Lewis R. Wolberg: The Technique Psychotherapy

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    H A N D B O O K O F

    SHORT-TERM

    PSYCHOTHERAPY

    LEWIS R. WOLBERG, M.D.

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    C o  p y ri g h t © 1980 Louis R Wolberg

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    Contents

    Preface, vii

    1. Mo d e ls of Sh o r t- te r m T h e r a p y , 1

    2. A R a t io n a le f or Dy n a m ic Sh o r t- t er m T h e r a p y , 2 23. Cr i t e r ia o f Selec tion , 30

    4. A Ge n e ra l Ou t l i ne o f Sh o r t- t er m T h e r a p y , 35

    5. Th e In i ti al In te rv iew: A. Com mon Ques t ions , 49

    6. T he Ini t ial In terview: B. Case Histor ies , 61

    7. C h o os in g a n I m m ed i at e Fo cu s , 9 0

    8. Choosing a Dyn amic Focus: A. Probing into the Past , 101

    9. Choos ing a Dynamic Focus : B . Some Comm on Dynamic Themes , 113

    10. Choos ing a Dynamic Focus : C . Pre sen ting In t e rp re t at ions,125

    11. T e c h n iq u e s in Sh o rt - te r m T h e r a p y , 135

    12. T h e Use o f Dr e a m s , 1 70

    13. Ca ta lyzing the The rapeu t i c Process: T he Use o f Hypnos is , 190

    14. Cr i si s In t e rven t ion , 208

    15. Ma k i n g a R e la x in g a nd E g o -B u i ld i ng T a p e , 2 23

    16. Ho m e wo r k Ass ig n me n ts , 2 35

    17. T e r m i n a t i o n o f Sh o r t- te r m T h e r a p y , 2 4 3

    References, 250

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    Preface

    In 1959, I chaired a seminar at the Post

    graduate Center for Menta l Heal th in New

    York Ci ty , dur ing which a number of par

    t i c i p a n t s p r e se n t e d m a t e r i a l d e t a i l i n g t h e i r

    thoughts about and exper iences wi th shor t

    term therapy. Helen Avnet , Direc tor of Re

    sea rch , Group Hea l th Insurance Company ,

    revealed the results of a project that lasted two

    and one-half years, in which a panel of 1,139

     psychiatrists treated pa tients on a shor t-te rm

     basis . O n term ination , 70 percent of the p a

    tients were rated by the panel as improved or

    recovered. I t was concluded that a large por

    t ion o f t he communi ty ’ s psych ia t r i c needs

    could be met by short-term treatments. Jules

    Ma sserm an de ta i led the his tor ica l-compara t ive

    and exper imenta l roots of shor t - te rm therapy,

    tracing i ts origins in the past . Sandor Rado

     presented m ateria l on motivational fa ctors tha t

    could provide guidelines for techniques in

    short-term therapy. Paul Hoch differentiated

    the characterist ics of short-term versus long

    term therapy. Franz Alexander dea l t wi th psy

    choanalytic contributions to short-term therapyin faci l i tat ing a correct ive emotional experi

    ence. Lothar Kalinowsky lectured on the use of

    so m a t i c t r e a t m e n t s i n sh o r t - t e r m t h e r a p y .

    Alexander Wolf dea l t wi th shor t - te rm group

     psychotherapy. M olly H a r ro w e r describ ed a

    research project related to outcome of long

    term and shor t - te rm therapy. Arlene Wolberg

    discussed the incorporat ion of case-work proce

    dures in a short-term program. I gave two lec

    tures, one on general aspects of technique and

    the other on the employment of hypnosis as an

    adjunct in shor t - te rm therapy. The seminar

    was publ ished la te r by Grune & St ra t ton

    under the title Short- term Psychotherapy.

    It is interesting in reviewing the current

    l i terature that independent studies have vali

    dated an astonishingly large percentage of the

    ideas and observations of this seminar. I t is

    relat ively recently, however, that there has

     been a sw ing tow ard sh or t-te rm th e rapy as a

     p r im ary and p referred t rea tm en t ra th e r than

    as an expedient . Even national psychoanalytic

    organiza t ions, s t rongholds of long- term t rea t

    ment, have begun to preach i ts virtues and

    have organized continuing-education courses

    on the subject . A host of art icles and a number

    of interest ing books have appeared, outl ining

     philosophies, goals , sel ec tion procedures and

    techniques tha t the authors have found va lua

     ble in their a ttem p ts to abbrev ia te trea tm ent.

    In the main, similari t ies of concepts have ex

    ceeded differences. Nevertheless, a great num

     ber of quest ions rem ain un an sw ered , and it is

    the purpose of the present volume to contribute

    to the resolution of some of these.

    One of the most cri t ical quest ions is related

    to the va lue of dynamic approaches in shor t

    term therapy. Most important ly , can we empi

    rically prove the effectiveness of a dynamically

     based sho r t- te rm the rapy ? Contro lled exp e r iments have been few, and even in these the dif

    ficult ies that shadow outcome studies tend to

    obscure results. Yet with al l our skepticism

    about quantifying brief cl inical operat ions suf

    ficiently to satisfy the criteria of objectivity,

    validity, and reliability so essential in scientific

    studies, discriminating experience establishes

     beyond reasonable doubt the usefuln ess of a

    dynamic orientat ion in any form of short-term

     psychotherapy. T h is applies w h e th er we are

    helping a person recognize and then to come to

    terms with his past , as in insight therapy, or

    el iminating effects of the past through rein

    forcement of adaptive behaviors, as in behavior

    therapy, or squeezing the past out of muscles

    and t issues as in the “new body therapies,” or 

    vii

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    viii HANDBOOK OF SHORT-TERM PSYCHOTHERAPY

    gaining a perspective on inner emotional ef

    fects of the past through sensory awareness

    techniques, or correct ing habitual past modes

    of thinking, as in cognitive therapy. Indeed, a

    dynamic approach, in my opinion, is the best

    design to follow in all forms of psychotherapy,

    however brief they may be, and while i t may

    not have an immediate dramatic influence on

    the personality structure, it can catalyze such

    changes eventually through i ts continuing in

    fluence on cognition.

    In this volume I have at tempted to bringtogether common elements in the chief models

    of short-term therapy currently in use and to

    evolve principles that can be employed by indi

    vidual therapists, i rrespective of their theo

    retical biases and styles of operation. How a

    d y n a m i c v i e wp o i n t m a y p r a c t i c a l l y b e i n

    troduced in any form of psychotherapy is one

    of my goals. The short-term method that I wil l

    describe is not presented with illusion that it is

    flawless, infallible, or universally applicable.

     N or may it prove equally help ful to al l t h e r a

     pi sts o r curative in ev er y case . It is, neverthe

    less, in my opinion, (and in the jud gm ent of

    therapists who have ut i l ized the method), an

    easily learned and effective technique servicea

     ble fo r the great majori ty of pat ients se en in

    cl inics and private pract ice. The method also

    takes into consideration the fact that there will

     be pa tients who are not go od subjec ts fo rshor t - te rm t rea tment and who wi l l requi re

    other forms of help. Under these circum

    stances, the method will function as a useful

    ini t ial diagnostic procedure, enabling the thera

     pis t to se lect modalit ies tha t wil l se rv e the p a

    tient best.

    The method a lso conta ins a means of pro

    vid ing con t inu ing the rapy fo r t he pa t i en t

    through assigned homework and the use of a

    casette tape, the making of which will bedescribed in detail. It has always confounded

    me tha t so many therapis ts assume tha t when

    the last formal treatment session has ended,

    the patient can sally forth like the fabled

     prince and princess to live happ ily ever af te r.

    The facts on the fol low-up are a grim denial of

    this fantasy. For example, in fol low-up re

    search of pat ients who had been treated in a

    comparison study with two forms of brief psy

    chotherapy (behavior therapy and psychoana-

    l y t i c a l l y o r i e n t e d p sy c h o t h e r a p y ) a n d wh o

    were discharged as improved, Patterson, et al

    (1977) found that one year after termin ation,

    ful ly 60 percent had sought out and obtained

    fur ther t rea tment . These f igures a re probably

    low because many discharged pa t ients who do

    not seek formal therapy uti l ize other forms of

    help or self-help to reduce their tension and

     better the ir ad justm ent. Lif e, after satisfacto ry p sy c h o th e r a p e u t ic t r e a tm e n t , co n t in u es to

     present a never ending ser ie s of challe nges th a t

    can tax coping capacities of even “ cur ed” pa

    tients. This is not al together bad, for in meet

    ing these challenges the individual has an op

     por tu n ity of s treng thening adaptive pa tte rns,

    much like a booster shot can enhance the effect

    of a pr ior vacc ina t ion. Shor t - te rm psychother

    apy offers the patient a means by which one’s

    future may be regulated, provided the therapist

     p repa res the p a tien t for an tic ipa ted events and

    contingencies and teaches a way of dealing

    with these, should they appear.

    As a handbook, this volume provides an out

    line of process in short-term therapy. Should

    extensive detai ls of technique be sought, they

    may be found elsewhere, including the third

    edit ion of my book The Technique of Psy

     choth erapy.  I t is recommended that the reader

    if not already acquainted with some techniques

    other than individual psychotherapy exper i

    ment with these to see whether they accord

    with one’s individual styles of working. In my

    opinion, a therapist’s usefulness is especially

    enhanced by knowledge of group therapy (see

    The Technique o f Psychotherapy,  3rd ed, pp.

