Anxiety-relieving short-term psychotherapy

Anxiety-arousal brief therapy (AABT) is a radical, specialized, and research-based form of brief dynamic psychotherapy (BDP) developed by psychiatry professor Peter Sifneos at Harvard Medical School for the treatment of specially selected patients. This article presents the basic technical and theoretical principles of AABT, along with a brief discussion of research findings regarding treatment effectiveness.

I. DESCRIPTION OF TREATMENT

PCT is a type of short-term therapy based on psychoanalytic principles. Psychoanalytic principles include the analysis of transference, resistances, defense mechanisms, and unconscious processes with a threefold goal: (a) exploring the patient’s psychodynamics; (b) facilitating the developmental process through insight (that is, by transforming the unconscious into conscious); and (c) working through unconscious factors that hinder the achievement of therapeutic goals.

Dr. Sifneos called his technique anxiety-awakening brief psychotherapy (AABP) to emphasize the fundamental component of his technique, which consists of constructive utilization of anxiety towards a higher level of mental organization (meaning increased capacity to tolerate anxiety, frustration, and uncertainty, prevalence of more adaptive ego defenses, better processing and reconciliation of internal conflict, better regulation of affect), as well as the acquisition of more adaptive coping mechanisms. Through the appropriate use of anxiety-provoking interventions (clarification, confrontation, interpretation), the therapist can increase emotional intensity during the session and maintain the patient’s anxiety at an optimal level where it can be utilized as a motivating force toward (a) understanding the nature of the core emotional conflict (i.e., the specific emotional conflict—such as the Oedipal conflict—that underlies the patient’s psychological difficulties) and recognizing the maladaptive defenses used to cope with it; (b) achieving emotional reeducation; and (c) acquiring new learning and problem-solving techniques, all within a short period of time. Therapy can be completed in 6-14 or, at most, 20 sessions.

The technique of PTKT consists of specific and interrelated components that form four successive stages: (a) the first contact between the patient and the therapist; (b) the initial stage of therapy; (c) the main stage of therapy; (d) the final stage of therapy and the process of termination.

A. Initial contact between patient and therapist

The first contact between the patient and the therapist includes two essential parameters: (a) the creation of a supportive therapeutic environment and (b) a psychiatric diagnostic assessment.

1. Creating a Supportive Therapeutic Environment: In PTCT, special emphasis is placed on developing a strong, collaborative relationship between patient and therapist. The therapist is very active throughout treatment. By judiciously alternating empathic, anxiety-provoking, supportive, and didactic interventions, the therapist can establish rapport to maximize the therapeutic alliance and use positive transference to create a safe environment in which self-discovery, new learning, emotional re-education, and change can occur. This involves educating the patient about the following issues: (a) the importance of establishing full, active interaction and collaboration to concretize, understand, and resolve the patient’s difficulties; (b) the demands and nature of treatment, which is focal, goal-oriented, problem-solving, anxiety-provoking, and the resistances that arise from this; and (c) the patient’s psychodynamics in relation to the focus of therapy. The PTSD patient is considered to be able to collaborate effectively with a therapist who focuses on the goal of successfully resolving the emotional conflicts underlying the difficulties within a short period of time, while achieving the agreed-upon therapeutic goals is viewed as a joint venture to solve the problem.
2. Psychiatric assessment is a comprehensive assessment of the patient’s personality organization and psychopathology, and consists of five integral components: 

a. Assessment of the patient’s complaints:

The assessor’s initial task is to help the patient organize the presentation of their primary complaints (i.e., ask appropriate questions and emphasize the importance of clarity, specificity, and openness for the successful outcome of their joint efforts) and to gather information regarding their initial onset, development, intensity, duration, sequence, temporal patterns, aggravating factors, and other data necessary to develop a clear understanding of the patient’s problems. Complaints presented by patients with PTSD include interpersonal problems, certain mild psychological symptoms such as anxiety, depression, grief reactions, chronic procrastination, obsessive preoccupation, monosymptomatic phobia, and physical symptoms of psychological origin (e.g., headaches).

b. Systematic clarification of the developmental history (anamnesis collection):

