International Journal of Intensive Short-Term Dynamic Psychotherapy

Int. J. Short-Term Psychother. 1, 83–106 (1986)

DOI: 10.1002/sho.166

Beyond Interpretation: Initial

Evaluation and Technique in
Short-Term Dynamic
Psychotherapy. Part II.
DAVID MALAN
Parker’s Close, Hartley Wintney, Hampshire RG7 8J6, England

This is the second part of a two-part article, the first part of which appears in this issue of the
journal. The article considers the basic problems of Short-term Dynamic Psychotherapy, namely (1) how
to develop techniques that maximize success, and (2) how to recognize suitable patients. In addition, there
is a deep theoretical problem: why is it that purely interpretative therapy, even when intense dynamic
interaction occurs, only a relatively small proportion of patients experience resolution of their neurosis?
Davanloo has developed a technique which leads to solutions to all these problems. The technique is
illustrated by an initial evaluation, begun in Part I and completed in the present Part. The article ends with
a discussion of the practical and theoretical consequences of this work.

Introduction
Part I of the present article (see Malan, 1985) opened with a statement of the two
basic problems of Short-term Dynamic Psychotherapy, namely how to establish
techniques that maximize success and how to find criteria for recognizing suitable
patients. Some of the principles underlying solutions to these problems appear to be
almost universal: The need to start with a thorough psychiatric and psychodynamic
evaluation; the use of some form of trial therapy in the initial interview; the principle
of planned therapy; and the use of the full range of interpretation in therapy itself,
including interpretation of the transference and the link with the past.
Most schools of Short-term Dynamic Psychotherapy (STDP) use these prin-
ciples but depend for their effectiveness on the fulfilment of certain additional
criteria, as follows: There needs to be some single basic conflict that can be used as
the ‘‘focus’’ of therapy; the patient needs to become deeply involved in the therapeu-
tic process and if possible in the transference relationship; and correspondingly he
must readily respond to interpretation and must not show too much resistance. In
other words, the need is for responsive, highly motivated patients, with an underly-
ing simplicity of psychodynamics.
These criteria already put a considerable restriction on the range of suitable
patients, but unfortunately they involve a further restriction as well. This is that they
are necessary but not sufficient conditions, so that even when they are fulfilled there
is no guarantee of success. The result is that when we consider the whole psychother-
apeutic population, we find that only a very small proportion receive substantial help
in terms of the resolution of their central conflict.
Of course the obvious solution is to fall back on long-term therapy, but unfortu-
nately here the picture is no more favorable. Quite apart from the fact that therapeu-
tic vacancies immediately become blocked by long-term patients, the proportion of
Copyright  1986 John Wiley & Sons, Ltd.
84 D. Malan

these patients who achieve substantial resolution of their central conflict appears to
be relatively small.
These considerations lead to two further practical problems, one concerned with
selection and the other with technique. If we wish to improve the efficiency of our
work, then we must achieve one or other, and if possible both, of the following: to
make our selection more accurate and/or to make our technique more powerful.
But there also lies in these observations a profound and as yet unsolved theoreti-
cal problem, which is concerned with the gap between dynamic interaction and
resolution, and can be formulated as follows: We are sure that therapeutic effects,
when they occur, result from dynamic interaction between therapist and patient.
This involves the sequence: material, interpretation, response; which leads to the
acquisition of emotional insight into hitherto unconscious feelings, and the experi-
ence of the transference relationship and its link with the past. There is little difficulty
in selecting patients who will interact in this way, so that this process occurs daily in
the majority of our therapies; yet why is it that in some patients it results in major
therapeutic effects, while in others it fails to do so? What is the difference between
the two?
If for the moment we concentrate on one of the practical problems, namely that
of making our technique more powerful, we may note that all traditional techniques
of dynamic psychotherapy, whether short- or long-term, depend essentially on the
use of interpretation and little else. It therefore appears that purely interpretative
techniques have been carried to the limit and have been found inadequate, and that
unless we are prepared to resign ourselves to this situation, something is needed over
and above interpretation. This has been the starting point of Davanloo’s
contribution.
The essential element in Davanloo’s technique consists of 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 the following phases can be
distinguished:

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

(2) An inevitable increase in resistance, which appears in the form of a series
of defences.
(3) Challenge to each defense the moment it appears.
(4) An inevitable rise in transference feelings. These are complex. Upper-
most is almost invariably the patient’s anger at not being allowed to use his
customary defences; but underneath this there often lie many ‘‘positive’’
feelings, which include sadness at previous lost opportunities for love and
closeness, together with appreciation for the therapist’s genuine attempts
to relieve the suffering to which the defences have given rise. The patient
does not wish to experience or show these painful and conflicting feelings,
and the result is a further rise in resistance, which now involves the
transference. The next stage therefore consists of:
(5) Challenge to the resistance in the transference, which leads eventually to
(6) Direct experience of the transference feelings.
(7) Stage 6 has the profound effect of unlocking the patient’s unconscious and
mobilizing the therapeutic alliance.

 1986 John Wiley & Sons, Ltd. Int. J. Short-Term Psychother. 1, 83–106 (1986)
 Initial Evaluation and Technique in Short-Term Dynamic Psychotherapy 85

(8) Now, for the first time, it becomes meaningful both to explore relation-
ships outside the transference and to begin to use interpretation.
(9) However, as each new area is explored and some new anxiety-laden area
is approached, there is often a return of resistance, so that the cycle begins
again at stage (3) with further challenge.
(10) The exploration that has been carried out in phase (8) enables the thera-
pist to make interpretations linking the resistance in the transference with
conflicts in other relationships, both current and past (transference–
current–past or TCP interpretations).
(11) This cycle may have to be repeated many times, but in the end the
resistance becomes exhausted. It is now possible to explore other relation-
ships and to make interpretations about them without reference to the
transference. This is the phase of pure ‘‘content.’’

One of the main aims of the two parts of the present article has been to illustrate
this process by means of a clinical example. Since Davanloo makes the principle of
trial therapy more central to his selection process than any other worker in this field,
the principles of both selection and technique can be illustrated by means of an initial
evaluation interview. The only essential ways in which such an interview will differ
from actual therapy arise from the need to take a full psychiatric and developmental
history. Therefore these two phases have to be added to those enumerated above.
Also, because of repetition and overlapping, the phases of an actual interview are
usually more complex than in a schematic description, so that the numbering given
above is best omitted.
It is important to use as an example a patient interviewed by Davanloo who
shows considerable resistance, and for that reason the following patient was chosen.
The evaluation process occupied two interviews, each of about 1 21 hours.

