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Guide I-071

Supportive-expressive therapy

Luborsky1984
A 35 · L 51 · M 1435 interventions in the Trinity explorer
Client cardCompare
[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: Luborsky (1984), Principles of Psychoanalytic Psychotherapy: A Manual for Supportive-Expressive Treatment, is the core manual. The CCRT method follows Luborsky & Crits-Christoph (1990; 2nd ed. 1998), Understanding Transference. The 16-session brief format follows Book (1998), How to Practice Brief Psychodynamic Psychotherapy: The Core Conflictual Relationship Theme Method; the version hint's short title refers to this book. Disorder adaptations are noted where they differ: depression (Luborsky et al., 1995), cocaine dependence (Mark & Faude, 1995/1997), GAD (Crits-Christoph et al., 1995/1996; Leichsenring et al., 2009) and social anxiety (Leichsenring et al., 2007).

Supportive-expressive (SE) therapy is a manualised psychoanalytic psychotherapy with two components:

  • Supportive. Builds and keeps up a helping alliance and the patient's level of functioning.
  • Expressive. Interpretive work that helps the patient understand one recurring maladaptive relationship pattern, the Core Conflictual Relationship Theme (CCRT). The CCRT is made up of a wish (W), the expected or actual response of others (RO) and the response of self (RS).

Change is thought to come from three sources:

  1. The patient's experience of a helping relationship.
  2. Growing self-understanding and mastery of the CCRT as it appears in current relationships, with the therapist and in the past.
  3. Taking in and keeping these gains, which is worked on especially around termination. [source: Luborsky 1984 (book not drawn on; curative-factor triad from author's working knowledge of the manual) [uncertain]; Chui & Barber 2017; Wiseman & Tishby 2017]

It was one of the first published psychodynamic treatment manuals. It was originally open-ended, and time-limited versions were later built for research. [source: Chui & Barber 2017]

2. Framework

Formats.

  • Open-ended (original). Individual, face-to-face, typically weekly sessions of about 45–50 minutes. [source: Luborsky 1984; Chui & Barber 2017]
  • Time-limited. Research versions run 12–52 sessions. [source: Chui & Barber 2017]
  • Book's brief form. 16 weekly face-to-face sessions, with the number fixed in advance so the ending can be planned. It is preceded by an evaluation interview for suitability. Book discusses when to deviate from the 16-session limit. [source: Figueroa 2005 review of Book; Psychiatric Services 1999 review of Book]
  • Adaptations.
    • Depression: 16-session time-limited version (Luborsky et al., 1995). [uncertain: session count]
    • Cocaine dependence (NIDA Collaborative Cocaine Treatment Study): SE was added to group drug counselling, about 36 individual sessions over 6 months (twice weekly, then weekly) plus monthly boosters. [source: CCTS rationale abstract confirms SE + group drug counselling; frequency [uncertain]; Crits-Christoph et al. 1999]
    • GAD: Leichsenring et al. (2009) used up to 30 sessions of 50 minutes. [source: Leichsenring et al. 2009]
    • Social anxiety: a 25-session, six-month manualised protocol. [source: Leweke et al. 2011 trial protocol abstract]
    • Optional maintenance or booster sessions after the active phase, e.g., four monthly sessions in Zilcha-Mano's trials. [source: Leibovich et al. 2020]

Phases (beginning, middle, termination is Luborsky's organisation; session numbers are Book's 16-session form).

PhaseGoalsTypical timing
0. Evaluation / selectionAssess suitability and choose how supportive vs expressive to be. For the brief form, look for adequate ego strength, the ability to relate meaningfully, motivation for inner change, psychological-mindedness and a problem that can be narrowed to one focus.1–2 interviews before treatment [source: Figueroa 2005; Psychiatric Services 1999]
1. BeginningSocialise the patient to treatment and the frame (frequency, length, fees, cancellations, duration). Explain how symptoms link to relationship difficulties. Set goals. Build rapport and the helping alliance. Collect relationship episodes (REs) and formulate the CCRT. In Book's form, present the CCRT as the focus.Book: early sessions (about 1–4) [uncertain: exact split] [source: Chui & Barber 2017; Psychiatric Services 1999 on Book's "initial evaluation and socialization phase"]
2. Middle (working through)Repeatedly recognise and interpret the CCRT across current relationships, the relationship with the therapist and early relationships. Keep up the alliance. Track symptom–CCRT links and growing mastery (new RS, a less negative expected RO).Book: about sessions 5–12 [uncertain] [source: Figueroa 2005; Wiseman & Tishby 2017]
3. TerminationWork through separation as it activates the CCRT. Interpret any return of symptoms. Recap the theme and the changes. Consolidate and take in the gains, and plan for after treatment.Book: sessions 13–16. Start earlier for patients preoccupied with loss or abandonment. [source: Ben David-Sela et al. 2020 citing Book 1998]

Criteria for moving between phases. The sources open to me give no formal criteria. The following is [synthesis] drawn from the phase goals:

  • Beginning to middle when all of these hold:
    • The patient understands their role and the frame.
    • Goals are agreed.
    • Early signs of a helping alliance are present.
    • Enough REs have been told to show a redundant W–RO–RS pattern (the CCRT research method uses about 10 REs).
    • In the brief form, the CCRT has been shared and the patient recognises it.
  • Middle to termination.
    • Time-limited: set by the calendar. The end date is fixed at the start and named regularly.
    • Open-ended: when goals are largely met, symptoms have improved, and the patient can spot the CCRT on their own and choose a different RS. A date is then agreed well in advance.

