| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ALL ISSUES | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Regular Article |
Received October 15, 1999; revised January 3, 2000; accepted February 3, 2000. From the Department of Psychology, The Hebrew University, The Israel Psychoanalytic Institute, and the Latner Institute for Psychotherapy Research, Herzog-Ezrat Nashim Hospital, Jerusalem. Address correspondence to Dr. Shefler, Department of Psychology, Hebrew University, Mount Scopus, Jerusalem 95105 Israel; e-mail: msshef{at}mscc.huji.ac.il
 |
Abstract |
|---|
 Top Abstract IntroductionSHORT-TERM DYNAMIC...TIME-LIMITED PSYCHOTHERAPYTHE TURMOIL OF ADOLESCENCEOFER: A CASE STUDY...DISCUSSIONReferences |
|---|
Key Words: Childhood and Adolescence • Short-Term Dynamic Psychotherapy
|
Introduction |
|---|
|
TopAbstractIntroductionSHORT-TERM DYNAMIC...TIME-LIMITED PSYCHOTHERAPYTHE TURMOIL OF ADOLESCENCEOFER: A CASE STUDY...DISCUSSIONReferences |
|---|
Vignette 1. Yuval, age 17½, was referred for treatment by his school guidance counselor. The guidance counselor doubted Yuval's ability to withstand his upcoming army service. Although Yuval functioned well and showed no blatant signs of emotional distress, he felt anxious about his immediate future. In the intake session, he raised key issues such as the struggle with his masculinity. He spoke about his changing body, physical strength, and as yet unrealized sexuality, and the influence of the impending army service on these struggles. He reported a preoccupation with peer and family relationships and expressed a vague apprehension regarding his ability to form new relationships. Yuval linked these misgivings to his army service. He appeared aware, open, intelligent, and sensitive. He understood that his difficulties were related to internal emotional processes. Overall, Yuval appeared to be a very pleasant young man.As I listened to Yuval, my impression was that he would benefit from a psychodynamic therapeutic approach. I explained that therapy is an extensive process, and Yuval responded, "I understand, but I'm being recruited into the army in another three and a half months. I hope I'll be able to meet the demands of the army. I'm not very worried, but even so, I thought I could use some help. That's why I came to you." Since I did not identify any clear emotional or functional crisis, I did not offer crisis intervention. Despite his doubts and moderate anxiety, I believed Yuval was competent to serve in the army. On the other hand, I respected his willingness to try therapy. I told him I understood his needs and thought that therapy was definitely appropriate. Because of the constraints of reality, however, I recommended he complete his army service, then seek treatment.
Yuval unenthusiastically accepted my suggestion, or at least the first part of it. Although I was dissatisfied with my recommendation, I did not know of any alternative at the time.
Vignette 2. Ilana, a 17-year-old student at a respectable urban high school, came to see me because her parents, who exerted a great deal of pressure on her, insisted that "nothing with her was right." In the previous year there was a sharp decline in Ilana's functioning and behavior. She was an attractive teenager who dressed provocatively and cared little about her personal hygiene. She seemed to try hard to make herself unappealing. Ilana had stopped investing in her studies and her previously high level of academic achievement had plummeted. She spent hours away from home and refused to tell her parents where she spent her time and with whom. From the little they could ascertain, they thought she was involved with kids who were inappropriate for her educational and social level. In Ilana's words, her parents thought she was "a really bad girl."Her blunt and staccato speech had a disparaging, scornful tone. She emphasized that she came to therapy under an ultimatum from her parents, whereas she herself was not troubled by what was happening to her. She did not understand why her parents were so worried. "On the contrary, things are finally going well for me. I'm doing what I want, as if I'm bringing myself to life." She was troubled, however, by her parents' threat that if she did not alter her behavior, whether on her own or with the help of a therapist, they would apply sanctions that would prevent her from maintaining the current lifestyle she enjoyed so much. For example, they threatened to ground her, restrict her use of the telephone, and cut down on allowance spending money. Ilana "gave in" to the pressure and decided to check out therapy.
In the intake session, I tried to uncover the pain that motivated Ilana's attempts to be different. To my surprise, she admitted that her life was not so fabulous. She had painful doubts regarding her identity, wondered about who loved her and what would happen if nobody loved her, and thought about whom she loved and to whom she was attracted. She was unsure of what she really wanted from herself and did not know what she feared. It was relatively easy to recognize Ilana's emotional distress, to express understanding, and to point out the genuine need for therapy.
Satisfied with this breakthrough, I suggested she give therapy a chance. Ilana began asking about how therapy was conducted, what was discussed, how long it lasted, and so forth. The idea of introspection and the sharing of thoughts, feelings, and images appealed to her. She loved to speak, think, and imagine. When I added that it was a long-term process, she asked, "How long?"
In expectation of her negative response, I vaguely and defensively stammered, "Uh...a year...two years."
Ilana leaned back in the armchair and declared, "No way. I'm not coming here for a year or two. Why such a long time? How much is there to say? There's no way. I'm not crazy."
I was unable to convince Ilana this was the right therapeutic strategy, and she left without scheduling another session. I felt I had missed a potential breakthrough.