    7 0 2 - 7 2 9 ) , f a m i l y t h e r a p y ( p p . 7 2 9 - 7 3 3 ) ,

    mari ta l (couple) therapy (pp. 733-740) , be

    havior therapy (pp. 685-701) , re laxat ion procedures (pp. 761-766) , and somat ic therapy

    (pp. 767-789) . Other techniques may per i

    odically be useful such as hy pnos is (pp. 791 — 

    809) , sex therapy (pp. 809-817) , and bib-

    l iotherapy (pp. 817-833). I t goes without say

    ing that knowledge of the therapeutic process

    from the ini t ial interview to termination (pp.

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    PREFACE ix

    353-684; 743-758) and especia l ly in terv iew

    ing techniques (pp. 360-382) are indispensi-

     ble.

    A f inal word of caution may be indicated.

    One should not assume that i t is always possi

     ble to duplicate or surpass w ith sho r t- te rm a p

     proaches w ha t can be done w ith  appropria te ly  

     se le cte d pa ti en ts   th rough longer - term treat

    ment. But, for the great m ajority of people

    seeking help for emotional problems, the time

    element is not the most important variable in

     psychotherapy. T im e is too frequently considered a magical device that acts like a de

    tergent , washing away accumulated neuro t ic

    residues. I t is assumed traditionally that the

    longer a patient remains in psychotherapy, the

    greater the benefits he will derive from it.

    Common practice, however, convinces that this

    is true only up to a certain point. Beyond such

    a point, resistances pile up in a disturbing

    number of pat ien ts , gains are neutra l ized , and

    a setback ensues. Peering into the causes ofthese misfortunes, we observe in therapy that

    goes on for too protracted a period an emerg

    ing sense of helplessness that may be concealed

     by various react ion formations. T h e conse

    quence is a sabotage of progress and ultimately

    an exacerbat ion of symptoms. The therap is t

    then becomes for the patient a crutch; without

    whom independent steps are avoided. This is

     pa rt icu la r ly the ca se in sicker pa tien ts whose

    dependency needs are h allm ark s of their basic

     personality structure , or w ho have, because of

     persistent anxiety, lo st their sen se of mastery

    and distrust their own capacities to function.

    Whatever gains may accrue f rom any evolv ing

    insights are neutralized by the cr ippling influ

    ence of the prolonged sheltered relationship.

    Play ing a wai t ing game in the hope that t ime

    will eventually dislodge a neurosis too fre

    quent ly resu l ts in pat ien t paralys is and thera

     pis t frustra tion .

    Such disconcerting phenomena give impetus

    to our efforts to shorten the therapeutic process

    without devitalizing its effect. This is not to

    deprecia te economic and o ther pract ical rea

    sons for abbreviat ing shor t- term therapy . Butapart from cost effectiveness and the need to

    minister to the growing multitudes of people

    who seek help , dynamic shor t- term treatment

    is justifi ed o nly if it can p rove itself to be a

    truly useful m eans of dealing with emotional

     p roblem s in the vast m ajori ty of ca ses. In my

    opinion, this proof has now been established.

    Acknowledgment is made to the Postgradu

    a te Cen te r fo r Men ta l Hea l th , under whose

    auspices this book was written, and to its Stafffor the s t imulat ion they insp ired . Thanks are

    due to G run e & Stra t ton , the publ ishers of my

     books Short- term Psychotherapy   and T h e D y

     nam ic s o f P ersonalit y   (with Jo hn Kildahl) for

     pe rm iss ion to utilize some m ate ria l from th ese

    volumes in Chapters 7, 8 , 9 and 16. Credit is

    also due to my secretary, Ann Kochanske, for

    her effective help with the physical preparation

    of the book an d th e checking of references.

    Lewis R. Wolberg, M .D.

     N ew York, N ew York

     N ovem ber 1, 1979

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    CHAPTER 1

    Models of Short-term Therapy

    Brief treatment is no newcomer on the

     psychotherapeutic scene. Chronic led in p r im i

    tive archives of earliest recorded history, par

    ticularly in Egypt and Greece, are accounts of

    what we may consider species of short- term

     psychotherapy. In these ancient docum ents

    there are transcribed elaborate r ituals to heal

    the afflicted, to solace troubled souls, and to

    assuage anguish and distress. Among such in

    terventions are tranquilizing nostrums, bodily

    manipulat ions , t rance incantat ions , persuas ive

    suggestions, and even rudiments of reinforce

    ment therapy , emotional cathars is , and in ter

     preta t ion of fantasies and d ream s. E labora t ions

    of these therapies continue to this day draped

    in the sophistication of modern theories. Up to

    the beginning of the twentieth century methods

    of treatment were short term; even the original

    Freudian techniques were implemented over a

     period of a few m onths. G ra d u a l ly p sychoana

    lytic methods stretched out in time, and the

    number of weekly sessions increased as efforts

    were directed at the task of resolving resistance

    to unconscious conflict. A few contemporaries

    of Freud, notably Adler , Ferenczi, Stekel, and

    Rank, tr ied heroically to shorten the pro

    tracted time of psychoanalysis, but their meth

    ods were repudiated by the off icial analytic es

    tab l ishment . Some Rankian and Stekel ian s t ra-

    tegems survived, nevertheless, and have been

    adapted to f it in with present-day styles and

    contemporary ideologies.

    Psychoanalytic Modifications in 

    Brief Dynamic Therapy

    I t was Franz Alexander in 1946 who most

    str ikingly challenged the validity of prolonged

    time as a necessary component of treatment

    methods directed at reconstructive goals. Reac

    tion to Alexander’s unorthodoxy was at f irst

    harsh , and a l though he was accused of aban

    doning the psychoanalytic ship, it is to his

    credit that he resisted recanting his convictions.

    Along with French he published a pioneer

    work on br ief therapy (Alexander & French ,1946) that questioned many of the assumptions

    of long-term classical psychoanalysis.

    In their volume the authors describe experi

    menting with varying the frequency of inter

    views, the alternative use of the chair and

    couch, deliberate interruptions of treatment

     p r i o r to t e r m i n a t i o n , s t r a te g ic p la y in g of

    studied roles, and combined use of psych other

    apy with drug and o ther t reatments . At the

    t ime their exper iments were considered as dar

    ing and innovative. Particular ly regarded as

    aber ran t were the emphasis on problem so lv

    ing and the consideration of therapy as a cor

    rective emotional experience that functioned to

     b reak up ol d reaction pa tterns . “ In some

    cases,” they wrote, “ the development of a full-f ledged transference neurosis may be desir

    able; in others i t should perhaps be avoided

    a l toge ther . I n some i t i s impera t ive tha t

    emotional discharge and insight take place

    gradually; in others, with patients whose ego

    strength is greater , interviews with great emo

    1

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    2 HANDBOOK OF SHORT-TERM PSYCHOTHERAPY

    t ional tension may be not only harmless but

    highly desirable. All this depends upon the

    needs of the patient in a particular phase of the

    t h e r a p e u t i c p r o c e d u r e . ” T h e m o d i f i c a t i o n s

    suggested were forms of psychoanalysis based

    on dynamic principles that attempt to secure a

    more harmonious environmental ad jus tment

    with enhanced development of one’s capacities.

    Frequent interviews over a long-term pe

    riod, they insisted, had a regressive conse

    quence o f ten g ra t i fy ing the pa t ien t ’ s de

     pendency ne eds . “ T h e in itial soothing effect ofthe prolonged outlook gradually becomes cor

    ruptive, and the therapist, faced with the task

    of driving the patient from his comfortable in

    fantile position, realizes anew how difficult it

    is to force anyone to give up acquired r ights.”

    I t was a fallacy, they contended, to assume

    that an analysis oriented around regressive

    mater ia l was more thorough than one focused

    on the immediate l i fe conf l ic t . Indeed ,

    regressive material was usually a sign of neu

    rotic withdrawal from a diff icult l ife situation.

    I t was the duty of the therapist to divert this

    re treat toward new at tempts to so lve problems

    from which the patient had f led in the past.

    Another disadvantage of too frequent sessions

    was that transference was not allowed to accu

    mulate, being drained off in small quantities at

    each session, thus lessening the emotional par

    t ic ipat ion. Th ey advised manip ulat ion of the

    frequency of sessions to intensify emotional

    reactions. A focus on the present helped reduce

    the evolvement of a transference neuroses and

    the substitution of transference gratif ications

    for real- life experiences. Putting into practice

    what had been learned in therapy encouraged

    the bolstering of self-confidence and the over

    coming of neuro t ic impairment . The pat ien t

    dur ing the course of h is exper imenting with

    new patterns was to be forewarned of failuresand the need to analyze the reasons for these

    should they occur , thus tu rn ing them to advan

    tage.

    With the development of community mental

    health facili t ies and the servicing of increasing

    groups of patients by staffs depleted through

    shrinking budgets, the necessity of l imiting

    t ime devoted to t reatment without des troying

    i ts ef fect iveness has rek indled in teres t in

    the observat ions of Alexander and French .

    Moreover , res tr ic t ion of payments to a des

    ignated number of sessions by insurance com

     panies has fo rc ed eve n those the rap is ts w ho by

    training and conviction are dedicated to long

    term therapy to modify their tactics and to

     b ring t r ea tm en t to a halt w ith in the confines of

    the a l lo ted re imbursement term. Economics

    has thus had a corrosive effect on ideology,

    which is probably all to the good in a fieldwhere bias and opinion have frozen profes

    sionals to postulates that could never have been

    otherwise thawed out and rev ised .

    The work o f A lexander and F rench p ro

    vided the foundation for other developing sys

    t e m s of d y n a m i c s h o r t - t e r m t h e r a p y a n d

    insp ired a num ber of analys ts who though

    loyal to the teachings of Freud refused to con

    sider them as d iv ine revela t ions (Marmor ,

    1979). While challenging classical analytic

    concepts, they vouchsafed th e validity of the

    dynamic design. Among the best known of con

    temporary contr ibu t ions to dynamic shor t- term

    therapy are the wr i t ings of Malan , S ifneos ,

    a n d Ma n n .

