Short-term goal-oriented group analytical psychotherapy (SFGAP)Translation author: Hagverdi E.R. 2023 Steinar Lorentzen, 2020 Short-term focused group-analytic psychotherapy (SFGAP): an integrative, research-based approach to change. Group Analysis (GA) is probably the most commonly used psychodynamic group therapy therapy in Europe. This is largely based on clinical experience, but the body of scientific evidence is growing every year. This article describes how the results of a randomized clinical trial (RCT) comparing the results of short-term (20 sessions; six months) and long-term (80 sessions; two years) ) group analytical, standardized treatment methods are integrated with the short-term ones used in this RCT. The method used in this RCT led to the emergence of a new type of therapy, short-term focused group analytic psychotherapy (SFGAP). Selection of suitable patients is based on assessing the level of personality organization and establishing for each patient a limited treatment focus based on his/her patterns of interpersonal problems and main complaints. The article describes how patients are assessed and prepared, how the treatment process develops, the stages of group dynamics, and the consequences of therapist interventions. The article is illustrated with a clinical case and group material. Key words: short-term focused group analytical psychotherapy, level of personality functioning, group analysis, time-limited therapy, psychodynamics. IntroductionPsychoanalytic and group-analytic treatments are long-term types of psychotherapies that have spawned several other shorter-duration therapy formats (in groups, for families, as environmental therapy, and for individuals). In this article I will introduce one such therapy, short-term Focused Group Analytic Psychotherapy (FAP), which is a modified version of Group Analytic Psychotherapy (GAP). In this article, I will introduce one model of psychotherapy, Short-Term Focused Group Analytical Psychotherapy (SFGAP), which is a modified version of Group Analytical Psychotherapy (GAP). Many of the core elements of this approach are based on clinical experience and systematic research. GAP is based on psychoanalytic and social psychological theories and was developed in England in the late 1930s by S.H. Foulkes, a German immigrant, psychiatrist and psychoanalyst. I began my group analytic training in the mid-1980s, during the last stage of my training as an individual psychoanalyst. Psychotherapy has been my main interest since I began specializing in psychiatry 15 years ago, and in addition to my psychoanalytic training. I have also had positive experiences working with groups in a therapeutic community (Henderson model; Jones, 1968). In 1984, armed with this experience, I enrolled in a group analysis training program run by the Norwegian Psychiatric Association with training staff from the Institute of Group Analysis (IGA), London (Lorentzen, Herlofsen, Karterud et al., 1995). I was lucky enough to be there. member of the organizing committee for this course for about 12 years, it was a great privilege to have Harold Behr as my small group leader (Behr and Hearst, 2005; Lorentzen, 1990). Being in a group with peers/colleagues and an experienced and warm facilitator who skillfully combined caring and empathy with a more relaxed reflective attitude allowed me to work through some personal issues that remained unresolved after my individual analysis. He also supervised me for several years after I becamepresenter and supervisor in the same program. In my practice, I led a number of groups, and the large number of subjects allowed me to realize a dream that I had cherished for years: to conduct systematic research in group psychotherapy. Thus, in the late 1980s, I began systematically collecting data on my own group of patients. Among the main findings of this naturalistic study was that GAP, with durations ranging from six to 84 months, was an effective treatment for approximately 80% of the 69 outpatients treated therapy (Lorentzen, Bøgwald and Høglend, 2002; Lorentzen: Short-term focused group-analytic psychotherapy (SFGAP) 345 Lorentzen and Høglend, 2004) Patients with mixed diagnoses (anxiety and depressive disorders, mild to moderate personality disorders) were treated in one of three groups that I led during my practice. In a follow-up study, we randomly sampled 167 similar patients and conducted standardized short-term or long-term analytic psychotherapy groups (20 or 80 weekly sessions). We found that although patients changed much faster in the short-term treatment groups, patient outcomes were similar in both treatments three years after baseline (two and a half years after the end of the short-term groups and one year after the end of the long-term groups). Another important finding was that patients with less personality pathology, on average, received sufficient help in short-term treatment, whereas those with more severe personality pathology did significantly better in long-term groups ((Lorentzen, Ruud, Fjeldstad et al. , 2013; Lorentzen, Fjeldstad, Ruud et al., 2015a, 2015b; Fjeldstad, Høglend and Lorentzen, 2016). We also found that patients in both groups had similar changes in self-image and autonomy. , while patients in long-term groups showed greater variation in affiliation scores (Lorentzen, Fjellstad, Ruud et al., 2015c). The two original treatment manuals (Lorentzen, 2004) were later translated into English thanks to the support of the Institute for Group Analysis in Londoea and. International Society for Group Analysis (Lorentzen, 2014). Support was due in part to the lack of quantitative research in GAP, which was reflected in reviews of the existing literature at the time (Lorentzen, 2006; Blackmore, Tantam, Parry et al., 2011). A lack of research evidence has weakened GAP's position in the UK's National Health Service, where, as in many other countries, cognitive behavioral therapy (CBT) has predominated. The manuals were primarily based on group analytic theories (Foulkes, 1986; Foulkes and Anthony, 1984), but also on time-limited theories, mainly psychodynamic therapies (Piper, McCallum, Joyce et al., 2001; Tasca, Ritchie, Conrad et al., 2001). al., 2006; Sandahl, Lundberg, Lindgren et al., 2011), as well as from experiences gained during my own training, practice and research in psychotherapy. Objectives The main purpose of this article is to present the SFGAP, a revised and expanded version. approach described in the original short-term therapy manual (Lorentzen, 2014). The purpose is twofold: I want to emphasize the central elements of the short-term therapy manual and integrate new data obtained from our research.1 Briefly about Short-Term Focused Group Analytical Psychotherapy (SFGAP)SFGAP is a broadly focused clinical approach aimed at alleviating mental distress, working to resolving internal conflicts and/or changing dysfunctional behavior. Patients suitable for short-term focused group analytic psychotherapy typically have a limited range of problems and moderately to highly developed personality organization (Kernberg, 1980; Caligor and Clarkin, 2010). Focustreatment is established in advance, usually consisting of symptoms and central dysfunctional relationships. When they are activated in interactions between group members, the therapist and group can work with them more intensively in the here and now. The goal is to begin a process of change in each patient that can continue after therapy ends. Therapy is carried out in a closed group. No one joins the group in the middle of therapy, and no one leaves the group before completion. Thus, the duration and number of sessions are the same for all participants. The group consists of 7-8 patients and 1-2 guides (therapists) and lasts 20 weekly sessions, each lasting 90 minutes. The theoretical framework is based on group-analytic and psychoanalytic theories, especially Faulks's ideas about the group-as-a-whole, clearly outlined in works by Pines (1994). In addition, object relations theory (Kernberg, 1975a) and the structural assessment of personality organization are central to therapy (Kernberg, 1984; Caligor and Clarkin, 2010; Caligor, Kernberg, Clarkin et al., 2018). Theoretical basis of SFGAP Psychoanalytic theories constitute the basis for GAP. Foulkes was strongly influenced by social psychology and sociology, being in contact with the ideas of people who later formed the basis of the Frankfurt School. He was equally influenced by his friendship with the sociologist Norbert Elias (Foulkes, 1942). Just as Faulks himself was trained in ego psychology, later group analysts paid more attention to self-psychology, object relations theory, and interpersonal theory (Pines, 1996a, 1996b; Brown, 1994; James, 1994). These theories emphasize individual personality development. self, the need for relationships and recognition. They complement classical psychoanalytic theories, in which intrapersonal conflicts and defense mechanisms are central. Other group analysts have also made important contributions to the expansion and development of group analytic theory and practice, such as Nitzun (2015), Schlapoberski (2016), and Behr (2005). Although SFGAP presents several psychoanalytic theories, I particularly appreciate Kernberg's object theories because he attempts to integrate ideas from psychoanalytic theory, structural theory, object relations theory, and self theory (Kernberg, 1975b, 1980, 1984). His initial theories about how personality organization (PO) could be dimensionalized into neurotic, borderline, and psychotic PO based on identity, maturity of defense mechanisms, and the presence of reality testing arose in connection with his work on severe personality disorders. These theories later informed further development into a dimensional system for assessing OL as a whole based on assessing a sample of structural elements of personality (Caligor, Kernberg, Clarkin et al., 2018). This assessment system is used to determine the level of mental organization of the individual and select the appropriate therapeutic strategy for a particular patient. Kernberg's object relations theory explains how a person develops by interacting with loved ones in early childhood and gradually builds an internal world of ideas that affects self-representation, attachment style, relationship capacity, cognitive processes, tolerance/emotional control, and externalizing behavior. The theory covers patient resources, psychopathology, dysfunctional behavior, and how aspects of the inner world emerge as transference-countertransference reactions, both in initial interviews and in the subsequent group situation. SFGAP