Brief Psychotherapy: An Overview

Psychodynamic Short-term Therapies

The “interpretive” short-term therapies all feature brevity, a narrow focus, and careful patient selection, but the common feature is the nature of the therapist's 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%–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 method 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 the 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, 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.

The therapist works with a “triangle of conflict”—which goes from examination of defenses to labeling affect, to impulse or behavior, in relation to the “triangle of persons.” This persons triangle begins with a problematic current object, one mentioned in the first half of the initial interview. Then investigation moves to the therapist, who the patient has just been protecting from anger, and then to the parent who taught such patterns in the first place. One or two circuits around the “conflict triangle” in relation to three points of the “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 non-psychotic, non-addicted, non-organic 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 Mann relied on a strict limit of exactly 12 sessions. Time is not just a reality, and 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, 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's 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 mid-point, 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 “non-psychological” 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 Beck aims at bringing the patient's “automatic” (pre-conscious) 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 with the patient's obsessive reiteration of the negative cognitive set. The patient's participation in the reasoning process provides a chance to experience the therapy before actually putting it into practice. Most of the work, however, is not done in sessions, but in homework in which the patient carries out the prescriptions of the therapist.

Interpersonal Therapy

Interpersonal psychotherapy (IPT), developed by Klerman and colleagues, is a highly formalized (“manualized”) treatment. It was developed primarily to treat patients with depression related to grief or loss, interpersonal disputes, role transitions, or interpersonal skill deficits, but its applicability has been broadened beyond depression to include couples' conflicts, personality disorders, and bipolar disorder, among others.

Temperamental fit between the patient and therapist plays a large role. Crits-Christoph notes that “patients who have more interest in examining the subtle, complex meanings of events and interpersonal transactions are a better match” for expressive treatment, whereas those with a more concrete style may prefer cognitive therapy or IPT (p. 157). This psychotherapy de-emphasizes the transference and focuses not on mental content, but on the process of the patient's interaction with others. In IPT, behavior and communications are taken at face value. Consequently, therapists who need to find creativity in their work may dislike IPT. The strength of the method is that it poses little risk of iatrogenic harm, even to the fragile patient, and even in the hands of the inexperienced therapist.

IPT theorists acknowledge their debt to other therapies in stance and technique, but claim distinction at the level of “strategies,” an orderly series of steps in evaluation and treatment. For patients with depression related to grief , they first review depressive symptoms, relate them to the death of the significant other, reconstruct the lost relationship, construct a narrative of the relationship, explore negative and positive feelings, and consider the patient's options for becoming involved with others.

For patients with interpersonal disputes that cause depression , they conduct a symptom review, relate symptom onset to the dispute, take a history of the relationship, dissect-out role expectations, and focus on correction of non-reciprocal expectations.

For patients with role transitions , they review the symptoms, relate the symptoms to life change, review positive and negative aspects of new and old roles, review losses, ventilate feelings, and find new role options. And finally, with patients with interpersonal deficits that lead to depression , they review symptoms and relate them to social isolation or unfulfillment, review past relationships, explore repetitive patterns, and (unlike the behavioral therapies) discuss the patient's conscious positive and negative feelings about the therapist, using them to explore the maladaptive patterns elicited earlier.

As one example of method , here is the algorithm for communication analysis : Therapists should identify:

• (1)

  Ambiguous or non-verbal communication.

• (2)

  Incorrect assumptions that one has indeed communicated.

• (3)

  Incorrect assumptions that one has understood.

• (4)

  Unnecessarily indirect verbal communication.

• (5)

  Inappropriate silence—closing off communication.

If the therapist identifies one or more of these, this list is run through another list of therapeutic investigations of the therapeutic relationship itself to give the patient concrete examples. Then decision analysis, the major action-oriented technique of IPT, is used to help the patient diagnose and treat depressogenic interpersonal problems by finding other options.

Strupp and colleagues also lay claim to the interpersonal model. In it, the focus the patient brings helps the therapist to generate, recognize, and organize therapeutic data. The focus is commonly stated in terms of a cardinal symptom, a specific intrapsychic conflict or impasse, a maladaptive picture of the self, or a persistent interpersonal dilemma. It is supposed to exemplify a central pattern of interpersonal role behavior in which the patient unconsciously casts himself or herself. The method for such investigations is narrative , “the telling of a story to oneself and others. Hence, the focus is organized in the form of a schematic story outline” to provide a structure for “narrating the central interpersonal stories” of a patient's life (Strupp & Binder, p. 68).

This narrative contains four structural elements or subplots that are the keys to the therapy:

• (1)

  Acts of self.

• (2)

  Expectations of others' reactions.

• (3)

  Acts of others toward the self.

• (4)

  Acts of self toward the self.

While learning this narrative, the therapist is expected at the same time to continually point out how these cyclic patterns cause recurrent maladaptation and pain. Co-narrating and co-editing these four subplots form the basis of the Strupp method.

The Core Conflictual Relationship Theme (CCRT) method is another formalized therapy that examines narratives. Based on Luborsky's CCRT, it assumes that each patient has a predominant and specific transference pattern, that the pattern is based on early experience, that it is activated in important relationships, that it distorts those relationships, that it is constantly repeated in the patient's life, and that it appears in the therapeutic relationship. A major difference in the CCRT method from examinations of the transference in the many dynamic brief therapies, however, is the systematic, active method of ferreting out the CCRT.

