11: Brief Psychotherapy: An Overview

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CHAPTER 11 Brief Psychotherapy: An Overview

Despite the notion that it is a long-term endeavor, most data indicate that psychotherapy as it is practiced in the real world has a short course. Therefore, it is usually “brief therapy” even if its duration is not specified as such at the outset. Well before the nationwide impact of managed care was felt, studies consistently showed that outpatient psychotherapy typically lasted 6 to 10 sessions. Data on national outpatient psychotherapy utilization obtained in 1987—early in the takeover of managed care—showed that 70% of psychotherapy users received 10 or fewer sessions. Only 15% of this large sample had 21 or more visits with their therapist.1

Interest in planned brief psychotherapy has grown enormously in the last two decades. Unfortunately, this interest has been sparked more by changing patterns of health care reimbursement than by an appreciation of the clinical value inherent in brief treatments. This overview of brief psychotherapy will first focus on specific “schools” of short-term treatments. Then the “essences” of most brief treatments will be distilled: brevity, selectivity, focus, and specific therapist activity. Finally, a detailed blueprint for a broadly workable eclectic brief therapy will be presented.

HISTORY OF BRIEF PSYCHOTHERAPY

Toward the end of the nineteenth century, when Breuer and Freud invented psychoanalysis, hysterical symptoms defined the focus of the work. These early treatments were brief, the therapist was active, and, basically, desperate patients selected themselves for the fledgling venture. In time, free association, exploration of the transference, and dream analysis replaced hypnosis and direct suggestion. So, as psychoanalysis evolved, the duration of treatment increased and therapist activity decreased.

Alexander’s (1971) manipulation of the interval and spacing of sessions (the therapeutic “frame”) explored the impact of decreased frequency, irregular spacing, therapeutic holidays, and therapist-dictated (rather than patient- or symptom-dictated) treatment schedules. All these frame changes enhanced the external reality orientation of psychotherapy. Then World War II produced large numbers of patients who needed treatment for “shell shock” and “battle fatigue.” Grinker and Spiegel’s (1944) treatment of soldiers ensconced brevity in the treatment armamentarium. Lindemann’s (1944) work with survivors of the Coconut Grove fire—with its focus on grief work—also occurred during this period.

The modern era started in the 1960s when Sifneos and Malan independently developed the first theoretically coherent, short-term psychotherapies. The increased activity of Ferenczi and Rank, Lindemann’s crisis work, Grinker and Spiegel’s push for brevity, Alexander and French’s flexible framework, and Balint’s finding and holding the focus were all technical innovations, but none constituted a whole new method. Malan and Sifneos each invented ways of working that were not a grab bag of techniques but each a whole new therapy, with a coherent body of theory out of which grew an organized, specified way of proceeding.2,3

Over time, as therapies became briefer, they became more focused and the therapist became more active. But brevity, focus, and therapist activity are ways in which short-term therapies differ, not only from long-term therapy, but also typically from one another. Patient selection makes up a fourth “essence” in the description of the short-term psychotherapies. Table 11-1 shows brevity, selectivity, focus, and therapist activity as the organizing principles for the therapies summarized in the columns below each “essence.”

MODERN BRIEF PSYCHOTHERAPIES

There are four general schools of brief psychotherapy: (1) psychodynamic; (2) cognitive-behavioral; (3) interpersonal; and (4) eclectic. Each has indications and contraindications,46 but it is worth acknowledging at the outset that there is no conclusive evidence that any one short-term psychotherapy is more efficacious than another.710

Psychodynamic Short-term Therapies

The “interpretive” short-term therapies all feature brevity, narrow focus, and careful patient selection, but the common feature is the nature of therapist activity. Psychoanalytic interpretation of defenses and appearance of unconscious conflicts in the transference appear in other short-term therapies (and are often downplayed), but only in these methods are interpretation and insight the leading edge of the method and, as in psychoanalysis, the main “curative” agents.