shares Faulks' understanding of the group as a whole, as a gestalt made up of all its members and greater than the sum of what each member represents. Faulks saw the individual as a social being and described how he/she is shaped by the cultural and historical heritage that each person brings to the group (the foundation matrix). Additionally, the group develops its own story through multi-polarinteractions and communication between participants (dynamic matrix). In addition, SFGAP, like long-term GAP, agree that all communications and interactions in a group are transpersonal and affect each person differently, on a conscious or unconscious level. The relationships between participants interact in a reciprocal manner, each participant influences other participants and the group as a whole. Thus, both individuals and the group as a whole exert significant influence through unconscious or conscious processes. These processes can be called the personal and social unconscious (Thygesen and Aagaard, 2002; Hopper, 2003) and they constitute forces that are understood as “psychological causation”. SFGAP argues that constructive processes of change can be initiated within a limited time, provided that patients must be properly prepared for therapy and meet certain criteria, for example, an established focus of treatment and a certain level of LC. Clinical experience and research evidence have shown that patients suitable for SFGAP should be selected through a thorough assessment, which may take three to five sessions. What should be assessed? The following factors are important in the initial assessment: articulation of the treatment goal, which should be related with a psychodynamic case formulation. In addition, it is necessary to assess a set of personality domains (structural elements of personality), such as, for example, identity, object relations, aggression (tolerance and control), defense mechanisms (maturity), moral standards, degree of pathological narcissism, attachment style, ability to reflect and a sense of reality. In general they overlap, but the first six together constitute a profile that gives the therapist a dimensional understanding of the level of personality organization (PO) and provides guidance for planning treatment strategies in psychodynamic therapy. The initial assessment also includes a clinical diagnosis. Finally, I usually include the patient's self-report of his interpersonal problems, based on the Interpersonal Problem Circle (IIP-circumplex; Alden, Wiggins and Pincus, 1990). Patients rate themselves on 64 items of interpersonal problems on a scale of zero to four: what they find difficult to do or do too much in their relationships with others. The profile shows how they see themselves compared to the other eight subscales: Dominance, Intrusion, Over-Nurturing, Exploitability, Unassertiveness, Social Avoidance, Coldness and Vindictiveness. How is the assessment carried out? All necessary information can be collected through clinical and psychodynamic interviews, with emphasis on current complaints and problems, when and how mental disorders began and developed. In addition, the history of the patient's personality development, a description of the personality, and information about close relationships over the years are important. Potential transference-countertransference patterns can often be inferred from a patient's description of a close relationship, but I also like to include a psychodynamic section in the interview, attempting to tune in and explore aspects of "distortions" and test hypotheses about connections between "there-and-then" and "here-and-there". and now". During this procedure, the patient's ability to observe himself, reflect on psychological connections, and reflect can be assessed. It is also important to assess the patient's level of adaptability and functioning in social and interpersonal relationships. The causes of symptoms and problems must be identified and traced back to problems in the mental structure. When selecting patients for SFGAP, it is important to recognize that treatment may be difficult, but successful for patients who can achieve social adjustment and improved levels of mental health. Agreement on the focus of treatment Agreement on the focus of treatment is between the patient and the therapist, and must be defined within a specific treatment focus. This focus may consist of one or moredysfunctional interpersonal patterns that are the patient's core symptoms and problems. This pattern should also be associated with a psychodynamic case formulation, which is a hypothesis linking personality vulnerabilities, stressors, and clinical effects as manifested by interpersonal symptoms and relationship problems. (Cabaniss, 2013). The Interpersonal Problems Profile (IIP) should also be included in the discussion. It is based on the patient's conscious perception of himself and does not fully reflect the patient's "true" interpersonal world, which also includes repressed or compartmentalized aspects of which the person can only vaguely be aware. The advantage of taking what the patient experiences as problematic as a starting point is that the profile often reveals unwanted (ego-dystonic) patterns that the patient may want to change. Information from three different sources: the IIP profile, clinical