Brevity takes time

To the Editor

I thank Professor Jureidini (2013) for his thoughtful reply. Psychoanalysts have long debated the necessary and sufficient duration of an analysis. Psychodynamic Psychotherapy and specific variants such as Crisis Intervention (with individuals, couples or families) and Brief or Focal Psychodynamic Therapy, developed as abbreviated forms of psychotherapy within the psychoanalytic frame. If Professor Jureidini locates his ‘minimalism’ within this framework, I shall return to barracks forthwith (Jureidini, 2013).

My objection is to a ‘minimalism’ which knowingly or inadvertently reinforces the already widespread trivialisation, ignorance and dismissiveness of psychodynamic views.

Though I cannot convey the emotional cadences, what I might say to Zoë at the end of an assessment interview that elucidated the themes summarised in my paper could be like this:

‘Zoë, I think I understand that your father, to whom you wished to be close, raises your hopes, and then lets you down. He did this when you were a child, and he did it again recently. I believe that hurts you deeply. When you met Jack [the boyfriend], you felt he was a trustworthy guy, who would not betray you like your dad. In fact, you might have believed that you and Jack shared similar qualities, and that he was like you – caring, loyal and honest, a true friend. So, when Jack dropped you, you copped a double hurt: not only did he hurt you, but he hurt you like your dad. You might then have felt: “I’ll never find anyone who loves me in a way I can trust!”. That would hurt a lot, and even cause you despair. Maybe it was made worse because you believed that your mother, who had to be strong all these years to look after you and your brother, would not understand your hurt about dad or Jack. If so, you would then have felt very alone, hurt, despairing, and maybe angry. So attacking yourself, even killing yourself, might have seemed the only solution, because that way you took control of how to stop your emotional pain.

I may not be right about all this, but could you think about what I’ve said?’

This kind of always provisional, psychodynamically based, narrative summary helps the patient feel understood and psychologically ‘held’, even (or especially) in a busy emergency department or hospital ward. While empathising with Zoë’s emotional pain, it alludes to other possible meanings of the overdose (e.g. control or revenge when she feels powerless or angry); this may be important in a patient who unconsciously fears her own anger. It suggests Zoë’s relationships with men are idealising attachments rather than sexual (a possible transference consideration in any future therapy), and permits many therapeutic ‘strategies’, including involving mother, or prescribing medication.

Whether and when these themes should be explored, discarded, or more relevant ones sought, is for the patient and therapist to determine in the context of a therapeutic alliance.