3. Guiding principles

[source for this section: Luborsky 1984 and Luborsky & Crits-Christoph 1998 (books not drawn on; principles stated from working knowledge, corroborated where marked by Chui & Barber 2017, Wiseman & Tishby 2017, Leibovich et al. 2018/2020, Leichsenring et al. 2009)]

  • Two components, mixed to fit the patient. More supportive for more impaired or fragile patients, more expressive for healthier ones. The mix can shift during treatment. Practical meaning: decide at evaluation, and re-decide each session, how much to interpret versus how much to stabilise.
  • The helping alliance comes first. Luborsky distinguished two types:
    • Type 1: the patient experiences the therapist as helpful and supportive.
    • Type 2: the patient experiences the two of you working together toward the goals.
    Practical meaning: watch for signs of both and repair before interpreting further. [source: Leibovich et al. 2020; Luborsky 1984]
  • One focal theme. The CCRT is the dynamic focus of SE. Practical meaning: tie most expressive responses back to the same W–RO–RS pattern rather than chasing new topics. [source: Wiseman & Tishby 2017]
  • The material is narratives about specific relationships. Practical meaning: ask for concrete incidents (who, what they wanted, what the other did, what they did and felt) rather than generalisations.
  • The pattern is pervasive. The CCRT shows up in current relationships, with the therapist (transference) and in early relationships. Practical meaning: when you notice the theme in one sphere, look for it in the other two.
  • Interpretations should be accurate to the wish and the response of others. Crits-Christoph, Cooper & Luborsky (1988) found that accuracy to the W and RO components was the part linked with outcome. Practical meaning: be sure your responses name what the patient wants and what they expect from others, not only how they react. [source: Wiseman & Tishby 2017 on interpretive accuracy and outcome; component-specific finding [uncertain]]
  • Symptoms are understood in their relational context. Symptoms tend to appear when the CCRT is activated (Luborsky's symptom-context method). Practical meaning: when a symptom surfaces or worsens, explore what relationship event came just before.
  • The listening–understanding–responding cycle sets the pace. Practical meaning:
    • Respond only once you understand the theme.
    • Keep responses near the patient's experience.
    • Then go back to listening to hear how the response landed.
  • Change shows mostly in RO and RS. Wishes tend to stay stable, while responses of others and of self change with improvement. Practical meaning: the aim is not to remove the wish but to help the patient pursue it with fewer negative expectations and more adaptive responses. [source: Johnsson & Stenlund 2010 summarising CCRT findings]
  • Avoid playing the expected response of others. Patients pull the therapist toward the RO. Practical meaning: use your own reactions as data and deliberately respond differently from the RO. [source: Wiseman & Tishby 2017; Leibovich et al. 2018]
  • Goals guide the work. Practical meaning: set goals early, link the CCRT to them, and revisit them. [source: Chui & Barber 2017]
  • The frame and the patient's role are made explicit. Practical meaning: socialise the patient at the start and come back to it when expectations drift. [source: Chui & Barber 2017]
  • The ending is part of the treatment. In time-limited SE, separation is present from the start. Practical meaning: name the end date and work through its meaning in CCRT terms. [source: Ben David-Sela et al. 2020]
  • Gains are taken in and kept. Practical meaning: help the patient own their new understanding and new responses, so the gains don't depend on the therapist.

4. Intervention inventory

The inventory has five groups:

  • A. Beginning and formulation
  • B. Supportive techniques
  • C. Expressive techniques
  • D. Termination
  • E. Disorder-specific adaptations

All example language is illustrative wording by the author of this guide, not quotation from the manuals. The step lists turn the sources into a usable sequence; where the ordering or detail is mine, it is marked [synthesis].

A1. Evaluation and selection interview

  • Purpose. Decide whether SE fits, whether the brief or open-ended form fits, and the starting supportive/expressive mix. [source: Figueroa 2005 and Psychiatric Services 1999 on Book; Luborsky 1984]
  • Steps.
    1. Take the presenting problem, history and current relationships.
    2. Ask for 2–3 specific relationship incidents, to sample the pattern and the patient's ability to reflect on it.
    3. Assess ego strength, verbal ability, capacity for meaningful relationships, motivation for inner change rather than symptom relief alone, and whether one interpersonal focus can be identified.
    4. More impaired, fragile, crisis-bound or less reflective patients get a more supportive mix or open-ended treatment. Healthier, focused patients get Book's 16-session expressive emphasis.
    5. Do standard risk assessment, and refer for other or added treatment (e.g., medication, more intensive care) where indicated.
  • Example language (illustrative). "Could you tell me about a specific recent time with someone that left you feeling the way you've described, what happened, step by step?"
  • Watch for.
    • The patient can tell concrete incidents and show some curiosity about their part in them: a good sign for the expressive work.
    • No identifiable focus, or severe instability: raise the supportive share or reconsider the time limit. [synthesis on the specifics]

A2. Socialisation (role-induction) interview

  • Purpose. Prepare the patient for how this therapy works so that expectations match the method. Luborsky took this from Orne & Wender's anticipatory socialisation interview. [source: Luborsky 1984 (not drawn on; derivation from Orne & Wender from working knowledge [uncertain]); Chui & Barber 2017]
  • Steps.
    1. Explain the rationale: problems and symptoms are often tied to repeated patterns in relationships, and talking about specific relationship experiences helps uncover them.
    2. Describe the patient's role (talk openly about what is on their mind, especially relationship events and feelings, including feelings about the therapist).
    3. Describe the therapist's role (listen, help understand, sometimes comment).
    4. Normalise what can happen: discomfort, uneven progress, strong feelings toward the therapist, wishes to quit.
    5. Go over the frame: frequency, length, fees, cancellations and duration or end date.
    6. Invite questions, and come back to this later if expectations drift.
  • Example language (illustrative).
    • "Most of our work will be looking closely at specific moments with people in your life, what you wanted, how they responded, how you reacted, because patterns there are often connected to how you've been feeling."
    • "At times you may have feelings about me or about coming here; those are useful to talk about too."
  • Watch for. Expectations of advice-giving or quick fixes. Re-explain, and link the method to the patient's own goals.

A3. Setting the frame and the time limit

  • Purpose. Give consistency and safety. In brief work, it also makes the ending part of the focus from the start. [source: Chui & Barber 2017; Ben David-Sela et al. 2020; Figueroa 2005]
  • Steps.
    1. Agree day, time, length and frequency.
    2. For time-limited work, state the total number of sessions and the calendar end date.
    3. Explain any maintenance or booster sessions.
    4. Count the remaining sessions aloud at intervals (e.g., at the midpoint and from session 12 or 13). [synthesis on the counting schedule]
  • Example language (illustrative). "We'll meet weekly for 16 sessions, so our last meeting will be on [date]. We'll keep that ending in view as we go."
  • Watch for. Frame breaches such as lateness, cancellations or fee issues. Treat them as possible CCRT expressions as well as practical matters.

A4. Collaborative goal setting

  • Purpose. Anchor the work. Goals support Type 2 (collaborative) alliance and later serve as markers of progress. [source: Chui & Barber 2017; Johnsson & Stenlund 2010 on comparing the CCRT with contract goals]
  • Steps.
    1. Ask what the patient wants to be different by the end.
    2. Translate vague goals into observable ones, including relationship goals as well as symptom goals.
    3. Write the goals down together.
    4. Once the CCRT is formulated, link it to the goals.
    5. Review the goals at the midpoint and at termination.
  • Example language (illustrative). "If this goes well, what would you notice yourself doing differently with your partner, or at work, by our last session?"
  • Watch for. Goals that belong to someone else ("my wife wants me to…"). Explore whose wish the goal expresses; this is often CCRT material.

