International Journal of Intensive Short-Term Dynamic Psychotherapy

Int. J. Short-Term Psychother. 1, 59–82 (1986)

DOI: 10.1002/sho.161

Beyond Interpretation: Initial

Evaluation and Technique in
Short-Term Dynamic
Psychotherapy. Part I
DAVID MALAN
Parker’s Close, Hartley Wintney, Hampshire RG27 8JG, England

The present article begins by describing the two basic questions in Short-Term Dynamic
Psychotherpy, namely what are the techniques that maximize success, and how may suitable patients be
recognized? A consideration of work at the Tavistock Clinic leads to the conclusion that purely interpreta-
tive techniques, whether of short- or long-term therapy, are inadequate. In the author’s view, Davanloo
has developed a technique that largely overcomes these limitations. This is illustrated by an initial
interview of great length and complexity, which therefore needs to be divided into two parts. The second
part follows. At the end of the second part the practical and theoretical consequences of Davanloo’s work
will be considered.

Introduction

The Theoretical and Practical Problems

‘‘If such results could be achieved—even exceptionally—in two interviews, how
could an analyst know that he did not overlook such a possibility in a large number of
cases? This case was the beginning of our decision to undertake a systematic study
into the possibilities of briefer, not superficial and merely supportive, but deeply
penetrating treatment.’’
This is Franz Alexander describing how he came to found the work of the
Chicago school on Short-Term Dynamic Psychotherapy. The patient to whom he
was referring, a scientist aged 51, was cured of his severe depressive attacks in two
sessions. Alexander brought him to the realization of his intense guilt-laden competi-
tiveness with his current colleagues, and traced this to its origins in the relation with
his father and brother in his early life. Follow-up was eight years.
In the following quotations from Alexander’s discussion of this case, I have
picked out in italics his reference to certain issues which will play a large part in the
present article (see Alexander and French, 1946, pp. 146ff):
‘‘All this proves that in psychotherapy there remains an imponderable factor, which
has to be left to intuition or else to luck . . . In this instance it may have been luck. It is
our premise, however, that luck can be replaced by a methodical procedure. . . . .
We can make an appraisal of the patient’s problem in psychodynamic terms and plan
our tactics accordingly. The technique of planned therapy is an attempt to replace
chance with prediction based on valid dynamic principles . . .’’

Copyright  1986 John Wiley & Sons, Ltd.

60 David Malan

He concludes: ‘‘Our task, our challenge, therefore, is to discover just in what

cases is such intensive therapy possible, and to establish the techniques necessary to
bring about beneficent results.’’

I do not know what Alexander would have felt about being compared to Beetho-
ven, but—as has been said of Beethoven’s last quartets—these passages from Alex-
ander, published in 1946, remain ‘‘always contemporary.’’ They describe in the
clearest possible terms the main issues facing any investigator of Short-Term Dy-
namic Psychotherapy.
It seems that many investigators have started from this same point: the observa-
tion that there are certain patients who receive a crucial piece of emotional insight in
a few sessions and obtain immediate relief from the problems that brought them to
therapy. This observation led to the work of the Chicago school under the leadership
of Alexander, as described above; it led to that of Sifneos (see Chapter 1 of his 1972
book Short-Term Psychotherapy and Emotional Crisis); and it figured very promi-
nently in the preliminary discussions of Balint’s team at the Tavistock Clinic in 1955
(see Malan, 1976, p. 349).
The similarities do not end there. The obvious questions that the investigator
now asks are, first, how these patients may be found, and second, what proportion of
the psychotherapeutic population they represent. Unfortunately, the answers are
almost always the same: these sporadic cases are drawn from a very large population
and are noticed because they are so striking; but anyone who begins systematically
looking for them cannot find them because they are so rare. However, during the
course of the investigation a crucial and much more favorable observation emerges,
which requires a digression if its full significance is to be understood.
If Alexander’s account of the above therapy is examined carefully, then it seems
that the therapist used certain elements of the technique of interpretative psycho-
therapy and not others. That is, he interpreted the patient’s denial (defence) of his
guilt-laden competitiveness (anxiety and impulse)—the ‘‘triangle of conflict’’—and
he made the link between this pattern in relation to current people and people in the
past—two corners of the ‘‘triangle of person’’—but it seems he did not need to make
any mention of the third corner of this second triangle, namely the transference.
Moreover, the patient showed very little resistance and responded immediately when
his defences were interpreted. In fact there are two other case histories in the same
chapter with exactly similar characteristics.
We are now in a position to describe the crucial observation mentioned above.
This is that any well trained investigator in this field soon gets drawn into using the
full range of techniques of interpretative psychotherapy, that is, the working through
of resistance and the completion of both triangles, including interpretation of the
transference and making the link between the transference and the past. He now
discovers that this makes his therapy far more powerful, more reliable, and more
widely applicable. The most striking example described by the Chicago school (see
Alexander and French, 1946, pp. 293–299) was the case of a young man of 19
complaining of severe depression, whose mother had died in a terrible accident when
he was three. He showed the greatest resistance against remembering anything about
her whatsoever, let alone any feelings; but he recovered from his depression after
re-living overwhelming feelings of love and grief for her through his relation with his
woman therapist.

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 Beyond Interpretation 61

This was an exceptionally dramatic case; but others less dramatic yet still very
striking, in which deep-seated and enduring changes result from using the full range
of interpretative techniques, have been observed by many workers in this field. By
this means the range of patients suitable for Short-Term Dynamic Psychotherapy—
for which I shall use the abbreviation STDP—is considerably widened. Up to 40
sessions may be required in the most difficult cases, but it is something of an
understatement to say that this is still more economical than a full-scale analysis.
There lies embedded in these case histories a profound theoretical problem that
is crucial to the whole issue to STDP and can be formulated as follows: Our technique
is powerful enough to enable us to recognize the problems underlying a patient’s
presenting complaints and to bring these conflicts into the open; but why is it that in
some favorable cases this results in unlocking the whole neurotic process, while in
some it fails to do so? What is the difference between the two? Or, even if we do not
know the difference theoretically, are there empirical signs by which we can tell the
difference practically? If so, what proportion of the psychotherapeutic population do
these favorable cases represent?

Selection and Technique: The Tavistock System

The Tavistock school has addressed itself to these questions for many years and
has arrived at partial answers. These are expressed in the following selection process:

(1) Patients who are obviously unsuitable, in whom uncovering psychotherapy

would be dangerous, are eliminated by taking a careful psychiatric history.
(2) This shades into, or is followed by, a comprehensive psychodynamic history.
(3) Provided there are no contraindications, the psychodynamic history is ac-
companied by trial therapy, in the form of carefully chosen interpretations.
(4) The patient’s response to interpretation is monitored.

The most suitable patients are then those who show the following characteristics,
which constitute the selection criteria:

(1) There are no contraindications.

