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220 Pla nne d Brief Psych othe rapysession may lead to important insights into the broader psychosocial context of specific problematicbehaviors (e.g., the presence of marital or work difficulties that exacerbate problem behaviors).

BIBLIOGRAPHYI . Baldwin JD, Baldwin J: Behavior Principles in Everyday Life. Englewood Cliffs, NJ, Prentice-Hall, 1981.2. Emmelkamp PMG: Behavior therapy with adults. In Bergin AE, Garfield S L (eds) : Handbook ofPsychotherapy and Behavior Change, 4th ed. New York, John Wiley and Sons, 1994, pp 3 7 7 4 2 7 .3. Emmelkamp PMG, Bourman TK, ScholingA : Anxiety D isorders. A P ractitioners Guide. Chichester, JohnWiley Son s, 1992.4. Griest JH: Behavior therapy for obsessive compulsive disorders. J Clin Psycho1 55:60-68, 1994.5. Noyes R: Treatments of choice for anxiety disorders. In Coryell W, Winokur G (eds): The Clinical6. Sloane R, Staples F, Cristol A, et al: Psychotherapy Versus Behavior Therapy. Cambridge, M A , Harvard7. Wachtel P: Psychoanalysis and B ehav ior Therapy. New York, Basic Books, 1977.

Management of Anxiety Disord ers. New York, Oxford University Press, 1991.University Press, 1975.

43. PLANNED BRIEF PSYCHOTHERAPYMark A. Blais, Psy D

1. What is the natural course of psychotherapy?Despite the common perception that psychotherapy is a long-term, even timeless, enterprise,most of the existing d ata indicate that psychotherapy as it is practiced in the real world is a time-lim-ited process. National outpatient psychotherapy u tilization dat a from 1987 (obtained before the na-tionwide impact of managed care) reveals that 70 of psychotherapy users received 10 or fewersessions, and only 15 received 21 or mo re sessions.I8 These data are highly co nsistent with find-ings from o ther utilizations studies. Clearly, most patients have a time-limited or brief psychother-apy experience.This chapter will help you deliver psychotherap y in an org anized, planned, and thoug htfulmanner that more closely matches the natural course of psychotherapy.2. How did brief psychotherapy develop?

Freud was on e of the first practitioners of brief psychothe rapy. A review of his early cases re-veals that he treated many patients in a span of weeks to m onths rather than years. Ov er time, as psy-choanalytic theory became more co mplex , the goals of psychoanalysis b ecame m ore amb itious, andthe length of treatment increased greatly. As early as 1925 this trend had bec ome a concern to som e.Alexander and French can b e conside red the true fathers of brief psychotherapy. T heir booksychoanalytic sychotherapy outlined the first systematic attempt to develop a shorter and moreefficient form of psychotherapy. Although not generally accepted in its time, this work laid the foun-dation for both psychoanalytic p sychotherapy and m odem brief psychotherapy.Th e modern era of brief treatment began with the work of Malan an d of Sifne os. At present,brief psychoanalytic psychotherapies are supplemented by several other time-limited treatments,

such as Becks cognitive therapy, Manns existential psychotherapy, and Klermans interpersonaltreatment of depression.3. How does brief psychotherapy differ from long-term psychotherapy?Four dimensions, considered common to all brief therapies, differentiate short-term from themore traditional long-term therapies: 1 ) the setting of a fixed time limit for the treatment, (2) hold-ing to specific patient selection criteria, 3 )using a treatment focus to limit the scope of the therapy,and (4) requiring increased activity by the therapist.

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P l a n n e d Brief P sy c h o t h e r a p y 22Summary o fSelected Planned Brief Psychotherapies

NUMBER OFTHERAPY SCHOOL SESSIONS TYPE OF FOCUS PATIENT SELECTIONAnalytic

SifneosAnxiety suppressingAnxiety provokingMalanDavanloo

ExistentialMannCognitiveBeckInterpersonal

KlermanEclecticBudman

Leibovich

4-1012-2020-30

1 4 0

I2 exactly

1-1412-16

20-4036-52

Crisis and copingVery narrow , Oedipalconflict and griefVery narrow, similar toSifneosResistance and sup-pressed angerCentral issue and term-inationAutomatic thoughtsPatients interpersonalexperienceInterpersonal, develop-On e borderline traitmental, and existential

Fairly open, less healthyVery selective, top 2-l0Respond s to trial interpreta-Less healthy, top 30 out-

outpatientstionpatients

Broad patient selection(passive-dependent)Very broad, not psychoticDepressed patient, any levelof healthBroad rangeBorderline outpatients

