The conceptualization and operationalization of the psychodynamic focus have been addressed by many authors, some of whom have developed operationalizations and even therapy models (e.g., Malan, 1963; Luborsky, 1984; Fosha, 2000; McCullough and Magill, 2009; Abbass et al., 2017). All of them emphasized the relevance of identifying the psychodynamic focus early on and working on it during the psychodynamic process. Each of these focus definitions have emphasis on different aspects. For example, one of the first in conceptualize the therapeutic focus, Malan (1976), described “focality” (p. 11) as an attempt by the therapist to tackle the patient’s “basic neurotic conflict” (p. 13), which was part of what he called the triangle of conflict. Strupp and Binder (1984) developed a conceptualization of the focus that represented a map of the main areas of the patient’s dysfunctional mental functioning and maladaptive relationship behavior called cyclical maladaptative pattern (Schacht et al., 1984). For Luborsky (1984), the focus had to do with a patient’s interpersonal relationships with important people in his or her life and the therapist (i.e., core conflictual relationship theme).

Despite the diversity of definitions and models, the similarities these authors present can be grouped into two dimensions. The first could be called “type of focus”, which points out to the theme of the focus. In this dimension two categories arise: those that emphasize interpersonal patterns (e.g., Luborsky, 1977); and those that refer to specific intra-psychic conflicts (e.g., Sifneos, 1972; Wallerstein, 1989). The first highlights the dysfunctional relationships as the fundamental factor in the development and continuity of disorders (e.g., Benjamin, 1974; Luborsky, 1977; Strupp and Binder, 1984). The second category (intra-psychic conflict) focuses on unconscious conflicts, clashing forces and tensions as the generators of the patient’s disorder (e.g., Sifneos, 1979; Perry et al., 1989; Wallerstein, 1989; McCullogh Vaillant, 1997).

The second dimension alludes to the composition of the focus: mono-schematic or multi-schematic (Barber and Crits-Christoph, 1993; Dagnino, 2012). This has to do with whether or not the authors consider the need to establish one or more foci at the beginning of the process. Mono-schematic has been the most prevalent conceptualization so far, but clinical wisdom and some research on the subject have shown that the reality implies a more complex approach, i.e., a multi-schematic approach (Crits-Christoph et al., 2005). In fact, this can be found in Balint’s early work (1972), when he proposed the existence of reference points to elicit therapeutic change. Considering the presence of multiple foci that are mutually agreed upon at the beginning of therapy and constantly borne in mind thereafter reduces the danger of the therapist imposing only one aspect of the dynamic on the patient (Thomä and Kächele, 1987). Multiple foci can change over time, enabling a sense of narrative cohesion that weaves together apparently unrelated sessions and helping organize the therapeutic experience (Coren, 2001; Dagnino, 2012).

A psychodynamic formulation is essential for the foci identification. Among the systems that allow us to do a thorough assessment it could be found the Psychodynamic Diagnostic Manual (PDM Task Force, 2006), the Shedler Westen Assessment Procedure (SWAP; Shedler and Westen, 2007), the Karolinska Psychodynamic Profile (KAPP, Weinryb and Rössel, 1991), and the Operationalized Dynamic Diagnosis (OPD; OPD Taskforce, 2001, 2008). The latter is used in this study since it has had a high acceptance among psychotherapists in the national context; there has been an increase of psychotherapists in the system’s training courses and has been progressively more used in mental health care centers. The OPD system allows to identify multiple foci that could be worked during the psychotherapeutic process. For OPD the foci are specific areas that are significant to the patient’s psychodynamics (Grande et al., 2004), and support the patient’s psychic or psychosomatic symptoms. This emphasizes the need for a distinctive comprehension of each patient and to consider change processes that are unique to each dyad (Ablon and Jones, 2005).

Operationalized dynamic diagnosis can identify as foci three main areas. Two of these were mentioned above by the authors who conceptualize the focus: dysfunctional interpersonal pattern and internal conflictual configuration. A third, new area is personality functioning which is also called structural vulnerabilities (in this article, these terms will be used interchangeably).

Regarding the dysfunctional relational pattern, many studies have shown that they are a major reason why patients seek help (Strupp and Binder, 1991). They are also fundamental to psychotherapy because a change in the patient’s mental representations result in a more flexible way of dealing with others, in turn providing more satisfaction with their interpersonal relationships (Cierpka et al., 2007; Gross et al., 2007). The OPD evaluates the relational pattern as a circular matrix of interaction and stands apart from other instruments because of its comprehensiveness, intermediate complexity, and inclusion of the interviewer’s subjective experience in the identification of the interactional pattern (Dagnino, 2012).