(2) The evaluator is able to make a comprehensive psychodynamic formulation.
(3) This formulation reveals an underlying simplicity in terms of a clear-cut
central theme running through the patient’s life—his ‘‘life problem.’’
(4) The patient has responded positively to interpretations on this theme. That is
he has given responses that confirm them, he has shown the capacity to work with
them without becoming unduly disturbed, and his motivation to work with them has
either been high from the beginning or has shown a marked increase.

The therapeutic process now consists of using this central theme or life problem
as the focus of a planned therapy: directing interpretations towards this problem
wherever possible, and using the full range of interpretative techniques, including
transference interpretations and the link with the past.
I believe that most of these principles are fundamental to short-term interpreta-
tive therapy and are therefore applicable to other schools as well. Indeed, all of them
were already formulated, at least implicitly, by Alexander and French in the 1940s.

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62 David Malan

The Tavistock System: The Question of Effectiveness

The crucial question, of course, is how effective are such systems, both qualita-
tively in terms of therapeutic results, and quantitatively in terms of the proportion of
patients with whom they are successful? Here, once more, I shall describe the
Tavistock conclusions.
Qualitatively speaking, the best results seem to involve nothing less than the
permanent and total resolution of the patient’s neurosis. If this seems a large claim,
then all I can say is that in certain patients no trace of the original disturbances could
be found in a follow-up interview up to seven or eight years since termination. In
other patients, though a small residue of problems could be detected, it was clear that
true resolution of a major part of the central problem had taken place. In these cases
selection and technique were clearly powerful and effective.
Thus this systematic work on a fairly large sample of patients—60 patients
treated, 48 followed up—demonstrated something of immense importance, namely
the feasibility of producing deep-seated and permanent changes with a technique of
STDP that, by employing all the possible components of interpretative psychother-
apy, shirked nothing and went to the heart of the patient’s problems.
What about quantitative considerations? Here, unfortunately, the picture is
much less favorable. There are two questions: (1) What proportion of patients
referred to us are selected for short-term therapy, and (2) What proportion of these
give ‘‘total’’ or ‘‘near-total’’ resolution, i.e., how accurate is the selection process?
The answers to these two questions are: (1) that no more than a few percent of
patients referred to us are selected, and (2) that of these about a quarter give the
major therapeutic results desired. If we refer back to patients of the type described at
the beginning of the present article, who can hardly be found at all, then this factor of
a quarter is obviously a great improvement. On the other hand, the situation could
also be described more pessimistically, by saying that only a very small proportion of
patients is considered suitable, and of these another relatively small proportion is
actually suitable.
We can therefore reformulate both the theoretical and the practical problems as
follows: We are sure that therapeutic effects follow from strong dynamic interaction
between therapist and patient—interpretation and response, the transference expe-
rience and its link with the past—and at initial interview we have no difficulty
whatsoever in selecting patients who will interact in this way; we believe that those
who give favorable therapeutic results will come from amongst patients with this
capacity, i.e., that this is a necessary condition; but it is not a sufficient condition, and
the problem of telling the favorable from the unfavorable patients at the beginning
remains unsolved. There is a major gap between dynamic interaction on the one
hand, and resolution of the neurosis on the other.
These two points taken together—the small proportion selected and the rela-
tively small proportion of these who recover—mean that we are facing something
like the ‘‘second order of small quantities,’’ which in mathematics is often considered
as equivalent to zero. In other words we are almost back to where we started: It is
true that we have made an observation of great theoretical significance; and we are
now able to use short-term methods in practice to transform the lives of a few
fortunate individuals; but we have not fulfilled our fundamental aims, which cannot
consist of anything less than significantly reducing the over-all burden of neurotic
suffering—or, if this should seem to be an over-inflated ambition—at least signifi-
cantly easing the pressure on busy psychotherapeutic clinics.

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 Beyond Interpretation 63

Long-Term Therapy
Of course long-term therapy is in a basically similar position. Here we can also
describe the situation at the Tavistock. A higher proportion of those referred to us
are regarded as suitable for long-term than for short-term individual therapy; but this
is balanced by the fact that vacancies immediately become blocked by these very
patients, so that for the vast majority individual therapy is simply not available. And
again, in a recent follow-up study (not yet published), of 84 patients who had
received more than 40 and up to 900 sessions, only about a fifth showed major
resolution. Moreover, as yet we have no inkling of how to distinguish between this
fifth and the other four-fifths in whom these changes do not occur. To echo Alexan-
der, it seems to be a matter of luck.

The Relation between Improvement and Response to Interpretation

Once more we can formulate the problem, now covering the whole of interpreta-
tive psychotherapy, in terms of the following paradoxical situation:
The theory of the origin of neurosis in unconscious conflict—whatever the
skeptics may say—is as firmly established as most scientific theories can be; this has
led to a highly refined technique of interpretative therapy, the principles of which are
equally well established and understood; and this technique is used with confidence
and skill in our day-to-day contact with patients. Our patients can then be described
on a continuum: At one end are those highly resistant patients who never respond
with anything but purely intellectual insight, and of course no one is surprised when
these show no improvements; at the other end are those relatively rare individuals
who not only respond but achieve deep emotional insight and recover; but in the
middle are the great majority, who respond almost daily to our interpretations,
apparently achieving emotional insight, but failing to show the therapeutic effects
that we are seeking. What then had happened to one of the central tenets of dynamic
psychotherapy, that when the unconscious conflict is brought into the open, experi-
enced, and worked through, the neurosis is resolved—‘‘where id was, ego shall be?’’
Traditional psychotherapists have no answer to this theoretical question; and the
only solution that they know to the practical issue is to go on as before, making daily
interpretations, trusting to luck, and keeping alive the hope that eventually this
process will lead to the desired therapeutic effects—which indeed it sometimes does,
but as our follow-up studies have shown, all too seldom.

Purely Interpretative Psychotherapy: Summing Up

The only possible conclusions are, first, that purely interpretative therapy,
whether long-term or short-term, has been carried to the limit and has been found
inadequate; and second, that unless we are prepared to accept this fatalistically, then
we need some more powerful kinds of intervention which can be used over and above
interpretation. This leads us back to the title of the present article, ‘‘Beyond interpre-
tation,’’ because it is this that I believe to be Davanloo’s most important discovery.

Davanloo’s Technique: Overview

What are these interventions? First of all, it needs to be emphasized that they do
not replace interpretation but are used before interpretation. The central interven-

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64 David Malan

tion is systematic challenge to the resistance, but this needs to be considered in the
context of the whole process of interaction between therapist and patient, in which it
is possible to distinguish the following phases:

(1) Systematic pressure on the patient to experience his true feelings.