By judiciously using open-ended and forced-choice questionnaires, the assessor can obtain a clear and coherent picture of the patient’s emotional development on a longitudinal basis. The history is collected sequentially from early childhood to the patient’s present life. The assessor explores specific areas, such as the earliest memories, childhood relationships with parents and other family members or significant figures, the family atmosphere and structure in early life, school history, patterns of interpersonal interaction and experiences during puberty, adolescence, and early adulthood, the history of sexual development, and medical history. A systematic elicitation of the developmental history is key to (a) identifying areas of conflict, maladaptive reactions, and recurring difficulties, and (b) understanding emotional problems in psychodynamic terms, which, in turn, allows the assessor to present the patient’s complaints in a psychodynamically reformulated form. 

c. Using appropriate selection criteria:

The evaluator uses five clear criteria to determine the patient’s ego strength, which can be used to determine whether the patient has the potential to achieve success in treatment in a short period of time. A candidate for PTCT should have: (a) the ability to limit the presentation of complaints (i.e., the patient, with appropriate support and preparation from the therapist, should be able to compromise and choose one of many problems for possible resolution); (b) a history of at least one significant relationship during childhood (i.e., altruistic, reciprocal); (c) the ability to interact flexibly with the evaluator (i.e., be willing to consider the other person’s point of view and be able to express positive or negative feelings openly and appropriately during the interview); (d) psychological sophistication (i.e., above-average intelligence and the ability to think psychologically); (e) motivation for change, not just symptom relief. Motivation for change indicates the patient’s willingness to work hard in therapy, accepting active responsibility for the therapeutic task. According to Dr. Sifneos, a patient’s motivation to change is perhaps the most important selection criterion because it predicts treatment outcome. A patient’s motivation to change is assessed based on seven subcriteria: (a) willingness to actively participate in the diagnostic assessment process itself; (b) honesty in reporting information about oneself; (c) ability to recognize that symptoms or difficulties have psychological roots; (d) introspection and curiosity (i.e., curiosity about oneself); (e) demonstration of openness to new ideas and the ability to change, explore, and experiment; (e) realistic expectations regarding the outcome of psychotherapy; (g) willingness to make necessary material sacrifices (i.e., the patient can compromise on the time of the session or the fee for therapy) to achieve a successful outcome.   

g.  Formulating a specific focus of psychotherapy:

Based on the information offered by the patient, the assessor constructs a dynamic formulation of the core conflict underlying the emotional difficulties, around which the treatment will unfold. The best therapeutic results can be achieved when the focus of treatment deals with unresolved oedipal conflicts, grief reactions, and certain difficulties related to loss or separation issues. About unresolved oedipal conflicts, which are a common focus for PTCT, Dr. Sifneos proposed considering three categories: in category A, the patient’s attachment to the parent of the opposite sex is based only on the patient’s fantasies of being a loved child, whereas in reality there is no evidence of actual indulgence on the part of the parent; category B represents more complex circumstances, in which the parent of the opposite sex evokes an intensification of the oedipal attachment; and in category B, which is the most difficult to resolve, Oedipal problems involve a complex situation in which there is a combination of a significant intensification of the Oedipal attachment and a real replacement of the parent of the same sex (for example, as a result of divorce or death).

d. “Therapeutic contract”:

The evaluator presents the therapeutic focus to the patient and seeks agreement regarding the resolution of underlying emotional conflicts. Furthermore, outcome criteria are formulated (including specific therapeutic goals against which treatment success will be assessed). Mutual agreement regarding the therapeutic focus strengthens the patient’s motivation to take active responsibility for expanding self-understanding and using insights to achieve desired emotional change. PTCT involves weekly forty-five-minute face-to-face interviews held at a mutually convenient time. The therapist informs the patient that therapy will be short-term, but there is no set number of sessions.

B. Initial stage of therapy

In the initial stages of therapy, the patient’s positive feelings toward the therapist predominate. The most important element of the technique involves the early use and explicit and detailed analysis of the patient’s positive transference feelings. This procedure allows the therapist to begin developing past-present connections and strengthening the therapeutic alliance.

