A Case Using Brief Psychodynamic Therapy

By Leanne Tamplin

Wendy is a 54 year old woman who has two adult children and has been married for twenty-nine years. Her husband, Steve, has recently and unexpectedly informed her that he no longer loves her and that he wants a divorce. Wendy was shocked to hear this, and she now reports that she is constantly crying and feels extremely anxious. Wendy has not told anyone about this situation, although she and Steve have agreed to explain his decision to their children within the week.

In this scenario, the counsellor will be using a brief psychodynamic approach. For ease of writing, the Counsellor is abbreviated to “C”.

Background

Wendy attended eighteen appointments over an eight month period. The first six appointments were held weekly, the next ten were fortnightly, and the last two were spaced out over two months. Wendy and Steve have been married for twenty-nine years and have lived in the same area for all of that time. They have two children – Damien 24 years of age, and Amanda 26 years. Damien still lives at home with his parents.

Wendy has not yet told anyone, neither family nor friends, about her situation and becomes anxious when she considers doing this. She and Steve have agreed to tell their children within the next week, and Steve plans to move out of the family home at that time. Wendy and Steve are no longer sleeping in the same bed, although up until his recent disclosure, they had been sleeping together and kissing and hugging from time to time. Wendy’s reported anxiety/depression symptoms included: difficulty sleeping, difficulty relaxing, thinking about Steve/their marriage/the future all the time, feeling exhausted, feeling “tightness” in her chest and her throat, a loss of appetite, crying several times every day, and a loss of interest in “everything”.

Session Details

In the initial appointment, Wendy reported a very distressing couple of weeks. She began to describe her situation starting at twelve months ago when Steve began attending a gym and reading personal development books. Wendy stated that at that time, Steve seemed to change, and she thought it was a part of a “mid-life crisis” that he would eventually recover from. Around the same time, Wendy confronted Steve because she felt that they weren’t communicating much and she was feeling “left out” of his new interests. At that time, Steve told Wendy that he thought they were “drifting apart”. As a result of this conversation, Wendy then made a concentrated effort to improve things – she created opportunities for them to be together, she encouraged their discussions with one another, and she shared more of herself and her feelings in their conversations. That was the last time they had discussed anything about their relationship, and Wendy thought that things had been much improved by her efforts over the last twelve months. When Steve told her over dinner a week ago that he didn’t feel that he loved her anymore and that he would like a divorce, Wendy was shocked and devastated.

C’s role in these initial stages was to listen, to assist Wendy to expand and elaborate on her story, to help her to identify her emotions, and to provide her with unconditional positive regard and a non-judgmental environment. From a psychodynamic perspective, these early sessions were also about developing a productive therapeutic relationship and trying to understand Wendy’s life from her perspective, that is, to walk in her shoes. C listened empathically and shared in the variety of emotions that Wendy reported, including shock, anger, sadness, devastation, betrayal, disappointment, frustration, disbelief, and a sense of complete lack of control. These were discussed at length, as well as the situations that had caused the emotions. As a brief psychodynamic counsellor expects that there will be around twenty appointments, or more, there was no need to hurry Wendy. C and Wendy travelled through each event and emotion as they occurred.

Wendy reported that although the sessions were difficult, she felt “relief” when she left and looked forward to her next appointment. She described an almost immediate, but minor, decrease in her anxiety symptoms, with a continuing reduction over time. After discussion, she re-introduced the use of her own relaxation strategies that she had used successfully in the past.

C encouraged Wendy to allow herself to express her feelings as much, and as often, as possible. In response to this suggestion, she began a journal and wrote in it regularly, she accepted and catered for times alone to cry, and she gradually began to discuss her situation with close and trusted family, friends, and work colleagues. This latter action required extensive discussion about her fears of disclosure and how she would manage the repercussions.

In the first three appointments, the focus was on “holding” Wendy during her crisis, and on allowing Wendy to express herself and to describe her situation in it’s entirety, without judgment or analysis. After this stage, however, C began reporting to Wendy any observations or thoughts about what was happening for her, as well as identifying patterns in her actions and highlighting significant steps that she had taken. For example, in session seven, C noticed that Wendy was reluctant to criticise Steve for his behaviour. C described this observation to Wendy and asked her if she had noticed it herself. Wendy had not noticed, but once it was brought to her attention, she said that she could see it clearly. She said that she still loved Steve, and that she held onto the hope that he would change his mind. She went on to describe her plan to take him back should that occur. C empathised with the sudden and drastic change that had occurred in Wendy’s life and her plans for the future, and normalised her reaction to cling to the possibility of her life returning to the familiar and to having some feeling of control. C also explored this further, asking Wendy: how likely she thought Steve’s return was; how this event might take place; and how she thought she would respond if it occurred. In this way, Wendy’s beliefs and feelings about Steve were opened up, accepted, and their impact was acknowledged. Wendy was later able to identify the value of this belief in keeping her “together” at this point, and also said that she understood the reality that he was unlikely to return. This is an important occurrence in brief psychodynamic therapy, as it is an example of the unconscious becoming conscious.