The focus in CCRT therapy, the “core conflictual relationship,” is discovered by eliciting several relationship episodes (REs), descriptions of problems appearing in present and past relationships. From these RE descriptions, three components are carefully teased out—the patient's wish (W) in relationships, the actual or anticipated response from others (RO), and the patient's response from self (RS). In the first phase of treatment, the repeated occurrence of the CCRT is documented. In the second phase, the childhood roots of the RO are worked through. In the last phase, termination-stimulated increases in the patient's RO and RS, response from others and from self, are analyzed against the backdrop of increased conscious awareness of W, the wish.

Eclectic Therapies

The “eclectic” brief therapies are characterized by combinations and integrations of multiple theories and techniques.

Horowitz and colleagues owe a debt to a broad literature on stress, coping, and adaptation that spans the cognitive, behavioral, phenomenological, and ego psychological realms. The point of departure is the normal stress response: the individual perceives the event, as a loss or death. The mind then reacts with outcry (“No, no!”) and then denial (“It's not true!”). These two states, denial and outcry, alternate so that the subjective experience is of unwanted intrusion of the image of the lost. Over time, “grief work” proceeds so that “working through” leads to completion.

The pathological side of this normal response to stress occurs in the stage of perception of the event when the individual is overwhelmed. In the outcry stage there is panic, confusion, or exhaustion. In the denial stage there is maladaptive avoidance or withdrawal by suicide, drug and alcohol abuse, dissociation, or counter-phobic frenzy. In the more complex stage of intrusion , the individual experiences alternation of flooded states of sadness and fear, rage and guilt, which alternate with numbness. If working through is blocked, there ensue hibernative or frozen states, constriction, or psychosomatic responses. If completion is not reached, there is ultimately an inability to work or to love.

Horowitz's therapy proceeds like the older models of Lindemann or Grinker and Spiegel, with ego psychology and information-processing theory woven in. The therapist identifies the focus—in this therapy usually a traumatic event or a loss—and tries to determine whether the patient is in the denial or the intrusion phase of maladaptation. In the denial phase, perception and attention are marred by a dazed state and by selective inattention. There is partial amnesia or emotional isolation. Information processing is crippled by disavowal of meanings. There is loss of a realistic sense of connection with the world. There is emotional numbness.

When the patient is stuck in the intrusion phase of the trauma response, perception and attention are marked by hypervigilance, overactive consciousness, and inability to concentrate. Emotional attacks or pangs of anxiety, depression, rage, or guilt intrude. Psychosomatic symptoms are common here as sequelae of the chronic flight-or-fight response.

A dozen or so sessions are used to focus on the recent stress event and work it through. In the early sessions the initial positive feelings for the therapist develop as the patient tells the story of the event. There ensues a sense of decreased pressure as trust is established. The traumatic event is related to the life of the patient as a psychiatric history is taken. In the middle phase of therapy, the patient tests the therapist and the therapist elicits associations to this stage of the relationship. There is a realignment of focus, with non-threatening surface interpretations of transference resistances. The patient is asked to understand why these resistances are currently reasonable based on past relationships. The therapeutic alliance deepens as this phase continues and the patient works on what has been avoided. There is further interpretation of defenses and warded-off contents, with linkage of these contents to the stress event. In the late middle phases, transference reactions toward the therapist are more deeply interpreted as they occur. There is continued working through of central conflicts, which emerge as termination relates them to the life of the patient. In termination there is acknowledgment of problems, as well as real gains and an adumbration of future work, for instance, anniversary mourning.

A major feature of Horowitz's work is defensive styles . The hysterical personality style has an inability to focus on detail and a tendency to be overwhelmed by the global; the compulsive style is the converse, with the patient unable to experience affect because of details. The therapist acts in either event to supplement the missing component and to damp out the component flooding the patient. With the global, fuzzy hysteric, the therapist asks for details; with the obsessional, the therapist pulls for affect.

In the borderline patient the tendency to split is damped out by anticipating that, with shame and rage, there is going to be a distortion of the patient's world into its good and bad polarities. For the patient with a narcissistic personality style, the tendency to exaggerate or to minimize personal actions is gently, but firmly, confronted. The schizoid patient is allowed interpersonal space. One of the great advantages of Horowitz's method is that it does not compete with other schools of short-term psychotherapy and it can be integrated or added in parallel.

The eclectic brief therapy of Budman and Gurman rests on the interpersonal, developmental, and existential (IDE) focus. A major feature here is the belief that maximal benefit from therapy occurs early, and the optimal time for change is early in treatment. They begin with a systematic approach that begins with the individual's reason for seeking therapy at this time . The patient's age, date of birth, and any appropriate developmental stage-related events or anniversaries are noted. Major changes in the patient's social support are reviewed. Especially important in the Budman–Gurman system is substance abuse and its contribution to the presentation at this time.

None of these ideas is novel, but the way they are combined systematically is nicely realized with reference to eliciting the precipitating event, its relation to the focus, the relation to development, and working through with a balance of techniques. The major focus in the IDE perspective includes the following:

• (1)

  Losses.

• (2)

  Developmental dys-synchronies.

• (3)

  Interpersonal conflicts.

• (4)

  Symptomatic presentations.

• (5)

  Personality disorders.

Budman and Gurman are not snobbish about the capacity of any one course of treatment to cure the patient completely, and they welcome the patient back again in successive developmental stages at developmental crises. A particular value of this treatment is that it is non-perfectionistic, both in pulling a particular phase of therapy to an end and the lack of a feeling of failure on resuming treatment. The picture one develops of this approach is of clusters of therapies ranging along important nodal points in the individual's development.