I am certain many therapists have encountered situations similar to these two vignettes. The vignettes illustrate the problems that arise when a therapist equipped with a long-term dynamic therapy approach encounters teenagers whose perception of time is so vastly different from that of adults, and who may be unmotivated. Because of the time limitations and different perspectives on time between therapists and adolescents, the sessions with Yuval and Ilana ended in feelings of helplessness, failure, incapability, and missed opportunity for the therapist and most probably for the help-seeking adolescents. In those days, the idea of attaining meaningful achievements in a short time was foreign. Short-term interventions were primarily crisis interventions that would later on potentially evolve into more extensive therapies.1–3 The myth of therapeutic perfection was dominant, and any thought of therapy that was limited in either time or scope was construed as resistance to in-depth therapy and as a defensive flight into health.4,5
Both vignettes demonstrate very early failures. Therapists who treat adolescents are familiar with the high attrition rate among adolescents in the initial phase of psychotherapy.6 Often, the reasons for the dropout are reminiscent of Ilana's story. The therapy lasts as long as the issue of extended time does not arise. In many instances, the initial mention of the time issue becomes the pretext for termination, either immediately or shortly afterwards.
Often therapists attribute the failure to the patient's not being suited to psychodynamic therapy. On the contrary, one of the leading training psychoanalysts in the Jerusalem Psychoanalytic Institute, Dr. Erich Gumpel, taught us: "The issue is not the patient's suitability for the therapy. It is our responsibility to find a therapy suitable for the patient."
Freud called psychoanalytic therapy "the pure gold" in his 1918 Budapest lecture. In certain eras, only those who could allow themselves the luxury of "pure gold" benefited from it. The pure gold metaphor is not limited to describing the financial resources that turned time into a dominant factor in selecting psychotherapy, both in the private and, especially, the public sector. It also describes the blend of sociocultural, developmental, educational, and life conditions that characterize potential patients.
Historically, short-term psychoanalytic therapies originated from the interaction between a patient in distress and a therapist seeking a creative, nonconformist solution to which the "pure gold" pathway did not lead.7 Reports of these therapies clearly cite the difficulty experienced by therapists who viewed the short-term treatments as patient-oriented compromises. Each of the therapies, however, emphasized the obligation to find solutions for patients whose needs could not be met by the classic long-term, in-depth approach, whether because of time issues or for other reasons. Innovations and creative thought in psychoanalysis, and in its offshoots, originated with analysts who were seeking not to fortify the analytic method, but to cope with its limitations when facing patients whose pain and suffering were not relieved by the analytic approach.
In this article, I briefly present the central principles of short-term and time-limited psychotherapies, the clinical characteristics of adolescents in need of psychotherapy, and the primary characteristics of adolescents as patients. As a continuation of the vignettes, I discuss the difficulties that arise with the suggestion of long-term therapy to adolescents and demonstrate the possible contributions of short-term psychotherapy for adolescents, along with its limitations and difficulties. In addition, I demonstrate these issues with excerpts from the intake and time-limited treatment of an adolescent male.
|
SHORT-TERM DYNAMIC PSYCHOTHERAPIES |
|---|
|
TopAbstractIntroductionSHORT-TERM DYNAMIC...TIME-LIMITED PSYCHOTHERAPYTHE TURMOIL OF ADOLESCENCEOFER: A CASE STUDY...DISCUSSIONReferences |
|---|
Any psychotherapeutic system may be defined as short-term psychodynamic psychotherapy if it meets the following criteria: the treatment is time-limited, focused, and offered to selected patients; it uses psychoanalytically inspired techniques; and the theory underlying the explanation for the disturbance is psychoanalytic in the wide sense of the term.26 Typical elements of this kind of treatment are active and directive psychotherapists, intense involvement in separation and termination issues, and regular follow-up procedures after termination.27
It is crucial to emphasize that short-term dynamic psychotherapies are appropriate for only a certain segment of the patient population. It is difficult to rate the percentage for whom such therapies are suitable because every treatment facility that offers short-term psychotherapy treats a different epidemiological and cultural population. The discussion of these issues has been polarized. Some clinicians and researchers argue that short-term dynamic psychotherapy is appropriate for 40% to 80% of patients suitable for long-term psychotherapy. Indications and selection criteria for time-limited psychotherapy (TLP) are presented clearly by Mann; they consist of symptom and character neuroses with the exclusion of the borderline and narcissistic range. The most critical patient attribute is the strength of the ego and its capacity to allow rapid affective involvement and equally rapid affective disengagement. This assumes patients' previous good functioning levels, potential for appropriate relationships, ability to interact with the therapist, high motivation for change, and psychological mindedness. On the basis of an empirical study conducted in Jerusalem,27,28 I believe that many patients ideally suited to long-term dynamic psychotherapy can benefit from short-term dynamic psychotherapy offered to them when circumstances of time, money, and personal resources are limited. Mann20 writes:
There is a very large group of patients for which the twelve-hour treatment plan is admirably suited, even indicated. Young men and women, roughly in middle or late adolescence, mostly college students, who present themselves with any multitude of psychological and somatic complaints make up the majority of this group. In the absence of the few severe disqualifying conditions, it is likely that the patient is in the midst of a maturational crisis. (p. 76)
As for the patients I described in the opening vignettes, today I could offer Yuval a short-term treatment that would almost certainly help him. With Ilana, I could try to bridge the resistance to long-term attachment by seriously offering a short-term trial that would provide a partial response to her troubles or increase her motivation to continue therapy.
Two considerations with respect to short-term treatments should be mentioned here. One is that short-term dynamic therapies, including TLP, are not only time-limited but also space-limited treatments. Focalizing the goals of treatment means limiting them by definition.
