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session may lead to important insights into the broader psychosocial context of specific problematic behaviors (e.g., the presence of marital or work difficulties that exacerbate problem behaviors). BIBLIOGRAPHY
I . Baldwin JD, Baldwin J: Behavior Principles in Everyday Life. Englewood Cliffs, NJ, Prentice-Hall, 1981. 2. Emmelkamp PMG: Behavior therapy with adults. In Bergin AE, Garfield SL (eds): Handbook of Psychotherapy and Behavior Change, 4th ed. New York, John Wiley and Sons, 1994, pp 377427. 3. Emmelkamp PMG, Bourman TK, Scholing A: Anxiety Disorders. A Practitioners Guide. Chichester, John Wiley & Sons, 1992. 4. Griest JH: Behavior therapy for obsessive compulsive disorders. J Clin Psycho1 55:60-68, 1994. 5. Noyes R: Treatments of choice for anxiety disorders. In Coryell W, Winokur G (eds): The Clinical Management of Anxiety Disorders. New York, Oxford University Press, 1991. 6. Sloane R, Staples F, Cristol A, et al: Psychotherapy Versus Behavior Therapy. Cambridge, MA, Harvard University Press, 1975. 7. Wachtel P: Psychoanalysis and Behavior Therapy. New York, Basic Books, 1977.

43. PLANNED BRIEF PSYCHOTHERAPY

Mark A. Blais, Psy.D.

1. What is the natural course of psychotherapy? Despite the common perception that psychotherapy is a long-term, even timeless, enterprise, most of the existing data indicate that psychotherapy as it is practiced in the real world is a time-limited process. National outpatient psychotherapy utilization data from 1987 (obtained before the nationwide impact of managed care) reveals that 70% of psychotherapy users received 10 or fewer sessions, and only 15% received 21 or more sessions.I8 These data are highly consistent with findings from other utilizations studies. Clearly, most patients have a time-limited or brief psychotherapy experience. This chapter will help you deliver psychotherapy in an organized, planned, and thoughtful manner that more closely matches the natural course of psychotherapy.

2. How did brief psychotherapy develop?

Freud was one of the first practitioners of brief psychotherapy. A review of his early cases reveals that he treated many patients in a span of weeks to months rather than years. Over time, as psychoanalytic theory became more complex, the goals of psychoanalysis became more ambitious, and the length of treatment increased greatly. As early as 1925 this trend had become a concern to some. Alexander and French can be considered the true fathers of brief psychotherapy. Their book Psychoanalytic Psychotherapy outlined the first systematic attempt to develop a shorter and more efficient form of psychotherapy. Although not generally accepted in its time, this work laid the foundation for both psychoanalytic psychotherapy and modem brief psychotherapy. The modern era of brief treatment began with the work of Malan and of Sifneos. At present, brief psychoanalytic psychotherapies are supplemented by several other time-limited treatments, such as Becks cognitive therapy, Manns existential psychotherapy, and Klermans interpersonal treatment of depression.

3. How does brief psychotherapy differ from long-term psychotherapy? Four dimensions, considered common to all brief therapies, differentiate short-term from the more traditional long-term therapies: (1) the setting of a fixed time limit for the treatment, (2) holding to specific patient selection criteria, ( 3 ) using a treatment focus to limit the scope of the therapy, and (4) requiring increased activity by the therapist.

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Summary o f Selected Planned Brief Psychotherapies

THERAPY SCHOOL NUMBER OF SESSIONS TYPE OF FOCUS PATIENT SELECTION

Analytic
Sifneos Anxiety suppressing Anxiety provoking Malan Davanloo 4-10 12-20 20-30 140 Crisis and coping Very narrow, Oedipal conflict and grief Very narrow, similar to Sifneos Resistance and suppressed anger Central issue and termination Automatic thoughts Patients interpersonal experience Interpersonal, developmental, and existential One borderline trait Fairly open, less healthy Very selective, top 2-l0% outpatients Responds to trial interpretation Less healthy, top 30% outpatients Broad patient selection (passive-dependent) Very broad, not psychotic Depressed patient, any level of health Broad range Borderline outpatients
~ ~

Existential
Mann
I2 exactly

Cognitive
Beck 1-14 12-16

Interpersonal
Klerman

Eclectic
Budman Leibovich
20-40

36-52

Adapted from Groves J: The short-term dynamic psychotherapies: An overview. In Ritan S (ed): Psychotherapy for the 90s. New York, Guilford Press, 1992.