    I n t h e s t u d y b y M a l a n ( 1 9 63 ) a t t h e

    T a v i s t o c k C l i n i c i n L o n d o n , t h e p a t i e n t s

    t reated were those who were ab le to explore

    their feelings and who gave the impression

    they could work with in terpret ive therapy . All

    of the therapists involved were psychoana-

    lytically oriented and willing to employ an

    active interpretive technique. Sessions totaled

    from 10 to 40. I t was possible, Malan wrote,

    under these condi t ions “ to ob tain qui te far -

    reaching improvements no t merely in symp

    toms, but also in neurotic behavior patterns in

     pat ien ts w ith relatively extensive and lo ng

    standing neuroses .” The bes t resu l ts wereachieved when (1) the pat ien t was h ighly moti

    vated , (2) the therap is t demonstra ted h igh en

    thusiasm, (3) transference developed early,

    especially negative transference, and was inter

     pre ted , a nd (4) grief a nd a nger became im p o r

    tan t issues as terminat ion approached . The

     prognosis w as also be st w here the p a t ien t and 

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    MODELS OF SHORT-TERM THERAPY 3

    therapist showed a strong willingness to get in

    volved— the former with an intense desire for

    help through unders tanding , the la t ter with

    sympathy while interacting objectively and not

    w i t h c o u n t e r t r a n s f e r e n c e . E v e n d e e p - s e a t e d

    neurotic behavior patterns could be lastingly

    changed . The technique i f p roper ly used car

    ried few dangers, even where penetrating in

    t e r p r e t a t i o n s w e r e m a d e f r o m d r e a m s ,

    fantasies, and the therapist-parent l ink of the

    transference that connected the present with

    chi ldhood exper iences . Malan modest ly suggested that a crucial ingredient in change

    might not be the technique employed, but the

    nonspec i f ic f ac to r o f the ana ly s t app ly ing

    himself enthusiastically to his technique ir

    respective of whether i t was analytic or non-

    analytic.

    In a later study published in his book

     F rontier o f B rie f P sychoth erapy,  Malan (1976 )

    confirmed his previous conclusions regarding

    the u t i l i ty of dynamic shor t- term therapy and

    described some principles of selection of suita

     bl e pa tien ts fo r th is form of t rea tm en t. In

    M al an ’s sample the pat ien ts were careful ly

    screened . Chosen were those who appeared “ to

    have the basic strength to stand up to uncover

    ing psychotherapy ,” “ who were responsive to

    in terpreta t ion ,” and who could help formulate

    a circumscribed focus around which therapy

    could be done. Sever i ty of pathology or

    chronicity were not considered. Of all factors

    in prognosis, motivation for insight and the

    ability to focus on significant material seemed

    to be of pr imary impor tance. These were con

    sidered to be measures of successful interac

    tions between pat ien t and therap is t . Pat ien ts

    who were excluded were alcoholics, homosex

    uals, drug addicts, those who had at one time

    made serious suicidal attempts, who had a pe

    riod of long-term hospitalization, who hadmore than one course of ECT, who suf fered

    f rom incapac i ta t ing ch ron ic obsess iona l o r

     p hob ic sy m p to m s , and w h o w e re gross ly

    destructive or self-destructive in acting-out. As

    was predicted, reasons for rejection were that

    the patient would have diff iculty in making

    contact, that a great deal of work would be

    needed to develop proper motivation for ther

    apy, that r igid and deep-seated issues required

    more work than the l imited t ime could a l low,

    that severe dependence and o ther unfavor

    able intense transference feelings would be

    too obstructive, or that depressive or psychotic

    d is turbances might be precip i ta ted or in ten

    sified.

    Sifneos (1972) , conf irming ma ny of M a la n ’s

    f indings, adds some other cr iter ia of selection

    for th is form of dynamic “ anxiety-provo king”

    therapy that lasts from 2 to 12 months. Suitab le pa t ien t s a r e those who possess f ive

    qualities: (1) existence of above-average in

    telligence, (2) possession of at least one mean

    ingful relationship in the past, (3) abili ty to

    i n t e r a c t w i t h t h e i n i t i a l i n t e r v i e w e r w h i l e

    manifes t ing appropr ia te emotions and a degree

    of flexibility, (4) ability to identify a specific

    chief complaint, (5) willingness to understand

    oneself, to work on oneself, to recognize one’s

    symptoms as psychological, to be honest in re

    vealing things about oneself , to participate ac

    tively in therapy, and to make reasonable

    sacrifices (Sifneos, 1978).

    For patients who are selected, sessions are

    held once weekly for 45 minutes in face-to-face

    interviews. The initial interview deals with

    his tory tak ing , par t icu lar ly “ a jud icious con

    frontation by open-ended and forced-choice

    type of questions.” As areas of conflict and

    maladapt ive react ions open up , the therap is t

    asks questions that will give him a clearer pic

    ture of the psychodynamics. He may then be

    able to make a connect ion between the un

    derlying conflicts and the superf icial com

     plain ts . Befo re lon g, transference fe el ings are

    apt to emerge. “The therap is t must then con

    front the patient with his transference feelings

    and use them as the main psychotherapeut ic

    tool .” T his facili tates tracing of on e’s emotional problems in the past and recognizing

    how conflicts give rise to one’s symptoms.

    Sooner or la ter res is tance appears . “The whole

    tone of the interviews star t to change,” silences

    a p p e a r , “ t h e w h o le i n te r v i e w s e em s f r a g

    mented .” Confrontat ion and c lar i f icat ion are

    employed as tools, but a transference neurosis

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    4 HANDBOOK OF SHORT-TERM PSYCHOTHERAPY

    is avoided. The patient must be confronted

    with his anger and his negative feelings, and

    these may f lair up with the therapist’s anxiety-

     provoking questions. In te rpre ta t ions help cla

    rify the patient’s reactions. Awareness of his

    own countertransference is vital, and the thera

     pist m ust m ake sure he is not using the pa tien t

    to gratify his own needs. Repeatedly demon

    strating how the patient deals with his conflicts

    and the adverse effects on him, the therapist

    acts as “an unemotionally involved teacher .”

    Tangible evidence of progress is shown by the p a t ie n t’s abili ty to rela te w ha t is going on to

     pas t so urces a nd by im provem ent in his in te r

     p e r so n a l re l a t io n sh ip s . T h e th e r a p is t m us t

    w o r k u n i n t e r r u p t e d l y t o w a r d t e r m i n a t i o n ,

    handl ing h is counter t ransference and real iz ing

    that “ there are cer ta in behavior pat terns which

    cannot be a l tered by psychotherapy .” At a pro

     pitious time term ina tion must be di scu ss ed.

    The patient’s reactions such as anger, de

     pression, and fear must be an tic ipa ted and

    handled.

    The following outlines technical processes in

    Sifneos’s techniq ue:

    1. T h e p a t i en t i s a sk ed to l is t i n o rd e r o f u rg en cy

    the problems tha t he would l ike to overcome.

    2 . I t is e s sen t ia l to d eve l op a rap i d t h e rap eu t i c

    a l l i ance wi th pa t ien t , s ince the pa t ien t ’s posi t ive

    fee l ings toward therap is t const i tu te a ch ief thera

     peutic to ol . A g reem en t m us t be reach ed r eg a rd in g

    the problem to be solved.

    3. T h e t h e r a pi s t r a p id l y a r r i ve s at a te n ta t iv e

     p sycho d yn am ics an d the u n d e r ly in g em o tio na l co n

    flicts.

    4. T h e focus i n t h e rap y i s o n t h ese co n fl ic ts , t h e

    objec t be ing to he lp the pa t ien t l earn new modes of

    solving difficulties.

    5. T h e t h e r a p is t m u s t c o n fr o n t p a t ie n t w it h

    anxie ty-provoking quest ions , he lp ing h im to face

    and examine areas o f d i f f icu l ty ra ther than to avoid

    them, and enabl ing h im to experience h is confl ic t sand to conso l ida te new so lu t ions for them.

    6 . If successfu l in reach ing the goals se t fo rth , the

     pa t ie n t should be ab le to u t i l iz e hi s l e a rn in g “ to

    dea l wi th the new cr i t i ca l s i tua t ions in the fu ture .”

    I t must be remembered that the basis of

    Sifneos’ app roac h wa s work w ith a clinic

     populat ion of self- refe rr ed, relatively well -edu

    cated young people “ who gave freely of their

    t ime and were eager to help .” While these re

    quirement s are ideal , the average therap is t wil l

    see a good number of less suitable patients ur

    gent ly demanding symptom rel ief whose prob

    lems are linked to inner conflicts and who do

    not fulfill the selection requirements of Sifneos.

    They might sti l l be considered for dynamic

    therapy , bu t anxiety-provoking tact ics may

    have to be avoided.

    Sifneos has not neglected consideration of

    other classes of patients not qualif ied for theanxiety-provoking technique but amenable to

    a n “ a n x i e t y - s u p p r e ss i v e ” f o r m o f t h e r a p y .

    Such therapy is designed for patients with

    weak ego s t ructures who habi tual ly have poor

    interpersonal relations and are disposed to

    lifelong emotional difficulties. Here the goal

    is to dissipate anxiety by such tactics as

    reassurance, advice giving, emotional catharsis ,

    environmental manipulat ion , persuas ion , hos

     p i ta liza tion , or medication. W h e re the pa tien t

    has adequate motivation to receive help, recog

    nizes that his symptoms are psychological, is

    able to main tain a job , a nd is willing to coop

    erate with the therap is t , he has the bes t oppor

    tunity for relief. Sessions last from a few

    minutes to an hour and are spaced every week,

    twice a week, or oftener. Brief cr isis supportive

    therapy lasts up to 2 months and is aimed at

    o v e r c o m i n g t h e e m o t i o n a l d e c o m p e n s a t i o n .

