Hanna Levenson on Time Limited Dynamic Psychotherapy

Hanna Levenson on Time Limited Dynamic Psychotherapy

by Randall C. Wyatt and Victor Yalom
Dr. Levenson lays out the principles for Time Limited Dynamic Psychotherapy (TLDP), and discusses how to make every session count.


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The Interview

Randall C. Wyatt: Good morning Hanna, nice to have with you with us. Did I pronounce it right?
Hanna Levenson: Either way. My real first name is Hanna-Mae. It’s a hyphenated first name. Hardly anyone knows that.
RW: I like that name, now we all know it. Let’s get right to the work you are most known for, Time Limited Dynamic Psychotherapy, otherwise known as TLDP. Usually when people think of psychodynamic psychotherapy, they think long term, psychoanalysis, or at least that the therapist wants it to be long-term. So it almost seems like an error, a typo or something.
HL: Yes, people do sometimes have trouble putting those two together, although Freud certainly did very, very brief therapies when he first started, and many were quite effective. His length of the therapy elongated as the theoretical parameters became more and more encumbered. So, it doesn’t have to be an oxymoron.

RW: Right. How did you first discover that it wasn’t an oxymoron, Time Limited Dynamic Therapy?
HL: My original entrance into the field is kind of indirect. I was originally trained as an experimental psychologist with emphasis on social psychology and personality theory. And then later on, as my interests and responsibilities grew more and more clinical, I, what they called, retreaded - lovely term - I retreaded into clinical psychology. So I didn’t become steeped in the tradition of long-term analytic therapy. I was used to working with groups, with individuals in a much more pragmatic way, more from a research standpoint than from an academic standpoint. But the whole arena of psychodynamics fascinated me. The emphasis on the unconscious, on conflict, and on transference and countertransference. So it just seemed natural to take that and adapt it to my understanding of social contexts. Plus my own style, I think, is more of a pragmatic, impatient, let’s-get-to-it style so that led me to the brief part.
RW: Impatient? What do you mean, impatient?
HL: It can cut both ways, because I often get feedback that I’m very, very patient in the clinical work, or when I’m teaching, but I’m impatient in that I’m really looking to make every session count. How can I get the most mileage, whether I’m teaching or doing clinical work? How can I help someone get from A to B in an efficient and yet as respectful way as possible? So I like seeing results, but I’m also fascinated with the process, so when I seek results I don’t necessarily mean just focusing on the end point. In those micro-interactions, can I see that the work has deepened? Can I see that the work is furthering?
RW: Well, impatience is a word that generally isn’t used in therapeutic lingo, not that I’m against it, since sometimes patience has its limitations as well. But I imagine you’re using impatience in the sense that it’s a good thing.
HL: Absolutely. I mean, people come in and they’re suffering; that’s the major reason people come in to therapy. They’re suffering, they’re in pain. And how can we be of help to them as soon as possible? Yet also having respect, not just for symptom relief, but for the bigger picture.
RW: What’s the bigger picture to you?
HL: The bigger picture to me includes what is the context in which the person lives? The social milieu? What is their personal background? What are the stressors that they’re dealing with? So, all of that.
Victor Yalom: You focus a lot on their long-term interactional or interpersonal patterns.
Hanna Levenson: Right. What is there about those that might cause someone to come in with symptoms of depression, anxiety or emptiness?

An Integrationist Point of View

VY: So it seems like you try to do two things. You’re trying to cover both bases - you’re trying to work with symptom relief, which there’s a lot of emphasis on in cognitive therapy. But you also try to do some structural personality changes.
HL: Right, and I also should say that originally I was very enamored of cognitive-behavioral techniques, as well as systems theory, which I come by legitimately with my interest in social psychology. So I don’t see these all at variance with one another. It somewhat puzzles me, to tell you the truth, that so many of my colleagues identify with a kind of strict orientation. So there’s the cognitive behaviorists, and then there’s the psychoanalysts, the humanists, and people who are interested in systems. And for me it all kind of really flows together, that these are all valuable orientations, ways of looking at the person, and all orientations are trying to be of help.