At the commencement of the twelfth session, Wendy reported that she had a terrible week where she had cried frequently. She had spoken to Steve and had been very disappointed with his distance and coldness towards her. She described these events while laughing and speaking quickly and minimising their significance. C challenged this incongruence between Wendy’s behaviour and her words, by describing the observation to Wendy. Wendy reported that she was probably speaking fast because she had just met with a friend who would not be able to handle the truth about her devastation. Her quick speaking and laughing, Wendy suggested, was how she acted “together” when she didn’t want people to know how distressed she really was. C asked if this was also how she felt in our counselling sessions (note: from a psychodynamic perspective, often an experience a client is describing in relation to others can be a reflection of the experience they are having in the counselling room). Wendy said that she did want to improve her well-being, and so had hoped that she would be “together” when she came to counselling this time.

C asked Wendy to discuss the consequences of appearing “not together”. During this conversation, Wendy said that she felt that it was hard to be herself and that, in fact, she had not been able to be herself since Steve told her twelve months ago that they were drifting apart. From that time on, she had been acting as if everything was okay, when really she felt scared and alone. C and Wendy then talked about the possible impact of this kind of “pretending” on her marital relationship, on the counselling relationship, and on her relationships generally. They discussed where this behaviour may have been learned (Wendy felt it was from her parents’ relationship) and what had caused her to begin using it. After some long conversation about this, Wendy admitted that she had not been happy in her marriage for some time because she was afraid of losing Steve and afraid of being “left out”. It was at that point that she saw her “pretending” in her marriage as a form of self-protection.

During this conversation, Wendy also said that laughing about her problems was to make it easier for her friend to cope with the sad news. Wendy realised that she tried to make her distress easier for everyone to cope with, including Steve. She reported that she was even making it as easy as possible for Steve to leave her. She decided then that she would no longer do this, and would instead be true to her own feelings and express them whenever necessary. She stated that she would start to be herself around Steve, and everyone else. From this point on in our sessions, whenever she noticed herself laughing and talking fast about her sadness, she slowed down, took a deep breath, and connected with her true self. Developing this kind of insight is integral to successful brief psychodynamic therapy, and it sometimes starts with the counsellor paying attention to a small but significant occurrence within the therapy room.

From session fourteen, Wendy began a level of mourning for the lost relationship and her lost future – she described the loss as if she had begun accepting that it was really over. Wendy decided to bring family photos to counselling and reflected on the great events in their marriage. Wendy also started speaking more easily about negative experiences in their marriage and described times when she had felt taken advantage of and belittled. C saw this as evidence of Wendy’s increasing acceptance of the reality that the marriage was not perfect, and also as a way for Wendy to move further away from it.

Wendy often stated “what do I do now?”. C encouraged Wendy to begin to think about the things she had always wanted to do but had sacrificed when she married to have a family. Over time, Wendy made some solid decisions about her future concerning:

• Full-time work
• Disclosing her story to others
• Travelling to an island for a holiday
• Not waiting for Steve’s next move before she made hers
• Making some goals for the next two years that she could achieve with or without Steve

When Wendy raised fears of her ability to accomplish the goals she had set herself, C would encourage her to reflect on the personal traits she had demonstrated in counselling, and in her ability to handle Steve’s decision. In particular, she could see her own strength, her courage, and her honesty with herself as attributes that could get her through. Gradually, Wendy became more assertive and started living her life “as if” he would not come back, even though she continued to hope that he would return.

Wendy was keen to start thinking about ending counselling in session sixteen. C and Wendy agreed to two more appointments over two months in order to reflect on her progress over the last six months and identify how she would continue to progress without counselling. At session eighteen, Wendy’s anxiety symptoms were no longer present and she was feeling more in control of her life. She continued to cry and mourn her lost relationship regularly, although the frequency of her tears had greatly reduced.

Key Concepts of Brief Psychodynamic Therapy Applied:

• Developing a positive therapeutic relationship, including the use of empathy
• “Holding” a client through a crisis – not physically, but psychological holding to give them a sense of stability and certainty.
• Looking at the here-and-now in the counselling relationship
• Making the unconscious, conscious and fostering insight
• The underlying belief that providing a safe environment for a client to explore their experiences will give them the opportunity to understand themselves better, change their patterns, and make sense of the situations at hand.