(2) An inevitable rise in resistance, which appears in the form of a series of
defences.
(3) Systematic challenge to each defence the moment it appears.
(4) An inevitable rise in transference feelings, which the patient does not wish to
experience or show, and which therefore lead to a further increase in resistance.
(5) Systematic challenge to the resistance, now in the transference, leading
eventually to
(6) Direct experience of the transference feelings.
(7) This has profound effects. The patient experiences great relief, his uncon-
scious becomes unlocked, and there is a major mobilization of his therapeutic
alliance.
(8) As a result:
(a) it is now possible for the first time to begin to make use of
interpretations;
(b) it is also possible to begin to explore relationships outside the transfer-
ence, both current and past, in a meaningful way;
(c) the patient may begin to make his own interpretations.
(9) Thus in phase (8) the technique begins to become much more like that of
interpretative therapy. However, as each new area is explored, there is often a return
of resistance, so that the cycle begins again at phase (3) with further challenge.
(10) The exploration that has been carried out in phase (8)(b) now enables the
therapist to introduce a new element, namely interpretations linking the resistance in
the transference with defence against feeling in other relationships (transference-
current-past or TCP interpretations).
(11) This cycle, which may have to be repeated many times, eventually leads to
the phase of pure ‘‘content,’’ in which the patient’s conflicts in other relationships can
be explored and interpreted without reference to the transference.

Davanloo makes the principle of trial therapy, mentioned above, more central to
his selection process than any other worker in this field, and therefore an initial
interview can be used to illustrate both of the twin issues of selection and technique
with which the present article is concerned. (For further reading see Davanloo, 1978
and 1980.)

Davanloo’s System of STDP: Technique and Selection Illustrated by an

Initial Interview

The Case of the Man from Southampton

The evaluator deliberately keeps himself ignorant of all details of the patient, the
aim of which is that everything should come out in a dynamic fashion for both
participants in the interview. The patient may be psychoneurotic, but equally he may
be ‘‘borderline’’ or may suffer from an even more serious condition such as schizo-
phrenia or manic-depressive psychosis. The evaluator watches with the utmost

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 Beyond Interpretation 65

vigilance and may receive clues about these conditions early in the interview, or
indeed the moment the patient walks into the room. In this case he will start from the
beginning with an entirely different technique. Otherwise he begins trial therapy in
the form of exerting pressure at once, but he watches for signs that the patient is
becoming unduly disturbed by this and he then immediately becomes less
confronting.
The opening phases of the interview may follow a number of different patterns
according to how accessible the patient’s feelings are, how resistant he is, and what
he feels about the situation in which he finds himself. This particular patient, a man
of 47, shows one of these typical patterns: he has had many years of previous
psychotherapy which had achieved little more than a consolidation and ossification
of his defences, as is evident from the very first moment of the interview. With such a
patient the two initial phases described above become telescoped. Also, because of
repetition and overlapping, the later phases are more complex than in the above
scheme, so that it is better not to number them.
From now on I shall refer to the evaluator by the less unwieldy term ‘‘therapist,’’
which of course is entirely accurate in an interview of this kind.

The Phase of Enquiry, Pressure, Resistance

TH: Could we start to see what is the nature of the difficulties that you have and you
want to get help for them?
PT: (sigh)
TH: What are the problems?
PT: I don’t know, it’s been a long time that I’ve been seeing doctors and in all that
time I don’t know that I would be able to identify the problem. . . .
TH: What is it that bothers you, the difficulties that you have?
PT: Well a lot of anxiety relating I think during the past year or so with the therapist
that I was seeing. I guess I became aware that I was feeling very guilty about
many things such as my sex life. Very guilty about my relationship with my wife
and my father, my family. I’ve left my family in England by coming here to
Canada and I haven’t had much communication with them and I haven’t been
happy about it. I haven’t been happy about . . . about my situation in life. I’ve
spent too much time working.

The whole atmosphere conveyed by this passage is of vagueness, lack of specific-

ity, skating over the surface, and flitting from one subject to another. Thus he
mentioned ‘‘anxiety’’ which apparently has some connection with guilt, but he does
not make clear what the connection is. He then speaks of guilt in a number of
different areas but in only one of them does he say what the guilt is about—namely
lack of communication with his family. The statement, ‘‘I haven’t been happy about
my situation in life’’ is hardly very informative. Finally, ‘‘I have spent too much time
working’’ may perhaps imply that he feels guilty about neglecting his personal
relationships, but he does not say so and leaves the listener to make his own
inference.
This is a point at which the interpretative technique and that of Davanloo show a
crucial divergence. In the interpretative technique the therapist might make the
above inference about neglecting personal relationships and help the patient out by

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66 David Malan

putting it to him in the form of a clarifying interpretation. If he received a positive

response he might go on to ask a question of the patient’s unconscious: ‘‘why should
you need to neglect your personal relationships?’’
There is no doubt that this approach would probably produce a drop in tension
and some useful dynamic information, but it entirely neglects the patient’s basic
position of resistance. Unless this can be brought into the open and resolved no true
unlocking of the patient’s unconscious will ensue.
Therefore the therapist carefully does not help out in this way; and since the
patient is showing so much resistance against even making clear the nature of his
difficulties, the therapist continues to put pressure on him to do exactly that, with the
aim of bringing the resistance more and more into the open.
In response there is further vagueness and then a moment of greater specificity:

PT: I started seeing a doctor for therapy a long time ago, about 20 years ago and uh
. . . I have seen doctors on and off since. Always for the reason that there seems
to be something wrong, things seem not to be going well. I seem to be very
worried and uh . . . Of course I would uh . . . I have suffered from a very severe
outburst of temper occasionally.

The therapist now increases the pressure by deliberately bringing in a stronger

word than ‘‘temper’’:

TH: Outburst of anger you mean?

PT: Yes.

This, however, did not seem to be the reason why the patient is now seeking
treatment. He returned to the word ‘‘anxiety’’ and the therapist now employed
a standard question which constitutes the next stage in the process of pressure.
The ultimate aim of all dynamic psychotherapy is that the patient should ex-
perience to the full the true feelings against which he has been defending himself
because they are loaded with anxiety or pain. In this phase of the interview,
therefore, the therapist deliberately exerts pressure towards the experience of
feeling. If the patient mentions some situation about which he has, or ought to
have, feelings, this pressure takes the form of asking ‘‘What do you (or did you)
feel about that?’’ If the patient mentions a feeling, the next question is ‘‘What
is it like when you feel. . .?’’ or ‘‘How do you experience. . .’’ whatever it is
that he has mentioned.
With highly responsive patients—who, as described above, are extremely rare—
this may lead to the actual experience of feeling and to therapeutic effects, and if
so well and good. Far more often, however, the patient’s unconscious becomes
alarmed, and the result is an increase of resistance. Thus, as the pressure is kept up,
the resistance comes more and more into the open, where it can be dealt with. In the
case of a patient such as the present this increase in resistance was inevitable. What
happened was that, in response to the word ‘‘anxiety,’’ the therapist asked, ‘‘What is
it like when you feel anxiety?’’ to which the patient said that he used the word
because that was the label given to him by his therapist. Intellectualization and
distancing could hardly be carried further.
The therapist kept up his probing and in the teeth of this kind of resistance
eventually managed to get clear that the patient suffers from long-standing problems

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 Beyond Interpretation 67

in his personal relations. The patient made the vague and general remark, ‘‘With
women I have a lot of problems,’’ so the therapist kept up the pressure on this
defence by asking him to give a specific example, but he was unable to do so. He
would only say that he ‘‘hides away.’’
During the course of this probing some factual information emerged: the pa-
tient has been married for 21 years, has been separated from his wife for the past two
years, and for the past few months has been living with another woman. He said that
he feels more comfortable with her and that sexual relations are better than with his
wife though he still feels some guilt.
It is worth noting that in the following passage the therapist carefully does not
ask ‘‘What do you feel guilty about?’’ which would be only too likely to lead to further
intellectualization. Instead he concentrates on trying to explore the actual experience
of guilt. The patient first gives an answer which does little more than paraphrase the
statement of guilt (‘‘I felt I should not be doing what I do’’); and then, when the
therapist persists, the patient’s unconscious becomes alarmed, and he falls back on
using the same defence as he had used for ‘‘anxiety’’—so that the interview is clearly
going round in circles:

PT: I still feel somewhat guilty about it but. . . .