Another too often neglected issue is the possibility that therapy will fail. Every treatment is an experiment, even if it is the most well-reasoned and controlled therapy conducted by the most experienced therapist. We hope for success, but the possibility of failure always exists, regardless of treatment length. Generally, we are more tolerant when traditional approaches fail than when innovative approaches fail. Treatment failure must always be treated as a very real possibility, yet the fear of it should not lead the therapist to select a certain method simply because failure would be better tolerated—especially since the chances are identical.11,12,27
|
TIME-LIMITED PSYCHOTHERAPY |
|---|
|
TopAbstractIntroductionSHORT-TERM DYNAMIC...TIME-LIMITED PSYCHOTHERAPYTHE TURMOIL OF ADOLESCENCEOFER: A CASE STUDY...DISCUSSIONReferences |
|---|
At the conclusion of the intake, the therapist formulates a central issue composed of four elements: 1) recognition of the patient's abilities, strengths, and accomplishments; 2) the time factor; 3) the dominant emotion in the patient's life; and 4) the patient's emotional self-perception. The therapist builds the central issue outside of the therapy sessions, preferably in a group context, and presents it to the patient at the beginning of the first treatment session.
Once the patient accepts the central issue, the therapeutic contract can be established, including the duration and frequency of sessions (usually 12 weekly sessions) and a clearly defined termination date.
Typically, three distinct stages emerge in the treatment. The first is termed the "honeymoon phase" because of the optimism that characterizes the initial closeness and understanding experienced in the new relationship and the awakening of hope that is projected onto the relationship. It is important to remember that prior to treatment, the patient generally experiences a period of suffering and loneliness. The honeymoon feeling derives from the disparity between the experience of suffering and loneliness and the experience of being understood.
The second treatment phase is characterized by ambivalence aroused by doubts regarding the therapist's ability to provide solutions and to actualize the newfound hope experienced in the honeymoon phase. The third phase, culminating in termination of the treatment, focuses on the imminent separation and is characterized by a wide array of emotions. In the supportive context of therapy, the therapist, who also experiences the separation, guides the patient toward a direct expression of the emotions surrounding separation. Successful processing of this phase engenders an experience of emotional integration revolving around a benevolent object.
|
THE TURMOIL OF ADOLESCENCE |
|---|
|
TopAbstractIntroductionSHORT-TERM DYNAMIC...TIME-LIMITED PSYCHOTHERAPYTHE TURMOIL OF ADOLESCENCEOFER: A CASE STUDY...DISCUSSIONReferences |
|---|
During adolescence, developmental progress becomes increasingly linked to the achievement of separation from past events. Jacobson33 described this stage as the sorrowful separation from the childish self and from childhood objects while approaching the yet unknown world of adulthood. Adolescents face the decisions that determine their futures: the selection of a mate, a profession, and a lifestyle.34 The pressure of making such critical choices can be very unsettling. For some adolescents these decisions generate an emotional frenzy, whereas others experience a pathological-depressive slowdown.6,35,36 Winnicott37 says: "It is not for the adolescent to take a long-term view which may come more naturally to those who have lived many decades" (p. 175). It is the parents' and, if need be, the therapist's role to take responsibility and to enable the adolescent to grow, fight, and fantasize. Otherwise, false maturity will occur, with its sad and dangerous consequences.
Heightened sensitivity to frustration and to a lack of love and support characterizes the narcissistic awakening that typically occurs in adolescence. This awakening can either set the adolescent on track toward healthy development or on the road toward personality disturbance or toward a narcissistic character first manifested in adolescence. Masochistic tendencies toward painful pleasure and passivity characterize adolescent fantasies among both males and females. In addition, preoccupation with issues of bisexuality, anxiety surrounding bodily change, and remnants of incestuous fantasies frequently become intensified.
Following are excerpts from a time-limited psychotherapy conducted with an adolescent.
|
OFER: A CASE STUDY IN TIME-LIMITED PSYCHOTHERAPY |
|---|
|
TopAbstractIntroductionSHORT-TERM DYNAMIC...TIME-LIMITED PSYCHOTHERAPYTHE TURMOIL OF ADOLESCENCEOFER: A CASE STUDY...DISCUSSIONReferences |
|---|
At his request, Ofer (age 17½) was referred for therapy by his parents following their consultation with his teacher. Although he could not specify what it was, Ofer felt something was not right with him; something was not working for him. The referral was prompted by a decline in his ability to concentrate and his fears regarding his upcoming army service. [In Israel, army service is compulsory and has become the norm. Almost all healthy young adolescents aged 18 have to do it. It is the melting pot of Israeli society, and especially for the boys in the process of becoming men. In many families and subsocieties, pressures are put on the boys toward joining certain elite units, following their fathers' or brothers' history or sometimes their unfulfilled ambitions. In many cases, the moratorium needed for a quiet process of working-through of the adolescent's developmental predicament is charged with stress caused by these norms and standards of manhood.]The following background information was gathered during a preliminary session held with Ofer's parents:
Ofer was the middle child of three. His older brother, Eyal, was 23 years old, and his younger sister, Sigi, was 14 years old.
Ofer's father, Reuven, was a 47-year-old construction engineer and a senior officer in the army reserves. Born into the seventh generation of his family in Israel, he grew up in Jerusalem and was educated in the public school system. Reuven served in a combat unit in the army. He was lightly wounded in the Six Day War but continued his regular service for another two years. Following his army service, he studied construction engineering at the Technion Institute. After graduation, he and a friend started a company that grew into a thriving business. Reuven was charismatic and assertive. Although he was not particularly pleasant, he was extremely honest.
Ofer's mother, Dina, was a 46-year-old native Israeli born to Holocaust survivors who met in Israel after each had emigrated from Europe. Despite the grim background, she reported a happy childhood: "We tried not to pay attention to it.... My parents made every effort not to create a ‘holocaust home.’ I don't know if we succeeded. I think so, but I don't really know."