A5. Eliciting relationship episodes (REs) in session

  • Purpose. Gather the raw material for the CCRT. REs are the patient's narratives about specific interactions with others, including with the therapist. [source: Wiseman & Tishby 2017; Johnsson & Stenlund 2010; Luborsky & Crits-Christoph 1998]
  • Steps.
    1. When the patient speaks in generalities, ask for a specific instance.
    2. Help fill in the four elements: who it was, what the patient wanted, how the other responded, and how the patient responded (thoughts, feelings, actions, symptoms).
    3. Ask how it ended.
    4. Note REs about the therapist (enactments) as well as those about others.
    5. Avoid leading questions about the wish; let the patient's words carry it.
  • Example language (illustrative). "Take me through that evening. What were you hoping for when you called her? … What did she say? … And what happened in you then?"
  • Watch for.
    • Thin or incomplete narratives. Gently ask for the missing component.
    • Repeated omission of the wish or the other's response can itself point to the conflict. [synthesis]

A6. Relationship Anecdotes Paradigm (RAP) interview

  • Purpose. A structured way to collect REs outside free session talk. It was developed for research but is usable clinically when session narratives are sparse. [source: Wiseman & Tishby 2017 (names the RAP); procedure details from Luborsky & Crits-Christoph 1998 [uncertain]]
  • Steps.
    1. Ask the patient to tell about 10 separate, specific incidents with other people, each one real and important to them.
    2. For each, ask when it happened, who it was with, what the other said and did, what the patient said and did, and how it ended.
    3. Include a mix of people (parents, partner, friends, colleagues).
    4. Do not interpret during the interview.
  • Example language (illustrative). "I'd like you to tell me about some specific times with other people, one at a time. For each, tell me who it was, what happened between you, what you did, and how it turned out."
  • Watch for. Patients who give summaries rather than incidents. Redirect to a single occasion. [synthesis on clinical use]

A7. Formulating the CCRT

  • Purpose. Identify the most frequent wish, response of others and response of self across REs. This is the treatment focus. [source: Wiseman & Tishby 2017; Johnsson & Stenlund 2010; Ben David-Sela et al. 2020]
  • Steps.
    1. Collect roughly 10 REs from sessions and/or the RAP.
    2. In each RE, mark every W (wish, need, intention toward the other or the self), RO (the other's actual or expected response) and RS (the patient's thought, emotion, behaviour or symptom).
    3. Label each in the patient's own terms first (tailor-made categories).
    4. Optionally translate the labels into the published standard categories (an earlier edition had about 35 W, 30 RO and 31 RS categories), to compare across REs.
    5. Count frequencies across REs. The most frequent W, RO and RS make up the CCRT.
    6. Note whether the RO and RS are mostly negative or positive, and whether the RO is actual or expected.
    7. Check the formulation against the patient's goals and symptoms.
    8. Look for a second pattern (Book's own case contained a secondary conflict he initially missed) and for a "progressive" (adaptive, deeper) wish beneath a regressive one.
    [source for steps 3–5: Johnsson & Stenlund 2010; step 6 from Luborsky & Crits-Christoph 1998 [uncertain]; step 8: Psychiatric Services 1999 review of Book (missed secondary conflict) and Leibovich et al. 2018 citing Book (progressive wish)]
  • Example formulation (illustrative). W: to be attended to and taken seriously. RO: others are preoccupied and dismissive (often expected rather than observed). RS: withdraws, says nothing, feels resentful and low.
  • Watch for.
    • Formulations built from your theory rather than the patient's narratives.
    • A "wish" that is really a response (e.g., "to avoid conflict" may be the RS to a deeper wish).
    • An RO that is expected but never tested.

A8. Sharing the CCRT as the focus

  • Purpose. In the brief form, make the core conflict the agreed focus, so the therapist can show how it gets in the way of the patient's well-being. [source: AJP 1999 and Psychiatric Services 1999 reviews of Book; Figueroa 2005]
  • Steps.
    1. By the end of the beginning phase, put the pattern into everyday words, drawing on two or three of the patient's own REs.
    2. Present the wish first and as understandable, then the expected response, then the patient's reaction and what it costs them.
    3. Ask whether it fits and invite corrections.
    4. Revise if needed.
    5. Agree that this will be the thread you follow.
    [ordering: synthesis consistent with Ben David-Sela et al. 2020's emphasis on foregrounding the wish]
  • Example language (illustrative). "In the times you've described, with your father, your manager, and last week with your friend, there's a wish to be taken seriously. You seem to expect you'll be brushed aside, so you go quiet, and then feel resentful and low. Does that fit?"
  • Watch for.
    • Recognition with feeling ("that's exactly it") or new REs offered spontaneously: confirmation.
    • Polite agreement with no elaboration: the fit may be poor.
    • The patient hearing it as criticism: this may itself be the RO being enacted. Explore it.

B. Supportive techniques. Luborsky grouped supportive techniques by whether they foster a Type 1 alliance (the patient feels helped) or a Type 2 alliance (the patient feels the two of you work together). The list below follows that grouping as I know it from the 1984 manual. The manual's exact wording and order are [uncertain]. The items are corroborated by the supportive-technique list used in SE trials (Leibovich et al. 2020): empathic, validating and understanding comments; genuine interest and respect; maintaining vital defences; maintaining self-object transferences; here-and-now and practical focus; noting gains and supporting goal attainment; working as a team. Adherence to these techniques is rated on the supportive subscale of the Penn Adherence–Competence Scale (PACS; Barber & Crits-Christoph 1996). [source: Leibovich et al. 2020]

B1. Conveying understanding and acceptance

  • Purpose. Type 1 alliance. The patient feels understood and not judged, which makes disclosure and later interpretation tolerable.
  • Steps.
    1. Reflect the patient's feeling and its reason in your own words.
    2. Validate what makes sense in it.
    3. Check that you have it right.
    4. Avoid premature interpretation when the patient most needs to feel heard.
  • Example language (illustrative). "It makes sense you'd be hurt, you'd been looking forward to it for weeks and it barely got a mention."
  • Watch for. Visible relief, more open disclosure and fuller REs signal it is working. Correction ("no, it's not that") is a chance to show you can take correction without retaliating.