The Case of the Man from Southampton

Recapitulation

The patient, a man of 47, had already been in therapy over a total span of 20
years, including a period of analysis at three times a week on the couch. All this
treatment had achieved little more than a reinforcement of his defences, and he
arrived at the interview already in a state of resistance, which took the form of
vagueness and distancing. He even seemed unable to describe the problems for
which he was seeking help. Thus phase 1 (pressure) and phase 2 (resistance) became
telescoped. The therapist tried to pin him down, without much success. The resis-
tance reached a peak when the patient, on being asked to describe his actual
experience of a particular feeling (in this case guilt) said that he used the word ‘‘guilt’’
because that was the label given to it by one of his previous therapists. Since he had
said exactly the same about the word ‘‘anxiety,’’ the interview was clearly going
round in circles. This initiated the phase of challenge to the resistance. The therapist
first forcefully pointed out the patient’s vagueness and then challenged each ‘‘tacti-
cal’’ defence as it arose, e.g., the use of phrases such as ‘‘I guess,’’ ‘‘maybe,’’ etc.,
which served the purpose of distancing the patient from his feelings.

 1986 John Wiley & Sons, Ltd. Int. J. Short-Term Psychother. 1, 83–106 (1986)
86 D. Malan

Here it is essential to emphasize that if the patient had shown any signs of being
unduly disturbed by this approach, thus indicating deeper, possibly borderline or
psychotic pathology, the therapist would have immediately changed his technique
and become more supportive.
As the interview proceeded, various nonverbal cues began to make clear that the
patient was beginning to become angry with the therapist because of the repeated
challenge to his defenses, but that he was trying to conceal this.
The therapist was not yet ready to bring the anger to the surface and continued
his exploration. Two important pieces of information now emerged; first that the
patient suffered at times from violently angry feelings which he found difficult to
control; and then that he experienced a ‘‘barrier’’ which prevented him from getting
emotionally close to his children.
Since the patient was clearly both angry with the therapist and maintaining an
emotional barrier against allowing the therapist close to him, there was now an
opportunity to try and bring the transference into the open. The patient admitted
under pressure first that he was ‘‘a little annoyed,’’ and then that he was ‘‘very
frustrated.’’ At the same time the nonverbal cues intensified—the patient was
sweating, fidgeting, taking deep breaths, and covering his feelings by smiling. It was
at this point that the therapist introduced the first interpretation, making the link
between the defences and the underlying feelings by pointing out that the smiling and
fidgeting were ways of dealing with his anger.
However, this interpretation represented only a passing moment. Sensing that
there was now the maximum tension between the patient’s feelings and his resis-
tance, the therapist introduced the most powerful challenge of all, the ‘‘head-on
collision.’’ This consisted of forcefully pointing out that if the patient continued with
his vagueness and distancing, the present interview would be useless to him as his 20
years of previous therapy had been.
Suddenly there was a major change in atmosphere, for the patient began crying,
thus revealing that beneath the anger there lay sadness and regret, and also—as
became clear later—warm feelings for the therapist, whose attempts to relieve him of
his defenses expressed genuine concern for his welfare.
This open emergence of transference feelings, first negative and then positive,
produced a marked rise in the therapeutic alliance. The patient was now able to
speak of his rage with his wife, which had led to serious accident-proneness, and
which he himself interpreted as an expression of suicidal impulses.
The therapist capitalized on this to offer a further interpretation in the form of a
question, asking whether there was a self-punishing pattern running through the
whole of the patient’s life, with which the patient fervently agreed.
Enquiry now revealed that the patient had seen five psychiatrists in all during the
past 20 years. This led to a most moving moment, in which the patient spoke with
deep appreciation of the therapist’s approach—addressing him by name—and con-
trasting it with the ineffectiveness of his previous therapists.
The active mobilization of the patient’s therapeutic alliance, which resulted from
the open expression of these feelings for the therapist, led to another crucial mo-
ment. Once more the patient gave his interpretation, now linking the transference
with the past, by explaining his withdrawn state at the beginning of the interview in
terms of the expectation that the therapist would ridicule him if he expressed what he
really felt, which was exactly what his father had done.
We may resume the account of the interview at this point.

 1986 John Wiley & Sons, Ltd. Int. J. Short-Term Psychother. 1, 83–106 (1986)
 Initial Evaluation and Technique in Short-Term Dynamic Psychotherapy 87

The First Phase of Enquiry: Developmental History

The therapist took the opportunity to enquire into the patient’s background with
special reference to the father.
The patient is the fourth of five children, with three older sisters and a brother
one year younger. He described his father as authoritarian, a forbidding figure, of
whom he was always frightened, and in whose eyes nothing he did was ever any good.
His father suffered from high blood pressure resulting in headaches and attacks of
heart failure, and at times used to go into states of withdrawal in which he refused to
speak to anyone. Twenty-one years ago he had suffered a serious exacerbation of his
physical condition which had prevented him from attending the patient’s wedding.
He had died not long afterwards.
This enquiry now enables the therapist to proceed with the next phase, which
consists of the systematic interpretation of the resistance. In this phase he repeatedly
interprets two corners of the triangle of conflict, namely the underlying feeling and
the defense against it, and two corners of the triangle of person, namely the
transference and its parallel to the relation with the father (transference–past or TP
interpretations). In interviews with other patients it is often important to include the
third corner of both triangles, i.e., the anxiety on the one hand, and current relation-
ships on the other, but in this particular interview it was not necessary.

Systematic Interpretation of the Transference Resistance in Terms of the

Relation with the Father

The therapist detects further signs of tension in the transference and therefore
breaks in with a question about the here-and-now. The patient’s relatively open
response shows that his resistance, though by no means at an end, has been consider-
ably loosened. It is worth noting here the extraordinary way in which the transfer-
ence situation picks out coincidences and parallels between the present and the past:

TH: How do you feel right now?

PT: I feel much as I would feel with him at that time when he would oblige me to
be more specific.
TH: Oh, he used to be the kind of person who wanted you to be more specific?
PT: Or he expected me to see things his way and if he was not satisfied with my
viewpoint that’s when he would ridicule me for having a different viewpoint
from him.
TH: So then the relationship there was of a kind, with your father, that if you did
not follow his views or you did not see the way he wanted you to see, then he
would ridicule you. And what was your reaction toward that?

The patient’s reply specifies the underlying feeling and the defense against it in
relation to the father, i.e., two corners of the triangle of conflict and one of the
triangle of person:

PT: I would become angry and I would not want to continue.

 1986 John Wiley & Sons, Ltd. Int. J. Short-Term Psychother. 1, 83–106 (1986)
88 D. Malan

The therapist makes the defense more explicit and then links this with the
transference, thus adding a second corner to the triangle of person:

TH: So then the situation with your father was that he was demanding, hmmm?
He was demanding but at the same time also everything had to be in his way
and if the thing was not in his way this would mobilize anger in you. And the
way, and the mechanism that you dealt with your anger was detachment.
Am I right then to say this is very clear, hmm? Now is that in operation here
with me? Do you see what I mean?
PT: Yes.
TH: Hmm?
PT: Yes.
TH: You want to keep things in a state of limbo, hmm? ‘‘Perhaps’’ or ‘‘guess’’
and so forth, hmm?
PT: I think, Dr. Davanloo, that . . .
TH: And the idea is that I am demanding.
PT: Yes, when I was a child with my father I was . . . it was very difficult to
accept the fact that I could not please him if he kept showing me how wrong
I was. It was very difficult to accept that and so now probably I continue the
same kind of behavior with anybody who I see to be in a position of
authority.