And so it seems natural for me to look at schema theory. It makes a lot of sense when you’re talking about someone’s pervasive dysfunctional style. It certainly makes sense to look at conflict and unconscious processes. It certainly makes sense to look at the system which might maintain that dysfunctional way of being. So it all just makes sense to hold it together in a more integrationist point of view.
RW: I certainly know what you mean, that a lot of people identify very closely with their own church be it CBT or psychoanalysis, or existential. Well, everybody has a favorite, but do you sense that they aren’t open to other theories, or they’re only open to one?
I have a colleague who very much identifies as a cognitive therapist, but I tease her that she’s a psychodynamic therapist in cognitive clothing.
I have a colleague who very much identifies as a cognitive therapist, but I tease her that she’s a psychodynamic therapist in cognitive clothing. Let me back up. If you open up the door of the experienced therapist and listen in, it’s often very hard to actually discern their orientation. Because I think we all get to be rather flexible and pragmatic and tuned in to what the client needs, with more and more experience. So I think it’s more the neophyte therapist that kind of latches onto a more rigid adherence to a theoretical orientation, and appropriately so, developmentally. Don’t get me wrong. I think that’s an important way of learning - to really steep oneself in one approach, and really push the limits of that approach.

The Essence of Time Limited Dynamic Psychotherapy

VY: Before we start comparing your approach to other approaches, what is the essence of Time Limited Dynamic Psychotherapy?
HL: The way I practice it, I really see it basically as psychodynamic in orientation, which is to say, looking at things like transference, countertransference, conflict, processes that are out of awareness, and combining that with aspects of cognitive and systems orientations. I don’t view people as being fixated in some early intrapsychic stage which is unchangeable. The person may develop a style, a way of being early in life, but that’s always open to change, depending upon other people, other social environments, other trauma that they might come in contact with, or other healing environments, and in my case, psychotherapy. I’m also very interested in the affective component of how someone puts their world together, and very much from attachment theory. So it all just makes sense that it hangs together for me.
RW: What do you take from attachment theory?
HL: I take from attachment theory that basically what drives human beings is not sexual and aggressive impulses, nor how to construe the environment in a more cognitive way, but rather the need to attach to other human beings, the need to be accepted, the need to feel close, and especially the need to feel secure. But that is inborn, and we all seek that. It’s just that things might go awry in that process.
RW: So how does this need for relationships play out in therapy, then, for you?
HL: Well, the person enters therapy and has a way of interacting with me, as well as what they tell me about their past way of interacting with others. I try, from those two sources of information, to formulate what have been some difficulties with attachment in the past, what kinds of security operations might the person need to have developed in order to stay as much connected as possible, and what might be necessary experientially and cognitively that would help them shift from maybe this lifelong dysfunctional pattern in life.
RW: Can you give an example of that?
HL: Let’s say there is a boy who was raised by very authoritarian, dogmatic, punitive, harsh parents. And so he develops a style, a way of being that is subservient, anxiety-ridden, placating. It makes sense given the pushes and pulls from his parents. It might be the only way for him to stay safe in that family, since at a very young age he’s totally dependent on them. He needs to come up with some kind of compromise - compromise on maybe his true emotional feelings, so that the more angry feelings, the more assertive feelings get suppressed. So he goes through his childhood in that way, and then in adulthood, since he’s now got a well-ingrained style and pattern, he continues to manifest this anxiety-ridden, placating way of presenting himself to others, and may even, unconsciously, seek out people who are more punitive, arbitrary, superior -- not because he’s masochistic, but because it’s what’s comfortable. It’s what he knows. So then he enters the therapy room, again being this placating, subservient, anxiety-ridden man.
VY: So what do you do about that, and how do you use the therapeutic relationship? How do you address these issues?
HL: In the sessions, I, the therapist, might find myself becoming more the expert than usual. I might find myself becoming more reassuring, maybe more advice-giving. Already I am adopting a style that would be the reciprocal, the complement, of this patient’s style. So, I not only observe his style and way of being and formulate according to that, but I’m also very cognizant of my own reactions to him, what I call interactive countertransference. And then by being aware of seeing how his behavior and interactions affect my own interactive countertransference, I think about what would need to shift in the here-and-now, in the therapy room, that could give him a new experience of himself, that could give him, perhaps, in this case more a sense of being assertive, more a sense of being angry even, and certainly more a sense of me as the therapist as not having all the answers, of not thinking less of him, of not shaming him.
