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Short-Term Treatment and Social Work Practice: An Integrative Perspectiveby Eda G Goldstein
Short-Term Treatment: An Overview
Mental health professionals in a variety of disciplines are using short-term methods in their practice more than ever before. Although brief treatment always has been part of the therapeutic repertoire, it received little positive attention in mental health circles until the 1940s. The first wave of interest in short-term and crisis intervention occurred during and just after World War II as a result of several concurrent developments: efforts to make traditional psychoanalytic psychotherapy more efficient, experiences with soldiers under battle conditions, attempts to help soldiers and their families when the former returned to civilian life, and work with the victims of disasters and those undergoing stressful life events. Despite the interest in short-term approaches, they were not widely assimilated into mainstream mental health services at that time.
Even after the revival of interest in brief treatment that occurred in the 1960s, it continued to be relegated to a second-class status in comparison to long-term treatment among psychodynamically oriented clinicians. Showing a prejudice in favor of so-called deeper and more intensive treatments, which were thought to be essential for the achievement of personality change, many psychotherapists viewed short-term intervention as shallow and superficial (Shechter, 1997; Wolberg, 1965).
THE RISE OF SHORT-TERM TREATMENT
Numerous factors have contributed to the diminished status and use of long-term treatment and the increased use of short-term and crisis intervention (BudmanandGurman, 1988; ParadandParad, 1990b; Shechter, 1997). Beginning in the 1960s, optimism about the ability of mental health treatment to help people led to efforts to make treatment accessible to greater numbers of individuals at earlier points in the emergence of their difficulties and for help with problems in living, as well as severe emotional disorders. The short-lived community mental health movement, ushered in by the Community Mental Health Centers Act of 1963 during the Kennedy presidency, was heavily weighted toward emergency and brief treatment. Even psychodynamically oriented clinicians experimented with short-term treatment, and new interventive models proliferated, including those that were cognitive and behavioral.
Another contributing factor to the changing nature of treatment was the criticism of traditional forms of intervention on the part of numerous special populations who sought greater opportunities for self-expression, freedom from oppression, and respect for their diversity. Among these groups were those reflecting counterculture lifestyles, people of color, women, and gays and lesbians, who tended to perceive long-term, psychodynamically oriented treatment as a form of social control, a means of blaming the victim, and a way of labeling difference as pathological. Self-help, consciousness-raising, and rap groups, along with other types of alternative helping methods, gained popularity and eroded the dominance of more traditional therapies.
As mental health treatment became more available, individuals sought help for a host of concerns that previously would not have been thought to warrant treatment. Less motivated for long-term treatment, clients expected treatment to focus on more here-and-now, reality-oriented problems. Often they possessed more knowledge about treatment options and were more vocal in questioning the utility of seemingly ill-defined and open-ended approaches with unspecified goals.
The accumulation of findings from practice research also supported the use of short-term approaches since many studies failed to show that more open-ended treatments were superior to brief intervention (KossandShiang, 1994; WellsandPhelps, 1990). Moreover, the use of long-term treatment was associated with high dropout rates. For example, in one study, as many as 80 percent of patients in mental health clinics and family service agencies, who were offered more ongoing intervention, were seen for six or fewer sessions (Garfield, 1986). Thus, despite clinicians' stated preferences for long-term treatment, intervention turned out to be short term by default rather than by design (BudmanandGurman, 1988, pp. 6-7). Additionally, as Wells (1990, p. 13) notes, there is some evidence to show that even for those who actually received long-term treatment, improvement occurred early, with 75 percent of clients making considerable progress within six months.
The economic climate of the past several decades has been another major cause of the dramatic increase in the use of briefer forms of treatment. New, more cost-conscious and seemingly efficient forms of delivering mental health care have proliferated, and reimbursement for, allocation of, and accessibility to mental health services have been greatly curtailed and circumscribed. Social agencies and hospitals, which have been the mainstays of service delivery in their communities, have been forced to slash their budgets, rearrange their priorities, downsize their staffs, engage in reengineering their operations, and offer more short-term intervention, sometimes to the exclusion of other types of treatment. Practitioners in these settings, as well as those in private practice, are being forced to reexamine their customary and preferred ways of helping others.