    Patients with serious diff iculties, however, may

    require support for a prolonged period.

    An in teres t ing form of dynamic br ief ther

    apy has been detailed by M an n (1973). A few

    of the principles were originally described by

    Rank (1936, 1947). Stressing the subjective

    and objective meanings of t ime (e.g. , separa

    tion, loss, death, etc.) both to the patient and

    t h e r a p i s t , M a n n c o n t e n ds t h a t a m b i g u i t y

    about t ime l imita t ions of therapy may act as adeterrent to acceptance of reality and the work

    to be done. Patients, he avows, are bound to

    “chi ld t ime,” an unconscious yearn ing for

    etern i ty , and must be brought to the accep

    tance of real is t ic l imited “ adul t t ime .” He out

    lines a f ix e d   12 session form of treatment based

    on psychoanaly t ic concepts around which he

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    has s t ructured a methodology . “ Exper ience

    has demonstrated that 12 treatment sessions is

     probably the m inim al time required for a

    series of dynamic events to develop, flourish,

    and be available for discussion, examination,

    and reso lu t ion .”

    The limited interview is concerned with

    clar ifying what the patient seeks from therapy.

    Two or more sess ions may be required here .

    In the course of this inquiry “ a formulat ion of

    the central conflict productive of the present

    mani festat ions of distress can be mad e . . . [thetherap is t ] te l l ing the pat ien t what is wrong

    with h im.” This may or may not accord with

    the patient’s incentive for seeking help. A de

    lineation of other unconscious dete rm ina nts is

    attempted by examining past sources of the

    central conflict. A diagnosis is made, and there

    is an assessment of the patient’s general psy

    chological state. There is then an estimate of

    how 12 hour sessions should be distributed: 12

    full sessions once weekly, 24 half-hour sessions

    over 24 weeks, or 48 sessions of 15 minutes

    over 48 weeks. The therapist expresses to the

     pat ien t hi s op inion of the p a t i e n t ’s chief p ro b

    lem and what he believes should be done. He

    consul ts h is calendar and announces the exact 

    date of termination. He settles dates and times

    of appointments and discusses the fee. He

    assures the patient that if they f ind the chosen

    central issue erroneous, they will move on to

    another issue. The patient is then given the

     pr ivil ege to accept o r re jec t the stated condi

    tions. Assuming that the patient has suff icient

    ego s t rength to negot ia te a t reatment agree

    ment and to to lera te a s t ructured schedule , ar

    rangements for therap y a re concluded .

    The in terv iews are conducted on as h igh an

    emotional level as possible, moving from adap

    tive issues to defenses to genetic origins of con

    flicts . This, of course, requires that the thera pis t be em path ic and th a t he have a high

    degree of comprehension of dynamics . The

    choice of the central issue will vary with the

    t h e r a p i s t ’ s u n d e r s t a n d i n g a n d e x p e r i e n c e .

    Since free association is impractical in short

    term therapy , some o ther form of communica

    t i on is n e e d ed . M a n n r e c o m m e n d s F e l i x

    De utsch ’s “ associa tive anamn esis” (Deutsch,

    1949) as one way of working.

    Even though a n um ber of confl ic tual themes

    vary, a common one, “the recurr ing life cr isis

    of separation-individuation is the substantive

     base upon which the tre a tm e n t res ts .” M as te ry

    of separation anxiety serves as a model for

    overcoming o ther neuro t ic anxiet ies . Among

     basic universal conf li ct s i tuat ions tha t re la te to

    the separat ion- indiv iduat ion theme are (1) in

    dependence ve r sus dependence , ( 2 ) ac t iv i ty

    versus pass iv i ty , (3) se lf - suf f ic iency versusina dequ ate self-esteem, and (4) “ unresolved or

    delayed gr ief.” M aste ry of separat ion- indiv id

    uation influences the mastery of all of the lat

    ter conf licts. Du r ing termina t ion of therap y the

     pat ien t wil l undergo a degree of anxiety re fle c

    tive of the adequacy of his resolution of the

    separat ion- indiv iduat ion phase of h is ear ly de

    velopment . One or another of the four bas ic

    universal conflicts will be activated during the

    terminat ion phase.

    Mann advises no t to compromise the 12-

    session time limit by making any promises to

    cont inue therapy af ter the a l lo t ted per iod has

    ended. In this way a f ixed time structure is

     presented to the pat ien t in which the d ra m a of

    es tab l ish ing a dependent re la t ionship and of

    working through the cr is is o f separat ion and

    achievement of autonomy is repeated in a set

    ting that permits a more satisfactory solution

    than the individual realized in his past early

    relationships. In other words, we are provided

    with two themes in therapy: the f irst , the

    central issue for which the patient seeks treat

    ment, and the second, the more basic separa

    t ion- indiv iduat ion theme. The fact that we

    focus on an agreed area of investigation and

    that the patient possesses knowledge of im

    minent term inat ion l imits the ex ten t o f re

    gress ion in the t ransference. The rap id mobilization of a positive transference in the first

    few sessions will br ing s ym ptom relief and a n

    outpouring of material. Although the focus is

    on the central issue, the adaptive maneuvers of

    the pat ient and the genetic roots of the central

    issue wil l soon become apparent . The thera

     pi st, however, m ust resis t the tem p ta t ion to

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    6 HANDBOOK OF SHORT-TERM PSYCHOTHERAPY

    deviate from the central theme. At all t imes,

    the therapist is active in “ suppor ting, en

    couraging , and educat ing the pat ien t .” This

    does not mean giving advice or guidance.

    About the seventh session the patient will

     be gi n to sens e d isappoin tm ent in th e rapy si nc e

    he is not allowed to talk about all of the things

    he wants to bring up and must confine himself

    to the central issue. At this point negative

    transference will appear , and ambivalence re

     pl aces posit iv e tr ansference. Resistance rears

    i ts head , and symptoms may re turn . Despi tethese reactions the therap is t must work towa rd

    termination. This will be diff icult for both pa

    tient and therapist since the emotions of termi

    nation and separation (such as grief and anger)

    will be disconcerting. The patient will show

    many defenses against termination that will

    have to be handled.

    Interpretation of the patient’s reactions is

    impor tan t as the pat ien t expresses h is am

     bivalent feeli ng s, the the rap is t enuncia ting th e

    idea that the patient’s responses are under

    standable since his expectations are not being

    fulf il led. Data from the patient’s past will

    allow for a relating of the patient’s reactions to

    early experiences with parental f igures. The

    last three sessions at least should be devoted to

    dealing with the patient’s feelings about termi

    nation.

    As to selection of patients for this type of 

    therapy , accord ing to Mann, most pat ien ts are

    candidates except those with borderline or psy

    chotic problems. Young people in a matura-

    tional cr isis have difficulties “ exquisitely re

    lated to the separat ion- indiv iduat ion process .”

    Regard ing therap is ts who can work with th is

    method, M an n says: “ I t is ev ident that th is

    kind of psychotherapy requires a high degree

    of skill , knowledge, and experience. Knowl

    edge of the psychoanalytic theories of mental

    functioning heavily buttressed by experience in

    the long-term treatment of patients is the f irst p rep ara t ion fo r this t rea tm en t p la n .”

    Another sys tem of dynamic shor t- term ther

    apy is described by Lewin (1970), who, follow

    ing the lead o f Berg le r (1949 ) , cons ide r s

    symptoms a consequence of psychic masoch

    ism, wh ich i s a un iver sa l ing red ien t o f

    neuroses. The need to appease guilt through

    suffering, he avows, can prevent progress in

    therapy . “ Ideally, the core of the pati en t’s

    masochism, his bad introject, should be ex

     pose d and replaced, a long w ith his sadisti c

    conscience.” While this may not always be

     po ss ib le , the le ast the the rap is t can do is to

    con f ron t the pa t ien t w i th h i s masoch ism.

    Assigning all of his problems and symptoms to

    self-punishment for guilt feelings in relation to

     pa ren ta l figures provides the pat ien t w ith a

    focus that, according to Lewin, helps shorten

    the therapeutic process.

    Eclectic Systems

    Spurred on by community need, by str ic

    tures on the number of sessions f inanced by

    third-party payments, and by dissatisfaction

    with the resu l ts o f long- term treatment , thera pi sts of al l denom inations have experim ented

    with br iefer methods and contr ibu ted wr i t ings

    to short- term theory and practice. Some of the

    techniques are a revival of the methods em

     ploy ed in the preanaly tic and early analytic

     period. Some a re replicas of established case

    work and counsel ing procedures . Others are

    more innovative, being influenced by behavior

    therapy , by the contemporary emphasis on ego

    functions, by an increasing interest in problem

    solv ing as a pr im ary means of enhancingadaptation, as well as by a resurgent f lexible

    eclecticism (Grayson, 1979). Accordingly, a

    number of models of shor t- term therapy have

     been in troduced, and some of th ese will be

    cited as examples. Other excellent models un

    doubtedly exist, but they cannot be included

     because of la ck of sp ace. An exam ple of how

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    florid the writ ings have become in short-term

    therapy is the annotated bibl iography of Wells

    (1976), who in reviewing the l i terature up to

    1974 de ta i l s 243 c i t a t ions cove r ing ma jor

     jo u rn a ls in psychiatry , psychology, and soci al

    work . These a r t i c l e s a re ca t egor i zed in to

    theoretical and review articles, individual adult

    therapy, individual therapy of children and

    adolescents, group therapy, family therapy,

    mari tal therapy, and treatment of hospital ized

     patients.