VY: How am I going to do this with a client?
HL: So that’s one thing. This is keeping me on my toes. Secondly, I would want him to have some insight into what’s going on. I want him to have a kind of cognitive understanding—
VY: From the experience and the insight or understanding?
HL: Exactly, both of those. And that makes my approach somewhat different than the traditional psychodynamic approach that is more insight-oriented. You know, the belief that insight will set you free. Well, we know now that insight unfortunately doesn’t set us free. I think it helps a lot, and it’s very interesting, but it doesn’t necessarily mean we’re going to be less depressed and less anxious, and so forth. So I want to go an experiential route, because nothing succeeds like having a new experience of something. And the truth be known, these are two sides of the same coin. It would be very hard to have a true new experience without some understanding and very hard to have a true insight without having an affective component.
VY: I always refer to a quote by Frieda Fromm-Reichman that patients need an experience, not an explanation.
HL: Right. Right, exactly. I’m very fond of that quote. I’m fond of a quote from Hans Strupp, "The supply of interpretations far exceeds the demand." Speaking of Hans Strupp, it’s very sad, he died last week. A real pioneer in our field. Eminent researcher, theoretician, but also just a mensch. Just a very decent human being. I was very saddened to hear it, he had such an impact on my work.
RW: You studied with Strupp?
HL: I didn’t study with him per se. He was doing his NIMH study in the mid 1980s, and I had read a draft of his book, which came out later in 1985, Psychotherapy in a New Key. Wonderful book. And so I had the chutzpah at the time to just invite myself to Nashville and say, "I think I’m doing something similar to what you’re doing. Can I come and take a look?" And at that point no one had done that, so they were a bit intrigued and very open. And I went, and had the chance to sit in on all of their training groups that were going on, and it was the beginning of a wonderful collegial relationship. And then we ended up publishing some papers together and some chapters together, and so we had a 20-year relationship.
RW: Do you see your work as similar to Strupp’s and his colleague’s work, or different?
HL: Yes, it’s similar in that the way I formulate is very much an adaptation of their way, really looking at what the interpersonal story is that the person is telling and the way he or she acts in the world. Where I differ is what I mentioned previously, is that they were emphasizing that if you have a good enough relationship, a good enough alliance, then go for the insight, go for the understanding. And I’m saying yes, a good enough relationship is of course critical no matter what kind of therapy you’re doing, but above and beyond that, I think you can be more focused in the experiential learning part. I don’t think it’s one size fits all. I think we can really hone in and be much more specific, kind of like an experiential version of insight. Something very unique to the individual.
VY: This might be a good segue back to the case you were presenting on, how you would do something experientially to address the interpersonal problems and patterns.
HL: Right, and in fact, Victor, you just nicely demonstrated one of the ways I do it, which is to maintain a focus. You got us back on the focus where we had left off, after a little side trip, and by your saying that, you bring me back to where we left off. This focusing is an extremely important factor in how most brief therapists work; bringing the person back to a central theme. And so that’s one of the ways I would do it in treating this anxiety-ridden man, for example.

One way I would keep a focus is to look for themes. What am I hearing about the redundancies in the way he acts in the world: what are his thoughts, his feelings, his wishes, his behaviors, chiefly of an interpersonal sort, since this is an interpersonal model. Second, what are his expectations about how others will behave? Third, what is the behavior of others? Of course, as seen though the eyes of a patient, we don’t have the others there, except for the therapist. How do they respond? And then fourth, how does that leave the person feeling about themselves? What is that person’s introject? How do they treat themselves? And then that, in turn, causes them to act, think, feel, etc, so we really have described a story about the person interpersonally.
RW: Where does the cyclical part come into play?
HL: I act, think, feel in a certain way and expect other people will treat me in such and such a way. In fact, they treat me in this way, and all of this leaves me feeling X about myself, which causes me to act, feel, think, and then what we have is a cyclical maladaptive pattern.
It’s cyclical; it feeds on itself. It’s maladaptive because it doesn’t work well for the person, and it’s a pattern because it occurs over time, over place, over people.
It’s cyclical; it feeds on itself. It’s maladaptive because it doesn’t work well for the person, and it’s a pattern because it occurs over time, over place, over people. So that’s what I’d be trying to do, from an insight-oriented place, help this client see this pattern. At the same time, I will be experientially working on reinforcing and highlighting those places where he is behaving differently, where he is moving out of this rut, and I’d be very mindful of myself and my own reactions, to see if I end up reenacting something dysfunctional with him, or can I step back and help provide him with some new experiential learning?