The above was spoken with deep feeling. It would be easy to make the mistake of
accepting this and not to see that it completely avoids the issue on which the therapist
was concentrating, namely the transference, and thus is still a manifestation of
resistance. The therapist relentlessly pursues his interpretation of the transference
resistance. The importance of this is quickly demonstrated:

TH: Mm hmm. Could we look into that, because you are talking about your
father and his demanding attitude and things have to be his way, okay.
Then this mobilizes anger in you and the way you dealt with your anger was
withdrawing and detaching, okay. Now my question was, if that is in
operation with me, namely anger in relationship with me and then with-
holding? I am questioning if that is in operation also here with me?
PT: I believe it to be when you talk to me about it, when you ask me. I don’t
recognize it until you ask me.
TH: Here with me you have experienced your anger and irritation, haven’t you?
PT: Yes, but until we talk like this now I haven’t. What I’m saying is that I don’t
recognize that what I feel is anger. Now that you’ve talked to me about it I
realize that I would like to say, ‘‘For Christ’s sake leave me alone. Don’t
keep asking me these questions.’’

Although the words as written might still seem to be rather indirect, in fact the
therapist knows from the patient’s manner that they represent the true experience of
anger and will lead to considerable relief. It is important to note that, in order to be
therapeutic, this experience of anger does not have to be dramatic—and indeed if the

 1986 John Wiley & Sons, Ltd. Int. J. Short-Term Psychother. 1, 83–106 (1986)
 Initial Evaluation and Technique in Short-Term Dynamic Psychotherapy 89

patient starts shouting and screaming at the therapist, or threatening him, then
something has gone wrong.
The therapist now searches for the relief, but still pursues manifestation of
residual resistance. This is a further example of the analogy with a bacterial infection
mentioned in Part I—the bacteria, or the resistance, ‘‘must be not merely knocked
out but counted out.’’

TH: Mm hmm. How do you feel right at this moment?

PT: A little more relaxed just because I’ve been able to see that I do in fact feel
anger because you keep saying to me . . .
TH: Have you noticed that when you get irritated with me, you move your eyes
away from me?
PT: Yes.
TH: Mm hmm?
PT: Yes, I’ve noticed.

Once more the therapist makes the TP link.

TH: Mm hmm. How was that with your father? I am talking about the eye
contact. You avoided him?
PT: I probably did because he was a very frightening figure.

The above passage marks the end of the analysis of the resistance in the
transference. From now on it is possible to explore other relationships directly and in
a highly meaningful way. Resistance does return, but it can be dealt with relatively
quickly and without further mention of the transference.

The Phase of Pure ‘‘Content’’

TH: How far back goes your earliest memory of your father? And what do you
remember you were doing in the past?

The patient said he was somewhat closer to his mother than to his father. He
went on to speak of his sister Diana who was attractive and their father’s favorite. He
has memories of her sitting on her father’s lap and receiving constant praise and
admiration from him. This led to his speaking of his brother, one year younger, who
also used to sit on their father’s lap and have good times with him, and in addition was
the favorite of their mother and the three sisters.
Thus the evidence suggested that the patient felt very much an outsider in his
own home. This was seriously exacerbated by World War II. The family home was
in Southampton, England, which was a main target for German bombing from 1940
onwards. The parents remained in Southampton but the children were evacuated to
various safer areas. Two sisters were sent away together to one foster family, and the
patient’s younger brother and the remaining sister to another; while the patient said
that he himself was singled out to be sent away alone, at the age of five, to a family in

 1986 John Wiley & Sons, Ltd. Int. J. Short-Term Psychother. 1, 83–106 (1986)
90 D. Malan

the country. He spent five unhappy years with that family. They had four daughters
ranging in age from 6 to 9, which to some degree mirrored the situation in his own
family. One memory was of sexual play with these four girls. He was caught and
punished severely by his foster parents.
He then mentioned, however, that the foster family lived near enough to enable
his parents to visit him at some weekends. This led to a moment illustrating the degree
to which the resistance had been weakened and the unconscious therapeutic alliance
mobilized by all the previous work on the transference. There suddenly emerged
spontaneously a fresh memory revealing an entirely different aspect of the relation
with his father.
There had been a time—as is found so often—when there was uncomplicated
warmth between the two of them. Again, as is found so often, this aspect of the
relation had been repressed by all the subsequent bitterness, and it emerged against
considerable resistance—thus illustrating the tension between the resistance and the
therapeutic alliance. Now, however, challenge is no longer necessary and resistance
can be handled much less forcefully:

PT: In fact that reminds me that even before the War I remember looking for my
father when he would return from work. I could see the pathway that he
would take approaching the house.

Recognizing the significance of this, the therapist directs the patient’s attention
to it:

TH: What is your memory of that path?

Resistance returns and the patient gives an evasive answer:

PT: It was just a path across the field.

The therapist encourages the patient to go on:

TH: Mm hmm.

The patient does go on but uses the defenses of wandering off into details,
leaving out the emotional content of the memory altogether:

PT: And I would see him walking from . . . he had to leave back and walk down
by the river and across the pathway and I would see him. We lived in a block
of . . .

The therapist simply brushes aside this defense and gives a direct interpretation
of the underlying feeling, putting the emotional content into words:

 1986 John Wiley & Sons, Ltd. Int. J. Short-Term Psychother. 1, 83–106 (1986)
 Initial Evaluation and Technique in Short-Term Dynamic Psychotherapy 91

TH: So you looked forward to your father.

The patient has been brought to a state in which this interpretation is enough to
bring out the feeling, with the emergence of another fresh memory:

PT: Yes, I did, and we lived on the top of a block of flats and I ran down to meet
him and fell down the stairs and knocked myself out. I cut my chin and had
to be taken to hospital. I just remembered that.
TH: Mm hmm. So then you must have felt close to your father.
PT: Yes. I guess I was.

He then revealed an all too familiar pattern of a serious deterioration in the

relation with his father around the time of puberty, in his case at the age of 11, which
was probably greatly intensified by the fact that he had just returned from five years
of separation. His sister Diana was a good student and the patient worked hard and
became an excellent student himself, but in spite of his efforts and good performance
all he got was anger and criticism.

PT: . . . because he seems to have stopped me progressing.

TH: He was an angry person, hmm? What was he like when he was angry?
PT: He was very frightening. You asked me to describe him earlier. I didn’t
describe him. He was physically very forbidding. He was dark-haired and
dark-eyebrowed and a very grim face.

Once more the patient begins to cry.

TH: Grim face?