TH: What is that you refer to as guilt when you say. . . .?
PT: Well I have always felt that I should not be doing what I do.
TH: Hmm. What happens to you after sex that you refer to as guilt?
PT: I refer to it as guilt because this is what it’s been labelled by, by therapists
previously.

The Phase of Challenge to the Resistance

The therapist has been waiting for this point, where the resistance has become so
manifest and so apparently immovable, and the next phase of the interview begins.
This may be described as follows:
The resistance is made up of individual defences, some of long standing such as
the distancing and intellectualization already mentioned, and some more ‘‘tactical,’’
designed at any given moment to keep feelings away or to divert the therapist’s
attention from sensitive areas.
The therapist now brings in a new kind of intervention, namely challenge to each
new defence as it arises, which become more and more powerful in step with the
increase in resistance.
These challenges lie far from the traditional interpretative technique and require
considerable discussion. They range from simply pointing out the patient’s defence,
through forcing the patient to make up his mind, challenging questions, the use of
deliberate irony, to using almost scathing language. The following are examples:

(1) The patient is distancing himself from his feelings by using the phrase ‘‘I
suppose’’;
TH: But you say ‘‘you suppose.’’
(2) The patient keeps his statement tentative:
TH: Was it satisfactory or wasn’t it?
(3) The patient makes out he cannot remember:
TH: How is your memory usually?

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68 David Malan

(4) The patient says ‘‘he thinks’’ his sex life was not satistactory:
TH: You think? You are not sure?
(5) The patient has been keeping everything vague:
TH: You constantly want to keep things in a state of limbo.

It is very important to describe the tone of these challenges, which is not

adequately conveyed by the written word alone. Though the words themselves may
sometimes seem harsh, the tone is always both firm and gentle—the ‘‘iron hand in the
velvet glove.’’ The challenges are directed not against the patient but against his
defences, in such a way as to make them feel useless and counterproductive. This has
two opposite effects: the part of the patient that is identified with them wishes more
and more desperately to cling onto them; while beneath this another part begins to
turn against them and to wish to be freed from them. The therapist reinforces the
latter by always putting his challenges in such a way as to convey that he is entirely on
the patient’s side: that his only aim is to enable the patient to feel the full range of his
emotions, to become free of his suffering, and to achieve his potential; and that he
will stop at nothing to enable the patient to reach this point—certainly he will not
spare him pain, but this pain will be far more bearable than the patient fears, and in
the end will be wholly beneficial. When patients speak about their feelings at
follow-up, this is the message that they remember. They do not feel that the therapist
has been in any way aggressive.
Side by side with these two opposite feelings about the defences, there arise two
opposite feelings about the therapist. In other words there is a rapid and intense rise
in transference, against which the patient defends himself in turn, which leads to a
further increase in resistance. This will be discussed more fully later, but for the time
being it is crucial for the therapist to realize that throughout the phase of challenge
the mounting resistance begins to have an increasingly important transference
component.
We may now take up the interview where we left off. The therapist opens by
confronting the patient with his vagueness and distancing:

TH: Now could we then clarify a few things, because I wonder if you notice you
generalize issues or difficulties that you have? You generalize it and somehow
also you remain vague. You see, for example, you say sexual difficulties or you
say you are not able to initiate, or you say you feel guilty, okay? These are all
labels, they are vague and we don’t understand what really you mean by any of
these issues. Do you notice that?
PT: Yes except that I don’t know how to say what I’m trying to say.

The patient went on to speak further about his marriage, in which there had been
problems of very long standing. However, he remained vague and repeatedly used
phrases such as ‘‘I guess,’’ ‘‘I don’t know,’’ and ‘‘maybe.’’ Phrases such as these are
very easily overlooked as just a manner of speaking, but in fact they are used by many
patients as tactical defences designed to distance them from any feeling they may be
describing. ‘‘Maybe I feel so-and-so’’ converts a declaration of feeling into a hypo-
thetical idea.
The therapist now decides to heighten the tension by enquiring for further detail
in the area of sexuality. In this passage the patient’s tactical defences are very much in
evidence. They are put in quotation marks to draw attention to them:

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 Beyond Interpretation 69

TH: How was sexual life before marriage?

PT: Well looking back ‘‘I don’t think’’ it was very good although for me at the time it
was good.

The therapist handles this defence by deliberate irony:

TH: You say ‘‘you think.’’ You mean you are not sure?
PT: ‘‘I don’t think’’ it was very different from what it was after.

The therapist responds by demanding greater specificity:

TH: Hmm. Now what was it like?

PT: For me it was exciting and ‘‘I suppose’’ it was more or less satisfactory.

Here the therapist simply draws attention to the defence:

TH: But you say ‘‘suppose.’’

PT: Well otherwise I would not have wanted to. . . .

The distancing in this remark is achieved by making it into an intellectual

inference, so that the patient keeps himself at one remove from the situation he is
describing. The therapist responds by demanding a direct statement:

TH: Was it satisfactory or wasn’t it?

PT: ‘‘I guess’’ not.
TH: But you say you ‘‘guess.’’

Finding that every verbal defence is challenged the patient falls back on silence.
Thus his resistance has become intensified, and the therapist immediately responds
by escalating the tension with stronger challenge:

TH: Do you notice you want to leave things in the state of limbo? ‘‘You know,’’
‘‘guess,’’ ‘‘perhaps,’’ hmm? Is it like that always?

At this point the patient gives an involuntary smile, which may be used to
introduce an important discussion.
In this technique the therapist is conducting a dialogue as much with the patient’s
unconscious as with his conscious. He therefore must exert the utmost vigilance in
detecting and responding appropriately to anything that the patient’s unconscious is
revealing. Often this may take the form of nonverbal communications, of which
involuntary smiles are an important example. These smiles are complex and usually
contain a mixture of components, serving both defensive and expressive functions.
In the present case the patient’s smile probably has the following components: (1) a
recognition of one of his long-standing patterns, (2) the communication that some
feeling, probably anger, has been touched off in him by the therapist’s repeated
challenge, and (3) a way of covering this anger at the same time as revealing it.
Thus, by means of his smile, the patient’s unconscious is informing the therapist
both that the defences are beginning to be loosened, and that the next phase of the
process, namely a rise in transference feelings, has begun. Much further work must

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be done before this can be brought into the open, but what the therapist must do
immediately is to draw attention to the smile. This has the effect of telling the
patient’s unconscious that it is betraying feelings that he is trying to conceal, which
heightens the tension further.