Adapted from G roves J: The short-term dynamic psychotherapies:A n overview. In Ritan S (ed): Psychotherapyfor the 90s.New York, Guilford Press, 1992.Comparison of Brief and Long Term Therapy

BRIEF LONG-TERMSpecific focused goalsSpecific time frameEmphasizes patient selectionHere and now focusAttempts to restore psychologic functioningThe therapist is active and directiveUses between-session homework

quickly

Broad goals: insight and character changeTime unlimitedDown-plays patient selectionInner life, historical focusTechniques can cause increased psychological

distress and temporary dysfunctionTherapist is nondirective; therapy unfoldsIs mostly limited to treatment hou r

4. What is the best attitude for learning brief therapy?The re must be a willing suspens ion of disbelief and cynicism abou t brief treatm ent. Trainees are

frequent ly taught tha t quick improvement i s suspect and l ikely represents a t ransient fl ight intohealth. This can be a hard lesso n to unlearn. Rem emb er, brief therapy is not a fad, but rather a formof treatment developed and refined over many years, based upon cl inical experience and treatmentoutcom e studies.I t must be recognized fr om the outset that therapy w il l end after a set number of sessions (or insome cases on a planned date). T his ca n be difficult, particularly for therapists trained in long-termtherapy, because this mind set has ramifications for all treatment decisions an d requires a clinician toreconside r every intervention during the treatmen t.Th e brief therapist should accept (and expect) that pat ients wil l return to therapy periodicallyacross the i r l i fe span . This perspec tive a l lows a br ie f therapis t to focu s on the pa t ient s currentdifficulties rather than attem pting a total lifelong cure.

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222 Planned Brief Psychotherapy5. For which patients is brief therapy appropriate?Patient selection is an important and distinguishing) part of brief therapy. Basically, patient se-lection is the art of finding the right patient with the right problem for brief psychotherapy. A two-ses-sion format is recommended to alleviate time pressure and allow the clinician to conduct a complete

psychiatric evaluation while also assessing the appropriateness of the patient for brief psychotherapy.6. Name some useful criteria for excluding or including a patient for brief psychotherapy.Exclusion criteria are best seen as categories either the condition is present or absent); if any ispresent, the patient should be considered a poor candidate for brief treatment. Inclusion criteria arebest viewed as dimensions and as such they are likely present to a varying degree in every patient.The more of these qualities a patient has, the better the candidate for brief psychotherapy.

Patient Selection Criteria fo r Br ief TherapyExclusion Criteria Inclusion CriteriaActively psychotic Moderate emotional distress

Abusing substancesAt significant risk for self harm Seeking relief from painAble to articulate or accept specific cause or circumscribedHistory of at least one positive mutual interpersonal relationshipFunctioning in at least one area of lifeAbility to commit to treatment contract

problem as focus of treatment

7. How does the brief therapist focus the treatment?Developing a treatment focus is probably the most misunderstood aspect of brief therapy. Manyclinicians write about the focus i n a mysterious and circular manner. It often appears as if thewhole success of the treatment rests on finding the one correct focus. Rather, what is needed for asuccessful brief treatment is the establishment of a functional focus; that is, a focus on which boththe therapist and patient can agree to work.

8. How is a functional focus established?One powerful, straightforward technique is the Why now? question used by Budman andGurman. It is applied by repeatedly asking the patient: Why did you come for treatment now?Why are you here now? Attention is directed to the current problem, rather than last weeks or to-morrows. Try this simple technique a few times to see how effective it can be.)For example, a male patient Pt) presents with significant depressive symptoms to a therapistTh) at a walk-in clinic.Th: 1 hear from what you say that you are depressed and are feeling terrible, but I wonderwhat made you come in today?Pt: I cant take it any more. I know I need help.Th: You cant take it. What makes it impossible to take it now?Pt: Its getting too bad. I just cant take it any more.Th: It sounds like something happened recently that made you realize how bad things were.What made you realize that you had to get help now?Pt: I just felt so bad I couldnt go to work yesterday. I stayed home in bed all day. I nevermiss work. I must be falling apart.This line of questioning led to establishing the patients physical inactivity as a functional focus

for treatment. As a result, his depression was successfully treated by increasing his physical activity.9. Describe some typical functional foci.Budman and Gurman describe five common treatment foci:Losses past, present, or pendingDevelopment dyssynchronies; being out of step with expected developmental stagesTherapists should be able to identify with this because years of extended schooling and trainingusually keep life events such as marriage and children on hold.)

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Planned Brief Psychotherapy 223Interpersonal conflicts (usually repeated disappointments in important relationships)Symptom atic presentations and desire for symptom reductionSevere personality impairment (In brief therapy, one aspect of personality im pairment can beselected as the focus of therapy .)