B. The main stage of therapy

The main stage of psychotherapy represents the apogee of PTCDT. The therapist uses repeated anxiety-provoking questions, confrontations, and clarifications, striving to maintain the boundaries of the agreed-upon therapeutic focus and also attempting to establish past-present connections, which is the fundamental technical aspect of CDP. The key distinguishing and innovative technical aspect of PTCDT involves interpretations in the form of suggestions, preceding the analysis and clarification of resistances and defense mechanisms. The therapist uses the anxiety generated by focal interpretive activity to make explicit the emotional conflicts underlying the focus and to help increase the patient’s motivation to develop new, more effective problem-solving strategies and to overcome old problems. In this way, the patient can clearly understand how their current interpersonal relationships are influenced by the unconscious repetition of interpersonal patterns from the past. Their expanding understanding of hidden conflicts, fantasies, feelings, needs, and defensive behaviors helps the patient gain the ability to take responsibility and control them. Therefore, by challenging the patient’s neurotic barriers and providing empathic understanding and support, the therapist can support the patient’s ability to tolerate conflict and explore new ways to resolve emotional conflicts. Using this process, the therapist helps the patient develop self-understanding and achieve emotional growth.

Although a thorough assessment has established that the PTCT patient is sufficiently motivated to decisively pursue therapeutic goals within a short period of time, the emotional intensity of anxiety-provoking focal interactions and unpleasant discoveries can at times provoke strong resistance and avoidance tactics. Using precise transcripts of some of the patient’s verbatim statements, the therapist, when resistance arises, can repeat the patient’s exact words to present facts that consolidate the patient’s interpretations. Another technical tool used to resolve impasses associated with resistance is “summarizing.” This involves a synopsis in which the therapist explains how they arrived at a certain conclusion based on the information provided by the patient. Furthermore, by reviewing the transcripts, the therapist can make short-term predictions regarding the course and future development of treatment.

The patient’s resistance and avoidance tactics may include discussing issues irrelevant to the focus of therapy or regression-like reactions (for example, the patient may find themselves in a state of apparently overwhelming anxiety), which in reality represent “pseudo-regression.” It is important to remember that the patient in PCT has sufficient ego strength and the ability to tolerate anxiety. In such circumstances, the therapist’s task is to explain to the patient the importance of focalization for success in achieving their specific, agreed-upon goals and to restore focus. By actively and systematically avoiding characterological issues from the early period (such as passivity, dependency, acting out, and manipulative tendencies), which may be used defensively, the therapist can prevent the emergence and reinforcement of regressive patterns of connection in the present and achieve resolution of the patient’s core conflicts within a short period of time.

As therapeutic work progresses, the patient gradually internalizes the therapeutic process. The patient’s demonstrated ability to use acquired knowledge to develop new attitudes and behavior patterns, as well as to develop original and effective ways of dealing with past and current problems, is evidence of progress.

D. The final stage of therapy and the process of completion

In the final stage of therapy, the therapist’s task is to see tangible evidence of change and to ensure (for example, by exploring specific examples brought by the patient) that the patient’s improvement is not a random change, a flight to health, or a transference cure, which represents a superficial, short-term improvement without a clear understanding of the psychodynamics surrounding the emotional conflicts underlying the existing difficulties. Gaining sufficient insight into the focal conflicts results in the discovery of tangible evidence of change and signals that the time has come for the process of closure. Consequently, treatment termination occurs precisely when both patient and therapist agree that the primary therapeutic goals have been achieved.

II. THEORETICAL BASIS

PTCT is based on psychoanalytic theoretical premises, consisting of six perspectives: topographic, dynamic, structural, genetic, economic, and adaptive. Human behavior or symptoms are interpreted as disguised representations of underlying unconscious processes (topographical perspective). The patient’s difficulties or symptoms are viewed as derivatives of conflict and dynamic interaction in general, and in particular, as a maladaptive compromise formation (dynamic perspective) between: (a) blocked and pleasure-seeking instinctual drives originating in the id, (b) restrictions from the reality-oriented ego, which activates defense mechanisms to maintain mental equilibrium, and (c) prohibitions imposed by the superego (structural perspective). Furthermore, the patient’s current conflict and maladaptive behavior pattern are viewed as part of a continuum from early childhood to adulthood (genetic or evolutionary view) that includes two major interrelated factors: (a) the nature of progression, regression, and fixation (economic view) in relation to psychosexual development (oral, anal, oedipal, latency, and genital stages) and (b) the quality of interpersonal relationships and the environmental influences and circumstances to which the individual is accustomed and in accordance with which he acts (adaptive view). 

