification of transference wishes can ease the strain on the ego from

drive demands. Direct interventions with the external environment to elicit

emotional or practical support, for example, can have a similar effect. Stress

on the ego from the super-ego can be reduced by questioning or challengingits judgements on the patients behaviour (Britton, 2003) or by the therapist

sharing certain of their own more benign values with which the patient may

then identify. In respect of any of these interventions the therapist will need

to be guided by his assessment of the developmental needs of the patient,

such as, for example, the need to establish firmer boundaries with others to

establish a more secure sense of autonomy and individuation, and by the

patients level of anxiety, maintaining this at a level that can maximize

learning, and therefore developmental transformation.

It will be evident from this list of some of the key features of SupportiveDynamic Therapy that the supportive therapist engages actively with the

patient in ways that will contrast with the generally more restrained stance of

the therapist working in expressive or interpretative ways. Moreover, except

when challenging primitive defences to support the patients reality testing the

supportive therapist adopts an essentially respectful position in relation to the

patients defences. The individual whose defence is maintaining control over

emotions should not be too quickly asked to relax this control (Pinkseret al.,

1991, p. 233). This again contrasts with expressive approaches which aim to

challenge defences actively and robustly to reach the patients core conflicts and

release hidden affects (Malan, 1976; Malan & Della Selva, 2006).

Rockland has highlighted that in some respects Supportive

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counter-transference. For in actively intervening with suggestions or advice,

for example, there is the possibility that the therapist may gratify their own

needs to be appreciated or admired, or other unconscious wishes. The need

to monitor the possibility of acting out in this way and of gauging the

developmental needs of the patient, in identifying those supportive features

that can have positive therapeutic effect is therefore a paramount technical

concern.

Intrinsic to supportive approaches is a minimal use of interpretations,

particularly transference ones. Michael Stadter provides a developmental

framework within which we can situate supportive approaches where there

is minimal interpretative work. Stadter draws upon Winnicotts (1945, 1963)

distinction between the infants experience of the environment mother and

that of the object mother. The function of the environment mother is to hold

the infant and meets his need to be soothed and responded to, with levels ofadaption appropriate to the degree of the infants dependence upon her. In

so doing the mother provides the infant with maternal ego-support. The

environment mother also lends her reliable presence to the infant in his play,

so that he can in time develop the capacity to be alone (Winnicott, 1958).

Winnicott contrasts this experience of the environment mother with the

infants experience of the object mother with whom he relates in excited

moments, and towards whom he experiences a powerful initially ruthless

and instinctual form of loving. Only gradually is there a coming together in

the infants mind of the environment mother and the object mother andthrough opportunities to make reparation the infant gradually and in time

develops the capacity for concern. Stadter (1996) suggests that these two

aspects of the experience of the mother are at the root of two different types

of transference in therapy. Where the patient relates to the therapist in a way

akin to the environment mother this form of transference has been referred

to as the contextual transference. This type of transference is prominent in

the early phases of treatment and in brief therapy may be predominant

throughout (Stadter, 1996, p. 55). In what he terms the focused

transference, the patients ways of relating to the therapist are based upontheir experience of the object mother, the therapist being related to in a more

direct way, involving the experience of strong and powerful affects, whereas

in the contextual transference the therapist is experienced more as a

background supportive presence. Significantly for the purposes of the

distinction between expressive/interpretive and supportive therapy he writes,

In my experience, when the contextual transference takes centre stage,

therapy usually is not very interpretative. Therapy that addresses the

focused transference tends to be more interpretive (Stadter, 1991, p. 55).

Stadter thus provides us with a way of understanding the contrasting

nature of the transference in expressive/interpretative and supportive

therapy and of reconciling these differences and the differences in technique



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encompassed within Winnicotts own distinction between management and

ordinary analytic technique (1954). Winnicott used the term management to

describe the environmental provision that the therapist will need at times to

provide for patients who have yet to negotiate the achievement of space

time unit status (Winnicott, 1954, p. 279). Stadters theoretical distinctions

seem to have a similar although wider applicability.

Stadters conceptualizations can enable us to make sense of the fact that

there is growing and sophisticated evidence that Dynamic Supportive

Therapy can lead to significant structural change over time and that as

Appelbaum comments this is accomplished without transference neurosis

and its resolution, without making the unconscious conscious, without

interpretations, and without insight into unconscious processes (Appel-

baum, 1989, p. 57).

