Brief Psychotherapies: Potent Approaches to Treatment

Psychiatric Times - Category 1 Credit

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Educational Objectives

After reading this article, you will be familiar with:

• The history of brief psychotherapy • Why there is a need for brief psychotherapy • The approaches of the various psychotherapies • The type of patient most suitable for brief psychotherapy.

Who will benefit from reading this article?
Psychiatrists, psychologists, primary care physicians, nurse practitioners, and other health care professionals. To determine whether this article meets the continuing education requirements of your specialty, please contact your state licensing and certification boards.

Brief psychotherapy is not the name of a specific model or theory of treatment. Rather, it describes an approach that attempts to make psychotherapy as efficient and practically helpful as possible within a limited time frame. The aim of brief therapy is to speed up the process of change, amplify patient involvement, and foster more focused psychotherapy sessions. Over the years, several approaches to brief psychotherapy have evolved. Some advocate a handful of sessions; others involve more than 20 sessions (eg, psychodynamic therapy).

A growing body of empirical evidence highlights not only the fact that short-term psycho­therapy produces positive outcomes but also that the likelihood of success can be linked to certain patient and therapist characteristics. The value of brief psychotherapies for a variety of conditions has been well documented.^1-3

A brief history of short-term approaches Some may be surprised to learn that treatments of brief duration have roots in psychoanalysis, which is often portrayed as the model that requires the longest time in treatment. In Studies on Hysteria, Freud4 described 3 of his cases that only lasted between 1 and 9 weeks. Furthermore, his successful treatment of famed composer Gustav Mahler’s impotence in a single, 4-hour session is a demonstration of the value of focus and brevity.⁵ Other psychoanalysts, such as Ferenczi and Rank,⁶ also made deliberate attempts to abbreviate the length of psychotherapy. However, it was Alexander and French7 who most systematically moved analysts toward briefer therapies in their classic work Psychoanalytic Therapy: Principles and Applications.

These psychoanalysts were the first to promote the idea of therapists serving as active change agents and to suggest that patient experience, not insight, is a primary factor in achieving benefit. They specifically noted the importance of the therapist in facilitating what they termed the “corrective emotional experience.” Here patient re-exposure to painful early experiences was actively fostered by therapists who responded in a more supportive, accepting, and constructive manner than did significant figures from the patient’s past.

Subsequent research reviews by Fisher and Greenberg^8,9 showed that Alexander and French were onto something important. It turns out that patient insights are not as central to change as many analysts assumed. Other prominent writers coming out of a psychoanalytic tradition (eg, Davanloo, Luborsky, Malan, Mann, Sifneos) have similarly supported the value of abbreviated variations of psychoanalysis. Interpersonal psychotherapy, which was first manualized in 1983, focuses on relationship issues but, unlike psychodynamic treatments, it does not make the therapeutic relationship a central focus.^10,11 Instead, it shortens treatment by concen­trating attention on role changes and the problems patients are having in their current relationships. Altering relationship expectations, examining patterns of communication with others, dealing with interpersonal crises, and using social supports are the main topics. In general, unlike short-term dynamic therapies, this approach down­plays connec­tions to the past and seeks symptom relief through more pragmatic interactions about how current relationships might be better handled.

The arrival of behavioral treatments in the 1950s also moved the literature to an appreciation of the possibilities of briefer treatments. Initially spearheaded by Skinner¹² and Wolpe,¹³ this work focused on the role of therapist as teacher and placed the emphasis on altering learned behavior patterns and developing new skills for coping with anxiety. The learning model was eventually melded with cognition by Ellis14 in his rational-emotive psychotherapy and ultimately developed by Beck and his followers into today’s cognitive therapy-a powerful, well-researched, respected, and manualized treatment.^15,16 Cognitive therapy is active and focused; it teaches patients to replace dysfunctional thought patterns with new, more adaptive ways of thinking. A tight treatment focus, an active therapist, and between-session assignments are designed to speed treatment progress.