Comparison of Brief and Long-Term Therapy

BRIEF LONG-TERM

Specific focused goals Specific time frame Emphasizes patient selection Here and now focus Attempts to restore psychologic functioning quickly The therapist is active and directive Uses between-session homework

Broad goals: insight and character change Time unlimited Down-plays patient selection Inner life, historical focus Techniques can cause increased psychological distress and temporary dysfunction Therapist is nondirective; therapy unfolds Is mostly limited to treatment hour

4. What is the best attitude for learning brief therapy?

There must be a willing suspension of disbelief and cynicism about brief treatment. Trainees are frequently taught that quick improvement is suspect and likely represents a transient flight into health. This can be a hard lesson to unlearn. Remember, brief therapy is not a fad, but rather a form of treatment developed and refined over many years, based upon clinical experience and treatment outcome studies. It must be recognized from the outset that therapy will end after a set number of sessions (or in some cases on a planned date). This can be difficult, particularly for therapists trained in long-term therapy, because this mindset has ramifications for all treatment decisions and requires a clinician to reconsider every intervention during the treatment. The brief therapist should accept (and expect) that patients will return to therapy periodically across their life span. This perspective allows a brief therapist to focus on the patients current difficulties rather than attempting a total lifelong cure.

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5. For which patients is brief therapy appropriate?

Patient selection is an important (and distinguishing) part of brief therapy. Basically, patient selection is the art of finding the right patient with the right problem for brief psychotherapy. A two-session format is recommended to alleviate time pressure and allow the clinician to conduct a complete psychiatric evaluation while also assessing the appropriateness of the patient for brief psychotherapy.

6. Name some useful criteria for excluding or including a patient for brief psychotherapy. Exclusion criteria are best seen as categories (either the condition is present or absent); if any is present, the patient should be considered a poor candidate for brief treatment. Inclusion criteria are best viewed as dimensions, and as such they are likely present to a varying degree in every patient. The more of these qualities a patient has, the better the candidate for brief psychotherapy. Patient Selection Criteria for Brief Therapy
~ ~ ~~

Exclusion Criteria Actively psychotic Abusing substances At significant risk for self harm

Inclusion Criteria Moderate emotional distress Seeking relief from pain Able to articulate or accept specific cause or circumscribed problem as focus of treatment History of at least one positive mutual interpersonal relationship Functioning in at least one area of life Ability to commit to treatment contract

7. How does the brief therapist focus the treatment? Developing a treatment focus is probably the most misunderstood aspect of brief therapy. Many clinicians write about the focus i n a mysterious and circular manner. It often appears as if the whole success of the treatment rests on finding the one correct focus. Rather, what is needed for a successful brief treatment is the establishment of a functional focus; that is, a focus on which both the therapist and patient can agree to work.

8. How is a functional focus established? One powerful, straightforward technique is the Why now? question used by Budman and Gurman. It is applied by repeatedly asking the patient: Why did you come for treatment now? Why are you here now? Attention is directed to the current problem, rather than last weeks or tomorrows. (Try this simple technique a few times to see how effective it can be.) For example, a male patient (Pt) presents with significant depressive symptoms to a therapist (Th) at a walk-in clinic. Th: 1 hear from what you say that you are depressed and are feeling terrible, but I wonder what made you come in today? Pt: I cant take it any more. I know I need help. Th: You cant take it. What makes it impossible to take it now? Pt: Its getting too bad. I just cant take it any more. Th: It sounds like something happened recently that made you realize how bad things were. What made you realize that you had to get help now? Pt: I just felt so bad I couldnt go to work yesterday. I stayed home in bed all day. I never miss work. I must be falling apart. This line of questioning led to establishing the patients physical inactivity as a functional focus for treatment. As a result, his depression was successfully treated by increasing his physical activity. 9. Describe some typical functional foci. Budman and Gurman describe five common treatment foci: Losses past, present, or pending Development dyssynchronies; being out of step with expected developmental stages (Therapists should be able to identify with this because years of extended schooling and training usually keep life events such as marriage and children on hold.)