The focus in Brief Dynamic Supportive Therapy

Establishing a focus is a central and defining feature of all approaches to

Brief Dynamic Therapy. However, little has been written about the process

of establishing a focus and its use in shaping the therapy where it is both

brief and supportive. Piper et al. in their manual for short-term dynamic

supportive therapy state only

the therapist highlights in his or her mind a constellation of relatedpsychodynamic conflicts around which his or her attention is focused. Theconflicts are conceptually related to the therapists estimate of the develop-mental level of the patients most important object relationships (Piper et al.,2002, p. 259).

In relation to this description of the focus Stadter makes a useful

distinction between a symptomatic focus which directs the work toward the

patients distress and the present orientated issues deriving from the distress

and a dynamic focus that selects a part of the patients underlying structure

to concentrate upon (Stadter, 1996, p. 134).I have earlier (Smith, 2006) put forward the general principle that a

dynamic focus that connects to a part of the patients underlying structure,

can make a significant contribution to bringing the patients material and felt

experience within the jurisdiction of form (Wright, 2005). In so doing it

contains and holds the patient by identifying shapes and patterns in the often

unstructured content of the material of the initial encounter. This containing

and holding function of a focus may have particular importance for Brief

Supportive Therapy because by its very nature the experience of being

contained and held will reduce the patients anxiety. As noted earlier,

maintaining the patients anxiety at an optimal level for learning and

development is a key technical consideration in supportive work. In this

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to resonate deeply with the patients felt experience, may have particular

relevance as a method for establishing a focus and containing the patients

anxiety in supportive therapy. A central issue is also specifically formulated

to support a patients self-esteem, which Pinsker et al. (1991) identifies as one

of the three areas that require particular attention in supportive therapy. The

other two areas are supporting the patients ego strengths and ability to adapt

to the external environment. In Brief Supportive Therapy a dynamic focus

(Stadter, 1996) or central issue will also therefore need to be formulated in

such a way that it can be used to guide the way the therapist addresses themes

relating to the patients ego-strengths and adaptive skills, if it is to function

effectively in bringing the patients material within the jurisdiction of form.

Gustafson (2006) has linked the notion of a dynamic focus with the

identification of the re-iterating patterns of a patients life which lead to an

imbalance in the exchanges that they have in their relationships with others.Imbalances in these exchanges result he suggests in psychological depletion.

In identifying some small alteration in the trajectory upon which their life

has been shaped, the therapist may enable the patient to alter the re-iterating

pattern and change the balance of their exchanges with others so that they

become more satisfying. Implicit in this conceptualization is the notion of

addressing the patients ego-strengths and adaptive capabilities, so that the

formulation of a change in the patients trajectory may also have a key

relevance to brief supportive work.

A leap across a basic fault

In his renowned book The doctor, his patient and the illness (1952), Michael

Balint suggests that a basic illness or basic fault involving to varying

degrees both the individuals mind and body can be considered to be at the

route of the complaint that he brings to his doctor. He writes

The origin of this basic fault may be traced back to a considerable discrepancybetween the needs of the individual in his early formative years (or possibly

months) and the care and nursing available at the relevant times. This creates astate of deficiency the consequences of which are only partly reversible (Balint,1952, p. 255).

He goes on to comment

Should this theoretical approach prove correct, all the pathological states oflater years, the clinical illnesses, would have to be considered symptoms orexacerbations of the basic illness brought about by the various crises in theindividuals development, both external and internal, psychological andbiological (Balint, 1952, p. 256).

The full force of the radical nature of this proposition resonates forcibly



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in which the doctor responds to the patients complaint will shape its course

and development, organizing it upon particular lines that may include the

balance of biological and psychological features. In this way the response of

the doctor may shape the trajectory of the patients illness in a way that is

similar to the change in trajectory that Gustafson identifies can result from

the interventions of the therapist in brief therapy.

Its an acknowledged maxim of brief therapy that one needs to attend to

the ending of the therapy from the beginning. Given Bronwyns history of

loss and traumatically severed attachments as well as the fragility of her ego,

attention to the ending assumed an even greater therapeutic significance.