PT: Very large strong hands which would hurt when he would punish me.
TH: He used to punish you physically?
PT: Sure.
TH: Mm hmm. What way he used to punish you?
PT: What with?
TH: What way he would?
PT: He would hit me either with his hand or with a strap.
TH: A strap. Where?
PT: On my backside.
TH: On your backside.
PT: Well, he would begin on my backside but of course since I would try to
avoid him the strap would go everywhere.
TH: Mm hmm. Mm hmm. So he was aggressive with you then, hmm?
PT: Yes.
TH: He was aggressive with you?
PT: Yes.

 1986 John Wiley & Sons, Ltd. Int. J. Short-Term Psychother. 1, 83–106 (1986)
92 D. Malan

The therapist has noted that the patient’s brother got on much better with the
father. Therefore he now opens up the relation with the brother, with special
reference to this triangular relationship, which he knows is likely to be highly
significant:

The Relation with the Brother

TH: This aggression was especially with you or was he like that with your
brother?

It emerged that he and his brother fought a great deal.

TH: Who had the upper hand in the fight?

PT: Who had the upper hand?
TH: Mm hmm. Who was the stronger?
PT: I think we were quite close. My father bought boxing gloves.
TH: Oh your father bought boxing gloves?
PT: My father bought two pair of boxing gloves and made us fight like this in
order to settle differences between us. He said, if you want to fight you have
to fight properly.
TH: How did you use to fight before he bought the gloves?
PT: Just scrapingly, kicking, wrestling on the floor.
TH: Mm hmm. Who was physically stronger?
PT: We were very close.
TH: Mm hmm.
PT: We were very close. Just by the fact that my brother was younger we were
very close in size.
TH: Mm hmm. But who was the winner?
PT: It was close enough so that . . .
TH: Did you have the upper hand?
PT: No, there was never a constant victor.
TH: Mm hmm.
PT: He would win, I would win, but it finished finally my brother had the upper
hand.
TH: Oh.
PT: Yes, because . . .
TH: How did it come that he had the upper hand?
PT: Because my father bought boxing gloves and taught us to fight with these.
TH: Mm hmm.
PT: And my brother happened to hit me so successfully that he knocked me
back into the china cabinet and broke the cabinet and that was the end of the
fighting because my mother wouldn’t allow it any more.
TH: Do you remember that incident?
PT: Yes, mm hmm.
TH: You mean, what do you remember when you try to remember . . .
PT: I remember only that my brother hit me so hard.

 1986 John Wiley & Sons, Ltd. Int. J. Short-Term Psychother. 1, 83–106 (1986)
 Initial Evaluation and Technique in Short-Term Dynamic Psychotherapy 93

TH: Where?
PT: On the chin, on the face. He knocked me right back and I crashed into the
cabinet and of course we couldn’t have any more of this kind of fighting,
and so that was the end of it and so I guess in my memory my brother was
victorious because in the last . . .

Throughout the whole of this passage the therapist has had in mind the fact that
the patient had previously acknowledged a self-sabotaging tendency in himself. The
mechanism behind this often appears to consist of the following: the patient ‘‘takes a
beaten position’’ in relation to other people as a way of defending himself against,
and punishing himself for, intense hostile feelings against some important person in
the past. The therapist prepares to bring this out:

TH: So you ended up being the beaten . . .

PT: Not only the black sheep but . . .
TH: The beaten boy.
PT: I guess so.

At this point the patient reveals by another involuntary smile that something
important has been touched. The therapist points this out and then goes straight for
the buried feeling:

TH: You’re smiling. How did you feel when he knocked you down? Did you
feel that you wanted to get at him?

Resistance at once returns:

PT: I don’t know. I suppose I did. I don’t know. I don’t remember that I did but
I suppose I did.
TH: You say that you used to fight back, hmm. Now you are badly hurt and you
are knocked down and humiliated, hmm. Hmm?
PT: Mm hmm.
TH: Then the question is how you felt.
PT: I don’t know how I felt.

Once more the therapist senses that resistance has been sufficiently weakened to
make it possible to break through by concentrating on the buried feeling or impulse
rather than by challenging the defenses. He therefore makes use of what has already
emerged in the relation with the patient’s wife:

TH: Hmm? We know that when you get into a fight and your wife humili-
ates you, banging the chair on your head and then throwing the television
and breaking things, at that time there is the feeling that you wish that you
could kill her.

 1986 John Wiley & Sons, Ltd. Int. J. Short-Term Psychother. 1, 83–106 (1986)
94 D. Malan

PT: Yes.
TH: Hmm?
PT: Yes.
TH: So the question is this. Was there any time the wish that you could do that to
your brother?

This brings a major response:

PT: I’m sure there was. Yes, because on one occasion I remember fighting with
him out of the home in the field.
TH: In the field, mm hmm.
PT: And I remember him walking away and when I remember him walking
away it reminds me of my son, it reminds me of my son, my younger son.
My brother was more calm, more placid, I guess.
TH: Mm hmm.
PT: Than I was. I was more excited and I did a terrible thing when he walked
away. I took a stone from the ground and threw it at him and hit him on the
back of the head.

Relentlessly the therapist pursues the implications of this incident, forcing the
patient to be explicit:

TH: If you didn’t have a brother what would have happened?

PT: Well, I would not have had a rival in the family would I?
TH: Mm hmm. So in a sense if you didn’t have a brother that means then you
didn’t have a rival.
PT: That’s right.
TH: And the rival is the one that in a sense knocked you down and beat you and
humiliated you.
PT: Yes.
TH: Now the question is, so then what does that mean? If you didn’t have a
brother?
PT: Well, that I would not have been beaten and humiliated obviously.
TH: But what does if you didn’t have a brother mean? Hmm? What is the
meaning of not having the brother? Hmm?
PT: I don’t know. Only that there would have been no one between my father
and myself, I imagine.
TH: Mm hmm. There would not have been anybody . . .
PT: Between.
TH: I mean there would not be in between you and your father, hmm? So then
there was a sibling rivalry between you and your brother, hmm?

This brings other spontaneous memories, with fresh insight:

PT: Certainly. Certainly. I was very guilty also of . . . I remember now since

 1986 John Wiley & Sons, Ltd. Int. J. Short-Term Psychother. 1, 83–106 (1986)
 Initial Evaluation and Technique in Short-Term Dynamic Psychotherapy 95

you talk about it. I’ve never thought about this before in my relationship
with my brother. But now I realize that there were many other ways much
less violent in which I was also humiliated and made to appear inferior to
my brother. When we were a little older and in socializing with the family
we would play cards . . .
TH: Mm hmm.
PT: And my brother was always able to play cards very successfully even as a
young boy. I could not. I could not take enjoyment from them and could
not grasp the game very well.
TH: Mm hmm.
PT: So he was a very successful participant in this kind of family game.
TH: So there also you were the loser.
PT: So I was the loser there. Also another thing comes to mind. At a very young
age it seems he became very adept in making electrical repairs, doing that
kind of thing. When something needed wiring, some attachment needed to
be done, he would do it. I couldn’t do it.
TH: Mm hmm.