In the internal conflictual configuration, the definition of conflict is not based on the traditional psychoanalytic conception but assumes that human behavior is constantly influenced by desires, thoughts, and unconscious representations (OPD, 2008). It refers to unconscious coalitions between basal motivational groups, e.g., the basic desire for care versus autarchy. It assumes that the internal pressure and opposite motives, maintained over a long period of time, lead to an elevated internal state of tension (Dagnino, 2012).

In relation to personality functioning, clinicians and researchers are moving away from the diagnosis of personality disorders to evaluate how personality functions (Diagnostic and Statistical Manual of Mental Disorders (5th ed. [DSM–5]; American Psychiatric Association, 2013) Section III Alternative Model for Personality Disorders (AMPD). When delivering psychodynamic psychotherapy, it is crucial to focalize on relevant topics or aspects of a patient’s functioning (Diener et al., 2007; Luyten et al., 2012; Drapeau et al., 2018). In OPD, personality functioning includes several psychoanalytic traditions such as ego-psychology (Bellak and Hurvich, 1969), self-psychology (regulation of self-esteem, self-reflection, identity), and internalized object relations (Kernberg, 1975).

The relational pattern, conflict, and personality functioning foci are interrelated. In fact, patients begin therapy troubled by more than one issue, requiring a multi-focal approach (Barber and Crits-Christoph, 1993; Dagnino, 2012). The interaction between foci can follow two paths. First, the relational pattern represents a surface where conflict can show up, and the quality of this engagement or coping is eventually directed to the patient’s functional capacities. The other path considers that personality functioning (co)determines the quality and character of the other foci, i.e., the extent of the personality vulnerabilities influences the difficulties the patient has acquired in his or her development (Rudolf et al., 2002; Dagnino, 2012).

No matter which path is followed, conflict and personality functioning relate like content and form (Mentzos, 1991); conflict refers to the “why” and personality functioning to the “how” of a disorder. They may be expressed through dysfunctional relational patterns as the manifestation of conscious or unconscious aspects of the psyche (OPD, 2008). In fact, relational patterns could be considered as a byproduct of the personality functioning and internal conflicts (Grande, 2007). Therefore, the work on the relational pattern may represent an indirect work on conflict or personality functioning.

The foci can also be understood as nodal points in a network of dynamic interrelations throughout the process (Dagnino, 2012). Some authors have suggested that a particular focus can dominate the therapy at one point in time and may subsequently be replaced by another (Balint et al., 1972; Thomä and Kächele, 1985; Stauss and Fritzsche, 2008; Summers and Barber, 2010). However, after identifying the foci no study has sought to look at how they are present throughout the psychotherapeutic process. This is the main aim of this study. As the psychotherapeutic work on foci is considered a mechanism of change (e.g., Messer and Warren, 1995) it is not only researching the psychotherapeutic process of brief psychodynamic therapy but also the mechanisms of change that allow patients to get better.

The most (clinically) useful way to research the psychotherapeutic process is through its segmentation into minor units of analysis as it is through this fine-grained analysis that the essential nature of the mechanisms leading to patients’ change can be understood (Rice and Greenberg, 1984). There are many labels for these segments, such as critical events (Fitzpatrick and Chamodraka, 2007), significant events (Elliott, 1989; Elliott and Shapiro, 1992), or change episodes (Krause et al., 2007). The latter designation is used in this study since it identifies fragments of sessions in which there is an intensification of the process of change that culminates in a specific moment of change (De la Cerda and Dagnino, 2021). From this viewpoint, change is in the modification of the subjective interpretation and explanation of the image of oneself and the world, which leads to new subjective theories (Groeben et al., 1988). These changes evolve throughout the therapeutic process, resembling a saw tooth pattern (Caro Gabalda, 2006), but with greater change complexity in the process of successful cases (Krause et al., 2007).

It is expected that the work on each focus can appear through change episodes at different depth levels and that this work will relate with the level of change complexity accomplished by the patient. This, in turn, will allow the patient to integrate these changes into his or her everyday life (Malan, 1976; Marziali, 1984; Crits-Christoph et al., 1988; Messer and Warren, 1995; Safran and Muran, 2000).