Working Psychodynamically in the Here-and-Now

VY: One thing I recall from the video that you made, Time Limited Dynamic Psychotherapy was that you actually articulate, put into words, your awareness about your own reactions. And I think that’s different, at least, from people’s stereotype of how more psychodynamic or analytic therapists use countertransference. That you really engage in the here-and-now with the patient, rather than kind of making a transference or countertransference interpretation that is more distant or in the third person, or leaves the therapist out of the equation.
HL: Right, for example, I might say to a patient, "You know, I notice I’m telling you a lot of what to do, and I seem overly sure of myself compared to how I usually am. I’m wondering what might be going on." And in doing that, I not only allow us to take a look at the here-and-now situation between the patient and myself, but I’m also saying, "I’m contributing to this dynamic between us."
So this is perhaps another, different point of view from the caricature of the analyst, which is that I’m not neutral. I’m not this benign, neutral, mirror representation. I am someone who gets hooked into acting and reacting to the pushes and pulls of the client.
So this is perhaps another, different point of view from the caricature of the analyst, which is that I’m not neutral. I’m not this benign, neutral, mirror representation. I am someone who gets hooked into acting and reacting to the pushes and pulls of the client.
VY: Well, I think it’s a really key point, because I think some of the modern dynamic people, the intersubjective folks, certainly the Gestalt and the existential and humanistic therapists, have talked for years about working in the here-and-now in the relationship. And I think one of the things therapists have the hardest time is really learning how to do that. Do you agree with that?
HL: Yes. I think somewhere students learned either at their parents’ knee or from their supervisors or teachers, if you can’t say anything nice, don’t say anything at all. And of course one always has to be tactful, in therapy as well as in life, because you want to be heard. But we are really depriving our clients of such critical, important information if we don’t share: "Well, this is what I’m struggling with as I interact with you." And clients are often very grateful for that feedback given all the usual caveats about the timing of it and the nature of the alliance, and all those things we need to be mindful of. But yes, I find it’s hard for beginning students to do that, and sometimes it’s hard for advanced therapists to do that, because what it does mean is you enter the fray.
You have to get down into the trenches with the client. You can’t stay up here in a lofty position, and it’s dirtier down there. It’s messier down there, and you don’t know exactly what’s going to happen down there.
You have to get down into the trenches with the client. You can’t stay up here in a lofty position, and it’s dirtier down there. It’s messier down there, and you don’t know exactly what’s going to happen down there.
VY: And you have to be more vulnerable as a therapist.
HL: Absolutely.
RW: So during the session as a therapist, you’re feeling more vulnerable. In what ways does that serve or not serve the therapy.
HL: Yes, in a healthy, open way. I don’t mean vulnerable in like, "Oh my goodness, I need to become protective. I need to erect a wall because I’m going to be hurt." That kind of vulnerability would not be helpful, and in fact sometimes I think the therapist seeks the expert position from on high because the therapist does feel too vulnerable. And then you have a defensive or what I call a security operation that sets in, that actually promotes keeping that distance. Rather, I am speaking of an open vulnerability. It’s a trust in the process - let’s put it that way. It’s a trust in the process.
RW: I’m thinking of the intersubjective wing of psychoanalysis and the well-known and prolific analyst Roy Schafer who talked about changing how we therapists speak about ourselves and our clients. Certainly there’s this line of thinking going on in a lot of existential-humanistic, and definitely psychoanalysis, as well. Can you give an example of any time recently where you’ve felt something in the room and you’ve shared it with a client, and it was either negative or difficult to say?
HL: Yes. There are many. Let’s see. A woman I saw, who was rather egocentric, and if one were to diagnose her, they would probably say that she has a narcissistic style.
Early on in our work she found that most everything I said was ineffective to her and sadly lacking. She said my comments were not deep enough, not on point, not psychoanalytic enough. This was a woman who had been in analysis.
VY: She was critical of you?
HL: Yes, she was quite critical of my interventions and of me; she wouldn’t broach it directly, but indirectly with side snide comments and a heavy hand. But of course this was one of the reasons that she had come into therapy. She was having significant difficulties with her daughters and her husband. One of her agendas in coming to therapy was to really shape up her daughters and her husband.