Beginning brief therapists should use these five comm on f oci to help organize their patientscomplaints and problems. The most important thing to remem ber is that you are not finding thefocus, only focus for the therapy.10. How does the therapist complete the evaluation?Brief therapy is deman ding for the therapist and patient. In addition to doing a full psychiatricinterview, by the completion of the second evaluation session you need to have I ) determinedwhether the patient is suitable for brief treatm ent; (2) developed a functional focus; and (3) articu-lated a clear treatment contract.The patient and therapist must agree on a treatment contract.The contract identifies the treat-ment focus and spells o u t details, such as the number of sessions, proced ure for missed appoint-ments, and guidelines for post-termination contact. Brief therapy typically lasts 10-24 sessions, butmay include as many as 50 sessions. (A 15-session treatment, not including the evaluation sessions,is a good length for a beginning brief therapist to start with). A flexible approach to missed appoint-men ts is recom mended, and if the patient has a valid reason, the therapist should try to reschedule. ifa session is missed without a valid reason, the missed session should be counted and the patientsmotivation should be explored, because this is resistance to treatment.11. What is another advantage besides the extra time) of a two-session evaluation?It allows an assessment of how the patient responds to the therapy (and therapist), providingimpo rtant additional info rmation abo ut the appropriateness of brief treatment. So m e for m of in-tervention at the end of th e first evaluation session is helpful in this regard. Th is initial interven-t ion can be as simple as summ arizing the patients problem and offering a tentative treatmentfocus or as complex as requiring the patient to fill out a psychological questionnaire. At the startof the second session, inqu ire about the intervention. If the patient responds po sitively (e.g., foundit helpful to think of the problem in this new light; is interested in the psychological test results)and/or is feeling better, it is a sign that brief therapy m ay wo rk. If the patient has not followe d upon the interven tion (e.g. , did not think ab out the potential focus) or reacted ang rily to it , i t is anegative sign.12. Can the functional focus change?

No. Once a functional focus has been established, the therapist must maintain it. O ne way is byworking consistently from within one style or orientation, of which there are basically three: (1) psy-chodynamic, (2) interpersonal, or (3) cognitive-behavioral. The one you use depends on your prefer-ence and, to some extent, you r patients problem.13. Describe the three approaches used in brief therapy.Most psychodynamic treatments are limited in their range of application and are appropriatefor only a small perc entag e of clinic patients, typically those suffering from re active or neuroticforms of depression (such as failure to grieve, fear of success and com petition, and triangular, con-flicted love relationships). These are demanding treatments for the therapist to undertake and requirethat the patient be able to tolerate considerable affective arousal.Brief interpersonal psychotherapy (IPT) w as developed by Klerman and colleagues specifi-cally to treat depression. It is a highly form alized (manualized) treatment often used in researchstudies. It can be considered a mix of psychoeducation and supportive therapy. In IPT, the patientssymptoms are explained (psychoeducation) and interpersonal interactions, expectations, and experi-ences are explored. IP T seeks to clarify what the patient wants to receive fro m relationships andhelps patien ts develop necessary social-interpersonal skills. N o effort is made to understand thedeeper unconscious meaning of the patients social interactions or desires.

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224 Plann ed Brief Psy chotherapyThe cognitive behavioral herapies, like Becks, are more broadly applicable, both in the per-centage of patients who can benefit and the range of problems that can be treated. These therapiesaim at bringing the patients autonomic (pre-consciou s) thoug hts into awareness and demon strat-ing how these thoughts maintain negative behaviors and feelings.

14. Are all three approaches employed simultaneously?No. A minimal, thoughtful am ount of mixing of techniques fr om different therapy styles is ac-ceptable. Therapeutic flexibility is necessary in brief treatment. It is important, however, to concep-tualize and work predominantly from within on e orientation to keep treatment fo cuse d and clear.Especially avoid uncritical wh olesale mixing of styles and orientations, because such wild treat-ment confuses and disappoints both the therapist and patient.

15. What does it mean to be an active therapist?Com pleting a psychotherapy in 12-15 sessio ns requ ires sus tained activity on the part of thetherapist to maintain treatment focu s and move the therapy pro cess forw ard. The brief therapistworks to structure every session, thereby increasing produ ctivity.