Dina was a good student and was accepted socially. She did not recall any particular problems. She served as an inspector in the air force and met Reuven on a rigorous hiking trip in which they both participated. He was her first serious boyfriend, and after dating for two years, they married when she was 22 years old. Neither of them described tensions or feelings of exaltation in the early years of their relationship. Dina studied at a teachers' college, and after graduating, she began working in the educational system. Today, she is the vice principal of her school. Over the years, she completed a master's degree, and she planned to begin doctoral studies. She was a very warm, sensitive, pleasant woman. She projected ease and optimism as well as the ability for depth.
Ofer's older brother, Eyal, served in an elite military unit. He had been an excellent student at his prestigious high school, the same school Ofer currently attended. Eyal was successful in every respect. He was strong, attractive, masculine, and accepted, and he knew what he wanted. Reuven could not conceal his pride when he said, "He never had even the slightest problem." Eyal was his father's buddy; they were the two men in the household. Reuven loved Eyal's successes and his unfaltering masculinity.
Ofer's parents described him as a typical middle child. He was vulnerable, uncertain of his position in the family and perhaps outside of the family as well. They considered him talented and saw no reason for him to fall short of reaching the same achievements as Eyal: "Everything we gave to Eyal, we also gave to Ofer." Ofer and Eyal had a very good relationship.
Ofer felt close to Eyal, identifying with and imitating him. Dina was not sure that Ofer possessed the same strengths as Eyal, whereas Reuven believed that "if he wants to, he can be exactly the same." Both parents treated the decline in Ofer's functioning as an ambiguous signal of distress that they understood as transient. "We have to get him back on track," said Reuven, "just so problems won't suddenly appear when he goes into the army." When I asked Reuven what he meant, he replied immediately, "So he won't wind up in some low-profile job." Dina was not sure it was so simple, but she could not explain further. She sensed something—not danger, but distress.
At the end of the session with Ofer's parents, I suggested Ofer call me to arrange a session. Reuven responded, "Just tell me when and he'll be there. He'll adapt himself to you. You can count on me." I replied that I was certain he would pass along the message and that Ofer should call me to arrange a session.
The following day Ofer called, and in a hesitant voice asked if I was Dr. Shefler. I heard his father in the background saying, "Whenever he wants you to come, say yes. He's very busy." Ofer sounded embarrassed. He told me he had heard about my session with his parents and he wanted to set up an appointment with me. I asked how urgent it was and he answered that he did not want to delay it. I suggested an appointment two days later. He sounded hesitant and repeated the date and hour over and over while he weighed it in his own mind. Then, he asked if there was another possible time.
I asked what was wrong with the time I suggested. He explained that he had made plans with a friend and it would be difficult for him to explain why he needed to cancel their plans. I suggested an alternate time and he accepted it without hesitation. When I offered directions to my office, he responded, "I'll find it myself." (From this short telephone call I could already identify two important issues: Ofer's struggle for independence and his motivation for treatment.)
Ofer arrived on time. In the doorway, I greeted a tall, attractive, broad, swarthy, muscular, modestly dressed young man. I reached out to shake his hand and was amazed at his soft, sweaty touch and limp handshake. Before we exchanged a word, I pondered the meaning of the contradiction between Ofer's solid appearance and his soft touch. (I thought: if it is so obvious, it must be essential.)
Ofer entered the room, sat, looked at me, and smiled. He seemed somewhat embarrassed. I asked what brought him to seek therapy. He replied, "I wanted counseling. Counseling about something, but I don't know what....I don't know what isn't working for me, but something is not right and I think it might have to do with the army. Maybe. Do you think that could be?"
I asked Ofer to describe what he felt, what was happening to him. He said that he felt tense, distracted, "but not anything so serious. I'm just not calm. I'm also doing less well in school. Not really on my grades, because I already have the grades I need. I'm having trouble concentrating and I'm nervous about the matriculation exams that are starting soon."
Ofer answered my questions openly, willingly, and accurately. I asked him to tell me his life story as it came to mind. He sank into the armchair, and into himself. Then, he began to recall his life in quite a bit of detail. I felt comfortable with the sense of quick emergence of working alliance. His early childhood was wonderful and he could not think of anything negative. He nostalgically recalled his home, preschool, and neighborhood as warm, pleasant environments. Ofer enjoyed sharing his memories. He loved his kindergarten teacher very much and fondly described her motivational tactics. She would ask, "Children, who knows how to dance as nicely as I do? Who are the children who eat as nicely and quietly as Shula?" (I felt annoyed by this description.) Ofer did not remember having a difficult transition from kindergarten to elementary school, or later from elementary to middle school.
Ofer remembered wanting to grow up quickly. He wanted to go to school, "like Eyal." He also wanted to learn judo, "like Eyal." He did not have any recollection of being jealous of Eyal because he always received the same things from his parents as Eyal did. Ofer was a good student and socially well adjusted. In all he did, Ofer marched faithfully in the shadow of Eyal.
I observed, "Eyal was very influential on you as a child."
Ofer validated my observation with a story: "When my sister was born, my aunt asked, ‘So, Ofer, are you ready for the baby to come home?’ I answered, ‘I don't want her to come home, but Eyal said it would be fun, so she should come home already.’"
Throughout his life, Eyal had a clear opinion about every aspect of Ofer's life, from his clothes, friends, girlfriends, and how his bedroom was arranged, to the positions he held in their youth movement.
Ofer was very close to his childhood school friends, especially Yaniv and Omri. He spent extensive time with them, in school, in their youth movement, and just hanging out. Yaniv was very similar to Eyal. He was strong and extremely masculine, and he wanted to join a combat unit in the army. Omri, on the other hand, was a young man with a host of problems.