Moreover I had agreed to contract with her only two sessions at a time so I

was uncertain how long the therapy would last. The theme of the focus that

we had identified included a need to find someone to turn to when she needed

support. When the sessions with me ended she would not have any one toturn to in her current environment, for she was essentially too isolated. The

very tentativeness of her engagement with me in counselling in the

supportive environment of the GP practice suggested that she would be

unlikely to engage in longer-term therapy in an unfamiliar out-patient

psychiatric hospital department. So I considered how I might actively alter

her external environment to support her ego in the way that Appelbaum

identifies. I made contact with a local well-established Support Group

intended for people with varying levels of psychiatric problems. The group

facilitator struck me as particularly empathic and from her description ofthe group it seemed ideally suited to Bronwyn, providing a number of

activity-based groups and outings as well as a more structured group in

which participants could talk and explore their difficulties.

I discussed this option with Bronwyn in one of the early ongoing

sessions, in which she had focused upon her isolation and her anxiety about

the judgements that others may make about her in relation to her sons anti-

social behaviour, worried about being tarred with the same brush. She was

interested in this plan although evidently apprehensive about making the

initial contact. I gave her the contact details of the organizer who I hadspoken to, and reassured her that she could expect to be welcomingly

received when she met her, in this way actively encouraging her to approach

the organizer, supporting her adaptive skills and ego-strengths in relation to

the focus of finding someone to turn to for support.

In the following session Bronwyn began by talking about a neighbour

who had a number of yapping dogs who caused her a lot of disturbance. She

had approached the neighbour about the problem but this had simply

resulted in an argumentative exchange and the nuisance had persisted

unchanged. Bronwyn recognized that her usual reiterating pattern was to

put up with the problem but she had decided to approach a Housing

Officer to seek out some help in getting some resolution to the problem.

434 J.D. Smith


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When she came to the session 2 weeks later she told me that she had felt very

nervous in approaching the Housing Officer but had none the less done so.

The Housing Officer had responded by offering to help in a constructive

way. This was a distinctly positive experience for Bronwyn and a significant

change in her familiar trajectory.

She went on to talk about her difficulties with her son. She had told me

that she thought that her son may be feeling sad because his father, a heroin

addict, maintained so little contact with him, and had rarely visited him as a

child. She also revealed a deeper capacity to empathize with her son by

speculating that her sons thwarted wishes for his fathers attention and

approval may have contributed to his delinquent behaviour. She went on in

a similarly reflective way to recall her own depression as a young mother and

commented that although she had done her best to look after him she

thought that her depression had resulted in him missing out on herattentiveness too. At this point I intervened and linking to the focal theme

suggested that from what she told me there was no one she felt she could turn

to for support as a young mother when she felt depressed. My aim here in

this intentionally supportive comment was to support her ego in relation to

any punitive judgements that her super-ego might make upon herself as a

mother, to facilitate some degree of emancipation of her ego from the

destructive attack of her super-ego (Britton, 2003). At this point she

expressed some feelings of despair and hopelessness about her sons

delinquent behaviour as he had decided to cut his electronic tag off whichwould result in his arrest. She added that it felt unbearable to know that her

son was behaving in this antisocial way, but in a later counselling session she

was to tell me that she was none the less blaming herself less.

Bronwyn expressed her nervousness about going to the support group

for the first time. With the aim of supporting her ego and containing her

anxiety I pointed out that she had also felt anxious about going to the

housing advisor to seek support with the disturbance caused by the yapping

dogs, but that she had successfully met this challenge.

She acknowledged that staying away from the world and not engagingwith others was not doing her any good, and that she needed to speak to

people and make contact with them. Through her own reflections and

independent discoveries (Balint, 1972) she was beginning to recognize that

her defence of withdrawal was adversely affecting her and it was gradually

becoming ego-dystonic. She began to tell me about her husbands murder

and how she had blamed herself for this. I encouraged her to explore this

narrative and as she did so she realized that she had in fact been trying to get

away from him at the time because he had been very violent towards her. On

one occasion he had punched her in the stomach so hard that she thought

she was going to die. I empathized with how frightened she must have felt

and linked this fear to the anxiety she experienced about engaging with



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gentle interpretation seemed to have a further containing effect upon her

anxieties.

A couple of sessions later she told me that she had been to the support

group. She had felt nervous but had found it helpful to hear about other

peoples problems and this had resulted in her noticing that she was not the

only pebble on the beach. There was also an opportunity to make a cake for

the group the following week and Browyn intended to take this opportunity.

She had thus found a place where she could not only have someone to turn to

for support but also one where her own reparative gestures could be received,

assisting the process of the coming together in her mind of the environment

and object mother. She described the achievement of going to the group as a

real leap, which I warmly acknowledged.

