Malan brief therapy

1. Introduction

Version followed: David Malan's Tavistock brief focal psychotherapy as consolidated in The Frontier of Brief Psychotherapy (1976) and Individual Psychotherapy and the Science of Psychodynamics (1979; chs 10, 16–22), building on the Balint-team research of A Study of Brief Psychotherapy (1963). It is NOT the later Davanloo-influenced ISTDP-style "pressure on defences" model (post-1974), which is noted only where it changes technique.

Malan's brief psychotherapy is a time-limited, focal, interpretive psychodynamic therapy. A carefully selected patient and therapist agree a single focus (a core conflict expressed as an interpretation), a fixed termination date is set at the outset, and the therapist actively interprets the conflict in the session and in the patient's relationships. Change is held to come from the patient experiencing previously warded-off feelings, at a pace they can bear, and from linking those feelings across current relationships, the relationship with the therapist and the parents (the T-C-P link). Malan's research aim was to show that brief therapy can produce deep and lasting change, not only symptomatic relief. Malan's stated session aim: put the patient "in touch with as much of their true feelings as they can bear." [source: BJPsych Bulletin obituary 2023; Wikipedia "David H. Malan"; Malan 1963 catalogue abstract]

Practical note: Malan's books are research-and-teaching texts with extended case material, not a session-by-session manual. The steps below operationalise what he describes; operational detail added by me is marked [synthesis]. Full texts of the 1963/1976/1979 books are not drawn on; claims taken from general knowledge of those books are marked [uncertain].

2. Framework

Format. Individual, face to face, once weekly, roughly 50 minutes [uncertain: standard Tavistock format]. Time-limited with a fixed end date agreed before therapy begins [source: psychology.town summary; Malan 1976]. Session counts: the 1963 Balint series ran from a few sessions up to about 40 [uncertain]; in the later Tavistock Brief Psychotherapy Workshop (set up 1967) the usual practice was a date-based limit of about 20 sessions for trainees and up to about 30 for experienced therapists, with an outer bound around 40 [uncertain: commonly cited figures from Malan 1976; exact numbers]. Follow-up interviews were part of the method (the 1992 Malan & Osimo volume reports long-term follow-up of 30 cases) [source: BJPsych obituary 2023].

Phase 1: Assessment and selection (1–3 meetings, plus optional projective testing).

Goals: psychiatric inquiry and differential diagnosis; a psychodynamic hypothesis that explains symptoms, precipitating factors and life pattern; test the patient's response to interpretation; gauge motivation for insight; identify a feasible focus; set outcome criteria; screen out contraindications. [source: Malan 1979 table of contents, chs 17–22; Malan 1963 contents: "psychodynamic assessment", "selection criteria"]
Tavistock assessments often included a projective test (Phillipson's Object Relations Technique) [uncertain].
Move on when: a focus can be formulated as a single essential interpretation; the patient has responded to trial interpretation with deeper feeling or new relevant material; motivation for insight is present; no exclusion criteria apply; the therapist can foresee no unmanageable dangers (see §4, Selection screen). [source: Malan 1976/1979, paraphrased; uncertain on exact wording]

Phase 2: Contract (end of assessment or session 1).

Goals: agree the focus in words the patient can use; state the termination as a calendar date (not just a number); explain the way of working (say what comes to mind; the therapist will point out patterns, including feelings about the therapist). [source: Malan 1976 date-based limit, uncertain]; [synthesis for wording]

Phase 3: Early focal work (roughly first quarter).

Goals: establish the working alliance; begin interpreting defence and anxiety around the focal conflict; start linking current relationships (C) to the therapist (T). Malan found that motivation and focality measured over the first few sessions predicted outcome better than at intake [uncertain: Malan 1976 finding as usually summarised].
Move on when: the patient can recognise the defence-anxiety-feeling sequence when pointed out and transference feelings have begun to appear.

Phase 4: Middle focal work (bulk of the therapy).