The therapist continued to focus on the patient’s hostile relationship with his
brother. It became clear that the turning point at which the patient had begun to take
a beaten position coincided with the final deterioration in his relation with his father.
‘‘He was so critical of me. Everything I did was wrong.’’ The situation eventually
became so bad that a cousin offered to take him into her home.

Other Family Relationships

The patient’s resistance was now so loosened that it became possible to conduct a
survey of all the patient’s relationships in this large and complex family.
Description of the serious deterioration in the relation with the father led to a
new memory, now involving the triangular relation with the mother. The father
became angry with the mother and called her a pig, at which the patient stood in front
of his mother and raised his fist, wanting to attack his father, who said that he would
disown him as his son.
The therapist then explored another triangular relation, namely that involving
the brother and the mother. Further memories emerged indicating that the brother
was the mother’s favorite, and that the patient felt the ‘‘black sheep’’ of the family,
utterly excluded.
Next, the relationship with his sisters. He said he had sexual feelings for two of
his sisters, Diana and Nancy. He was very attracted to Diana’s body and particularly
her large breasts. He was constantly curious to see as much as he could and as he grew
older his sexual interest became stronger and he had recurrent dreams about playing
with her genitals and other sexual activities.
There now emerged a link with the patient’s later life. He said that his wife and
Diana have very similar builds and that his wife had been very attractive to him in the
past, but not any more. He then revealed that he was also very curious about his
mother’s body when she was dressing, and that with her too it was her large breasts
that attracted him.

 1986 John Wiley & Sons, Ltd. Int. J. Short-Term Psychother. 1, 83–106 (1986)
96 D. Malan

The Link between the Past and the Patient’s Current Life

All this enabled the therapist to give interpretations pointing out that there must
be a link between these early relationships and the patient’s later difficulties with
women, although there was no time to explore this area in any depth:

TH: How do you feel talking about these things? You see, the picture is becom-
ing much more clear that in a sense in these early years there is this battle
ground of you, your father, the hostile relationship between you and your
father. So there is also this hostile relationship with your brother, okay? But
then there are a lot of women around, hmm? So you are surrounded with
women, hmm? Now one thing that we know, okay, is that in your current
life you have a serious problem with women.
PT: Mm hmm.
TH: So the fundamental question to ask is what is in the past of your life in
relationship to all these women which in a sense plays a role in your
problem in relationship with women in the current life. Do you see what I
mean?
PT: Yes.
TH: This is a fundamental basic issue that has to be looked at, that you have.
One can say that there are two sides in the early part of your life. One side is
this tremendous hostile relationship between you and your father, you and
your brother. Now we know it was a very devastating situation there
with your brother and so forth, but then you are surrounded by many
women. . . .

The Father’s Death

At the beginning of the present interview, all that the patient could remember of
his feelings towards his father consisted of hostility and fear. After the experience of
warm feelings towards the therapist, and probably in consequence of it, he discov-
ered memories making clear that the early relation with his father had been warm
and close, and that the hostility had arisen from a serious deterioration after the
patient’s return from evacuation and around the time of puberty. This discovery of
an earlier good relation is a pattern frequently encountered; and a further pattern is
that as the father ages and mellows, and particularly if he becomes ill and is about to
die, the possibility of warmth returns. However, this warmth is so contaminated by
guilt-laden hostility and grief about disappointed love, that it may be largely re-
pressed; and when the father dies the exceedingly painful feelings of loss may never
see the light of day and the whole process of mourning may be aborted. Nevertheless,
when the patient’s resistance against experiencing his true feelings has been loosened
by the process described above, it is possible to reach all these buried feelings with
the help of exactly the same technique as is used in crisis therapy, namely by
re-creating the memories and scenes surrounding the loved person’s death. This is
true even when—as in the present case—the death may have occurred as much as 20
years before. The therapist knows that the de-repression of these feelings is an
essential step in the therapeutic process, and that it must be undertaken before the
interview ends.

 1986 John Wiley & Sons, Ltd. Int. J. Short-Term Psychother. 1, 83–106 (1986)
 Initial Evaluation and Technique in Short-Term Dynamic Psychotherapy 97

The passage that follows illustrates very clearly both the return of resistance and
the fact that—after the long process leading up to the true experience of both
negative and positive feelings for the therapist—the resistance can be penetrated
relatively easily and without further reference to the transference.

TH: Do you remember when you saw your father last? Before he died? How
long before he died did you see him?
PT: I saw him in March.
TH: What do you remember? Where was he when you saw him?
PT: In bed. Sick.
TH: At home?
PT: Yes.
TH: What do you remember? How did he look like?
PT: Sick.
TH: Could you describe the way he looked?
PT: Weak. No, I don’t think I can. I can remember only . . . I mean I don’t have
a clear picture of him and the picture that I have of him is a much earlier
picture.
TH: Hmm?
PT: The picture I have of him in my mind is a much earlier period . . .
TH: Mm hmm.
PT: When he was more vital, more aggressive and more frightening. Then he
was in bed sick. He was an old man but I don’t have a clear picture of him in
my mind.
TH: Mm hmm.
PT: No, I must have seen him the last occasion on the day that I left to return to
Canada.
TH: You visited him?
PT: Yes, but I don’t remember actually seeing him.
TH: What was his sickness?
PT: He suffered constantly from attacks of heart failure. Finally he deteriorated
and died.
TH: How did you feel toward him when you were visiting him and he was dying?

The patient skates around the really painful aspects of his feeling:

PT: Well, I explained earlier that I felt much less angry towards him because I
. . . by then I had begun to realize that I had been feeling angry towards him
and had never realized it before.
TH: But my question was how you felt toward him because now he was a beaten
...
PT: I felt sorry, very sorry.

The therapist makes the source of the pain more explicit:

TH: He was now a beaten dying man and toward this beaten dying man at one
time you had wished that you could wipe him out.

 1986 John Wiley & Sons, Ltd. Int. J. Short-Term Psychother. 1, 83–106 (1986)
98 D. Malan

PT: I felt very sorry at that time that we had not been closer, that I had not been
able to be closer to him. I felt very sorry that I had not been able to know
him better and be able to talk to him, and I felt very sorry that I could do
nothing for him when he was in that condition.
TH: So it must have been very painful.
PT: Yes, it was. It was very sad. And I remember that just a few months later
when he died and I heard that he had died it was extremely difficult then.

The therapist now sets about re-creating one of the most emotionally laden
moments:

TH: Do you remember the last good-bye to your father?

The patient is immediately defensive:

PT: No, I just told you. I don’t remember.

TH: The last good-bye.
PT: No, I don’t remember the last occasion when I said good-bye to him.

The therapist simply ignores the defense and reacts as if the patient had said he
remembered this occasion very clearly:

TH: How did he react to you?