Ofer described his parents as warm, loving, giving people: "I don't lack anything." He was pleased with his physical appearance and liked his face and his body. "I'm good-looking, so they say, and I know it."
Ofer had experience with girls. At the age of 16, he had sexual relations with a girl who had a reputation for being sexually promiscuous: "I didn't want to, but she puts out for everyone and then she tells everyone how each guy was."
THERAPIST: How did you feel?OFER: Trapped. I was scared to death but at the same time I felt desire. She was disgusting—fat, repulsive, but she knew how to do what everyone wanted and dreamed of. She just put out without any problem. If she told everyone that I didn't sleep with her, I would get a reputation for being gay. That would be the worst.
THER.: Why?
OFER: Because that's what they say about Omri (the second friend). He's not like that at all, but they say he is.
THER.: And what they say matters so much.
OFER: Right. It matters a lot. It's everything.
Ofer was involved with a girl his age, Merav, although they were not in a steady relationship. They spoke often, spent time together, and went on trips together. They "fooled around" with each other, but were not sleeping together.
OFER: Eyal keeps asking, "So...?" I don't want to yet. Sometimes I masturbate and think about her. I like that, but Eyal says, "You're not a man." And then sometimes I get frightened that maybe Eyal is right. How is it that Omri is my friend? So, I decide not to see him anymore, that I don't need him. But, he's a good friend and a really nice kid. We're friends. We really like talking and laughing together. And then I get together with him again. But don't think that I have a sexual thing for him.THER.: Why would I think that? Because that's what Eyal said?
OFER: How did you know? Eyal says he's seen him with all sorts of characters. And also, there's the way he looks at me. But that's him. And so what? He's a good friend of mine.
The conclusion of the first session surprised him.
OFER: It's already over? We didn't get to everything and the time flew by.THER.: "It's hard to leave something so pleasant."
We arranged another session for the following week.
Second Session. After a short silence, I began (with the aim of directing Ofer to the affective climate of the first session):
THER.: How did you feel about our session last week?OFER: So-so.
THER.: Can you say more about that?
OFER: Look, it's uncomfortable to talk about these things. I don't know how this can help. What can possibly happen? You have experience and you'll tell me things, but so what?
THER.: I hear your concern that you'll have to please me and be what I tell you to be.
OFER (smiles): Yeah. My father asked me, "So, what did he say? You should listen to him. He's not me; he knows."
THER.: And you want to think about what you say, what you think, and, mainly, what you want.
OFER (looks at me as if he did not understand what I said): I'm not at all sure what I want. Everything's so confusing. I have this. I don't have that. I don't have any direction, and everyone says yes to this, no to that. I don't know what I want, especially right now.
THER.: What do you mean?
OFER: For example, I'm not very interested in school. But, everyone says it's very, very important—school determines my future. I get anxious before exams. Even though I feel pressured, I somehow manage to pull myself together and I usually get high grades. It doesn't make me feel particularly good. I study because it's supposed to be important for the future, but I don't get satisfaction from my success in school.
I asked about the army.
OFER: You've hit on the major problem. I don't know. Eyal's stories are very stimulating, but scary. I'm afraid of being wounded, getting injured. I work out and I'm strong, but the thought of getting hurt, that my body can be torn apart, broken, terrifies me.THER.: You're afraid that, like Eyal, you must serve in a place or a position in which you're likely to be physically injured.
OFER: Yeah, something like that, but I'm not a weakling or a coward. I'm not afraid of dying. I'm afraid of getting hurt.
THER.: I see you're strong, but I hear you saying, "Look, what I have is valuable. I'm not sure I'm willing to run the risk of ruining it."
Ofer had a very interesting approach to the army. He understood that he had no choice. He had an obligation to serve in the army, but he was unsure whether he wanted to be with his friends, to do something that interested him like electronic warfare or anti-aircraft operation, or to go with the typical combat choice, "like Eyal."
OFER: Do you understand? I'm the good boy who does what's expected of him. [He shares a memory from sixth grade.] There was an exam that I hadn't studied for. I got my paper and wrote on it, "I can't write anything, because I don't know anything, because I didn't study." The teacher was so nice. She said to me, "Ofer, I don't understand what happened to you. Sit and study right now. You can take the test tomorrow." I didn't want to, so she said to me, "Fine. Tomorrow, I'll test you on the material." I didn't want to. I wanted to fail. I don't even know why, but that's what I wanted. But, she completely ran me over. And what do you think happened in the end? I studied at home, and the next day I did what she wanted. [Ofer bursts into bitter tears.]THER.: It's so painful when you have your own will and it gets run over.
Ofer listened, and calmed down within a few minutes.
THER.: And what do you really want to do?OFER: I don't know.
THER.: That's very confusing.
Presentation of the Central Issue. Indeed, the process of formulating the central issue is also confusing. I found it very helpful to discuss the central issue with a group of TLP therapists. The intake is presented by the therapist, and each of the participants suggests what seems to be central for him or her, regarding the four elements of the central issue: the recognition of the patient's abilities, strengths, and accomplishments; the time factor; the dominant emotion in the patient's life; and the patient's emotional self-perception. The group discussion on each of the elements, as well as the formulation of the central issue, clarifies the relative relevance of each of them to the therapist and helps the therapist to come to the optimal choice.
In this case, I selected a central issue focused on the dependence-independence conflict and the emotional experience of anxiety, which causes Ofer to experience himself as weak and unconfident. At the same time, I made a conscious choice not to focus on other aspects of Ofer, such as the struggle with his sexual identity and depressive features. I presented the central issue to Ofer as follows:
Although you are a healthy, strong young man, throughout your whole life you have been preoccupied with the question of whether you are allowed to be what you want to be. You are very uncertain, and every time you decide to be yourself, you are filled with anxiety and doubt your abilities.