The Active TherapistStructure each sessionGive homework assignmentsDevelop and use the working allianceLimit silences and vagueness

Use confrontation and clarificationQuickly address negative and overly positive transferenceLimit regressionUse supervision

16. Discuss important factors for the active therapist in structuring sessions.Starting each session with a summary of important material from the last session and restatingthe treatment focu s organizes therapy and keeps the treatment on track. Giving homework to the pa-tient to be completed between sessions helps increase the imp act of therapy on the patients currentlife and situation and m onitor the patients m otivation fo r change. If the patient does not com pletethe homework, the motivation for change must be explored.The working alliance between therapist and patient mu st be developed quickly. It is frequentlyinvoked to return the patient to the treatment focu s. Patients may attempt to escap e the anxiety inher-ent in brief therapy by bringing up interesting but diverting material. The therapist should meet suchtactics with reminders of the agreed-upon focus (thus invoking the working alliance) and queriesabout how the new material relates to it. Prolonged silences (by either the therapist or patient) areconsidered unp roductive in brief therapy and also ar e quickly confronted as resistance.The brief therapist must know how to limit regression.Two useful techniques are 1) organiz-ing interpretations about events in the here and now, using eith er the therapy relationship or the pa-tients current life situation , rather than aro und early developmental traumas; and (2) moving thepatient away from feelings and into thoughts-What are you thinking rather than W hat are youfeeling? Regressions within sessions are permitted and even encouraged in som e short-term w ork.For example, it is quite comm on, when employing a treatment mod eled after that of Sifneos, to keepa patient focused on an anxiety-provoking conflict despite mild confusion o r panic.17. What are two valuable tools in brief therapy?

The brief therapist makes heavy use of confrontationand clarification.Confrontation helpsthe patient recognize when he or she is avoiding or resisting the treatment focus, usually as a resultof anxiety. Clarification techniques are used w henever the patient is comm unicating in a vague o r in-com plete manner. Usually the therapist asks for specific examples of unclear situations or feelings.18. How does transference manifest in brief therapy?Regardless of the style of therapy you em ploy (psy chodyn amic, cognitive, o r interpersonal)patients inevitably react to som e of your interventions based on their past experiences. When such

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Planned Brief Psychotherapy 225reactions are negative (You always criticize me) or excessively positive (You know me betterthan anyone on earth), they m ust be explored a nd interpre ted quickly. Rapid attention can helpkeep the patients transference under control and reduce the likelihood of it becoming a major re-sistance to treatment.19. Is supervision unnecessary due to the short-term nature of this type of treatment?As in all psychotherapy, supervision is im porta nt in both learning a nd practicin g brief psy -chotherapy. Supervision by an experienced colleague provides an excellent vehicle for beginningtherapists. More advanced practitioners find that so m e form of ongoing supervision, either formal o rinfor ma l, help s maintain th e treatment fo cu s and aids in identifying s ubtle, but often imp ortan t,changes in the patients mann er. Such subtle changes can represent the first signs of transference.20. What are the phases of brief therapy?The initial phase includes evaluating and assessing patient appropriateness for brief therapy, se-lecting a treatment focus, and establishing the main treatment orientation. For the patient this phaseis usually accom panied by slight symptom reduction and m ildly positive transference. Both of thesefactors help with the quick development of a working alliance.In the middle phase, the work gets m ore difficult. Typically the patient b ecom es concernedabout the time limit and, in addition to the treatment focu s, issues of dependency b ecom e important.The patient often feels worse, and the therapists faith in the treatment p rocess is tested. The earlymiddle ph ase of brief therapy can be p articularly hard for the therapist, w ho m ust be active in sus-taining treatment focus, keeping the patient w orking, and countering patient sk epticism while pro-jecting optimism. G ood supervision is invaluable during this phase for the beginning brief therapist.In the termination phase, therapy tends to settle down. The patient accepts that treatment willend as planned and that sym ptom s will decrease. Now, in addition to the treatment focus, post-ther-apy plans and the patients feelings about termination are explored . Amon g the m ost comm on ter-mination problem s is the introduction of new material by the patient. The therapist may be temptedto explore the new information and extend the therapy. This is usually a mistake, because the pa-tient likely is attempting to avoid the treatment focus, and in m ost cases the treatment should end asplanned.21. How do I handle post-treatment contact with the patient?This difficult question must be answered individually by each therapist. During training, the be-ginning therapist should have the experience of handling the intense feelings (both his or her ownnd the the patients) that accompany the termination of a treatment in which there will be 11 post-