For all the reasons cited, social workers, among other mental health providers, are using time-limited treatment with ever greater numbers of clients. Some practitioners are embracing this development enthusiastically, while others are resigning themselves to it out of necessity. On the positive side, short-term approaches may be highly responsive to what clients want and expect. Consumers seek or are mandated to seek help for a wide range of problems, many of which can be addressed appropriately by brief forms of intervention. For example, a young adult may enter treatment after the breakup of a relationship and may benefit from supportive work aimed at assisting him in dealing with issues of loss and blows to self-esteem. Similarly, a mother who seeks help in disciplining an acting-out youngster may be able to benefit from brief, educative work focused on parenting skills, and a truant adolescent boy may benefit more from a simple change in his school setting than from open-ended ongoing treatment of his personality problems.
Even if clients present with more complex treatment issues that might warrant a more open-ended approach, they may not want or be amenable to such intervention. Proceeding when the goals of the worker and client are divergent runs the risk of causing the client to withdraw from treatment. It is preferable to try to meet the client's expectations if possible, as illustrated in the following example.
Mrs. Pierce, a twice-divorced, recently remarried 40-year-old woman, came for help because of marital problems that were leading her to want to separate from her new husband. She recounted incidents in which he had ignored her needs and wishes and gave evidence of her concerns that he was seeing another woman. Although the worker accepted the client's view of her husband, she learned that Mrs. Pierce had a history of repetitive instances in which her suspiciousness of men's motives led her to distance herself from them and she thought that she was contributing to her unsuccessful relationships. Concerned that the client might leave her current husband, only to repeat her pattern again and again, the psychodynamically trained worker thought that it would be advisable for Mrs. Pierce to get help in understanding the origins of her long-standing feelings of distrust, her sense of inadequacy, and her fears of rejection so that she could modify her ways of perceiving and relating to her husband and other men. The client, however, expressed an interest only in getting help in summoning the courage to leave her spouse.
Despite the rationale for briefer forms of intervention, many practitioners remain skeptical, if not overtly negative, about the proliferation of short-term methods. Although their opposition may reflect bias against brief intervention, many clinicians also believe that the current emphasis on short-term treatment is misguided and ill conceived as a result of philosophical, political, and economic reasons.
Whether viewed from a positive or negative perspective, the use of short-term approaches challenges practitioners to expand and change their attitudes about the nature of the treatment process, learn new interventive strategies, and address greater external demands for accountability.
SHORT-TERM TREATMENT MODELS IN MENTAL HEALTH PRACTICE
There are three main types of short-term treatment models that are being used extensively in mental health practice: (1) the psychodynamic model, (2) the crisis intervention model, and (3) the cognitive-behavioral model. The table on pp. 20-21 compares the major characteristics of these models.
The Psychodynamic Model
The short-term psychodynamic treatment model consists of a variety of approaches that modify some of the basic assumptions of traditional psychoanalytic theory and treatment and embody more contemporary psychodynamic theories. Short-term psychodynamic psychotherapy generally is used with clients who have circumscribed problems that are embedded in either mild or moderate long-standing conflicts and maladaptive personality traits and patterns. Although their goals are restorative and supportive in some instances, most time-limited psychodynamic models aim at selective personality change and resolution of underlying conflicts. They have clearly defined selection criteria that favor highly motivated and well-functioning clients who have circumscribed problems and tend to exclude a wide range of individuals whose difficulties are more severe, pervasive, and chronic.