Her difficulties in her relationship with her son were another continuing

theme, but it became clear that she was increasingly standing up to him anddrawing lines with him more firmly and without provoking him. She

described how he had been playing music late one night. She had asked him

to turn the noise down twice but he had effectively ignored her. Eventually,

summoning an appropriate level of aggression she told him to turn it off

completely and he had then complied. She had also told him that she

wanted him to tidy up after himself and that he needed to do this if he was

going to continue to stay with her. She felt pleased with herself that she had

elicited appropriate respect from her son. I conveyed my own pleasure at

this outcome actively supporting her assertiveness and praising herachievement.

Her reports of her assertiveness with her son continued and she made it

clear to him that if he persisted in being verbally abusive towards her he

would have to find his own flat. Her persecutory anxiety that neighbours

would be punitively judgemental and critical of her because of her sons

behaviour diminished and became replaced by an expression of concern at

the hurt and damage that he may have caused other people in the locality.

Termination in Brief Supportive Dynamic Therapy

As we neared the ending of the 12 sessions, which we had been continuing to

contract two at a time, she referred to the sadness she felt on learning that

the support group she had started to attend might only receive funding for a

further year. I empathized with her sadness and interpreted the sadness that

she might be feeling in relation to the ending of the counselling sessions. She

became a little bemused when I made this and similar interpretations in

relation to her sadness around the ending of the sessions with me. I decided

not to challenge her resistance to exploring her feelings in relation to the loss

of her relationship with me more directly. Instead I focused upon thinking

with her about ways in which she could sustain a connection to her

436 J.D. Smith


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continuing need for someone that she could turn to when she felt low or

needed support.

Bauer and Kobos (1987) note in relation to the termination of brief

supportive therapy that

Patient affect regarding ending, while not avoided, is framed in terms of thenaturally occurring sadness to be expected when losing a source of support orgratification. No attempt is made to undo resistances against terminationfeelings. The emphasis is on a continuing relationship with no effort made toresolve the transference component of their relationship (1987, p. 269).

This contrasts markedly with the more decisive confrontation of defences

against the expression of affects in relation to termination that characterizes

most interpretive approaches to brief therapy such as Manns (1973).

Stadter (1996) explores the question of what may be happeningunconsciously when a patient expresses little affect or apparent sense of

loss in relation to the termination of brief therapy. He speculates whether

this may indicate that the relationship has been superficial or whether, as

Mann would be likely to maintain, the patient is denying or defending

against the emotional impact of the termination because it evokes earlier

painful trauma associated with separation and loss. As an alternative

hypothesis he suggests that some patients may experience the therapist as a

transitional object and as Winnicott (1951) noted, where the transitional

object is no longer needed it is not mourned, it is simply discarded, andtransformed into the wider cultural field. Experiencing the therapist as a

transitional object that is discarded on termination rather than mourned

may be more likely in brief supportive therapy where the transference,

linked to the environment mother, has taken the form of being essentially

contextual and where therefore the therapist is experienced more as a

background presence. Where the patient knows that there is the possibility

of returning in the future for a further series of sessions, this may also

increase the likelihood of the therapist being experienced as a transitional

object, one that can be picked up again later if needed.Despite some uncertainty about its long-term future Bronwyn continued

to attend the support group and to actively participate in other groups such

as a relaxation class as well as outings. It was clear that it would be a very

important resource for her as the sessions with me ended. As they did so, I

arranged a follow-up appointment 3 months later and informed her that if

she experienced further difficulties in the future she could ask her GP to re-

refer her for more counselling in the surgery. As part of my routine I

provided the GPs with a written summary of Bronwyns counselling

sessions, which included an outline of the focus, and of Bronwyns need to

have someone to turn to for support. The summary was collaboratively shared

with Bronwyn and I sought her agreement to sharing its contents with the



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prepared so that they could provide her with ongoing emotional support

and a longer term secure base after the counselling sessions ended.

When she returned for the follow-up session she told me that her son had

decided to turn himself in to the police and she commented with some pride

that this had taken some guts. She was continuing to attend the support

group and had talked about her sons delinquency and received supportive

responses from other members of the group. Prior to his arrest her son had

in fact chosen to move out into his own flat with some friends, and although

there had been some nights when he had stayed with her she had continued

to effectively draw lines with him. She had subsequently written to him in

prison and he had replied acknowledging that he had hurt her by his

delinquent activity and expressing regret for having done so. Moved by this

letter she had decided to keep it safely stored in her flat, a token of a deeply

satisfying exchange with her son.