B2. Showing genuine interest, respect and liking

  • Purpose. Type 1 alliance. Luborsky saw developing a liking for the patient as part of the supportive stance [uncertain: wording]. [source: Leibovich et al. 2020 ("genuine interest and respect")]
  • Steps.
    1. Remember and refer back to details of the patient's life.
    2. Show curiosity about their experience.
    3. Treat their views as worth considering.
    4. If you notice dislike or boredom, treat it as countertransference data (see C7) rather than acting on it.
  • Example language (illustrative). "Last time you mentioned your sister's visit was coming up, how did it go?"
  • Watch for. Patients with a rejecting expected RO may test this. Being consistently interested over time matters more than any single statement.

B3. Supporting the wish to reach treatment goals, with realistic hope

  • Purpose. Type 1 alliance and morale. Link the work to what the patient wants, and convey grounded rather than empty optimism. [source: Leibovich et al. 2020 (supporting goal attainment); "realistic hopefulness" from Luborsky 1984 working knowledge [uncertain]]
  • Steps.
    1. Restate the patient's goal as legitimate.
    2. Name concrete reasons for hope, such as strengths, past coping and early movement.
    3. Avoid guarantees.
  • Example language (illustrative). "Wanting to speak up at work is a reasonable goal, and you've already done it once with your friend, which tells us it's possible for you."
  • Watch for. Hope that sounds false to the patient. Tie it to evidence they recognise.

B4. Recognising the patient's growing abilities and gains

  • Purpose. Reinforce change and build the patient's ownership of it. This is a key route to taking in the gains. [source: Leibovich et al. 2020 ("noting gains"); Ben David-Sela et al. 2020 (pointing to adaptive RS)]
  • Steps.
    1. Notice new behaviours, especially new RS within the CCRT, and new self-observation (the patient spotting the pattern themself).
    2. Name them specifically.
    3. Ask how it felt.
    4. Credit the patient rather than the therapy.
  • Example language (illustrative). "You noticed yourself starting to go quiet and said what you wanted anyway. That's new."
  • Watch for. Patients who dismiss gains. Explore that, since it may be part of the RS. Avoid praise so frequent it becomes noise.

B5. Fostering the "we bond" (Type 2 alliance)

  • Purpose. Build a sense of shared work toward shared goals. [source: Leibovich et al. 2020 (working as a team); Luborsky 1984 (Type 2 alliance)]
  • Steps.
    1. Use joint language ("we", "let's look at").
    2. Refer back to understandings you reached together.
    3. Invite the patient to add to the formulation and to test it between sessions.
    4. Acknowledge their contributions to understanding.
  • Example language (illustrative). "We've seen this pattern a few times now. Let's see whether it was there on Tuesday too."
  • Watch for. The patient starts doing the analysing ("I think that was the same thing again"). This is a sign of a Type 2 alliance and of internalisation.

B6. Supporting adaptive defences and current functioning

  • Purpose. Keep or restore the patient's usual level of functioning. Do not undermine the defences that hold work, relationships and self-care together, especially in more impaired patients or during crises. [source: Chui & Barber 2017; Leibovich et al. 2020 (maintaining vital defences; here-and-now, practical focus)]
  • Steps.
    1. Notice which coping strategies are keeping the patient functioning.
    2. Refrain from interpreting them while they are needed.
    3. In crises, shift to a here-and-now, practical focus: problem-solving, structure, and links to supports.
    4. Return to expressive work once the patient is stable.
  • Example language (illustrative). "Throwing yourself into work this month may be what's holding things together, let's not take that apart right now. What would make this week manageable?"
  • Watch for. Overuse can drift into advice-giving that bypasses the CCRT focus. Check whether support is serving functioning or avoidance.

B7. Maintaining a self-object (idealising or mirroring) transference

  • Purpose. In the Zilcha-Mano trials' version, leave a supportive positive transference uninterpreted when it sustains the patient. [source: Leibovich et al. 2020. This is a later, Kohut-informed item; whether it appears in Luborsky 1984 is [uncertain]]
  • Steps.
    1. If the patient idealises you or needs your admiration, and this is stabilising, do not interpret it.
    2. Accept it and offer accurate mirroring.
    3. Interpret it later only if it begins to block the work.
  • Example language (illustrative). "I can see how much work went into that presentation."
  • Watch for. Idealisation that turns into dependence or blocks the patient's own agency. That is the point to begin expressive work on it.

B8. Monitoring the helping alliance

  • Purpose. Detect early whether the patient experiences you as helpful (Type 1) and the work as joint (Type 2). [source: Luborsky 1984 (helping-alliance types); Leibovich et al. 2020]
  • Steps.
    1. Each session, note the signs:
      • Positive: the patient reports feeling helped, joins in the work, refers back to understandings.
      • Negative: feeling misunderstood, passivity, lateness, missed sessions.
    2. Ask briefly how the work is going, especially after a difficult session.
    3. Repair by acknowledging your part and reconnecting to the goals.
    4. Optionally use a brief self-report alliance measure. [step 4: synthesis]
  • Example language (illustrative). "Before we finish, how did today feel? Was there anything I said that didn't sit right?"
  • Watch for. Alliance dips mid-treatment as expressive work intensifies. Expect them and repair them (see section 5).

B9. The ICEF steps for strengthening the alliance (later development)

  • Purpose. A step model from Zilcha-Mano's group for strengthening the alliance within an SE framework. It works without interpretation, by declining to enact the CCRT's RO. This is not part of Luborsky (1984). [source: Leibovich et al. 2018]
  • Steps.
    1. Identify the progressive wish beneath the regressive one, using the CCRT and your countertransference.
    2. Reflect on countertransference. Recognise how your feelings may be joining in the enactment, and work through them.
    3. Enhance empathy by learning the history of how the CCRT developed.
    4. Freedom from enactment. Make a deliberate act of freedom (Symington's term) that steps out of the expected RO, for example postponing criticism, offering admiring mirroring, or noticing small positives.
  • Example language (illustrative). For a patient who expects criticism and provokes it: "The way you organised your week around your son's exams shows real care." This is offered instead of the critical comment the interaction is pulling for.
  • Watch for. The patient softening and bringing more. A reflexive return to the old RO in you signals the enactment has resumed.