    In 1965 Beliak and Small wrote a book (thesecond edition of which appeared in 1978)

    that differentiated emergency from brief psy

    c h o t h e r a p y . T h e y c o n t e n d t h a t e m e r g e n c y

    treatment is a temporary approach uti l ized in

    crisis, while brief psychothe rapy is a “ fore

    shortened applicat ion of t radit ional psychother

    apy, called into being either by the life situation

    of the patient or by the set t ing in which treat

    ment is offered.” T he y offer a form of brief psy

    chotherapy that is rooted in orthodox psycho

    analytic theory and directed at symptoms or

    maladaptat ions, avoiding the reconsti tut ion of

     personality tha t may, nevert heless, come about

    autonomously. Br ief psychotherapy may stabi

    lize the indiv idual sufficiently so th at “ he may

     be enabled to continue w ith more exte nsiv e psy

    chotherapy.” The t ime span a l lo t ted for t rea t

    ment is one to six sessions. A positive trans

    ference is fostered, free association avoided, and

    interpretat ion tempered, being coupled with

    other types of intervention like medical, envi

    ronmental , etc . Brief therapy, they observe, is

    useful in nearly every kind of emotional dis

    turbance, even psychosis. While extensive re

    structu ring of the chara cter is desired and possi

     bl e, o r where acting-out ex is ts , however, it is

    not suitable.

    A detailed history is essential with a com

     ple te explo ra tion of the p resenting problem,the precipi tat ing factors, the contemporary l i fe

    si tuat ion, and the developmental history, in

    cluding family relationships. The object is to

    und erstand the present i l lness “ in dynamic

    terms and related to preceding genetic , de

    velopmental , and cultural events.” Out of this,

    so m e i m m e d i a t e t h e r a p e u t i c h e l p m a y b e

    rendered tha t can take the form of a minor

    i n t e r p r e t a t i o n . P sy c h o t h e r a p y i s p l a n n e d

    “ wi thin the f ramework of what the pa t ient is

    wil l ing to engage in,” in contrast to the posi

    tion taken by some therapists like Sifneos to

    the effect that “the patient must f i t the treat

    ment chosen for him by the expert .” In Beliak

    and Small’s method dreams may be el ici ted,

     projecti ve te sting like the T h e m at ic A pp ercep

    tion Test used, and hypnosis employed to

     b ring out repressed materia l. An a t tem p t is

    made to establish causal factors in relat ion to p rec ip ita ting incidents and spec if ic histo rical

    events and structures. Judicious use of inter

     p re ta t ion to im p ar t insig ht, reassurance and

    support when necessary, counseling, guidance,

    conjoint family therapy, group therapy, drugs,

    e lec t roconvulsive therapy (as in suic ida l

    depressions) , and envi ronmenta l manipula t ion

    will call for a good deal of flexibility, diag

    nostic acumen, and cl inical judgment on the

     p a r t of the therapis t . E m p has is in work ing-through i s upon immedia te learning. “The

    maintenance of the posi t ive relat ionship,” they

    state, “ avoids a sense of rejection in the

    terminating process and permits the patient to

    retain the therapist as a benign, introjected

    f igure .” Trea tment i s ended by informing the

     pa tien t th a t the therap is t is available in the fu

    ture when needed.

    The l i terature is replete with descript ions of

    special techniques vaunted by the authors as

    un ique ly e f fec t ive fo r shor t - t e rm the rapy .

    Thei r enthusiasm is understandable because

    therapists become skil led in certain methods to

    which they are by personali ty, operat ional

    style, and theoret ical bias at tuned. Lest we be

    come too rhapsodic over any set of methods,

    however , we must remember tha t whi le they

    may be effective in the hands of some, they

    may not be useful for al l therapists. Matching patient and method is al so a challenging p ro b

    lem (Burke et al, 1979). Except for a few syn

    dromes, such as behavior therapy for phobias

    and pharmacotherapy for psychoses, outcome

    studies fail to credit any special interventions

    with global superiori ty over other approaches.

    Indeed, stat ist ics indicate equivalent improve

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    ment rates for a host of available techniques.

     Nevertheless, a study of the various modalities

    in contemporary use is rewarding if no more

    than to provide us with models that may selec

    tively be useful.

    Among the most common techniques , in ad

    dition to those previously cited under dynamic

    therap ies , are interpretive methods   tha t d r aw

    their substance from classical (Freudian) and

    n o n c l a s s i c a l ( A d l e r i a n , S t e k e l i a n , R a n k i a n ,

    Jungian , and Reich ian) psychoanalys is as wel l

    as from  behavio ral m od els .  The list that follows includes the more formal modalities cur

    rently in use:

    1.  A u to g e n o u s tr a in in g   (Crosa, 1967; Luthe,

    1963; Schultz & Luthe, 1959).

    2.  B eh a v io ra l m odels   (Ayllon & Azrin, 1968;

    Ba ndu ra, 1969; Crow e et a l, 1972; Fe rber e t a l ,

    1974; Ferster , 1964; Fran ks, 1964; Frank s &

    Wi l son , 1975 ; Ghad i r i an , 1971 ; Hand & La-

    Montagne, 1974; Hofmeister , 1979; Lazarus, 1976;

    Lick & Bootzin , 1970; Pat terson, 1973a, 1973b,

    1974; Richardson & Suinn, 1974; Stuar t , 1969;

    Suinn et al , 1970; Wolpe, 1964).

    3.  B io energeti cs  (Lowen, 1958; Palmer , 1971) .

    4.  B io fe e d b a c k   ( B l a n c h a r d & Y o u n g , 1 9 7 4 ;

    G l u e c k & S t r o e b e l , 1 9 7 5 ; S t r o e b e l & G l u e c k ,

    1973).

    5. C a s e w o r k t h e r a p y   ( K e r n s , 1 9 7 0 ; U p h a m ,

    1973; Wat t ie , 1973; A. Wolberg, 1965) .

    6. Cogni t ive learning   ( B a k k a r & B a k k a r - R a b -

    dau, 1973; Greene, 1975) .7. Cogni t ive therapy   (Beck, 1971, 1976; Ell is,

    1957, 1965, 1973; Glicken, 1968; Rush, 1978).

    8. Conf ron ta t ion me thods   (G. Adler & Buie,

    1974; G. Adler & Myerson, 1973; Garner , 1970a,

    1970b; Godbole & Falk , 1972; Kaswan & Love,

    1969; Sifneos, 1972).

    9. C o u n s e l i n g m e t h o d s   ( G r o s s & D e r i d d e r ,

    1966).

    10.  D ance a n d m o vem e n t th era py   (Smal lwood,

    1974).

    11.  D ecis io n th era py   (Greenwald, 1974) .

    12.  E m o ti o n a l ca th arsis   (Nichols, 1974).

    13.  E S T   (Kettle, 1976).

    14 . Gestal t therapy   (Peris, 1969; A. C. Smith,

    1976).

    15. G o a l a t t a i n m e n t s c a l in g   ( L a F e r r i e r e &

    Calsyn, 1978) .

    16. Guided af fect ive imagery   (Koch, 1969).

    17 .  H y p n o s is   ( C r a s i l n e c k & H a l l , 1 9 7 5 ;

    F r a n k e l , 1 9 7 3; M o r r a , 1 9 6 7 ; R a b k i n , 1 9 7 7;

    Spiegel, 1970; Spiegel & Spiegel, 1978; Stein,

    1972; Wolberg, 1948, 1964, 1965) .

    18 .  In te rp r e tiv e m e th o ds   (K. A. Adler, 1972;

    Ansbacher , 1972; Bar ten, 1971; D. Beck, 1968;

    D a v a n l o o , 1 9 7 8 ; D a v a n l o o & B e n o i t , 19 7 8 ;

    Gi l lman , 1965 ; M. Moreno , 1967 ; Smal l , 1971 ;

    Wahl , 1972) .

    19.  M e d ia tio n   (Car r ing ton , 1977 ; Car r ing ton &

    Ephron , 1975) .

    20.  M ili e u th era p y   (Becker & Goldberg, 1970;Clark, 1972; Goldberg, 1973; Knobloch, 1973;

    R a s k i n , 1 9 7 1 ; S t a i n b r o o k , 1 9 6 7 ; V i s h e r &

    O ’Sul l ivan, 1971; Wilkins, 1963) .

    21.  M u ltim o d a l th era p y   (Lazarus , 1976) .

    22. Persuasion   (Mal tz , 1960) .

    23. P r i m a l t h e ra p y   ( Janov, 1970) .

    24 . P r o g r a m m e d p s y c h o t h e r a p y   ( H . Y o u n g

    1974).

    25. Psycho imag ina t ion therapy   (Shorr , 1972).

    26. Psychosyn thes i s   (T ien, 1972) .

    27.  R e a lit y th e ra p y   (Glasser , 1965; Glasser &

    Zunin, 1972) .

    28.  R e la x a ti o n   (Benson et al , 1974).

    29. Scream therapy   (Casriel , 1972).

    30. S e n s i t i v i t y t r a i n i n g   ( Q u a y t m a n , 1 96 9;

    Schutz , 1967) .

    31. Soc ia l t herapy   (Bierer , 1948; Fleischl &

    Wolf, 1967).

    32 . Somat i c t herapy   ( D a s b e r g & V a n P r a a g ,

    1 9 7 4 ; H a y w o r t h , 1 9 7 3 ; H o l l i s t e r , 1 9 7 0 ; K a l -

    inowsky & Hippius, 1969; Ostow, 1962) .33. Structural in tegrat ion   (Rolf , 1958; Sperber et

    al, 1969).