PT: He didn’t have much to say. He wished me well in my forthcoming
marriage.
TH: He wished you, hmm. Do you remember the occasion when he wished you
well?
PT: I remember the day of the wedding when I dressed and went to say good-bye
to him.
TH: Oh, you went to see him before you went to the wedding, hmm?
PT: Yes, because I was staying in the house.
TH: Hm hmm. Many years back he was an aggressive, hostile man, but now he
was so sick that he couldn’t come to your wedding.
PT: I don’t remember realizing that he was close to death. I didn’t realize it at the
time.
TH: But he was so sick that he couldn’t attend, hmm?
PT: Yes.
TH: How did he relate to you then?
PT: I remember only that he was more friendly towards me than he had been for
a long time.
TH: Mm hmm. It was a warmer . . .
PT: Yes.
TH: Mm hmm.
PT: And simply because he didn’t have the vitality. It seemed that he didn’t have
the vitality to be . . .

 1986 John Wiley & Sons, Ltd. Int. J. Short-Term Psychother. 1, 83–106 (1986)
 Initial Evaluation and Technique in Short-Term Dynamic Psychotherapy 99

TH: Then it must have been a very painful occasion for you because at one time
you wished him ‘‘out.’
PT: Yes.
TH: Hmm?
PT: Yes.
TH: How do you feel now when you remember dressing up and going down and
visiting your father before you went to your wedding? How do you feel?
PT: I feel sad. I feel sad because I know I was sad at the time when he was in the
condition that he was in.
TH: So there was a part of you that wished . . .
PT: I felt very sorry. I have felt very sorry for many years now since I have
begun to get an understanding of the conflict which existed between us
which I didn’t recognize before.

The therapist now concentrates on another highly emotional occasion:

TH: Now what do you remember of the funeral, his . . .?

PT: I didn’t attend the funeral.
TH: Did you want to go to the funeral?
PT: Yes.
TH: And what happened.
PT: I didn’t have the money available at the time to travel to England.
TH: Was that the only factor or it was less painful for you?
PT: I don’t remember considering whether I should or should not go.
TH: But this is not you, is it?
PT: I beg your pardon?
TH: You see, I mean you are a sensitive person, aren’t you? And you felt that
you wished, you were wishing of the father that you didn’t have. You
wanted, hmm? So you were very much touched when he was incapacitated.
PT: Yes, I was very affected.
TH: Mm hmm. And then we know a part, I mean you are a sensitive person or
aren’t you?
PT: Yes.
TH: Hmm? So do you think that in a sense a part of you wanted to go but a part
of you didn’t want to face it, hmm? A part of you didn’t want to face that
dead body, hmm? That you wanted to avoid, hmm? Where is he buried?

The breakthrough has occurred—the patient is crying, very sad.

PT: He was cremated.

TH: Mm hmm.
PT: And the ashes disposed of in the grounds of the crematorium in Southamp-
ton. I have never visited there.
TH: You have never visited? Did you wish to visit?
PT: Sometimes, but when I’ve been to England I have not visited.
TH: Mm hmm. But did you feel that you wanted to?

 1986 John Wiley & Sons, Ltd. Int. J. Short-Term Psychother. 1, 83–106 (1986)
100 D. Malan

PT: Yes, I did.

TH: Mm hmm. So it is a sort of avoiding . . .
PT: I have not wanted to reveal that I wanted to.

The patient is sobbing.

TH: Mm hmm. Mm hmm. So there is a very painful thing there, isn’t there?
Hmm?
PT: Yes.
TH: But avoiding it is not going to resolve it, is it?
PT: No.
TH: Hmm?
PT: No.
TH: So then you have been in the process of . . . and your not going to
Southampton, maybe also part of it had to do with finance, but if we look at
it you felt much more comfortable to avoid it, isn’t it.
PT: Yes, yes.
TH: So then you have a lot of mixed feelings about your father, isn’t there?
PT: Yes, yes, I remember little things.

The revived mourning process is beginning, but time is running short and the
therapist has to begin to close up the interview.

Final Phase: The Patient’s Response to the Interviews

The therapist now explores the patient’s reaction to the interviews, watching
particularly for motivation to continue:

TH: But do you think that in a sense—of course in these two session we only
touched the surface of your difficulties, your problems, very very surface
part, okay—but do you think what we did, if you did it on a more regular
basis rather than to continue to avoid, to face all your feelings, all these
buried feelings that you have, this might be of help to you?
PT: Yes, because although I find it very uncomfortable to talk to you in this
way, to be obliged to try to face these things and give answers. . . .
TH: But do you think it might be . . .
PT: Yes.
TH: Hmm?
PT: Yes, the practice which have gone through of being on the couch and being
allowed to try to make progress at my pace has obviously not been very
fruitful because I keep avoiding the issue. I simply have to learn . . .
TH: To face this.
PT: To face.
TH: Because, if you come to put all the memories and all feelings that you have
in the right perspective, then you don’t have to continue like this. Then you
can hopefully, possibly, be a free man, hmm? Because in a sense you are
really repeating the life of the past.

 1986 John Wiley & Sons, Ltd. Int. J. Short-Term Psychother. 1, 83–106 (1986)
 Initial Evaluation and Technique in Short-Term Dynamic Psychotherapy 101

The therapist ends by saying that the patient will be contacted later about
starting treatment.

Summary of the Course of the Interview

To recapitulate, the essential features of the technique consist of the first six
phases enumerated above:

(1) Pressure towards the experience of true feeling,

(2) Rise in resistance,
(3) Challenge to resistance,
(4) Rise in transference, with resistance now in the transference,
(5) Challenge to resistance in the transference, leading to
(6) Direct experience of transference feelings.

With the simpler and less resistant patients this sequence may need to occur only
once. With a patient such as the one just described, who arrived at the interview
already in a state of high resistance, it may have to be repeated several times.
A condensed account of this repeated sequence shows the following;
The patient’s initial resistance takes the form of vagueness and distancing, which
the therapist systematically challenges (phases 1 to 3).
Soon nonverbal cues indicate that the patient has become angry at not being
allowed to use his defenses, but is trying to conceal this and not to acknowledge it
even to himself (phase 4).
The therapist now breaks in, asking the patient how he feels at this very moment.
He systematically challenges the patient’s evasion, ending up by the ‘‘head-on
collision’’ with the resistance. This consists of forcefully pointing out that if the
patient continues in this fashion the interview will be as useless to him as all his
previous treatment has been.
This repeated cycle enables the patient to begin to acknowledge and finally to
experience fully all his complex feelings in the here-and-now. These consist, first, of
anger with the therapist, then of intense sadness at the prospect of repeating all his
past failures and going away from this interview empty-handed, and finally of deep
warmth and appreciation at the therapist’s genuine concern for his welfare (phase 6).
The true experience of all these feelings produces an unlocking of the patient’s
unconscious and a marked rise in the therapeutic alliance. The result is that, as the
cycle is repeated, interpretation begins to play an increasing part. In the early part of
the cycle the therapist did in fact give one interpretation, pointing out that the
patient’s smiling and fidgeting were ways of defending himself against his anger.
Even more important, the patient began to make his own interpretations, e.g., that
his accident-proneness was a form of suicide. This culminated in his spontaneously
explaining his resistance at the beginning of the interview as due to his expectation
that the therapist would behave like his father and ridicule him if he showed his real
feelings.
This led to a new phase in which the therapist systematically analyzed the
resistance in the transference by interpreting it in terms of the patient’s relation with
his father.
Now it was possible to enter the phase of pure ‘‘content,’’ in which the patient’s