C. Expressive techniques. Luborsky (1984) described the expressive work as a repeating four-phase cycle. The cycle and the CCRT-centred response are core to the manual. The finer sub-guidelines below are stated from working knowledge of the book, and are marked [uncertain] or [synthesis] where they go beyond the sources.

C1. The four-phase cycle: listening, understanding, responding, returning to listening

  • Purpose. Pace the expressive work so that responses rest on understanding and their effect is checked. [source: Luborsky 1984 (cycle from working knowledge [uncertain] on detail)]
  • Steps.
    1. Listen openly to the patient's narratives.
    2. Understand by recognising which part of the CCRT is active right now.
    3. Respond with a brief comment on that part.
    4. Return to listening. Observe the patient's next associations to judge whether the response landed (confirmation, elaboration, new REs) or missed (deflection, compliance, withdrawal).
    5. Repeat the cycle many times per session.
  • Example language (illustrative). See C4.
  • Watch for. Responding before understanding, which produces generic comments. Never responding, which makes the therapy feel aimless to the patient.

C2. Listening

  • Purpose. Gather the CCRT as it shows itself, without steering the content. [source: Luborsky 1984 [uncertain on detail]; Chui & Barber 2017]
  • Steps.
    1. Let the patient lead.
    2. Attend especially to relationship narratives, shifts in feeling, symptoms mentioned, and references to you.
    3. Note the sequence of topics, since it often shows the links.
    4. Hold back from responding until a pattern is discernible. When it isn't, ask for specifics (A5).
  • Example language (illustrative). "Go on…" or "What happened next?" Minimal prompts.
  • Watch for. Long stretches with no REs, such as abstract talk or reports of events without people in them. Gently ask for a specific interaction.

C3. Understanding: recognising the active CCRT

  • Purpose. Match today's material to the formulated CCRT, or notice that it doesn't fit and revise. [source: Wiseman & Tishby 2017; Luborsky & Crits-Christoph 1998]
  • Steps.
    1. For each new RE, silently identify the W, RO and RS.
    2. Compare them with the CCRT.
    3. Note which sphere the RE comes from (current, therapist, past).
    4. Note whether the RO is actual or expected.
    5. Note whether the RS is old or shows change.
    6. Pick the one component that is closest to the patient's awareness right now. [step 6: synthesis]
  • Example (illustrative internal note). "Wish to be taken seriously; expected RO: dismissed (never actually asked); RS: went quiet, then a headache."
  • Watch for. Forcing every story into the formulation. If several REs don't fit, revise the CCRT or look for a second theme.

C4. Responding: CCRT-focused interpretation

  • Purpose. Help the patient see the recurring pattern and its cost. Accurate interpretation of the core pattern is linked to better outcome. [source: Wiseman & Tishby 2017; Wikipedia CCRT entry; component accuracy finding from Crits-Christoph, Cooper & Luborsky 1988 [uncertain]]
  • Steps.
    1. Keep it short and in the patient's language.
    2. Start near the surface. Typically name the RS and the expected RO the patient can already feel, then link them to the wish.
    3. Name the wish as understandable, not as the problem.
    4. Link to one or two parallel REs from other spheres when the patient is ready.
    5. Then return to listening (C1, step 4).
    6. Do not stack several interpretations at once.
    [steps 2, 3 and 6: synthesis consistent with Book's and Ben David-Sela et al.'s emphasis on the wish]
  • Example language (illustrative). "When you wanted your manager to back your idea, you seemed sure he'd wave it away, so you didn't raise it, and then felt flat all afternoon. That's the same thing you described with your father."
  • Watch for.
    • Working: the patient adds a new example, feels something, or corrects and refines the formulation.
    • Not working: intellectual agreement with no feeling, or the patient feels accused. Accusation can be the RO appearing with you; take it up as in C6.

C5. Linking symptoms to the CCRT (symptom-context)

  • Purpose. Show that symptoms (anxiety, depressed mood, cravings, physical symptoms, forgetting) come up in relational contexts where the CCRT is activated. This turns symptoms into chances for understanding. [source: Luborsky's symptom-context method (Luborsky 1996) [uncertain on detail]; Leichsenring et al. 2009 (CCRT "associated with the symptoms")]
  • Steps.
    1. When a symptom is reported or appears in the session, ask what happened just before, in the outside event or in the session itself.
    2. Identify the W, RO and RS in that context.
    3. Offer the link tentatively.
    4. Track over sessions whether the symptom eases as the pattern is worked on.
  • Example language (illustrative). "You said the panic came on as you were waiting for her reply. What were you wanting from her right then, and what did you expect she'd say?"
  • Watch for. If a symptom appears mid-session, look at what you or the patient just said. It may be a transference trigger.

C6. Transference work: the CCRT with the therapist

  • Purpose. Use the here-and-now relationship as the most immediate RE. The CCRT is understood as an operational form of transference. [source: Wiseman & Tishby 2017; Johnsson & Stenlund 2010 (enactments as REs with the therapist); Luborsky & Crits-Christoph 1998]
  • Steps.
    1. Listen for references to you, including disguised ones (stories about other helpers, doctors, teachers).
    2. Notice enactments such as lateness, compliance, testing or withholding.
    3. When there is clear evidence and the alliance can hold it, name the parallel gently.
    4. Ask about the patient's actual experience of you.
    5. Distinguish the expected RO from what you actually did.
    6. In the supportive emphasis, take up transference mainly when it threatens the work.
    [step 6: source Psychiatric Times supportive-component article (general supportive practice) plus synthesis]
  • Example language (illustrative). "I wonder if something like that happened here last week. When I mentioned the end date, you went quiet. Did part of you expect I'd brush aside how you felt about it?"
  • Watch for.
    • The patient testing the expected RO directly with you. That is a chance for a corrective experience.
    • Premature transference interpretation can feel accusatory. Make sure the alliance is solid first.

C7. Monitoring countertransference

  • Purpose. Recognise when you are being pulled into the RO role, and use that as data rather than acting it out. [source: Wiseman & Tishby 2017; Leibovich et al. 2018; Psychiatric Services/AJP reviews of Book]
  • Steps.
    1. After sessions, note your feelings toward the patient (impatience, boredom, wish to rescue, criticism).
    2. Ask whether they match the RO in the CCRT.
    3. If so, plan a non-RO response (see B9) and consider whether to interpret the enactment.
    4. Use supervision or consultation for persistent reactions.
  • Example (illustrative internal note). "I'm feeling dismissive of her complaints, the very RO she fears. Next session: take them seriously first."
  • Watch for. Book's reviewers note that countertransference can undermine the focus itself, for example by drifting off the CCRT.