    34. S y m b o l d r a m a   (Leuner , 1969) .

    35. Transact ional analysis   (Brechenser , 1972;

    Hol l ensbe , 1976 ; Joh nso n & Cha towsk y , 1969 ;

    Sharpe, 1976) .

    36 . Video tape p layback    (Alger, 1972; Berger,

    1970 , 1971 ; Gonen , 1971; M eln ick & T im s , 1974 ;

    Silk, 1972).

    Less formal therap ies have dra wn on the fo llowing techniques:

    1.  B u d d h is t S a li p a tt h a na ,  o r “mind fu lness med i

    ta t ion ”  (Dea therage , 1975) .

    2. C o m m u n i c a t i o n t h e o r y   (Kusnetzo ff , 1974; R.

    C. Mar t in , 1968) .

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    MODELS OF SHORT-TERM THERAPY 9

    3.  D rea m ana ly s is   (Mer r i l l & Cary , 1975) .

    4. “ E m o t iv e - r e c o n s t ru c t iv e p s y c h o t h e r a p y ”

    ( E R P ) ,   wh ich combines the use o f imagery wi th hy

     p erven t ila t ion (Fu lch ie ro , 1976; M o r r i s o n & Co-

    meta, 1977).

    5. “ F i s c h e r - H o f f m a n p r o c e s s   ( A . C . S m i t h ,

    1976).

    6. “F l om p m e t h o d ”   (Hage l in & Laza r , 1973) .

    7.  M o n ta th e ra p y   (Reynolds, 1976) .

    8.  N a ik a n   ( Ishida, 1969).

    9. “Paradox ica l i n t en t ion ”  (Fra nkl , 1965, 1966) .

    10. Social sk i l ls t ra ining   (Argyle et al , 1974).

    11. Soc ia l sys t ems approaches  (Clark , 1972) .12. Story te l l ing   (De La Tor r e , 1972) .

    13. Team sys t ems approaches   (Dressier et al ,

    1975).

    14 . “ T h e r a p e u t i c p a r a d o x ” t e c h n i q u e   ( F u l

    chiero, 1976).

    Special techniques have also been recom

    mended for part icular syndromes:

    1. Conversion react ions   (Dickes, 1974).

    2.  D ep ress iv e re actions  (Campbe l l , 1974 ; Neu e t

    al , 1978; Regan, 1965; Sokol, 1973).

    3.  H y s te r ic a l p e r s o n a l i ty d is o r d e rs   (Se ibov ich ,

    1974).

    4. Obsessive-compulsive d isorders   (Suess, 1972).

    5. Phob ias   (Skynner , 1974) .

    6. P s y c h o s o m a t i c c o n d i t i o n s   ( M e n t z e l , 1 9 6 9 ;

    Meyer , 1978; Meyer & Beck, 1978) .

    7. S e x u a l p r o b l e m s   (Kaplan, 1974; Levi t , 1971;

    Mear s , 1978 ; Spr ingman , 1978) .

    8. S m o k i n g h a b i t s   (M ar ro ne e t a l , 1970 ; H .

    Spiegel, 1970).

    9. U n r e s o lv e d g r i e f   (Volka n, 1971).

    10 . U ntow ard reac tions to phy s i ca l i ll ness   (E . H.

    Stein e t a l , 1969; Tuckman, 1970) .

    11 . War neuroses   (Pruch & Brody, 1946) .

    Moreover, selected interventions have been

    advised for specific categories of patients:

    1.  A lc oho li cs   (Kr immel & Falkey, 1962) .

    2.  D y in g p a tie n ts   (Cramond , 1970) .

    3. Geriatric pat ients   (Godbole e t a l , 1972; Gold-

    f a rb & Turner , 1953) .

    4. Univers i t y s tuden t s   (Bragan, 1978; Ki l leen &

    Jacobs , 1976 ; Lore to , 1972 ; W. Mi l l e r , 1968) .

    The use of shor t - te rm approaches in pr i

    mary ca re and medica l se t t i ngs has been

    described by Bleeker (1978), Budman et al

    (1979), Conroe et al (1978), and Kirchner et al

    (1978). Although not focused direct ly on short

    t e r m t h e r a p y , t h e c o n t r i b u t i o n s o f S t r u p p

    (1972) and Frank (1973) to related aspects of

    t rea tment a re noteworthy.

    Short-Term Therapy in Outpatient Clinics

    The urgency in many cl inics to al ter tact ics

    of psychotherapy in l ine with the requirements

    of the patients being treated as well as the dis

     position of th e com m unity has resulte d in th e

    sh i f t i n g f r o m l o n g - t e r m t r e a t m e n t t o wa r d

    eclect ic short-term programs. For example, atthe Montrea l Genera l Hospi ta l in Canada a

    change in the t rea tment phi losophy away f rom

    the long-term object ive of personali ty recon

    struction was necessary for practical reasons:

    (1) because the kind of pat ient populat ion the

    clinic dealt with was unable to utilize a

     prolonged therapeutic re la tionsh ip and (2 ) be

    cause some of the therapists were not f i t t ingly

    trained or were unable to spend a sufficiently

    long t ime to fol low through wi th appropr ia te

    t rea tment measures (Davanloo, 1978; St raker ,

    1968) . The resul t was a “ high dropout ra te orthe rapid development of chronic cl inic de

     pendency .” In addit ion, w a it ing li sts became

    so great that acute emotional crises could not

    receive needed help. A brief psychotherapy

     p ro g ra m w as sta rted in 1961 based on psy

    chodynamic formula t ions. Pa t ients who did  

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    10 HANDBOOK OF SHORT-TERM PSYCHOTHERAPY

    not qualify for the program received support-

    t ive kinds of help, pharmacotherapy, social

    service assistance, ward care, and so on, ac

    cording to their needs. With this pragmatic

    change the dropout rate decreased over five

    t imes, and staff interest and morale were

    grea t ly s t r eng thened . Fo l low-up s tud ie s 2

    years after intake revealed that 66 percent of

    the total case load had benefited sufficiently to

    need no further therapy. Patients selected for

    and treated with brief psychotherapy showed

    an 84 percent remission rate.Largely through Davanloo’s efforts three

    International Symposia were organized, in

    1975, 1976, and 1977, bringing together pro

    fessionals in terested in br ie f app roac hes .

    Davanloo’s methods resemble those of Sifneos

    and Malan. Evalua t ion cr i te r ia for dynamic

    therapy are, first, the assay of the ability to es

    tablish meaningful relat ionships based on the

     p a t ie n t’s hav ing had previous emotional ti es

    with other people. Even in the first interview

    the patient’s capacity to interact with the ther

    apist will be obvious. Second, there is an esti

    mate of the ego’s capacity to experience and

    tolerate anxiety that will be mobilized in the

    interview. Third, motivation for t rue change

    must be differentiated from a desire to satisfy

    an infanti le need in therapy. Fourth, psycho

    logical mindedness and capacity for introspec

    tion are judg ed carefully. Fifth, the most crucial criterion is the patient’s ability to respond

    cons t ruc t ive ly to in t e rp re t a t ion dur ing the

    evaluation interview. Sixth, the degree of in

    telligence is an important factor in the choice

    of approach. Seventh, the evaluator must de

    termine the richness and flexibility of available

    defenses since these correlate with effective

    uti l izat ion of dynamic therapy. Davanloo is

    wedded to classical analytic formulations, such

    as the structural hypothesis, and frames hislanguage in these terms. There is general

    agreement among most therapis ts wi th Davan

    loo’s belief that selection of a psychothera

     peuti c focus is vital in shor t-te rm th e rapy and

    tha t “ ident if ica t ion and understanding of the

     psychodynamics and psych olo gic al pr oce sse s

    underlying the patient’s psychological prob

    lems i s the key i ssue in the evalua t ion

     process.”

    Other cl inics that have remodeled the struc

    ture of their services along short-term l ines

    a lso repor t an improved remission ra te among

     pa tients and a heightened staf f moral. T h e

    number of sessions devoted to treatment is con

    sidered arbitrary and has tended to cluster

    around lower l imits, which in some studies

    have yielded results equal to treatment with

    numer i ca l ly h ighe r se ss ions . E r re ra e t a l(1967) compared the results of pat ients at the

    Yale-New Haven Medica l Center Psychia t r ic

    Outpat ient Cl inic who were in therapy for

    from 6 to 10 sessions with a similar populat ion

    who received 21 or more treatment sessions

    and found th at “ there was no significant differ

    ence in the improvement rates, nei ther as

    recorded by the therapists nor evaluated by the

    ra t e r s . ”

    Lingering doubts as to the extent of help pa

    tients receive has been all but dissipated by the

    experience of cl inics that have converted their

    services along short-term l ines and conducted

    follow-up inquiries. At the Boston Universi ty

    Medical Center Psychiatric Clinic, for ex

    ample, a study was conducted by Haskell et al

    (1969) as to what happened to patients after

    12 weeks in short-term therapy. Significant

    changes were found in the group as a whole

    (abou t 71 perc ent) on five mea sure s of de

     pression, anxiety , and overall improvement.

    Even thoug h i t was felt “ that the type of pa

    tient who responds to t ime-l imited therapy dif

    fers markedly from the type who responds to

    long-term therapy,” no clear-cut cri teria were

    apparent .