interviews, and impressions from personal meetings with the patient provide the therapist with a good basis for formulating a psychodynamic case history (hypothesis), as well as a treatment focus that can be discussed with the patient. Taken together and compared with information from interviews, the profile can indicate hypotheses about how unconscious representations of self and objects are organized and emotionally charged. In addition, this provides another opportunity to test the patient's ability to reflect and reflect on the connections/discrepancies that appear in the material. The focus may also be one or more internal conflicts, such as between autonomy and dependence, or a “symptom complex” such as an eating disorder (Tasca et al., 2006) or pathological grief (Piper et al., 2001). Patients with mild to moderate personality pathology and a tendency to act out may also be treated in time-limited groups. The problematic personality traits or specific impulsive behavior must in these cases be identified and carefully examined as a potential threat to therapy, and ultimately selected as the focus of treatment. Level of Personality Organization When assessing opportunities for change, an initial assessment of the level of personality organization is important. since the ability to change during time-limited therapy usually requires a certain amount of ego strength. Patients must be able to tolerate a relatively structured framework of therapy that includes early self-disclosure, receiving feedback from others, and focusing on the here and now. Space does not allow for a detailed examination of how the six above-mentioned areas can be assessed, so I will briefly describe some of the areas that should be addressed during clinical/psychodynamic interviews: Identity covers three dimensions: the ability to invest in study/work/leisure time, and how much how effective a person is in these areas, how important these areas are, and how satisfying they are. How are self-image related and how continuous over time? Can the patient give a clear, coherent picture of himself? Assessing other people's perceptions involves the patient selecting the most important person in his life and describing him in detail. Is the resulting description a consistent, complete, varied description of a real person, or consists only of single adjectives? The object relationship assessment is based on the number of friends mentioned and the quality and stability of the friendships. Information about romantic relationships is especially important: whether intimacy and sex are combined, whether the patient is reliable and whether he has a tendency to leave friends and partners. The maturity of defense mechanisms is determined by the presence of higher-level mechanisms such as sublimation, humor and anticipation of stress and plans for how to cope with it, all mechanisms that lead to better adaptation and less rigiditypersonality. Lower levels of defense mechanisms are characterized by a tendency to idealize/devalue others, externalization, black-and-white thinking (splitting), and suspicion of the motives of others. Aggression may be self-directed, such as neglect of physical health, high risk behavior, or self-destructive tendencies. When aggression is directed at others, it can lead to loss of patience; the patient feels bad when others succeed; the patient enjoys the suffering of others or has a tendency to cause psychological or physical harm to others. Moral standards may be more or less important in guiding a person's actions. Some people may act immorally if the likelihood of being caught is low. Others may be too hard on themselves. Some may like to deceive others and perhaps even commit criminal acts. Does a person usually feel guilty when doing Some may like to deceive others and perhaps even commit criminal acts. It is important to understand whether a person usually feels guilty when he/she does something wrong, or only when caught in the act of a crime? Narcissism can manifest itself as chronic conflicts and disturbances in social relationships, with a sense of self that is heavily dependent on the admiration of others, with low level of functioning at work and/or with strong feelings of envy or preoccupation with comparisons with others. There are many ways to evaluate PO (see next section). I recommend that clinicians who are less experienced in assessing personality structure and PO refer to Caligor et al. (2018), who provides a more detailed description of the five levels of personality organization: normal, neurotic, and high, moderate, and low borderline PO (It should be noted that the concept of "borderline PO" is broader than the diagnosis of "borderline personality disorder" in the DSM-5 Caligor also scores various areas on a scale from one (normal) to five (severe pathology) and offers clinical markers for varying degrees of PO. I consider patients scoring three or less (normal, neurotic, or high levels of borderline PO) , are most suitable for treatment with SFGAP. However, this view is mainly based on my own thoughts, based on comparison of several detailed case studies of group patients with the clinical markers mentioned above, future prospective and controlled studies will be necessary for definitive answers. that we as professionals must also use our clinical experience