Whereas the learning-based brief therapies rely heavily on skills-teaching and homework-based rehearsal, the relationship brief therapies emphasize interpersonal experience as a change vehicle. Central to these approaches is the idea that individuals internalize their interpersonal experiences, cementing their identity in the process. When these experiences have been conflicted, the person internalizes a fragmented, negative, and/or inconsistent sense of self. This disrupts mood and action and potentially impairs future relationships. Unlike the contextual therapist, the relationship therapist emphasizes the internal experience of clients and its social origins. Unlike the learning therapist, the relationship therapist stresses the curative impact of the helping relationship, rather than didactic instruction.
The brief relationship therapies differ from their longer-term siblings—client-centered and psychoanalytic treatment—in their focus on specific relationship patterns and relative emphasis upon the present. The Interpersonal Therapy for Depression (IPT) introduced by Gerald Klerman and colleagues links the depressive syndrome to several core issues, including delayed grief reactions, interpersonal role disputes, role transitions, and interpersonal deficits. Clients are helped to appreciate the interpersonal sources of their feelings, making their depression more understandable and less threatening. Sessions then focus on addressing the interpersonal challenges, interrupting the client's negative focus on self and promoting constructive action.
The psychodynamic brief therapies make particular use of in-session events between therapist and client to facilitate change. Like their longer-term counterparts, the brief dynamic therapies emphasize that problem patterns in the client's life will be replayed within the therapeutic relationship. This transference offers an opportunity for clients to see their patterns as they are occurring, to appreciate the costs of these patterns, and to initiate efforts to engage the therapist in a more constructive mode. Once clients are able to become better observers of their patterns within the sessions and initi ate efforts at change, their successes can serve as templates for shifting those patterns in other, extrathera-peutic relationships.
The underlying model of problem creation and maintenance is also shared between the brief and longer-term analytic approaches. Early childhood conflicts are defended against through a variety of mechanisms. If these conflicts are repressed or otherwise left unresolved, they tend to resurface whenever the individual faces similar challenges in later life. At such times, people are apt to regress to their prior, less mature modes of coping. Whereas these defensive modes may have worked in the past, they are no longer adaptive for the current, adult context and yield new, painful consequences. For instance, a child who was abused may have warded off her anxiety by learning to dissociate. This no longer proves adaptive, however, in coping with conflict in mature working and loving relationships.
The brief and longer-term dynamic therapies differ in three crucial respects:
1. Therapist activity: In longer-term analysis, interpretation is a gradual process that is only undertaken after considerable work has been done to resolve resistances (defensive patterns that interfere with the therapy). The interpretive stance of the brief dynamic therapist is much more active, emphasizing present-day manifestations of patterns rather than their historical roots. Such practitioners as Lester Luborsky, Hans Strupp, and Hanna Levenson narrow their focus to specific cyclical interpersonal patterns that lead to mal-adaptive outcomes. Instead of waiting for clients to recognize these patterns on their own, brief dynamic therapists are much more likely to actively interpret their presence and associated consequences.
2. Use of confrontation: Longer-term analytic therapies emphasize interpretation as a primary intervention mode in dealing with resistances. Such brief dynamic therapists as Peter Sifneos and Habib Davanloo replace this interpretative work with a more direct confrontation of defenses, vigorously pointing out their maladaptive nature. This tends to heighten clients' anxiety level, placing them in greater touch with the thoughts, feelings, and impulses being defended. The brief analytic therapist largely abandons the analytic blank screen and instead acts as a catalyst for change by strategically heightening anxiety and bringing conflicts to life within sessions.
3. Corrective emotional experiences: The goal of traditional analysis is to foster insight into unconscious interpersonal conflicts and their consequences and support novel, adaptive efforts to deal with these. The brief dynamic therapist, building on the framework first offered by Franz Alexander and Thomas French, attempts to speed this process by offering immediate relationship experiences that challenge the client's repetitive patterns. Davanloo's work, for instance, derives much of its power by goading repressed patients into expressions of anger against the therapist. By responding to this anger constructively, the therapist actively disconfirms the client's expectations of rejection and abandonment, making it easier to deal with conflict openly. This strategic use of the therapeutic relationship in brief dynamic therapy draws significant inspiration from interpersonal therapies, including the work of Sullivan. Providing powerful emotional experiences that challenge client patterns is more important than offering verbal insight into these patterns.
Although briefer than traditional psychoanalysis, many short-term dynamic therapies are longer term than other brief modalities. Indeed, it is not unusual for a brief dynamic therapy to extend for 20 sessions or longer, falling well outside the utilization guidelines and benefit limits of many managed healthcare plans. Once again, this is typically a function of the breadth of change being sought. The brief dynamic therapies generally target long-standing conflicts that have interfered significantly with emotional functioning. Because of the time required for these conflicts to play themselves out in the transference, for the therapist to earn the trust of an interpersonally troubled individual, and for adaptive efforts to take root, it is difficult to imagine brief dynamic work of only a few sessions. In summary, it appears that the term brief therapy actually masks a variety of interventions of differing scope and duration, with highly directive and focused modes at the shortest end of the continuum and more exploratory and broad treatments at the opposite end.
A great deal of what we know about the effectiveness of therapy and the processes that contribute to favorable outcomes is derived from investigations of treatments that are brief. For this reason, researchers have noted that the outcome literature in therapy actually is a literature on brief therapy outcome.
Reviewers of the literature on brief therapy outcome have generally concluded that short-term treatments are effective in helping people who are suffering from situational and less severe disorders, such as anxiety and grief. There is also ample evidence that brief therapy is helpful in the treatment of trauma and stress-related disorders. More chronic disorders, such as major depressive and psychotic conditions, appear to be more refractory to brief intervention.