    Clinics associated with colleges have also

    noted excellent results with a small number of

    sessions (Miller , 1968; Speers, 1962; W hi ttington, 1962). Because college students are at

    an age level where problems in identi ty, reso

    lution of dependency with emergence of au

    tonomy, and firming of sexual role are being

    worked through, they are , as a group, bound

    to experience a good deal of stress. The pres-

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    MODELS OF SHORT-TERM THERAPY 11

    ence of a facility tha t can offer the m crisis- stude nts. Fo r exam ple, a review of 3,000

    or iented psycholog ica l services can be ex- s tudents who appl ied for he lp a t the Ci ty

    tremely helpful in fostering a better adjust- College of San Francisco showed that the

    ment. Experience indicates that relat ively few average n um ber of contacts was below three

    sessions are necessary for the great majo ri ty of (Am ada, 1977).

    Walk-In Clinics and Crisis Intervention

    Th e grow th of commu ni ty psychia try hasencouraged a mul t i tude of shor t - te rm pro

    grams organized for purposes of crisis inter

    vention and the dealing with emergencies (An-

    nexton, 1978; Donovan et al , 1979; D. Gold

    stein, 1978; Robbins, 1978). Walk-in clinics

    that bring help to virtual ly thousands of people

    have sprouted throughout the count ry . An ex

    ample is the Intake Reception Service at the

    Psychiatric Clinic of the Maimonides Medical

    Service in Brooklyn, N.Y., which functions as

    a walk-in clinic offering immediate help to

    anyone applying (Gelb & Al lman, 1967) . Four

    to eight individual sessions are given. If more

    therapy is needed, maximal use is made of

    group and family therapy. Professionals from

    different disciplines are used, including psy

    chia t r i s t s , psychologists , psychia t r ic soc ia l

    workers, and psychiatric nurses. An experi

    enced therapist may be accompanied by a ther

    apist in training, who part icipates as an ob

    server. Thus the session operates as a t raining

    tool. Indications for referring a patient to a

     psychiatr ist therap is t a re any of the fo ll owin g:

    (1) somatic symptoms, (2) mental illness in a

     pa tient who is dangerous to himself or o th ers,

    (3) a need for medications, (4) history of at

    tempted or threatened suicide, or (5) a special

    r e q u e s t f o r a p sy c h i a t r i s t . T h e a p p r o a c h

    uti l ized is dynamically oriented and is not considered, in the words of Gelb and Allman

    (1967) “ an emergency shor tcut or a poor sub

    stitute for an unattainable ideal but is, in itself,

    the most effect ive and human approach to our

     pati ents . . . .” Im m edia te , act iv e, em phat ic and

    accurate confrontat ion with neurotic function

    ing is more effective than “ years of passivework ing- th rough .” Pa t i en t s who requ i re more

    help after therapy ends are invited to return

    “anytime the need arises,” but not on a con

    tinuing basis. This approach has resulted in a

    60 percent improvement rate within five visi ts.

    This improvement ra te , tha t i s about two-

    thirds of the patients receiving therapy, is

    substantiated by many other walk-in cl inics

    (Gottschalk et al , 1967; Jacobson & Wilner,

    1965). In a large study of over 8,000 patients

    treated on an emergency basis only 10 percent

    r e q u i r e d c o n t i n u i n g l o n g - t e r m t h e r a p y

    (Coleman & Zwerl ing, 1959) . The va lue of

    short-term group crisis intervention has also

     been demonstra ted . In a study of 78 cases

    receiving six group sessions compared with 90

    control cases in unlimited groups or individual

    therapy, the shor t - te rm group cases demon

    strated greater improvement on a 5-point scale

    of functioning (Trakas & Lloyd, 1971).

    Walk-in cl inics designed to provide im

    med ia t e goa l - l imi t ed he lp (Be l i ak , 1964 ;

    Coleman & Zwerling, 1959; Jacobson et al ,

    1965; Normand et al, 1967; Peck et al, 1966)

    general ly concern themselves with crisis inter

    vention and usually restrict the total number of

    sessions to six or less. Referral for more ex

    tended care is provided where necessary. Al

    though the work-up done in different cl inicswil l vary, i t general ly includes some dynamic

    formulat ion of the problem, an assay of exist

    ing ego strengths and weaknesses, and an est i

    mate of the degree of pathogenici ty of the cur

    ren t env i ronment . Toward th i s end Normand

    et al (1967) have described a join t ini t ial int er

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    12 HANDBOOK OF SHORT-TERM PSYCHOTHERAPY

    view conducted by a psychiatr ist-social worker

    team. Such a team maximizes the selection of

    an approach to the ex is t ing problem and

    outlines a blueprint for action. A working hy

     pothesis is form ulated a t tem p t ing to relate

    in trapsychic and/or environmental aspects to

    the disturbed behavior or the symptoms, and it

    is around this hypothesis that choice of inter

    ventions is made from a wide range of sup

     port ive, educational, and ins ight-oriented a p

     proaches. Should no im provem ent occur, the

    working hypothes is is reformulated . This ap proach has proven itsel f to be practical “ as an

    aid to providing high quality mental health

    services for the poor” in the face of even

    o v e r w h e l m i n g l y i m p o s s i b l e e n v i r o n m e n t a l

    deprivations. There is a feeling that patients

    from lower socioeconomic classes do better

    w i t h s h o r t - t e r m c r i s i s i n t e r v e n t i o n t h e r a p y

    than with any o ther approach (Haskel l e t a l ,

    1969; Meyer et al, 1967; Sadock et al, 1968.)

    Walk-in clinics thus provide a vital need in

    the pract ice of community psychiatry by mak

    ing treatment immediately and easily accessible

    to all classes of patients. M an y prob lems can

     be m anaged through this m eans tha t othe rwise

    would go unat tended . On the basis of an an al

    ysis of many interviews in the psychiatr ic

    walk- in c l in ic of the Massachuset ts General

    Hospital in Boston, which handles about 40

    walk-in patients each day (15,000 visits per

    year) , Lazare et al (1972) have listed 14 cate

    gories of patients.

    1. Pa t i en t s who wan t a s t r ong pe rson to p ro tec t

    and con t ro l t hem. ( “ P lease t ake over . ” )

    2. T h o s e w h o n e ed s o m e on e w h o w il l he l p t h em

    main ta in con tac t wi th r ea li t y . (“ Help me know I

    a m r e a l .” )

    3. Tho se w ho f ee l so empty they need suc-

    corance . ( “Care fo r me .” )

    4 . Tho se who need some c lini c o r pe r son a round  

    for secur i ty purposes though the contact be occa

    s iona l . (“ Always be the r e . ” )

    5. Tho se r idden wi th gu il t who seek to confess.

    (“ T a k e a w a y m y g u i lt . ” )

    6. T h o s e w h o u r g e nt l y n e ed t o t a lk t h in g s ou t.

    (“ Let me get i t off my chest ” )

    7 . Tho se w ho des i re adv ice on p r ess ing is sues .

    ( “ T e l l m e w h a t t o d o . ” )

    8 . Tho se who seek to so r t ou t t he i r conf l ic t ing

    ideas . ( “ Help me pu t t h ings in pe r spec t ive . ” )

    9 . Thos e who t ru ly have a des i re fo r se l f-under -

    s t and ing and ins igh t i n to the i r p rob lems . (“ 1 wan t

     p s y c h o th e ra p y .” )

    10. Tho se w ho see the i r d i scomfor t a s a med ica l

     p rob le m th a t needs the m in is t ra t io ns of a physic ia n.

    ( “ I need a phys ic i an .” )

    11. Tho se who r ea lly seek some p rac t i ca l he lp

    l ike disabi l i ty assis tance, legal a id , or o ther in ter

    cessions in their l ife si tuati on. (“ I need you r legal

     p o w e r s ” )

    12. Tho se w ho c r ed i t t he i r d if fi cul ty to ongo ingcur r en t r e l a t ionsh ips and wan t t he c l in i c to in t e r

    cede . ( “ Do it f o r me .” )

    13. T h o s e w h o w a n t i n f o r m a ti o n a s t o w h e r e to

    get help to sat i sfy var ious needs, actual ly seeking

    some comm uni ty r esource . ( “ Te l l m e where I can

    ge t wha t I need .” )

    1 4. N o n m o t i v a t ed o r p s y ch o ti c p e rs o n s w h o a r e

     b rou g h t to the cl inic agains t th e i r wil l. (“ I w a n t

    n o t h i n g . ” )

    Where the therap is t is percept ive enough to

    recognize the patient’s desire and where he is

    capable of gratifying or at least acknowledging

    that he unders tands the request , he wil l have

     been able to s tar t a w ork ing re la tionship.

    Should he bypass the pat ien t’s immediate p lea

    for help or probe for conflicts and other dy

    namic forces under ly ing the request , therapy

    may never get star ted. Obviously, fulf il l ing the

     pa t ie n t ’s desire a lone m ay not ge t to the bottom of the p ati en t’s troubles, but i t will be an

    avenue through which one will be able to coor

    dinate and u t i l ize the data gathered in the

    diagnostic evaluating interview. In clinics or

     priva te the rapy w here the re is la ck of c on

    gruence between what the pat ien t seeks and

    what the therapist decides to provide, the

    dropout ra te af ter the f i r s t in terv iew is1as

    high as 50 percent (Borghi, 1968; Heine &

    Trosman , 1960 ) .The c la im tha t sho r t - te rm t r ea tmen t acco rds

    wi th super f ic ia l i ty o f goa ls has no t been

     proven, especially w here the rapy is conducted

    along even modest dynamic lines. Thus, a type

    of cr is is in tervent ion that a ims a t more than

    symptom rel ief is described by M. R. H arr is e t

    a l (1963) , who t reated a grou p of 43 pat ien ts

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    MODELS OF SHORT-TERM THERAPY 13

    with up to seven sessions with the objective of

    (1) resolution of the stress factor precipitating

    the request for help and (2) clarifying and

    resolving, if not the basic conflict, the second

    ary derivative conflicts activated by the cur

    rent stress si tuat ion. “ O ur hypothesis is that

    such explora t ion and working through fa

    cil i tated the establishment of a new adaptive

     ba lance .” D u r in g the rap y the motivation fo r

    fur ther t rea tment was a lso evalua ted. Thi r ty-

    eight (88 percent) of the patients were helped

     by brief therapy . T h i r tee n (3 0 percent) of the p a t i e n t s c o n tin u ed in lo n g - te rm t r e a tm e n t .