and consider factors such as patient-therapist fit, therapist experience, and availability of supervision. Kaligor et al.'s system is a clinical version of the Structured Interview to Assess Personality Organization (STIPO-R; Clarkin, Kaligor, Stern, et al., 2016). The interview and evaluation form are available at http://www.borderlinedisorders.com. It is also possible to use other structured interviews or standardized questionnaires to diagnose the level of organization of personality, such as DSM-5, section III (American Psychiatric Association, 2013), OPD-2 (OPD Task Force, 2008) and PDM-2 (Linguardi and McWilliams, 2017). This is very helpful because therapists may vary in their training, experience with certain patients, workplace assessment procedures used, and personal preferences. Motivation It is important that the patient is willing and able to begin the process of change in a relatively short period of time for successful therapy. One positive sign is when patients become inspired during therapy sessions, such as showing an increased interest in self-discovery and constructive use of feedback from the therapist. Summary Instructions The therapist should explain to the patient what he can expect in group therapy and justify the choice of this treatment method. It is also important to discuss mutual expectations, including possible negative ones.patient expectations and uncertainty about therapy. To increase the patient's motivation to expect a positive outcome, productive experiences in group sessions can be mentioned, including also research results. Ultimately, a contract is reached between the patient and the therapist, which includes rules such as the importance of advance notice of planned absences and maintaining confidentiality with other group members. Case Study: Who can benefit from therapy? Dorothy2 is a 39-year-old married teacher with two sons in aged six and seven years. She was referred for treatment because she had suffered several episodes of depression since the birth of her second child, which resulted in several periods of sick leave. For several years, in addition to working a demanding job, she has been primarily responsible for household chores and raising the children, as her husband is away from home for long periods of time due to work away from home. Personal History Dorothy grew up as the fourth child of eight in large but poor family. Her mother was an anxious person who worried about almost everything, and also suffered from episodic depression for most of her life. Her father was a strict, silent, hard-working man, prone to sudden and unexpected outbursts of anger, and the patient was afraid of him most of the time. Current Situation She has unstable self-esteem and is easily disappointed by her husband, whom she describes as controlling and dominant. She often gets irritated and angry with him, but reacts mainly with guilt and horror. She can sometimes shake the children roughly if they make too much noise or fight, but at school she usually manages to swallow her irritation with her colleagues and students. However, she may sometimes say hurtful comments and also feel intense jealousy towards some of her colleagues whom she considers to be the director's choice. She frequently experiences headaches and neck/shoulder pain. Diagnosis After evaluation, a diagnosis of recurrent depressive disorder was made. She also had some somatoform symptoms and personality pathology (!), but not a personality disorder. In her IIP-C profile, she describes herself as more distant and avoidant, but also more submissive, vulnerable, and overprotective than others. Inner World Information about specific traits in her significant others and the nature of her interpersonal dysfunction may support the inner world hypothesis with " self" and "object" ideas characterized by a lack of positive confirmation, anxiety, and poorly controlled anger that color her perceptions of herself and others. The internal state may manifest itself in a particular choice of object (for example, her husband) or in characteristic personality traits or behaviors that “protect her” from fear of rejection by others, such as social avoidance or excessive control. This behavior is partly irrational and motivated more by her inner world than by who the other person actually is.Level of Personality OrganizationVarious structural elements were examined during the assessment interviews. The patient had an unstable self-image, needed a lot of confirmation from others in her work, and easily felt resentful and neglected. She also had difficulty giving detailed descriptions of her husband and children. There were also issues of intimacy and sexual satisfaction. Her anger could sometimes frighten her, but she could usually control it, except in times of stress, when she could also lose control and be prone to black and white thinking, denial, and projection. Alternatively, she may have become self-deprecating and blamed herself to a degree that was disproportionate to what actually happened. Her moral standards seemed quite high and she usually felt guilty after hurting children, but neverapologized. Her envy and need for support and admiration indicated problems with narcissism. She was classified as having a high level of neurotic personality organization with a mean score of 