therapy contact. Th is teaches the therapist how to deal openly with these powerful and importantfeelings. In ongoing practice, how ever, it is important to encourag e patients to return f or treatmentwhen new difficulties develop, and to foster the understanding that help is available if needed.Patient care should be guided by the understanding that Therapy is for living and not vice versa.The brief psychotherapist practices as a primary care physician, available to help patients with (psy-chological) troubles or crises that develop.22. How does brief psychotherapy relate to managed care?In a managed care environment, payors are encouraging the use of shorter treatments such asplanned brief psychotherapy. However, managed mental health care and brief psychotherapy are notidentical. Managed health care is primarily concerned with controlling cost. Planned brief psy-chotherapy represents a clinically proven procedure for helping some patients in need of psychiatricservices. To be administered properly, brief psychotherapy must be based on clinical, not financial,considerations. Although m any patients covered by m anaged care contracts benefit from brief psy-chotherapy, not all patients are appropriate. Many variables are involved in selecting patients forbrief psychotherapy-but men tal health insurance coverage is not one of them . Finally, therapy thatis considered brief for clinical work (i.e., 15-20 sessions) may be considered too long by managedcare companies, who often suggest 6-8 sessions.

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226 Marital and Family TherapiesBIBLIOGRAPHY

1. Alexander F, French T Psychoanalytic Psychotherapy. New York, The Ronald Press, 1946.la . Beck AT: Cognitive therapy for depression and panic disorder. Western J Med 151 9-89, 1989.2. Beck S , Greenberg R: Brief cognitive therapies. Psychiatr Clin North Am 2: 1-22, 1979.2a. Book H E How to Practice Brief Psychodynamic Psychotherapy: TheCoreConflictual Relationship Them e3.4.5.6 .7.8.9.10.I

12.13.14.15.

16.17.18.19

Method. Washington, DC, American P s~ ch ol og ic ~lssociation Press, 1998.Budman S , Gurman A: Theory and Practice of Brief Therapy. New York, Th e Guilford Press, 1988.Burk J, White H, Havens L: Which sho rt-term therapy? Arch Gen Psychiatry 36: 177-1 86, 1989.Davanloo H: Short-Term Dynam ic Psychotherapy. New York, Jason Arons on, 19 80.Ferenczi S , Rank : The Development of Psychoanalysis. New York, Nervous and Mental DiseaseFlegenheime r W: H istory of brief psychotherapy. In Horner A (ed): Treating the N eurotic Patient in BriefGoldin V Problems of technique: In Horner A (ed): Treating the Neurotic Patient in Brief Psychotherapy.Groves J : Essential Papers on Short-Term Dynamic Therapy. New York, New York University Press, 1996.Groves J : The short-term dynamic psychotherapies: An overview. In Rutan S ed): Psychotherapy for theHall M, Arnold W, Crosby R: Back to basics: The importance of focus selection. Psychotherapy 4578-584,Horner A : Principles for the therapist. In Horner A (ed): Treating the Neurotic Patient in BriefHorath A, Luborsky L: The role of the therapeutic alliance in psychotherapy. J Consult Clin Psycho1Klerman G , Weissman M, Rounsaville B, Chevron E : Interpersonal Psychotherapy of Depression. NewLeibovich M : Short-term psychotherapy for the borderline personality disorder. Psychother Psychosom

Malan D: The Frontier of Brief Psychotherapy. New York, Plenum M edical Book C ompany, 1976.Mann J: Time-Limited Psychotherapy. Cam bridg e, Harvard University P ress, 1973 .Olfson M , Pincus H A: Outpatient psychotherapy in the United States. 11: Patterns of utilization. Am JSifneos P: Short-Term Anxiety Provoking Psychotherapy: Treatment Manu al. New York, Basic Books,

Publishing Company, 1925.Psychotherapy. New Jersey, Jason Arons on, 1985, pp 7-24.New Jersey, Jason Aronson, 198 5, pp 56-74.

90s. New York, Guilford Pres s, 1992.1990.Psychotherapy. New Jersey, Jason A ronson, 1985 , pp 76-85.61:561-573, 1993.York, Basic Book s, 1 984.35:257-264, 1981.

Psychiatry 151:1289-1294, 1994.1992.

44. MARITAL A N D FAMILY TH ER APIESMargaret Roath, M.S .W . , LCSW

1. What a re marital and family therapies?Marital and family therapies are therapeutic modalities whose focus of assessment and treat-ment is on the relationship, not on the individual. Assessment includes gathering data related to thefollowing areas:History of the relationshipGoals of the individuals in the relationshipCoping mechanisms which have beenPrecipitant for seeking therapy--why now?

Communication patterns, bothconstructive and destructiveDescription of the strengths ofUnmet needs of the individualsunsuccessful the relationshipor what changed? in the relationshipAssessment of the precipitant for seeking marital or family therapy is especially important in deter-mining the relationship equilibrium-which may have worked previously for all members of therelationship, but is now out of balance. The precipitant might be a change in external circumstancesor a change within an individual that is affecting the relationship.