TH: You smile when I said that. Hmm? Do you notice that you repeatedly use ‘‘I
guess,’’ ‘‘maybe?’’
PT: Yes.
TH: Is this only here or is this always in every issue, that you are uncertain
about. . . .?
PT: That’s typical, yes.

The therapist is content with this for the time being and returns to enquiry.
Although there is still much resistance, the loosening of defences eventually leads
into the crucial area of violence. The patient said that he never felt close to his wife
and was very often impotent. He described his wife as a bad housekeeper, which, he
said, frustrated him. This word ‘‘frustrated’’ is often used as a way of watering down
anger or rage. His response to his wife was to become detached, withdrawn, and
depressed. After much probing he eventually admitted that he had episodes of anger
towards her, with a great deal of lashing out; and he described an incident in which
she had struck him with a chair.
The therapist wishes to get a picture of the degree of physical danger in this kind
of situation. This is part of the psychiatric enquiry:

TH: Where, struck you where? On your head you mean?

PT: She tried to hit my head.
TH: And then.
PT: I deflected the blow with my arm and she threw the television to the floor, a large
portable, she threw it to the floor and broke it.
TH: And then?
PT: So she expressed her anger much more violently than I did mine. She always
did.

The patient said that as far as actual physical acts were concerned he went no
further than slapping her face. However, under pressure, he got as far as saying that
on occasions, ‘‘I said to myself, ‘I will kill you.’ ’’

TH: So far then what you describe is there has been this lashing back and forth
between you and your wife and then your wife has been physical and then there
have been occasions that you have slapped your wife, and there have been
occasions that you have felt intense rage, but you have held on to your intense
rage with your wife. Does this occur with any other relationship, with any other
person, colleagues, friends, any other situation?
PT: It has occurred but not in recent years.
TH: When?
PT: It occurred in a store I remember. In a store downtown. I don’t remember the
details but I was ‘‘frustrated’’ by the clerk in the store. I went so angry so quickly
I . . . I was holding an umbrella and I smashed the umbrella on the counter.

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 Beyond Interpretation 71

TH: You mean actually you did it?

PT: Yes.
TH: You must have been very angry then?
PT: Yes.

The therapist now attempts to undo the obvious displacement of the impulse
from a person to a thing, which results in two phenomena already described,
namely distancing accompanied by an involuntary smile:

TH: Did you feel that you wanted to smash it on his head?
PT: I guess so.
TH: But you say ‘‘you guess.’’ You smile when you. . . .

The patient is thoroughly alarmed by having his violence against a person

brought into the open. He quickly interrupts and falls back on a new defence, loss of
memory, which is forcefully challenged:

PT: Because I don’t remember distinctly that I . . .

TH: How is your memory usually?
PT: Not very good.
TH: Your memory is not good. Hmm. What work do you do?
PT: I’m in public relations.
TH: You mean you have problems with your memory in your work in public
relations?
PT: I guess my memory regarding my personal life is not very good.
TH: My question was, do you have problems with your memory in your professional
life?
PT: No.
TH: No. So then your memory is good, otherwise you would have difficulty in your
work in public relations.
PT: Well I don’t have difficulty with day-to-day or current . . .
TH: But when it comes to your personal life you find. . . .
PT: Recalling matters with my personal life, I have much more difficulty.

Having thus brought home to the patient that his loss of memory is a defensive
move against feelings in personal relations, the therapist returned to further enquiry.
It emerged that the patient has two sons, aged 18 and 16. His wife (from whom, it will
be remembered, he is separated) had a great many problems with their eldest son and
wants to put him out of her home. The patient wants to bring him into his own home.
He described his relation with his sons as ‘‘polite and civilized’’ and he admitted that
he was unable to get emotionally close to them.
This is a moment of great importance and considerable complexity. In order to
understand the issue involved we need to return to the discussion of the effects of the
therapist’s repeated challenges, which was begun at the opening of the previous
section.
It was stated there that these challenges have two opposite effects on the
patient’s attitude to his defences, namely to wish to cling on to them, while under-
neath there is a wish to be freed from them. At the same time the patient is

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72 David Malan

responding in two opposite ways to the therapist himself. On the one hand, he
becomes more and more angry at not being allowed to use his customary defences;
while underneath this he is responding with many positive feeling—warmth, love,
and sadness—to the caring expressed in the therapist’s efforts to establish emotional
contact with him and make him free. These are realistic, direct responses, and as such
cannot be described as ‘‘transference;’’ but since the conflict between anger and love
lies at the heart of most human neuroses, the patient’s feelings for the therapist
immediately link with all his important past relationships, and thus they become
overwhelmingly ‘‘transference’’ in nature.
The patient now redoubles his efforts to keep these transference feelings at
bay—the negative feelings for fear of rejection or loss of control, and the positive
feelings because in the past closeness has been associated with disappointment—and
thus his resistance steadily increases. The therapist watches for signs both that the
resistance is now in the transference, and that the tension between defences and
underlying feelings has reached a certain pitch. These signs are often nonverbal, e.g.,
the patient may sit more and more immobile, grip the arms of the chair, clench his
fists, or carefully avoid the therapist’s eyes. The therapist then directs all his efforts
towards bringing the underlying transference feelings into the open. The procedure
is usually to break in and ask the patient how he feels at the present moment, and
then to challenge the ensuing series of defences in the same way as before. Almost
invariably it is the anger that needs to be dealt with first. Thus the next and most
crucial phase of the interview begins.

The Phase of Challenge to the Resistance in the Transference

The therapist makes use of the opportunity provided by mention of the patient’s
lack of emotional contact with his children, which of course parallels the transference
situation:

TH: You find a barrier between yourself and your children?

The patient begins an intellectualized answer which the therapist interrupts, thus
deliberately interfering with the patient’s defensive thought process:

PT: Yes, as a child matures, I guess, becomes more. . . .

TH: Is this with other people as well?
PT: I think so, I’ve always. . . .
TH: But you say you think so.
PT: I have always. . . .

The therapist now opens up the issue of transference:

TH: Let me to question you: how do you feel when I repeatedly bring to your
attention about this keeping things in the state of limbo? Do you see what I
mean?

