TIME LIMITED PSYCHOTHERAPY WITH ADOLESCENTS

The article presents treatment and follow-up of a 17-yearold youth, using James Mann’s time-limited psychotherapy
method.

SHORT-TERM DYNAMIC PSYCHOTHERAPIES: Freud’s early work with Katharina8 and Dora,9 and also with
Gustav Mahler and Bruno Walter, were of short duration.

Any psychotherapeutic system may be defined as short-term psychodynamic psychotherapy if it meets the following
criteria: the treatment is time-limited, focused, and offered to selected patients; it uses psychoanalytically inspired
techniques; and the theory underlying the explanation for the disturbance is psychoanalytic in the wide sense of the
term. Typical elements of this kind of treatment are active and directive psychotherapists, intense involvement in
separation and termination issues, and regular follow-up procedures after termination.

It is crucial to emphasize that short-term dynamic psychotherapies are appropriate for only a certain segment of the
patient population.

The most critical patient attribute is the strength of the ego and its capacity to allow rapid affective
involvement and equally rapid affective disengagement. This assumes patients’ previous good functioning
levels, potential for appropriate relationships, ability to interact with the therapist, high motivation for change,
and psychological mindedness.
Once the patient accepts the central issue, the therapeutic contract can be established, including the duration
and frequency of sessions (usually 12 weekly sessions) and a clearly defined termination date.

Typically, three distinct stages emerge in the treatment. The first is termed the “honeymoon phase” because of
the optimism that characterizes the initial closeness and understanding experienced in the new relationship and the
awakening of hope that is projected onto the relationship. It is important to remember that prior to treatment, the
patient generally experiences a period of suffering and loneliness. The honeymoon feeling derives from the disparity
between the experience of suffering and loneliness and the experience of being understood.

The second treatment phase is characterized by ambivalence aroused by doubts regarding the therapist’s ability to
provide solutions and to actualize the newfound hope experienced in the honeymoon phase.

The third phase, culminating in termination of the treatment, focuses on the imminent separation and is characterized
by a wide array of emotions. In the supportive context of therapy, the therapist, who also experiences the separation,
guides the patient toward a direct expression of the emotions surrounding separation. Successful processing of this
phase engenders an experience of emotional integration revolving around a benevolent object.

Jacobson33 described this stage as the sorrowful separation from the childish self and from childhood objects while
approaching the yet unknown world of adulthood. ( well I feel our adolescents embark on a different journey of sorts.
The phase of transition isn’t critically limited to adolescents. It starts before that and doesn’t necessarily end with the
end of adolescence either. Eg- I remember my friend, I was around 8 I guess and she was 10, whenever anybody
would come to her home, her mother would ask her to make tea for the guests. Uske haat ki chai famous thi, which
astounded me, for I always associated such tasks to being an ‘adult’ as if. And then when now I listen to many of
clients, I again am struck by the fact that an 18 year old has been living alone in delhi, fighting goons, going to doctor
for check ups, c hanging pgs twice an year, and she does all of this alone. And her training started way earlier, when
she would assist her mother with the household tasks. And yet she is a kid in many ways I am sure, maybe in her
naivety too at times. But this taking on new role isn’t simply limited to doing household chores. It goes beyond that,
it also includes taking on the emotional baggage too at times, it goes back to the time when she was 5 or 6, and
noticed how stressed her father can be because of her older siblings. And from then, she thought of herself not as a
child but more as an additional parent, a third parent of sorts. Who takes care of her siblings just as her parents do,
who doesnt acknowledge her own needs, for she doesn’t see herself in that role anymore. For she is also one of the
‘providers’ now) and as I was saying, we don’t get to make choices for ourselves even when we might be 40. So I am
not sure if there is a such a clear dichotomy ever in our society, between being an adult and a child. For instance, the
decision to abort a female child isn’t that of the fathers alone many a times. It also contains the contempt of the
father’s parents, which act as a catalyst. I wonder if we are ever truly separate from our parents in the sense as
mentioned above, being one’s own person, autonomous.
These days, when I do come across such fb statuses like “be yourself”, “ don’t give a damn about the world”, I feel
that isn’t true independence either that those people are talking about. Rather the manner in which they talk about
alienating themselves from the world, it seems to reveal that maybe at some point they cared deeply for the ‘world’
and were not cared back for, which is why they have this sort of an attitude, which unfortunately is glorified. We are
glorifying the suffering of such people by oscillating to the other extreme of their situation, which isn’t a solution at
all.

