- Mental Health
Brief Therapy: A Student Essay On Brief Therapy
Brief therapy refers to a family or group of related interventions in which the therapist deliberately limits both the goals and the duration of contact (Wells, 1994). Brief therapy involves a wide range of approaches to psychotherapy, which unlike traditional therapies, set specific goals and limit the number of sessions (Nugent, 1994).
This essay briefly outlines the main features of brief therapy and critically evaluates it’s benefits and limitations. Despite controversial opinions, it is a very useful therapeutic tool for many mental health issues facing the average population, though severe addictions and psychoses often require long-term intervention.
It is important that the referral for brief therapy is based upon cautious and thorough assessment of client suitability, and therapists are aware of the cultural context and values of clients before attempting to confront or change their thinking or behaviour (Corey, 1996).
Flexibility with regards to techniques, spacing and duration of sessions, interruptions and follow-up assessments is important, depending on each individual case and the skill of the therapist (Rawson, 2002). However, further research into brief therapy is needed, which will help practitioners make prescriptions with greater accuracy and effectiveness (Castelnuovo-Tedesco, 1967).
Characteristics Of Brief Therapy:
Psychoanalysis began as brief therapy, but later dynamic theories became longer and more open ended (Coren, 2001). Stress-related emergencies of World War II necessitated the development of brief interventions, with the aim of symptom reduction and prevention of breakdown. The growing demand for mental health services, budget constraints and economic pressures further created the need for efficient and accessible intervention, making brief therapy popular in the ‘80's and ‘90's (Nugent, 1994).
Ferenczi (1951) and Rank (1945) pioneered ways to reduce treatment. Although most brief interventions range from seven to 25 sessions (Sperry, 1989) there is no clear consensus as to the duration. Boundaries of time, place, security, confidentiality, therapist non-disclosure and conduct are stressed, while the environment must discourage a sense of timelessness and cozy self-reflection (Molnos, 1995).
Brief therapy also involves directive skills and an active role by the therapist, who focuses on making goals as clear as possible, helping the client in systematic, step-by-step problem solving and using the pressure of time limit as a key towards change (Wells, 1982). It is thus defined by the therapist’s endeavour to improve the client’s condition in a short period of time (Shulman, 1989) while helping him develop skills to manage future problems more effectively (Nugent, 1994).
In short, brief therapy involves the following basic principles: Time-limitation, focus on change, working alliance, therapist’s pro-activeness and optimism, flexibility of technique as well as focus on termination issues (Koss & Shiang, 1994)
Types Of Brief Therapy:
Brief therapy has also been adapted to the majority of intervention theories, though it usually stems from psychodynamic or cognitive-behavioral theories. Some of the major models are:
- Interpersonal-developmental-existential approach
- Multimodal therapy
- Reality therapy
- Three-stage approach
- Solution focused brief therapy
- Neuro-linguistic programming
- Mann’s 12 session model
- Single-session therapy
- Two-plus-one model
- Contextual modular therapy (Feltham, 1997).
Critical Evaluation Of Brief Therapy:
The significance of brief psychotherapy is not only a medical but a social one and it is widely practiced in clinical and institutional settings such as primary care, mental health services, industry, education and therapeutic work with the elderly or bereaved (Coren, 2001). It is of special relevance to the general physician because the patients he sees are the ones best suited for this form of treatment (Castelnuovo-Tedesco, 1967).
In cases where large populations must be served through managed health care, brief therapy encourages fair and equal distribution of services to as many people as possible (Austad & Berman, 1991). In fact, psychotherapy has evolved from a long-term psychoanalytically dominated method that was once available mainly to socially privileged clients, into a brief service accessible to a much wider population. (Wells, 1994).
However, there has been a lot of controversy regarding the morality and effectiveness of brief therapy, which is seen as essentially short and superficial, with questions about the permanence and depth of its results (Wilson, 1996). Comparing eight contemporary short-term therapies, Sperry (1989) concluded that none of them agreed upon a unified definition, targets or aims, nor the ideal client to treat. Even the title itself connotes a sense of negativity and shortage (Feltham, 1997). Hence, a wide variety of terms have been used like time-conscious psychological therapy, time-sensitive, time-efficient and cost-effective therapy (Budman & Gurman, 1988).
Moreover, most psychotherapists, particularly those working in the private sector hold the view that long-term, open ended therapy is the superior form of intervention (Wilson, 1996) and the longer the therapy endures, the better the patient’s improvement. E.g. Cognitive Behaviour therapy has been criticized for being superficial, technique-oriented and simplistic, denying the importance of client’s past, the role of unconscious factors and working only on eliminating symptoms, without exploring the underlying causes of difficulties (Corey, 1996).
Yet empirical evidence shows that both long-term and short-term therapy give equal results, which proves that brief treatment is capable of delivering as much service in less time (Wells, 1994). Some of the recent research has in fact, demonstrated that therapeutic interventions designed for shorter number of sessions are more effective than longer interventions (Sperry, 1989) though results from a randomized trial show that while short-term psychotherapy produced quicker benefits, long-term therapy produced more durable gains (Knekt et al., 2008).
Research on crises demonstrates that most people only seek therapy when they are in severe crisis and therapy must be devised in a way to work within the time limit in which the crisis naturally resolves itself (Wells, 1994). Brief therapy is thus often highly beneficial to previously well-functioning individuals involved in a situational crisis, as it aims at relieving current conflicts rather than personality changes (Castelnuovo-Tedesco, 1967). In fact, the therapist himself can view this service as similar to ‘intermittent parenting’ of a client (Mander, 2003).