Considering the above, the aims of this study were to (1) identify the presence and depth level of each focus at the beginning, middle, and final phases of the psychotherapeutic process, (2) evaluate how each focus changes during the psychotherapeutic process, and (3) evaluate the relationship between foci and the level of patients’ change (level of hierarchy). It is expected that the focus on personality functioning will be more present in the initial phase since it supports the work on the other foci. When looking at the trajectories of each focus during the process, it is expected that the relational pattern focus will be stable and the conflict focus will increase its presence throughout the therapies, especially in the middle part of the process. It is also expected that the personality functioning focus will decrease in favor of conflict focus. Finally, it is expected that patients’ subjective change will be more complex when the presence and level of conflict focus is higher.

The study used a multiple single subject design with mix analysis. The sample comprised 13 psychotherapeutic processes of brief psychodynamic psychotherapy, which were selected from a database with 25 individual psychotherapeutic records from different theoretical orientations, collated during FONDECYT projects 1030482 and 1060768. All psychotherapies were conducted in Chile and had a maximum of 25 sessions (mean = 18), with a weekly frequency, in a face-to-face modality.

The inclusion criteria for the selection of the 13 psychotherapeutic processes were two: (1) psychodynamic therapeutic orientation and (2) successful outcome using the Outcome Questionnaire (OQ-45.2, Lambert et al., 1996). Specifically, a total reliable change index (ICC) higher than 17 points (De la Parra and Von Bergen, 2001) was considered successful, since it is the amount of change considered to be reliable beyond statistical error.

Change episodes were the unit of analysis. A total of 208 change episodes were identified through the GchI (Krause et al., 2007, see procedure). They were extracted from 246 psychotherapy sessions. The number of episodes of change within therapeutic processes ranged from 5 to 46, with a mean of 16 episodes (SD = 11.35).

Patients were mostly single women (Table 1) who consulted at various mental-health outpatient care centers. Reasons for consultation varied, although all of them presented mainly depressive symptoms (according to the clinicians’ diagnosis).

There were eleven therapists – six women and seven men – with a mean age of 42 years (SD = 5). They had at least a master’s degree, psychoanalytic training or training in brief psychodynamic psychotherapy. Two of them – one woman and one man – did two psychotherapeutic processes, the rest conducted only one. Psychotherapists had a mean of 22 years of experience (SD = 3). None of them had OPD training or knew about the system when conducting the psychotherapies.

The initial foci, idiosyncratic for each patient, were identified using the OPD-2 manual (see procedure).

First phase: change episode identification. To identify change episodes two independent trained raters observed in situ the psychotherapy and coded all the change episodes they could identify. When the session ended, raters compared their codes. For the episodes in which they did not agree, the research team discussed until consensus was reached (inter-subjective validation) (Hill et al., 1997).

As shown in Figure 1, change episodes are first identified by singling out a moment of change (which constitutes the end of the episode). Then, this is worked backward; to identify when the interaction related to the theme started the rater revise the preceding interactions until they found the starting point [for more information regarding this procedure please refer to Krause et al. (2007)].

Raters on the second and third phases were therapists formally trained in OPD (OPD Taskforce, 2008), who underwent 100 h of theoretical and practical training and applied the method to clinical interviews.

Second phase: foci identification: two raters identified the OPD foci (dysfunctional relational pattern, main conflict, and main vulnerability of personality functioning) from the videos and transcripts of the first two interviews of the 13 therapies of the sample.

Third phase: foci presence and depth level: The first author received the identified foci for each patient. Then she prepared a document that included clinical vignettes and descriptions of how these foci could be observed in the material. This document, the videos and transcripts were provided to a second group of raters. They received the transcripts of each change episode randomly to avoid any bias. Hence, they did not know which session of the process the transcripts corresponded to Dagnino (2012).

All 13 processes had signed an informed consent that authorized the use of such records for research purposes, not limited to the project in which they were conducted. Authorization for the use of these data for the present study was granted by the Ethics Committee from Pontificia Universidad Católica de Chile and Universidad Alberto Hurtado, following the declaration of Helsinki (64th WMA General Assembly, Fortaleza, Brazil, October 2013).

When analyzing the therapeutic process, psychotherapeutic phases were constructed considering the number of sessions of therapy divided by three (i.e., beginning, middle, and final). For example, for a therapy that had 13 sessions, 5 were labeled “initial,” 4 were labeled “middle,” and 4 were labeled “final.”