Dr. Sifneos developed PTCBT while he was director of the Psychiatric Clinic (1954-1968) at Massachusetts General Hospital (a teaching hospital for Harvard Medical School). The model for PTCBT was a 28-year-old male patient who complained of an acute onset of nervousness and phobias associated with all forms of transportation. He came to the clinic requesting therapy to overcome his fears, as he wanted to get married within three months. Dr. Sifneos decided to work in a therapeutic mode, and after eight sessions, the work was completed. Subsequent observation revealed lasting dynamic characterological changes, and the patient’s focal problems were resolved. The successful results of this treatment prompted Dr. Sifneos to methodically examine the patient’s character structure and develop criteria for selecting candidates suitable for this type of psychotherapy. It was in this manner that the assessment process and the anxiety-evoking technique were developed. In summary, the assessment, techniques, and outcomes that have been studied and refined over many years have made PCT a systematic, comprehensive, and useful form of psychotherapeutic treatment.

III. EMPIRICAL RESEARCH

PTC is the oldest form of brief therapy based on systematic research in the United States, and its effectiveness has been confirmed by several long-term outcome studies in the United States and Europe. Between 1960 and 1987, Dr. Sifneos led research studies conducted under comprehensive controls. These included follow-up studies of “experimental” patients who received treatment immediately and “control” patients on a waiting list who received treatment over time. Impressive observational data were presented, and studies in Europe showed similar and significant separate results, according to a report by Dr. Ragnhil Huisby (Norway) in 1985.

An important educational and research tool in PCT is the use of video recording, which Dr. Sifneos called “the psychiatrist’s microscope.” Video recording of the assessment, treatment, and follow-up of patients who are willing to participate in the study and provide informed consent enables a thorough and systematic analysis of the therapeutic process and outcome, as well as a close comparison of the patient’s condition before and after treatment. Evaluation of PCT effectiveness in post-treatment studies is based on the assessment of eight specific outcome measures, which relate to improvements in the patient’s psychological or physical symptoms, interpersonal relationships, self-understanding, acquisition of new knowledge, development of new, effective problem-solving strategies, self-esteem, performance in work or academic settings, and the development of new, helpful attitudes. According to follow-up studies, PCT patients are able, after completing their work, to effectively use the new knowledge and problem-solving skills they learned during treatment to solve new problems through a process Dr. Sifneos called “internalized dialogue.” This process, which promotes continuous development and growth, is directly related to the patient’s ability to reconstruct the dialogue with the therapist in order to reproduce the therapeutic effect for resolving new difficulties.

IV. SUMMARY

Anxiety-Arousing Brief Psychotherapy (AABP) is an innovative, specialized, and systematically researched form of brief dynamic psychotherapy (BDP) developed by psychiatry professor Peter Sifneos at Harvard Medical School. It is based on psychodynamic theoretical premises and is the preferred method for treating mild neurotic symptoms in appropriately selected patients. Key technical principles include establishing a therapeutic focus, using anxiety-arousing interventions, early use of positive transference to strengthen the therapeutic alliance and establish past-present connections, avoiding characterological issues to prevent the development of regressive modes of connection, and achieving timely closure. PTCT is characterized by the establishment of specific, clear criteria for patient selection (namely, a limited focus, a history of significant relationships, flexible interaction with the assessor, psychological sophistication, and a high motivation for change), as well as criteria for evaluating therapy outcomes (namely, improvements in symptoms, interpersonal relationships, work or academic functioning, development of self-understanding, new knowledge and problem-solving strategies, self-esteem, and new effective life attitudes). The effectiveness of PTCT has been confirmed by comprehensive scientific studies in the United States and Europe.

Acknowledgments

The author is deeply grateful to Dr. Peter Sifneos for reviewing the manuscript and offering valuable comments and suggestions.