Goals: repeated working through of the focal conflict on both triangles; transference interpretation, especially transference-to-parent (T/P) links, which correlated with good outcome [source: Wikipedia "David H. Malan"; Malan 1963]; keep to the focus with selective attention [uncertain on phrase].
Move on when: the termination date approaches (by calendar, not by readiness); in practice begin explicit termination work about one-quarter to one-third of the way from the end [synthesis].

Phase 5: Termination.

Goals: work through feelings about ending (grief, anger, rejection, dependency) as transference and as a repetition of the focal conflict, linked to past losses; keep the date. [source: Malan 1979 ch 16 "Termination and Breaks in Treatment"; Malan 1963 radical technique included work on termination, uncertain]

Phase 6: Follow-up.

Goals: reassess against the psychodynamic outcome criteria fixed at assessment; Malan's follow-ups ran for years [source: BJPsych obituary; Malan & Osimo 1992]. Clinical frequency for a practitioner: e.g. 3–6 months and 1 year after ending [synthesis].

3. Guiding principles

Selection is part of treatment. Practical meaning: put real effort into assessment; a wrong selection is the commonest route to failure. [source: Malan 1963 contents; Malan 1979 chs 17–22]
Brief is not superficial. Practical meaning: aim at the core conflict, not just symptom relief; well-selected patients with fairly long-standing problems can change deeply. [source: BJPsych obituary; Malan 1963 abstract, radical vs conservative views]
Radical, active, interpretive technique. Practical meaning: interpret early and actively, including the transference; do not wait passively for material. [source: Wikipedia "David H. Malan" ("radical interpretive approach")]
One focus, held throughout. Practical meaning: formulate the focus as an interpretation and keep returning to it; let other material pass unless it links back. [source: Malan 1976, uncertain on wording]
Fixed time limit set as a date. Practical meaning: name the end date at the start and keep it; the ending is itself therapeutic material. [source: psychology.town; Malan 1976, uncertain]
Use both triangles together. Practical meaning: in every intervention ask which corner of conflict (defence, anxiety, hidden feeling) and which corner of persons (other, transference, parent) you are addressing. Malan's skill test: "knowing which part of which triangle to include at any given moment." [source: Wikipedia "Malan triangles", quoting Grant & Crawley 2002 p. 123]
The T-C-P link is the core interpretive aim. Practical meaning: aim, over the therapy, to show the same feeling-conflict with the therapist (T), current others (C) and parents (P); T/P links mattered most for outcome. [source: Wikipedia "David H. Malan"; Malan 1979 ch 10]
Reach the hidden feeling at a bearable pace. Practical meaning: each session aims for maximal contact with true feeling the patient can tolerate; monitor anxiety and back off if it becomes disorganising. [source: BJPsych obituary quote]
Defence and anxiety before hidden feeling. Practical meaning: name how the patient avoids and what they fear before naming the feeling itself. [uncertain: standard reading of Malan 1979 ch 10; not verified verbatim]
Let the patient's response judge the intervention. Practical meaning: a correct interpretation is followed by deepening rapport, new relevant material or feeling; increased defence or flatness means revise. [source: Malan 1979 ch 10 "The Dialog of Psychotherapy", paraphrased, uncertain]
Challenge the defence, not the person. Practical meaning (post-1974 refinement): when confronting avoidance, make clear you are on the patient's side against the defence. Malan: "the challenge was to the defences, not to the patient directly." [source: Wikipedia "David H. Malan"]
Therapist involvement and enthusiasm. Practical meaning: be engaged and invested in the focus; Malan's 1963 series linked therapist involvement to good outcome. [uncertain: finding recalled from Malan 1963]
Define outcome criteria in advance. Practical meaning: write down before therapy what would count as real psychodynamic change for this patient, and judge the result against it, not against symptom relief alone. [source: Malan 1963 abstract ("a method for assessing results"); Malan & Osimo 1992]
Respect the consequences of making contact. Practical meaning: even an assessment interview that reaches deep feeling can destabilise a fragile patient; plan for that. [source: Malan 1979 ch 22 title "The Consequences of Making Contact"; content paraphrased, uncertain]

4. Intervention inventory

Malan does not number his techniques; the inventory below groups what he describes into assessment, contract, in-session and ending interventions. Sources: Malan 1963 (contents), 1976, 1979 (chapter structure via publisher TOC), secondary pages listed in Sources. All example language is illustrative unless quoted.

