Brief Therapy

(1-14-04)

Brief therapy, short-term therapy, time limited therapy: making time a defining element in the psychotherapy relationship

A caution in using qualitative terms: When I was a graduate student behavior therapy was considered “short term therapy” from many perspectives; at the same time a typical course of Wolpe style behavior therapy ran from 15 to 30 sessions. In today’s world 15 to 30 sessions would often be consider4ed “long term” therapy. The meaning of “brief” is obviously relative to what is considered “long” or “typical.” A typical course of classical psychoanalysis often involved three to five years of treatment with 2 to 3 sessions a week (4 and 5 sessions a week might occur by were unusual in standard practice; as was once a week treatment). Against this context–300 to 750 sessions–any therapy than ran for months instead of years and for less than 50 sessions was considered “limited.”

More than a precise number of sessions or duration of treatment, I would argue that the critical feature of the “briefer” therapies is that time becomes an explicit defining feature in the therapeutic contract. The leads to specific (or limited) goals and a prestructured organizational framework: “We are going to meet so many times with the goal of accomplishing this end.” Implicit in this statement of a clear view of the starting and ending point, and the pathway that will lead from one to the other. Open ended therapy contacts are defined by broad, mutually agreed upon goals but do not specify the rate of change–outcome is defined only in terms of outcome–success or failure (“premature termination”).

Several developments contributed to the interest in briefer therapies over the past several decades:

1. Reports that much of the identifiable change in psychotherapy occurred within the first 10 sessions.
2. Reports that more sessions were associated with neither better outcome or better follow-up than fewer sessions (low dose-depended outcome). These findings have been disputed and other data has been put forward that does suggest a dose-dependent relationship with outcome over the first 20 to 30 sessions.
3. Increasing interest in how to make psychotherapy available to larger segments of society/meet the need/demand for psychological services.
4. Economic incentives favoring briefer therapies.
5. Increased interest in so-called “symptomatic treatments” such as behavior therapy, marital counseling, problem solving strategies which focused on specific treatments goals rather than change of basic personality patterns/traits.

Continuing developments have bolstered interest in briefer therapies:

1. Managed care strongly encouraged briefer treatments.
2. Highly structured, especially “manualized” treatments have become a principal focus of psychotherapy outcome research–the brief therapies were easily adaptable to this model of research.
3. Empirical evidence supporting the effectiveness of brief therapies accumulated.
4. Virtually all therapeutic models and schools have been able to offer brief therapy alternatives:
   • psychoanalytic/psychodynamic/object relations (c.f., Shefler, 2001; Donovan, 2003; Winston & Winston, 2002)
   • solution focused/narrative (c.f., Milner & O’Byrne, 2002)
   • cognitive-behavioral (c.f., Hudson-Allez, 1997)
5. The major of presenting problems can be approached from a brief therapy model:
   • most presenting concerns of individuals (c.f., Hudson-Allez, 1997)
   • work with adolescents (Mufson, Moreau, Weissman, & Klerman, 1993)
   • couple counseling (Donovan, 2003, Halford, 2001)
   • crisis intervention (Goldring, 1997)
   • group therapy (Yalom, 1983)
   • parent training (Miller, 1975)
   • family therapy (Homrich & Horne, 2000)

Common aspects to many brief therapies

1. Problem/solution vs. pathology/understanding focus
2. Active/involved vs. passive/reserved therapist
3. Active/experimental vs. passive/receptive client
4. Sharply focused and delimited therapeutic goals
5. Therapeutic emphasis on the power of thought/image and language for change
6. Utilization of life beyond the therapy session in the process of change
   • homework
   • social focus

References

Crits-Christoph, P., &Barber, J. B. (1991). Handbook of Short-term Dynamic Psychotherapy. United States: Basic Books.

Donovan, J. M. (2003). Short-term Object Relations Couples Therapy: The five-step model. New York: Brunner-Routledge.

Goldring, J. (1997). A Quick Response Therapy: A time-limited treatment approach. Northvale, NJ: Jason Aronson.

Gustafson, J. P. (1997). The Complex Secret of Brief Psychotherapy: A panorama of approaches. Northvale, NJ: Jason Aronson.

Halford, W. K. (2001). Brief Therapy for Couples: Helping couples help themselves. New York: Guilford Press.

Hudson-Allez, G. (1997). Time-limited Therapy in a General Practice Setting: How to help within six sessions. London: Sage Publications.

Milner, J., & O’Bryne, P. (2002). Brief Counseling: Narratives and solutions. New York: Palgrave.

Shefler, G. (2001). Time-limited Psychotherapy in Practice. New York: Brunner-Routledge.

Wells, R. A. (1994). Planned Short-term Treatment, 2nd ed. New York: Free Press.

Winston, A., & Winston, B. (2002). Handbook of Integrated Short-term Psychotherapy. Washington, D. C.: American Psychiatric Publishing.