Focus intensity was a variable constructed based on each focus presence and depth. To construct this new variable, it was first identified which focus was present and then the score for the depth of that focus was copied into the new variable. So, when the dysfunctional relational pattern (Focus 2) was present, the depth of the dysfunctional relational pattern was copied to the new variable; when the conflict focus (Focus 3) was present, the depth of the conflict focus was copied; and when the personality functioning focus (Focus 4) was present, the depth of the personality was copied. In the first and second objectives, the analyses were conducted considering the focus intensity as a continuous variable. For the third objective the focus intensity was treated as dichotomic variables: low presence and depth (scores from 0 to below 2) and high presence and depth (scores from 2 to the highest).

Complexity of change was considered a continuous variable following the GChI instrument. This is a continuous variable with 19 change indicators hierarchically ordered from least to most complex.

Two generalized estimating equations (GEE) were used, as data were nested within therapeutic processes. The two GEEs had as the dependent variable the focus intensity. In the first GEE, the dependent variable was the focus intensity measured as a continuous variable, and the within-subject effects were the phase to which the session belonged to and the type of focus. Pairwise comparisons were adjusted for multiple comparisons using Bonferroni. This analysis informed the first and second objectives.

The second GEE had as a dependent variable the complexity of change measured as a continuous variable and the within-subject effect were the focus intensity (as categories) and the type of focus. Pairwise comparisons were also adjusted for multiple comparisons using Bonferroni. This analysis informed the third objective.

The focus intensity in the three phases and the type of focus were examined. Results showed that the model was significant [χ² (8 df) = 42.59, p ≤ 0.001, Cramer’s V = 0.26]. To explore where the differences were, pairwise comparisons using Fisher’s Least Significant Differences were conducted.

When the phases were analyzed, significant differences were found in the focus intensity in the initial phase between conflict and structural vulnerability (Mean difference: 0.525, p = 0.04), as Figure 2 shows.

When each focus was analyzed, significant differences were found in the focus intensity for structural vulnerabilities between the initial and final phase (Mean difference = −0.449, p = 0.04), and between the middle and the final phase (Mean difference = −359, p = 0.036). No differences were found in this focus when comparing the initial and middle phase, even though an increased tendency can be observed. The other two foci (relational pattern and conflict) did not show any difference throughout the process.

The complexity of the patients’ change was predicted by the focus intensity (as categories) and the type of focus. Results showed that the model was significant [χ² (5 df) = 18.33, p = 0.003, Cramer’s V = 0.17, see Figure 3].

When the focus intensity was analyzed, significant differences were found in the complexity of patients’ change in low intensity between Relational Pattern and Conflict (Mean difference = 0.268, p = 0.047), and between Relational Pattern and Structure Vulnerability (Mean difference = 0.499, p = 0.01). No other significant difference was found.

Finally, from the figure we can see how the complexity of patient change occurs between levels 8 and 10.

This study provided the basis for generating scientific knowledge of brief psychodynamic psychotherapy. Particularly by doing so through systematic observation and evaluation repeated over time (Chassan, 1979). This type of psychotherapy is and will continue to be a relevant approach especially in institutional work.

An important contribution of this study was the development of the Foci Presence Scale and Depth (Dagnino and de la Parra, 2010). As Grande et al. (2004) argue, there is a need for development of an observational instrument of psychodynamic processes on the aspects worked through. This instrument can be used for training and practice on clinical settings since it encourages to observe the presence of foci in relevant segments. Therefore, practitioners gain a “royal road” to the way psychotherapy works with patients’ problems (Lepper, 2009). Greenson (1967) said that if the therapist knows what to say and when to say it, the interaction between patient and therapist points out to success. Formulating the interventions with knowledge has great impact on a helpful relationship.

One of the main limitations of this study is that the sample was composed of patients who showed medium integration of personality functioning. This means that, even though there were vulnerabilities, these were moderate. In further research it would be interesting to see how foci, especially the personality functioning focus, evolve in patients with more baseline impairments (OPD Taskforce, 2008).

Also, as the aim of the study was to study successful psychotherapies and significant segments with change episodes, no comparison with unsuccessful psychotherapies or segments where no subjective change appears (e.g., stuck episodes) were conducted. This limits the conclusions that could be reached because as there is no comparison group, we cannot be certain that what we observed here would not be present in unsuccessful psychotherapies as well.

For future research it would be interesting to look at the association between the presence and level of foci with other elements of change, for example, the course of the alliance between patient and therapist or the therapist’s identification of foci, session by session.

The results of this study reveal the importance of continuing to study therapeutic foci and to do it from a process view. Focalization and interventions on foci are central aspects when developing effective psychotherapeutic processes. This line of research will not only provide knowledge about foci and brief psychodynamic psychotherapy as an effective treatment, but will also help to develop practical orientations for clinical practice.