Psychodynamic Practice Vol. 14, No.

4, November 2008, 421439

A leap across a basic fault: Brief Supportive Dynamic Therapy

Jonathan D. Smith*
South London & Maudsley Mental Health Trust (Received September 2007; nal version received November 2007) The author explores the evidence-base and selection criteria for a shortterm supportive dynamic approach for patients whose psychological mindedness and quality of object relationships is low. Illustrating this approach with a case example he outlines the central features of Supportive Dynamic Therapy. He describes a psychodynamic conceptual and developmental framework that can be used to guide the therapists interventions and responses, and modulate the patients anxiety. A dynamic focus presented in the form of a central issue is shown to have a signicant function both in containing the patients anxiety, and in giving shape to the therapists eorts to support the patients ego-strengths and adaptive abilities. The therapeutic work can be seen to result in an alteration in the trajectory or reiterating pattern of the patients life. Keywords: Brief Supportive Dynamic Therapy; evidence-base; dynamic focus; ego-strengths; super-ego; contextual transference; focused transference; 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 rst 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

*Email: jdsmith@jar59.fsnet.co.uk
ISSN 1475-3634 print/ISSN 1475-3626 online 2008 Taylor & Francis DOI: 10.1080/14753630802364699 http://www.informaworld.com

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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 diculties 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 unconscious conicts, 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 eectiveness, 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 Dynamic are added to the term. In contrast Rockland has commented
Too often supportive therapy is viewed as simplistic, not requiring psychodynamic sophistication. Yet when supportive psychotherapy is grounded in psychodynamic understanding and carried out in accord with psychodynamic principles, it becomes a very creative, exciting and intellectually 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 supportive therapy 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 signicant 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 practice Counsellor by her GP, Dr Davis, because she had a long-standing

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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 dicult and that she had a mild learning diculty. Her sleep was erratic and she experienced diculty in concentrating. She was oered 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 diculties with her 19-year-old son who was in trouble with the police. She arrived on time for this rst appointment. She presented as rather awkward and hesitant at rst 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 how he 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 vocational course 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 diculty. She remained friends with this former partner and they met 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 halfsister 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 Bronwyn received little attention and generally felt that she did not t in to

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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 knife attack. 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 eorts to elicit more clarity yielded little further information. Towards the end of the rst 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 about whether 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 reected 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 the reiterating patterns of her life. That she had a mild learning disability seemed to be conrmed by the rather bemused way in which she responded to my interpretative links. Above all, however, I noted how she expressed so little aect 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 aects (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 oer her. In the Mental Health Trust which employed me 12 sessions after assessment was the limit of my remit.

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Towards the end of this rst 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 been no-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 diculty in sustaining a condence 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 Aects, self-esteem, time and strengths. My intention was to provide Bronwyn with a focus that resonated 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 Therapy In 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 denes as a diculty in experiencing or describing aects. I had found it especially striking how little Bronwyn had been able to connect to her feelings, and how at 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 is linked 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 reect 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 ight 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 identication, externalization and projection outwards of her own aggressive impulses onto others such as her son. These ego weaknesses and distortions were

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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 aects, 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 ecacy of an interpretive/exploratory form of short-term psychodynamic therapy with a psychodynamically supportive model. 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 in interpretative therapy in the area of self-esteem. These ndings represent reasons to provide interpretative therapy to high-QOB patients and supportive therapy 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 specic conclusions from their data about the use of transference interpretations by the therapist.
For high-QOR patients the greater the use of transference interpretations the stronger the therapeutic alliance. For low-QOB patients, the greater the use of transference interpretations the weaker the therapeutic alliance. There is also some evidence for low-QOB patients that the greater the use of transference interpretations 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 ndings of Piper et al. (2002), together with the Rocklands criteria of suitability for supportive therapy, strongly suggested that Bronwyn

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should be oered a supportive therapy with a minimum use of transference interpretations. Rening 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 rst 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 point I experienced some relief. Bronwyn had not felt able to tell anyone about the incident. She had thought about conding 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 her anxiety 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 identication 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 the focus that I had established with her in the rst 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 rmly 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 signicant 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 question of her capacity to be assertive with her son as an area for us to

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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. Signicantly 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 eect of improving Bronwyns morale and self-esteem as well as enabling her to consider whether in order to protect 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 nding it helpful to come to counselling to talk about these diculties 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 oer was twelve. She also requested that 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 circumstances. 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 dicult 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 identied a correspondence between parental behaviours and the types of interventions that mark a supportive approach. The monitoring and regulation of anxiety at an optimal level for the promotion of learning and development is one of the

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therapeutic functions which she identies 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 of anticipatory anxiety and aids in the mastery of excessive levels of anxiety and guilt (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 nonverbal 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 or non-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 sucient to enable learning and development to resume. Appelbaum goes on to write:
In adult health the consoling presence of the mother has been absorbed into the comforting aspects of the super-ego: in adult illness those identications fail to perform the soothing function and the presence of the therapist is then required (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 reectiveness, corresponding to the infants quiet alertness, and in which they are most likely to gain from the therapeutic process. Stern has identied ways in which the parents attunement promotes the play of the infant as well as the development of a capacity for intersubjective relatedness. Attunement involves the parent responding in a dierent modality to the infants play in such a way that the pace, intensity or rhythm of the activity is in some way reected back to the infant. Appelbaum suggests that the empathic resonance of the therapist in which the therapist nds words to reect 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 therapists accurate empathic interventions prolong the patients capacity to participate in psychotherapy, rather than disrupting the work with aect storms, leaving the scene, or denial and withdrawal as anxiety mounts (Appelbaum, 1989, p. 50).