C8. Linking across spheres and to origins

  • Purpose. Show how current, transference and early relationships share the CCRT. Understanding its origins increases empathy and makes the pattern feel less fixed. [source: Figueroa 2005 (focus covers childhood relationships with parents, current relationships and the therapist); Leibovich et al. 2018 (history of how the CCRT developed)]
  • Steps.
    1. Once a current pattern is recognised, ask whether it feels familiar from earlier in life.
    2. Explore early REs in the same W–RO–RS terms.
    3. Frame the original RS as having made sense then.
    4. Contrast then and now, which opens room for testing the expected RO in the present.
  • Example language (illustrative). "Going quiet may have been the safest thing to do as a child in that house. I wonder whether it's still as necessary with the people you have now."
  • Watch for. Historical exploration that becomes an escape from present relationships. Keep returning to current REs.

C9. Working through

  • Purpose. Change comes from recognising the CCRT repeatedly, across many contexts, not from one insight. [source: Figueroa 2005; Psychiatric Services 1999 review of Book; Chui & Barber 2017]
  • Steps.
    1. In the middle phase, keep identifying the CCRT in each new RE.
    2. Invite the patient to spot it first.
    3. Explore variations, such as which people evoke it more and less.
    4. Note exceptions where a different RO or RS happened.
    5. Link it to the goals.
  • Example language (illustrative). "You've spotted the pattern three times this week. Was there any moment it went differently?"
  • Watch for.
    • The patient increasingly anticipates the pattern and chooses differently. Grenyer & Luborsky's "mastery" of the CCRT describes this. [mastery construct: Grenyer & Luborsky 1996 [uncertain]]
    • Repetition without movement: see section 5, "stuck".

C10. Testing the expected RO and trying a new RS

  • Purpose. Help the patient discover that others may not respond as expected, and practise new responses. [source: Book's emphasis on the expected RO, via the reviews (partly [uncertain]); Leichsenring et al. 2009 (therapists encourage approaching feared situations and use the experiences to work on the CCRT)]
  • Steps.
    1. Once a feared RO is clearly expected rather than observed, ask what evidence there is.
    2. Explore what the patient could do differently to pursue the wish.
    3. Encourage them to approach the relevant situation.
    4. In the next session, review the outcome in W–RO–RS terms, whatever happened.
  • Example language (illustrative). "You've been certain she'd laugh at the idea, but you've never actually asked. What might happen if you did?"
  • Watch for. Framing it as homework compliance rather than exploration. Disconfirming experiences are the strongest signs of change.

C11. Tracking the progressive CCRT

  • Purpose. Monitor change, which usually shows in the RO and RS rather than the wish, and make it explicit to the patient. [source: Johnsson & Stenlund 2010 (W stable; RO and RS change with improvement); Ben David-Sela et al. 2020 (regressed versus progressed CCRT)]
  • Steps.
    1. Periodically review recent REs for a higher proportion of positive or less negative RO and RS.
    2. Note new adaptive RS.
    3. Reflect this back to the patient (B4).
    4. At termination, present both the old and the new pattern.
  • Example language (illustrative). "A few months ago, wanting to be heard led straight to silence. These last weeks it's led you to say so, and twice people actually listened."
  • Watch for. Change confined to the therapy room. Look for it in outside REs.

D. Termination techniques.

D1. Working through termination in CCRT terms

  • Purpose. Ending activates the CCRT, often around separation, loss or rejection. In time-limited SE, separation is present from the start. The manual expects symptoms to return around termination and treats this as material to understand, not as failure. [source: Ben David-Sela et al. 2020 (citing Book 1998 and Mann 1973); return of symptoms from Luborsky 1984 working knowledge [uncertain]]
  • Steps.
    1. In Book's form, open termination work by sessions 13–16. Start earlier for patients preoccupied with abandonment or loss.
    2. Ask what the ending stirs up.
    3. Identify the wish (e.g., to be held in mind), the expected RO (e.g., being dropped) and the RS (e.g., withdrawing early, devaluing the therapy, symptoms returning).
    4. Interpret any return of symptoms in that light.
    5. Distinguish this ending, which was planned and is explained, from the feared RO.
  • Example language (illustrative). "The low mood came back the week after we counted four sessions left. I wonder whether ending here feels like being let go of, the way you've described before."
  • Watch for.
    • Missed sessions or new crises near the end. Name them as possibly ending-related before problem-solving.
    • Patients who end early to pre-empt the loss: an RS to address directly.

D2. Recapitulation, consolidation and taking in the gains

  • Purpose. Help the patient leave with a usable understanding of their pattern and ownership of their changes, so gains last. [source: Ben David-Sela et al. 2020 (termination socialisation; integrating the regressed and progressed CCRT; "preparation for the day after"); Luborsky 1984 (incorporation of gains) [uncertain on wording]]
  • Steps.
    1. Termination socialisation. Specify how many sessions remain, discuss expectations for the ending, cover options after treatment and when to seek help again, and mention maintenance sessions if offered.
    2. Review the goals against progress.
    3. Summarise the CCRT together, both the old pattern and the new RS the patient has shown.
    4. Reframe gains as practical guidance ("when you notice X, you now know you can Y").
    5. Anticipate normal temporary regression after the ending.
    6. In the final session, keep interventions minimal: brief references to earlier adaptive moments, closing the narrative.
  • Example language (illustrative). "If you find yourself going quiet and resentful again, that's the old pattern. You've learned to catch it and say what you want, even if it takes a day or two."
  • Watch for.
    • The patient attributing all gains to the therapist. Redirect toward their own actions (B4).
    • Over-ambitious new interpretations in the final sessions.

D3. Handling termination ruptures

  • Purpose. Resolve strains in the alliance that arise around ending. This three-step model is a later development within SE, not in Luborsky (1984), and its authors note it has not been directly tested. [source: Ben David-Sela et al. 2020]
  • Steps.
    1. Declaration. Name the rupture in CCRT terms, foregrounding the wish that was heard.
    2. Acknowledgment. Validate the patient's experience supportively and explore it through metacommunication.
    3. Integration. Present both the regressed and the progressed CCRT, pointing to times the patient used new, adaptive RS.
    4. If the rupture comes at the very end, acknowledge the feeling, note the limited time, and briefly recall earlier adaptive moments.
  • Example language (illustrative). "I think you're telling me you wanted this to matter to me as much as it does to you, and the ending makes it seem it doesn't."
  • Watch for. The patient being able to stay with disappointment without withdrawing. That is a live demonstration of the new RS.