Leaping: to a conclusion

Employing a dynamic focus that shapes the therapists interventions to

support the patients self-esteem, ego-strengths and ability to respond

adaptively to the environment is shown by the case illustration of Bronwyn

to add significantly to the therapeutic effectiveness of a Brief Dynamic

Supportive approach. As well as containing the patients anxiety it provides

a flexible guide for the therapist in responding to the patients material. Itcontributes to the ability of the therapist to track a new trajectory, one that

can connect to the patients basic fault. The development of new ego

strengths and enhanced self-esteem can alter the organization of the basic

fault, in such a way that the patient is able to develop more satisfying and

adaptive exchanges with others. Bronwyn described this as a leap, one might

add across a basic fault towards a new more secure base or beginning. A

psychodynamic developmental framework shaped and guided the use of

supportive techniques which included a direct manipulation of her external

environment and interventions to support her ego and facilitate a degree ofemancipation from a critical punitive super-ego. Bronwyns anxiety levels

were monitored closely and interventions were made to maintain them at an

optimal level to facilitate exploration and developmental transformation.

The nature of the transference was mainly contextual and the responses of

the therapist could be said to largely fall within the rubric of the term

management, as coined by Winnicott.

References

Appelbaum, A.H. (1989). Supportive therapy: A development perspective. InL.H. Rockland (Ed.), Supportive therapy: A psychodynamic approach. New York:Basic Books

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Balint, M. (1952). The doctor, his patient and the illness. London: Churchill-Livingstone.

Balint, M., Ornstein, P.H., & Balint, E. (1972). Focal Psychotherapy: An example ofapplied psychoanalysis. London: Tavistock.

Bauer, G.P., & Kobos, J.C. (1987). Brief therapy; short-term psychodynamicintervention. Northvale, NJ & London: Jason Aronson.

Britton, R. (2003). Sex, death and the super-ego: Experiences in psychoanalysis.London: Karnac Books.

Coren, A. (2001). Short-term psychotherapy: A psychodynamic approach. Basing-stoke: Palgrave.

Gustafson, J.P. (2006). Very brief psychotherapy. Hove, East Sussex &New York:Routledge.

Kohut, H. (1984). How does analysis cure?Chicago, IL: University of Chicago Press.Malan, D. (1976). The frontier of brief psychotherapy. London & New York: Plenum

Press.Malan, D., & Osimo, F. (1992). Psychodynamics, training and outcome in brief

psychotherapy. Oxford: Butterworth-Heinemann.Malan, D., & Della Selva, P.C. (2006). Lives transformed: A revolutionary approach

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Interpretative and supportive psychotherapies: Matching therapy and patientpersonality. Washington, DC: American Psychological Association.

Pinsker, H., Rosenthal, R., & McCullough, L. (1991). Dynamic SupportivePsychotherapy. In P. Crits-Christoph, & J.P. Barber (Eds.), Handbook ofshort-term dynamic psychotherapy. New York: Basic Books.

Rockland, L.H. (1989). Supportive therapy: A psychodynamic approach. New York:Basic Books.

Sifneos, P.E. (1987). Short-term dynamic psychotherapy: Evaluation and technique.New York: Plenum Press.

Smith, J.D. (2006). Form and forming a focus: In brief dynamic therapy.Psychodynamic Practice, 12(3), 261279.

Stadter, M. (1996). Object Relations Brief Therapy: The therapeutic relationship inshort-term work. Northvale, NJ: Jason Aronson.

Stern, D. (1984). The interpersonal world of the infant: A view from psychoanalysis anddevelopment psychology. New York: Basic Books.

Winnicott, D.W. (1945). Primitive emotional development. In Through paediatrics to

psychoanalysis. London: Hogarth Press.Winnicott, D.W. (1951). Transitional objects and transitional phenomena. In

Through paediatrics to psychonanalysis. London: Hogarth Press.Winnicott, D.W. (1954). Metapsychological and clinical aspects of regression within

the psychoanalytic set-up. In Through paediatrics to psychoanalysis. London:Hogarth Press.

Winnicott, D.W. (1958). The capacity to be alone. In The maturational processes andthe facilitating environment. London: Hogarth Press.

Winnicott, D.W. (1963). The development of the capacity for concern. In Thematurational processes and the facilitating environment. London: Hogarth Press.

Wright, K. (2005). The shaping of experience. British Journal of Psychotherapy, 21,

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