Another line in the development of briefer psychotherapy treatment approaches emphasizes the role of the therapist as collaborative problem solv­er. In these so-called strategic therapies, exemplified by such writers as de Shazer,¹⁷ Erickson and Haley,18 and Walter and Peller,19 the therapist actively helps patients interrupt and redirect self-defeating, poorly chosen attempts to solve their current problems. Through such techniques as reframing problems and creating directed tasks, patients are moved toward new ways to act and ways to generate alternative behaviors from those that are maladaptive. The chief goals are to improve independent functioning and alleviate symptoms. It is assumed that future treatments may be needed to prevent relapse and maintain treatment gains.

The need for brief therapy work
All the treatments outlined in this article are responsive to the need to provide more services in less time because of the high demand for mental health services and the limited, inadequate supply of therapists. Briefer psychotherapies are also dictated by the restrictions imposed by insurance companies and the tight economic resources that are common in clinics, hospitals, and counseling centers. By necessity, treatments have had to become swifter and more targeted.

In addition, psychotherapies have had to objectively demonstrate their benefits to compete in the marketplace of available services. Or as Green­berg²⁰ has so concisely put it: “In the future there will be no income without outcome.” Indeed, brief psychotherapies have played an important role in demonstrating the worth of “talking cures” in an era of evidence-based practice. An avalanche of research has been spurred as a result of most psychotherapy now being conducted based on brief formats. In fact, since short-term approaches are the most studied, they account for most of the literature on psychotherapy outcomes.

All the approaches outlined above have been subjected to scientific scrutiny. The accumulated evidence from hundreds of studies and many meta-analyses leaves no doubt about the effectiveness of brief psychotherapy treatments.^1-3,21-24

Brief therapies have produced evidence of changes in brain function-just as medications do.^25,26 Moreover, in studies of depression treatments, benefits from brief therapies have been shown to exceed those from antidepressants in preventing relapse while producing fewer adverse effects.^21,27

Differences and similarities among brief psychotherapies
There are several ways in which various brands of brief psychotherapy differ from or resemble each other. Among the dissimilarities are the length of treatment expected, the breadth of goals, the emphasis on here-and-now issues versus interweaving the past and the present, and the level of therapist directiveness. In general, the brief psychodynamic and interpersonal treatments are more extended, have broader goals, present more integration of past and present, and are less directive than the strategic- and solution-focused approaches. The cognitive and behavioral approaches lie between the other brands on these dimensions.

The similarities among the treatments may be of greater importance. The research literature, while acknowledging the benefits of psychotherapy, has had difficulty in proving that one type of therapy is superior to others, which suggests that common factors may be the most significant ingredients for producing change.^24,28,29 Among the common ingredients across all psychotherapies are the facilitation of a strong alliance between therapist and patient, the attempt to create patient mastery experiences, the confrontation and resolving of problems, and the aim of instilling hope and positive expectations regarding the future. Although they may emphasize different techniques, each of the brief psychotherapy models progresses through a series of similar phases⁷:

• Engagement
• Discrepancy
• Consolidation

In the initial engagement phase, the therapist sets up a collaborative atmosphere, fosters accelerated alliance formation and, through exploration, establishes a focused framework and a set of goals. Patients are encouraged to view their problems from a variety of angles that make intuitive sense. This promotes more optimistic expectations of what may be accomplished.

In the discrepancy phase, novel experiences are created that move the patient toward new understanding of his or her discomforts while trying out additional ways of approaching problems. The aim is to promote new learning during a state of heightened emotion. Success with new behavior patterns leads to feelings of mastery over internal conflicts.

In the consolidation phase, the goal is to strengthen the changes that have been made. Patients are urged to continue to try out new behaviors that seem more successful than their old behaviors. This process is similar to what Freud labeled “working through.” This concept stresses that patients need to be repeatedly faced with examples of how past feelings and perceptions are unnecessarily distorting their reactions to current issues and interpersonal relationships.⁹ At this point, after noting significant changes, many short-term therapies might advocate reducing the frequency of sessions (while increasing treatment duration) to make sure that changes are internalized and that gains are maintained over time.