4.1 Psychiatric inquiry and differential diagnosis

Purpose / when: first assessment meeting; establish diagnosis, risk and history before any dynamic work, so that contraindications are not missed. [source: Malan 1979 ch 18 title "The Importance of the Psychiatric Inquiry and Differential Diagnosis"]
Steps: (1) Take presenting complaint, onset and course. (2) Ask specifically about previous breakdowns, hospital admissions, suicide attempts, self-harm, substance use, ECT, psychotic symptoms. (3) Take a developmental and relationship history (parents, siblings, losses, current partner, work). (4) Note the precipitating event of the current episode and its timing. (5) Complete a standard suicide/risk assessment where indicated. [synthesis for step order]
Example language (illustrative): "Before we look at what lies behind this, I need to understand the facts: when did it start, and has anything like it happened before?"
Watch for: a history that triggers exclusion (see 4.6); a precipitant that already hints at the conflict (e.g. symptoms beginning when a partner left).

4.2 Psychodynamic assessment: forming the dynamic hypothesis

Purpose / when: throughout assessment; produce a hypothesis that explains the symptoms, the precipitant and the life pattern as one conflict, and forecasts what therapy will stir up. [source: Malan 1979 ch 19 "The Psychodynamic Assessment and Psychotherapeutic Forecasting"; Malan 1963 "psychodynamic assessment"]
Steps: (1) Collect recurring patterns across relationships (C and P corners). (2) For each pattern, ask what feeling seems to be avoided (hidden feeling), what the patient fears would happen if it were felt (anxiety), and how they avoid it (defence). (3) Check whether the precipitant activated that conflict. (4) Write the hypothesis in one or two sentences. (5) Forecast: what will happen in the transference, especially around dependence and ending? [synthesis for steps; triangle content per Malan 1979 ch 10]
Example (illustrative formulation): "Since childhood she has protected herself from anger at people she depends on (hidden feeling) because she fears losing them (anxiety) by becoming over-helpful and self-blaming (defence); her depression began when her husband's illness made her caretaking unrewarded."
Watch for: a hypothesis that explains everything but predicts nothing; Malan valued hypotheses that are testable by the patient's response and by outcome. [uncertain]

4.3 Trial interpretation

Purpose / when: assessment, once a tentative hypothesis exists; to test whether the patient can use interpretive work. A key selection criterion was the patient's capacity to respond to interpretation. [source: Malan 1976/1979; uncertain]
Steps: (1) Choose a piece of material from this interview that shows the conflict. (2) Offer a short interpretation, usually linking defence or anxiety to a feeling, and if possible linking a current relationship to the interview situation or to a parent. (3) Stop and observe: feeling, associations, new memories, agreement or disagreement with substance. (4) If the response is defensive, offer one more, gentler version. (5) Record the response as evidence for selection.
Example language (illustrative): "You've told me three times today that you don't want to be a burden. I wonder if that is also what you're feeling here with me, and whether it hides some resentment at having to manage alone, as you did with your mother."
Watch for: good response = deepened feeling, tears or anger with relief, new relevant material, spontaneous linking; poor response = intellectual agreement with no feeling, bland denial, confusion, or marked disturbance (a warning sign; see 4.6 and §5).