But as I was feeling this barrage from her, I could feel myself moving further and further back in my chair and becoming more and more unable to say anything. Certainly I was trying to get a good alliance with her, but it was becoming increasingly difficult.
So I finally said to her, "You know, you’re a force to be reckoned with, aren’t you?" And it kind of startled her.
So I finally said to her, "You know, you’re a force to be reckoned with, aren’t you?" And it kind of startled her. She said, "What do you mean?" And I described my reaction and that I was very aware that I was feeling very ineffective and not competent. Well, this came as a complete surprise to her. She had no intention of wanting to do that, and it was very useful information and something we referred back to time and time again in our work.

Those moments become earmarked, which allows me to say another aside, that I’ve often found that being this open about my countertransferential reactions, can actually build an alliance. It isn’t like you have to wait to have a good alliance before you could say something like this, but like with this woman, you need to find a way to bring yourself back into the room, find a way to bring yourself back into relationship with the person.
VY: It’s hard to genuinely engage her if you’re feeling like you have to stifle all these negative feelings you’re having.
HL: Absolutely.

Becoming Aware of and Using Countertransference

VY: Given that you agree that this is a hard skill for therapists to learn, other than having personal supervision with you, for example, what are some ways that you find that are helpful for therapists to learn how to do this? Because it’s very different than what therapists usually learn in grad school or most post-graduate education.
HL: That’s a great question, Victor. I find that if you can record, preferably videotape, but at least audio-record your work, it’s enormously helpful. When we’re in the therapy room, especially for beginning therapists, it is so difficult to keep track of all that is happening: one’s own feelings, what’s going on in the transference, what’s going on affectively with the client, nonverbal information, etc. So being able to listen to an audiotape after a session, or even better yet watch a videotape of what goes on while the therapist or trainee as observer is in a different emotional state, really allows therapists to see all kinds of things.
VY: And what do you listen for, or watch for?
HL: The therapist’s nonverbal behavior. I might wonder: What am I doing? Why am I doing that, rubbing my hands a lot? What’s going on there? I’m having trouble looking at the client. What’s going on there? What’s that tone in my voice? I sound tremulous. I sound angry.
RW: It sounds like the first step is to be more aware of what kind of countertransference reactions are getting engendered. So then the second step is how to find a way to put those feelings into words in a way that’s going to be helpful.
HL: Yes, and also acknowledging that there is a reality to the client’s perception. That’s another thing. So that when the client says, "Well, am I boring you?" Rather than saying "Well, what makes you say that?" And then they’ll say, "Well, you’re yawning and your eyes are at half-mast." Then what do you say? "Do other people always look bored to you?" Do you take it out of the room? Do you take it to a safe place distant from you, or do you say something like, "You know, I think you’re right. I wasn’t aware of it but I think I was drifting off. Can we go back and take a look at what was just going on between the two of us? When did you notice that I was not as present? When did you notice that I was looking bored?" It is giving some validity, as an interpersonal slice of life, to the client’s perceptions. It isn’t all projection.
RW: That’s an amazing, amazing concept in itself, which I say with some irony, that the therapist will acknowledge that the client’s perceptions are accurate or have some validity, and aren’t just something to be questioned and wondered about.
VY: In fact, to deny what actually is, is anti-therapeutic in a sense. If they are having an accurate perception and you’re denying it, well, that’s no help to them.
HL: Right, and you said, "If they’re having an accurate perception." From an interpersonal therapist’s point of view, you would not even wonder right there about the accuracy.
RW: There’s no one objective reality. There are two interpersonal realities.
HL: Right, because if I say they’re having an accurate perception, that means that I have to be all-knowing. I have to know all of my unconscious processes, I have to be aware of everything, and I can determine as the therapist on high what is accurate and what isn’t. So my assumption is that maybe it doesn’t fit for where you are. I know sometimes when I’m listening very intently, I can look angry. I might furrow my brow, and so I know enough about myself that when I’m really looking and listening intently, it can come across as angry.