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Interpersonal conflicts (usually repeated disappointments in important relationships) Symptomatic presentations and desire for symptom reduction Severe personality impairment (In brief therapy, one aspect of personality impairment can be selected as the focus of therapy.) Beginning brief therapists should use these five common foci to help organize their patients complaints and problems. The most important thing to remember is that you are not finding the focus, only a focus for the therapy.

10. How does the therapist complete the evaluation? Brief therapy is demanding for the therapist and patient. In addition to doing a full psychiatric interview, by the completion of the second evaluation session you need to have ( I ) determined whether the patient is suitable for brief treatment; (2) developed a functional focus; and (3) articulated a clear treatment contract. The patient and therapist must agree on a treatment contract. The contract identifies the treatment focus and spells out details, such as the number of sessions, procedure for missed appointments, and guidelines for post-termination contact. Brief therapy typically lasts 10-24 sessions, but may include as many as 50 sessions. (A 15-session treatment, not including the evaluation sessions, is a good length for a beginning brief therapist to start with). A flexible approach to missed appointments is recommended, and if the patient has a valid reason, the therapist should try to reschedule. if a session is missed without a valid reason, the missed session should be counted and the patients motivation should be explored, because this is resistance to treatment. 11. What is another advantage (besides the extra time) of a two-session evaluation? It allows an assessment of how the patient responds to the therapy (and therapist), providing important additional information about the appropriateness of brief treatment. Some form of intervention at the end of the first evaluation session is helpful in this regard. This initial intervention can be as simple as summarizing the patients problem and offering a tentative treatment focus or as complex as requiring the patient to fill out a psychological questionnaire. At the start of the second session, inquire about the intervention. If the patient responds positively (e.g., found it helpful to think of the problem in this new light; is interested in the psychological test results) and/or is feeling better, it is a sign that brief therapy may work. If the patient has not followed up on the intervention (e.g., did not think about the potential focus) or reacted angrily to it, it is a negative sign. 12. Can the functional focus change? No. Once a functional focus has been established, the therapist must maintain it. One way is by working consistently from within one style or orientation, of which there are basically three: (1) psychodynamic, (2) interpersonal, or (3) cognitive-behavioral. The one you use depends on your preference and, to some extent, your patients problem.
13. Describe the three approaches used in brief therapy. Most psychodynamic treatments are limited in their range of application and are appropriate for only a small percentage of clinic patients, typically those suffering from reactive or neurotic forms of depression (such as failure to grieve, fear of success and competition, and triangular, conflicted love relationships). These are demanding treatments for the therapist to undertake and require that the patient be able to tolerate considerable affective arousal. Brief interpersonal psychotherapy (IPT) was developed by Klerman and colleagues specifically to treat depression. It is a highly formalized (manualized) treatment often used in research studies. It can be considered a mix of psychoeducation and supportive therapy. In IPT, the patients symptoms are explained (psychoeducation) and interpersonal interactions, expectations, and experiences are explored. IPT seeks to clarify what the patient wants to receive from relationships and helps patients develop necessary social-interpersonal skills. No effort is made to understand the deeper unconscious meaning of the patients social interactions or desires.

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The cognitive-behavioral therapies, like Becks, are more broadly applicable, both in the percentage of patients who can benefit and the range of problems that can be treated. These therapies aim at bringing the patients autonomic (pre-conscious) thoughts into awareness and demonstrating how these thoughts maintain negative behaviors and feelings.

14. Are all three approaches employed simultaneously? No. A minimal, thoughtful amount of mixing of techniques from different therapy styles is acceptable. Therapeutic flexibility is necessary in brief treatment. It is important, however, to conceptualize and work predominantly from within one orientation to keep treatment focused and clear. Especially avoid uncritical wholesale mixing of styles and orientations, because such wild treatment confuses and disappoints both the therapist and patient.