4.4 Assessing motivation for insight

Purpose / when: assessment and first few sessions; Malan treated motivation for insight (not just for symptom relief) as a major predictor and re-rated it over the early sessions. [uncertain: Malan 1976 finding as commonly summarised]
Steps: (1) Ask what the patient hopes will change and how they think it will happen. (2) Observe whether they engage with trial interpretations as about themselves. (3) Note whether they bring material linking to the focus at the next meeting. (4) Re-rate after sessions 3–4; rising motivation is favourable, falling motivation a warning. [synthesis for the rating schedule]
Example language (illustrative): "What would you want to understand about yourself, not just get rid of?"
Watch for: motivation only for relief or for being looked after; motivation that collapses after the first interpretation.

4.5 Formulating the focus (and assessing focality)

Purpose / when: end of assessment; to define the single conflict the therapy will address. Malan's usual aim was to state the focus as an essential interpretation on which the therapy would rest [uncertain: wording recalled from Malan 1976]. Focality (whether patient and therapist can stay with a focus) was the second major predictor in his studies [uncertain].
Steps: (1) From the hypothesis (4.2), choose the conflict that links symptom, precipitant and transference most directly. (2) State it as one sentence in triangle terms (defence / anxiety / hidden feeling; with whom). (3) Check feasibility: can it plausibly be worked through by the date you will set? (4) Translate it into plain words for the patient. (5) In the first sessions, note whether material keeps returning to it; if not, revise once, early. [synthesis for steps 3–5]
Example language (illustrative): "The thread I think we should follow is how you keep yourself from feeling angry at people you need, because some part of you fears they'll leave, and how that leaves you depressed instead."
Watch for: foci that are too broad ("her relationships"), too many themes, or a focus requiring regression or long dependence to reach (warning per Malan's selection dangers, 4.6).

4.6 Selection screen (contraindications and foreseeable dangers)

Purpose / when: end of assessment, before offering brief therapy. [source: Malan 1979 chs 20–21 titles "Indications for Brief Psychotherapy" and "Contra-Indications to Uncovering Psychotherapy"]
Steps: (1) Check for the exclusion history Malan's workshop used: serious suicide attempts, drug addiction, long-term hospitalisation, more than one course of ECT, chronic alcoholism, incapacitating chronic obsessional or phobic symptoms, gross destructive or self-destructive acting out [uncertain: list from Malan 1976 as reproduced in secondary texts]. (2) Check for foreseeable dangers: inability to make contact; need for prolonged work to generate motivation or break through rigid defences; inevitable involvement in deep-seated issues unlikely to be worked through in the time; severe dependence or intensely negative transference; risk of intensified depressive or psychotic disturbance [uncertain: same source]. (3) If any apply, refer for longer-term or different treatment.
Historical note: the original exclusion list also named homosexuality, reflecting the psychiatry of its time. This criterion is obsolete and pathologising and must not be used; sexual orientation is not a contraindication. [synthesis; current ethics]
Example language (illustrative): "I think what you're dealing with deserves more time than this short format allows; I'd recommend a longer therapy, and here is how we can arrange that."
Watch for: pressure (service waiting lists, patient eagerness) to over-include.

4.7 Setting psychodynamic outcome criteria

Purpose / when: end of assessment; to define in advance what real change would look like for this patient. [source: Malan 1963 abstract (method for assessing results); Malan & Osimo 1992]
Steps: (1) From the hypothesis, list what a resolved conflict would look like in behaviour and feeling (e.g. can express anger directly and remain close). (2) Include symptom criteria and relationship/work criteria. (3) Write them before therapy starts; do not change them afterwards. (4) Use them at termination and follow-up.
Example (illustrative): "Criteria: able to say no to her mother without guilt-driven depression; able to show irritation with her husband and then make up; no need to be indispensable at work."
Watch for: criteria that only describe symptom loss; Malan distinguished symptom relief from psychodynamic change. [source: BJPsych obituary]

4.8 Contracting the focus and a fixed termination date

Purpose / when: at the offer of therapy; to make the time limit and focus explicit so that ending becomes usable material. [source: psychology.town (end date set before therapy began); Malan 1976, uncertain on details]
Steps: (1) Share the focus in plain words (4.5). (2) Give the end date as a calendar date, counting in known breaks. (3) Explain the method: speak freely; the therapist will point out patterns, including feelings towards the therapist. (4) Agree arrangements for missed sessions (they are not added on) [synthesis]. (5) Mention follow-up.
Example language (illustrative): "We'll meet weekly until 14 March, and stop then. We'll keep to the thread we've agreed. I'll often point out how things you describe with others seem to happen here with me too."
Watch for: the patient bargaining about the date at the start (early sign of the dependence/ending conflict; note it, do not extend).