So when the person says, "Gee, you look angry with me," I may know there’s something being misperceived. But nonetheless, I take what they’re saying as important, and we can explore that and we can process that, and maybe at some point it gets to my actually sharing with them, "I’m really listening very intently, but I know I can come across as angry, and what’s that like for you?" And I can also say to them, "You know, I’m not feeling angry at all, but I really appreciate your courage, your willingness to take the chance of letting me know that."

What to Self Disclose and what to Hold Back

RW: Let’s go to another level of self-disclosure. How do you decide what to disclose to the client or to keep hidden? Obviously you don’t say every single thing on your mind. You don’t do that with anybody.
HL: Right.
RW: What guides you in disclosing to the client about your own process?
HL: Excellent question. What guides me is the formulation. In fact, the formulation guides me in everything. The formulation leads to my goal, the goals lead me to my interventions. So that in getting that formulation, going back to that cyclical maladaptive pattern, if I have an idea about what is the style, what the person invites in others, what is their own self-concept, etc., then that is going to allow me to devise some experiential and insight oriented goals, and then that is what’s going to guide me.

So for example, with the person who comes in who’s placating and subservient, I’ll be listening for any opportunity where he might say something assertively. Anything where he might say, "I want," especially if it might seem to contradict something I’m saying, for example. So I would want to highlight those times, capture those times, elongate those times, dwell on those times. However, let’s say there’s someone who comes in who is quite hostile, that that’s part of their cyclical maladaptive pattern, and in reciprocation they invite hostility or subservience, and that’s what gets them into difficulty. Then if they keep challenging me, then that might not be something that I’d want to reinforce, that I might want to focus on.
VY: You might instead reinforce the time when they’re more vulnerable or softer.
HL: Exactly, exactly. So what happens in a session is really driven from how I am formulating the case, and what are my goals. So I really need to keep those at the forefront. This also gives me the opportunity to maybe make a little segue in this interview and say that I use this approach even when I’m doing long-term therapy, and I enjoy doing very long-term therapy, as well as briefer therapies. But I do tend to keep a more focused approach when I’m aware of the formulation and my goals.
RW: And so what’s the difference? The way you practice sounds not so different than the way I practice, using insight, experience, here-and-now work, transference, and countertransference. What makes it short term? What makes it time-limited or long?
HL: In general, and a gross overstatement, I try and make every session count, because I don’t know how long I’m going to see the person; that’s up to the client, for the most part. So we know that 80 to 90 percent of clients drop out before the 12th session, whether or not they’re in managed care. People stop when they have gotten enough out of therapy, or it’s reached that kind of threshold between cost-benefit, it wasn’t what they had in mind, they’re not being helped and so forth.

So people drop out of therapy and therapists frame it as a premature termination, which again is a little presumptuous. I’m trying to make every session count, not knowing if I’ll see them for five sessions or five years, at the outset. Certainly as time goes on, you have a better idea if you’ll be seeing them longer term or not. So for me there isn’t so much of a clear dividing line between brief and long term therapies.
VY: How do you decide? Do you decide in advance, this is going to be a time-limited therapy?
HL: For some modes of brief therapy, Mann’s model for example, the time-limited nature of the therapy is very critical. In TLDP, it’s not critical. In fact, I think if Hans Strupp and Jeffrey Binder had a chance to rename their approach, it would be something more like "Focused Dynamic Therapy." And take the "time-limit" out of it, because it doesn’t so much weigh on the brevity of time. Really what heats up the session is the focus on what’s happening in the here-and-now, and being very aware of that in the here-and-now.