OFER: A CASE STUDY IN TIME-LIMITED PSYCHOTHERAPY

The following day Ofer called, and in a hesitant voice asked if I was Dr. Shefler. I heard his father in the background
saying, “Whenever he wants you to come, say yes. He’s very busy.” Ofer sounded embarrassed. He told me he
had heard about my session with his parents and he wanted to set up an appointment with me. I asked how urgent it
was and he answered that he did not want to delay it. I suggested an appointment two days later. He sounded hesitant
and repeated the date and hour over and over while he weighed it in his own mind. Then, he asked if there was
another possible time.

I asked what was wrong with the time I suggested. He explained that he had made plans with a friend and it would
be difficult for him to explain why he needed to cancel their plans. I suggested an alternate time and he accepted it
without hesitation. When I offered directions to my office, he responded, “I’ll find it myself.” (From this short
telephone call I could already identify two important issues: Ofer’s struggle for independence and his motivation for
treatment.)

Ofer arrived on time. In the doorway, I greeted a tall, attractive, broad, swarthy, muscular, modestly dressed
young man. I reached out to shake his hand and was amazed at his soft, sweaty touch and limp handshake. Before
we exchanged a word, I pondered the meaning of the contradiction between Ofer’s solid appearance and his soft
touch. (I thought: if it is so obvious, it must be essential.)

Presentation of the Central Issue. Indeed, the process of formulating the central issue is also confusing. In this case,
I selected a central issue focused on the dependence- independence conflict and the emotional experience of anxiety,
which causes Ofer to experience himself as weak and unconfident. At the same time, I made a conscious choice not
to focus on other aspects of Ofer, such as the struggle with his sexual identity and depressive features.

I presented the central issue to Ofer as follows:

Although you are a healthy, strong young man, throughout your whole life you have been preoccupied with the
question of whether you are allowed to be what you want to be. You are very uncertain, and every time you decide
to be yourself, you are filled with anxiety and doubt your abilities.

Ofer sank into the armchair, listened intently, wiped his face, cried a little, and thought. After a few minutes of
silence,( well that again I don’t see happening with my clients, it might be a cultural thing) he spoke:

OFER: I was afraid you’d say something else.

THER.: What did you think I would say?
OFER: That I need to understand that my father and Eyal just want what’s best for me. That they are more
experienced.
My father told me that whatever you say, it’s the truth. He also said that I would see he is right. Eyal has experience,
but my father has even more. They know what somebody like me needs and what’s right for me. That’s what they
said about you, that you know what I need.
THER.: Everyone else knows what you want and what you need. What about you? [This interpretation stems directly
from the central issue.]
OFER: I dream about what I want, but I don’t believe in it and I don’t share it with anyone. I do what I’m supposed to
do; that’s what they want from me. But it’s not really so far from what I want.
THER. (taking a directive role): You’re coming around the bend now. What do you really want?
OFER: (embarrassed): You’ll laugh at me. I don’t have an answer. As okay as I am, I don’t know the answer to such
a simple question.
THER.: Simple question? I told you before, I think it’s a central and frightening question for you.
OFER: How do you know these things?
THER.: I listen to you and feel what you are experiencing.

OFER: And what does that matter?

THER.: At the moment, what matters most is what’s happening to you, what you want.
OFER: I have a lot of stories like those ones. My whole life has been like that. But I don’t feel pathetic. ( can that be a
negation of sorts)
THER.: You’re not pathetic. You’re strong, virile, and you don’t know yet how to please yourself. ( maybe the
therapist wanted to come across as a supportive therapist and not focus on it as negation)
OFER: What can be done? ( clients do ask that)
THER.: In therapy, we’ll try to figure that out together, how you came to experience yourself so that you don’t
let yourself want anything without feeling comfortable about the fact of your wanting. We’ll focus the therapy
on that.

The Treatment Process: In Ofer’s imagination,as well as in the therapeutic reality, I was there for him and took him
seriously.

Ofer shared memories revolving around the same theme: He was not allowed to please himself; he could only
please others. At first, he spoke about his wishes enthusiastically. Then, he grew angry as he delved into the pain of
his unfulfilled wishes. Ofer was most interested in his relationship with Merav. He asked me about love, saying he
would listen to me but would decide alone. He tried to get close to her, but she didn’t want to be any closer. He felt
vulnerable and angry both with her and with me. He said that I misled him because talking did not help. He
discovered that not everything he wanted could happen, and returned to the idea that perhaps it was preferable not to
want anything for himself. That way he would avoid disappointment. Ofer continued thinking about what he wanted
from Merav. He realized that, like her, he was not ready for full sexual intimacy. Though he was embarrassed by this
realization, he was not ashamed to discuss it with me. He may have felt protected by the focus on his ability to please
rather than the hidden content behind that ability, such as his desires.