Despite the fact that each of the psychodynamic short-term models to be discussed below has somewhat different origins, goals, foci, selection criteria, and practice principles, they share common assumptions and features:
Common Features of Psychodynamic Approaches
1. The belief that early childhood experiences are a major contributor to adult dysfunction
2. The view that presenting problems generally are embedded in long-standing personality conflicts and patterns
3. The use of selection criteria such as a history of adequate adjustment, problems of acute or recent onset, strong motivation, and ability to relate easily
4. A quick and focused assessment
5. Setting of treatment goals that include either selective or more global personality change
6. The early establishment of a working alliance
7. A focus on core conflicts or relational themes that are manifested in the client's history and the treatment relationship
8. The utilization of active techniques such as clarification, confrontation, and interpretation
9. The use of time limits that can be negotiated fiexibly in some instances
Although the classical psychoanalytic model has been associated traditionally with in-depth, long-term treatment aimed at restructuring the personality, many authors have commented on the short-term nature of Freud's early cases and the fact that initially psychoanalysis was not long term (Flegenheimer, 1982; Shechter, 1997; Stadter, 1996; Wolberg, 1980). Nevertheless, the techniques that are characteristic of Freudian psychoanalysis are geared to helping the patient undergo a controlled regression in which early memories and childhood experiences are explored. The patient's revival of important aspects of his or her relationships with significant others in early life in the treatment or transference to the analyst or therapist provides the basis for therapeutic work. The patient's distorted perceptions of the therapist can be analyzed and interpreted in order to help the patient gain insight into the nature of his or her problems and their roots. Traditionally, the analyst was to remain neutral, anonymous, and abstinent or nongratifying so as to maximize the patient's transference.
Interested in making psychoanalysis more efficient and available to a greater range of patients, Ferenczi and Rank (1925) were the first psychoanalysts to address the issue of time in the treatment process. Rank believed that setting and adhering to a time limit in treatment would prevent regression and force the patient to deal with reality. Ferenczi emphasized the importance of using active techniques, such as suggestion and direct advice, in order to maintain the client's level of functioning, help the patient focus on his or her difficulties, and foster motivation (Flegenheimer, 1982, p. 27). Ferenczi and Rank's views were radical for the time and were neither endorsed nor accepted by the psychoanalytic community. Their work fell into disrepute for some time.
Two decades later, Alexander and French (1946) published a pioneering book, Psychoanalytic Therapy, the first systematic presentation of short-term psychodynamic psychotherapy. As Koss and Shiang (1994, p. 665) point out, Alexander and French believed that psychoanalytic principles could be beneficial, irrespective of the length of treatment, and sought to adapt selective psychoanalytic techniques in order to "give rational aid to all those who show early signs of maladjustment" (1946, p. 341). Drawing on the earlier work of Ferenczi and Rank, they also questioned some of the basic assumptions of the traditional psychoanatytic approach: that depth of treatment was related to length; that brief treatment was temporary and superficial while the resuits of long-term treatment were stable and profound; and that it was necessary to prolong treatment in order to overcome the patient's resistance to change (BudmanandGurman, 1988, p. 2).
Alexander and French tried to avoid techniques that fostered regression and emphasized therapy over real-life experiences. Among the more directive and active techniques that they advocated were (1) the manipulation of the frequency of sessions in order to confront the patient's dependency on the therapist; (2) the utilization of temporary interruptions to determine the patient's reactions to termination; (3) emphasis on the patient's affective experience in the here and now, with attention to relevant historical material; (4) direct encouragement of the patient to face conflicts and problems and to put what he or she learned in therapy into practice; and (5) the therapist's assumption of a role that was diametrically opposed to the earlier parental roles in order to promote an emotionally corrective experience that would foster the patient's functioning and ability to engage in more satisfactory interpersonal relationships.
Like Ferenczi and Rank, Alexander and French were ahead of their time and provided the foundation for all later psychodynamic short-term approaches. Nevertheless, their work was controversial at best and minimized and denounced at worst within the psychoanalytic community. In social work, however, it found a more appreciative audience.
Following is a summary of the salient characteristics of the better-known and more recent psychodynamic short-term models.