Ofer sank into the armchair, listened intently, wiped his face, cried a little, and thought. After a few minutes of silence, he spoke:
OFER: I was afraid you'd say something else.THER.: What did you think I would say?
OFER: That I need to understand that my father and Eyal just want what's best for me. That they are more experienced. My father told me that whatever you say, it's the truth. He also said that I would see he is right. Eyal has experience, but my father has even more. They know what somebody like me needs and what's right for me. That's what they said about you, that you know what I need.
THER.: Everyone else knows what you want and what you need. What about you? [This interpretation stems directly from the central issue.]
OFER: I dream about what I want, but I don't believe in it and I don't share it with anyone. I do what I'm supposed to do; that's what they want from me. But it's not really so far from what I want.
THER. (taking a directive role): You're coming around the bend now. What do you really want?
OFER: (embarrassed): You'll laugh at me. I don't have an answer. As okay as I am, I don't know the answer to such a simple question.
THER.: Simple question? I told you before, I think it's a central and frightening question for you.
OFER: How do you know these things?
THER.: I listen to you and feel what you are experiencing.
OFER: And what does that matter?
THER.: At the moment, what matters most is what's happening to you, what you want.
OFER: I have a lot of stories like those ones. My whole life has been like that. But I don't feel pathetic.
THER.: You're not pathetic. You're strong, virile, and you don't know yet how to please yourself.
OFER: What can be done?
THER.: In therapy, we'll try to figure that out together, how you came to experience yourself so that you don't let yourself want anything without feeling uncomfortable about the fact of your wanting. We'll focus the therapy on that.
I offered a 12-session therapeutic contract. I wanted to finish the treatment by the end of spring, before Ofer's matriculation exams began. Because Ofer had planned a vacation previously, we scheduled 10 sessions and set a clear termination date.
OFER: How do you know that will be enough?THER.: Does that worry you?
OFER: It doesn't worry me. I'm just not sure.
THER.: It's hard to imagine that we've barely begun and you already have to think about ending.
OFER: I'm not worried. I'm just asking.
The Treatment Process. Rather than provide a detailed description of the treatment, I will briefly describe the process. Ofer got into the therapy quite easily. He was optimistic, and he enjoyed talking and sharing. It was easygoing and pleasant for both of us. Ofer found in me a nonthreatening adult who did not demand he please him and who encouraged him to think independently. In Ofer's imagination, as well as in the therapeutic reality, I was there for him and took him seriously. I enjoyed his youthfulness, charm, and rapid response to therapy, as is typical during the initial honeymoon phase.Ofer shared memories revolving around the same theme: He was not allowed to please himself; he could only please others. At first, he spoke about his wishes enthusiastically. Then, he grew angry as he delved into the pain of his unfulfilled wishes. Ofer was most interested in his relationship with Merav. He asked me about love, saying he would listen to me but would decide alone. He tried to get close to her, but she didn't want to be any closer. He felt vulnerable and angry both with her and with me. He said that I misled him because talking did not help. He discovered that not everything he wanted could happen, and returned to the idea that perhaps it was preferable not to want anything for himself. That way he would avoid disappointment. Ofer continued thinking about what he wanted from Merav. He realized that, like her, he was not ready for full sexual intimacy. Though he was embarrassed by this realization, he was not ashamed to discuss it with me. He may have felt protected by the focus on his ability to please rather than the hidden content behind that ability, such as his desires.
Ofer decided not to join any elite combat unit, and whatever would happen, so be it. He described a conversation with his friend Yaniv, in which Yaniv remarked, "We've been together such a long time and now you're leaving me?" Ofer retreated and thought perhaps he would join an elite unit, but then realized he did not want to. He stood up to Yaniv and said, "You want to be in the [elite] unit and that's right for you. I don't. It's not right for me. Believe me, it's not. But we're friends, and there are the weekends and after the army." Yaniv replied, "If you're afraid, I'm with you. I'll help you get over it." Ofer answered, "I'm not afraid. I just don't want to do it. If you want to be with me, come with me to anti-aircraft."
OFER: Computers are so interesting—missiles and all sorts of serious things, and they don't destroy you in the unit. It has double meaning. I told you—I'm afraid of being injured and I want to do something in electronics. Besides that, I have the feeling you don't think about the army the same way as my father does.THER. Now you have to start thinking like me.
Ofer laughed, and I added that it was hard for him to accept that I wanted what he wanted for himself. At this point, Ofer felt tense about the break planned for after the fifth session.
OFER: I'm used to coming here and I enjoy it. If I don't come, it's like I'll get weaker.THER.: Does the same thought come to mind when you think about what will happen after the therapy is over? Is this reinforcement only temporary and when we finish therapy and separate, you'll feel differently?
OFER: I can always continue coming, can't I?
THER.: I know it's hard to see yourself alone, without me.
The combination of strong therapeutic alliance and the awakening separation anxiety aroused the ambivalence usually present at the second stage of therapy. Ofer said, "I think I'll miss you, but I'll call to consult with you."
I asked if he would miss the advice or the closeness with someone who does not tell him what he should want, but permits him freedom instead. He answered, "I'm slowly becoming my own advisor."