Sifneos’s anxiety-provoking therapy (1972, 1992) is an ideal example of a brief psychodynamic psychotherapy. This treatment runs 12 to 20 sessions and focuses narrowly on issues (such as the failure to grieve, fear of success, or “triangular,” futile love relationships). The therapist serves as a detached, didactic figure who holds to the focus and who challenges the patient to relinquish both dependency and intellectualization, while confronting anxiety-producing conflicts. One can think of this method as a classical oedipal-level defense analysis with all of the lull periods removed. One limiting feature is that it serves only 2% to 10% of the population, the subgroup able to tolerate its unremitting anxiety without acting out.

An illustrative contrast, Sifneos’s anxiety-suppressive therapy, serves less healthy patients who are able to hold a job and to recognize the psychological nature of their illness, but who are unable to tolerate the anxiety of deeper levels of psychotherapy. Anxiety-provoking psychotherapy is longer, less crisis oriented, and aimed at the production of anxiety—which then is used as a lever to get to transference material. (In psychoanalysis, transference emerges, but in short-term therapy it sometimes is elicited.)

Malan’s method11,12 is similar, but the therapist discerns and holds the focus without explicitly defining it for the patient. (In the initial trial, if the therapist has in mind the correct focus, there will be a deepening of affect and an increase in associations as the therapist tests it.) A unique feature of this treatment is that Malan sets a date to stop once the goal is in sight and the patient demonstrates capacity to work on his or her own. A fixed date (rather than the customary set number of sessions) avoids the chore of keeping track if acting out causes missed sessions or scheduling errors.

Malan’s work is reminiscent of the British object-relations school. Like Sifneos, he sees interpretation as curative, but he aims less at defenses than at the objects they relate to. In other words, the therapist will call attention to behavior toward the therapist, but rather than asking what affect is being warded off, Malan wants to know more about the original object in the nuclear conflict who set up the transference in the first place. Malan’s later work converges toward that of Davanloo’s,8,13,14 so that his and Malan’s approaches are conceptually similar.

Davanloo’s method can appear dramatically different from all others in terms of therapist activity. The therapist’s relentless, graduated, calculated clarification, pressure, and challenge elicit the anger used to dig out the transference from behind “superego resistance.” Davanloo begins by criticizing the patient’s passivity, withdrawal, or vagueness, while pointing out the body language and facial expressions demonstrating them. Patients who do not decompensate or withdraw are then offered a trial interpretation: the patient’s need to fail and clumsiness in the interview disguise aggression toward the therapist; the patient’s need to become “a cripple,” to be “amputated” and “doomed,” disguises rage.

As shown in Figure 11-1, the therapist works with this “triangle of conflict”—which goes from defense (D) to affect (A) to impulse (I), in relation to the “triangle of persons.” This begins with a problematic current object (C), one mentioned in the first half of the initial interview. Then investigation moves to the therapist (T), who the patient has just been protecting from anger, and then to the parent (P) who taught such patterns in the first place. One or two circuits around the “D/A/I” (conflict) triangle in relation to three points of the “C/T/P” (persons) triangle constitute the “trial therapy.” This is a more elaborate version of the trial interpretations Malan and Sifneos use to test motivation and psychological-mindedness. Davanloo’s patients lack the ability to distinguish between points in the “conflict [Defense/Affect/Impulse] triangle” or to experience negative affects directly. By trolling the D/A/I triangle around the “persons [Current object/Therapist/Parent] triangle,” Davanloo forces the frigid patient to feel and creates a mastery experience for the patient.

These are nonpsychotic, nonaddicted, nonorganic individuals who have a combination of retroflexed aggression and punitive superegos, but at the same time, enough observing ego to discount the apparent harshness. His patients find the seemingly harsh Davanloo method supportive; up to 35% of an average clinic’s population are said to tolerate it, a range broader than either Sifneos or Malan claimed. Failures of the Davanloo “trial therapy” typically are referred to cognitive therapy.

The dynamic-existential method of James Mann15,16 relied on a strict limit of exactly 12 sessions. Time is not just a reality, a part of the framework, but time is an actual tool of treatment. Twelve sessions, which Mann chose somewhat arbitrarily, is sufficient time to do important work but short enough to put the patient under pressure. This set number with no reprieve is both enough time and too little. It thrusts the patient and the therapist up against the existential reality they both tend to deny: Time is running out.