MALAN'S INTENSIVE BRIEF PSYCHOTHERAPY. In two books based on his studies at the Tavistock Clinic in London, Malan (1963, 1976) outlined an approach to short-term treatment that relied heavily on the technique of classical interpretation of a central conflict or important aspect of the patient's psychopathology. His research indicated that change included not only symptom relief but also modifying basic and entrenched neurotic behavior patterns. The number of weekly treatment sessions ranged from 10 to 40, and the best results occurred when patients showed (1) high motivation for insight, (2) good ego strength, (3) the ability to formulate a specific focus, (4) the ability to establish a quick transference to the therapist, (5) favorable reactions to interpretation, and (6) the ability to deal with their emotional reactions to termination. The therapist's enthusiasm was considered a major factor associated with good outcome.
SIFNEOS'S SHORT-TERM ANXIETY-PROVOKING PSYCHOTHERAPY. Like Malan, Sifneos (1972, 1979, 1987) developed a short-term treatment model that used interpretation of a patient's oedipal conflict as it appeared in the transference to the therapist as the major tool of therapy. In order to help the client focus on the main problem area, Sifneos relied heavily on confrontation and other anxiety-arousing techniques, which often created anger and resistance that needed to be addressed.
The duration of treatment ranged from 7 to 20 weekly sessions. Sifneos's selection criteria were among the most stringent and exclusionary of all the short-term psychodynamic models and stressed the presence of numerous patient characteristics, including (1) aboveaverage intelligence; (2) possession of at least one meaningful relationship in the past; (3) psychological mindedness; (4) ability to interact with the therapist in an affective manner; (5) motivation beyond symptom relief; (6) honesty, curiosity, and openness to self-reflection; (7) willingness to make accommodations and sacrifices; (8) receptivity to new ideas; and (9) realistic goals (Stadter, 1996; Wolberg, 1980).
Sifneos also proposed a brief treatment model, anxiety-suppressive therapy, for patients who showed weaker egos, impaired interpersonal relationships, and chronic difficulties. The goal was to reduce anxiety through more supportive measures, such as reassurance, advice giving, ventilation, environmental manipulation, persuasion, hospitalization, and medication (Wolberg, 1980).
DAVANLOO'S INTENSIVE SHORT-TERM DYNAMIC PSYCHOTHERAPY. Davanloo (1978, 1980, 1991) was another proponent of a highly confrontational and interpretive approach, which had definite selection criteria. Stadter (1996, p. 72) views this model as the most forceful and persistent of the short-term psychodynamic approaches. Davanloo himself referred to his methods as relentless. The model also is the most ambitious in that it aims for complete personality or structural change.
The evaluation process can take up to six hours, usually during the course of one day. The length of the treatment depends on the severity of the patient's problems and rate of progress and can vary from as little as 1 to as many as 40 sessions. The emphasis of the treatment is on uncovering unconscious conflict through systematic challenging and interpreting of resistances, making the therapy process highly intense and affectively charged. Discussion of termination is kept at a minimum.
MANN'S TIME-LIMITED PSYCHOTHERAPY. A unique approach to short-term treatment is found in the work of Mann (1973, 1991). Like Rank, Mann made a conscious use of time and the struggle around separation and loss in his short-term treatment model. His approach is highly structured, with a rigid adherence to time limits. The approach consists of a formulation phase followed by 12 sessions, which may be spaced at varying intervals. Selection criteria include patients who can rapidly establish a therapeutic relationship and possess an ability to tolerate loss.
After determining the central issue to be addressed in the treatment during the assessment period, the therapist gives the patient the formulation of the problem, even if it is at variance with the patient's stated complaint, and how the work will proceed. All treatment deals with the theme of separation-individuation as a basic universal conflict that influences the resolution of all later conflicts. Despite the patient's presenting problem, the formulation always relates to the patient's negative self-image, which Mann believes is linked to unresolved separation and loss issues in a patient's life. Because of the treatment's time limit, the therapist helps the patient deal with the establishment of a dependent relationship amid the reality of the impending separation and loss. Presumably the therapy provides the patient with a more optimal setting in which to master separation anxiety and achieve autonomy.