During the following passage several important issues need to be borne in mind.
The therapist has said a number of things that are likely to have made the patient

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 Beyond Interpretation 73

annoyed, but on the face of it nothing to make him intensely or violently angry.
However, such a judgment ignores three factors: first, the therapist is forcing the
patient towards experiencing his lifelong pain; second, we know from information
already given (the relation with his wife, and the man in the store) that the patient’s
anger is potentially extreme and physically violent; and third, we may infer with
some confidence that it has its roots in immense unexpressed anger aroused in the
distant past, i.e., that it is ‘‘transference’’ in the true sense of the word; and thus,
although it possesses the ‘‘as if’’ quality of all transference feelings, it is right to
regard it as of great intensity. Therefore the therapist knows the degree of defensive-
ness contained in such words as ‘‘frustrated’’ or ‘‘a little annoyed,’’ and, armed with
this knowledge, he has the confidence to challenge everything the patient says short
of acknowledging the true quality of what he is feeling.
Now taking up the interview where we left off:

TH: . . . . Do you see what I mean?

PT: Yes, I’m, I’m (laughs), I feel ‘‘a little annoyance’’ at it but then I realize
that. . . .

The therapist draws attention to the laugh and follows with the standard ques-
tion directing the patient towards his actual experience:

TH: But you say you feel annoyance with me and then at the same time you smile.
You notice that, huh? What is it like when you feel annoyed with me?

The patient first gives a watered down description of anger and then quickly
moves away to many descriptions of the physical manifestations, not of anger, but of
anxiety:

PT: Well I’ve been sitting here very ‘‘frustrated.’’ I’m sweating, you know. I’m
sweating and getting very uncomfortable. I can’t even talk to you very comforta-
bly and very relaxed about things.
TH: But when you say you don’t feel comfortable, what is the way you experience
this here with me?
PT: I smoke, I don’t know what to do with my hands, I’m sweating.
TH: Hmm. So one is sweating, one is fidgeting. What else do you experience? You
said annoyed.

The patient begins to reveal his inner tension by taking deep breaths, but
continues with a remark that contains the defences of distancing, intellectualization,
and passivity:

PT: I guess I experience a feeling of inferiority because I feel that you (sigh) . . .

The therapist draws attention to the nonverbal cues:

TH: And you frequently take a deep sigh, isn’t that? You smile again. Now let’s
look to your annoyance. You said you feel annoyed. What is the way you ex-
perience this being annoyed?

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74 David Malan

The patient gives a much more strongly felt response, but the therapist senses
that he is still avoiding the true quality of his feelings. Almost always, when the
patient’s response contains a mixture of communication and defence, it is the
defence that the therapist must challenge:

PT: I guess I swear to myself when you . . . when you point out to me my behavior. I
say, ‘‘Jesus Christ, again, again and again.’’
TH: Now you are avoiding the issue of annoyance. You said you felt annoyed with
me. What was the way you experience that?
PT: Well as far as I know that’s the way I experience it. If that’s not explaining. . . .

The therapist now opens up the issue of violence:

TH: Did you feel that you wanted to lash out at any moment?
PT: No, no, not that bad, no.
TH: It was not that level huh?
PT: (Laughs) No I don’t think I need to hit you.
TH: Hmm. Now you are reassuring me that you don’t, but you felt angry with me,
hmm?
PT: Yes.

The Issue of Interpretation

Careful study of the whole of the interview so far will reveal that it contains no
trace of an interpretation. This is the major difference between the present technique
and that of other workers in this field. In the opening stages of the interview the aim is
not to give an interpretation, which essentially tells the patient what he feels, but to
use a question which asks him what he feels, and then to deal with his ways of
avoiding answering it.
The trouble with telling the patient what he feels, even when this is accompanied
by showing him how he is defending himself against it and why (in other words
interpreting the triangle of conflict), is that the therapist is saying it for the patient
and thus inviting him to cling on to some of his resistance and avoid the true
experience of his feelings. Only the most responsive patients—who, as described
above, represent only a small proportion of the psychotherapeutic population—
refuse to take advantage of this invitation.
As will be seen, interpretation does play a crucial part in the present technique,
but only when the patient’s unconscious has been brought close beneath the surface.
In fact the therapist now senses that this is beginning to happen, and therefore he
gives the first true interpretation in the whole interview, linking the impulse of anger
in the transference with the patient’s defence against it. However, this is only a
passing moment, and the therapist returns very quickly to challenging the defences.

The First Interpretation

TH: And one way you dealt with your anger was smiling, hmm?
PT: I don’t know.
TH: And another was fidgeting hmm?

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 Beyond Interpretation 75

PT: I guess I don’t recognize that as anger really, I mean I don’t recognize what you
identify as anger. I have not recognized it as anger until you started to talk to me
about it.
TH: But you yourself said that you felt annoyed.
PT: Yes when you asked me. I didn’t . . .
TH: And yet if I hadn’t asked you what . . .
PT: I would not have realized that I was angry with you for trying. . . .
TH: You mean you had not realized or would not have declared that you were
annoyed?
PT: Well I think I would not have realized maybe until later than I would have had a
chance to think about what happened here and I would have realized that I was
angry. I’m angry because you are putting me on the spot. You’re trying to. . . .

The Phase of Head-On Collision with the Resistance Leading to

Partial Breakthrough

Thus, although the therapist knows that the patient’s unconscious is close
beneath the surface, he also realizes that the patient’s responses in the above passage
are highly resistant, consisting of intellectualizing about his feelings rather than
experiencing them. This situation of maximum tension between unconscious and
resistance is the moment to bring out the most powerful intervention of all—the
‘‘final push’’—namely the forceful demonstration to the patient of the consequences
of maintaining his resistant position.
This intervention is of a kind that plays no part in interpretative therapy and it
requires considerable discussion. It appears to consist of nothing more than exhorta-
tion, a type of intervention that in psychoanalysis has been utterly discredited by long
and bitter experience. It is true that it is exhortation, but it is being used in particular
circumstances, with the patient in a specific inner state, to which he has been brought
by all the previous events of the interview. One of Davanloo’s most important
observations is that, even in a patient as resistant as this, the part of the unconscious
that is striving to communicate itself to the therapist and obtain relief—the uncon-
scious therapeutic alliance—is potentially an even more powerful force than the
resistance. All the time that the therapist has been challenging the defences, the
patient’s unconscious has been being activated and brought nearer to the surface.
This is the point at which the therapist senses that it is right to throw in his reserves,
which have been held back for this very moment. The therapist’s ‘‘exhortation’’
then become a major reinforcement to the therapeutic alliance and his most power-
ful tool.
In addition, there are many other important components to this intervention.
First, the therapist conveys that the responsibility lies entirely with the patient—if he
wants relief he must give up his defences. Second, by the use of the word ‘‘we’’ the
therapist conveys his willingness to collaborate with the patient’s therapeutic alli-
ance. Third, the therapist repeatedly makes the link between the emotional barrier
in the transference and the barrier that the patient puts up between himself and other
people (the transference-current or T-C link). This kind of intervention is, once
more an interpretation. Fourth, there are examples of ‘‘speaking to the patient’s
unconscious,’’ when the therapist describes the patient as ‘‘making him useless’’ and
later emphasizes the self-defeating nature of this. The deeply hidden ideas conveyed