2.5, meaning she was in the range in which she would most likely benefit from SFGAP.Focus of TherapyAfter careful exploration and discussion of all available information, she and the therapist agreed on the following goals for her therapy: She should challenge and examine her own avoidance and withdrawal from others, and analyze the extent to which these maneuvers protected her inner world and maintained dysfunctional relationships with others. Finally, she was given the behavioral task of disclosing more of her feelings to other people. This should have been done at least once in the second session and should have included both her desires for closeness and intimacy and her feelings of anxiety and resentment because others had violated her personal boundaries. Group Dynamics Many clinicians and researchers have observed and described the specific dynamics that occur in closed groups and consists of four relatively distinct and characteristic phases or stages: involvement, differentiation, interpersonal work and completion (Brabrender and Fallon, 2009). Each phase typically presents specific challenges for therapists, each patient, and the group as a whole that must be "solved" before the group and patients can move forward in the process (Lorentzen, 2013). During the engagement phase (two to four sessions), a positive feeling often arises" being on the same boat,” but also individual anxiety about whether others will accept group members or not. In the first session, the therapist greets the other participants and invites each to introduce himself and talk about the treatment focus he/she has discussed with the therapist (turn-taking). The therapist comments and asks follow-up questions, connecting similar topics among the participants and inviting responses from other patients. Moreover, the therapist emphasizes that the group represents a unique opportunity to be open and interact with other people, and mentions the differences between group psychotherapy and other social situations. In this way, the process of building boundaries around the group and introducing a special way of "being together" begins. Through comments and questions, the therapist also begins to build an analytic culture and demonstrates how this is done. In the differentiation phase (two to four sessions), patients often begin to think about their position in the group: “Who is important or not so important, what is my status in the group and can I assert myself?” Sometimes friction arises in the group when one or several participants establish their position in opposition to what the therapist says. Development of connections between group members begins from the very beginning, and requires each patient to open up, listen and comment on others. It is necessary to develop strategies for reflecting others' experiences, defining one's position, and revealing vulnerable parts of one's personality. The therapist uses the features of the different phases as a backdrop to understanding the group dynamics and to intervene constructively to move the group forward. The interpersonal work phase is the longest (eight to twelve sessions). Although accounts of events external to the group should be welcomed, much of the therapeutic work should take place in the here-and-now interaction where each patient's dysfunctional interpersonal patterns most often emerge. Work in the Interpersonal Phase The group was in the early stage of the interpersonal phase when someone noticed that Dorothy seemed to be withdrawing from the other participants and not interacting with them. What happened before this? She responded rather irritably, after some hesitation that Steve, a young man who was often quite intrusive and not very empathetic (his focus of therapy, among other things, was working on these aspects), interrupted her in the middlephrases. She just talked about her husband, who abandoned her to the mercy of fate, leaving all responsibility for the children and the house on her shoulders. Steve was very hurt by her comment, especially the fact that she claimed that he was impolite in his approach to her. Henry, who had problems with aggression and was easily submissive, exploited, and/or conflict-avoidant, immediately began to explain that Steve was not actually interrupting, but was very determined to tell the group about something positive he had experienced in work. This example suggests a typical group progression where three patients in a row "comment" to each other and simultaneously reveal aspects of their slightly dysfunctional, relationship patterns (personality aspects) that they have agreed/chosen to work on in the group.Group Work. Interventions: The therapist, who had been quietly observing the group for a while, noted how Steve brushed off Dorothy when she talked about how her husband had let her down. He also noticed how her slightly aggressive response triggered a reaction in Henry and caused him to enter the arena to deny and mask signs of conflict. The therapist thought that Steve himself had been abandoned and let down by his father as a child when his father met another woman and moved out city ​​where they lived, and that Steve has since denied that it was difficult for him. In addition, the therapist wondered whether Dorothy's story was creating an imbalance in his inner world, where the painful