4.9 Mapping the triangle of conflict in session material

Purpose / when: continuously, as a silent clinical activity guiding every intervention. Corners: defence (D), anxiety (A), hidden feeling (HF, earlier called impulse). [source: Wikipedia "Malan triangles"; Malan 1979 ch 10]
Steps: (1) While listening, label in your head: what is being avoided now (HF), signs of fear or tension (A), and the manoeuvre (D: changing subject, intellectualising, vagueness, compliance, self-attack, smiling over pain). (2) Note which corner is most visible. (3) Choose an intervention that moves one corner closer to awareness (4.10–4.12).
Example language: none (internal mapping).
Watch for: confusing anxiety with the hidden feeling (e.g. treating guilt or fear as the core feeling when it is a response to anger or grief).

4.10 Pointing out and clarifying the defence

Purpose / when: when a defence is active and visible in the session, typically before the hidden feeling can be reached. [uncertain: "defence and anxiety before feeling" as standard reading of Malan 1979]
Steps: (1) Describe the behaviour neutrally and concretely, as it happens. (2) Ask or suggest what it does for the patient. (3) Link it, when possible, to the same defence outside (C) or in childhood (P). (4) Observe the response; repeat later if needed rather than pressing hard in the moment (Malan's gentler post-Davanloo stance: persistent rather than abrasive). [source: BJPsych obituary; Wikipedia "David H. Malan"]
Example language (illustrative): "Just as you started on your father's funeral, you moved to the traffic this morning. Did you notice that? I wonder if it's a way of stepping back from something painful."
Watch for: the defence lessens and affect rises (working); the patient feels criticised (reframe: you are against the defence, not them; see principle in §3).

4.11 Interpreting the anxiety

Purpose / when: when the defence is recognised but the patient still cannot approach the feeling; name the feared consequence.
Steps: (1) Ask or suggest what the patient fears would happen if the feeling were felt or shown. (2) Make the fear specific (loss, retaliation, guilt, damaging the other). (3) Link the fear to its origin (P) and to its appearance with the therapist (T). [source: triangle structure per Malan 1979 ch 10; steps synthesis]
Example language (illustrative): "It seems that if you let yourself be angry with him, you're afraid he'd simply go, the way your mother withdrew whenever you were difficult."
Watch for: relief, recognition, a shift towards the feeling; or escalating anxiety that needs slowing and support (§5, overwhelm).

4.12 Reaching and naming the hidden feeling

Purpose / when: when defence and anxiety have been addressed and the feeling is near the surface; the aim of every session. [source: BJPsych obituary quote]
Steps: (1) Name the feeling directly and specifically (anger, grief, longing, love, envy, guilt over aggression). (2) Invite the patient to stay with it now rather than talk about it. (3) Hold silence; do not rush to reassure. (4) Afterwards, help the patient connect it with the relationship it belongs to.
Example language (illustrative): "There's a lot of grief there, isn't there. Let's not move away from it."
Watch for: genuine feeling with relief and new memories (working) versus a dramatic or flooding response without reflective capacity (slow down).