STRUPP AND BINDER'S TIME-LIMITED DYNAMIC PSYCHOTHERAPY. The work of Strupp and Binder (1984) began at Vanderbilt University and drew on the work of Sullivan (1953). Their model, along with that of Luborsky, was among the first psychoanalytic approaches to employ a treatment manual, thus making it easier to implement and study systematically. It was used with patients who showed a range of functioning and personality traits, including resistance, hostility, and negativity.
The duration of the treatment is limited but flexible and ranges from 25 to 40 sessions in instances where personality problems are mild rather than severe. In this model, intrapsychic conflicts are redefined as interpersonal in nature. The therapeutic process relies heavily on the therapist's empathic responsiveness to and ability to address the patient's cyclical maladaptive patterns of relating as they appear in the therapeutic interaction rather than on the use of technical interventions in creating change. Thus, no particular techniques are emphasized. The research findings generated in the use of this model have shed light on the importance of the therapist's personality in treatment outcome.
LUBORSKY'S SUPPORTIVE-EXPRESSIVE PSYCHOTHERAPY. Luborsky's (1984) model incorporated ego psychological theory and practice principles to a greater extent than other models. It emphasized both the supportive relationship between the therapist and patient and the technical interventions in facilitating change. Although Luborsky suggested screening out the most severely disturbed and antisocial patients, as well as those who had environmental problems, he believed that the model could be used broadly.
Like Strupp and Binder, Luborsky thought that the duration of treatment was related to the severity of the patient's problems. He recommended 25 sessions that sometimes were spread over time rather than occurring weekly. In more severe cases, Luborsky (1984, p. 67) indicated that as many as 40 sessions might be necessary. Treatment goals are individualized and are supposed to be consistent with what the patient perceives as his or her main difficulties and needs. The therapist employs the full range of psychotherapeutic techniques. A major component of the model is its focus on a patient's core conflictual relationship theme as it is reexperienced in the relationship with the therapist. A manual of procedures that Luborsky developed in conjunction with this his model has been used extensively.
OBJECT RELATIONS AND SELF-PSYCHOLOGICAL MODELS. As psychodynamic frameworks that differed from classical Freudian theory and psychoanalytic ego psychology have gained a wider audience, some theorists have begun to apply their principles to short-term treatment. For example, Stadter (1996) has drawn on object relations theories in his perspective, and Baker (1991) and Seruya (1997) have put forth a selfpsychological model of brief treatment. Although similar in some respects to the other models discussed so far, these newer approaches are important in their alerting the practitioner to a different and broader range of past and existing factors that give rise to certain types of dysfunction than do either Freudian theory or ego psychology. They emphasize the importance of the therapist's ability to provide a holding environment and/or an empathic selfobject experience for the patient.
There are several important limitations associated with the use of psychodynamic approaches. First, as noted by Koss and Shiang (1994, p. 671 ), the majority of individuals who seek help from mental health settings do not meet their selection criteria and thus would not be considered suitable for brief treatment. This fact would not constitute so much of a problem if other types of treatment were readily available. Given the constraints of services, however, an exclusive reliance on a psychodynamic model may result in inappropriate treatment. A second problem in the use of psychodynamic approaches is that they are not suited to patients who are beset by environmental difficulties or seeking help with more concrete needs and immediate concerns. A third difficulty in using these models is that they often employ techniques, such as confrontation and interpretation, that may be contraindicated with some individuals.
The Crisis Intervention Model
Crisis intervention is a form of brief treatment, but not all short-term intervention is crisis oriented. Because all individuals, regardless of their particular personality and strengths, are potentially vulnerable to having their equilibrium disrupted by extremely stressful life events, crisis intervention can be used with a wide range of clients so long as they have been thrown into a state of crisis.
The crisis intervention model originated in part from the study and treatment of soldiers who developed so-called war neuroses and combat fatigue during World War II (GrinkerandSpiegel, 1945). Psychiatrists and other mental health professionals, who were charged with the task of helping soldiers return to their battlefield assignments quickly, used emergency interventions that seemed to be effective in many instances, particularly when treatment occurred at or near the front lines. Treatment was based on the belief that soldiers could regain their equilibrium and return to active duty if they were given immediate, supportive help. It was observed that such prompt attention prevented regression, secondary gain, guilt, feelings of failure, stigmatization, and loss of peer support (ParadandParad, 1990a, p. 13). Additionally, the return of soldiers to civilian life after the completion of their military service necessitated readjustment of both the veterans and their families. Many sought help for transitional difficulties that seemed to respond to brief interventions.