E. Disorder-specific adaptations. These are additions to A–D, not replacements.

E1. Depression

  • Purpose. Time-limited SE for major depression (Luborsky et al., 1995, in Barber & Crits-Christoph, Dynamic Therapies for Psychiatric Disorders). [source: book chapter; features below are [uncertain]]
  • Steps (as I understand the adaptation):
    1. Use the standard beginning (A1–A8).
    2. Link mood drops to relational contexts using C5, attending especially to experiences of loss, rejection and helplessness within the CCRT.
    3. Give support (B-group) a larger role while the patient is severely depressed.
    4. Do standard suicide risk assessment and coordinate with medication management where used.
  • Example language (illustrative). "The heaviness started Sunday evening, after your call with your mother. What were you hoping for from that call?"
  • Watch for. Hopelessness about therapy itself. Treat it as an RO expectation (that help won't come) as well as a symptom.

E2. Cocaine (and opiate) dependence

  • Purpose. SE added to drug counselling. It was tested in the NIDA Collaborative Cocaine Treatment Study alongside group drug counselling, building on earlier SE work with methadone-maintained opiate patients. Adaptation texts: Mark & Luborsky (1992, unpublished manual); Mark & Faude (1995 chapter; 1997 book). [source: CCTS rationale abstract (SE plus group drug counselling); adaptation details below from working knowledge [uncertain]]
  • Steps (as I understand the adaptation):
    1. Give heavier initial weight to the supportive relationship and to abstinence as a shared goal.
    2. Coordinate with the drug counselling and monitoring the patient receives.
    3. Ask about drug use and cravings each session.
    4. Explore each use or lapse as an RE: what was wanted, what was expected from others, and how the drug served as the RS or as a substitute route to the wish.
    5. Address the drug's place in the patient's relationships.
  • Example language (illustrative). "Let's go through Friday step by step, from the argument with your brother to the moment you called your dealer. What did you need right then?"
  • Watch for.
    • Intoxicated sessions: reschedule.
    • Escalating use: increase structure and coordinate care.
    • Interpretation offered as an excuse for use. Keep linking understanding to the abstinence goal. [synthesis]

E3. Generalised anxiety disorder

  • Purpose. An interpersonally oriented SE for GAD (Crits-Christoph et al., 1995 manual chapter; 1996 open trial with 26 patients). In the version Leichsenring et al. (2009) used, the focus is on the CCRT associated with the GAD symptoms.
  • Key features.
    • A positive alliance is emphasised as a corrective emotional experience, given hypothesised insecure attachment.
    • Worry is conceptualised as a defence against more threatening fantasies or feelings.
    • Therapists encourage patients to approach feared situations and use those experiences to work on the CCRT.
    • Up to 30 sessions of 50 minutes. [source: Leichsenring et al. 2009; Crits-Christoph et al. 1996 abstract]
  • Steps.
    1. Formulate the CCRT from interpersonal REs, not from worry content.
    2. When the patient worries in session, ask what relational feeling or fantasy the worry may be covering.
    3. Encourage approach to avoided situations (C10) and debrief them in CCRT terms.
    4. Actively keep the alliance warm and steady.
  • Example language (illustrative). "You moved quickly from your daughter's silence to worrying about her grades. If we stay with the silence for a moment, what do you feel?"
  • Watch for. The authors suggest a stronger focus on the process of worrying might improve outcomes, so attend to how the patient worries, not only what about.

E4. Social anxiety disorder

  • Purpose. A manualised SE-based short-term psychodynamic therapy for social phobia (Leichsenring, Beutel & Leibing 2007), delivered as a 25-session protocol over six months in the SOPHO-NET programme. [source: Leweke et al. 2011 trial-protocol abstract; manual content [uncertain]]
  • Steps (as I understand the adaptation):
    1. Formulate a CCRT around social fears, typically a wish for acceptance or recognition, an expected RO of criticism or humiliation, and an RS of withdrawal, shame or anxiety.
    2. Encourage the patient to face feared social situations.
    3. Work with shame and self-esteem.
    4. Use the therapeutic relationship to test the expected RO.
  • Example language (illustrative). "You expected the group to find your comment stupid. What actually happened when you spoke?"
  • Watch for. Avoidance of the sessions themselves. The therapy is a social situation, so address it as an RE (C6).

5. Handling problems

Each item says whether it is drawn from the sources or is [synthesis]: my own guidance, applying SE's logic where the sources are silent.