 1986 John Wiley & Sons, Ltd. Int. J. Short-Term Psychother. 1, 83–106 (1986)
102 D. Malan

conflicting feelings could be explored and interpreted in all his relations throughout
his life, without any further reference to the transference.
During this phase some patients show very little resistance and their unconscious
therapeutic alliance actively collaborates with the therapist. In the patient this active
collaboration had already been shown previously by his spontaneous interpretations,
particularly his making the link between the transference and his father. In the
‘‘phase of pure content’’ he showed a different pattern, namely that of going into
resistance as each new anxiety-laden area was explored. Now, however, all the
therapist needed to do was not to employ challenge, but to sweep the resistance aside
by persisting in his questioning. Then the therapeutic alliance came into operation.
In the most dramatic example the therapist asks the patient what he felt when he was
knocked down and humiliated by his brother, to which he answers ‘‘I don’t know how
I felt.’’ The therapist then points out that the patient had openly expressed the wish
to kill his wife, and this quickly brings out the incident in which the patient had hit his
brother on the back of the head with a stone.
The final example of this penetration of the resistance by simply persisting with a
line of questioning occurred in connection with the father’s death. The patient says
he doesn’t remember considering whether or not he should go to England for the
funeral. The therapist says ‘‘But this is not you. You are a sensitive person.’’ The
patient says he has never visited the crematorium: ‘‘But did you wish to visit?’’
‘‘Sometimes, but I haven’t done so.’’ ‘‘But did you feel that you wanted to?,’’ ‘‘Yes I
did.’’ ‘‘So it is a sort of avoiding.’’ ‘‘I have not wanted to reveal that I wanted to,’’ and
the patient is sobbing.

The Patient’s Psychopathology

In the end it is possible to reconstruct the whole of the patient’s psychopathol-
ogy, which is very complex and can only be briefly summarized here. Foremost is the
feeling of exclusion from his family, enormously intensified by his evacuation during
the war, and compounded by the fact that his siblings were sent away in pairs,
whereas he was sent away alone. This gave rise to violent jealousy and hatred of his
rivals in several triangular situations, particularly that involving his brother and his
father. Next there is the whole area of his buried hatred of his father, beneath which
lay love and grief, the whole made unbearable by his father’s final illness and death.
Then there are his complex relations with the women in his family, which includes
jealousy, hostility, and guilt-laden sexual feelings. It is clear that all this has caused
serious inhibitions in his relations with women ever since. There are also indications
that he experiences a repetition of his early family situation in the form of jealousy in
the triangular relation involving his wife and his sons. The end product of all these
conflicts has been a severely and chronically impoverished character, who uses
intellectualization, distancing, and serious self-directed aggression as his main defen-
sive mechanisms. Yet these character defenses have been penetrated in two inter-
views, revealing the intense, guilt-laden, and almost unbearably painful feelings
underneath.

Essential Features of the Technique

Of all the features of this interview there are two that need special emphasis. The
first is ‘‘tactical,’’ the technique of challenging resistance rather than interpreting it.

 1986 John Wiley & Sons, Ltd. Int. J. Short-Term Psychother. 1, 83–106 (1986)
 Initial Evaluation and Technique in Short-Term Dynamic Psychotherapy 103

The second is more strategic and does involve interpretation, namely the systematic
dissolution of resistance, mostly in the transference, over and over again as each new
aspect arises. These strategic principles are identical with those of psychoanalysis;
but whereas there the process takes hundreds of hours (if indeed it can be accom-
plished at all), here the defences can be exhausted within two interviews.
The consequences all follow from the extraordinary power of the technique in
terms of its capacity to dissolve resistance. These can be described under the
following headings:

Therapeutic Consequences
After an interview of this kind the patient’s whole psychic system is made
permanently more fluid. During subsequent days and weeks most patients experi-
ence an upsurge from their unconscious in the form of fresh memories and significant
dreams. Their motivation to continue working in this way, which starts so low,
remains permanently enhanced, and they are prepared to wait almost indefinitely for
a chance to do so. When therapy begins, often with a therapist different from the
original evaluator, the therapist’s task is made much easier. Of course resistance
returns, but it often can be removed quite easily, and it rarely if ever needs such a
prolonged challenge as was necessary in the first interview.
As a result, though a certain amount of working through is necessary, instead of
the therapeutic process appearing to go round in circles—as it does in so much
long-term therapy—steady progress is made towards the resolution of each aspect of
the neurosis as it arises. It is then possible to deal with every aspect of even a complex
neurosis like that of the patient just described. In such a patient, therapeutic effects
usually begin to appear within the first 5–8 sessions, and therapy should be com-
pleted within 20–30 sessions, with total resolution of the neurosis at termination and
further confirmed at follow-up many years later.

Consequences in Terms of Selection

The first consequence is concerned with the accuracy of selection. After an
interview of this kind, the evaluator can be virtually certain that a skilled therapist
can achieve total resolution of the neurosis within the limits of short-term therapy. In
other words, whereas with the Tavistock technique the evaluator could only say that
successful results will come from among patients with certain characteristics—i.e.,
could define the necessary conditions—with this technique the evaluator can define
the necessary and sufficient conditions.
The difference clearly comes from the power, and hence the completeness, of
the process both of initial evaluation and of therapy. In the patient described above it
seems that all his neurotic conflicts were either reached directly or brought close to
the surface at initial evaluation; and not only does this predict that they can be
reached and worked through in therapy, but the very completeness predicts that total
resolution will follow. In other words the gap between dynamic interaction and
resolution, described at the beginning of the present article, has been closed.
On the other hand, the value of much of the Tavistock work is confirmed, in the
sense that many of the selection criteria and the basic principles of the selection
process hold equally well in Davanloo’s system, and are thus probably shown to be
general principles fundamental to STDP. These are as follows:

 1986 John Wiley & Sons, Ltd. Int. J. Short-Term Psychother. 1, 83–106 (1986)
104 D. Malan

(1) The need for a comprehensive psychiatric history;

(2) The elimination of unsuitable patients;
(3) The use of trial therapy;
(4) The formulation of positive selection criteria:
(a) The ability to make a comprehensive psychodynamic formulation;
(b) The ability to plan therapy:
(c) A positive response to trial therapy, especially in terms of response to
interpretation and an increase in motivation.

The Tavistock principle that does not apply in Davanloo’s technique is the need
for a basic simplicity or ‘‘focality’’ in the patient’s problems. As mentioned above,
the power of the technique is such that even problems of great complexity can be
resolved within the limits of short-term therapy, each aspect of the neurosis being
brought into the open and resolved in turn.
It is very important that this difference between the two systems should be
emphasized, since after the publication of the Tavistock work the principle of
‘‘focality’’ or simplicity of psychodynamics has been widely accepted as a necessary
condition to all forms of STDP. In Davanloo’s system this is no longer so.