15. What does it mean to be an active therapist? Completing a psychotherapy in 12-15 sessions requires sustained activity on the part of the therapist to maintain treatment focus and move the therapy process forward. The brief therapist works to structure every session, thereby increasing productivity.
The Active Therapist
Structure each session Give homework assignments Develop and use the working alliance Limit silences and vagueness Use confrontation and clarification Quickly address negative and overly positive transference Limit regression Use supervision

16. Discuss important factors for the active therapist in structuring sessions. Starting each session with a summary of important material from the last session and restating the treatment focus organizes therapy and keeps the treatment on track. Giving homework to the patient to be completed between sessions helps increase the impact of therapy on the patients current life and situation and monitor the patients motivation for change. If the patient does not complete the homework, the motivation for change must be explored. The working alliance between therapist and patient must be developed quickly. It is frequently invoked to return the patient to the treatment focus. Patients may attempt to escape the anxiety inherent in brief therapy by bringing up interesting but diverting material. The therapist should meet such tactics with reminders of the agreed-upon focus (thus invoking the working alliance) and queries about how the new material relates to it. Prolonged silences (by either the therapist or patient) are considered unproductive in brief therapy and also are quickly confronted as resistance. The brief therapist must know how to limit regression. Two useful techniques are (1) organizing interpretations about events in the here and now, using either the therapy relationship or the patients current life situation, rather than around early developmental traumas; and (2) moving the patient away from feelings and into thoughts-What are you thinking rather than What are you feeling? Regressions within sessions are permitted and even encouraged in some short-term work. For example, it is quite common, when employing a treatment modeled after that of Sifneos, to keep a patient focused on an anxiety-provoking conflict despite mild confusion or panic. 17. What are two valuable tools in brief therapy? The brief therapist makes heavy use of confrontation and clarification. Confrontation helps the patient recognize when he or she is avoiding or resisting the treatment focus, usually as a result of anxiety. Clarification techniques are used whenever the patient is communicating in a vague or incomplete manner. Usually the therapist asks for specific examples of unclear situations or feelings. 18. How does transference manifest in brief therapy? Regardless of the style of therapy you employ (psychodynamic, cognitive, or interpersonal) patients inevitably react to some of your interventions based on their past experiences. When such

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reactions are negative (You always criticize me) or excessively positive (You know me better than anyone on earth), they must be explored and interpreted quickly. Rapid attention can help keep the patients transference under control and reduce the likelihood of it becoming a major resistance to treatment.

19. Is supervision unnecessary due to the short-term nature of this type of treatment? As in all psychotherapy, supervision is important in both learning and practicing brief psychotherapy. Supervision by an experienced colleague provides an excellent vehicle for beginning therapists. More advanced practitioners find that some form of ongoing supervision, either formal or informal, helps maintain the treatment focus and aids in identifying subtle, but often important, changes in the patients manner. Such subtle changes can represent the first signs of transference.

20. What are the phases of brief therapy? The initial phase includes evaluating and assessing patient appropriateness for brief therapy, selecting a treatment focus, and establishing the main treatment orientation. For the patient this phase is usually accompanied by slight symptom reduction and mildly positive transference. Both of these factors help with the quick development of a working alliance. In the middle phase, the work gets more difficult. Typically the patient becomes concerned about the time limit and, in addition to the treatment focus, issues of dependency become important. The patient often feels worse, and the therapists faith in the treatment process is tested. The early middle phase of brief therapy can be particularly hard for the therapist, who must be active in sustaining treatment focus, keeping the patient working, and countering patient skepticism while projecting optimism. Good supervision is invaluable during this phase for the beginning brief therapist. In the termination phase, therapy tends to settle down. The patient accepts that treatment will end as planned and that symptoms will decrease. Now, in addition to the treatment focus, post-therapy plans and the patients feelings about termination are explored. Among the most common termination problems is the introduction of new material by the patient. The therapist may be tempted to explore the new information and extend the therapy. This is usually a mistake, because the patient likely is attempting to avoid the treatment focus, and in most cases the treatment should end as planned.

21. How do I handle post-treatmentcontact with the patient? This difficult question must be answered individually by each therapist. During training, the beginning therapist should have the experience of handling the intense feelings (both his or her own and the the patients) that accompany the termination of a treatment in which there will be 110 posttherapy contact. This teaches the therapist how to deal openly with these powerful and important feelings. In ongoing practice, however, it is important to encourage patients to return for treatment when new difficulties develop, and to foster the understanding that help is available if needed. Patient care should be guided by the understanding that Therapy is for living and not vice versa. The brief psychotherapist practices as a primary care physician, available to help patients with (psychological) troubles or crises that develop. 22. How does brief psychotherapy relate to managed care? In a managed care environment, payors are encouraging the use of shorter treatments such as planned brief psychotherapy. However, managed mental health care and brief psychotherapy are not identical. Managed health care is primarily concerned with controlling cost. Planned brief psychotherapy represents a clinically proven procedure for helping some patients in need of psychiatric services. To be administered properly, brief psychotherapy must be based on clinical, not financial, considerations. Although many patients covered by managed care contracts benefit from brief psychotherapy, not all patients are appropriate. Many variables are involved in selecting patients for brief psychotherapy-but mental health insurance coverage is not one of them. Finally, therapy that is considered brief for clinical work (i.e., 15-20 sessions) may be considered too long by managed care companies, who often suggest 6-8 sessions.