4.13 Triangle-of-person links (C/P, C/T, T/P) and the T-C-P link

Purpose / when: whenever a feeling or pattern appears in one corner (current Other, Transference, Parent/past); the cumulative goal is a full T-C-P link. T/P links correlated with good outcome in Malan's series. [source: Wikipedia "David H. Malan" (good outcome correlated with interpretations linking transference to childhood); Wikipedia "Malan triangles"; Malan 1979 ch 10]
Steps: (1) Identify the corner the material is in. (2) Make a two-corner link first (often C/P early, C/T next). (3) When the feeling appears towards you, make the T link explicitly and as close as possible in time to the event. (4) Complete with the P corner (T/P), then all three. (5) Combine with the conflict triangle: the same D-A-HF in each person corner.
Example language (illustrative): "What you describe with your manager — holding back irritation, then feeling flat — seems to have happened here when I changed our time last week. And it's what you did with your father when he was drinking. Each time the anger goes underground and you end up depressed."
Watch for: intellectual agreement without feeling (the link is premature; return to defence/anxiety); new memories, emotional recognition, spontaneous links by the patient (working).

4.14 Transference interpretation (including negative transference)

Purpose / when: whenever feelings about the therapist bear on the focus, especially around dependence, disappointment, breaks and the time limit. Part of Malan's "radical" technique. [source: Wikipedia "David H. Malan"; Malan 1979 ch 9 "The Relation with the Therapist: 'Transference'"]
Steps: (1) Listen for allusions to the therapist in material about others (disguised references, e.g. complaints about unhelpful professionals). (2) Bring them into the room tentatively. (3) Welcome negative feelings; do not defend yourself. (4) Link to C and P (4.13). (5) Keep transference work on the focal conflict.
Example language (illustrative): "You've been talking about the GP who never really listens. I wonder whether some of that is about me, too — that I'm one more person who'll see you for a while and then stop."
Watch for: confirmation via feeling and more open material; strong negative transference early may signal unsuitability (4.6).

4.15 Keeping the focus: selective attention and selective neglect

Purpose / when: throughout; to keep a brief therapy from drifting into open-ended exploration. [uncertain: phrase associated with Balint/Malan focal therapy]
Steps: (1) Before each session, recall the focus sentence. (2) In session, follow and interpret material that links to it; acknowledge but do not pursue unrelated themes. (3) When the patient drifts, gently relate the new material to the focus or note that it lies outside it. (4) If a different conflict keeps dominating, consider in supervision whether the focus was wrong (revise only early).
Example language (illustrative): "That matters, and I notice it's another situation where you ended up looking after everyone else — the same thread we've been following."
Watch for: the therapist (not only the patient) losing the focus; sessions that feel interesting but unconnected.

4.16 Monitoring the dialogue: using the patient's response

Purpose / when: after every intervention; to judge accuracy and pacing. [source: Malan 1979 ch 10 title "The Dialog of Psychotherapy"; content paraphrased, uncertain]
Steps: (1) After an intervention, attend to the next few minutes: does feeling deepen, rapport increase, new linked material appear? (2) If yes, continue along that line. (3) If the patient becomes flatter, more defended, compliant or confused, consider that the intervention was premature, wrong, or wrongly phrased; go back to defence/anxiety or to a different corner.
Example language (illustrative): "That didn't seem to fit. Help me see where I got it wrong."
Watch for: accepting verbal agreement as confirmation.

4.17 Working with breaks in treatment

Purpose / when: before and after holidays, cancellations by either party; breaks rehearse the ending and evoke the focal conflict. [source: Malan 1979 ch 16 title "Termination and Breaks in Treatment"; content paraphrased, uncertain]
Steps: (1) Announce your breaks early. (2) In the sessions before and after, listen for reactions (lateness, missed sessions, sudden symptom return, talk of others leaving). (3) Interpret them in T and link to C/P and the focus.
Example language (illustrative): "You missed the session after my week away and said it didn't matter. I wonder if it mattered more than you could let yourself feel."
Watch for: reactions that are denied entirely; these are often the clearest focal material.

