B rief psychodynamic psy- chotherapy (BPP) may be to the psychiatrist what laser technology has become to the surgeon: a faster, more precisely focused.
I Trends
Psychotherapy that takes weeks, not years BPP:
Evelyne Michaels
B rief psychodynamic psychotherapy (BPP) may be to the psychiatrist what laser technology has become to the surgeon: a faster, more precisely focused method of treating certain specific problems. The technique is not new. In fact, says Dr. Howard Book, it has been around for some 60 years. "The roots of BPP lie within, not outside of, the psychodynamic tradition", he says. Book, the psychiatrist-in-chief at Toronto's Women's College Hospital, is directing a new advanced training program in BPP, and says the method has caught on with psychiatrists and their patients, but not all psychiatrists skilled in traditional psychotherapy can adapt to the demands of BPP without additional training. Brief psychodynamic psychotherapy is a sophisticated form of intensive psychotherapy that aims at achieving a small yet significant change in a large area of personality functioning within a specific time period. While long-term psychotherapy aims broadly and can take years, BPP aims narrowly and rarely lasts beyond 16 weekly sessions spread over 4 months. The therapy is much more directed than long-term treatment, Book says. Within the first two or three sessions, the psychiEvelyne Michaels is a freelance writer living in Toronto. 842
CMAJ, VOL. 140, APRIL 1, 1989
atrist must discover and choose the patient's central problem. This may not be the only problem, he says, but it must be the one that the patient is best able to deal with. He says that once the goal of the therapy has been established, the therapist must focus on it even if the patient brings up other important problems or themes.
could take years of long-term therapy to solve, she can still be helped by BPP", he says. For example, a therapist might choose to focus on her recurring inability to establish a
satisfying relationship
because
she continues to choose unavailable men, which has resulted in her depression. The patient might want to talk about her
"At the very best a patient may be able to use this awareness
[gained through BPP] to change her behaviour and gain control over a
problem."' Dr. Howard Book To illustrate its potential ap-
plication, he offers a hypothetical case history: "Let's say a woman presents to a doctor saying she's depressed. The doctor finds out that she recently broke up with her boyfriend and has had several other unsuccessful relationships, often with married men. While this woman may have certain deep-seated problems that
boss, whom she dislikes, or her unhappy childhood, but a psy-
chiatrist employing BPP must not let her be distracted from her main problem. Does BPP work? Although there have been relatively few studies involving its effectiveness, evidence suggests that it can be helpful for many patients. "At the very least a patient can
~ . :.
U of T offers 10-month .BPP .course Most doctors keep up wi:t innovation'S--.l n their feld y. attending theocs..o....nal sem m d a j..ourand scan .n.a.r nas, but the O .........ofC.nnuing Medical :E.dui.catio..n .at the University of Toronto. is offering something different to Ontario psychiatrists. The university, in conjunction with. Wo-
men'Js Colle.ge:.H..o.spital,:has Z~~~~~~~
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:developed. a 1.:0-.m. onth..training program ford.octr h want ...:to.become.:.. expert in an i.n.-: .f creasina.r...... a.s e. b f psk nor::.wn .:treatment . ..................
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.chodynam.ic ..... ..........psy.c
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.(BP ).
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D)r. Howavrd Book, director of the new program :and psychiatrist-in-chief at..the hospital, says the c:ourse.is:eu..nique 3,:-hourea Itois open.::opsyin Canada. sessio:jnQW:ocure work$y ..chiatistswh...... hae a.ined. fellowship sta.t.s... anr...e.u hr :ntl.ydevotn g at:.;ieathe' f hour'l .echiatristandcif psyc :pr.a.cce t.o long-tenn therapy or psychoanalysis. The program offers an intense, At l.......
h.o.
gain an intellectual and emotional awareness of a central problem and this can be useful", says Book. "At the very best a patient may be able to use this awareness to change her behaviour and gain control over a problem." BPP is not a shorter, more superficial form of long-term psychotherapy, he emphasizes, and in many ways may be more difficult and demanding for both the psychiatrist and the patient. Because the goal of the therapy is restricted and must be established very early in treatment, there's more pressure on the doctor to be correct in his or her assessment and to keep the therapy focused. Terminating therapy can also be difficult. "It's hard for the patient and the therapist, who may feel the work is unfinished - which it often is - even though one particular problem
of indiv--id.u.a.l ps.co rapy involvng onging9 supie-rviso cases . .:: The tra.ni.ng ce.... lends the theore.ti.cal..:..an..d....the: practical with in-de.pth study of standard BPP. textbooks, as well as case conferences that make use of procedure notes, audiovisual-.,:';recording and one-way .mi.nor. .visu.alization.
Participants. discu"ss i..mportant ow -to seaspects ..of BPP *lect patie..n.ts. h.ow tofcus on ..theshort-m.... go....f trapy, *how to. .timelm.its and how to terminate tratet. Teachi.ngfa.....X.cu.lty for this program inclu.de... Drs. Christine Dunbar, Harvey Golombek and Kas..Tuters, all of whom are univ.ersity-affiliated psychoanaa.n.d ...... psychiatrists lysts. Dr:. E.lsa .Marziali, psy-
chotheray rtesearcherwithrt .Uner.s...t.y o.f. T t is a c nsu..ta.nt......... Th e pr.:osgram. has. attracted
psychiatryat the. University o.f . of MediPennsylvania Schoo
cine d autho:r of me.... 100 pape.rs on psychotherap Man, an.dJa.mes researh... . one of the....early modern proponents :of. BPP since the publication of his 1964 text, TimeLimited Psychotherapy. Mann is professor emeritus of psychiatry at the Boston University School o`Af..Medicine. .Thi year:tree psychia-
into the prog... *accepted ........... .a Upon....ucessfu.completion,
in they will earn a certificate : BPP fm .....Wmens College Hospital an:d :the U of T's Faculty of Medicine. The program, which runs from.September to Ju;n;e, can accept up to eight .can.didates. Tuitionl costs $2000.. Applications may be .obtaine.d by writing Dr.
*Howard Book,:director,uAd .vanced Fellowship .Trainin
Progam i...n Bref.Pyho namic Psycho.....the.rapy, 984 :Bay experts: Dr. Letr Lu.borsky, St.g, Suiteh ru302 Toronto, Ont. M5S 2A5. professor.ofpsychology in..........og
.two: inte. rn..ato....n.a.l ..y re
has been explored", observes Book. BPP is not suitable for every patient, he adds. It is inappropriate for those with major psychoses or severe personality disorders. The ideal patient is someone who can engage quite quickly and the technique has proved valuable for treating problems ranging from depression and anxiety to relationship difficulties. One reason for BPP's growing popularity is that it makes research into the outcome of psychotherapeutic treatment easier - it is extremely difficult to study large numbers of patients in therapy that lasts 5, 10, or even 15 years. Another major impetus behind the movement towards shorter therapy is patient demand. As more people request
treatment for a variety of problems, the current availability of qualified psychiatrists is being stretched beyond the limit. By shortening treatment time, says Book, BPP will improve patient access to psychotherapy. BPP also promises to be more cost effective. Not only does brief psychodynamic psychotherapy cost less, but it could have a ripple effect. Many patients show up in doctors' offices and emergency rooms with physical complaints caused by underlying emotional problems, and they often seek medication to make them feel better. If BPP -- the psychiatrist's laser - is appropriate and accessible to some of these patients, says Book, it could mean less medication, less hospitalization, and less time spent receiving expensive medical treatment.E CMAJ, VOL. 140, APRIL 1, 1989
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