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Transcript of 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
e-Book Copyright © 2014 International Psychotherapy Institute
All Rights Reserved
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Created in the United States of America
For information regarding this book, contact the publisher:
International Psychotherapy Institute E-Books
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www.freepsychotherapybooks.org
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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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MODELS OF SHORT-TERM THERAPY 5
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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MODELS OF SHORT-TERM THERAPY 7
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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8 HANDBOOK OF SHORT-TERM PSYCHOTHERAPY
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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14 HANDBOOK OF SHORT-TERM PSYCHOTHERAPY
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