4.18 Termination work

Purpose / when: final third of therapy, intensifying near the date; ending usually evokes the focal conflict (loss, anger at being left, dependence). Working through feelings about termination was part of the technique associated with good outcome in Malan's studies [uncertain: 1963/1976 finding as recalled]. [source: Malan 1979 ch 16]
Steps: (1) Remind the patient of the date regularly from about two-thirds of the way through [synthesis for timing]. (2) Invite and interpret feelings about ending, especially disappointment, anger and grief, as they appear in T. (3) Link them to past losses (P) and current relationships (C). (4) Review what has changed against the agreed focus. (5) Keep the date; do not extend because feelings intensify (that is the work). (6) Arrange follow-up.
Example language (illustrative): "We've four sessions left, and you've said it's fine to stop. Yet you've been talking about friends who drift away. I think part of you feels I'm abandoning you, as you felt when your father left, and you're angry, and it's hard to say so to me."
Watch for: working = patient can feel and voice grief/anger about ending and still value the therapy; warning signs = flight into health, sudden crisis, requests to extend (see §5).

4.19 Follow-up assessment

Purpose / when: months to years after ending; assess durable psychodynamic change against criteria fixed at assessment. [source: BJPsych obituary; Malan & Osimo 1992]
Steps: (1) Meet once, ideally at agreed intervals. (2) Ask open questions about the areas covered by the outcome criteria, without prompting. (3) Rate against the criteria. (4) If change is partial or lost, consider further treatment.
Example language (illustrative): "Tell me how things have been since we stopped, with your husband, your mother, at work."
Watch for: symptom absence with the old defence intact (Malan would not count this as full psychodynamic recovery). [source: BJPsych obituary on deep vs superficial change; interpretation uncertain]

4.20 Persistent challenge to defences (post-1974 development; outside the version followed)

Purpose / when: included for completeness because Malan adopted it after watching Davanloo's videotaped ISTDP from 1974. He kept the persistent confrontation of defences but judged Davanloo's abrasive element unnecessary, holding that gentle but persistent blocking of defences would exhaust them and produce alliance. [source: BJPsych obituary; Wikipedia "David H. Malan"]
Steps (brief, as described): (1) Identify the defence as it occurs. (2) Point it out again each time it recurs, clearly on the side of the patient's wish to feel. (3) Avoid hostile or contemptuous tone. Full operational technique belongs to ISTDP/experiential dynamic therapy and is not covered here.
Example language (illustrative): "There it is again — the shrug just as the feeling comes. Can we not let it take over this time?"
Watch for: the patient experiencing pressure as attack; rupture (§5).

5. Handling problems

Malan's primary defence against most problems is selection (4.6) and the triangle-guided interpretation of whatever happens as focal material. Specific guidance beyond that is largely my own and is marked.