Concurrently, other investigators became interested in the reactions of individuals to disasters and stressful life events. Lindemann's classic paper, "Symptomatology and Management of Acute Grief" (1944), delineated identifiable stages of the grief process of the survivors of the tragic Coconut Grove nightclub fire in Boston, in which hundreds of individuals lost their lives or were injured. According to Lindemann, an important component of grief resolution is the survivor's ability to master various affective, cognitive, and behavioral tasks. He observed that people could resume and even improve their precrisis level of functioning after a crisis, or they could deteriorate. Lindemann believed that those who showed more maladaptive solutions to their grief could be helped to cope more effectively with their mourning through intervention, and he developed an interventive approach of 8 to 10 sessions.
Lindemann's work, along with that of Caplan (1964), led to more systematic study of how people cope with disasters and other stressful life events and to the establishment of community-based crisis intervention services. Caplan, in his work at Harvard University in the 1950s, was instrumental in the development of programs that provided early intervention to those experiencing acute situational stress in an attempt to facilitate crisis resolution and to forestall more serious problems.
In the 1950s and 1960s, crisis theory expanded greatly. One of the hallmarks of this period was a greater delineation of different types of crises — for example, those resulting from developmental and maturational stages, life and role transitions, and traumatic events. Others who contributed to this body of knowledge were Hill (1958), Janis (1958), Kaplan (1962, 1968), Langsley and Kaplan (1968), Lazarus (1966), Le Masters (1957), Parad (1971), Parad and Caplan (1960), Rapoport (1962, 1967), Selye (1956), Strickler (1965), and Tyhurst (1958).
Crisis theory is based on the assumption that an individual strives to maintain equilibrium through an ongoing series of adaptive measures and problem-solving techniques. A crisis represents an upset in that equilibrium in which the person's customary coping strategies are inadequate to deal with the task at hand. Although some crisis theorists suggest that all people who experience a similar event will respond in a similar manner, others have focused on the unique meaning that the individual attaches to a particular situation. For example, Jacobson, Strickler, and Morley (1968) differentiate between generic and individual intervention, the former focusing on the common reactions of all the people who experience the same event and the latter emphasizing the more unique reactions of each person. Although the active state of crisis is time limited, usually lasting four to six weeks, intervention can facilitate crisis mastery, prevent more maladaptive solutions, and allow for the reworking of underlying conflicts. It is crucial that crisis intervention be undertaken as near to the stressful event in time and proximity as possible. Due to the client's state of helplessness and vulnerability, he or she is more open to influence and change during a crisis.
Crisis intervention usually occurs in 4 to 12 sessions. The therapist attempts to convey an empathic understanding of the patient's state of disequilibrium and establish a working alliance with the patient. The therapist becomes a benign authority figure who provides a sense of safety and strength.
The goals of crisis intervention usually are limited to the resolution of the crisis, but this is not always a simple matter. For example, Langsley and Kaplan (1968, pp. 4-5) suggest a recompensation type of crisis intervention that helps the client return to his or her precrisis level of functioning and a limited psychotherapy model that deals with the underlying conflicts that have been reactivated. There may be instances, however, when it is not possible to help an individual resolve a crisis without dealing with these underlying issues since it is the triggering of these past conflicts and experiences that transformed the stressful current situation into an actual crisis.
Jacobson, Strickler, and Morely (1968) identify four levels of crisis intervention: (1) environmental, where the therapist serves as a referral source; (2) general support, involving ventilation, active listening, acceptance, and reassurance; (3) generic, in which the therapist deals with the common reactions that individuals who experience the same type of event are likely to show; and (4) individual, in which the therapist uses his or her understanding of the patient's personality dynamics to foster the development of
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