Quantitative Consequences
Whereas with the Tavistock technique only a few percent of patients are suit-
able, with Davanloo’s technique this proportion is immensely higher. In a consecu-
tive series of general psychiatric patients seen at out patient Psychiatric Department
of The Montreal General Hospital—in contrast to the Tavistock series, where the
patients were carefully selected from those already referred for psychotherapy—the
figures were as in Table 1.
Recent work with even more difficult patients suggests that the proportion of
suitable patients can be raised to about 35%.
The number of sessions required varies from 1–5 with simple symptomatic
neuroses, to about 40 with highly complex character neuroses.

Theoretical Consequences and Conclusion

Here we may return to the questions that I raised at the beginning when
considering the position of purely interpretative therapy, whether short-term or
long-term.
In traditional short-term therapy the situation is as follows: the therapist selects
patients with a clear-cut central problem and aims to work this through to the
maximum degree within a limited number of sessions. There is no difficulty in

Table 1. Proportion of Patients Suitable for STDP in Davanloo’s Series

Total number of general psychiatric patients: 617

Taken into STDP with Davanloo: 172 (28%)
Successful results (total resolution): 143 (23%)
Proportion of successful results in the 172 treated: 143/172 = 83%
Of these 60% had follow-up ranging from two to nine years.

 1986 John Wiley & Sons, Ltd. Int. J. Short-Term Psychother. 1, 83–106 (1986)
 Initial Evaluation and Technique in Short-Term Dynamic Psychotherapy 105

selecting patients who respond to this process in each session, and it frequently leads
to dramatic responses to interpretation and intense experiences; but in all too many
cases this does not result in the desired resolution of the neurosis.
The advocates of long-term therapy as the only true way of achieving deep-
seated changes will say that if therapy had gone on for long enough then the
resolution would have occurred; and that the reason for the failure of short-term
methods in these cases is the lack of sufficient working through, and the failure to
deal with the complexities of the neurosis and all the over-determinations. In some
cases no doubt this is true, but every honest psychotherapist will admit that in many
of his long-term cases, probably the majority, something similar happens to the
events that I described in short-term therapy; namely that apparent working through
does take place, with daily response to interpretation, fresh insight, and the experi-
ence of buried feelings—particularly in the setting of the transference neurosis—but
the therapeutic effects fail to materialize. Systematic follow-up, such as that carried
out recently at the Tavistock Clinic (not yet published), reveals that this observation
is correct. What has gone wrong?
It seems to me that Davanloo’s work has found the answer to this question,
which can only be understood clearly after a long preamble:
Traditional therapy is based on obtaining positive responses to interpretation.
Every such response can be placed on a continuum between purely cognitive at one
end and purely affective at the other, with various combinations of the two in
between. A purely cognitive response—‘‘I know what you say is true but I do not feel
it’’—is not a positive response. A highly positive response, on the other hand, would
be a purely affective one, such as the patient breaking down into tears about the loss
of someone dear to him and sobbing without words for a long time.
This does happen, but not very often, and in between the two extremes there are
various intermediate stages. In traditional interpretative therapy the therapist is
usually satisfied if the patient’s response shows some or all of the following
characteristics: there is a drop in tension and an increase in spontaneity and rapport,
the patient is clearly more in touch with his feelings, and fresh communications
emerge which confirm the interpretation and elaborate upon it. When therapy is
going well there is then often a ‘‘leapfrogging’’ process in which (1) the patient goes
further than the therapist has, (2) the therapist is then able to go further than the
patient has, and (3) the two of them work towards some painful or anxiety-laden
feeling.
However, it must be remembered that such responses contain a mixture of
affective and cognitive components, and the question is always whether the affective
component is sufficient for the therapeutic process to be successful. We know from
follow-up studies that sometimes it is, but from the same follow-up studies we also
know that in many cases—indeed in the majority—it is not.
We can postulate that each patient contains a kind of reservoir of pathogenic
conflict—the analogy of an abscess is often used—and that the aim of therapy is to
drain this reservoir until it is empty. According to therapy, each time the patient
responds to an interpretation and thus is brought nearer to the experience of his
underlying feelings, or each time a link is made, a small amount of pathogenic
material is drained from the reservoir. This is what is meant by working through.
But the evidence now suggests that this is not necessarily so. Suppose it were true
that there is a threshold in the cognitive/affective continuum, below which not

 1986 John Wiley & Sons, Ltd. Int. J. Short-Term Psychother. 1, 83–106 (1986)
106 D. Malan

merely very little but no working through takes place—nothing is drained from the
reservoir. If this were true the therapist could go on making interpretations and
receiving responses indefinitely, without any appreciable therapeutic effects whatso-
ever. In that way therapy becomes endless.
It follows from this that the patient can use response to interpretation as resis-
tance. He keeps the therapist happy by giving the impression that his problems are
being worked through, whereas in fact nothing of the kind is taking place at all.
The mistake the therapist is making is not to realize that he is operating
below the threshold at which true working through takes place, and therefore
to work with the component of response to his interpretations, or the component of
communication—which indeed is present—rather than the component of resistance.
Only when he systematically works with the resistance and eventually brings the
patient to a point above the threshold, where there is sufficient true experience of the
underlying feelings, can genuine therapy begin.
Moreover, it appears from Davanloo’s work that merely interpreting resistance
is not enough. On the contrary, first the resistance has to be systematically chal-
lenged, and then the consequent transference feelings have to be brought into the
open and truly experienced. Only by this means can most patients be brought above
the threshold where interpretation becomes therapeutically effective. It is these twin
interventions that constitute the core of Davanloo’s technique and his most impor-
tant and most original contributions.
These early phases usually need to be followed, as in the above interview, by a
phase in which the residual resistance is systematically dissolved by interpretation,
including many links with other relationships in the patient’s life. When this has been
done an immensely important consequence follows, which is an observed fact but
which traditional therapists may have difficulty in believing. This is that the reservoir
does not contain a huge volume of pathogenic conflict which has to be drained drop
by drop over a long period. Nor is it under such pressure that weakening the defenses
causes it to erupt in uncontrollable explosions of affect such as occur in many
encounter groups. On the contrary, it can often be drained quickly and relatively
smoothly, with quiet yet intense experience, each component being dealt with once
for all. The final result is total resolution—the reservoir is left permanently empty.
Perhaps we may end with two statements that sum up one of the main points in
the above argument: ‘‘The most devastating and pernicious form of resistance is
response to interpretation;’’ and ‘‘The greatest mistake a therapist can make is not to
recognize when response to interpretation is being used as resistance.’’

References
Malan, D. H. (1985). Beyond interpretation: Initial evaluation and technique in short-term dynamic
psychotherapy. Part I. International Journal of Short-Term Psychotherapy, 1, 59–82.

 1986 John Wiley & Sons, Ltd. Int. J. Short-Term Psychother. 1, 83–106 (1986)