Last Sessions. In the final sessions, Ofer appeared to have solved his problems. He had chosen a military framework. He also found the appropriate distance to keep from Omri. That distance contained a level of closeness that was not threatening and did not arouse suspicion, yet did not entail too great a distance from someone he loved. He realized that even with Omri's problems, he did not want to lose the friendship. Ofer discovered that not everything had a definitive solution, but that there was a middle ground.At the same time, Ofer began to take an interest in another girl but did not know how to break off his relationship with Merav. He did not know what to tell her, what she would think of him if he told her the truth, or what she wanted. Parallel to his romantic interests, Ofer spoke about the possibility of continuing his relationship with me by telephone after he was drafted. Separation is difficult, even if it is what you want, and it is even more difficult when you don't know what you want. Ofer was flooded by thoughts of separation, in his everyday life and in therapy.
Toward the end, Ofer's mood varied from session to session. He brought a booklet for me to one session, and in another session he asked what I would buy him when he was drafted. He wondered what we had done in therapy and suddenly paid attention to the cost. He was disappointed at having to pay for therapy, as if that made it less genuine. A few minutes later, he stated that he did not know why, but he felt close and comfortable with me:
"You're like a friend, but you're not a friend; you're like a father, but you're not my father; you're like Eyal, but you're not Eyal; you're like Merav, but you're not Merav."
I asked what it meant for him that I was like everyone else, but not like anyone else. Ofer responded, "Maybe that I'm more with myself. It's clearer to me."
Ofer appeared to be in a festive mood in the last session. He entered the room confidently, looked around, and soaked in everything. He conducted a very deep and moving summary of what had transpired in therapy. He pointed out various shades of emotion and problems that had troubled him, as well as those that still troubled him. I felt truly sorry to terminate a therapy that was so beneficial, clear-cut, and fun with such an endearing and responsive youth. I would have continued therapy with him had it been possible. It seemed that he would have made the same choice. I both desired and mourned the separation from Ofer. I was pleased with his increased confidence, freedom of choice, and autonomous desires. He was planning and taking action in all areas of his life. Ofer's parting handshake was firm and strong.
Follow-up. I phoned Ofer three months after termination. Dina informed me that he was in the army and would return my call during his weekend leave. He called two weeks later. He did not think he could manage to see me, but he said he would be happy to speak on the telephone. He was in basic training in the anti-aircraft framework. "The guys" were great; he felt accepted and was interested in what he was learning. He felt no existential threat.
Ofer said, "I think of you sometimes. When I don't know what I want, I play a game: What would Gaby say? And then my imagination starts working and whatever I imagine seems to be what I want. It's getting easier, like we spoke about in therapy."
He was in a new relationship with someone and felt they loved each other as adults do. It felt natural to him, and he had not yet told Eyal about the relationship.
Ofer then said, "I need to speak to you about something serious. Omri needs therapy. He's having trouble. I convinced him he needs therapy. I said I'd find him an excellent therapist, someone he can count on. He's willing to see you and I promised him I'd speak to you about it."
I was touched by the thought, but I did not think it was appropriate or practical. Perhaps it was Ofer's way of continuing therapy with me, through Omri. I answered, "I don't think that's the best idea, for you or for Omri. It's preferable that he see someone uninvolved, who will be just for him."
Ofer responded, "Maybe you're right. And that way, you stay mine."
|
DISCUSSION |
|---|
|
TopAbstractIntroductionSHORT-TERM DYNAMIC...TIME-LIMITED PSYCHOTHERAPYTHE TURMOIL OF ADOLESCENCEOFER: A CASE STUDY...DISCUSSIONReferences |
|---|
Adolescents comprise one of the groups in the general population that require the greatest amount of emotional treatment. Therapists who treat adolescents must be flexible and possess creative ability in order to connect with their patients.12 These are also the recommended characteristics for therapists doing different sorts of brief dynamic therapies.
Clinicians and researchers agree that adolescents, as a patient group, have exceptionally high dropout rates.38 Considering the social and psychological characteristics of adolescents, we often find that the goals of the parents or therapist are discordant with the goals of the adolescent patient.6 Treatment failure is often attributed to the gap between the expectations of the therapist and those of the adolescent regarding the depth, goals, and methods of treatment, as illustrated in the vignette of Ilana. Although similar gaps often exist in therapist–adult patient dyads, the typical adult response to the gap differs from the adolescent response. Generally, the adult patient is willing to listen and can be persuaded to try to understand the therapeutic process even though it is perceived as frustrating or threatening. Ofer's maturity certainly was of help regarding this point.
Adolescents, however, tend to react more impulsively to frustration or disappointment, and the resistance to treatment is more likely to transform into a sudden dropout, whether expected or not. Therefore, the literature emphasizes that therapy with adolescents focuses more heavily on the conscious and preconscious realms.6 Thus, confrontation and clarification techniques are used more frequently than interpretation, as illustrated in the treatment of Ofer. Early investment in formation of the therapeutic alliance ultimately enables both therapist and patient to withstand the painful experience of transference and its interpretation. Many adolescents, however, drop out of therapy before they even reach this first stage.39 This was the case with Ilana in the second vignette.
Adolescents perceive therapists as adults and as "other." Therefore, it is crucial for the therapist to facilitate the encounter between the "adult other" and the adolescent who feels afraid, withdrawn, and embarrassed, and often does not understand why this encounter is necessary at all. The adolescent's doubts are exacerbated by uncertainty about the duration, the goals, and the process of psychodynamic therapy. Although the full therapeutic potential is at the patient's disposal, he or she does not always want to use it or know how to do so. The feeling that the primary responsibility falls on the patient is often construed as threatening and oppressive regardless of the actual content of the therapy. Also, the expectation that the patient is to talk about whatever comes to mind bothers many adolescents. The inner obscurities of adolescence invite clarity, focus, and guidance that is assertive and confident, yet respectful and sensitive. One can notice easily how calm and trustful Ofer became when he noticed he was being guided by the central issue of his treatment.