To get to your question, Victor, about do I decide ahead of time or do I decide as the person comes in, it’s a mutual decision. Again, it’s not a unilateral decision. So what is the person interested in? Where do they see they want to go? I do believe in having windows of opportunity where we might stop the ongoing process of the work and reflect, where are we? Are we at an ending place? Or a client might say, "Gee, I think I’m at a place where I can end." Or we might just say, "So where are we and what have we gotten out of our work?" There should be windows of opportunity all along the way to reevaluate. It helps keep everyone on the same page, and I think also helps us put our clients’ needs first.
VY: So we’re not just assuming longer is better.
HL: Definitely not assuming longer is better. As my colleague Michael Hoyt has said, "Better is better."
RW: Better is better, Hoyt can make that a book title.
HL: I think he has. Yes,
better is better, not longer is better!
better is better, not longer is better!

Is Cognitive Behavioral Therapy the Gold Standard?

VY: In the media, almost every time there’s an article now - somehow brief and cognitive therapy especially, seem to take all the limelight. It’s referred to repeatedly as the gold standard, proven, that it’s empirically validated. Psychoanalysis is often set up as the straw man, where Woody Allen goes forever and never gets better. You’ve been involved in lots of research, and my sense is that good therapy is always good therapy, regardless of these orientation differences. Do you agree that the research shows that cognitive therapy is so superior, and if not, why is it getting all the attention?
HL: Well, it certainly is getting a lot of attention. I do keep up on this literature and I write an updated review chapter on cognitive therapy about every ten years for the Review of General Psychiatry. One of the reasons that the research is coming out favoring cognitive therapy has a lot to do with NIMH funding. NIMH uses the medical model and experimental design as the gold standard and cognitive therapy certainly lends itself to discreet interventions that are made in experimental control designs. In addition, the research design often involves having patients who do not suffer from any other condition other than one diagnosis. So no complex cases, you must find subjects who have an anxiety disorder but who are not addicted to substances, who are depressed but don’t have marital difficulties, who do not have a medical problem, and so on.
VY: Pretty hard to find.
HL: Yeah, pretty hard to find, but you can find them for research purposes. So while the studies are easier to do, easier to analyze, and the results can be shown in a clear-cut way, the transition for the practicing therapist dealing with the populations in the real world, is problematic and might not hold much water. The studies do not generalize or apply readily to real clinical populations. However, I also want to say it could certainly lead to wondering about certain interventions that could be incorporated into messy or real clinical situations.

I should note that I’m very impressed by the research of Louis Castonguay and Marv Goldfried who have done a beautiful job of really looking at a more sophisticated version of cognitive therapy which takes into account factors such as the therapeutic relationship, the alliance. Safran’s book on interpersonal processes and cognitive therapy is also one of my favorites.
RW: It is my read that APA’s position on evidence based interventions, in particular, Norcross’ work, has room for the therapeutic alliance and relationship as part of these protocols and manuals in addition to the more CBT technique like approaches.
HL: Unfortunately, the evidence based focus on the therapeutic relationship had to come up as a reaction to much pressure -- it would have been nice if we could have been more proactive and been out in front of the curve.
VY: Back to the protocols, I’m interested. From your experience in the CBT world, do CBT therapists follow the protocol, perhaps, that’s not "better" to them as well.
HL: Right, that would not be the best approach for their clients. You have to do an idiosyncratic formulation. You have to know when, for this particular individual who’s sitting across from you, when to follow the protocol and when not to, or when the protocol must be adjusted. Jackie Persons’ work in this area is superb.
VY: So I take it you’re not a big fan of manualized treatment?
HL: I’m not a big fan of rote manualized treatments. I think manualized treatments can be wonderful to teach from but not with the point of view of follow it exactly, do this, then this, then this - kind of in a robotic fashion.
VY: Unless you’re treating robots. Even in these severe research conditions you describe, is it in fact the case that cognitive behavioral approaches show superior results to just an experienced, integrated eclectic clinician?
HL: Depends on the study. Some of them show clear-cut advantage. For others the results are more complex. I’m also very mindful as a researcher that who conducts the outcome research, is very critical - that one of the best predictors of the outcome of the study is the theoretical allegiance of the investigator.
VY: So when you read these same articles that I do in Newsweek and the popular media referring to CBT as the gold standard in therapy, what’s your reaction to that?
HL: Take it with a grain of salt. I’m going to have to leave soon, just to give you a head’s up.