    Three patients (7 percent) returned for a

    second brief series of contacts. During inter

    viewing with this t reatment, efforts were made

    to establish connections between conflicts and

    the precipi tat ing stress since this enabled the

     patien t to “ be better able to cop e w ith hi s

    distress and achieve a new psychic equil ib

    r ium.” Histor ica l mater ia l was ut i l ized only

    when i t was spontaneously brought up and related direct ly to the current difficulty. The au

    thors dec lare tha t where long-standing vex

    ations exist , motivation for further t reatment

    “ may in fact be increased by the exp erience of a

    successful brief therapeutic t ransaction.” Adop

    tion of a psychodynamic stance in crisis inter

    vention can enhance the quali ty of results, as

    Louis (1966) and other s have pointed out .

    Of al l devastat ing stressful experiences, the

    death of a loved one, or a person on whom the

    survivor is dependent, is perhaps the most mis

    managed. Apart from token consolat ions, a

    consp i racy o f s i l ence smoulde r s unde r t he

    assu mp t ion tha t t ime i t se lf wi ll hea l a l l

    wounds. That t ime fai ls miserably in this task

    is evident by the high rate of morbidity and

    mortal i ty among survivors fol lowing the fatal

    event (Kraus & Lilienfeld, 1959; Rees & Lut-

    kins, 1967; M. Young et al, 1963).

    Recognition of these facts has led to some

    crisis intervention programs to provide short

    term help for the bereaved in the service of

     both prevention and rehabil i ta t ion (Gerber,

    1969; Silver et al, 1957; P. R. Silverman,

    1967). Success of these programs presages

    t h e i r f u r t h e r d e v e l o p m e n t a n d e x p a n s i o n .

    Gerber (1969) has described some methods for

    fostering emancipation from the bondage of

    grief and readjustment to present real i t ies.

    These include (1) helping the cl ient to put into

    words his or her feelings of suffering, pain,

    gui l t , not ions of abandonment and anger as

    well as the nature of the past relat ionship with

    the deceased, good and bad; (2) organizing a

     p lan of acti vit ie s tha t d raw s upon availableresources and friends; (3) lending a hand in

    resolving practical difficulties involving hous

    ing, economic, legal , and family rearrange

    ments; (4) making essential referrals for medi

    cal assistance including prescript ion of drugs

    for depression and insomnia and offering future

    assistance. Service to a bereaved person is often

     bes t recom mended by th e famil y physicia n,

    and such recommendat ions may be a requi re

    ment. An initial home visit by a social worker

    or other professional or t ra ined paraprofes-

    sional may be necessary before the client will

    accept office visits.

    Dealing with Unresponsive Patients

    Despite our best efforts to shorten therapy

    there wil l be some patients who wil l need con

    tinuing treatment. Clinics only too often be

    come clogged with such chronic patients whose

    t r e a t m e n t b e c o m e s i n t e r m i n a b l e . T h i s c a n

    result in long waiting lists and an end to ready

    access to therapy for even emergency prob

    lems. This is not to depreciate the value of pro

    longed treatment in some long-standing emo

    tional problems. However, from a pragmatic

    standpoint , for the great majori ty of chronic

     pa tients o ther modes of m anagem ent a re not

    only helpful , but actually are more at tuned to

    the continuing needs of these patients. Such al

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    ternative methods involve, perhaps for the re

    mainder of a patient’s life, occasional short

    (10- to 15-minute) visits with a professional

     person on a m onth ly or b im onth ly ba si s,

    supervision of drug intake, introduction into a

    group ( therapeutic, social, or rehabilitative) ,

    a n d u t i l i z a ti o n o f a p p r o p r i a t e c o m m u n i ty

    resources. What the therapist tr ies to avoid for

    such a patient is stimulating dependency on

    himself personally.

    An eight-year exper iment a t an outpat ien t

    clinic dedicated to the therapy of the chronically il l at the University of Chicago Hos

     pitals and Clinics is reported by R ada et al

    (1969). The clinic is open every Thursday

    afternoon for  2 / i   hours, patients being seen in

    order of arr ival. Patients are accepted only

    after a diagnostic evaluation and initial work

    up by the referral sources to make sure they

    will be suitable for the clinic routines. The

    staffing is by psychiatric residents, medical

    students, a social worker , receptionist, and twoattending staff supervisory psychiatr ists , the

    latter four being the only permanent staff .

    Upon arr ival, the receptionist greets the pa

    t i e n t — a n d i f t h e y c om e , t h e fa m i l y — a n d

     brings the pa t ien t in to the w a it ing room ,

    where light refreshments (cookies and coffee)

    a r e se rved . Pa t ien t in te r ac t ions a r e en

    couraged. Individual interviews are for 15 to

    25 minutes to ascertain the present physical

    and emotional s ta te , to regulate the drug in

    take i f d rugs are taken , to of fer recommenda

    tions for intervening activities, and to make an

    appoin tment for the next t ime. The pat ien ts are

    then re turned to the wai t ing area for more

    coffee and socialization. Family and couples

    therapy are done i f necessary . Frequency of

    visits range from weekly sessions to once every 6

    mon ths a l though pa t ien t s may r e tu rn vo lun

    tarily if they need help. Should the pa tient dro pout of therapy, he is permitted to return in

    times of stress without having to go through a

    readmission procedure. After the clinic hours

    the staff meets brief ly (30 to 45 minutes ) to dis

    cuss the da y’s problems. T he two at tending psy

    chiatr ists do not see individual patients (except

    in emergencies) ; they serve as administrative

    superv isors and act ive par t ic ipants in the wai t

    ing area exper ience and the s taf f g roup meet

    ings. Patien ts see the same the rapis t (a resident)for 3 months to a year and know that they will

     be transfer red to an o the r professional from time

    to t ime. Diagnost ic categor ies vary , approxi

    mately ha lf being psychot ic , the rem ainde r hav

    ing severe neuroses and personality disorders.

    Fees general ly suppor t the c l in ic and are re la

    tively low.

    Short-term Hospitalization and Its Alternatives

    Shr inking budgets have made i t mandatory

    to take a hard look at costs versus benefits not

    only in regard to psychotherapy, but also

     pro trac ted psychiatric hospi ta lizat ion. A part

    f r o m p r a g m a t i c d i s a d v a n t a g e s o r i m p r a c t i -

    ca l i t ie s o f cos t /be nef i t s , p ro longed in s t i tu

    tionalization fosters regression and paralyzingdependencies— plus ex tended separat ion f rom

    c o m m u n i t y l i f e . T h e s e u n f o r t u a n t e c o n t i n

    gencies have sponsored shifts from long-term

    confinement to short- term detention organized

    around the objective of early discharge. Al

    ternatives to hospitalization have also been ex

     plored. Fo r exam ple , in an experim en ta l p ro

    gram Davis e t a l (1972) demonstra ted that a

    team led by visiting nurses going to the homes

    of patients to oversee proper medication could

     prevent hospi ta lizat ion and im prove re la t ion

    ships within the family. Another example is

    the f ind ing by Zwer l ing and Wilder (1962)

    that a day-care treatment facili ty could oftenact as an adequate subst i tu te for an inpat ien t

    uni t . There are , never theless , s i tuat ions when

    hospitalization is essential, for example, to

     provide security fo r d is turbed or suicidal p a

    t i e n t s o r w h e r e c r i s i s - o r i e n t e d t h e r a p y i s

    needed and it cannot be done on an outpatient

     ba si s. A li mite d hopsi ta l stay may be al l tha t is

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    MODELS OF SHORT-TERM THERAPY 15

    required . Even in ch i ldren shor t- term hospi ta l

    ization is sometimes considered (Shafii et al,

    1979).

    That i t is possible to reduce the time of hos

     pita lization of patien ts adm itted to an ins ti tu

    tion through a cr isis intervention program

    utilizing a wide range of treatment modalities

    has been demonstrated by Decker and Stub-

     blebine (1972) in a 2 i i   yea r study of 315

    y o u n g a d u l t s . A t t h e C o n n e c t i c u t Me n t a l

    Heal th Center a program of br ief (3-day) in

    tensive hospitalization and 30-day outpatientcare has been used to deal with patients

    r e q u i r i n g h o s p i t a l i z a t i o n ( W e i s m a n e t a l ,

    1969 ) . I n the hosp i ta l , c r i s i s in te rven t ion

    methods are employed toward res tor ing the

     pa tient to the previous level of functioning. O n

    discharge there is a 1-month outpatient period

    of treatment, which is considered a follow-up

    measure. An agreement is made in advance as

    to this l imited time arrangement to insure that

    treat men t does not go on indefinitely. “ On e ef

    fect of the time-limited contract is to establish a

    ‘set’ whic h prom ote s rapid identification of

     p roblem areas and requ ires patients to be gin

    quickly developing new modes of dealing with

    these problems.” The patient is seen each day

     by severa l st aff m em bers w ho are usual ly

    nurses or aides in order to discharge de

     pendence on the godlike figure of the doctor.

    To expose patients to different tactics, a fixed

    style of approach is deliberately not used.

    Team members a lso in teract with pat ien ts in

    daily group therapy and family therapy. Self-

    reliance is stres