Ofer decided not to join any elite combat unit, and whatever would happen, so be it. He described a conversation
with his friend Yaniv, in which Yaniv remarked, “We’ve been together such a long time and now you’re leaving
me?” Ofer retreated and thought perhaps he would join an elite unit, but then realized he did not want to. He stood up
to Yaniv and said, “You want to be in the [elite] unit and that’s right for you. I don’t. It’s not right for me. Believe
me, it’s not. But we’re friends, and there are the weekends and after the army.” Yaniv replied, “If you’re afraid, I’m
with you. I’ll help you get over it.” Ofer answered, “I’m not afraid. I just don’t want to do it. If you want to be with
me, come with me to anti-aircraft.”

OFER: I’m used to coming here and I enjoy it. If I don’t come, it’s like I’ll get weaker.
THER.: Does the same thought come to mind when you think about what will happen after the therapy is over?
Is this reinforcement only temporary and when we finish therapy and separate, you’ll feel differently?
OFER: I can always continue coming, can’t I?
THER.: I know it’s hard to see yourself alone, without me.

Last Sessions. In the final sessions, Ofer appeared to have solved his problems. He had chosen a military framework.
He also found the appropriate distance to keep from Omri. That distance contained a level of closeness that was not
threatening and did not arouse suspicion, yet did not entail too great a distance from someone he loved. He realized
that even with Omri’s problems, he did not want to lose the friendship. Ofer discovered that not everything had a
definitive solution, but that there was a middle ground.

Toward the end, Ofer’s mood varied from session to session. He brought a booklet for me to one session, and in
another session he asked what I would buy him when he was drafted. He wondered what we had done in therapy
and suddenly paid attention to the cost. He was disappointed at having to pay for therapy, as if that made it less
genuine. A few minutes later, he stated that he did not know why, but he felt close and comfortable with me:

“You’re like a friend, but you’re not a friend; you’re like a father, but you’re not my father; you’re like Eyal,
but you’re not Eyal; you’re like Merav, but you’re not Merav.” ( just as it happened with me) I asked what it
meant for him that I was like everyone else, but not like anyone else. Ofer responded, “Maybe that I’m more
with myself. It’s clearer to me.”
I was pleased with his increased confidence, freedom of choice, and autonomous desires. He was planning and taking
action in all areas of his life. Ofer’s parting handshake was firm and strong.

Ofer said, “I think of you sometimes. When I don’t know what I want, I play a game: What would Gaby say?
And then my imagination starts working and whatever I imagine seems to be what I want. It’s getting easier, like we
spoke about in therapy.” ( just as I think I planned to do and still do at times, when my therapy ends)

Ofer then said, “I need to speak to you about something serious. Omri needs therapy. He’s having trouble. I
convinced him he needs therapy. I said I’d find him an excellent therapist, someone he can count on. He’s willing to
see you and I promised him I’d speak to you about it.” I was touched by the thought, but I did not think it was
appropriate or practical. Perhaps it was Ofer’s way of continuing therapy with me, through Omri. I answered, “I don’t
think that’s the best idea, for you or for Omri. It’s preferable that he see someone uninvolved, who will be just for
him.” Ofer responded, “Maybe you’re right. And that way, you stay mine.”

SUMMARY: Clearly, there are other important issues that were not addressed in the therapy, such as the conflict
between activity and passivity, the question of sexual identity, Ofer’s competitive relationships with other men,
and the narcissistic features in his personality. These selective neglects can frustrate the therapist and sometimes
the patient. That is the price of choosing a focus. In contrast to the therapeutic costs, Ofer’s more organized
and positive self-concept were invaluable gains for him.

Adolescents, however, tend to react more impulsively to frustration or disappointment, and the resistance
to treatment is more likely to transform into a sudden dropout, whether expected or not. Therefore, the literature
emphasizes that therapy with adolescents focuses more heavily on the conscious and preconscious realms.6 Thus,
confrontation and clarification techniques are used more frequently than interpretation,
as illustrated in the treatment of Ofer.

The feeling that the primary responsibility falls on the patient is often construed as threatening and oppressive
regardless of the actual content of the therapy.

One can notice easily how calm and trustful Ofer became when he noticed he was being guided by the central issue of
his treatment.

The limited nature of short-term therapies prevents the adolescent from feeling frightened. Even if the therapeutic
task is partial, it is more likely to conclude with a feeling of success than of failure.

There are many manifestations of successful shortterm therapy outcome. They include significant lessening, whether
conscious or not, of the emotional burden or distress that led to the referral; symptomatic relief; or the sense of
freedom of choice, either internally or externally. Success might also be a later decision to continue or to return for
additional therapy, whether short-term and focused or longer and more encompassing. Winnicott37 claims that
“growing up means taking the parents’ place. It really does” (p. 164). In order to avoid false maturation, time and
support should be given to the adolescent in supporting him or her to achieve real maturation.