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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-condence (Kohut, 1984). Interventions that support the patients self-esteem are considered to be a central component of Supportive Dynamic Therapy and have been identied as such by Pinsker, Rosenthal and McCullough (1991). They have also identied 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, oer encouragement, give praise for certain behaviour or achievements and oer direct advice. The therapist may even prohibit or rmly 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 gratication 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 eect. Stress on the ego from the super-ego can be reduced by questioning or challenging its 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 rmer 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 Supportive Dynamic 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 (Pinkser et al., 1991, p. 233). This again contrasts with expressive approaches which aim to challenge defences actively and robustly to reach the patients core conicts and release hidden aects (Malan, 1976; Malan & Della Selva, 2006). Rockland has highlighted that in some respects Supportive Dynamic Therapy may place a greater strain upon the therapists

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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 eect 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 of adaption 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 and through 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 dierent 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 upon their experience of the object mother, the therapist being related to in a more direct way, involving the experience of strong and powerful aects, whereas in the contextual transference the therapist is experienced more as a background supportive presence. Signicantly 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 dierences and the dierences in technique within a unied conceptual framework. It is one that can also be

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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 signicant 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 (Appelbaum, 1989, p. 57). The focus in Brief Dynamic Supportive Therapy Establishing a focus is a central and dening 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 related psychodynamic conicts around which his or her attention is focused. The conicts are conceptually related to the therapists estimate of the developmental 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 signicant 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 respect Manns model of presenting the patient with a central issue, intending

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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 specically formulated to support a patients self-esteem, which Pinsker et al. (1991) identies 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 eectively in bringing the patients material within the jurisdiction of form. Gustafson (2006) has linked the notion of a dynamic focus with the identication 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 discrepancy between 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 a state of deciency 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 of later years, the clinical illnesses, would have to be considered symptoms or exacerbations of the basic illness brought about by the various crises in the individuals development, both external and internal, psychological and biological (Balint, 1952, p. 256).

The full force of the radical nature of this proposition resonates forcibly even 50 years after it was written. For Balint further suggested that the way

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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 identies 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 signicance. 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 identied included a need to nd someone to turn to when she needed support. When the sessions with me ended she would not have any one to turn 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 identies. 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 of the 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 diculties. 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 antisocial 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 had spoken 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 nding 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 Ocer to seek out some help in getting some resolution to the problem. Once again I expressed my encouragement of her seeking out some support.

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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 Ocer but had none the less done so. The Housing Ocer had responded by oering to help in a constructive way. This was a distinctly positive experience for Bronwyn and a signicant change in her familiar trajectory. She went on to talk about her diculties 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 reective 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 her attentiveness 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 o which would 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 rst 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 engaging with others was not doing her any good, and that she needed to speak to people and make contact with them. Through her own reections and independent discoveries (Balint, 1972) she was beginning to recognize that her defence of withdrawal was adversely aecting 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 others in the world outside. This combination of supportive empathy and

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gentle interpretation seemed to have a further containing eect 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 diculties in her relationship with her son were another continuing theme, but it became clear that she was increasingly standing up to him and drawing lines with him more rmly 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 eectively ignored her. Eventually, summoning an appropriate level of aggression she told him to turn it o 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 her achievement. 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 nd his own at. 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 developing strengths and capacity to assert herself eectively as well as her

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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 aect regarding ending, while not avoided, is framed in terms of the naturally occurring sadness to be expected when losing a source of support or gratication. No attempt is made to undo resistances against termination feelings. The emphasis is on a continuing relationship with no eort made to resolve the transference component of their relationship (1987, p. 269).

This contrasts markedly with the more decisive confrontation of defences against the expression of aects 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 happening unconsciously when a patient expresses little aect or apparent sense of loss in relation to the termination of brief therapy. He speculates whether this may indicate that the relationship has been supercial 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, and transformed into the wider cultural eld. 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 diculties in the future she could ask her GP to rerefer 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 GPs, which she gave readily. In this way the GPs in the surgery were also

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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 at with some friends, and although there had been some nights when he had stayed with her she had continued to eectively 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 at, 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 signicantly to the therapeutic eectiveness of a Brief Dynamic Supportive approach. As well as containing the patients anxiety it provides a exible guide for the therapist in responding to the patients material. It contributes 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 of emancipation 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. In L.H. Rockland (Ed.), Supportive therapy: A psychodynamic approach. New York: Basic Books.

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