A number of methodological factors appear to mediate brief therapy outcomes, generating several important conclusions:
• Outcomes are a function of the time of assessment: As the large National Institute of Mental Health (NIMH) study of depression found, outcomes tend to be more favorable at the end of treatment than at longer-term follow-up periods. The phenomenon of relapse is especially acute for disorders with long-term, chronic courses, such as major depressive disorder, compared with more situa-tional anxiety problems.
• Outcomes are a function of the criterion being measured: Change in therapy appears to not occur all at once, but in phases. Symptom relief—reduced depression, anxiety, anger—tends to precede functional improvements in work, home, and interpersonal spheres. A brief therapy is most likely to look successful if symptom relief is the criterion. More interesting, clients appear to draw on different criteria in assessing change than their therapists, stressing symptom relief measures. They thus rate brief therapy outcomes more highly than their therapists, who place greater emphasis on measures of functioning.
• Outcomes are a function of the client population: Research by Kenneth Howard and colleagues found that, overall, change occurs relatively quickly—within the first few sessions—for the majority of neurotic clients. Adding sessions beyond the first 10 brings sharply diminished returns. Clients with personality disorders and severe psy-chopathology, however, continue to benefit from sessions beyond brief parameters and display only modest change within the first 10 visits.
• The achievement of a rapid alliance is crucial to brief therapy outcome: Howard's work also suggests that successful clients tend to experience a rise in well-being early in treatment, as they bond with their therapists and perceive the possibility of change. The failure to reach a working alliance early in therapy is a poor prognostic indicator of brief therapeutic outcome.
An important finding of the aforementioned NIMH study is that different forms of therapy conducted within brief parameters, including cognitive and interpersonal, did not produce unique changes among clients. That is, therapies with different explanatory models and intervention techniques may produce very similar types of outcome, as well as similar magnitudes of change. This supports the notion that common factors may be the most important effective ingredients in short-term work. Indeed, therapy may be brief to the extent that it can harness these common ingredients and apply them intentionally and systematically to targeted problem patterns.
Studies of change processes in brief therapies tend to support this common factors hypothesis. It appears that brief therapy is not so much different from time-unlimited treatment as an intensification of longer-term modalities. The brief therapist emphasizes the effective ingredients in all therapies and attempts to maximize these in a planned, deliberate manner so as to catalyze desired changes. This can be described as a several-step process, an overarching, integrative model of brief therapy that can account for the shared elements among the contextual, learning, and relationship approaches:
1. Engagement: The earliest phase of therapy features a vigorous encounter between therapist and client in which the dimensions of the presenting problems are explored. Very often, this features a ventilation of the emotional upset that has brought the individual for help. By listening attentively, inquiring actively, and responding sensitively, the therapist facilitates a building of rapport and trust.
2. Pattern search: Bernard Beitman has emphasized the importance of pattern searching in the earliest phases of treatment. Presenting problems such as depression, anxiety, and relationship conflicts frequently arise under specific conditions. By asking for many examples of presenting problems, it is possible for therapist and client to identify the similarities among these instances and the conditions that serve as contexts for the generation of distress.
3. Translation: Clients typically enter therapy only after they have unsuccessfully attempted other means for solving their problems. As a result, by the time they sit for their first session, they are typically somewhat frustrated and discouraged. Not infrequently, the ways in which they have defined their problems—and hence the possible solutions to these—have led them to a dead end. When a brief therapist translates presenting problems into the new terms of a pattern—helping clients see this pattern for themselves—the result is often a sense of relief and hope. If the brief therapist has been effective in building trust and rapport and successfully identified outstanding patterns, the translation can serve as a mutual focus for therapy, engaging the client's readiness for change.
4. Discrepancy: A key process feature across the brief therapies is the attempt to elicit problem patterns within therapy sessions. This helps to heighten emotional experiencing and more deeply process efforts at change. It also speeds the change process by allowing clients to work directly on targeted patterns. Because the brief therapist takes an active role in eliciting problem patterns, brief therapies can be anxiety provoking for clients. Indeed, the heightened anxiety may serve as a spur for change. Many of the techniques specific to the brief therapies— exposure methods in behavioral desensitization, journal keeping in cognitive restructuring approaches, confrontation in the short-term dynamic methods, directed tasks in strategic work—allow clients to experience their problem patterns in a controlled and safe context. This allows for the possibility of responding to these patterns in a discrepant and adaptive manner, generating true corrective emotional experiences.
5. Consolidation: Once new, constructive patterns have appeared, the task of the brief therapist is to aid in their internalization. Although initial change can bring meaningful symptom relief, clients remain at significant risk of relapse if they have not truly made a new pattern part of their cognitive, behavioral, and emotional repertoire. Accordingly, the latter phases of brief therapy feature significant efforts at rehearsal and generalization, encourging clients to extend their in-session changes to out-of-session contexts. Frequent feedback from therapists and rehearsal of anticipated future challenges facilitate generalization, as the focus comes full circle, from the identification of problem patterns to the facilitation of adaptive responses. Not infrequently, therapy moves to an intermittent basis of meeting as clients develop the capacity to sustain this consolidation on their own.
The term brief therapy subsumes a variety of treatment approaches derived from different models of change and spanning a range of treatment durations. Brief therapies share a number of procedural elements, including criteria for inclusion and exclusion, the maintenance of a sharp treatment focus, a high degree of therapist activity and client involvement, and concerted efforts to elicit and rework client patterns within and between sessions. Brief therapies range from very short-term strategic and solution-focused modalities to cognitive-behavioral and cognitive-restructuring models and more extended short-term dynamic approaches. All appear to be effective in helping people deal with situational problems and less severe anxiety and stress concerns but may be limited in sustaining change among clients with chronic and severe disorders.
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