feelings associated with self-image and object-image connecting his father and Steve early on were repressed. As a result, he decided to take a closer look at this sequence. He was well aware that the people involved might not realize that parts of their treatment focuses had been activated, but he felt that the group was safe enough to work on these issues. An intervention can be as simple as, "Let's stop for a moment. I think there's something important going on here!" All group members are then invited to explore the sequence that affected everyone (transpersonal perspective). Through this intervention, attention is directed from the explicit level of the sequence of interactions to the dynamic determinants of relational patterns (latent level). The sequence can be repeated and potentially offers an arena for learning and for “corrective emotional experiences” (Palvarini, 2010). Beginning with the here and now of the incident, reducing the negative aspects of an argument and defining them as communication attempts, it is possible to stimulate group members to explore and reflect. If stereotypical reactions from those involved in the process are met with warmth, interest and understanding, new things can happen learning, as opposed to escalating conflict, which leads to “retraumatization” for those involved. At the beginning of the termination phase (two to three sessions), the therapist may remind the group that the end of therapy will soon occur. Patients may feel that they have not gotten “enough” from both therapy and their lives. Feelings associated with separation and loss may be voiced. Some may be looking forward to conducting their therapy sessions differently than they have over the past 18 weeks. Anxiety that they will not be able to cope on their own is activated, the therapy process is assessed, important points are summarized, changes are noted and remaining problems are summed up throughout the therapy. In addition, each patient's resources, as well as old and potential new relationships and activities, are brought up and discussed as meaningful resources in order to maintain their relevance after treatment ends. What happened to Dorothy? Several of her dysfunctional interpersonal strategies were activated and explored in the group during therapy, and new ways of interacting were tried. After completing treatment, she rated herself as less evasive, less vulnerable, and more confident (lesssubordinate) than before therapy, and gradually became more able to set boundaries for children in a more constructive way. When she was assessed after two and a half years, it was noted that she continued to change for the better. She agreed with her husband to find a job closer to home, and she would have fewer problems with students. She also experienced decreased neck/shoulder pain and did not experience new episodes of depression. The TherapistIn SFGAP, the therapist must encourage the development of relationships among group members from the outset and be a model of desired interpersonal transactions. He/she must keep patients on track, manage the progression of individual patients and groups through the various phases of the process, and keep the work in the here and now. The therapist is usually more active at the beginning of therapy, but adjusts to the patients' level of activity and backs off when group members are performing well. One of the most important goals is to stimulate participants' interest in the more hidden determinants of individual behavior as well as group processes. Conclusion The main changes in this therapy compared to the original manual (Lorentzen, 2014) are a greater emphasis on the assessment/selection of individual patients (level of personality organization ) and greater explicit structure in the treatment framework. In addition, each patient should have a specific target treatment focus based on elements of interpersonal problems and chief complaints, and related to the patient's unique psychodynamic history. SFGAP is a time-limited, structured, directed and interactional therapy, and interventions are primarily addressed in the here and now. The treatment process consists of four phases, which provide an important intermediate step for understanding how the group develops and for guiding the therapist in the selection of interventions. SFGRP is an appropriate therapy for patients with normal, neurotic, or high levels of borderline personality organization, while patients with psychotic disorders, severe personality disorders, substance abuse, or organic disorders are not likely to benefit from this treatment.ORCID iD Steinar Lorentzen https ://orcid.org/0000-0002-3213-6362Notes: It is difficult to capture the complexity of this challenge in a short article. However, I intend to publish a book on the same topic soon, in Norwegian, which will hopefully be translated into English. Confidential information regarding clinical material has been altered or suppressed so that identification of its source is not possible. References Alden LE, Wiggins JS and Pincus AL (1990) Construction of circumflex scales from the Inventory of Interpersonal Problems. Journal of Personality Assessment 55(3–4): 521–536. American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders, 5th edition. 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