Running out of Time

RW: What time to you have to be out of here?
HL: I probably should leave here at noon.
RW: So, can we ask a few more questions? Seems there is a limit on our time here as well.
HL: Please.
RW: What types of client is TLDP intended for? Adults, kids, couples, families?
HL: Good question. Yes, it can be done with individuals, couples, families and groups because of the systems orientation, so it’s going to be looking at interpersonal interactions. It was designed for individuals. I have taken it to the level of dealing with couples, and I know others talk about the similarities with Irvin Yalom’s approach to group therapy, but I don’t know anyone who is purposefully looking at a TLDP perspective within groups per se.
RW: What’s the most satisfying part about doing clinical work for you?
HL: Just the honor of being let into people’s lives. It is really so phenomenal to be let into the depths of their lives like so few people are, and I feel very honored by that.
VY: You’ve obviously been practicing for a few years now, and you’ve trained hundreds of therapists. What are some things that you know now about doing therapy that you didn’t know originally or when you were younger? What are some key points for young or developing therapists that you could pass on to them?
HL: Don’t be afraid.
Don’t be afraid to share who you are, to really make who you are work for you.
Don’t be afraid to share who you are, to really make who you are work for you. Yes, the theories are important, the expertise is important, the learning is critical, but that which is uniquely within you, make that work for you. If you have a good sense of humor, make that work for you. If you’re more reserved, make that work for you. Whatever it is, that’s what makes for the best therapy possible.
RW: That’s a very good point. Some theories of therapy are extroverted therapies in what they call on the therapist to do. Psychoanalysis pulls for a more of an introverted approach, meaning the therapist is more reserved and less interactive. CBT is a more of an extroverted approach, where you’re coaching more, and so forth. Yet some quiet CBT therapists are wonderful, and some analysts find a way to practice using their extroverted personality.
HL: Yes, make it work for you.
If you can bring the combination of who you are and your unique gifts combined with the expertise, that’s unbeatable.
If you can bring the combination of who you are and your unique gifts combined with the expertise, that’s unbeatable.
RW: I think you’re right. Many of the master therapists that we’ve interviewed have focused on the therapist bringing themselves to the encounter of psychotherapy. That whatever you do--the more you can bring yourself into your work, the better it is. And I think it has a lot to do with countering much of what we have been taught, but also it has to do with being vulnerable and being willing to take risks. Well I see we're at the limit of our time today, so I want to thank you for engaging in this thought-provoking discussion.
HL: I’ve enjoyed it myself. Thank you.

Copyright © 2007 Psychotherapy.net. All rights reserved. Published February 2007.
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Hanna Levenson Dr. Levenson has been specializing in the area of brief therapy—as a clinician, teacher, and researcher—for over 25 years. She directs the Brief Psychotherapy Program at California Pacific Medical Center, and is a professor at the Wright Institute. She has published over 70 articles and two books, Time-Limited Dynamic Therapy: A Guide to Clinical Practice, and The Concise Guide to Brief Dynamic Psychotherapy. Levenson also made a video on Time Limited Dynamic Therapy website. To learn more about her work, visit Hanna Levenson's website.

Randall C. Wyatt Randall C. Wyatt, PhD is a practicing psychologist in Oakland and Dublin, California. He specializes in working with post-traumatic stress, cross-cultural therapeutic relationships and couples therapy and has extensive teaching experience.

Victor Yalom Victor Yalom, PhD is the founder and resident cartoonist of Psychotherapy.net. He maintained a busy private practice in San Francisco for over 25 years, but now sees only a few clients, devoting the bulk of his time to creating new training videos for Psychotherapy.net. He has produced over 100 videos, conducted workshops in existential-humanistic and group therapy in the US, Mexico, and China, and currently leads consultation groups for therapists.  More info on Victor and his artwork and sculpture at sfpsychologist.com.

CE credits: 1

Learning Objectives:

  • List the core principles of Time Limited Dynamic Psychotherapy (TLDP)
  • Explain how TLDP integrates a wide variety of theoretical orientations
  • Describe perspectives on countertransference and therapist self-disclosure

Articles are not approved by Association of Social Work Boards (ASWB) for CE. See complete list of CE approvals here