Besides, long-term therapy is more costly and requires a great investment of time while brief therapy does not cause much disruption to one’s daily life. E.g. families are often prepared to allow family therapy for a limited period of time and the therapist has to use this restriction by utilizing appropriate methodology (Coren, 2001).
Brief therapy however, is not just limited to the removal of stressful symptoms but significant personality changes are possible, depending on the client and the therapist’s skill. Since time-limited therapies propose that people continue to grow throughout their lives, they can support this development by focusing on obstacles rather than disease or deficits (Coren, 2001).
All major models of brief term therapy recognize that the existential reality of an agreed time limit is a powerful force for change (Wilson, 1996).
According to Bandler (1993) "it's easier to cure a phobia in ten minutes than in five years” as the human mind does not learn slowly but quickly. E.g. In Intensive short-term psychotherapy, Davanloo (1978) wasted no time in identifying early signs of transference by pointing out to the client his passive-aggressive stance. While such approaches are criticized for their confrontational techniques, others view it as a way of communicating and reaching out to the client (Coren, 2001).
In fact, the active role of the therapist, the expectations concerning the length of therapy, and the specificity of goals facilitate therapy and avoid some of the pitfalls of long-term psychotherapy (Garfield, 1989).
Time limits provide structure, encourage clients to be independent and self-reliant and increase optimism and hope that improvement is possible within a short period (Rawson, 2002). They also help to concentrate the patient’s material and the therapist’s work and prevent therapy from becoming aimless and diffuse (Malan, 1979).
Brief therapy is thus not the hurried and superficial activity it’s critics suggest, but is simply a different way of therapy and counseling and as much “tender loving care” can be conveyed in brief as in lengthy therapy (Feltham, 1997).
Limitations Of Brief Therapy:
However, although brief therapies reflect contemporary trends, they are also in danger of losing what is distinctively therapeutic and becoming the best form of “commodity” on the therapeutic market or a “quick fix” (Coren, 2001). But as Randolph (1992) argues, brief therapy is realistic and geared to the needs of clients and not just the restraints of the market.
Even the proponents of brief therapy question it’s appropriateness for different client groups (Wilson, 1996) and agree that it is not suitable indiscriminately for all kinds of psychiatric problems. Whitaker (1996) stresses that eating, personality and sexual disorders and alcohol and drug addiction is not easily curable through brief intervention. However, in Koegler and Brill's (1967) experience, even quite ill patients respond positively to brief therapy, combined with tranquilizing drugs.
According to Garfield (1989) except for very seriously disturbed individuals, brief treatment can be considered for most patients in touch with reality, experiencing some discomfort, and who make the effort to seek help. Special care must be taken with patients with suicidal risk, as brief therapy rarely offers enough protection or time to resolve their difficulty, though it serves to prepare clients for long-term treatment or highlight the need for it (Castelnuovo-Tedesco, 1967)
Wolberg (1965) states that the best strategy is to assume that every patient, irrespective of diagnosis, will respond to short-term treatment unless he proves to be resistant to it, although he made exception for major disorders and psychoses. However, he used short-term methods in treating chronic disease, obsessive-compulsive neurosis and borderline schizophrenia with “gratifying results."
Moreover, the clinical criteria for therapy must underlie a well-defined and thorough assessment model like the DSM IV (Cooper & Archer, 1999). Also, clients must have a right to both open-ended and time-limited therapies though, in practice this is often influenced by extraneous factors, patient’s financial resources and the therapist’s availability (Coren, 2001).
A follow-up session is often important to evaluate the final result, and in cases where desired results are not obtained, provisions should be made for long-term treatment or one or more "courses" of brief psychotherapy (Castelnuovo-Tedesco, 1967).
It can be very challenging for a therapist to achieve fixed goals within a short available time, hence the goals must be realistic. Instead of rigid rules about termination, contracts should be flexible, so that after the initial agreement of brevity, clients are given the choice to stop or opt for longer treatment, without being pressurized to do so.
Also, the “repeated hellos and goodbyes” (Mander, 2003) can be difficult for both the client and therapist. As Wolberg (1965) states, there is no time to make mistakes in brief therapy as it requires the “wisdom born of experience.” Thus, not only does it take time to establish a good working alliance, but being able to let go of clients, manage issues of loss, as well as achieve maximum benefits for the client within limited time requires maturity, skill and experience and can put great demands on the therapist.
It would be useful if the recent innovations in brief therapeutic practice can be incorporated into the diverse, empirically based foundation that was the major strength of the original version (Wells, 1994). Also, instead of promising miracle cures in unrealistically few sessions, brief therapy needs to use models of treatment applicable to a large number of people in different settings. Lastly, awareness of unconscious processes like transference, symbols and metaphors as well as knowledge of the developmental theory can help make brief encounters more productive (Coren, 2001).
In a climate of limited resources, time and funding, not only is there an increasing demand for brief therapy (Wilson, 1996) but it is being recognized in it’s own right rather than a modification or ‘diluted’ version of traditional therapy (Coren, 2001). Thus brief therapy can be used very effectively, provided different therapists aim to match their techniques and clinical experience according to individual client needs.