  • Stuck: the CCRT is recognised but nothing changes. [synthesis, built on C9–C11]
    1. Check whether you are interpreting only the RS. Shift to the wish and the expected RO, the components whose accuracy matters most.
    2. Look for an untested expected RO and move to C10 (approach and test).
    3. Ask what the patient fears would happen if the pattern changed. Change can threaten another wish, which is a sign of a second CCRT; Book's own case had a missed secondary conflict.
    4. Review the goals together.
    5. Look for an enactment between you, such as "insight" offered to please you.
  • Intellectualised agreement with no feeling. [synthesis]
    1. Go back to the most recent, emotionally live RE, ideally one involving you.
    2. Slow down and ask what the patient feels right now as you talk about it.
    3. Use fewer, shorter interpretations.
  • Resistance: the patient rejects the formulation or deflects. [partly sourced: the CCRT is built from the patient's own narratives (Wiseman & Tishby 2017); responses are steered by return-to-listening (C1); remainder synthesis]
    1. Treat rejection as information. Ask what doesn't fit and revise.
    2. Check whether the interpretation was experienced as the RO, e.g., criticism. If so, name that, acknowledge your part, and lead with the wish next time.
    3. Return to supportive work (B1–B5) before re-approaching.
  • Overwhelm or regression: crisis, flooding, disorganisation. [source: supportive component maintains or restores functioning (Chui & Barber 2017; Leibovich et al. 2020); specifics are synthesis]
    1. Shift the mix toward support (B6): here-and-now, practical problem-solving, structure, links to supports.
    2. Suspend deep or transference interpretation.
    3. Do standard risk assessment for suicide or harm and follow your service's crisis protocols.
    4. Resume expressive work once the patient is stabilised. Later, explore the crisis as an RE.
  • Non-adherence: missed or late sessions, approach tasks not attempted. [synthesis]
    1. Handle the practical side of the frame first.
    2. Then explore it as a possible RS within the CCRT. For example, missing sessions may express the expected RO ("you won't really want to see me") or a wish for distance.
    3. For approach tasks, drop the homework framing. Explore what made approaching feel too risky and what RO was anticipated.
    4. In substance-use work, coordinate with counselling and drug monitoring (E2).
  • Alliance ruptures mid-treatment. [source: alliance focus and repair priority from Luborsky's helping-alliance concept and Leibovich et al. 2018/2020; termination ruptures from Ben David-Sela et al. 2020; general mid-treatment procedure is synthesis]
    1. Notice withdrawal or confrontation markers.
    2. Invite the patient's experience of you without defensiveness and acknowledge your contribution.
    3. Then, if the alliance can bear it, link the rupture to the CCRT.
    4. If the rupture repeats the RO, deliberately respond differently (B9).
    5. Use the declaration, acknowledgment, integration steps (D3) at any phase. Applying them outside termination is [synthesis].
  • The patient cannot produce relationship episodes: vague, global, or event-without-people talk. [synthesis, built on A5–A6]
    1. Ask for one specific recent occasion.
    2. Use the RAP format to structure it.
    3. Start from the session itself ("how was it coming here today?") as an immediate RE.
  • The formulation doesn't fit, or there are two themes. [source: Psychiatric Services 1999 review (Book's missed secondary conflict); synthesis on handling]
    1. Re-score recent REs.
    2. Say openly that you are revising.
    3. In brief work, choose the theme most linked to the goals and symptoms, and name the other as context.
  • The therapist is enacting the RO: impatience, boredom, criticism, rescuing. [source: Wiseman & Tishby 2017; Leibovich et al. 2018]
    1. Reflect after the session (C7) and seek supervision.
    2. Plan a non-RO response.
    3. If the enactment was visible to the patient, acknowledge it and explore its impact.
  • The patient wants advice or skills, not exploration. [synthesis]
    1. Re-socialise (A2).
    2. Offer limited practical support where functioning requires it (B6).
    3. Explore the request in CCRT terms: what is wanted from you, and what is expected if you don't provide it.
    4. Consider referral or combined treatment if a skills-based approach is clearly preferred.
  • Dependence or idealisation blocking agency. [source: B7 per Leibovich et al. 2020; handling is synthesis]
    1. Let the idealisation stand while it sustains the patient.
    2. As termination approaches, or when it blocks self-directed change, explore it as part of the CCRT.
    3. Redirect credit for gains to the patient (B4).
  • Request to extend a time-limited treatment. [source: Book discusses when and how to deviate from the limit (Psychiatric Services 1999 review); specifics are synthesis]
    1. Explore the request first as termination material (D1).
    2. Extend or refer only for clear clinical reasons, such as a new crisis, unresolved risk, or a need better suited to longer-term work, ideally after the planned end.
    3. Offer maintenance or booster sessions where available.
  • Symptoms return near the end. [source: Luborsky 1984 working knowledge [uncertain]; Ben David-Sela et al. 2020 on normal regression]
    1. Interpret the return in CCRT and separation terms (D1).
    2. Reassure the patient that it is often temporary.
    3. Prepare them for the "day after" (D2).
  • Lapses in substance-use adaptations. [synthesis consistent with E2]
    1. Treat each lapse as an RE to understand, not a failure.
    2. Increase structure and coordination of care.
    3. Reschedule intoxicated sessions.

Sources

Sources

Pages not read

  • PMC2786223, an SE article.
  • The full Trials article and the PubMed abstract for the cocaine study. Access was refused.

Books and papers cited (not drawn on; used from working knowledge and marked [uncertain] where detail depends on them)

  • Luborsky, L. (1984). Principles of Psychoanalytic Psychotherapy: A Manual for Supportive-Expressive Treatment. Basic Books.
  • Luborsky, L., & Crits-Christoph, P. (1990; 2nd ed. 1998). Understanding Transference: The Core Conflictual Relationship Theme Method. Basic Books / APA.
  • Book, H. E. (1998). How to Practice Brief Psychodynamic Psychotherapy: The Core Conflictual Relationship Theme Method. APA.
  • Barber, J. P., & Crits-Christoph, P. (Eds.) (1995). Dynamic Therapies for Psychiatric Disorders (Axis I). Basic Books. Includes the chapters by Luborsky et al. on depression, Crits-Christoph et al. on GAD, and Mark & Faude on cocaine.
  • Mark, D., & Faude, J. (1997). Psychotherapy of Cocaine Addiction: Entering the Interpersonal World of the Cocaine Addict. Jason Aronson.
  • Mark, D., & Luborsky, L. (1992). A manual for the use of supportive-expressive psychotherapy in the treatment of cocaine abuse. Unpublished manuscript, University of Pennsylvania.
  • Crits-Christoph, P., et al. (1999). Psychosocial treatments for cocaine dependence: NIDA Collaborative Cocaine Treatment Study. Archives of General Psychiatry, 56, 493–502.
  • Leichsenring, F., Beutel, M., & Leibing, E. (2007). Psychodynamic psychotherapy for social phobia: a treatment manual based on supportive-expressive therapy. Bulletin of the Menninger Clinic, 71, 56–83.
  • Luborsky, L. (1996). The Symptom-Context Method: Symptoms as Opportunities in Psychotherapy. APA.
  • Crits-Christoph, P., Cooper, A., & Luborsky, L. (1988). The accuracy of therapists' interpretations and the outcome of dynamic psychotherapy. Journal of Consulting and Clinical Psychology, 56, 490–495.
  • Grenyer, B. F. S., & Luborsky, L. (1996). Dynamic change in psychotherapy: mastery of interpersonal conflicts. Journal of Consulting and Clinical Psychology, 64, 411–416.
  • Barber, J. P., & Crits-Christoph, P. (1996). Development of a therapist adherence/competence rating scale for supportive-expressive dynamic psychotherapy. Psychotherapy Research, 6, 81–94.
  • Orne, M. T., & Wender, P. H. (1968). Anticipatory socialization for psychotherapy. American Journal of Psychiatry, 124, 1202–1212.
  • Symington, N. (1983). The analyst's act of freedom as agent of therapeutic change. International Review of Psycho-Analysis, 10, 283–291.
  • Mann, J. (1973). Time-Limited Psychotherapy. Harvard University Press.
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