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76 David Malan

by these implied interpretations are concerned with the patient’s need to combine his
revenge, his defence against it, and his guilt, by making his attack on the people who
have failed him take the form of self-sabotage. Finally, there is also compassion for
the patient’s predicament, and the readiness to extend the hand of warmth and
closeness the moment the patient is ready—because the therapist knows that be-
neath the lifelong hatred lies the patient’s own love, and the grief about what he has
missed first through circumstances and then through his own vindictiveness. For it is
these feelings that this most powerful intervention will eventually uncover:

TH: So then the situation is of a kind that you want to be vague, you want to keep
things uncertain and in the limbo stage, and I am attempting to focus on your
difficulties, hmm? Isn’t that? And you constantly want to keep things in the state
of limbo. Hmm?
PT: Yes.
TH: And then what this brought up is you felt annoyed with me, and we saw the way
you dealt with your annoyance with me, okay? Now let me to question you this.
If you remain vague and if you remain evasive and continue to generalize and
not be specific, then what would be the end result of this session with you hmm?
You said you have had 20 years treatment, and it hasn’t got you anywhere
obviously. So then the end result of this session would be of no use to you
wouldn’t it? Hmm.
PT: Not very much use.
TH: So in a sense if you continue to be vague and if you continue to be evasive and
generalize and keep things in a state of limbo then we would not get to
understand the core of your problem, the end result would be that I would be
useless to you like the 20 years of your past therapy, okay? Now my question is
this. Why do you want to do that? Because obviously it is very evident that you
say there is a problem that you put a barrier between yourself and other people.
Is that barrier here between you and me? Hmm? How do you feel right now?
Hmm?

The therapist has clearly timed his intervention well, for this highly resistant,
apparently emotionless patient now puts his head in his hands and begins to cry. This
is the first emergence of the positive feelings beneath the negative, but it is still
essential to continue dealing with the negative feelings and the resistance against
them.

TH: How do you feel right now? Hmm?

PT: What you’ve told me made me feel angry for sure.
TH: But what was it like when you felt angry?
PT: (Recovering from his bout of crying). . . . I felt angry, I guess I was
disappointed.
TH: Mm hmm. What was it like when you felt angry with me? You experienced that,
didn’t you?
PT: Yes.
TH: So what was it like when you felt angry with me? Was it similar to how you feel
with other people or different?
PT: I guess it was similar.

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 Beyond Interpretation 77

TH: Hmm?
PT: It was similar I suppose. I just don’t know.
TH: Mm hmm. Mm hmm. Now you had. . . .

Again the patient’s eyes fill with tears:

PT: I got very upset just now because what you were saying indicated to me that for
whatever reason there is no good in your sitting there and talking to me like this
unless we can get something out of it.
TH: Mm hmm.
PT: As you say it would be pointless to spend some time together and not make some
progress of some sort.
TH: Mm hmm.
PT: Which indicated that you would. . . .
TH: But that is probably one of the major problems that we should focus on.
PT: Yes. I know.

Dealing with resistance shows an important parallel with eliminating a bacterial

infection with an antibiotic—in order to prevent a recurrence it is essential to
continue with treatment long after the condition has apparently disappeared. ‘‘The
bacteria must be not merely knocked out but counted out.’’ Therefore the therapist
continues to hammer at the defences:

TH: Because what we see is this: you are putting a barrier between yourself and me.
Is it that or isn’t it?
PT: Yes it is.
TH: You are hiding behind a wall.
PT: Yes.
TH: And up to the time there is this wall, then obviously we cannot get to understand
the core of your problem. So the question is, what are we going to do with this
wall. Because I assume this is the problem in any other relationship. Am I right
to say that possibly this is the way that it is in every other relationship, that you
set up a barrier between yourself and the other person?
PT: Probably right, yes.
TH: Have you ever had a person in your life that you felt that you wanted . . .?

The patient, now much less resistant, is ahead of the therapist and interrupts:

PT: A person with whom there was no barrier at all?

PT: Mm hmm.
PT: No.
TH: Mm hmm. So this is a lifelong problem hmm? (The patient looks away) Do you
notice that when you become tearful you avoid me? Hmm? You avoid both the
eye contact as well as not looking at me. Why? Because you are talking about the
closeness, hmm? (Long silence) And still you are avoiding me.

The patient is sobbing.

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78 David Malan

Further Exploration, Including the Psychiatric Enquiry

Sensing that the patient needs relief from this intensity of feeling for the time
being, the therapist first explored the way the barrier manifests itself with other
people, and then took the opportunity for some psychiatric enquiry. The patient said
‘‘I feel inferior. I always sell myself cheap and let myself be exploited.’’
This led into his talking about episodes of depression. Enquiry revealed that he
has suicidal ideas, e.g., the thought of jumping from a high building, but he had never
made or planned a suicidal attempt. However, his resistance was now so much
weakened that his therapeutic alliance provided an important piece of information,
together with his own interpretation of it, namely that he is accident-prone—‘‘an-
other way of suicide.’’ The therapist at once asks for details, which leads into some
major dynamic work outside the transference. In the following passage there is much
evidence for weakening of defences: the patient is spontaneously communicating
highly dynamic material, he shows clear and genuine insight, and his therapeutic
alliance almost directs the therapist to enter into the world of very disturbing
impulses. In other words the patient’s unconscious has begun to be unlocked, which
has happened as a consequence of the previous intense transference experience.

Dynamic Exploration of a Current Relationship

PT: . . . Suicidal.
TH: Mm hmm.
PT: Even if you don’t want to recognize it . . .
TH: What are they exactly like, these accidents that you have had?
PT: You mean what were the circumstances?
TH: Mm hmm. I mean one example.
PT: One example is very closely related to my relationship with my wife.
TH: Mm hmm.
PT: Many years ago when we were intending to leave the city and would drive to the
coast on holiday and we had plans to leave early in the morning and we had to
prepare clothes and pack the car and so on and this process of a woman getting
ready took so much longer than I was prepared for that I became very angry. I
didn’t show it to her. I didn’t talk about the fact that she was late and that she was
taking the whole wardrobe just to go to the coast for two weeks, I didn’t talk
about it. But then I drove the car very dangerously because I was so angry and I
drove through a stop sign. I didn’t see it.
TH: You mean you didn’t see the stop sign, mm hmm?
PT: And I drove right into a truck, so we were very fortunate that my wife was not
killed because the truck hit the car.
TH: You were driving the car and then the truck . . .
PT: Came from the right-hand side.
TH: Mm hmm. And that is the side that your wife was, mm hmm. And who would
have been killed first?
PT: My wife.
TH: But then you said on the spell of your rage when you get this attack of rage with
your wife you have thought to yourself of killing your wife. Hmm? Hmm?
PT: Before I knew my wife I had a bad car accident when I turned the car over going

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 Beyond Interpretation 79

through the mountains and the snow, when the conditions were such that if one
were very careful it was very easy to drive.