The adolescent seeking emotional treatment struggles with conflicts concerning dependence versus independence, activity versus passivity, separation, and self-image. These conflicts cause many adolescents to experience tremendous difficulty in connecting to an adult therapist for a significant amount of time. The suggestion of long-term therapy easily deters adolescents from entering into the therapeutic relationship.6,20 As in the case of Ilana, some adolescents know from the outset that they are unwilling to become attached to the therapy or the therapist. I am certain that where I felt an opportunity had been missed, Ilana also felt a loss. Often, adolescents who are less than clear in their desire and less than assertive in their decisions attempt therapy, but feel torn and conflicted by their resistance. When their resistance overcomes them, those adolescents drop out of therapy, seemingly feeling independent and decisive. Yet they often feel they have failed or missed an opportunity as a result of their fear that long-term commitment will squelch their independence.
Adolescents are attracted to short-term dynamic therapy because it is active, direct, and defined. Furthermore, short-term therapies distinguish between central and secondary issues and limit the emotional resources required. The limited nature of short-term therapies prevents the adolescent from feeling frightened. Even if the therapeutic task is partial, it is more likely to conclude with a feeling of success than of failure, as illustrated so clearly in the treatment and follow-up of Ofer. The myth of perfection is not fulfilled, nor probably are many adolescents seeking perfection in therapy. It should be kept in mind that having overcome the developmental predicament successfully, the adolescent patient may be inclined to return later on to therapy if and when needed.
There are many manifestations of successful short-term therapy outcome. They include significant lessening, whether conscious or not, of the emotional burden or distress that led to the referral; symptomatic relief; or the sense of freedom of choice, either internally or externally. Success might also be a later decision to continue or to return for additional therapy, whether short-term and focused or longer and more encompassing. Winnicott37 claims that "growing up means taking the parents' place. It really does" (p. 164). In order to avoid false maturation, time and support should be given to the adolescent in supporting him or her to achieve real maturation. In Ofer's case, time was limited both in real life and in treatment, and yet the intensive empathic opportunity to grow by developing the abilities to find out what he wanted and to choose on his own were the core of his treatment.
The narcissistic feature of adolescence poses one of the primary difficulties in short-term treatment of adolescents. Adolescents' perceptions of themselves as unique can endanger the therapeutic alliance and, consequently, the entire treatment. Therapists make use of empathic listening in order to understand the patient rapidly and deeply. Although all patients expect this type of understanding, adolescent patients simultaneously experience their sense of uniqueness as precluding closeness, understanding, and containment. The therapist's rapid identification of a problematic focus can leave the adolescent feeling threatened and vulnerable. Adolescents experience the therapist's suggestion of focus as a hurtful reduction of their full grandeur (as they perceive themselves) that leaves them feeling deprived of an unlimited and plentiful relationship. They also feel very exposed and embarrassed early on. In instances of a consolidated narcissistic disturbance, this type of situation is likely to lead to an explosion of the treatment.
I would like to conclude this article with a few words about the therapist in TLP. Just as the patient is expected to be eager and highly motivated to change, the therapist is expected to lead this process of change directly, both by deep understanding of the basic conflicts of the patient and by sensitivity to the patient's chronic and enduring pain, to which the therapist relates with empathy. The therapist in TLP must detect and use quickly the psychodynamic processes taking place in therapy. The therapist should be a person capable of making quick decisions and choices, and also able to get involved affectively and to separate quickly. The TLP therapist is preferably an experienced and well-analyzed person who, perhaps more so than colleagues doing long-term nonfocal dynamic therapy, is ready to define clearly the central issue in the patient's life, to state it clearly for the patient at the first stage of therapy, and to follow up outcomes of treatment later on. Balint summarized the TLP therapist's action as "Go in, work quick, and get out." I would add that TLP can be done effectively only if the therapist is enthusiastically convinced that he or she can do it. Much has been written about therapists' resistances to TLP and methods to overcome it.12,40,41 The writers all agree that the ideal TLP therapist is an experienced psychoanalytically oriented psychotherapist with active, decisive personal traits.
Ofer was an emotionally healthy youth with much available ego strength. The special conditions of the society in which he was raised forced him to cope with complex pressures and tensions. Despite the decline in functioning, he tried to maintain a healthy image. Against the backdrop of these pressures, a deeper neurotic problem arose. The problem concerned Ofer's ability to choose what he wanted to be, with whom he wanted to fraternize, and in which directions he wanted to develop. The time-limited therapy he received focused on these questions, as well as the anxiety aroused whenever he confronted them and the burgeoning emotional doubts regarding his self-image. The therapist took an active, directive stance and used empathic interventions, enabling Ofer to explore his ability to please himself in a secure and protected manner. The follow-up phone call supported the impression that Ofer had made gains in this area.
Notwithstanding the contained nature of the accomplishments and the selective neglect of other emotional areas in this therapy, the available conditions and means were used to perform important work. This situation exemplifies the experience of many adolescents, bolstering the impression of a good fit between short-term psychotherapy and adolescence.
|
References |
|---|
|
TopAbstractIntroductionSHORT-TERM DYNAMIC...TIME-LIMITED PSYCHOTHERAPYTHE TURMOIL OF ADOLESCENCEOFER: A CASE STUDY...DISCUSSIONReferences |
|---|
This article has been cited by other articles:
|
|
 |
|
  R. T.-W. Chan Interpersonal Psychotherapy as a Treatment Model for Depressed Adolescents with Chronic Medical Problems Clinical Child Psychology and Psychiatry, January 1, 2005; 10(1): 88 - 101. [Abstract] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ALL ISSUES | SEARCH | TABLE OF CONTENTS |