Patient selection criteria for brief therapy
As noted, short-term psychotherapies come in a variety of packages. Nonetheless, all approaches attempt to attain positive results in a relatively brief period. In fact, some of the approaches, such as interpersonal therapy, explicitly set the total number of sessions in a discussion with the patient at the beginning of treatment. p> But not all patients and diagnoses can be adequately handled in a significantly abbreviated time frame. Typically, a variety of factors need to be considered in making an assessment of suitability for a briefer treatment. There are several major issues to consider when deciding whether psychotherapy of less than 20 sessions is likely to be the best approach.^1-3

Among the prime considerations is whether the problems described are long-standing or of recent vintage. Chronic problems are likely to be embedded in overlearned behavioral and emotional patterns that require longer treatment. A short-term approach is contraindicated if the initial presentation suggests more severe issues that are over­­whelming and disabling to everyday functioning. A high level of severity will likely hamper the patient’s ability to engage actively in treatment efforts during sessions and in assignments between sessions.

Research indicates that psychotherapy works best when there is a good therapeutic alliance between the patient and the therapist.^30,31 Anything that delays the formation of such an alliance will lengthen and slow down treatment progress. Therefore, it is less probable that patients with histories of poor interpersonal relationships will be able to easily adapt to the intensity of the therapy relationship and achieve rapid gains. Past traumas, such as abuse or rape, may also be expected to slow the progress of therapy. Here a patient’s lack of trust or sense of vulnerability may lead to resistance, hesitation about revealing too much, and caution about entering the treatment relationship.

Another signal that therapy may need to be lengthened is the level of the patient’s social supports. Those with few or nonexistent supports may seek the support in therapy that they are not receiving elsewhere, and they may be resistant to more precise and rapid goals for change that would attenuate the treatment relationship. Since brief treatments rely on focus, patients with multiple complex problems tend to be more difficult to treat than those who present with more easily targeted concerns, such as a phobia or a narrowly delineated marital problem.

Also, we should mention the issue of stages of change so well described by Prochaska and Norcross.³² Patients enter treatment with wide variations in their readiness for change, which ranges from those who deny the need for change to those who are primed to make changes. Those who deny the need may require weeks of exploration before they are able to commit to taking actions suggested by a briefer approach.

Needed therapist attributes
In some ways, briefer treatments may require a higher level of skill to rapidly identify central issues, accelerate the formation of a meaningful treatment relationship, inspire hope, and provide a framework in which patients will feel free to try new solutions for old problems. Benefits from psychotherapy may be greatly diminished if a therapist blindly adheres too strictly to a therapy manual.²⁹ Successful psychotherapy, at its base, is an interpersonal encounter and not just a rote application of impersonal techniques to a passive recipient.

The importance of listening to patients is highlighted by Lambert and Archer.³³ Patients’ prognosis was greatly improved when the therapist elicited feedback from patients about how therapy was progressing. Apparently, getting honest feedback promotes needed change in the therapeutic pro­cess. This enhances the treatment relationship, intensifies patient involvement in the process, and increases patient satisfaction. Research also indicates that treatment benefit is significantly related to qualities that competent therapists bring to the encounter. The more a clinician is perceived to be empathic, caring, open, and sincere, the better the outcome.³⁴

Over several decades, the empirical literature has documented that treatment has the power to harm as well as to help. It can make patients worse than they would have been without therapy. Of particular interest is the indication that specific therapist qualities can foster a decline. The concept of therapist pathogenesis is of note.^35,36 Pathogenesis refers to the degree to which therapists allow their own needs to supercede those of the patients who are dependent on them. A series of studies with very disturbed patients underscores the relationship between the level of therapist path­ogenesis and negative treatment outcomes.^35,36

Training implications
In 2002, the Psychiatry Residency Review Committee (RRC) recognized a need to train psychiatrists in a series of core competencies. The RRC mandated that psychiatric residency programs include training in 5 different forms of psychotherapy, one of which is brief psychotherapy. This mandate has sparked added interest in learning about brief psychotherapy and has led to the publication of materials about how clinicians can get started in learning the basics of brief psychotherapy approaches.¹

While reading is a start, evidence suggests that the attainment of proficiency requires more. The need for carefully designed courses and the chance to develop skills through supervised practice experiences is crucial. In general, additional therapist training has been shown to correlate with greater improvement in patients’ symptoms and decreased rates of attrition and recidivism.³⁷ Extended training opportunities must take into account not only the techniques of specific treatment models but the discovery that there are common factors that underlie and power all successful psychotherapy treatments.

CME POST-TEST

References:

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