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BIBLIOGRAPHY

1. Alexander F, French T Psychoanalytic Psychotherapy. New York, The Ronald Press, 1946. la. Beck AT: Cognitive therapy for depression and panic disorder. Western J Med 151:9-89, 1989. 2. Beck S, Greenberg R: Brief cognitive therapies. Psychiatr Clin North Am 2: 1 1-22, 1979. 2a. Book H E How to Practice Brief Psychodynamic Psychotherapy: The Core Conflictual Relationship Theme Method. Washington, DC, American Ps~chologic~l Association Press, 1998. 3. Budman S, Gurman A: Theory and Practice of Brief Therapy. New York, The Guilford Press, 1988. 4. Burk J, White H, Havens L: Which short-term therapy? Arch Gen Psychiatry 36: 177-1 86, 1989. 5. Davanloo H: Short-Term Dynamic Psychotherapy. New York, Jason Aronson, 1980. 6. Ferenczi S, Rank 0: The Development of Psychoanalysis. New York, Nervous and Mental Disease Publishing Company, 1925. 7. Flegenheimer W: History of brief psychotherapy. In Horner A (ed): Treating the Neurotic Patient in Brief Psychotherapy. New Jersey, Jason Aronson, 1985, pp 7-24. 8. Goldin V Problems of technique: In Horner A (ed): Treating the Neurotic Patient in Brief Psychotherapy. New Jersey, Jason Aronson, 1985, pp 56-74. 9. Groves J: Essential Papers on Short-Term Dynamic Therapy. New York, New York University Press, 1996. 10. Groves J: The short-term dynamic psychotherapies: An overview. In Rutan S (ed): Psychotherapy for the 90s. New York, Guilford Press, 1992. 1 I . Hall M, Arnold W, Crosby R: Back to basics: The importance of focus selection. Psychotherapy 4578-584, 1990. 12. Horner A : Principles for the therapist. In Horner A (ed): Treating the Neurotic Patient in Brief Psychotherapy. New Jersey, Jason Aronson, 1985, pp 76-85. 13. Horath A, Luborsky L: The role of the therapeutic alliance in psychotherapy. J Consult Clin Psycho1 61:561-573, 1993. 14. Klerman G, Weissman M, Rounsaville B, Chevron E: Interpersonal Psychotherapy of Depression. New York, Basic Books, 1984. 15. Leibovich M: Short-term psychotherapy for the borderline personality disorder. Psychother Psychosom 35:257-264, 1981. 16. Malan D: The Frontier of Brief Psychotherapy. New York, Plenum Medical Book Company, 1976. 17. Mann J: Time-Limited Psychotherapy. Cambridge, Harvard University Press, 1973. 18. Olfson M, Pincus HA: Outpatient psychotherapy in the United States. 11: Patterns of utilization. Am J Psychiatry 151:1289-1294, 1994. 19. Sifneos P: Short-Term Anxiety Provoking Psychotherapy: A Treatment Manual. New York, Basic Books, 1992.

44. MARITAL AND FAMILY THERAPIES

Margaret Roath, M.S.W., LCSW

1. What a r e marital and family therapies? Marital and family therapies are therapeutic modalities whose focus of assessment and treatment is on the relationship, not on the individual. Assessment includes gathering data related to the following areas: History of the relationship Communication patterns, both Goals of the individuals in the relationship constructive and destructive Coping mechanisms which have been Description of the strengths of unsuccessful the relationship Precipitant for seeking therapy--why now? Unmet needs of the individuals or what changed? in the relationship Assessment of the precipitant for seeking marital or family therapy is especially important in determining the relationship equilibrium-which may have worked previously for all members of the relationship, but is now out of balance. The precipitant might be a change in external circumstances or a change within an individual that is affecting the relationship.
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