No other short-term therapy seems to require so much of the therapist. And even if this method does not appeal to all short-term therapists, almost every subsequent theorist in the field seems to have been influenced by Mann to some degree—even Budman and Gurman,17 whose use of time appears so unlike Mann’s. It is described somewhat in detail here because the interaction of therapist activity with phases of treatment is so clearly highlighted.

Underlying the focus the patient brings, Mann posits a “central issue” (analogous to a core conflict) in relation to the all-important issue, “time itself.” The therapist is a timekeeper who existentially stays with the patient through separations, helping master the developmental stages in which parents failed the patient. Mann’s theoretical point of departure (which probably followed the empirical finding that 12 sessions was about right) is Winnicott’s18 notion that time sense is intimately connected to reality testing, a “capacity for concern,” and unimpaired object relationships. A better sense of time and its limits is the soil for growing a better sense of objects.

During evaluation, the therapist begins to think about the “central issue” (such as problems with separation, unresolved grief, or failure to move from one developmental stage to another—delayed adolescence especially). This central issue is couched not in terms of drive or defense, but existentially, in terms of the patient’s chronic suffering. If the patient is moved by this clarification, the therapist solicits the patient’s agreement to work for a total of 12 sessions. The patient will at this point express some disbelief that 12 sessions is enough. But if the evaluation has been accurate and the method is suited to this patient, the therapist should look the patient in the eye and say that 12 sessions—and only 12—will be just enough.

The early sessions are marked by an outpouring of data and by the formation of a positive or idealizing transference. During this phase the therapist’s job is to hold the focus on the central issue and allow the development of a sense of perfection. At about the fourth session, there is often an appearance of disillusionment and the return of a focus on symptoms. At this point the therapist makes the first interpretation that the patient is trying to avoid seeing that time is limited and avoiding feelings about separation. This sequence is repeated, and it deepens through the middle of therapy.

After the midpoint, session 6, overt resistance often occurs, perhaps lateness or absence on the part of the patient, and the emergence of negative transference. The therapist examines this in an empathic and welcoming way while inwardly examining countertransference issues that may impede the work. And finally, in the latter sessions comes a working through of the patient’s pessimism and recollection of unconscious memories and previous bad separation events, along with an expectation of a repetition of the past. By the therapist’s honest acceptance of the patient’s anger and ambivalence over termination, the patient moves from a state of neurotic fear of separation and its attendant depression to a point where the patient is ambivalent, sad, autonomous, and realistically optimistic.

Cognitive-Behavioral Brief Therapies

The behavioral therapies have a decades-long history and a good record of achievement. The cognitive therapies are the inheritors of this earlier track record. What the two have in common is that neither addresses “root causes” of disorders of mental life, but focus almost exclusively on the patient’s outward manifestations. These “nonpsychological” or “non–insight-oriented” styles of therapy are broadly applicable, both in terms of patients and problems. (For the cognitive-behavioral therapies, see Chapter 16.)

The method of Aaron Beck1921 aims at bringing the patient’s “automatic” (preconscious) thoughts into awareness and demonstrating how these thoughts affect behavior and feelings. The basic thrust is to challenge them consciously, and to practice new behaviors that change the picture of the world and the self in it. Beck says that an individual’s interpretation of events in the world is encapsulated in these fleeting thoughts, which are often cognitions at the fringes of consciousness. These “automatic thoughts” mediate between an event and the affective and behavioral response. The patient labors under a set of slogans that, by their labeling function, ossify the worldview and inhibit experimenting with new behaviors.

The therapist actively schedules the patient’s day-to-day activity, and the patient is asked to list in some detail actual daily activities and to rate the degree of “mastery” and “pleasure” in each. These allow the therapist to review the week with the patient and to sculpt behaviors. Cognitive rehearsals are also used to help the patient foresee obstacles in the coming week. The therapist repeatedly explains the major premise of the cognitive model, that an intermediating slogan lies between an event and the emotional reaction. This slogan may take a verbal or pictorial form. The therapist then, using Socratic questioning, elicits from the patient statements of fact that lead to a more accurate conceptualization of the problem, while at the same time actively interfering

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