Since the patient has so clearly acknowledged the self-destructive nature of these
acts, the therapist opens up the question of whether this is a phenomenon pervading
the whole of his life:

TH: Do you feel that you function at the level of your potentiality or do you feel that
these difficulties which are diffuse and longstanding have interfered with your
functions?
PT: Nobody has talked to me the way you do about identifying the problem, Dr.
Davanloo. Nobody ever spoke to me in that way before.

For this tight-laced, inhibited man to address his therapist by name is an

expression of great warmth, and another indication of the amount of freeing that has
taken place.

TH: Mm hmm.
PT: And I certainly have not been able to analyze it myself and identify the problem,
put my finger on it.
TH: Mm hmm, but the problem is there, basic problem is there, hmm?
PT: Yes.
TH: So is there then a sort of self-sabotaging and self. . . .
PT: Yes.
TH: And self-punishing pattern in you.
PT: Yes, there is.
TH: Hmm?
PT: Constantly.
TH: That in a sense you carry this suffering with yourself in life.
PT: Yes.
TH: Mm hmm.

The patient now spontaneously offers another deep interpretation of his own
actions:

PT: I think that’s what led to my wife and I staying together for so many years, over a
long period when we should have realized many years ago for whatever reason
things were not right.
TH: Mm Hmm.
PT: And we should. . . .
TH: Hm hmm.
PT: We should do something about it.
TH: Mm hmm.
PT: It’s been impossible.

The therapist now takes the opportunity to take the history of the patient’s
previous treatment—a further part of the psychiatric enquiry.

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80 David Malan

Psychiatric Enquiry (Continued)

TH: How many psychiatrists have you seen altogether in the past 20 years?
PT: About five.

It emerged that he has been in psychotherapy on and off for the past 20 years,
including a period of psychoanalysis at three times a week on the couch. All his
therapies ended in an atmosphere of mutual recrimination—with him blaming the
therapist for not having helped him, and the therapist blaming him for not having
worked. He said, ‘‘I understood that it would finally help me.’’
This remark produced a transition to a most moving and important moment. The
patient began contrasting his experience in the present interview with that in his
previous therapy.

Return to the Transference

PT: There is one big difference with you and that’s an interest in my welfare. You
said if we spend an hour . . . if we spend time together and I keep avoiding the
issue then we don’t make any progress. And when you said that I was overcome.
I became very . . . (his voice breaks, and at the same time he smiles) . . . see, it
happens again.

Relentlessly the therapist points out the residual defensive—contained in the

smile:

TH: What happens? Your feeling, you mean? You smile, isn’t that?

This might seem harsh, but it is not, for the patient immediately acknowledges
the defensiveness:

PT: Yes, I try. I guess I smile to cut it out.

TH: Maybe could we look at this.

Now we can observe the effects of this constant erosion of the defenses, for
suddenly the patient’s therapeutic alliance emerges and spontaneously makes a kind
of link which represents a crucial step in almost all dynamic psychotherapy.

Further Partial Breakthrough: The Link between the Transference and

the Past

PT: Then I immediately think of my father, and the fact that a more mature person
such as yourself should express any interest at all in my welfare, that’s all.
TH: It brings your father in your mind?
PT: Yes.
TH: What sort of thought comes to your mind about your father?
PT: I find I’m not sure really. Just the fact, it’s very confused. Well, just the fact that
you should express any interest at all in my welfare even from a very profes-
sional viewpoint, ahh.
TH: But you say it brings your father into your mind?

 1986 John Wiley & Sons, Ltd. Int. J. Short-Term Psychother. 1, 59–82 (1986)
 Beyond Interpretation 81

Resistance is not yet at an end:

PT: Just the idea of my father, that’s all.

But now it can be penetrated by simply repeating the question:

TH: What sort of thought comes into your mind about your father?
PT: Well, I guess the fact that the difficulties which I have trouble discussing with
you are perhaps the kinds of things which I should have been able to discuss with
my father.
TH: You mean there was difficulty in discussing things with . . .
PT: Considerable difficulty. I did not discuss anything with him after the time when
he seemed to ridicule me for wanting to talk to him and for having difficulty in
talking to him.
TH: He was ridiculing you?
PT: Whether in fact he was or not I don’t know but I have the impression that he did.
TH: You mean you have memories of the occasions that your father was ridiculing
you? What way he used to ridicule you?
PT: The easiest way to explain it would be to make a comparison now and to say that
when you see me getting upset if I do and I start to cry or something, then if you
were to do what my father did, you would point and laugh at me and say look,
you’re getting upset. That’s exactly what he would do when I was in conversa-
tion with him.

So, suddenly the patient has spontaneously explained his resistance against
showing his true feelings in terms of his expectation that the therapist would ridicule
him, like his father—an illustration of the point made above that the patient’s
feelings in the here-and-now almost always have roots going back into the distant
past.

Conclusion to Part I

The above passage marks the beginning of a phase of exploration alternating

with systematic interpretation of the resistance. The exploration is mostly of the
relation with the father, and there emerge other parallels between this and resistance
in the transference. The therapist is then able to interpret two corners of the triangle
of conflict and two corners of the triangle of person, i.e., the defence against the
underlying feeling both in the transference and in the past. The end result is a further
breakthrough of feeling in the transference, after which no further reference to the
transference is made, and the interview proceeds by exploration and interpretation
of the patient’s early family relationships. This is the phase of pure ‘‘content.’’ These
two phases will be described in Part II, which will conclude with a discussion of the
practical and theoretical consequences of the development of this extremely power-
ful technique.
For the time being it is worth re-emphasizing the basic principles illustrated by
the interview: pressure towards the experience of feeling leads to resistance; chal-
lenge to the resistance leads to intensification of the transference, which in turn leads
to further resistance; further challenge brings the patient to the true experience of

 1986 John Wiley & Sons, Ltd. Int. J. Short-Term Psychother. 1, 59–82 (1986)
82 David Malan

both negative and positive transference feelings; this results in a massive mobiliza-
tion of the therapeutic alliance; and now at last it is meaningful to introduce
interpretation. As is shown by the history of this patient’s previous therapy, a
technique that employed interpretation alone, without this long and intensive prepa-
ration, would almost certainly have been wholly ineffective.

References

Alexander, F. and French, T.M. (1946). Psychoanalytic therapy. New York: Ronald Press. Reprinted by
University of Nebraska Press, Lincoln, NE (1980).
Davanloo, H. (1978). Basic principles and technique in short-term dynamic psychotherapy. New York:
Spectrum Publications.
Davanloo, H. (1980). Short-term dynamic psychotherapy. New York: Jason Aronson.
Malan, D.H. (1976). The frontier of brief psychotherapy. New York: Plenum.
Sifneos, P.E. (1972). Short term therapy and emotional crisis. Cambridge, MA: Harvard University Press.

 1986 John Wiley & Sons, Ltd. Int. J. Short-Term Psychother. 1, 59–82 (1986)