Patient stuck / no movement on the focus. Check the focus: is the material consistently elsewhere? Revise early (by about session 4–5) if so [synthesis]. Check whether you have been interpreting the hidden feeling before the defence and anxiety; return to D and A [uncertain: standard reading of Malan 1979]. Look for the stuckness itself as transference (e.g. compliant waiting for the therapist to do the work) and link it T-C-P [source: Malan 1979 ch 10, synthesis for application].
Intellectualised agreement ("yes, I see the pattern"). Treat as a defence (4.10): note the absence of feeling and ask what would happen if they felt it [synthesis]. Malan's aim is felt contact, not insight in words [source: BJPsych obituary].
Resistance as defence in the room. Point out the defence concretely each time, as against the defence, not the person; Malan later favoured persistence over abrasiveness [source: Wikipedia "David H. Malan"; BJPsych obituary]. Avoid power struggles: if the patient feels accused, acknowledge it and repair (see ruptures).
Overwhelm / rising anxiety, disorganisation, dissociation. Malan's bound: as much feeling as the patient can bear [source: BJPsych obituary]. Slow down: move from hidden feeling back to anxiety, offer more structure, summarise, ground in the present relationship, end the session with reflection rather than at peak affect [synthesis]. If anxiety becomes disorganising across sessions, or psychotic or severe depressive features appear, this is one of Malan's foreseeable dangers; reassess suitability, consider psychiatric review and a different or longer treatment [source: Malan 1976 dangers list, uncertain].
Suicidal ideation or self-harm emerging. Conduct a standard structured risk assessment and follow local protocols; brief uncovering therapy may need to pause or convert to supportive or longer-term care [synthesis]. Serious suicide attempts were an exclusion criterion for the Tavistock series [uncertain].
Missed sessions, lateness, non-attendance. Do not add sessions to the end (keeps the date) [synthesis]. Interpret the absence in the focal frame, often as avoidance of feeling towards the therapist or rehearsal of ending (4.17) [source: Malan 1979 ch 16 theme, uncertain]. Repeated non-attendance early suggests low motivation (4.4): discuss openly whether brief therapy is right now.
Negative transference and ruptures. Welcome and interpret the anger or disappointment towards you; link to C and P; acknowledge your real contribution (e.g. a mistimed interpretation) before interpreting [synthesis for acknowledgement step]. Intense, persistent negative transference early was a foreseeable danger in Malan's selection criteria [uncertain]; if it dominates, reconsider fit.
Growing dependence / requests to extend. Interpret the request as part of the focal conflict around dependence and loss (4.18); keep the date [source: fixed time limit, psychology.town; Malan 1976, uncertain]. Exception: genuine clinical deterioration with risk, where you refer on rather than extend the brief contract [synthesis].
Flight into health near the end. Gently question the sudden wellness as a possible defence against feelings about ending; invite those feelings in T [synthesis, consistent with Malan's termination emphasis].
Crisis or symptom relapse in the last sessions. Expect it; interpret as a reaction to ending linked to past loss, while assessing risk; do not reopen the contract by reflex [synthesis].
Patient brings a new, unrelated problem mid-therapy. Acknowledge, relate to the focus if possible (4.15), and agree to review it at the end or at follow-up [synthesis].
Therapist losing the focus or over-involvement. Malan valued therapist involvement and enthusiasm [uncertain] but focus can slip. Write the focus sentence on your session notes; use supervision (Tavistock workshop practice was group supervision of each case) [uncertain: workshop format, not confirmed in the sources].
Assessment interview destabilises the patient. Malan warned about the consequences of making contact [source: Malan 1979 ch 22 title]. Do not end an assessment at peak emotional opening; summarise, assess safety, and make sure there is a plan and a follow-up contact even if brief therapy is not offered [synthesis].
Patient fits the exclusion profile but service pressure demands brief work. Prefer referral to appropriate care; if you must proceed, shift towards a supportive, less uncovering stance and document the reasoning [synthesis]. Not addressed by the sources.
Cultural and identity considerations. Not addressed in the sources. Check that the focus and its triangle of persons reflect the patient's family structures and meanings (e.g. caregivers other than parents in the P corner) [synthesis]. The historical inclusion of homosexuality as an exclusion criterion must not be followed (see 4.6).

Sources

Sources:

Books cited (full texts not drawn on; claims from them marked [uncertain] where not confirmed):

Malan, D. H. (1963). A Study of Brief Psychotherapy. London: Tavistock; Springfield, IL: Thomas.
Malan, D. H. (1976). The Frontier of Brief Psychotherapy: An Example of the Convergence of Research and Clinical Practice. New York: Plenum.
Malan, D. H. (1976). Toward the Validation of Dynamic Psychotherapy: A Replication. New York: Plenum.
Malan, D. H. (1979). Individual Psychotherapy and the Science of Psychodynamics. London: Butterworths.
Malan, D. H., & Osimo, F. (1992). Psychodynamics, Training, and Outcome in Brief Psychotherapy. Oxford: Butterworth-Heinemann.
Grant, J., & Crawley, J. (2002). Transference and Projection. Buckingham: Open University Press (secondary source for the triangle quotation).
Ezriel, H. (1952) and Menninger, K. (1958): origins of the conflict and person triangles respectively, per Wikipedia "Malan triangles".

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